OSCE 2014 Reviewer

2016B OSCE Unicorns
OSCE 2014 REVIEWER

OUTLINE o This already consists about 30% of the total grade per
I. Introduction station. Do not waste it.
II. HEENT and Ophthalmology
 They will limit the skills to be demonstrated to those that can
a. Visual Acuity
be done quickly within a limited time frame.
b. Pupillary Exam
c. Visual Field Examination: Confrontation o So it might not be strategic to focus too much on skills
d. Ocular Motility that take forever to learn
e. Digital Tonometry ***This trans is made possible by the efforts of the Alpha Sigma Phi
f. Direct Fundoscopy Fraternity. They were extremely kind to allow us to video the
g. Head Examination demonstrations as a complement to this.
h. Neck Examination Links to the videos can be found in the Master Blog 
i. Thyroid Gland Examination
j. Otoscopy HEENT EXAMINATION
k. Weber Test
l. Rinne Test GENERAL TIPS FOR OPHTHA-HEENT
m. Oral cavity & Oropharyngeal Examination
n. Anterior Rhinoscopy 1. Don’t examine at once! Remember to prepare the area first
o. Posterior Rhinoscopy (e.g. darkening room, positioning the patient and self) and get
p. Indirect Laryngoscopy needed equipment.
III. Cardiovascular Examination 2. Know thy equipment: how to assemble, how to hold, how to
a. Inspection use.
b. BP Determination 3. If structures are paired (I.e. eyes or ears), ALWAYS CHECK
c. Locating Apex Beat BOTH STRUCTURES
d. Carotid Pulse
4. In OPHTHA, it’s traditional to check the RIGHT EYE FIRST. It’s
e. Auscultation
f. Jugular Venous Pulse recommended to check the BAD EYE FIRST.
IV. Respiratory Examination 5. In ENT, check the GOOD EAR FIRST
a. Posterior Chest Exam
b. Anterior Chest Exam OPHTHALMOLOGIC EXAMINATION
V. Skin Examination VISUAL ACUITY
VI. Abdominal Examination a. Distance Vision
a. Pain
i. Position the patient 20 feet or 6 meters away from the chart.
b. Inspection, Auscultation, Percussion, Palpation
c. Special Techniques Use appropriate chart for the patient.
VII. Surgery ii. Ask the patient to occlude the good eye.
a. Axilla Exam iii. Ask the patient to read the visual acuity chart for distance.
b. Breast Exam Encourage the patient to read as much as capable.
c. Rectal Exam
d. Nasogastric Tube Insertion Reporting findings from a Distance Chart
e. Male Urethral Catheterization
f. Female Urethral Catheterization
g. Basic Suturing
h. Two Hand Surgical Knot
i. One Hand Surgical Knot
j. Instrument Knot Tying
Report findings closest to the
VIII. Neurology
a. CN Assessment series of letters that the
b. Motor Exam patient is able to read.
c. Sensory Exam
d. Reflex Exam E.g. Patient able to read all
rd
e. Cerebellar Exam letters of 3 line: 20/70
f. Meningeal Exam
IX. Pediatrics Patient able to read only 3
a. APGAR Scoring th
letters of 4 line: 20/50 -1
b. Head Circumference
c. Choosing the Correct Sphygmomanometer Cuff
d. Anthropometric Assessment of Children Patient able to read only 1
th
letter of 4 line: 20/70 +1
INTRODUCTION
REMEMBER!
 BE CONFIDENT! st
o Dr. Zotomayor said before: “as long as it looks like you iv. If patient cannot read the 1 letter of the chart, let the
are doing the correct thing, you will still get full credit. patient come closer, taking note of the change in distance
Can’t find the IJV? Just make it look like you did and give (e.g. it will be reported as 15/200, 10/200 and so forth)
some normal value.” v. If patient cannot read at 5 meters, ask patient to count
 MOST (IF NOT ALL) SUBJECTS ARE NORMAL fingers. Report as: “counting fingers”
o So, if you will give a guess on values, keep it within the vi. If patient cannot count fingers, wave hand in front of
expected range. patient and ask if hand waving is seen. Report as: “hand
 Always GREET THE PATIENT FIRST and EXPLAIN WHAT YOU movement”.
WILL DO
OSCE Unicorns | Renan, Jian, MJ, Kyle, Lil, Cielo, Master Jerald, Arianne, Jobs, Martin Page 1 of 27
OSCE 2014 REVIEWER
vii. If patient cannot see hand wave, shine a light on each DIGITAL TONOMETRY
quadrant and ask the patient to point out the light. Report a. Instruct the patient to look down (do not close the eyes).
as: “Light projection”. Examiner rests forefingers of both hands on superior aspect of
viii. If patient cannot determine light direction, shine a light on the patient’s right globe.
the patient and ask if light can be perceived. Report as: b. May rest other fingers on patient’s forehead.
“Light perception”. c. Examiner gently and alternatively depresses both forefingers on
ix. If light cannot be perceived, report as: “No light perception” the globe while assessing the tone.
d. Repeat procedure on the other eye.
b. Near Vision
DIRECT FUNDOSCOPY
i. Position the patient. Use an appropriate near vision chart.
a. Darken room. Shine the light at the back of your hands. Change it
ii. Ask the patient to occlude the good eye.
to the appropriate size and color.
iii. Ask the patient to read the near vision chart. Encourage the
patient to read as much as possible.
KNOW YOUR OPHTHALMOSCOPE
iv. Report findings as for the distance vision chart.
 Radius of light: Use smallest radius of light for constricted pupils,
PUPILLARY EXAMINATION and largest radius of light for dilated pupils
a. Dim light, ask the patient to fixate on a distant target  Color: Yellow light is used to LOCATE structures. Green light is used
b. Shine penlight directly into eye (laterally or inferiorly). Don’t to identify any retinal HEMORRHAGES.
stand in front of the patient or allow the patient to look directly  Shape: The slit light is used to assess the corneal surface
into the light.
c. Observe direct pupillary response.
d. Observe consensual pupillary response.
e. Repeat steps a-d in other eye
VISUAL FIELD EXAMINATION: CONFRONTATION
a. Set-up
i. Position the patient. Occlude the eye not being tested.
ii. Seat yourself facing the patient at a distance of 1 meter.
Close the eye directly opposite the patient.
iii. Ask the patient to fixate on your nose. b. Turn lens disc to 0 diopter.
b. Implementation ADJUSTING THE DIOPTERS

i. Extend your arm. Move your fingers into the visual field.  It is important to adjust the diopter to the proper setting.
Start from the temporal fields. The 0 diopter assumes that the physician has 20/20 vision.
ii. Ask the patient to tell you when your fingers are first  If you do not have perfect vision, adjust the diopter until the
spotted. patient’s eyelashes have the clearest resolution at 15
iii. Repeat this pattern in the upper and lower temporal inches.
quadrants.
iv. Do finger counting in one hand. Do it in all four quadrants. c. Hold ophthalmoscope in your right hand to examine right eye,
Test at least 2 times per quadrant. and vice versa.
v. Perform simultaneous finger counting.
PROPER OPHTHALMOSCOPE HOLD
OCULAR MOTILITY
a. Sit facing the patient. Hold finger at eye level 10-14 inches in
front of the patient. Ask the patient to look ahead.
b. Ask the patient to follow your finger as you move target into the
cardinal fields of gaze and up and down along midline. Elevate
upper lid with finger on your free hand to observe down gaze.
c. Note any nystagmus.
th
 Hold the ophthalmoscope as shown. You may extend the 5
finger as an indicator that you are close to the patient
d. Instruct patient to stare into a distant target.
e. Check patient’s red-orange reflex at 15 inches. Approach the
patient slowly. Steady instrument by resting ulnar border of the
hand against the patient’s cheek, while the thumb of the free
hand raises the upper eyelid.
f. If red-orange reflex is lost, move away from the patient and
relocate it.
g. Dial opthalmoscope focusing lens to clarify fundus image.
h. Angle the opthalmoscope 15º temporal to fixation.
i. Locate optic disc, by following a retinal blood vessel. Assess cup
to disc ratio and artery to vein thickness ratio (Normal for both:
Figure 2: Cardinal Fields of Gaze. Note that it is an "asterisk", not an "H"
2:3 or 0.6)
j. Examine surroundings of optic disc.
k. Examine macular area.
l. Examine the other eye.
OSCE 2014 REVIEWER
f. Look for any damage to the ear canal, any unusual discharge.
HEAD AND NECK EXAMINATION
Note the landmarks on the tympanic membrane and its
HEAD EXAMINATION
appearance.
a. Explain the procedure to the patient.
g. Perform the procedure on the affected ear.
b. Inspect and examine the hair, scalp, skull, and face.
c. Check for abnormalities in turgor and color. Check also for signs WEBER TEST
of edema & appropriate facies. a. Explain the procedure to the patient.
d. Palpate lymph nodes starting from the pre-auricular nodes, all b. Using the base of the tines, strike the thenar eminence.
the way upwards and around the ear until the subclavicular c. Place the tuning fork in the midline of the head (vertex, glabella,
nodes. chin, or bridge of the nose).
d. Ask the patient if the sound is louder on one side or is heard
NECK EXAMINATION
midline.
b. Inspect and palpate the cervical lymph nodes. RINNE TEST
b. Using the base of the tines, strike the thenar eminence.
c. Place the vibrating tuning fork near the ear canal then on the
mastoid process.
d. Ask the patient whether the sound is louder when the tuning
fork is by the canal or on the mastoid process.
e. If the finding is “Rinne negative” and “Rinne equal”, Rinne
threshold testing must be done.
MOUTH, NOSE & THROAT EXAMINATIONS

ORAL CAVITY & OROPHARYNGEAL EXAMINATION
Figure 1 Locations of Cervical Lymph Nodes b. Focus the head mirror properly.
c. Note any masses or unusual pulsations of the neck. c. Inspect lips, gingival, tongue, and sublingual areas using tongue
d. Feel for any deviation of the trachea. depressor.
e. Observe sound and effort of the patient’s breathing. d. Depress the anterior 2/3 of the tongue and instruct the patient
to say, “Aah”.
THYROID GLAND EXAMINATION e. Visualize the oropharyngeal structures.
b. Inspect the anterior neck area. ANTERIOR RHINOSCOPY
c. Ask patient to flex neck slightly forward to relax the SCMs. a. Explain the procedure to the patient.
d. Go behind the patient and press fingers of both hands on the b. Focus head mirror properly.
patient’s neck, the index finger just below the patient’s cricoid c. Hold nasal speculum properly with the non-dominant hand.
cartilage. HOLDING THE NASAL SPECULUM
e. Ask the patient to swallow.
f. Feel for the thyroid isthmus and lateral lobes. Take note of the
size, shape, and consistency of the gland.
EAR EXAMINATION
OTOSCOPY
b. Ask the patient which is the affected ear. Do otoscopy first on
the unaffected ear.
c. Use the largest possible speculum to allow better visualization of  Place the thumb at the fulcrum of the nasal speculum. The
the tympanic membrane. index finger is used to retract the nares.
HOLDING THE OTOSCOPE d. Insert nasal speculum gently.

