Clinical Skills Flashcards

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1
Q

Shortness of Breath associated symptoms

A

RESPIRATORY and CARDIAC
> On exertion vs at rest? position? Paroxysmal nocturnal?
> + chest pain = MI, PE, infection
> + fever, chills, night sweats, weight loss = infection, cancer, emphysema
> + orthopnea, PND = CHF
> + stridor = large airway obstruction, croup
> + calf pain = deep vein thrombosis, PE
> + edema = CHF
> + cough = asthma, COPD, ILD

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2
Q

Cough associated symptoms

A

> Acute (<3wks), subacute, chronic (>8wks); time of day, exertion
+ sputum:
……… Frothy pink: Pulmonary edema
……… Rusty: pneumococcal pneumonia
……… Brown/black: chronic pneumonia, bronchitis, cancer
……… Yellow/green: CF, acute infection, lung abcess
……… Red jelly: Klebsiella infection
……… Blood: TB, cancer, PE
+ SOB = asthma, COPD, ILD
+ worse at night = CHF
+ Sour taste in mouth = GERD
+ Fever, weight loss, voice horsness = RED FLAGS
+ Brassy/barky cough = croup

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3
Q

Hoarsness associated symptoms

A

>

  • Worse in the cold = asthma
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4
Q

Chest pain/tightness associated symptoms

A

Tightness = angina
Tearing/ripping pain (& back pain) = aortic dissection
> + Relieved promptly by nitroglycerin = angina
> + Better leaning forward = pericarditis
> + Worse on inspiration & stabbing pain = PE, pericarditis, pneumonia, pneumothorax, rib fracture
> + Worse with palpation = rib fracture, costochondritis
> + pain shooting down arms = MI

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5
Q

Stridor associated symtoms

A

>

  • during inspiration = foreign body extra-thoracic
  • Soft sound = epiglottitis
  • Harsh = viral upper respiratory tract infection
  • Brassy/barky cough = croup
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6
Q

Can’t miss diagnosis of chest pain

A

P → Pulmonary embolism: pleuritic chest pain, increased HR, SOB
E → Esophageal rupture: vomiting, epigastric pain, anxiety
T → Tension pneumothorax: tracheal deviation, sudden SOB, PCP
M → MI: retrosternal chest pain, radiating to arms/jaw, sweaty, low BP
A → Aortic dissection/rupture: tearing, upper back pain, BP diff right and left
C → Cardiac tamponade: SOB, Beck’s triad (low BP, JVD, muffled heart sounds)

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7
Q

Beck’s triad

A
  1. Low BP
  2. JVD
  3. Muffled heart sounds

CARDIAC TAMPONADE

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8
Q

Respiratory Exam

A

—INSPECTION—

> Work of breathing:
→ tripod, pursed lips
→ nasal flaring
→ accessory muscles
→ paradoxical breathing
→ tracheal tug
→ suprasternal
→ intercostal indrawing
→ able to complete sentences

> Rhythm of breathing:
→ Cheyne stokes: periodic breathing, gradually slower (CHF, ICP, CO poisoning
→ Kussmaul: rapid, deep laboured breathing (metabolic acidosis, DM)
→ Shallow: inhibited breathing (+ pleuritic chest pain = PE, pericarditis, pneumonia, rib fracture)
→ Cushing’s triad: irregular respiration, bradycardia, widened pulse pressure

> Assistive Equipment
Scars, medical devices
Cachexia and sarcopenia (muscle wasting)
Barrel chest, flail chest
Pectus excavatum, carinatum
Scoliosis, kyphosis
Central cyanosis
Peripheral cyanosis
Clubbing (chronic hypoxia, cyanotic heart disease, lung cancer, ILD)
Tar staining

—PALPATION—
>Laryngeal height (<4cm = hyperinflation)
>General (masses)
>Bilateral chest expansion (low in asthma, COPD, thoracic scoliosis)
>Tracheal deviation (away from pathology = tension, toward = collapse)
>Tactile fremitus (vibration high over consolidation, low over pleural effusion)

—PERCUSSION—
>Intercostal
>Diaphragmatic excursion

—AUSCULTATION—
>General
>Consolidation
>Forced expiration time (>9sec = COPD, asthma)

