CLINICAL SKILLS FOR. OSCEs 5 TH EDITION NEEL BURTON

Transcription

1 CLINICAL SKILLS FOR OSCEs 5 TH EDITION 5 NEEL BURTON

2 Contents v Contributors Preface OSCE tips ix xi xiii I. GENERAL SKILLS 1. Hand washing 1 2. Scrubbing up for theatre 3 3. Venepuncture/phlebotomy 5 4. Cannulation and setting up a drip 7 5. Blood cultures Blood transfusion Intramuscular, subcutaneous, and intradermal drug injection Intravenous drug injection Examination of a superficial mass and of lymph nodes 18 II. CARDIOVASCULAR AND RESPIRATORY MEDICINE 10. Chest pain history Cardiovascular risk assessment Blood pressure measurement Cardiovascular examination Peripheral vascular system examination Ankle-brachial pressure index (ABPI) Breathlessness history Respiratory system examination PEFR meter explanation Inhaler explanation Drug administration via a nebuliser 50 III. GI MEDICINE AND UROLOGY 21. Abdominal pain history Abdominal examination Rectal examination Hernia examination Nasogastric intubation Urological history Male genitalia examination Male catheterisation Female catheterisation 73

3 vi Contents IV. NEUROLOGY 30. History of headaches History of funny turns Cranial nerve examination Motor system of the upper limbs examination Sensory system of the upper limbs examination Motor system of the lower limbs examination Sensory system of the lower limbs examination Gait, co-ordination, and cerebellar function examination Speech assessment 100 V. PSYCHIATRY 39. General psychiatric history Mental state examination Cognitive testing Dementia diagnosis Depression history Suicide risk assessment Alcohol history Eating disorders history Weight loss history Assessing capacity (the Mental Capacity Act) Common law and the Mental Health Act 130 VI. OPHTHALMOLOGY, ENT AND DERMATOLOGY 50. Ophthalmic history Vision and the eye examination (including fundoscopy) Hearing and the ear examination Smell and the nose examination Lump in the neck and thyroid examination Dermatological history Dermatological examination Advice on sun protection 156 VII. PAEDIATRICS AND GERIATRICS 58. Paediatric history Developmental assessment Neonatal examination The six-week surveillance review Paediatric examination: cardiovascular system Paediatric examination: respiratory system Paediatric examination: abdomen Paediatric examination: gait and neurological function Infant and child Basic Life Support Child immunisation programme Geriatric history Geriatric physical examination 188

4 Contents vii VIII. OBSTETRICS, GYNAECOLOGY, AND SEXUAL HEALTH 70. Obstetric history Obstetric examination Gynaecological history Gynaecological (bimanual) examination Speculum examination and liquid based cytology test Breast history Breast examination Sexual history HIV risk assessment Condom explanation Combined oral contraceptive pill (COCP) explanation Pessaries and suppositories explanation 220 IX. ORTHOPAEDICS AND RHEUMATOLOGY 82. Rheumatological history The GALS screening examination Hand and wrist examination Elbow examination Shoulder examination Spinal examination Hip examination Knee examination Ankle and foot examination 245 X. EMERGENCY MEDICINE AND ANAESTHESIOLOGY 91. Adult Basic Life Support Choking In-hospital resuscitation Advanced Life Support The primary and secondary surveys Management of medical emergencies 260 acute asthma 260 acute pulmonary oedema 260 acute myocardial infarction 261 massive pulmonary embolism 262 status epilepticus 262 diabetic ketoacidosis 262 acute poisoning Bag-valve mask (BVM/ Ambu bag ) ventilation Laryngeal mask airway (LMA) insertion Pre-operative assessment Syringe driver operation Patient-Controlled Analgesia (PCA) explanation Epidural analgesia explanation Wound suturing 278

5 viii Contents XI. DATA INTERPRETATION 104. Blood glucose measurement Urine sample testing/urinalysis Blood test interpretation Arterial blood gas (ABG) sampling ECG recording and interpretation Chest X-ray interpretation Abdominal X-ray interpretation 311 XII. PRESCRIBING AND ADMINISTRATIVE SKILLS 111. Requesting investigations Drug and controlled drug prescription Oxygen prescription Death confirmation Death certificate completion 326 XIII. COMMUNICATION SKILLS 116. Explaining skills Imaging tests explanation Endoscopies explanation Obtaining consent Breaking bad news The angry patient or relative The anxious or upset patient or relative Cross-cultural communication Discharge planning and negotiation 344