e. Open the blades of the nasal speculum gently.
f. Withdraw nasal speculum with the blades partially open.
POSTERIOR RHINOSCOPY
b. Focus head mirror properly.
c. Warm the mirror.
d. Depress the anterior 2/3 of the tongue.
e. Ask the patient to breathe through the nose.
f. Rotate the mirror behind the soft palate.
INDIRECT LARYNGOSCOPY
th
 Hold the otoscope like a pencil, with the 5 finger as an anchor a. Explain the procedure to the patient.
b. Focus the head mirror properly.
d. Using your thumb and index finger, pull the pinna of the ear of c. Warm the laryngeal mirror on buccal mucosa or light source.
the adult backwards and upwards. If the patient is a child, pull d. Instruct the patient to stick out the tongue.
the pinna backwards and downwards. e. Hold the tongue using gauze.
e. Insert the speculum ¼ to ½ inch into the ear canal. f. Instruct the patient to breathe through the mouth.
OSCE 2014 REVIEWER
g. Hold the laryngeal mirror like a pencil.
h. Introduce the mirror through the side of the mouth.
i. Instruct the patient to say “E”.
CARDIOVASCULAR EXAMINATION
INSPECTION
a. observe the chest and note deviations such as barrel chest,
obesity, visible thrills, and dynamic precordium
b. look for peripheral and central cyanosis
 peripheral: assess the fingers
 central: assess the lips, and conjunctivae
BLOOD PRESSURE DETERMINATION

a. Explain the procedures to the patient
b. Correctly apply the BP bladder over the brachial artery
c. Check the tightness of the cuff.
 make sure 2 fingers can fit in between the cuff and the arm
d. Acquire palpatory BP. Then, the manometer is deflated
e. Reinflate the manometer, take auscultatory BP
 inflate cuff to 20-30mmHg above the obtained palpatory BP
f. Deflate the manometer at around 3mmHg/beat
g. Report the acquired BP
JUGULAR VENOUS PRESSURE
LOCATING THE APEX BEAT  reflects the right atrial pressure
a. explain the procedure briefly to the patient  best estimated using the right internal jugular vein since it has a
b. Expose the anterior chest more direct channel to the right atrium
c. Inspect the precordium  The internal jugular vein is not readily seen since it hides
 if you see something pulsating, that is a dynamic underneath the SCM. If you see a vein immediately (in a normal
precordium (abnormal) patient), even without tangential lighting, that is not the internal
 not seeing anything signifies an adynamic precordium jugular vein
(normal)
d. Use the palmar aspect (specifically, the ball) of the hand to look PROCEDURE
for the most lateral impulse. This is the point of maximal a. Explain briefly what is to be done
impulse b. Position yourself to the right of the patient
e. Use a finger to determine the amplitude of the impulse c. Patient is positioned ≥30 degrees (incline)
f. identify the apex beat  regardless of the patient’s position, the sternal angle
remains only 5cm above the right atrium
CAROTID PULSE d. Turn the patient’s head to the left
a. Make sure the patient is lying down with the head of the bed e. Locate the right internal jugular vein by using tangential lighting.
elevated to about 30 degrees After which, locate the highest point of pulsation in the internal
b. Inspect the neck for carotid pulsations jugular vein
c. Place left index and middle finger on the right carotid artery at  the highest point of pulsation is usually the weakest point at
the lower third of the neck, and feel for pulsations which pulsations happen before it no longer becomes visible
d. Slowly increase pressure until maximal pulsation is felt. Slowly f. Place the ruler correctly at the Sternal Angle of Louis
decrease pressure until best sense of arterial pressure is felt g. Place a rectangular object making a 90 degree angle with the
ruler and make a horizontal line resting on top of the jugular
AUSCULTATION pulsation
a. Make sure patient is relaxed in a supine position  the object must be parallel to the floor, else the reading
b. Use the diaphragm of the stethoscope to listen throughout the becomes automatically false
precordium h. Read the vertical distance and report the findings measured in
c. Auscultate the aortic region centimeters
 found between the 2nd-3rd ICS at the right sternal border
d. Auscultate the pulmonic region NORMAL: 3-4cm/mmH2O
 found between the 2nd-3rd ICS at the right sternal border  anything higher than that suggests CHF, constricting
e. Auscultate the tricuspid region pericarditis, cardiac tamponade, et cetera
 found between 4th-5th ICS at the left sternal border  a low reading is suggestive of dehydration
f. Auscultate the mitral region  adding 5 to the JVP yields the CVP
 found near the apex and heard between the 5th-6th ICS in
the MCL
To remember the sequence of Aortic (2), Pulmonic (2), SKIN EXAMNIATION

Tricuspid (4), then Mitral (5) a. Explain briefly what is to be done
Always Pray To ME! b. Report on the following characteristics:
 S1: Low-pitch; interventricular; louder, synchronous with the i. Color
peripheral pulse ii. Turgor
iii. Texture
 S2: High-pitch; semilunar
iv. Warmth
OSCE 2014 REVIEWER
c. Describe  Causes of unilateral decrease or delay in chest expansion
i. Primary Skin Lesion include chronic fibrosis of the underlying lung or pleura,
ii. Presence or absence of secondary skin lesions pleural effusion, lobar pneumonia, pleural pain with
iii. Nail beds (as to color, shape, presence of clubbing, or associated splinting, and unilateral bronchial obstruction.
cyanosis)
TACTILE FREMITUS
iv. Color, quantity, distribution of hair
v. Presence of masses, pigmentation, and lesions on scalp  Fremitus refers to the palpable vibrations transmitted to the
bronchopulmonary tree to the chest wall as the patient is speaking.
RESPIRATORY EXAMINATION
POSTERIOR CHEST EXAM
Techniques of examination
a. Explain briefly to the subject what is to be done in order to elicit
cooperation and reduce anxiety.
b. Adequately expose the posterior chest wall. Drape accordingly.
c. Ask the subject to sit with the trunk bending slightly forward and
cross arms and hold shoulders. This position widens the
interscapular space and increases your access to the lung fields.
Inspection
 From a midline position behind the patient, note the shape of the
chest and how the chest moves, including:
a. Deformities or asymmetry a. Use either the ball (the bony part of the palm at the base of the
b. Abnormal retraction of the interspaces during inspiration. fingers) or the ulnar surface of your hand to optimize the
Retraction is most apparent in the lower interspaces. Retraction vibratory sensitivity of the bones in your hand.
is seen in severe asthma, COPD, or upper airway obstruction. b. Ask the patient to repeat the words “ninety-nine” or “one-one-
c. Impaired respiratory movement on one or both sides or a one.” If fremitus is faint, ask the patient to speak more loudly or
unilateral lag (or delay) in movement. Unilateral impairment or in a deeper voice.
lagging of respiratory movement suggests disease of the c. Identify and locate any areas of increased, decreased, or absent
underlying lung or pleura. fremitus (comparing both sides).
 Fremitus is typically more prominent in the interscapular
Palpation area than in the lower lung fields, and is often more
 As you palpate the chest, focus on areas of tenderness and prominent on the right side than on the left. It disappears
abnormalities in the overlying skin, respiratory expansion, and below the diaphragm.
fremitus. Intercostal tenderness is observed over inflamed pleura.  Asymmetric decreased fremitus is felt on unilateral pleural
a. Identify tender areas. Carefully palpate any area where pain has effusion, pneumothorax, and neoplasm from decreased
been reported or where lesions or bruises are evident. Example, transmission of low-frequency of sounds.
bruises over a fractured rib.  Asymmetric increased fremitus is felt on unilateral
 Assess any observed abnormalities such as masses or sinus tracts pneumonia from increased transmission.
(blind, inflammatory, tubelike structures opening onto the skin).
Percussion
Although rare, sinus tracts usually indicate infection of the
underlying pleura and lung (as in tuberculosis and actinomycosis.)  Percussion is one of the most important techniques of physical
examination. Percussion of the chest sets the chest wall and
POSTERIOR CHEST EXPANSION underlying tissues into motion, producing audible sound and palpable
vibrations.
 Percussion helps you establish whether the underlying tissues are air-
filled, fluid-filled, or solid. It penetrates only about 5 cm to 7 cm into
the chest, however, and therefore will not help you to detect deep-
seated lesions.
 The technique of percussion can be practiced on any surface. As you
practice, listen for changes in percussion notes over different types of
materials or different parts of the body.
Steps:
a. Hyperextend the middle finger of your left hand (pleximeter
finger). Press its distal interphalangeal joint firmly on the surface
to be percussed. Avoid surface contact by any other part of the
hand because this dampens out vibrations. Note that the thumb
nd th th
and 2 , 4 , and 5 fingers are not touching the chest.
a. Place your thumbs at the level of the 10th ribs, with fingers
loosely grasping and parallel to the lateral rib cage.
b. As you position your hands, slide them medially just enough to
raise a loose fold of skin on each side between your thumb and
the spine.
c. Ask the patient to inhale deeply. Watch the distance between
your thumbs as they move apart during inspiration, and feel for
the range and symmetry of the rib cage as it expands and
contracts.
OSCE 2014 REVIEWER
 When comparing two areas, use the same percussion technique in
both areas. Percuss or strike twice in each location. It is easier to
detect differences in percussion notes by comparing one area with
another than by striking repetitively in one place.
 Learn to identify five percussion notes.
b. Position your right forearm quite close to the surface, with the
hand cocked upward. The middle finger (plexor finger) should be
partially flexed, relaxed, and poised to strike.
 Percuss one side of the chest and then the other at each level in a
ladder-like pattern (as shown by the numbers).
o Omit the areas over the scapulae—the thickness of muscle
and bone alters the percussion notes over the lungs.
o Identify and locate the area and quality of any abnormal
percussion note.
c. With a quick sharp but relaxed wrist motion, strike the

