BiteMedicine - Lecture 34 (OSCE Masterclass - Examinations ...

• Requires some basic knowledge of clinical examinations

• Clinical examination station (OSCE)• What do they involve?• One way to prepare: ‘Retrospective approach’• Cardiovascular examination: 3 cases• Respiratory examination: 2 cases

2

Aims and Objectives

EXAMINATION ROUTINE

3

Clinical examination station: what do they involve? 3 PARTS

PRESENTATION

VIVA

EXAMINATION ROUTINE

4

Clinical examination station: what do they involve?

PRESENTATION

VIVA

• Perform each step of the routine confidently

• Pick up on signs

• Present findings systematically• List appropriate differentials based on

findings

• Answer questions systematically• Explain your thinking

5

Clinical examination station: how to prepare?

EXAMINATION ROUTINE

PRESENTATION

VIVA



• Present findings systematically

• List appropriate differentials based on findings

• Answer questions systematically

• Explain your thinking

‘Retrospective approach’1. Formulate an OSCE Cases List

2. Prepare your ‘VIVA’ for those cases• Positive signs of diagnosis• ‘Typical’ findings presentation• Risk factors• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

6

Clinical examination station: how to prepare?‘Retrospective approach’3. Finalise your examination routine

• Each step of the routine• Signs you are looking for• Your speech

4. Practice your examination routineon friends

5. Go to the wards/clinics looking foryour cases

EXAMINATION ROUTINE

PRESENTATION

VIVA







7

Clinical examination station: make your examination routine

Routine Presentation

Inspect the dorsal surface:• Temperature• Clubbing (cyanotic heart disease)• Joint deformity• Tar staining• Tendon xanthomata

Inspect the palmar surface:• Glucose monitoring• Capillary refill • Carpal tunnel release scars

If I can start by looking at your hands please

The hands are symmetrically warm and there is no evidence of:• Digital clubbing• Joint deformity• Tar staining• Tendon xanthomata

There are no obvious • Blood glucose monitoring marks• Carpal tunnel release scars

General Inspection

“Looking around the bed I can see blood glucosemonitoring equipment suggesting diabetic disease”

Remember to comment on absence of positive signs.

8

Cardiovascular examination: The Routine

(1)

Hands

• Tar staining• Smoking history

• Finger pricks• Diabetic

“Looking at the fingertips I cannot see any finger prick marksfrom blood glucose monitoring”


9


(2)

(3)

Arms

• Bruising

“Looking at the arms, I can see extensive bruising. This mayindicate prolonged anticoagulant use (?AF)”


10


Eyes

• Corneal arcus• Age, hyperlipidaemia

• Xanthelasma• Hypercholesterolaemia

Remember to comment on absence of positivesigns.

11


(4)

(5)

Chest

• Inspect: scars, chest wall deformities• Palpate: apex beat, heaves and thrills• Auscultate


12


(6)

Legs

• CABG scars• Pitting oedema


13


(7)

14


‘Retrospective approach’• Formulate an OSCE Cases List

• Prepare your ‘VIVA’ for those cases• Positive signs of diagnosis• ‘Typical’ findings presentation• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

• Make your examination routine• Each step of the routine• Signs you are looking for• Your speech

EXAMINATION ROUTINE

PRESENTATION

VIVA







What cases could come up?1. Mitral regurgitation2. Aortic stenosis3. Prosthetic heart valves: aortic, mitral or both4. Stable chronic heart failure5. Ischaemic heart disease: CABG scars

This is not a definitive list• But by preparing for these you will be better at:

• Your exam routine• Looking out for important signs• Formulating your findings systematically• Tackling the VIVA

15

Cardiovascular examination: OSCE Cases list

I performed a cardiovascular examination on this patient• Who has signs suggestive of mitral regurgitation

My main positive findings are:1. XXX2. YYY

My relevant negative findings are:1. XXX (Risk factors)2. YYY (Signs of decompensation)3. ZZZ (POSSIBLE associated features)

Overall, this points towards a diagnosis of mitral regurgitation withno signs of decompensation

16

How to present your findings?

