Dear Batch 6

We now have approximately spent 5 years in medical school together. We went through
tough times; however, we struggled and succeeded. We managed to overcome whatever
obstacle medical school has faced us with, by working together as a team and supporting
each other as brothers. During this short period of time, we managed to accomplish a lot.
Our achievements outstood in so many aspects, whether scientific or extracurricular. I am
always proud and honored to be a functioning part of such a cooperative, productive team.
These notes are merely an example of our achievements. Hoping that we, and the
coming batches at KSAU-HS, benefit the most of these notes in exams and in the future as
doctors. Finally, I would like to thank my collogues, Batch 6, for the generous support they
gave me to finish these notes. Special thanks go out to: Abdulaziz Al-Alwan, Mohammed AlQadi, Waleed Al-Humaid, and Hesham Al-Mofada, for their participation in reviewing and
editing these notes.

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Quick Review for OSCE | Ahmad AlBrahim

Introduction
These notes are just a guide for a quick review of the most important clinical
examinations. For more details about performing certain exams or understanding
certain terminologies, you can go back to your reference book.
Before OSCE:
o Sleep well: Sleeping well is more beneficial than studying all night long.
o Bring all your equipment: Stethoscope, hammer, ophthalmoscope"
o The key to OSCE success is practice.
o Behave in a polite, professional way.
Before starting any examination:
o Wash your hands.
o Introduce yourself.
o Explain to the patient, take permission and maintain privacy.
o Before examining the patient, you should comment on:
Consciousness and alertness.
Is the patient in distress, pain or comfortable.
Connection to: O2, ECG monitor or IV line access.
o After you finish, thank the patient and cover him\her.
Contents:
o
o
o
o
o
o

Respiratory Examination
Cardiovascular Examination
GI and Renal Examination
Rheumatological Examination
Neurological Examination
Endocrine Examination

References:
o Nicholas J Talley Clinical Examination, 6th Edition.
o Notes during Clinical Skills Sessions at KSAU-HS.
Reviewed and edited by:
o Abdulaziz Al-Alwan
o Mohammed Al-Qadi
o Waleed Al-Humaid
o Hesham Al-Mofada
Don't forget us from your Dua'a and best of luck in your exam and your future
career.

Quick Review for OSCE | Ahmad AlBrahim

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Respiratory Examination
Position and Exposure:
o Sitting position and expose the patient down to the waist.

General Inspection:
o O2 mask, Metered Dose Inhaler.
o Respiratory rate "normal: 16-20".
o COPD: Use of accessory muscles, muscle indrawning, pursed lips
breathing, leaning forward.
o Stridor "with inspiration: URT obstruction", Hoarseness "larynx and
laryngeal nerve or inhaled steroid use".
Hands:
o Clubbing "cyanotic congenital heart disease, infective endocarditis, lung
Cancer, lung fibrosis, lung abscess, bronchiectasis, liver cirrhosis,
inflammatory bowel disease, and celiac disease".
o Peripheral Cyanosis.
o Wrist tenderness "hypertrophic osteoarthropathy".
o Nicotine staining.
o Wasting and weakness "lung cancer >T1".
o Flapping Tremor (CO2 retention e.g. COPD).
o Pulse rate "tachycardia".
Face:
o Horner's syndrome "myosis, ptosis, anhydrosis" lung cancer.
o Mouth: Central cyanosis under the tongue.
Neck:
o Lymph nodes and the use of accessory muscles.
o Trachea: central or slightly deviated to the right.
If it was deviated then abnormality present e.g. collapsed lung,
very large pneumothorax, or large pleural effusion.
Tracheal tug "it goes down with inspiration COPD".
CVS and leg:
o JVP, apex, leg edema "cor pulmonale".
o DVT.

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Chest Examination
Position and Exposure:
o Sitting position and expose the patient down to the waist.
Inspection:
o
o
o
o
o

Respiratory rate, movement of the chest and symmetry.

