osce final

inspection GI tract - end of bed

patient is LYING DOWN

on patient

• well/ unwell

• Distressed/in pain/breathless versus comfortable/no obvious pain

• Any jaundice or pallor

• Obviously under or overweight (you can refer to patient’s body mass index or body habitus here)

• any abdominal masses or scars and if the abdomen is moving normally with respiration

Surroundings/Bedside clues:                    

• Medication

• Intravenous cannulation

• Parenteral nutrition

• Sick bowl/vomiting bag

inspection GI tract - bedside, hands

patient is sat

• leuconychia/ opacification of nail bed (liver disease)

• palmar erythema (liver disease)

• palmar crease pallor (anemia)

• dupuytrens contracture (thickening palmar fascia)

• clubbing (palpate/ vs each other)

• hepatic flap/ asterixis - Ask patient to stretch out the arms in front separate the fingers and extend the wrists for 15 seconds

inspection GI tract - bedside, upper limbs

patient is sat

bruising

• ecchymoses

• petechiae

muscle wasting

scratch marks

spider naevi (central arteriole from which radiate small vessels like spider’s legs)

gynecomastia

tattoos

Found on arms, neck and chest.

Greater than 2 or 3 is abnormal and may be caused by chronic liver disease.

inspection head and neck - GI tract

patient is sat

eyes

• jaundice

• conjuctival pallor (press down)

• fatty deposits skin around eyes

mouth (use flashlight)

• ulcers

• white patches tongue (candida infection)

• cracking mouth corners

• glossitis

lymph nodes

lymph node palpation neck

2 fingers walking

behind patient

1. Submental
2. Submandibular
3. Parotid
4. Preauricular
5. Postauricular
6. Occipital
7. Anterior cervical
8. Supraclavicular
9. Posterior cervical

GI inspection- GI exam

patient lies flat

comment on exposure - ideally i want no pants to check for hernias

• scars

• gynecomastia

• mass

• distention

• striae

• stoma

GI exam - general abdomen palpation

patient lies flat

palpate area of pain last

9 areas

• light palpation first- one hand/ 2 “push down without removing hands”

• deep palpations - 2 hands, same technique

describe

• soft/ hard

• tender/ non tender

• guarding

• mass

Gi exam; liver palpation

patient lies flat

• Begin in the right iliac fossa with the examining hand aligned parallel to the right costal margin. Ask the patient to breathe in and out slowly through the mouth. move up from there in a straight line

• During inspiration the hand is held still and the lateral margin of the forefinger waits for the liver edge to strike it.

• On expiration the hand is advanced by 1-2cms closer to the right costal margin.

• If the liver edge is identified the surface of the liver should be felt. It may be hard or soft, tender or non-tender, regular or irregular and pulsatile or non-pulsatile. The normal liver edge may just be palpable below the coastal margin on deep palpation especially in thin people.

GI exam- spleen palpation

patient lying down

The spleen enlarges inferiorly and medially. Begin with the examining hand in the right iliac fossa and with the same technique used to examine for the liver slowly move the hand towards the left costal margin.

• press on inhale, move on exhale - DIAGONAL

If the spleen is not palpable a two-handed technique is recommended. The left hand is placed posterolaterally over the left lower ribs and the right hand is placed on the abdomen parallel to the left costal margin (midline). As the right hand is advanced towards the left coastal margin the left hand compresses firmly over the rib cage. This enables a slightly enlarged soft spleen to be felt as it moves down towards the right iliac fossa.

If the spleen is still not palpable the patient is rolled onto the right side towards the examiner and palpation is repeated. Begin palpation close to the left costal margin (midline). Splenomegaly becomes just detectable if the spleen is one-and-a-half to two times enlarged.

GI exam- kidney palpation

patient lies down

To palpate the right kidney the examiners left hand slides underneath the back to rest with the heel of the hand under the right loin.

• The fingers remain free to flex at the metacarpophalangeal joints in the area of the renal angle.

• The examiner’s right hand is placed over the right upper quadrant.

• Press over the renal angle by flexing the fingers of the posterior hand. The kidney can be felt to float upward and strike the anterior hand.

