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To accompany your Annual checklist.

This brief document will help you see what you need to complete and a checklist for your SLE's!

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To accompany your Annual checklist.

This brief document will help you see what you need to complete for the Women, Child and Family placement block and gives you a checklist for your SLE's!

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To accompany your Annual checklist.

This brief document will help you see what you need to complete and a checklist for your SLE's!

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Recognising physical signs in a range of skin tones with Mind the Gap 

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Recognising physical signs in a range of skin tones with Mind the Gap 

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Conceived of by medical student Malone Mukwende and written in conjunction with senior clinical tutors in SGUL, this handbook starts to bridge the longstanding gaps in the medical student curriculum by providing information on how many common skin signs present in different skin tones. An excellent read, and this link is to the free version hosted on the creator's website.

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800+ OSCE Stations | OSCE Practice | OSCE Bank | OSCE Cases

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An OSCE bank of 800+ OSCE stations with answers & checklists, providing everything you need to prepare for your OSCEs (including running mock OSCEs). OSCE case types include clinical examination, procedures, communication skills, data interpretation, emergency ABCDE scenarios and documentation.

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Listen to breath sounds, murmurs and all things audible here

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Listen to breath sounds, murmurs and all things audible here

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Be sure to make a free account and listen to all the wonderful sounds our bodies can make!

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Lessons, Drills, Quizzes
Ready to sharpen your clinical skills? Take on our ECG interpretation, blood pressure and auscultation lessons, drills and quizzes. Most of the content is free. Registration is optional.

ECG rhythms classes:
Authors, Reviewers and Developers
Thomas O'Brien.
ECG monitor simulation: Steve Collmann
12 Lead Lecture: Dr. Michael Mazzini, MD, Cardiologist.
Spanish ECG: Breena R. Taira, MD, MPH
Auscultation: Diane Wrigley, PA
Respiratory: William French
Special thanks for the medical mentorship of Dr. Raymond Murphy.
Cardiology: Dr. Jonathan Keroes, MD, Cardiologist,
Auscultation review: Dr. Barbara Erickson, PhD, RN, CCRN
Electrophysiology review: Dr. Pedro Azevedo, MD, Cardiology
Last Update: 11/10/2022

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Practical Clinical Skills | ECG | Heart Sounds, Murmurs, Lung Sounds

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Learn ECG, blood pressure measurement, lung sounds, and heart sounds. Our mostly free training includes drills, quizzes and reference guides. For all medical professionals.

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This ECG recording OSCE guide provides a clear step-by-step approach to recording an ECG, with an included video demonstration.

Gather equipment

Gather the appropriate equipment:

ECG machine: to record the ECG.

Self-adhesive ECG electrodes: to attach the ECG leads to the patient.

Razor: may be required to remove hair to provide adequate electrode contact with the skin.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "I need to record an ECG which is an electrical trace of the heart. The procedure will involve placing some sticky pads onto your chest and limbs. I will then connect these sticky pads to the ECG machine's leads to record the tracing."

If the patient is a female, explain the need for a chaperone: "One of the female ward staff members will be present throughout the procedure, acting as a chaperone, would that be ok?"

Gain consent to proceed with ECG recording.

Adequately expose the patient's chest for the procedure (offer a blanket to allow exposure only when required). Exposure of the patient's lower legs and wrists is also necessary to apply the limb leads.

Ask the patient to lay on the clinical examination couch with the head of the couch at a 45° angle.

Check if the patient has any pain before continuing with the clinical procedure.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Electrode placement

A 12-lead ECG involves the use of 10 electrodes, six on the chest and four on the limbs.

Begin by checking the expiry date of the electrodes to ensure they are within date.

It is important to ensure each electrode has good skin contact, which may involve cleaning or shaving the areas where you need to place electrodes. If this is the case, make sure to explain this clearly to the patient and gain consent before proceeding. See below for more details on how to improve skin contact with electrodes.

Chest electrode and lead placement (V1 - V6)

Apply the six chest electrodes in the following locations:

V1: 4th intercostal space at the right sternal edge.

V2: 4th intercostal space at the left sternal edge.

V3: midway between the V2 and V4 electrodes.

V4: 5th intercostal space in the midclavicular line.

V5: left anterior axillary line at the same horizontal level as V4.

V6: left mid-axillary line at the same horizontal level as V4 and V5.

Once all electrodes have been applied, attach the associated chest leads, with the cable for each lead lying inferior to the electrode (to reduce tension on the wire).

Limb electrode and lead placement

Apply the four limb electrodes on a distal bony prominence in the following locations:

Red (RA): on the ulnar styloid process of the right arm.

Yellow (LA): on the ulnar styloid process of the left arm.

Green (LL): on the medial or lateral malleolus of the left leg.

Black (RL): on the medial or lateral malleolus of the right leg.

Once all electrodes have been applied, attach the associated limb leads, with the cable for each lead lying inferior to the electrode (to reduce tension on the wire).

Some people find the mnemonic " useful for remembering the placement of the limb leads, starting clockwise from the right wrist.

Improving skin contact with the electrodes

Hair can sometimes make it difficult to achieve good skin contact and as a result, you may need to use a razor to remove the hair at the electrode site.

If the skin is particularly oily you can clean the site with an alcohol wipe and allow to dry prior to electrode application.

If the skin is visibly soiled it should be cleaned, ideally with soap and water, then dried prior to electrode application.

Avoid pressing hard on the centre of the electrodes as this can cause the gel to spill outwards reducing the ability of the electrode to stick to the skin.

Recording the ECG trace

1. Turn the ECG machine on and ensure ECG paper has been loaded into the machine.

2. Double-check all the electrodes are attached in the appropriate locations.

3. Politely ask the patient to remain still and not talk during the recording as muscle activity can interfere with the ECG trace.

4. Press the appropriate button on the ECG machine to record the ECG trace. If the ECG trace is poor, double-check the connections to ensure there is good skin contact.

To complete the procedure...

Once an ECG trace has been obtained, switch off the ECG machine.

Detach the ECG leads from the electrodes and then remove the electrodes carefully, warning the patient this may feel uncomfortable.

Explain to the patient that the procedure is now complete.

Thank the patient for their time.

Label the ECG with the patient's details:

Dispose of PPE appropriately and wash your hands.

Document your findings in the patient's notes (see our guide to ECG documentation).

To learn about interpreting ECGs, see our how to read an ECG guide.

Reviewer

Michelle Spence
Senior nurse practitioner

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How to Record an ECG - OSCE Guide | Procedure | Geeky Medics

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A step-by-step guide to recording an ECG in an OSCE setting, with an included video demonstration.

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OSCE Sense is the home of clinical OSCE practice. All of our mock OSCEs are free, and peer reviewed. It's the tool we wish we had at medical school.

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Here you can find your full placement Checklist!!

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800+ OSCE Stations | OSCE Practice | OSCE Bank | OSCE Cases

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An OSCE bank of 800+ OSCE stations with answers & checklists, providing everything you need to prepare for your OSCEs (including running mock OSCEs). OSCE case types include clinical examination, procedures, communication skills, data interpretation, emergency ABCDE scenarios and documentation.

# data[].attributes.attachment_link.description
OSCE Sense is the home of clinical OSCE practice. All of our mock OSCEs are free, and peer reviewed. It's the tool we wish we had at medical school.

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Powerpoint for 2023/24 FY1/2 teaching on managing acute mental health presentations 

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Powerpoint for 2023/24 FY1/2 teaching on managing acute mental health presentations 

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https://www.canva.com/design/DAFq9Yt6Ufc/uvzjBfTYqboTeTWy5O8BEw/view?utm_content=DAFq9Yt6Ufc&utm_campaign=designshare&utm_medium=link&utm_source=publishsharelink

A guide to the Mental State Exam with an example based on real life acute presentations!

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Taking an arterial blood gas (ABG) involves using a needle and syringe to directly sample blood from an artery (typically the radial artery). Below is a step-by-step guide to taking an arterial blood gas sample in an OSCE setting, with an included video demonstration.