pleximeter finger with the right middle finger, or plexor finger.
Aim at your distal interphalangeal joint. You are trying to
transmit vibrations through the bones of this joint to the
underlying chest wall.
d. Strike using the tip of the plexor finger, not the finger pad.
Withdraw your striking finger quickly to avoid damping the
vibrations you have created.
 Dullness replaces resonance when fluid or solid tissue replaces

air-containing lung or occupies the pleural space beneath your
percussing fingers. Examples include: lobar pneumonia, in
which the alveoli are filled with fluid and blood cells; and
pleural accumulations of serous fluid (pleural effusion), blood
(hemothorax), pus (empyema), fibrous tissue, or tumor.
 Generalized hyperresonance may be heard over the
hyperinflated lungs of COPD or asthma, but is not a reliable
Remember: sign.
 Your finger should be almost at right angles to the pleximeter. A  Unilateral hyperresonance suggests a large pneumothorax or
short fingernail is recommended to avoid self-injury. possibly a large air-filled bulla in the lung.
 The movement is at the wrist. It is directed, brisk yet relaxed, and a
bit bouncy. DIAPHRAGMATIC EXCURSION
a. Determine the level of diaphragmatic dullness during quiet
Percussion Notes: respiration
 With your plexor or tapping finger, use the lightest percussion that b. Holding the pleximeter finger above and parallel to the
produces a clear note. expected level of dullness, percuss downward in progressive
o A thick chest wall requires heavier percussion than a thin one. steps until dullness clearly replaces resonance.
o However, if a louder note is needed, apply more pressure with c. Confirm this level of change by percussion near the middle of
the pleximeter finger (this is more effective for increasing the hemothorax and also more laterally.
percussion note volume than tapping harder with the plexor
finger).
 When percussing the lower posterior chest, stand somewhat to the
side rather than directly behind the patient. This allows you to
place your pleximeter finger more firmly on the chest and your
plexor is more effective, making a better percussion note.
OSCE 2014 REVIEWER
 if bronchovesicular or bronchial breath sounds are heard in
locations distant from those listed, suspect that air-filled lung has
been replaced by fluid-filled or solid lung tissue.
Normal Breath Sounds:

 Vesicular, or soft and low pitched. They are heard through
inspiration, continue without pause through expiration, and then
fade away about one third of the way through expiration.
 Bronchovesicular, with inspiratory and expiratory sounds about
equal in length, at times separated by a silent interval. Differences
in pitch and intensity are often more easily detected during
expiration.
 Bronchial, or louder and higher in pitch, with a short silence
between inspiratory and expiratory sounds. Expiratory sounds last
 Note that with this technique, you are identifying the longer than inspiratory sounds.
boundary between the resonant lung tissue and the duller
structures below the diaphragm. You are not percussing the Techniques:
diaphragm itself. You can infer the probable location of the a. Listen to the breath sounds with the diaphragm of a stethoscope
diaphragm from the level of dullness. after instructing the patient to breathe deeply through an open
 Now, estimate the extent of diaphragmatic excursion by mouth.
determining the distance between the level of dullness on full  Use the pattern suggested for percussion, moving from one
expiration and the level of dullness on full inspiration, normally side to the other and comparing symmetric areas of the
about 5 cm or 6 cm. lungs.
 An abnormally high level suggests pleural effusion, or a high  If you hear or suspect abnormal sounds, auscultate adjacent
diaphragm as in atelectasis or diaphragmatic paralysis. areas so that you can fully describe the extent of any
abnormality.
 Listen to at least one full breath in each location.
 Be alert for patient discomfort due to hyperventilation (e.g.,
light headedness, faintness), and allow the patient to rest as
needed.
b. Note the intensity of the breath sounds.
 Breath sounds are usually louder in the lower posterior
lung fields and may also vary from area to area.
 If the breath sounds seem faint, ask the patient to breathe
more deeply. You may then hear them easily. When
patients do not breathe deeply enough or when they have a
thick chest wall, as in obesity, breath sounds may remain
diminished.
 Breath sounds may be decreased when air flow is decreased
Auscultation (as in obstructive lung disease or muscular weakness) or
 Auscultation of the lungs is the most important examining when the transmission of sound is poor (as in pleural
technique for assessing air flow through the tracheobronchial tree. effusion, pneumothorax, or COPD).
Together with percussion, it also helps the clinician to assess the c. Assess if there is a silent gap between the inspiratory and
condition of the surrounding lungs and pleural space. expiratory sounds. A gap suggests bronchial breath sounds.
Involves: d. Listen for the pitch, intensity, and duration of the expiratory
 listening to the sounds generated by breathing, and inspiratory sounds.
 listening for any adventitious (added) sounds, and
 if abnormalities are suspected, listening to the sounds of the Adventitious (Added) Sounds:
patient’s spoken or whispered voice as they are transmitted
through the chest wall.
 If you hear crackles, especially those that do not clear after cough,
listen carefully for the following characteristics. These are clues to
the underlying condition:
OSCE 2014 REVIEWER
 Loudness, pitch, and duration (summarized as fine or coarse
crackles). Fine late inspiratory crackles that persist from
breath to breath suggest abnormal lung tissue.
 Number (few to many)
 Timing in the respiratory cycle
 Location on the chest wall
 Persistence of their pattern from breath to breath
 Any change after a cough or a change in the patient’s
position. Clearing of crackles, wheezes, or rhonchi after
coughing or position change suggests inspissated secretions,
as in bronchitis or atelectasis.
 In some normal people, crackles may be heard at the lung bases
anteriorly after maximal expiration. Crackles in dependent portions TACTILE FREMITUS
of the lungs may also occur after prolonged recumbency. a. Compare both sides of the chest, using the ball or ulnar surface
 If you hear wheezes or rhonchi, note their timing and location. of your hand.
 Fremitus is usually decreased or absent over the
precordium.
b. When examining a woman, gently displace the breasts as
necessary.
 Increased transmission of voice sounds suggests that air-filled

lung has become airless.
ANTERIOR CHEST EXAM
 When examined in the supine position, the patient should lie Percussion
comfortably with arms somewhat abducted.  Percuss the anterior and lateral chest, again comparing both sides.
 A patient who is having difficulty of breathing should be examined  The heart normally produces an area of dullness to the left of the
in the sitting position or with the head of the bed elevated to a sternum from the 3rd to the 5th interspaces. Percuss the left lung
comfortable level. lateral to it.
 Person with severe COPD may prefer to sit leaning forward, with
lips pursed during exhalation and arms supported on their knees or
a table.
Inspection
 Observe the shape of the patient’s chest and the movement of the
chest wall. Note:
o Deformities or asymmetry
o Abnormal retraction of the lower interspaces during
inspiration. Supraclavicular retraction is often present. Usually
seen in severe asthma, COPD, or upper airway obstruction.
o Local lag or impairment in respiratory movement. This
suggests an underlying disease of lung or pleura.
Palpation  Dullness replaces resonance when fluid or solid tissue replaces air-
 Identification of tender areas. Tender pectoral muscles or costal containing lung or occupies the pleural space. Because pleural fluid
cartilages corroborate, but do not prove that chest pain has a usually sinks to the lowest part of the pleural space (posteriorly in a
musculoskeletal origin. supine patient), only a very large effusion can be detected
 Assessment of observed abnormalities anteriorly.
 The hyperresonance of COPD may totally replace cardiac dullness.
CHEST EXPANSION  In a woman, to enhance percussion, gently displace the breast with
a. Place your thumbs along each costal margin, your hands along your left hand while percussing with the right. The dullness of right
the lateral rib cage. middle lobe pneumonia typically occurs behind the right breast.
b. As you position your hands, slide them medially a bit to raise Unless you displace the breast, you may miss the abnormal
loose skin folds between your thumbs. percussion note.
c. Ask the patient to inhale deeply.
d. Observe how far your thumbs diverge as the thorax expands, and
feel for the extent and symmetry of respiratory movement.
OSCE 2014 REVIEWER
ABDOMINAL EXAMINATION
Things to consider before you begin:
a. ALWAYS FOLLOW THIS SEQUENCE THROUGHOUT ALL
EXAMINATION TECHNIQUES:
1) Introduce yourself to the patient.
2) Explain the procedure to the patient
3) Expose region to be examined.
4) Perform procedure.
5) Redrape/cover the exposed region again.
6) Thank the patient for their time.
b. Proper positioning of the patient:
 Alternatively, you may ask the patient to move her breast for you.  Supine, with head resting on pillow
 Identify and locate any area of abnormal percussion note.  Arms at the side or folded across chest (to relax
 Percuss in progressive steps downward in the right midclavicular abdominal muscles)
line. Identify the upper border of liver dullness. A lung affected by  Knees should be bent (to 45 degrees) with soles of feet
COPD often displaces the upper border of the liver downward. It planted on the examination table (to relax abdominal
also lowers the diaphragmatic dullness posteriorly. muscles) IMPORTANT!!
 Proper draping  move gown up till below the nipple
line, move drape down to level of symphysis pubis
c. ASK THE PATIENT first if there are any areas of tenderness.
Examine these areas last.
d. Examination procedure begins with Inspection, Auscultation,
Percussion, and Palpation; not IPPA. Doing percussion first
could affect bowel sounds.
Prior to palpation or percussion, WARM YOUR HANDS FIRST! Cold

hands might cause the patient’s abdominal muscles to contract,
preventing thorough examination of the visceral structures.
When REPORTING FINDINGS:

NORMAL FINDINGS
 As you percuss down in the left side of the chest, the resonance of Abdomen is protuberant with active bowel sounds. It is soft and
normal lung usually changes to the tympany of the gastric air non-tender; no palpable masses or hepatosplenomegaly. Liver span
bubble. is 7 cm in the right midclavicular line; edge is smooth and palpable
1 cm below right costal margin. Spleen and kidneys not felt. No
Auscultation costoverterbral angle tenderness (Negative Goldflam test)
 Listen to the chest anteriorly and laterally as the patient breathes
with mouth open, somewhat more deeply than normal. Compare TYPES OF PAIN
symmetric areas of the lungs, using the pattern suggested for VISCERAL PAIN
percussion and extending it to adjacent areas as indicated.  May occur when hollow abdominal organs (ie. Intestines, or biliary
 Listen to the breath sounds, noting their intensity and identifying tree) contract forcefully or are distended/stretched
any variations from normal vesicular breathing. Breath sounds are  May also occur when solid organs are enlarged and their capsules
usually louder in the upper anterior lung fields. Bronchovesicular are stretched
breath sounds may be heard over the large airways, especially on
the right.
 Identify any adventitious sounds, time them in the respiratory
cycle, and locate them on the chest wall.
 If indicated, listen for transmitted voice sounds.
Types of visceral pain
Visceral RUQ pain: think alcoholic hepatitis (liver distention

against capsule)
Visceral periumbilical pain: think acute appendicitis
(gradually changes to parietal RLQ pain d/t peritonitis)
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PARIETAL PAIN
 Inflammation of the parietal peritoneum
 Steady aching pain more severe than visceral pain  more
localized
 Aggravated by coughing or movement
REFERRED PAIN
 More distant sites which are innervated at same spinal level as
disordered structures
 Develops as initial pain becomes more intense
 Well-localized; may be superficial or deep
Pain referral to back: duodenal or pancreatic pain

