i dont think i'm well prepared at all..i'm just trying to study properly, because it's better to do something really well or not at all..anyway thanks for the vote of confidence! makes me feel not 'so alone' too! & i found this oct 30th 2007 OSCE
list after rummaging around a lot..
Cannulation
Pap smear
MMSE
Needle stick injury - nurse is the patient
child vomiting- counsel the mother
Endoscopy - discuss to patient
Headache - hx taking
primary survey -pt with pelvic fracture
Ear examination
Abdominal pain- hx taking
Breast examination
spacer - discuss tp pt. dad
dry cough -hx and disccuss the ddx
Pain in the right hand - history taking
post MI - discuss to pt life modification
HPN station (aspirin, ace inhibitor, statins) explain to pt.
hope thats of some use. they always say last 6 months stations. all the best to you too.
Hey,Buddy.
thanks a lot,dear nsa. it is really a big offer to new plabbers.
I'll also browse and post if i find latest six months. I sent a pm to the doctor who said he/she will post them too. no reply yet. Maybe busy and can't come to this forum.
well then,all the best to you too and please keep up the good work.
regards
oh my GOD! im so very sorry!!!! when i rechecked the part of 7 sisters i posted for you- a lot of it is missing!!! i thought i had copied & pasted everything! i cant tell u how sorry i am!! why didnt u tell me/ didnt u even read it?
here is the rest! i ws giving the same material to another friend in the forum & i saw that it's only upto q 28!im so very sorry!!!
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Q.28 A patient is to be discharged after MI. Give advice about medications (Aspirin, GTN, Beta blockers).
Introduction, and then you may say: “Now you are feeling much better, and you are ready to go home today. I would like to have a little chat with you about your medication.
Take the Beta blocker bottle and show it to the patient: This is propranolol. It prevents chest pain. You should take one tablet every 6 hours for the first 2 days, and 2 tablets twice a day afterwards. Swallow the tablet with a glass of water. It is a long term treatment (usually for 2-3 years). Please do not stop taking this medication suddenly. Because this may cause the pain to worsen and will affect your condition. This medication sometimes causes side effects in some people. If you get any of the following symptoms tell your doctor immediately: headache, sleepiness, bad dreams, dizziness, light headedness, shortness of breath, wheeze, slow pulse, SKIN rash, dry eye , tiredness, cold hands and feet.
Show the patient the bottle of Aspirin. This is Aspirin, you should take it once a day with a glass of water, sometimes it causes irritation of stomach, and it to prevent this it should be taken after meal (on full stomach). This is a long term treatment. This drug prevents blockage of the blood vessels of the heart, which may result in another heart attack. The side effects are mainly stomach irritation then it might cause tummy pain, blackish discoloration of stool. Other unusual bleeding also it might cause shortness of breath and wheeze. If you notice any of these features, or if you notice any bleeding contact your doctor immediately.
Show the patient the bottle of Glycerol Trinitrate. This is GNT, you should take it in case if you have chest pain, also you can take it before exercise, it will increase your exercise limit. Put 1 tablet under your tongue and wait till it dissolves in your mouth. Don’t swallow it. The possible side effects include headache, flushing, dizziness especially when you get up suddenly (postural hypotension). These side effects are usually short term. If you notice any of these consult your doctor. I would like to assure you that it is not habit forming or addictive.and it has very short expiry date.
Q.29 Give advice about changing life style to overweight patient, who had MI ready to discharge tomorrow.
Introduction, and then you may say: “You remember that you came few days ago with sudden chest pain, you are coming along very nicely and you are ready to go home tomorrow. I think it would be a good idea if we have a little chat before going home.
The tests showed that you had heart attack, which is a condition where one of the vessels which supply blood to the heart becomes blocked by a clot. That area is damaged and is replaced by a scar. This process takes from days to weeks and it is better not to put a great strain on the heart at this time. Within 2-3 months at most, the hearts of many patient are functioning just about, as well as they were before the attack.
A part from medication which I’ll talk to you about later. There are some points about a little change in your life style:
1. Diet: it would be a good idea if you consider reducing your weight and avoid saturated fat especially high fat diary product as butter, fatty meat, palm, coconut oil. You can eat more fresh fruit and vegetables, chicken (without SKIN ), fish, skimmed, and semiskimmed milk, grill, don’t fry.
2. Exercise: you can start exercise gently and increase it with time. Try to avoid walking in cold winds and climbing up steep hills. About sports you can take up with golf, cycling, swimming, beside walking; but avoid sports with vigorous exercise as squash and weight lifting.
3. Smoking: you should give up smoking as it increases risk of recurrent attacks.
4. Alcohol: 1 or 2 glasses of wine or ½-1 pint of beer/ one measure of spirit don’t affect the heart but more than this may give harm to the heart.
5. Sexual intercourse: it increases the work of the heart and in some people causes chest pain or shortness of breath. But in majority of cases, sexual activity can be resumed as soon as you are able to take other forms of moderate exercise as walking up stairs without symptoms. GTN tablet before intercourse, can help but you should give up immediately if you get chest pain.
6. Driving: you can start after 4 weeks and it is better if you try short runs in the neighborhood accompanied by a friend. Inform your driving license authority.
7. Work: you can go back to work in 4-12 weeks depending on type of work.
8. Stress: It would be a good idea if you take up relaxation therapy and avoid stressful condition as much as you can.
9. Avoid air travel for at least 6 weeks.
Q.30 A patient with heart failure. Examine cardiovascular system.
Introduction, and then may begin by saying: “I would like to examine your heart and vessels:
1. Examine the face:
a. Eyes: for corneal arcus, xanthelasma, palpebral conjuctiva for pallor and ophthalmoscopy (hypertension, endocarditis).
b. Cheeks: for malar flush (Mitral Stenosis).
c. Tongue and mucous membrane of mouth, for central cyanosis.
2. Examine the hands: note wether warm (vasodilation) or cold (vasoconstriction), dry or moist, any pallor, cyanosis, and any tobacco staining. Look for xanthomas. Examine nails for clubbing and splinter heamorrhage.
3. Radial pulse:
a. With opposite 3 fingers (right fingers for left hand and vice versa). Check rate and rhythm. Calculate radial pulse for at least 15 sec.
b. For collapsing pulse: raise the arm while feeling across the pulse with fingers of other hand.
4. Brachial pulse: use thumb (left thumb for left arm and vice versa), for character, just medial to biceps tendon.
5. Measure blood pressure: sitting and standing.
6. Carotid pulse: ask the patient to lie down. Use the thumb (right thumb for left carotid and vice versa). It gives more information about character.