Gather equipment

Gather the appropriate equipment:

Gloves

Apron

Pre-heparinised arterial blood gas syringe and bung or cap

Arterial blood gas needle (23 G)

Alcohol wipe (70% isopropyl)

Gauze or cotton wool

Tape

Lidocaine 1% (1 mL)

Subcutaneous needle (25-27 G)

Small syringe for lidocaine (1-2 ml)

Sharps container

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "I need to take a sample of blood from an artery in your wrist to accurately assess your oxygen levels. The procedure will be a little painful, however, it should only take a short amount of time. If you want me to stop at any point, just let me know. The procedure does involve some risks which include bleeding, bruising, infection and very rarely permanent damage to the artery being sampled from."

Check for any contraindications to arterial blood gas sampling:

Absolute contraindications: peripheral vascular disease in the limb, cellulitis surrounding the site or arteriovenous fistula.

Relative contraindications: impaired coagulation (e.g. anticoagulation therapy, liver disease, low platelets <50).

Check if the patient has an allergy to local anaesthetic (e.g. lidocaine).

Gain consent to proceed with arterial blood gas sampling.

Adequately expose the patient's wrist for the procedure.

Position the patient so that they are sitting comfortably, ideally with their wrist supported by a pillow. If a bed is available, the patient can lay down for the procedure (this is sometimes preferable, particularly if the patient is prone to vasovagal syncope).

Ask the patient if they have any pain before continuing with the clinical procedure.

How oxygen therapy impacts ABG results

should be greater than 10 kPa when oxygenating on room air in a healthy patient.

If the patient is receiving oxygen therapy their should be approximately 10kPa less than the % inspired concentration FiO₂ (so a patient on 40% oxygen would be expected to have a PaO₂ of approximately 30kPa).

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Modified Allen's test

Before taking a sample from the radial artery, a modified Allen's test should be performed to assess the collateral arterial supply of the hand from the ulnar artery. The idea behind this assessment is to make sure the patient's hand isn't exclusively reliant on the radial artery for its blood supply, in which case sampling should be avoided.

To perform a modified Allen's test:

1. Ask the patient to clench their fist.

2. Apply pressure over the radial and ulnar artery to occlude both vessels.

3. Ask the patient to open their hand, which should now appear blanched. If the hand does not appear it suggests you are not completely occluding the arteries with your fingers.

4. Remove the pressure from the ulnar artery whilst maintaining pressure over the radial artery.

5. If there is adequate blood supply from the ulnar artery, the normal colour should return to the entire hand within 5-15 seconds. If the return of colour takes longer, this suggests poor collateral circulation Do not perform arterial blood gas sampling on a hand that does not appear to have an adequate collateral blood supply.

It should be noted that there is no evidence performing this test reduces the rate of ischaemic complications of arterial sampling.

Preparation

Oxygen and body temperature

Note the patient's body temperature and if the patient is currently receiving oxygen therapy, note the oxygen delivery device and flow rate.

These factors can significantly affect results and are taken into account by the arterial blood gas analyser.

Equipment

Remove all equipment from its packaging so that it is easily accessible during the procedure.

Attach the needle, with its protective cover intact, to the pre-heparinised ABG syringe.

Positioning

Position the patient's hand preferably on a pillow for comfort with the wrist extended by approximately 20-30°.

Procedure

Palpation

Assess the course of the radial artery to determine where you plan to perform arterial sampling:

1. Palpate the radial artery over the wrist of the patient's non-dominant hand to identify an ideal puncture site. You should use the tips of your fingers to clearly map out the course of the radial artery and then identify a distal site where the artery is most pulsatile. The radial artery is typically most superficial over the lateral anterior aspect of the wrist.

2. Once you have identified your planned puncture site, clean it with an alcohol wipe for 30 seconds and allow it to dry before proceeding.

3. Wash your hands again.

4. Don a pair of gloves and an apron.

Local anaesthetic

Pain associated with arterial blood gas sampling can be markedly reduced by the use of subcutaneous local anaesthetic. The British Thoracic Society recommends the routine use of local anaesthetic for obtaining ABG samples except in the context of an emergency or if the patient is unconscious.

Prepare and administer lidocaine subcutaneously over the planned puncture site (aspirate to ensure you are not in a blood vessel before injecting the local anaesthetic). See our guide to subcutaneous injection for more details.

Allow at least 60 seconds for the local anaesthetic to work.

Arterial puncture

1. Remove the protective cover from the ABG needle and then flush through the heparin from the syringe.

2. Hold the patient's wrist extended by approximately 20-30°.

3. Palpate the radial artery with your non-dominant hand's index finger around 1cm proximal to the planned puncture site (avoiding contaminating the planned puncture site that you previously cleaned).

4. Warn the patient you are going to insert the needle.

5. Holding the ABG syringe like a dart, insert the needle through the skin at the insertion site at an angle of 30-45°.

6. Continue to advance the needle slowly towards the pulsation until you feel a sudden reduction in resistance and see a rush of blood back into the ABG syringe (this is known as "flashback").

7. The ABG syringe should then begin to self-fill in a pulsatile manner. If this doesn't happen, it may indicate you have gone through or missed the artery and therefore need to re-adjust your position based on your understanding of the course of the radial artery (e.g. change in angulation or slight withdrawal of the needle).

8. Once the required amount of blood has been collected, remove the needle and apply immediate firm pressure over the puncture site with some gauze. Secure the gauze with some tape and continue to apply pressure.

9. Engage the needle safety device (often a clip that covers the needle or a bung that the needle is inserted into).

10. Remove the ABG needle from the syringe and discard it immediately into a sharps bin.

11. Carefully expel any air from the sample if present, place a cap onto the ABG syringe and invert it gently.

12. Attach a sticker containing the patient's details to the ABG sample.

13. Continue to apply firm pressure to the puncture site for 3-5 minutes to reduce the risk of haematoma formation.

ABG reference ranges

To complete the procedure...

Explain to the patient that the procedure is now complete.

Thank the patient for their time.

Dispose of your PPE and equipment into an appropriate clinical waste bin.

Wash your hands.

Take the ABG sample to be analysed as soon as possible after being taken as delays longer than 10 minutes can affect the accuracy of results.

Document the ABG results in the patient's notes (see our guide to ABG documentation).

References

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

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How to take an Arterial Blood Gas (ABG) - OSCE Guide | Geeky Medics

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A step-by-step guide to performing arterial blood gas (ABG) sampling in an OSCE setting, with an included video demonstration.

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This female catheterisation guide provides a step-by-step approach to performing catheterisation in an OSCE setting.

Gather equipment

1. Clean the top of a procedure trolley using a disinfectant wipe.

2. Collect the equipment required for the procedure and place it within reach on the clean trolley:

Plastic apron

Two pairs of sterile gloves

Sterile water-filled syringe (10ml) for inflation of the catheter balloon.

0.9% sodium chloride (10mls)

Lidocaine (1%) anaesthetic lubricating gel for insertion into the urethra.

Male urinary catheter (12/14 french): these are also used for females in most cases.

Catheter pack: including cotton wool balls, sterile gauze, sterile drapes, absorbent pad and gallipot (a.k.a. a small pot).

Catheter bag

Urine collection bowl (a.k.a. a receiver)

3. Check the expiry date on the catheter, sterile water, normal saline and lidocaine gel.

4. Ensure a clinical waste bin is placed nearby.

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.

Don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "Today I need to insert a catheter. This will involve inserting a thin flexible tube into the bladder. The procedure will feel a little uncomfortable but shouldn't be painful. I'll insert some local anaesthetic into the urethra to make the procedure as comfortable as possible."

Explain the need for a chaperone: "One of the other staff members will be present throughout the procedure, acting as a chaperone, would that be ok?"

Gain consent to proceed with catheterisation.

Check if the patient has any allergies (e.g. latex).

Ask the patient if they have any pain before continuing with the clinical procedure.

Explain to the patient that they'll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.

Equipment preparation

Setting up the sterile field

1. Setup up the sterile field by first removing the outer packaging from the catheter pack and then opening the catheter pack from the corners without touching the inner surface of the field. Make sure to keep the catheter packaging as you'll need to transfer the sticky label containing the details of the catheter into the patient's notes.

