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123The Objective Structured Clinical Examination Review Mubashar Hussain Sherazi Elijah Dixon Editors

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

The Objective Structured Clinical Examination Review

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

Mubashar Hussain Sherazi Elijah Dixon Editors The Objective Structured Clinical Examination Review

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

Editors Mubashar Hussain Sherazi Mallacoota Medical Centre Mallacoota Victoria Australia Elijah Dixon Foothills Medical Centre Division of General Surgery University of Calgary Calgary Alberta Canada ISBN 978-3-319-95443-1 ISBN 978-3-319-95444-8 (e Book) https://doi. org/10. 1007/978-3-319-95444-8 Library of Congress Control Number: 2018961419 © Springer Nature Switzerland AG 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

To my affectionate and wonderful wife, Uzma, for her continued support throughout the writing of this book and within my whole life. To my lovely children, Moiz, Noor, and Muhammad, for their enduring inspiration and encouragement. Mubashar Hussain Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

vii Statement of Purpose The Objective Structured Clinical Examination Review consists of 16 chapters, and each chap-ter is a collection of important and common case scenarios for Objective Structured Clinical Examination (OSCE). The selection of case scenarios has been customized to make this book beneficial for a wide variety of audience preparing for OSCEs. Medical students can use this book as a study aid. This book will help candidates preparing for Medical Council of Canada Qualifying Examination II (MCCQE II), National Assessment Collaboration OSCE (NAC OSCE), United States Medical Licensing Examination Step 2 CS (USMLE Step 2 CS), Professional Linguistic Assessment Board (PLAB) Part 2, and the Australian Medical Council (AMC) Clinical Examination. Over the years, I took a number of assessments and OSCEs. I attended many preparation courses and read a number of OSCE books. I also have over a decade of clinical experience. The idea behind this book was to combine the clinical knowledge with the clinical experience about the OSCE.  My aim was to keep it concise and to the point. I have taken much care to keep the language very simple and easy to understand. You will feel that you are actually in the scenario and running it by yourself. Mnemonics and lengthy details have been avoided to make topics easy to go through. The history and physical examination patterns are explained in such a way that should be easy to memorize and follow. Photographs and tables are added for better understanding of various topics. In most of the stations, areas of difficulties and common pos-sible errors have been mentioned. For many stations, it is important to rule out red flags and important differential diagnosis. Red flags have been enlisted wherever required. Differential diagnoses are given in the start of each station. Specific instructions are also added in specific situations. Ending the station with wrap up is one important part of each station. Wrapping up for most of the stations has been explained in detail, and patient information has also been added throughout the book. Disclaimer It is important to mention here that The Objective Structured Clinical Examination Reviews should not be used as a textbook. It is recommended to use a recommended text or reference books for basic knowledge and understanding of the general topics. The Objective Structured Clinical Examination Reviews has not been officially endorsed by any medical college or aforementioned licensing and examination bodies. This book contains a number of important and high-yield topics, but does not cover all the possible topics and scenarios for OSCE.  Please follow your local and regional guidelines for emergency management plan and protocols. Checklists in the counseling stations and the clinical examination patterns are one possible way of going through these scenarios; one can customize these checklists accordingly to per-Preface

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

viii sonal ease and comfort. The authors and contributors of this book have tried their best not to disclose or copy any actual scenario or actual case discussion from any of the actual examina-tion. No name of any patient or doctor is thus used in this book in any scenario. Your suggestions and feedback are welcome at sherazimh@gmail. com. Mallacoota, VIC, Australia Mubashar Hussain Sherazi, BSc, MBBS, Licentiate Medical Council of Canada (LMCC), MRCGP (INT), Cert EM (Australia)Preface

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

ix Dr. Elijah Dixon for patronizing and his supervision throughout the writing of this book. Ms. Maureen K.  Pierce for her guidance and her continuous support, which made it easier for me to complete many topics. Special Thanks Special thanks to Dr. Pieter Nel (Director Emergency Department, Mackay Base Hospital, Mackay, QLD, Australia) and Dr. Neale Thornton (Deputy Director Emergency Department and Education Services, Mackay Base Hospital, Mackay, QLD, Australia) for their support. Photograph Contributors Many thanks to my colleagues and dear friends for their efforts and sincere participation dur-ing the photography sessions. I must mention their names here: Dr. Peter Latham (ICU registrar, Noosa Hospital, QLD, Australia) Dr. George Howell (ED Registrar, Mackay Base Hospital, QLD, Australia) Dr. Enyioma Anomelechi (ED Registrar, Noosa Hospital, Noosa, QLD, Australia) Dr. Jasmine Davis (GP registrar, Mackay Base Hospital, QLD, Australia) Reviewers Dr. Umair Khalid Pediatric Resident, Mackay Base Hospital, Mackay, QLD, Australia Chapters: General Surgery, Cardiovascular System, Genitourinary, Endocrine, Ethics and Geriatrics Dr. Michael Kwan General Surgeon, South Health Campus, Calgary, AB, Canada Chapter: General Surgery Jeremy Wiens, BSc N, RN, MN, NP Nurse Practitioner -General Surgery, South Health Campus, Calgary, AB, Canada Chapter: Respiratory System Dr. Uzma Bukhari, MBBS General Practitioner, Sahiwal, Pakistan Chapter: Gastrointestinal System and Skin Acknowledgments

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

x Mackenzie Whitfield B. Sc (Student) University of Victoria, BC, Canada Chapters: Musculoskeletal system, Respiratory system and Nervous system M.  Moiz Shah Bachelor of Business Administration (student), Mount Royal University, Calgary, AB, Canada Chapters: Introduction and Ethics Acknowledgments

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

xi 1 Objective Structured Clinical Examination Introduction................... 1 Mubashar Hussain Sherazi 2 The Nervous System ................................................. 13 Asif Hashmi and Mubashar Hussain Sherazi 3 Psychiatry ......................................................... 67 Mubashar Hussain Sherazi 4 The Cardiovascular System........................................... 111 Mubashar Hussain Sherazi 5 The Respiratory System.............................................. 131 Mubashar Hussain Sherazi 6 The Gastrointestinal System .......................................... 177 Mubashar Hussain Sherazi 7 Ethics ............................................................. 205 Mubashar Hussain Sherazi 8 The Genitourinary System............................................ 219 Mubashar Hussain Sherazi 9 General Surgery and Trauma ......................................... 245 Mubashar Hussain Sherazi 10 The Musculoskeletal System .......................................... 271 Majid Sajjadi Saravi and Mubashar Hussain Sherazi 11 Obstetrics and Gynecology............................................ 323 Mubashar Hussain Sherazi and Uzma Bukhari 12 Pediatrics .......................................................... 355 Umair Khalid and Mubashar Hussain Sherazi 13 The Endocrine System ............................................... 395 Mubashar Hussain Sherazi 14 Hematology ........................................................ 411 Mubashar Hussain Sherazi 15 Skin............................................................... 429 Mubashar Hussain Sherazi 16 Geriatrics.......................................................... 443 Mubashar Hussain Sherazi Index.................................................................. 457Contents

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

xiii Uzma Bukhari, MBBS General Practitioner, Sahiwal, Pakistan Asif Hashmi, MBBS, FCPS, DCN, MSc HSEduc Department of Medicine, Armed Forces Hospital, KANB, Jubail, Saudi Arabia Umair  Khalid, MD Child & Adolescent Unit, Mackay Base Hospital, Mackay, QLD, Australia Majid Sajjadi Saravi, MD Department of Family and Community Medicine, University of Toronto, Family Health Team, Southlake Regional Health Centre, Newmarket, ON, Canada Mubashar Hussain Sherazi, BSc, MBBS, Licentiate Medical Council of Canada (LMCC), MRCGP (INT), Cert EM (Australia) Mallacoota Medical Centre, Mallacoota, VIC, Australia Contributors

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

1 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_1Objective Structured Clinical Examination Introduction Mubashar Hussain Sherazi Introduction to the Objective Structured Clinical Examination Since it was described and published in 1975 by Harden and his colleagues, the objective structured clinical exami-nation (OSCE) has evolved into a modern testing tool for evaluation of the clinical skills of physicians and medical students [1 ]. The OSCE has been integrated into the licensing and evaluating examination systems of medical education and licensing authorities around the world. In Canada, two important examples of the OSCE are the final licensing exam of the Medical Council of Canada Qualifying Examination Part II (MCCQE II) and National Assessment Collaboration OSCE (NAC OSCE), which has become a mandatory requirement for most of the provisional licensing colleges for international medical graduates (IMG) applying for residency training through the Canadian Residency Matching Service (Ca RMS). Similar OSCE examinations are conducted by various colleges for interna-tional medical graduates for practice-ready assessments in Canada [2-4]. In the USA, the US Medical Licensing Examination Step 2 Clinical Skills (USMLE Step 2 CS) is one of the required licensing exams and is essentially an OSCE [5]. In the United Kingdom, the Professional and Linguistic Assessment Board (PLAB) Part II and Membership of Royal College of General Practitioners (MRCGP) clinical skill assessment also have a similar OSCE pattern [6, 7]. The Australian Medical Council Clinical Examination is an integrated multidisciplinary structured clinical assess-ment consisting of a 16-component multi-station assessment. It assesses clinical skills in medicine, surgery, obstetrics, gynecology, pediatrics, and psychiatry. It also assesses the ability to communicate with patients, their families, and other health workers [8]. The OSCE is also widely used all over the world as an important part of clinical clerks/medical students' evalua-tions in medical schools. The main advantage of the OSCE is its ability to assess candidates' multiple dimensions of clinical competences: History taking Physical examination Medical knowledge Interpersonal skills Communication skills Professionalism Data gathering/information collection Understanding about disease processes Evidence-based decision-making Primary care management/clinical management skills Patient-centered care Health promotion Disease prevention Safe and effective practice of medicine The OSCE uses standardized patients. The examiner either observes in person or the scenarios are recorded for the examiners to later watch the interaction between the candi-date and the standardized patients. The candidates will be assessed throughout the station from entering into the room till they finish the station and leave the room. What to Expect in OSCE? The OSCE consists of a circuit of a number of stations (10-14), each lasting 5-15 min. Please read and follow the guide-lines for your particular OSCE.  The candidates are required to rotate through each station. Each station starts with the station's information printed on a piece of paper (candidate's M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia1

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

2 information) placed on the door outside of the respective sta-tion. Candidates are given a few minutes to read and prepare notes before entering each station. Candidates are expected to perform one of the following or in some stations more than one: Obtain a focused or detailed history. Focused or detailed physical examination. Assess and address the patient's issues. Answer specific questions related to the patient. Interpret X-rays, electrocardiograms (ECGs), blood gases, or the results of other investigations. Make a diagnosis. Write admission orders. These examinations include problems mostly in [2]: -Medicine -Pediatrics -Obstetrics and gynecology -Preventive medicine and community health -Psychiatry -Surgery -Musculoskeletal system Each station has an examiner and a simulated patient trained for the particular scenario. The examiner assesses the candidate's skills on a standardized checklist provided by the examining body. How to Prepare? The OSCE is best prepared by joining a study group or with at least 2-3 study partners. Study groups for the OSCE are invaluable. I remember, when I was prepar-ing for an OSCE in Canada, we use to study twice a week for 4-5  h each day and then practice scenarios once a week. Proper feedback and criticisms are also crucial while practic-ing OSCE scenarios. Some people feel comfortable to do counseling and history taking on video calls, and they prac-tice mostly on these. Each member can also contribute in making common presentations that they know well and then they can challenge the rest of the group with these. Then the group can also discuss and assess each other. Make a Study Plan It is important to make a study plan well ahead of the exami-nation day. Some people prepare for about 6  months, 2-3 months of just individual studying and the rest practic-ing in a study group. It varies individually, depending on your clinical training, practice experience, clinical knowl-edge, and understanding of the particular OSCE. Identifying the objectives that you think you need the most to study is vital. Focus on common and critical patient presentations. Making a list of the most important differen-tial diagnoses, creating checklists, and asking the most rele-vant questions in a limited time frame are crucial for time management. While practicing, if you think that you are not doing well on a certain topic, then simply spend more time on it and discuss it in your study group. Develop Your Interview Skills This is one of the most important components of any OSCE.  Clinical knowledge, fluency and grasp of the English language, and practicing before the actual exam are key components of developing interview skills. In the OSCE there is a finite amount of information that one needs to know to get through the exam. It is all about prioritization and stra-tegic thinking. So in any situation, you must remember what checklists or key questions are important and not to be missed. Are There Books and Courses About the OSCE? For many OSCE exams, there are not many recommended books or specific reference materials. You can still find rec-ommendations about OSCE study guides in various online study groups and from doctors who have already taken these OSCEs. There are no approved preparatory courses. Some medical faculties offer programs. Some candidates find these courses very helpful, and some do not. In most of these courses, I think you will have an opportunity to become familiar with the OSCE pattern and format. Day of Examination Some general tips for your day of OSCE: Make sure you get enough sleep before the examination day and you are well rested. Examination anxiety is your biggest enemy, so try to remain cool and calm. Avoid preparing up to the last minute. I recommend you finish your study and practice about 24 h before the exam. Be confident and do your best. Do not use a sedative the night before. Set multiple alarms and ask someone to check on you to make sure that you wake up on time. Give yourself ample time to get ready for the examination. If your examina-tion is in the morning, make sure you have a good break-fast. If your examination is in the afternoon, then have a good lunch but not too much. If you are in the habit of drinking coffee or tea, do have one as per your normal routine. Dress well, business formal dress code. I personally like a suit and tie with an appropriately matched shirt, belt, and shoes. The most important fact about clothing is to always try wearing your expected attire before examination day. Check for size, comfort, stains, or difficult to remove M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

3 wrinkles. Try not to wear expensive watches or jewelry. Many OSCEs instruct candidates not to wear any per-fumes; make sure you follow the instructions. For female colleagues, try to avoid extensive makeup, high heels, sandals, facial piercing, or strange hairstyles. What to Bring to the OSCE? A stethoscope (nonelectronic) A reflex hammer A plain white lab coat without a university or hospital crest (check size and fitting before the exam) Registration and Orientation Follow the examination instructions. Arrive on time and bring any necessary documentation such as a government- issued identification (ID) or admission card. Your personal belongings such as keys, papers, wallets, cell phones, as well as coats will be collected. So try to bring minimum stuff with you to the examination center. These items will be stored until after the examination. Get your identification badge, stickers, and in most of the examinations a small notebook will be provided. You can write notes while taking the examination. Only one note-book will be provided, and no pages can be added. The notes in the notebook will not be scored. This notebook must be returned intact at sign-out. No pages or parts can be torn or ripped out. Exam Security Once the examination starts, candidates are not permitted to talk to other candidates. There should not be any access to any communication devices. Some OSCEs will not permit you to wear watches of any kind during the examination. You can time yourself with clocks placed in each room. How to Begin Y our OSCE Station? Finally, you are in your OSCE exam. You are standing in front of the first station with your back toward the door with the first station stem pasted on it. You are hearing the instruc-tions and countdown to start the first station. This is the time to run a quick checklist: Take few deep breaths and make yourself relax. Is your exam ID badge attached well on your pocket? Is your pencil ready to write? Have you prepared a new sheet on your notebook? Do you have stickers ready for the station? Have you secured the rest of the stickers for the next sta-tions in your lab coat? Is your stethoscope and hammer properly placed in your pockets?The bell will ring, and you will be asked to turn to the door and then read the stem (Box 1. 1). The exam will start. READ THE INSTRUCTIONS CAREFULLY. What to remember/write on your notebook from the stem on the door of station? Patient name and age Chief complaint Purpose of visit Setting (clinic or emergency room) Also if patient was brought by someone else What is the station asking for: history only or history and physical examination or history and counseling or physi-cal examination only I will break down the patient information like this (Box 1. 2). How to Plan? After reading the stem, ask yourself: Which system is involved? Formulate ~3 differential diagnosis. What are three to four important relevant questions that MUST be asked to rule out the differentials? Any mnemonics or words you want to go through during the station. Quickly review some important questions or sequence you want to use (Box 1. 3). Box 1. 1 Candidate Information/Doorway Information A 35-year-old female, Miss XYZ, presented in your clinic with low mood. Obtain a detailed history and address her concerns. Box 1. 2 Make a Plan in Your Mind A 35-year-old female, Miss XYZ, presented in your clinic with low mood. Obtain a detailed history and address her concerns. Box 1. 3 What to Write in Your Notebook Miss. XYZ Age: 35 History and concerns Setting: clinic Low Mood Depression (mnemonic for screening or questions) 1 Objective Structured Clinical Examination Introduction

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

4 Take a deep breath and tell yourself: “I am ready and I will do this well. ” The bell will ring or you will be asked to move to your first station. Starting the Interview: Knock on the door. Go into the room with a smile and confi-dent face. In some of the OSCE, it is required by the candidates to give two name/exam registration number stickers/labels to the examiner before starting the interview. Greet the exam-iner and hand over the required stickers. The next thing will be hand-wash or alcohol rub. It is very important for physical examination stations. If using a hand sanitizer, then try not to put too much on your hands. Try to rub it into the palms quickly. Make sure your hands are dry if a patient offers a handshake. If you forget to clean your hands at the start, but remember while starting a physical examination, then ask for sanitizer if you cannot find it or wash your hands. Patient Interaction Greet and introduce yourself and state your role/position in the patient's evaluation. Confirm the ID of the patient by ask-ing for the patient's name and age. You can have a quick peek at your page and read the patient's name again before asking. Ask the patient how he or she wants to be addressed? As the history questions start, confirm the source and reliability of the historian. Mention the purpose for the visit. Explain to the patient whether you will be taking an inter-view or will be doing a physical examination or both. Example Opening the Interview There are many ways to open the discussion/interview. Here are a few examples for the opening lines. It can be modified according to the station requirements and for adequate time management. History Station “Good morning/good afternoon. I am Dr..... I am your attending physician for today. Are you Mr. /Mrs. /Miss... ? Are you... years old?”Pattern 1: In some stations, the stem information might not have a chief complaint, or sometimes there are more than one presenting complaints. If you are not sure how to start, in these situa-tions, the best way to open up the conversation is: “What brings you to the hospital/clinic today?” (It is very important to remember in which setting you are examining the patient. ) Or “How can I help you today?” Then allow the patient to talk and listen carefully. The patient will speak about the chief complaint and some vital information about the history of the present illness. The patient may tell about the purpose of the visit or any concern. During this time, one should formulate and rearrange the list of questions and differentials. Before asking further questions about the details of the chief complaint, I like to ask the patient: “Is it alright if I ask you some questions about it? At the end we will discuss about the treatment plan and if you have any questions or concerns, please feel free to ask during the discussion. ” Pattern 2: If the chief complaint is obvious from the stem, then the usual start should be, for example: History and Physical Examination Stations: “Good morning/good afternoon. I am Dr..... I am your attending physician for today. Are you Mr. /Mrs. /Miss... ? And you are... years old? “I understand you are here because of... ” “Is it alright if I ask you a few questions? I would also like to do a relevant physical examination of.... In the end, we will discuss about the management plan. ” “During the history or examination, if you have any ques-tions or you feel any discomfort, please let me know. ” For examination stations, have a look around the room. What tools are available? If any tools are there, it is likely that the examiner wants you to use these. History and Counseling Stations: “Good morning/good afternoon, I am Dr..... I am your attend-ing physician for today. Are you Mr. /Mrs. /Miss... ? And you are... years old? I understand you are here because of..... Is it alright if I ask you some questions about it? Then in the end, we will discuss about the management plans and will also dis-cuss if you have any concerns. Do you have any questions?” If a Patient Asks a Question or Expresses Some Concern Before the Interview Starts: The interview should always start with an open-ended ques-tion. Sometimes the patient may ask a question or reveals Abuse Hypothyroid Don't Forget Safety check Drug History Contract to contact M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

