Alongside a good abdominal examination it’s important to remember that many patients you encounter in hospital may already have abdominal pathology. Stomas are common things to come across and examination can be a skill frequently assessed in OSCEs.  If you aren’t really sure what a stoma is, a good place to start is with our summary of the different stoma types.

First of all, stomas are tougher than they look! A gentle examination of a patient’s stoma isn’t going to cause the bag to fall off or cause the patient any pain or discomfort; if these bags have to stay in place and not leak as the patient goes about their daily routine they are going to be able to withstand some gentle movement by medical students and in all honestly you won’t have to touch it that much anyway.

Introduction

Introduce yourself to the patient

Confirm patient details – name / DOB

Explain procedure and obtain consent

Wash hands

Expose patient adequately

Position patient supine at a 45 degree angle

Ask the patient:

“Do you have any pain in your tummy?”

“Have you had any problems with your stoma?”

Inspection

Site

LIF: Colostomy

RIF: Ileostomy or urostomy

Number of lumens

1 and in RIF: End ileostomy or urostomy

1 and in LIF: End colostomy

2 joined and in RIF: Loop ileostomy

2 joined and in LIF: Loop colostomy

Spout

Spout present:

• Ileostomy (contents toxic to skin)
• Urostomy

No spout: Colostomy

Effluent (what’s coming out)

Hard stool – Colostomy

Soft stool – Ileostomy

Urine – Urostomy

Remember to feel the bag!

Surrounding skin quality

Any inflammation or excoriations? – infection / poor stoma maintenance 

Any evidence of complications?

Haemorrhage – Peristomal skin inflammation

Parastomal hernia – Risk of bowel strangulation and necrosis

Prolapse – High output

Retraction – Obstruction

Auscultation

Auscultate for bowel sounds:

• Absent bowel sounds – ileus
• High pitched tinkling indicates obstruction

To complete the examination…

Wash hands

Thank patient

Summarise findings

“Some Naughty Surgeons Never Stay in the Evenings and Like Porches”

• Site
• Number of lumens
• Spout
• Nature of effluent
• State of surrounding skin
• Evidence of complication
• Likely type of stoma
• Possible pathology/procedure

Example

“This patient has a stoma in the left iliac fossa with one lumen and no spout. The effluent is solid faeces and the surrounding skin is intact with no evidence of inflammation. There is no evidence of complications. This is most likely an end colostomy. To complete my examination I would perform a full gastrointestinal exam.“

References

Chest x-rays (CXR) are a frequently performed radiological investigation that you’ll be expected to be capable of interpreting (as due to the sheer volume of chest x-rays requested they are often not reported immediately). Therefore before hitting the wards as doctors it is essential that you develop the ability to interpret chest x-rays, of particular importance is the ability to recognise findings that require immediate medical attention.

Confirm details

Always begin by checking the following:

• Patient details (name / DOB)
• Date and time the film was taken
• Any previous imaging (useful for comparison)

Assess image quality

Then briefly assess the quality of the image: A mnemonic you may find useful is ‘RIPE’:

• Rotation – the medial aspect of each clavicle should be equidistant from the spinous processes
• Inspiration – 5-6 anterior ribs, the lung apices, both costophrenic angles and lateral rib edges should be visible
• Projection – AP vs PA film
• Exposure – left hemidiaphragm visible to the spine and vertebrae visible behind heart

CXR interpretation (ABCDE approach)

Airway

Trachea

Is the trachea significantly deviated?

• The trachea is normally located centrally or just slightly off to the right
• If the trachea is deviated, look for anything that could be pushing or pulling at the trachea.
• Also inspect for any paratracheal masses / lymphadenopathy

Pushing of trachea – e.g. large pleural effusion / tension pneumothorax

Pulling of trachea – e.g. consolidation with lobar collapse

Rotation of the patient can give the appearance of a deviated trachea, so as mentioned above, check the clavicles to rule out rotation as the cause.

Pleural effusion with tracheal deviation ²

Carina and Bronchi

The carina is located at the point at which the trachea divides into the left and right main bronchus.

On a good quality CXR this division should be visible and is an important landmark when assessing nasogastric tube placement, as the NG tube should dissect the carina if it is correctly placed (i.e. not in the airway).

The right main bronchus is generally wider, shorter and more vertical than the left main bronchus. As a result it is more common for inhaled foreign objects to become lodged here (as the route is more direct). 

Depending on the quality of the CXR you may be able to see the main bronchi branching into further subdivisions of bronchi which supply each of lobe.

Carina and Bronchi (Normal CXR)

Hilar structures

• The hilar consist of the main pulmonary vasculature and the major bronchi.
• Each hilar also has a collection of lymph nodes which aren’t usually visible in healthy individuals.
• The left hilum is often positioned slightly higher than the right, but there is a wide degree of variability between individuals.
• The hilar are usually the same size, so asymmetry should raise suspicion of pathology.

Hilar enlargement can be caused by a number of different pathologies:

• Bilateral symmetrical enlargement is typically associated with sarcoidosis.

• Unilateral / asymmetrical enlargement may be due to underlying malignancy.

Abnormal hilar position can also be due to a range of different pathologies. You should (as with the trachea) look for any evidence of the hilar being pushed (e.g. by an enlarging soft tissue mass) or pulled (e.g. lobar collapse).

Breathing

Lung fields

Inspect the lung fields:

• When looking at a CXR we divide each of the lungs into 3 zones, each occupying 1/3 of the height of the lung.
• These zones do not equate to lung lobes (e.g. the left lung has 3 zones but only 2 lobes).
• Inspect each of the zones of the lung first ensuring that lung markings occupy the entire zone.
• Compare each zone between lungs, paying close attention for any asymmetry (some asymmetry is normal and caused by the presence of various anatomical structures e.g. the heart).
• Some lung pathology causes symmetrical changes in the lung fields, which can make it more difficult to recognise, so it’s important to keep this in mind (e.g. pulmonary oedema).

Increased density in a given area of the lung field may suggest pathology (e.g. consolidation / malignant lesion).

The complete absence of lung markings within a segment of the lung field should raise suspicion of pneumothorax.

Pleura

Inspect the pleura:

• The pleura are not normally visible in healthy individuals.
• Inspect the borders of each of the lungs to ensure lung markings extend all the way to the edges of the lung fields (if there appears to be an area lacking lung markings with decreased density this may suggest the presence of a pneumothorax).
• Fluid (hydrothorax) or blood (haemothorax) can also accumulate in the pleural space, causing an area of increased opacity.

If a pneumothorax is suspected, you should reassess the trachea for evidence of deviation away from the pneumothorax which would be in keeping with a tension pneumothorax. This is a medical emergency requiring immediate intervention. If a tension pneumothorax is suspected clinically (shortness of breath and tracheal deviation) then immediate intervention should be performed without waiting for imaging as this condition will result in death if left untreated.  

Pleural thickening can be caused by mesothelioma.

Cardiac

Assess heart size

In a healthy individual the heart should occupy no more than 50% of the thoracic width (e.g. a cardiothoracic ratio of <0.5).

This rule only applies to PA chest x-rays (as AP films exaggerate heart size), so you should not draw any conclusions about heart size from an AP film.

If the heart occupies more than 50% of the thoracic width (on a PA CXR) then this suggests abnormal enlargement (cardiomegaly). Cardiomegaly can occur for a wide variety of reasons including valvular disease, cardiomyopathy, pulmonary hypertension and pericardial effusion.

Assess heart borders

Inspect the borders of the heart which should be well defined in healthy individuals:

• The right atrium makes up most of the right heart border.
• The left ventricle makes up most of the left heart border.

The heart borders may become difficult to distinguish from the lung fields as a result of various pathological processes (e.g. consolidation) which cause increased opacity of the lung tissue.

• Loss of definition of the right heart border is associated with right middle lobe consolidation
• Loss of  definition of the left heart border is associated with lingular consolidation

Cardiomegaly ²

Diaphragm

The right hemi-diaphragm is in most cases higher than the left in healthy individuals (as a result of the underlying liver).  The stomach underlies the left hemi-diaphragm and is best identified by the gastric bubble located within it.

The diaphragm should be indistinguishable from the underlying liver in healthy individuals on an erect CXR, however if free gas is present (often as a result of bowel perforation), air accumulates under the diaphragm causing it to lift and become visibly separate from the liver. If you see free gas under the diaphragm you should seek urgent senior review, as further imaging (e.g. CT abdomen) will likely be required to identify the source of free gas.

Pneumoperitoneum ³

Costophrenic angles

The costophrenic angles are formed from the dome of each hemi-diaphragm and the lateral chest wall.

In a healthy individual the costo-phrenic angles should be clearly visible on a normal CXR as a well defined acute angle.

Loss of this acute angle (sometimes referred to as costophrenic blunting) can suggest the presence of fluid or consolidation in the area. Costophrenic blunting can also occur secondary to lung hyperinflation (seen in diseases such as COPD) as a result of diaphragmatic flattening and subsequent loss of the acute angle.

Costophrenic blunting secondary to pneumonia ²

Everything else

Mediastinal contours

The mediastinum contains the heart, great vessels, lymphoid tissue and a number of potential spaces where pathology can occur.  The exact boundaries of the mediastinum aren’t particularly visible on a CXR, however there are some important structures that you should assess.

Aortic knuckle:

• Left lateral edge of the aorta as it arches back over the left main bronchus.
• Loss of definition of the aortic knuckles contours can be caused by an aneurysm.

Aorto-pulmonary window:

• The aorto-pulmonary window is a space located between the arch of the aorta and the pulmonary arteries.
• This space can be lost as a result of mediastinal lymphadenopathy (e.g. malignancy).

Aortic knuckle and Aortopulmonary window

Bones

Inspect the visible skeletal structures looking for any abnormalities (e.g. fractures / lytic lesions).

