OSCE1- Physical Skills Steps, December 2008

Transcription

1 M1: M3: Model: PATIENT CENTERED MEDICINE 1 OSCE1- Physical Skills Steps, December 2008 Case prompter instructions: Please circle the appropriate answer that best reflects the student s knowledge/practice of each of the following physical exam skill steps. 1 If the student did the step satisfactorily, 0.5 If the student did the step, but the technique was NOT satisfactory, 0 If the student omitted the step. WASH YOUR HANDS BEFORE BEGINNING. HEAD & NECK: 1. Locate and identify the parotid glands. Student should point to area behind and superficial to mandible, below the zygomatic arch and in front of the ear. 2. Locate and identify the submandibular salivary glands. Student should point to area deep to or at the inner surface of the mandible 3. Locate and identify the superficial temporal arteries. = the continuation of the external carotid artery as it emerges from the Parotid gland, between the TMJ and the ear. As it runs anterior to the ear over the zygomatic arch into the temporal region of the skull. 4. Locate and identify the Papillae of the ducts of the submandibular glands. =Wharton s duct, located in the mouth at the base of the tongue, on both sides of the midline lingual frenulum. Student should ask patient to curl up their tongue or touch the tongue to the roof of the mouth to demonstrate these ducts at the base of the tongue 5. Locate and identify the opening of the Parotid glands. =Stensen s duct, located in the mouth at the 2 nd upper molar on the buccal mucosa by a small papilla 6. Locate and examine the trapezius muscles. (Tests CN XI = Spinal Accessory Nerve) Technique should be to ask patient to shrug shoulders upward. 7. Locate and examine the sternocleidomastoid muscles. (Also tests CN XI = Spinal Accessory Nerve) Technique should be to ask patient to turn head to each side against 1st year student s hand. As the patient turns head to each side, observe the contraction of Page 1 of 11

2 the opposite sternocleidomastoid. The right sternocleidomastoid contracts and turns patient s head to patient s left. 8. Locate and identify the borders of the anterior triangles (each side of the neck is divided into 2 triangles, by the diagonally running sternocleidomastoid muscle) Anterior triangle borders- mandible, sternocleidomastoid muscle, and midline of neck. 9. Locate and identify the external jugular vein by performing a Valsalva maneuver The external jugular vein is identified behind the clavicular head of the sternocleidomastoid or roughly about the middle third of the clavicle and then passes diagonally over the surface of the sternocleidomastoid and up behind the angle of the mandible. A Valsalva maneuver is a forced expiration against a closed glottis Student may need to lay the patient supine or at 30 or 45 degrees to best demonstrate this step. 10. Locate and the carotid artery In the lower neck, the carotid artery is deep to the sternocleidomastoid muscle and as you move higher up the neck, the carotid artery is anterior to the sternocleidomastoid muscle The student should only palpate for one carotid at a time!! 11. Locate and identify the location of the thyroid gland Student may ask the patient to take a sip of water to facilitate this step. Student places finger pads of both hands so that the index fingers are just below the cricoid cartilage. Ask the patient to swallow and the student attempts to feel the thyroid rising under their finger pads. Student s fingers should be a little lateral to midline. The thyroid has 2 lateral lobes and a midline isthmus and is usually located between the levels of the C5 and T1 vertebrae Locate and identify the structures that make up the external ear Cartilaginous ear- auricle- pinna. Outermost rim- helix, antihelix is internal to helix, and the tragus lies in front of the external auditory meatus. The ear lobule has no cartilage. 13. Locate and identify the external auditory canals The canal is behind the tragus of the ear. The canal is normally about 2-3 cm long in adults. 14. Locate and examine the tympanic membrane with an otoscope Student makes sure the otoscope light works, and uses an ear speculum for the exam. Student should stand close to the patient and warn the patient before they start. Student gently pulls the ear upward and backward to straighten the canal Page 2 of 11