Pain referral to right shoulder or right posterior chest: biliary tree
Pain referral to epigastric area: pleurisy or acute MI
INSPECTION Places to auscultate for bruit

Checklist: c. Friction rubs
a. Skin:
 Listen over the liver and spleen for these. Could indicate
 Scars liver tumor or gonococcal infection around the liver, or
 Striae (white or silver: normal; pink-purple: think splenic infarction.
Cushing’s)
 Dilated veins (think inferior vena cava obstruction or PERCUSSION
hepatic cirrhosis)  Percuss all four quadrants and assess for distribution of tympany
 Rashes, other lesions and dullness.
b. Umbilicus: check for inflammation or bulges (hernia)  Normal findings:
c. Abdominal contour o RUQ: dullness due to liver
 Flat, rounded, protuberant, or scaphoid (markedly o LUQ: tympany overlying gastric air bubble and splenic flexure
concave or hollow) of the colon
 Bulging flanks (think ascites, but may also just be fat)
 Symmetry Protuberant abdomen, typanitic throughout: intestinal obstruction
 Visible organs or masses (liver or spleen) Dullness in both flanks: assess for ascites
d. Movements Reversed normal findings: situs inversus (air bubble on right, liver
 Pulsations of the aorta may be visible on left)
AUSCULTATION PALPATION
a. First use one hand and start with light palpation. Fingers should
Usually, all four quadrants should be auscultated. However, for the be flat and together over abdominal surface, palpation being
benefit of time, one can start examination at the RLQ because this is done in a gentle dipping motion.
the location of the cecum, the largest part of the colon. Listen for 1 b. Proceed with deeper palpation using two hands, one over the
full minute. other, and note masses.
c. Look for rebound tenderness. Press down with fingers firmly and
a. Bowel sounds slowly, then withdraw quickly.
 Normal bowel sounds 5-34 per min
 Above 34: HYPERACTIVE bowel sounds (possibly Peritonitis presents with abdominal pain upon light percussion. DO
intestinal obstruction) COUGH TEST first to check for peritonitis before proceeding with
 Below 5: HYPOACTIVE (possibly paralytic ileus) percussion or palpation. Mark area of tenderness. If positive for
b. Abdominal bruits pain, do not proceed with rebound tenderness test anymore.
 Bruits indicate turbulent blood flow, a possible sign of an
aneurysm or stenosis Some patients with peritonitis will already feel pain even by just
 If positive for bruit, DO NOT attempt to percuss or stroking the skin of the abdomen with a finger.
palpate. You might rupture the aneurysm
SPECIAL TECHNIQUES - LIVER
 Identify RMCL. (right mid-clavicular line)
 Identifying upper border of the liver:
nd
o Start percussing at 2 ICS proceeding inferiorly until
percussion note changes from resonant to dullness.
 Identifying lower edge of liver: either palpation or percussion.
o Palpation
 Begin from the level of the iliac crest at the ASIS, asking
the patient to take deep breaths.
 Palpation proceeds upwards until lower liver edge is
palpated
OSCE 2014 REVIEWER
a. Place your left hand behind the patient, parallel to and Normal liver span in MCL = 6 -12cm
supporting the right 11th and 12th ribs. Normal liver span in midsternal line = 4-8cm (harder to measure
b. Press your left hand forward due to anatomy)
c. Ask the patient to take a deep breath. Then try to palpate When palpated, liver is slightly tender.
the liver’s edge by the right hand.
SPECIAL TECHNIQUES - KIDNEYS
GOLDFLAM
a. Expose patient’s back. Put non-dominant hand, palm-down over
the costovertebral angle.
Liver palpation according to Bates
d. For obese patients, try the “hooking technique”

Place hands side by side on the right abdomen below the
border of the dullness. Press in your fingers and up
toward the costal margin. Ask the patient to take a deep
breath.
b. Deliver a blow with the ulnar surface of your fist upon the
dorsum of the non-dominant hand. Control your strength in
order not to hurt patient too much
c. Positive Goldflam test: presence of pain
While placing non-dominant hand over costovertebral angle, ask

patient if the process already hurts. Usually, tenderness due to
inflammation can be elicited already by pressure. DO NOT
Hooking technique PROCEED WITH KIDNEY PUNCH if tenderness is present
o Percussion
SPECIAL TECHNIQUES - ASCITES
a. Begin percussing from the level of the iliac crest
FLUID WAVE
proceeding superiorly until percussion note changes from
a. Ask the patient or an assistant to press the edges of both hands
tympany to dullness
firmly down the midline of the abdomen
b. While examiner taps one flank sharply with his/her fingertips,
the other hand feels on the opposite flank for an impulse
transmitted through the fluid.
c. Positive result: An impulse is felt through the opposite side
SHIFTING DULLNESS
a. While the patient is supine, map the borders of tympany and
Percussion for the liver span dullness on the patient’s abdomen via percussion
b. Ask the patient to turn to one side, repeat percussion, and mark
the borders again.
TIPS DURING EXAMINATION
c. Positive result: change in borders between tympany and
 Mark the position where the note changes from tympany to
dullness
dullness, then measure with a ruler
 Pre-measure your palm along the crease (horizontally) so that
you could make approximations on what you have measured.
The length of your finger could also be used for rough
approximation of your measurement.
OSCE 2014 REVIEWER
OBTURATOR SIGN
a. Flex patient’s right thigh at the hip, with knee bent, and rotate
the leg internally at the hip.
b. Positive obturator sign: Right hypogastric pain
SPECIAL TECHNIQUES - APPENDICITIS

ROVSING’S SIGN
a. Press deeply and evenly in the LLQ then withdraw your fingers
b. Positive Rovsing’s sign: Pain in the RLQ during left-sided
pressure
SPECIAL TECHNIQUES – ACUTE CHOLECYSTITIS

MURPHY’S SIGN
a. Hook left thumb or fingers of right hand under costal margin and
ask patient to take a deep breath.
b. Positive Murphy’s sign: sharp increase in tenderness with a
sudden stop in inspiratory effort
PSOAS SIGN
a. Place hand above patient’s RIGHT knee and ask patient to raise
that thigh against your hand  CONTRACTS psoas muscle Two ways of eliciting Murphy’s sign.
b. Alternatively, ask patient to turn to his left side and extend his
SURGERY
right leg at the hip.  STRETCHES psoas muscle
AXILLA EXAM
c. Positive Psoas sign: Increased abdominal pain on either
a. Introduce self
maneuver
b. Explain briefly to the patient what is to be done
c. Ask permission to expose patient
d. Inspect skin of each axilla
 Use left had to palpate right axilla and vice versa
 Fingers must lie directly behind pectoral muscle pointing
toward midclavicle
e. Palpate axillary nodes
i. Central axillary
ii. Pectoral
iii. Lateral
iv. Subscapular
Eliciting psoas sign by flexing hip
Eliciting psoas sign by extending hip

f. Ask patient to put on robe
g. Report assessment and thank the patient
OSCE 2014 REVIEWER
BREAST EXAMINATION  This examination requires gentleness, slow movement of a finger,
a. Inspect the breasts in four positions calm demeanor, and an explanation to the patient of what he or
i. Arms at sides she may feel
ii. Arms over head Procedure:
iii. Hands pressed against hips a. Use side-lying position (this allows good views of the perianal
iv. Leaning forward and sacrococcygeal areas): lying on left side with buttocks close
 Note for size, symmetry, contour, and appearance of skin to the edge of the table near you. Flex the hips and knees (esp.
b. Inspect the nipples. Compare: top leg) to stabilize position and visibility
i. Size b. Drape patient appropriately. Adjust light for better view.
ii. Shape c. With gloved hands, spread buttocks apart.
iii. Direction of pointing (e.g. inversion, retraction, and
deviation)
Also note:
i. Rashes
ii. Ulcerations
iii. Discharge
c. Palpate the breasts, including augmented breasts.
 Breast tissue should be flattened and the patient supine.
 Palpate a rectangular area extending from the clavicle to
the inframammatory fold or bra line, and from the clavicle
to the posterior axillary line and well into the axilla for the
tail of Spence.
 Note: consistency, tenderness and nodules
d. Use vertical strip pattern, or a circular or wedge pattern. d. Inspect sacrococcygeal and perianal areas for:
 Lumps
 Palpate in small, concentric circles
 Ulcers
e. For lateral portion of breast, ask patient to roll onto opposite
 Inflammation
hip, place her hand on her forehead, but keep shoulders pressed
 Rashes
against the bed or examining table.
 Excoriations
 Palpate any abnormal areas, noting lumps or tenderness.
 Anal and perianal lesions include:
i. Haemorrhoids
ii. Warts
iii. Herpes
iv. Syphilitic chancre
v. Carcinoma
 A perianal abscess produces a painful, tender, indurated
and reddened mass.
 Pruritus ani causes swollen, thickened, fissured skin with
excoriations
e. Examine the anus and rectum.
 Lubricate your gloved index finger
f. For the medial portion, ask patient to lie with her shoulders flat  Explain to the patient what you will do, and tell him to
against the bed, place her hand at her neck, and lift up her elbow expect some discomfort
until it is even with her shoulder.  Ask patient to strain
 Place the pad of your lubricated gloved finger over the anus.
As the sphincter relaxes, gently insert your fingertip into the
canal pointing to the umbilicus
f. If you feel the sphincter tighten, pause and reassure the patient.
Proceed when the sphincter relaxes
 If severe tenderness prevents you from further
examination, do not force it. Instead, place fingers on both
sides of the anus and gently spread the orifice, asking the
patient to strain or bear down. Look for a lesions, especially
an anal fissure which might be causing the tenderness
g. If you proceed without undue discomfort, take note of the
following:
i. Anal sphincter tone
 Normally, the anal sphincter muscles close snugly
g. Palpate each nipple. Palpate and inspect along the incision lines around your finger
of mastectomy. ii. Note: sphincter tightness in anxiety, inflammation or
scarring; laxity in some neurologic diseases
RECTAL EXAMINATION
 Make sure that the patient is relaxed before
 This can be omitted in adolescents, but must be included in middle-
proceeding
aged and older persons to decrease the risk of missing an
iii. Tenderness
asymptomatic carcinoma.
iv. Induration
 May be due to inflammation, scarring or malignancy
OSCE 2014 REVIEWER
v. Irregularities or nodules d. Examine patient’s nose for deformities or obstructions and
 To bring a possible lesion into reach, take your finger decide which nostril to use.
off the rectal surface, ask the patient to strain down, e. Using the tube, measure the length from the tip of the nose, to
and palpate again. the tragus then to the xiphisternum. Mark the tube.
h. Insert your finger as far into the rectum as possible. Rotate
clockwise to palpate as much of the surface on the right side,
then rotate counter clockwise to palpate the surface posteriorly
and the left side
f. Lubricate the first 4 – 8 cm of the tube. If available, you may also