Distress, accessory muscles, way of setting.
Scars "chest tube, tracheostomy".
Rash, radiotherapy marks, tattoo.
Deformities kyphoscoliosis, kyphosis, barrel chest,
pectus "carinatum or excavatum-Marfan's-".
o Prominent veins "SVC obstruction ".
Palpation:
o
o
o
o

Neck examination: see above.

Tenderness.
Expansion: Should be 5cm male, 2cm female.
Tactile vocal fremitus (99 or 44).

Percussion: (supraclavicular, clavicle, intercostals-4 region) always compare.

o
o
o
o

Normally resonant.
Air "pneumothorax, emphysema or GIT" hyper resonant.
Liver, tumor, fibrosis, and infection dull.
Fluid "pleural effusion" stony dullness.

Auscultation: (usually by using the diaphragm of your stethoscope).

o Breath sounds:
Normally vesicular.
Bronchial consolidation.
Intensity "high or low".
Crackles: Course "bronchiectasis". Fine "fibrosis".
Wheezes: Asthma, COPD, tumor "airway obstruction".
o Vocal fremitus (99 or 44) "clear if consolidation".

Quick Review for OSCE | Ahmad AlBrahim

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Cardiovascular Examination
Position and Exposure:
o Supine and tilted up at 45 degree position, and expose the chest.

General Inspection:
o Dyspnea, cachectic, Marfans, Downs, Turner syndromes.
Hands:
o Clubbing, peripheral cyanosis, nicotine staining.
o Infective endocarditis "splinter hemorrhages, Oslers nodes painful-,
Janaway lesion".
o Tendon xanthomata (type II),tuberuptive and palmer (type III).
Pulse:
o Rate (normal: 60-100 beat per minute).
o Rhythm (regular, irregularly irregular "a fib").
o Delays (Radio-radial delay "aortic dissection or subclavian artery
stenosis" and Radio-femoral delay "coarctation of aorta").
o Collapsing pulse: AR, hyperdynamic conditions "pregnancy, PDA,
thyrotoxicosis".
Blood Pressure: layingstanding.
o Postural hypotension: >15 mmHg drop in systolic when standing up".
o Pulsus Paradoxus: drop 10 mmHg with inspiration cardiac tamponade
and severe asthma".
Face:
o Eyes: Xanthelasma, arcus senilis, pallor, jaundice.
o Mouth: central cyanosis, High arch palate (Marfans), teeth "IE".
Neck:
o JVP: which is visible not palpable, 2 pulse/cycle, decrease with
respiration. Should be < 8 cm.
kussmaul's sign: JVP increases with inspiration constrictive pericarditis or RVH.
a-wave: atrial contraction, v-wave: atrial filling.
Cannon a-wave: complete heart block, giant a-wave: TS, giant v-wave: TR.
o Carotid: palpate one for character and auscultate the two.
Back:
o Percussion: plural effusion.
o Auscultation: inspiration crackles LVF.
o Sacral edema.
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 Abdomen:
o Hepatomegaly: RVF, and Ascites.
o Splenomegaly.
o Aortic aneurysm "palpate and auscultate" + renal bruit.

Legs:
o Femoral artery "palpation, auscultation".
o All peripheral pulses "popliteal, dorsalis pedis, post. tibial".
o Edema "15s".
Funduscopy:
o Roth's spot "IE", HTN "silver wiring, AV nipping, exudates, and
papilledema".

Precordium Examination
Inspection:
o Scars: (e.g. midline sternotomy for CABG, left axillary scar for Mitral
replacement). Pace maker (below the left & right clavicle). Deformities.
o Visible pulsations and apex beat (position).
Palpation:
o Apex beat: Position: 5th intercostal space, mid-clavicular line.
Character:
Pressure loaded "forceful, sustained" AS & HTN.
Volume loaded "displaced, non-sustained" AR & MR.
Tapping apex "palpable S1" MS.
Dyskinetic "diffuses moves" HF.
o Left parasternal heaves: RV hypertrophy, LA enlargement.
o Thrills: palpable murmur & Palpable P2 "pulmonary HTN".

