Documente Academic
Documente Profesional
Documente Cultură
These notes are just a guide for a quick review of the most important clinical
examinations and history taking in surgery block. For more details, you can go
back to your reference book.
Before OSCE:
o Sleep well: Sleeping well is more beneficial than studying all night long.
o Bring all your equipment: Stethoscope, ophthalmoscope"
o The key to OSCE success is practice.
o Behave in a polite, professional way.
Before starting any examination:
o Wash your hands.
o Introduce yourself.
o Explain to the patient, take permission and maintain privacy.
o Before examining the patient, you should comment on:
Consciousness and alertness.
Is the patient in distress, pain or comfortable.
Connection to: O2, ECG monitor or IV line access.
o After you finish, thank the patient and cover him\her.
References:
o Nicholas J Talley Clinical Examination, 6th Edition.
o Browses's Introduction to the Symptoms & Sign of Surgical Disease,
4thEdition.
o Lecture Notes Ophthalmology, 11th Edition.
o The Hand Examination and Diagnosis, 3rd Edition.
o Toronto Notes (Orthopedic, Ophthalmology, Otolaryngology-Head &
Neck Surgery), 2010.
o Notes during Clinical Skills Sessions at KSAU-HS.
Contents:
o General Surgery
o Orthopedics
o Anesthesia
o Ophthalmology
o ENT
o Plastic Surgery
Inspection: Best done from the patients feet side of the bed.
o Hernias: Let the patient stand, and then ask the pt. to cough and sit.
o Contour and Distention (5 F: Feces, fetus, flatus, Fat, Fluid).
o Symmetry: Movement with respiration (pattern of breathing).
o Scars: Appendectomy, peritoneal dialysis, nephrectomy, ascites.
o Prominent veins "portal HTN", caput medusa around the umbilicus.
o Umbilicus "inverted or everted".
o Striae, bruising, rashes, visible peristalsis, pigmentation.
Palpation: Ask if there is any pain and observe the patient's face.
o Tenderness:
Superficial: Guarding, rigidity, rebound.
Deep: deep masses, Murphy's sign.
o Organomegaly:
a) Liver: Palpate the liver edge & percuss for span "8-12 cm" from above.
b) Spleen: You can't go above it, has a notch, and enlarges inferomedially.
Palpate "pt. flat" & "pt. lying over his right side".
Percuss over left costal margin-anterior Axillary line with
full expiration.
Auscultation:
o Bowel sounds: Exaggerated: Proximal to the obstruction.
Absent: paralytic ileus or distal to the obstruction".
o Bruit: Renal "Renal artery stenosis. Liver "Hepatocellular carcinoma".
Others:
o Special test for appendicitis: Obturator, Psoas, Rovsing signs.
o Lymph nodes: including supraclavicular (Virchow's node).
o Rectal and genitalia examination + Back & leg examination (edema).
Page |3 Quick Review for OSCE | AlBrahim-Al-Enezi
History of a Lump
Age and gender.
When did he/she notice the lump? Is it the first time?
What made the patient notices the lump?
Site.
Predisposing events.
Symptoms of the lump: pain, discharge, disfiguring, or restrain certain
movements, respiratory or swallowing, change in voice.
If discharge: Quantity, quality, color, smell.
Associated Symptoms: fever, weight loss, night sweats, fatigue.
Has the lump changed? Size, shape, color, tenderness since first notice
Does the lump ever disappear? On lying down or exercise.
Previous exposure to radiation to the neck.
Any other lump.
Treatment done for this lump before.
What does the patient think caused the lump?
Examination of a Lump
Wear gloves and proper exposure (If in the limb, expose both for comparison).
Inspection:
o Site, size, shape, color, surface, and edge (well or ill defined), symmetry.
o Discharge (color, quantity, quality-mucous, purulent, blood- , and smell).
o Skin changes, scar, and area around the mass.
Palpation:
o Temperature, tenderness.
o Consistency (stony hard, firm, rubbery, soft), Surface (smooth or
irregular)
o Mobility, fixation to skin, attached to underlying tissue, going above it.
o Pulsatility, reducibility, fluctuation, translumination (fluid-filled lesion).
Percussion: Resonant or dull, fluid thrill.
Auscultation: Bruit if A-V malformation.
Surrounding tissues:
o Regional lymph nodes.
o Local tissues: skin, muscles, vessels, and nerve supply.
