cmecde 5896

 

General skills

Station 8 Intravenous drug injection 17

After the procedure

• Ensure that the patient is comfortable and ask him to notify a member of the healthcare team

if he notices any adverse effects (it may be necessary to monitor the patient).

• Ask him if he has any questions or concerns.

• Thank him.

• Sign the prescription chart and record the date, time, drug, dose, and injection site of the intravenous injection in the medical records.

• Indicate that you would have your checking colleague countersign it.

Clinical Skills for OSCEs

18 Station 9

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

inflammation 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.

General skills

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.

Submental

Anterior cervical

Submandibular

Parotid

Preauricular

Posterior

auricular

Occipital

Posterior

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.

Clinical Skills for OSCEs

20 Station 9 Examination of a superficial mass and of lymph nodes

Anterior

group

Apical

group

Posterior

group

Supraclavicular

and infraclavicular

groups

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:

• 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.

Fibroma:

• 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.

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’.

Skin abscess:

• Collection of pus in the skin.

• Very likely to be red, hot, and tender.

• May be indurated.

21Cardiovascular and respiratory medicine

Station 10

Chest 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 nature of his chest pain,

and obtain his consent.

• Ensure that he is comfortable.

The history

• Name, age, occupation, and ethnic origin.

Presenting complaint and history of presenting complaint

• Ask about the nature of the chest pain. Use open questions and give the patient the time to

tell his story. Also remember to be empathetic: chest pain can be a very frightening experience.

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

• As with any pain history, the mnemonic SOCRATES can help develop your differential diagnosis:

– Site: where exactly is the pain?

– Onset and progression: when did the pain start and how has it changed or evolved?

– Character: what type of pain is it (e.g. dull, sharp, or crushing)?

– Radiation: does the pain move anywhere (e.g. into the jaw, arm, or back)?

– Associated symptoms and signs: ask specifically aboutsweating, nausea and vomiting,shortness of breath, cough, haemoptysis, dizziness, and palpitations

– Timing and duration: does the pain occur at particular times of the day? How long does each

episode last?

– Exacerbating and alleviating factors: does anything make the pain better or worse (e.g. exercise, movement, deep breathing, coughing, cold air, large or spicy meals, alcohol, rest, GTN,

sitting up in bed)?

– Severity: “How would you rate the pain on a scale of 1 to 10, with 1 being no pain at all and 10

being the worst pain you have ever experienced?”

– effect on everyday life: ask in particular about exercise tolerance and sleep

• Ask about any previous episodes of chest pain.

Past medical history

• Current, past, and childhood illnesses.

• In particular, ask about risk factors: coronary heart disease, myocardial infarction, stroke, pneumonia, pulmonary embolism, deep vein thrombosis, hypertension, hyperlipidaemia, diabetes,

smoking, alcohol use, and recent long-haul travel.

• Recent trauma or injury.

• Surgery.

Drug history

• Prescribed medication, including the oral contraceptive pill if female.

• Over-the-counter medication.

• Illicit drugs.

• Allergies.