cmecde 258

 

Clinical Skills for OSCEs

70 Station 27 Male genitalia examination

Figure 20. Normal testis and appendages (A), hydrocoele (B), epididymal cyst (C), and varicocoele (D).

Examination of the lymphatics

• Palpate the inguinal nodes in the inguinal crease. Remember that only the penis and scrotum

drain to the inguinal nodes, as the testicles drain to the para-aortic lymph nodes.

After the examination

• Cover up the patient.

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• Consider a rectal examination to examine the prostate.

• Consider an ultrasound scan if you detect a bulky or painful mass in the scrotum or cannot

palpate the testes.

[Note] In cases of an acutely tender testicle, testicular torsion, which is a surgical emergency, must be ruled out. Epididymoorchitis also presents as an acutely tender testicle, with the patient requiring admission for IV antibiotics.

Conditions most likely to come up in a male genitalia examination station

Hydrocoele:

• collection of fluid in the tunica vaginalis

surrounding the testis.

• presents as unilateral (or less commonly bilateral)

scrotal swelling.

• not tender.

• fluctuant.

• transilluminant.

Epididymal cyst:

• arises in the epididymis.

• epididymal cysts may be multiple and bilateral.

• unlike in a hydrocoele, the testis is palpable quite

separately from the cyst.

• smooth and fluctuant.

• transilluminant.

Varicocoele:

• dilated veins along the spermatic

cord.

• almost invariably left-sided.

• ‘bag of worms’ upon palpation.

• there may be a cough impulse.

• likely to disappear upon lying down.

Direct inguinal hernia (see Station 24)

(B)

Spermatic

artery

vein

(A)

Epididymis

Tunica

vaginalis

(C) (D)

71GI medicine and urology

Station 28

Male catheterisation

Specifications: A male anatomical model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Position him flat on the couch with legs apart and groin exposed.

The equipment

On a clean trolley, gather:

• A catheterisation pack • A 12–16 french Foley catheter

• Saline solution • A catheter bag

• Two pairs of sterile gloves • A 10 ml syringe containing sterile water

• A 10 ml pre-filled syringe • Adhesive tape

containing 2% lignocaine gel

(Instillagel®)

The procedure

• Gather the equipment (a male catheter is longer than a female one).

• Check the expiry date of the catheter.

• Open the catheter pack aseptically onto a trolley, attach the yellow bag to the side of the trolley,

and pour saline solution into the receiver.

• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml

lignocaine gel into separate syringes.

• Wash and dry your hands.

• Put on sterile gloves.

• Drape the patient. Some recommend tearing an appropriately sized hole into the drape and

passing the penis through it.

• Place a collecting vessel in the patient’s entre-jambes/crotch.

• With your non-dominant hand, hold the penis with a sterile swab.

• With your dominant hand, retract the foreskin and clean the area around the urethral meatus

with saline-soaked swabs.

• Instil 10 ml of lignocaine gel into the urethra. Hold the urethral meatus closed.

• Indicate that the anaesthetic needs about 5 minutes to work.

• Change into a new pair of sterile gloves.

• Hold the penis so that it is vertical.

• Holding the catheter by its sleeve, gently and progressively insert it into the urethra. Upon feeling resistance from the prostate, hold the penis horizontally so as to facilitate insertion.

• Once a stream of urine is obtained, inject 10 ml of sterile water to inflate the catheter’s balloon,

continually ensuring that this does not cause the patient any pain.

• Gently retract the catheter until a resistance is felt.

• Attach the catheter bag.

• Reposition the foreskin.

• Tape the catheter to the thigh.

Clinical Skills for OSCEs

72 Station 28 Male catheterisation

After the procedure

• Ensure that the patient is comfortable.

• Thank the patient.

• Discard any rubbish.

• Record the date and time of catheterisation, type and size of catheter used, and volume of urine

in the catheter bag.

Examiner’s questions

Indications for catheterisation:

• hygienic care of bedridden patients.

• monitoring of urine output.

• acute urinary retention.

• chronic obstruction.

• collection of a specimen of uncontaminated urine.

• irrigation of the bladder.

• imaging of the urinary tract.

Contraindications:

• pelvic trauma.

• previous stricture.

• previous failure to catheterise.

• severe phimosis.

Complications:

• paraphimosis (from failure to reposition the foreskin).

• urethral perforation and creation of false passages.

• bleeding.

• infection.

• urethral strictures.