5 some concern in the start. In this situation, that concern or question should be addressed first before exploring the his-tory of present illness. Example: Station: Patient with Fatigue. The patient may ask, “Doc, why I am so tired these days?” This question/con-cern must be addressed before asking any other question. One way of responding to this question is, “I understand you are here because of fatigue. As I am seeing you for the first time, let me ask you a few questions and let's sort out why you have this fatigue and then we can deal with it accordingly. ” How to Build Rapport with the Patients? Building a good patient rapport is one of the important steps that will determine the overall outcomes of your interaction with this patient. Following are a few tips that can help you make a quick and better rapport with the patients. Know Your Patient: The patient's interview starts when you start the introduction, asking patient name, ID, and age. Then ask, “Mr. /Miss... how would you like me to address you?” This one question can help during the rest of the inter-view in making the patient comfortable and relieving anxiety about seeing a new doctor. Calmness: We must try our best to be in control of the com-munication, remain calm, and look competent and confident. Empathy: We should be able to empathize with our patients. We must use sentences such as, “It must be hard for you” or “It must be a frightening experience!” These will make good bridges. Communication is another integral component of a good doctor-patient relationship. Communication skills help us to understand a patient's needs, concerns, and thoughts. You will be able to find hidden agendas. In almost all the OSCE stations, your communication skills will be assessed. But in some stations, communication skills will be the main skill that will be assessed by the examiner. The key components of OSCE where communication skills are considered to be important are: Getting informed consent Decision-making stations Breaking bad news Dealing with anxious patients or relatives Communicating with family members and relatives Describing and explaining diagnosis, investigation, and treatment Giving advice on lifestyle, health promotion, or risk factors Communicating with other healthcare professionals Giving instructions on discharge Communicate Well: Effective communication between a doctor and a patient is the keystone of establishing a trustful relationship. It is important to analyze if the patient is under-standing the questions and giving relevant answers. Be a good listener. You must listen carefully while the patient is describing the concerns. You should assess and respond accordingly to verbal and nonverbal body language. Keep good eye contact, respond with appropriate facial expres-sions, and respond to the patient's verbal and nonverbal cues during the interview. Anticipate Their Concerns: Try to address the patient's concerns. This will express that you care and you want to provide the best possible care to the patient. Educate: A doctor should also be a scholar. As stated by the Royal College of Physicians and Surgeons of Canada, “As scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others” [9]. Patients want us to educate them regarding their disease or health issues, and they want to know about the treatment plans. It is important to counsel patient about their diagno-ses and treatment plans. Besides having a discussion, we can offer reading material, websites, and community resources. Follow-Up: To build a long-term relationship with the patient, it is essential to make an appropriate follow-up plan with the patient. It will show that you care. How to Conduct a Good Interview? A good interviewer should have the following approach: Be professional. Mature. Be positive. Be polite. Be understanding. Express or offer support. 1 Objective Structured Clinical Examination Introduction

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

6 Show respect. Not being judgmental in approach. Patient-centered approach. Maintains and offers confidentiality. Not be assertive, dominating, or use sarcastic language. Maintain good communication skills. Ready to educate patient. Avoid medical jargon. Willingness to discuss patient concerns. Take care of patient comfort. Show empathy and support. Be a good listener and avoid unnecessary interruption. Controls temper in difficult situations. Respects and interacts positively with colleagues. Details of History Taking Quick Recap: First step was to read and analyze the candidate information. Second step was starting the interview: Knock on the door. Enter the station. Hand-wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner if required or show your ID badge. Now sit on the chair or stand on the right side of the patient and start the interview. Third step: Opening: “Good morning/good afternoon. I am Dr..... I am your attending physician for today. Are you Mr..... And are you... years old?” Fourth step: Start with the chief complaint and continue with the rest of the history: Chief complaint: It is the presenting complaint in the patient's own words. History of present illness: If following pattern 1 (already mentioned), then the interview has already started. While listening carefully, the patient will give initial information. The patient will provide important information, and while listening you should tailor your next questions. Please do not interrupt the patient unless the patient starts talking about something that is not clearly related to the presenting or chief complaint. If following pattern 2, then the first question should be asked regarding the chief complaint, and usually it is about its ONSET.  The first three questions usually related to the chief complaint are its onset, course, and duration. At times the patient may have given answers for these three questions in his/her initial statement. If not, then you can start with onset. Onset: “How did it start?” “Did it start suddenly or gradually?” Course: “Did it change since it started or has it stayed the same?” “Was it present all the time? Or does it come and go?” Setting: “What were you doing when it started?” Duration: “When did it start? How long have you been feeling sad/ tired/fatigued/anxious?” Character: “Can you please explain it more?” Frequency: “How often does this happen?” Timings: “Any particular timings?” Events Associated: “Can you please tell me, is there any particular event that has triggered your symptoms?” Relevant Associated Symptoms: “Did you notice... (name any other symptoms of the same systems or from other systems that may coexist)?” Can also ask here about fever, chills, or weight loss. Relieving Factors: “Does anything relieve the symptoms?” Precipitating Factors or Aggravating Factors: “Does anything aggravate the symptoms?” Functional status or severity or impact on life activities? Rule Out: Differentials How to Interrupt the Patient if Going Off Track While Giving History: “Excuse me, Mr. /Mrs. /Miss.... I understand that these are important issues, but I would like to ask some additional M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

7 questions of your current problem so we can come to a man-agement plan. ” Review of Systems: It can be done at the end of the present illness questions: Gastrointestinal tract: Nausea, vomiting, diarrhea, constipation, change in bowel habits, acid reflux, appe-tite, blood in vomiting or bowel movements, and jaundice Respiratory: Cough, wheeze, sputum, hemoptysis, and chest pain Genitourinary: Hematuria, change in color of urine, dys-uria, polyuria, change in frequency of urine, nocturia, and anuria Cardiovascular: Chest pain, palpitations, dyspnea, syn-cope, orthopnea, and peripheral edema Neurology: Problems with vision, headache, motor or sensory loss, loss of consciousness, and confusion Constitutional Symptoms: Fatigue and malaise, night sweat, fever, and weight loss. Risk Factors Past Medical and Surgical History: “Any medical and surgical illnesses?” “Do you have any previous health issues?” “Do you have any health issues related to your lung, heart, or kidney?” “Previous blood transfusion?” “Have you had any previous hospitalization or previous surgery?” “Emergency admission history?” Medication History: “Are you taking any medication pre-scribed, over the counter or herbal? If so, have there been any side effects?” Allergic History: “Do you have any known allergies?” Past Psychiatry History: Previous psychiatric illness, diagnosis, treatments, and hospitalizations. Social History: “Do you smoke? Or does anyone else in your home or close at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specially ask about intravenous (IV) drug use. Foreign Travel: “Any recent travel?”Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Family History: “Now I am going to ask some questions about your family. ” “How is your family like?” Relationship with the family members? Any mental illnesses present/past, alcohol, drugs, crimi-nal, suicidal attempts? “Do you have family members or friends to discuss your problems?” Personal History: “Please tell me about yourself. ” (Can be asked in any sequence, marital status, occupation, and religion) “Do you have problems at work? How are you doing at work?” “Do you have any recent event in the family such as an accident or someone died?” Self-Care and Living Condition: “What do you do for liv-ing? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. If the patient is a child, add questions about BINDES (birth history, immunizations, nutrition, development, envi-ronment, and social) here: Birth History: Birth history includes prenatal, natal, and postnatal histories. You need to tailor the prenatal, natal, and postnatal questions according to context. If the birth history is not relevant to the presentation of the child, then one general question will be sufficient such as “Any issues with the pregnancy/birth of the child?” Prenatal: -“Was it a planned pregnancy?” -“Did you have any regular follow-up?” -“Did you have any ultrasound scans? Was it normal or not?” -“During your pregnancy did you have any fevers or skin rash?” -“Any contact with sick person or cats?” -“Any medication, smoking, drugs, or alcohol?” -“Screened for human immunodeficiency virus (HIV), syphilis, group B strep (GBS), hepatitis B? Blood group?” Natal (Delivery): -“Term baby or not?” 1 Objective Structured Clinical Examination Introduction

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8 -“What was the route?” C-section (C/S), spontaneous vaginal delivery (SVD), or assisted vacuum delivery (A VD) -“How long was the labor/delivery?” (18 h is normal for primi, 12 h for multipara) -“Early gush of water?” (premature rupture of membranes) -“Any need for augmentation/induction?” -“What was the Apgar score?” (1 and 5 min) -“Did the baby cry immediately?” -“Did your baby need any special attention/admission to special care?” -“Any bulging or bruising on baby's body?” -“When were you sent home?” (C/S 3  days, SVD 1 day). -“After delivery did you have any fever, vaginal dis-charge, or on any medication?” -“Were you told that your baby had any congenital deformity?” Natal (Birth): -Vaginal or CS -Spontaneous or assisted labor (i. e., forceps delivery) -Premature rupture of membranes (PROM) or fever -Baby: full term/preterm, weight at birth, Apgar score if known -Did the child need any resuscitation at birth? Postnatal or Newborn Period: -Mom: fever, bleeding, or any other complication -Baby: jaundice, screening tests, congenital anomalies, suckling, and weight gain Immunization If the parent states that the child is not immunized, you need to inquire for the reason. If the child is not vaccinated due to a reason that points toward neglect, then look for child abuse red flags. Inquire further about weight gain and develop-mental milestones. If it is due to religious beliefs, you do not have to inquire further. Otherwise, move on to nutrition. Nutrition: Mom's medications Complications during pregnancy such as diabetes, bleed-ing, or hypertension Multiple pregnancies Infections such as TORCH -Toxoplasmosis, Other (syphilis, varicella zoster, parvovirus B19), Rubella, Cytomegalovirus, Herpes Mom's age Planned or unplanned pregnancy Weight: -What is the current weight -Birth weight -Maximum weight Is the child breast fed? Or bottle fed? -Frequency, amount, supplement, formula fortified, weaning If formula, then ask about type/brand. Growth charts (height, weight, head circumference) Feeding: -Formula: -“When did you start the formula?” -“Was baby ever breast fed?” If yes, then ask, “Why stopped?” -“Did you consider breast feeding?” -“What type of formula do you use?” -“Has there been any change in the feeding? Did you add any solid food or supplements (any fortified serials or iron)?” If any diarrhea, when did it start (before the solid food or after)? Development History: Gross motor, fine motor, vision, hearing/speech, and social Are they developing according to their milestones? For example: -Six months: head control, grasp a toy, generalized reactions, smiles, and babbles -Eighteen months: sitting without support; walking/ running, good fine motor control (swapping objects/ turning pages); 1-15 words and has self-awareness -Thirty months: jump, go up/down stairs without assis-tance, symbolic thought Are they growing along growth centiles? How do they compare to their siblings? Any comments from their teachers at school or daycare? Environment: “With whom does the child live at home?” “Any other children?” “Relation between your child and others?” “Who spends most of the time with the child?” “Financially how do you support yourself?” “Do you live in your own house?” “Does anyone at home drink or use drugs?” Building -basement (mold) Old houses (lead poisoning) Children attending school: -School performance: comparing the grades between now and previous If the patient is a teenager, then add these questions here: Home: “How is your living like?” “Who lives with you?” M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

9 “Are your parents married, divorced, or separated?” “How long you have been living in your current resi-dence? What does your parent do for work?” Education: “Which grade you are in?” “What school do you go to?” “How are your grades?” “Do you like going to school?” “Have you made any future plans in studies?” Employment: “Are you currently working?” “What kind of work do you do?” “How many hours in a week?” “Future career aspirations?” Activities: “Do you have friends?” “Do you have a best friend?” “What do you do outside of school?” “Any hobbies?” Alcohol: “People your age sometimes have problems with exces-sive drinking. Do you ever have such problems?” “Do your friends bring alcohol to the parties you attend?” Diet: “People your age sometimes they have concerns about their body weight, shape, and image? Do you ever have such concerns?” Drugs: “People your age sometimes experiment with street drugs. Have you ever tried street drugs?” “Do your friends experiment with street drugs or bring any drugs to school or parties?” Sexual Activity: “Are you in a relationship? Are you sexually active?” “Some people your age are uncertain about their sexual orientation. Do you have any concern about it?” “Do you know about sexual or physical abuse? Have you ever experienced or had any event that is concerning?” Suicide: “Have you ever thought about harming or killing yourself or others?” “Any current plans?” “Any previous attempts?” If the patient is more than 65 years old, add these ques-tions here:Activities of Daily Living (ADLs): Walking: Getting around the home or outside. Also labeled as ambulating. Transferring: Being able to move from one body posi-tion to another. This includes being able to move from a bed to a chair or into a wheelchair. Dressing and grooming: Selecting clothes, putting them on, and managing one's personal appearance. Feeding: Being able to get food from a plate into one's mouth. Bathing: Washing one's face and body in the bath or shower. Toileting: Getting to and from the toilet, using it appro-priately, and cleaning oneself. Instrumental Activities of Daily Living (IADLs) Finances: Such as paying bills and managing financial assets. Transportation: Driving or by organizing other means of transport. Shopping and meal preparation: Getting a meal on the table. It includes shopping for clothing and other items required for daily life. Housecleaning: Cleaning kitchens after eating and keep-ing one's living space clean and tidy. Keeping up with home maintenance. Communication: Using telephone and mail. Medications: Obtaining medications and taking them as required. Any problem with balance? Any difficulty in peeing/urination? Any issues with sleeping? Any change in vision/hearing? Any recent change in memory? Wrap Up: Describe the diagnosis. Management plan. Laboratory tests. Possible medical treatment. Duration of treatment and side effects. Further information: websites/brochures/support groups or societies/toll-free numbers. Follow-up. Contract for safety. Tips for a Good Physical Examination The details of different physical examinations will be dis-cussed later in different chapters. There will be at least one but most of the time two or up to three examination stations in the OSCE.  You will be asked to actually examine a simu-1 Objective Structured Clinical Examination Introduction

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

10 lated patient. Some patients may have positive signs, and it is very important to pick up these signs during the examination. Here are few tips to improve your physical examination skills: Practice, practice, and practice before the actual examination. An important thing to practice is explaining and taking consent from a patient about a particular examination. You should be able to answer and describe: Who are you? What examination will you be doing? And why are you doing this examination? Proper draping and appropriate positioning. Taking care of the patient's comfort throughout the examination. Practice well all the major systems and joints (back, hip, knee, foot, shoulder, hand, elbow). There are great videos on physical examinations online; use these as guides and quick references. It is recom-mended to watch these videos multiple times; it will add to your memory and quick reviewing. Try to time yourself with a stopwatch and assess how much time you are requiring to complete an examination and how much time you will actually have in the real examination. Then try to practice in time mode and improve your timings for each examination. Organize yourself and opt for a systematic approach to save time, for example, in the general physical examina-tion, always start from the hand, check the pulse and blood pressure; face; neck; chest; and so on. Do not carry out genital, breast, or rectal examinations. Even in the scenario, if you need to do a particular exam, just mention it and the examiner will give you the findings or will say it is normal. If an oral question is required, then it is better to ask the examiner instead of the patient. Recognize the manifestations of a disease and then apply your knowledge to look for specific signs of disease manifestations. For example, in acute appendicitis, feel for right iliac fossa tenderness and rebound tenderness. Navigating Through the Stations During the Examination In the orientation session, you will be told about navigating through the examination. Usually signs will be posted to help you navigate the exam. There are staff members who can also show you which way will be your next station. Sometimes there will be a rest station. The most important thing not to do in the rest station will be thinking about the previous stations. Try to relax, drink some water, check your tie knot, check your labels, check your tools, and be ready for the next station. If you finish the patient encounter early, you must wait quietly. If you remember something more that you would like to do, you may re-engage the patient at any time until the final signal/announcement -except in stations with oral questions. A set amount of time is allowed for moving to the next station and for reading the posted instructions. During this time, remove the bar code identification label from the sheet, to have it ready to give to the examiner. At the sound of the signal, enter the room and proceed with the required task. Document Writing Candidate Information: You have been working as a resident in general surgery. You have just attended a patient with acute diverticulitis, acute appendicitis, or acute cholecystitis. Please write admission notes. Or a patient presents with abdominal pain (RUQ, RLQ, or LLQ), please take a brief history and write admis-sion notes. The history should be very clear to direct you to a diag-nosis, and the examiner may give you positive examination findings or an imaging report, for example, a computed tomography (CT) scan of the abdomen confirming a diagnosis. Starting the Scenario: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner if required or show your ID badge. Sit on the chair or stand on the right side of the patient and start the interview. Abdominal pain scenarios have been discussed in detail in Chap. 9 on general surgery. Here we shall only focus on admission note or order writing [10]. You will be given a pencil or pen and a blank piece of paper on which you will write the admission note for one of the aforementioned scenarios (see Table 1. 1). M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

11 Neck: Respirator y system: Cardiovascular : Abdomen: Neurolo gy: Labs o rdered: Imaging results/ordered : ASSESSMENT/IMPRESSION: Abdominal pain due to...... PLAN: Adm it to General Surgery under Dr...... NPO apart from meds IV fluid: D5 0. 5% NS at 125 ml/hr x 2 L EKG Urine C+ S Morphine 2 mg IV q 2-4 hr PRN pain CT abdomen and pelvis with contras t GI consul t Signature: Dr...... Time and date Table 1. 1 An example of how to write an admission note DATE: CHIEF COMPLAIN T: Abdominal pain........ hours/da ys/months History of present illness : Site Onse t Course Duratio n Characte r Radiation Alleviating factors Exacerbating factors Severit y Similar pain befor e Nausea Vomiting Diarrhe a Constipation Loss of appetite Black/blood y stool s Sick contacts, Suspicious food consumed Feve r/chills, SOB, Chest pain, Headache Dysuria Past medical history: Past surgical history: Medications: Allergy: Family history: Social history: PHYSICAL EXAMINATION: Vitals: General ph ysical examination: HEENT:Admission Orders: Acute Diverticulitis Now let us write an admission orders for a patient with diver-ticulitis (Table 1. 2). How to Fail the OSCE? There are more ways to fail than to pass the OSCE.  Some are listed here: Poor performance through the station Poor organization Inadequate history taking -miss asking about important parts of history Inadequate knowledge Could not address patient concerns and problems Interrupting patient Arguing with the patient Giving patient misinformation Poor communication skills Inadequate physical examination Unprofessional behavior 1 Objective Structured Clinical Examination Introduction