i.Rotate the hand further counter clockwise and turn your body
use a local anesthetic spray on the patient’s throat.
somewhat away from the patient to
g. Pass the tube into the nostril and then posteriorly, a short
examine the posterior surface of the
distance at a time.
prostate gland.
i. You will feel the tube turn a corner at the nasopharynx and
 This will make the patient feel like
a slight obstruction as it passes into the esophagus
urinating.
h. If the patient is able, ask him to swallow as the tube passes the
j. Sweep your finger over the prostate
pharynx to assist in insertion. A brief sip of water may help.
gland and identify/check for:
i. Advance the tube up to the pre-measured distance
i. Lateral lobes and median sulcus
j. To check for correct placement:
ii. Size
i. Aspirate with a bulb syringe and check the pH of the fluid
iii. Shape
aspirated. pH should be < 6 to confirm that it is gastric fluid.
iv. Consistency
ii. With the bulb syringe, instil air through the tube while
v. Nodules
auscultating both lung areas, then epigastric area (this
vi. Tenderness
method, though, is apparently no longer considered
***Normal prostate: rubbery and nontender
appropriate in the UK and health care workers are advised
k. If possible, extend your finger above the prostate to the region of
against using it)
seminal vesicles and peritoneal cavity. Note nodules or
k. Secure the tube to the patient’s nose by applying some tape. You
tenderness
can also curl it back over their ear and secure the end to the
l. Gently withdraw your finger, wipe the patient’s anus or give him
cheek.
tissues so he can do it himself.
m. Note the color of any fecal matter on your glove and test for
NOTES
occult blood
n. Return patient his clothes, explain that the procedure is over and  If resistance is felt, try rotating the tube whilst advancing. Never
thank the patient. force the tube in. Wag pilitin ang ayaw!
 Partially pre-freezing the tube can ease its passage
NASOGASTRIC TUBE INSERTION  A more accurate method of checking tube placement: X-Ray
 A plastic tube is inserted through the nose, down the back of the imaging (the tube should be below the diaphragm in the region of
throat, esophagus, and into the stomach the gastric bubble)
 The “bore” of the tube (large = 16; medium = 12; small = 10) is MALE URETHRAL CATHETERIZATION
dictated by its purpose. For short- or medium-term nutritional  A urinary catheter has a balloon near the tip which is inflated via a
support with defective swallow, a fine-bore tube is used. Larger sidearm near the other end. Once inside the bladder, the inflated
bores are used to drain the stomach contents and decompress balloon prevents it from falling or being pulled out.
intestinal obstruction
 Contraindications: severe facial trauma and basal skull fractures MATERIALS
 Complications: aspiration, tissue trauma, electrolyte loss, tracheal  Sterile gloves - consider Universal Precautions
or duodenal intubation, perforation of esophagus or stomach  Sterile drapes
 Cleansing solution e.g. Savlon
MATERIALS  Cotton swabs
 NG Tube  Forceps
 Sterile gloves  Sterile water (usually 10 cc)
 KY Jelly (lubricant)  Foley catheter (usually 16-18 French)
 Bulb/asepto syringe  Syringe (usually 10 cc)
 Stethoscope  Lubricant (water based jelly or xylocaine jelly)
 Collection bag and tubing
PROCEDURE
a. Introduce yourself, confirm the patient’s identity, explain the PROCEDURE
procedure and make sure you have the patient’s consent
a. Wash hands thoroughly. Confirm patient’s identity, explain
b. Wash hands thoroughly, put on gloves
procedure, and obtain verbal consent
c. Ideally, the patient should be seated upright (often with head
tilted slightly forwards)
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b. Unwrap all equipment onto a trolley in an aseptic fashion and FEMALE URETHRAL CATHETERIZATION
pour saline solution over the cotton balls. a. Wash hands thoroughly. Confirm patient’s identity, explain
c. Position patient supine with genitalia exposed. Raise bed to a procedure, and obtain verbal consent
comfortable height. b. Unwrap all equipment onto a trolley in an aseptic fashion and
d. Wash hands again and put gloves on. Create a hole in the pour saline solution over the cotton balls.
center of the towel and drape over the patient so the penis c. Position patient supine with knees flexed and legs apart (dorsal
can be reached through the hole. recumbent). Raise bed to a comfortable height.
e. From here on, use your non-dominant hand to hold the penis d. Wash hands again and put gloves on. Create a hole in the center
with some gauze. of the towel and drape over the patient.
f. Clean the penis with the wet cotton balls, working away from e. From here on, use your non-dominant hand to hold the labia
the meatus. Remember to retract the foreskin and clean apart, approaching the patient from the right hand side, leaning
beneath! over their ankles so as to reach the genitalia from below.
g. Lift penis to a vertical position, carefully position the nozzle of f. Clean the genitalia with the wet cotton balls, working in a pubis-
the lubricant gel inside the meatus and instill the full 10ml anus direction. Use each cotton ball once only.
slowly. (Can be aided by gentle “milking” action.) g. Carefully position the nozzle of the lubricant gel inside the
h. Open wrapping of the catheter. Be careful not to touch the meatus and instill 5mL.
catheter! h. Open wrapping of the catheter. Be careful not to touch the
i. Insert the tip of the catheter into the urethral meatus and catheter!
advance slowly but firmly by feeding it out of the remaining i. Insert the tip of the catheter into the urethral meatus and
wrapper. advance slowly but firmly by feeding it out of the remaining
j. On passing through the prostate, some resistance may be felt wrapper.
which, if excessive, may be countered by adjusting the angle of j. On entering the bladder, urine should start to drain. Advance
penis by pulling it into horizontal position between the catheter to the hilt to ensure the balloon is beyond the urethra.
patient’s legs. k. Inflate the balloon with 10ml of saline via the catheter side arm.
k. On entering the bladder, urine should start to drain. Advance Warn patient to alert you to any pain and watch her face.
catheter to the hilt to ensure the balloon is beyond the urethra. l. Remove syringe and withdraw catheter until resistance is felt.
l. Inflate the balloon with 10ml of saline via the catheter side m. Attach draining tube and catheter bag.
arm. Warn patient to alert you to any pain and watch his face. n. Record residual urinary volume.
m. Remove syringe and withdraw catheter until resistance is felt.
n. Attach draining tube and catheter bag.
o. Replace the foreskin, clean, and redress the patient as
necessary.
NOTES
 Some female patients are easier to catheterize in a different
position lying on their side with their knees raised.
 Lack of urine drainage may be caused by: blockage of gel, empty
bladder or catheter misplacement
NOTES  Always record residual volume. This is essential in cases of urinary
 Lack of urine drainage may be caused by: blockage of gel, empty retention
bladder or catheter misplacement  Consider the use of prophylactic antibiotics before the procedure
 Always record residual volume. This is essential in cases of urinary  Complications: pain, infection, misplacement and trauma.
retention  Beware of latex allergy!
 Consider the use of prophylactic antibiotics before the procedure
 Complications: pain, infection, misplacement and trauma. BASIC SUTURING
 Patients with prostate disease can often experience some mild  Basic suturing, or stitching, has many practical applications outside
hematuria following catheterization. Don’t worry but watch the field of surgery
carefully and be sure the bleeding diesn’t continue or form into  Whether you are called upon to suture a central line in place or are
clots. stitching up a laceration, it’s a skill you should practice before you
 Beware of latex allergy! need to use it. Undoubtedly, the best way to learn is by watching a
surgeon and then doing it yourself.
a. First assess the wound and decide on the size of the suture
material
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b. Before suturing, irrigate the wound, and remove any foreign i. Face: 5 – 7 days
bodies and any non-viable or infected tissue. ii. Scalp: 7 -10 days
c. Use a needle holder such as toothed forceps where possible, to iii. Limbs and trunk: 12 – 14 days
minimize the risk of needle stick injury
TWO-HAND SURGICAL KNOT TYING
d. Hold the needle 2/3 of the way from the needle tip
a. White strand placed over extended index finger of left hand
e. Lift the skin edge farthest away without pinching or damaging it
acting as a bridge, and held in palm of left hand. Purple strand
f. Pierce the skin with the needle at 90˚
held in right hand.
g. Rotate your wrist to pass the needle into the middle of the
wound
h. Release the forceps and clasp the needle again as it protrudes
into the wound, rotating it out of the wound.
i. Press the near side with the closed forceps to evert the skin
edge, and pass the needle through, taking a smooth semicircular
course to exit at 90˚ angle to the wound edge
i. This ensures a square bite and good eversion of the wound
j. Perform a surgeon’s knot
SURGEON’S KNOT
 This is used for slippery structures in order to keep the knot closed
at the first loop
b. Purple strand held in right hand brought between left thumb and
a. Pull suture until a short amount of suture material is left
index finger.
b. Take needle out of needle holder
c. Place needle holder in the center between the skin edges parallel
to the wound.
d. Wrap the suture that is attached to the needle twice around the
needle holder starting the loop from the top of the needle holder.
e. Grab short end of the suture on the other side using the needle
holder
f. Pull and have the knot lie flat.
g. Let go of the short end, it should be at the other side of the
wound.
h. Place the needle holder to the center again, parallel to the
wound.
i. Wrap the suture that is attached to the needle once around the
needle holder (note that for this time, the loop will start at the c. Left hand turned inward by pronation, and thumb swung under
other side of the wound. Again, begin the loop at the top of the white strand to form the first loop.
needle holder)
j. Pull and have the knot lie flat.
k. Let go of the short end.
l. Repeat steps 8-11 twice
m. Cut the suture ends approximately 1 cm above the knot
d. Purple strand crossed over white and held between thumb and
index finger of left hand.
Removing the Sutures

