cmecde 5697

 

167 cm

160 cm

Height

Women

183 cm

175 cm

167 cm

160 cm

20 25 30 35 40 45 50 152 cm

Age (years)

15 55 60 65 70 75 80 85

320

340

360

380

400

420

440

460

480

500

520

540

560

580

600

620

640

660

680

300

PEFR (litres per minute)

Clinical Skills for OSCEs

48 Station 19

Inhaler explanation

Read in conjunction with Station 116: Explaining skills.

The traditional pressure Metre Dose Inhaler (pMDI) is most likely to feature in an OSCE, but you could

also be examined on other common inhalers.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Check his understanding of asthma and of the inhaler.

• Explain to him that an inhaler device delivers aerosolised bronchodilator medication for inhalation. If used correctly, it provides fast and efficient relief from bronchospasm (airway irritation

and narrowing). He can take up to two puffsfrom the inhaler, asrequired, up to four times a day.

If he finds himself using the inhaler more frequently than this, he should speak to his doctor.

Possible side-effects are a fast heart rate, shakiness, and headaches.

• Ask him if he has any concerns.

Pressure Metre Dose Inhaler (pMDI)

Demonstrate and ask the patient to:

• Vigorously shake the inhaler to mix the drug.

• Remove the cap from the mouthpiece.

• Hold the inhaler between index finger and thumb.

• Breathe out completely.

• Place the inhaler in the mouth such as to make an airtight seal with lips.

• Breathe in steadily and deeply, and simultaneously activate the inhaler once only.

• Remove the inhaler, hold breath for 10 seconds, and then breathe out slowly.

• Repeat the procedure after 1 minute if relief is insufficient.

• Check the patient’s understanding by asking him to carry out the procedure in front of you.

• Ask if he has any questions or concerns.

If the patient has difficulty co-ordinating breathing in and inhaler activation, he may

benefit from a breath-activated inhaler or the added use of a spacer.

Breath-activated pressure Metre Dose Inhaler

The procedure isthe same as above, except that the medication is automatically released on inspiration.

Note that a breath-activated pMDI cannot be used with a spacer.

Pressure Metre Dose Inhaler with spacer

Spacers increase the amount of medication delivered to the lungs if the patient is limited by poor

technique or respiratory effort.

• Assemble the spacer.

• Vigorously shake the inhaler to mix the drug.

• Remove the cap from the mouthpiece.

• Fit the inhaler into the spacer.

• Sit up straight and breathe out completely.

• Place the spacer in the mouth such as to make an airtight seal with lips.

Cardiovascular and respiratory medicine

Station 19 Inhaler explanation 49

• Activate the inhaler as normal.

• Breathe in steadily and deeply, hold breath for 10 seconds, and then breathe out slowly.

• Advise the patient that the spacer should be washed every month with soap and warm water

and left to air dry. It should be replaced every six months.

Dry Powder devices (Accuhaler)

• Open the device using the thumb-grip, exposing the mouthpiece and the dose lever.

• Press down on the lever to dose the device (this produces a click).

• Breathe out completely and continue as per the pMDI technique, although there is no need to

co-ordinate activation and inhalation. Inhalation must be relatively hard and deep to produce

enough force to break up the powder and draw it into the lungs.

• Shut the device and note the number of remaining doses on the counter.

Clinical Skills for OSCEs

50 Station 20

Drug administration via a nebuliser

A nebuliser transforms a drug solution into a fine mist for inhalation via a mouthpiece or face mask.

Drugs used in nebulisers include bronchodilators, corticosteroids, and antibiotics (e.g. colistin).

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the need for a nebuliser and the procedure involved, and ensure consent.

• Explain the drug in the nebuliser, most likely salbutamol, and its common side-effects (for

salbutamol, tremor).

• Obtain consent.

The equipment

• An air compressor and tubing • Drug or drug solution (e.g. salbutamol 2.5 ml)

• A nebuliser cup in a vial

• A mouthpiece or mask • Diluent (e.g. sodium chloride 0.9%) if needed

• A syringe

The procedure

• Consult the prescription chart and check:

– the identity of the patient

– the prescription: validity, drug, dose, diluent, route of administration, date and time of

starting

– drug allergies

• Ask a colleague (registered nurse or doctor) to confirm the name, dose, and expiry date of the

drug on the vial.

• Place the air compressor on a sturdy surface and plug it into the mains.

