General Approach To Combined stations (examination & procedures) Flashcards
Why is it important to recognise combined stations early?
- They require a
different approachto simple consultations; -
If not recognised early you run the risk of your history being too long at the expense of the
examination / procedure and managementportion of the consultation.
How to recognise a combined station?
► Bottom of the task:
* May ask to perform a relevant examination / procedure;
* Very often it won't tell you!!!
► Look at your surroundings after entering the station:
* Search for manikins;
* Eye and ears manikins may be uncovered;
* Other types of manikins may be covered with blue drapes (easy to miss it)!
► Familiarity with cases:
* Know which manikins topics are tested;
* Organise it according to manikins types;
* Organise it according to presenting complaints.
How to approach a combined EXAMINATION station?
3-3-2
◉ History ➔ 3 mins
➜ DDX (focus on):
* 1-2 (red flags) not to miss conditions;
* 1-2 common conditions;
◉ Examination ➔ 3 mins:
* Explain the examination and what it involves;
* Get consent;
* Request a chaperone;
* Preparations (exposure/positioning/etc..);
* Performing the examination.
◉ Management ➔ 2 mins:
* When the bell rings at the 6 minute mark return to your seat!!!
* Address 2 key themes in the scenario.
FOCUS!!
Do not ask questions if you don’t know why you are asking it.
Preparation e.g.:
* Empty bladder;
* Eye drops.
How to approach a combined PROCEDURE station?
2-4-2
◉ History ➔ 2 mins
* Build rapport briefly (talk briefly);
* Go straight into explaining the procedure;
* Do pre-procedure checks;
◉ Procedure ➔ 4 mins:
* There is more of a practical focus that is why more time is needed.
◉ Management ➔ 2 mins:
* When the bell rings at the 6 minute mark return to your seat!!!
* Address 2 key themes in the scenario.
FOCUS!!
Do not ask questions if you don’t know why you are asking it.
Verbalising VS performing the actual EXAMINATION in a combined station?
The following should be verbalised:
➔Basic observations:
- BP
- HR
- SPO₂
- Temperature
- +/- BMI
➔ Other specific examinations:
- Relevant systems or body parts
➔ Bedside tests:
- ECG
- Urine dipstick
- Urinary pregnacy test
- Capilary glucose
- Peak flow
- Bilirubinometer
In a combined station, it’s not needed to perform all examinations, just the specific examination related to the manikin provided, the rest of the examinations should be verbalised.
Examination
Describe how to perform an abdominal EXAMINATION.
Examination:
- Inspection
- Palpation
- Percurssion
- Auscultation
Relevant test’s:
- Murphys sign in suspected gallblader disease (billiary colic, cholecystitis, cholangitis);
- Rebound tenderness and Rovsing's sign in suspected appendicitis;
- Shifting dullness for abdominal swellings (heart failure, liver cirrhosis, ovarian ca);
- Palpation for expansile epigastric mass in suspected AAA.
Verbalise these tests
- ECG
- Urine dipstick
- Pregnancy test (women of reproductive age)
The examiner may provide you with verbalised test results that will aid in diagnosis and management.
What are the steps of an abdominal examination?
• Inspection
• Palpation
• Percussion
• Auscultation
Describe the step by step of INSPECTION of the abdominal examination.
With patient lying flat on the bed with arms by their side and legs uncrossed.
Check for:
• Scars (midline, paramedian, pararectal, transverse, others);
• Striae (ascites, intrabdominal malignancy, Cushing’s syndrome, obesity, pregnancy);
• Abdominal distension (fat, fluid, flatus, faeces, fetus or fulminant mass);
• Caput medusae: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis);
• Hernias: ask the patient to cough and observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).
• Cullen’s sign: bruising of the tissue surrounding the umbilicus associated with haemorrhagic pancreatitis (a late sign).
• Grey-Turner’s sign: bruising in the flanks associated with haemorrhagic pancreatitis (a late sign).
• Stomas: if present assess the location, contents and consistency of stool.
Describe the step by step of PALPATION of the abdominal examination.
- Ask if they have pain, palpate those areas last;
- Observe the face for discomfort;
LIGHT PALPATION
• Tenderness (where and grade of pain);
• Rebound tenderness (peritonitis due to appendicitis, etc);
• Voluntary guarding;
• Involuntary guarding/rigidity (associated with peritonitis e.g. appendicitis, diverticulitis);
• Rovsing’s sign: palpation of the left iliac fossa causes pain to be experienced in the right iliac fossa (indicates peritoneal inflammation of any cause affecting the left and/or right iliac fossa);
• Masses;
DEEP PALPATION
If any masses are identified during deep palpation, assess the following characteristics
• Location;
• Size and shape;
• Consistency (smooth, soft, hard, irregular);
• Mobility;
• Pulsatility (e.g. abdominal aortic aneurysm);
PALPATE THE LIVER
• Start at the right iliac fossa;
• Ask patient to take deep breath and as they begin to do this palpate the abdomen. If present the liver should be felt during inspiration.