Percussion: Unnecessary in the CVS examination (except lung bases)

Auscultation: 4 areas, bell/diaphragm, comment on S1, S2, murmurs, added

sounds (e.g. rub), axilla, carotid radiation.
Murmur: site, timing, radiation, grade (1-6... >4 thrill), character (rumbling: MS, harsh:
AS & VSD, blowing: MR).
AS: Harsh ejection systolic, radiating to the carotids best heard on the aortic area.
MR: Blowing pan-systolic, radiating to the axilla best heard on the apex.
AR: Diastolic decrescendo, best heard on the aortic area.
MS: Rumbling diastolic, best heard on the apex associated with opening snap.
VSD: pan-systolic over the tricuspid area. PDA: continuous over the pulmonary area.
Maneuvers: left lateral position "apex", sitting with full expiration "AR & rub".

Quick Review for OSCE | Ahmad AlBrahim

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GI & Renal Examination

Position and Exposure:
o Lying flat on one pillow & expose from the nipples to the mid-thigh.
General Inspection:
o Liver related: Jaundice, pigmentation "hemochromatosis",
encephalopathy, xanthomata "Primary Biliary Cirrhosis PBC-".
o Renal related: dehydration, hyperventilation "metabolic acidosis", and
hiccups.
Hands:
o Liver related: Clubbing, leuconychia "low albumin", palmer erythema
"estrogen", flapping tremor "encephalopathy" and arthropathy
"hemochromatosis", Dupuytren's contracture "alcoholic liver disease".
o Renal related: leuconychia, half & half nail.
Arms:
o Liver related: spider naevi, bruising "low coagulation factors", wasting,
and scratch marks "pruritus".
o Renal related: AV fistula "palpates and auscultate".
Eyes:
o Jaundice, anemia, iritis "IBD".
o Kayser-Fleischer ring "Wilson's disease" & Xantholesma "PBC".
Mouth:
o Dryness, angular stomatitis "iron deficiency".
o Ulcer "IBD", telengectasia.
Neck:
o Lymph nodes: left supraclavicular nodes "Virchow's nodes" gastric ca.
o JVP, carotid "atherosclerosis".
Chest:
o Liver related: Spider nivae, gynecomastia & hair loss.
o Renal related: Pericarditis "uremia", CHF, pulmonary edema.
Back and leg:
o Renal osteodystrophy to the vertebrae.
o Edema and bruising.

Rectal and urogenital Examination + Urine dipstick test.

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Abdominal Examination
Position and Exposure:
o Lying flat on one pillow with both hands on the side & expose from the
nipples to the mid-thigh.
Inspection: Best done from the patients foot side of the bed.
o Contour and Distention (5 F: Feces, fetus, flatus, Fat, Fluid).
o Scars: Appendectomy, peritoneal dialysis, nephrectomy, ascites.
o Prominent veins "portal HTN", caput medusa around the umbilicus.
o Umbilicus "inverted or everted".
o Striae, bruising, rashes, visible peristalsis, pigmentation.
o Hernias: Let the patient stand, and then ask the pt. to cough.
Palpation: Ask if there is any pain and observe the patient's face.
o Tenderness "superficial and deep".
o Organomegaly:
a) Liver: Palpate the liver edge
Percuss for span "8-12 cm" from above and below.
b) Spleen: You can't go above it, has a notch, and enlarges infer-medially.
Palpate "pt. flat" & "pt. lying over his right side".
Percuss over left costal margin-anterior Axillary line with
full expiration.
Note: Splenomegaly causes:
Hematological "hemolytic anemia, thalassemia major, CML, lymphoma, MM".
Infection "malaria, CMV, IM, HIV, schistosomiasis, infective endocarditis".
Connective tissue disease "SLE, RA" & Infiltrative "Sarcoidosis, Amyloidosis".
Congestion "CHF, portal or splenic vein thrombosis".
Others: storage disease, Idiopathic.
Hepatosplenomegaly "Chronic liver failure with Portal HTN, acromegaly".
c) Kidneys: bimanual examination "balloting".
d) Bladder: percussion.
Percussion:
o Ascites (Shifting dullness & fluid thrill "huge ascites").
Auscultation:
o Bowel sounds "Exaggerated: obstruction or absent: paralytic ileus".
o Renal bruit "Renal artery stenosis".
o Liver bruit "Hepatocellular carcinoma".
Quick Review for OSCE | Ahmad AlBrahim

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Rheumatological Examination
Hand Examination
Position and Exposure:
o The patient's hands on a pillow & exposed till above the elbow.

