topics / مواضيع

  33Cardiovascular and respiratory medicine Station 14 Peripheral vascular system examination In this station you may be asked to restrict your examination to the arterial or venous system only. You must therefore be able to separate out the signs for either (see Table 6). Before starting • Introduce yourself to the patient. • Confirm his name and date of birth. • Explain the examination and obtain his consent. • After checking for any pain, ask him to expose his feet and legs and to lie down on the couch. The examination Inspection • General appearance: body habitus, missing limbs or digits, surrounding paraphernalia such as walking aids, oxygen, cigarettes. • Skin changes: pallor, shininess, loss of body hair, atrophie blanche (ivory-white areas), haemosiderin ­pigmentation, inflammation, eczema, lipodermatosclerosis. • Thickened dystrophic nails. • Scars. • Signs of gangrene: blackened skin, nail infection, amputated toes. • Venous and arterial ulcers.

  Cardiovascular and respiratory medicine Station 12 Blood pressure measurement 27 Examiner’s questions Causes of secondary hypertension: • Endocrine causes: – high catecholamines, e.g. phaeochromocytoma – high glucocorticoids, e.g. Cushing’s syndrome – high mineralocorticoids, e.g. Conn’s syndrome – high growth hormone, e.g. acromegaly – hyper- or hypo-thyroidism – hyperparathyroidism • Renal disease • Vascular causes: – renal artery stenosis – coarctation of the aorta • Pregnancy: – gestational hypertension – pre-eclampsia (+ oedema and proteinuria) • Drugs: – NSAIDs, steroids, oestrogen, illicit drugs Complications of hypertension: • Cerebrovascular accident (haemorrhage or ischaemic infarct). • Retinopathy. • Ischaemic heart disease. • Left ventricular failure. • Renal failure. • Atherosclerosis. • Aneurysm. Investigations in hypertension: • C

 Clinical Skills for OSCEs 22 Station 10 Chest pain history Family history • Parents, siblings, and children. Ask specifically about heart disease, hypertension, and other heritable cardiovascular risk factors. Social history • Employment. • Housing. • Hobbies. After taking the history • Ask the patient if there is anything else that he might add that you have forgotten to ask. This is an excellent question to ask in clinical practice, and an even better one to ask in exams. • Thank the patient. • Summarise your findings and offer a differential diagnosis. • State that you would like to examine the patient and possibly order some investigations, in particular: • ECG to look for or help rule out ischaemic heart disease. • Blood tests including – troponins to look for or help rule out myocardial infarction – D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the diagnosis but a positive result does not confirm it) – inflammatory

  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 to