The left kidney is examined in the same way. Keep the right hand on the anterior aspect of the abdomen, placing it in the left upper quadrant, while the left hand is placed in the left renal angle, flexing at the MCP joint.

It is unusual to feel a normal kidney, although the lower pole of the right kidney may be palpable in thin people, without renal pathology.

aaa palpation - gi exam

patient lies down

Arterial pulsation from the abdominal aorta may be felt in the epigastric area of thin people, without aortic pathology. Check for an abdominal aortic aneurysm (AAA) at the midpoint between the xiphisternum and the umbilicus using the technique shown in the video. You are checking for an expansile pulsation found when a AAA is present.

• hands 10cm apart, above imbillicus

• inch closer slowly

• say when feel pulse/ distance, comment if fell mass

percussion liver- GI exam

patient lies down

The liver borders should be percussed to determine the liver span.

• Start percussing from the right iliac fossa to the right costal margin along the midclavicular line.

• Dullness defines the liver’s lower border- ask patient to keep a finger there

• Define the upper border of the liver by percussing along the midclavicular line from above. Normally the upper level of liver dullness is the sixth rib in the right midclavicular line.

• Determine the liver span by measuring the distance between the two borders with a ruler. The normal liver span is usually between 12 and 15cms.

percussion spleen- GI exam

patient lies down

Percuss from the right iliac fossa to the left costal margin

• move diagonally

• should be resonant throughout

ascites assessment - GI exam

usually only done if distended

patient lies down flat

• percuss across abdomen- dullness is an ABNORMAL finding

shifting dullness

• patient turns towards you

• wait 30 sec

• percuss side of abdomen→ if change from dull to resonant → SHIFTING DULLNESS

fluid thrill

• patient lies flat

• patient pushes down on their abdomen midline, with their fingertips pointing at pubic bone

• i press down on side of abdomen

• tap other side of abdomen with back of fingers

• no thrill should be felt

GI exam- abdomen auscultation

patient lies flat

• disinfect stethoscope

Place the diaphragm of the stethoscope just below the umbilicus. Bowel sounds can be heard intermittently. They should be described as either present or absent.

• ideally wait 30 sec

additional tests GI exam

• ankle- pitting oedema

• hernias groin

• rectal exam

general inspection thyroid exam

patient is sat

• neck and arms exposed

• legs bare below knee

at end of bed

• equipement (IVs, oxygen, walking aids, meds…)

• tremor

• sweating

• neck swelling

• scars

• colour

• body habitus

thyroid exam- upper limbs observation

bedside

• clubbing

• acropachy (general hand swelling)

• palmar erythema

• take pulse- comment on rhythm and take rate

• tremor- piece of paper

• goitre

• plamar crease pallor

thyroid exam - eyes

exophtalmos

• in front and above patient

lid lag

• arch above head to below nose

• H

  • double vision

  • pain

thyroid neck inspection

front and side

• scars

• masses

• symmetry

movement of thyroid/ mass with swallowing/ tongue sticking out

palpation thyroid

behind patient , both hands

• immobile

• swallows/ tongue sticking out

• lymph nodes

  • cervical

  • supraclavicular

percussion thyroid

·       Percusses for retrosternal extension – should strike middle phalanx of third finger with other third finger

auscultation thyroid

both lobes

look for bruit

pemberton’s sign

thyroid exam

• Asks patient to hold arms

above head assessing for

facial plethora

o Asks patient elevate both

arms until they touch

sides of face, observes

for facial congestion

and cyanosis, as well as

respiratory distress after

approximately one minute

lower limb exam- thyroid

• Observes distal legs for

swelling & skin changes

(pretibial myxoedema)

• Proximal Myopathy – asks

patient to stand from a

seated position with arms

crossed.