Soft tissues

Inspect the soft tissues for any obvious abnormalities (e.g. large haematoma).

Tubes / Valves / Pacemakers

Lines (e.g. central line / ECG cables).

Artificial valves (e.g. aortic valve replacement).

Pacemaker (often located below the left clavicle).

References

Nasal examination can sometimes appear in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. Technique is very important in this station. This nasal examination OSCE guide provides a step by step approach to the station.

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain examination

“Today I’d like to examine your nose, this will involve me having a feel of the outside of the nose and also gently looking inside the nose”

Gain consent “Does everything I’ve said make sense?“  “Are you happy for me to go ahead?“

Inspection

External

Look at the external surface of the nose noting:

• Skin changes – e.g. skin lesions / erythema 
• Deformity – inspect the nose from the front, side and standing behind the patient
  • Note any deviation in the nasal bones or cartilage

Internal

1. Ask the patient to look forwards, keeping their head in the neutral position.

2. Carefully elevate the tip of the nose with your thumb, so that the nasal cavity becomes visible. Use a pen torch or otoscope as a light source to externally illuminate the cavity.

3. Inspect the nasal mucosa for any abnormalities (including the septum).

4. Inspect and compare the nasal cavities alignment (note any septal deviation).

Further assessment

Further inspection can be done using an otoscope with a large speculum attached (inserting only the very tip into the nose), or using Thudicum’s speculum which essentially just widens the nasal cavity to allow you to peer in using a light source. 

Whichever method you use, you should inspect the various elements visible:

• Nasal vestibule – skin changes (e.g. ulceration) / swelling / asymmetry
• Nasal septum –  polyps / deviation
• Inferior turbinates – asymmetry / inflammation / polyps

The turbinates are projections of bone, covered in nasal mucosa, that control airflow through the nose, exposing it to a large surface area of mucosa which both warms and cleans the air prior to it arriving at the lungs.

Palpation

Nasal bones and cartilage

Palpate the nasal bones assessing:

• Alignment
• Tenderness or irregularity (if suspicious of fracture in trauma)

Palpate the nasal cartilage assessing:

• Alignment
• Tenderness

Palpate the infraorbital ridges and assess eye movement if there is a history of trauma to screen for an orbital blowout fracture. The classical signs are of infraorbital tenderness, epistaxis and restricted eye movement (usually on vertical gaze).

Nasal airflow

There are two common methods via which to formally assess nasal airflow shown below.

Method 1

1. Place your thumb over the nostril not being assessed to occlude air flow.

2. Ask the patient to breath in through their nose and note the degree of airflow.

3. Repeat assessment on the other nostril, noting any difference in apparent airflow.

Reduce airflow through a particular nostril may indicate the presence of something blocking that air passage, such as a polyp or a deviated nasal septum.

Method 2

1. Place a cold shiny surface, such as a metal tongue depressor under the nose.

2. Observe for misting of the metal surface as the patient breathes, compare the misting pattern of the two nostrils.

Absence of misting, or a disparity in the amount of misting between the nostrils may suggest unequal or absent airflow through a particular nostril.

To complete the examination

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations

• Assessment of sense of smell
• Regional lymph node examination
• Flexible nasoendoscopy

Completing a death certificate is a station in many-a final year OSCE, and more importantly is something that will need to be done in day-to-day life as a junior doctor. Knowing what to write where will speed this process up – great for the family and for you!

This guide will go through:

• What to do when a patient has died and you are asked to do the death certificate
• Some helpful tips and pointers
• A copy of a blank Medical Certificate of Cause of Death form for you to print off and practice with
• A few worked examples

What to do when a patient has died

• Assess patient and confirm death, clearly documenting in the notes (see our guide here)
• Discuss the death with the consultant in charge of the patient’s care (or a senior registrar) – this will help to clarify the cause to be written on the certificate.
• Liaise with bereavement office to organise an appropriate time to attend with the patient’s medical notes to complete the death certificate and any other paperwork.
• Complete Medical Certificate of Cause of Death form.
• Perform a full external examination of the patient’s body in the mortuary (ensure no implantable devices present, check for bruising/pressure sores/any suspicious findings).

The Death Certificate

Click here to download a PDF copy of the blank death certificate here for use in the cases at the end of the guide.

Completing the death certificate

Personal details of the deceased

• Age – you should record the age of the deceased in completed years or, if under one year, in completed months
• Place of death – you should record to the best of your knowledge the precise place of death (e.g. the name of the hospital, or a private address)

Circumstances of certification

• Last seen alive by me – record the date you last saw the deceased alive
• Information from post-mortem – indicate if the cause of death takes into account information gained from a post-mortem or not
• Seen after death – indicate who saw the deceased after death

Part I – Cause of death

• Consider the main causal sequence of conditions that lead to death.
• The disease or condition that led directly to death should be documented on the 1a line.
• You should then work your way back through the other diseases that led to the eventual cause of death until you reach the underlying cause of death which initiated this chain of events. The lowest completed line in part 1 should therefore contain the underlying cause of death.
• Some deaths may have only one condition that lead directly to death, such as a sub-arachnoid haemorrhage. In these cases it’s acceptable to complete only line 1a.
• When stating the cause of death, be as specific as you are able to given the information you have. An example might be stating “Adenocarcinoma of the right main bronchus” rather than “Lung cancer”.
• In some circumstances there can be 2 separate conditions that led directly to death and in these cases you should enter them both on the same line and then in brackets state that these are joint causes of death.

A few things that you CAN NOT write as a 1a:

• “Failures” as a sole 1a – heart / kidney / liver / respiratory (Congestive Cardiac Failure is ok)
• Asphyxia
• Asthenia
• Cachexia
• Cardiac arrest
• Coma
• Exhaustion
• Old Age/frailty as a sole cause of death (and this can only be used in those over 75)

Part II – Conditions that may have contributed to the death 

• Part II allows you to document other conditions that were not part of the main causal sequence of death, but likely played a role in hastening the death.
• An example might be ischaemic heart disease in a patient who died of pneumonia.
• It is NOT somewhere where you should list the patient’s entire past medical history.

Other details at the bottom of the certificate

• You should sign the death certificate and print your name in block capital letters beside it.
• You should document your GMC number beside or under your name too
• You should write down your GMC approved qualifications (often something like MBBS Medicine & Surgery)
• Most commonly the residence is filled in as the hospital’s address (not your own personal address).
• If the patient died in hospital, document the consultant’s name on the little line at the bottom of the certificate (easily missed).

Counterfoil

• There is a counterfoil on the left hand side which gets left in the death certificate book
• You need to document the patient’s name, the cause of death (Part 1) and conditions potentially contributing to death (Part 2).
• You also need to document your personal details again.

Other Hints/Tips

• _____ day of ______ refers to the “Fifth” day of “April 2015” (sounds simple, but I know someone who wrote “Tuesday” in an OSCE…).
• Numbers should be written out in words
• 1a should be the disease, illness or complication which led to death and not a mode of dying.
• Circle the 1/2/3 & a/b/c with regards to post-mortem.

The back of the death certificate

There’s two boxes on the back of the death certificate that you may need to complete in certain circumstances:

• Box A – If you have referred a death to the coroner put your initial here. It should be noted however that if you have simply discussed the case with the coroner and they have said no referral is required then you DO NOT need to complete this box.
• Box B – If you may be in a position to provide more information about the cause of death in the future then you need to initial this box. This is the case when there are pending investigations not yet back or performed (e.g. histology, microbiology culture results, genetic analysis, post-mortem information). A request for this information will be sent to the consultant responsible for the patient

Reasons to refer to the Coroner…

• Unknown cause of death
• Sudden or unexpected death (inclusive of all deaths <24hours after admission to hospital)
• Deceased person not seen by a doctor within 14 days before death
• The death is considered suspicious/unnatural/violent
• The death may be due to an accident, self-neglect or neglect on the behalf of others
• The death is/could be due to the deceased’s prior employment (including industrial disease)
• The death may be due to an abortion
• The death occurred during an operation or before recovery from anaesthetic
• The death occurred during or shortly after a period of police custody
• The death may be suicide

These are (helpfully!) written on the back of the MCCD form.

How to refer to the Coroner

Coroners are often lawyers (and occasionally doctors, or dual-qualified). Talk to the Bereavement Team within the hospital with regards to getting in touch with the Coroner’s Office local to you.

Cases

Following on from this are some cases to work through with questions. You may want to print out a copy of the blank death certificate to fill out and treat it as a mock OSCE. Hidden in the tabs are the suggested answers.

Case 1

Mrs June Morbid was an 87 year old lady, whom you last attended to yesterday, on the ward round with the consultant (Dr Spot). She had suffered with advanced Parkinson’s disease and had been admitted 4 days previously with an aspiration pneumonia. This did not respond to antibiotic treatment, and the decision to palliate was made by the consultant after discussion with the family. Mrs Morbid peacefully passed away last night with her family around her, and her death was verified by your colleague on the night shift. You have been asked to fill in the death certificate after your ward round.

Completed death certificate

Completed death certificate

Case 2

Mr Clive Matchstick (86 years old) was admitted to the ward a week ago from a local nursing home having vomited. Whilst in hospital he developed urinary incontinence and sepsis. He was treated for urosepsis, but unfortunately passed away. You confirmed his death this morning and had reviewed him last night before going home with his consultant Dr Johnson . He has a past history of: ischaemic heart disease,  type 2 diabetes mellitus, Charcot’s deformity on the left foot and an amputation of the big toe on the right.