7. Examine JVP: patient supine at 45º (semi-recumbant position) with head supported and turned slightly to the left (deep to sternal and clavicular heads of sternocleidomastoid muscle). Measure height in cm from venous pulse to sternal angle. JVP is raised if measured height is beyond 4cm.
8. Examine chest:
a. Inspection: Skeletal abnormalities such as pectus excavatum or kyphoscoliosis, check for any scar. And for any pulsation (double apex, HOCM, diffuse anterior MI).
b. Palpation: of parasternal area for thrill and parasternal heave; place the hand on the left chest, with long axis of hand paralell to anterior axillary line. Palpate cardiac impulse, place the hand perpendicular to the anterior axillary line. Check for sustained hyperkinetic or diffuse. Localise the apex beat with one finger. Ask the patient to roll onto left side while palpating.
c. Auscultation:
i. Apex: with the bell of the stethoscope, while the patient is lying in left lateral position.
ii. Tricuspid valve: with the diaphragm, on the lower left sternal edge and patient lying flat.
iii. Pulmonary valve: second left intercostal space.
iv. Aortic: second right intercostal space.
v. Aortic regurgitation, pericardial rub: sit the patient up, make her/him lean forward, and ask her/him to expire and listen with diaphragm at lower left sternal edge.
vi. Aortic stnosis: listen at the second right intercostal space.
9. Examine the back: listen for basal crepitation, check for sacral oedema.
10. Examine the abdoman: check for enlarged or pulsatile liver , enlaged kidneys, aortic pulsation and renal bruit.
11. Femoral pulse: check for radio-femoral delay.
12. Lower limbs: check popliteal, posterior tibial, dorsalis pedis pulses and check for oedema.
Q.31 A patient with intermittent claudication, examine pulses of lower limbs.
Introduction, then you may say: “I have heard that you have pain when you walk. I would like to examine your legs. Could you please slip off clothes form your bottom half to your underwear. And pop up on the couch.
Inspection: look for any hair loss, shiny red SKIN , ulcers and gangrene; especially behind the heel, between toes, in bunion area, and on dorsum of foot.
Palpation:
1. With dorsum of hand for heat changes.
2. For pulses: dorsalis pedis: lateral to extensor hallucis tendon proximally.
3. posterior tibial: 1-2cm below and behind medial maleolus.
4. popliteal: flex the knee to 30º and feel with fingers of both hands.
5. Femoral: midway between anterior superior iliac spine and pubic tubercle.
6. Peroneal: 1cm medial to lateral malleolus (replaces anterior tibial artery in %5 of cases)
N.B.: if dorsalis pedis is not felt, feel for anterior tibial artery: just above level of ankle anteriroly in midway between 2 malleoli.
If history is typical of intermittant claudication and pedal pulses are present, ask the patient to walk for few minutes and then re-examine the pulses which may disappear, because the increased blood flow decreases pulse pressure.
Buerger’s test: ask the patient to lie on her/his back, and to lift both legs and keep knees straight, supported by examiner’s hands while the patient is asked to flex and extend the ankle and toes to a point of mild fatigue. The test is said to be positive if the sole of foot became cadaveric pallor and veins on dorsum of foot gutter. Then ask the patient to sit and lower feet, in minutes they become reddened, cyanotic colour over affected foot.
Investigation:
1. Blood tests: FBC, U&E, ESR, lipid profile, syphilis serology.
2. Ankle brachial pressure index: it is normally around 1, in intermittent claudication: 0.9-0.6.
3. Arteriography.
Q.32 A 50 year old patient with rectal bleeding. Take history and make diffrential diagnosis.
Introduction, and then you may say: “As far as I know you are passing bood (have bleeding) from your back passage. I would like to ask you a few questions then we will talk about what we will do.
How long have you had the bleeding? (Duration) How much blood did you pass? (amount) Is the blood mixed with or on the surface of stool? Can you tell me the colour of the blood? Is it bright red or dark red? Or black? Do you feel urge to pass motion? Do you feel the need to pass motion and when you try nothing comes out? Does the blood come before, during or after passing motion? Any blood on toilet paper or pants? Do you have any pain during passing motion? Have you passed any pus, mucous or discharge with stool? Did you notice any lump passing from your back passage? Do you have any tummy pain? Do you have any changes in your bowel habit? Any diarrhoea? Constipation? Do you feel any distension of your tummy? Passing wind more than usual? Felt sick? (nausea) Been sick? (vomiting) Have you had similar condition in the past? Do you have bleeding from any other site?
Are you on any medication? Has anyone else in your family had similar condition? Any bowel disease or tumour in your relatives? Do you eat a lot of vegetables and fruits? Do you have any disease? Any fever (temperature)? Have you lost weight recently? Have you traveled abroad?
Differential diagnosis:
1. Colon and rectal carcinomas.
2. Diverticular diseases.
3. Haemorrhoids.
4. Inflammatory Bowel Disease (Crohn’s disease and Ulcerative Colitis).
Q.33 & 34 A 35 year old patient with diarrhoea. Take history and make differential diagnosis.
Introduction, and then you may say: “As far as I know you pass loose motion. I would like to ask you few questions about your condition.
How long have you had this? Is it watery or loose stool? How many times do you open your bowel? Is it always watery or sometimes you get formed or hard stool? Is there any blood, mucous, pus with the stool? What colour is the blood? Is it bright red or dark? Is it mixed with stool? Any unusual smell of the stool? Do you feel urge to pass motion? Do you feel the need to open bowel and nothing comes?
Do you have any tummy pain? Any wind? Have you felt sick? Have you been sick? Have you lost weight recently? Do you have any fever (temperature)? Have you traveled abroad recently? Have you had similar condition in the past? Do you take any medication regularly? Do you have any joint pain, SKIN rash, redness of eye ? Has anyone else in your family had a similar condition? How is your appetite?
Differential diagnosis:
1. Inflammatory bowel disease as Crohn’s disease and Ulcerative colitis.
2. Infections (bacillary or amoebic dysentery).
Q.35 A patient with right upper quadrant pain. Take history and make differential diagnosis.
Introduction, and then you may say: “As far as I know you have pain in your tummy. I would like to ask you few questions about that.
