The Complete OSCE & Clinical Skills Reference

Preparation

WIPE. Position reclined at 45°. Expose the chest (offer a blanket; patients need not remove a bra). Ask about pain first.

General inspection (end of bed)

Comfortable or breathless at rest? Cyanosis, pallor, oedema, cachexia? Around the bed: GTN spray, oxygen, ECG leads, medications, mobility aids, fluid restriction signs, pillows (orthopnoea).

Hands

Colour/temperature, tar staining, finger clubbing, splinter haemorrhages, Janeway lesions, Osler's nodes (infective endocarditis), xanthomata, capillary refill (<2 s). Radial pulse: rate, rhythm. Radio-radial delay. Offer to check for a collapsing pulse. Assess BP in both arms.

Face / neck

Conjunctival pallor, corneal arcus, xanthelasma, central cyanosis (under tongue), high-arched palate/dental hygiene. Assess JVP (head turned slightly left, look for internal jugular pulsation). Perform hepatojugular reflux if indicated. Palpate carotid pulse (character/volume — one side at a time).

Precordium

Inspect: scars (midline sternotomy, lateral thoracotomy), pacemaker/ICD box, visible pulsations, chest deformity.
Palpate: apex beat (normally 5th ICS, midclavicular line) — displaced? Heaves (left parasternal = RV hypertrophy), thrills.
Auscultate: four valve areas (aortic — 2nd right ICS; pulmonary — 2nd left ICS; tricuspid — lower left sternal edge; mitral — apex) with diaphragm and bell, while palpating the carotid to time S1/S2. Accentuation manoeuvres: roll left in expiration (mitral stenosis, bell at apex); sit forward in expiration (aortic regurgitation, left sternal edge); listen at axilla (mitral regurgitation radiation) and carotids (aortic stenosis radiation).

Complete

Auscultate lung bases (crepitations = pulmonary oedema), palpate for sacral and pedal oedema.

Key findings & significance

Ejection-systolic murmur radiating to carotids = aortic stenosis; pansystolic radiating to axilla = mitral regurgitation; early diastolic at LSE = aortic regurgitation; irregularly irregular pulse = AF; raised JVP + peripheral oedema + basal crepitations = congestive heart failure.

Closing & presentation

Preparation

WIPE. Position at 45°. Expose the chest.

General inspection

Respiratory distress, use of accessory muscles, pursed lips, audible wheeze/stridor, cough, cachexia, cyanosis. Around bed: oxygen delivery device and flow rate, inhalers/nebuliser, sputum pot (inspect colour/volume), cigarettes.

Hands

Tar staining, clubbing (fibrosis, bronchiectasis, malignancy), peripheral cyanosis, fine tremor (beta-agonists), CO2 retention flap (asterixis), bounding pulse (CO2 retention). Count respiratory rate while appearing to take the pulse.

Face / neck

Conjunctival pallor, central cyanosis, pursed lips, Horner's syndrome (Pancoast tumour). JVP (raised in cor pulmonale). Palpate cervical/supraclavicular lymph nodes from behind.

Chest

Inspect: scars, deformity (barrel chest, pectus), asymmetry.
Palpate: tracheal position (central?), cricosternal distance, apex beat, chest expansion (upper and lower, compare sides).
Percuss: compare left/right, apices to bases and axillae (resonant / dull / hyperresonant / stony dull).
Auscultate: breath sounds (vesicular/bronchial), added sounds (wheeze, coarse/fine crackles, pleural rub); vocal resonance.
Repeat all on the posterior chest. Check for sacral/pedal oedema.

Key findings

Stony dull + absent breath sounds = pleural effusion; dull + bronchial breathing + crackles = consolidation; hyperresonant + reduced sounds = pneumothorax/COPD; fine end-inspiratory crackles = pulmonary fibrosis; bilateral wheeze = asthma/COPD.

Closing

Preparation

WIPE. Position supine, one pillow, expose from xiphisternum to pubic symphysis while maintaining dignity.