If you have an idea, then back yourself from the start. It gets the examiner listening

RELEVANT negatives

99% of the time your patient will be STABLE

Peripheral

17

Cardiovascular examination: Case 1

Central

Auscultation• Ejection systolic murmur

• Loudest at aortic region• Exacerbated on patient

sitting forward, and on heldexpiration

• Radiation to carotids

18

Question: 1

What grade would you classify ‘an audible murmur with your stethoscope with no palpable thrill’

1. Grade 12. Grade 23. Grade 34. Grade 45. Grade 5

19

Cardiovascular examination: Case 1 – Aortic StenosisPlease present your findings?

I performed a cardiovascular examination on this patient who has signs suggestive of AORTIC STENOSIS

My main positive findings are:

• On auscultation, I could hear normal 1st & 2nd heart sounds with a systolic murmur between S1 & S2

• The systolic murmur was:

• Character: ejection systolic

• Region: loudest over the aortic region

• Augmentation: end-expiration with the patient sitting forward

• Radiation: carotids

20

Cardiovascular examination: Case 1 – Aortic StenosisPlease present your findings?

My relevant negative findings are:

• No signs of vascular risk factors e.g. nicotine staining

• No peripheral stigmata of infective endocarditis

• No scars to suggest coronary artery bypass graft or valve replacement

• No signs of decompensation e.g. peripheral oedema

This points towards a diagnosis of grade 3 aortic stenosis with no evidence of decompensation

21

Cardiovascular examination: Case 1 – Aortic StenosisWhat are your differentials?1. Aortic stenosis

• Narrowed valve orifice • Cause: calcification (elderly) or bicuspid valve

(young)

2. Aortic sclerosis • Normal orifice but thickened aortic valve leaflets• >65• Ejection systolic murmur but no radiation to

carotids

3. Mitral regurgitation• Pansystolic murmur (BRRRR)

• Heard loudest over mitral region• Augmented on held expiration, with patient

lying on L side with radiation to axilla

22

Cardiovascular examination: Case 1 – Aortic StenosisWhat are possible complications of aortic stenosis?

• Complications from the valve• Infective endocarditis• Embolic disease e.g. stroke (from a

disintegrating calcific valve)• Haemolytic anaemia

• Complications from impaired outflow• Left ventricular failure

23

Cardiovascular examination: Case 1 – Aortic StenosisHow would you investigate this patient?

Bedside• Basics observations: HR, BP• Urine dip: proteinuria for infective endocarditis;

glycosuria for diabetes• ECG: L ventricular strain

Bloods• FBC: haemolytic anaemia• Inflammatory markers: CRP and ESR for infective

endocarditis

24

Cardiovascular examination: Case 1 – Aortic StenosisHow would you investigate this patient?

Imaging• CXR

• Signs of pulmonary oedema (cardiomegaly)• Calcification of aortic valve

• ECHO: gold standard test to diagnose & assess severity• Severe: valve area <1cm2 and gradient

>40mmHg

Special• Coronary angiography: measure gradient across

valve and assess for concomitant coronary artery disease (8)

25

Cardiovascular examination: Case 1 – Aortic StenosisHow would you manage this patient?Conservative• Patient education:

• Diabetic control• BP control • Dental hygiene

Medical • BP control: ACE inhibitor, calcium blocker,

diuretics

Surgical• Aortic valve replacement: open repair or

TAVI• EUROSCORE used to decide which

surgical option • TAVI preferred for high risk patients

26

Grading murmursFreeman & Levine Grading for heart murmurs

• Grade 1: Faintest murmur• Grade 2: Faint murmur• Grade 3: Loud murmur, no thrill• Grade 4: Loud murmur + palpable thrill• Grade 5: Murmur heard with stethoscope partially on chest + thrill• Grade 6: Murmur heard with stethoscope held off chest

Peripheral

27

Cardiovascular examination: Case 2

Central

Auscultation:• CLICKING NOISE• Metallic 2nd heart sound• Ejection systolic murmur

28

Question: 2

What is the likely diagnosis?

1. Bioprosthetic aortic valve2. Bioprosthetic mitral valve3. Metallic aortic valve4. Metallic mitral valve5. Atrial fibrillation

29

Question: 3

Which of the following is NOT a feature of a biological prosthetic valve?