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12 Inability to counsel the patient properly Putting patient at harm or risk Wasted too much time on history and missed most of the physical examination Missing valuable information Poor professional judgment Looked nervous and rushed through Best of luck for your OSCE. References 1. Harden RM, Stevenson M, Downie WW, Wilson GM.  Assessment of clinical competence using objective structured examination. Br Med J. 1975;1:447. https://www. bmj. com/content/1/5955/447. Accessed 2 Apr 2018 2. Medical Council of Canada Qualifying Examination Part II. http:// mcc. ca/examinations/mccqe-part-ii/. Accessed 2 Apr 2018. 3. Medical Council of Canada. National assessment collaboration examination. http://mcc. ca/examinations/nac-overview/. Accessed 2 Apr 2018. 4. Medical Council of Canada. Practice-ready assessment. http://mcc. ca/projects-collaborations/practice-ready-assessment/. Accessed 2 Apr 2018. 5. USMLE Step 2 CS. http://www. usmle. org/step-2-cs/. Accessed 2 Apr 2018. 6. General Medical Council. What is the PLAB 1 exam? https://www. gmc-uk. org/doctors/plab/23453. asp. Accessed 2 Apr 2018. 7. Membership of Royal College of General Practitioners. MRCGP Clinical Skills Assessment (CSA). http://www. rcgp. org. uk/train-ing-exams/mrcgp-exams-overview/mrcgp-clinical-skills-assess-ment-csa. aspx Accessed 2 Apr 2018. 8. Australian Medical Council Limited. AMC clinical examination. https://www. amc. org. au/assessment/clinical-exam. Accessed 2 Apr 2018. 9. Royal College of Physicians and Surgeons of Canada. Scholar definition. http://www. royalcollege. ca/rcsite/canmeds/framework/ canmeds-role-scholar-e. Accessed 2 Apr 2018. 10. Wiprud R.  Improving patient care. 30 standardized hospital admis-sion orders. Fam Pract Manag. 2001;8(9):49-51. https://www. aafp. org/fpm/2001/1000/p49. html Patient Name: Date: Age: Adm it to: General Su rgery Diagnosis: Acute diverticulitis Condition: Stable Vital signs: Stable Allergies: Diet: Nothing to eat and drink, beside oral medicatio n Nursing: Daily weig hts and intake and output Activity: as tolerated Labs: CBC, Electroly te, urea, creatinine, CR P in the morning. Imaging: CT abdom en and pelvis with contrast IV: NS 1L at 125 ml/h Medication: Metronidaz ole 500mg IV BID (check with y our hospital guidelines) Ceftriaxone 1G IV daily Morphine 5 mg IV q 2-4 hr PRN pain Paracetamol 1000mg q 6 h prn for pain or feve r Signed: dated and time Position and Name of doctor Table 1. 2 Admission orders for diverticulitis M. H. Sherazi

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13 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_2The Nervous System Asif Hashmi and Mubashar Hussain Sherazi History Overview: The Nervous System In an objective structured clinical examination (OSCE), one can expect to have at least one station from the nervous sys-tem. Usually it is a history taking with physical examination station. One can also expect to be asked to perform a detailed examination only. Commonly asked tasks are cranial nerve examination, motor/sensory system examination, or cerebel-lar system examination. In these stations it is important to analyze the doorway information to customize the physical examination. It will be difficult to complete all the steps of a particular nervous system examination in a limited time frame. A lot of practice is required before the examination to complete these stations in the given time. For a history and physical examination station, only the most important and relevant questions should be asked, and sufficient time should be allocated to the physical examination and for a wrap-up in the end. This chapter outlines common nervous system-related topics important for the OSCE.  See Table  2. 1 for an over-view of the pattern of history taking required for nervous system stations. The nervous system examination does need some gadgets such as a hammer, a measuring tape, cotton wool, a pin, and a tuning fork. Please check with your examination guidelines if these will be provided in the examination room, or you may need to bring these. If you will be bringing your own gadgets, then make sure to take these with you after finishing each examination. Common Nervous System Symptoms for the Objective Structured Clinical Examination Common presenting symptoms are: Headache Seizure Tremor Vertigo Hearing loss Weakness or sensory/motor loss Confusion Delirium Depressed level of consciousness Falls Head injury Detailed History: Nervous System History is the most important component of the nervous sys-tem evaluation. In many neurologic patients with symptoms such as headache and seizures, the physical examination may be unremarkable, and the clinical assessment almost entirely depends upon the history. A detailed nervous system history allows the physician to answer the following questions: 1. Where is the likely lesion in the nervous system? 2. What could be the possible nature of this lesion? 3. Can the patient's clinical condition be explained by a neu-rological lesion at a single location, or is there more than one lesion? 4. Is the patient's problem limited to neurology only or a systemic cause that needs to be elucidated?A. Hashmi ( *) Department of Medicine, Armed Forces Hospital, KANB, Jubail, Saudi Arabia M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia2

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

14 5. What physical signs should be looked for in a particular patient? A focused history will determine the appropriate nervous system examination of the relevant part of the nervous system. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID). Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician for today. Are you Mr. /Mrs....? And you are... years old?” Chief Complaint Chief complaint or the reason the patient is visiting the clinic. “What brings you in today?” History of Present Illness Take the history from the patient. Information may be required from family members or other witnesses, if necessary. Table 2. 1 Quick review of history taking of the nervous system Introduction Confirm patient (ID) name and age Chief complaint In the patient's own words History of present illness Analysis of the chief complaint: Onset -sudden or gradual Nature of progression -slow, rapid, continuous, or intermittent Duration Associated factors Symptoms related to the same system Symptoms related to adjacent systems Constitutional symptoms Predisposing, aggravating, and relieving factors Red flags/risk factors Impact on body Constitutional symptoms Rule out differential diagnosis Handedness Review of systems Cardiovascular Respiratory Gastrointestinal Genitourinary Past medical and surgical history Medical illnesses Any previous or recent surgeries Hospitalization history or emergency admission history Medication history Current medications (prescribed, over the counter, and any herbals) Allergic history/triggers Family history Family history of same symptoms Family history of any long-term or specific medical illness Any long-term diseases Home situation -who do you live with? Personal history (Only if relevant to the stem) Birth history Early childhood to adolescence Adulthood Onset of the illness Any diagnosis Occupation history How do you support yourself? Social history Smoking Alcohol Street drugs Sexual history (M/F/both) Educational Vocational If adult female: Menstrual history (LMP) Gynecology history Obstetrics history Table 2. 1 (continued) If teen: Home Education Employment Activities Drugs Sexual activity If child: Birth history Immunization Nutrition Development Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Red flags Laboratory tests Further information websites/brochures/support groups or societies/toll free numbers Follow-up A. Hashmi and M. H. Sherazi

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15 Ask for handedness -right or left. Right-handed individu-als have a left-dominant hemisphere, and most of the left- handed (over two-thirds) patients may also have a dominant hemisphere on the left side. Discern the main complaint of the patient. A simple ques-tion “what brings you to my clinic today?” may prompt the patient to provide relevant information. Listen carefully to the patient, and then ask pertinent ques-tions to find the specific details of this “main” complaint. 1. If the main problem is progressive, e. g., motor weakness or sensory deficit: Onset -sudden or gradual Nature of progression -slow, rapid, continuous, intermittent Evolution to and a period at maximum deficit Continuing progression or recovery to present state 2. If the main problem is recurrent with discrete events, e. g., fits: Time of first episode Pattern of events over time; is there any clustering (cluster headache, trigeminal neuralgia) Rate of recurrence -maximum number of attacks in a given time Longest attack-free interval Description of a typical attack Relation to activity and posture Condition between attacks Date of last event Factors precipitating, aggravating, or alleviating the episodes 3. If the main problem is intermittent and fluctuating, e. g., headache: Establish that all events are more or less the same. Frequency and distribution of attacks over time. Details of individual events. Factors precipitating, aggravating, or alleviating the episodes. 4. If the main problem is pain: Intensity and severity of pain (on a scale of 10) Quality of pain If pain is present, then ask pain questions: Onset Course Duration Progression Quality of pain (burning, throbbing, dull) Radiation Severity (scale of 1-10) Timing (time of the day) Pain before Point of most painful spot Aggravating Alleviating Associated symptoms Constitutional Symptoms: Fatigue and malaise, night sweats, fever, weight loss Review of the Systems: Especially those that may be related to the main complaint Past Medical History: “Have you had any previous health issues?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries?” Medication History: “Are you taking any medication pre-scribed, over the counter, or herbal? If so, have there been any side effects?” If the patient says no, continue to the next question. Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specially ask about intrave-nous (IV) drug use (red flag for back pain). Family History: Marital status, number of children, any significant history in first-degree relatives Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for liv-ing? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional Status or severity or impact on life activities. If teenager, then add these questions: Home, education, employment, activities, drugs, and sexual activity 2 The Nervous System

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16 If adult female, add these questions: Menstrual history (LMP), gynecology history, and obstetric history If the patient is more than 65 years old, add these questions: “Any problem with balance?” “Any difficulty with peeing/urination?” “Any issues sleeping?” “Any change in vision/hearing?” “Any recent change in memory?” “Are you taking any regular medications? Do you have any prescribed medicine? Are you taking any over the counter medicine?” Wrap-Up: Describe the diagnosis. Laboratory tests. Management plan. Duration of treatment and side effects. Red flags. Further information websites/brochures/support groups or societies. Follow-up. Physical Examination: Upper Limbs You have been asked to examine the upper limbs of a 32-year- old female. Vital Signs: Heart rate (HR), 76/min, regular; blood pres-sure (BP), 120/65 mm Hg; temp, 36. 5 °C; respiratory rate (RR), 14/min; O2 saturation 99%. No history is required for this station. Please do not per-form a rectal, genitourinary, or breast examination. Equipment Required: Hammer Cotton wool Paper pin Tuning fork 128 Hz The upper limb examination is used to determine the skills of the candidates during assessment of the nervous sys-tem. Upper limbs may be involved in brain diseases involv-ing pyramidal, extrapyramidal, and cerebellar systems or those affecting the spinal cord, its exiting roots, and periph-eral nerves supplying the upper limbs. The deficit may be progressive in parkinsonism or intermittent in multiple scle-rosis (MS). The neurological signs may involve a focal area such as in carpal tunnel syndrome or may be diffuse as in brachial monoparesis. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....I am your attending physician. Are you Miss... ? And you are 32 years old?” “Is it alright if I examine both of your arms, forearms, and hands? I will be doing some particular tests during which I will show you how to do some maneuvers. Please ask me if you do not understand how to do these during the examina-tion. During the examination, if you feel uncomfortable at any time, please let me know. ” Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Miss... vital signs are within the normal range. ” General Physical Examination “I need to ask you a couple of questions as a part of my examination:” “What is the date today?” “Do you know where you are right now?” Comment: “Patient is oriented and alert. ” Or “Patient is in distress!” Or “Patient is sitting comfortably and she is well oriented and alert. ” Look for any abnormal findings in the hands, face (eyes, nose, lips, and mouth), and neck. Exposure: Expose the patient's upper body on both sides. Ask the patient if there is pain anywhere in the upper limbs. Inspection: Look for any swelling, erythema, atrophy (arms and fore-arm muscles wasting), deformity (any limb deformity), skin changes/rash/scar marks, abnormal posturing, fas-ciculation, and tremors of resting hands or involuntary movements (Fig.  2. 1). Observe for clues around the bed: walking aids or wheelchair. A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

17 Tone: Muscle tone is the state of contraction of healthy muscles and can be estimated by moving the limbs passively. Ask the patient to keep the arms fully relaxed while checking the tone. Hold the patient's wrist with one hand, support the upper arm with your other hand, and flex and extend the elbow joint. Holding the forearm with the left hand, flex and extend the patient's wrist, moving the wrist through its full range of motion (ROM). Hold the patient's hand as if you are shaking the hand, support the elbow at 90° flexion with your other hand, and repeatedly supinate and pronate the forearm. Feel for increased tone -spasticity, rigidity, and cog-wheeling (Figs.  2. 2 and 2. 3). Pronator Drift: Ask the patient to hold her arms out in full extension with her palms facing up and eyes closed. Observe the hands and arms for pronation, which indicates an upper motor neuron lesion (Fig.  2. 4a, b). Power: Always stabilize the corresponding joints while testing power. Test one side at a time and compare like for like. Use your full strength to oppose the movement. Shoulder elevation -C4 Shoulder abduction -C5 Elbow flexion -C5, C6 Elbow extension -C7 Wrist extension -C6, C7 Finger flexion -C8 Finger abduction -T1 Grading Power: 5: Normal power 4: Able to move the joint against a combination of gravity and some resistance 3: Active movement against gravity 2: Able to move with gravity eliminated 1: Trace contraction 0: No contraction Shoulders Abduction (C5-Deltoid): Patient abducts the shoul-ders, raises the arm to horizontal, and is pushing it up against resistance. Ask the patient to keep her shoul-ders at this level and to not let you push them down (Fig.  2. 5). Adduction (C7/6-Latissimus Dorsi, Teres Major, Sternal Head of Pectoralis Major): With the upper arm horizontal, keep a hand below the arm just above the elbow to resist when the patient is pushing down. Ask the patient to push down with her arms and to not let you push her arms upward (Fig.  2. 6). Fig. 2. 1 Begin inspection of upper body Fig. 2. 2 Assessing arm tone Fig. 2. 3 Assessing the elbow, wrist, and hand joints tone 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

18 Elbow Flexion (C5/6-Biceps): After supinating the forearm, hold the forearm with your right hand just proximal to the wrist and support the elbow with your left hand. The patient tries to flex the arm at elbow against resistance. Tell the patient not to let you pull her arm away from her-self (Fig.  2. 7). Repeat on the other side. Extension (C7-Triceps): The patient tries to extend the arm at elbow against resistance. Tell the patient to push her forearm away from her body (Fig.   2. 8). Repeat it on the other side. Supination (C6/7-Supinator): With the forearm extended at the elbow, have the patient try to supinate the forearm against resistance (the palm faces downward and the patient tries to make it face upward). ab Fig. 2. 4 (a, b) Assessing for pronator drift Fig. 2. 5 Assessing power of shoulders: abduction Fig. 2. 6 Assessing power of shoulders: adduction Fig. 2. 7 Assessing elbow flexion: biceps A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

19 Wrist Extension (C6/7-Extensor Carpi Radialis Longus, Extensor Carpi Ulnaris): The patient holds the arm straight and is asked to make a fist. Ask the patient to cock her wrist back and not to let you push it down. Stabilize the wrist with one hand and push it down with your other hand (Fig.  2. 9). Repeat this on the other side. Flexion (C6/7-Flexor Carpi Radialis): Patient holds the arm straight and is asked to make a fist. Stabilizing the wrist with one hand, ask the patient to flex the hand at the wrist against resistance (Fig.   2. 10). Tell her not to let you push her wrist up. Fingers Finger Extension (C7/8-Extensor Digitorum): The wrist and fingers are placed in a straight position and the patient maintains extension of the metacarpophalangeal joints against the downward force applied by the exam-iner's finger. Tell the patient to put her fingers out straight and not to let you push them down (Fig.  2. 11). Finger Flexion (C7-Flexor Digitorum Superficialis and Profundus): Flexion at proximal interphalangeal joints is executed by the flexor digitorum superficialis and at the distal interphalangeal joints by the flexor digitorum profundus. The patient is asked to bend her fingers and try to oppose extension (Fig.  2. 12). Abduction of Little Finger (C8/T1-Abductor Digiti Minimi): With the back of the hand and fingers resting upon a surface, the patient is asked to move the little fin-ger away from other fingers against the resistance of the examiner. Tell the patient to move her little finger away from the other fingers and not to let you oppose it. Abduction of Index Finger (C8/T1-First Dorsal Interosseous): With the palm of the hand and fingers Fig. 2. 8 Assessing elbow extension: triceps Fig. 2. 9 Wrist extension Fig. 2. 10 Wrist flexion Fig. 2. 11 Finger extension 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

20 resting upon a surface, the patient is asked to move the index finger away from other fingers against resistance of examiner. Tell the patient to move her index finger away from the other fingers and not to let you oppose it (Fig.  2. 13). Abduction of Thumb (C8/T1-Abductor Pollicis Longus and Brevis): For abduction, ask the patient to point her thumb to the ceiling at a right angle to the palm against resistance. Flexion of Thumb (C8/T1-Flexor Pollicis Brevis): For flexion, ask the patient to move the thumb against resis-tance across the palm (Fig.  2. 14). Reflexes Explain to the patient that you will strike the tendons with a soft hammer, which is not going to hurt the patient. Ask the patient to relax. Place a finger over the tendon being tested and strike it with the tendon hammer. Biceps Reflex (C5/6): Flex the elbow at a right angle, and rest the forearm in a semipronated position across the patient's chest. Place your index finger over the biceps Fig. 2. 12 Finger flexion Fig. 2. 13 Finger abduction Fig. 2. 14 Flexion of distal interphalangeal (DIP) joints Fig. 2. 15 Bicep reflex A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

21 tendon, and tap with a hammer in the antecubital fossa (Fig.   2. 15). Observe the contraction of biceps muscles and compare on both sides. Triceps Reflex (C7): Flex the elbow at a right angle, and rest the forearm in a pronated position across the patient's chest. Strike the triceps tendon just above the olecranon (Fig.   2. 16). Observe the contraction of the triceps muscles and compare on both sides. Supinator Reflex (C5/6): Flex the elbow a little and rest the forearm in a slightly pronated position. Tap your fin-ger overlying the styloid process of the radius (Fig.   2. 17). Observe the supination of the elbow and compare on both sides. A lesion at C5/6 level may abolish the biceps and supinator jerks with brisk flexion of fingers (inversion of reflex), which is indicative of hyper-excitability of the anterior horn cells below this level. Sensation Light Touch (Posterior Column) Sensation: -Touch the patient's sternum with the cotton wool wisp to show how it feels. -Ask the patient to close her eyes and say “yes” every time she can feel the cotton wisp. -Using a wisp of cotton wool, gently touch the skin (do not stroke) of each of the dermatomes (Fig.   2. 18) of the upper limbs (Fig.   2. 19). Compare one side to the other by asking the patient if it feels the same on both sides. Pinprick (Spinothalamic) Sensation: -For pinprick, repeat the steps used for light touch, but this time using the sharp end of a pin (Fig.  2. 20). -Ask the patient to close her eyes and say “sharp” every time they feel a sharp sensation or “blunt” if it feels blunt. If sensations are diminished peripherally, test from a distal point and move proximally to identify “glove” sensory loss. Vibration Sensation (Dorsal/Posterior Columns): -Ask the patient to close her eyes. Tap a 128 Hz tuning fork and place its round base onto the patient's sternum to demonstrate what it feels like buzzing and when it stops. -Place it onto the bony interphalangeal joint of the thumb (Fig.   2. 21). Ask the patient if she feels it buzz-ing. Then ask her to tell you when it stops buzzing and hold the prongs to stop vibration. -If the patient cannot feel the vibration, move proxi-mally to the bony prominences of the wrist and olecra-non until she feels it. Position Sense (Dorsal/Posterior Columns): -Hold the distal phalanx of the thumb by its sides using your index finger and thumb, and let the patient watch and recognize up and down movements when you move the thumb “upward” and “downward,” respec-tively (Fig.  2. 22a, b). -Ask patient to close her eyes and tell you if her thumb is being moved up or down. Move it three times, and go to a proximal joint (wrist and elbow) if patient can-not feel the movement. Coordination Finger-to-Nose Test: -Ask the patient to touch her nose with the tip of her index finger, and then touch the tip of your finger (Fig.   2. 23a, b). Position your finger so that the patient has to fully outstretch her arm to reach it. Ask her to continue to do this finger-to-nose motion as fast as she is able. -Repeat the test using the patient's other hand. Fig. 2. 16 Triceps reflex Fig. 2. 17 Supinator reflex 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

