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Cardiovascular Examination Muhammed Akunjee and Nazmul Akunjee GP Principals, London, UK Zeshaan Maan, Surgical Trainee, London, UK and Mina Ally Foundation Doctor, Dartford, UK © Scion Publishing Ltd, 2012 ISBN 978 1 904842 78 1 First published in 2012 All rights reserved. No part of this book may be reproduced or transmitted, in any form or by any means, without permission. A CIP catalogue record for this book is available from the British Library. Scion Publishing Limited The Old Hayloft, Vantage Business Park, Bloxham Road, Banbury, Oxfordshire OX16 9UX www.scionpublishing.com Important Note from the Publisher The information contained within this book was obtained by Scion Publishing Limited from sources believed by us to be reliable. However, while every effort has been made to ensure its accuracy, no responsibility for loss or injury whatsoever occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the authors or publishers. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention. Readers should remember that medicine is a constantly evolving science and while the authors and publishers have ensured that all dosages, applications and practices are based on current indications, there may be specific practices which differ between communities. You should always follow the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which you are practising. Artwork by Nazmul Akunjee, London, UK Cover design by amdesign, Banbury, UK Typeset by Manila Typesetting Company, Philippines Printed by MPG Books Group, UK Contents Foreword vii Preface viii About the authors ix Acknowledgments x Abbreviations xi Section 1 – History taking skills 1.1 Chest pain 1 1.2 History of palpitations 9 1.3 Shortness of breath 15 1.4 Cough 22 1.5 Abdominal pain 28 1.6 Nausea and vomiting 35 1.7 Dysphagia 42 1.8 Jaundice 48 1.9 Haematuria 54 1.10 Headache 59 1.11 Loss of consciousness 67 1.12 Loss of vision 73 1.13 Red eye 79 1.14 Hearing loss 85 1.15 Depression 91 1.16 Suicide risk assessment 98 1.17 Alcohol 105 1.18 Psychosis 113 Section 2 – Examinations 2.1 Cardiovascular examination 121 2.2 Respiratory examination 135 2.3 Abdomen examination 146 2.4 Inguinal scrotal examination 157 2.5 Rectal examination 165 2.6 Cranial nerves examination 171 2.7 Upper limb motor examination 180 2.8 Lower limb motor examination 188 2.9 Upper limb sensory examination 195 2.10 Lower limb sensory examination 202 2.11 Gait and co-ordination 206 2.12 Eye examination 215 2.13 Ear examination 226 2.14 Peripheral vascular examination: arterial 233 2.15 Peripheral vascular examination: venous 239 2.16 Examination of a lump 245 2.17 Thyroid examination 252 2.18 Lymph nodes examination 259 vi | Contents Section 3 – Procedures 3.1 Hand washing 267 3.2 Surgical scrubbing 272 3.3 Wound swabbing 276 3.4 Taking a blood pressure 280 3.5 Body mass index 287 3.6 Recording an ECG 293 3.7 Measuring blood glucose 306 3.8 Urine dip testing 313 3.9 Venepuncture 319 3.10 Blood cultures 326 3.11 Cannulation and IV infusion 330 3.12 Blood transfusion 336 3.13 Peak flow meter explanation 342 3.14 Inhaler explanation 347 3.15 Spacer device explanation 352 3.16 Setting up a nebulizer 356 3.17 Arterial blood gas sampling and analysis 360 3.18 Nasogastric intubation 367 3.19 Male catheterization 373 Answers to Common clinical scenarios 379 Index 385 Foreword It is often said within medical education that ‘assessment drives learning’. This means that regardless of what a student has been taught throughout the year, they will focus on those topics that actually come up in the exam at the end of the year. With the widespread uptake of OSCEs in medical schools to assess clinical skills, students have now adapted accordingly. All across the world students walk into cubicles on exam day and mindlessly repeat ‘I would like to wash my hands’ before being told it is unnecessary. They will religiously chant ‘There is no clubbing or cyanosis’, while ignoring the patient’s amputated digit. The focused, snapshot style of the OSCE has made many students perform in an artificial and robotic way. This style is reinforced by the many exam-oriented ‘Pass MBBS!’ books available on the market, books that tell students the ‘secrets’ of what to say to get through the exam. Medical educators across the world are increasingly recognizing this problem, and are trying to find ways to avoid such checklist-induced performances. Given this background, this book, Clinical Skills Explained comes as a timely and welcome breath of fresh air. The philosophy behind this book is that there is more to learning clinical skills that simply ticking off boxes on a checklist. At the same time students must learn within a context and style that