6 18 Station 9 Clinical Skills for OSCEs Examination of a superficial mass and of lymph nodes Before starting Introduce yourself to the patient. Confirm his name and date of birth. If allowed, take a brief history from him, for example, onset, course, effect on everyday life. Explain the examination and obtain consent. Consider the need for a chaperone. Ask the patient to expose the lump completely; for example, by undoing the top button of his shirt. Position him appropriately and ensure that he is comfortable. The examination (IPPA: Inspection, Palpation, Percussion, Auscultation) Inspect the patient from the end of the bed, looking for other lumps and any other signs. Inspect the lump and note its site, colour, and any changes to the overlying skin such as inflamma tion or tethering. Note also the presence or absence of a punctum. Ask the patient if the lump is painful before you palpate it. Is the pain only brought on by palpation or is it a more constant pain? Wash and warm your hands. Assess the temperature of the lump with the back of your hand. Palpate the lump with the pads of your fingers; if possible, from behind the patient. Consider: number: solitary or multiple size: estimate length, width, and height, or use a ruler or measuring tape shape: spherical, ovoid, irregular, other edge: well or poorly defined surface: smooth or irregular consistency: soft, firm, hard, rubbery fluctuance: rest two fingers of your left hand on either side of the lump and press on the lump with the index finger of your right hand: if your left hand fingers are displaced, the lump is fluctuant pulsatility: rest a finger of each hand on either side of the lump: if your fingers are displaced, the lump is pulsatile mobility or fixation: consider the mobility of the lump in relation both to the overlying skin and the underlying muscle compressibility and reducibility: press firmly on the lump to see if it disappears; if it immediately reappears, it is compressible; if it only reappears upon standing or coughing, it is reducible Percuss the lump for dullness or resonance. Auscultate the lump for bruits or bowel sounds. Transilluminate the lump by holding it between the fingers of one hand and shining a pen torch to it with the other. A bright red glow indicates fluid whereas a dull or absent glow suggests a solid mass. Examine the draining lymph nodes (see below), or indicate that you would do so. After examining the lump Ensure that the patient is comfortable. Ask him if he has any questions or concerns. Thank him. Wash your hands. Summarise your findings and offer a differential diagnosis. If appropriate, suggest further investigations, e.g. fine needle aspirate cytology (FNAc), biopsy, ultrasound, CT.

7 Station 9 Examination of a superficial mass and of lymph nodes 19 Lymph node examination Head and neck The patient should be sitting up and examined from behind. With the fingers of both hands, palpate the submental, submandibular, parotid, and pre- and post-auricular nodes. Next palpate the anterior and posterior cervical nodes and the occipital nodes. General skills Preauricular Posterior auricular Occipital Parotid Submandibular Submental Posterior cervical Anterior cervical Figure 3. Lymph nodes in the head and neck. Upper body Palpate the supraclavicular and infraclavicular nodes on either side of the clavicle. Expose the right axilla by lifting and abducting the arm and supporting it at the wrist with your right hand. With your left hand, palpate the following lymph node groups: the apical the anterior the posterior the nodes of the medial aspect of the humerus Now expose the left axilla by lifting and abducting the left arm and supporting it at the wrist with your left hand. With your right hand, palpate the lymph node groups, as listed above.

8 20 Station 9 Examination of a superficial mass and of lymph nodes Clinical Skills for OSCEs Anterior group Supraclavicular and infraclavicular groups Apical group Posterior group Figure 4. Lymph nodes of the upper body. Lower body Palpate the superficial inguinal nodes (horizontal and vertical), which lie below the inguinal ligament and near the great saphenous vein respectively, then the popliteal node in the popliteal fossa. Conditions most likely to come up in a lump examination station Epidermoid (sebaceous) cyst: Fibroma: Results from obstruction of sebaceous gland. May be red, hot, and tender. Spherical, smooth. Attached to the skin but not to the underlying muscle. May have a punctum which may exude a cottage cheese discharge. Lipoma: Common and benign soft tissue tumour. Skin-coloured and painless. Spherical, soft and sometimes fluctuant. Not attached to the skin and therefore mobile and slippery. Common and benign fibrous tissue tumour. Skin-coloured and painless. Can be sessile or pedunculated, hard or soft. Situated in the skin and so unattached to underlying structures. Skin abscess: Collection of pus in the skin. Very likely to be red, hot, and tender. May be indurated.