Match the compressor unit gas flow rate with that recommended on the nebuliser

chamber. When treating hypercapnic or acidotic patients (for example, patients with

COPD), use compressed air not oxygen. If required, therapeutic oxygen can be delivered

simultaneously via nasal cannulae.

Nebuliser

cup

Tubing

Compressor

Mouthpiece

Figure 13. Nebuliser set-up.

Cardiovascular and respiratory medicine

Station 20 Drug administration via a nebuliser 51

• Wash your hands.

• Open the vial of drug solution by twisting off the top.

• With the syringe, carefully draw up the correct amount of drug solution.

• Remove the top part of the nebuliser cup and place the drug solution into it.

• Re-attach the top part of the nebuliser cup and connect the mouthpiece or face mask to the

nebuliser cup.

• Connect the tubing from the air compressor to the bottom of the nebuliser cup.

• Switch on the air compressor and ensure that a fine mist is being produced.

• Ask the patient to sit up straight.

• If using a mouthpiece, ask him to clasp it between histeeth and to seal hislips around it. If using

a mask, position it comfortably and securely over his face.

• Ask him to take slow, deep breaths through the mouth and, if possible, to hold each breath for

2–3 seconds before breathing out.

• Continue until there is no drug left and the nebuliser begins to splutter (about 10 minutes).

• Turn the compressor off.

• Ask the patient to take several deep breaths and to cough up any secretions.

• Ask him to rinse his mouth with water.

• Wash your hands.

• Sign the prescription chart.

If the patient feels dizzy, he should interrupt the treatment and rest for about 5 minutes.

After resuming the treatment, he should breathe more slowly through the mouthpiece.

After the procedure

• Tell the examiner that you would clean and disinfect the equipment.

• Sign the drug chart and record the diluent used, and the date, time, and dose of the drug in

the medical records.

• Indicate that you would have your checking colleague countersign it.

• Ask the patient if he has any questions or concerns.

• Ensure that he is comfortable.

Clinical Skills for OSCEs

52 Station 21

Abdominal pain history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the cause of his abdominal

pain, and obtain his consent.

• Ensure that he is comfortable.

Ensure that the patient is nil by mouth (NBM). Acute abdomen is a surgical complaint

and the patient must therefore be kept nil by mouth until the need for surgery has been

excluded.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

Determine:

• Site of pain e.g. right iliac fossa.

• Onset and progression.

• Character e.g. sharp, dull, aching, burning – allow the patient to use his own words.

• Radiation.

• Associated symptoms and signs.

• Timing and duration.

• Exacerbating and alleviating factors.

• Severity on a scale of 1 to 10.

Ask about:

• Systemic signs and symptoms: fever, jaundice, loss of weight or anorexia, effect on everyday

life.

• Upper GI signs and symptoms: dysphagia, indigestion (heartburn), nausea, vomiting, haematemesis.

• Lower GI signs and symptoms: diarrhoea or constipation, melaena or rectal bleeding, steatorrhoea.

• Genitourinary signs and symptoms: frequency, dysuria, haematuria.

• Gynaecological signs and symptoms: length of menstrual period, amount of bleeding, pain,

intermenstrual bleeding, last menstrual period.

Ensure that you explore, and respond to, the patient’s ideas, concerns and expectations (ICE).

Past medical history

• Previous episodes of abdominal pain.

• Current, past, and childhood illnesses.

• Previous hospital admissions and surgery.

GI medicine and urology

Station 21 Abdominal pain history 53

Drug history

• Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics, and the

contraceptive pill.

• Over-the-counter medication and herbal remedies.

• Recreational drugs.

• Allergies.

Family history

• Parents, siblings, and children. Ask specifically about colon cancer, irritable bowel syndrome,

inflammatory bowel disease, jaundice, peptic ulceration, and polyps.

Social history

• Alcohol consumption.

• Smoking.

• Recent overseas travel.

• Tattoos and piercings.

• Employment, past and present.

• Housing.

• Contact with jaundiced patients.

After taking the history

• Ask the patient if there is anything that he might add that you have forgotten to ask.

• Ask the patient if he has any questions or concerns.

• Thank the patient.

• State that you would carry out a full abdominal examination and order some key investigations

such as urinalysis, serum analysis, and an abdominal X-ray, as appropriate.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in an abdominal pain history station

Appendicitis:

• More common in younger adults.

