OSCE

Question 1

Urinalysis: Causes of glucose in urine

Answer 1

Diabetes Mellitus
SGLT2i
Renal tubular disease

Question 2

Urinalysis: what causes bilirubin in urine?

Answer 2

Conjugated bilirubin

Biliary obstruction e.g. pancreatic cancer

Question 3

Urinalysis: causes of Ketones in urine

Answer 3

Indicates fatty acid metabolism
Starvation
Diabetic ketoacidosis

Question 4

Urinalysis: causes of high or low specific gravity

Answer 4

= amount of solute dissolved in the urine

Low = dilute urine

• diabetes insipidus
• Acute tubular necrosis

High = concentrated urine

• dehydration
• diabetes Mellitus
• proteinuria e.g. nephrotic syndrome

Question 5

Urinalysis: causes of high or low pH

Answer 5

Normal range 4.5 - 8

Low = starvation, diabetic ketoacidosis, sepsis
High = UTI, vomiting, diuretics

Question 6

Urinalysis: causes of blood in urine

Answer 6

UTI
Renal stones
Nephrotic syndrome
Malignancy in urinary tract

Question 7

Urinalysis: causes of protein in urine

Answer 7

Nephrotic syndrome

Chronic kidney disease

Question 8

Urinalysis: causes of nitrates in urine

Answer 8

Breakdown product of gram negative organisms e.g. e.coli

UTI

Question 9

Urinalysis: causes of high or low urobilinogen in urine

Answer 9

Normal bilirubin breakdown product 0.2-1.0 mg/dL

Low = biliary obstruction
High = haemolysis e.g. anaemia, malaria

Question 10

Urinalysis: causes of leukocyte esterase in urine

Answer 10

= an enzyme produced by neutrophils, so it indicates the presence of white blood cells in urine

UTI
Anything that causes haematuria

Question 11

Respiratory exam

Answer 11

End of bed - ask how they’re feeling
Look at hands - hold out hands for tremor,CO2 flap, finger clubbing
Pulse and resp rate
Look at eyes, pull down lids
Look inside mouth and under tongue
Feel trachea
Chest expansion
Percuss front then axilla
Auscultate front then axilla (4 places anterior and 3 axilla)
Repeat on back
Lymph nodes
JVP - 45 degrees, look to left
Look at legs for oedema, rashes, DVT

Question 12

Peak Flow Measurement

Answer 12

Ask if they’ve done this before
Make sure peak flow is marked with EU standard
Use clean tube and reset meter
Best to stand or sit up straight
Deep inspiration
Lips tightly around but keep fingers off of meter
Deep inspiration and hard expiration
Record best of 3 attempts
Put tube in bin
Get patients height
Compare on chart

Question 13

Full Cardio Examination

Answer 13

End of bed assessment - make sure exposed
Hands - finger clubbing, cap refill
Pulse - check of radio-radial delay, collapsing pulse
Blood pressure
Eyes and mouth
Examine chest
Locate apex beat and feel for heaves
Feel for thrills
Auscultate all 4 areas with different pressure on stethoscope
Turn on left hand side and listen at apex to accentuate mitral stenosis
Sit forward and hold breath out and listen at parasternal edge for aortic regurgitation
Feel and Auscultate the carotids
Auscultate lung bases
JVP
Check for sacral and peripheral oedema

Question 14

Precordial Examination

Answer 14

Inspections
Palpation - heaves at apex, thrills over each area
Auscultate at 4 areas with both pressures of stethoscope
Turn on left hand side and listen at apex for mitral stenosis
Sit forward and hold breath out and listen at parasternal edge for aortic regurgitation
Feel and auscultate carotid arteries
Listen at lung bases front and back

Question 15

Peripheral Vascular examination

Answer 15

Inspect all sides and in between toes
Feel for temperature all the way down
Feel all pulses
Cap refill
Check for oedema
Check for calf tenderness
Buerger’s test? With patient lying down, hold both legs up for 1/2mins then sit them up and swing legs down. Look at colour changes throughout

Question 16

GI Abdominal Exam + extra renal tests

Answer 16

Lie patient on back and fully expose down to ASIS
Inspect all areas
Sit down to be eye level with abdomen
Ask about pain
Palpate all nine areas first superficially then deep and look at patient throughout
Palpate for liver
Palpate for spleen and repeat with the rolled onto right
Palpate kidneys - bounce hand at back and see if you can feel from anterior surface, mostly looking for pain
Percuss liver up and down
Percuss up to spleen from RIF

If renal, Percuss for bladder - upper abdo down to pubic symphysis

Percuss from midline to flank then if you heard dullness, roll patient over, wait 10 seconds and re-percuss to see if it shifts
Auscultate for bowel signs - need to be absent for 2 mins before you can say theyre absent

Question 17

Rectal Examination

Answer 17

Ask if theyve had this before
Explain exam and squeezing, get consent, explain chaperone and how to undress
Patient should be lying on left hand side with knees up to chest
Inspect
Insert finger and feel 360 degrees - prostate is on anterior wall
Assess anal tone
Look at finger when removed
Cover patient and clean up

