Introduce, explain, glance from end of bed
Say "Could you hold out your hands please"
nails for clubbing, splinter haemorrhages. Press on the nails for
capillary refill time. Say, "could you turn your hands over" and feel
Feel the radial pulses of both hands
initially. Then feel for femoro-radial delay. Finally record the pulse
for 15s, and then the respiratory rate for 15s. Aortic stenosis has a slow rising pulse character.
Say "Do you
have any pain or stiffness in your shoulder, would you mind if I lifted
your arm up?" Hold the arm with your left hand at the radial pulse, and
right hand at the elbow and lift the arm up above the patient's head. Aortic regurgitation gives a collapsing pulse character.
Say "would you like me to measure the blood pressure" to the examiner
Head and neck
Look in the eyes. Pull down
lid for conjunctival pallor (anaemia). Look in the mouth for central cyanosis
Say "could you turn your head to the left" and look to see if the venous pressure is raised
Carotid pulse with finger tips
Expose the praecordium. If this is a women you will be expected to remove her bra.
for scars (midline, left or right thoracotomy). If seen check for
scars on the arms and legs to see if veins have been stripped for a
CABG (if not is this scar for a valve repair?)
the apex beat: start lateral and inferior to where it should be (5th
intercostal space, midclavicular line) and work in until found. Then
count down ribs to see if it is displaced. Note its nature (e.g.
Feel for heaves with the bottom half of your palm,
either side of the lower sternum. Feel for thrills with the palmer side
of your fingers either side of the upper sternum
Say "Can you roll to your left." Re-palpate the apex beat
the apex beat with the bell and the diaphragm.
the patient rolled back, then auscultate all other valve areas with
just the diaphragm. The valve areas are illustrated in the illustration below. A useful mnemonic is "All Prostitutes Take Money" for Aortic, Pulmonary, Tricuspid, Mitral valve areas going from left to right upper then lower chest. Auscultate the carotids for bruits and radiation.
The murmur of aortic stenosis is loudest at the right sternal edge 2nd intercostal space and sometimes radiates to the carotids, it is termed ejection systolic because of its increasing and then decreasing volume in systole. The murmur of mitral regurgitation is loudest at the apex beat and is termed pansystolic because it is of equal volume throughout systole. The murmur of mitral stenosis occurs over the apex beat during the end of diastole, and is "rumbling" in character.
Say "would you
mind leaning forward. When I tell you to do so, could you take a deep
breath in and then blow it all the way out and hold it." Place your
diaphragm over the 5th intercostal space left sternal edge, and then
then get them to perform the breathing manouvre and hold their breath.
Listen for aortic regurgitation.
Keep them sat forward. Now auscultate their back at the lung bases for
crackles. Press down on their sacrum for sacral oedema
Valve areas. A = Aortic, P = Pulmonary, T = Tricuspid, M = Mitral (Apex Beat). (Adapted from Patrick J. Lynch. Creative Commons Attribution 2.5 License 2006).
their legs and inspect them (see the
examination). Palpate the
popliteal, posterior malleolar and dorsalis pedis pulses. Press on
their shins for at least 3s for ankle oedema.
"I would like to"
Examine the abdomen for hepatomegaly (portal venous congestion in congestive cardiac failure)
Look at the temperature chart (endocarditis)
Look at the fundi (hypertension, diabetes)
Common Conditions for OSCEs
Probably the commonest OSCE station of them all.
Valvular heart disease:
Usually systolic murmurs. The commonest are
the positive findings, and the relevant negatives. The examiner has
seen you examine the patient so he knows that you know that you should
look at the nails, but he doesn't want to hear about it if you didn't
find anything (he has also examined the patient). For example:
This is Mr Jones, he is a gentleman who looks comfortable at rest.
His pulse is 70, irregularly irregular. He is not tachypnoeic. His blood pressure is 140/80.
has a malar flush. He venous pressure is raised and he has ankle
oedema. There are no other peripheral stigmata of disease.
His apex beat is undisplaced but tapping. He has a mid-diastolic murmur
at the apex accentuated in the left lateral position.
diagnoses is atrial fibrillation and mitral stenosis, causing
congestive cardiac failure. There are no features of endocarditis.