• Diffuse central pain that then shifts into the right iliac fossa.

• Aggravated by movement, touch, coughing.

• Associated with nausea and vomiting, fever, anorexia.

Gastro-oesophageal reflux disease:

• Retrosternal burning.

• Clear relationship with food and alcohol, but no relationship with effort.

• Aggravated by lying down and alleviated by sitting up and by antacids or milk.

• May be associated with odynophagia (pain on swallowing) and nocturnal asthma.

Clinical Skills for OSCEs

54 Station 21 Abdominal pain history

Peptic ulceration:

• Severe epigastric pain, during meals in the case of gastric ulcers, and between meals and at

night in the case of duodenal ulcers.

• Aggravated by spicy food, alcohol, stress.

• Associated with bloating, heartburn, nausea and vomiting, anorexia, haematemesis, melaena.

• Predisposed to by NSAIDs, alcohol, and smoking.

Biliary colic:

• Constant but episodic epigastric or right upper quadrant pain that may radiate to the back

and shoulders.

• Can be provoked by eating a large, fatty meal.

• Associated with nausea and vomiting and diarrhoea.

• Presence of fever may indicate biliary tract infection (cholecystitis).

• Risk factors for gall stones are fat, forty, female, and pregnant or fertile (‘the 4 Fs’), the

contraceptive pill, and HRT.

Acute pancreatitis:

• Acute, severe epigastric pain radiating to the back.

• May be alleviated by sitting forward (‘pancreatic position’) or by remaining still.

• Associated with nausea and vomiting, diarrhoea, anorexia, fever.

Ureteric colic:

• Severe pain in the loin that radiates to the groin.

• Often colicky but may be constant.

• Associated with nausea and vomiting.

• Predisposed to by dehydration.

Diverticulitis:

• Left iliac fossa pain and tenderness.

• Aggravated by movement.

• Associated with fever, nausea, anorexia, constipation, diarrhoea.

• More common in the elderly.

Colorectal cancer:

• Signs and symptoms may include change in bowel habit, tenesmus, change in stool shape,

rectal bleeding, melaena, bowel obstruction leading to constipation, abdominal pain,

abdominal distension, and vomiting, fatigue, anorexia, weight loss.

Irritable bowel syndrome:

• Chronic abdominal pain or discomfort.

• Associated with frequent diarrhoea or constipation, bloating, urgency for bowel movements,

tenesmus.

Remember that basal pneumonia, diabetic ketoacidosis, and an inferior myocardial

infarct can also present as abdominal pain.

55GI medicine and urology

Station 22

Abdominal examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Obtain consent to examine his abdomen.

• Say to the examiner that you would normally expose the patient from nipplesto knees, but that

in this case you are going to limit yourself to exposing the patient to the groins.

• Position the patient so that he is lying flat on the couch, with his arms at his side and his head

supported by a pillow.

• Ensure that the patient is comfortable.

The examination

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health,

nutritional status, and any other obvious signs).

• Next observe the surroundings, looking in particular for the presence of a nasogastric tube,

intravenous infusion, urinary catheter, drain, or stoma bag.

• Inspect the abdomen for its contours and any obvious distension, localised masses, scars, and

skin changes. Ask the patient to lift his head up and to cough. This makes hernias more visible

and, if the patient has difficulty complying with your instructions, suggests peritonism.

Inspection and examination of the hands

• Take both hands, noting their temperature and looking for:

– clubbing

– palmar erythema (liver disease)

– nail signs: leukonychia/‘white dash’ (hypoalbuminaemia) and koilonychia/‘spoon-shaped

nails’ (iron deficiency)

– Dupuytren’s contracture (cirrhosis, old age; see Figure 15)

• Test for asterixis or ‘liver flap’ (hepatic failure) by showing the patient how to extend both arms

with the wrists dorsiflexed and the palms facing forwards. Ask him to hold this posture for at

least 10 and ideally 30 seconds.

Subcostal

Flank/loin

Lanz

Grid iron

Mercedes ( )

Roof top/gable ( )

Midline

Paramedian

Pfannenstiel

Hernia

J-shaped/’hockey stick’

Figure 14. Abdominal scars.

Clinical Skills for OSCEs

56 Station 22 Abdominal examination

• Next, feel the pulse for at least 15 seconds and measure the respiratory rate.