1. Preferred for younger patients2. Preferred if history of peptic ulcer3. Preferred for women of child-bearing age4. Less durable5. Shorter life span

30

Cardiovascular examination: Case 2 – Valve ReplacementPlease present your findings?

I performed a cardiovascular examination on this patient who has signs suggestive of AORTIC VALVE REPLACEMENT


• Midline sternotomy scar with no associated graft scars on the arms or legs• Multiple bruises • On auscultation, a metallic 2nd heart sound, consistent with a prosthetic valve• I also heard a systolic murmur

• Character: ejection systolic• Region: loudest over the aortic region• Augmentation: end-expiration with the patient sitting forward• Radiation: none

31

Cardiovascular examination: Case 2 – Valve ReplacementPlease present your findings?

My relevant negative findings are:• No signs of vascular risk factors e.g. nicotine staining• No peripheral stigmata of infective endocarditis• No scars to suggest coronary artery bypass graft or valve replacement• No signs of decompensation e.g. pulmonary or peripheral oedema

This points towards a metallic prosthetic aortic valve with a flow murmur• The valve seems to be functioning well with no signs of complications e.g.

infective endocarditis or CCF• The bruising on the patient’s arms is likely from anti-coagulant therapy

32

Cardiovascular examination: Case 2 – Valve ReplacementWhy do you think patient has had a valve replacement?

What are the indications for an aortic valve replacement?• Severe aortic stenosis: symptomatic, EF < 50%• Acute aortic regurgitation: secondary to aortic dissection• Infective endocarditis not responding to medical therapy

Factors to consider when deciding on valve replacement?• Severity of valve dysfunction (ECHO to measure this)• Any decompensation e.g. heart failure (LV EF)• Patient choice

33

Cardiovascular examination: Case 2 – Valve ReplacementWhat are the complications of a prosthetic valve?

Paravalvular leak• If the base of the valve becomes free

Obstruction• Thrombus

Subacute bacterial infective endocarditis• Early IE: Staph epidermidis (from skin)• Late IE: Strep viridans (haematogenous spread)

Haemolysis• Due to turbulence

Valve failure • Mechanical failure, calcification

POSH + valve failure

34

Cardiovascular examination: Case 2 – Valve ReplacementWhat different types of prosthetic valves do you know about?

Types Features Mechanical 1. Ball and cage e.g. Starr-Edwards

2. Tilting disc e.g. Bjork-Shiley3. Bileaflet e.g. St. Jude

• Longer lifespan• Requires anticoagulation

Biological 1. Porcine e.g. Carpentier Edwards • Less durable• Doesn’t require anticoagulation

• Older patient• Higher bleeding risk

Peripheral

35

Cardiovascular examination: Case 3 Central

(3)

(7)

36

Cardiovascular examination: Case 3 – CABGPlease present your findings?

I performed a cardiovascular examination on this patient who has signs of a coronary artery bypass.


• Midline sternotomy scar with associated saphenous graft on the L leg indicating a coronary artery bypass graft

• I also noticed a vertical 6cm scar on the neck along the distribution of the carotid artery• Finger pricks from glucose monitoring• Bilateral pitting oedema up to the mid-shin

37

Cardiovascular examination: Case 3 – CABGPlease present your findings?

My relevant negative findings are:• No signs of other vascular risk factors e.g. nicotine staining, tendon xanthomata• Normal heart sounds, with no added sounds or murmurs• No peripheral stigmata of infective endocarditis

This points towards coronary artery disease with a coronary artery bypass graft and a likely carotid endarterectomy

38

Cardiovascular examination: Case 3 – CABGWhat are the risk factors for coronary artery disease?

Modifiable Non-modifiable Smoking Family history

BP Age

Diabetes Male

Hyperlipidaemia Ethnicity

Obesity

39

Cardiovascular examination: Case 3 – CABGWhat is a coronary artery bypass graft?

• A healthy artery/vein from elsewhere (e.g. saphenous vein) is grafted

• The grafted vessel bypasses the blocked portion of the coronary artery à creates a new path for oxygenated blood to flow to heart muscle

40

Cardiovascular examination: Case 3 – CABGWhat is a coronary artery bypass graft?