Question 18

Diabetes Lower limb exam

Answer 18

Remove socks and shoes and expose to at least the knee
Inspect all parts of the legs
Feel temperature all the way down
Feel the two foot pulses
Check for peripheral oedema
Cap Refill
Use 10g monofilament needle to check sensation at tip of 1st and 3rd toes and at metatarsal heads of 1st, 3rd and 5th toes
Look at inside of shoes for insoles and at outside for wear

Question 19

Thyroid Examination

Answer 19

Inspect patient as a whole
Look at nails
Look at eyes
See if they are able to stand from seated position
Inspect neck fully
Look while swallowing water
Ask them to breath deeply to check for stridor

Question 20

Otological examination

Answer 20

Inspection
Palpate mastoid and tragus
Otoscopy: use right hand for right ear, rest hand on cheekbone. Pull pinna out and up
Hearing test: At arms length, cover one ear and whisper to another. Repeat word back to me
Webers - centre of head
Rinne
Rombergs test - balance

Question 21

Upper Limb Neuro Exam

Answer 21

Inspection
Arms outstretched palm down - look for essential tremor
Arms outstretched palm up - close eyes and look for movement
Assess tone - rigidity is always present, spasticity is velocity-dependent
Power -
Reflexes - biceps, supinator and triceps. Test once then if absent try reinforcement
Sensation - pain eyes open, light touch with eyes closed, vibration with tuning fork, proprioception move DIP of index finger up or down with eyes closed

Question 22

Lower Limb Neuro Exam

Answer 22

Inspection
Assess tone - Rolling each leg, flexing and extending the knee, dorsiflex ankle with knee flexed
Assess power - Hip, knee, ankle up and down and side to side, big toe only (isolates L5)
Reflexes - Knee, ankle and plantar, reinforce only if necessary
Sensation - Show on upper before testing lower, medial and lateral thigh, antero-medial and lateral calf, lateral foot
Proprioception

Question 23

Cerebellar Examination

Answer 23

Gait - walking, heel-to-toe, Rombergs for balance
Eyes - H test
Speech - British constitution, baby hippopotamus
Upper Limb - finger to nose, rapid hand movements, rebound phenomenon, assess tone, reflexes
Lower limb - heel-to-shin, rapid foot movements, assess tone, reflexes

Question 24

Breast Examination

Answer 24

Explain + Chaperone + how to undress
Sit on edge of couch - inspect
Lift hands above head
Hands on waist
Lying flat on bed with arms above head - palpate breasts, ask about pain
Palpate Axilla - anterior, posterior, medial, apex

Question 25

Pregnant Abdo Exam

Answer 25

Patient lying semi-up fully exposed down to ASIS Inspect bump Feel bump and measure from top of fundus to pubis symphysis Feel for position of foetus If late pregnancy - feel for head, if can feel it all in abdomen its 5/5 not engaged. If cant feel any in abdomen, it is 0/5 fully engaged Auscultation with Pinard Horn and feel maternal pulse at same time

Question 26

Female Pelvic Exam

Answer 26

Abdo exam first - inspection, palpation, percuss for fluid, ausculation Feet together, knees apart, scooch bum down to edge of bed Inspection - gently part labia If an older women, ask to cough to check for prolapse Bimanual examination - Lube finger, part labia and insert one finger, then two if 1 is ok Feel cervix Feel fornices Feel uterus - push fingers anteriorly and press down on suprapubic area Feel adnexa Feel pouch of douglas - should be concave, if convex it indicates a mass

Question 27

Female Speculum Exam

Answer 27

Set-up everything first - while patient is undressing Lubricate speculum only a little Put in with handles on right then rotate and hold open - may be ratchet Look at cervix Take smear test - rotate 10 times on cervix, 5 times in pot May need to take swabs ‘Unlock’ speculum and retract slightly looking at walls then take out rotating again

Question 28

Haematology Examination

Answer 28

``` Hands Face - eyes and mouth Look at neck - may need water Feel neck lymph nodes Feel axillary lymph nodes Inspect abdomen Feel inguinal lymph nodes Palpate abdomen - 9 areas superficial and deep, feel for liver and spleen and kidneys. If spleen not felt roll over Percuss - Liver and spleen Percuss for ascites Auscultate for bowel sounds and bruits ```

Question 29

Spine Examination

Answer 29

Expose spine and ask about pain Inspect from all sides Feel all the way down to sacroiliac joints Feel muscle bulk each side looking for spasm Chest expansion if ankylosing spondylitis suspected Move neck all directions Move back - flexion, extension, lateral and rotation Special test - Schober’s test, make dots on SI joints and 10cm above and 5cm below, bending forward should increase the gap to at least 20cm

Question 30

Hip Examination

Answer 30

Expose hips, with only underwear below waist and ask about pain Look with patient standing Gait Lying flat on couch look again more closely Feel - lateral thigh of hip, ASIS and down inguinal area Move - Flexion (active), internal and external rotation (hip 90 move foot in and out), adduction and abduction (leg straight and move out and cross over while holding opposite hip) (all passive) Special Tests: Trendelenburg’s - hold hands and ask patient to stand on one leg Limb lengths - True from ASIS to medial maleolus, apparant from xyphoid process to medial maleolus Thomas’ test (DONT NEED TO DO) - put hand on lumbar spine, ask patient to flex hip and see if the other leg slightly flexes as well