22 Fig. 2. 19 Testing light touch sensation using a wisp of cotton Fig. 2. 20 Testing pinprick sensation Th1 C6 C7C8C5 L1C2 C3C4 C5 Th1 Th2 Th3 Th4 Th5 Th6 Th7 Th8 Th9 Th10 Th11 Th12 L2 L3 L4 L5L1 S2 S3 S1S1S2S2S1 L5 L4L3L2L1Th12Th11Th10Th9Th8Th7Th6Th5Th4Th3Th2Th1C3C2 C4 C5 C6 C7 C8 S5S4 S3S3 L4L5Fig. 2. 18 Dermal segmentation (dermatomes). (Reprinted with permission from Keegan and Garrett [7]) A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

23 -An inability to perform this test accurately (past- pointing/dysmetria) may suggest cerebellar ataxia. Here, the movement error tends to occur at a right angle to the intended direction of movement. Dysdiadochokinesia: -Ask the patient to flex the elbow at a right angle and then alternately tap the palm of her other hand with supination and pronation of flexed forearm. Demonstrate the action to the patient and ask her to mimic this rapid alternating movement (Fig.  2. 24a, b). -Encourage her to do this alternating movement as fast as she is able. Repeat the test using the patient's other hand. The rapidly alternating movements may become slow, irregular, and incomplete in cerebellar ataxia. Fig. 2. 21 Using a tuning fork to test a patient's vibration sensation ab Fig. 2. 22 Position sense. (a) Moving thumb upward. (b) Moving thumb downward ab Fig. 2. 23 (a) Finger-nose test step 1. (b) Step 2 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

24 Wrap-Up To complete the examination, suggest further assessments by examining the lower limbs and cranial nerves. Thank the patient and cover her. Wrap up your findings and ask the patient if she has any concerns. Checklist: Physical Examination Upper Limb See Table  2. 2 for a checklist that can be used as a quick review before the examination. Physical Examination: Lower Limbs Candidate Information: You have been asked to examine the lower limbs of a 32-year- old female. Vital Signs: HR, 76/min, regular; BP, 120/65 mm Hg; temp, 36. 5 °C; RR: 14/min, O2 saturation 99% No history is required for this station. Please do not per-form a rectal, genitourinary, or breast examination. Equipment Required: Hammer Cotton wool Paper pin Tuning fork 128 Hz The lower limb examination is another area used to deter-mine the skills of the candidates during assessment of the nervous system. Lower limbs are commonly involved in lesions of the spinal cord, its exiting roots, and peripheral nerves supplying the legs and feet. The deficit may be pro-gressive in parkinsonism or intermittent in multiple sclero-sis. Lower limbs are also involved in diseases of pyramidal, extrapyramidal, and cerebellar systems. Careful assessment of gait may provide very useful information in neurological diseases. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 32 years old?” “Is it alright if I examine your thighs, legs, and feet (lower limbs)? I will be doing some particular tests during which I will show you how to do some maneuvers and ask you to duplicate them. Please ask me if you do not under-stand how to do these during the examination. During the examination, if you feel uncomfortable at any point, please let me know. ” Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Miss... vital signs are within normal range. ” Or comment if they are not. ab Fig. 2. 24 (a, b) Dysdiadochokinesia test A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

25 General Physical Examination: “I need to ask you a couple of questions as a part of my examination. ” (You may skip these questions if it is a history and physical station): “What is the date today?” “Do you know where are you now?” Comment: “Patient is oriented and alert. ” “Patient is in distress!” Or “patient is sitting comfortably and she is well oriented and alert. ” Look for any abnormal findings in the hands, face (eyes, nose, lips, and mouth) and neck. Exposure Expose the patient's lower limbs to underwear (shorts are most appropriate). Ask the patient if she has any pain in the lower limbs. Gait Assess Patient Walking Ask the patient to walk to the end of the room, turn slowly, and walk back (Fig.   2. 25). Assess speed, distance between the legs (broad-based in ataxia), posture, and swinging of arms (stooping and loss of arm swinging in Parkinson's disease) or hemiplegic gait. Ask the patient to walk in a straight line. Assess balance (swaying to any side). Ask the patient to walk heel-to-toe (tandem gait). This requires precision of equilibrium and assesses even mini-mal impairment of balance. Table 2. 2 Checklist for upper limb physical examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair, or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/drape Ask for vital signs -interpret the vital signs Vitals Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation) “Vital signs are within normal range. ” Or comment if they are not General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal finding in the hands, face (eyes, nose, lips, and mouth), and neck Exposure: Expose patient's upper body on both sides Ask if the patient currently has pain anywhere in the upper limbs Inspection: Look for any: swelling, erythema, atrophy (arms and forearm muscles wasting), deformities (any limb deformity), skin changes/ rash/scar marks, abnormal posturing, fasciculation, and tremors of resting hands or involuntary movements Palpation: Tone, pronator drift Power: Shoulders, elbow, wrist, fingers Reflexes: Biceps reflex, triceps reflex (C7), supinator reflex (C5/6) Sensation: Light touch (posterior column) sensation and pinprick (spinothalamic) sensation Vibration sensation (dorsal/posterior columns) and position sense (dorsal/posterior columns) Coordination: finger-to-nose test and dysdiadochokinesia Wrap-up To complete the examination, suggest further assessments by examining the lower limbs and cranial nerves Thank patient and cover the arms Wrap up your findings and ask the patient if she has any concerns Fig. 2. 25 Assessing patient's walk 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

26 Ask the patient to walk on heels (heel-walking) to assess the dorsiflexors of feet. Ask the patient to walk on toes (toe-walking) to assess the plantar flexors of feet. Ask the patient to stand with her feet together. Hold her hands, and ask her to sit down and stand up to assess strength of proximal lower limb muscles. The Romberg's test is a test for proprioception, vestibu-lar system, and visual inputs. Ask the patient to stand with her feet together and eyes closed. Observe the patient for a minimum of 30 seconds. Stand on the side of the patient dur-ing this test with an outstretched arm in front and another behind the patient to stop her falling over (Fig.   2. 26). A posi-tive test is indicated by loss of balance (swaying/falling over) suggesting sensory ataxia or vestibular deficit. Inspection Ask the patient to lie comfortably on the bed. Look for any: swelling, erythema, atrophy (thighs and leg muscles wasting), deformity (any limb deformity), skin changes/rash/scar marks, abnormal posturing, fascicula-tion, or involuntary movements. Observe for clues around the bed such as walking aids or wheelchairs. Tone Muscle tone is the state of contraction of healthy muscles and can be estimated by moving the limbs passively. Ask the patient to keep the legs fully relaxed while checking the tone. Holding each knee, roll the patient's leg side to side, and watch the foot -it should flop independently of the leg (Fig.  2. 27). Hold the knee with hands under both sides of the knee and briskly lift leg off the bed at the knee joint (Fig.   2. 28). Observe the heel, which should remain in contact with the bed in normal people. Power Always stabilize the corresponding joints while testing power. Test one side at a time and compare like for like. Use your full strength to oppose the movement. Great toe extension -L5 Knee extension -L3 and L4 Hip flexion -L2 Hip Flexion (L1/2/3-Iliopsoas): Extend the knee, and push down with your hand on quadriceps above the knee, asking the patient to raise her leg off the bed and not to let you push it down (Fig.  2. 29). Fig. 2. 26 The Romberg's test Fig. 2. 27 Checking a patient's muscle tone by rolling a patient's leg side to side A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

27 Extension (L4/5/S1-Gluteus Maximus): In a supine patient with knee extended, raise the thigh off the bed by placing a hand under the thigh and ask the patient to push her leg straight down and try to touch the bed. You can place the left hand on the side of hip to feel the contrac-tion of the gluteus maximus (Fig.  2. 30a, b). Adduction (L2/3-Adductor of Hip): In a supine patient with knee extended, abduct the leg, hold the lower leg with your left hand, and feel the adductors in the upper thigh with your right hand, and ask the patient to bring her leg back to the midline (Fig.  2. 31). Abduction (L4/5-Gluteus Medius, Gluteus Minimus, and Tensor Fasciae Latae): In a supine patient with the knee extended, place the patient's legs together, hold the lower leg with your right hand, and support the opposite hip with your left hand. Ask the patient to separate the legs. Knee Extension (L3/4-Quadriceps): Bend the knee fully and flex the hip; supporting the knee with your left hand, press against the shin with your right hand, and ask the patient to attempt to straighten her leg (Fig.  2. 32). Flexion (L5/S1-Hamstrings): Bend the knee partially and hold the leg with your right hand while supporting the thigh with your left hand. Ask the patient to bend her knee against your force by attempting to touch her heel to her hip (Fig.  2. 33). Ankle Dorsiflexion of Ankle (L4 -Tibialis Anterior): Ask the patient to pull the top of her foot toward her head and to not let you push it back (Fig.  2. 34). Plantarflexion of Ankle (S1/2 -Gastrocnemius and Soleus): Ask the patient to push her foot downward against your hand and to not let you push it up (Fig.  2. 35). Fig. 2. 28 Checking a patient's muscle tone by lifting a patient's leg at the knee joint Fig. 2. 29 Hip flexion ab Fig. 2. 30 (a, b) Hip extension 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

28 Inversion (L4/5-Tibialis Posterior): Ask the patient to push her foot inward against your hand. Eversion (L5/S1-Peroneus Longus and Brevis): Ask the patient to push her foot out against your hand. Big Toe Extension (L5-Extensor Hallucis Longus): Flex the big toe, pressing against the nail of the big toe (distal phalanx) with your thumb (Fig.   2. 36). Ask the patient to push her big toe upward and to not let you push it down. Flexion (S1-Flexor Hallucis Longus): Pressing against the pulp of the big toe with two fingers, ask the patient to push her big toe downward and to not let you push it up (Fig.  2. 37). Fig. 2. 32 Knee extension Fig. 2. 33 Knee flexion Fig. 2. 34 Dorsiflexion of ankle Fig. 2. 35 Plantar flexion of ankle Fig. 2. 31 Hip adduction A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

29 Reflexes Explain to the patient that you will strike the tendons with a soft hammer, which is not going to hurt the patient. Ask the patient to relax. Knee Jerk (L3/4)-Passively flex the knee in a supine patient, pass your left hand under the knee, and gently tap the patellar tendon an inch above the tibial tuberosity (Fig.   2. 38). Observe the contraction of the quadriceps muscles and compare both sides. Ankle Jerk (L5/S1)-In a supine patient, externally rotate the hip and flex the knee slightly. Dorsiflex and evert the foot with the palm of the left hand, and strike the posterior surface of Achilles tendon with the hammer in the right hand (Fig.   2. 39). Observe the contraction of calf muscles and compare both sides. Plantar Response (S1)-After warning the patient, scratch the sole of the foot with a key or an orange stick. Start at the heel along the lateral edge to the ball of the big toe. Observe the big toe. A normal response causes draw-ing together of all flexed toes. In Babinski's extensor plantar response, extension of the big toe is followed by fanning of all other toes. Ankle Clonus-Position the patient's leg to flex the knee and ankle at a 90° angle. Hold the calf with your left hand and rapidly dorsiflex the forepart of the foot with your right hand (Fig.   2. 40). Keep the foot in this position and observe for regular oscillation of dorsiflexion/plantarflex-ion of the ankle. Sustained clonus (>5) indicates an upper motor neuron lesion and is always associated with a brisk ankle jerk. Fig. 2. 36 Big toe extension Fig. 2. 37 Big toe flexion Fig. 2. 38 Knee jerk test Fig. 2. 39 Ankle jerk test 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

30 Sensation Sensory test with a piece of cotton on these spots: Medial side of thigh -L2 Medial femoral condyle -L3 Medial malleolus -L4 Dorsal surface of third toe -L5 Lateral surface of heel -S1 Light touch (posterior column) sensation: Touch the patient's sternum with the cotton wool wisp to show her how it feels. Ask the patient to close her eyes and say “yes” every time she feels it against her skin. Using a wisp of cotton wool, gently touch the skin (do not stroke) of each dermatome of the lower limbs (Fig.   2. 41). Compare one side to the other by asking the patient if it feels the same on both sides. Pinprick (spinothalamic) sensation: For pinprick, repeat the steps used for light touch, this time using the sharp end of a pin. Ask the patient to close her eyes and say “sharp” every time she feels a sharp sensation or “blunt” if she feels a blunt sensation (Fig.   2. 42). For patients with paraparesis, start from the distal ends (feet) and move upward to local-ize the upper sensory level. If sensations are diminished peripherally, test from a distal point and move proximally to identify “stocking” sensory loss. Vibration sensation (dorsal/posterior columns): Ask the patient to close her eyes. Tap a 128 Hz tuning fork and place its round base onto the patient's sternum to dem-onstrate how it feels when it is buzzing and when it stops. Place it onto the bony interphalangeal joint of the big toe (Fig.   2. 43). Ask the patient if she feels it buzzing. Then ask her to tell you when it stops buzzing and hold the prongs to stop vibration. If the patient cannot feel the vibration, move proxi-mally to bony prominences of medial malleolus, tibial tuberosity, and anterior superior iliac spine until she feels it. Position sense (dorsal/posterior columns): Hold the distal phalanx of the big toe by its sides using your index finger and thumb and let the patient watch and recognize up and down movements when you move the toe upward and downward, respectively (Fig.  2. 44a, b). Fig. 2. 40 Ankle clonus Fig. 2. 41 Testing light touch sensation of lower limbs using a wisp of cotton Fig. 2. 42 Pinprick sensation of lower limbs A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

31 Ask patient to close her eyes and tell you if you are mov-ing her toe up or down. Move it three times and go to a proximal joint (ankle and knee) if the patient cannot feel the movement. Coordination Heel-to-shin test may only be done if gait cannot be tested. Ask the patient to lift her right leg up, place it on her left knee, and run her heel down the shin from the knee to ankle (Fig.  2. 45a-c). Repeat it with other leg. An inability to perform this test may suggest cerebellar disorder, impaired position sense, or loss of motor strength. Wrap-Up: To complete the examination, suggest further assessments by neurological examination of the upper limbs and cra-nial nerves. Thank the patient and tell her that she can now cover up. Wrap up your findings and ask the patient if she has any concerns. Checklist: Physical Examination Lower Limbs See Table  2. 3 for a checklist that can be used as a quick review before the exam. Physical Examination: Cerebellar Syndromes Candidate Information: A 52-year-old female comes to your clinic with an unsteady gait, which she has experienced for the last 6 months. Vital Signs: Temp, 36. 5 °C; HR, 74; BP, 137/80; RR, 15 Please examine her gait and then perform any relevant neurological assessments to complete your examination. Differential: Immediately consider the differential of gait disorders that may be presented here. Hemiplegic gait Cerebellar ataxic gait Parkinsonian gait (shuffling festinant gait) High-stepping gait of peripheral neuropathy/sensory ataxia Waddling gait of proximal muscular weakness Fig. 2. 43 Using a tuning fork to test vibration sensation in the big toe ab Fig. 2. 44 Testing position sense. (a) Moving toe upward. (b) Moving toe downward 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

32 The aim of the examination is to identify and classify the gait first and then carry out appropriate relevant neurological examinations to make a clinical diagnosis. Common Causes of a Unilateral Cerebellar Lesion: Cerebellar infarction Cerebellar hemorrhage Multiple sclerosis Tumors (primary or metastasis) Cerebellar arteriovenous malformation Cerebellar abscess Causes of Bilateral Cerebellar Lesions: Multiple sclerosis damaging both cerebellar hemispheres Alcohol (Wernicke's encephalopathy or cerebellar degeneration) Infections (viral cerebellitis, human immunodeficiency virus [HIV], syphilis, tuberculosis) Autoimmune (Miller-Fisher syndrome, paraneoplastic cerebellar degeneration) Neurodegenerative disease (multiple system atrophy) Hereditary ataxias: -Spinocerebellar, Friedreich's ataxia-telangiectasia -Autosomal dominant cerebellar ataxia of late onset Drugs (phenytoin, lithium) Metabolic (vitamin B 12 deficiency) Clinical Features of Friedreich's Ataxia: Onset in children or young adults (autosomal recessive) Impaired dorsal column sensations (joint position and vibration) in legs Extensor plantar responses with absent ankle jerks Optic atrophy Diabetes mellitus (DM) Cardiomyopathy Kyphoscoliosis Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Ms....? And are you 52 years old? I would like to perform some tests; I will ask you to do some maneuvers; if you do not understand or feel difficulty in doing any of these movements, please let me know. ” The basic aim is to establish and delineate the cerebellar features and to determine the presence of involvement of other systems in nervous system. a cb Fig. 2. 45 (a-c) Heel-to-shin test A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

