Physical examination

• Clean your hands prior to beginning.

• Start with the hands—look for clubbing and splinter haemorrhages.

• Face—look around the eyes for xanthalasma and a corneal arcus. Gently examine the conjunctivae for pallor or petechial haemorrhages. A malar flush is an uncommon finding suggestive of mitral stenosis. Look at the lips and tongue for central cyanosis.

• Palpate for a collapsing or water-hammer pulse by placing three fingers of your right hand loosely around the wrist, covering the radial area but not applying pressure. Support the elbow and check for any shoulder discomfort before lifting the patient’s arm. If a collapsing pulse is present you will feel the sharp pulse in the radial area.

• Palpate the apex beat by placing your fingers flat on the chest parallel to the ribs in the 5th intercostal space mid-clavicular line.

• Examine for a heave by placing the heel of your hand firmly over the left parasternal position.

• Palpate for thrills by placing the flat of your fingers at the apex and then on both sides of the sternum.

• Ask yourself whether the first or second heart sound is easily heard, loud or soft.

• Roll the patient onto their left side. Listen with the bell using light pressure at the apex, specifically the mid-diastolic low-pitch rumbling murmur of mitral stenosis.

• Sit the patient up and ask them to lean slightly forwards. Using the diaphragm, listen over the right and left upper sternal edges at end-expiration for the high pitched murmur of aortic regurgitation.

• Listen over the carotids on end-expiration and in the left axilla for radiation of any murmurs.

• If you hear a murmur, palpate the carotid pulse while you auscultate.

• Ask to check the blood pressure.

• Comment on the heart sounds—S1 (closure of the mitral valve) and S2 (closure of the aortic valve).

• Describe any murmurs (systolic or diastolic, loud/harsh or soft, mid to late or pan), including where they were loudest and whether they radiate.

• Comment on any other tests and suggest a differential diagnosis.

• Suggest appropriate initial investigations—ECG and transthoracic echocardiography are reasonable initial investigations for possible valvular heart disease.

• Clean your hands prior to beginning.

• Face—look for xanthelasma.

• Scars—look for scars on the abdomen (aortic aneurysm repair), groin (angiography) or medial aspect of thighs (bypass grafting).

• Ulcers—comment on arterial ulcers (punched out, usually over medial malleoli) or venous (anterior aspect of shin, associated with venous eczema and skin changes).

• Skin changes—loss of hair and skin thinning.

• Feet—examine dorsum and plantar aspects and between toes for ulcers.

• Feel for the skin temperature in the feet.

• Palpate the major pulses—radial, carotid, aortic, femoral, popliteal and dorsalis pedis.

• Check for radio-femoral delay after palpating radial pulse—explain this to the patient.

• Check for capillary refill time over big toe.

Buerger’s test—With patient lying on their back, raise their feet to 45° for 2 minutes. Then sit the patient on the edge of the bed with legs down. A positive test (peripheral arterial disease) occurs when legs initially go pale when raised then hyperaemic (red) when down.

The following suggest the requirement for urgent assessment (the 6 P’s): pallor, perishing cold, pulseless, paresthesia, paralysis, pain on squeezing muscle.

Pain at rest, non-healing ulcers and gangrene require urgent vascular assessment.

You may be asked to use a Doppler machine to detect the pulses or to complete the ABPI, so familiarise yourself with these investigations. You may also be asked to look at an angiogram and comment on lesions.

You may be asked about the treatment of peripheral arterial disease including prevention.

• Clean your hands prior to beginning.

• Look for central cyanosis in the tongue and lips.

• Neck—examine the JVP, which may be raised in cor pulmonale or fixed in superior vena cava obstruction. Examine the patient for lymphadenopathy.

• Chest—examine front, back and sides for scars (lobectomy/pleural drain scars).

• Look for hyper-expansion and poor or unequal chest wall movement.

• Count the respiratory rate and look for accessory muscle use.

• Inspect for peripheral oedema (end of the examination).

