OSCE Year 3

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ENT[edit]

See Also[edit]

Neuro Exam[edit]

Glasgow Coma Scale

Neuro exam could either be cranial nerve + pathological reflex exam, BPPV/Meniere's exam, or leprosy exam. Each is quite different and requires a different anamnesis, physical exam, prescription, and education.

BPPV or Meniere's[edit]

  1. Introduction
  2. Anamnesis
  3. Informed consent
  4. Wash hands
  5. Vital signs
  6. Romberg's test
  7. Finger-to-nose test
  8. Check some relevant cranial nerves
  9. Check for nystagmus
  10. Dix-Hallpike maneuver
  11. Treat with Epley's maneuver. (In the past, medication was prescribed. It is not recommended anymore.)
  12. Educate the patient: if the patient feels nausea/dizziness when getting up from a laying down position, ask the patient to get up sideways instead.

Leprosy[edit]

Ulnar nerve palpation
Peripheral nerves palpation
Nerve enlargement in leprosy
  • Leprosy is also known as Hansen's disease.
  • Know the names of the nerves you're checking for enlargement.
  • Be able to tell the difference between multibacillary (>5 lesions) and paucibacillary (<6 lesions) and their treatments, including which drugs need to be taken under supervision (note: the WHO guidelines differ from standards of practice in the USA where rifampicin is taken daily).
  • After the exam, refer the patient to the lab. The patient needs to have AFB (acid-fast) smear done using a sample from their skin lesion.

Videos of Leprosy Exam[edit]

Cranial Nerve Exam[edit]

  1. Olfactory nerve: Ask if the patient has noticed changes in the ability to smell.
  2. Optic nerve: Use a Snellen chart and a flash-light to check pupillary reflexes in each eye.
  3. Oculomotor nerve: Draw an "H" in the air with your finger. Ask the patient to follow with their eyes only. Check for double-vision.
  4. Trochlear nerve: (Same as #3)
  5. Trigeminal nerve:
    • Sensory: Touch the jaw, cheek, and forehead with patient's eyes closed and check for sensation. Do corneal reflex by touching cotton in eyes.
    • Motor: Ask patient to clench teeth and feel masseter (sides of forehead) and temporalis muscles (below ear-lobes). Ask patient to open mouth while you push their chin up.
  6. Abducent nerve: (Same as #3)
  7. Facial nerve: Ask patient to puff cheeks, smile with teeth visible, and crease forehead (act surprised).
  8. Vestibulocochlear nerve: Perform Rinne and Weber tests. Usually if the patient has followed verbal instructions until now without a problem, this nerve is working fine.
  9. Glossopharyngeal nerve: Ask patient to say "Aaaah!"
  10. Vagus nerve: (Same as #9) Ensure uvula does not deviate.
  11. Accessory nerve: With patient facing left, ask them to face right and resist by pushing on their face in the opposite direction. Do for opposite side. Ask patient to lift shoulders (i.e. shrug) while pushing down with your hands onto the patient's shoulders.
  12. Hypoglossal nerve: Ask patient to stick tongue out. Check for deviation.

Pathological Reflexes Exam[edit]

The cases that may come up include a chief complaint of headache.

Youtube Videos of Pathological Reflexes[edit]

  1. Romberg's test: Stand beside standing patient. Ask them to close eyes and watch for sway.
  2. Tandem gait test: Patient walks heel-to-toe and then with eyes closed without falling.
  3. Hoffman's sign: Hold patient's hand and tap their middle-finger from above. Index finger movement: positive.
  4. Chaddock's sign: Stroke on lateral side of ankle. Positive: Babinski reflex. (UMN lesion)
  5. Oppenheim's sign: Stroke anterior tibial region. Positive: Babinski reflex. (UMN lesion)
  6. Gordon's sign: Squeeze calves. Positive: Babinski reflex. (UMN lesion)
  7. Schaefer's sign: Squeeze achilles tendon. Positive: Babinski reflex. (UMN lesion)
  8. Brudzinski's test: Patient supine. Flex neck. Positive: patient lifts legs up. (meningitis)
  9. Kernig's test: Patient supine with knee and hip at 90° angles. Extend leg at knee. Positive: pain. (meningitis)
  10. Lasegue's straight-leg raise test: Patient supine. Lift leg holding the ankle with knee fully extended. Positive: pain in sciatic nerve distribution.

Catheter (Foley) Insertion[edit]

This station requires students to know the indications, contraindications, and risks of complications of catheterization before beginning, and also know the parts of the catheter and what they are used for. Know the amount and type of liquid used to inflate the balloon. Don't forget to test the balloon before installing the catheter. The doctor may ask further questions such as: how often does the urine bag need to be changed? how long can we leave a patient catheterized? can you catheterize a conscious patient?

See Also[edit]

Posterior Eye Exam[edit]

Fundus of the eye
Foveal reflex
Labeled right eye fundus
Ophthalmoscope

Students will be expected to perform a short anamnesis, informed consent, actually using the (direct) ophthalmoscope to inspect a patient's eyes, and then they'll be presented with a picture of the fundus and asked to interpret it.