a. Clean the wound with antiseptic solution
b. Use forceps or a blade and pull the suture out across rather than
away from the wound e. Right hand releases purple strand. Then left hand supinated, with
c. Time taken to remove non-absorbable sutures depends on the thumb and index finger still grasping purple strand, to bring
location:
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purple strand through the white loop. Grasp the purple strand
with right hand.
j. Left hand rotated inward by pronation with thumb carrying

f. Purple strand released by left hand and grasped by right. purple strand through loop of white strand. Purple strand is
Horizontal tension is applied with left hand toward and right grasped between right thumb and index finger.
hand away from operator. This completes the first half of the
hitch.
k. Horizontal tension applied with hand away from and right hand
nd
toward the operator. This completes the 2 half hitch.
g. Left index finger released from white strand and left hand again
supinated to loop white strand over left thumb. Purple strand
held in right hand is angled slightly to the left.
l. The final tension on the final throw should be as nearly

h. Purple strand brought toward the operator with the right hand horizontal as possible.
and placed between left thumb and index finger. Purple strand
crosses over white strand.
i. By further supinating left hand, white strand slides onto left ONE-HAND SURGICAL KNOT TYING
index finger to form a loop as purple strand is grasped between a. While holding the string from both ends with both palms facing
left index finger and thumb. you (the right hand is holding the blue end, and the left hand is
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holding the white end). Extend the index and thumb of the right
hand like a gun.
b. Rotate the right hand downward and inward so that the string
will hit the dorsal side of the thumb and index finger.
g. Grab the blue end with the right index finger and thumb and pull.
By this time, the palm of your right hand is facing you. (Take note
the hand at the top left of the picture below)
c. Make a triangle or a number “4” by placing the index finger of

the right hand across the white string.
h. Extend the right middle, ring, and pinkie fingers and wrap the
blue end of the string around the three fingers
d. Pull the white end by the right index finger.
i. Place the white end of the string right beside the blue end of the
string
e. Extend the right hand’s index finger, pulling a more distal part of
the blue end of the string. By this time, the blue end must have
gone around the white end of the string.
j. Flex the right middle finger pulling the white end of the string
f. Pull the blue end of the string by grasping it in between the right
index and middle finger.
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k. Extend the right middle finger pulling the blue end of the string.
c. Pull the suture through the loop and set the knot down properly
using only the instrument for traction. The traction must be
exerted in the plane of the knot. Pull the short end (purple)
toward you and the long end away. (TOWARDS)
l. Grasp the blue end of the string with the right middle and ring
fingers, Let the right thumb and index fingers’ grip on the blue
end of the string go, and pull.
d. Start the second hitch by again wrapping the long end about the
instrument, but in this instance, do it in the opposite direction.
Begin with the instrument behind the long end of the suture.
(UNDER)
m. Voila! You are done!
 Remember, as the name suggests, use only your dominant hand to

do this
 For you lefty’s out there, just exchange left with right and vice versa
in the instructions, and you’re good. e. After making the loop about the instrument, grasp the short end
(purple) of the suture with the instrument and pull it through the
INSTRUMENT KNOT TYING
loop.
a. The short end (purple) can be pulled quite short. Make a loop of
the long end of the suture about the instrument beginning with f. After pulling the short end through the loop, set the short end in
the instrument in front of the suture. (OVER) place, pulling the short end away from you and the long end
toward you. (AWAY)
 Remember: Over – Towards; Under - Away
b. Grasp the short end of the suture by the hemostat which is

through the loop.
OSCE 2014 REVIEWER
NEUROLOGICAL EXAMINATION iii. mouth retraction
 Always introduce yourself to the patient iv. showing of teeth
 Always explain the procedure before doing it. v. whistling
 Testing would go like... test for the Cranial Nerve I for example. vi. puffing out cheeks
Then all the things needed for all cranial nerve testing would be laid vii. wrinkling of skin over neck
out on the table. It is up to you to know which of the things on the  Be able to identify which muscles are being tested for each
table you need to use. expression.
 They could also ask you to localize a lesion. b. Listen to labial articulations.
i. Say “lalalala”
CRANIAL NERVES
CN I – OLFACTORY NERVE CN VIII – VESTIBULOCOCHLEAR / AUDITORY
a. Test one nostril at a time with eyes closed  Discussed in more detail with HEENT
b. Use at least three test substances for testing. a. Rubbed fingers heard at what distance (test both left and right)
i. Eg. Coffee, vanilla, tobacco b. Tuning fork test (Rinne and Weber's)
ii. Avoid using alcohol as test material
CN IX & X – GLOSSOPHARYNGEAL & VAGUS
CN II – OPTIC NERVE a. Check for swallowing reflex
a. Visual acuity (with glasses if available) - review the proper b. Check gag reflex- tongue depressor to posterior 1/3 of tongue
reporting and grading of visual acuity
CN XI - ACCESSORY
b. Confrontation/Visual fields
a. Inspect sternocleidomastoid and trapezius contours
i. should be equidistant from the doctor's examining hand,
b. Check head movements and shoulder shrugging
approximately the patient and doctor is 1 meter apart.
i. also test against resistance
c. Opthalmoscopy
i. Fundus: disc, vessels, venous pulse, retina
CN XII - HYPOGLOSSAL
CN III, IV, VI – OCULOMOTOR, TROCHLEAR, ABDUCENS a. Inspect oral cavity
a. Pupillary constriction: reaction to light and accommodation b. Ask patient to stick out tongue.
i. Direct and consensual i. Note tongue deviation, atrophy and fasciculations.
ii. swinging light reflex c. Assess speech. Ask patient to say:
b. EOM, convergence, Optokinetic reflex i. La la la
ii. Mi mi mi
 CN II and III are discussed in more detail in the ophtha exam. There iii. Go go go
is not much difference except in the testing of EOMs where in
MOTOR EXAMINATION
Neuro: hand movements for testing EOM should outline the letter
 Test in a rostrocaudal sequence
H, while in optha, and asterisk(going inward) PLUS Neuro: you can
 Test the range of motion first before testing the strength
test the eyes simultaneously, while in optha test one eye at a time
 Movements tested
for EOMs.
 Flexion
CN V – TRIGEMINAL  Extension
Corneal Reflex (Sensory) Assessment  Abduction
a. Use free piece of cotton  Adduction
b. Bring in a wisp of cotton from the lateral side to touch the lateral  Internal Rotation
side of the cornea of the adducted eye.  External Rotation.
c. Bring the cotton directly in from the side to avoid entering field  Always test both sides
of vision
STRENGTH OF SHOULDER AND LATISSIMUS DORSI
Face Sensation Assessment Shoulder
a. Test for a. Ask the patient to extend arms forward, to the sides and above
i. Pain (toothpick) the head
ii. Temperature: may use any metal object like neuro hammer b. Inspect from the front and back
or tuning fork; test for cold and warm(rub the neuro c. After assessing the range of motion, ask the patient to abduct
hammer with your hands) arms then attempt to push down as the patient resists it.
iii. Light touch (wisp of cotton)
iv. Pressure (may use hand) Latissimus Dorsi
b. Compare results on both sides a. Ask the patient to extend arms to both sides
b. Apply upward pressure on both elbows, ask the patient to resist
Motor Assessment – Masseter & Temporalis Muscles
a. Ask the patient to close and clench his/her jaw STRENGTH OF UPPER ARM MUSCLES
b. Feel for superficial temporal muscles Elbow Flexor
c. Compare bulk of muscle concerned a. Patient flexes forearm
d. Palpate then grade. b. Examiner puts one hand on shoulder, other hand on wrist
c. Attempt to straighten patient's forearm
 handout in Neuro exam handed over by the department also
mentions the testing of Jaw Jerk (should not be present or only Elbow Extensor
slight in normal individuals- pronounced in UMN lesions) a. Patient flexes forearm
b. Examiner's hand on the wrist of the patient, ask the patient to
CN VII – FACIAL extend forearm as you apply resistance
a. Test for:
i. forehead wrinkling
ii. eyelid closure
OSCE 2014 REVIEWER
STRENGTH OF FOREARM MUSCLES MYOTOMES
Wrist Flexor
a. Ask the patient to make a fist and hold the wrist flexed against
your effort to extend it.
b. Attempt to extend the patient's wrist by hooking your finger
around the patient's fist and flex your own wrist.
Wrist Extensor
a. Rest the patient's forearm flat on his thigh or tabletop.
b. Ask the patient to dorsiflex the wrist as you try to press it down
with the butt of your palm on the patient' knuckles
STRENGTH OF FINGERS
Finger Extension
a. Ask the patient to place his/her hand palm down with fingers
hyperextended.
b. Turn your hands over(palm side up) then press against the
patient's fingers
Finger Flexion
a. Grab patient's wrist with one hand( to steady the arm)
b. Instruct the patient to grip on your fingers and ask him/her not
to let your fingers get away as you try to extract your fingers
from the patient's grip.
 Note: functional position of the hand: slightly dorsiflexed-> optimal
hand position to exert the strongest grip.
STRENGTH OF THIGH MUSCLES