Completed death certificate

Completed death certificate

Case 3

Mr Samuel Clock (75 years old) had been an in-patient on the ward you are working on for 2 weeks. He was being treated for a community-acquired pneumonia which was a CURB-65 score of 4. His condition had progressively worsened when you reviewed him with his consultant Dr Tyvand last night and the decision was made to switch to a palliative approach of management. He passed away this morning, with his wife by his side. You confirmed his death on the ward. He has a past medical history of ischemic heart disease, hypertension, mesothelioma, type 2 diabetes and benign prostate hypertrophy.

Completed death certificate

This is a trick question (cheeky, I know)…

This is a situation where the medical practitioner should have a conversation with the Coroner prior to issuing any certificate of cause of death as a post-mortem will most likely be required. Mesothelioma is a is almost always attributed to asbestos exposure and therefore falls into category of disease related to occupation which may have contributed to the death. The damage most often occurs 20 – 60 years after asbestos exposure. It would be very unlikely that you would issue a certificate, but if the Coroner instructed that you could do so, it might look a bit like this.

Completed death certificate

References

1.  Southampton University Hospitals NHS Trust – Medical Certificate of Cause of Death – Notes for doctors – LINK

Intramuscular (IM) injections administer medication deep into the muscle tissue, enabling faster absorption and larger systemic doses than subcutaneous injections. This guide discusses how to perform an IM injection in an artificial OSCE setting and should not be used as a guide to administering injections to actual patients without first consulting your local medical school or hospital guidelines. Check out the Intramuscular (IM) injection OSCE mark scheme here.

Introduction

Introduce yourself

Wash hands

Confirm the patient’s details

Explain the procedure

Check the patient’s understanding of the medication being given, and explain the indication for the medication.

Check for allergies

Check if the patient has a bleeding disorder or takes anticoagulant medication (possible contraindications).

Gain consent to proceed

Gather equipment

• Equipment tray
• The medication to be administered
• Patient’s prescription
• Syringe – the smallest syringe that will accommodate the medication volume
• Injecting needle – (21–23 gauge) – 25mm in length is standard 
• Drawing up needle 
• Antiseptic swab –  70% isopropyl alcohol wipe
• Gauze or cotton swab
• Sharps container (for disposal of the needle)
• Apron
• Non-sterile gloves

7 Rights

Return to the patient. Before proceeding, check the 7 rights of medication administration

1. Right person – check the patient’s arm band against the name on the prescription. Where possible aim to use 2 identifiers (e.g. from the patient and the arm band)

2. Right drug – check the labelled drug against the prescription – ensure expiry date is appropriate

3. Right dose – check the dose against the prescription

4. Right time – confirm when the last dose was given

5. Right route

6. Right to refuse – has the patient consented?

7. Right documentation of prescription and allergies – does the patient have any allergies?

Once these have been confirmed prepare the medication. Always use a separate drawing up needle and injection needle.

Injection steps

1. Wash hands.

2. Don gloves and apron.

3. Draw up the appropriate medication into the syringe using a drawing needle.

4. Remove the drawing needle and attach the needle to be used for injection.

5. Choose an appropriate site. Common sites include:

• Deltoid (upper arm)
• Ventrogluteal (upper outer buttock) – ideal for larger volumes
• Vastus lateralis (anterior lateral thigh)
• Do NOT use a site that is inflamed, irritated, bruised or contains scar tissue.

See the end of the guide for further information regarding the most commonly used sites.

If multiple injections are given, use different sites for each subsequent injection. If frequent injections are given, rotate sites.

6. Position the patient to provide optimal access to your chosen site.

7. Swab the site with an antiseptic swab and wait until it is dry.

8. Gently place traction on the skin with your non-dominant hand away from the injection site, continuing the traction until the needle has been removed from the skin. This is known as the Z track technique (see below).

9. Warn the patient of a sharp scratch.

10. Holding the syringe like a dart in your dominant hand, pierce the skin at a 75 – 90 degree angle. Insert the needle quickly and firmly, with the bevel facing upwards, leaving approximately 1/3 of the shaft exposed (however this varies between sites and patients).

11. Aspirate to check the location of the needle. If blood appears, remove the syringe and prepare a new injection (explaining what occurred to the patient).

12. If no blood appears on aspiration, inject the contents of the syringe while holding the barrel firmly. Inject the medication slowly at a rate of approximately 1ml every 10 seconds.

13. Remove the needle and immediately dispose of it appropriately (into a sharps container).

14. Release the traction on the skin.

15. Apply gentle pressure over the injection site with a cotton swab or gauze.  Do NOT rub the site.

Z – track technique – releasing the traction on the skin changes the alignment of the subcutaneous and muscle tissue layers, ‘locking’ the medication into the muscle layer.

To complete the procedure

Replace cotton swab with a plaster.

Thank the patient

Discuss post injection care:

• Warn them that the injection site may be sore for one or two days, but this is normal.
• Other potential complications include: haematoma, persistent nodules, local irritation (and rarely anaphylaxis).
• Advise the patient to watch for a developing rash, breathing difficulty or other relevant concerning symptoms. They should discuss this with a doctor if concerned.

Wash hands

Document that the medication has been given on the medication chart and in the patient’s notes.

Have the patient observed for 15 – 30 minutes for adverse effects.

Injection sites

Below are some more details surrounding the common sites used for IM injections, however these are brief notes and therefore should NOT be relied upon in isolation for carrying out IM injections, instead you should consult your local medical school or hospital guidelines.

Deltoid site

Position of patient

• Have the patient sitting down, with their entire shoulder and arm exposed.
• Position their elbow flexed and ask them to relax.

Site of injection

• Palpate the lower edge of the acromial process and inject approximately 2.5cm below this.

Ventrogluteal site

In the past the dorsogluteal site was very popular, however due to potential complications such as sciatic nerve injury or superior gluteal artery injury it is now not recommended. Instead the ventrogluteal site is used as a safer alternative as it avoids all major nerves and blood vessels.

Position of patient

• The patient can be prone, semi-prone or supine for this procedure, so choose whichever is most comfortable for the patient.

Site of injection

• Place palm of your right hand over the greater trochanter of the patients left hip (or vice versa).
• Extend your index finger to touch anterior superior iliac crest.
• Then stretch your middle finger to form a V (thumb pointing towards the front of leg)
• Insert the needle into the V at 90 ̊

References

The ankle-brachial pressure index (ABPI) is a non-invasive method of assessing the extent of chronic peripheral arterial disease in the lower limbs.  It is a ratio composed of the blood pressure in the brachial artery and the pressures in the foot arteries (dorsalis pedis and the posterior tibial artery). This guide provides a step by step approach to performing ABPI measurement in an OSCE setting.

Introduction

Wash hands

Introduce yourself – state your name and role

Confirm patient details – name / DOB

Explain the procedure:

• “I would like to measure the pressures in your arm and ankle”
• “This will involve inflating a cuff around your arm and ankle briefly and listening to your pulse with this probe”
• “It shouldn’t be painful, but it may feel a little tight temporarily, please let me know if you want to stop at any point”

Check understanding: “Do you understand everything I’ve mentioned? Do you have any questions?”

Check if the patient currently has any pain: “Do you have any pain anywhere?”

Rule out diabetes: “Do you suffer from diabetes?” (see reasoning below)

Gain consent: “Are you happy for me to continue with the assessment?”

Calcified vessels in diabetes sufferers will lead to artificially high ABPI values due to vessels which are not compressible. In such cases measure the Toe pressure (with a special toe cuff) rather than the ankle pressure. This is called the Toe Brachial Pressure Index (TBPI).

If the patient has leg ulcers these can be covered in sterile cling-film and the cuff applied as above, provided the patient doesn’t feel discomfort

Gather equipment

• Sphygmomanometer
• Doppler probe
• Ultrasound gel

Check probe is functioning correctly (battery / sound volume)

Measure ABPI

Measuring the brachial pressure

1. The patient must be lying supine for the measurements on an examination couch.

2. Place the sphygmomanometer cuff over the left arm proximal to the brachial artery (avoiding any cannulas) and position the doppler probe on the brachial artery at a 45° angle (medial to the biceps tendon at the antecubital fossa).

3. Inflate the cuff 20-30 mmHg above the pressure at which the doppler pulse is no longer heard. Deflate the cuff slowly and note the pressure at which you first detect a pulse from the doppler. This is the systolic pressure in that vessel.

4. Now repeat this process on the right brachial artery.

5. The higher of the two pulses will be used as part of the ratio.

Measuring the ankle pressure

1. Place the sphygmomanometer on the left ankle and position the doppler probe over the posterior tibial artery (behind the medial malleolus of the foot). Measure the pressure in the same way as for the brachial artery: inflate and deflate the cuff slowly to detect the pressure at which blood returns to the posterior tibial artery.

2. Repeat this process (keep the sphygmomanometer in the same place) at the dorsalis paedis artery of the left foot (lateral to the extensor hallucis longus tendon).

3. Use the highest of the two pressures obtained from the posterior tibial artery (PTA) and dorsalis pedis (DP) for the ratio of the left ABPI.

4. Repeat the same process on the right ankle to work out the ratio for the right ABPI.

To complete the examination…

Thank the patient

Wash hands

Record left and right ABPI in the patient’s notes

Suggest further assessments and investigations

• Take a thorough history from the patient
• Perform a full peripheral arterial exam
• Bloods: FBC, U&Es, glucose, cholesterol
• Further imaging – duplex ultrasound / CT or MRI angiogram

Examiner question: “If you find an abnormal ABPI result, what would be the next steps in investigation and management?”