33 Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Miss... vital signs are within normal range. ” Or comment if there are any abnormal findings. Observe Walking and Standing “Is it alright if I ask you to walk?” Ask the patient to walk slowly to the end of the room, turn slowly, and walk back (Fig.  2. 25). Observe the following in the gait: -How the patient starts off: Is she slow to start? -Posture of the patient during walking. -Slow walking speed, small length of stride (short paces), and broad width of stance (broad base): Patients with lesions of the vermis of cerebellum may have lurching gait. -Slow stepwise turning due to fear of falling. -Ask the patient to walk heel-to-toe (tandem gait) to assess balance. Stand beside the patient because patients with cerebellar deficit find it impossible to walk heel-to-toe. Romberg's test: Ask the patient to stand with her feet together, initially with the eyes open and then with eyes closed. Stand on the side of the patient during this test with an outstretched arm in front and another behind the patient to stop her from falling over (Fig.   2. 26). A posi-tive test is indicated by loss of balance (swaying/falling over) suggesting sensory ataxia or vestibular deficit. Romberg's test is negative in isolated cerebellar disorders. Additional Examination Position the patient on a chair approximately an arm's length away. The patient shall be at your eye level. Observe the fol-lowing from the head downward: Square wave jerks in the primary position of eyes. The patient is asked to fix her gaze at your finger held at the center of her vision. Square wave jerks may be visible when you observe the eyes in neutral position. The eyes drift off their target (in this case, the examiner's finger) randomly, and a quick saccade pulls the eyes back to the neutral position. Ask the patient to follow your slowly moving finger hori-zontally and then vertically. The normal pursuit move-ments may be broken in to jerky advances (saccadic Table 2. 3 Checklist for lower limb physical examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/drape Ask for vital signs -interpret the vital signs Vitals Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation) “Vital signs are within normal range. ” Or comment if they are not General physical examination (may skip these questions if it is a history and physical station)Check that patient is alert and orientated Look for any abnormal finding in the hands, face (eyes, nose, lips, and mouth), and neck Exposure: expose the patient's lower limbs to underwear (shorts are most appropriate) Ask the patient if there is any pain in the lower limbs Check gait Romberg's test Inspection: look for any swelling, erythema, atrophy (arms and forearm muscles wasting), deformity (any limb deformity), skin changes/rash/ scar marks, abnormal posturing, fasciculation, and tremors of resting hands or involuntary movements Palpation: tone Power: great toe, ankle, knee, and hip Reflexes: knee jerk, ankle jerk, plantar response, and ankle clonus Sensation: light touch sensation and pinprick sensation Vibration sensation and position sense Coordination: heel-to-shin test Wrap-up To complete the examination, suggest further assessments by examining the upper limbs and cranial nerves Thank patient and cover the legs. Ask the patient if they have any concerns Wrap up your findings to the examiner 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

34 pursuits) rather than smooth following of the finger. This happens because of insertion of saccades into pursuits. Nystagmus: Horizontal nystagmus tends to be more spe-cific in cerebellar disease. Cerebellar dysarthria: Speech may have a “scanning” character and appears to be broken into syllables. Ask the patient to repeat after you “railway station. ” This may appear as “ra—il—way ss—ta—tion. ” Rebound phenomenon: Ask the patient to put her hands straight in front of her and to close her eyes. “I will tap on your arm; try to keep them in the same position. ” Heavily tap the right forearm down and look for an upward drift of the arm after it is tapped down. Repeat it with the other arm. Finger-to-nose test: Ask the patient to touch her nose with the tip of her index finger and then touch the tip of your finger. Position your finger so that the patient has to fully outstretch her arm to reach it. Tell the patient to repeat this as fast as they are able (Fig.   2. 23a, b). Ask the patient to perform the same movements with her eyes closed. Impaired position sense would make this more difficult for the patient. Repeat the test using the patient's other hand. Assess the precision and depth of the move-ment. Past-pointing means that the patient's finger overshoots or moves past the target: their nose as well as the examiner's finger. Intention tremors are detected during movement. Observe the patient when she is performing the finger- nose test. The tremor gets worse when the patient is intending to approach the target (finger or nose) and tends to occur at a right angle to the intended direction of movement. Dysdiadochokinesia: Ask the patient to flex the elbow at a right angle, and then alternately tap the palm of her other hand with supination and pronation of flexed fore-arm. Demonstrate the action to the patient and ask her to mimic this rapid alternating movement. Tell her to repeat this movement as fast as possible (Fig.   2. 24a, b). Repeat the test using the patient's other hand. Patients with cere-bellar deficit may be very slow and haphazard and unable to perform this rapidly alternating movement. Hypotonia: Check the tone in the upper limb. Cerebellar syndromes tend to cause hypotonia. Pendular knee jerk: Ask the patient to hang the legs from the edge of chair or bed. Tap the patellar tendon and observe the knee jerk (Fig.   2. 46). The leg may move like a pendulum (three times or more). Heel-shin test is not required to assess coordination in lower limbs when her gait has been examined in detail (Fig.  2. 45a-c). Remember: Unilateral cerebellar lesions produce unilateral signs, whereas bilateral cerebellar involvement causes bilat-eral findings. Lesions of cerebellar vermis predominantly affect gait and sitting balance, with relative sparing of eye movements and speech. Wrap-Up: To complete the examination, suggest further assessments by neurological examination of cranial nerves and long tracts. Thank the patient and tell her that she can now cover up. Explain your findings to the examiner. Question: Describe briefly the gait of your patient. (Questions may be asked by the patient or the examiner. ) Answer: “My patient starts off rather normally and has a normal posture, but she appears to be cautious during her walk due to imbalance. She tends to walk on a broad base with her feet wide apart. She takes considerable time in turning due to her small and careful steps as she sways to both sides. She finds it impossible to walk heel-to-toe (tan-dem gait) due to significant imbalance and tends to sway on both sides. Her Romberg's test is negative. ” Question: How would you classify the gait of your patient? Answer: “The gait of my patient appears to be ataxic and signifies an underlying cerebellar disorder. ” Question: What other neurologic findings were present in your patient to favor your diagnosis? Answer: “The relevant neurologic examination in my patient revealed: Horizontal nystagmus in both eyes. Scanning speech or cerebellar dysarthria in which she breaks the syllables. Fig. 2. 46 Pendular knee jerk A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

35 Intention tremors and rebound effect in both arms. Past-pointing during finger-to-nose test. Dysdiadochokinesia -meaning she was very slow and haphazard when asked to perform rapidly alternating movements with both arms. “I could not elicit a pendular jerk although knee reflexes were preserved on either side. ” Question: What is your final clinical diagnosis? Answer: “My patient appears to have a cerebellar disorder. ” Physical Examination: Cranial Nerves Candidate Information: Please perform examination of the motor cranial nerves (III, IV, VI, motor part of V, VII, X, and XI, XII) or examination of the cranial nerves for the eyes (II, III, IV, V, VI, and VII) in a 52-year-old female. Generally, candidates are not asked to examine all cranial nerves in 10 min. The command may rather be more specific. Nevertheless, candidates must systematically practice and learn to examine all cranial nerves. Remember, you must fin-ish your examination in given time. Ensure that relevant equipment is available with you before you start with your examination. Equipment Required: Pen torch Snellen chart Ophthalmoscope Hammer Cotton wool Paper pin Tuning fork 512 Hz Mydriatic eye drops (not required for OSCE) Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Ms.... ? Are you 52 years old? I have been asked to examine your cranial nerve. I will be doing some tests and will ask you to follow some maneuvers. Please let me know if you have any question or you feel uncomfortable. ” Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) Comment on the vital signs findings: “Miss... vital signs are within normal range. ” Inspection: Position patient on the side of the bed or on a chair approximately an arm's length away and at your own eye level. Look for facial asymmetry, specific facial appearances, drooping of eyes or squint, and abnormality of speech. Observe for clues around the bed: walking aids or wheelchair. Olfactory (Cranial Nerve I: Special Sensory Nerve for Smell) Ask for any change in sense of smell. With eyes closed, ask patient to identify commonly used smells (e. g., coffee/clove/peppermint). Test each nostril separately. Occlude the other nostril by pressing with a finger. Avoid using irritants such as ammonia as they may also stimulate trigeminal nerve. CN I examination is usually not done in OSCE settings. Optic (Cranial Nerve II: Special Sensory Nerve for Vision) Test each eye separately for: Visual acuity. Color vision. Field of vision. Pupils are usually tested with CN-III.  Optic is afferent for pupillary reflexes. When OSCE is limited to CN-II exami-nation, pupils may be tested with optic nerve. Fundoscopy. Visual Acuity Ask about the use of glasses. Make patient wear her glasses for distant vision. The patient should be positioned at 6 m from the Snellen chart. In a room smaller than 6  m, the patient can be asked to stand on the side of the chart 3 m away from a mirror. Ask the patient to cover one eye and read the smallest possible line of the chart. If the patient reads the 6/6 line, you would record vision as 6/6. Repeat above steps for the other eye. 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

36 Color Vision Generally color vision is not assessed in OSCE settings. Visual Fields The visual field is the extent of the field of vision in each eye. It is limited by the margin of the orbit, nose, and cheek. The extent of the patient's visual field is compared in each eye separately with those of examiner's by a simple technique known as confrontation method: Position yourself facing the patient, approximately 2 to 3 feet away. Give very clear instructions to the patient for the test: “Cover your left eye with your left hand, but do not put your hand over the bridge of your nose. With your right eye, focus on my left eye and do not move your head or eyes during the test. I will wiggle my fin-ger. You must tell me when you can first see my finger-tip moving. ” Cover your right eye with your right hand, and focus with your left eye directly at the patient's right eye. Hold up your left hand, ensuring it is at equal distance between the patient's face and your own. Position the tip of your index finger at the outer border of one of the quadrants of your visual field, and then slowly bring your finger inward, toward the center of your visual field (see Fig.   2. 47a, b), until you yourself first see the finger. Ask the patient to point out when she can see your finger. Perform this process for upper and lower quadrants in your left (patient's right) field of vision. Switch your hands while repeating the same process in your right (patient's left) field of vision. A visual field defect is suggested by inability of the patient to see your fingertip when you are able to see it. Test all four quadrants of the field of vision in each eye separately. Fundoscopy (Not required for OSCE) Darken the room and ask the patient to focus on a distant object. Use your right eye to examine the patient's right eye and left for the patient's left. Position yourself at about 18 in. away from the patient's eyes. Shine the light in the eye, and, through the fundoscope, observe for the red reflex. Gradually, move in closer and look into the eye with the fundoscope. Assess optic disc shape, color, margins, cupping, vascular impulse, and number of vessels on the disc surface. The easiest way to locate the disc is to find a vessel and follow it to the disc. Assess the retina for cotton wool spots, hemorrhages, and neovascularization. Ask the patient to look directly into the light and assess the macula. Oculomotor (Cranial Nerve III), Trochlear (Cranial Nerve IV), and Abducent (Cranial Nerve VI) CN-III: Motor nerve for extraocular muscles (superior, medial, and inferior rectus, inferior oblique and levator palpebrae superioris) and visceral motor for pupillary constrictor and ciliary muscles. CN-IV: Motor nerve for superior oblique muscle. (Easy to remember SO4) CN-VI: Motor nerve for lateral rectus muscle. (Easy to remember LR6) These nerves control ocular movements and are tested together. A lesion involving one or more of these three nerves may cause: Abnormalities of ocular movements Squint Diplopia Pupillary abnormalities a b Fig. 2. 47 Visual field test. (a) The four quadrants of the field of vision. (b) Assessing the visual fields A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

37 Testing Eye Movements The eye movements are pursuits (slow, following move-ments), saccades (fast, jerky movements), and conjugate eye movements. Pursuit movements are slow movements that depend upon fovea and occipital cortex. The patient is asked to keep her head still and visually follow your finger as it moves horizontally and vertically slowly across the field of vision at about 2-3 feet distance (Fig.   2. 48). Start your index finger from the midline and move through the vari-ous axes of eye movement. The purpose of making an “H” shape is elaboration of eye movements in primary and secondary functional position of extraocular muscles. Observe for restriction of vertical and horizontal eye movements, and note any nystagmus. Ask the patient to report any double vision. Saccades are rapid alternate gaze movements that depend upon frontal lobes and pontine gaze centers. The patient is asked to change the gaze between two objects held at least 30° apart. Hold your finger at a 30-degree distance from your nose, and ask the patient to switch her gaze between your nose and your finger. Conjugate movements: The two eyes normally move together in various directions to keep the visual axes on the target. The gaze movements depend upon brain-stem integration of cranial nerve nuclei of all three cra-nial nerves. Conjugate movements are affected by upper motor neuron lesions. Internuclear ophthalmo-plegia of conjugate lateral gaze occurs due to unilateral lesion of medial longitudinal fasciculus in midbrain or upper pons. On attempted lateral gaze, the adducting eyes show impaired deviation and abducting eyes show rhythmic nystagmus. The lesion is on the side of impaired adduction. Testing Pupils The afferent nerve for pupillary reflex is CN-II (optic), and the efferent is the CN-III (oculomotor) nerve. Use a good light source in a dim room light to check the pupils. Ask the patient to look at a distance and examine each eye separately. Normal pupils are equal in size and round and symmetrical in shape. If one pupil is larger than other, it may be difficult to decide which one is abnormal. Usually the pupil that is less mobile is the abnormal one. Direct pupillary reflex: Bring a bright light from behind or from side of the eye and shine into the pupil; observe constriction of that pupil. A normal pupil should contract almost immediately, and the removal of the light causes rapid dilatation to previous state. Lack of pupillary con-striction or a sluggish response may suggest interference with reflex pathway. Repeat it on the other side. Consensual pupillary reflex: Shining a bright light into one eye causes constriction of pupils in both eyes. This happens because some of the optic nerve fibers decussate in optic chiasma. Shining light in one eye, therefore, acti-vates brainstem oculomotor nuclei concerned with pupil-lary constriction bilaterally. A normal consensual response is indicated by constriction of the contralateral pupil. Lack of a normal consensual response may suggest dam-age to afferent pathways in optic nerves or to the Edinger- Westphal parasympathetic nucleus in the midbrain. Accommodation reflex: Hold a finger approximately 4 inches away from the nose of the patient. Ask the patient to look at a distance and then quickly focus at your finger. Observe for convergence of both eyes and constriction of pupils. The complete CN-III palsy may be associated with the following findings: Ptosis. Divergent squint, due to unopposed action of lateral rec-tus muscle. Eye moves only laterally (lateral rectus) and a little down-ward (superior oblique). Dilated pupil with no response to light (pupillary- affecting) due to loss of function of pupillary constrictor fibers and unopposed over activity of sympathetic inner-vation. Compressive lesions of the third nerve such as an aneurysm of posterior communicating artery usually affect pupillary constricting fibers, which travel on the upper and outer surface of the nerve. SROD OS LR IRIO MR SOSR LR IRFig. 2. 48 Testing eye pursuit movements. OD oculus dexter (right eye), OS oculus sinister (left eye), SR superior rectus, LR lateral rectus, IR inferior rectus, IO inferior oblique, MR medial rectus, SO superior oblique 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

38 Third nerve palsy, however, may be incomplete or partial when the pupil on the affected side remains reactive to light (pupillary-sparing). This may happen with vascular lesions such as hypertension and diabetes, which tend to damage the interior of the nerve sparing the pupillary constricting fibers on its surface. The CN-IV palsy may be associated with the following findings: Diplopia on looking downward and inward, as in walking down the stairs or reading Tilting of the head to side opposite of palsy to minimize diplopia The CN-VI palsy may be associated with the following findings: Inability to abduct the eye on the affected side Diplopia on lateral gaze to the affected side Trigeminal (Cranial Nerve V) Mixed sensorimotor nerve for facial sensations and muscles of mastication Sensory: Assess light touch and pinprick sensation on three divisions of the trigeminal nerve. Light Touch (Posterior Column) Sensation: Touch the patient's sternum with the cotton wool wisp to show how it feels. Ask the patient, “Close your eyes and say 'yes' every time you feel it. ” Using a wisp of cotton wool, gently touch the skin (do not stroke) of three divisions of the CN-V (Figs.   2. 49 and 2. 50): -For ophthalmic division (V1) -Forehead -For maxillary division (V2) -Cheek -For mandibular division (V3) -Jaw Ophthalmic division Maxillar y division Mandib ular division Fig. 2. 49 Dermatomes of the trigeminal nerve: ophthalmic, maxillary, and mandibular divisions. (Adapted from https://en. wikipedia. org/wiki/ Trigeminal_nerve#/media/ File:Trig_innervation. svg under terms of Attribution 3. 0 Unported (CC BY 3. 0). https://creativecommons. org/ licenses/by/3. 0/) A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

39 Compare one side to the other by asking the patient if it feels the same on both sides. Pinprick (Spinothalamic) Sensation: For pinprick, repeat the steps used for light touch, but this time using the sharp end of a pin. Ask the patient “close your eyes and say 'sharp' every time you feel it sharp or 'blunt' if you feel it blunt. ” Corneal reflex is not done in the OSCE settings. Do men-tion about it. CN-V is afferent for cornea. Motor: Testing of motor functions involves assessment of muscle power of masseter, temporalis, and pterygoids and eliciting the jaw jerk. Ask the patient to clench her teeth, while you feel with your fingers the bulk of masseter and temporalis bilaterally (Fig.  2. 51). Ask the patient to open her mouth and note for any devia-tion. The healthy pterygoids will push the jaw to the weaker side. Repeat the test against resistance of your fingers under the jaw and note any deviation. Jaw Jerk: Explain to the patient that you will strike the jaw with a hammer, which is not going to hurt the patient. Ask the patient to open her mouth slightly. Place your thumb horizontally across the chin, and, with four fingers, feel the masseter muscle. Ask the patient to close her eyes and gently tap your thumb with a hammer. Try to feel the contraction of masseter muscle. Jaw jerk is absent in most normal people. A brisk complete closure of the jaw due to contraction of mas-seter indicates an upper motor neuron lesion. Facial (Cranial Nerve VII): Motor nerve for muscles of the face, platysma, and stape-dius; taste fibers from anterior two-thirds of tongue. Inspect for facial asymmetry -eyebrow sagging, the absence of the nasolabial fold on the affected side, and deviation of the mouth to the non-affected or healthy side. Examine for facial weakness affecting one side of the face. To assess this, examine the movements of the fore-head, eyes closure, and mouth (Fig.  2. 52a-d). Ask the patient to raise eyebrows/frown and look for any asymmetry of the forehead. Ask the patient to close the eyes tightly; assess the ability of the patient to resist eye opening. Ask the patient to show the teeth -note for deviation of angle of mouth. In seventh nerve palsy, the angle of mouth is pulled toward the healthy side. Examine external auditory meatus for zoster vesicles or scabbing (Ramsay Hunt syndrome). Ask the patient for disturbed taste, as the facial nerve car-ries signals for taste from the anterior two-thirds of the tongue. Ask the patient for hyperacusis or reduced ability to toler-ate ordinary levels of noise, as the facial nerve has a branch that supplies stapedius. Distinguish a lower motor neuron from an upper motor neuron facial palsy. In upper motor neuron lesion involv-ing pyramidal tract, contralateral muscles moving the mouth are affected, whereas the muscles of the forehead and eye closure are spared. Lower motor neuron type facial weakness equally involves the facial muscles of the forehead and eye closure on affected sides. In unilateral paralysis of CN-VII and CN-X, the healthy side will pull the weaker side. In unilateral paralysis of CN-V and CN-XII, the healthy side will push to the weaker side. Vestibulocochlear (Cranial Nerve VIII) Special sensory nerve subserving hearing and equilibrium through its cochlear and vestibular components, respectively Fig. 2. 50 Light touch sensation of the face using a wisp of cotton Fig. 2. 51 Testing motor functions of the face and jaw 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