Knee Extensors
a. With the knees flexed, instruct the patient to extend
SENSORY EXAMINATION
b. Apply resistance and repeat (a)
PROPRIOCEPTION
Knee Flexors Digital Position Sense
a. Knee still flexed in 90 degree angle a. Explain briefly what is to be done
b. Ask the patient to resist as you try straightening the leg. b. Support patient’s hand or foot and grasp the 4th digit at the
sides
STRENGTH OF ANKLES AND TOES
c. Wiggle it in the correct manner w/o it touching other digits
a. Ask the patient to dorsiflex, invert and evert the feet
i. Ask if the finger is positioned up, down or in a neutral
b. Inspect and palpate the legs
position
c. Check for strength by manual opposition
d. Plantar flexion testing
Romberg’s Position Sense
i. Have the patient walk on the balls of his/her feet.
a. Explain briefly what is to be done
MOTOR GRADING b. Ask patient to stand with feet together. Then observe for
5 Normal Strength swaying.
4 Moves joint through full range against resistance c. Ask patient to close the eyes. Note for increase in swaying.
greater than gravity but examiner can overcome the VIBRATION SENSE
action(make a percentage estimate of strength to a. Explain briefly what is to be done
compensate for broad range of this number) b. Place the tuning fork in the in the right position while assessing
3 Moves part full range against gravity but not against for patient's ability to detect the vibration.
any resistance c. Test with patient's eyes open and closed
2 Moves part only when positioned to eliminate
gravity STEREOGNOSIS AND TACTILE AGNOSIA
1 Only flicker of contraction of muscle but cannot a. Explain briefly what is to be done
move joint b. Ask the patient to close his eyes
0 Complete paralysis c. Use different object and ask patient to identify using sense of
touch
d. Test both hands.
From Neuro Handout: Check for tone, Spasticity,
Rigidity and Gegenhalten.
OSCE 2014 REVIEWER
back up and falls backward across the crevice between your
From Neuro Handout:
thumb and forefinger, thus returning to the initial position.
 Ask patient to close eyes.
 Always test both sides and make sure that the stimulus being BICEPS REFLEX
applied is comparable to the opposite side that is being a. Have the patient sit.
tested b. Ask the patient to rest his/her hands on the knees while forming
 What to test: a 90 degrees angle at the elbow.
o Touch c. The examiner’s thumb places a tension on the patient’s biceps
 use cotton on the patient’s biceps tendon (at the area of the antecubital
o Pin fossa).
 toothpick/pointed end of Neuro hammer d. The examiner strikes his thumbnail a crisp blow.
o Position
 test distally first (DIP joint) and once this is intact, it TRICEPS REFLEX
is assumed that the more proximal parts are also a. Have the patient sit.
intact b. The examiner dangles the patient’s forearm over his/her
 if there is abnormality, move to the more proximal (examiner) hand at a 90 degree angle. (Alternative: The examiner
joint cradles the patient’s forearms in his/her (examiner) hand with
o Vibration Sense the elbow forming a 90 degree angle)
 tuning fork on joint. Test both upper and lower c. Strike the triceps tendon (near the bony tip of the elbow).
extremites(usually on the DIP of fingers, and on BRACHIORADIALIS REFLEX
toes.) a. Have the patient sit.
o Temperature b. The examiner cradles the patient’s forearm in one hand, placing
o Graphesthesia the thumb on top of the radius.
o Stereognosis c. The examiner strikes his/her thumbnail rather than the patient’s
o Two-point discrimination radius.
o Lateralization  Note: The examiner may cradle both forearms side by side for
 apply sensation/touch one part of the patient, then accurate comparison of the responses of the two arms.
ask him/her to point where the sensation is felt
o Romberg PATELLAR REFLEX
a. Have the patient sit with the legs dangling over the edge
DERMATOMES of the table.
b. The examiner observe the degree of the pendulousness
which usually amounts to three after-wings before the leg
stop swinging. Normally, the foot swings back and forth in
an exact straight line.
c. The examiner places a hand on the patient’s knee.
d. The examiner strikes the patellar tendon a crisp blow. The
examiner should see and feel the magnitude of the
response.
ANKLE REFLEX
a. Have the patient sit with legs dangling over the edge of the table.
Have him/her completely relax the leg.
b. The examiner dorsiflexes the foot to place slight tension on the
triceps surae muscle.
c. The examiner strikes the Achilles’ tendon.
GRADING
RESPONSE GRADE
No response 0
Diminished 1+
Normal 2+
Brisk Normal 3+
Hyperreflexia 4+
METHODS OF ELICITIING THE EXTENSOR TOE SIGN

DESCRIPTIVE EPONYM MANEUVER
NAME
REFLEX EXAMINATION Plantar toe reflex Babinski Move an object along the
USE OF THE PERCUSSION HAMMER lateral aspect of the toe
a. Dangle the hammer loosely between the thumb and forefinger, Chaddock Move an object along the
allowing it to swing like a pendulum. lateral aspect of the foot
b. Simultaneous extension of the elbow added to the wrist swing Achilles-toe reflex Schaeffer Squeeze hard on the Achilles
adds further velocity to the tip of the hammer, thus delivering a tendon
crisp blow. Shin-toe reflex Oppenheim Press your knuckles on the
c. If the velocity of the hammer head is great enough and the wrist patient’s shin and move them
and grip loose enough, the hammer head bounces all the way down
OSCE 2014 REVIEWER
Calf-toe reflex Gordon Squeeze calf muscles have abnormal rapid alternating movement testing secondary to
momentarily akinesia or rigidity, thus creating a false impression of
Pinprick toe reflex Bing Make multiple light pinpricks dysdiadochokinesia.
on the dorsolateral surface of
the foot
CEREBELLAR EXAMINATION
ATAXIA
a. Ask the patient to stand and walk.
b. Observe for broad-based stance and gait.
c. Tandem walking: step along a straight line, placing the heel on
one foot directly in front of the toe of the other (eyes not looking
down). This is the most sensitive clinical test for gait ataxia.
d. Characteristics of cerebellar gait abnormalities POINT-TO-POINT MOVEMENT EVALUATION
i. irregular cadence  Finger to Nose Test
ii. slightly short step length a. Ask the patient to extend their index finger and touch their nose,
iii. wide base and then touch the examiner's outstretched finger with the same
iv. erratic shifting of weight and step finger.
b. Ask the patient to go back and forth between touching their nose
ARM ATAXIA and examiner's finger.
 Postural tremor and tremor of the arms finger-to-nose test c. Once this is done correctly a few times at a moderate cadence,
a. Ask the patient to extend the arms straight out in front of you. ask the patient to continue with their eyes closed.
Note for wavering or incoordination during this volitionally d. Normally this movement remains accurate when the eyes are
maintained posture, and for frank rhythmic postural tremor. closed.
b. Ask the patient to place his index finger (facing him) on the tip of e. Repeat and compare to the other hand.
his nose. Observe for frank tremors that increase as the finger Dysmetria is the clinical term for the inability to perform point-to-point
approaches the nose (intention tremor). Instruct patient to place movements due to over or under projecting ones fingers.
the tip of his index finger (facing the examiner) on the tip of
examiner’s finger. When the patient fails to precisely do this, this
is termed as dysmetria.
c. Have the patient perform this test thrice. Have patient
alternately touch his nose, to your finger and to his several times.
DYSDIADOCHOKINESIA
a. Ask the patient to hold out his hand, and to supinate and pronate
them as rapidly as possible.
ROMBERG SIGN
a.Stay behind the patient.
b.Ask the patient to stand with feet together.
c.Ask the subject to stand erect with feet together and eyes closed.  Heel-to-Shin Test
Stand close by as a precaution in order to stop the person from a. With the patient lying supine, instruct him or her to place their
falling over and hurting himself or herself. right heel on their left shin just below the knee and then slide it
d. Watch the movement of the body in relation to a perpendicular down their shin to the top of their foot.
object behind the subject (corner of the room, door, window b. Have them repeat this motion as quickly as possible without
etc.). making mistakes.
e. A positive sign is noted when a swaying, sometimes irregular c. Have the patient repeat this movement with the other foot.
swaying and even toppling over occurs. The essential feature is d. An inability to perform this motion in a relatively rapid cadence is
that the patient becomes more unsteady with eyes closed. abnormal.
 WARNING: This is not done to test for cerebellar function. The heel to shin test is a measure of coordination and may be abnormal
Abnormalities found are indicative of sensory ataxia. If ataxia is if there is loss of motor strength, proprioception or a cerebellar lesion. If
noted even with eyes open (not Romberg test anymore), this may motor and sensory systems are intact, an abnormal, asymmetric heel to
indicate cerebellar problems. shin test is highly suggestive of an ipsilateral cerebellar lesion.
COORDINATION
 Coordination is evaluated by testing the patient's ability to perform
rapidly alternating and point-to-point movements correctly.
RAPID ALTERNATING MOVEMENT EVALUATION
a. Ask the patient to place their hands on their thighs and then
rapidly turn their hands over and lift them off their thighs.
b. Once the patient understands this movement, tell them to
repeat it rapidly for 10 seconds.
c. Normally this is possible without difficulty. This is considered a
rapidly alternating movement.
Dysdiadochokinesis is the clinical term for an inability to perform rapidly
alternating movements. Dysdiadochokinesia is usually caused by
multiple sclerosis in adults and cerebellar tumors in children. Note that
patients with other movement disorders (e.g. Parkinson's disease) may
OSCE 2014 REVIEWER
GAIT d. Therefore, if a patient loses their balance after standing still with
a. Have the patient walk across the room under observation. Gross their eyes closed, and is able to maintain balance with their eyes
gait abnormalities should be noted. open, then there is likely to be lesion in the cerebellum. This is a
b. Ask the patient to walk heel to toe across the room, then on positive Romberg.
their toes only, and finally on their heels only.
c. Normally, these maneuvers possible without too much difficulty.
d. Be certain to note the amount of arm swinging because a slight
decrease in arm swinging is a highly sensitive indicator of upper
extremity weakness.
e. Also, hopping in place on each foot should be performed.
Walking on heels is the most sensitive way to test for foot dorsiflexion
weakness, while walking on toes is the best way to test early foot
plantar flexion weakness.
Abnormalities in heel to toe walking (tandem gait) may be due to To conclude the gait exam, observe the patient rising from the sitting
ethanol intoxication, weakness, poor position sense, vertigo and leg position. Note gross abnormalities.
tremors. These causes must be excluded before the unbalance can be
attributed to a cerebellar lesion. Most elderly patients have difficulty
with tandem gait purportedly due to general neuronal loss impairing a
combination of position sense, strength and coordination. Heel to toe
walking is highly useful in testing for ethanol inebriation and is often
used by police officers in examining potential "drunk drivers".
MENINGEAL EXAMINATION
BRUDZINSKI’S SIGN
b. Ask him/her to lie supine on the examining table.
c. With the patient relaxed, the examiner places his/her hand
under patient’s occiput and gently attempts to flex the neck.
Note: A positive Brudzinki’s sign causes flexion and adduction of the legs
as the head is flexed.
ROMBERG TEST
a. Have the patient stand still with their heels together. KERNIG’S SIGN
b. Ask the patient to remain still and close their eyes. If the patient a. Explain the procedure.
loses their balance, the test is positive. b. Ask the patient to lie supine with the knees bent on the
c. To achieve balance, a person requires 2 out of the following 3 examining table.
inputs to the cortex: 1. visual confirmation of position, 2. non- c. The examiner keeps the patient’s knees bent while flexing the
visual confirmation of position (including proprioceptive and limb at the hip.
vestibular input), and 3. a normally functioning cerebellum.
OSCE 2014 REVIEWER
d. When the patient’s thigh reaches the vertical position, very
gently straighten the knee.
Note: A positive Kernig’s sign will make the patient wince in pain, and
the reflex hamstring spasm will prevent further straightening of the leg.
PEDIATRICS
APGAR SCORING
Memorize or perish!
0 1 2  Reflects brain growth
Appearance Blue limbs; pink o Small Head – premature closure of sutures or
Pink limbs; pink
(Color) Blue body microcephaly
body
(acrocyanosis) o Big Head – hydrocephalus
Pulse Rate Absent < 100 bpm > 100 bpm o Average Birth HC – 35cm
Grimace (Reflex  Most likely, they will use a model of a normal baby
Absent Grimace Cough/Sneeze
Irritability)
Activity Memorize this table or perish!
Limp Some flexion Active motion
(Muscle Tone) Age Head Circumference Add
Respiratory st
1 Year 4” (10cm increase) + 10 cm
Absent Slow, irregular Good, crying
Rate st
1 4 months ½ inch per month = 2”
7 – 10: 4 – 6: 1 – 3: Next 8 months ¼ inch per month = 2”
Normal Might need resuscitation Needs resuscitation nd
2 Year 1” (2.54 cm increase) +2.54 cm
rd th
3 – 5 Year ½ inch per year = 1.5”
Sample Case th
10 – 20 Year
th
½ inch per 5 years = 1.5”
A newborn boy, MJ, was found to have cyanotic lips, pulse rate of 75
bpm, showing some grimace, some flexion, and some irregular Sample Case
breathing. What is the APGAR score? Does the patient need If you have a 1 year old baby, what is the expected head circumference?
resuscitation?
ANSWER:
ANSWER:
Average HC at birth: 35cm + 1 year (10cm)
 cyanotic: 0
HC at 1 year = 45cm
 grimace: 1
 PR of 75 bpm: 1
CHOOSING THE CORRECT SPHYGMOMANOMETER CUFF FOR CHILDREN
 some flexion: 1
 Same principles apply: 2/3rd of the arm must be covered.
 irregular breathing: 1
 this was given as a competency check last OSCE
APGAR SCORE: 4 → Might need resuscitation
HEAD CIRCUMFERENCE
 Taken up to 3 years
o most remarkable increase in size at 1 year
o brain same as adult weight/size by 10 years old
 To measure:
o tape measure runs from the supraorbital ridge to the
occiput in the path that leads to the largest possible
measurement
 Landmarks
o Glabella: anterior; between eyelashes and supraorbital Here is a table you won’t ever be able to memorize!
ridge
o Occiput: posterior; most prominent part
OSCE 2014 REVIEWER
ANTHROPOMETRIC ASSESSMENT OF CHILDREN Scenario 2: they will ask you to compute for BMI and assess the
In this station, there will be a question taped on the desk, along with a nutritional status of the patient
calculator, and a pile of growth charts. Let’s just assume for the worst
case scenario and they will only give you a pocket calculator for the
computations. Don’t worry, we’ll walk you through this. In reading this The equation in order to get the BMI of any person is this:
part of the reviewer, make sure you have a copy of the growth charts by ( )
the WHO. ( )
Scenario 1: They will ask you to just assess the child based on his/her OR
weight for age or height for age.
( )
If they give us a question like this in the OSCE, there is a great possibility ( )
that they will mess with us by giving the English units, and not the metric
units. Hence, we must convert them using these equations: 2
*Remember, it is kilograms ÷ meters . The conversion here for length or
height is from inch to CENTIMETERS, but the equation requires it in
METERS. But don’t you worry. All you have to do is to just divide the
centimeter value by 100 before calculating for BMI.
Note: Some growth charts will include lines indicating 1 and -1, 2 and -2,
Once the weight or height is converted, select the appropriate growth
and 3 and -3. So again, READ THE LABELS PROPERLY
chart needed. Make sure it’s for the correct measurement, sex, and age
of the patient so read the label of the growth chart properly.
Sample question:
Bimby (boy) is 2 years old and is 30 inches in height and weighs 12 kgs.
Find the age of the child on the X-axis and the height or weight along the
What is Bimby’s BMI?
Y-axis and plot the point where they will meet in the grid.
Bonus: Based on Z-Scores, what is Bimby’s nutritional status?
Given:
Weight = 12 kg
Height = 30 inches
Step 1: convert units to metric or English, whichever you prefer.