• Chest expansion—usually best seen on the posterior chest wall.

• You may be asked to check peak flow so be prepared to do so.

You may be presented with a chest radiograph or some pulmonary function tests (including a flow volume loop) to interpret after examining the patient. As with your physical examination, you should comment in a structured manner. Radiograph interpretation is discussed in further detail in station 7.2.

Calculate the FEV1/FVC—this is called the FEV1%.

FEV1% < 70 suggests obstructive lung disease (the lower the figure the more severe the obstructive disease).

• Ask for consent and offer a chaperone.

• Clean your hands and put on a pair of gloves.

• Examination of the scrotum is best performed with the patient standing. You will also need to examine the groin so this must be visible—explain that you will need to examine the lower abdomen to the upper thigh. Allow the patient privacy to undress.

• Check with the patient whether there is any pain or tenderness before you start.

• With each testis in turn, immobilise one side by placing one hand behind it, and use the index finger and thumb to palpate the entire body of the testis, and then the cord structures and epididymis at the top of each testis.

• If you palpate a swelling, try to ascertain whether it is separate to the testis or part of it, or part of the epididymis. If you cannot get ‘above’ the swelling, it may be an inguinal hernia.

• Finally, palpate both groins for any swelling and for inguinal lymph nodes which may be present in epididymitis (but remember that testicular tumours spread to the para-aortic nodes).

A digital rectal examination or breast examination is frequently encountered, both of which require a similar approach, with similar considerations of communication and consent. Refer to Macleod’s Clinical Examination (rectal examination, pp. 207–8; breast examination, pp. 239–42) for the clinical knowledge, and you can use this station (and adapt the mark-sheet) to practise your general approach to intimate examinations.

• Clean your hands prior to beginning.

• Move to the hands—look for finger clubbing, leukonychia, palmar erythema and a liver flap (asterixis).

• Face—look at the sclerae for signs of jaundice and the conjunctiva for pallor (possible GI malignancy).

• Neck—examine the JVP, which may be raised in congestive cardiac failure. Examine the patient for lymphadenopathy in the left supra-clavicular fossa only (see diagram).

• Chest—have a brief look for spider naevi and gynaecomastia.

• Abdomen—look for spider naevi, caput medusa (enlarged veins around the umbilicus indicative of portal hypertension) and distension. It is helpful to crouch at the bedside and look across the abdomen, which can help to identify organomegaly or masses even before palpating the abdomen. Comment on any scars, herniae or stomas.

• Inspect legs for peripheral oedema (this can be done at the end).

• Palpate the nine areas of the abdomen first superficially, then more deeply, whilst looking at the patient’s face. Try to keep your hand flat on the abdomen and bend your hand rather than poking your finger tips in.

• Palpate for organomegaly, this time with your hand tilted so that you are palpating mainly along the index finger. For the liver, start in the right iliac fossa gently palpating upwards on inspiration and moving sequentially upwards. For the spleen, use the same technique starting in the right iliac fossa and moving diagonally towards the left hypochondrium.

• In a standard examination you would also ballot the kidneys.

• Palpation may be difficult if the abdomen is very distended or in the presence of ascites.

• If the abdomen is distended, percuss horizontally across the abdomen at the level of the umbilicus to assess for dullness in the flanks. If there is dullness, proceed to test for shifting dullness.

A standard abdominal examination, usually on a healthy volunteer.

Other focused abdominal stations could include renal disease or haematological disease. Think about the ways in which you would adjust your clinical examination to make it particularly relevant to these systems.

As well as the examination above, you may be asked questions at the end about investigation and management of the patient. Basic investigation of patient presenting with liver disease would include:

• Bloods—bilirubin, liver enzymes (ALT, AST, Alk phos, GGT), INR and prothrombin time, albumin, full blood count, U + E

• Autoantibodies—antimitochondrial antibody, anti-smooth muscle antibody, anti-nuclear antibody

• Screening for other diseases—immmunoglobulins, ferritin and transferrin, α₁-antitrypsin, ceruloplasmin, α-fetoprotein

• Screening for infection—hepatitis B and C, cytomegalovirus, Epstein–Barr virus, HIV.