Indications for CABG• Left main stem disease• Triple vessel disease• Angina not responding to medical therapy• Unsuccessful PCI

41

Cardiovascular examination: Case 3 – CABGHow would you investigate this patient?Bedside

• Basics observations: HR, BP• Urine dip: proteinuria for infective endocarditis; glycosuria for diabetes • ECG: evidence of ischaemic changes e.g. t-wave inversion

Bloods• BNP: raised in heart failure

• Marker released from ventricles from ↑ stretch

Imaging• CXR: assess for pulmonary oedema • ECHO: assess left ventricular ejection fraction

Special• Coronary angiography

42


‘Retrospective approach’• Formulate an OSCE Cases List• Prepare your ‘VIVA’ for those cases

• Positive signs of diagnosis• ‘Typical’ findings presentation• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

• Make your examination routine• Each step of the routine• Signs you are looking for• Your speech

EXAMINATION ROUTINE

PRESENTATION

VIVA







What cases could come up?

1. Lobectomy

2. Pneumonectomy

3. Pulmonary fibrosis

4. Bronchiectasis

5. COPD

43

Respiratory examination: OSCE Cases list

Peripheral

• RR 20

44

Respiratory examination: Case 1

Central

• Reduced chest expansion• Auscultation:

• Fine end inspiratory crackles inlower zones that do NOT clear oncoughing

(9)

45

Question: 4

Which of following is NOT a cause of pulmonary fibrosis?

1. Methotrexate2. Ankylosing spondylitis 3. Rheumatoid arthritis 4. Silicosis5. COPD

46

Respiratory examination: Case 1 – Pulmonary fibrosis

Please present your findings?

I performed a respiratory examination on this elderly gentleman who has signs of PULMONARY FIBROSIS

My main positive findings are:• Digital clubbing• Tachypnoea with a respiratory rate of 20 breaths/min• Decreased chest expansion bilaterally• On auscultation:

• Fine, end-inspiratory crackles in the lower zones that did not clear on coughing

47

Respiratory examination: Case 1 – Pulmonary fibrosisPlease present your findings?

My relevant negative findings are:• Reassuringly, not requiring oxygen currently• No CO2 retention flap • No signs of decompensation (cor pulmonale – raised JVP)

This points towards a diagnosis of interstitial lung disease (PULMONARY FIBROSIS)

• The absence of an evident cause e.g. rheumatological disease (arthropathy, rash)

• And given the patient’s age make the most likely diagnosis IDIOPATHIC PULMONARY FIBROSIS

48

Respiratory examination: Case 1 – Pulmonary fibrosisWhat are the possible causes of pulmonary fibrosis

Upper zone fibrosis Lower zone fibrosis Sarcoidosis Idiopathic pulmonary fibrosis: most common

cause

Occupational• Coal worker’s pneumoconiosis • Silicosis

Occupational• Asbestosis

Rheumatological • Ankylosing spondylitis

Rheumatological• Rheumatoid arthritis • SLE

Hypersensitivity pneumonitis Radiation

Cystic fibrosis Drugs• Methotrexate, Bleomycin, Amiodarone

49

Respiratory examination: Case 1 – Pulmonary fibrosisWhat are r differentials?

• Pulmonary fibrosis: think of possible causes• Bronchiectasis• Chronic lung abscess

Fibrosis Bronchiectasis Dry cough Productive cough (Sputum pot)

Fine end-inspiratory crackles Coarse crackles which change on coughing

50

Respiratory examination: Case 1 – Pulmonary fibrosisHow would you investigate this patient?

Bedside• Sputum MCS: superimposed infection

Bloods• FBC: anaemia of chronic disease

• Anaemia will exacerbate SOB

• ABG: type 1 respiratory failure

• Markers suggesting aetiology

• Rheumatoid arthritis: RhF, anti-CCP

• Sarcoidosis: increased ACE, hypercalcaemia

51

Respiratory examination: Case 1 – Pulmonary fibrosisHow would you investigate this patient?