Remember, height used is METERS, not CENTIMETERS.
30 inches X 2.54 = 76.2 cm

76.2cm ÷ 100 = 0.762 m
Step 2: Write the weight and height at the margin of the sheet so that
you won’t forget
Memorize the table above. This is how we will determine the nutritional
status of the patient. Step 3: Calculate for BMI
On the calculator, type in the weight in kilograms then divide it by the
Sample Question: height in meters twice.
A 4 year old boy was brought to the clinic for check-up. Upon
assessment the weight of the boy is 12 kg. What is the Z score In short, type this on the calculator:
classification of the nutritional status of the boy? 12 ÷ 0.762 ÷ 0.762
Given: This will give a BMI of 20.67

Weight = 12 kg
Age = 4 years old Step 4: Assess whether the patient is normal, possible risk of overweight,
overweight, wasted, or severely wasted. Select the appropriate growth
Step 1: Select the weight for age growth chart for boys. chart for BMI for age of BOYS. And you will see that the BMI is above the
line of +3 making Little Bimby overweight.
Step 2: Look for the patient’s age along the x-axis of the growth chart.
Scenario 3: They will ask us to determine the current nutritional status
Step 3: Look for the patient’s height along the y-axis of the growth chart. of the patient based on their age and their birth weight, or height
Step 4: Plot the point where the age and weight of the patient would For a question like this, there will be no need for the growth charts, but
meet we will need the calculator. Just remember the equations that were
given during the first LE. In case you have forgotten, here are the tables:
Since the patient’s weight for age lands between -2 and -3, then we can
say that the patient is wasted. Age Wt in Grams
Infants <6 months Age (months) X 600 + BW
6-12 months Age (months) X 500 + BW
2 years and up Age in years X 2 + 8
OSCE 2014 REVIEWER
Expected weight
4-5 months BW X 2 Never give up
1 year BW X 3
Cheer up; toward your dreams, never give up
2 years BW X 4
3 years BW X 5 Get up, get up, you can do it
5 years BW X 6 Wake up, wake up
7 years BW X 7 Don’t worry, everything will be fine, never give up
10 years BW X 10 Because it’s you, it’s you, believe in yourself
Never give up
Computations for height
- Bang & Zelo, “Never Give Up”
Ht in cm Age in years X 5 + 80
1 year 1 ½ X BL or 30 in
2 years ½ mature height NO FEAR
3 years 3 feet tall
Let’s face the OSCE bravely, guys!
4 years BL X 2
13 years BL X 3 “For God hath not given us the spirit of fear; but of power,
and of love, and of a sound mind.”
Now that you have computed for the expected weight or height, we can 2 Timothy 1:7
determine the patient’s current nutritional status. In order to do this,
use this equation:
Height Weight
Normal >95% >90%
Stunted Wasted
mild 90 – 95% 80 – 90%
Moderate 85 – 90% 70 – 80%
Severe <85% <70%
The above table shows the range for normal, mild, moderate, and
severe malnutrition for weight and height.
Sample Question: Baby D was born 52 cm in length. She is now 4 years

old and is now 3 feet tall. What is the nutritional status of the patient?
Given:
Birth length: 52 cm
Current Height: 3 feet = 36 inches = 91.44 cm
Current Age: 4 years old
Step 1: Multiply birth length by 2 since by age 4, the birth length must
have doubled
52 cm X 2 = 104 cm
Step 2: Get the percentage of the actual height compared to the

expected height
91.44 ÷ 104 X 100 = 87.92%
Step 3: Determine the nutritional status
Given that the percentage is between 85 – 90%, we can say that Baby D
is moderately stunted.

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2016B OSCE Unicorns

OSCE 2014 REVIEWER

b. Implementation ADJUSTING THE DIOPTERS

MOUTH, NOSE & THROAT EXAMINATIONS

HOLDING THE OTOSCOPE d. Insert nasal speculum gently.

BLOOD PRESSURE DETERMINATION

To remember the sequence of Aortic (2), Pulmonic (2), SKIN EXAMNIATION

c. With a quick sharp but relaxed wrist motion, strike the

 Dullness replaces resonance when fluid or solid tissue replaces

Normal Breath Sounds:

 Increased transmission of voice sounds suggests that air-filled

Prior to palpation or percussion, WARM YOUR HANDS FIRST! Cold

When REPORTING FINDINGS:

Types of visceral pain

Visceral RUQ pain: think alcoholic hepatitis (liver distention

Pain referral to back: duodenal or pancreatic pain

INSPECTION Places to auscultate for bruit

Liver palpation according to Bates

d. For obese patients, try the “hooking technique”

While placing non-dominant hand over costovertebral angle, ask

SPECIAL TECHNIQUES - APPENDICITIS

SPECIAL TECHNIQUES – ACUTE CHOLECYSTITIS

Eliciting psoas sign by extending hip

f. Lubricate the first 4 – 8 cm of the tube. If available, you may also

Removing the Sutures

j. Left hand rotated inward by pronation with thumb carrying

l. The final tension on the final throw should be as nearly

c. Make a triangle or a number “4” by placing the index finger of

d. Pull the white end by the right index finger.

m. Voila! You are done!

 Remember, as the name suggests, use only your dominant hand to

b. Grasp the short end of the suture by the hemostat which is

STRENGTH OF THIGH MUSCLES

METHODS OF ELICITIING THE EXTENSOR TOE SIGN

Step 1: convert units to metric or English, whichever you prefer.

30 inches X 2.54 = 76.2 cm

Given: This will give a BMI of 20.67

Sample Question: Baby D was born 52 cm in length. She is now 4 years

Step 2: Get the percentage of the actual height compared to the

91.44 ÷ 104 X 100 = 87.92%

Step 3: Determine the nutritional status

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