General inspection

Comfortable/in pain, jaundice, cachexia, distension. Around bed: stoma bags, drains, catheter (urine colour/volume), feeding tubes, medications.

Hands

Clubbing, leuconychia, koilonychia, palmar erythema, Dupuytren's contracture, asterixis (hepatic flap). Arms: bruising, excoriations, AV fistula.

Face / neck

Jaundiced sclera, conjunctival pallor, glossitis, angular stomatitis, aphthous ulcers, fetor hepaticus. Palpate left supraclavicular node (Virchow's node — Troisier's sign).

Chest / torso

Spider naevi, gynaecomastia, loss of body hair.

Abdomen

Inspect: scars, stomas, distension, striae, caput medusae, visible peristalsis, Cullen's/Grey-Turner's signs, hernias (ask to cough).
Palpate (ask about pain first; painful area last): light palpation of all nine regions watching the face, then deep palpation for masses. Palpate liver (RIF upward on inspiration), spleen (RIF to left costal margin), ballot both kidneys, palpate/assess for expansile aortic pulsation, palpate bladder.
Percuss: liver span, splenic dullness, bladder, shifting dullness (ascites).
Auscultate: bowel sounds, aortic/renal bruits.
Complete: state you would examine hernial orifices, external genitalia, and perform a digital rectal examination (DRE).

Key findings

Hepatomegaly, splenomegaly, palpable expansile mass (AAA), ascites (shifting dullness), RIF mass (appendix/Crohn's/caecal cancer).

Closing

Preparation

WIPE. Expose both arms fully, patient sitting.

General inspection

Posture, wasting, fasciculations, tremor, abnormal movements, scars; walking aids/splints around bed.

Sequence — Tone, Power, Reflexes, Coordination, Sensation

Tone: passively move wrist/elbow — spasticity (clasp-knife, UMN), rigidity (Parkinson's), hypotonia (LMN).
Power (MRC 0–5): shoulder abduction (C5), elbow flexion (C5/6)/extension (C7), wrist extension (C6), finger extension (C7), finger abduction (T1), thumb abduction (C8/T1). Compare sides.
Reflexes: biceps (C5/6), supinator (C6), triceps (C7). Reinforce if absent.
Coordination: finger-to-nose (dysmetria/intention tremor), dysdiadochokinesia.
Sensation: light touch, pinprick, vibration, proprioception across dermatomes C5–T1; compare sides.

Key findings

UMN pattern = increased tone, hyperreflexia, weakness of extensors, upgoing plantars; LMN pattern = wasting, fasciculations, hypotonia, hyporeflexia. Pyramidal weakness affects extensors more than flexors in the upper limb.

Closing

Preparation

WIPE, expose both legs.

Inspection & gait

Wasting, fasciculations, scars, deformity, foot drop. Walk 10 m, turn, return; heel-to-toe (ataxia); Romberg's test (proprioception).

Examination

Tone: roll the leg, lift the knee briskly; test for ankle clonus.
Power: hip flexion (L1/2)/extension (L5/S1), knee flexion (S1)/extension (L3/4), ankle dorsiflexion (L4)/plantarflexion (S1), big toe extension (L5).
Reflexes: knee (L3/4), ankle (S1), plantar (Babinski — upgoing = UMN).
Coordination: heel-to-shin.
Sensation: light touch, pinprick, vibration, proprioception across L1–S1 dermatomes.

Closing

As above — complete neuro exam, cranial nerves, history, and present findings.

Preparation

WIPE, patient seated, gather equipment (pen torch, Snellen chart, ophthalmoscope, cotton wool, neurotip, tuning fork 512 Hz, tongue depressor, something to smell).