• Moving up, inspect the arms for bruising, scratch marks, injection track marks, and tattoos

(risk of hepatitis).

Inspection and examination of the head, neck, and upper body

• Ask the patient to look up and then inspect the sclera for jaundice.

• Gently retract the eyelid and inspect the conjunctiva for pallor.

• Ask the patient to open his mouth, and note any odour on the breath (alcohol, foetor hepaticus,

ketones). Inspect the mouth, looking for signs of dehydration, furring of the tongue (loss of

appetite), angular stomatitis (nutritional deficiency), atrophic glossitis (iron deficiency, vitamin

B12 deficiency, folate deficiency), ulcers (Crohn’s disease), and the state of the dentition.

• If you suspect alcoholism or an eating disorder, feel for enlargement of the parotid glands.

• Assess the jugular venous pressure (JVP).

• Palpate the neck for lymphadenopathy, making sure to take in the left supraclavicular fossa

(Virchow’s node, gastric carcinoma).

• Examine the upper body for signs of chronic liver disease: gynaecomastia, caput medusae, and

spider naevi (more than five is considered abnormal).

Palpation of the abdomen

Before you begin, ask the patient to identify any area of pain or tenderness.

• Sit or kneel beside the patient and use the palmar surface of your fingers to lightly palpate in

all nine regions of the abdomen (Figure 16), beginning with the region furthest away from any

pain or tenderness. By flexing and extending your metacarpophalangeal joints, palpate for

tenderness, rebound tenderness, guarding, and rigidity. Keep looking at the patient’s face for

any signs of discomfort.

• Repeat the procedure, this time palpating more deeply so as to localise and describe any

masses.

Figure 15. Dupuytren’s contracture.

cmecde 65

 

Cardiovascular and respiratory medicine

Station 17 Respiratory system examination 43

• Examine the lymph nodes from behind with the patient sitting up. Have a systematic routine

for examining all of the submental, submandibular, parotid, pre- and post-auricular, occipital,

anterior cervical, posterior cervical, supra- and infra-clavicular, and axillary lymph nodes (see

Station 9).

• Palpate for tracheal deviation by placing the index and middle fingers of one hand on either

side of the trachea in the suprasternal notch. Alternatively, place the index and annular fingers

of one hand on either clavicular head and use your middle finger (called the Vulgaris in Latin)

to palpate the trachea.

Palpation of the chest

Ask the patient if he has any chest pain.

• Inspect the chest more carefully, looking for asymmetries, deformities, and scars.

• Inspect the precordium and palpate for the position of the cardiac apex. Difficulty palpating for

the position of the cardiac apex may indicate hyperexpansion, although this is not a specific

sign.

[Note] Carry out all subsequent steps on the front of the chest and, once finished, repeat them on the back of the chest.

This is far more elegant than to keep asking the patient to bend forwards and backwards like a Jack-in-the-box.

Pulmonary anatomy is such that examination of the back of the chest yields information about the lower lobes,

whereas examination of the front of the chest yields information about the upper lobes and, on the right-side,

also the middle lobe (Figure 10).

• Palpate for equal chest expansion, comparing one side to the other. Reduced unilateral chest

expansion might be caused by pneumonia, pleural effusion, pneumothorax, and lung col lapse.

If there is a measuring tape, measure the chest expansion.

Figure 10. A right lateral view demonstrating lobar

anatomy. Posterior assessment gives information

about the lower lobes, whereas examination from

the front looks at the upper and middle lobes (the

latter only on the right).

Upper lobe

Lower lobe

Middle lobe

Clinical Skills for OSCEs

44 Station 17 Respiratory system examination

Percussion of the chest

• Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not

forget to percuss over the clavicles and on the sides of the chest. For any one area, is the resonance increased or decreased? A hyper-resonant or tympanic note may indicate emphysema

or pneumothorax, whereas a dull or stony dull note may indicate consolidation, fibrosis, fluid,

or lung collapse. If you uncover any variation in the percussion note, be sure to map out its

geographical extent.

• Test for tactile fremitus by placing the flat of the hands on the chest and asking the patient to

say “ninety nine”.