3 for easy visualization. This maneuver assists in visualization in majority of patients (UP, OUT, and BACK). 15. Locate and identify the Pre & post auricular lymph nodes Preauricular - parotid lymph nodes would be in front of the ear Post-auricular- mastoid lymph nodes would be behind the ear and superficial to the mastoid process. 16. Locate and identify the Occipital lymph nodes At the base of the skull, posteriorly. 17. Locate and identify the Submental lymph nodes A few centimeters behind the tip of the mandible (chin). 18. Locate and identify the Superficial cervical lymph nodes These are superficial to the surface of the sternocleidomastoid muscles. 19. Locate and identify the posterior cervical lymph nodes These are located along the anterior border of the trapezius muscles. 20. Locate and identify the supraclavicular lymph nodes These are part of the deep cervical lymph nodes, located in the angel formed by the clavicle and the clavicular head of the SCM. THORAX: 21. Locate and identify the suprasternal notch. Above manubrium of the sternum, and between the two sternal heads of the sternocleidomastoid. 22. Locate and identify the sternal angle of Louis. The boney ridge joining the manubrium to the body of the sternum The 2 nd costal cartilages are adjacent to the sternal angel. 23. Locate and identify the spinous process of C7 and T1. If the patient flexes their neck, these are the two most prominent spinous processes on the neck. 24. Locate and identify the inferior angle of the scapula. Lowest part of the scapula, normally located horizontally at the 7 th rib or 7 th intercostal space. 25. Locate and identify the midsternal line. A vertical line that runs through the middle of the sternum and xiphoid process. 26. Locate and identify the midclavicular line. A vertical line running through the midpoint of the clavicle and inferiorly. Page 3 of 11

4 27. Locate and identify the anterior axillary line. A vertical line running inferiorly from the anterior axillary muscle fold. 28. Locate and identify the posterior axillary line. A vertical line running inferiorly from the posterior axillary muscle fold. (The purpose of all the above is to help the student describe and locate findings vertically and horizontally around the thorax. Please stress this point.) 29. Locate and identify the surface markings of the lungs, fissures, and lobes. LUNGS: Anteriorly, the apex of each lung rises about 2 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6 th rib at the midclavicular line. Laterally: the lower lung border crosses the 8 th rib at the midaxillary line. Posteriorly: the lower border of the lung lies at about the level of T 10. During normal breathing, the lower border of the lung may descend about 5-6 cm as the diaphragm contracts. FISSURES and LOBES: Each lung is roughly divided in half by an obliquemajor fissure. This fissure can be approximated by a line from T3 spinous process posteriorly and then runs obliquely down and around the chest to the 6 th rib in the midclavicular line. Posteriorly, above this line are the upper lobes, and below is the lower lobe. The right lung also is further divided by a horizontal-minor fissure. Anteriorly, this fissure runs from about the 4 th rib and then travels roughly horizontally around the chest wall to the 5 th rib in the midaxillary line. Above this fissure is RUL, and below is RML. Key teaching point: The right middle lobe does not have a posterior projection. To exam the RML, you need to auscultate/percuss in the lateral and anterior chest. 30. Locate and identify the surface markings of the trachea and major bronchi Location of trachea bifurcation into right and left mainstem bronchi: Anteriorly: at sternal angle Posteriorly: at spinous process of T 4 Trachea should be in the midline, or just slightly to the right of midline and it runs from the base of the neck, inferiorly and then behind the manubrium of the sternum. 31. Test for respiratory expansion Technique: First, the student should inspect the chest wall for symmetric expansion. Second, the student places their hands on the lower posterior chest wall with their thumbs at about the level of the 10 th rib and parallel to the 10 th rib. As the student grasps the lower chest wall, they should slide their thumbs medially so that they raise a vertical skin fold medial to their thumbs and lateral to the patient s spine. Student should then ask the patient to take a deep breath. As the patient breathes deeply, the student s hands and thumbs should move laterally and equally about 2 5 inches as the chest expands. The skin fold the student Page 4 of 11