Nerve-by-nerve

I Olfactory: any change in smell?
II Optic: acuity (Snellen), visual fields by confrontation, blind spot, pupillary light reflexes (direct/consensual), accommodation, RAPD (swinging light), colour vision, fundoscopy.
III, IV, VI Oculomotor / Trochlear / Abducens: inspect for ptosis/strabismus; eye movements in an "H" pattern (diplopia, nystagmus).
V Trigeminal: sensation in three divisions (ophthalmic/maxillary/mandibular), muscles of mastication (clench jaw), jaw jerk, corneal reflex.
VII Facial: facial symmetry at rest; raise eyebrows, screw eyes shut, puff cheeks, show teeth (forehead spared = UMN lesion); taste anterior two-thirds.
VIII Vestibulocochlear: whisper test; Rinne's and Weber's tests.
IX, X Glossopharyngeal / Vagus: uvula position, say "ahh", cough, swallow, gag reflex.
XI Accessory: shrug shoulders (trapezius), turn head against resistance (sternocleidomastoid).
XII Hypoglossal: tongue wasting/fasciculation, protrude tongue (deviates toward lesion side).

Key findings

Facial droop sparing forehead = UMN (stroke); whole side including forehead = LMN (Bell's palsy).

Closing

Preparation

WIPE, expose legs and arms, patient supine.

Inspection

Colour, trophic changes (hair loss, shiny skin), ulcers (arterial — punched-out, painful, on toes/pressure points; venous — gaiter area, shallow), gangrene, scars, missing digits, venous eczema/varicosities.

Palpation

Temperature, capillary refill, radial/brachial pulses; abdominal aorta (expansile?); femoral, popliteal, posterior tibial, dorsalis pedis pulses; radio-femoral delay.

Special tests

Buerger's test (angle of pallor + reactive hyperaemia), ankle-brachial pressure index (state you would measure), auscultate for femoral/carotid bruits.

Key findings

Absent pulses + arterial ulcers + cold pale limb = peripheral arterial disease; the 6 Ps (Pain, Pallor, Pulselessness, Paraesthesia, Perishingly cold, Paralysis) = acute limb ischaemia.

Closing

ABPI, Doppler, angiography, cardiovascular risk assessment.

Screening questions

(1) Any pain/stiffness/swelling in muscles, joints or back? (2) Any difficulty dressing? (3) Any difficulty with stairs?

Examination

Gait: observe walking — symmetry, stride, arm swing, turning, antalgic/Trendelenburg/Parkinsonian gait.
Arms: inspect; hands behind head (shoulder), arms out (elbow extension), turn hands over, make a fist, oppose thumb to each finger, squeeze MCPs for tenderness.
Legs: supine — inspect; hip/knee flexion; internal rotation of hip; patellar tap (effusion); inspect feet, squeeze MTPs.
Spine: inspect from behind (scoliosis, muscle bulk); lateral cervical flexion (ear to shoulder); "touch toes" (lumbar flexion); inspect from side (kyphosis/lordosis).

Record on a grid as Appearance (A) and Movement (M) normal/abnormal for each area.

Closing

Focused regional (REMS) examination of any abnormal joint.

Preparation

WIPE, seat patient with space behind for neck palpation, expose neck.

General inspection

Body habitus (weight loss = hyper; gain = hypo), agitation vs lethargy, hoarse voice, clothing.

Hands / eyes

Thyroid acropachy, onycholysis (Plummer's nail), palmar erythema, sweating, fine tremor (paper on outstretched hands), pulse (tachy/AF in hyper; brady in hypo). Eyes: exophthalmos/proptosis, lid retraction, lid lag, ophthalmoplegia, chemosis (Graves').

Neck

Inspect (goitre; ask to swallow water — moves up; ask to protrude tongue — thyroglossal cyst moves). Palpate from behind: size, symmetry, nodules, tenderness, movement on swallowing; lymph nodes; tracheal deviation. Percuss for retrosternal dullness. Auscultate for a bruit.

Legs

Pretibial myxoedema, reflexes (slow-relaxing = hypo), proximal myopathy (stand from sitting).