40 Auditory Testing Gross hearing testing with whispered or conversational sounds is very difficult to quantify and may be interpreted erroneously. Ask the patient if she can hear her telephone ring and has she noticed a change in her hearing recently? Assess each ear separately. Explain to the patient that she is required to repeat words or numbers that you will be saying in her ear. Stand to the side of the ear to be tested, and mask the ear not being tested by rubbing the tragus. Start with a whis-pered sound approximately at 3  inches and then at 6 inches from the ear. Ask the patient to repeat the num-ber or word back to you. If there is no response, use a conversational sound at 2 feet. Test the other ear in the same way. Rinne's test compares hearing by air and bone conduc-tion. Tap a 512 Hz tuning fork, and hold it in line with external auditory meatus (air conduction) (Fig.   2. 53a), and then place its base onto the mastoid process (bone conduction) (Fig.   2. 53b). Ask the patient if the sound is louder in front of the ear or behind the ear. Air conduction is better than bone conduction in normal persons and in mild sensorineural deafness (Rinne's positive). In con-ductive deafness, bone conduction is better than air con-duction (Rinne's negative). Remember some caveats with Rinne's test: -Rinne's test becomes negative in conductive deafness only when the difference between air and bone con-duction exceeds 40 db. -Rinne's test becomes false negative in severe unilateral sensorineural deafness (dead ear) when hearing is nor-mal in the contralateral ear. In such cases, both air con-duction and bone conduction are reduced equally in the diseased ear, but sounds are passed via bone con-duction through the normal ear. Weber's test: Tap a 512 Hz tuning fork and place its base in the midline of the forehead (Fig.   2. 54). Ask the patient if the vibrating sounds are heard in the midline or if these are lateralized to one ear. Interpret Weber's test as under: -Sound is heard in the midline equally well in both nor-mal ears. ab cd Fig. 2. 52 (a-d) Assessing facial weakness by examining movements of the forehead, eyes, and mouth A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

41 -In conductive deafness in right ear, bone conduction will be better than air conduction (Rinne negative in right ear), and Weber's test will be lateralized to the right side through bone conduction.-In mild sensorineural deafness in right ear, air conduc-tion will be better than bone conduction (Rinne's test positive in right ear), and Weber's will be lateralized to the left side because it has better cochlear function than the right ear. -In severe sensorineural deafness in the right ear (dead ear), both air conduction and bone conduction may be absent, but Rinne's test will be false negative in the right ear due to use of bone conduction in the normal left ear. Weber's test will be lateralized to viable left side. Vestibular Testing The vestibular system maintains the normal posture by work-ing in conjunction with visual and proprioceptive inputs, which are integrated and modulated by cerebellar influences. Most specific tests for vestibular function are not done in OSCE settings except gait, Romberg's test, and eye move-ments. The candidate, however, may remember that patients with suspected vestibular dysfunction may undergo special vestibular assessment. Testing of gait: When asked to walk with eyes open, the patients with peripheral vestibular dysfunction tend to sway to the affected side. Romberg's test: The patient is asked to stand with the feet together, initially with eyes open and then with eyes closed. Patients with peripheral vestibular dysfunction tend to sway to the affected side, whereas those with lesions of the posterior column will fall when the eyes are closed. Eye movements: Observe the eyes in primary position of the gaze. Test for pursuits and saccades (see CN-III previ-ously). The nystagmus of vestibular dysfunction has a slow labyrinthine component and a fast central corrective phase and is increased when the patient moves the eyes in the direction of the fast component. ab Fig. 2. 53 Rinne's test. (a) Air conduction. (b) Bone conduction Fig. 2. 54 Weber's test for lateralization 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

42 Position testing (Hallpike's maneuver) Caloric test Fistula test Glossopharyngeal (Cranial Nerve IX) Glossopharyngeal (CN-IX) is not tested in OSCE settings. Vagus (Cranial Nerve X) Motor nerve for muscles of palate, pharynx, and larynx. Damage to the vagus nerve is assessed through its palatine branches by assessment of the soft palate and uvula. Ask patient about regurgitation of fluids through the nose during swallowing. Ask patient to say “egg” and note for palatal dysarthria where it may sound “eng. ” In unilateral lesions, note any obvious deviation of the uvula. Ask patient to say “ah” and observe upward move-ments of both sides of palatal arches; note for any devia-tion. In unilateral palatal palsy, the uvula is pulled to the healthy side. In bilateral lesions, the palate remains motionless. Gag reflex is not done in OSCE settings. Do mention about it. Accessory (Cranial Nerve XI) Motor nerve to trapezius and sternocleidomastoid muscles. Ask patient to shrug shoulders and resist your pushing down (Fig.  2. 55a). Ask patient to turn the head to one side. Now push the chin toward the midline and ask patient to resist you push-ing it (Fig.  2. 55b). Hypoglossal (Cranial Nerve XII) Motor nerve to tongue muscles. Ask patient to open the mouth, and inspect the tongue in the floor of the mouth for wasting and fasciculation at rest. Ask patient to protrude tongue, and note for any devia-tion (Fig.   2. 56). In unilateral tongue paralysis, healthy muscles push the midline raphe to the weaker side (Fig.  2. 57a, b). Place your finger on the patient's cheek, and ask the patient to push her tongue against your finger. Wrap-Up: To complete the examination, suggest further assessments by examining the upper and lower limbs. Thank the patient. Explain your findings to the examiner. History and Physical Examination: Stroke/ Transient Ischemic Attack Candidate Information: A 64-year-old male is brought by ambulance to the emer-gency department (ED) because he had a “spell. ” ab Fig. 2. 55 Assessing motor nerve to trapezius and sternocleidomastoid muscles. (a) Patient shrugs shoulders while doctor pushes down. (b) Patient turns the head while doctor pushes against face A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

43 Vital Signs: HR, 89/min, regular; BP, 150/85 mm Hg; temp, 36. 8 °C; RR, 17/min; O2 saturation, 99% Take a focused history and perform a focused physical examination. Please do not perform rectal, genitourinary, or breast examination. Differentials: Transient ischemic attack (TIA) versus stroke (throm-botic, embolic, lacunar, hemorrhagic) Space-occupying lesions Herpetic encephalitis Brain abscess Drug overdose Trauma Epilepsy Hepatic encephalopathy Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the history. Opening: Good morning/good afternoon. I am Dr....I am your attending physician. Are you Mr....? And you are 64 years old? Is it alright if I ask you a few questions about your recent 'spell'? I would also like to do a relevant physical examination. In the end we will discuss the plan. During the history or examination if you have any questions or if you feel any discomfort, please let me know. Is this alright? Fig. 2. 56 Check tongue for any deviation Fig. 2. 57 Hypoglossal nerve palsy. (a) Right tongue mounding at rest. (b) Tongue deviation, the healthy left side pushing midline raphe to the right. (Reprinted with permission from Shikino et al. [8]) 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

44 History of Present Illness: Onset: “Did the symptoms start suddenly or gradually?” Course: “Are the symptoms changing with time? Are these getting worse or getting better?” Duration: “How long?” Site: “Which side? Or both?” -Face -Arm -Leg -Whole one side Severity of symptoms: “How weak is it? Able to move at all? Or partially weak?” Handedness: “Are you right handed or left handed?” Associated Symptoms: Numbness and tingling Slurred speech Dizziness Changes in vision: double vision, curtain drop (TIA), or light flashes (retinal detachment) Loss of consciousness Headache Fever Nausea or vomiting Sweating Skin changes (color, swelling, and warmth) Recent head or spine trauma Risk Factors: Age (elderly) High blood pressure High cholesterol High blood sugar (Diabetes mellitus) Family history of heart attacks or stroke Atrial fibrillation Prior myocardial infarction (MI) Obesity Drug abuse Smoking Clotting disorder/hypercoagulable state Peripheral vascular disease Lifestyle (no exercise, fatty food) Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” History of stroke, TIA, heart attacks, chest pain, hyperten-sion (HTN), DM, atrial fibrillation, neurological disease (sei-zures, migraine, MS, aneurysms)? Medication History: “Are you taking any medication (ASA, clopidogrel, warfarin), prescribed, over the counter, or herbal and any side effects?” If patient says no, then con-tinue to next question. Allergic History: “Do you have any known allergies?” Personal History: “Please tell me about yourself. ” Can be asked in any sequence: marital status, occupation, religion, education, type of residence, living conditions. “Do you have problems at work? How are you doing at work?” “Have you had any recent event in the family such as an accident or someone died?” Social History: “Do you smoke or does anyone else in your home or someone close at work smoke?” “Do you drink alcohol?” If yes then further ask: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes: “Which one? How long? When?” Specially ask about IV drug use (red flag for back pain). Family History: Marital status, number of children, any significant history in first-degree relatives Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for a living?” “Working status and occupation?” “Educational status?” “Who lives with you?” Support: “Do you have good family and friends support?” Functional status or severity or impact on life activities? Stroke-/TIA-Related Examination Mention here: “I am going to perform a physical examina-tion. Should we start?” Vitals: Start with checking ABC (airway, breathing, circulation). Continue with the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, tem-perature, and O2 saturation. ) Comment on the vital signs findings: Vital signs are nor-mal or mention if any abnormal finding. (Look for hypertension) General Appearance: Level of consciousness Distress or calm Brief mental status A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

45 Inspection: Face/eyes/limbs/gait Cranial Nerve Examination: II/III/IV/V/VI/VII/VIII/X/ XI Muscle Tone: Upper and lower limbs Muscle Power: Upper and lower limbs Reflexes: Babinski's extensor Sensory: Light touch and pinprick Two-point discrimination Cerebellar Examination Cardiovascular: Listen for the heart sounds (observe for murmur/heart failure/arrhythmia, carotid bruit) Respiratory System: Listen for respiratory sounds. Wrap-Up Question: What is the next step in management? Answer: Blood tests: Complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, electrocardiogram (ECG), computed tomography (CT) head (urgent). Further tests: Holter, 2D echo, carotid Doppler. Call medical unit/stroke team/neurology on call immedi-ately after ordering CT head for further management. Physical Examination: Unilateral Facial Weakness: Bell's Palsy Candidate Information: A 38-year-old female comes to your clinic with unilateral facial weakness for the past 2 days. Vital Signs: Temp, 36. 8 °C; HR, 84; BP, 120/68; RR, 12 Please perform appropriate neurological examination. No history is required for this station. Please do not perform a rectal, genitourinary, or breast examination. Differential: Immediately consider the differential of unilateral facial weakness. Unilateral facial weakness may be of a lower motor neuron type due to lesions of facial nucleus or infra-nuclear structures such as facial nerve or of upper motor neu-ron type due to involvement of supranuclear areas such as corticospinal tract. The key aim of the examination is to confirm unilateral facial weakness, identify and classify the type of facial weak-ness (lower or upper motor neuron type), and then perform the relevant neurological examination to find the underlying cause. It is imperative for the examiner to verify that there is no evidence of neurological deficit of any associated cranial nerve or of long tracts, e. g., pyramidal tract. The exact cause of Bell's palsy remains unknown, but possible etiologies include: Viral infection Diabetes mellitus Hypertension Ear disease -infection of the middle ear or cholesteatoma Parotid tumor Facial trauma to the temporal bone or stylomastoid foramen Rare causes include: -Lyme disease -tick bite in an endemic region plus rash, arthritis, or hearing loss. -HIV infection -this facial nerve palsy is 100 times more common in HIV-positive patients than in immu-nocompetent patients. -Syphilis. -Systemic lupus erythematosus. -Sjögren's syndrome -causing dry eyes and dry mouth. -Sarcoidosis -may cause bilateral facial nerve palsies. -Heerfordt's syndrome -a combination of facial nerve palsy, anterior uveitis, and enlargement of the parotid gland. -Melkersson-Rosenthal syndrome -granulomatous condition causing swelling of the face, oral mucosa, gums, and lips, which is associated with recurrent facial nerve palsy. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 38 years old? Is it alright if I examine you for your facial weakness, and then we will discuss about the plan? During the examination if you feel any discomfort, please let me know. ” 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

46 Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Miss... vital signs are within normal range. ” You should do a full neurological examination in all patients who complain of facial weakness. If the patient has any other neurological signs then Bell's palsy is ruled out. Inspection: Pronator drift has a high sensitivity for diagnosing stroke. Inspect for facial asymmetry -eyebrow sagging, the absence of the nasolabial fold on the affected side, and deviation of the mouth to the non-affected or healthy side. Distinguish a lower motor neuron from an upper motor neuron facial palsy. In upper motor neuron lesion involving pyramidal tract, contralateral muscles moving the mouth are affected, whereas muscles of the forehead and eye closure are spared. Lower motor neuron type facial weakness equally involves the facial muscles of the forehead and eye closure on affected sides. Examine for facial weakness affecting one side of the face. To assess this, examine the movements of the fore-head, eyes closure, and mouth (Fig.  2. 58). Ask the patient to raise her eyebrows/frown and look for any asymmetry of forehead. Ask the patient to close her eyes tightly; assess the ability of the patient to resist opening her eyes. Ask the patient to show her teeth -note for deviation of angle of mouth. In seventh nerve palsy angle of mouth is pulled toward the healthy side. Look for a parotid mass. Localization for Cause of Bell's Palsy Examine external auditory meatus and mouth for zoster vesicles or scabbing (Ramsay Hunt syndrome). Cranial nerve examination for cerebellopontine angle lesions. Examine for extraocular eye movements (sixth nerve palsy causing failure of abduction), fifth cranial nerve (loss of corneal reflex and impaired facial sensation), and eighth cranial nerve (ipsilateral hearing loss). Localization for Site of Bell's Palsy Asking the patient for disturbed taste as the facial nerve carries signals for taste from the anterior two-thirds of the tongue. Check for excessive tears on the affected side as the facial nerve carries fibers to the lacrimal glands. Ask the patient for hyperacusis or reduced ability to toler-ate ordinary levels of noise as the facial nerve has a branch that supplies stapedius. Wrap-Up: To complete the examination, suggest further assessments by neurological examination of cranial nerves and long tracts. Thank the patient and cover her. Droop y eyelid, dr y eye, or excessive tears Facial paralysis, twitching, or weakness Drooping cor ner of mouth, dry mouth, or impaired taste Fig. 2. 58 Bell's palsy. (Modified from original drawing by Patrick J.  Lynch, medical illustrator. Under license of CC BY 2. 5 (https:// creativecommons. org/ licenses/by/2. 5). https:// upload. wikimedia. org/ wikipedia/commons/3/33/ Bells_palsy_diagram. svg) A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

47 Question: What is your clinical diagnosis? Answer: “My patient appears to have Bell's palsy on the... side. ” Question: What is Bell's palsy? Answer: “It is a paralysis of one side of the face due to peripheral facial nerve dysfunction. It typically comes on over 12-36 h. Many patients experience pain around the ear, altered taste, or a feeling of facial numbness a day before developing the facial weakness. “The weakness is initially progressive, reaching its maxi-mum within 2-3 weeks. Most untreated patients recover over 3 months. ” Question: What neurologic findings are present in favor of your diagnosis? Answer: “Facial asymmetry with sagging of left eyebrow and flat-tened left nasolabial fold. ” “On frowning, the left forehead has less wrinkling. ” “The left eye is opened with minimal force as compared to the right when the patient attempts to resist opening of her eyes. ” “The angle of the mouth is pulled to the right when the patient is asked to show her teeth. ” “Fifth, sixth, and eighth cranial nerves are tested as nor-mal. There is no pronator drift and I could not see any vesicle in the external ear. ” Question: When would you recommend a cranial imag-ing for a case of Bell's palsy? Answer: Cranial imaging is generally reserved for patients in whom: The physical signs do not fully fit the picture for Bell's palsy. The neurological deficit continues to progress beyond 3 weeks. There is no improvement at 3 months. Question: How would you treat a case of Bell's palsy? Answer: Most of the patients with Bell's palsy will recover without any drug treatment. Oral prednisolone, if given early within 72  h, results in better outcomes for patients. Prednisolone tablet is given for 10 days, 50 mg/day for 10 days or 60 mg for 5 days, followed by 10 mg daily reductions for a total course of 10 days. Question: What is the role of antiviral agents? Answer: Antiviral agents have been shown to be ineffective when used alone and offer no benefit when used in combina-tion with prednisolone. However, they may be recommended where herpetic vesicles are seen (Ramsey Hunt syndrome). Question: When should you refer the patient for eye care? Answer: If the patient is unable to close the eye properly, she will need an urgent eye care referral. It is important to assess if the patient is able to close the eyes properly. The patient can use artificial tears, eye lubricants, and eye pads during the night and should wear glasses. In severe cases patients may need surgery to protect the cornea, such as tarsorrhaphy, to narrow the distance between the eyelids. Alternatively, botulinum toxin can be injected into the upper eyelid to keep it closed. Question: When should you refer a patient with Bell's palsy to a neurologist? Answer: Patients with Bell's palsy are referred to a neurol-ogist if the: Diagnosis is in doubt. Presentation is atypical. Symptoms slowly progress beyond 3 weeks. Patient does not recover function by 3 months. Patient has bilateral facial palsy. Patient is pregnant. Question: What is the outcome of Bell's palsy and what are the factors affecting such outcome? Answer: The outcome is usually good with or without treatment. Approximately 70% of untreated patients will make a full, spontaneous recovery, and 85% of untreated patients will make a near normal recovery within 6 months. The chances of recovery appear to be the same with or with-out treatment. Factors conferring a more favorable functional include children (<14 years), patients with post-auricular pain, patients having incomplete paralysis, and patients with normal taste, hearing, salivation, and lacrimation. Outcome may be less favorable in people with diabetes and in pregnant women. Question: What is the role of physical therapy? Answer: There is no evidence that physical therapy has any beneficial role in treatment of facial palsy. 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

48 History: Headache: Migraine Candidate Information: A 33-year-old female comes to your clinic with recurring headache. Vital Signs: Temp, 36. 7 °C; HR, 80; BP, 110/65; RR, 16 Please take a detailed history. No examinationis required for this station. Differential: Immediately consider the common differential of headache that may be presented here. Remember, few patients with headache have clinical signs, and clinical assessment depends upon the history. Migraine. Tension headache. Temporal arteritis. Cluster headache. Subarachnoid hemorrhage/epidural hematoma. Brain tumor. Meningitis. Cerebral abscess. Please do not forget to rule out underlying drug seeking behavior, spouse abuse, and depression in patients pre-senting with vague headaches. It is important to identify the features in history that may fit into those of primary headaches. Symptoms suggestive of secondary headaches are carefully explored to rule out any sinister cause. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 33 years old? Is it alright if I ask you few questions about your headache, and then we will discuss about the plan? During the history if you have any question or you feel any discomfort, please let me know. ” History of Present Illness: “Tell me about your headache. Is that right that you have been having recurring episodes of headache?” Onset: “How did it start? Sudden versus gradual?” Course: “Is it increasing or decreasing or is it the same?” Duration: “How long has it been going on?” “How long for each attack?” “How frequent?” Variation: “Did you notice any variation?” -“Is it the same throughout the day?” -“Does it awaken you at night?” Patterns of pain? Quality (throbbing, constricting, pressing/tightening, stabbing, burning, ice pick-like) Region: “Where is it exactly?” (unilateral, bilateral, occipital) “Is the part where it hurts tender (temporal arteritis), and do you feel a cord-like structure there?” Severity: “How will you mark your pain from 0-10? 10 being the worst and 0 as no pain. ” Timings -Duration of untreated pain/relation with aura? “How old were you when your headache began? Age of onset?” “What is the pattern of the headache episodes since its beginning?” “How frequent is the pain?” “Has it happened before?” Radiation: “Front, side, back of head, or in the eyes, ears, or throat?” “Can you say it is the worst headache of your life?” Triggers (not when single episode) “How has it affected your daily life?” “How are you coping with it?” “What brings on the attack?” -Sleep deprivation or sleep excess (weekend migraine) -Travel -Extremes of weather -Bright lights -Loud noise -Strenuous exercise -Menstruation -Sexual activity -Strong emotions -Lack of food -Special food or drink Referred Pain: Eyes: “Did you notice any redness or need eyeglasses?” Sinusitis: facial pain or recent flu symptoms Throat pain Dental pain Neck pain Memory: “Did you notice any changes in your concentration?” “Did you recently tend to forget things?” A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