How long has the pain been there? (Duration). How long does it last? Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where it is? (Site). Does it always stay in the same place or does it spread? (Radiation). Can you describe what it feels like? (Character: aching, comes and goes, colicky, gripping, burning, stabbing). Does anything seem to make it better (Relieving factors) Does the pain feel better when you lie down or roll around. Does anything seem to make it worse? (meals, fatty meals, hunger). How is your appetite? Do you feel sick? Have you been sick? Any change in your bowel habit? In colour of stool? Do you have fever (temperature)? (always, comes and goes, recently?). Any cough, chest pain? (Pneumonia). Do you pass water more than usual? Any burning sensation? Any change in the colour of urine? (UTI). Do you have any itching of your SKIN , or any change in colour of SKIN and eyes? (Jaundice). Have you had any recent blood transfusion?
Have you had any similar condition in past? Are you on any medication? Have you travelled abroad recently? Has anyone else in your family had a similar condition?
Differential diagnosis:
1. Acute cholecystitis .
2. Acute hepatitis.
3. liver abscess.
4. Pyelonephritis.
5. Basal pneumonia.
6. Peptic ulcer.
7. Acute appendicitis (Sub-hepatic).
Q.36 Examine the upper abdomen of the patient (of Q.35) and give differential diagnosis.
Introduction, then you may start by saying: “I would like to examine your tummy. Would you please pop up on the couch and undress your tummy”.
Lie the patient supine on couch with head supported to relax muscles of the abdomen. Then expose the abdomen form xyphosternum to mid-thigh.
Inspection:
1. Check the shape and symmetry of abdomen (scaphoid, or distended), any SKIN lesions like scar of previous operations. Check the hair distribution. Look of any tortuous dilated superficial veins.
2. Movement: respiratory, peristalsis, pulsation. Inspect tangentially for any abnormal movement.
3. Hernia: epigastric, umbilical, incisional, inguinal, femoral (ask the patient to cough, and to stand to inspect the hernial orifices).
Palpation:
1. Light palpation: ask the patient to report any soreness (tenderness) and look at the patient’s face for grimace. Ask him/her if there is pain and where it is exactly, and begin from area remote from the pain area. Place the hand on abdomen, test muscle tone by light dipping movements starting from left in the order showed on the figure:
xyphoid
pubis
2. Deep palpation: the same technique for superficial palpation but more deeply. To detect organs.
3. Palpation during inspiration:
a. liver : place hand in right upper quadrant with fingers pointing upward. (towards the left axilla) lateral to rectus muscle. Palpate while patient takes a deep breath and go up with each inspiration till it reaches right costal margin. Murphy’s sign: place fingers over gall bladder area (at the cross point of midclavicular line and costal margin, at the nineth costal cartilage) and ask the patient to take a deep breath. If he/she feels pain the sign is positive.
b. spleen : place hand in right upper quadrant and palpate as the patient takes deep breath (ask him/her to look to other side). Go up with each inspiration till it reaches left costal margin. If still not palpable lie the patient in left lateral position with left hip and knee flexed, support lower rib cage with left hand and palpate with the right hand. Normally the spleen lies in a posterolateral postion beneath 9th-11th ribs with anterior border extending to midaxillary line.
c. Kidneys: bimanual technique: place one hand posteriorly below the lower rib cage and the other hand over the upper quadrant (both hands are perpendicular to anterior axillary line position) push your two hands together as the patient breathes. Palpate the right kidney first then the left.
d. Ask the patient to cough while palpating hernial orifices (inguinal).
Percussion:
1. For upper border of liver : percuss on mid-axillary line starting from right lower costal margin. Normally the liver extends to beneath the 5th rib.
2. spleen : percuss with patient holding breath in full inspiration, form below to above left costal margin in posterior axillary line.
3. Urinary bladder: in supra pubic area.
4. Shifting dullness: percuss from centre of the abdomen to left flank until getting dull note. Keep finger in place and ask the patient to roll to right side, wait few seconds, and percuss. Ascites is suggested if note becomes resonant and is confirmed if dull note is noticed towards the umbilicus.
5. Fluid thrill: ask the patient to put his/her hand on his/her abdomen in sagital plane. With your left hand in patient’s left flank, flick the SKIN of right flank with right hand. If impulse is felt the thrill is positive and it indicates the presence of ascites.
6. Percuss the renal angle for tenderness.
Auscultation: For bowel sounds, around umbilicus, (for 3 minutes before saying it is abscent). Look for bruit over renal angle and aorta.
Digital Rectal Examination: is essential and must not be omitted.
During examination of the abdomen if there is pain, check for rebound tenderness, and if there is ascites consider dipping technique of palpation.
Q.37 A patient with pain in the right upper quadrant of the abdomen. Take history and examine him/her.
Introduction, and then you may begin by saying: “As far as I know you have pain in your tummy, I would like to ask you a few questions about your condition.
History: how long has the pain been there? (Duration). How long does it last? Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where it is? (Site). Does it spread anywhere? (Radiation). Can you describe what it feels like? (Character). Does anything seem to make it better or worse?
Have you noticed any change in your weight recently? How is your appetite? Do you feel sick? Have you been sick? Did you notice any change in colour of stool? Any fever? Do you have any cough or chest pain? (Pneumonia). Any burning sensation when passing water? Any change in colour of urine? (UTI). Do you pass water more than usual? Any similar condition in the past?
Examination: I would like to examine your tummy, would you please pop up on the couch, lie on your back and undress your tummy? (Expose for xyphisternum to mid thigh).
1. Inspection: while standing for symmetry, movement with respiration. And hernial orifices. Tangentially for movement with respiration.
2. Palpation: light palpation: start from left upper quadrant; leave the right upper quadrant till the last. Test for muscle tone. Keep looking at the patient’s face for grimace. Palpate during inspiration for liver , spleen , right and left kidneys.
3. Percussion: of upper border of liver , spleen , urinary bladder, shifting dullness, fluid thrill, percuss renal angles.
4. Auscultation: for bowel sounds, and for bruit over the renal angle and aorta.
5. Do Digital Rectal Examination.
6. Examine the lower right chest:
a. Percussion for dullness (consolidation or pleural effusion).
b. Auscultation: for bronchial breathing or absent breath sounds (consolidation or pleural effusion).
c. Vocal resonance (which increases in consolidation, and decreases in pleural effusion).
Q.38 A patient who is about to have laparoscopic cholecystectomy. Explain treatment.
Introduction, and then you may say: “So you will have your gall bladder taken out by laparoscopy, do you know anything about this procedure?
This operation takes about 1-2 hours. A general anaesthetic is given, so you will be asleep during the procedure.
The doctor is going to make 4 small cuts on your tummy, each is less than 1cm. One is below the breast bone, one just below the right rib cage, one is near navel and the 4th one is on the lower part of the right side of the tummy, near the bikini line. A telescope like instrument is passed through one of these cuts and the instruments are used by the surgeon through the other cuts.
