Missionary Orthopod in the Making

So I passed my finals but I’m not quite free yet. On top of being on our 1st year clinical rotations in the hospital, we also have to practice for our clinical skills exam. For this exam, you and your partner need to perform different clinical skills like taking a blood pressure, observing the retina with your ophthalmoscope, doing an abdominal exam, etc. all within 50 minutes. The rooms that you are doing the exam in is a voyeur’s paradise. It is rigged with cameras and microphones so that they can see and hear everything that you are doing. I take my exam on Tuesday, so wish me good luck. Below is the check list for the exam:

The OSCE:

Student will need to perform an appropriate upper extremity vascular exam to evaluate a patient for a dissecting aneurysm of the aortic arch, DBM or HTN.

_____Compares simultaneously one upper extremity pulse (radial or brachial)
Blood Pressure in upper extremity
_____Support arm at heart level
_____Place cuff about 1 inch above antecubital fossa with inflatable bag over brachial artery
_____Palpate brachial artery. Inflate cuff 30-40 mm Hg above where brachial artery pulsation is
obliterated
_____Release cuff about 2mm Hg/sec while listening with diaphragm of stethoscope over brachial artery.
_____Report pressure
_____Must do within 2 minutes
_____Starts to do the Blood Pressure in the other arm
Pass/Repeat

Student should be able to assess for one of the following exams and complete the ophthalmoscope exam:
____visual fields by confrontation
____pupillary responses (light-direct and consensual)
(convergence and accommodation)
____extraocular muscle function
OR ____third cranial nerve function

Ophthalmoscope exam – testing will be with the traditional ophthalmoscope (< 2 minutes)
_____Left hand – left eye student examiner – left eye of patient
_____Right hand – right eye student examiner – right eye of patient
_____Dim room lights; patient at height comfortable for examiner
_____Check red reflex with 0 diopter at 18 inches from eye
_____Start with black (green) 12-20 lens at 1 inch from eye and focus down through anterior chamber, vitreous, to retina by using successively smaller black lenses
_____Examine optic disc – have student state cup to disc ratio
_____Trace vessels into 4 quadrants of retina
_____Look for macula
have patient look at light OR
move light temporally 2 disc diameters
Pass/Repeat

Student should be able to examine the middle ear.
_____Hold otoscope in upside down position
_____Pull back and up on pinna
_____Stabilize hand on patients head while inserting scope
_____Observe TM – have student describe what s/he sees
_____Watch for patient discomfort
Pass/Repeat

Student should be able to evaluate the lymph nodes most likely to be affected by one or more of the following conditions (examiner needs to choose 2 areas if time permits):
Lip Cancer
_____Tonsillar*
_____Submandibular
_____Submental
_____Superficial cervical*
_____Deep cervical*
German measles (Rubella)
_____Posterior auricular
_____Posterior cervical
Ovarian cancer/testicular cancer
_____Supraclavicular
Pharyngitis _____*One side at a time so as not to _____Tonsillar* compress both carotids
_____Deep cervical*
_____Superficial cervical*
Conjunctivitis
_____Preauricular

Pass/Repeat

Student should be able to evaluate for the presence of a thyroid nodule.

Thyroid gland from the front
_____Observation with and without swallowing
_____Locate the isthmus of the gland about one fingerbreadth below the level of the cricoid
_____Student to tilt patient’s head to one side, the side he wishes to examine first
_____Apply pressure with the pad of the thumb at the level of the isthmus, diverting the gland toward the side that is to be examined
_____In the groove anterior to the SCM, using the pads of the second and third fingers of the opposite hand, palpate the gland at the level of the isthmus with and without swallowing. Student should offer patient a cup of water to facilitate swallowing if the patient has difficulty
_____Repeat entire procedure for the opposite side