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9
Q

Rhythms of Breathing

A

→ Cheyne stokes: periodic breathing, gradually slower (CHF, ICP, CO poisoning
→ Kussmaul: rapid, deep laboured breathing (metabolic acidosis, DM)
→ Shallow: inhibited breathing (+ pleuritic chest pain = PE, pericarditis, pneumonia, rib fracture)

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10
Q

Cushing’s triad

A
  1. irregular respiration
  2. bradycardia
  3. widened pulse pressure
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11
Q

Resp sounds

A

FINE CRACKLES: on inspiration → distal lower process (fibrosis, CHF)

COARSE CRACKLES: on inspiration →proximal lower process (pneumonia, pulmonary edema, adult RDS)

STRIDOR: on inspiration → upper obstruction (croup, epiglottitis, bacterial tracheitis, retropharyngeal abscess, peritonsullar abscess, foreign body)

PLEURAL RUB: on expiration → pleural inflammation (effusion, PE, pleuritis)

WHEEZE: on expiration → lower distal airway diameter (asthma, COPD)

RHONCUS: on expiration → lower proximal airway diameter by mucus (pneumonia, CF)

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12
Q

Palpitations associated symptoms

A

**DDx: cardiac arrhythias, sinus tachycardia

>

  • affected by sleeping = vagal tone-mediated Afib or long-QT syndrome
  • Duration <5min = low likelihood arrhythmia
  • Regular rapid-pounding sensation in neck = cardiac arrhythmia, AVNRT
  • drugs that prolong QT = anti-arrhythmatics, antihistaminses, anti-depressants
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13
Q

Fatigue associated symptoms

A

>

  • muscle weakness = neuromuscular etiology?
  • acute infectious symptoms = influenza, EBV mononucleosis
  • mood changes = psychiatric causes, depression
  • unintentional weight loss = cancer
  • hematological questions:
    ……. Adequate oxygenation: energy, SOB, exertional capacity, skin/colour changes, menorrhagia, trauma, easy bruising
    ……. Blood loss: hematemesis, hemoptysis, hematochezia, melena, hematuria, menorrhagia, trauma, easy bruising
    ……. Hematological-oncology: constitutional symptoms
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14
Q

Cardiac Exam

A

—INSPECTION—

> General: resp distress, diaphoresis, weight, consciousness, scars, pacemaker

> Eyes: conjunctiva pallor, icterus, arcus senilus (hyslipidemia)

> Head: pallor, central cyanosis

> Hands: splinter hemorrhages, janeway lesions, osler nodes, resp, cap refill, tremor (thyrotoxicosis)

> JVP: occludable, non-palapble, biphasic, low with elevation, high with AJR

> Abdomin: ascites, pulsations, scars

> Legs: edema, erythema, sacrs, vascular insufficiency

> Xanthoma: yellow deposits (hyperlipidemia)

> Coagulopathy: hematomas (petechiea, purpura, ecchymosis, telangiectasis)

—PALPATION—

> AJR
heaves, thrills
PMI (location, amplitude, duration, size; lean forward, left side)
Edema
Central and upper limb pulses

—AUSCULTATION—

> CV: S3 “montreal” loose & high volume; S4 “toronto” stiff & high pressure
Carotid bruits: duration, intensity, pitch
*Carotid upstroke: no delay between murmur onselt and carotid pusle (aortic stenosis or regurgitation)

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15
Q

Head and neck exam

A
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16
Q

Peripheral Vascular Exam

A
17
Q

Volume status exam

A

—INSPECTION—
>Mental status (person, place, time)
>Work of breathing
>Sunken eyes
>Central cyanosis, mucous membranes, longitudinal tongue furrows

—PALPATION—
>Skin turgur, cap refill, temperature
>radial pulse
>edema, tempertature
>distal pulses
>dry axilla
>carotid pusle, JVP, AJR

—AUSCULTATION—
>Resp
>Cardio

18
Q

Hypervolemia associated symptoms

A

>

  • SOB, orthopnea, PND, edema = CHF

>

  • Oliguria/anuria, insomnia, pruritus, fatigue, nausea/vomiting, weight loss = renal failure