Rectal Examination
Position and Exposure:
o Lying flat on left side while flexing the hip & knee.
Inspection:
o Thrombosed external hemorrhoid.
o Skin tags, rectal prolapse, anal fissure.
o Ask the patient to bear down then inspect.
Palpation:
o Wear gloves & lubricate your finger.
o Place finger at anus until the patient relaxes then gently insert your finger
and note sphincter tone at the anal verge.
o Ask the pt. to bear down; this will bring high rectal masses down.
o Palpate all walls of the rectum for masses, tenderness, or polyps.
o Palpate the prostate then check your finger for signs of bleeding.
Rectal Bleeding
Bleeding:
o Onset, frequency, progression, color (bright red or mixed), amount.
o On stool, mix or on towel paper & stool shape.
o Aggravating and relieving factors.
o Associated Symptoms: pain, change in bowel habits, defecation problem
(tenesmus or straining), abdominal mass, weight loss, and fatigue.
o Previous bleeding & bleeding from other sites.
o Anemia: Tiredness, shortness of breath, palpitation.
Past History & medication: ulcers, abdominal surgery.
Family History: Cancer, IBD and anemia.
Social History: Travel, dietary habits, effects on life, smoking, and alcohol.
Examination of an Ulcer/Wound
Wear sterile gloves, proper exposure, and take vital signs.
Inspection:
o Site, size, shape, depth.
o Base: Color and type of tissue (scab, Eschar, granulation tissue).
o Edge:
Sloping venous, healing ulcer.
Punched out ischemia.
Undermined TB.
Rolled Basal Cell Carcinoma.
Everted Squamous Cell Carcinoma.
Thyroid Examination
Position and Exposure:
o Sitting & expose the neck and the chest. Mention about dressing.
Hand:
o Acropachy "thyrotoxicosis".
o Palms: "Sweaty or dry".
o Palmer Erythema.
o Pulse (rate, rhythm "atrial fibrillation", collapsing pulse thyrotoxicosis-).
o Tremor (ask the pt. to extend his hand with the fingers separated).
Eye:
o 6 Cardinal eye movement, ask if there is diplopia to any of the direction.
o Exophthalmos, proptosis "Grave's".
o Lid lag (the lid lag behind the orbit should be performed slowly).
o Anemia, Jaundice.
o Mouth: Macroglossia "Hypothyroidism".
Neck:
Inspection:
o Swelling, bulging, Scars, color, dilated veins "thoracic inlet block".
o Swallow water "thyroid swelling".
o Put out the tongue. If it moves with protruding it thyroglossal cyst.
Palpation: Thyroid is usually not palpable.
o Little bit flexed , From Behind R and L lobes (Push with one hand and
examine with the other).
o If nodule, describe: site, size, shape, mobility, consistency, tenderness,
and surface,overlying skin. "Same for lymph node/lump description".
o Lymph nodes (Cervical and supraclavicular).
o Tracheal deviation.
Auscultation: Ask the pt. to hold the breath to listen for bruit "thyrotoxicosis".
Lower Limb
Pretibial myxedema (Non pitting, Itching, Anterior Chin) "Grave's disease".
Reflexes:
o Hyperthyroidism: Brisk movement (hyperreflexia).
o Hypothyroidism: slow relaxation phase.
Proximal muscle weakness: Ask the patient to stand up without using his
hands & test the power of arm abduction.
Inspection:
Hand in natural position:
o Symmetry: Size, shape, and contour.
o Skin changes: Dimpling, erythema, ulceration, pea du orange.
o Lump and visible veins.
o Nipple: nipple retraction and spontaneous discharge.
Hands over head:
o Any changes in the breast.
o Assess the axilla.
Hands against the hip: to contract pectoralis muscles.
Example how to comment: Both breasts look symmetrical and the apparent
size looks the same. There is erythema on lower outer quadrant at the right
breast, there is peudo orange on the upper inner quadrant of the left breast
between 2 and 4 oclock, there is dimpling on the outer upper quadrant of the
right breast at 10 oclock.
Palpation:
The patient lay down in 45 degree with the hands behind her head.
Palpate the normal size first.
Using one hand (the other one to support) with the palm of your fingers,
palpate the whole 4 quadrants including the axillary tail.
Palpate the nipple-areola complex by squeezing it looking for discharge.
If you find a lump, describe it: SSSSS: Site - Size Shape - Skin attachment (or
muscle attachment) Surface - (consistency and mobility)
Consistency: Soft firm hard. Mobility: Mobile fixed.