Answer: “If mild disease is present, this may be managed conservatively. If further imaging is needed, then a duplex ultrasound of the lower limb arteries can be undertaken. Prior to surgical or endovascular interventions a CT or MR angiogram may be needed.“

Summary

Left ABPI = (Highest pressure of either left PTA or DP) ÷ (Highest brachial pressure)

Right ABPI = (Highest pressure of either right PTA or DP) ÷ (Highest brachial pressure)

Example

• Right brachial artery: 120 mmHg
• Left brachial artery: 125 mmHg
• Right DP: 80 mmHg
• Right TP: 75 mmHg

Right ABPI = 80/125 = 0.64

Interpret results

Errors can occur due to:

• Irregular pulse (AF)
• Cuff positioned incorrectly
• Calcified vessels (diabetes)

References

Mr Peter Gogalniceanu – Surgeon 

Writing in a patient’s notes is something you’ll be required to do at some point during your training, so it’s important that you’re aware of how to document appropriately. Accurate documentation is also incredibly important from a medicolegal perspective with the phrase “If it isn’t in the notes, it didn’t happen!” often referenced when discussing the issue. This guide provides an overview of the process of documenting in a patient’s notes and hopefully should make you feel a little more prepared when you have your first attempt on the ward.

The basics

Ok, so a blank continuation sheet has been thrust towards you and you’ve been asked to document something- let’s remind ourselves of the basics of documentation.

What should I use to write with?

You need to use a pen with black ink (as this is the most legible if notes are photocopied).

Patient details

For every new sheet of paper your first task should always be documenting at least three key identifiers for a patient:

• Full name
• Date of birth
• Unique patient identifier
• Patient’s home address

If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.

Location details

You should indicate the patient’s location on the continuation sheet:

• Hospital
• Ward

Patient identifiers

Making a new entry in the notes

So at this point you should already be holding a pen with black ink and you should have ensured the continuation sheet has the patient’s name, date of birth and unique identifier at the top.

How to make an entry in a patient’s notes

1. Add the date and time (in 24hr format) of your entry 

2. Write your name and role as an underlined heading

3. Make your entry in the notes below this heading (see our other documentation guides for more detail on making different types of entries in the notes)

4. At the end of your entry to need to include the following:

• Your full name
• Your grade/role (e.g. Medical student/F2/Neurology registrar)
• Your signature
• Your professional registration number (e.g. GMC number)
• Your contact number (e.g. phone/bleep)

Documentation example

Other things to be aware of…

What if your entry spans more than one page?

If your entry in the notes happens to span more than one page:

1. Write “continued on next page” or “continued” with an arrow pointing off the page after the entry on the first page

2. Write your name and signature at the end of this partial entry

3. Add the patient’s name, date of birth and unique identifier to the new page

4. Write the date and time of the entry on the second page

5. Write your name and role, followed by the word “continued” as an underlined heading

6. You can now continue the entry from the previous page

7. At the end of this entry you need to include all of your details as shown in step 4 of the previous section

Although this might seem tedious it’s actually really important, as it ensures the chronology of your entry is clear to others reading it later.

What if you are too busy dealing with sick patients to write in the notes at the time?

You should always try to document your patient encounters as promptly as possible to reduce the risk of you forgetting key details and also to ensure other team members are aware of any changes to a patient’s condition or management plan. However in reality this isn’t always possible, for instance if you’re dealing with an acutely unwell patient you need to prioritise their management over the documentation of the sequence of events.

When you return to the patient’s notes at a later time you need to:

1. Ensure the continuation sheet has the patient’s 3 key identifiers as previously described

2. Document the current time and date of your entry

3. Write your name and grade as an underlined title

4. Begin the entry by stating that this is written in retrospect, with the time the entry is referring to documented

5. Complete the entry in the notes

6. At the end of this entry you need to include all of your details as shown in step 4 of the making an entry in the notes guide above.

Written in retrospect example

What if I write something incorrectly in the notes?

If you make a mistake whilst making your entry (e.g. factual error/spelling error):

• Simply cross the mistake out with a single line through the erroneous words
• Write your signature in addition to the time and date beside the area crossed out
• Do not use Tipp-Ex to erase the errors
• Do not excessively scribble over the errors to make them unreadable

Example of error correction

Filing the documentation appropriately

You should ensure that you file your documentation in the appropriate place within a patient’s notes, this differs significantly between hospitals, so always ask the team if you’re unsure.

Make sure to put the patient’s notes back in the appropriate trolley or storage area on the ward once you’re finished.

Summary

Hopefully that was a useful overview of the basics of documenting in patient notes. We’ve got more guides discussing other aspects of documentation in more detail which you can check out here. If you have any documentation tips of your own you’d like to share just comment below and we’ll try our best to incorporate them .

References

1. Royal College of Physicians – Generic medical record keeping standards. 30th June 2015. [LINK]

In addition to knowing how to record and interpret an ECG, it’s also important to know how to appropriately document an ECG. This guide provides a structured approach to documenting ECGs in a patient’s notes, with examples.

Documentation basics

Before we discuss how to document the ECG itself, we need to cover the basics that apply to all documentation in a patient’s notes. You can check out our detailed guide to writing in the notes here for more information.

What should I use to write with?

You need to use a pen with black ink (as this is the most legible if notes are photocopied).

Patient details

For every new sheet of paper (including the ECG itself) your first task should always be documenting at least three key identifiers for a patient:

• Full name
• Date of birth
• Unique patient identifier
• Patient’s home address

If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.

Location details

You should indicate the patient’s location on the continuation sheet:

• Hospital
• Ward

  Patient identifiers

Beginning your entry in the notes

So at this point you should already be holding a pen with black ink and you should have ensured the continuation sheet has the patient’s name, date of birth and unique identifier at the top.

1. Add the date and time (in 24hr format) of your entry 

2. Write your name and role as an underlined heading

3. Make your entry in the notes below this heading (see the next section for details)

Beginning an entry

Documenting the ECG results in the notes

1. Document the time and date that the ECG was performed (as this may be significantly different than the time you are documenting)

2. Write the indication for the ECG (e.g. chest pain / tachycardia)

3. Document your interpretation of the ECG (see our guide to interpreting an ECG here):

• Rate
• Rhythm
• Axis
• PR interval
• QRS complex
• QT interval
• ST segment
• T waves

4. Document your overall impression of the ECG (e.g. ST elevation myocardial infarction)

5. Document your plan based on the ECG findings 

Documentation of ECG example

Completing the entry in the notes

At the end of your entry to need to include the following:

• Your full name
• Your grade/role (e.g. Medical student/F2/Neurology registrar)
• Your signature
• Your professional registration number (e.g. GMC number)
• Your contact number (e.g. phone/bleep)

Completing the documentation

Elbow examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. You should feel confident diagnosing local joint issues such as bursitis, but also be able to identify stigmata of systemic diseases such as psoriasis (plaques) and rheumatoid arthritis (nodules). Check out the elbow examination mark scheme here.

Introduction

Wash hands

Introduce yourself – state your name and role

Confirm patient details – name and DOB

Explain examination:

“I’d like to examine your elbow. This will involve having a look and feel of the joint, in addition to assessing the joint’s movement”

Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?”

Gain adequate exposure- ideally you should be able to see the entire limb

Position patient – palms facing forwards with arms by their side (anatomical position)

Look

Inspect from front

Scars – suggestive of previous injury / surgery

Swelling / erythema of the joint – may suggest acute injury / inflammatory arthritis / infection

Carrying angle – 5-15 degrees – females tend to have more significant carrying angles than males

Inspect from side

Fixed flexion deformity – often post traumatic 

Olecranon bursitis – the swelling overlying the olecranon is often most noticeable from this angle

Scars / swelling / erythema 

Inspect from the back

Rheumatoid nodules – firm lumps on the elbow / olecranon – indicate systemic rheumatoid disease

Psoriatic plaques – well defined pink / red elevated lesions with silvery scale

Feel

Temperature – a hot joint may indicate inflammatory arthritis or infection

Palpate the joint lines –  including the epicondyles and olecranon for any localised tenderness

Move

Assess each of the movements of the elbow joint actively and passively:

• Elbow flexion – 145º
• Elbow extension –  0º
• Pronation – 70º
• Supination – 85º

When moving the joint passively assess for crepitus.

Special tests

Medial epicondylitis – a.k.a. “Golfer’s elbow”

Wrist flexion against resistance

1. The patient should be seated for this assessment, with their elbow flexed at 90º

2. Palpate the medial epicondyle with one hand and hold the patient’s wrist with your other hand

3. Ask the patient to actively flex the wrist against resistance whilst their elbow is also flexed

A positive test would be a complaint of discomfort along the medial aspect of the elbow in the region of the medial epicondyle.

Golfer’s elbow test

1. The patient should be seated or standing

2. Stabilise the elbow whilst palpating the medial epicondyle 

3. Passively supinate the forearm 

4. Extend the patient’s wrist

5. Extend the patient’s elbow fully

A positive test would be a complaint of discomfort along the medial aspect of the elbow in the region of the medial epicondyle.

Lateral epicondylitis – a.k.a. “Tennis elbow”

Cozen’s test

1. Stabilise the patient’s elbow, placing your fingers over the patient’s lateral epicondyle

2. Ask the patient to make a fist and pronate the forearm

3. Ask the patient to radially deviate the wrist

4. Ask the patient to extend their wrist against your resistance

A positive test would involve pain felt over the area of the lateral epicondyle 

Mill’s test

1. Position the patient standing

2. Stabilise the elbow whilst also palpating the lateral epicondyle 

3. Passively pronate the patient’s forearm

4. Flex the patient’s wrist

5. Extend the forearm fully 

A positive test would involve pain felt over the area of the lateral epicondyle 

To complete the examination…

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations

• Examine the joint above and below (shoulder / wrist)
• Full neurovascular examination of the upper limbs
• Further imaging of the joint if indicated – X Ray / CT / MRI

Ankle and foot examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. Check out the ankle and foot examination mark scheme here.

Introduction

Wash hands

Introduce yourself – state your name and role

Confirm patient details – name and DOB

Explain examination:

“I’d like to examine your ankles and feet. This will involve having a look and feel of these joints, in addition to assessing the joints’ movement”

Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?”