Imaging• CXR: reticulonodular shadowing and reduced lung

volume• High resolution CT: diagnostic investigation

• Fibrosis + honeycomb lung

Special• Spirometry: restrictive pattern• Bronchoalveolar lavage: lymphocyte predominant

washings are associated with better prognosis • Lung biopsy

Restrictive Obstructive

FEV1 or ↓ ↓FVC ↓

FEV1/FVC >70% <70%

(10)

Peripheral

52

Respiratory examination: Case 2

Central

• Central trachea• Decreased chest expansion on L• Dullness to percussion on L lower

zone• Reduced air entry on L lower zone

53

Question: 5

Which of the following are indications for a lobectomy?

1. Malignancy2. COPD3. Chronic lung abscess4. Tuberculosis5. All of the above

54

Respiratory examination: Case 2 – LobectomyPlease present your findings?

I performed a respiratory examination on this patient who has signs of a L sided lobectomy


• Flattening and deformity of the L posterior chest wall with a L lateral thoracotomy scar in situ

• Decreased chest expansion on the L side

• Dullness to percussion on the L lower zone

• On auscultation, reduced air entry to the L lower zone

55

Respiratory examination: Case 2 – LobectomyPlease present your findings?

My relevant negative findings are:

• No signs of mediastinal shift: central trachea, apex beat non-displaced

• No signs of decompensation (no CO2 retention flap, no evidence of cor pulmonale)

• No signs of other treatment e.g. no supraclavicular scar (seen for surgery for TB)

This points towards a L sided lobectomy• In the exam, try and specify a cause for the surgery • In this case, it is not obvious, so you could list a few indications

56

Respiratory examination: Case 2 – LobectomyWhat are the indications for a lobectomy/pneumonectomy?1. Malignancy

• Clubbing, nicotine staining• Pancoast syndrome: Horner’s syndrome + wasting of small muscles of the hand

2. Previous surgery for old TB apical lesions• Used to be common to perform upper lobe lobectomy for apical TB

3. Bronchiectasis with recurrent haemoptysis• Clubbing with coarse inspiratory crackles

4. Chronic lung abscess

5. COPD• Nicotine staining • Wheeze

57

Respiratory examination: Case 2 – LobectomyThis patient has had a lobectomy for lung cancer, what are the possible complications of lung cancer?

Local Paraneoplastic Metastatic Horner’s syndrome• Damage to the

sympathetic chain in apical tumours (Pancoast syndrome)

SVC obstruction• Facial oedema and

erythema• Engorged neck veins

SIADH

ACTH

PTH-rP

Lambert-Eaton syndrome

BLAB:• Bone

• Liver

• Adrenal

• Brain

58

Recap‘Retrospective approach’1. Formulate an OSCE Cases List2. Prepare your ‘VIVA’ for those cases

• Positive signs of diagnosis• ‘Typical’ findings presentation• Risk factors• Signs of decompensation• List of differentials• Complications• How would you investigate this patient?• How would you manage this patient?

3. Finalise your examination routine• Each step of the routine• Signs you are looking for• Your speech

EXAMINATION ROUTINE

PRESENTATION

VIVA







59

References

1. Christidy at English Wikipedia / Public domain2. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)3. U/ttriber. https://i.redd.it/ls1p27ofe4i41.jpg4. Afrodriguezg / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)5. Oleg Tymofii / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)6. KVDP / Public domain7. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)8. Frank Gaillard / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)9. Desherinka / CC BY-SA (https://creativecommons.org/licenses/by-sa/4.0)10. Drriad / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

All other images were acquired under the basic license from Shutterstock and not suitable for redistribution

https://creativecommons.org/licenses/by-sa/3.0

https://i.redd.it/ls1p27ofe4i41.jpg






60

Further information

Fill out a feedback form to receive yourCertificate of Attendance!

Want to get involved? Contact us at [email protected] to get your information pack.

Stay up-to-date!• Website: www.bitemedicine.com• Facebook: www.facebook.com/biteemedicine• Instagram: @bitemedicine• Email: [email protected]

Presenter’s contact details• Instagram: @arun.kiru• Youtube: Arun Kiru• Twitter: @ArunKirupakaran• Email: [email protected]

http://bitemedicine.com

https://twitter.com/ArunKirupakaran

http://doctors.org.uk

BiteMedicine - Lecture 34 (OSCE Masterclass - Examinations ...

Documents

Transcript of BiteMedicine - Lecture 34 (OSCE Masterclass - Examinations ...