Look:
Nail:
o Psoriasis "pitting, onycholysis, hyperkeratosis, oil drop".
o Splinter hemorrhage "SLE".
Skin:
o Tightness "scleroderma" & Erythema "inflammation".
o Rash "psoriasis".
o Scars "e.g. fasciotomy for carpal tunnel syndrome".
Muscle: wasting "between metacarpal bones".
Bones: subluxation, dislocation.
Joint:
o Swelling.
o Deformities: RA ulnar deviation of MCP, radial deviation of the wrist,
swan neck, boutonniere, Z-deformity of the thumb.

Feel:
Temperature.
Tenderness over the joint line.
Swelling:
o Bony swelling "OA": Heberden's nodes "DIP", Bouchard's nodes "PIP"
o Effusion "RA".

Move:
Passive and active movement "limitation, crepitus"
Function: Undo a button or write with a pen "practical".
o Grip strength: Squeeze a pen.
o Key grip: Between the thumb and forefinger.
o Opposition strength.

Special test:
Carpal Tunnel syndrome:
o Phalen's sign: Flex both wrists for 30 sec. parasthesia.
o Tinel's sign: Tapping over flexor retinaculum parasthesia.
Subcutaneous nodule of RA palpation near the elbow over the olecranon.
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Knee Examination
Position and Exposure:
o Lying down & expose both knees and the thighs.

Look:
Nail: Look for any change.
Skin:
o Atrophy and tightness, erythema, rash, scars.
Muscle:
o Wasting.
o Lower limb swelling "ruptured Baker's cyst" due to RA
Bones: Subluxation, dislocation.
Joint:
o Swelling and Backer's cyst "knee is fully extended".
o Deformities: Valgus and varus.

Feel:
Temperature "slide the dorsum of the hand over the thigh downward to the
knee the knee should be colder-".
Tenderness over the joint line.
Swelling
o Bony swelling
o Effusion: patellar tap "huge", milking sign "mild".

Move:
Passive and active movement "limitation, crepitus".

Special test:
McMurray's test: Knee & hip are flexed in 90 degree, and feel the joint line.
o Medial meniscus: External rotation + abduction + extension.
o Lateral meniscus: Internal rotation + adduction + extension.
Varus and valgus stress test: Knee is flexed in 30 degree.
o Varus +: Lateral Ligament tear.
o Valgus +: Medial Ligament tear.
Drawer Test: For anterior & posterior cruciate ligaments.

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Neurological Examination
Neck:
Meningeal signs:
o Neck stiffness: Lying flat then flex the neck.
o Brudziniski sign: Neck flexion lead to hip flexion.
o Kerning sign: Pain after flexion of the hip + extension of the knee.
Carotid bruit: 70% stenosis.

Cranial nerves
(I)Olfactory nerve: Done if anosmia "most common cause: URTI".
(II)Optic nerve:
o Visual acuity "each eye, Snellen's chart (6m).
o Visual fields: Confrontation test (1m away) test the 4 quadrants.
o Fundoscopic exam:
Disc "papilledema-obliterated margins-, atrophy-pale-".
4 quadrants "DM and HTN changes".

(III, IV, VI)Oculomotor, trochlear nerves and abducens:

o Pupil:
Inspection: Ptosis, size, shape, regularity.
Light reflex: From the side (direct & consensual).
Afferent pupillary defect "Marcus Gunn Pupil": Paradoxical dilation of the affected eye.
Accommodation: Constriction after conversion.
o Eye movements : X and H shape "look for Nystagmus and diplopia"
III: Ptosis and dilated pupil.
IV "SO": Weakness when eye goes in & down.
VI "LR": Weakness of lateral movement.
(V) Trigeminal nerve:
o Corneal reflex: V1 sensory. VII motor.
o Sensation (sharp and light touch): Ophthalmic, maxillary, mandibular.
o Motor: The jaw deviates to the affected site.
Inspection: Wasting of masseter or temporal.
Clinch the teeth: Masseter, open the mouth: Ptyrigoid.
o Jaw jerk: If exaggerated "pseudopulbar palsy UMNL".