73GI medicine and urology

Station 29

Female catheterisation

Specifications:  A female anatomical model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm her name and date of birth.

• Explain the procedure and obtain her consent.

• Ask her to undress from the waist down and place a sheet over her.

The equipment

On a clean trolley, gather:

• Two pairs of sterile gloves • A 10 ml pre-filled syringe containing 2% lignocaine gel

• A catheterisation pack (Instillagel)®

• Saline solution • A 10 ml syringe containing sterile water

• A 12–16 french Foley catheter • A catheter bag

• Adhesive tape

The procedure

• Gather the equipment.

• Open the catheter pack aseptically onto a trolley, attach the yellow bag to the side of the trolley,

and pour antiseptic solution into the receiver.

• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml

lignocaine into separate syringes.

• Wash and dry your hands.

• Put on a pair of sterile gloves.

• Ask the patient to remove hersheet and lie flat on the couch, bringing her heelsto her buttocks

and then letting her knees flop out.

• Drape the patient.

• Place a collecting vessel in the patient’s entre-jambes/crotch.

• Use your non-dominant hand to separate the labia minora.

• Clean the area around the urethral meatus with saline-soaked swabs.

• Coat the end of the catheter with lignocaine gel and instil 5 ml of lignocaine into the urethra.

• Indicate that the anaesthetic needs about 5 minutes to work.

• Change into a new pair of sterile gloves.

• Holding the catheter by its sleeve, gently and progressively insert it into the urethra.

• Once a stream of urine is obtained, inject 10 ml of sterile water to inflate the catheter’s ­balloon,

continually ensuring that this does not cause the patient any pain.

• Gently retract the catheter until a resistance is felt.

• Attach the catheter bag.

• Tape the catheter to the thigh.

Clinical Skills for OSCEs

74 Station 29 Female catheterisation

After the procedure

• Ensure that the patient is comfortable.

• Thank the patient.

• Discard any rubbish.

• Record the date and time of catheterisation, type and size of catheter used, volume of water

used to inflate the balloon, and volume of urine in the catheter bag.

Figure 21. Preparing to insert the

catheter.

75Neurology

Station 30

History of headaches

‘I’m very brave generally’, he went on in a low voice: ‘only today I happen to have a headache’.

Lewis Carroll, Through the Looking Glass

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 headaches,

and obtain consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

First use open questions to get the patient’s history, and elicit his ideas, concerns, and expectations.

Rule out head injury before enquiring about the pain:

• Site. Ask the patient to point to the site of the pain.

• Onset.

• Character, for example, sharp, dull, throbbing, band-like constriction.

• Radiation.

• Associated factors:

– nausea and vomiting

– visual disturbances such as double vision and fortification spectra

– photophobia

– fever, chills

– weight loss

– rash

– scalp tenderness

– neck pain, stiffness

– myalgia

– rhinorrhoea, lacrimation

– altered mental status

– neurological deficit (weakness, numbness, ‘pins and needles’)

• Timing and duration.

• Exacerbating and relieving factors; for example, activity, stress, eye strain, caffeine, alcohol,

dehydration, hunger, certain foods, coughing/sneezing).

• Severity. Ask the patient to rate the pain on a scale of 1 to 10, and determine the effect that it

is having on his life.

Clinical Skills for OSCEs

76 Station 30 History of headaches

Past medical history

• Current, past, and childhood illnesses.

• Ask specifically about headache, migraine, hypertension, cardiovascular disease, and travel

sickness as a child.

• Surgery.

Drug history

• Prescribed medication. Ask specifically about withdrawal from NSAIDs, opioids, glyceryl

trinitrate, and calcium channel blockers.

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Family history

• Parents, siblings, and children.

• Ask about migraine and travel sickness.

Social history

• Employment, past and present.

• Housing.

• Mood. Depression is a common cause of headaches.

• Smoking.

• Alcohol use. Alcohol is a common cause of headaches.

• Diet: tea and coffee, cheese and yoghurt, chocolate.

After taking the history

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

• Ask him if he has any questions or concerns.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a physical examination and some investigations to confirm your diagnosis and exclude life-threatening causes of headaches (see box below).

Neurology

Station 30 History of headaches 77

Conditions most likely to come up in a history of headaches station

Tension headaches:

• constant pressure, ‘as if the head were being

squeezed in a vice’.

• pain typically last 4–6 hours but this is highly

variable.

• may be precipitated by stress, eye strain,

sleep deprivation, bad posture, irregular meal

times.