enables them to do well in their exams. It bridges the gap between the detailed textbooks on physical examination and the books on how to ‘do’ OSCEs. Students can learn clinical examination in a natural and practical way, whilst at the same time developing their awareness of what they need to be able to do to pass their clinical exams. The authors are talented at summarizing what one needs to know in clear, simple language. The colourful diagrams and summary boxes make quick review and revision much easier. Medical students in their early years will benefit greatly from the integrated approach that these doctors have used in this handbook. With a bit of luck, this integrated approach will eventually find its way into the OSCEs themselves. At that point both our teaching and assessment will realign to what they are originally supposed to do: produce good doctors. Dr Deen M Mirza Assistant Professor Family Medicine, UAE University GP Appraiser (Sutton and Merton PCT) International Editor for the London Journal of Primary Care Preface Medical school education has undergone a number of evolutionary changes in the past few decades. Gone are the days of didactic, lecture-based pre-clinical teaching held in constrained lecture theatres, detached from day to day clinical practice. Replacing this is a new integrated curriculum allowing for hands-on practical and clinical skills experience right from the outset. The examination process has also changed to reflect this, with Objective Structured Clinical Examination (OSCE) stations substituting the now defunct subjective vivas that more often than not were based on chance rather than individual skill and knowledge. Unfortunately, the OSCE system has not necessarily been the perfect replacement for vivas. Increasingly, medical educators are realizing that a generation of student doctors are now focusing more on how to pass exams rather than how to be good clinicians. Their efforts and knowledge are concentrated more on shortcuts that may be crammed just prior to the examinations rather than actually knowing what they are doing, why they are doing it and its implications. Many students are beginning to fear opening up the large textbooks that contain much detail on aetiology, physiology and pathology, preferring the short, sharp crash course-esque books on how to pass exams. Clinical Skills Explained endeavours to try and bridge between these two approaches. As the name suggests, it aims to explain the complexities of the common medical skills, examinations and procedures that doctors will be employing on a regular basis and attempts to clarify the rationale behind each task. It has been designed and formatted in an easily understandable way, peppered with useful information such as top tips, colourful pictures, the latest medical guidelines and then common case scenarios to revise and test your understanding. Each chapter is presented with background knowledge and relevant pathophysiology before moving on to a comprehensive systematic approach on how to tackle the skill at hand. We have written the book to cover the essential topics and common skills that you would be expected to face in the first three clinical years at medical school. Hence, we have intentionally left out skills such as female catheterization, setting up a syringe driver, breast examination, injection techniques etc. such that the book neither becomes too cumbersome, nor irrelevant to the course material tested in the earlier clinical years. We hope that Clinical Skills Explained will be a valuable text that will accompany you on your clinical journey throughout the years of medical school. We believe that it will help you excel in your exams and also go on to be not only a competent, but a distinguished medical practitioner. Muhammed Akunjee and Nazmul Akunjee London, December 2011 About the authors Dr Muhammed Akunjee (MBBS, MRCGP, PGCME, PGCDM) is currently a GP Principal in North London (since 2007) and Clinical Director for the local PCT. He qualified from Guy’s, Kings and St. Thomas’s Medical School in 2002 and completed his MRCGP gaining a distinction in 2006. During this time he was also awarded first prize for the Roche / RCGP Registrar award. As an undergraduate he was awarded the War Memorial Prize and distinction in Psychology / Sociology. He was also awarded a number of bursaries and research awards including the Leukaemia Research Fund Bursary, the Rayne Institute Research Prize, the British Medical & Dental Student’s Fund Bursary, and the King’s College Lightfoot Award. Dr Akunjee is actively involved in medical student teaching and is currently a clinical skills tutor as well as an OSCE examiner at a London university.
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