Download Respiratory CSL

STATION 1.
John Murphy is a 40 yr old man who has presented with
cough.
The GP has asked you to take a history from him.
EXAMINER SHEET STATION 1
STUDENT NAME____________
Inadequate Adequate
Introduces self – first and second names and role
(medical student).
Checks identity of patient
Gains consent to take history
Establishes reason for presentation
Elicits patient’s ideas, concerns and expectations.
Asks about respiratory symptoms, cough, sputum,
haemoptysis, wheeze, dyspnoea
Asks about systemic symptoms, fever, malaise,
weight loss.
Asks about duration of symptoms and diurnal
pattern
Asks about relieving and exacerbating factors
Asks about smoking
Asks about pets, exercise, cold weather impact on
symptoms
Asks about occupational exposure to dusts and
chemicals
Asks whether patient has used anything to relieve
his symptoms
Specifically asks about previous history of
respiratory illness or atopy
Specifically asks about family history of respiratory
illness or atopy
Conducts thorough review of systems
Checks history back to patient
Addresses patient concerns
Demonstrates empathy
What is most likely to be causing this patient’s symptoms?
Good
ASTHMA
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
PASS
STATION 1
PATIENT SCENARIO
You are a 40 year old man.
You have had a dry cough for the past six weeks.
It came on with a cold/ viral illness and has not cleared up.
It is worse at night and is preventing you from sleeping.
You feel a bit more short of breath than usual when you exercise and have to stop
due to the cough after a few minutes of moderate exercising eg. Brisk walking.
You have no haemoptysis and have not noticed any wheeze.
You feel well otherwise, no weight loss, a bit tired from lack of sleep.
You have tried something herbal for the cough which your wife gave you but to no
effect.
You are concerned that this could be the beginnings of Emphysema which your
father died of aged 68yrs.
You have no other symptoms.
You are a smoker 5-10 cigs per day. Have tried unsuccessfully to quit – willpower
only.
You had “a bit of asthma” as a child but “grew out of it”. No inhalers since age 10.
You have a dog which sleeps in your bedroom. You are married with 3 children, one
of whom has eczema.
You have worked in an office and have no exposure to dust etc.
You have no brothers and sisters and your mother is alive and well aged 75.
STATION 2
The GP has asked you to examine this 65 year old male Mike
Smith with left sided pleuritic chest pain for 2 days.
He has recently had a cough but otherwise has no symptoms.
He is a smoker of 10 per day and in excellent health.
Apart from asking him to identify where the pain is there is no
need to take a history.
Tell the examiner what you are looking for as you proceed.
EXAMINER SHEET : STATION 2
STUDENT NAME _______________
Inadequate
Adequate
Good
Uses hand gel.
Introduces self to patient, first and second
names and medical student.
Checks patient identity
Gains consent for examination
Asks the patient where the pain is.
General Inspection
Comments that the patient looks well, is
not tachypnoic or cyanosed and in no
distress.
Offers to check temp and resp rate
Checks pulse
Examines hands and comments on
clubbing and flap.
Checks tongue for central cyanosis
Checks for cervical LN and trachea.
Inspects the chest
Palpation – checks chest expansion
Assesses tactile vocal fremitus
Feels for chest wall tenderness at site of
pain – taking care not to hurt patient.
Percussion – elicits percussion note,
anteriorly, posteriorly and laterally,
including clavicles
Auscultation – Auscultates both lung
fields and apices.
Offers to check legs for signs of DVT.
Provides clear instructions to the patient
during the examination.
Thanks patient.
What differentials would you consider here? Suggest 3.
Muscle Strain
Rib fracture
Pneumonia/ LRTI
PE
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
PASS
STATION 3:
This is an explanation station.
Mary McCarthy is a 70 year old lady.
She came to see the GP last week with gradual onset of
breathlessness over a 3 month period.
He sent her for a CXR which has shown changes consistent with
interstitial lung disease.
He has asked you to talk to her about her CXR result and to tell
her he will be referring her to a consultant for further tests.
You may ask questions if you need further information to help
you explain the situation to her.
STATION 3
PATIENT SCENARIO
You are Mary McCarthy a 70 yr old lady.
You saw the GP last week because you have been getting more and more breathless
over the past 3 months.
You have a dry cough and thought you might have a chest infection that wasn’t
clearing.
The GP said it could be your heart and sent you for a CXR.
You are concerned and wanted to see the GP himself. Instead one of his “assistants”
comes in to see you.
Up to 3 months ago you were fit and well. Now you are breathless climbing the
stairs and on hills.
You are a non smoker.
You have no past medical history and are on no medications.
You have no symptoms other than feeling a bit tired and down in yourself due to
your breathlessness.
You worked as a secretary and then a housewife. No exposure to dust, chemicals,
mouldy hay or birds. No family history of lung disease.
You have 3 adult children who live nearby. Your husband is in good health and you
live in a bungalow.
You are cross that you are seeing a student. You are irritated at being asked the
same questions the GP has already asked you.
You want to know why you have this problem now in your lungs when you have
never been a smoker. You want to know if it will get worse or if there is treatment
available.
You want to know what kind of tests the hospital doctor will perform and are
worried at having to be admitted due to the risk of infection. “Everybody knows
hospitals are filthy”.
EXAMINER SHEET STATION 3
STUDENT NAME_____________
Inadequate Adequate Good
Introduces self, first and second name and explains
role.
Checks patient identity
Gains consent for consultation
Ascertains patients understanding of reasons for CXR
Suggests XR changes needing further investigation.