2. Using aseptic non-touch technique (ANTT) place the catheter, lidocaine gel syringe, sterile water syringe and sterile gloves onto the field.

3. Pour the 0.9% sodium chloride solution over the cotton balls which should already be located within the gallipot of the catheter pack.

Positioning the patient

1. With the patient lying supine, ensure the bed is at an appropriate height for you to comfortably carry out the procedure.

2. Wash your hands again and don a pair of sterile gloves.

3. Ask your chaperone to remove the sheet covering the patient's genitals to allow you to maintain sterility.

4. Place a sterile absorbent pad underneath the patient's genital region, ensuring you maintain sterility.

Cleaning the genital region

1. Part the labia with your non-dominant hand.

2. With your dominant hand pick up a cotton ball and use a single stroke moving downwards to clean the urethral meatus and surrounding genital region. Dispose of the first cotton ball into the clinical waste bin and continue to repeat this process with a new cotton ball each time until the area has been thoroughly cleaned.

3. Discard your used gloves, wash your hands again and don a new pair of sterile gloves.

4. Place the sterile drape over the patient's genitals, positioned such that the genitals remain visible through the central aperture of the drape. Some drapes come with a hole already present for this purpose, whereas others will require you to create one.

5. Place the sterile urine collection bowl below the genitals but on top of the sterile drape.

Inserting the local anaesthetic

1. Warn the patient that the anaesthetic gel might initially sting, but then should quickly cause things to become numb.

2. Part the labia with your non-dominant hand.

3. With your dominant hand place the nozzle of the syringe of anaesthetic gel into the urethral meatus.

4. Empty the entire 5mls of anaesthetic gel into the urethra at a slow but steady pace.

5. Allow 3 to 5 minutes for the lidocaine gel to reach its maximum effect.

Inserting the catheter

Preparation

1. Pick up the catheter which should be on your sterile field in its wrapper.

2. Remove the tear-away portion of the wrapper near the catheter tip, making sure not to touch the catheter.

3. Part the labia with your non-dominant 'dirty hand'.

Insertion

4. Warn the patient you are about to insert the catheter.

5. Insert the exposed catheter tip into the urethral meatus using your dominant 'clean hand'.

6. Advance the catheter slowly whilst gradually removing more of the wrapper to expose more of the catheter. If there is significant resistance you should remove the catheter and consider a repeat attempt or specialist input from urology.

7. You should continue to advance the catheter until it is fully inserted into the urethra. As you enter the bladder urine should begin to drain from the catheter.

Balloon inflation

9. Once the catheter is fully inserted, inflate the catheter balloon with the 10ml syringe of sterile water to secure it within the bladder. Before doing this, ask the patient to let you know immediately if they experience any discomfort as you inject the water. If the patient begins to experience discomfort during the injection of the water stop immediately as this may indicate the tip of the catheter is within the urethra.

10. Once the balloon is fully inflated, remove the syringe and gently withdraw the catheter until resistance is noted, confirming the catheter is held securely within the bladder.

Attaching the catheter bag

11. Attach the catheter bag tubing to the end of the catheter securely.

12. Position the catheter bag below the level of the patient to facilitate effective drainage of urine.

Final steps

13. Clean away any urine spillage or excess lubricating gel and cover the patient with the sheet.

14. Dispose of your equipment into a clinical waste bin.

15. Provide the patient with privacy to get dressed.

To complete the procedure...

Explain to the patient that the procedure is now complete and that they should seek review if the catheter becomes painful or if they begin to feel unwell.

Dispose of PPE appropriately and wash your hands.

Ask the nursing staff to monitor the patient's urine output and to contact you if they have any concerns.

Document the details of the procedure in the patient's notes:

Your personal details including your name, job role and GMC number.

The date and time the procedure was performed.

Confirmation that verbal consent was obtained.

The details of the chaperone who was present including their name and job role.

The indication for catheterisation.

The volume of water injected into the catheter balloon (e.g. 10mls).

The size of the catheter inserted (e.g. 14 french)

The type and volume of local anaesthetic used.

Any complications experienced during the procedure.

The residual volume of urine drained.

The appearance of the urine drained (e.g. straw-coloured, blood-stained).

Affix the sticky label from the catheter packaging beside your notes.

Reviewer

Graham Bone
Senior Clinical Lecturer in Medical Education

# data[].attributes.attachment_link.title
Female Catheterisation - OSCE Guide | Geeky Medics

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Improve Article 👀 This female catheterisation guide provides a step-by-step approach to performing catheterisation in an OSCE setting. 1. Clean the top of a procedure trolley using a disinfectant wipe. 2. Collect the equipment required for the procedure and place it within reach on the clean trolley: Plastic apron Two pairs of sterile gloves Sterile water-filled syringe (10ml) for inflation of the catheter balloon.

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Improve Article 👀

This male catheterisation guide provides a step-by-step approach to performing catheterisation in an OSCE setting, with an included video demonstration.

Gather equipment

1. Clean the top of a procedure trolley using a disinfectant wipe.

2. Collect the equipment required for the procedure and place it within reach on the clean trolley:

Plastic apron

Two pairs of sterile gloves

Sterile water-filled syringe (10ml) for inflation of the catheter balloon.

0.9% sodium chloride (10mls)

Lidocaine (1%) anaesthetic lubricating gel for insertion into the urethra.

Male urinary catheter (12/14 french)

Catheter pack: including cotton wool balls, sterile gauze, sterile drapes, absorbent pad and gallipot (a.k.a. a small pot).

Catheter bag

Urine collection bowl (a.k.a. a receiver)

3. Check the expiry date on the catheter, sterile water, normal saline and lidocaine gel.

4. Ensure a clinical waste bin is placed nearby.

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.

Don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the procedure will involve using patient-friendly language: "Today I need to insert a catheter. This will involve inserting a thin flexible tube into the penis to reach the bladder. The procedure will feel a little uncomfortable but shouldn't be painful. I'll insert some local anaesthetic into the penis to make the procedure as comfortable as possible."

Explain the need for a chaperone: "One of the other staff members will be present throughout the procedure, acting as a chaperone, would that be ok?"

Gain consent to proceed with catheterisation.

Check if the patient has any allergies (e.g. latex).

Ask the patient if they have any pain before continuing with the clinical procedure.

Explain to the patient that they'll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Equipment preparation

Setting up the sterile field

1. Set up the sterile field by first removing the outer packaging from the catheter pack and then opening the catheter pack from the corners without touching the inner surface of the field. Make sure to keep the catheter packaging, as you'll need to transfer the sticky label containing the details of the catheter into the patient's notes.

2. Using aseptic non-touch technique (ANTT) place the catheter, lidocaine gel syringe, sterile water syringe and sterile gloves onto the field.

3. Pour the 0.9% sodium chloride solution over the cotton balls which should already be located within the gallipot of the catheter pack.

Positioning the patient

1. With the patient lying supine, ensure the bed is at an appropriate height for you to comfortably carry out the procedure.

2. Wash your hands again and don a pair of sterile gloves.

3. Ask your chaperone to remove the sheet covering the patient's genitals to allow you to maintain sterility.

4. Place a sterile absorbent pad underneath the patient's genital region, ensuring you maintain sterility.

Cleaning the penis

1. Hold the penis with your non-dominant hand using some sterile gauze and ensure the patient's foreskin is retracted (if present).

2. With your dominant hand, pick up a cotton ball and use a single stroke moving away from the urethral meatus to clean an area of the glans. Dispose of the first cotton ball into the clinical waste bin and continue to repeat this process with a new cotton ball each time until all areas of the glans have been cleaned.

3. Discard your used gloves, wash your hands again and don a new pair of sterile gloves.

4. Place the sterile drape over the patient's penis, positioned such that the penis remains visible through the central aperture of the drape. Some drapes come with a hole already present for this purpose, whereas others will require you to create one.

