A few questions about osce regarding technique

I have my Year 2 osce resit in one weeks time I have a few miscellaneous questions which I could not exactly find the answer to on the net, and book.

1. for cranial nerve examination, specifically for optic nerve 2, I understand you get the patient to keep their glasses on for visual acuity, but what about the other tests (visual fields, reflexes) and also the H test for CN3, 4 and 6, do you get them to keep their glasses on for that?

2. for cardiovascular examination, should one comment about the character and volume for the radial pulse and brachial pulse, or is this only reserved for that of the carotid pulse? Also importantly, I understand one should ideally listen to the valve areas (A, P, T, B) with both the diaphragm and bell. But for murmurs (mitral stenosis, mitral regurg, aortic stenosis and aortic regurg) I know the "hold on the out breath bit" bit does one use bell or diaphragm to best hear these murmurs?
i.e. do you use bell or diaphragm to listen to each murmur

3. For testing asterixis, is it acceptable to ask the patient to put their hands out with their wrists cocked back whilst they are reclining (45 degree angle) or should I ask them to sit up?

4. What signs in the hands, specifically in the palms can one check for in the resp and cardiovascular exam? (apart from the signs of IE in CV exam and tar staining for Resp).

I would appreciate your help in answering these questions!

Thanks in advance

​Wow, a lot of really specific questions! I understand you're anxious about your retake, but I would encourage you to not get TOO bogged down with the small details. Remember that forgetting something small will not fail your exam, and being very robotic in your examination will not come across well either. It's good to be slick, but still friendly with the patient.

Anyway, to answer your questions:

1. Leave glasses on for everything (except fundoscopy). Think about it logically: if you test their visual fields without glasses on, and they struggle, can you be sure if they're struggling because they have a visual field defect, or because their vision is poor? You need to make sure you're testing the right thing

2. Only assess character at the carotid. I have occasionally been asked to comment on it at the radial/brachial, but have also been told by different people that you can't properly assess it at those pulses, so I understand the source of your confusion. But to be safe and save time I would only comment on character at the carotid. Again thinking logically: you're going to feel all 3 pulses anyway, and it's only necessary to comment on character once, so you may as well do it at the largest pulse, irrespective of whether it's possible at the other pulses

Personally, I only use the bell on the mitral area. That's all I have ever been taught to do. I think using diaphragm and bell in every area just wastes time. So I use just diaphragm on the other three areas, and diaphragm + bell on mitral area, and diaphragm + bell again when performing the manoeuvre for mitral regurg. I've never heard anything different using the bell anyway so I wouldn't get too hung up on it.

3. It doesn't matter. I would assess it while reclining just for patient comfort. But if it slips your mind and you remember later, just do it while they're lying flat. Just for the record, you only see asterixis after a patient is pretty encephalopathic, so your chance of actually seeing this sign in an OSCE is pretty much zero.

4. Other than those you mentioned: capillary refill time (for peripheral shutdown), clubbing (bronchiectasis, fibrosis), palmar erythema (fibrosis, supposedly). Don't worry hugely about the hands though. In the marksheet there is usually one tickbox that says something like "assessed hands for clubbing etc.", so as long as you give them a decent once over and mention some signs you should be ok.

Again, the only sign you're really likely to see in the hands at an OSCE is clubbing, so that's what you should look for mostly closely. And it's a pretty strong hint at a diagnosis too if you do get it, so actually quite useful for guiding the rest of your examination

Hope that's helpful, and if you do have any more questions then fire away

​ x

Ghotay's explanations were great! Just chipping in...
1. With CN2 and 3, I always ask the patient to remove their glasses when I test for direct/consensual response with pupillary reflexes, and when I do the swinging test for RAPD/Marcus Gunn just because glasses get in the way of things and the glare makes it hard to see but that's just personal preference! You probably know this already (I didn't until a lot later), but don't forget to test for pupillary reflexes if you are asked to examine CN3 as an isolated cranial nerve in the absence of CN2, because of the efferent pathway.

4. It's worth knowing all the possible reasons behind clubbing and categorising by all the different systems! The most common cases I've seen on the wards are clubbing due to cyanotic heart disease/congenital heart disease, and as Ghotay said, bronchiectasis and fibrosis, which you may very well get on the day because these patients can be quite stable. I always used to mix this up: COPD and asthma are not causes of clubbing (lung malignancy is however and as smoking is a risk factor, that would need to be ruled out).

With the angry patient scenario, I've always tackled it by being calm. The angry patient may be standing up and shouting at you from above which can be intimidating. If that happens, I always make sure I don't stand up as well so not to be confrontational and just politely ask the patient to sit down. Never raise your voice with the angry patient. A pause/short period of silence works really well too. Try to empathise by showing that you understand their anger but like you said, without sounding patronising. I find that recognising their anger helps "I can see that you are very frustrated/angry....", and then explore why they are angry. The point of the station is not so you can find a solution - it's more about how you handle this difficult situation by putting your communication skills to the test.

You sound like you know a lot just judging by the specific questions you've asked!! Have confidence in yourself is key! Good luck!!

4. It's worth knowing all the possible reasons behind clubbing and categorising by all the different systems! The most common cases I've seen on the wards are clubbing due to cyanotic heart disease/congenital heart disease, and as Ghotay said, bronchiectasis and fibrosis, which you may very well get on the day because these patients can be quite stable. I always used to mix this up: COPD and asthma are not causes of clubbing (lung malignancy is however and as smoking is a risk factor, that would need to be ruled out).

It's interesting you mention that specifically, because I was overhearing a nurse and a registrar talking just today about how the majority of the patients they've seen with clubbing actually had COPD. Which is interesting if you think about it. Other causes of clubbing are widely thought to be related to inadequate blood flow to the nail bed (simplification, the exact pathophysiology is not known), and COPD is common and causes hypoxia, so why wouldn't it cause clubbing? What's special about bronchiectasis, for example, compared to COPD? Physiologically it's not that different. Strange.

Anyone, OP just ignore this. For the purposes of your OSCE, COPD is not a cause of clubbing.

And noa dvice about angry patients sorry. My uni didn't have communication stations nearly as difficult as that

Ok thanks, yes thats a very good point about the isolated cranial nerve, I would have forgot to do it until now lol

...Bit weird but I find the TSR medic community to be more helpful than the older years I know hahaha...

I see you made a post saying medical school is too easy - did it get a lot harder in year 2? I am going to start at the same medical school as you next month