• Checks ankle jerks

how to give IM injection

• explain possible side effects (bruising, pain…)

• check

  1. dose

  2. route

  3. patient

  4. time

  5. allergies

  6. reason

  7. drug

• wash hands

• check expiry dates

• wash hands and put on gloves

• make sure site does not have bruising/ irritation

• clean site with acohol swab

  • circular motion inside out

  • wait to dry

• draw up meds

• replace needle with 23g injection needle

• uncap, make sure no air

• retract skin

• 90 degree angle

• retract needle

• administer meds

• remove needle and apply pressure to site

• put safety cover on needle/ DO NOT RECAP

• put needle in sharps bin

• bandaid

thank patient- ask them to wait around

discard equipement

wash hands

document

NG tube insertion

• explain procedure gain consent

• wash hands

• measure tube

  • from nostril - ear lobe - xiphoid sternum

  • look for number you arrive at

• wash hands again and put on gloves

• make sure patient comfy and nasal passage clear

• lubricate tube inside bag 2-4cm

• instruct patient to sip water/ swallow when feel tube back of throat

• insert tube- stay floor nostril

• tape tube when inserted to estimated stop lenght

  • on nose

  • on tubing

• check tube is in place

  • xray

  • aspirate from tube and test with test strip

    • insert syringe into port

    • close port

• once confirmed in right place - can start feeding

thank patient and make sure comfy

discard equipment

wash hands

document

urinalysis

• ask patient to pee in cup

• prep equipment, wash hands and put on gloves

• check urine dipstick expiry date

• dip test strip in urine

• wait 2 minutes

• compare colours vs references

• thank patient

• dispose of equipement

• wash hands

• document

pregnancy test

• make sure test is not expired

• wash hands, put on gloves

• pipette urine, put 3-4 drops on cassette

• wait

  • one line - neg

  • 2 lines - positive

  • no lines- invalid test

blood glucose

normal range;

• 4-5.9 fasting

• >7.8 non fasting

introduce self, gain consent

• prep equipment, make sure not expired

• wash hands, put on gloves

• make sure fingertip clean and dry

• equipment turned on- strip in

• prick side of finger

• squeeze finger- wipe first drop

• bring strip to drop

thank patient

discard equipment

wash hands

document

warfarin pros and cons

pros

• once daily

cons

• delayed onset → prescribe at least 3 months (DVT, PE…)

• monitor ++

• drug interactions

• cant take during pregnancy/ within 6 months GI/ CNS bleed/ 2 days post op

warfarin moa

inhibits protein factor 2, 7, 9 and 10

antagonist; vitamin k

test; INR (1 week)

doac pros and cons

pros

• rapid onset

• less drug interactions

• less monitoring required

cons

• multiple doses throughout day may be required

• cant take if renal/ liver disease

• cant take pregnancy

doacs moa

factor Xa/ thrombin competitive receptor

many reversal agents, i.e charcoal, heamodialysis

need to consider age, weight and liver/ kidney pathology when prescribing

warfarin dosages

1mg; brown

3mg; blue

5mg; pink

dosages available doac

5mg

20mg

60mg

150mg

apixaban

5mg doac BD

2.5= renal dose OR if 2/3 of the following

• if over 80

• below 60kg

• creatinine over 133

• crcl 15-29

dagibatran

150mg doac BD

110 if renal OR

• over 80

• 75 and increased bleeding risj

• on verapamil

• crcl 30-50

edoxaban

60mg daily doac

renal; 30mg or

• below 60kg

• ciclosporin/ erythromycin/ dronedarone/ ketoconazole

• crcl 15-50

rivaroxaban

20mg daily

renal dose; 15mg

• crcl 15-50

signs and symptoms of bleeding

• low hb

• blood in urine/ stool/ sputum

• lightheaded/ weakness

• intracranial bleed (confusion/ seizure/ vision loss)

what to do if life threatening bleed on warfarin

stop warfarin

give vitamin k IV slowly

give PCC - depends on weight

what to do if INR not in 5 range

lower; stop warfarin and wait

higher; stop warfarin; give 1mg vitamin k PO and recheck levels at 24h

bleeding with patient on DOAC

• imaging (angio/ endo)

• arterial blood gas

• balance crystalloids/ vasopressors and maintain Hb >7

give PCC or antidote (i.e  Idarucizumab)

• charcoal if recent injection

education doac

•Indication for treatment

•Duration of treatment (lifelong for AF)

•How to take their medication i.e. once/twice daily, at the same time each day, with food for rivaroxaban

•Importance of strict adherence

•How to manage missed doses

•Signs and symptoms of bleeding to look out for

•Medications to avoid (incl. OTC)

•Inform all doctors and dentists that you are taking a DOAC if having any surgical or dental procedures