5. Place the sterile urine collection bowl below the penis but on top of the sterile drape.

Inserting the local anaesthetic

1. Hold the penis vertically with your non-dominant hand using a piece of sterile gauze.

2. Warn the patient that the anaesthetic gel might initially sting, but then should quickly cause things to become numb.

3. With your dominant hand place the nozzle of the syringe of anaesthetic gel into the urethral meatus.

4. Empty the entire 10mls of anaesthetic gel into the urethra at a slow but steady pace.

5. Continue to hold to the penis in the vertical position to ensure the gel remains within the urethra and allow 3 to 5 minutes for the lidocaine gel to reach its maximum effect.

Inserting the catheter

Preparation

1. Pick up the catheter which should be on your sterile field in its wrapper.

2. Remove the tear-away portion of the wrapper near the catheter tip, making sure not to touch the catheter.

3. Hold the penis again using sterile gauze with your non-dominant 'dirty hand'.

Insertion

4. Warn the patient you are about to insert the catheter.

5. Insert the exposed catheter tip into the urethral meatus using your dominant 'clean hand'.

6. Advance the catheter slowly whilst gradually removing more of the wrapper to expose more of the catheter. The key to removing the wrapper without also pulling the catheter back out is to ensure you have a good grip on the penis as you gently pull back on the wrapper. As you pass the prostate you may note some resistance and the patient may experience some discomfort. If the resistance is significant and the patient appears very uncomfortable you should remove the catheter and consider a repeat attempt or specialist input from urology.

7. You should continue to advance the catheter until it is fully inserted into the penis. As you enter the bladder urine should begin to drain from the catheter.

Balloon inflation

8. Once the catheter is fully inserted, inflate the catheter balloon with the 10ml syringe of sterile water to secure it within the bladder. Before doing this, ask the patient to let you know immediately if they experience any discomfort as you inject the water. If the patient begins to experience discomfort during the injection of the water stop immediately as this may indicate the tip of the catheter is within the urethra.

9. Once the balloon is fully inflated, remove the syringe and gently withdraw the catheter until resistance is noted, confirming the catheter is held securely within the bladder.

Attaching the catheter bag

10. Attach the catheter bag tubing to the end of the catheter securely.

11. Position the catheter bag below the level of the patient to facilitate effective drainage of urine.

Final steps

12. Replace the patient's retracted foreskin (if present) as failure to do so can result in the development of paraphimosis.

13. Clean away any urine spillage or excess lubricating gel and cover the patient with the sheet.

14. Dispose of your equipment into a clinical waste bin.

15. Provide the patient with privacy to get dressed.

To complete the procedure...

Explain to the patient that the procedure is now complete and that they should seek review if the catheter becomes painful or if they begin to feel unwell.

Dispose of PPE appropriately and wash your hands.

Ask the nursing staff to monitor the patient's urine output and to contact you if they have any concerns.

Document the details of the procedure in the patient's notes:

Your personal details including your name, job role and GMC number.

The date and time the procedure was performed.

Confirmation that verbal consent was obtained.

The details of the chaperone who was present including their name and job role.

The indication for catheterisation.

The volume of water injected into the catheter balloon (e.g. 10mls).

The size of the catheter inserted (e.g. 14 french)

The type and volume of local anaesthetic used.

Any complications experienced during the procedure.

The residual volume of urine drained.

The appearance of the urine drained (e.g. straw-coloured, blood-stained).

Affix the sticky label from the catheter packaging beside your notes.

Reviewer

Graham Bone
Senior Clinical Lecturer in Medical Education

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Male Catheterisation - OSCE Guide | Geeky Medics

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A step-by-step guide to performing male catheterisation in an OSCE setting, with an included video demonstration.

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As promised, my scanned written notes on MAOIs. They can be tricky to get your head around without a visual cue, so here you go!

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Ear Examination: Otoscopy - Rinne's - Weber's 

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Ear Examination: Otoscopy - Rinne's - Weber's 

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Hearing assessment and otoscopy frequently appears in OSCEs and you'll be expected to identify relevant signs using your clinical examination skills. This guide provides a step-by-step approach to performing hearing assessment and otoscopy in an OSCE setting, with an included video demonstration.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the examination will involve using patient-friendly language: "Today I'd like to examine your ears, this will involve me having a look inside your ears using a special piece of equipment known as an otoscope. I'd also like to assess your hearing."

Gain consent to proceed with the examination.

Ask the patient if they have any pain before proceeding with the clinical examination.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

General inspection

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current clinical status:

Hearing aids: note if the patient is wearing a hearing aid and ask the patient to remove this when performing otoscopy.

Mobility aids: items such as wheelchairs and walking aids give an indication of the patient's current mobility status. The patient may have vestibulocochlear nerve pathology causing both hearing and balance issues.

Gross hearing assessment

Preparation

Ask the patient if they have noticed any change in their hearing recently.

Explain that you're going to say 3 words or 3 numbers and you'd like the patient to repeat them back to you (choose two-syllable words or bi-digit numbers).

Assessment

1. Position yourself approximately 60cm from the patient's ear and then whisper a number or word.

2. Mask the ear not being tested by rubbing the tragus. Do not place your arm across the face of the patient when rubbing the tragus, it is far nicer to occlude the ear from behind the head. If possible shield the patient's eyes to prevent any visual stimulus.

3. Ask the patient to repeat the number or word back to you. If they get two-thirds or more correct then their hearing level is 12db or better. If there is no response use a conversational voice (48db or worse) or loud voice (76db or worse).

4. If there is no response you can move closer and repeat the test at 15cm. Here the thresholds are 34db for a whisper and 56db for a conversational voice.

5. Assess the other ear in the same way.

Weber's test

Explain to the patient that you are going to test their hearing using a tuning fork.

1. Tap a 512Hz tuning fork and place in the midline of the forehead. The tuning fork should be set in motion by striking it on your knee (not the patient's knee or a table).

2. Ask the patient "Where do you hear the sound?"

These results should be assessed in context with the results of Rinne's test before any diagnostic assumptions are made:

Normal: sound is heard equally in both ears.

Sensorineural deafness: sound is heard louder on the side of the intact ear.

Conductive deafness: sound is heard louder on the side of the affected ear.

A 512Hz tuning fork is used as it gives the best balance between time of decay and tactile vibration. Ideally, you want a tuning fork that has a long period of decay and cannot be detected by vibration sensation.

Rinne's test

1. Place a vibrating 512 Hz tuning fork firmly on the mastoid process (apply pressure to the opposite side of the head to make sure the contact is firm). This tests bone conduction.

2. Confirm the patient can hear the sound of the tuning fork and then ask them to tell you when they can no longer hear it.

3. When the patient can no longer hear the sound, move the tuning fork in front of the external auditory meatus to test air conduction.

4. Ask the patient if they can now hear the sound again. If they can hear the sound, it suggests air conduction is better than bone conduction, which is what would be expected in a healthy individual (this is often confusingly referred to as a "Rinne's positive" result).

Summary of Rinne's test results

These results should be assessed in context with the results of Weber's test before any diagnostic assumptions are made:

Normal result: air conduction > bone conduction (Rinne's positive)

Sensorineural deafness: air conduction > bone conduction (Rinne's positive) - due to both air and bone conduction being reduced equally

Conductive deafness: bone conduction > air conduction (Rinne's negative)

Conductive vs sensorineural hearing loss

Conductive hearing loss occurs when sound is unable to effectively transfer at any point between the outer ear, external auditory canal, tympanic membrane and middle ear (ossicles). Causes of conductive hearing loss include excessive ear wax, otitis externa, otitis media, perforated tympanic membrane and otosclerosis.

Sensorineural hearing loss occurs due to dysfunction of the cochlea and/or vestibulocochlear nerve. Causes of sensorineural hearing loss include increasing age (presbycusis), excessive noise exposure, genetic mutations, viral infections (e.g. cytomegalovirus) and ototoxic agents (e.g. gentamicin).

External ear

Inspection

Pinnae

Inspect the pinnae for:

Asymmetry: by comparing the pinnae you may identify subtle unilateral pathology.

Deformity of the pinnae: this may be acquired (e.g. cauliflower ear) or congenital (e.g. anotia, microtia, low-set ears).

Ear piercings: can be a potential source of infection, an allergen and a cause of trauma.

Erythema and oedema: typically associated with otitis externa.

Scars: indicative of previous surgery.