Gain adequate exposure – both legs should be exposed from the knee down

Position patient – ask patient to stand up straight with their feet aligned facing forwards

Look

Gait

Is the patient demonstrating a normal heel strike / toe off gait?

Is each step of normal height? – increased stepping height is noted in foot drop

Is the gait smooth and symmetrical?

Examine the patient’s shoes – evidence of asymmetrical wearing may indicate abnormal gait 

Inspect from the front

Symmetry of feet and ankles

Toe alignment – hallux valgus of the big toe may be noted

Bunions – located at the 1st metatarsal phalangeal joint (MTP) joint

Toe clawing?

Scars – suggestive of previous injury / surgery

Calluses – may indicate foot / gait deformity or poorly fitting footwear

Swelling or erythema of the foot or ankle – may suggest injury / inflammatory arthritis / infection

Inspect from the side

Foot arches – observe for evidence of flat feet (pes planus) or high arched feet (pes cavus)

If patient has flat feet ask to stand on tiptoes – supple flat feet will correct / rigid flat feet will not

Inspect from the back

Foot / ankle symmetry – heel alignment – valgus or varus deformity?

Achilles tendon – any obvious deformity / discontinuity / erythema?

Feel

Ask the patient to lay on a bed

Assess temperature and compare between legs – ↑ temperature may indicate inflammatory pathology

Assess pulses in both feet – posterior tibial and dorsalis pedis 

Palpate the achilles tendon:

• Position the patient kneeling on a chair
• Palpate the gastrocnemius muscle and achilles tendon
• Note any focal tenderness, swelling or gaps in the tendon (suggestive of rupture)

Palpate the joints and bones

Work distal to proximal – assess for tenderness / swelling / irregularity  

• Squeeze MTP joints – observe patient’s face for discomfort
• Tarsal joint
• Ankle joint 
• Subtalar joint
• Medial / lateral malleoli
• Proximal fibula

Move

Active and passive assessment

Assess each of the following movements actively and passively (feeling for crepitus)

Foot plantarflexion – “push your feet downwards, like pushing a car pedal” – 30-40 º

Foot dorsiflexion – “point your feet towards your head” – 12-18 º

Toe flexion – “curl up your toes”

Toe extension – “point your toes towards your head”

Foot inversion

Foot eversion

Passive assessment only

Assess each of the following movements passively

Midtarsal joints – hold ankle with one hand whilst moving the forefoot through dorsiflexion, plantarflexion, adduction, abduction, supination and pronation. 

Special tests

Simmonds’ test

Simmonds’ test is used to assess for rupture of the achilles tendon

1. Ask patient to kneel on a chair with their feet hanging off the edge

2. Squeeze each calve in turn

3. Normally the foot should plantarflex

4. If the achilles tendon is ruptured there will be no movement of the foot

To complete the examination

Thank patient

Wash hands

Suggest further assessments and investigations

• Examine the knee and hip joint 
• Full neurovascular examination of the lower limbs
• Further imaging of the relevant joints if indicated (Xray / CT / MRI)

Testicular examination can occasionally appear in OSCEs and if it does you need to have practiced the routine to look slick and professional. This testicular examination OSCE guide provides a structured approach to examining the testicles. This is an intimate examination and therefore extra attention should be paid to the communication aspect to ensure the patient feels as comfortable as possible. Check out the testicular examination OSCE mark scheme here.

Introduction

Wash hands

Introduce yourself – name / role

Confirm patient details – name / DOB

Explain examination:

“I need to carry out an examination of your testicles, this will involve firstly inspecting the testicles and surrounding area, then I will examine the testicles“

“I’m required to have a chaperone present, this will most likely be a nurse from the ward, are you ok with that?“

Gain consent :

“Do you understand everything I’ve said?“  

“Are you happy for me to examine you?“

Get a chaperone – this is absolutely essential and often carries significant marks in the OSCE

Position patient – examination of the testicles is best performed with the patient standing

Expose patient – exposure should be from the waist down

Don gloves 

Inspection

General inspection

Inspect the patient’s genital region and the surrounding areas (i.e. penis / groin / lower abdomen):

• Skin changes – rash / bruising / swelling
• Scars
• Obvious masses

Inspection of the scrotum

Ask the patient to hold their penis out of the way to allow easier inspection of the scrotum.

Inspect the scrotum from the front, sides and the posterior aspect by lifting the scrotum.

Inspect the scrotum for the following…

• Skin changes – rash / ulcers / erythema (e.g. cellulitis / fungal infection)
• Scars – may provide clues as to previous operations (e.g. vasectomy)
• Masses – note any obvious lumps, these will require examination later
• Swelling – unilateral or bilateral? / associated with erythema? 
• Bruising
• Necrotic looking tissue – Fournier’s gangrene is a diagnosis not to be missed!

Palpation

Examine each testicle individually.

If abnormalities have been identified on inspection or the patient is concerned about a particular testicle, start examination on the other testicle.

Ask the patient to report any pain or discomfort they experience during the examination.

Testes

Use your thumb and index finger to gently palpate the whole testicle.

If you are unable to locate a testicle, palpate along the path of the inguinal ligament for an undescended testicle (if the patient also has a scar this would suggest a previous orchidectomy)

If a mass is found assess the following…

• Size / shape
• Regularity – regular vs irregular
• Consistency – hard (solid) / soft (cystic) / “Bag of worms” (varicocele) 
• Discomfort – try to identify the specific area causing pain
• Are you able to get above the mass?- No = inguinal scrotal hernia

Is the mass fixed to the testicle or separate?

• Separate + hard (solid) = epididymitis / orchitis
• Separate + cystic (soft / fluctuant) = epidermal cyst / spermatocele

Is there a cough impulse? – presence of a cough impulse suggests hernia / varicocele

Does the mass transilluminate? – transillumination suggests the mass is fluid filled – e.g. hydrocele

Epididymis

Palpate the epididymis (located at the posterior aspect of the testicle).

Pain in the epididymis may suggest epididymitis.

Phren’s test

If testicular pain is relieved by elevating the testes this is strongly suggestive of epididymitis.

Spermatic cord

Start palpation at the superior aspect of the testicle using your thumb and index finger.

The spermatic cord should be palpable connecting to the testicle at this region.

Palpate along the cord assessing for masses and tenderness.

Lymph nodes

Assess the local lymph nodes in the inguinal region for evidence of lymphadenopathy (scrotal infection).

To complete the examination

Thank patient

Allow patient time to get dressed

Dispose of gloves

Wash hands

Summarise findings 

“Today I performed a testicular examination on John Doe, a 42 year old gentleman. On inspection there were no abnormalities identified, however on palpation there was a 1cm smooth solid mass noted on the left testicle. The mass was non tender and fixed to the underlying testicle. I was able to get above the mass and there was no cough impulse or transillumination.  Some lymphadenopathy was noted in the left inguinal region“

Suggest further assessments and investigations

• Full abdominal examination
• Ultrasound scan of the testicles 

This guide aims to provide a structured approach to performing a newborn baby assessment in an OSCE setting. Check out the newborn baby assessment OSCE mark scheme here. 

Background

The Newborn Infant Physical Examination (NIPE) must be performed within 72 hours of birth by a qualified practitioner.¹

The purpose of the examination of the newborn is:²

• To screen for abnormalities
• To make referrals for further tests or treatment as appropriate
• To provide reassurance to the parents

Where to perform the NIPE

The NIPE exam should be undertaken in a private area which provides confidentiality for parents when personal information is being discussed.

The room should be warm and well lit (preferably natural light, especially if jaundice is to be assessed).²

You’ll ideally require a changing mat to carry out the examination on.

Always make sure that the mother/parents are present for the newborn check, as an important part of the reason for the check is to answer queries and give reassurance.

Introduction

Wash hands:

• Hand hygiene is essential before and after the newborn check
• Always wash and use alcohol gel on your hands before examining the newborn
• Alcohol gel must dry completely before handling the newborn

Introduce yourself to the parents – state your name and role

Explain that you need to carry out a routine head to toe examination of their child.

Gain consent:

• Parents should have received the National Screening Committee leaflet ‘Screening tests for you and your baby’ in the antenatal period
• If the parent has not read the information booklet they must be given a copy to read before to the examination
• The aims and limitations of the examination should fully explained

Ask parent to undress the child down to their nappy.

Encourage the parents to ask questions during the check and to participate where appropriate.

The optimal way to perform the newborn check is by examining from head to toe sequentially. 

Questions to ask the parents

Below are some key points you would ideally cover in a full assessment of a newborn baby. It should be noted however that in the context of an OSCE you are unlikely to be expected to cover all these history points due to time constraints. 

• Maternal history:
  • Pregnancy – date,time and type of delivery / complications/ high risk antenatal screening results
  • Family history – hearing problems / hip dislocation / childhood heart problems

• Newborn history – feeding pattern / sleep pattern / urination / passing of meconium

Weight

Ensure that the baby’s weight is recorded and check on a weight chart whether the baby is:

• Small for dates (<10th centile)
• Appropriate weight for dates (10th-90th centile)
• Large for dates (>90th centile)

General inspection

Colour:

• Pallor
• Cyanosis
• Jaundice
• Rashes/erythema

Cry – note the volume (a weak cry may be an indicator the newborn is unwell)

Posture – note any gross abnormalities of posture (e.g. hemiparesis/Erb’s palsy)

Tone

Assess tone by gently moving the newborn’s limbs passively and observing the newborn when they’re picked up (your assessment of tone should continue throughout the examination).

The term “floppy infant syndrome” is used to describe abnormal limpness when an infant is born. Infants who suffer from hypotonia are often described as feeling and appearing as though they are “rag dolls”. Hypotonic infants often have difficulty feeding, as their mouth muscles cannot maintain a proper suck-swallow pattern, or a good breastfeeding latch.