In the past we used to take out gall bladder by open surgery with a cut of 10cm long, but this new procedure has many advantages over the previous one: first the cuts are smaller and they cause less upset to the body. Muscles are not affected. It is less painful. You can return home and to work quicker. However, sometimes during the procedure conversion to open method is necessary.
We have to put a what we call N/G tube through nostrils down to the stomach, and another tube in your arm to give fluid to your blood.
After operation you may feel pain in your tummy, chest and shoulder (caused by air inflation).
As any surgical procedure, this operation may have some complications:
1. Infection: of the wound is the most common complication and antibiotics are given to decrease the chance of this from happening.
2. Bleeding: there may be some bleeding from the wound.
3. Pain: at the wound site and often pain is in the right shoulder for a day or two after operation and you will be given medication to relieve the pain.
4. Damage to bile duct: may happen during the procedure.
5. Blood clots: may develop in the vein of the leg and prevent this from happening you will wear elastic stockings before, during, and after the procedure. And you will be encouraged to walk as soon as possible.
Usually we use dissolvable (absorbable) stitches. After the operation, you will be able to drink after 4 hours and, usually you can start eating the day after the operation, and you may go home on the day after. In general, you will be kept in hospital until you are able to eat, drink and your pain is controlled.
After discharge:
1. For diet: initially you should decrease fat in your diet.
2. At work: you are able to return to light work after 2 weeks.
3. Driving and sex: you can start as soon as you don’t have pain and is confortable.
4. Wound care: you can bath/shower as normal but avoid rubbing the wound or wearing tight cloths. That may irritate it.
5. Appointment after 6 months.
Q.41 The nurse on duty bleeped you and told you that a patient who had right hemicolectomy is not doing well. Her blood pressure decreased and pulse rate increased. What would you tell her on telephone, on ward and after examining the patient.
I am now examining a patient in the casualty, but I will come as soon as I can. (You go to the ward as soon as possible).
Who was the nurse who bleeped me about the patient whom she was worried about? The one who is now six hours after having right hemicolectomy and now he/she is unwell? The nurse said that that the patient’s name was Mrs Simpson. In which bed is she? (to make sure that you see the right patient).
Check the case sheet for the notes (history and examination) and read the operation note. Then go to bed, check the chart, take brief history and any exam needed. (check the abdomen, and auscultate heart, lung, and look at the legs).
Who is the nurse looking after Mrs Simpson. Can somebody, please, tell me where you keep the request forms on this ward?
I realise how much pressure your are under, but I am really worried about Mrs. Simpson. It is very important that we keep a very careful eye on her. I think she may be bleeding and she may have to go back to theatre.
1. I am just arranging for some blood to be cross-matched for her.
2. I will be getting in touch with the registrar on duty.
3. Could you change the drip to Haemaccel. I will write this in the chart. She is already on antibiotics and heparin, so I don’t think that we need to give her anything else at present.
4. Could you make sure that the observations are taken regularly every 15 minutes?
5. Can you please tell me where I can find the ECG machine? I have not contacted the theatre or anaesthetist yet. I thought I would better to wait until she has been seen by the registrar, but it seems pretty likely that she may need to go back to the theatre.
6. Do you know if any of her relatives are here? I need to speak to them.
Good morning, I am Dr (you), the doctor on duty. As far as I know you are Mrs Simpson’s daughter. I need to have a word with you. (Take her to a side room). What is your name? So Ms (the daughter), your mother’s operation went very well and we think that we have removed all of her growth. However, unfortunately, she developped another problem, which we think will only be temporary. It seems possible that she may be bleeding. We arranged for her to have blood transfuson and hopefully that will be enough. But we may need to take her back to theatre.
You know this may happen sometimes, but should not make any difference in the long term. She should be well. As soon as we know more, I will let you know. I am sorry but I have to go to sort things out.
Q.42 Obtain an informed consent from a patient for a herniorrhaphy and give post-op advice
Introduction, and then you may say: “I am going to have a word with you about your hernia and possibility of surgical treatment. And to take your consent about the operation”.
Do you know what a hernia is?
In anyone there are weak areas in the lower part of the front of the tummy. The coverings of the tummy contents together with some of these contents, such as part of the gut, may push through these weak areas into the upper part of the thigh, groin area or sometimes down the scrotum that is the sac of the testicles.
The predisposing factors that can lead to hernia are: lifting heavy objects, straining as in constipation, being overweight, and chronic cough.
As the gut and coverings pass through these weak areas, it might happen that the inside of the gut get blocked, and in this case we need to do emergency operation with higher possibility of complications than if we do planned operation.
In the operation we return the contents of the tummy, as gut and covering, back into the proper position and the weak area is repaired either by the use of synthetic mesh or darning by nylon or reposition of the muscles.
About Anaesthesia
, well, you will have either general Anaesthesia
, where you will be put to sleep and then wake up after the operation. Or spinal Anaesthesia
where you will be given injection into the backbone and you will feel numb from waist below.
You will wake up from general Anaesthesia
in the recovery area and once you wake up you will be taken back to ward. You will probably feel sleepy for a couple of hours, you may feel sick, get headache or sore throat, this will pass but be sure to inform the nursing or medical staff should this become worse.
As any operation this may have complications like:
1. Wound infection.
2. Bleeding and collection of blood in the area.
3. Recurrence of hernia.
4. Pain, sensation of pins and needles in the area of operation.
5. Infertility. (Very rare< %1) and as you are in good hands, we will find the structures related to fertility and put them away from the work field.
6. General: urine retention, chest infection, clots in the leg and lung.
You will remain in hospital for 1-2 days after operation, if dissolvable suture are used then, they will dissolve by themselves if not removed within 7 days.
1. You have to rest for one week.
2. Back to work within 2 weeks (desk work), after 3 months (manual work).
3. Drive within 1-2 weeks or when comfortable
4. Sex: as soon as it is comfortable.
5. Diet: a lot of vegetables and fruits.
6. Smoking: stop it, if possible.
Is everything clear to you? Do you have any questions to ask me? This is the consent from for operation would you mind reading and signing it please?
Q.43 A 22 year old patient with a past history of migraine, now the pain is different. The patient has vomited, following head injury and a period of loss of consciousness. And wants to have painkiller’s prescription and go home.
Introduction, and then you may say: “As far as I know you have headache, I would like to ask you a few questions about your condition”.
How long have you had the headache? Is it similar to, or different from the previous headache? Did the headache come suddenly or gradually? Is it there all the time or does it come and go?
N.B.: if chronic we can ask: How often do you get headaches? How long do they last?
