cmecde 789

 

GI medicine and urology

Station 22 Abdominal examination 57

Palpation of the organs

• Liver – Ask the patient to breathe in and out and, starting in the right iliac fossa, feel for the

inferior liver edge using the radial aspect of your index finger. Each time the patient inspires,

move your hand closer to the costal margin and press your fingers firmly into the abdominal

wall. The inferior liver edge may be felt as the liver descends upon inspiration, and can be

described in terms of regularity, nodularity, and tenderness.

• Gallbladder – Palpate for tenderness over the tip of the right ninth rib. Positive Murphy’s sign

(cholecystitis) is cessation of breathing on inspiration, and wincing, as the tender gallbladder

comes into contact with your fingers.

• Spleen – Palpate for the spleen as for the liver, once again starting in the right iliac fossa. Press

the tips of your fingers firmly against the abdominal wall so that your hand is pointing up and

leftwards. If the spleen is enlarged, the splenic notch may be ‘caught’ as the spleen descends

upon inspiration.

• Kidneys – Position the patient close to the edge of the bed and ballot each kidney using the

technique of deep bimanual palpation. Place one hand flat over the anterior aspect of the flank

(right hand for left kidney, left hand for right kidney), and press down whilst using the other

hand to push the kidney up from below.

Midclavicular line

Transpyloric plane

Intertubercular plane

16.1

16.6

16.5

16.4

16.3

16.2

Figure 16. Regions of the abdomen.

16.1 Epigastric

16.2 Left hypochondriac

16.3 Left lumbar

16.4 Left iliac fossa

16.5 Suprapubic/hypogastric

16.6 Umbilical

Clinical Skills for OSCEs

58 Station 22 Abdominal examination

• Aorta – Palpate the descending aorta with the tips of your fingers on either side of the midline,

just above the umbilicus. Pressing your fingers firmly into the abdominal wall, assess whether

the aorta is pulsatile and whether it is expansile, i.e. whether it causes the fingers of your right

and left hands to move apart.

Percussion

• Liver – Percuss out the entire craniocaudal extent of the liver. In the mid-clavicular line, start

above the right fifth intercostal space and progress downwards. The normal liver represents an

area of dullness which typically extendsfrom the fifth intercostalspace to the edge of the costal

margin. Beyond this point, the abdomen should be resonant to percussion.

• Spleen – As for the liver, percuss the spleen to determine its size.

• Bladder – Percuss the suprapubic area for the undue dullness of bladder distension.

• ‘Shifting dullness’ – this sign indicates ascites. Percuss down the right side of the abdomen. If an

area of dullness is detected, keep two fingers on it and ask the patient to roll over onto his left.

After about 30 seconds, re-percuss the area which should now sound resonant. The change in

the percussion note reflects the redistribution of ascitic fluid under the effect of gravity.

• ‘Fluid thrill’ – this sign indicates severe ascites. Ask the patient to place his hand along the midline of his abdomen. Then place one hand on one flank, and flick the opposite flank with your

other hand in an attempt to elicit a thrill.

Auscultation

Auscultate over:

• The mid-abdomen or ileocaecal valve for bowel sounds (Table 10). Listen for 30 seconds before

concluding that they are normal, hyperactive, hypoactive, or absent.

• The abdominal aorta for aortic bruits suggestive of arteriosclerosis or an aneurysm.

• 2.5 cm above and lateral to the umbilicus for renal artery bruits suggestive of renal artery

stenosis.

Table 10. Principal causes of altered bowel sounds

Hypoactive • Constipation.

• Drugs such as anticholinergics and opiates.

• General anaesthesia.

• Abdominal surgery.

• Paralytic ileus (absent bowel sounds).

Hyperactive • Diarrhoea of any cause.

• Inflammatory bowel disease.

• GI bleeding.

• Mechanical bowel obstruction (high pitched bowel sounds).

After the examination

• Cover up the patient and thank him. Enquire about and address any concernsthat he may have.

• Indicate to the examiner that you would normally test for pedal oedema, examine the hernia

orifices and the external genitalia, and carry out a digital rectal examination. You would also

look at the observations chart, dipstick the urine, and consider investigations such as ultrasound scan, FBC, LFTs, U&Es, clotting screen, pregnancy test, and urine drug screen.

• Summarise your findings and offer a differential diagnosis.

GI medicine and urology

Station 22 Abdominal examination 59

Conditions most likely to come up in an abdominal examination station

Chronic liver disease:

Wilson’s disease

• May result from alcoholic liver disease, viral hepatitis, right heart failure, haemochromatosis,

Wilson’s disease.

• Signs may include clubbing, palmar erythema, leukonychia, metabolic flap, hyperventilation,

bruising, jaundice, gynaecomastia, spider naevi, caput medusae, scratch marks, hepatomegaly,

ascites, pedal oedema, Dupuytren’s contracture (alcohol), tattoos (hepatitis C), signs of right

heart failure such as raised JVP and pedal oedema, bronzing of the skin (haemochromatosis),

Kayser–Fleischer rings (Wilson’s disease).