9 28 Station 13 Cardiovascular examination Clinical Skills for OSCEs 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 degrees, and ask him to remove his top(s). 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). Is he breathless or cyanosed? Is he coughing? Does he have the malar flush of mitral stenosis? Observe the patient s surroundings, looking in particular for items such as a nitrate spray, an oxygen mask, ECG electrodes, and IV lines and infusions. Inspect the chest for any scars and the precordium for any abnormal pulsation. A median sternotomy scar could indicate coronary artery bypass graft ing (CABG), valve repair or replacement, or the repair of a congenital defect. A left submammary scar most likely indicates repair or replacement of the mitral valve. Do not miss a pacemaker if it is there! Inspection and examination of the hands Take both hands noting: temperature: feel with the back of your hand colour, in particular the blue of peripheral cyanosis and the orange of nicotine stains nail bed capillary refill time: press the nail for 5 seconds; it should refill within 2 seconds any presence of clubbing (endocarditis, cyanotic congenital heart disease) any presence of Osler nodes and Janeway lesions (subacute infective endocarditis) any presence of splinter haemorrhages (subacute infective endocarditis) any presence of koilonychia or spoon nails (iron deficiency) Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregular rhythm suggests second degree heart block, whereas an irregularly irregular rhythm suggests atrial fibrillation or multiple ectopics. Raise the patient s arm above his head to assess for a collapsing/water hammer pulse (aortic regurgitation). Ask the patient whether he has any shoulder pain first. Simultaneously take the pulse in both arms to exclude radio-radial delay (aortic arch aneurysm). Indicate that you would also exclude radio-femoral delay (coarctation of the aorta). As you move up the arm, look for bruising, which may indicate that the patient is on an anticoagulant, and for evidence of intravenous drug use, which is a risk factor for acute infective endocarditis. Indicate that you would like to record the blood pressure (see Station 12). A wide pulse pressure is typically seen in aortic regurgitation; a narrow pulse pressure in aortic stenosis.

10 Station 13 Cardiovascular examination 29 Inspection and examination of the head and neck Inspect the eyes, looking for peri-orbital xanthelasma and corneal arcus, both of which indicate hyperlipidaemia. Gently retract an eyelid and ask the patient to look up. Inspect the conjunctivus for pallor, which is indicative of anaemia. Ask the patient to open his mouth, and look for signs of central cyanosis, dehydration, poor dental hygiene (subacute bacterial endocarditis), and a high arched palate (Marfan s syndrome). Palpate the carotid artery and assess its volume and character. A slow-rising pulse is suggestive of aortic stenosis, a collapsing pulse of aortic regurgitation. Never palpate both carotid arteries simultaneously. Assess the jugular venous pressure (see Figure 6) and, if possible, the jugular venous pulse form: ask the patient to turn his head slightly to one side, and look at the internal vein medial to the clavicular head of sternocleidomastoid. Assuming that the patient is reclining at 45 degrees, the vertical height of the jugular distension from the angle of Louis (sternal angle) should be no greater than 4 cm: if it is greater than 4 cm, this suggests right heart failure, fluid overload, or tricuspid valve disease. Cardiovascular and respiratory medicine Palpation of the heart Ask the patient if he has any chest pain. Determine the location and character of the apex beat. It is normally located in the fifth intercostal space at the mid clavicular line. The apex may be: impalpable: obesity, dextrocardia, situs inversus displaced, suggesting volume overload (mitral or aortic regurgitation) heaving, suggesting pressure overload and left ventricular hypertrophy (aortic stenosis) tapping, suggesting mitral stenosis Place the flat of your hands over either side of the sternum and feel for any heaves and thrills. Heaves result from right ventricular hypertrophy (cor pulmonale) and thrills from transmitted murmurs. 4 cm Height of jugular venous distention Angle of Louis (sternal angle) 45 Figure 6. Assessing the jugular venous pressure.