Hard as a skull, firm like a nose, soft like the cheek.
Breast history
ID: name, age, marital status, pregnancy.
Present complaint: lump, bleeding, discharge, skin changes, pain (if advanced or
inflammatory).
o Breast lump: onset, site, how did you notice it, trauma, progression,
painful, skin changes, relation to menstruation (fibrocystic change),
previous history.
o Breast pain: Complete history of pain, relation to menstruation.
o Nipple discharge: Uni/bilateral, color (bloody, milk), volume.
o Nipple retraction: Uni/bilateral, symmetry.
Hormonal History: Menarche, menopause, number of pregnancies, breast-
feeding, hormonal use (HRT or OCP).
Others: weight loss, anorexia, fatigue.
Metastasis:
o Bone pain.
o Cord compression: Back pain, sensory, motor, urinary/bowel symptoms.
o Liver: Jaundice, itching, RUQ pain.
o Lung: Cough, pain, shortness of breath.
o Brain: Seizure, mental changes, headache.
Past history, medication and allergy: previous radiation exposure, personal
history of cancer "ovarian or colon", regular screening mammography, breast self-
exam, previous investigation.
Family history: 1st degree, age of diagnosis, uni\bilateral.
Social History: Smoking, alcohol, obesity.
Systemic review.
Differential Diagnosis:
Fibroadenoma.
Fibrocystic change including breast cyst.
Mastitis.
Breast cancer.
Orthopedics
Spine Examination
Look: The patient is standing and from the back and side.
Deformity: Normal lordosis and kyphosis, abnormal sceliosis.
Muscle wasting and swelling.
Skin changes: Scars, redness, caf au lait spot, hair patches.
Feel:
Cervical: Spine and trabezius.
Lower: Spines, sacroiliac J., paraspinal muscles.
Move:
Cervical: Flexion, extension, 2 lateral bending, 2 rotations.
Lower: The same while holding the patient's pelvis.
Special test:
Straight leg raising (L5): Flex the hip and extend the knee then raise the leg.
Femoral stretch test (L3-L4): Extend the hip and flex the knee
Cervical:
o Dermatomes: C4: Supraclavicular. C5: Lateral Forearm. C6: Thumb. C7:
Middle finger. C8: Little finger. T1: Medial forearm. T4: Nipple. T10:
Umbilicus.
o Myotomes: C4: Shoulder elevation. C5, 6: Elbow flexion. C6, 7: Wrist
flexion. C7, 8: Elbow & wrist extension. C8, T1: Finger abduction.
o Reflexes: C5: Biceps. C6: Brachioradialis. C7: Triceps.
Lower:
o Dermatomes: L2: Anterior thigh. L3: Knee. L4: Medial Leg. L5: Lateral Leg.
S1: Sole. S2: Posterior thigh.
o Myotomes: L2, 3: Hip flexion. L3, 4: Knee extension. L4, 5: Ankle
dorsiflexion. L5: Big toe dorsiflexion. S1, 2: Planter flexion.
o Reflexes: L4: Patellar. S1: Achilles.
P a g e | 13 Quick Review for OSCE | AlBrahim-Al-Enezi
Shoulder Examination
Look:
Muscle wasting (anterior: Pectoralis major, lateral: Deltoid and posterior:
Trabezius), symmetry, skin changes (redness, caf au lait spot, hair patches),
deformity, and swelling.
Feel:
o Temperature.
o Bones: Manubriosternal J., manubrioclavicular J., clavicle, coracoid,
acromion, spine of scapula, inferior angle.
o Soft tissues: Anterior: Pectoralis major, lateral: Deltoid, posterior:
Trabezius.
Move:
Extension, flexion, abduction, adduction, lateral & medial rotation,
circumduction, then passive movement and feel for any crepitus.
Special tests:
Serratus anterior: push on the wall then see the back (winged scapula).
Shoulder stability (if you suspect dislocation):
o Apprehension test: abduction and external rotation.
o Relocation test: Apprehension is relieved by post. pressure.
o Sulcus sign: Subacromial indentation with distal traction.
o Posterior apprehension test: adduction, internal rotation.
Rotator cuff tests (if you suspect rotator cuff pathology):
o Apley scratch test: Quick screening test.
o Jobe's test (Empty can test): Supraspinatus
o Lift-off test: Subscabularis.
o Posterior cuff test: Infraspinatus & teres minor.
o Cuff impingement: Neer's test and Hawkins-Kennedy test.