Key findings

Diffuse goitre + eye signs = Graves'; single nodule = adenoma/cyst/malignancy; multinodular goitre.

Closing

TFTs, thyroid autoantibodies, ECG, ultrasound ± biopsy.

Breast examination: Chaperone essential. Inspect (arms relaxed, raised, hands on hips) for asymmetry, skin changes (peau d'orange), nipple inversion/discharge. Palpate all quadrants + axillary tail with flat fingers, examine axillary/supraclavicular nodes. Report using clock-face + distance from nipple. Triple assessment (exam + imaging + biopsy).

Testicular examination: Chaperone. Inspect and palpate each testis, epididymis, cord; transilluminate any swelling (cystic = hydrocele). "Can't get above it" = inguinoscrotal hernia.

Fundoscopy/ophthalmoscopy: darken room, red reflex, examine disc (cup:disc, papilloedema, cupping), vessels, macula. Diabetic/hypertensive retinopathy signs.

Ear (otoscopy) / ENT: inspect pinna, otoscopy of canal and tympanic membrane; nasal and throat inspection.

Dermatology: describe lesion using SCAM (Site, Colour/Configuration, Associated secondary change, Morphology), distribution, ABCDE for melanoma. Systematic full-skin inspection.

Equipment

Gloves/apron, tourniquet, alcohol/chlorhexidine 2% wipe, cannula, extension set/bung, 10 mL 0.9% saline flush, dressing, gauze, sharps bin, tape.

Procedure

WIPE + consent + allergies (latex/chlorhexidine). ANTT throughout. Apply tourniquet ~7–10 cm proximal; select a straight, palpable, non-mobile vein (avoid joints, dominant arm). Clean for 30 s, allow to dry. Don gloves. Anchor skin, insert bevel-up at 10–30°, watch for flashback, advance slightly, then advance cannula off the needle while withdrawing the needle. Release tourniquet, apply pressure over the vein, remove needle to sharps bin, cap/attach extension, secure dressing, flush to confirm patency (no swelling/pain). Document date, time, site, gauge, batch.

Similar preparation and ANTT. Use vacuum system or needle + syringe. Identify vein, clean, insert bevel-up, fill bottles in correct order, release tourniquet before withdrawing, apply pressure, dispose of sharps, label bottles at the bedside. Never re-sheath a needle.

Equipment

Catheter pack, sterile gloves (×2 pairs), appropriate catheter (12–16 Fr; larger if prostatic disease), 10 mL sterile water, lidocaine anaesthetic gel, cleaning solution (0.9% saline), catheter bag, drape.

Procedure

WIPE + consent + chaperone. Clean trolley, open pack with ANTT. Patient supine, expose. Wash hands, don first sterile gloves. Place drape. Hold penis with sterile gauze in non-dominant ("dirty") hand, retract foreskin, clean glans with single strokes (discard each swab). Instil lidocaine gel into urethra, wait 3–5 min. Change to second sterile gloves. Insert catheter using no-touch technique (advance while retracting sleeve), pass to the hilt; expect resistance at prostate. Wait for urine flow before inflating balloon with sterile water. Withdraw gently until resistance. Attach bag. Replace the foreskin (prevent paraphimosis). Document residual volume, catheter size, batch, date.

Recording

Consent, expose chest, prepare skin. Limb leads (Red–right arm, yeLLow–left arm, gReen–left leg, black–right leg). Chest leads: V1 4th ICS right sternal edge, V2 4th ICS left sternal edge, V3 between V2/V4, V4 5th ICS midclavicular line, V5 anterior axillary line same level, V6 midaxillary line same level. Confirm calibration (25 mm/s, 10 mm/mV).

Systematic interpretation

Confirm details/calibration → Rate (300 ÷ big squares, or count R waves ×6 on rhythm strip) → Rhythm (regular/irregular, P waves, P:QRS relationship) → Axis (leads I and aVF) → P wave → PR interval (0.12–0.20 s / 3–5 small squares) → QRS (<0.12 s; morphology, Q waves) → ST segment (elevation/depression) → T waves → QT interval.