Cluster headaches (‘suicide headaches’):

• excruciating unilateral headache that is of

rapid onset.

• located in the periorbital or temple area, may

radiate to the neck or shoulder.

• associated with autonomic symptoms such as

ptosis, conjunctival injection, lacrimation.

• each headache lasts from 15 minutes to 3

hours.

• headaches most often occur in ‘clusters’: once

or more every day, often at the same time of

day, for a period of several weeks.

Migraines:

• unilateral, dull, throbbing headache lasting

from 4 to 72 hours.

• may be aggravated by activity.

• associated with nausea, vomiting,

photophobia, phonophobia.

• about half experience prodromal symptoms

such as altered mood, irritability, or fatigue

several hours or days before the headache.

• about one-third experience an aura,

commonly consisting of visual disturbances or

neurological symptoms, before or along with

the headache.

• frequency of headaches varies considerably,

but average is about 1–3 a month.

Cranial arteritis:

• unilateral pain in the temporal region.

• associated with scalp tenderness, jaw

claudication, blurred vision, and tinnitus.

• three times more common in females.

• mean age of onset is 70 years.

• urgent treatment is required to prevent

sudden loss of vision.

Cervical spondylosis:

• occipital headaches associated with cervical

pain.

• cervical pain may radiate to the base of the

skull, shoulder, or hand and fingers.

• may be associated with weakness, numbness,

or pins and needles in the arms and hands.

Meningitis:

• severe and bilateral headache.

• may be associated with high fever, neck

stiffness, photophobia, phonophobia, altered

mental status.

Subarachnoid haemorrhage:

• thunderclap headache (‘like being kicked in

the head’) that is of very rapid onset.

• may be associated with vomiting, altered

mental status, neck stiffness, photophobia,

visual disturbances, seizures.

Raised intracranial pressure

• dull, throbbing headache associated with

vomiting, ocular palsies, visual disturbances,

altered mental status.

• may be worse in the morning and may wake

the patient up from sleep.

• aggravated by coughing and head

movement.

• alleviated by standing.

Sinusitis:

• dull and constant headache or facial pain

over the sinuses.

• may be associated with flu-like symptoms and

facial tenderness.

• may be aggravated by bending over or lying

down.

Trigeminal neuralgia:

• intense unilateral facial pain (‘like stabbing

electric shocks’) lasting from seconds to

minutes.

• may occur several times a day.

• triggered by common activities such as

eating, talking, shaving, and tooth-brushing.

• may be associated with a trigger area on the

face.

Clinical Skills for OSCEs

78 Station 31

History of ‘funny turns’

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 collapse, and

obtain consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

First use open questions to get the patient’s story, and elicit their ideas, concerns and expectations.

Think about the common causes of a funny turn, as these should inform your line of questioning.

Ask about:

• Whether the patient remembers falling.

• If the fall was witnessed and if a collateral history is available.

• The circumstances of the fall:

– had the patient just arisen from bed? (postural hypotension)

– had the patient just suffered an intense emotion? (vasovagal syncope)

– had the patient been coughing or straining? (situational syncope)

– had the patient been turning or extending his neck? (carotid sinus syncope)

– had the patient been exercising? (arrhythmia)

– did the patient have any palpitations, chest pain, or shortness of breath? (arrhythmia)

• Any loss of consciousness and its duration.

• Prodromal symptoms such as aura, change in mood, strange feeling in the gut, sensation of

déjà vu.

• Fitting, frothing at the mouth, tongue biting, incontinence.

• Headache or confusion, or amnesia upon recovery.

• Injuries sustained, especially head injury.

• Previous episodes.

Past medical history

• Current, past, and childhood illnesses. Ask specifically about epilepsy, hypertension, heart problems, stroke, diabetes (autonomic neuropathy), cervical spondylosis, and arthritis.

• Surgery.

Drug history

• Prescribed medication. Drugs such as antipsychotics, tricyclic antidepressants, and antihypertensives can cause postural hypotension. Insulin can cause hypoglycaemia.

• Over-the-counter medication.

• Recreational drugs.

• Recent changes in medication.

Neurology

Station 31 History of ‘funny turns’ 79

Family history

• Parents, siblings, and children.

• Ask specifically about epilepsy and heart problems.

Social history

• Smoking.

• Alcohol use.

• Employment, past and present.

• Housing.

• Effect of falls on patient’s life.