Note: In all orthopedic examination you have to mention that you would examine the
function of the joint and you would examine joint above and joint below the joint you are
examining).
Elbow Examination
Look:
Rheumatic nodule, deformity, skin changes, and muscle atrophy.
Feel:
Triangle1: medial epicondyle, lateral epicondyle, olecranon(triangular in
flexion, linear in extension).
Triangle2: lateral epicondyle, olecranon and radial head.
Soft tissues: biceps tendon, triceps tendon.
Move:
Extension, flexion, pronation, supination.
Special tests:
Medial epicondylitis (Golfer's elbow): Resisted flexion.
Lateral epicondylitis (Tennis elbow): Resisted extension.
Varus and valgus stress test: Supinated and flexed 5 degree.
Page | 15 Quick Review for OSCE | AlBrahim-Al-Enezi
Neurological: ulnar, median and radial nerves.
Hip Examination
Look: (Patient Standing &Supine)
Deformity (flexion deformity) & Leg length discrepancy.
Ant. Sup. Iliac spine symmetry.
Scars, skin changes, swelling.
Feel:
Greater trochanter and Ant. sup. Iliac spine.
Move:
Flexion, extension.
Lateral and medial rotation (in knee extension and flexion).
Abduction & adduction (The pelvis by on hand and the leg by the other one).
Special test:
Thomas test: For flexion deformity (flex the other leg and put your hand under
his back and check the lordosis then check the leg raising and push on it).
Trendelunburg: Put your hands behind on the pelvis then ask the pt. to raise
his leg then see if your hand dropped on the other pelvis, if it is +, check the
superior gluteal nerve.
Faber test: For sacroiliac j. (Flexion, abduction and external rotation then push
on the leg to see if he has any pain). Not IMP.
Rectus femoris: Like stretch femoral test but if the pain on the back(nerve) or
on the thigh( rectus femoris).
Neurological:
o Femoral nerve (M: Knee extension, S: Ant. Of the thigh, medial of the
thigh and leg-saphanous n.).
o Obterator n. (M: Thigh adduction).
o Sciatic n. (M: knee flexion).
o Tibial n. (M: Planter flexion, S: Planter of the foot).
o Deep peroneal n. (M: Dorsiflexion, S: First web space).
o Superficial peroneal n. (M: Eversion, S: Dorsum of the foot)
Feel:
Temperature: Anterior and posterior.
Tenderness and effusion:
o Bones: Patella, tibial tuberosity, fibula, joint line.
o Muscles: Quadriceps, hamstring.
o Ligaments: patellar ligament.
o Popliteal fossa.
Move:
Active: Flexion: 130-140 and Extension: should be 0.
Passive: For tenderness and crepitation.
Neurological:
Deep peroneal, superficial peroneal and tibial nerves.
Gait
Special test:
Anterior drawer test: Lying down then check the stability of the ankle by
holding the leg and moving the foot.
Talar tilt: Foot is stressed in inversion.
Reflex:
Calcaneal tendon S1
Neurological:
Deep peroneal, superficial peroneal and tibial nerve.
Gait:
On the toes and on the ankle then complete the regular gate.
Look:
Deformity (proximal and distal), swelling, bleeding, and exposed bone.
Describe the wound:
o Size, site, shape, edge.
o Floor: depth, visible structure, foreign body.
Neurovascular Examination:
Upper limb:
o Vascular: Radial pulse, ulnar pulse, allen's test, and capillary refill.
o Neurological: Radial, median and ulnar nerves (sensory and motor).
Lower limb:
o Vascular: Dorsalis pedic pulse and posterior tibial pulse.
o Neurological: Superficial peroneal, deep peroneal and tibial nerves.
Management:
Remove obvious foreign material.
Cover wound with sterile dressing soaked in warm normal saline.
Realign the limb and splint.
Reexamine the neurovascular.
X-ray.
IV antibiotics:
o Gustilo class 1 (<1cm) cefazolin 72 hrs. (gram +ve)
o Gustilo class 2 (1-10 cm) cefazolin + gentamicin. (gram +ve and -ve)
o Gustilo class 3 (>10 cm) cefazolin + gentamicin + penicillin. (+,-, clostridia)
Tetanus vaccine.