Head

Size

Measure head circumference and record it in the baby’s notes.

Microcephaly is a medical condition in which the brain does not develop properly resulting in a smaller than normal head. Microcephaly may be present at birth or it may develop in the first few years of life.³

Macrocephaly is a condition in which the head is abnormally large; this includes the scalp, the cranial bone, and the contents of the cranium.  Macrocephaly may be pathological, but many people with abnormally large heads or large skulls are healthy. Pathologic macrocephaly may be due to megalencephaly (enlarged brain), hydrocephalus (water on the brain), cranial hyperostosis (bone overgrowth), and other conditions.⁴

Shape

Inspect the shape of the head and note any abnormality.

Inspect the cranial sutures and note if they are closely applied, widely separated or normal.

Head moulding is common after birth and resolves within a few days.

Caput succedaneum is a neonatal condition involving a serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins (often crossing suture lines) caused by the pressure of the presenting part of the scalp against the dilating cervix (tourniquet effect of the cervix) during delivery. Caput succedaneum does not usually cause complications and usually resolves over the first few days. ⁵

Cephalhaematoma is a firm swelling caused by haemorrhage between the skull and the periosteum secondary to rupture of blood vessels crossing the periosteum. Because the swelling is subperiosteal its boundaries are limited by the individual bones and therefore the swelling clinically will be noted not to cross suture lines (in contrast to a caput succedaneum). ⁶

Craniosynostosis is a condition in which one or more of the fibrous sutures in an infant skull prematurely fuses by turning into bone, thereby changing the growth pattern of the skull which can result in raised intracranial pressure and damage to intracranial structures.  Surgical intervention is required with the primary goal being to allow normal cranial vault development to occur. This can be achieved by excision of the prematurely fused suture and correction of the associated skull deformities. ⁷

Fontanelle

Palpate the anterior fontanelle – note if it feels flat (normal), sunken or bulging (abnormal)

A tense bulging fontanelle may suggest raised ICP – e.g. hydrocephalus

A sunken fontanelle may suggest dehydration.

Skin

Colour – pallor / cyanosis / erythema / jaundice

Bruising / lacerations – may be secondary to trauma during childbirth

Facial birthmarks:

• Salmon patch
• Port wine stain
• Dry abrasions

Vernix – waxy or cheese-like white substance found coating the skin of newborn human babies (normal)

Other potential findings

Mongolian spot is a benign, flat, congenital birthmark with wavy borders and irregular shape. It is most commonly blue in colour and can be mistaken for a bruise. They normally disappears within 3-5 years after birth. ⁸

Naevus flammeus nuchae, often called stork bite or nevus simplex, is a congenital capillary malformation present in newborns. It is a common type of birthmark in a newborn and is usually temporary. ⁹

Milia are tiny white spots. They are blocked pores. About half of infants have milia on their face, most resolving within the first few weeks of life.

Capillary haemangiomas  (“port wine stains”)

Toxic erythema of the newborn is a common and benign condition seen in newborn infants. It presents with various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules.  It is unusual for an individual lesion to persist for more than a day and the newborn is otherwise well throughout the episode.¹⁰

Neonatal jaundice can be physiological, appearing at 2-3 days and resolving by day 10. It can also be caused by a wide range of different pathologies including haemolytic disease, infection and Gilbert’s syndrome.

Face

Appearance – note any dysmorphic features

Asymmetry – e.g. facial nerve palsy

Trauma – likely to have occurred during labour (e.g. instrumental delivery)

Nose – patency of nasal passages

Eyes

Inspect the eyes for evidence of erythema or discharge (e.g. conjunctivitis).

Inspect the sclera by gently retracting the lower eyelid noting any discolouration (e.g. jaundice)

Position and size – inspect pupils for cataracts

Assess for red reflex:

• Use your ophthalmoscope to assess for red reflex
• An absent red reflex may suggest congenital cataracts or rarely neuroblastoma

Subconjunctival hemorrhages – these look dramatic but are benign, you should however document their presence

Ears

Inspect the pinna – asymmetry / prominence / accessory auricles

Note any skin tags

All infants should have a hearing screening test prior to discharge from hospital.

Mouth and palate

Clefts of hard or soft palate – directly observe and palpate

Tongue and gums – inspect for evidence of tongue-tie (ankyloglossia)

Neck and clavicles

Length of neck – e.g. abnormally short in Turner’s syndrome

Webbing of the neck – e.g. Turner’s syndrome

Neck swellings – e.g. Cystic hygroma

Clavicular fracture – secondary to traumatic birth (e.g. shoulder dystocia) 

Upper limbs

Inspect for symmetry – ensure equal in size and length 

Inspect fingers – ensure correct number and morphology 

Inspect palms – should have two palmar creases on each hand 

Palpate brachial pulses

Polydactyly is a congenital abnormality where there are supernumerary fingers or toes.

A single palmar crease is associated with Down’s syndrome.

Chest

Inspect

Chest wall deformities (e.g. pectus excavatum)

Chest wall expansion – asymmetry may be noted unilateral lung pathology (e.g. pneumonia)

Lungs

Note any respiratory distress (e.g. intercostal recession) – normal respiratory rate is 30-60 in newborns

Auscultate the lungs:

• Auscultate to ensure there is air entry bilaterally
• Listen for any added sounds – wheeze / crackles / grunting

Heart

Auscultate the heart:

• Use a paediatric stethoscope
• Normal heart rate is around 120-150 bpm
• Listen for any added sounds (murmurs)
• If a murmur is noted, try to identify where it is heard loudest and if it radiates anywhere

Abdomen

Inspect for evidence of abdominal distension

Inspect for evidence of any inguinal hernias – will need paediatric surgical review

Palpate the abdomen:

• Liver – should be no more than 2cm below costal margin
• Spleen – should not be palpable
• Kidneys – only palpable on deep bimanual palpation
• Bladder – should not be palpable

Umbilicus

Inspect for any discharge or hernias

Note any offensive smell – may suggest infection

Genitalia

Note any ambiguity of genitalia – e.g. congenital adrenal hyperplasia

Males:

• Normal prepuce (exclude hypospadia)
• Normal urinary stream – (should be observed by 24 hrs – dribbling suggests posterior urethral valves)
• Hydroceles – collection of fluid in the scrotum – transilluminates
• Palpate scrotum to ensure both testes are present – absence suggests they may be undescended

Females:

• Inspect labia – ensure they not be fused
• Inspect clitoris – ensure it is normal size
• Vaginal discharge – white discharge is normal due to maternal oestrogens 

Lower limbs

Inspect limb symmetry – should be equal in size and length

Assess tone in both lower limbs

Assess movement in both lower limbs

Palpate femoral pulses

Assess for oedema

Assess knees – hyper-extensile/dislocatable 

Ankle deformities – e.g. talipes

Ensure correct number of digits on each foot

Hips

Barlow’s and Ortolani’s test are carried out as part of the routine newborn examination to detect hip joint instability and dislocation. Although both legs can be assessed at the same time, it is optimal to stabilize the pelvis with one hand and manipulate one leg at a time.¹¹

Barlow’s test

1. Barlow’s test is performed by adducting the hip (bringing the thigh towards the midline) whilst applying light pressure on the knee with your thumb, directing the force posteriorly. ¹²

If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, producing a palpable sensation of subluxation or dislocation.

If the hip is dislocatable the test is considered positive.  The Ortolani maneuver is then used to confirm the positive finding (i.e. that the hip actually dislocated).

Ortolani’s test

Ortolani’s test is used to confirm posterior dislocation of the hip joint.¹³

1. Flex the hips and knees of a supine infant to 90 degrees

2. Then with your index fingers placing anterior pressure on the greater trochanters, gently and smoothly abduct the infant’s legs using your thumbs

A positive sign is a distinctive ‘clunk’ which can be heard and felt as the femoral head relocates anteriorly into the acetabulum.

This tests assesses specifically for posterior dislocation of the hip.

Back and spine

Inspect the spine for:

• Scoliosis
• Hair tufts
• Naevus
• Abnormal skin patches
• Birthmarks
• Sacral pits

Hair tufts and sacral pits can be associated with underlying neural tube defects (spina bifida).

Anus

Inspect the anus for patency

Meconium should be passed within 24 hours

Reflexes

Assess the newborn’s reflexes

Palmar grasp reflex is a primitive reflex. It appears as early as 16 weeks in utero and persists until five or six months of age. When an object is placed in the infant’s hand and strokes their palm, the fingers will close and they will grasp it with a palmar grasp.¹⁴

Sucking reflex – causes the child to instinctively suck anything that touches the roof of their mouth, and simulates the way a child naturally eats.

Rooting reflex – present at birth and disappears around four months of age, as it gradually comes under voluntary control. The rooting reflex assists in the act of breastfeeding. A newborn infant will turn its head toward anything that strokes its cheek or mouth, searching for the object by moving its head in steadily decreasing arcs until the object is found.¹⁵

Stepping reflex – present at birth, though infants this young cannot support their own weight. When the soles of their feet touch a flat surface they will attempt to walk by placing one foot in front of the other. This reflex disappears at six weeks due to an increased ratio of leg weight to strength. It reappears as a voluntary behavior around eight months to one year old. ¹⁶

Moro reflex – present at birth, peaks in the first month of life, and begins to disappear around 2 months of age. It is likely to occur if the infant’s head suddenly shifts position, the temperature changes abruptly, or they are startled by a sudden noise. The legs and head extend while the arms jerk up and out with the palms up and thumbs flexed. Shortly afterward the arms are brought together and the hands clench into fists, and the infant cries loudly.¹⁷

To complete the examination…

Share the results of the assessment with the parents, explaining the reason for any referrals you feel are required

Ask if the parents have any further questions

Thank the parents

Offer to dress the baby or allow parents to do so (depending on their preference)

Wash hands

Document your findings and suggest any relevant investigations or referrals 

References

Examination of a skin lesion frequently appears in OSCEs.  You’ll be expected to pick up the relevant clinical signs using your examination skills. This guide provides a clear step by step approach to examining a skin lesion in an OSCE setting.