Can you tell me exactly where you feel the pain? Does it spread anywhere? Can you describe what it feels like? Does anything seem to make it better? Or does anything make it worse? Does anything seem to bring on the headache? Do you see spots or flashing lights? Do you feel sick? Have you been sick? Does light or noise irritate you? Were you aware all the time or did you feel sleepy or lost consciousness? Do you feel weakness in an arm or leg or get double vision? Do you feel pain or difficult to move your neck? Do you have any problem with vision, hearing, giddiness, dizziness, weakness, numbness? Sinusitis, ear pain?
Exclude meningitis, chronic headache, space occupying lesion.
Well Ms/Mrs/Mr (patient), It seems that your headache now is different from the previous headache, that is the migraine. There is possibility that you have a condition we call it Subarachnoid Haemorrhage (SAH), that is bleeding between the brain and its covering. This condition is important to treat early, so it is very important to remain in hospital and we need to run some tests for you. So we will do an x-ray scan of your head and we may need to take a tiny drop of fluid from your back.
Q.44 A patient presenting with epilepsy. Take history and examine him/her.
History:
Introduction, and then you may say: “As far as I know you had a seizure. Is it the first time or you had seizures before? How did you feel before you had the seizure? Any mood changes?
Did you feel any warning beforehand? Strange voice, smell, flashing light, or upper tummy discomfort? Where were you when the seizure happened? Do you remember anything about the seizure? Did you fall over and injure yourself? Did you bite your tongue or wet yourself? Any limb pain or weakness? Headache? Drowsiness after the seizure?
Do you drink at all? How much? Any injury to the head? Any fever (temperature)? Any prolonged headache? Any history of DM
, hypertension, renal diseases, liver diseases? Any family history of epilepsy?
Examination:
1. Head: any bruises, laceration or depressed fractures.
2. eye : size of pupil and reaction to light, jaundice, pallor, bruises around eyes, ophthalmoscopy.
3. nose : blood or discharge.
4. ear : Blood or discharge, bruises on mastoid process.
5. Mouth: tongue bite, cyanosis, acetone smell, alcohol smell.
6. Neck: stiffness, and carotid bruit.
7. Chest: respiratory rate, auscultate for abnormal sounds.
8. Heart: auscultate for murmur and arrhythmia.
9. Abdomen: distension, tenderness and hepatosplenomegaly.
10. Upper limb: pulse rate, blood pressure, sensory sensation and motor power, reflexes.
11. Lower limb: sensation, motor power, and reflexes.
Q.45 Take history from a patient, whose epilepsy is getting worse.
Introduction, and then you may begin with: “As far as I know, you had some fits recently. And before that you had no fits. I would like to ask you several questions.
Are you on medication for epilepsy? What kind of medication? Do you take the medication regularly on their times? How is your sleep? (Sleep deprivation) Have you done any unusual exercise? (Physical stress) Do you have any stress in work or at home? (Psychological stress) Were you feverish? (Infection) Do you drink at all? How much? Did you have any recent changes in your drinking habit? Is there a special time when the fits happen? Did you notice anything that brings on the fit? Like watching TV for long-time, disco, hard music? Have you had any injury to your head? (Secondary cause) Have you had headache for a long period of time? Have you been sick? (Secondary cause, as increased intracranial pressure) Do you feel thirsty more than usual? Passing water more than usual? (DM
) Any weakness in the leg or arm? Do you take any medication? Any recreational drugs?
Q.46 A 56 year old female patient presenting to A&E with numbness in her left hand. Take history and give an advice.
Introduction, and then you may say: “As far as I know you had sensation of pins and needles in your hand. I would like to ask few questions and then I will explain to you what we will do.
1. When did that happen?
2. How long did it last?
3. Have you had similar conditions in the past?
4. Have you had any weakness in the arm or leg?
5. Have you had any change or loss of vision?
6. Have you had any giddiness or dizziness? Any difficulty with hearing?
7. Have you had any difficulty with speaking?
8. Do you have any headache?
9. Have you had any loss of consciousness?
10. Have you had any trauma to the head?
11. Do you have any pain in the neck, joint, or heart problem?
12. Do you have DM
, hypertension?
13. Do you smoke? How many cigarettes a day?
14. What about your diet? Do you eat a lot of fatty meals or salt?
15. Has anyone else in your family had similar condition?
16. Do anyone in your family have hypertension, DM
, CVA, early death, or hyperlipidaemia.
17. Are you on any medication? Did you use contraceptive pills?
Well it seems likely that you have a condition called TIA. It is a condition where a blood vessel of the brain becomes blocked temporarily and then re-open again. I will now examine you and then do some tests. After that it is important that you stop smoking, do more exercise, eat more vegetables and fruits, less fatty meals, salts and try to loose weight.
Also we will give you some medication to help preventing clot formation in the future and so prevent stroke or heart attack.
You should not drive for one month.
Q.47 Examine lower limb in a patient with peripheral neuropathy.
Introduction, then you may say: “I would like to examine your legs. Would you please undress your bottom ½ to your underwear and pop up on the couch.
Inspection:
1. Foot: look for atrophic changes (loss of hair and shiny SKIN ), check pressure areas for ulcer, gangrene and callosities. Look for small muscle wasting, pes cavus, and claw toes.
2. Ankle: deformity (charcot joint).
3. Leg: muscle wasting.
4. Knee: deformity (charcot joint).
5. Thigh: muscle wasting.
Sensation:
1. Touch: ask the patient to close eyes, test segments and compare (cotton piece).
2. Pain: ask the patient to close eyes, use pin, compare (baseline sensation on the sternum). Ask the patient if quality changes (hypo or hyperaesthesia).
3. Deep pain: firm pressure to toe nail, and squeeze the calf.
4. Joint position: ask the patient to close eyes, check interphalangeal joint of hallux if impaired move to proximal joints till sensation is felt.
5. Vibration: ask the patient to close eyes, check the baseline sensation by tuning fork on the sternum, then on base of big toe, medial malleolus, tibial shaft and tuberosity, and iliac crest.
6. Temperature: mentioned.
7. Two point discrimination:
Reflexes:
1. Knee jerk (L3, L4): flex the lower leg at knee joint of 60º
2. Ankle jerk (S1): flex the leg at the knee joint and extend at the ankle.
3. Plantar reflexes: (S1, S2).
Motor System:
1. Power: (grading of muscle power is set between 0-5) flexion, extension, adbduction, adduction of hip joint against resistance. Flexion, extension of knee against resistance. Dorsiflexion, plantar flexion, of foot with inversion and eversion. Dorsiflexion and plantar flexion of toes.
