cmecde 569

 

Oedema (non-pitting)

Venous ulcers

Varicose veins

Scars due to varicose vein surgery

Trendelenburg test

Perthes’ test (if after the gold medal)

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

Clinical Skills for OSCEs

36 Station 15

Ankle-brachial pressure index (ABPI)

Specifications: You are most likely to be requested to measure the ABPI for one arm and ankle only.

Calculating and interpreting ABPI

Figure 8. Calculating ABPI.

Table 7. ABPI interpretation

ABPI Interpretation

> 0.95

0.5–0.9

< 0.5

< 0.2

Normal

Claudication pain

Rest pain

Ulceration and gangrene

Higher of the two right ankle pressures

Higher of the two arm pressures

Higher of the two left ankle pressures

Higher of the two arm pressures

Right arm

systolic pressure

Left arm

systolic pressure

Right ankle

systolic

pressure

Left ankle

systolic

pressure

Posterior tibial

Dorsalis pedis

Posterior tibial

Dorsalis pedis

Right ABPI Left ABPI

Cardiovascular and respiratory medicine

Station 15 Ankle-brachial pressure index (ABPI) 37

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Position him at 45° with his sleeves and trousers rolled up.

• Ensure that he is comfortable.

• Wash your hands.

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

The procedure

Brachial systolic pressure

• Place an appropriately sized cuff around the arm, as for any blood pressure recording.

• Locate the brachial pulse by palpation and apply contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff and record the pressure at which the signal reappears.

• Repeat the procedure for the other arm or state that you would do so.

• Retain the higher of the two readings.

Take care not to allow the probe to slide away from the line of the artery.

Ankle systolic pressure

• Place an appropriately sized cuff around the ankle immediately above the malleoli.

• Locate the dorsalis pedis pulse by palpation or with the hand-held Doppler probe and apply

contact gel at this site.

• Angle the hand-held Doppler probe at 45° to the skin and locate the best possible signal. Apply

only gentle pressure, or else you risk occluding the artery.

• Inflate the cuff until the signal disappears.

• Progressively deflate the cuff, and record the pressure at which the signal reappears.

• Repeat the procedure for the posterior tibial pulse, which is posterior and inferior to the medial

malleolus.

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

that you would do so.

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

After the procedure

• Clean the patient’s skin of contact gel and allow him time to restore his clothing.

• Clean the hand-held Doppler probe of contact gel.

• Wash your hands.

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

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

• Thank the patient.

Clinical Skills for OSCEs

38 Station 16

Breathlessness history

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

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

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint

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

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

History of presenting complaint

Ask about:

• Onset, duration, and variability of breathlessness.

• Provoking and relieving factors. Provoking factors include stress, exercise, cold weather, pets,

dust, and pollen; relieving factors include rest and use of inhaler or GTN spray.

• Severity:

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

before?”

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

use?”

– paroxysmal nocturnal dyspnoea: “Do you wake up in the middle of the night feeling breathless?”

• Associated symptoms(wheeze, cough,sputum, haemoptysis, fever, nightsweats, anorexia, loss

of weight, lethargy, chest pain, dizziness, pedal oedema).

• Effect on everyday life.

• Previous episodes of breathlessness.

• Smoking and alcohol.

Past medical history

• Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever),

PE/DVT, pneumonia, bronchitis, and tuberculosis.

• Previous investigations (e.g. bronchoscopy, chest X-ray).

• Previous hospital admissions and previous surgery.

Drug history

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

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

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Cardiovascular and respiratory medicine

Station 16 Breathlessness history 39

Family history

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

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

Social history

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

• Recent long-haul travel.

• Exposure to tuberculosis.

• Contact with asbestos (mesothelioma).

• Contact with work-place allergens involved in, for example, baking, soldering, spray painting.

• Contact with animals, especially cats, dogs, and birds (bird fancier’s lung).

After taking the history

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

• Thank the patient.

• Summarise your findings and offer a differential diagnosis.

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

your diagnosis.

Conditions most likely to come up in a breathlessness history station

Asthma:

• Breathlessness, chest tightness, wheezing and coughing.