5 created should also decrease in size as the chest wall expands. If the student starts too close to the midline over the spine, there is usually not enough loose skin available to create a skin fold. 32. Test for tactile fremitus Purpose for examining for tactile fremitus: detects palpable vibrations transmitted through the broncho- pulmonary tree to the chest wall. In a normal patient, both right and left lungs have normal and equal/ symmetric vibrations that the examiner appreciates. Increased, decreased, or absent tactile fremitus of one lung as compared to the other is abnormal. Admittedly this is a rough assessment tool at best, but as a scouting technique it directs the examiner s attention to possible abnormalities and to areas where the examiner wants to pay particular attention later on in the rest of the lung exam. Technique: Ideally, the student should ask the patient to grab their opposite shoulder with their hands so as to move the scapulae laterally and increase the examinable area of the posterior lung fields. -Must be done on skin, not over a gown or an article of clothing -Student should place either the dorsal surface of their fingers or the ulnar surface of their hands and fifth fingers or the ball of their hand (metacarpal phalangeal joints of fingers 2-5) on PATIENT s posterior chest, beginning at the top of the chest first. Any of these three positions helps optimize the examiner s appreciation of vibration through the bones of their hands/fingers. -Student then asks the PATIENT to keep repeating a phrase such as ninety-nine or one-one-one while they examine the PATIENT for tactile fremitus. -If the student cannot appreciate the fremitus at first, they should ask the PATIENT to speak more loudly or in a deeper voice. -The student should examine for tactile fremitus in at least three locations posteriorly (upper, middle, and lower chest wall) and then one area laterally (remember the right middle lobe has no posterior projection.) 33. Demonstrate the technique of percussion Purpose of percussion: to determine if the tissues 5-7 cm deep to/underlying the percussed site are air filled (normal lung), fluid filled (pleural effusion), or solid (tumor/mass). Technique of percussion: -Ideally, the student should ask the PATIENT to grab their opposite shoulders with their hands so as to move the scapulae laterally and increase the examinable area of the lung fields. -Must be done on skin, not over a gown or an article of clothing. -Student places the end of (from the DIP joint to the tip of the finger) their index or middle finger firmly against the PATIENT s posterior chest, ideally in an intercostal space and not over a rib. -No other part of the student s hand should be resting on the PATIENT s posterior chest. If they rest more of their finger or hand against the posterior chest, the student dampens the percussed sound. -Using the other hand hand s index and/or middle finger, the student quickly Page 5 of 11

6 strikes at the finger on the chest and also withdraws the percussing finger quickly. If the percussing finger is left on the chest, this will also dampen the percussed sound. -The action of percussion works best if the percussing hand s wrist is already close to the chest wall and the act of percussing comes from flexion at the wrist. Flexion of the percussing finger alone does not provide enough strength to create a percussed sound. Also, if the percussing hand is far from the PATIENT s chest, it is very difficult to accurately strike the finger on the chest. -The student should always start at the top of the lungs and should always compare right side to left at a given level. How many areas that need to be percussed is debatable. Bates recommends 7 different areas posteriorly and 3 anteriorly. It is probably sufficient for the student to assess the same areas by percussion as they did by tactile fremitus upper, middle, and lower posterior chest wall and then lateral chest wall. 34. State the five percussion notes and their characteristics Intensity Pitch Duration Example of Location Flatness: soft high short thigh Dullness: medium medium medium liver Resonance: loud low long normal lung Hyperresonance: very loud lower longer none normally Tympany: loud high gastric air bubble or puffed-out cheek 35. Locate and count and describe the patient s radial pulse Technique = student should use finger pads (not tips), and describe beats/min, rhythm 36. Identify and locate the apex and base of the heart Answer = base is the junction between the heart and the great vessels; lies just below sternal angle. Identify and locate the apex of the heart Answer = apex is the tip of the LV; normally found in midclavicular line, about 5 th intercostal space ABDOMEN: Patient should be in a gown and have a draping sheet and be supine for the abdomen exam. Student should pull out the ledge from the exam table for the patient s legs. Student should help to make sure the patient is appropriately draped, but ideally let the patient lift up their gown to expose the abdomen and have the sheet draped across the pelvis. Patient s arms should be at their side, NOT above their heads. Page 6 of 11