CrCl calculation

for doacs

education warfarin

keep consistant food with vitamin k intake week to week (chickpeas, leafy greens, avocado, olive oil, blue cheese…)

check in with doctor before starting new supplements

no more than 2 units of alcohol daily

example warfarin dose adjustment

considerations of prescribing insulin

• right insulin

• right device

• right dose (IN UNITS)

• right strength

• right time (to meals/ regimen; GIVE BOLUS 30 MINUTES OR LESS BEFORE MEAL)

BRAND NAME ONLY (i.e novorapid flexpen)

basic management type 1 DM

1 basal

3 bolus before meals

hypoglycemia symptoms

injection sites insulin

how should diabetes patient monitor drug

4 is the floor

if this randomly happens/ no factor like skipping meals/ drinking; reduce basal by 20%

general inspection CNS exam

Craniotomy scars

Skin lesions

Ptosis – drooping of the upper eyelid.

Proptosis/exophthalmos – abnormal protrusion of the eyeball

Asymmetry

CN I assessment

• Purely sensory nerve.

• This nerve is not tested routinely, ask patient if they have any difficulty with their sense of smell?

• If the answer is no, move to the second cranial nerve.

• If patient complains of loss of smell [anosmia] test each nostril separately with bottles containing essences of familiar smells such as coffee.

CN II- visual acuity

Visual acuity is tested with the patient wearing his or her glasses.

Ask patient if they have any difficulty with their vision.

 

            “Can you see the clock on the wall?”

            “Can you read the newspaper?”

 

• Each eye should be tested separately.

• A portable Snellen’s chart will enable you to perform a more formal test.

• Formal testing with a standard Snellen’s chart requires the patient to be 6 metres from the chart. Unless the room is very large, this is done using a mirror or a modified chart (3 metres). Normal visual acuity is present when the line marked 6 can be read with each eye (6/6 acuity).

• A patient who is having visual problems should be asked to count fingers held up in front of each eye in turn, and if this is not possible then perception of hand movement should be assessed.

• Failing this light perception only may be present.

CN II visual fields

Visual fields are assessed by positioning yourself in visual confrontation about a metre away from the patient. Always remove the patient’s glasses. Test the visual fields of your patient against your own. To test the patient’s left eye visual fields:

 

• Ask patient to cover their right eye with their right hand and close your left eye.

• Ask patient to “keep looking at my eye”.

• Test their left temporal vision against your right temporal vision by moving your right wagging finger from the periphery towards the centre.

• “Tell me when you see my finger move”

• The temporal field should be tested in the horizontal plane and in the upper and lower temporal quadrants.

• Change your hands and repeat on the nasal side, tell the patient to keep their hand where it is

• Any areas of field defect are mapped out.

• The visual fields of the right eye are assessed using the same approach.

CN III, IV and VI - light reflex

glasses off- patient looks ahead

With a pocket torch, shine the light from the side [so the patient does not focus on the light and accommodate] into one of the pupils to assess its reaction to light.

Normally the pupil into which the light is shone constricts briskly. This is the direct light reflex.

Simultaneously the other pupil constricts in the same way. This is the consensual light reflex and occurs if the associated nerves are functioning correctly.

Repeat this procedure on the other side.

CN III, IV and VI - accomodation

Ask the patient to look into the distance and then to focus on your finger held near the patient’s nose. There is normally constriction and convergence of both pupils. This is called the accommodation response.

glasses off

CN III, IV and VI- eye movement

Assess for eye movement, diplopia [double vision] and nystagmus [abnormal jerky eye movements].

 

“Look at my finger and follow it with your eyes”

 

Ask the patient to look laterally left and right, continue moving the finger to complete a H PATTERN (while keeping their head steady i.e. not moving head).

no glasses, 1m away

check neutral gaze (ptosis)→ starting point

CN V- sensory

Test in the three divisions of the nerve comparing each side with the other

            Forehead -       Ophthalmic

            Maxilla -          Maxillary

            Lower jaw –     Mandibular

 

Test for light touch using cotton wool. Test this on the patient’s sternum first so they know what kind of sensation to expect.

• eyes closed

The patient should be instructed to say “yes” each time the touch of the cotton wool is felt. Do not stroke the skin, touch it.