NPO and prepare for OR
Open reduction indications: NO CAST (No union, Open fracture, neurovascular
Compromise, intra-Articular fracture, Salter-Harris 3,4,5, and polyTrauma) +
Pathologic fracture, failed closed reduction, can't apply traction, potential
improved function.
Pre-Operative Assessment
History:
Name, age, weight, height.
Pre OP Diagnosis (proposed surgery).
o CVS: HTN, MI, other cardiac.
o Pulmonary: Asthma, COPD, recurrent URTI, sleep apnea.
o GI: GERD, last meal.
o Liver.
o Renal: Renal failure, dialysis.
o Endocrine: DM, thyroid.
o CNS: Seizure, stroke.
o Rheumatology: rheumatoid arthritis and other autoimmune diseases.
o Hematology: Coagulation problems.
o Ob/Gyn.
Previous surgeries, anesthesia, and complication.
Allergies & medications.
Smoking, alcohol, drug abuse.
Family History: malignant hyperthermia.
Examination:
Vital signs.
CVS & Respiratory.
Airway assessment:
o (I) Tempormandibular joint (TMJ) click.
o (II) Mouth opening: 2 fingers wide laryngoscope width-.
o (III) Thyromental distance: 3 fingers.
o (IV) Range of movement of the neck: should 30 degree.
o Mallampati score.
o Teeth and deformity.
Site for IV.
Investigations
o Labs: CBC, PT, PTT, Electrolytes, LFT, blood sugar, Beta HCG.
o CXR, ECG, Echocardiogram.
ASA and Plan of anesthesia.
Explain about eating, medications, and consent form.
Acute painful:
Acute angle closure glaucoma "corneal edema and clouding":
o Symptoms: blurred vision, pain, red eye, photophobia, and watering.
o History of recurrent attacks precipitated in the dark (pupillary dilation).
o Signs: decreased visual acuity, corneal clouding, high IOP, reduced
accommodation, fixed/dilated pupil, and red eye.
o Treatment:
Acetazolamide IV then oral (decrease secretion).
Topical pilocarpine (constrict pupil).
Beta-Blocker (decrease secretion).
Surgery (iridotomy/iridectomy).
Keratitis:
o Symptoms: Severe pain, red eye (peri-limbus), discharge, trauma history.
o Treatment:
Viral (HSV): Oral acyclovir, topical steroid unless dendritic
ulcer present.
Bacterial: Topical antibiotics.
Corneal ulcer/abrasion:
o Symptoms: Red eye, pain, watery, photophobia.
o Diagnosis: Fluorescein with blue light.
o Treatment: Antibiotics ointments +_ eye cover pad.
Acute transient:
Migraine and amaurosis fugax (shutter across vision).
Acute painless:
Vitreous hemorrhage.
Central vein/artery occlusion (whole visual field). Branch (peripheral field).
Retinal detachment: Floater, flashing, curtain like visual loss.
Ischemic optic neuropathy: Giant cell arteritis (jaw claudication, shoulder pain)
Acute bilateral:
Visual pathway lesion.
Uveitis.
Chronic painless:
Refractive error.
Cataract: decreased vision with glaring.
Chronic glaucoma.
DM macular edema.
Age related macular degeneration.
Chronic painful:
Chronic uveitis.
Corneal disease.
- Endophthalmitis:
after surgery.
- Orbital cellulitis
Ear Examination
Inspection:
o Pinnae (Auricle): helix, antihelix, tragus, antitragus & behind the ear.
o Look for atresia, microtia, scars, redness, swelling, and discharge.
Palpation:
o Palpate for tenderness.
Hearing:
o Tuning fork test (512 Hz): Rinne's test & Weber test.
o Audiometry: if air-bone gap CHL. if both under 20 SNHL.
o Tympanometry: if flat perforationhigh ear canal volume- or effusion.
Nose Examination
Inspection:
o Deformity, scars, skin changes.
Nose speculum:
o Deviated nasal septum (DNS)
o Discharge (mucous, purulent, bloody)
o Polyps, turbinate hypertrophy.
Mouth Examination:
o Lips: Nevus, hemangioma.
o Mucosa, teeth, tongue and below it.
o Hard palate, soft palate, uvula, and oropharynx.
o Tonsils (between ant. and post. Pillars).
Nerve:
o Sensation: 2PD "dynamic < 3mm, static < 6mm"
o Motor: R: index extension, M: OK sign, U: Froment's sign.
o Carpal Tunnel syndrome: Phalen's & Tinel's signs.