2. Co-ordination:
a. Heel shin test: ask the patient to put right heel on left knee and move it down and up (touch examiner finger before place it on knee).
b. Heel toe test of gait: ask the patient to walk on straight line.
3. Tone:
a. Flex and extend the knee passively.
b. Rotate internally and externally of the leg with knee extended.
c. Test for clonus: sharply push the patella down with knee extended and maintain pressure. Support flexed knee with one hand and with the other, briskly, dorsiflex the foot and maintain pressure.
Q.48 Examine cranial nerves II-VII of this patient.
Introduction, then you may say: “I would like to examine your cranial nerves, or I will examine the nerves of the head”.
Optic nerve (II):
Ask the patient: do you use glasses, or contact lenses? He/she should put these on during the exam if any.
Do you have any problem with your vision?
Sit directly opposite to the patient:
1. Visual acuity: ask the patient to close one eye with his/her hand and to read anything available in the room (e.g. exam paper).
2. Colour vision: with one eye still closed ask patient to tell the colour of anything available (shirt, tie).
3. Visual field: ask the patient to close opposite eye with one hand and to use the other as follows:
a. Ask the patient to look at examiner’s opposite eye .
b. Examine the outer aspect of visual field with a waggling finger, bring it into field of vision in a curve not straight-line approach from periphery at several points (upper, lower, nasal and temporal) and ask the patient to respond when seeing the moving finger.
c. Test control visual field by moving finger across visual field.
Repeat the 3 exams on the other eye .
4. Mention the need to examine retina by ophthalmoscope.
5. Pupillary reflexes:
a. Inspect for size and symmetry of pupils.
b. Reaction to light: ask the patient to look at a distance. Put your hand in the middle, in front of nose . Shine torch from one side and below. Look for direct and consensual reaction. Repeat for the other.
c. Reaction to accommodation: ask the patient to look at a distance. Then to look at an object held close to eye . Observe change of pupil size. (Normally it is smaller).
6. Visual inattention: ask the patient to look at your nose . Stretch your hands and move first a finger then another one. Then move both and ask the patient to report which finger is moving.
Oculomotor (III), Trochlear (IV), and Abducens (VI) nerves:
1. Inspection: for any abnormality: squint, nystagmus.
2. eye movement: ask the patient not to move the head and just move eyes and to report any double vision. Ask the patient to follow your finger held 60cm away. Move the finger up down, to right up, to right down, to left up and left down. (If the patient has diplopia, test each eye separately).
3. Test convergence: ask the patient to focus on finger as it is brought from a distance to tip of nose .
Trigeminal nerve (V):
1. Sensory: ask the patient to close eyes, test touch (cotton) on front of nose and forehead. (V1 Ophthalmic). Cheeks (V2 Maxillary). Jaw area (V3 Mandibular). Check on both sides. Repeat for pain with pinprick Ask the patient to respond verbally. Mention the need for temperature and two-point discrimination.
2. Motor:
a. Inspect: muscles of mastication for wasting (temporalis).
b. Ask the patient to open jaw against resistance (pterygoides, mylohyoid and anterior belly of diagastric).
c. Ask the patient to clench teeth and palpate masseters.
3. Relexes:
a. Corneal Reflex: ask the patient to look to other side and approach from side with cotton.
b. Jaw jerk: place the index finger over tip of patient’s mandible with mouth slightly open. Tap examiner finger with a hammer.
Facial (VII) nerve:
1. Inspect the patient’s face for any asymmetry, blinking and eye closure.
2. Motor function: ask the patient to raise eyebrow, and then to close eye as strongly as possible and try to open it by finger. Ask the patient to show teeth, blow out cheeks against closed mouth. Purse mouth and whistle.
3. Sensory: taste sensation in the anterior 2/3rd of the tongue (mention it).
4. Lacrimation (shrimer’s test): put botting paper for 5 minutes. If the wetting is more than 10mm the lacrimation is normal. (Mention it).
Q.49 Unconscious patient. Perform primary and secondary survey.
Firstly, you have to stabilize the neck if there is any risk of neck injury.
Primary survey:
1. Hello, how are you, would you please open your mouth and put out your tongue? (Check airway if it is clear. If not, remove any obstructions, such as blood, teeth, and foreign bodies.
2. Inspect respiratory rate, bilateral chest movement. Then auscultate to check for air entry on both sides. If there is no respiration intubate and ventilate. If respiration is compromised put O2 mask. If there is tension pneumothorax, insert a wide bore cannula in second intercostals space at mid calvicular line.
3. Check pulse pressure, and blood pressure. If pulse is absent then consider the patient is arrested and treat accordingly. If in shock start shock treatment.
4. Determine level of consciousness according to GCS, or AVPU:
GCS:
a. Best motor response: obeys commands (6), localizes pain (5), withdraws or pulls limb away to painful stimulus (4), flexor response to pain “decorticate posture” (3), Extensor response to pain “decerebrate posture” (2), no response to pain (1).
b. Best verbal response: normally oriented (5), disoriented (4), inappropriate speech (3), incomprehensive sounds (2), none (1).
c. eye opening: spontaneous eye opening (4), eye opening to voice (3), eye opening to pain (2), none (1).
N.B: response to pain is best tested by pressure on supraorbital ridge.
AVPU: Alert, response to Vocal stimulus, response to Pain, Unresponsiveness.
5. Exposure to check for further injuries, and covering the patient to avoid hypothermia.
N.B: Ask the patient if he/she feels any pain (assess verbal response), ask him/her to raise hand and to squeeze your fingers (motor) and look for eye opening.
Secondary survey:
1. Head: Signs of injury as bruising, laceration, bony deformity, depressed skull FRACTURE .
a. Eyes: any foreign bodies, redness, perforation, size of pupil. Papillary reflexes, corneal reflexes, bruises around the eye . (suggestive of anterior cranial fossa FRACTURE ).
b. nose : blood, discharge, (bright red discharge suggestive of rhinorrhoea).
c. ear : blood, discharge (let blood discharge on sheet, and look for double ring: mixed blood and CSF ). Bruises over mastoid (consider middle cranial fossa FRACTURE ).
d. Mouth: check stability of maxilla and mandible. Check for airway, any unstable false teeth or foreign body.
2. Neck: check for subcutaneous emphysema, cervical spinous processes, venous dilatation, tracheal deviation.
3. Chest: inspect respiratory movement, check for any penetrating or cramming injury. Paradoxical movement of flail chest. Palpate for tenderness, crepitus or rib FRACTURE . Percuss and auscultate checking for heamo/pneumo-thorax.