• Wash hands and apply gloves.

• Ensure that the patient is appropriately exposed (ideally this would be nipples to knees—but to preserve dignity would normally just expose abdomen).

• Looking at the stoma: Note appearance (flush with skin or has a spout?), health (colour should be pink/red and appear moist and glistening), stoma contents (comment if absent) and colour, consistency and volume.

• Palpate abdomen for any surrounding tenderness, masses or the presence of parastomal hernias.

• In addition you should percuss the abdomen and auscultate for bowel sounds (indicating a functioning bowel).

For completion you should offer to perform a digital stomal examination using the index finger with gloves and lubricant (not expected in the OSCE).

Although these are unlikely to feature within the OSCE, it is important to comment on their presence or absence to demonstrate that you are aware of possible complications including:

• Bleeding or fissuring;

• Parastomal hernias;

• Stomal prolapse, retraction or necrosis;

• Separation of the mucocutaneous edge;

• Narrowing or obstruction of the stoma lumen;

• Diarrhoea or constipation; and

• Iatrogenic injury, e.g., resulting from rubbing of clothing.

• Gain consent and explain the need for a darkened room with the use of a bright light that may be ‘dazzling but not damaging’.

• Check whether the patient requires glasses and that they are available.

• The Snellen (or LogMar) chart should be used 6 m away from the patient.

• Ask the patient to cover one eye with their hand and read the lowest line possible on the chart before switching eyes.

• If the patient is not able to make out any of the letters on the chart, then assess their ability to count fingers, see hand movement or distinguish between light and dark.

• Ask the patient to cover one eye with a hand and cover your eye directly opposite their covered one, i.e., the contralateral eye to theirs.

• Ask the patient to stare directly ahead into your eye at all times—to detect any unwanted eye movement.

• Extending your arm outwards, wiggle your index finger in each of the four outer quadrants of their visual field; ask the patient to say ‘yes’ when they see your finger move and bring it in from the periphery inwards until it is seen.

• If sensory inattention is suspected, ask the patient to stare forwards at you with their eyes open whilst testing both visual fields at the same time.

• Use the hat pin to detect the patient’s blind spot (and your own) by asking the patient to cover an eye as before (and you do the same) and focus on your eye then, holding the pin laterally, move it horizontally and inwards until it disappears and reappears in your vision.

• Asking the patient to stare straight ahead, shine the light from the side directly at each pupil and look for constriction of both pupils (direct and indirect reflexes).

• Test accommodation by asking the patient to fix on a point in the distance, then quickly focus on your finger close to their nose—look for constriction of both pupils.

• Hold your index finger vertically and, whilst asking the patient to keep their head still, slowly move your finger in the shape of an H to assess each ocular muscle.

• Look for nystagmus and ask the patient about any diplopia.

• Remember that nystagmus can be normal on extreme gaze.

• If diplopia is detected, establish the direction and ask the patient to close one eye to confirm whether it is binocular.

• The direction that the diplopia is worse in corresponds with the direction of action of the affected muscle.

• State that you would want to dilate the pupils for best visualisation of the fundus—unlikely in an OSCE (unless already done).

• Remember to adjust the dial to correct for your own refractive error before starting if removing your glasses.

• Test for the red reflex by standing back from the patient and shining the ophthalmoscope at each eye whilst looking through it; any abnormalities would appear opaque.

• Examine the patient’s left eye using your left eye, holding the ophthalmoscope in your left hand, and vice versa, whilst asking the patient to stare at a point in the distance.

• Get as close as you can to the patient without knocking heads and do not forget to breathe!

• Adjust the dial until the fundus comes into focus then follow the path of a blood vessel to the optic disc and assess the disc and surrounding retina and arteries for any abnormalities such as haemorrhages or scarring.

