FEV1 /reversibility

Variable obstruction

Reversible obstruction

O2 saturation or ABG Assessment of respiratory failure

IgE, allergen skin tests Detection of allergic stimuli

ABG, arterial blood gas; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; CT, computed tomography; FEV1, forced expiratory volume in 1 second;

IgE, immunoglobulin E; WCC, white cell count.

OSCE example 1: Respiratory history

Mrs Walker, 55 years old, presents to the respiratory clinic with cough and wheeze.

Please take a history

• Introduce yourself and clean your hands.

• Ask an open question about why this person has come to the clinic.

• Explore each presenting symptom:

• Cough:

– Onset, duration?

– Productive? If so, characterise sputum volume and colour, and any blood.

– Triggers? Did it start with an upper respiratory tract infection? Is it provoked by exercise or environment?

– Time pattern – nocturnal (suggests asthma or reflux)?

– On angiotensin-converting enzyme inhibitors?

• Wheeze:

– What exactly does the patient mean by ‘wheeze’?

– When does it occur – at night or during exercise?

– Provoking factors – infection, environment, contact with animals, dust, beta-blockers?

– Any relieving factors – inhalers?

– Associated respiratory symptoms – breathlessness, chest pain, fevers/rigors, weight loss.

• Ask about past respiratory diagnoses, particularly childhood wheeze or asthma, rhinitis/hay fever and prior respiratory treatments/admissions.

• Explore past non-respiratory illness: for example, eczema (suggests atopy), hypertension or angina (on beta-blockers?), other prior illnesses.

• Take a drug history – prescribed medications, including inhalers/nebulisers and recreational drugs.

• Ask about any known allergies.

• Take a social history: smoking, occupation, contact with animals.

Investigations • 91

5

OSCE example 2: Respiratory examination

Mr Tate, 82 years old, reports increasing breathlessness over several weeks.

Please examine his respiratory system

• Introduce yourself and clean your hands.

• Note clues around the patient, such as oxygen, nebulisers, inhalers or sputum pots.

• Observe from the end of the bed:

• Scars, chest shape, asymmetry, pattern of breathing, accessory muscle use.

• Chest wall movement, paradoxical rib movement, intercostal indrawing.

• Examine the hands: clubbing, tar staining, muscle wasting.

• Check for tremor and flap.

• Measure respiratory rate unobtrusively.

• Examine the face: anaemia, cyanosis, Horner’s syndrome and superior vena cava obstruction.

• Examine the neck: jugular venous pressure, tracheal deviation, cricosternal distance.

• Examine the anterior chest wall:

• Palpate: apex beat, right ventricular heave, expansion of the upper and lower chest.

• Percuss: compare right with left, from top with bottom, then axillae.

• Auscultate: deep breaths; compare right with left, from top with bottom, then axillae. Repeat, checking vocal resonance.

• Examine the posterior chest wall (commonly in OSCEs, you may be directed to examine either anterior or posterior):

• Ask the patient to sit forwards.

• Inspect the back for scars, asymmetry and so on.

• Palpate:

– Cervical lymph nodes.

– Chest expansion of the upper and lower chest.

• Percuss: ask the patient to fold his arms at the front to part the scapulae; compare right with left, from top to bottom.

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat, checking vocal resonance.

• Check for pitting oedema over the sacrum and lumbar spine.

• Thank the patient and clean your hands.

Summarise your findings

The patient has finger clubbing, a raised respiratory rate, and diminished expansion with dullness to percussion and loss of breath sounds at the right

base. A small scar suggests prior pleural aspiration.

Suggest a differential diagnosis

Signs suggest a large right pleural effusion.

(Away from patient’s bedside) A large unilateral effusion with finger clubbing suggests an underlying neoplasm. Alternatives include chronic

empyema and tuberculous effusion.

Suggest initial investigations

Chest X-ray to confirm effusion and possibly show an underlying tumour. Ultrasound to reveal pleural disease and loculation, and guide aspiration.

Pleural aspiration for cytology, culture and biochemical analysis.

OSCE example 1: Respiratory history – cont’d

• Establish whether there is a family history of respiratory disease (including asthma).

• Ask about any other patient concerns.

• Thank the patient and clean your hands.

Summarise your findings

Mrs Walker is a 55-year-old cook who gives a 6-month history of wheeze disturbing her sleep, associated with an unproductive cough. Her symptoms

vary from day to day and sometimes make climbing stairs difficult. She smokes 10 cigarettes a day and has a 20-pack-year smoking history.

Suggest a differential diagnosis

The most likely diagnosis is asthma (variable, nocturnal symptoms) and the differential is chronic obstructive pulmonary disease.

Suggest initial investigations

Spirometry and reversibility, peak-flow diary, chest X-ray, blood count for eosinophils, serum immunoglobulin E, and skin tests to common allergens.

92 • The respiratory system

Integrated examination sequence for the respiratory system

• Introduce yourself and seek the patient’s consent to chest examination.

• Position the patient: resting comfortably, with the chest supported at about 45 degrees and the head resting on a pillow.

• Carry out general observations: note any clues around the patient, such as oxygen, nebulisers, inhalers, sputum pots, etc.

• Observe from the end of the bed:

• Scars.

• Chest shape, asymmetry.

• Pattern of breathing:

– Respiratory rate.

– Time spent in inspiration and expiration.

– Pursed-lip breathing.

• Chest wall movement, paradoxical rib movement, intercostal indrawing.

• Accessory muscle use.

• Examine the hands:

• Clubbing, tar staining, muscle wasting.

• Check for tremor and flap.

• Measure respiratory rate unobtrusively.

• Examine the face:

• Check for anaemia, cyanosis, Horner’s syndrome and signs of superior vena cava obstruction.

• Examine the neck:

• Jugular venous pressure, tracheal deviation and cricosternal distance.

• Examine the anterior chest wall:

• Palpate: apex beat, right ventricular heave, expansion of upper and lower chest.

• Percuss: compare right with left, from top to bottom, then axillae.

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat positions, asking the patient to say ‘one, one, one’ for

vocal resonance.

• Examine the posterior chest wall: ask the patient to sit forwards so that you can:

• Inspect the back for scars, asymmetry and so on.

• Palpate:

– Cervical lymph nodes.

– Expansion of the upper and lower chest.

• Percuss: ask the patient to fold their arms at the front to part the scapulae. Compare right with left, from top to bottom (see Fig. 5.16A–C for

positions).

• Auscultate: deep breaths; compare right with left, from top to bottom, then axillae. Repeat positions, asking the patient to say ‘one, one, one’ for

vocal resonance.

• Check for pitting oedema over the sacrum and lumbar spine.

6

The gastrointestinal system

John Plevris

Rowan Parks

Anatomy and physiology 94

The history 94

Common presenting symptoms 94

Past medical history 102

Drug history 102

Family history 102

Social history 102

The physical examination 103

General examination 103

Abdominal examination 104

Hernias 110

Rectal examination 111

Proctoscopy 113

Investigations 113

OSCE example 1: Abdominal pain and diarrhoea 116

OSCE example 2: Jaundice 117

Integrated examination sequence for the gastrointestinal system 117

94 • The gastrointestinal system

and 2000 kcal/day for females. Reduced energy intake arises

from dieting, loss of appetite, malabsorption or malnutrition.

Increased energy expenditure occurs in hyperthyroidism, fever

or the adoption of a more energetic lifestyle. A net calorie

deficit of 1000 kcal/day results in weight loss of approximately

RH

RF

LHE

UR

H

LF

RIF LIF

B

C

A

 1 Oesophagus

 2 Stomach

 3 Pyloric antrum

 4 Duodenum

 5 Duodenojejunal flexure

 6 Terminal ileum

 7 Caecum

 8 Appendix (in pelvic position)

 9 Ascending colon

10 Transverse colon

11 Descending colon

12 Sigmoid colon

3 Spleen

4 Pancreas

1 Liver

2 Gallbladder

1

2 4

3

4 3

5

1

2

9

7

8

6 12

11 10

Fig. 6.1 Surface anatomy. A Abdominal surface markings of

non-alimentary tract viscera. B Surface markings of the alimentary tract.

C Regions of the abdomen. E, epigastrium; H, hypogastrium or

suprapubic region; LF, left flank or lumbar region; LH, left hypochondrium;

LIF, left iliac fossa; RF, right flank or lumbar region; RH, right

hypochondrium; RIF, right iliac fossa; UR, umbilical region.

6.1 Surface markings of the main non-alimentary tract

abdominal organs

Structure Position

Liver Upper border: fifth right intercostal space on full

expiration

Lower border: at the costal margin in the mid-clavicular

line on full inspiration

Spleen Underlies left ribs 9–11, posterior to the mid-axillary line

Gallbladder At the intersection of the right lateral vertical plane and

the costal margin, i.e. tip of the ninth costal cartilage

Pancreas Neck of the pancreas lies at the level of L1; head lies

below and right; tail lies above and left

Kidneys Upper pole lies deep to the 12th rib posteriorly, 7 cm

from the midline; the right is 2–3 cm lower than the left

Anatomy and physiology

The gastrointestinal system comprises the alimentary tract,

the liver, the biliary system, the pancreas and the spleen.

The alimentary tract extends from the mouth to the anus and

includes the oesophagus, stomach, small intestine or small bowel

(comprising the duodenum, jejunum and ileum), colon (large

intestine or large bowel) and rectum (Figs 6.1–6.2 and Box 6.1).

The abdominal surface can be divided into nine regions by the

intersection of two horizontal and two vertical planes (Fig. 6.1C).

The history

Gastrointestinal symptoms are common and are often caused by

functional dyspepsia and irritable bowel syndrome. Symptoms

suggesting a serious alternative or coexistent diagnosis include

persistent vomiting, dysphagia, gastrointestinal bleeding, weight

loss, painless, watery, high-volume diarrhoea, nocturnal symptoms,

fever and anaemia. The risk of serious disease increases with age.

Always explore the patient’s ideas, concerns and expectations

about the symptoms (p. 5) to understand the clinical context.

Common presenting symptoms

Mouth symptoms