Auscultation of the chest

• Ask the patient to take deep breathsthrough the mouth and, using the diaphragm of the stethoscope, auscultate the chest in the same locations as for percussion. Start at the apex of one

lung, in the supraclavicular fossa, and compare one side to the other. Normal breath sounds

are described as ‘vesicular’ and have a low pitched and rustling quality. Reduced breath sounds

may indicate consolidation. Listen carefully for added sounds such as wheezes (rhonchi), crackles (crepitations), bronchial breathing, and pleural friction rubs.

• Test for vocal resonance by asking the patient to say “ninety nine”. Both consolidation and

pleural effusions can lead to a dull percussion note, but in consolidation vocal resonance is

increased whereas in pleural effusion it is decreased. Both vocal resonance and tactile fremitus

(see above) provide the same sort of information.

Inspection and examination of the legs

• Inspect the legs for erythema and swelling. Palpate for tenderness and pitting oedema. A

unilateral red, swollen, and tender calf suggests a DVT, whereas bilateral swelling may indicate

right-sided heart failure.

Figure 11. Palpating for equal chest expansion: upper, middle and lower lobes.

Cardiovascular and respiratory medicine

Station 17 Respiratory system examination 45

After the examination

• Indicate that you would look at the observations chart, examine a sputum sample, measure the

peak expiratory flow rate, and order some simple investigations such as a chest X-ray and a full

blood count.

• Cover the patient up and ensure that he is comfortable.

• Thank the patient.

• Wash your hands.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a respiratory system examination station

Chronic obstructive pulmonary oedema (COPD):

• Signs may include breathlessness, breathing through pursed lips, cough, hyperinflated chest,

cyanosis, warm hands, tar staining, asterixis, bounding pulse, rhonchi, reduced breath sounds,

signs of right heart failure (cor pulmonale).

Cryptogenic fibrosing alveolitis:

• Signs may include breathlessness, dry cough, cyanosis, clubbing, reduced chest expansion,

fine late inspiratory crackles, signs of right heart failure (cor pulmonale).

Lobectomy

• Look carefully for a scar and listen for reduced or absent breath sounds.

Clinical Skills for OSCEs

46 Station 18

PEFR meter explanation

Read in conjunction with Station 116: Explaining skills.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Check his understanding of asthma and of the PEFR meter.

• Explain the importance of using a PEFR (Peak Expiratory Flow Rate) meter and the importance

of using it correctly.

• Explain that the PEFR meter is to be used first thing in the morning and at any time he has

symptoms of asthma.

Explain the use of a PEFR meter

Demonstrate and ask the patient to:

• Attach a clean mouthpiece to the meter.

• Slide the marker to the bottom of the numbered scale.

• Stand or sit up straight.

• Hold the peak flow meter horizontal, keeping his fingers away from the marker.

• Take as deep a breath as possible and hold it.

• Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece.

• Exhale as hard as possible into the meter.

• Read and record the meter reading.

• Repeat the procedure three to six times, recording only the highest score.

• Check this 21score against the peak flow chart or his previous readings.

• Check the patient’s understanding by asking him to carry out the procedure.

• Ask him if he has any questions or concerns.

Cardiovascular and respiratory medicine

Station 18 PEFR meter explanation 47

Interpret a PEFR reading

Figure 12. Expected peak flow rates in litres per minute according to age, sex, and height.

If the patient has been given a diary or chart to track PEFR variation:

• Explain that he must record a reading (best of three attempts) in the morning, afternoon, and

evening.

• Show him how to plot readings on the chart.

Height

Men

190 cm

183 cm

175 cm

cmecde 569

 

Oedema (non-pitting)

Venous ulcers

Varicose veins

Scars due to varicose vein surgery

Trendelenburg test

Perthes’ test (if after the gold medal)

[Note] The 6 Ps of limb ischaemia: pain, pallor, pulselessness, paraesthesia, paralysis, and perishingly cold.

Clinical Skills for OSCEs

36 Station 15

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

Figure 8. Calculating ABPI.

Table 7. ABPI interpretation

ABPI Interpretation

> 0.95

0.5–0.9

< 0.5

< 0.2

Normal

Claudication pain

Rest pain

Ulceration and gangrene

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

Right arm

systolic pressure

Left arm

systolic pressure

Right ankle

systolic

pressure

Left ankle

systolic

pressure

Posterior tibial

Dorsalis pedis

Posterior tibial

Dorsalis pedis

Right ABPI Left ABPI

Cardiovascular and respiratory medicine

Station 15 Ankle-brachial pressure index (ABPI) 37

Before starting

• 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.