After taking the history

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

• Ask him if he has any questions or concerns.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a physical examination and some investigations to confirm your diagnosis.

Conditions most likely to come up in a history of ‘funny turns’ station

Simple faint:

• loss of consciousness lasting from a few

seconds to a few minutes is preceded by

nausea, sweatiness, dizziness or tightness

in the throat.

• provoked by stressful, anxiety-provoking,

or painful situations (vasovagal syncope),

by coughing or straining (situational

syncope), or by applying pressure upon

the carotid sinus, for example, by wearing

a tight collar, turning the head, or shaving

(carotid sinus syncope).

Postural hypotension:

• loss of consciousness preceded by

dizziness, light-headedness, confusion, or

blurry vision.

• provoked by postural change.

• causes include hypovolaemia (e.g.

dehydration, bleeding, diuretics,

vasodilators), drugs (e.g. tricyclic

antidepressants, antipsychotics, alpha

blockers), and certain medical conditions

(e.g. diabetes, Addison’s disease).

Clinical Skills for OSCEs

80 Station 31 History of ‘funny turns’

Arrhythmia (cardiac syncope):

• may be either a bradycardia or

tachycardia.

• may be provoked by exertion.

• may be associated with palpitations, chest

pain, shortness of breath, fatigue.

• history of heart disease/risk factors for

heart disease are very likely.

• patient should be hospitalised and

placed on a cardiac monitor to rule out

ventricular tachycardia, which can result

in sudden death.

• less commonly, cardiac syncope can be

caused by an obstructive cardiac lesion

such as aortic or mitral stenosis.

Generalised tonic-clonic seizure:

• sudden loss of consciousness

accompanied by fitting, frothing at the

mouth, tongue biting, incontinence.

• seizure lasts for about 2 minutes.

• seizure is followed by confusion and

amnesia.

• seizure may be preceded by an aura

which may involve déjà vu, dizziness,

unusual emotions, altered sense

perceptions, or other symptoms.

Transient ischaemic attack:

• most frequent symptoms include loss of

vision, aphasia, unilateral hemiparesis,

and unilateral paraesthesia.

• symptoms last for a few seconds to a few

minutes and never for more than 24 hours

(by definition).

• loss of consciousness can occur, although

it is very uncommon.

cmecde 9858

 

GI medicine and urology

Station 24 Hernia examination 63

Table 12. Differential diagnosis of a lump in the groin

Superior to the inguinal ligament Inferior to the inguinal ligament

• Indirect or direct inguinal hernia.

• Incisional hernia.

• Sebaceous cyst.

• Lipoma.

• Undescended testis.

• Femoral hernia.

• Lymph node.

• Sebaceous cyst.

• Lipoma.

• Saphena varix.

• Femoral artery aneurysm.

• Psoas abscess (rare).

• Undescended testis.

• Scrotal mass (see Station 27).

Before starting

• Introduce yourself to the patient.

• Explain the examination and obtain consent.

• Ask for a chaperone.

• Ask the patient to lie on the couch and to expose his abdomen from the umbilicus to the knees.

• Ensure that he is comfortable.

• Warm up your hands.

Ensure the patient’s dignity at all times.

The examination

Inspection and palpation

• Inspect the groins(both sides!) for an obviouslump. If a lump is visible, determine itslocation in

relation to itssurrounding anatomical landmarks. Also determine itssize,shape, colour, consistency, and mobility. Is it tender to touch? Can it be transilluminated? (See Station 9: Examination

of a superficial mass and of lymph nodes.)

• Look for old surgical scars (incisional hernia).

• Ask the patient to stand up and look again.

Cough impulse and cough tests

(The patient is still standing.)

• Ask the patient to cough and look again.

• Test the lump for a cough impulse. Place two fingers over the lump and ask the patient to

cough once more.

• If you are satisfied that the lump is an inguinal hernia, ask the patient to reduce the lump. Once

the lump is fully reduced, place two fingers over the internal ring and ask the patient to cough.

– if the lump does not reappear it is an indirect inguinal hernia. Release your fingers and ask

the patient to cough again

– if the lump reappears medially it is a direct inguinal hernia

• Once again ask the patient to reduce the lump. This time place two fingers over the external

ring and ask the patient to cough.

Clinical Skills for OSCEs

64 Station 24 Hernia examination

– if the lump does not reappear it is a direct inguinal hernia. Release your fingers and ask the

patient to cough again

– if the lump reappears laterally it is an indirect inguinal hernia

• Percuss the lump for resonance (bowel involvement).

