3rd Year Flashcards
(68 cards)
1
Q
General Obs & NEWS chart
A
-O2 sats
-temperature
-pulse
-RR
-level of consciousness
-BP
OTHER: blood glucose (normal=3.9-5.5, 2hrs post meal <7.8), urine output= oliguria=<400ml per day, normal = ~2L/day, so around 80ml per hr)
2
Q
Prescribe fluids and interpret fluid charts
A
1) ASSESS FLUID BALANCE
- look at I/O chart
- U&E electrolytes
- patient’s volume status (ABCDE- airway, breathing- RR and O2sats, ausculate lungs, circ- pulse, BP, cap refill, JVP, D- GCS, E- wounds, drains, catheter output, peripheral oedema, fluid chart, bleeds, if <30mls/hr=oliguria, passive leg raising, orthostatic hypotension, skin turgor, dry mucous membranes
- thirst?
IF HYPOVOLAEMIA- resusciation fluids
IF EUVOLAEMIA- maintenance
HYPERVOLAEMIC- NO FLUIDS
RESUSICTATION FLUIDS
- 500ml Nacl/hartmanns over 15mins and reassess
- continue up to 2000ml
- if still hypovolaemic—> vasopressor
- consider cause- bleeding/vomiting/infection-abx?
ROUTINE MAINTENANCE
-orally is ideal
-if not and no abnormal fluid distributions then…
1. 25ml/kg/day WATER
2. 1mmol/kg/day Na/K/Cl
3. 50g/day GLUCOSE
If obsese prescribe to their ideal body weight
Cautious in elderly, renal or cardiac impairement and malnourished patients who may get refeeding syndrome
>3days move to NG fluids
REPLACEMENT/REDISTRIBUTION
-if ongoing losses, redistribution, electrolyte deficinecies
3
Q
Venepuncture
A
- intro and informed consent
- check patieng name, DOB with wristband
- hand sanitation and PPE
- clean tray
- gather equipment
- attach needle to vacuette
- position arm and attach tourniquet
- palpate veins and select one
- don gloves
- clean skin
- insert needle
- fill sample bottle
- release tourniquet and apply pressure as you remove needle
- correct disposal of waste
- clean tray and wash hands
- complete blood bottle labelling at bedside
- thank patient
4
Q
Urinalysis
A
- intro and informed consent
- wash hands and gloves
- check urine sample against patients wristband
- observe colour and clarity of sample
- check expiry date of test strips
- immerse strip in sample
- tap off excess urine
- keep strip horizontal
- compare colours at times
- dispose of waste correctly
- wash hands
Possible findings:
- nitrites = infection
- leukocytes= less strong indication of infection
- ketones= dehydration usually. DKA.
- blood = kidney stones/malignancy/nephritic syndrome
- protein= >3g = nephrotic syn, vs less than 3g = nephritic syndrome. Hypertension.
- glucose = diabetes
- dark urine= jaundice?
- frothy= nephrotic syndrome
- offensive odour= infection
- sweet odour= diabetes
- bilirubin = biliary obstruction ie pancreatic cancer,
- specific gravity- low= diabetes insipidus, ATN. High= dehydration, diabetes, nephrotic syndrome.
- pH- low= sepsis, met acidosis, DKA, starvation. High= UTI, alkalosis, diuretics
- urobilogen- increased levels- haemolysis vs decreased levels = biliary obstruction
- urinary sodium- high = diuretics, nephropathy, adrenal insufficiency vs low= GI vomiting or diarrhoea
5
Q
Injecting insulin
A
- introduce and check patient name etc
- informed consent
- full PPE
- confirms name w wristband
- check drug chart for name, dob, hospital, allergies, name and dosage of drug, mode of administration, signed and dated
- ask for drug allergies
- gather ewuipment
- check name, dosage and expiry date of insulin, inspect and swab top of insulin w alcohol wipe
- use orange insulin syringe and draw up air, inject into bottle and turn vial upside doen and withdraw correct dose
- tap out air bubbles
- remove needle
- clean injection site
- pinch skin and inject needle at 90°
- hold for 10 seconds
- dispose of sharps
- record time, date, sign in charts
6
Q
Basic life support
A
- consider safety before approaching patient
- assess response and call for help
- A- airway- head and tilt and chin lift
- Breathing/ look, listen and feel for 10 secs
- C- pulse
- call 999, cardiac arrest
- 30 compressions to 2 breathes
- defib ?