 

Test for pain (sharp touch) using neurotip. Test this on the patient’s sternum first so they know what kind of sensation to expect.

The patient should be instructed to say whether it feels “sharp” or “dull” each time the neurotip is applied.

We do not routinely test corneal reflex.

ASK if feel same on both sides

CN V- motor

Inspect for wasting of the temporal and masseter muscles.

Ask patient to clench their teeth and palpate for contraction of the masseter muscles. Then get them to open the mouth (pterygoid muscles) and hold it open while the examiner attempts to force shut. (a unilateral lesion of the motor division causes the jaw to deviate towards the weak or affected- side). The jaw jerk reflex is not routinely tested.

CN VII

look for symmetry- rest and actions below

• open eyes wide and up and raise brows

• blow cheeks

• squit eyes shut - try and force open them

• show teeth

• tense neck muscles

CN VIII

            Ask the patient if they have any problems with their hearing?

            Cover one of the patient’s ears with your hand and whisper into the other ear.

 

If deafness is suspected perform Rinne’s test and Weber’s test

rinne test

            A vibrating tuning fork (256 Hertz) is placed on the mastoid process behind the ear. When the sound is no longer heard it is placed in line with the external meatus. Normally the sound is audible at the external meatus (as air conduction > bone conduction). This is termed Rinne-positive.

 

With conduction [middle ear] deafness, no note is audible at the external meatus. This is termed Rinne-negative.

 

With nerve deafness the note is audible at the external meatus, as air and bone conduction are reduced equally, so that air conduction is better as is normal i.e. Rinne-positive.

put fork by ear after- should hear better when by ear

weber test

            A vibrating tuning fork is placed on the centre of the forehead. Normally the sound is heard in the centre of the forehead. With nerve deafness the sound is transmitted to the normal ear. With conduction deafness the sound is heard louder in the abnormal ear.

CONDUCTIVE/ NEURAL

CN IX and X

Ask the patient to open their mouth and inspect the palate with a torch. Note any displacement of the uvula. Ask the patient to say ‘Ah’. If the uvula is drawn to one side, this indicates a unilateral tenth nerve palsy. The uvula is pulled towards the normal side.

CN XI

patients remove shirt

• look for muscle wasting

Ask the patient to shrug their shoulders and feel the bulk of the trapezius muscles and attempt to push the shoulders down.

 

·      Ask the patient to turn their head against resistance and feel the bulk of the sternocleidomastoids. Feel for the sternocleidomastoid on the side opposite to the turned head. There will be weakness on turning the head away from the side of a muscle whose strength is impaired.

CN XII

1- look for fascicuitations of tongue in mouth

2- stickj tongue out immbile

3- move

            It is the motor nerve for the tongue

·      Ask the patient to stick out their tongue and then move it from side to side. It will deviate towards the weaker side if there is a unilateral lower motor neuron lesion.

6 medication rights

• patient

• drug

• time

• route

• dose

• documentation

ports IVs/ installation

IV;

meds; shorter

insert IV spike into longer port

make sure roller clamp is closed/ roll down towards narrower end

flip bag over and squeze chamber until halfway full

open roller clamp to make sure line has no air

attach line to IV and hang bag

how to prep IV medication

• Make sure the working surface is clean

• Observe hand hygiene

• Uncap the drug vial and clean top with an alcohol square. Allow to dry.

• Remove the needle and syringe from the packaging. Attach the needle to the syringe

• Remove the cap from the needle. Insert the needle into the water vial and withdraw the required amount.

• Insert the water into the drug vial via the needle add the required amount to the drug. This is done by holding the vial on its side and adding the water

• Keeping the needle inserted in the vial. Gently mix the water and drug until there is no powder left

• If the needle is removed please reinsert syringe with a fresh needle. Pull back on the plunger of the syringe, withdrawing the fluid into it. Make sure the needle remains in the fluid

• This medication can then be added to the infusion bag

To add fluid to an infusion bag

• Make sure you have the correct fluid

• Clean the port on the fluid bag used for adding medication

• Insert the needle with the syringe attached and push the fluid forward

• Observe hand hygiene after completion of procedure

 

Aftercare

Dispose of equipment according to hospital policy

Document procedure

Observe patient for adverse reaction