7 Student should be on patient s right side. This is the classic position for the abdomen exam. 37. Identify and locate the costal margin The costal margin is made of the cartilaginous border of ribs 7 10 anteriorly. 38. Identify and locate the xiphoid process The xiphoid process is a midline fingerlike projection from the most inferior part of the body of the sternum. 39. Identify and locate the midline which is overlying the linea alba Linea alba runs from the xiphoid process inferiorly to the symphysis pubis. 40. Identify and locate the rectus abdominis muscle Student may ask patient to raise their head and shoulders from the supine position. These muscles run about 7-10 cm lateral to and parallel to the linea alba. The lateral border of the rectus abdominis muscle is known as the linea semilunaris. The rectus abdominis muscle arises from the pubic crest and inserts onto the anterior surface of ribs 5-7 and the xiphoid process. 41. Identify and locate the umbilicus Normally at about L3 to L5. Granted, the umbilicus position depends on patient s weight, size, etc. 42. Identify and locate the symphysis pubis The symphysis pubis is a cartilaginous joint in the midline where the 2 pubic bones articulate. 43. Identify and locate the pubic tubercle The pubic tubercle is a bony prominence, which may or may not be palpable on the pubic bone. The pubic tubercle is about one inch lateral to the midline. Moving from medial to lateral, you have the symphysis pubis, pubic crest, and then pubic tubercle. 44. Identify and locate the anterior superior iliac spine This is the most anterior part of the iliac crest. It is usually prominent and palpable. 45. Identify and locate the inguinal ligament The inguinal ligament extends from the pubic tubercle to the anterior superior iliac spine. The inguinal ligament separates the abdomen above from the thigh below. 46. Identify and locate the iliac crest The iliac crest is the superior edge of the wing-like portion of the ilium bone. Page 7 of 11

8 Anteriorly the iliac crest ends in the anterior superior iliac spine. Posteriorly, the iliac crest ends as the posterior superior iliac spine. 47. Identify and locate the surface markings of the four abdominal quadrants (RUQ, LUQ, RLQ, LLQ) The four quadrants of the abdomen are defined by a vertical line running through the umbilicus and a horizontal line running through the umbilicus. Remember, right and left are defined as the patient s right and left. 48. Identify and locate the surface markings of the colon The colon is approximately 5 feet in length. The colon begins in the RLQ as the cecum. The appendix is also located in the RLQ and joins the cecum inferior to the ileocecal junction. The colon then turns into the ascending colon as it ascends to hepatic flexure (just under the liver) at about the 9 th intercostal space. The transverse colon is the longest and most mobile part of the colon. It runs from the hepatic flexure in the RUQ to the splenic flexure in the LUQ. The colon then turns into the descending colon. At the level of the pelvic brim, the descending colon becomes the sigmoid colon and finally terminates in the rectum and anus. 49. Identify and locate the surface markings of the spleen The spleen is normally just inferior to the diaphragm in the LUQ at the level of the 9 th -11 th ribs, POSTERIOR to the left midaxillary line. 50. Identify and locate the surface markings of the pancreas The pancreas is normally not palpable as it is a deep retroperitoneal organ. The pancreas lies in both RUQ and LUQs. The head of the pancreas lies within the C-shaped curve of the duodenum to the right of the patient s midline. The body of the pancreas crosses the midline at about L1 and L2. The tail of the pancreas extends upward and to the left to the hilar surface of the spleen, roughly at the mid-clavicular line. 51. Identify and locate the surface markings of the kidneys The kidneys are bean shaped organs, about 11 cm long, 5-6 cm wide, 3 cm thick, and about 4-5 cm from the midline at the level of about T12 through the L3 vertebrae. The kidneys are posterior/retroperitoneal organs. Their upper poles are protected by the 11 th and 12 th ribs posteriorly. The inferior poles may be 3-4 cm above the iliac crests. The right kidney is slightly lower than the left kidney. 52. Identify and locate the abdominal aorta The abdominal aorta begins as a direct continuation of the thoracic aorta at the level of T12 to L1 where the thoracic aorta passes through the diaphragm at the Page 8 of 11

9 aortic hiatus in the midline. The abdominal aorta descends in front of the bodies of the first four lumbar vertebrae in the midline or slightly to the left of the midline. At L4, the aorta bifurcates (remember the umbilicus is L3-L5) into common iliac arteries. The total length of the abdominal aorta is about 10 cm and normally its diameter is about 2.5 cm. 53. Identify and locate the renal arteries These are located in the RUQ and LUQ. The renal arteries arise at right angles off the abdominal aorta at about L1 or L Identify and locate the iliac arteries The common iliac arteries are a direct continuation of the abdominal aorta. The common iliac arteries divide into internal and external iliac branches about 4 cm laterally from the midline. 55. Identify and locate the femoral arteries The femoral artery is a continuation of the external iliac artery as it runs posterior to the inguinal ligament at about the midpoint of the inguinal ligament. 56. Auscultate abdomen in four quadrants In the abdominal exam, auscultation always comes before palpation since any contact with bowel can increase the bowel s motility. Gently place the diaphragm of the stethoscope on the abdominal wall. Normally there are 5-34 bowel sounds per minute. 57. Palpate for horizontal and vertical superficial inguinal lymph nodes The horizontal superficial inguinal lymph nodes are INFERIOR to the inguinal ligament. These drain the superficial portions of the lower abdomen and buttock, the external genitalia (but not the testes) the anal canal, the perineal area, and the lower vagina. The vertical superficial inguinal lymph nodes cluster near the upper part of the saphenous vein. The student palpates medial and parallel to the femoral artery below the inguinal ligament. These lymph nodes drain the lower limb, perineum, anterior abdominal wall to the umbilicus, gluteal region and parts of the anal canal. 58. Palpate the abdomen superficially The student places a hand flat on the abdomen and while keeping the fingers together, uses gentle, light dipping motions to palpate. ALL 4 QUADRANTS must be palpated. Page 9 of 11