49 Alleviating Factors: “Did you try any medication? What were the results?” Aggravating Factors: Bring up with bright lights (migraine) Eating (jaw claudication) Alcohol (cluster headache) Lying down or bending forward or on coughing or lifting weight (increase intracranial pressure [ICP]) Certain foods (migraine) Eye strain or poor vision (vision correction) Coughing or straining Physical activity (walking, climbing stairs) Associated Symptoms: “In addition to your headache did you notice any other symp-toms?” (Try and go through constitutional symptoms first as you may forget them. ) Nausea and/or vomiting Fever Neck pain Skin rash Ear infection Photophobia (an abnormal sensitivity to or intolerance of light) Phonophobia (a fear of sounds, noise, and one's own voice) Neurology Screen: Loss of consciousness Weakness/numbness in the limbs Difficulty in balance or repeated falls Difficulty finding words Vision changes: What type of problem? Hearing abnormalities Difficulty swallowing Changes in bowel/urine; loss of bladder control Any seizure Trigeminal autonomic features (lacrimation, nasal con-gestion, rhinorrhea, conjunctival injection, facial sweat-ing, ptosis, miosis) Screen for Mood Disorder: “How is your mood nowadays?” If patient says good, then skip further psychiatric screening. Otherwise go through the mood screening. Constitutional Symptoms: Fever, night sweats, loss of weight, loss of appetite Past Medical History: “How is your health otherwise? Do you have any previous health issues?”Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “What relieving treatment have you used for your headache? Have you tried any long-term treat-ment for your headache? Are you taking any other medica-tion, prescribed, over the counter, or herbal? Are you taking oral contraceptives?” Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have similar symptoms or any ongoing health problem?” Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both? Number of partners. ” Self-Care and Living Condition Functional status or severity or impact on life activities? Wrap-Up Question: What would you like to do next? Answer: “I would like to do general physical and neurologi-cal examination. I would also like to order some tests. ” Question: Do you want to do any neuroimaging? Answer: “The choice of doing neuroimaging would depend upon the findings of history and clinical examination. See below. ” Question: What acute treatment would you recommend to abort an attack? Answer: “The acute attack of migraine can be aborted by use of appropriate doses of a nonsteroidal anti-inflammatory drug (NSAID) (aspirin or ibuprofen), or a triptan (sumatrip-tan or zolmitriptan or almotriptan, etc. ). ” Question: Doctor, what is going on with me? Answer: Explain about migraine. “Headache is the most common symptom seen in neurology practice. Lifetime prevalence of headache is up to 99%. Though often incapaci-tating, most headaches are not caused by potentially serious neurological illness. The most common primary headaches are migraine and tension-type headaches. ” “Migraine is the most common cause of disabling head-ache in the general population, particularly in women. It usu-ally starts at puberty. A small percentage of patients have their pain preceded by an aura (migraine with aura), which is 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

50 mostly in the form of fully reversible visual symptoms including positive features (e. g., flickering lights, spots, or lines) and/or negative features (i. e., loss of vision or homon-ymous visual symptoms). Other patients may experience fully reversible unilateral sensory symptoms including posi-tive features (i. e., pins and needles) and/or negative features (i. e., numbness) or fully reversible dysphasic speech distur-bance (motor deficit is not a feature of migraine aura). At least one aura symptom develops gradually over >5 minutes and/or different aura symptoms occur in succession over >5 minutes; each symptom lasts >5 and <60 minutes. ” “The frequency of pain in migraine is extremely variable. An occasional attack in lifetime to recurrent and incapacitat-ing three to four attacks a week. The pain is unilateral in more than 50% of patients but tends to switch sides in subse-quent attacks. ” Question: When would you ask for neuroimaging? Answer: Thunderclap headache Headache of increasing frequency or severity Persistent vomiting and increasing frequency or severity of headache on waking Headache triggered by coughing, straining, or postural changes History of seizures, confusion, or altered consciousness Any symptoms suggestive of focal neurological deficit Any focal neurological signs Papilledema Question: How can you avoid or prevent another episode of headache? Answer: “Some patients find it very helpful to avoid the trig-gers that precipitate the headaches. In other patients, who have frequent and severe attacks, daily medication to prevent further attacks may be started. These drugs are selected for individual patients and may include beta blockers (proprano-lol), antiepileptic drugs (topiramate or valproate), pizotifen, methysergide, and NSAIDs such as naproxen. Patients tak-ing estrogen-containing oral contraceptives are advised to stop these preparations. ” Question: How would you reassure your patient? Answer: “Headache is an extremely common symptom, and only a minority of the population does not have headaches. Although she has distressing and incapacitating symptoms, they have no potential harmful effects if neurological exami-nation and relevant investigations are normal. ” “Minimal disruption of social life and employment by migraine is also reassuring. ” “Long-term prognosis and life expectancy in patients with migraine without aura are good. ”“The attacks are manageable using the most appropriate drugs available in the market. ” “Some treatments may be expensive, but the cost is still less than being absent from work or being substantially less effective even when present at work. Further Reading Temporal arteritis (TA): Description of TA is very important. TA is seen in elderly. Unilateral lancinating pain with swell-ing and tenderness in the temporal area (when combing hair), jaw claudication, amaurosis fugax, or sudden blindness usu-ally in one eye, with underlying symptoms (50%) of polymy-algia rheumatica (subacute onset <2 weeks of symmetrical aching, tenderness and morning stiffness in shoulder and proximal limb muscles +/-mild polyarthritis, tenosynovitis, carpal tunnel syndrome [10%], fatigue, fever, decrease in weight, anorexia and depression) should raise the suspicion of temporal arteritis. No weakness or atrophy. Increased CRP/ESR, CK normal. TA responds well to steroids. Prednisolone should be started immediately. The risk is irre-versible bilateral vision loss, which can occur suddenly if not treated [1]. ” History and Physical Examination: Meningitis Candidate Information: An 18-year-old female presents with fever, photophobia, and neck stiffness. Please manage the patient. Vital Signs: HR, 110/min, regular; BP, 110/70  mm Hg; temp, 39. 0 °C; RR, 19/min; O2 saturation, 99% Take a brief history and perform a focused physical examination. Please do not perform rectal, genitourinary, or breast examination. Please address the patient's concerns. Differentials: Meningitis Acute encephalitis Intracranial abscess Brain tumors Subarachnoid hemorrhage Meningitis: Elderly and immunocompromised: Streptococcus pneumoniae, Listeria monocytogenes, tuberculosis (TB), gram-negative organisms Adults and older children: S. pneumoniae, Haemophilus influenzae type b, Neisseria meningitidis, gram-negative bacilli, and L. monocytogenes Younger than 4 years and unvaccinated: N. meningiti-dis, S. pneumoniae Infants and young children: H. influenzae type b A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

51 Neonates: group B streptococci, L. monocytogenes, Escherichia coli Hospital-acquired and post-traumatic meningitis: Klebsiella pneumoniae, E. coli, Pseudomonas aerugi-nosa, Staphylococcus aureus Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand or sit on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 18 years old? I am going to ask you few questions, and then I will do physi-cal examination. Should we start?” History of Present Illness: (Start with fever: onset, course, and duration) “When did your fever start?” “How did it start? Gradual or sudden?” “Is your fever getting better or worse?” “Did you check your fever with a thermometer? What was the temperature?” “Do you feel hot and cold/chills/rigors?” Associated Symptoms: Increased intracranial pressure: Headache, confusion, visual changes (photophobia), irritability, nausea, vomit-ing, seizure Meningeal: Photophobia, neck stiffness, rigor, myalgia, diaphoresis Risk Factors: Malnutrition, head injury, mastoiditis, otitis media, endocarditis, pneumonia, immunosuppression (AIDS, splenectomy) Environmental Risk Factors: Daycare centers, household contact, nursing home, and travel to endemic regions. Contact with meningitis at work or school. Precipitating or Aggravating Factors: “Is there anything that makes your symptoms better or worse?” Review of Systems: “Any cough?” “Shortness of breath?” “Any hoarseness?” “Any problem with listening to sound/loud sound (phonophobia)?” “Any chest pain?” “Any rash?” “Any muscle aches?” “Any abdominal pain?” “Any nausea/vomiting?” “Any loss of appetite?” “Any change in bowel habits?” “Any change in urination?” “Have you had any fatigue?” “Have you had contact with any sick individuals recently?” “Any recent travel?” Past Medical History: “How is your health otherwise? Do you have any previous health issues?” Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any previous surgeries?” Medication History: “Are you taking any prescribed medi-cations? Any over the counter or herbal remedies?” Allergic History: “Do you have any known allergies?” Family History: “Is anyone in your family having similar symptoms or any ongoing health problems?” Social History: “Do you smoke? Do you drink any alco-hol? Have you ever tried any recreational drugs? Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “Where do you live?” Functional Status: “How is this impacting you?” Meningitis Examination: “Now I will start the examination. Should we start?” Start with reviewing the vital signs. Vital Signs: HR, 125/min, regular; BP, 110/70  mm Hg; temp, 39. 0 °C; RR, 19/min; O2 saturation, 99% Comment on the vital signs: there is tachycardia and high temperature of 39. Then go through ABC (airway, breathing, circulation): Start with checking ABC Quick Glasgow Coma Scale evaluation. General appearance: -Level of consciousness -Distress or calm -Brief mental status 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

52 Inspection: face, eyes, limbs, gait (papilledema) Meningeal: Stiff neck with passive movements (moving chin toward chest) Kernig's sign: Pain and resistance on passive knee exten-sion when hip fully flexed (Fig.  2. 59a, b). Brudzinski's sign: Abrupt neck flexion in the supine patient resulting in involuntary flexion of the hips and knees (Fig.  2. 60a, b). Muscle tone: Upper and lower limbs Muscle Power: Upper and lower limbs Reflexes Babinski's extensor Sensory: -Light touch and pinprick -Two-point discrimination Cerebellar examination Cranial nerve examination: II, III, IV, V, VI, VII, XI Cardiovascular: Listen for the heart sounds (observe for murmur/heart failure/arrhythmia, carotid bruit) Respiratory system: Listen for respiratory sounds. Wrap-Up: Comment on your findings. Thank the patient and tell the patient they can now cover up. Ask the patient if she has any questions. Question: What is the next step in management? Answer: Blood tests: CBC, electrolytes, BUN, CRP, creatinine, blood culture, PCR for S. pneumoniae or N. meningitidis; CT head is indicated to rule out alternative diagnosis in patients with altered consciousness or focal neurological signs. Arrange for lumbar puncture (mention that you will need to get an informed consent from the patient). Question: What are the contraindications for lumbar puncture? Answer: Focal infection at the site of puncture ab Fig. 2. 59 (a, b) Kernig's sign ab Fig. 2. 60 (a, b) Brudzinki's sign A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

53 Bleeding tendency (systemic anticoagulation, thrombocytopenia) Clinical signs of raised intracranial pressure: -Altered level of consciousness -Focal neurology -Recent seizures Brain stem signs (pupillary changes/posturing/irregular respiration) Abnormal CT head (Arnold-Chiari malformation) Cardiopulmonary compromise: which may further dete-riorate with positioning for lumbar puncture Question: Bacterial meningitis is commonly caused by which bacteria? Answer: Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, Group B streptococci, and Listeria monocytogenes. S. pneumoniae causes pneumococcal meningitis. N. meningitidis: usually local outbreaks among young adults. There is increased incidence in late winter or early spring. There are five subtypes that cause serious illness, which are A, B, C, Y, and W-135. Meningococcal menin-gitis is endemic in parts of Africa, India, and other devel-oping nations. Periodic epidemics occur in sub-Saharan Africa as well as among religious pilgrims travelling to Saudi Arabia for the Hajj. Question: What is going on with me? Can you please tell me more about meningitis? Answer: Meningitis is an inflammation of the meninges, which are the coverings of the brain and the spinal cord. It can be caused by viruses, bacteria, parasites, and even by fungi. Viral meningitis is common. Management of viral meningitis is mainly supportive treatment. Antibiotics are not used for viral meningitis and most patients recover fully. Bacterial meningitis can be serious and can cause a number of complications. Patients with bacterial meningitis are promptly treated with antibiotics and supportive treatment. Question: What are the symptoms? Answer: Meningitis can make the patient very sick. The symptoms may develop over a short period of time in a day or two and then can rapidly become worse. Adults with men-ingitis may have high temperature, severe headache, neck pain/stiffness, sensitivity to bright lights (photophobia), con-fusion, alerted conscious level, aches, and pain in the body. There may be a rash of tiny, red purple spots or bruises caused by bleeding under the skin and can occur anywhere on the body. This is a serious sign and indicates blood poi-soning with meningococcal strain. Question: Is there a vaccine? Answer: A vaccine against four of the meningococcal sero-groups (A, C, Y, W-135) is available. This vaccine is recom-mended by some groups for college students, particularly freshmen living in dorms or residence halls. The vaccine is safe and effective (85-90%). It can cause mild side effects such as redness and pain at the site of injection lasting up to 2 days. Immunity develops within 7-10 days and lasts up to 5 years. History and Counseling: Seizures Candidate Information: A 28-year-old female reports to your clinic. She has been diagnosed with a seizure disorder and intends to seek advice concerning her seizures. Please take a brief history and counsel the patient. Differentials: Adults: -Trauma: Head injury, post brain injury seizure -Metabolic: Hypoglycemia, hyponatremia, hypoxia, hypocalcemia -Brain: Intracranial hemorrhage, tumor, TIA -Infections: Meningitis, encephalitis -Substance abuse: Drug withdrawal -Sleep disorders: Narcolepsy -Pseudo seizures -Syncope -Panic attacks Children: -Genetic and congenital abnormalities -Infections -Trauma -Metabolic Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand or sit on the right side of the patient and start the interview. 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

54 Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 28 years old? I understand you here because you were diagnosed to have seizures. I am going to ask you few questions. I will be happy to answer your questions and concerns. ” History of Present Illness: (History about seizure) Onset: “At what age did you have your first fit?” or “When did the seizure begin?” Duration: “How long does the seizure last?” Frequency: “How often? Have you had similar episodes before?” “Has there been any change in pattern recently?” “Do you think something is making these seizure worse?” Recurrence or provoked/unprovoked (triggered by nonad-herence to anti-seizure medicines, sleep deprivation, stress, medicines interaction, alcohol/drug withdrawal, infection or any other illness) “Are these coming more frequently?” “When was the last fit?” Aura: “Did you notice any symptoms that may warn you of a seizure? Like numbness, paresthesia, strange taste, smell, flashing lights, rising abdominal sensation, dreamy state, deja vu or jamais vu, dizziness or fainting sensation?” “What did the episode look like/feel like?” “Did someone observe your fits?” (Need to take collateral history from bystanders. ) Symptoms suggestive of generalized tonic-clonic seizures: Loss of consciousness, rigidity, crying out, cyanosis, cya-notic, head turning, eye deviation, staring or eye deviation, jerky movement, urine/fecal incontinence, salivation, lip smacking, chewing, picking up cloths, tongue bite. Events after episode: Confusion, somnolence, paralysis, trouble with speech, amnesia, tiredness, muscle ache, headache and a desire to sleep. Rule Out Differentials: Vasovagal syncope: Light-headedness, diaphoresis, visual changes (blurred vision), and nausea. Infections: -Any cough? -Shortness of breath? -Any chest pain? -Any headache? -Any rash? -Any muscle aches? Neck pain? -Any abdominal pain? -Any nausea/vomiting?-Any contact with sick individuals recently? -Any recent travel? Cardiac: -Palpitation -Chest pain -Shortness of breath History of head injury Past Medical History: “How is your health otherwise? Do you have any previous health issues?” Birth trauma, epilepsy, seizure disorder, head injury, stroke, central nervous system (CNS) infection Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any previous surgeries?” Medication History: “Are you taking any prescribed medi-cations? Any over the counter or herbal remedies? Anti- seizure medicines?” If yes, then ask about adherence and plasma levels. If non complaint then should ask: “How frequent?” Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have a sei-zure disorder? Or any other ongoing health problems?” Social History: “Do you smoke? Do you drink any alco-hol? Have you ever tried any recreational drugs? Drug withdrawals?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Functional Status: “How is this impacting you?” Wrap-Up: If patient was diagnosed with generalized tonic-clonic epi-lepsy, ask if patient wants to know about it. If the diagnosis has not been established yet, then the next step will be to perform a complete neurological examination followed by ordering tests. These should include routine blood test (full blood count, electrolytes, liver and kidney function tests, blood glucose), pregnancy tests in young females, and ECG. A CT scan of head is indicated if there are features suggesting altered consciousness, focal neurological signs, history of brain injury, known HIV status, suspected intra-cranial infection, and bleeding disorders. An electroen-cephalogram (EEG) can be planned according to the history clues. A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