>

  • Frothy urine, ascites, thrombotic events, recent infect = nephrotic synd

>

  • weakness, fatigue, weight loss, anorexia, bruising, jaundice = liver cirrhosis
19
Q

Hypovolemia associated symptoms

A

>

  • hematochezia, bright red blood per rectum = lower GI bleed

>

  • melena stools, hematemesis = upper GI bleed

>

  • recurrent diarrhea/vomiting, recent antibiotics = C. diff

>

  • recent infection = sepsis

>

  • trauma = traumatic brain injury, spinal injury

>

  • liver disease = hypoalbuminemia decreasing oncotic pressure

>

  • low sodium/fluid diet = insufficient intake
20
Q

Kidney Exam

A

—PALPATION—

> Ballottement of the kidneys
Costovertebral angle tenderness
Bladder palpation

—AUSCULTATION—

> Abdominal bruits

21
Q

Urinary changes associated symptoms

A

—UTI—
Frequency
Urgency
Nocturia
Dysuria

—BPH—
Weak
Intermittent
Straining
Emptying (incomplete)

—GENERAL—
Amount: low (AKI, shock, obstruction) or high (DM, primary polydipsia)
Blood: with no pain = bladder cancer
Colour: frothy (proteinuria), dark (glomerulonephrotos)
Catheter: UTI
Odour: UTI

22
Q

Flank pain differential

A

Pyelonephritis: fever, night sweats, chills, malaise

Nephrolithiasis: progressivley worsening, unilateral, colicky pain, hematuria, nausea/vomiting, dysuria, urgency

Pancreatitis

Bowel obstruction

Abdominal aortic aneurysm

23
Q

Right upper quadrant pain

A
  • Liver
  • Gallbladder (collisistitis)
  • Kidneys (stones, UTI)
24
Q

Right lower quadrant pain

A
  • Inguinal hernia
  • Appendicitis
  • Bowel obstruction
  • Perferation
  • Ovarian cyst rupture
  • Ectopic pregnancy
  • Ureteric stone
  • PID
  • Endometriosis
  • Ovarian torsion
25
Q

Acute female pelvic pain differential

A
  • Pregnancy
  • Bilateral: pelvic inflammatory disease (onset after menses, worse with jarring movements, pain with intercourse)
  • Unilateral: ruptured, ovarian cyst, ovarian torsion, ectopic, nephrolithiasis, pyelonephritis, inguinal hernia
    … > Left: diverticulitis
    … > Right: appendicitis
26
Q

Acute male pelvic pain differential

A
  • Epididymitis: inflammation of tube at back of testicle (focal pain)
  • Testicular torsion (diffuse pain)
  • Acute bacterial prostatitis ( + constitutional symptoms)
27
Q

Lymph nodes

A
  • Occipital
  • Pre-auricular
  • Post- aurcular
  • Parotid (jawbone corner)
  • Tonsillar
  • Submandibular (mono, pharyngitis, laryngitis, sinusitis)
  • Submental (mono, EBV)
  • Superficial posterior cervical (TB, lymphoma, head+neck cancer)
  • Superficial and deep anterior cervical (pharyngitis, mono)
  • Supraclavicular (right: lung cancer, gastric cancer, retroperitoneal cancer; left: lymph, thoracic, retroperitoneal cancer, infection)
  • Sub-clavicular
  • Axillary (lateral, medial, anterior, posterior, central, apical, deep)
  • Epitrochlear (medial elbow)
  • Ingiunal
  • Popliteal

SIZE <1cm
SHAPE regular borders
TENDERNESS not
CONSISTENCY soft
MOBILITY mobile

**hard and immobile = call oncology

28
Q

Palpable lymph nodes DDx

A

Infection = palpable, enlarged, tender, soft, mobile

Malignancy = palpable, enlarged, hard, non-tender, non-mobile

29
Q

Virchow’s node

A

Left supraclavicular lymphadenopathy

  • Classically represents abdominal cancer metastasis, though may also be seen in non-GI malignancies (breast, pelvic, lymphoma)