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

exercise, and emotion.

• Symptoms respond to bronchodilators.

• There may be a history and family history of atopy.

Chronic obstructive pulmonary disease:

• Breathlessness, cough, wheeze.

• Chronic progressive disorder characterised by fixed or only partially reversible airway

obstruction (cf. asthma).

• History of smoking.

Pneumonia:

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

haemoptysis and pleuritic chest pain.

Clinical Skills for OSCEs

40 Station 16 Breathlessness history

Tuberculosis:

• Breathlessness, cough, haemoptysis, weight loss, malaise, fever, night sweats, pleural pain,

symptoms of extrapulmonary disease.

• More likely in certain high-risk groups such as immigrants, the homeless and the

immunocompromised.

Pulmonary embolism:

• Breathlessness, sometimes with pleural pain and haemoptysis.

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

Lung cancer:

• Symptoms may include breathlessness, stridor, cough, haemoptysis, anorexia, weight loss,

lethargy, pleural pain, hoarseness, Horner’s syndrome, effects of distant metastases.

• History of smoking in most cases.

Heart failure:

• Left ventricular failure leads to pulmonary oedema.

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

oedema.

• There is a cough which produces pink frothy sputum.

Panic attack:

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

• Associated with chest tightness and hyperventilation.

41Cardiovascular and respiratory medicine

Station 17

Respiratory system examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him at 45°, and ask him to remove his top(s).

• Ask him if he is in any pain or distress.

• Ensure that he is comfortable.

• Wash your hands.

The examination (IPPA)

General inspection

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

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

wheeze, stridor)?

• Note:

– the rate, depth, and regularity of his breathing

– any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine

– any asymmetry of chest expansion

– the use of accessory muscles of respiration and planting of hands

– the presence of operative scars, including in the axillae and around the back

• Next observe the surroundings. Is the patient on oxygen? If so, note the device (see Tables 40

and 41 in Station 113), the concentration (%), and the flow rate. Look in particular for inhalers,

nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there

is a sputum pot, make sure to inspect its contents.

Inspection and examination of the hands

• Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated

by a bluish discoloration of the fingertips.

• Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less

than 2 seconds for the nail bed to return to its normal colour.

• Look fortarstaining and finger clubbing. When the dorsum of a fingerfrom one hand is opposed

to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s

window) is formed at the base of the nailbeds. In clubbing, this diamond-shaped window is

obliterated, and a distal angle is created between the fingers (see Figure 9). Respiratory causes

of clubbing include carcinoma, fibrosing alveolitis, and chronic suppurative lung disease (see

Table 8).

• Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an

apical lung tumour that is invading or compressing the roots of the brachial plexus.

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

the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards.

Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine

tremor may be related to excessive use of B2 agonist.

• During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the

bounding pulse of carbon dioxide retention?

• Indicate that you would like to measure the blood pressure.

Clinical Skills for OSCEs

42 Station 17 Respiratory system examination

Table 8. The principal causes of clubbing

Respiratory causes

Bronchial carcinoma

Fibrosing alveolitis

Chronic suppurative lung disease

Cardiac causes

Infective endocarditis

Cyanotic heart disease

Gastrointestinal causes

Cirrhosis

Ulcerative colitis

Crohn’s disease

Coeliac disease

Familial

Table 9. The principal causes of asterixis

Hepatic failure

Renal failure

Cardiac failure

Respiratory failure

Electrolyte abnormalities (hypoglycaemia, hypokalaemia, hypomagnesaemia)

Drug intoxication, e.g. alcohol, phenytoin

CNS causes

Inspection and examination of the head and neck

• Inspect the patient’s eyes. Look for a ptosis (an upper lid that encroaches upon the pupil) and

for anisocoria (pupillary asymmetry). Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis

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

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

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

• Assess the jugular venous pressure (JVP) and the jugular venous pulse form (see Station 13). A

raised JVP is suggestive of right-sided heart failure.

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

other hand, a diamond-shaped window is formed at the base of the nailbeds. In clubbing, this diamond-shaped

window is obliterated, and a distal angle is created between the fingers.