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain the examination

Gain consent

Expose the lesion(s) and ensure the patient is comfortable

Obtain a chaperone if a lesion is present in an intimate area

General inspection

Around the bed

Note any clues around the bed as to a diagnosis – e.g. medication/creams

The patient

Observe if the patient appears comfortable at rest

Observe the number of skin lesions

Observe the location and distribution of any skin lesions:

• Acral – affecting distal areas, hands and feet
• Extensor – extensor surfaces, elbows, knees
• Flexural – flexural surfaces, axillae, genital areas, cubital fossa
• Follicular – arising from hair follicles
• Dermatomal – corresponding with nerve root distribution
• Seborrhoeic – associated with areas where there are sebaceous glands, face and scalp

Close inspection of individual lesions

Size of the lesion

Assess the size of the lesion – width/height (if raised)

Configuration of the lesion(s)

Configuration refers to the shape or outline of skin lesions. The pattern of multiple lesions or shape of an individual lesion can assist in diagnosis.

Assess if the lesion is discrete or confluent

Assess the shape of the lesion(s)

Assess the border of the lesion(s) – well defined vs poorly defined

Colour of the lesion

Assess the colour of the lesion

Morphology

Assess the form and structure of the lesion:

• Is the lesion flat, raised above the plane of skin or depressed below the plane of skin?
• Is the lesion

Assessment of a pigmented lesion

If lesion is pigmented use the ABCDE assessment method³

Asymmetry more suggestive of sinister pathology

Border irregularity

• Are the edges of the lesion well defined?
• Less defined borders are more suggestive of sinister pathology

Colour variation or changes:

• Is the colour consistent?
• Two or more colours within one lesion is more suggestive of sinister pathology

Diameter:

• Has there been a change in size of the lesion?
• Increasing size, particularly over 6mm diameter is more concerning

Elevation/evolution:

• Changes in colour, size, symmetry, surface characteristics, and symptoms.
• Symptoms include itching, bleeding and scabbing of the lesion

If you feel a lesion is concerning you should perform a comprehensive systematic examination of other areas:

• Inspect the rest of the skin for suspicious pigmented lesions or dysplastic naevi
• Palpate major lymph nodes in the regional drainage area

Palpation of skin lesions

Don gloves the skin lesion is felt to be infective or is likely to expose you to bodily fluids (e.g. blood/pus).

Assess surface characteristics of the lesion

Texture – smooth/rough – e.g. roughness in hyperkeratosis (scales)

Flat, raised or depressed?

Crust – if present, are you able to remove crust and see what is underneath?

Temperature – is the lesion warm?

Assess deeper characteristics of the lesion

Consistency – hard/soft/firm/fluctuant

Mobility – is the lesion attached to the underlying/overlying tissue?

Tenderness – is the lesion tender on palpation?

Systemic examination

Nails, hands and elbows

Assess the nails, hands and elbows for signs associated with dermatological disease

Hair and scalp

Inspect the hair and scalp

Mucous membranes

Inspect oral mucosa to evidence of skin disease (e.g. pigmented lesions/bullae)

To complete the examination…

Thank patient

Wash hands

Summarise findings

Suggest further assessments and investigations:

• Perform relevant examinations of any systems that may be related to dermatological findings
• Swabs/skin scrapings of lesions – microbiology/virology/fungal culture
• Dermatoscopy of lesions – melanocytic and vascular lesions
• Biopsy of lesions

References

1. British Association of Dermatologists. Handbook for Medical Students and Junior Doctors. Published 2014. Available [HERE]

2. Dermnet New Zealand. Dermatology terminology. Published 1997.  Revised 2017. Available [HERE]

3. NICE – Clinical Knowledge Summaries. Melanoma and pigmented lesions. Revised March 2011. Available [HERE]

Introduction

Effective hand washing is a key skill all healthcare workers need to be capable of performing. Hands are the main method of pathogen transmission in the healthcare context and therefore hand hygiene is paramount.  Your hand washing technique will be assessed regularly both as a student and qualified health professional therefore it’s important you understand how to perform effective hand hygiene.

When to wash your hands

The “My 5 moments for hand hygiene“ approach describes the key moments when healthcare workers should perform hand hygiene.

The 5 moments of hand hygiene

1. Before touching a patient

2. Before clean/aseptic procedures

3. After body fluid exposure/risk

4. After touching a patient

5. After touching patient surroundings

How to wash your hands with alcohol hand rub

You should clean your hands using an alcohol-based formulation if your hands are NOT visibly soiled.

The entire process of hand washing with alcohol based formulations should take around 20-30 seconds.

The benefits of alcohol-based formulations over soap and water include:

• Faster to clean your hands
• More effective 
• Better tolerated by the skin on your hands

Limitations of alcohol-based formulations:

• Not effective if hands are visibly soiled
• Not effective at eradicating spore forming organisms (e.g. C.difficile)

Step by step guide

1. Apply a palmful of the product in a cupped hand, covering all surfaces

2. Rub hands palm to palm

3. Rub your right palm over the dorsum of your left hand, with fingers interlaced, then vice versa

4. Rub your hands together palm to palm with fingers interlaced

5. Rub the backs of your fingers to opposite palms with your fingers interlocked

6. Place your left thumb in your clasped right palm and rotationally rub the thumb, then repeat using your right thumb and clasped left palm

7. Rotationally rub the clasped fingers of your right hand into the left palm and vice versa

8. Allow your hands to dry

How to wash your hands with soap and water

The entire process of handwashing with soap and water should take around 40-60 seconds.

You should always wash your hands (with soap and water) if:

• They are visibly soiled with blood or bodily fluids
• You suspect you have come into contact with spore forming organisms (e.g. C.difficile)
• You have just been to the toilet

Step by step guide

1. Wet hands with water

2. Apply enough soap to cover all hand surfaces

3. Rub hands palm to palm

4.Rub your right palm over the dorsum of your left hand, with fingers interlaced, then vice versa

5. Rub your hands together palm to palm with fingers interlaced

6. Rub the backs of your fingers to the opposite palm with your fingers interlocked then vice versa

7. Place your left thumb in your clasped right palm and rotationally rub the thumb, then repeat using your right thumb and clasped left palm

8. Rotationally rub the clasped fingers of your right hand into the left palm and vice versa

9. Rinse hands with water

10. Dry hands thoroughly with a single use paper towel

11. Use the towel to turn off the tap

References

1. WHO Guidelines On Hand Hygiene In Health Care. 1st ed. Geneva: World Health Organization, 2009. Available from [LINK].

Taking blood cultures is a relatively common OSCE station.  You’ll be expected to demonstrate your clinical skills and ability to communicate effectively. This blood culture collection OSCE guide provides a clear, concise, step by step approach to obtaining blood cultures. There is wide variation in the type of equipment used for obtaining blood cultures and therefore you should always follow your medical school or local hospital’s guidance. You should note however that blood cultures should ALWAYS be obtained via a fresh stab and not use existing peripheral lines. If a patient has a central line blood may be taken from this if investigating a source of infection where the line is a potential source, however this should be done in combination with a peripheral sample (which should be taken first).

Introduction

Wash hands

Introduce yourself

Confirm patient details – name / DOB

Explain procedure:

“I need to take a blood sample, which will require inserting a needle into your vein.“

“It will feel like a sharp scratch and shouldn’t take too long.“

“The sample is to look for any infection in the blood.“

Gain consent – “Do you understand everything I’ve said?” “Are you ok for me to go ahead?“

Gather equipment

Collect all equipment needed for the procedure and place it within reach on a tray or trolley, ensuring that all the items are clearly visible.

• Clean procedure tray
• Apron
• Non-sterile gloves
• Tourniquet – single use
• Blood sampling device with blood culture bottle adapter (e.g. winged blood collection set)
• Blood culture bottles x 2 (anaerobic & aerobic)
• Sharps container
• Cleaning swab x 3 (2% chlorhexidine in 70% isopropyl alcohol)
• Sterile gauze
• Sterile plaster
• Tape
• Laboratory forms, labels and transportation bag

Preparation

Ensure the patient is lying or sitting comfortably – place a pillow under their arm if possible.

1. Prepare blood collection set using aseptic non-touch technique (ANTT)

2. Position the patient’s arm in a comfortable extended position that provides adequate exposure of the planned venepuncture area

3. Inspect the antecubital fossa or forearm for a suitable vein (it should ideally be visible without applying the tourniquet)

4. Apply the tourniquet about 4-5 finger widths above the planned venepuncture site

5. Palpate the vein:

• Choose a vein has a sizeable lumen and feels “springy”
• Tapping a vein gently can make it easier to visualise and feel

6. Thoroughly clean the site:

• Use 2% chlorhexidine in 70% isopropyl alcohol to disinfect the patient’s skin and allow to dry
• If the patient’s skin is visibly soiled use soap and water to clean the site
• Once the skin has been disinfected you should not touch the site again (even with gloves on)

7. Wash your hands:

• Using alcohol gel and the World Health Organisation’s hand hygiene technique show in our guide here
• If your skin is visibly soiled you should wash your hands using soap and water

8. Don apron and gloves

9. Remove caps from the blood culture bottles immediately prior to taking the sample and clean the top of each with a separate cleaning swab, allowing the alcohol to evaporate for 30 seconds before proceeding with bottle inoculation.