Explains reason for referral
Explains will be at clinic rather than admission
Outlines likely tests which might be done – bloods,
spirometry, CT scan, bronchoscopy and biopsy.
Suggests possibility of pulmonary fibrosis
Does not frighten the patient
Elicits patients concerns
Does not use medical jargon
Acknowledges the patients frustration
Addresses patient concerns
Demonstrates empathy
Asks about occupational exposures
Asks about farming background
Asks about other risks, birds , previous radiotherapy
Asks about medications
Checks patient understanding
Asks patient to repeat back explanation
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
.
PASS
STATION 4.
Examine the respiratory system in this 70 year old heavy smoker
with unexplained weight loss.
EXAMINER SHEET : STATION 4
STUDENT NAME _______________
Inadequate
Adequate
Good
Uses hand gel.
Introduces self to patient, first and second
names and medical student.
Checks patient identity
Gains consent for examination
General Inspection – Comments on no
cachexia, not tachypnoic or cyanosed and
in no distress. Use of accessory muscles.
Offers to check resp rate
Examines hands and comments on
clubbing and wasting of the small
muscles of the hand.
Examines for flap
Comments on pulse volume specifically
bounding pulse.
Offers to check for Horners syndrome
Checks tongue for central cyanosis
Checks for cervical LN and trachea.
Inspects the chest – comments on
hyperinflation.
Palpation – checks chest expansion
Assesses tactile vocal fremitus
Percussion – elicits percussion note,
anteriorly, posteriorly and laterally,
including clavicles
Auscultation – Auscultates both lung
fields and apices.
Provides clear instructions to the patient
during the examination.
Thanks patient.
Ask student to summarize findings on examination.
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
PASS
STATION 5
Mrs. Annie O’Sullivan is a 50 yr old woman with breathlessness
who has presented to A+E.
You are doing an attachment there and are asked by the
consultant to take her history.
STATION 5
PATIENT SCENARIO
You are Mrs. Annie O’Sullivan a 50 year old woman.
This evening while watching TV at home you became breathless over a period of a
few minutes.
You felt as though you couldn’t take a proper full breath, felt a bit faint (light
headed – as though you might pass out, black spots in front of eyes) and were
sweating. You couldn’t move and were very frightened.
Your symptoms settled gradually over half an hour but you are very concerned so
you called your friend to drive you to hospital.
You are concerned that there is something serious causing this problem.
This is the fourth such episode you have had over the past 6 weeks or so. They
generally happen in the evenings when you are sitting down relaxing.
You have no cough, no sputum, no haemoptysis, no recent surgery or immobility,
no long haul flights, no dyspnoea in between episodes.
No chest pain, occasional palpitations. No PND, no orthopnoea, no exertional
dyspnoea.
Your periods have become irregular over the past year, you now have one every 6-8
weeks and they are heavier than they used to be. You have not had any hot flushes or
sweats.
You have no significant past medical history.
You smoke 10 cigs per day. You are a non drinker.
You work as a teacher which you are finding increasingly stressful as you get older
. You are a widow with no children but you have a good social life and plenty of
friends.
Your sister has rheumatoid arthritis and has had clots in her legs.
You have no other symptoms.
EXAMINER SHEET STATION 5
STUDENT NAME____________
Inadequate Adequate
Good
Introduces self, first and second name and role
Gets consent to take history
Elicits reason for presentation
Shows empathy
Elicits patient concerns
Addresses patient concerns appropriately
Asks re temporal pattern of symptoms
Asks re severity of dyspnoea
Asks re cough, sputum, haemoptysis
Asks re palpitations, othopnoea, PND, ankleoedema
Asks re associated nausea, sweating.
Asks re smoking history
Asks re risks for DVT
Past Medical History – asks re anxiety, respiratory
problems.
Asks re medications including over the counter
preps.
Family history – elicits hx of sisters illness
SH – elicits stress in job
Systems review :Menstrual History – elicits irregular
heavy periods
Asks about symptoms of menopause – flushes and
night sweats.
Systems review- comprehensive SR.
Summarises history back to patient .
Examination of this patient was within normal limits.
List the two most likely diagnoses.
Anxiety/ Hyperventilation/ Menopause
Recurrent PE
Anaemia
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
PASS
STATION 6
James Sheehan a 19 year old male has presented to A+E with
sudden onset pleuritic chest pain 3 days after a flight.
Examine his respiratory system and tell the examiner what you
are looking for as you proceed.
EXAMINER SHEET : STATION 6
STUDENT NAME _______________
Inadequate
Adequate
Good
Uses hand gel.
Introduces self to patient, first and second
names and medical student.
Checks patient identity
Gains consent for examination
General Inspection – Comments on
patient height, tachypnoic or cyanosed
and in no distress. Use of accessory
muscles.
Offers to check resp rate
Examines hands and comments features
of Marfan’s, long thin fingers.
Offers to check pulse.
Checks tongue for central cyanosis and
looks for high arched palate.
Checks for central trachea.
Inspects the chest – comments on
absence of deformity
Palpation – checks chest expansion
Assesses tactile vocal fremitus
Percussion – elicits percussion note,
anteriorly, posteriorly and laterally,
including clavicles
Auscultation – Auscultates both lung
fields and apices.
Provides clear instructions to the patient
during the examination.
Thanks patient.
Ask student to summarize findings on examination.
Please give a global rating of this student: FAIL
BORDERLINE
Comment on strengths:
Comment on weaknesses:
PASS