• Observe the degree of extension below the costal margin (if present);
• Consistency (if hepatomegaly present) of the liver edge nodular = liver cirrhosis)
• Tenderness: hepatitis or cholecystitis (as you may be palpating the gallbladder);
• Pulsatility: pulsatile hepatomegaly is associated with tricuspid regurgitation.
PALPATE THE GALLBLADDER
• In healthy individuals, the gallbladder is not usually palpable. If the gallbladder is palpable it suggests enlargement secondary to biliary flow obstruction (e.g. pancreatic malignancy, gallstones) and/or infection (e.g. cholecystitis).
• Palpate on the right costal margin in the mid-clavicular line. • If the gallbladder is enlarged, a well-defined round mass that moves with respiration may be noted.
• Tenderness suggests a diagnosis of cholecystitis whereas a distended painless gallbladder may indicate underlying pancreatic cancer (particularly if also associated with jaundice).
• Murphy’s sign: Position your fingers at the right costal margin in the mid-clavicular line at the liver’s edge. Ask the patient to take a deep breath. If the patient suddenly stops mid-breath due to pain, this suggests the presence of cholecystitis;
PALPATE THE SPLEEN
In healthy individuals, you should not be able to palpate the spleen. A palpable spleen at the edge of the left costal margin would suggest splenomegaly
• Begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine;
• Ask the patient to take a deep breath and as they begin to do this palpate the abdomen with your fingers aligned with the left costal margin. Feel for a step as the splenic edge passes below your hand during inspiration;
• Repeat this process of palpation moving 1-2 cm superiorly from the right iliac fossa each time towards the left costal margin.
BALLOT THE KIDNEYS
• In healthy individuals, the kidneys are not usually ballotable, however, in patients with a low body mass index, the inferior pole can sometimes be palpated during inspiration.
PALPATE THE AORTA
• In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
• If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).
PALPATE THE BLADDER
• A distended bladder can be palpated in the suprapubic area arising from behind the pubic symphysis (e.g. urinary obstruction/retention).
Describe the step by step of the abdominal PERCUSSION examination.
PERCUSS THE LIVER
• Percuss from the right iliac fossa upwards until both inferior and upper border are localised (resonant to dull);
PERCUSS THE SPLEEN
• If on palpation splenomegaly is felt only.
PERCUSS THE BLADDER
• Percuss downwards in the midline from the umbilical region towards the pubic symphysis. A distended bladder will be dull to percussion.
ASSESS SHIFTING DULLNESS
• Percussion can also be used to assess for the presence of ascites by identifying shifting dullness.
Describe the step by step of the abdominal AUSCULTATION examination.
BOWEL SOUNDS
Auscultate over at least two positions on the abdomen to assess bowel sounds.
• Normal bowel sounds: typically described as gurgling;
• Tinkling bowel sounds: typically associated with bowel obstruction.
• Absent bowel sounds: suggests ileus.
BRUITS
Auscultate over the aorta and renal arteries to identify vascular bruits suggestive of turbulent blood flow:
• Aortic bruits: auscultate 1-2 cm superior to the umbilicus, a bruit here may be associated with an abdominal aortic aneurysm.
• Renal bruits: auscultate 1-2 cm superior to the umbilicus and slightly lateral to the midline on each side. A bruit in this location may be associated with renal artery stenosis.
Describe the steps of the abdominal examination?
- Inspection
- Palpation
- Percussion
- Auscultation
- Relevant special tests:
- Murphys sign:
• In suspected gallbladder disease (biliary colic, cholecystitis, cholangitis).
• Rebound tenderness + Rovsing’s sign (in suspected appendicitis).
• Shifting dullness for abdominal swellings (liver cirrhosis, heart failure, ovarian cancer).
• Palpation for expansive epigastric mass (suspected AAA).
On the combined stations for abdominal examination, which bedside tests should be verbalised/requested?
• ECG
• Urine dipstick
• Pregnancy test for women of reproductive age
Describe the steps for the eye examination.
- Inspection of front of the eye + Fundoscopy.
- +/- visual acuity.
- +/- visual fields.
You should verbalise the full eye examination.
• Front of the eye — Torch / slit lamp.
• Back of the eye — Fundoscopy (“using this special instrument”).
• Visual acuity (“how far you can see”).
• Visual fields (“how wide you can see”).
• Pressure of the eyes — Tono pen.
In the IIH station, assume you have to examine both eyes (unless told otherwise).
Describe the steps of the “ear examination”.
- Inspection
- Palpation (including tragos test)
- Otoscopy
- +/- tuning fork tests