Key patterns

ST elevation in contiguous leads = STEMI (localise: II/III/aVF inferior, V1–V4 anteroseptal, I/aVL/V5–6 lateral); irregularly irregular no P waves = AF; broad complex tachycardia = VT until proven otherwise; saw-tooth = flutter; peaked T/wide QRS = hyperkalaemia.

Manoeuvres: head-tilt/chin-lift (medical); jaw thrust (trauma/suspected c-spine).

Adjuncts: oropharyngeal (Guedel) airway — size from incisors to angle of jaw, insert upside-down and rotate 180° (only if no gag reflex); nasopharyngeal airway — size to nostril/little finger, lubricate, insert bevel to septum (caution in base-of-skull fracture).

Bag-valve-mask: two-person technique preferred, EC grip, high-flow O2 with reservoir, ventilate ~10/min watching chest rise. Suction as needed. Escalate to supraglottic airway (i-gel)/intubation per scope of practice.

Scene: danger/scene safety, PPE, mechanism, number of patients, resources (METHANE if major incident). <C> catastrophic haemorrhage control first (direct pressure, tourniquet, haemostatic dressing) in trauma. Response: AVPU/ACVPU.

A — Airway: patency, talking = patent; look/listen for obstruction (stridor, gurgling, snoring). Open airway, adjuncts, suction; protect c-spine in trauma.
B — Breathing: RR, SpO2, symmetry, chest auscultation/percussion, tracheal position, work of breathing. Treat: oxygen to target, decompress tension pneumothorax, seal open wounds.
C — Circulation: pulse (rate/volume), capillary refill, BP, skin, external bleeding, IV/IO access, fluids. 12-lead ECG.
D — Disability: GCS/ACVPU, pupils (PEARL), blood glucose, posture, limb movement.
E — Exposure: expose to examine (rashes, injuries, bleeding), temperature, prevent hypothermia, dignity.

Reassess ABCDE after every intervention and on any deterioration.

Recognition: sudden onset, ABC problem (Airway swelling/stridor, Breathing wheeze/hypoxia, Circulation hypotension) usually with skin changes (urticaria, angioedema) after an allergen.

Management (Resuscitation Council UK, May 2021): remove trigger, call for help, ABCDE, lie flat with legs raised (sit up if breathing difficulty; left lateral if pregnant).

High-flow oxygen; IV fluid bolus 500–1000 mL crystalloid (adult); larger volumes may be needed in severe shock. Antihistamines and steroids are no longer part of initial emergency treatment — antihistamines are third-line for cutaneous symptoms only; steroids were removed from the routine algorithm in 2021.

Recognition: suspected infection + signs of organ dysfunction. Screen with NEWS2. High-risk (red) category (UK Sepsis Trust): aggregate NEWS2 ≥7, or NEWS2 5–6 with lactate >2 mmol/L or known AKI.

Recognition: FAST (Face, Arm, Speech, Time) for prehospital screening; ROSIER in the ED (adds leg weakness and visual fields, subtracts for loss of consciousness/syncope and seizure; score >0 = stroke likely). Always check blood glucose (hypoglycaemia is a stroke mimic; treat if <3.5 mmol/L). UK evidence found ROSIER was not superior to FAST prehospital, so FAST remains the standard ambulance screen.

Management: ABCDE, document time of onset (critical for thrombolysis/thrombectomy windows), blood glucose, pre-alert a hyperacute stroke unit, minimise on-scene delay, avoid unnecessary BP lowering prehospital.

Recognition: central/crushing chest pain ± radiation to jaw/arm, sweating, nausea, dyspnoea; may be atypical/silent in diabetics, women, and the elderly.

Management (NICE NG185): ABCDE, 12-lead ECG early (and repeat).

Roles: team leader, compressions, airway, drugs/access, defibrillator, scribe/time-keeper.

