OSCE Hub

Mark Scheme:

1. Introduces self and confirms patient details
2. Obtains verbal consent
3. Adequately exposes patient (waist up) and positions at 45 degrees
4. Performs general inspection (SOB, pallor, oedema)
5. Inspects hands (clubbing, splinter haemorrhages, Janeway lesions/Osler nodes)
6. Palpates radial pulse for rate and rhythm
7. Checks for radio-radial delay
8. Measures/simulates blood pressure measurement
9. Assesses JVP (height and waveform)
10. Palpates carotid pulse
11. Inspects face (malar flush, xanthelasma, anaemia)
12. Inspects chest for scars and pacemakers
13. Palpates apex beat (location and character)
14. Palpates for heaves and thrills
15. Auscultates 4 valve areas (diaphragm and bell)
16. Auscultates carotid bruits and axillary radiation
17. Performs dynamic manoeuvres (E.g. roll to left, sit forward)
18. Checks for sacral and pedal oedema
19. Auscultates lung bases for crepitations
20. Thanks patient and covers them up
21. Suggests further assessments (ECG, Fundoscopy, Urine dip)

Key Points:

Listen at the Mitral area with the bell in the left lateral position for OS/MS murmurs
Listen at the Left Sternal Edge sitting forward in expiration for AR murmurs
JVP height should be measured vertically from the sternal angle (<3cm)
Apex beat is typically 5th intercostal space, mid-clavicular line
Always offer to check peripheral pulses and blood pressure to finish

Common Errors:

Forgetting to palpate the carotid while auscultating to time the first heart sound
Inadequate exposure of the patient
Not checking for sacral oedema
Confusing thrills (palpable murmurs) with heaves (ventricular hypertrophy)
Failure to mention fundoscopy in hypertensive patients

Mark Scheme:

1. Introduces self and gains consent
2. General inspection (respiratory distress, accessory muscles, inhalers, oxygen)
3. Inspects hands (clubbing, peripheral cyanosis, CO2 tremor/asterixis)
4. Palpates radial pulse and respiratory rate
5. Inspects face (conjunctival pallor, central cyanosis, Horner's syndrome)
6. Inspects neck (JVP, accessory muscle use)
7. Inspects chest for scars and symmetry
8. Assesses trachea position (centrality)
9. Measures cricosternal distance
10. Assesses chest expansion (anterior and posterior)
11. Percusses chest (symmetrical, included axillae)
12. Auscultates chest (symmetrical, included axillae)
13. Assesses vocal resonance
14. Inspects back and repeats percussion/auscultation
15. Checks for sacral oedema
16. Checks for pedal oedema
17. Reports findings accurately
18. Professionalism and patient comfort

Key Points:

Dullness to percussion suggests consolidation, fluid, or collapse
Hyper-resonance suggests pneumothorax or emphysema
Vocal resonance increases over consolidation and decreases over fluid/air
Reduced cricosternal distance (<3 fingers) suggests hyperinflation
Fine end-inspiratory crackles are characteristic of pulmonary fibrosis

Common Errors:

Forgetting to check for a flapping tremor (CO2 retention)
Not percussing or auscultating in the axillae
Failing to compare sides symmetrically
Moving the stethoscope too quickly before a full breath is completed
Not assessing the posterior chest properly

Mark Scheme:

1. Introduction and consent
2. Positions patient flat with one pillow
3. Exposes from symphysis pubis to mid-chest
4. General inspection (jaundice, cachexia, distension)
5. Inspects hands (clubbing, leuconychia, koilonychia, palmar erythema, Dupuytren's)
6. Checks for asterixis (hepatic flap)
7. Inspects arms (bruising, track marks, spider naevi)
8. Inspects face (eyes for jaundice/anaemia, mouth for ulcers/glossitis)
9. Inspects neck/chest (Virchow's node, spider naevi, gynaecomastia)
10. Inspects abdomen (scars, caput medusae, striae)
11. Light palpation (4 quadrants, watching patient's face)
12. Deep palpation (4 quadrants)
13. Palpates liver (starts in RIF, moves up with inspiration)
14. Palpates spleen (starts in RIF, moves diagonally to LUQ)
15. Palpates kidneys (balloting)
16. Palpates aorta (expansile vs pulsatile)
17. Percusses for liver and spleen borders
18. Checks for shifting dullness (ascites)
19. Auscultates for bowel sounds and bruits
20. Offers PR, Hernial orifices, and External Genitalia exam