55 Question: I have just been diagnosed as having epilepsy. I want to know what can I do and cannot do? Answer: “People with seizures should try to lead as normal a life as possible. There are, however, some safety precau-tions that should be taken to avoid injury. These include avoiding potentially dangerous activities, e. g., swimming unaccompanied, working at rooftops and unguarded heights, and working near heavy machinery or fire. There is also a restriction on driving for patients with uncontrolled seizures. ” Question: When can I start driving? (Last seizure 4 months back) Answer: “You are currently not allowed to drive with your last seizure only 4  months ago (please check with your regional guidelines). When you are seizure free for 1 year you may apply for reinstatement of your license. A medical review committee may be asked to look at your case and make an assessment based on your circumstances. ” Question: Can I use oral contraceptives? Answer: “Some of the antiepileptic drugs (AEDs) such as phenobarbitone, phenytoin, carbamezapine, oxcarbazepine, and topiramate accelerate the liver metabolism of combined oral contraceptives (COCs) and progesterone-only contra-ceptives and reduce their efficacy. Lamotrigine is not an enzyme-inducing agent but also interacts with COCs. The blood concentration of lamotrigine is lowered by the estro-gen component of COCs. This may be clinically relevant if seizure frequency is increased after initiation of COCs. In this case, the dose of lamotrigine may have to be increased on initiation of COCs and reduced on withdrawal. There is, however, no restriction on use of non-hormonal contraception in women with epilepsy. ” Question: Is it safe to get pregnant and have children? Answer: “Epileptic women usually have normal preg-nancies, though their relative risks are perhaps double than those for the non-epileptic population. Yes, it is safe to be pregnant with seizures. You must discuss this issue with your neurologist and obstetrician before you plan to get pregnant. The levels of lamotrigine can sometimes fall in pregnancy by 50%, particularly in the second and third trimesters. The dose of lamotrigine needs careful adjustment and monitoring of drug levels can be useful. There is no conclusive evidence of an increase in obstetric risk in epilepsy. ” Question: Risk to fetus? Answer: “Well-controlled seizures with no falls in preg-nancy offer no risk to the fetus. Although AEDs, especially valproate, have been linked to congenital abnormalities in the fetus, the risk with mono-therapy with lamotrigine is almost the same as for women with epilepsy taking no AEDs. You should start taking folic acid tablets, 5  mg daily, from at least 3  months prior to conception. ” Question: What are the chances of my children having the same disease? Answer: “In general, seizure frequency in children of epileptic women is about four times the general popula-tion's risk of seizure regardless of the seizure type of mother. The risk is higher with inherited forms of epi-lepsy, in mothers who have had seizures at a relatively younger age, and presence of EEG abnormalities in child at risk. ” “Genetic counseling may be helpful in the precise quanti-fication of risk. ” Question: What are the employments that I should avoid with epilepsy? Answer: “There are no restrictions for people with seizures to work at most places, but epileptics are not hired as pilots or underwater divers. They must avoid working at heights or with dangerous machinery. ” “Oversedation due to AEDs is rarely a problem, but it may affect a patient's ability to work. ” Question: Can I plan for a holiday to the Far East? Answer: “People with seizures are encouraged to live a normal life. Long-distance travel with time zone changes may cause sleep deprivation. Benzodiazepines may help. Excess alcohol and lack of sleep may provoke seizure in some epileptics. You should carry enough amounts of AEDs when travelling. 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

56 Further Reading: See Table  2. 4 for comparison between symptoms of syncope and seizure and Table  2. 5 for compari-son between seizure and pseudoseizure. History and Examination: Dizziness: Benign Paroxysmal Positional Vertigo Candidate Information: A 54-year-old woman presents to your clinic complaining of dizziness. Vital Signs: Temp, 36. 6 °C; HR, 89; BP, 140/79; RR: 15 Please take a focused history and perform the relevant examination. Differential: Immediately consider the common differential of vertigo that may be presented here. Remember, history plays a key role in the diagnosis because many patients with vertigo may have no apparent clinical signs. A careful history from the patient and any witnesses is essential, as the history alone may provide the diagnosis or at least guide to the appropriate examination or test. Benign paroxysmal positional vertigo (BPPV) Acute vestibular neuronitis Ménière's disease Vestibular migraine Stroke Multiple sclerosis Intracranial neoplasms The aim of the history taking from a patient with recur-ring vertigo is to identify the features in the history that may fit into those of peripheral vestibular lesions. Symptoms sug-gestive of brainstem lesion are carefully explored to rule out any potentially serious cause. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand or sit on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr....I am your attend-ing physician. Are you Miss... ? And you are 64 years old? Is it alright if I ask you a few questions about your dizziness, and then we will discuss about the plan? During the history if you have any question or you feel any discomfort please let me know. ” History of Present Illness: The potential diagnoses vary widely and include neurologi-cal, cardiovascular, metabolic, vestibular, and psychological conditions. 1. When a patient complains of dizziness, it is important to clarify this symptom first. Determine that the patient's symptoms are those of vertigo. 2. Determine whether the patient has a peripheral or cen-tral cause of vertigo. Carefully ask for associated symptoms. Vertigo versus another type of dizziness: -Vertigo: Ask open questions, such as “Tell me what it feels like?” Do you feel anything moving around you?” Most patients will often make a gesture of rotating a finger around their head or indicate a revolving Table 2. 5 Comparison between seizure and pseudoseizure Seizure Pseudoseizure Age Any Less common in elderly Duration Brief May be prolonged; sometimes for long time, with intermittent relaxation Isolation Alone or in presence of others Rare alone Trigger Uncommon Emotional, Forced eye closure, Pelvic thrust, Side-to-side head movement, Crying Symptoms Stereotypic Synchronous Face involved Rigidity, clonic jerking Injury Frequent Rare Timing Any Never during sleep Urinary incontinence May be present Rare Table 2. 4 Comparison between symptoms of syncope and seizure Syncope Seizure Aura Light-headedness or dizziness Specific aura Duration Brief Brief or can be prolonged Time Daytime Any time Position Upright Any position Injury Rare Frequent Autonomic features Present Uncommon Postictal Rare Postictal confusion Urinary incontinence Rare Variably present A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

57 spinning motion with their hand. Avoid asking a lead-ing question using the word “spinning. ” -Light-headedness: Ask “Did you feel faint or is there a feeling of black out?” -Disequilibrium: Ask “Do you feel unsteady on your feet or off balance?” Timing and onset: “When did the symptoms start?” Time course: “Is it worsening, resolving, or fluctuating?” Persistence: “Is it constant or occurring in episodes?” Duration of symptoms: “How long do the symptoms last?” Be careful in differentiating the duration of vertigo, feeling of off balance, and feeling of being unwell. “Vertigo is spontaneous or provoked?” Provoking factors may include standing or exercise, suggesting postural hypotension or changing position in bed or tilting the head back or bending forward, suggesting BPPV. Condition between episodes: “Do the symptoms go away completely between episodes?” History of ear symptoms (tinnitus, hearing loss, pain, dis-charge), neurological symptoms, or visual symptoms. Associated symptoms -Nausea and vomiting or motion sickness -Neurologic symptoms such as loss of consciousness or altered level of consciousness, motor weakness, speech disturbance, headache -Symptoms suggestive of auras of complex partial sei-zures such as strange taste, feeling odd or déjà vu, automatisms including lip smacking, chewing, or pick-ing on objects -Cardiac symptoms such as palpitations -Abnormal movements like limb jerking or tongue biting -Headache -Psychiatric symptoms such as mood disturbance or anxiety symptoms Past History: “How is your health otherwise? Have you had any similar symptoms previously? Is there a past history of ear disease?” Ask for other risk factors for inner ear dis-ease, such as head injury. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any other medica-tion, prescribed and over the counter or herbal?” Consider ototoxic medication or antihypertensive drugs (any recent changes in dosing). Family History: “Has anyone in your family had similar symptoms or any ongoing health problems?” Personal/Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?”Examination: “Now, I am going to perform a physical examination. ” Have the patient seated on a chair in front of you. Look for: Pulse rate and rhythm, heart sounds: Assess for car-diac causes. Postural blood pressure: A drop in systolic blood pres-sure of ≥20 mm Hg or diastolic blood pressure of ≥10 mm Hg within 3  minutes of standing suggests orthostatic hypotension. Ears: Otoscopy of both ears, tuning fork tests of hearing (see CN-VIII). Eye movements: Observe the eyes in primary position of the gaze. Test for pursuit, saccades, and nystagmus, spon-taneous and gaze evoked (see CN-III). The nystagmus of vestibular dysfunction has a slow labyrinthine component and a fast central corrective phase and is increased when the patient moves the eyes in the direction of the fast component. Neurological examination: Pronator drift has a high sen-sitivity for diagnosing stroke. Patients with a suspected TIA should have an ABCD2 score done to assist in strati-fying the risk of subsequent stroke. Examine cranial nerves and look for cerebellar signs. Inspect for facial asymmetry: Eyebrow sagging, absence of the nasolabial fold on the affected side, and deviation of the mouth to the non-affected or healthy side (see CN-VII). Gait: When asked to walk with eyes open, patients with peripheral vestibular dysfunction tend to sway to the affected side. Romberg's test: The patient is asked to stand with the feet together, initially with eyes open and then with eyes closed. Patients with peripheral vestibular dysfunction tend to sway to the affected side. Vestibulo-ocular reflex tests are performed in specialist neurotology clinics. Mention about position testing by Dix-Hallpike maneuver and caloric test. Maneuvers that evoked nys-tagmus, such as the Dix-Hallpike maneuver, are help-ful for diagnosing benign paroxysmal positional vertigo. Wrap-Up: Thank the patient. Wash hands. Suggest further assessments by examining relevant cra-nial nerves and hearing testing. Question: When would you ask for neuroimaging in a case of vertigo? Answer: Neuroimaging is usually requested in patients of vertigo with: 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

58 Focal neurologic signs and symptoms Risk factors for cerebrovascular disease Progressive unilateral hearing loss Suspected developmental defects such as Arnold-Chiari Magnetic resonance imaging is more appropriate than computed tomography for diagnosing vertigo because of its superiority in visualizing the posterior cranial fossa. Question: When would you refer a patient with dizzi-ness urgently? Answer: All patients with red flags warrant urgent referral for assessment and management. Focal neurological symptoms or signs Patients with suspected TIA or minor stroke (ABCD2 score ≥4) Unilateral, sudden hearing loss New headache Normal vestibulo-ocular reflex (VOR) as assessed by the head impulse test (which would imply that the vertigo does not originate in the peripheral vestibular system) Cardiac symptoms and signs such as irregular heart rate, associated chest pain or breathlessness, and electrocardio-gram (ECG) abnormalities Question: What are peripheral vestibular causes of vertigo? Answer: Benign paroxysmal positional vertigo (BPPV) Acute vestibular neuronitis Ménière's disease Otosclerosis Cholesteotoma Question: What are central causes of vertigo? Answer: Cerebellopontine angle lesions Vestibular migraine Transient ischemic attack or stroke Multiple sclerosis Question: What is going on (vertigo) with me? Answer: “Vertigo in a majority of patients is caused by vestibular dysfunction. The symptoms of these common causes of vertigo tend to be self-limiting because either the pathology resolves or the patient develops compensatory mechanisms. These patients are usually completely well between attacks. Few patients with potentially serious non-vestibular causes can present with vertigo or similar symp-toms. A thorough and focused history and appropriate physical examination is required to exclude these less com-mon conditions. ” Benign Paroxysmal Positional Vertigo: “BPPV is a recurrent, transient (lasting for 30 seconds to a minute), positional vertigo, which is specifically induced with head movements. The whole episode is self-limiting that lasts for a few weeks. ” “The underlying pathophysiology is otoconial debris col-lecting in one of the semicircular canals, usually posterior, and stimulating the canal when head movements are directed along the same plane as the canal. ” BPPV can be diagnosed with the Dix-Hallpike maneuver (a positional maneuver in which the patient's head is turned sideways and then the patient is tipped backward such that the head overhangs the edge of the couch). The nystagmus has a latency period of a few seconds before it comes on; it is rotatory and directed toward the ground. It fatigues down and upon repeating the Dix-Hallpike maneuver; it is much less severe. Vestibular Neuronitis: “Vestibular neuronitis is a sponta-neously occurring single attack of sudden, severe and con-tinuous vertigo, nausea and/or vomiting, and imbalance. The vertigo and nausea typically lasts for about a week, during which the vertigo is constant, even when the head is held completely still. Patients exhibit spontaneous nystagmus when instructed to look forward. The nystagmus of vestibu-lar neuronitis is mostly horizontal, with some rotatory (tor-sional) component, and is unidirectional. Patients with vestibular neuronitis can remain upright using 'furniture walking. ” Ménière's Disease: “Ménière's disease presents as recur-rent episodes of vertigo associated with hearing loss and tin-nitus. The attacks occur spontaneously and are sustained for hours, associated with a sensation of fullness in the ear. There may be severe nausea and vomiting. During a vertigo attack, the patient is completely incapacitated. ” A definite diagnosis of Ménière's disease depends upon all three of the following criteria: 1. At least two spontaneous episodes of rotational vertigo lasting at least 20 min. 2. Audiometric confirmation of a sensorineural hearing loss. 3. Tinnitus and/or a perception of aural fullness. Although these criteria exclude most other vestibular con-ditions, they cannot exclude non-vestibular diseases such as the presence of acoustic neuroma. A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

59 Stroke and Transient Ischemic Attacks (TIA): “Cerebrovascular events can affect the brainstem resulting in vestibular symptoms due to involvement of the vestibular nuclei. Vertigo is of sudden onset and may be sustained for hours. The presence of focal neurological symptoms and signs help in localization. ” Brainstem Tumors: “The possibility of a brainstem tumor such as cerebellopontine angle lesion must be con-sidered in patients who present with persistent vertigo, asymmetrical cochlear symptoms -such as hearing loss and/or tinnitus in one ear only -and involvement of mul-tiple cranial nerves in that area; e. g., trigeminal and facial nerve. ” Cerebellar Syndromes: “Patients with a cerebellar stroke have persistent vertigo and nausea. They are unable to stand. A downbeat nystagmus in a patient with vertigo may suggest pathology at the cranio-cervical junction. ” Management: Unresponsive Patient Candidate Information: A 42-year-old female was found unresponsive in the hospital parking lot. She has been brought to the emergency room. Please manage the patient. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: “The primary goal of examination of an unresponsive patient is to determine the cause of unresponsiveness (coma) and take immediate remedial measures to save the life and stabi-lize the patient. ” (Please read and follow the Basic Life Support, Advanced Cardiac Life Support, and Advanced Trauma Life Support protocols [2-6]). Triage Immediately: Once you enter the room, call the patient's name and gently shake her shoulder or hand. Apply painful stimuli to supraor-bital or sternal area. Say that the patient is unresponsive to verbal and painful stimuli. Shout for help!Mention to the Examiner: I will start with the primary sur-vey (ABCDE). Call the patient by name or check: Airway -Is the airway patent? -Open mouth to inspect tongue and teeth. -Clear mouth, if required. -Give oxygen through a face mask. -Protect airway. -Check for trachea (mid line). -Comment on airway. Breathing -Is the patient breathing? -Check respiratory rate. Observe for abnormal respira-tory pattern such as Cheyne-Stokes, acidotic breathing. -Pulse oximetry to keep Sa O 2 >95%. -Inspect the chest for asymmetry. -Auscultate the chest. -Rule out pneumothorax. Circulation -Check pulse, BP, temperature, and random capillary glucose. -Cardiac monitoring/12-lead ECG. -Pass two large-bore cannulas (G14/G16), one on each arm. -Draw blood for Lab -CBC, electrolytes (Na, K, Ca, Mg), coagulation screening, urea and creatinine, liver function tests (LFTs), glucose, thyroid profile, blood culture (if indicated). -Toxicology screen and alcohol level. -Group and Rh. Drugs-Use the following as indicated: -Thiamine 100 mg IV -Dextrose water 50 m L of 50% IV -Naloxone 0. 4-2 mg IV Disability and Neurological Status-Rapid neurologi-cal assessment should be done next: -During the primary survey a basic neurological assess-ment is made, known by the mnemonic A VPU Alert Verbal stimuli response Painful stimuli response Unresponsive -Or by using GCS (Table 2. 6) -Pupils: size, symmetry and reaction. -Any lateralizing signs. E: Exposure/Environmental Control-Clothes may need to be cut off for proper exposure, but one needs to keep in mind the prevention of hypothermia. After a quick examination cover up the patient, and prevent heat loss with warming devices, such as warmed blankets. 2 The Nervous System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

60 Secondary Survey: (When the patient is hemodynamically stable) History: -Allergy: “Do you have any known allergies?” -Medication: “Do you take any regular or prescribed medications?” -Previous medical history: “Do you have any known medical conditions?” -Last meal: “When was the last time you ate or drank something?” -Event history: “What happened?” -Try to get as much details as possible about how they feel. -Ask questions about pain. Can they feel any pain? If yes, then explore pain. Head-to-toe examination: -Check for vital signs again. -Bleeding: Check the body from head-to-toe for any signs of bleeding. -Abnormal smells: Acetone (ketosis), alcohol, or ammonia (uremia) -Head and neck: Is there any bleeding, swelling, or dent in the scalp or on the face? Eyes (Pupils): Normal pupillary size, shape, and light reflexes indicate a functioning brainstem and point to a metabolic cause of coma, a bilateral hemispherical lesion, or unilateral hemispherical lesion with secondary pressure on midbrain. Pupils become pinpoint with heavy doses of opioids and are widely dilated with atropine poisoning. Nose: Is there any blood or clear fluid coming from the nostrils? Mouth: Look for mouth injuries or burns in their mouth, loose dentures, and any foreign bodies. Ear: Observe for an appropriate response when talking to patient. Do an ear examination. Is there any blood or clear fluid coming from either ear? Skin: Note the color, marks, turgor, rash, and tem-perature of their skin. Neck: Feel for trachea, neck, and cervical spine tenderness. -Signs of meningeal irritation are elicited in meningi-tis and subarachnoid hemorrhage. -Chest: Observe the chest for rise and fall. Feel the rib cage to check for any deformity or sensitivity. -Collar bone, arms, and fingers: Feel all the way along the collar bones to the fingers for any swelling, sensitivity, or deformity. Check that the patient can move elbows, wrists, and fingers. Look for any needle marks on the forearms. -Spine: Log roll needs minimum of four people to com-plete it, one stabilizing the neck, two log rolling, and one palpating the spine. Palpate the entirety of the spine. Look at the back of the chest and back for any injuries. Also do a rectal exam. -Abdomen: Gently feel the abdomen to check for any signs of internal bleeding. -Hips and pelvis: Feel both hips and the pelvis for signs of a fracture. Check clothing for any signs of incontinence, which may suggest a bladder injury. -Legs: Check the legs for any bleeding, swelling, deformity, or soreness. Ask the patient to raise one leg and then the other and to move the ankles and knees. -Toes: Check the movements and feeling in the toes. Compare both feet and note the color of the skin. Additional investigations with secondary survey: -CT scans. -Ultrasound. -Contrast X-rays. -Angiography. -See Table  2. 7 for some medical conditions requiring urgent intervention. Wrap-Up: Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Table 2. 6 Glasgow coma score Eye opening (E) Verbal response (V) Motor response (M) Spontaneous 4Oriented 5Obeys verbal command6 To verbal command3Disoriented and converses4Localizes painful stimuli5 To pain 2Inappropriate words3Withdraws from pain stimuli4 No eye opening1Incomprehensible sounds2Abnormal flexion (decorticate) to painful stimuli3 No verbal response1Abnormal extension (decerebrate) to painful stimuli2 No motor response1 Total 15Table 2. 7 Common medical conditions that require urgent intervention Status epilepticus EEG Antiepileptics Raised intracranial pressure CT brain Treat Acute stroke CT brain Thrombolytics Hypertensive encephalopathy CT brain Antihypertensives Myocardial infarction ECG and troponins Thrombolytics Meningitis/encephalitis CSF and blood cultures Antibiotics EEG electroencephalogram, CT computed tomography, ECG electro-cardiography, CSF cerebrospinal fluid A. Hashmi and M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf