cmecde 5697
Read in conjunction with Station 116: Explaining skills.
also be examined on other common inhalers.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Check his understanding of asthma and of the inhaler.
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.
• 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
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.
• 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.
Drug administration via a nebuliser
Drugs used in nebulisers include bronchodilators, corticosteroids, and antibiotics (e.g. colistin).
• 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
• An air compressor and tubing • Drug or drug solution (e.g. salbutamol 2.5 ml)
• A mouthpiece or mask • Diluent (e.g. sodium chloride 0.9%) if needed
• Consult the prescription chart and check:
– the prescription: validity, drug, dose, diluent, route of administration, date and time of
• Ask a colleague (registered nurse or doctor) to confirm the name, dose, and expiry date of the
• 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.
Cardiovascular and respiratory medicine
Station 20 Drug administration via a nebuliser 51
• 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
• 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.
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).
• Ask the patient to take several deep breaths and to cough up any secretions.
• Ask him to rinse his mouth with water.
• 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.
• 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
• 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.
• 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
• 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
Presenting complaint and history of presenting complaint
• Site of pain e.g. right iliac fossa.
• Character e.g. sharp, dull, aching, burning – allow the patient to use his own words.
• Associated symptoms and signs.
• Exacerbating and alleviating factors.
• Severity on a scale of 1 to 10.
• Systemic signs and symptoms: fever, jaundice, loss of weight or anorexia, effect on everyday
• 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).
• Previous episodes of abdominal pain.
• Current, past, and childhood illnesses.
• Previous hospital admissions and surgery.
Station 21 Abdominal pain history 53
• Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics, and the
• Over-the-counter medication and herbal remedies.
• Parents, siblings, and children. Ask specifically about colon cancer, irritable bowel syndrome,
inflammatory bowel disease, jaundice, peptic ulceration, and polyps.
• Employment, past and present.
• Contact with jaundiced patients.
• 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.
• 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
• 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:
• 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.
54 Station 21 Abdominal pain history
• 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.
• Constant but episodic epigastric or right upper quadrant pain that may radiate to the back
• 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
• 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.
• 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.
• Left iliac fossa pain and tenderness.
• Associated with fever, nausea, anorexia, constipation, diarrhoea.
• 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.
• Chronic abdominal pain or discomfort.
• Associated with frequent diarrhoea or constipation, bloating, urgency for bowel movements,
Remember that basal pneumonia, diabetic ketoacidosis, and an inferior myocardial
infarct can also present as abdominal pain.
• 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
• Ensure that the patient is comfortable.
• 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:
– palmar erythema (liver disease)
– nail signs: leukonychia/‘white dash’ (hypoalbuminaemia) and koilonychia/‘spoon-shaped
– Dupuytren’s contracture (cirrhosis, old age; see Figure 15)
with the wrists dorsiflexed and the palms facing forwards. Ask him to hold this posture for at
least 10 and ideally 30 seconds.
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
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).
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
• Repeat the procedure, this time palpating more deeply so as to localise and describe any
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