Skin lesions: look for evidence of pre-malignant (actinic keratoses) and malignant (e.g. basal cell carcinoma, squamous cell carcinoma) skin changes.

Mastoid

Inspect the mastoid region:

Erythema and swelling: typically associated with mastoiditis.

Scars: indicative of previous surgery (e.g. mastoidectomy).

Pre-auricular region

Inspect the pre-auricular region (in front of the ear):

Pre-auricular sinus/pit: a common congenital deformity that appears as a dimple in the pre-auricular region. These sinuses can sometimes become infected and require surgical drainage.

Lymphadenopathy: typically associated with an ear infection (e.g. otitis media, otitis externa).

Conchal bowl

Inspect the conchal bowl for signs of active infection such as erythema and purulent discharge.

Palpation

Palpate the tragus for tenderness which is typically associated with otitis externa.

Pre-auricular lymph nodes

Post-auricular lymph nodes

Cauliflower ear

Cauliflower ear is an irreversible condition that develops as a result of repeated blunt ear trauma. Blunt trauma causes bleeding under the perichondrium of the pinna, stripping away the ear's cartilage. This cartilage normally relies on the perichondrium for its nutrient supply and as a result, once separated it becomes fibrotic, causing distortion of the ear's architecture.

Congenital deformity of the ears

There are several types of congenital ear deformity including:

Anotia: a complete absence of the pinna.

Microtia: underdevelopment of the pinna.

Low-set ears: the ears are positioned lower on the head than usual. Low-set ears are a feature of several genetic syndromes including Down's syndrome and Turner's syndrome.

Otoscopy

To help decide which ear to examine first:

Check if the patient has any ear discomfort and if so examine the non-painful side first.

Ask the patient which is their "better" ear and examine this one first (this can be useful for comparison).

Inserting the otoscope

1. Ensure the light is working on the otoscope and apply a sterile speculum (the largest that will comfortably fit in the external auditory meatus).

2. Pull the pinna upwards and backwards with your other hand to straighten the external auditory canal.

3. Position the otoscope at the external auditory meatus:

The otoscope should be held in your right hand for the patient's right ear and vice versa for the left ear.

Hold the otoscope like a pencil and rest your hand against the patient's cheek for stability. This will prevent damage to the ear if there is sudden movement.

4. Advance the otoscope under direct vision. Be gentle with the otoscope and ensure movements are slow and considered otherwise you will cause discomfort.

External auditory canal assessment

5. Inspect the external auditory canal for:

Excessive ear wax: the most common cause of conductive hearing loss.

Erythema and oedema: typically associated with otitis externa.

Discharge: may suggest otitis externa or otitis media with associated tympanic membrane perforation.

Foreign bodies: these may include cotton buds, insects and other small objects.

Tympanic membrane assessment

6. Systematically inspect the four quadrants of the tympanic membrane (TM) to avoid missing pathology.

Colour

A healthy TM should appear pearly grey and translucent.

Erythema suggests inflammation of the TM which can occur in conditions such as acute otitis media.

Shape

A healthy TM should appear relatively flat.

Bulging of the TM suggests increased middle ear pressure, which is commonly caused by acute otitis media with effusion (there is often an associated visible fluid level).

Retraction of the TM suggests reduced middle ear pressure, which is commonly caused by pharyngotympanic tube dysfunction secondary to upper respiratory tract infections and allergies.

Light reflex

The light reflex (also known as the "cone of light") is visible when a light is shone onto the TM.

If a TM is healthy, the cone-shaped reflection of light should appear in the anterior inferior quadrant.

In the left ear, the light reflex should be positioned at approximately 7 o'clock to 8 o'clock.

In the right ear, the light reflex should be positioned at approximately 4 o'clock to 5 o'clock.

Absence or distortion of the light reflex is associated with otitis media (due to bulging of the TM).

Perforation

Note the size and the position of any perforations of the TM.

Causes of TM perforation include infection (e.g. otitis media with effusion), trauma (e.g. diving-related), cholesteatoma and insertion of tympanostomy tubes (also known as grommets).

Cholesteatoma typically causes perforation in the superior part of the TM and there may be visible granulation tissue and discharge in this region.

Scarring

Scarring of the TM is known as tympanosclerosis and can result in significant conductive hearing loss if it is extensive.

Tympanosclerosis often develops secondary to otitis media or after the insertion of a tympanostomy tube.

Final steps

7. Withdraw the otoscope carefully.

8. Repeat your assessment on the other ear, comparing your findings. If the patient has an infection in one ear, you should change the speculum on the otoscope before examining the other ear.

9. Discard the otoscope speculum into a clinical waste bin.

Otitis media and otitis externa

Acute otitis media is an inflammatory condition of the middle ear that can be caused by viruses and bacteria. Typical findings on otoscopy include a bulging red, yellow or cloudy tympanic membrane with an associated air-fluid level behind the membrane. There may also be discharge in the auditory canal if the tympanic membrane has perforated.

Otitis externa is an inflammatory condition of the outer ear that can affect the auricle, external auditory canal and external surface of the tympanic membrane. The condition is usually caused by a bacterial infection. Typical findings on examination include erythema of the auricle and external auditory canal with associated pain. Other findings may include oedema of the auditory canal causing narrowing, regional lymphadenopathy and discharge in the ear canal.

To complete the examination...

Explain to the patient that the examination is now finished.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Summarise your findings.

Example summary
"Today I examined Mr Smith, a 25-year-old male. On general inspection, the patient appeared comfortable at rest and there were no abnormalities noted on inspection of the external ear." "Otoscopy revealed normal tympanic membranes and auditory canals. There was no evidence of hearing loss on assessment." "In summary, these findings are consistent with a normal examination of the ears." "For completeness, I would like to perform the following further assessments and investigations."
Further assessments and investigations

Cranial nerve examination: to identify evidence of facial nerve pathology.

Audiometry and tympanometry: to screen for hearing loss.

Reviewers

Mr Krishan Ramdoo
ENT Registrar
Mr Ben Cosway
ENT Registrar
References

Show references

1. CNX OpenStax. Adapted by Geeky Medics. Otitis externa. Licence: [CC BY 4.0].

2. B. Welleschik. Adapted by Geeky Medics. Mastoiditis. Licence: CC BY-SA.

3. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Basal cell carcinoma. Licence: CC BY 3.0 DE.

4. Future FamDoc. Adapted by Geeky Medics. Actinic keratosis. Licence: CC BY-SA.

5. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Melanoma. Licence: CC BY 3.0 DE.

6. MartialArtsNomad.com. Adapted by Geeky Medics. Cauliflower ear. Licence: CC BY.

7. Lisa Leathwood, Maureen Risch. Adapted by Geeky Medics. Low-set ears. Licence: CC0.

8. Klaus D. Peter, Gummersbach, Germany. Adapted by Geeky Medics. Microtia. Licence: CC BY 3.0 DE.

9. Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities. Adapted by Geeky Medics. Anotia.

10. By Michael Hawke MD. Adapted by Geeky Medics. Normal tympanic membrane. Licence: [CC BY 4.0].

11. By Michael Hawke MD. Adapted by Geeky Medics. Tympanic membrane perforation. Licence: [CC BY 4.0].

12. By Michael Hawke MD. Adapted by Geeky Medics. Cholesteatoma. Licence: [CC BY 4.0].

13. By Michael Hawke MD. Adapted by Geeky Medics. Acute otitis media. Licence: [CC BY 4.0].

14. Didier Descouens. Adapted by Geeky Medics. Tympanosclerosis. Licence: CC BY-SA.

15. Adrian L James. Adapted by Geeky Medics. Tympanic membrane retraction. Licence: CC BY-SA.

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Ear Examination | Otoscopy - Rinne's - Weber's | Geeky Medics

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A structured approach to ear examination, hearing assessment (including Rinne's and Weber's test) and otoscopy in an OSCE setting, with an included video demonstration.

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Explaining effective inhaler technique is a common OSCE scenario and requires you to both describe and demonstrate the skill. This step-by-step guide describes how to explain inhaler technique in an OSCE setting.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Check the patient's current understanding of inhaler technique, allowing you to better tailor your explanation.

Position the patient so that they are sitting comfortably.