  1. Anamnesis:
    1. Determine if the patient wears glasses or contact lens; what number lens do they wear? (Remember this number!) Also, ask the patient if they have diabetes mellitus or hypertension. (Ask the patient if you need to perform a visual acuity test - the doctor will say no).
  2. Performing posterior eye exam:
    1. Inform the patient that you'll be doing an eye exam using the ophthalmoscope. It isn't painful and dangerous but you'll need to shine a light into their eyes and get very close to their face. Get their consent and proceed.
    2. Ensure the room is dark.
    3. Ask the patient to remove their glasses. Set their lens number onto the ophthalmoscope.
    4. If the patient is wearing contact lens, you must leave the number on the ophthalmoscope at zero. (not sure!)
    5. Hold the ophthalmoscope properly: like an ice-cream cone but with your index finger vertical.
    6. Left-left-left, right-right-right: inspect the patient's left eye, with your left eye, using your left hand. Then, inspect the patient's right eye, with your right eye, and right hand.
    7. Ask the patient to look at something behind you in the distance the entire time.
    8. Turn the ophthalmoscope on and start from about 30 cm away by trying to focus the circle of light into their pupil.
    9. At first, the image of the fundus visible through the ophthalmoscope will be blurry, but eventually when you get very, very close to the patient (almost touching), you will be able to see the blood vessels on the fundus.
    10. If you can see some blood vessels, move slightly towards the patient's lateral side while following the blood vessels to the optic disc.
    11. Mention that you can see the optic disc, which appears like a bright full-moon in the night-sky, where all the blood vessels converge. Also mention the macula, the dark area.
    12. The foveal reflex is hard to see but it appears as a tiny light in the middle of the macula. It's not important to find this during the OSCE.
  3. Interpretation:
    1. After performing the eye exam, you'll be presented with a photograph that you need to interpret:
    2. Identify the optic disc (optic nerve head, aka. papil of the optic nerve), optic cup, and macula.
    3. Identify the veins and arteries: veins are thicker and darker than the arteries (actually, the retinal arteries lack a muscular coat, so they are more correctly called arterioles.) The diameter of the arteries is about 2/3 that of the veins.
    4. Ensure you can identify a few common diseases such as glaucoma and diabetic retinopathy just by looking at the photograph. The doctor may ask some questions such as: what other exams are performed when glaucoma is suspected?

See Also[edit]

IV Line[edit]

Infusion.jpg

This is a 15 minute station that can involve one of three scenarios: hemorrhagic shock, non-hemorrhagic shock, or dehydration. The doctor may ask questions such as how often an IV line needs to be reinstalled and if you must puncture more distally or proximally.

Hemorrhage class Blood loss Signs
1 0-15% ↑HR.
2 15-30% ↑HR, ↓BP, and ↑RR.
3 30-40% ↑HR, ↓BP, and ↑RR, oliguria.
4 >40% ↑HR, ↓BP, and ↑RR, anuria.

Differences between veins and arteries[edit]

  1. Veins are superficial and thus, easier to access.
  2. Veins have a more steady blood pressure.
  3. Veins have thinner walls, so they're easy to penetrate.
  4. Veins have a larger lumen.
  5. Veins are less mobile than arteries.

Local terms[edit]

Plabott
a portmanteau of "plastic bottle". This is another name for the infusion bag.
Abbocath
Abbocath is the name of the company that produces the over-the-needle catheters that are locally known by this name.
Grojok
when the stopper is released completely. So, instead of dripping, the infusion flows freely down the tube.

Types of solutions given via IV[edit]

  • Crystalloids: (cheap, semi-permeable)
    1. Hypotonic: e.g. 5% dextrose in water (D5W).
    2. Isotonic: Isotonic is usually the most commonly used solution, specifically, ringer lactate. e.g. ringer lactate (RL) and 0.9 NaCl.
    3. Hypertonic: 3%, 6% 7.5% normal saline.
  • Colloids: (expensive, stay longer in the blood vessels)
    1. Protein: e.g. serum albumin, gelatin.
    2. Non-protein: e.g. starches, dextrins.
  • Packed RBCs: usually frozen, so it needs to be warmed to 37C.

Usually, crystalloids are always given first no matter what. This is because packed RBCs require some time to be warmed and the patient's blood-group to be assessed. Crystalloids will quickly restore fluid into the body's tissues. Colloids may be given afterwards to keep the fluid volume inside the vessels high if needed.

Indications[edit]

Fluid resuscitation for electrolyte balance or dehydration. Also, to give medications intravenously.

Contraindications[edit]

  1. IV line cannot be started in an area of the body where there is: edema, burns, injury, recent surgery (e.g. mastectomy), phlebitis, or sclerosis (scar tissue).
  2. Where ____ score is less than _.

Complications[edit]

Infection, air embolism, hemorrhage, hematoma, thrombophlebitis.

See Also[edit]