• Wash your hands.

• State that you would allow him 5 minutes resting time before taking measurements.

The procedure

Brachial systolic pressure

• 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.

Ankle systolic pressure

• 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

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 posterior tibial pulse, which is posterior and inferior to the medial

malleolus.

• Repeat the procedure for the dorsalis pedis and posterior tibial pulses of the other ankle orstate

that you would do so.

• For each ankle, retain the higher of the two readings.

After the procedure

• 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.

• Wash your hands.

• Calculate the ABPI and explain its significance to the patient.

• Ask the patient if he has any questions or concerns.

• Thank the patient.

Clinical Skills for OSCEs

38 Station 16

Breathlessness history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the nature of his breathlessness, and obtain his consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint

• Ask about the nature of the breathlessness. Use open questions.

• Elicit the patient’s ideas, concerns and expectations (ICE).

History of presenting complaint

Ask about:

• 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.

• Severity:

– exercise tolerance: “How far can you walk before you get breathless? How far could you walk

before?”

– sleep disturbance: “Do you get more breathless when you lie down? How many pillows do you

use?”

– 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).

• Effect on everyday life.

• Previous episodes of breathlessness.

• Smoking and alcohol.

Past medical history

• 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.

Drug history

• Prescribed medication (especially bronchodilators, NSAIDs, b-blockers, ACE inhibitors,

amiodarone, and steroids) and route (e.g. inhaler, home nebuliser).

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Cardiovascular and respiratory medicine

Station 16 Breathlessness history 39

Family history

• Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic

fibrosis, tuberculosis, and emphysema (a1-antitrypsin deficiency).

Social history

• Smoking: 1 pack year is equivalent to 20 cigarettes per day for 1 year.

• Recent long-haul travel.

• Exposure to tuberculosis.

• 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).

After taking the history

• Ask the patient if there is anything else he might add that you have forgotten to ask.

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to examine the patient and carry out some investigations to confirm

your diagnosis.

Conditions most likely to come up in a breathlessness history station

Asthma:

• Breathlessness, chest tightness, wheezing and coughing.

• Symptoms worse at night and in the early morning, and exacerbated by irritants, cold air,

exercise, and emotion.

• 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

obstruction (cf. asthma).

• History of smoking.

Pneumonia:

• Breathlessness accompanied by fever, cough, and yellow sputum, and in some cases by

haemoptysis and pleuritic chest pain.

Clinical Skills for OSCEs

40 Station 16 Breathlessness history

Tuberculosis:

• 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

immunocompromised.

Pulmonary embolism:

• Breathlessness, sometimes with pleural pain and haemoptysis.

• There may be predisposing factors such as recent surgery, immobility, or long-haul travel.

Lung cancer:

• 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.

Heart failure:

• Left ventricular failure leads to pulmonary oedema.

• Symptoms include breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, pedal

oedema.

• There is a cough which produces pink frothy sputum.

Panic attack:

• Rapid onset of severe anxiety lasting for about 20–30 minutes.

• Associated with chest tightness and hyperventilation.

41Cardiovascular and respiratory medicine

Station 17

Respiratory system examination

Before starting

• 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.

• Wash your hands.

The examination (IPPA)

General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health, nutritional status, and any other obvious signs). In particular, is he visibly breathless or cyanosed?

Does he have to sit up to breathe? Is his breathing audible? Are there any added sounds(cough,

wheeze, stridor)?

• Note:

– 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

Table 8).

• 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.

• Test for asterixis (see Table 9), the coarse flapping tremor of carbon dioxide retention, by asking

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.

Clinical Skills for OSCEs

42 Station 17 Respiratory system examination

Table 8. The principal causes of clubbing

Respiratory causes

Bronchial carcinoma

Fibrosing alveolitis

Chronic suppurative lung disease

Cardiac causes

Infective endocarditis

Cyanotic heart disease

Gastrointestinal causes

Cirrhosis

Ulcerative colitis

Crohn’s disease

Coeliac disease

Familial

Table 9. The principal causes of asterixis

Hepatic failure

Renal failure

Cardiac failure

Respiratory failure

Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia)

Drug intoxication, e.g. alcohol, phenytoin

CNS causes

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

are strongly suggestive of Horner’s syndrome, which may result from compression of the sympathetic chain by an apical lung tumour.

• Next inspect the sclera and conjunctivae for signs of anaemia.