Splenomegaly:

• Causes include portal hypertension (usually complicating liver cirrhosis), lymphoproliferative

and myeloproliferative diseases, haemolytic anaemias, and infections such as infectious

mononucleosis/glandular fever and malaria.

Polycystic kidney

Renal transplant

Scars

Hernias (see Station 24)

Clinical Skills for OSCEs

60 Station 23

Rectal examination

Rectal examination is commonly indicated in cases of rectal or GI bleeding (suspected or actual),severe

constipation, faecal or urinary incontinence, anal or rectal pain, suspected enlargement of the prostate

gland, and urethral discharge or bleeding. It can also be used to screen for cancers of the rectum, colon,

and prostate.

Specifications: A plastic model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure to him, emphasising that it might be uncomfortable but that it should

not be painful, and obtain his consent.

• Ask for a chaperone.

• Ensure privacy.

• Ask the patient to lower his trousers and underpants.

• Ask him to lie on his left side, to bring his buttocks to the side of the couch, and to bring his

knees up to his chest (Sims’ or left lateral recumbent position).

The examination

• Put on a pair of gloves.

• Gently separate the buttocks and inspect the anus and surrounding skin. In particular, look out

forskin tags, excoriations, ulcers, fissures, external haemorrhoids, prolapsed haemorrhoids, and

mucosal prolapse.

• Lubricate the index finger of your right hand.

• Position the finger over the anus, as if pointing to the genitalia.

• Ask the patient to bear down so as to relax the anal sphincter.

• Gently insert the finger into the anus, through the anal canal, and into the rectum (Figure 17).

Anal canal

Prostate

Rectum

Bladder

Penis

Urethra

Scrotum Figure 17. Digital rectal

examination.

GI medicine and urology

Station 23 Rectal examination 61

Note any pain upon insertion.

• Test anal tone by asking the patient to squeeze your finger.

• Rotate the finger so as to palpate the entire circumference of the anal canal and rectum. Feel

for any masses, ulcers, or induration and for faeces in the rectum. If there are any faeces in the

rectum, assess their consistency.

– in males, pay specific attention to the size, shape, surface, and consistency of the prostate

gland. Assess whether the midline groove is palpable

– in females, the cervix and uterus may be palpable

• Remove the finger and examine the glove. In particular look at the colour of any stool, and for

the presence of any mucus or blood.

• Remove and dispose of the gloves.

After the examination

• Clean off any lubricant or faeces on the anus or anal margin.

• Give the patient time to put his clothes back on.

• Ensure that he is comfortable.

• Address any questions or concerns that he may have.

• Present your findings to the examiner, and offer a differential diagnosis.

Conditions most likely to come up in a rectal examination station

Benign prostatic hypertrophy (BPH):

• In BPH the prostate is enlarged in size (>3.5 cm) and slightly distorted in shape, but it is still

rubbery and firm, with a smooth surface and a palpable midline groove.

Prostate carcinoma

• In prostate carcinoma, the prostate is also enlarged and asymmetrical, but this time it is hard

and irregular/nodular and the midline groove may no longer be palpable.

Clinical Skills for OSCEs

62 Station 24

Hernia examination

Inguinal anatomy

Figure 18. The inguinal canal runs along the inguinal ligament, from the internal (deep) ring to the external

(superficial) ring. The inguinal ligament stretches from the anterior superior iliac spine to the pubic tubercle. The

internal ring lies approximately 1.5 cm superior to the femoral pulse, itself in the midline of the inguinal ligament.

The external ring lies immediately superior and medial to the pubic tubercle. NAVY: Nerve, Artery, Vein, Y-fronts.

Definition of a hernia

A hernia is defined as the protrusion of an organ or part thereof through a deficiency in the wall of the

cavity in which it is contained. There are many different types of hernia but the onesthat are most likely

to be examined and discussed in an OSCE are indirect and direct inguinal hernias and femoral hernias.

Their principal differentiating features are summarised in Table 11. The differential diagnosis of a lump

in the groin is listed in Table 12.

Table 11. Principal differentiating features of indirect and direct inguinal and femoral hernias

Indirect hernia (through

inguinal canal)

Direct hernia (through

Hesselbach’s triangle)

Femoral hernia (below inguinal

ligament)

• Neck of hernia is superior to

the inguinal ligament/pubic

tubercle and lateral to the

inferior epigastric vessels.

• Accounts for 80% of inguinal

hernias.

• Irreducible.

• Can strangulate.

• Neck of hernia is superior to

the inguinal ligament/ pubic

tubercle and medial to the

inferior epigastric vessels.

• Accounts for 20% of inguinal

hernias.

• Easily reducible.

• Rarely strangulates.

• Neck of hernia is inferior

and lateral to the inguinal

ligament pubic tubercle.

• Higher incidence in females,

but still less common overall.

• Often irreducible.

• Frequently strangulates.

Femoral hernia Indirect inguinal hernia

Vein

Artery

Nerve

Muscle

Inguinal ligament

External inguinal ring

Internal inguinal ring

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