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

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.