7th Trimester OSCE Review

1
7th Trimester OSCE Review

• Physical Examination
• Tracey A. Littrell, BA, DC, DACBR

2
History

• Chief complaint
• How to elicit?
• History of Present Illness
• 18 HPI
• Are these the only questions you need?
• Past Health History
• 2 MIST

3
Inspection/Observation

• An important skill for EACH system/region of the
  body
• Vitals
• Head and Neck
• EENT
• Lungs and Heart
• Abdomen

4
Vital Signs

• Pulse (60-100 bpm)
• May be taken at temporal, carotid, brachial,
  radial, femoral, popliteal, posterior tibial,
  dorsal pedis
• Rate, rhythm, amplitude, contour, and compare
  symmetry/synchronicity
• Respiration (10-20 breaths pm)
• Observe while pretending to take pulse
• Rate, rhythm, depth
• Temperature (under 100.2 is normal)
• Blood Pressure
• Palpatory first (add 40)
• Report Phase 1 (systolic), Phase 4
  (mid-diastolic), and Phase 5 (end-diastolic)
• Systolic 100-140
• Diastolic 60-90

5
Head and Neck

• Lymph nodes
• Cervical chain
• Thyroid
• Posterior or anterior approach
• Just like palpating for lymph nodes, but must
  hold one side of the gland to palpate

6
EENT

• Least to most invasive (no light to light)
• Snellen (20 ft) or Sloan (10 ft)
• Always use 20 ft conversions
• Always test monocular and binocular vision
• Cardinal planes of gaze (either H or asterisk)
• Peripheral fields testing (stand in front, must
  cover one eye)
• Accommodation (no light, watch pupils)
• Corneal light reflex (mirror image light source)
• Direct and indirect (consensual)

7
EENT Ophthalmoscopy

• Ophthalmoscopy
• Will likely have co-axial type
• Light at full illumination
• Match the eyes and the hand (right eye, right
  eye, right hand)
• Index finger on lens selection wheel
• Give patient SPECIFIC distant point to view
• Approach from approx 30 degrees
• Identify
• Red reflex, follow it in to the vessels and disc
• Find the disc
• Evaluate size, borders, cup to disc ratio,
  vessels
• Any AV nicking, cotton wool spots, exudates,
  microaneurysms, hemorrhages, or cupping?
• Find the macula last
• Look temporally to view, or ask the patient to
  look into the light to view

8
EENT

• Nose (speculum cover)
• Thumb on nose, head tilted back, ask patient to
  hold breath
• Mouth (no cover)
• 5 Ts Tissue, teeth, tonsils, tongue, and throat
• Tongue blade no more than ½ way back
• Say long Aaaaahhhhh
• Ears (speculum cover)
• Weber and Rinne
• Otoscope hand position matters

9
Lungs and Heart Posterior Thorax

• Inspection
• Palpation
• Thoracic expansion
• Tactile fremitus
• Percussion
• All regions, comparing segment to segment
• Diaphragmatic excursion
• Auscultation
• All regions, comparing segment to segment
• Vocal resonance?

10
Lungs and Heart Anterior Thorax

• Palpation?
• Percussion?
• Auscultation
• Begin at the apex again, compare segment to
  segment
• Heart
• Locate the PMI/apical impulse
• Palpate for thrills at A PET M(onkey)
• Auscultate at all 5 points
• Listen for S1, S2, extra sounds, murmurs,
  arrhythmias, skips

11
Cardiovascular system and extremities

• Inspection
• Edema, varicosities, thrombophlebitis
• Capillary refill
• Jugular venous pulse
• Hand veins
• Indicator of right heart activity
• Capillary refill
• Should return in approximately 3 seconds

12
Abdomen

• Inspection
• Hold breath, half sit-up and hold
• Auscultation
• Bowel sounds high-pitched, 5-35 per minute, per
  region
• Vascular sounds low-pitched, aorta, iliac,
  femoral, renal
• Reflexes
• Percussion
• Must know expected sounds for bowel
• Size percussion for liver and spleen
• Palpation
• Must be last step
• Light (1cm), Moderate (2-3cm), and Deep (4cm) for
  abdomen
• Liver (palpation plus punch)
• Spleen
• Kidneys (palpation plus punch)
• Specific exams
• Murphys
• McBurneys
• Rebound tests (McBurneys, Rovsings,
  Blumbergs), heel jar, iliopsoas, obturator

13
Hints

• Stand outside the room and make a plan
• Put the steps in order of least to most invasive
  or least to most sensitive
• Always perform bilaterally or at least indicate
  that you would do so if you feel youre running
  out of time
• Dont make me guess what you know TELL ME WHAT
  YOU KNOW
• Be confident and demonstrate that!
• DONT ACT LIKE YOU DONT KNOW WHAT YOURE DOING!