11 30 Station 13 Cardiovascular examination Auscultation points C C Mid-clavicular line Clinical Skills for OSCEs A P T M Ax Figure 7. Auscultation points. Auscultation of the heart Listen for heart sounds, additional sounds, murmurs, and pericardial rub. Using the stethoscope s diaphragm, listen in the: aortic area right second intercostal space near the sternum pulmonary area left second intercostal space near the sternum tricuspid area left third, fourth, and fifth intercostal spaces near the sternum mitral area (use the stethoscope s bell) left fifth intercostal space in the mid-clavicular line Manoeuvres and points to remember: ask the patient to bend forward and to hold his breath at end-expiration. Using the stethoscope s diaphragm, listen at the left sternal edge in the fourth intercostal space for the middiastolic murmur of aortic regurgitation ask the patient to turn onto his left side and to hold his breath at end-expiration. Using the stethoscope s bell, listen in the mitral area for the mid-diastolic murmur of mitral stenosis listen over the carotid arteries for any bruits and the radiation of the murmur of aortic stenosis listen in the left axilla for the radiation of the murmur of mitral regurgitation For any murmur, determine its location and radiation, and its duration (early, mid, late, pan or throughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done by palpating the carotid or brachial artery to determine the start of systole. Grade the murmur on a scale of I to VI according to its intensity (see Table 4). Common conditions associated with murmurs are listed in Table 5.

12 Station 13 Cardiovascular examination 31 Table 4. Grading murmurs I II III IV V VI Barely audible murmur Soft and localised murmur Murmur of moderate intensity that is immediately audible Murmur of loud intensity with a palpable thrill As above, murmur audible with only stethoscope rim on chest wall As above, murmur audible even as stethoscope is lifted from chest wall Table 5. Common conditions associated with murmurs Aortic stenosis Mitral regurgitation Aortic regurgitation Mitral valve prolapse Slow-rising pulse, heaving cardiac apex, ejection/early-systolic murmur best heard in the aortic area and radiating to the carotids and cardiac apex Displaced thrusting cardiac apex, pan-systolic murmur best heard in the mitral area and radiating to the axilla, patient may be in atrial fibrillation Collapsing pulse, thrusting cardiac apex, diastolic murmur best heard at the lower left sternal edge Mid-systolic click, late-systolic murmur best heard in the mitral area RILE: Right-sided murmurs are heard loudest on Inspiration whereas Left-sided murmurs are heard loudest on Expiration Cardiovascular and respiratory medicine Chest examination Percuss and auscultate the chest, especially at the bases of the lungs. Heart failure can cause pulmonary oedema and pleural effusions. Abdominal examination Palpate the abdomen to exclude ascites and/or hepatomegaly. Check for the presence of an aortic aneurysm. Ballot the kidneys and listen for any renal artery bruits. Examination of the ankles and legs Inspect the legs for scars that might be indicative of vein harvesting for a CABG. Palpate for the pitting oedema of cardiac failure: check for pain and then press for 5 seconds on the patient s legs. If oedema is present, assess how far it extends. In some cases, it may extend all the way up to the sacrum or even the torso ( anasarca ). Assess the temperature of the feet, and check the posterior tibial and dorsalis pedis pulses in both feet.

13 32 Station 13 Cardiovascular examination After the examination Clinical Skills for OSCEs Indicate that you would look at the observation chart, dipstick the urine, examine the retina with an ophthalmoscope (for hypertensive changes and the Roth s spots of subacute infective endocarditis), and, if appropriate, order some key investigations, e.g. FBC, ECG, CXR, echocardiogram. Cover the patient up and ensure that he is comfortable. Thank the patient. Summarise your findings and offer a differential diagnosis. Conditions most likely to come up in a cardiovascular examination station Murmurs (see Table 5). Heart failure. Median sternotomy scar, with or without scar on the lower leg (vein harvesting). Pacemaker.