(VII) Facial:
o Inspection: Asymmetry "UMNL: intact upper face due to dual supply"
o Motor: Look up "wrinkles", close your eye" power", puff your mouth
"buccinators m.", show me your teeth.

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 (VIII) Vestibulocochlear: Tested by rubbing your fingers.

o Weber Test: Tuning fork in the middle.
o Renee test: Air and bone conduction.
(IX & X) Glossopharyngeal and Vagus: Usually examined together.
o Inspection: Say "Aaah" then see soft palate and Uvula, if deviated "pulled
to unaffected side".
o Gag reflex: (sensory IX, motor X).
(XI) Accessory:
o Trapezius: Shrug the shoulder.
o Sternocleidomastoid: Each turns the head to the opposite side.
(XII) Hypoglossal:
o Inspection: Wasting and fasciculation.
o Motor: Protrude the tongue "it will deviate to the affected site".

Cerebellar Examination
Eyes:
o 6 cardinal gazes: Nystagmus.
o Rebound test "tennis match" right, left, up, and down.
Speech: Look for dysarthria "scanning speech".
Head and Trunk: Look for titubation.
Upper limbs: Always compare.
o Inspection: Bulk and movement.
o Tone and reflexes: Hypotonia and hyporeflexia.
o Finger-nose test: Intention tremor & dysmetria "fully extended".
o Rapid alternating movement test: Look for "Dysdiadokinesia".
o Delecoctasia.
o Touch the thumb's creases by the tip of his forefinger.
o Rebound: Flex the elbow with resistance.

Lower limbs:
o
o
o
o

Tone and reflexes: Hypotonia and hyporeflexia.

Rapid movement: By hitting rapidly on the floor.
Heel to shin examination.
Romberg's test: Stand as a cross " if imbalance with"(eye open
cerebellar- or closed-sensory ataxia-).

Gait:
o Wide gait.
o Heel-to-toe "Tandem gait".
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Upper Limb neurological Examination

Inspection:
o Posture: stroke "flexion, adduction, and pronation of the arm".
o Muscle wasting: Proximal, distal.
o Abnormal movement: Tremor, fasciculation "LMNL".
o Skin: Herpes zoster, NF.
o Drift: UMNL "down", cerebellar "up", proprioception "choreaform".
Tone: Examine the wrist and elbow. "The patient should be relaxed".
o Velocity independent: Extrapyramidal "Parkinson's disease" cogwheel
rigidity and lead pipe.
o Velocity dependent: UMNL, clasp knife with Fast movement.
o Hint: Ask the patient to tab in his lab to distract him.
Power:
5: Normal. 4: Mild resistance. 3: Against gravity. 2: Exclude gravity. 1: Flickering. 0: No
C5, 6: Elbow flexion. C6, 7: Wrist flexion.
C7, 8: Elbow & wrist extension. C8, T1: Finger abduction.
Reflexes:
0 No reflex
1 Hyporeflexia with reinforcement.
2 Normal
3 Hyperreflexia- brisk
4 Clonus (sustained or not)
Coordination: cerebellar examination.

Sensory system:
o Lateral Spinothalamic: Pain & temperature "ask if it's sharp or dull"
o Posterior column:
Vibration: 128 Hz, close eye, over the DIP joint.
Proprioception: DIP of the little finger "up and down".
o Light touch: "dorsal column, anterior spinothalamic ".
o Cortical sensation: Graphesthezia "numbers", & astrognosis "pen".