To add clinical signs to a simulated patient, abnormal fundoscopy photographs could be provided with the candidate being asked to describe the findings (or use a patient with diabetic eye disease). Alternatively, the examiner may provide a normal fundoscopy photograph, so do not try to identify abnormalities that are not actually there in an attempt to impress!

• Explain that you may be discussing your findings with the examiner during the examination.

• Wash your hands.

• Ensure that the patient is adequately exposed—with the lower limbs fully visible and any clothing removed.

• Comment on additional findings present such as insulin injection sites in the tops of the thighs or any walking aids visible next to the bed.

• Ask the patient to look away or close their eyes.

• Working your way up the lower limbs, comparing one leg with the other, touch each leg sequentially and ask the patient to comment each time they feel the touch.

• Use a dabbing rather than stroking motion and time each touch irregularly to avoid anticipation by the patient.

• Confirm any areas of reduced or absent sensation.

• Explain to the patient the need to assess pinprick and demonstrate normal sensation over the sternal edge.

• Ask the patient to report whether the sensation is sharper or blunter than normal whilst moving systematically up the limbs, comparing limb with limb.

• Hold the distal phalanx of the great toe at the sides and move it up and down, confirming this with the patient.

• With the patient’s eyes closed ask them to confirm whether subsequent small movements in a random order are ‘up’ or ‘down’.

• Do not press on the top or bottom of the toe when performing this to avoid giving any pressure clues.

• Compare each side with the other.

• Touch the patient with a cold object, e.g.,+ a tuning fork, and ask if it feels cold over sequential parts of the lower limbs, moving upwards.

• Thank the patient and ensure that they are adequately covered up.

• Wash hands or apply alcohol hand gel.

• Present findings concisely to the examiner, focusing on important positive findings rather than a long list of negatives.

• Clean your hands prior to beginning.

• Look for posture—is the arm held in flexion at elbow and wrist (pyramidal pattern suggesting UMN lesion)?

• Compare both sides—is there any muscle wasting or are any fasciculations present?

• Clasp knife increase in tone suggests an upper motor neurone lesion.

• Cog wheel (or ‘lead pipe’) increases are seen in extrapyramidal lesions (e.g., Parkinson’s disease).

• Test shoulder abduction (C4), then adduction (C5).

• Elbow flexion (C6), then extension (C7).

• Wrist flexion (C7), then extension (C6).

• Finger abduction (T1).

• Supinator (C6)—strike supinator tendon on lateral side forearm and observe for elbow extension.

• Triceps (C7)—strike triceps tendon just above elbow on posterior surface and observe for elbow extension.

• Pyramidal drift—ask patient to hold both arms out in front of them, palms up and then close their eyes—if the arm pronates, the test is positive, suggesting an upper motor neurone lesion.

• You should say you would like to examine the rest of the neurological system including cranial nerves and lower limbs. In this station you could quickly look for signs of upper motor neurone weakness of the face (facial drooping on right) and the leg.

2. Partial anterior circulation stroke (PACS)—2/3 of the above or cortical dysfunction by itself.

3. Lacunar stroke (LACS)—limited motor/sensory deficits without cortical dysfunction.

4. Posterior circulation stroke (POCS)—cerebellar dysfunction/visual defects/brainstem events.

You may be asked to assess lower limb weakness instead—do this following the same pattern and decide: is it unilateral or bilateral and is it a UMN or LMN lesion?

• Clean your hands prior to beginning.

• Check for tone in lower limbs.

• Look for bradykinesia—ask patient to rapidly tap index finger and thumb together. Also look for a progressive reduction in amplitude—both suggest idiopathic PD.

• Ask patient to write a sentence—look at grip (can they pick up the pen?) and at writing (typically smaller than normal in idiopathic PD).

• Examine gait—ask patient to walk a short distance, turn around and walk back. Look for arm swing, difficulty turning, bradykinesia, shuffling gait, freezing, festinant gait (Parkinsonism).