• Ask the patient to open his mouth and inspect the underside of the tongue for the blue discoloration of central cyanosis.

• 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.

Figure 9. Clubbing. When the dorsum of a finger from one hand is opposed to the dorsum of a finger from the

other hand, a diamond-shaped 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.

cmecde 632

 

33Cardiovascular and respiratory medicine

Station 14

Peripheral vascular system examination

In this station you may be asked to restrict your examination to the arterial or venous system only. You

must therefore be able to separate out the signs for either (see Table 6).

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• After checking for any pain, ask him to expose his feet and legs and to lie down on the couch.

The examination

Inspection

• General appearance: body habitus, missing limbs or digits, surrounding paraphernalia such as

walking aids, oxygen, cigarettes.

• Skin changes: pallor, shininess, loss of body hair, atrophie blanche (ivory-white areas), haemosiderin ­pigmentation, inflammation, eczema, lipodermatosclerosis.

• Thickened dystrophic nails.

• Scars.

• Signs of gangrene: blackened skin, nail infection, amputated toes.

• Venous and arterial ulcers. Remember to look in the interdigital spaces.

• Oedema.

• Varicose veins (ask the patient to stand up). Varicose veins are often associated with incompetent valves in the long and short saphenous veins.

Do not make the common mistake of asking the patient to stand up before having

examined for varicose veins.

Palpation and special tests

• Ask about any pain in the legs and feet.

• Assess skin temperature by running the back of your hand along the leg and the sole of the

foot. Compare both legs.

• Capillary refill. Compress a nail bed for 5 seconds and let go. It should take less than 2 seconds

for the nail bed to return to its normal colour.

• Peripheral pulses (compare both sides).

– femoral pulse at the inguinal ligament

– popliteal pulse in the popliteal space (flex the knee)

– posterior tibial pulse behind the medial malleolus

– dorsalis pedis pulse over the dorsum of the foot, just lateral to the extensor tendon of the

great toe

• Buerger’s test:

– lift both of the patient’s legs to a 15 degree angle and note any collapse of the veins (‘venous

guttering’), which is indicative of arterial insufficiency

– lift both of the patient’s legs up to the point where they turn white (this is Buerger’s angle);

if there is no arterial insufficiency, the legs will not turn white, not even at a 90 degree angle

Clinical Skills for OSCEs

34 Station 14 Peripheral vascular system examination

– ask the patient to dangle his legs over the edge of the couch; in chronic limb ischaemia,

rather than returning to its normal colour, the skin will slowly turn red like a cooked lobster

(reactive hyperaemia)

• Oedema. Firm ‘non-pitting’ oedema is a sign of chronic venous insufficiency (compare to the

‘pitting’ oedema of cardiac failure).

• Varicose veins. Tenderness on palpation suggests thrombophlebitis.

• Trendelenburg’s test:

– elevate the leg to 90 degrees to drain the veins of blood

– occlude the sapheno-femoral junction (SFJ) with two fingers

– keep your fingers in place and ask the patient to stand up

– remove your fingers: if the superficial veins refill, this indicates incompetence at the SFJ

• Tourniquet test:

– elevate the leg to 90 degrees to drain the veins of blood

– apply a tourniquet to the upper thigh

– ask the patient to stand up: if the superficial veins below the tourniquet refill, this indicates

incompetent perforators below the tourniquet

– release the tourniquet: sudden additional filling of the veins is a sign of sapheno-femoral

incompetence

[Note] The tourniquet test can be repeated further and further down the leg, until the superficial veins below the

tourniquet no longer refill.

Auscultation

• Femoral arteries.

• Abdominal aorta.

• Renal arteries.

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• If appropriate, indicate that you might also measure the ABPI (see Station 15) and examine the

cardiovascular system and abdomen (aortic aneurysm).

Cardiovascular and respiratory medicine

Station 14 Peripheral vascular system examination 35

Table 6. Examination of the arterial or venous system only

Arterial system Venous system

Pallor

Shininess

Dystrophic nails

Loss of body hair

Arterial ulcers

Signs of gangrene

Skin temperature

Capillary refill

Peripheral pulses

Buerger’s test

Auscultation of femoral arteries and aorta

ABPI (if time permits, see Station 15)

Atrophie blanche

Pigmentation

Inflammation

Eczema

Lipodermatosclerosis