Ask the patient if they have any pain or shortness of breath before beginning your explanation of inhaler technique.

You might also be interested in our collection of 900+ OSCE Stations that cover clinical examination, procedures, communication skills and data interpretation.

Explanation

Overview

Provide a general overview of the patient's inhaler:

"You have been started on ....(name of inhaler)...for your asthma."

"This is what the inhaler looks like."

"This is the mouthpiece, this is the canister containing the medication and this is the dose counter."

Different types of inhaler

Reliever (e.g. salbutamol inhaler)

"(Name of inhaler) is a reliever. This is useful to help relieve sudden asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn't need this more than three times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puff(s)) when you feel short of breath."

Preventer (e.g. beclomethasone inhaler)

Explain what a preventer inhaler is and when it should be used:

"(Name of inhaler) is a preventer - it helps to reduce the swelling in the airways and stops them from tightening up. You use this inhaler to reduce the risk of having asthma attacks. I would like you to inhale ...(x puff(s))...(x time(s) a day)...everyday. It's really important that you don't miss doses, as regular use is key to keeping your asthma under control."

"You should rinse your mouth after you use this inhaler as otherwise, you might develop a sore and inflamed mouth."

SMART (Single Maintenance and Reliever Therapy) regime (e.g. Symbicort, Fostair, Duoresp, Spiromax)

"Symbicort is used as both a preventer and a reliever. You need to use this regularly ...(x puff(s))...twice a day to prevent symptoms and ...(x puff(s))...each time you have an attack."

"You should rinse your mouth after you use this inhaler as otherwise, you might develop a sore and inflamed mouth."

Check the patient's understanding

Ask the patient to summarise the key points back to you to check their understanding:

"To make sure you've understood everything I've said could you tell me what type of inhaler you have and when it should be used? Don't worry if you can't remember everything right away, we can always go back over the important information."

Demonstrate effective inhaler technique

The guide below focuses on correct inhaler technique using a pressurised metered-dose inhaler (pMDI), which is most commonly used in OSCE scenarios. ²

Ensure you clearly explain and demonstrate each of the following steps to the patient using a dummy inhaler.

Things to do before using the inhaler

Device test

1. Remove the cap and shake the inhaler well.

2. Point the mouthpiece away from you and press the canister to release a puff into the air.

Dose counter

Some pMDI's have a dose counter which shows the number of remaining doses left in the inhaler. Advise the patient to check the inhaler is not empty and to seek a replacement whilst they still have several doses left.

Expiry date

The expiry date shows when the medication within the inhaler will expire and no longer be effective. The expiry date is typically located on the metal canister of the inhaler. Advise the patient to seek a replacement in advance of their inhaler expiring and to avoid using it after the expiry date.

Procedure

Preparation

1. Hold the inhaler upright.

2. Remove the cap from the inhaler and inspect to make sure there is nothing inside the inhaler mouthpiece.

3. Shake the inhaler well.

Inhalation

4. Sit or stand up straight and slightly tilt your chin up. This position helps the medication to better reach the lungs.

5. Breathe out gently and slowly away from the inhaler until your lungs feel empty.

6. Put your lips around the mouthpiece of the inhaler to create a tight seal.

7. Start to breathe in slowly and steadily whilst at the same time pressing the canister on the inhaler once.

8. Continue to breathe in slowly until your lungs feel full.

9. Remove the inhaler from your mouth and seal your lips.

10. Hold your breath for 10 seconds, or as long as you are comfortably able to.

11. Breathe out gently, away from your inhaler.

Final steps

12. Once you have finished using your inhaler, replace the cap. If you've used an inhaler that contains steroids, rinse your mouth with water to reduce the chance of side effects.

Multiple doses

Assess the patient's inhaler technique

Provide feedback based on what you observe to allow the patient to refine their technique.

Point out the positives... "You are doing X&Y very well"... then introduce room for improvement ... "but doing A&B may help your inhalers work more effectively for you."

Continue to repeat the cycle of observation and feedback until the patient is able to use their inhaler effectively.

Spacer devices

Spacers are used to improve drug deposition in the lungs. They are also useful for reducing the side effects of high dose inhaled corticosteroids by decreasing the amount of drug deposited in the mouth. Commonly used spacers include Volumatic and AeroChamber.

Ensure you clearly explain and demonstrate each of the following steps for effectively using a spacer to the patient:

1. Prepare the inhaler as previously explained.

2. Attach the inhaler mouthpiece to the spacer device.

3. Breathe out gently and slowly away from the spacer until your lungs feel empty.

4. Place your lips around the spacer mouthpiece to create an effective seal.

5. Release one dose of the inhaler into the spacer device.

6. Breathe deeply, both in and out, through the spacer mouthpiece several times.

7. Administer a second dose if required.

Spacer device care instructions

It should never be wiped dry as this can cause static within the device and drug particles will stick to sides of the spacer as a result.

Spacers should be replaced at least once a year.

Closing the consultation

Check if the patient has any questions regarding inhaler technique.

Palpitations and tremor: salbutamol can cause tachycardia and tremor, particularly at higher doses.

Oral thrush: steroid inhalers can cause candidiasis, particularly if the patient doesn't wash their mouth out effectively after each use.

Advise that if the patient has an asthma attack that does not respond to their salbutamol inhaler after 10 puffs (with 30 seconds between each puff) they should call 999 for urgent medical assessment.

Provide an information leaflet for the relevant inhaler device.

Arrange a follow-up appointment to re-assess the patient's inhaler technique.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

References

1. James Heilman, MD. Adapted by Geeky Medics. Oral candidiasis. Licence: CC BY-SA. Available from [LINK].

2. Asthma UK. How to use a pMDI inhaler. Accessed on 12th June 2020. Available from: [LINK].

3. Tradimus. Adapted by Geeky Medics. Spacer device. Licence: CC BY-SA. Available from: [LINK].

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Inhaler Technique - OSCE Guide | Spacer Technique | Geeky Medics

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Fundoscopy (ophthalmoscopy) frequently appears in OSCEs and you'll be expected to pick up the relevant clinical signs using your examination skills. This guide provides a step-by-step approach to performing fundoscopy. It also includes a video demonstration.

Gather equipment

Gather the appropriate equipment:

Ophthalmoscope

Mydriatic eye drops

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Introduction

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Briefly explain what the examination will involve using patient-friendly language.

Example explanation
"I will be using a magnifying tool called an ophthalmoscope to look at the back of your eyes with the lights off." "To do this, I'll need to get quite close to your face. I'll place a hand on your forehead to prevent us from bumping into each other." "I'll also be using some eye drops to dilate your pupils. The dilating drops will cause your vision to be temporarily blurry and you'll be more sensitive to light, so you'll not be able to drive for several hours afterwards."
Gain consent to proceed with the examination.

Position the patient sitting on a chair.

Ask if the patient has any pain before proceeding.

Inspection of the external eye

Inspection of the external eyes including the anterior segment can provide a lot of valuable clinical information.

See our anterior segment examination guide for a more detailed approach.

General inspection

Ask the patient to look straight ahead and inspect both of the eyes assessing the following:

Peri-orbital regions

Eyelids

Eyes (including pupils)

Note any abnormalities such as:

Swelling

Redness

Discharge

Prominence of the eyes

Abnormal eyelid position: ptosis can be a sign of Horner's syndrome (often very subtle ptosis with miosis) and oculomotor nerve palsy (can vary from partial to complete ptosis and usually with a 'down and out' eye position and an enlarged pupil)

Abnormal pupillary shape, size and/or asymmetry

Pupillary assessment

The pupil is the hole in the centre of the iris that allows light to enter the eye and reach the retina.

Inspect the patient's pupils for abnormalities.

Pupil size

Normal pupil size varies between individuals and depends on lighting conditions (i.e. smaller in bright light, larger in the dark).

Pupils can be smaller in infancy and larger in adolescence, then often smaller again in the elderly.