• Auscultate the lump for bowel sounds (bowel involvement).

Figure 19. The cough test with two fingers over the internal ring (A) and then over the external ring (B).

After the examination

• Indicate that you would also examine the femoral pulses, inguinal lymph nodes, and scrotum.

• Cover up the patient.

• Ensure that he is comfortable.

• Thank him.

• Summarise your findings and offer a differential diagnosis. Don’t fret over your diagnosis as

even experienced surgeons are notoriously poor at differentiating between indirect and direct

inguinal hernias. Apart from inguinal and femoral hernias, other (more rare) types of hernia are

epigastric hernias that occur in the epigastric area in the midline, Spigelian or semilunar hernias that occur on the outer border of the rectus muscles, umbilical and paraumbilical hernias

that occur at or around the navel, and incisional hernias that occur at the site of an old surgical

incision.

• Wash your hands.

Direct hernia

(A) (B)

Indirect hernia Direct hernia Indirect hernia

65GI medicine and urology

Station 25

Nasogastric intubation

Specifications: A mannequin in lieu of a patient.

Choice of NG tube

Nasogastric (NG or Ryle’s) tubes can be used for feeding or drug administration, to decompress the

stomach, to obtain a sample of gastric fluid, or to drain the stomach’s contents (e.g. after an overdose

or if emergency surgery is required). If the tube is being used for aspiration or drainage, a gauge of 10

or greater is required. If not, a fine bore tube should be preferred.

The equipment

• A pair of non-sterile gloves • Tape

• An NG tube of appropriate size • Stethoscope

• K-Y/lubricant jelly • A 20 ml syringe and some pH paper

• Xylocaine spray • A spigot or catheter bag

• A glass of water with a straw • A vomit bowl

Before starting

• Introduce yourself to the patient.

• Explain the need for an NG tube and the procedure for inserting it, and ensure consent.

• Position the patient upright and ask about nostril preference/examine the nostrils.

• Ensure that the patient is comfortable.

The procedure

• Gather the equipment.

• Wash your hands and don the gloves.

• Measure the length of NG tube to be inserted by placing the tip of the tube at the nostril and

extending the tube behind the ear and then to two fingerbreadths above the umbilicus.

• Lubricate the tip of the NG tube with K-Y jelly.

• Spray the preferred nostril with xylocaine or indicate that you would do so.

• Insert the NG tube into the preferred nostril and slide it along the floor of the nose into the

nasopharynx (aim straight back towards the occiput).

• Ask the patient to tilt his head forward and to swallow some water through a straw as you continue to advance the tube through the pharynx and oesophagus and into the stomach. Each

time the patient swallows, advance the tube a little bit further.

• If the patient coughs or gags, slightly withdraw the tube and leave him some time to recover.

• Insert the tube to the required length.

• Ensure that the tip of the tube is in the stomach.

– inject 20 ml of air into the tube and listen over the epigastrium with your stethoscope

– pull back on the plunger to aspirate stomach contents. Test the aspirate with pH paper to

confirm its acidity (pH < 6). If a fine-bore tube has been inserted, it may not be possible to

aspirate stomach contents

– request a chest X-ray or indicate that you would do so

• Tape the tube to the nose and to the side of the face.

• Attach a spigot or catheter bag to the NG tube.

Clinical Skills for OSCEs

66 Station 25 Nasogastric intubation

After the procedure

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

• Ensure that he is comfortable.

• Thank him.

• Make an entry in the patient’s notes confirming that the NG tube has been successfully placed.

[Note] The principal complications of NG tube insertion are aspiration and tissue trauma.

67GI medicine and urology

Station 26

Urological 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 urological

complaint, and obtain consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

• Ask about the main presenting complaint. Ask open questions.

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

• Determine the time course of events and the severity of the problem.

• Ask specifically about:

– pain: for any pain, ask about site, onset, character, radiation, associated factors, timing

(duration), exacerbating and relieving factors, and severity

– fever

– frequency: “Are you passing water more often than usual?”

– nocturia: “Do you find yourself waking up in the middle of the night to pass water?” “How often?”

– urgency: “When you need to pass water, how long can you wait?”

– incontinence: “Are there times when it can no longer wait and you end up going there and then?”

– dysuria: “When you pass water, is there any pain or burning?”

– haematuria: “When you pass water, is there any blood in your urine? Does it colour all of your

urine or only some of it?”

