Makindo Medical Notes

Related Subjects: |OSCE Eye Exam |OSCE Ear Exam |OSCE Abdominal Exam |OSCE Ascites Exam |OSCE Jaundice Exam |OSCE Testicular Exam |OSCE Inguinal Exam |OSCE Upper limb Neurology |OSCE Lower limb Neurology |OSCE Face Neurology

Be ready to suggest possible diagnosis and investigations. One would want to measure bilirubin and liver function tests and FBC and consider an abdominal Ultrasound. In an older person with pronounced jaundice and well enough for an exam a gallstone in the common bile dict or Ca head of pancreas are likely. The later is usually painless. Management is an ERCP and removal of stones or stenting.

Introduction

• Hand Hygiene: Wash your hands thoroughly before beginning.
• Patient Introduction: Introduce yourself, verify the patient’s name, date of birth, and explain that you will be performing an examination to assess for jaundice.
• Consent & Privacy: Obtain informed consent and ensure the patient is in a well-lit, private setting with appropriate draping for comfort.
• Context: Briefly explain that jaundice is the yellow discoloration of the skin and sclera caused by elevated bilirubin levels, often related to liver or biliary pathology.

Equipment Needed

• Examination gloves
• Good natural or artificial lighting (a penlight may be used for close inspection)
• Optional: Stethoscope for a focused abdominal examination if indicated
• Towel or drape to maintain the patient’s dignity

Background Information

Step 1: General Inspection

• Positioning: Ask the patient to sit or lie down comfortably with the upper body exposed while ensuring privacy. Inspect are they emaciated and wasted and cachexic might suggest advanced malignancy or long standing alcoholism.
• Skin Examination: Inspect the white of the eyes the sclera for yellow colouration, also the face, neck, chest, and upper limbs for a yellow tint. Use natural light if possible for subtle changes. Examine the palms, soles, and nail beds for discoloration or clubbing or palmar erythema
• Observation of Other Signs: Note any associated signs such as spider angiomata, palmar erythema, or dilated veins.

Step 2: Eye Examination

• Scleral Inspection: Examine the sclera (white of the eyes) for a yellowish hue, known as scleral icterus. Ask the patient if they have noticed any changes in their eye color.

Step 3: Inspection of Mucous Membranes

• Examine the oral mucosa, including the underside of the tongue and inner cheeks, for a yellow discoloration.

Step 4: Focused Abdominal Examination

• Palpation: Ensure patient relaxed and lying flat and then gently palpate the right upper quadrant to assess for hepatomegaly or tenderness, which may suggest liver pathology.
• Percussion: Percuss the liver span if indicated to further evaluate for an enlarged liver. Look for ascites or splenomegaly that can be associated with chronic liver disease.

Step 5: Additional History and Observations

• Ask about any accompanying symptoms:
  • Changes in urine color (e.g., dark urine) or stool color (e.g., pale or clay-colored stools).
  • Fatigue, abdominal pain, or weight loss.
• Check for a history of liver disease, alcohol use, or exposure to hepatotoxic substances.

Step 6: Closure

• Feedback: Thank the patient for their cooperation.
• Summarize your findings, explaining that the observed yellow discoloration suggests jaundice, and discuss the need for further investigations (e.g., liver function tests, ultrasound).
• Ensure the patient is comfortably re-dressed and privacy is maintained.
• Hand Hygiene: Wash your hands again and document your findings clearly in the patient’s notes.

Key Points for OSCE

• Ensure excellent lighting to detect subtle yellow discoloration.
• Systematically examine the eyes, skin, mucous membranes, and abdomen.
• Correlate your physical findings with the patient’s history for a comprehensive assessment.
• Communicate each step clearly to keep the patient at ease.

Common Pitfalls

• Using poor lighting, which may result in missed or underestimated jaundice.
• Failing to examine all relevant areas (sclera, palms, soles, mucous membranes).
• Rushing the examination or not explaining the procedure adequately to the patient.
• Not correlating physical findings with other signs of liver dysfunction.

References & Further Reading

• Clinical Examination by Talley & O’Connor
• Geeky Medics OSCE Resources
• OSCEstop – Online OSCE practice resources