Pass/Repeat

Student should use proper percussion technique to evaluate diaphragmatic excursion.
Lung – have student percuss hemidiaphragm at held inspiration and held expiration
_____Patient to cross arms in front
_____Firm pressure with middle finger of non-dominant hand on chest. Quick rhythmic strike of middle finger of dominant hand just proximal to nail of middle finger on chest wall, going from area of resonance to dullness
_____Examiner to be comfortable, off to side of patient preferred, not cramped
_____Short crisp note desired
_____Mark levels with pen
Pass/Repeat

Student should be able to perform a cardiac exam with the patient upright or supine and be able to do appropriate maneuvers to assess for a variety of extra heart sounds and murmurs.
Heart – ask student to do a cardiac exam with the patient sitting upright or supine

_____Observe precordium for apical movement
_____Palpate with the index and middle fingers or the ball of the hand. (Student must find the angle of
Louis)
_____2nd LICS (Pulmonic valve area)
_____2nd RICS (Aortic valve area)
_____Palpate with the ball of the hand:
_____Left parasternal border 4th ICS
_____Apex (May locate apex with the fingertips after found with the ball of the hand)
_____Have student mark apex with pen if identified so area can be double-checked later by you.
_____Auscultate with diaphragm:
_____2nd RICS
_____2nd LICS
_____4th LICS
_____Apex
_____Make sure student pushes firmly with diaphragm
_____Auscultate with bell:
_____4th LICS
_____Apex
_____Make sure student applies light pressure with bell
_____Check for AI (if sitting) by listening with diaphragm at:
_____2nd RICS
_____3rd LICS
____ _Apex
_____Patient leaning forward with forced exhalation (make sure forced exhalation is not held too
long)
_____Check for mitral stenosis (if supine) with the patient lying down.
_____Patient lies on left side
_____Student relocates apex by palpation
_____Listen with bell lightly and diaphragm at apex

Pass/Repeat

Student should be able to assess the JV pulse as it relates to intravascular volume and the mechanical events of the cardiac cycle.
JVP
_____Identify “a” wave and “x” descent
_____Must examine from patient’s right side
_____Must use internal jugular pulsation
_____Measure height above sternal angle, +5cm.
_____Ask student to determine the JVP in cm.
Pass/Repeat

Student should be able to use the proper technique to identify the presences of intra abdominal solid organs.

_____Percuss edge of spleen
_____SPLEEN patient to be rolled to right—start low in LLQ and work up while supporting patient
_____LIVER using your fingertips oriented toward the head press inward and move your hand upward toward the right costal margin. Start palpating in the right lower quadrant. If after reaching the right costal margin, the liver edge is still not palpable, ask the patient to take a deep breath as you palpate.
_____KIDNEYS both from right side—ballottement just distal to ribs – make sure the student isn’t palpating too low (ballot-apply pressure with the L hand from below and squeezing down-ward from above with the flat of the right hand as the patient takes a deep breath)
_____AORTA in the epigastrium (palpate the pulsation of the aorta in the midline between two
hands at the level above umbilicus)
Pass/ Repeat

Student should be able to assess: extremity reflexes

_____Biceps bilaterally
_____arm flexed at 90 degrees and supported either by examiner or on patient’s own lap
_____place thumb over biceps tendon firmly
_____quick tap with pointed end of reflex hammer on examiner’s thumb – look for wrist
motion
______Triceps bilaterally
_____arm held out to side by examiner or resting quietly in patient’s lap at 90 degrees
_____strike triceps tendon briskly with pointed end of hammer
_____compare symmetrically
_____Brachioradialis bilaterally
_____support patient’s forearm
_____strike tendon about 2” distal to insertion at elbow
_____compare symmetrically
_____Quadriceps bilaterally
_____place the knee in a bent and relaxed position dangling over the edge of the exam table
_____briskly tap just below the knee while you palpate the muscle just above the knee
_____compare symmetrically
_____Achilles bilaterally
_____with the patient sitting, support the sole of the dangling foot
_____briskly tap the Achilles tendon just above the heel
_____compare symmetrically Pass/Repeat