4. Heart: auscultate for heart sounds.
5. Abdomen: inspect for injury or echymosis, laceration, distension. Palpate for tenderness, guarding. Auscultate for bowel sounds. Do digital rectal examination, check sphincter tone, and prostate.
6. Diagnostic peritoneal lavage: (if in doubt) below umbilicus, put drip of 1L N/S and aspirate.
7. Pelvis: compressed and distracted manually to check for stability or pain, examine penis for blood drops (if present, do not catheterize).
8. Extremities: inspect for bruises, laceration, or deformity. Palpate for tenderness and stability. Check pulses, sensory exam, reflexes, motor exam and muscle tone.
X-ray of spine (cervical), CXR, pelvic x-ray, blood for hematocrit, grouping and cross match, electrolytes, urea, glucose and ABGs. Do ECG.
Q.50 Epileptic young lady on carbamazepine, going on holiday. Give advice.
Introduction, then you may begin by saying: “ you are going to have a wonderful time in the next few weeks. Where are you going? With whom, are going? Before you go, I would like to say a few words about what you should avoid while being on holiday.
Advice about medication:
First make sure that you take enough medication with you. You are going to a very sunny place and you are on carbamazepine treatment. Remember that this medication makes you more sensitive to sunlight. Therefore you can easily get sunburn. To avoid this, don’t stay in the sun between 11:00am and 3pm; keep yourself covered especially during this hottest time of the day. Don’t wear clothes that you can see through if you hold them up to the light, they let UV light through. Try to wear a hat (especially if light coloured hair). Always use high-factor sun-protection cream. Apply regularly especially if you are swimming.
General advice:
Let other people with you know that you have epilepsy so that they can help if necessary.
It is a good idea to wear Medic-Alert chain or bracelet, which is very useful way of letting other people know that you have epilepsy, so that they can help, should this be necessary.
Sports:
You can play tennis, basket ball, go jogging, running, swimming and what is important about swimming, that you shouldn’t do it alone. Always go with a strong swimmer who can help you in case an attack occurs. Also avoid excessive exercise and allow yourself enough time to rest.
Sports that could be dangerous are those where people cannot reach you easily, should a seizure happen. Such as horse riding, parachuting, hang-gliding, para gliding; or those involving water such as scuba diving.
Sleep, TV, and disco:
Sleep is also very important, less sleeping hours would trigger an attack, this is most likely to happen after getting up early following late nights. A regular pattern of sleep should reduce this risk.
The flashing light of disco, and flicking light of TV can trigger an attack. Try to limit the period of time you spend in disco and try to stay away from flashing light. When watching TV stay at least eight feet away form screen and three feet away when playing computer games.
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Q.51 A patient with epilepsy. Give an advice on medication.
Introduction, then you may begin by saying: “I would like to say few words about your medication.
1. Aim and blood level: the aim of medication is to control fits. It is not a cure for epilepsy. The medication works by abolishing or reducing the excessive electrical activity within the brain . Fits can be completely abolished in up to 80% of people with epilepsy using currently available drugs. Medication can be successfully withdrawn in some people after they have a period of years free from fits.
2. After absorption from intestine, the medication travels in the blood to the brain where it produces its effect. And as the rate of elimination of the drug differs from one person to another we usually measure the blood level of the medication and according to the level we adjust the dose that suits each individual.
3. How to take it: because the effect of most anti-epileptic drugs wear off quickly they have to be taken twice or three times a day. The exception is phenytoin and vigabatrin, those drugs maintain their effect longer and can be taken once daily.
4. It is important to take the medication at the same time each day. Taking it before or after a meal should not affect performance. If you miss a dose, take it as soon as you realize but do not take double dose. You should continue to take the medication as prescribed, don’t try to stop the drug by yourself. Otherwise the fits may return and even worse than before.
5. Side effects: as any other medication, anti-epileptics have some side effects. Most of the unwanted ones are proportional with large dose being taken. The symptoms produced by over dosage of these medications are: sleepiness, dizziness, feeling sick, double vision, and unsteadiness of feet, SKIN rashes and itching. These effects can be eliminated or minimized by decreasing the dose of the drug.
6. Anti-epileptics make some medications less effective than usual because they speed their breakdown in the liver . The best example of this is CCP that is why people on those medications need to increase the dose of Oestrogen pill. Also they have effect on medication that prevents blood clots (or medication that thins blood). Alcohol can reduce the effect of anti-epileptic drugs and by doing so, provokes fit in some people. Therefore alcohol consumption should be kept to a minimum. A pint of beer, 2 glasses of wine, or 2 measures of spirit should be considered the maximum alcohol intake in 24 hours.
7. Stopping the drug: the medication should be taken regularly and should not be stopped or changed abruptly. And if you will be free of fits for 2 years, we may try to stop the medication by decreasing gradually its dose. This process should be carefully planned for, because there is a chance for fits to return and unfortunately, there is no way to predict those in whom the fits may return.
8. Complementary treatment: which relieves stress and promote relaxation as yoga and hypnosis.
Is everything clear to you? Do you want me to repeat anything for you? I will bring a leaflet about anti-epileptic medication, which you can keep and read, and have a good idea about those medication.
Q.52 Epileptic patient started on carbamazepine. Counsel.
Introduction, and then you may start by saying: “I would like to have a word with you about carbamazepine, the medication you need for epilepsy (fits).
1. Aim and blood level: the aim of this medication is to control fits. It is not a cure for epilepsy. It works by abolishing or reducing the excessive electrical activity in the brain . Fits can be completely abolished in up to 80% of people with epilepsy on medication; which can be successfully withdrawn later, if the patient has epilepsy free period of 2 years. After absorption from the intestine the medication travels in the blood to reach the brain where it produces its effect. And as the rate of elimination of the drug differs from person to person, we usually measure the blood level of the medication. And according to that level we adjust the dose that suits each individual.
2. How to take it: you start by taking one tablet twice a day and it is important to take the tablet at the same time each day, say at 08:00 am and 08:00pm. After 2 weeks, start by taking 2 tablets twice a day, and then we will draw blood from you to check the blood level of the medication. This will allow us to determine the dose that you need. You should be careful to take the medication at time and don’t try to stop it, or decrease the dose by yourself, otherwise fits may return and be difficult to control. If you miss a dose just take the tablet as soon as you remember but don’t take double dose.