7
Q
Catheterisation
A
8
Q
ABG interpretation
A
- confirm if arterial / venous sample
- acidosis or alkalosis?
- paO2 (11-13)
- paCo2 (4.7-6)
- HCO3- (22-26
- BE (-2-+2)
- summarise findings- met/resp/mixed acidosis/alkalosis. Cause? -hypo/hyperventilation, type 1/2 resp failure, GI vomiting, diuretics, lactic acid, DKA, Conn’s etc
- also look at Cl, K,
- base excess
- anion gap
Reason is likely in Hx
Eg: post surgery complication of atelectasis/pneumonia —> V/Q mismatch type I resp failure (alongside PE and early asthma) vs late asthma is type II resp failure or normal ABG.
9
Q
Hyponatraemia management
A
- Evaluate fluid balance chart, clinical signs such as dry mucous membranes, skin turgidity, BP, JVP, are they on drugs such as SSRIs/diuretics/carbamazepine?
- Check serum osmolality
- If normal-high= hyperglycaemia, hyperlipidaemia, hyperproteinaemia, alcohol, kidney failure, hypertonic infusions
- More likely LOW SERUM OSMOLALITY- <275
- If low- assess volume status (BP, pulse, JVP, oedema
- If HYPOVOLAEMIC- 2 options: if urinary sodium is less than 15 hypoNa is due to vomiting/diarrhoea vs if urinary sodium >15, hypoNa is due to diuretics/nephropathy/adrenal insufficiency. Treatment: 1L 0.9% saline over 2-4hrs. DONT INCREASE SODIUM BY MORE THAN 12 MMOL IN 24 HOURS OR CAN CAUSE ENCEPATHOPATHY.🧠
- ISOVOLAEMIC- hypoNa due to water intoxication, SIADH (if high urine osmolality>100), hypothyroidism, kidney failure. Treatment: if asymptomatic= water restriction vs symptomatic= furosemide diuresis or hypertonic saline.
- HYPERVOLAEMIC- liver/heart/kidney failure, nephrotic syndrome. Treat: water and sodium restriction.
10
Q
Blood transfusion guidlines
A
- <65 w no CVD/CerebroVD if Hb<70
- > 65 w no underlying if Hb<80
- CVD/CBV If Hb<90
- bone marrow failure if hb <90
Plt when <10 or <20 if added risk factors, or <50 lumbar puncture/laparotomy
11
Q
Counsel patients on risks of steroid medication
A
- explain need for steroids
- explain alterantive treatments (ie- immunosupressive meds)
- explain risks (CUSHINGs)
- explain protective meds- PPIs, monitoring glucose, bisphosphonates, Ca, Vit D, co-trimoxazome prophylaxis
- give steroid alert card
- ask concerns ?
12
Q
DKA management
A
DKA is when youre…
1) DIABETIC (fasting glu>7, or 2hr post prandial >11.1)
2) KETONES >3
3) ACIDOSIS venous pH<7.3 or Hco3 <15
- ABC and IV access
- IV fluids- 0.9% NaCl at high rate except if <16yrs/pregnant/elderly/low body weight/heart or kidney failure as risk of cerebral oedema
- wait 1hr
- insulin fixed rate at 0.1units/kg/hr- draw up 50units actrapid, add to 49.5ml 0.9% NaCl in 50ml syringe so conc= 1unit/ml
- monitor potassium- if 3.5-5.5 then give 40mmol
- treat precipitating cause of DKA
- reassess- hourly glu and ketones, if CBG<14mmol/L give 10% dextrose w/ 0.9% nacl, only switch to subcutaneous insulin when ketones <0.6 mm/L
13
Q
Hypoglycaemia management
A
Mild- oral replacement of short and long acting glucose
Mod- glucose gel, IM glucagon >4mmol Glu, long acting carb
Sev- IV glucose (75ml 20% or 150ml 10%), long acting carb
14
Q
Diabetic foot exam
A
INSPECTION
-pallor, ulcers, scars, hair loss, calluses, venous guttering, charcot athropathy (fractures in bottom foot- red hot foot)
PALPATE
- TEMP
- posterior tibial and dorsalis pedis pulse
SENSATION
-pulp of hallux, 3rd digit, MTP jt 1,3,5
GAIT
+ vibration, proprioception, ankle jerk
15
Q
Hyperkalaemia management
A
1) K less than 6- stop meds
2) K more than 6 AND ECG changes (tall tented T waves, flattened p waves, broad QRS, prolonged PR) or K more than 6.5 start treatment:
- 10mls 10% Calcium gluconate over 5mins
- 10 units actrapid with 50ml 50% glucose for 5mins
- 10mg salbutamol nebs
- if still hyperK then use furosemide aswell
BEWARE OF HYPOGLYCAEMIA IF <7 THEN TREAT W 250ml 10% glucose at 50ml/hr
Potassium binder to minimise rebound hyperkalaemia
Causes
Rhabodmyolsis, tumour lysis syndrome, low insulin, addisons, acidosis, renal impairment, ace inhibitors, potassium sparing diuretics- amoliride, spironolactone, NSAIDs, B blockers
16
Q
Peripheral arterial disease exam
A
GENERAL- 1. missing limbs, 2. ulcers, skin changes, 3. pallor, cyanosis, 4. hair loss, poor wound healing, 5. muscle wasting, dependent rubor, gangrene. Midline sternotomy scar for previous CABG.
UPPER LIMB
- inspect and compare
- colour
- temp
- cap refill
- radial pulse
- radio-radial delay
- brachial pulse
- BP
CAROTID PULSE-palpate and auscultate
ABDO
- visible pulsations
- palpate
- auscultate aorta and renal arteries
L LIMBS
- inspect and compare
- colour
- temp
- cap refill
- femoral pulse
- radio-femoral
- auscultate femoral
- popliteal
- posterior tibial
- dorsalis pedis
- sensation
BUERGERS TEST- raise feet to 45°, observe colour and hang legs back down- should flood w colour again- if PAD theyll go blue initially as ischaemic tissue deoxygenates blood and then rubor as it vasodulates in respobse to waste products of anaerobic resp. Buerger angle= angle they go pale.
17
Q
CXR interpretation
A
D- details- patient, AP, Left or right, previous x ray films?
