Part 1: VOLUME STATUS EXAM

Introduction

Knock, enter the room, wash/sanitize hands and introduce yourself as a medical student
Greet the patient, ask the patient’s name, explain the exam and ask for consent
Always take vitals before your physical exam (however for the sake of the OSCE the vitals will be provided so ask for vitals aloud)
- Include orthostatic vitals for this exam
Advise and request patient to drape according to the exam being performed (mention what type of exposure is necessary)

Patient can sit on the examination table for the inspection exam

Mental status	Orientation to person, place, time
Head	Hypervolemia: Periorbital edema Hypovolemia: Sunken eyes, dry mucous membrane (inside mouth & nose), longitudinal tongue furrows, central cyanosis
Neck	Hypovolemia: Skin turgor (<2 sec normal)
Arms	Hypovolemia: Dry axilla (blot with tissue)
Abdomen	Hypervolemia: Ascites
Hands	Capillary refill time, peripheral cyanosis
Legs	Hypervolemia: Peripheral edema
JVP	Detailed instruction in special test section

*For supine patients, consider examining dependent areas such as the sacrum

Transition statement and consent to begin palpating
Assess the JVP to assess for volume overload or hypovolemia
Assess for peripheral edema to assess for hypervolemia
Assess for skin turgor by pinching the skin just below the suprasternal notch.
- Report if skin turgor recoil occurs within the normal 2 seconds range
Assess capillary refill time by asking patients to raise their arm above the heart
- Press down on the nail bed, release, and measure time for reperfusion (check on both hands)
- Report if they have a normal capillary refill time
  - < 2 seconds for males
  - < 3 seconds for females
  - < 4 seconds for elderly
Assess for RV heave – may be present with RV dysfunction, enlargement

Resp: Listen to sounds of breathing
- Ask patient to cross their arms to displace scapulae
- Diaphragm of the stethoscope:
  - Auscultate posteriorly, anteriorly and laterally on the right side (for the middle right lobe)
  - Comment on any other sounds heard: e.g., crackles, wheeze, stridor
Cardio: Listen for abnormal heart sounds, murmurs
- Diaphragm of the stethoscope:
  - Listen to precordial areas: aortic, pulmonic, tricuspid and mitral
  - S1 and S2 heart sounds
  - Briefly mention S3/ S4 and murmurs (comment on: the grade, quality and pattern of the murmur in case it is present)

Begin this exam by performing the volume status exam (See above). In addition to the volume status exam, perform the following:

Inspect the abdomen for its shape, signs of ascites (eg. bulging flanks), surgical scars, catheters

Transition statement and consent to begin palpating
Kidney Ballottment
- Prior to ballotting the kidneys, ask patient to keep their arms across their chest
  - Use pancaking manoeuvre to attempt ballottement of kidneys
  - Report whether the kidneys are palpable or not
  - If palpable, report on tenderness, mass or cysts that may indicate pathology
CVA Tenderness
- To assess for costovertebral angle tenderness, inform the patient that the test will involve you lightly tapping the back to assess for pain
- Support with the contralateral hand to avoid inducing trauma
- Marked tenderness would indicate a positive sign and possible inflammation of the kidneys (capsule)

Listen for renal bruits
- Using the bell of your stethoscope, auscultate for renal bruits by locating the renal arteries ~5cm superior and 5cm lateral to the umbilicus
- Listen bilaterally