10. Place the sharps bin and equipment tray (containing your sample bottles, gauze and plaster) within easy reach in preparation for venepuncture.

Insertion of the needle

1. Prepare the blood collection system using ANTT (some blood collection systems require some assembly such as attaching an to the needle)

2. Unsheathe the needle

3. Anchor the vein from below with your non-dominant hand by gently pulling on the skin distal to the insertion site

4. Warn the patient of a sharp scratch

5. Insert the needle through the skin at a 30 degree angle or less, with the bevel facing upwards (you should feel a decrease in resistance as the needle enters the vein)

6. Advance the needle a further 1-2 mm into the vein after the decrease in resistance is felt

7. Lower and anchor the needle to the patient’s skin

8. Use the other hand to attach the aerobic blood culture bottle to the adapter, piercing the blood culture septum and allowing the bottle to fill with 10ml of blood (using the bottle’s graduation lines to accurately gauge sample volume)

9. Remove the aerobic bottle and then attach the anaerobic bottle, also filling it with 10ml of blood

10. Release the tourniquet

11. Withdraw the needle and then apply gentle pressure to the site with some sterile gauze

12. Ask the patient to hold the gauze in place whilst you dispose of the needle into a sharps container

13. Apply a dressing to the patient’s arm (cotton wool / gauze / plaster)

14. Discard the used equipment into the appropriate waste bin 

To complete the procedure…

Thank patient

Wash hands

Fill out patient details on the sample bottles at the bedside

Send the blood samples to the lab for testing

Document the following in the patient’s notes:

• Reason for sample
• Time and date of sample
• Site the sample was obtained from
• Your name, signature and contact details

References

1. Taking blood cultures. A summary of best practices. UK Government Web Archive. Published 2011 [LINK]

2. WHO guidelines on drawing blood: best practices in phlebotomy. Published 2010. [LINK]

3. WHO Guidelines on Hand Hygiene in Healthcare: a Summary. Published 2009. [LINK]

Subcutaneous (SC) injections pierce the epidermis and dermis of the skin to deliver medication to the subcutaneous layer. It is a common route of delivery for medications such as insulin and low molecular weight heparin (LMWH). This guide discusses how to perform subcutaneous injection in an artificial OSCE setting and should not be used as a guide to administering injections to actual patients without first consulting your local medical school or hospital guidelines and undertaking the necessary training. Check out the subcutaneous (SC) injection OSCE mark scheme here.

Introduction

Introduce yourself

Wash hands

Confirm the patient’s details

Explain the procedure

Check the patient’s understanding of the medication being given and explain the indication for the medication.

Gain consent to proceed

Check for allergies

Check if the patient has a preferred injection site and if the patient is receiving regular subcutaneous injections, ensure that the injection sites are rotated.

Gather equipment

• Equipment tray
• The medication to be administered
• Patient’s prescription
• Syringe – the smallest syringe that will accommodate the medication volume
• Injecting needle – (26–30 gauge) – 13-16mm ¹
• Drawing up needle / Blunt filter needle (these filter out sub-visible particles of glass, rubber and other residues when drawing up from glass ampoules)
• Gauze or cotton swab
• Sharps container (for disposal of the needles)
• Non-sterile gloves

The 7 Rights

Return to the patient. Before proceeding, check the 7 rights of medication administration

1. Right person – check the patient’s arm band against the name on the prescription. Where possible aim to use two identifiers (e.g. from the patient and the arm band)

2. Right drug – check the labelled drug against the prescription – ensure expiry date is appropriate

3. Right dose – check the dose against the prescription

4. Right time – confirm when the last dose was given

5. Right route – see below

6. Right to refuse – has the patient consented?

7. Right documentation of the prescription and allergies – does the patient have any allergies?

Once these have been confirmed prepare the medication. Always use a separate drawing up needle and injection needle.

 Injection steps

1. Wash hands

2. Don gloves 

3. Draw up the appropriate medication into the syringe using a drawing up needle.

4. Remove the drawing up needle and immediately dispose of it in the sharps bin, then attach the needle to be used for injection.

5. Choose an appropriate site, common sites include: ¹

• Abdomen (avoid injecting within a 2 inch radius around the umbilicus) – this is the preferred site if giving a low molecular weight heparin injection
• Upper outer aspect of arm
• Outer aspect of the upper thigh
• Upper buttock
• See examples of site locations here

Do NOT use a site that is inflamed, irritated, bruised or contains scar tissue

If multiple injections are given, use different sites for each subsequent injection.

If frequent injections are given, rotate sites.

6. Position the patient to provide optimal access to your chosen site.

7. Cleaning the site:

• WHO does not recommend the use of alcohol based cleansing wipes prior to administration of subcutaneous medication as this can predispose an individual to developing hardened skin at the injection site ²^,³
• If the skin is visibly soiled it should be cleaned with soap and water
• Routine cleaning is not required prior to subcutaneous injection

8. Pinch a 5cm fold of skin between the thumb and index finger (using your non dominant hand) – pinching the skin increases the depth of the subcutaneous tissue available.

9. Warn the patient of a sharp scratch.

10. Pierce the skin at a 45 – 90 degree angle, aiming to remain in the subcutaneous tissue layer. Insert the needle quickly and firmly, with the bevel facing up.

11. Aspirate to check the location of the needle:

• If blood appears, remove the syringe and prepare a new injection (explaining the reason for this to the patient)
• It is not necessary to aspirate when administering insulin or heparin. ¹
• There is variation in the guidelines with some suggesting aspiration is never required, you should follow your local guidelines

12. If no blood appears on aspiration inject the contents of the syringe while holding the barrel firmly. 

13. Remove the needle and immediately dispose of it appropriately (into a sharps container).

14. Apply gentle pressure over the injection site with a cotton swab or gauze.  Do NOT rub the site.

15. Replace cotton swab or gauze with plaster 

To complete the procedure

Thank the patient

Discuss post injection care:

• Warn them that the injection site may be sore for one or two days, but this is normal.
• Other potential complications include: haematoma, persistent nodules, local irritation (and rarely anaphylaxis).
• Advise the patient to watch for a developing rash, breathing difficulty or other relevant concerning symptoms. They should discuss this with a doctor if concerned.

Wash hands

Document that the medication has been given on the medication chart and in the patient’s notes.

References

1. BD. Subcutaneous Injection Guidelines for Needle Length and Gauge Selection. Published 2012. Retrieved from: [ [LINK]

2. World Health Organisation – WHO Best Practices for Injections and Related Procedures Toolkit. Retrieved from: [LINK]

3. Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Yvan Hutin et al. 2003. Retrieved from: [LINK]

Temporomandibular dysfunction or TMD refers to a range of disorders causing pain in the pre-auricular area and muscles of mastication. It is the most common non-dental cause of orofacial pain and often goes hand in hand with other chronic pain disorders such as headaches and fibromyalgia. This article will discuss the aetiology and clinical signs of TMD and then outline its management.

Anatomy

Figure 1 showing the temporomandibular joint. The meniscus is located between the head of the mandibular condyle and the glenoid fossa of the temporal bone and can contribute to clicking and locking of the joint.

Causes

Multifactorial pathophysiology with no conclusive theory on the exact cause of the condition but thought to relate to:

• Stress
• Low mood
• Bruxism (Tooth grinding)
• Co-morbidities such as chronic pain (Fibromyalgia, Chronic Fatigue Syndrome, Back pain, Headache)
• Trauma to the teeth/face causing malocclusion (an abnormal bite)

Clinical features

Pain in the pre-auricular area (can radiate to jaw/temporal region)

Clicking (due to “sticking” of the meniscus/disc)

Locking (where the disc becomes trapped preventing the jaw from closing)

Trismus (reduced mouth opening)

Examination

Inspection

This should include inspection of the mouth and teeth to rule out any dental pathology and an examination of the patient’s occlusion (bite).

Palpation

Palpation of the TMJs bilaterally and the muscles of mastication should help define where the pain is located. Place your fingertips just anterior to the tragus to feel for clicking, locking and local tenderness. In addition, patients often complain of pain along the insertions of the masseter and temporalis muscles and so it is worth palpating there too.

Ask the patient to open and close their mouth whilst palpating the joint to detect clicking. Any deviation or locking of the jaw can be observed at this point (i.e. where the mouth doesn’t open fully in a straight line.)

Management

The aim of treatment is to eliminate pain and aid a return to normal jaw function. The vast majority of cases can be managed conservatively with only a small minority requiring invasive surgical management.

Conservative management

Explanation and reassurance – probably the most important aspect of management as explaining the benign nature of the condition often helps significantly

Identification of problem habits such as nail biting and chewing gum

Jaw exercises (advice sheets are available online and in OMFS units)

Pharmacotherapy

• Regular NSAID treatment – reduction in pain and inflammation around the TMJ.
• A short course of Amitriptyline (a tricyclic antidepressant) can be used in more severe cases of pain.

Splint therapy – often helps reduce bruxism and jaw clenching at night. Requires referral to a Dentist or Oral Surgery unit.

Physiotherapy – improves joint function through jaw stretch and muscle relaxation.

Acupuncture – Often done by the physiotherapist alongside physiotherapy.

Surgical management

Only to be considered for patients refractory to the above measures.

It includes procedures such as:

• Arthrocentesis
• Arthroscopy
• Arthroplasty
• TMJ replacement surgery (rare)

Always consider other important differential diagnoses such as giant cell arteritis and oropharyngeal tumours and ask for help if unsure.

References

1. Dwonkin SF. The OPPERA study: Act One. J pain 2011; 12: T1-T3
2. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular Disorders. BMJ2015;350:h4154
3. Ghurye S, McMillan R. Pain-Related Temporomandibular Disorder – Current Perspectives and Evidence-Based Management. Dental Update 2015; 42 (6): 533-546
4. TMJ image: Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.