Key Points:

A liver edge may be normal if smooth; a pulsatile liver suggests tricuspid regurgitation
Splenomegaly always grows towards the RIF and you cannot 'get above it'
Shifting dullness requires the patient to roll and wait 15 seconds
Spider naevi (>5 in SVC distribution) are significant for chronic liver disease
Always ask if the patient has any pain before touching the abdomen

Common Errors:

Starting palpation too close to the costal margin for the liver/spleen
Not looking at the patient's face for signs of pain during palpation
Forgetting to auscultate for bowel sounds
Failure to offer PR or hernia examination
Inadequate exposure (leaving the shirt on)

Mark Scheme:

1. Introduction, consent, and exposure (shoulders to hands)
2. General inspection (wasting, fasciculations, tremor, involuntary movements)
3. Assesses muscle tone (wrist, elbow, shoulder)
4. Assesses power (shoulder abduction, elbow flex/ext, wrist flex/ext, finger ext/abd, thumb abd)
5. Tests reflexes (Biceps C5/6, Triceps C7, Supinator C5/6)
6. Assesses coordination (Finger-to-nose, Dysdiadochokinesia)
7. Tests sensation: Light touch (Dermatomes C5-T1)
8. Tests sensation: Pinprick
9. Tests sensation: Vibration (on bony prominence)
10. Tests sensation: Proprioception (distal interphalangeal joint)
11. Reports findings using a screening or focused approach
12. Professionalism and patient rapport

Key Points:

LMN lesion signs: Atrophy, fasciculations, hypotonia, hyporeflexia
UMN lesion signs: Hypertonia (spasticity), weakness, hyperreflexia
C5: Shoulder abduction; C6: Elbow flexion; C7: Elbow extension; C8: Finger flexion; T1: Finger abduction
Proprioception involves holding the sides of the digit, not the top/bottom
Always compare left and right sides

Common Errors:

Incomplete dermatome coverage (missing T1 or C5)
Poor technique for testing reflexes (not letting the hammer swing)
Moving the digit too far during proprioception testing
Not checking for pronator drift
Failure to identify the difference between spasticity and rigidity

Mark Scheme:

1. Introduction and consent
2. CN II: Pupil light reflex (direct/consensual), Acuity (Snellen), Fields, Fundoscopy (mention)
3. CN III, IV, VI: Inspection (ptosis), Eye movements (H-shape), looking for nystagmus or diplopia
4. CN V: Sensation (3 divisions), Motor (muscles of mastication), Jaw jerk, Corneal reflex (mention)
5. CN VII: Facial symmetry, Raise eyebrows, Close eyes against resistance, Puff cheeks, Smile
6. CN VIII: Crude hearing, Weber’s and Rinne’s tests
7. CN IX, X: Palatal elevation ('Ah'), Cough, Swallow
8. CN XI: Shrug shoulders (Trapezius), Turn head against resistance (Sternocleidomastoid)
9. CN XII: Tongue inspection (wasting/fasciculations), Protrusion, Tongue-in-cheek power
10. Summarises findings accurately

Key Points:

CN III palsy: 'Down and out' eye, ptosis, dilated pupil
CN VII (LMN) involves the forehead (bells palsy); UMN spares the forehead
Rinne's: Normal = Air conduction > Bone conduction
Weber's: Localises to the affected ear in conductive loss, unaffected in sensorineural
Always ask about taste and smell if CN I or VII are suspected

Common Errors:

Not asking the patient about double vision during eye movements
Incomplete testing of the ophthalmic, maxillary, and mandibular branches of CNV
Incorrectly interpreting Weber's/Rinne's results
Neglecting the 'H' pattern for eye movements
Forgetting to check the tongue for fasciculations (sign of MND)

Mark Scheme:

1. Introduction and consent
2. General inspection (weight, agitation, clothing, eyes)
3. Inspects hands (tremor, thyroid acropachy, palmar erythema)
4. Palpates pulse (tachycardia, AF)
5. Inspects face and eyes (exophthalmos, lid lag, lid retraction)
6. Inspects neck (scars, goitre)
7. Asks patient to swallow water and observe movement
8. Asks patient to protrude tongue (thyroglossal cyst)
9. Palpates thyroid from behind (using both hands)
10. Palpates thyroid while patient swallows water
11. Palpates cervical lymph nodes
12. Percusses over manubrium (retrosternal goitre)
13. Auscultates thyroid (bruits)
14. Tests reflexes (delayed relaxation in hypothyroidism)
15. Tests for proximal myopathy (stand up from chair, no hands)
16. Checks for pretibial myxaedema

Key Points:

Thyroid swellings move up with swallowing; thyroglossal cysts move up with tongue protrusion
Graves' disease is associated with exophthalmos and pretibial myxaedema
Pemberton's sign: Facial flushing when raising arms (suggests retrosternal goitre)
Fine tremor (hyperthyroidism) can be elicited by placing paper on the back of hands
Always palpate the thyroid from behind the patient

Common Errors:

Forgetting to offer a glass of water for the swallowing test
Palpating the thyroid from the front
Neglecting to look for Pemberton’s sign in a large goitre
Failing to check the pulse for AF
Not checking for lid lag

Mark Scheme:

1. Introduction and consent
2. Patient positioned with feet exposed/shoes off
3. Inspection: Skin (colour, dryness), Nails (fungal infection, ingrown)
4. Inspection: Deformities (Charcot, claw toes, bunions)
5. Inspection: Ulcers (locations, between toes, heels), Calluses
6. Palpation: Temperature (using back of hand)
7. Palpation: Capillary refill time
8. Palpation: Pedis dorsalis and Posterior tibialis pulses
9. Neurological: 10g Monofilament testing (9-10 sites per foot)
10. Neurological: Vibration sense (big toe)
11. Neurological: Ankle reflexes
12. Gait assessment
13. Checks footwear (wear patterns, foreign objects inside)
14. Management: Suggests regular podiatry, glycemic control, appropriate footwear

Key Points:

Monofilament: Press until it bends; avoid calloused areas
Charcot arthropathy: Hot, swollen, red foot (mimics cellulitis) without pain/fever
Neuropathic ulcers: Usually on pressure points (soles); painless
Ischaemic ulcers: Usually on distal points (toes); painful and pale
Always check between the toes for maceration or hidden ulcers

Common Errors:

Forgetting to check the heels or between the toes
Applying the monofilament to a callus
Not checking the temperature of the joints (Charcot)
Failure to inspect the inside of the patient’s shoes
Not assessing the pulses

Mark Scheme:

1. Introduces self and builds rapport
2. Appearance and Behaviour (grooming, eye contact, psychomotor agitation/retardation)
3. Speech (rate, rhythm, volume, tone)
4. Mood (subjective feeling) and Affect (objective observation: range, reactivity, congruency)
5. Thought Form (flight of ideas, loosening of associations, circumstantiality)
6. Thought Content (delusions, obsessions, overvalued ideas)
7. Risk Assessment (harm to self, harm to others, neglect)
8. Perception (hallucinations, illusions)
9. Cognition (orientation in time, place, person)
10. Insight and Judgement
11. Professionalism throughout sensitive questioning

Key Points:

Affect is what you see; Mood is what they say
Delusions are fixed, false beliefs out of keeping with cultural background
Hallucinations occur in the absence of an external stimulus
Insight: Do they think they have a problem? Do they want help?
Always ask about 'Safety/Risk' directly

Common Errors:

Focusing only on mood and ignoring thought form
Forgetting to ask about risk to others
Confusing illusions (misinterpreted stimuli) with hallucinations
Not assessing eye contact or rapport
Using overly clinical jargon with the patient

Mark Scheme:

1. Introduction and consent
2. Inspection of palms (wasting, erythema, scars)
3. Inspection of dorsum (swelling, deformity, skin changes)
4. Identifies specific deformities (Boutonniere's, Swan-neck, Z-thumb)
5. Checks for Heberden’s and Bouchard’s nodes (OA)
6. Checks for ulnar deviation and MCP swelling (RA)
7. Palpates temperature
8. Palpates pulses
9. Palpates joints: Squeeze test (MTPs)
10. Palpates each joint (bimanual technique for PIPs/DIPs/MCPs)
11. Assesses Movement: Active (Make a fist, spread fingers)
12. Assesses Movement: Passive (Wrist flex/ext)
13. Function: Grip strength
14. Function: Pincer grip
15. Function: Picking up a coin/unbuttoning
16. Examines elbows for rheumatoid nodules or psoriasis

Key Points:

Rheumatoid Arthritis vs Osteoarthritis (RA spares DIPs; OA involves DIPs)
Boutonniere: PIP flexed, DIP hyperextended
Swan-neck: PIP hyperextended, DIP flexed
Psoriatic arthritis: Dactylitis ('sausage digit') and nail pitting
Always check the elbows and ask about other joint pains

Common Errors:

Not performing the 'squeeze test' (meta-carpo-phalangeal squeeze)
Forgetting to check the elbows
Ignoring the nails (pitting/onycholysis)
Failing to assess functional tasks (pincer grip)
Applying too much pressure to inflamed joints

Mark Scheme:

1. Introduction and consent
2. General inspection (nystagmus, speech, posture)
3. Speech: Assessment of 'British Constitution' or 'West Hants' (Slurred/Scanning dysarthria)
4. Eyes: Smooth pursuit and saccades (Nystagmus)
5. Arms: Outstretched for rebound phenomenon
6. Arms: Assessment of tone (Hypotonia)
7. Arms: Finger-to-nose test (In-intention tremor, past-pointing)
8. Arms: Dysdiadochokinesia (Fast hand slapping)
9. Legs: Heel-to-shin test
10. Legs: Pendular knee jerk reflex (mention/test)
11. Gait: Tandem gait (heel-to-toe)
12. Romberg's test (to differentiate from sensory ataxia)
13. Summary of findings (DANISH mnemonic: Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia)

Key Points:

Cerebellar lesions cause IPSILATERAL signs
Romberg's test is for sensory ataxia (proprioception), NOT cerebellar function (though often performed)
Scanning speech involves broken-up syllables
Nystagmus in cerebellar disease is usually 'coarse' and maximal when looking towards the side of the lesion
Gait is typically broad-based and unsteady

Common Errors:

Confusing Romberg's test (positivity means sensory ataxia, not cerebellar disease)
Not testing gait/tandem walking
Testing nystagmus too quickly
Forgetting to assess speech
Not checking for 'rebound' phenomenon

Mark Scheme:

1. Introduction and consent
2. Adequate exposure (down to underwear)
3. Inspection: Standing (Postural, scars, skin changes, swelling)
4. Inspection: Pelvic tilt/Symmetry
5. Gait assessment (Antalgic or Trendelenburg gait)
6. Trendelenburg test (Stand on one leg)
7. Palpation (Patient lying flat): Greater trochanter (tenderness), Joint line/Groin
8. Movement (Active then Passive): Flexion (Normal 120)
9. Internal and External Rotation (Flex hip/knee to 90 degrees first)
10. Abduction and Adduction (Fix pelvis with one hand)
11. Thomas's Test (To check for fixed flexion deformity)
12. Leg length measurement (True: ASIS to Medial Malleolus; Apparent: Umbilicus to Medial Malleolus)
13. Thanks patient and summarises findings

Key Points:

Thomas's Test: Hand under lumbar spine; positive if the other leg lifts off the couch
Trendelenburg test: Identifies weak hip abductors (Gluteus medius/minimus)
Internal rotation is often the first movement lost in OA hip
True leg length: Measured from bony point to bony point
Referred pain: Always consider the knee if the hip exam is normal

Common Errors:

Inadequate exposure
Forgetting to fix the pelvis when measuring abduction/adduction
Not assessing gait
Incorrectly performing Thomas's test (forgetting the hand under the spine)
Ignoring leg length discrepancy