Pupil symmetry

Note any asymmetry in pupil size ( anisocoria). This may be longstanding and physiological or be due to acquired pathology. If the difference in pupil size becomes greater in bright light such as when facing a window in daylight, this would suggest that the larger pupil is the pathological one. This is because the normal pupil will constrict in brighter light accentuating the difference in size. If the difference is more pronounced in dim lighting, this would imply the smaller pupil is abnormal as the larger pupil would then dilate while the pathologically small pupil remains the same size.

Examples of asymmetry include a larger pupil in oculomotor nerve palsy and a smaller one in Horner's syndrome.

Pupil shape

Pupils should be round. Abnormal shapes can be congenital or due to pathology (e.g. posterior synechiae associated with uveitis) or previous trauma and surgery.

Peaked pupils in the context of trauma are suggestive of globe rupture (the peaked appearance is caused by the iris plugging the leak).

Pupil colour

Asymmetry in pupillary colour is most commonly due to congenital disease.

In rare cases, asymmetry of colour can suggest Horner's syndrome, with the paler washed-out iris being pathological.

Pathology which may be noted during general inspection

Examples of pathology you may note during general inspection of the eye include:

Periorbital erythema and swelling: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis (posterior to the orbital septum)

Eyelids: lumps (benign or malignant), oedema, ptosis and entropion/ectropion

Eyelashes: loss of eyelashes (can be associated with malignant lesions), trichiasis (eye lashes rubbing on the cornea) and blepharitis collarettes

Pupils: abnormal size, shape, colour and symmetry (see above)

Conjunctival injection (redness): this can be diffuse, sectorial or limbal. Dilated inflamed blood vessels can be due to infection, allergy, trauma and inflammation.

Cornea: diffuse haziness in acute angle-closure glaucoma or a patch of white infiltrate due to a corneal ulcer. Staining of the cornea with fluorescein suggests epithelial loss. A dendritic pattern is seen with herpes simplex infection.

Anterior chamber: a fluid level may be noted in hyphaema (blood - red in colour) or a hypopyon (inflammatory cells - yellow in colour).

Discharge: watery discharge is typically associated with allergic or viral conjunctivitis or reactive physiological production (e.g. corneal abrasion/foreign body). Purulent discharge is more likely to be associated with bacterial conjunctivitis. Very sticky, stringy discharge can suggest chlamydial conjunctivitis while blood staining can be seen with gonococcus.

Causes of red eye

Below is a non-exhaustive list of causes of red eye, with their associated clinical features.

Painless red eye:

Conjunctivitis: diffuse conjunctival injection (unilateral or bilateral), discharge, swollen conjunctiva (chemosis) and debris. Bacterial conjunctivitis typically has more purulent discharge than viral or allergic conjunctivitis.

Subconjunctival haemorrhage: a flat, bright red patch on the conjunctiva with sharply defined borders and normal conjunctiva surrounding it.

Episcleritis: sectoral area of subconjunctival injection (unilateral). The subconjunctival injection in episcleritis is superficial and, as a result, moveable with a swab (using topical anaesthesia) pressed gently on the conjunctiva.

Dry eye: caused by deficiencies in tear production and maintenance secondary to conditions such as blepharitis (obstruction of meibomian glands). Clinical features include diffuse conjunctival injection (unilateral or bilateral), inflamed lid margins with crusting and matted eyelashes.

Painful red eye:

Scleritis: deep pinkish localised conjunctival injection (unilateral), visual acuity may be reduced, minimal watery discharge, photophobia and a tender globe (causing the patient to wake at night). Symptoms tend to progressively worsen and individuals commonly have other connective tissue diseases.

Uveitis: circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, reduced visual acuity, watery discharge, photophobia and pain are common clinical features.

Corneal abrasion: eye redness, pain, watering and photophobia are common clinical features. Epithelial defects can be very hard to see with the naked eye but stain brightly with fluorescein drops and a cobalt blue light.

Corneal ulcer: typical clinical features include pain, watering, photophobia and a staining epithelial defect with associated haziness (infiltrates). The epithelial defect may appear fluffy, irregular and apparent even without a slit lamp.

Acute angle-closure glaucoma (AACG): typical clinical features include significant pain leading to vomiting, circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a mid-dilated unreactive pupil.

Foreign bodies: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical features include redness, pain, watering and a 'foreign body sensation'. Foreign bodies may be hidden under the top and bottom of the eyelid.

Ophthalmoscope overview

Parts

Parts of the ophthalmoscope include:

Viewing window: this is where you look through to observe the eye

Filter switch: allows you to select a light filter (e.g. blue cobalt light)

Aperture dial: adjust the size of the light beam

Diopter dial: adjusts the lens used to view the eye

Diopter power display: shows the current lens being used

Rheostat: adjusts the intensity of the light beam

On/off switch: turns the device on and off

Aperture size (beam size)

Ophthalmoscopes typically allow you to select from a range of different apertures including:

Micro aperture: used for viewing the fundus through very small undilated pupils

Small aperture: used for viewing the fundus through an undilated pupil

Large aperture: used for viewing the fundus through a dilated pupil and for the general examination of the eye

Slit aperture: can be helpful in assessing contour abnormalities of the cornea, lens and retina as it makes elevation easier to see

Filter

Filters can be used to highlight specific pathology:

Cobalt blue filter: used to look for corneal abrasions or ulcers with fluorescein dye (see our anterior segment examination guide for more details)

Red-free filter: used to look at the centre of the macula and other vasculature in more detail

Preparation for fundoscopy

1. It is essential to darken the room for the examination. Make sure the patient is positioned seated prior to turning out the lights to avoid accidents.

2. Dilate the patient's pupils using short-acting mydriatic eye drops such as tropicamide 1%. You will be unable to monitor pupil reactions once dilating drops have been applied, furthermore assessing vision, colour vision, double vision and visual fields will be less accurate once drops are instilled.

3. Ask the patient to look straight ahead for the duration of the examination (asking the patient to fixate on a distant target such as a light switch can cause confusion if you then obstruct the view of this target).

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Assess the fundal reflex

Correct terminology

The term fundal reflex is preferred over red reflex as the colour of the healthy reflex varies depending on a patient's skin colour.

In patient's with lighter skin, the reflex typically appears orange-red in colour, whereas in those with darker skin, the reflex can be yellow-white or even blue in colour.

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the fundal reflex adjust the diopter dial to correct for your refractive error so that you can see the patient and their eye clearly from a distance:

If you have normal visual acuity, you can set the diopter dial to 0.

If you have a refractive error but are planning to wear glasses/contact lenses that correct this when using the ophthalmoscope you can also set it to 0.

If you have a refractive error and are not going to wear your glasses/contact lenses you should adjust the diopter dial to match your prescription (e.g. -2).

How to assess for the fundal reflex

1. Look through the ophthalmoscope, shining the light towards the patient's eye at a distance of approximately one arm's length.

2. Observe for a reddish/orange/white/yellow/blue reflection in each pupil, caused by light reflecting back from the vascularised retina.

Causes of an absent fundal reflex

Absence of the fundal reflex in adults is often due to cataracts in the patient's lens blocking the light. Other causes include vitreous haemorrhage and retinal detachment.

Absence of the fundal reflex in children can be due to congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma.

Assess the fundus

Ophthalmoscope settings

To set up the ophthalmoscope for assessing the fundus, adjust the diopter dial so that it is the net result of yours and the patient's refractive error:

If you and the patient have normal visual acuity, set the dial to 0 (e.g. 0 + 0 = 0).

If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive error of 0 and add the patient's refractive error to this (e.g. 0 + -2 = -2).

If the patient has a refractive error and you have normal visual acuity set the dial to the net refractive error. An example of this would be (your refractive error of 0) + (patient's refractive error of -2) = a setting of -2.

If the patient has a refractive error and you have a refractive error set the dial to the net refractive error. An example of this would be (your refractive error of +3) + (patient's refractive error of -2) = a setting of +1.

If things appear out of focus during the assessment, simply adjust the diopter dial until things look sharper.

Assess the optic disc

1. If you are assessing the patient's right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the hand not holding the ophthalmoscope onto the patient's forehead to prevent accidental collision between yours and the patient's face.

2. Approaching from a 10-15 degree angle slightly temporal to the patient, move closer whilst maintaining the fundal reflex.

3. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches point like arrows towards the optic disc).

4. Once you identify the optic disc assess its characteristics including the contour, colour and the cup ("3Cs"):

Contour: the borders of the optic disc should be clear and well defined. If the borders appear blurred it may suggest the presence of optic disc swelling (papilloedema) secondary to raised intracranial pressure.

Colour: a healthy optic disc should look like an orange-pink doughnut with a pale centre. The orange-pink colour represents well-perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of optic neuritis, advanced glaucoma and ischaemic vascular events.

Cup: the cup is the pale centre of the orange-pink doughnut mentioned previously. The pale colour of the cup is due to the absence of neuroretinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as the "cup-to-disc ratio". A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally considered normal. An increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can occur in glaucoma.

Assess the retina

5. Methodically assess each quadrant of the retina and the associated vascular arcades in a clockwise or anticlockwise fashion looking for evidence of pathology:

Superior temporal (ST)

Superior nasal (SN)

Inferior nasal (IN)

Inferior temporal (IT)

Types of retinal pathology

Arteriolar narrowing: subtle, with generalised arteriolar narrowing with typical copper or silver wire appearance. Most commonly associated with the early stages of hypertensive retinopathy.

Arteriovenous nipping/nicking: areas of focal narrowing, and compression of venules at sites of arteriovenous crossing. The typical appearance involves bulging of retinal veins on either side of the area where the retinal artery is crossing. Most commonly associated with grade 2 hypertensive retinopathy.

Dot and blot haemorrhages: arise from bleeding capillaries in the middle layers of the retina and may look like microaneurysms if small enough. They are most commonly associated with diabetic retinopathy.

Flame haemorrhages: larger haemorrhages with a flame-like appearance caused by rupture of pre-capillary arterioles or small veins in the retinal nerve fibre layer. Most commonly associated with grade 3 hypertensive retinopathy, thrombocytopaenia, retinal vein occlusion and trauma.

Cotton wool spots: appear as small, fluffy, whitish superficial lesions and represent infarcts of the neuro-retinal layer. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.

Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking microaneurysms. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.

Neovascularisation: formation of new blood vessels that appear as a net of small curly vessels, with or without associated haemorrhages. They may be located on the optic disc or elsewhere on the retina. They are most commonly associated with advanced proliferative diabetic retinopathy.

Pan-retinal photocoagulation: the primary treatment for proliferative diabetic retinopathy. Clinically it is seen as clusters of pale burn marks on the retina which have been created by the laser used in the treatment process.

Branch retinal vein occlusion: blockage of one of the four retinal veins, each of which drains about a quarter of the retina. Typical signs include flame haemorrhages, dot and blot haemorrhages, cotton wool spots, hard exudates, retinal oedema, and dilated tortuous veins.

Assess the macula

6. Finally, inspect the macula by asking the patient to briefly look directly into the light of the ophthalmoscope. The macula is found lateral (temporal) to the optic nerve head and is yellow in colour. The central part of the macula, the "fovea" is about the same diameter as the optic disc and appears darker than the rest of the macula due to the presence of an additional pigment.

Types of macula pathology

Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking microaneurysms. They are most commonly associated with diabetic retinopathy, grade 3 hypertensive retinopathy and retinal vein occlusions.

Drusen: yellow-white flecks scattered around the macular region representing remnants of dead retinal pigment epithelium. Most commonly caused by age-related macular degeneration.

Cherry-red spot: associated with central retinal artery occlusion which typically presents with sudden profound visual loss.

Assess the other eye

Repeat assessment of the fundal reflex and fundus on the other eye. You will need to approach the patient from the opposite side and hold the ophthalmoscope in your other hand.

Video demonstration: How to visualise the fundus

To complete the examination...

Explain to the patient that the examination is now finished.

Thank the patient for their time.

If mydriatic drops were instilled, remind the patient they cannot drive for the next 3-4 hours until their vision has returned to normal.

Dispose of PPE appropriately and wash your hands.

Summarise your findings.

Further assessment and investigations

All of the following further assessments and investigations are dependent on the patient's presenting complaint and in most cases, none of them would need to be performed:

Amsler chart: to assess for central visual loss and distortion which is commonly associated with macular degeneration.

Cranial nerve examination: to further assess for evidence of cranial nerve pathology (e.g oculomotor nerve).

Blood pressure: if there are concerns about hypertensive retinopathy.

Capillary blood glucose: if there are concerns about diabetic retinopathy.

Retinal photography: to better visualise any abnormalities noted on fundoscopy.

References

Show references

1. James Heilman, MD. Adapted by Geeky Medics. Allergic conjunctivitis. Licence: CC BY-SA.

2. Adapted by Geeky Medics. Bacterial conjunctivitis. Licence: Public domain.

3. FiP. Adapted by Geeky Medics. Subconjunctival haemorrhage. Licence: CC BY-SA.

4. Imrankabirhossain. Adapted by Geeky Medics. Episcleritis. Licence: CC BY-SA.

5. Kribz. Adapted by Geeky Medics. Scleritis. Licence: CC BY-SA.

6. Adapted by Geeky Medics. Blepharitis. Licence: Public domain.

7. Jonathan Trobe, M.D. Adapted by Geeky Medics. Anterior uveitis. Licence: CC BY.

8. Jonathan Trobe, M.D. Adapted by Geeky Medics. Acute angle-closure glaucoma. Licence: CC BY.

9. EyeMD (Rakesh Ahuja, M.D.). Adapted by Geeky Medics. Hypopyon. Licence: CC BY-SA.

10. Tripp on Flickr. Adapted by Geeky Medics. Pre-septal cellulitis. Licence: CC BY 2.0.

11. Waster. Adapted by Geeky Medics. Miosis. Licence: CC BY.

12. Evan Herk. Adapted by Geeky Medics. Foreign body. Licence: CC BY-SA.

13. James Heilman, MD. Adapted by Geeky Medics. Corneal abrasion. Licence: CC BY-SA.

14. Yoanmb. Adapted by Geeky Medics. Corneal ulcer. Licence: CC BY SA.

15. Jonathan Trobe, M.D. Adapted by Geeky Medics. RAPD. Licence: CC BY.

16. Adapted by Geeky Medics. Fundal reflex. Licence: Public domain.

17. Imrankabirhossain. Adapted by Geeky Medics. Cataract. Licence: CC BY-SA.

18. Adapted by Geeky Medics. Retinoblastoma. Licence: Public domain.

19. Adapted by Geeky Medics. Retinal detachment. Licence: Public domain.

20. Yandle on Flickr. Adapted by Geeky Medics. Normal fundus. Licence: CC BY 2.0.

21. Jonathan Trobe, M.D. Adapted by Geeky Medics. Papilloedema. Licence: CC BY.

22. Frank Wood. Adapted by Geeky Medics. Hypertensive retinal disease. Licence: CC BY.

23. Adapted by Geeky Medics. Cotton wool spots. Licence: Public domain.

24. National Eye Institute. Adapted by Geeky Medics. Pan-retinal photocoagulation. Licence: Public domain.

25. Ku C Yong, Tan A Kah, Yeap T Ghee, Lim C Siang and Mae-Lynn C Bastion. Adapted by Geeky Medics. Licence: CC BY. Retinal branch occlusion.

26. National Eye Institute. Adapted by Geeky Medics. Pan-retinal photocoagulation. Licence: Public domain.

27. Adapted by Geeky Medics. Drusen. Licence: Public domain.

28. National Eye Institute. Adapted by Geeky Medics. Macular oedema. Licence: Public domain.

29. Achim Fieß, Ömer Cal, Stephan Kehrein, Sven Halstenberg, Inez Frisch, Ulrich Helmut Steinhorst. Adapted by Geeky Medics. Cherry red spot. Licence: CC BY.

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Fundoscopy (Ophthalmoscopy) - OSCE Guide | Geeky Medics

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A step-by-step guide to performing fundoscopy (ophthalmoscopy) and assessment of the anterior eye in an OSCE setting with an included video demonstration.

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Concerns: Medical Staff Escalation Process

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Concerns: Medical Staff Escalation Process

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Advice from foundation doctors - UK Foundation Programme