Scars due to varicose vein surgery
Perthes’ test (if after the gold medal)
Ankle-brachial pressure index (ABPI)
Specifications: You are most likely to be requested to measure the ABPI for one arm and ankle only.
Calculating and interpreting ABPI
Higher of the two right ankle pressures
Higher of the two arm pressures
Higher of the two left ankle pressures
Higher of the two arm pressures
Cardiovascular and respiratory medicine
Station 15 Ankle-brachial pressure index (ABPI) 37
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the procedure and obtain his consent.
• Position him at 45° with his sleeves and trousers rolled up.
• Ensure that he is comfortable.
• State that you would allow him 5 minutes resting time before taking measurements.
• Place an appropriately sized cuff around the arm, as for any blood pressure recording.
• Locate the brachial pulse by palpation and apply contact gel at this site.
• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply
only gentle pressure, or else you risk occluding the artery.
• Inflate the cuff until the signal disappears.
• Progressively deflate the cuff and record the pressure at which the signal reappears.
• Repeat the procedure for the other arm or state that you would do so.
• Retain the higher of the two readings.
Take care not to allow the probe to slide away from the line of the artery.
• Place an appropriately sized cuff around the ankle immediately above the malleoli.
• Locate the dorsalis pedis pulse by palpation or with the hand-held Doppler probe and apply
• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply
only gentle pressure, or else you risk occluding the artery.
• Inflate the cuff until the signal disappears.
• Progressively deflate the cuff, and record the pressure at which the signal reappears.
• Repeat the procedure for the posterior tibial pulse, which is posterior and inferior to the medial
• Repeat the procedure for the dorsalis pedis and posterior tibial pulses of the other ankle orstate
• For each ankle, retain the higher of the two readings.
• Clean the patient’s skin of contact gel and allow him time to restore his clothing.
• Clean the hand-held Doppler probe of contact gel.
• Calculate the ABPI and explain its significance to the patient.
• Ask the patient if he has any questions or concerns.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Ensure that he is comfortable.
• Ask about the nature of the breathlessness. Use open questions.
• Elicit the patient’s ideas, concerns and expectations (ICE).
History of presenting complaint
• Onset, duration, and variability of breathlessness.
• Provoking and relieving factors. Provoking factors include stress, exercise, cold weather, pets,
dust, and pollen; relieving factors include rest and use of inhaler or GTN spray.
– exercise tolerance: “How far can you walk before you get breathless? How far could you walk
– sleep disturbance: “Do you get more breathless when you lie down? How many pillows do you
– paroxysmal nocturnal dyspnoea: “Do you wake up in the middle of the night feeling breathless?”
• Associated symptoms(wheeze, cough,sputum, haemoptysis, fever, nightsweats, anorexia, loss
of weight, lethargy, chest pain, dizziness, pedal oedema).
• Previous episodes of breathlessness.
• Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever),
PE/DVT, pneumonia, bronchitis, and tuberculosis.
• Previous investigations (e.g. bronchoscopy, chest X-ray).
• Previous hospital admissions and previous surgery.
• Prescribed medication (especially bronchodilators, NSAIDs, b-blockers, ACE inhibitors,
amiodarone, and steroids) and route (e.g. inhaler, home nebuliser).
• Over-the-counter medication.
Cardiovascular and respiratory medicine
Station 16 Breathlessness history 39
• Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic
fibrosis, tuberculosis, and emphysema (a1-antitrypsin deficiency).
• Smoking: 1 pack year is equivalent to 20 cigarettes per day for 1 year.
• Contact with asbestos (mesothelioma).
• Contact with work-place allergens involved in, for example, baking, soldering, spray painting.
• Contact with animals, especially cats, dogs, and birds (bird fancier’s lung).
• Ask the patient if there is anything else he might add that you have forgotten to ask.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to examine the patient and carry out some investigations to confirm
Conditions most likely to come up in a breathlessness history station
• Breathlessness, chest tightness, wheezing and coughing.
• Symptoms worse at night and in the early morning, and exacerbated by irritants, cold air,
• Symptoms respond to bronchodilators.
• There may be a history and family history of atopy.
Chronic obstructive pulmonary disease:
• Breathlessness, cough, wheeze.
• Chronic progressive disorder characterised by fixed or only partially reversible airway
• Breathlessness accompanied by fever, cough, and yellow sputum, and in some cases by
haemoptysis and pleuritic chest pain.
40 Station 16 Breathlessness history
• Breathlessness, cough, haemoptysis, weight loss, malaise, fever, night sweats, pleural pain,
symptoms of extrapulmonary disease.
• More likely in certain high-risk groups such as immigrants, the homeless and the
• Breathlessness, sometimes with pleural pain and haemoptysis.
• There may be predisposing factors such as recent surgery, immobility, or long-haul travel.
• Symptoms may include breathlessness, stridor, cough, haemoptysis, anorexia, weight loss,
lethargy, pleural pain, hoarseness, Horner’s syndrome, effects of distant metastases.
• History of smoking in most cases.
• Left ventricular failure leads to pulmonary oedema.
• Symptoms include breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, pedal
• There is a cough which produces pink frothy sputum.
• Rapid onset of severe anxiety lasting for about 20–30 minutes.
• Associated with chest tightness and hyperventilation.
41Cardiovascular and respiratory medicine
Respiratory system examination
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Position him at 45°, and ask him to remove his top(s).
• Ask him if he is in any pain or distress.
• Ensure that he is comfortable.
Does he have to sit up to breathe? Is his breathing audible? Are there any added sounds(cough,
– the rate, depth, and regularity of his breathing
– any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine
– any asymmetry of chest expansion
– the use of accessory muscles of respiration and planting of hands
– the presence of operative scars, including in the axillae and around the back
• Next observe the surroundings. Is the patient on oxygen? If so, note the device (see Tables 40
and 41 in Station 113), the concentration (%), and the flow rate. Look in particular for inhalers,
nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there
is a sputum pot, make sure to inspect its contents.
Inspection and examination of the hands
• Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated
by a bluish discoloration of the fingertips.
• Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less
than 2 seconds for the nail bed to return to its normal colour.
• Look fortarstaining and finger clubbing. When the dorsum of a fingerfrom one hand is opposed
to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s
window) is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is
obliterated, and a distal angle is created between the fingers (see Figure 9). Respiratory causes
of clubbing include carcinoma, fibrosing alveolitis, and chronic suppurative lung disease (see
• Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an
apical lung tumour that is invading or compressing the roots of the brachial plexus.
the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards.
Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine
tremor may be related to excessive use of B2 agonist.
• During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the
bounding pulse of carbon dioxide retention?
• Indicate that you would like to measure the blood pressure.
42 Station 17 Respiratory system examination
Table 8. The principal causes of clubbing
Chronic suppurative lung disease
Table 9. The principal causes of asterixis
Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia)
Drug intoxication, e.g. alcohol, phenytoin
Inspection and examination of the head and neck
• Inspect the patient’s eyes. Look for a ptosis (an upper lid that encroaches upon the pupil) and
for anisocoria (pupillary asymmetry). Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis
• Next inspect the sclera and conjunctivae for signs of anaemia.
• Assess the jugular venous pressure (JVP) and the jugular venous pulse form (see Station 13). A
raised JVP is suggestive of right-sided heart failure.
window is obliterated, and a distal angle is created between the fingers.
No comments:
Post a Comment