O2 saturation or ABG Assessment of respiratory failure
IgE, allergen skin tests Detection of allergic stimuli
IgE, immunoglobulin E; WCC, white cell count.
OSCE example 1: Respiratory history
Mrs Walker, 55 years old, presents to the respiratory clinic with cough and wheeze.
• Introduce yourself and clean your hands.
• Ask an open question about why this person has come to the clinic.
• Explore each presenting symptom:
– Productive? If so, characterise sputum volume and colour, and any blood.
– Time pattern – nocturnal (suggests asthma or reflux)?
– On angiotensin-converting enzyme inhibitors?
– What exactly does the patient mean by ‘wheeze’?
– When does it occur – at night or during exercise?
– Provoking factors – infection, environment, contact with animals, dust, beta-blockers?
– Any relieving factors – inhalers?
– Associated respiratory symptoms – breathlessness, chest pain, fevers/rigors, weight loss.
• Ask about any known allergies.
• Take a social history: smoking, occupation, contact with animals.
OSCE example 2: Respiratory examination
Mr Tate, 82 years old, reports increasing breathlessness over several weeks.
Please examine his respiratory system
• Introduce yourself and clean your hands.
• Note clues around the patient, such as oxygen, nebulisers, inhalers or sputum pots.
• Observe from the end of the bed:
• Scars, chest shape, asymmetry, pattern of breathing, accessory muscle use.
• Chest wall movement, paradoxical rib movement, intercostal indrawing.
• Examine the hands: clubbing, tar staining, muscle wasting.
• Measure respiratory rate unobtrusively.
• Examine the face: anaemia, cyanosis, Horner’s syndrome and superior vena cava obstruction.
• Examine the neck: jugular venous pressure, tracheal deviation, cricosternal distance.
• Examine the anterior chest wall:
• Palpate: apex beat, right ventricular heave, expansion of the upper and lower chest.
• Percuss: compare right with left, from top with bottom, then axillae.
• Ask the patient to sit forwards.
• Inspect the back for scars, asymmetry and so on.
– Chest expansion of the upper and lower chest.
• Check for pitting oedema over the sacrum and lumbar spine.
• Thank the patient and clean your hands.
base. A small scar suggests prior pleural aspiration.
Suggest a differential diagnosis
Signs suggest a large right pleural effusion.
empyema and tuberculous effusion.
Suggest initial investigations
Pleural aspiration for cytology, culture and biochemical analysis.
OSCE example 1: Respiratory history – cont’d
• Establish whether there is a family history of respiratory disease (including asthma).
• Ask about any other patient concerns.
• Thank the patient and clean your hands.
Suggest a differential diagnosis
Suggest initial investigations
Integrated examination sequence for the respiratory system
• Introduce yourself and seek the patient’s consent to chest examination.
• Observe from the end of the bed:
– Time spent in inspiration and expiration.
• Chest wall movement, paradoxical rib movement, intercostal indrawing.
• Clubbing, tar staining, muscle wasting.
• Measure respiratory rate unobtrusively.
• Check for anaemia, cyanosis, Horner’s syndrome and signs of superior vena cava obstruction.
• Jugular venous pressure, tracheal deviation and cricosternal distance.
• Examine the anterior chest wall:
• Palpate: apex beat, right ventricular heave, expansion of upper and lower chest.
• Percuss: compare right with left, from top to bottom, then axillae.
• Examine the posterior chest wall: ask the patient to sit forwards so that you can:
• Inspect the back for scars, asymmetry and so on.
– Expansion of the upper and lower chest.
• Check for pitting oedema over the sacrum and lumbar spine.
OSCE example 1: Abdominal pain and diarrhoea 116
Integrated examination sequence for the gastrointestinal system 117
94 • The gastrointestinal system
and 2000 kcal/day for females. Reduced energy intake arises
from dieting, loss of appetite, malabsorption or malnutrition.
Increased energy expenditure occurs in hyperthyroidism, fever
or the adoption of a more energetic lifestyle. A net calorie
deficit of 1000 kcal/day results in weight loss of approximately
8 Appendix (in pelvic position)
Fig. 6.1 Surface anatomy. A Abdominal surface markings of
non-alimentary tract viscera. B Surface markings of the alimentary tract.
C Regions of the abdomen. E, epigastrium; H, hypogastrium or
suprapubic region; LF, left flank or lumbar region; LH, left hypochondrium;
LIF, left iliac fossa; RF, right flank or lumbar region; RH, right
hypochondrium; RIF, right iliac fossa; UR, umbilical region.
6.1 Surface markings of the main non-alimentary tract
Liver Upper border: fifth right intercostal space on full
Lower border: at the costal margin in the mid-clavicular
Spleen Underlies left ribs 9–11, posterior to the mid-axillary line
Gallbladder At the intersection of the right lateral vertical plane and
the costal margin, i.e. tip of the ninth costal cartilage
Pancreas Neck of the pancreas lies at the level of L1; head lies
below and right; tail lies above and left
Kidneys Upper pole lies deep to the 12th rib posteriorly, 7 cm
from the midline; the right is 2–3 cm lower than the left
The gastrointestinal system comprises the alimentary tract,
the liver, the biliary system, the pancreas and the spleen.
The alimentary tract extends from the mouth to the anus and
includes the oesophagus, stomach, small intestine or small bowel
(comprising the duodenum, jejunum and ileum), colon (large
intestine or large bowel) and rectum (Figs 6.1–6.2 and Box 6.1).
The abdominal surface can be divided into nine regions by the
intersection of two horizontal and two vertical planes (Fig. 6.1C).
Gastrointestinal symptoms are common and are often caused by
functional dyspepsia and irritable bowel syndrome. Symptoms
suggesting a serious alternative or coexistent diagnosis include
persistent vomiting, dysphagia, gastrointestinal bleeding, weight
loss, painless, watery, high-volume diarrhoea, nocturnal symptoms,
fever and anaemia. The risk of serious disease increases with age.
Always explore the patient’s ideas, concerns and expectations
about the symptoms (p. 5) to understand the clinical context.
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