Peripheral nerve:
o
o
o
o
o
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Radial: Motor: Good sign. Sensory: Snuff box. Lesion: Wrist drop.
Median: motor: OK sign. Sensory: Middle finger.
Ulnar: Motor: Abduction. Sensory: Lateral hand. Lesion: Claw-hand.
Brachioradialis: Motor: Elbow flexion. Sensory: Lateral forearm.
Axillary: motor: Abduction. Sensory: Over the deltoid.
Quick Review for OSCE | Ahmad AlBrahim

Lower Limb neurological Examination

Inspection: Urinary catheter, fasciculation, wasting.
Tone: Examine the Knee & ankle.
Clonus: Dorsiflex the ankle then push it up strongly Sustained rhythmic contraction.
Power:
L2, 3: Hip flexion. L3, 4: Knee extension. L4, 5: Ankle dorsiflexion. S1, 2: Planterflexion.
L3, 4: Squat & stand. L4, 5: Stand on the heel. S1: Stand on the toe.
Reflex: Jendrassik's maneuver for reinforcement.
o Knee jerk "L3,L4"
o Ankle jerk "S1,S2"
o Babinski sign "L5,S1,2": Stimulate the toe Babinski: Toe up
Coordination: Cerebellar examination.
Sensory
o Dermatomes:
Upper Limb: C5: Lateral Forearm. C6: Thumb. C7: Middle finger. C8: Little finger.
T1: Medial forearm. T4: Nipple. T10: Umbilicus
Lower Limb: L2: Ant. thigh. L3: Knee. L4: Med. Leg. L5: Lat. Leg. S1: Sole. S2: Post. thigh.
o Cutaneous reflex :
Abdominal reflexes "T6-T9, T9-T11, T11-L1" reflex
contraction of muscle "absent in UMNL".
Cremesteric "L1-L2"inner thigh downward stimulation.
Anal reflex: Pinprick > Contraction.
Peripheral nerve :
o Lateral cutaneous of the thigh.
o Femoral (L2-L4): Motor: quadriceps "knee extension", knee jerk.
Sensory: Inner thigh and leg.
o Sciatic (L4-S2): Motor: Knee flexion, ankle jerk, Sensory: All
o Common peroneal (L4-S1) Motor: Dorsiflexsion and eversion.
Sensory: Lateral and dorsum of foot. No reflexes.
Note: The difference between common peroneal foot drop and L5 foot drop that the latter
has weakness of knee flexion and loss of inversion +sensory distribution of L5.
Gait: Usual gait then:
o Heel to toe "tandem gait": Cerebellar.
o Romberg's test: Stand as a cross "should be balanced".
(Eyes are opened cerebellar- and closed-sensory ataxia-).

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Endocrine Examination
Thyroid Examination
Position and Exposure:
o Sitting & expose the neck and the chest.

Hand:
o
o
o
o
o

Acropachy "thyrotoxicosis".
Palms: "Sweaty or dry".
Palmer Erythema.
Pulse (rate, rhythm "atrial fibrillation", collapsing pulse thyrotoxicosis-).
Tremor (ask the pt. to extend his hand with the fingers separated).

o
o
o
o

6 Cardinal eye movement, ask if there is diplopia.

Exophthalmos, proptosis "Grave's".
Lid lag (the lid lag behind the orbit should be performed slowly).
Anemia, Jaundice.

Eye:

Neck:
Inspection:
o Swelling, bulging, Scars, color, dilated veins "thoracic inlet block".
o Swallow water "thyroid swelling".
o Put out the tongue "thyroglossal duct".
Palpation:
o Little bit flexed , From Behind R and L lobes (Push with one hand and
examine with the other )
o If nodule, describe: site, size, mobility, consistency, tenderness, and
surface/overlying skin. "same for lymph node/lump description"
o Lymph nodes (Ant. and Post. cervical, sub mental, sub mandibular, pre
auricular, and supraclavicular )
Auscultation: bruit "thyrotoxicosis".
Lower Limb
Pretibial myxedema (Non pitting, Itching, Anterior Chin) "Grave's disease".
Reflexes
o Hyperthyroidism: Brisk movement-hyperreflexia-.
o Hypothyroidism: slow relaxation phase.

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