– hesitancy, poorstream and terminal dribbling (if male): “When you are standing at the toilet do

you have to wait before you are able to pass water? Is the jet as strong as it ever was? What about

after, does urine continue to trickle out?”

– back pain, leg weakness, fatigue, weight loss, nausea, anorexia, itching

– vaginal/urethral discharge, genital sores

– testicular masses, testicular pain

– sexual dysfunction

– sexual contacts

Past medical history

• Past urological problems.

• Ask specifically about UTI, renal colic, diabetes mellitus, hypertension and vascular disease, and

gout.

• Current, past, and childhood illnesses.

• Surgery.

Drug history

• Prescribed medication including anticholinergics and anticoagulants.

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Clinical Skills for OSCEs

68 Station 26 Urological history

Family history

• Parents, siblings, and children. In particular, has anyone in the family had a similar problem?

• Ask specifically about polycystic kidney disease and bladder cancer.

Social history

• Employment. Has the patient ever worked with chemicals or dyes?

• Housing.

• Travel.

• Alcohol consumption.

• Smoking.

After taking the history

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

• Thank the patient.

• State that you would carry out abdominal and genital examinations and order some key investigations, e.g. urine dipstick, urine microscopy and culture, U&Es, PSA levels, cystoscopy, CT KUB

(Kidney, Ureter, Bladder).

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a urological history station

Urinary tract infection:

• Most common in young females.

• Common symptoms are frequency, urgency,

dysuria, haematuria, and a pressure above the

pubic bone.

• If the infection is above the bladder, there

may be fever, nausea, and back pain.

• There may be a history of recent sexual

intercourse.

Benign prostatic hypertrophy:

• Most common in elderly males.

• Common symptoms are frequency, nocturia,

urgency, incontinence, hesitancy, poor stream

and intermittency, and terminal dribbling.

Prostate carcinoma:

• Most common in elderly males.

• Symptoms, when present, are similar to those

seen in benign prostatic hypertrophy with

the possible addition of dysuria, haematuria,

sexual dysfunction, weight loss, and bone

pain.

• There may be a family history.

Bladder carcinoma:

• Three to four times more common in males

than in females.

• More common in the elderly.

• Painless haematuria is characteristic, but

there may also be dysuria and/or frequency.

• Associated with smoking and occupational

exposure to chemicals and dyes.

Renal calculus:

• More common in males than in females.

• Severe pain in the loin that radiates to the

groin.

• the pain is often colicky but it may be

constant.

• The pain may be associated with nausea and

vomiting.

• Haematuria is a common finding.

• Dehydration is a common predisposing factor.

69GI medicine and urology

Station 27

Male genitalia examination

Specifications: You may be asked to examine the male genitalia on a real patient or, more likely, on

a pelvic mannequin.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain consent.

• Ask for a chaperone.

• Ask the patient to lie on the couch and expose his groin area.

• Ensure that he is comfortable.

Ensure the patient’s comfort and dignity at all times.

The examination

General inspection

• From the end of the couch observe the patient’s general appearance. The patient’s age can give

you an indication of the most likely pathology.

• In particular, note the distribution of facial, axillary, and pubic hair.

• Look for gynaecomastia.

Inspection and examination of the male genitalia

Penis

• Inspect the penis for lesions and ulcers.

• Retract the foreskin and examine the glans penis and the external urethral meatus for red

patches and vesicles. Is there a discharge? Can a discharge be expressed? If there is a discharge,

indicate that you would swab it for microscopy and culture. Remember to replace the foreskin.

Scrotum

• Inspect the scrotum for redness, swelling, and ulcers. Are the testicles present? Is their lie normal? If a testicle is absent, is it retracted or undescended? If you find a scar, the absent testicle

may have been surgically removed.

• Be conscious of the patient’s face in case of pain, and palpate:

– the testis

– the epididymis

– the spermatic cord

• If you locate a mass, try to get above it. If you cannot, it islikely to be a hernia so test for a cough

impulse (see Station 24). Determine the size, shape and consistency of the mass.

• Next, transilluminate the mass using a pen torch. Is it a cyst or a solid mass? If it is a cyst, is it a

hydrocoele or an epididymal cyst? If it is a solid mass, is it tender? Is it testicular or epididymal?

• If you suspect a varicocoele, a collection of varicosities in the pampiniform venous plexus, examine the patient in the standing position and test for a cough impulse. Note that varicocoeles

are almost invariably left-sided.

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