10 59. Palpate the abdomen deeply The student may use a 2 handed technique, exerting pressure from the top hand and palpating with the bottom hand. Again, ALL 4 QUADRANTS must be palpated deeply. 60. Palpate for the liver edge and spleen With their right hand at about the level of the umbilicus and lateral to the rectus abdominus muscle, the student presses gently up and in while asking the patient to take a deep breath. If the liver edge is not palpated, the student repositions their right hand closer to the costal margin and repeats the step to try to feel the liver edge pass beneath their fingers as the patient takes a deep breath. Again, if the liver edge is not felt, the student then places their right hand just under the patient s right costal margin and repeats the step. The student may place their left hand behind the lower ribs and lift up while attempting to palpate the liver edge with the right hand. A common mistake is to start with the right hand too high, at the level of the costal margin. If the liver edge is below the costal margin, the student may never feel the edge if they start too high. Normally a spleen tip is not felt. The same examination approach is used for the spleen. The student should place their right hand at about the level of the umbilicus, lateral to the rectus abdominis muscle and gently press up and in as the patient takes a deep breath. The student may place their left hand behind the lower ribs and lift up. This technique is repeated as the student s right hand is eventually placed next to the patient s left costal margin. 61. Percuss for the liver span The goal of this step is to measure the vertical span of the liver in the right midclavicular line. The student must percuss both above the liver (in the lung area) and below the liver to hear the different percussion notes of air in the lungs and bowels as opposed to the solid percussion note of the liver. In the abdomen, the student should start at the level of the umbilicus and then percuss up toward the liver. The student should not percuss over the gown. A normal adult liver span is 6-12 cm in the right midclavicular line. 62. Palpate for the kidneys In most normal adults, the kidneys are not palpable. In a very thin and relaxed person, you may feel the lower pole of the right kidney. The student is trying to trap the lower pole of the kidney between their hands as the patient takes a deep breath. To palpate for the right kidney, the student places their right hand below the costal margin in the RUQ, lateral to the rectus abdominus muscle but parallel to Page 10 of 11

11 it, and place their left hand BELOW and parallel to the 12 th rib. (The left hand is between the lower end of the rib cage and the iliac crest note that this is a LOWER position than the step when the liver edge is being palpated) While the left hand is lifting up, the patient is asked to take a deep breath and at the peak of inspiration, the student presses deeply into the right upper quadrant just below the costal margin and attempts to capture the right kidney between their two hands. Then the patient can breathe out and the student slowly releases the pressure from their right hand, feeling at the same time for the kidney to slide back into its expiratory position higher up. If the kidney is trapped the patient is aware of a capture and release sensation. The right kidney is normally lower than the left. The left kidney is rarely palpable, but the same technique is used. Or the student may move to the patient s left side and use their left hand to feel deep while their right hand lifts up from behind the patient. 63. With patient in right lateral decubitus position, palpate for the spleen. Remember, a spleen tip is not normally felt. If the spleen is palpable, it is usually 3x its normal size. As the spleen enlarges, it enlarges diagonally from the left upper quadrant (LUQ), toward the right lower quadrant (RLQ). It enlarges anteriorly, downward, and medial). Also, remember that the spleen is normally posterior to the midaxillary line. By having the patient lay on their right side, gravity may bring the spleen forward and to the right into a palpable location. Again the student may place their left hand behind the left lower ribs and then they gently press up and in as the patient takes a deep breath. WASH YOUR HANDS Page 11 of 11