Sequence: confirm arrest (unresponsive, not breathing normally), start CPR 30:2, compressions 100–120/min, depth 5–6 cm, full recoil, minimal interruptions. Attach defibrillator/monitor.

Once an advanced airway is placed: continuous compressions with ventilation ~10/min. Treat reversible causes — 4 Hs (Hypoxia, Hypovolaemia, Hypo/hyperkalaemia/metabolic, Hypothermia) and 4 Ts (Thrombosis, Tension pneumothorax, Tamponade, Toxins). Post-ROSC: ABCDE, 12-lead ECG, targeted temperature/oxygenation, transfer.

Threshold: blood glucose <4.0 mmol/L ("4 is the floor").

Protect from injury, do not restrain, airway/oxygen, check blood glucose, time the seizure.

Exclude hypoglycaemia, eclampsia, and other causes.

Recognition: known/new diabetic with hyperglycaemia (typically >11 mmol/L), ketonaemia (>3 mmol/L)/ketonuria, and acidosis (venous pH <7.3 or bicarbonate <15 mmol/L); polyuria, polydipsia, vomiting, abdominal pain, Kussmaul breathing, dehydration, reduced consciousness. Precipitants: infection, missed insulin.

Prehospital management: ABCDE, blood glucose and ketones, IV isotonic fluids (0.9% saline) as priority for dehydration, cardiac monitoring, 12-lead ECG (hyperkalaemia), pre-alert. Insulin and potassium correction are hospital-based.

After the C-ABCDE primary survey and treatment of life threats: rapid then thorough head-to-toe secondary survey — head/face, neck (c-spine), chest (palpate ribs, auscultate), abdomen/pelvis (do not spring the pelvis; suspect and bind if mechanism suggests), long bones, spine (log-roll), neuro.

AMPLE history: Allergies, Medications, Past history, Last meal, Events. Analgesia, splinting, tranexamic acid if indicated, packaging, and time-critical transfer to a major trauma centre.

Declaration/report — METHANE: Major incident declared, Exact location, Type, Hazards, Access, Number of casualties, Emergency services required.

Primary triage — Triage Sieve: rapid physiological sort into Priority 1 (Immediate/red), Priority 2 (Urgent/yellow), Priority 3 (Delayed/green), and Dead. Walking = P3; then assess breathing/respiratory rate/circulation. Ten Second Triage (TST) is now used in UK practice as a first, very rapid categorisation tool.

Secondary triage — Triage Sort: physiological scoring (respiratory rate, systolic BP, GCS) to refine priorities. Principles: triage, treat, transport — do the most for the most.

Five principles: presume capacity; support decision-making; unwise decisions ≠ incapacity; act in best interests; least restrictive option.

Two-stage test: (1) Functional — can the person Understand the relevant information, Retain it, Weigh it up, and Communicate their decision? (2) Diagnostic — is any inability caused by an impairment of, or disturbance in, the functioning of the mind or brain (s.2(1))?

Capacity is decision- and time-specific. If the person lacks capacity, act in their best interests (or per a valid advance decision/LPA). Document clearly.

Mental health: rapport, risk assessment (thoughts of self-harm/suicide, plan, means, protective factors), risk to others, and a mental state examination (appearance, behaviour, speech, mood, thought, perception, cognition, insight). Consider Mental Health Act pathways and appropriate escalation.

Safeguarding: recognise indicators of abuse/neglect (physical, emotional, sexual, financial, domestic), document objectively, act on concerns, share information appropriately, follow local safeguarding referral routes; consider children and other vulnerable adults in the household.

Presenting complaint → History of presenting complaint (SOCRATES for pain: Site, Onset, Character, Radiation, Associations, Timing, Exacerbating/relieving, Severity) → systems review → past medical/surgical history → drug history and allergies → family history → social history (smoking, alcohol, occupation, living situation, function) → ideas, concerns, expectations (ICE) → summarise and safety-net.