3. Side effects: as any other medication, this drug causes some side effects, most of which are related to intake of large doses. And can be minimized or eliminated by decreasing the dose of the drug. These side effects are, headache, dizziness, drowsiness, feeling sick, double vision, and unsteadiness of gait, SKIN rashes especially upon exposure to sun. And in few people, the drug may affect the blood cells production, which leads to recurrent fever, sore throat, mouth ulcers, widespread SKIN rashes, and bruising of SKIN . So if any of these symptoms occur, consult the doctor immediately.
4. Carbamazepine makes some medications less effective because it speeds their breakdown in the liver . The best example is CCP. That’s why people on this medication need higher dose of Oestrogen pills. Also it decreases effect of some drugs that prevent blood clotting. So it is important that your doctor knows whether you are taking such drugs or not. Alcohol can reduce the effect of carbamazepine therefore, may provoke fit. So alcohol consumption should be kept to a minimum. A pint of beer, 2 glasses of wine, 2 measures of spirit should be considered as maximal intake in 24 hours.
N.B: some over the counter drugs interact with anti-epileptic medications, so contact your doctor before buying any none-prescription drugs as well.
Offer the patient to provide a leaflet about carbamazepine, and ask if he/she understands what has been told.
Q.53, 54 A young female patient with epilepsy. Give advice about life style.
Introduction, and then you may say: “As far as I know you have epilepsy. I would like to have few words with you about a minimal change you may need to do in your life style.
1. General advice: it is a good idea to plan your day to allow enough time for work, rest and different activities. Eat regular meals, and avoid prolonged period without food. Regular pattern of sleep reduces the probability of seizures, which are more likely to happen when getting up early following late nights. Make sure that you have sufficient medication with you when you go away form home. It is a good idea to wear Medic-Alert chain or bracelet to let people know about your condition so that they can help you, also let people living with you know that you have epilepsy and teach them how to deal with seizures.
2. At home:
a. Living room: stay away from fire, and if possible choose a soft carpet. Fit safety glass in windows and doors.
b. In kitchen, don’t cook on your own. In general, microwaves are safer than cookers, but if you use cooker then use the back burners and turn the sauce pan handle towards the back of the cooker to make them less likely to knock over. Carry the plates to the pan and not vice versa. In bad room: choose a wide-low level bed.
c. In bathroom: let people, living with you, know that you will have a shower or bath, and don’t lock the door. In general, showers are safer than baths. But if you use bath, don’t have the water too hot and turn off the tap before you get in. and it is better to keep the water shallow.
d. At work: avoid works that involve operating machinery or going up to high open spaces.
e. Driving: you must not drive by law until you are one year fit free, with or without medication and you need to inform Driving and Vehicle Licensing authority.
f. Leisure time: It is a good idea to carry on sports such as jogging, tennis, basketball, and swimming. But for swimming you have to be always with a strong swimmer who can help you. Avoid being overtired, dangerous sports such as horse riding, parachuting, paragliding. As it is difficult for people to reach you when help is needed.
3. About alcohol: Same advice as in previous question.
4. TV: stay 8 feet (3m) away from screen, and 3 feet (1m) away when playing pc games.
Q.55 A patient with (COAD) chronic obstructive airway disease. Examine the respiratory system.
Introduction, then you may say: “I would like to examine your chest, would you please undress to your waist and sit on the couch”.
Inspection:
1. Hands: check for cyanosis, clubbing. (Inspect the fingers laterally, test for fluctuation of the nail bed). Check for nicotine staining, wasting of interossei, flapping TREMOR . Palpate for wrist tenderness (for arthritis of Pulmonary Osteoarthropathy), take pulse pressure and at the same time take respiratory rate (normally it is 14/min).
2. Face: Eyes: check for ptosis and constricted pupil (Horner’s syndrome). Ophthalmoscopy for dilated veins, and papillaedema of hypercapnia. Mouth and tongue: for central cyanosis.
3. Neck: examine cervical lymph nodes from behind Submental, submandibular, tonsillar, anterior triangle, supraclavicular, and scalene (at sternal head of sternocleidomastoid muscle, and ask the patient to turn head slightly to same side).
Chest:
1. Inspection: of respiration for
a. Depth.
b. Pattern (any cheyne stokes breathing, intercostals or diaphragmatic, abnormal respiration: asymmetrical, like in flail chest. Indrawing of supraclavicular, intercostals muscles, and contraction of cervical muscles).
c. Shape: increased AP diameter (barrel chest), Kyphoscoliosis, Pectus excavatum, Pectus carinatum, scar, bruises, discharging sinuses, dilated veins. (Inspect posterior chest as well).
2. Palpation:
a. Trachea. Position with index finger. Cricosternal space with 2 fingers, and normally it is 4-5cm.
b. Palpate apex beat to get idea about site of mediastinum. Palpate lightly for tenderness for FRACTURE , or for tumour or crepitus of subcutaneous emphysema.
c. Check for Chest expansion: from behind with two hands just below the scapula for symmetry and range, normally it is 5cm.
d. Check for vocal fremitus: in two different places anteriorly, posteriorly and at the axilla.
3. Percussion:
a. Anteriorly in supraclavicular, clavicular, infraclavicular, and from 2nd to 6th intercostal spaces.
b. Laterally: from axilla down for 3 intercostal spaces.
c. Posteriorly: at the apex by placing finger vertical on border of trapezius muscle medial to border of scapula at level of spine (do it 3 times).
4. Auscultation:
a. Anteriorly: supraclavicular, infraclavicular, (do it 2 times).
b. Lateraly: axilla, do it once.
c. Posteriorly: below spine of scapula, for 3 times.
N.B: Avoid auscultation within 2-3cm of midline, because sounds of bronchial vocal resonance are heard at that place.
When examining the back ask the patient to fold arms across anteriorly.
Examine bilaterally and compare.
Q.56 Teach a patient how to read Peak flow meter, and comment on results.
N.B: Peak flow meter is the instrument used to monitor the progress or response to treatment. PEER is the maximal speed in L/min which a patient can blow air out of his lung. It changes with sex, age, height, and time of the day (lowest in the morning in asthmatics).
Introduction, then you may say: “Now I would like to examine your lung function. You should stand up in order to breathe more easily. This instrument is called Peak flow meter; you should put your mouth here around mouthpiece. And catch the instrument from the side to allow the marker to slide freely. Then blow or breathe out into it sharply. This will cause the marker to fly up and show me the result which we call PEER. Please breathe out into it as hard as you can.
(After the patient breathe). Thank you, one more time please.
After breathing for second time). Thank you and for the last time.
(After breathing for the third time) Thank you.
We take the result and plot it on the chart. There are two types of charts, one for men and another for women. Each has the ho
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