R- radiograph quality- rotation, inspiration, penetration, exposure
A- airways- trachea and bronchi
B- breathing- lung apices, pleura
C- circulation- heart
Diaphragm- costophrenic angles
Extras- bones/artefacts
White out= effusion Air bubble= GI perf- pneumoperitoneum Diffuse/localised opacification= cancwr Consolidation= infection Collapsed ling= sail sign = blackout
18
Q
AXR interpretauon
A
D- details- patient, previous films, AP/PA, erect/supine
R-radiograph quality- rotation, penetration, exposure
O- obvs abnormality- perforation/volvulus/obstruction/mass/dilatation- wider than margins ie small bowel>3cm and coiled spring appearance and possibly see fecaes in inguinal region-mottled appearance, hernias, large bowel obstruction= >6cm, sigmoid volvus= coffee bean vs caecum volvulus= fetal appearance, stricture, carcinoma. Riglers sign= double wall- free air in abdomen means bowel wall can be seen on both sides-clearly dermacated- perforation. IBS- lead pipe colon-loss of haustrations, toxic megacolon- colonic dilatation without obstruction, thumbprinting= mucosal thickening of haustra
B-bowel gas pattern- small bowel (central, 3cm), large bowel (6cm, haustrae), caecum 9cm
Organs- lungs, liver, gallbladder (calcified stones/cholecystectomy clips), stomach, psoas, kidneys, spleen, bladder
B-bones- ribs, lumbar vertebrae, coccyx, sacrum, pelvis, proximal femurs
Findings: obstruction, free air (perforation), IBD, calcifications-stones/metastases, uteric stent
19
Q
PEFR measurement
A
- intro and patient consent
- attach blue disposable mouthpiece to peak flow meter
- stand and hold horizontally
- dont place fingers over scale
- deep breath, make tight seal with lips, fast blast
- record and repeat 2 more tjmes
- record highest of 3
20
Q
GI exam
A
-intro and consent
INSPECTION (2 parts, end of bed, then full body close examination)
- end of bed-comfortable? Around bed- O2? Kidney dish? Breakfast?)
- hands (perfusion/sweaty/clubbing/nicotine/erythema/duputyrens/temp/liver flap)
- JVP
- face (jaundice, anaemia, xanthalasma, corneal arcus, central cyanosis, ulcers (eg crohns)
- scars (midline/laparotomy/appendicectomy)
- stomas
- dilated veins
- pulsations
- spider naevi
- gynaecomastia
- easy bruising
- hands for finger clubbing, palmar erythema, duputyrens contracture, liver flap, koilonychias (spoon shaped nails in anaemia), leukonychia
- face- eyes for jaundice, anaemia
PALPATE ALL NINE REGIONS
- light
- deep (press with top hand)
- palpate for liver
- palpate for spleen
- ballot kidneys
PERCUSS
- liver (if lower edge palpable- percuss from midclavicular to find upper edge)
- spleen
- fluid level if ascites- midline to flanks until dull- roll to opposite side and compare percussion
AUSCULTATE
60seconds until bowel sounds
Renal stenosis
SPECIAL TESTS
- murphy’s sign for cholecystitis - right hypochondrium-inspiration- PAIN
- Rovsing’s sign- LIF palpation= pain in RIF
- grey turners sign -flanks, cullen sign- grey umbilicus = pancreatitis necrosis
- cough test
-finsih w PR, GENITAL exam
Guarding- INVOLUNTARY contraction on palpation
Rigidity - constant contraction
Rebound tenderness
Peritonitis - perf
21
Q
Oral cavity exam
A
GENERAL INSPECTION
PALPATE
- parotid/submandibular salivary glands
- cervical lymph nodes
- temporalis and masseter
- TMJ
INTRA ORAL
- dentil hygeine
- salivary flow (glands)
- gingiva
- tongue (papillae/strawberry tongue)
- buccal mucosa- lichen planus? Ulcers? Candidias?
- hard and soft palate
- floor of mouth
- oropharynx-midline uvula?
- teeth
22
Q
PR exam
A
- intro and patient details
- INFORMED CONSENT- today i have been required to examine your back passage in regard to your …. Eg: bowel issues etc. What that will involve is me having a look around the area, asking you to bear down and then slipping a gloved finger up your back passage and feeling all 4 walls. It shouldnt be painful, but it might be uncomfortable. I will have …. here at all times as a chaperone. Does that sound okay?
INSTRUCT PATIENT
- remove underwear and put on this drape
- lie on your left side facing that wall
- bring knees up to chest
- buttocks to the edge of the bed
INSPECT
- pull cheeks apart and look for skin tags, anal fissures, haemorrhoids, chancre, warts, blood,
- ask patient to bear down (prolapse)
PALPATE
- all 4 walls
- prostate- size, consistency, edges, lobes, sulcus
- SQUEEZE
OBSERVE GLOVED FINGER FOR MELAENA/MUCOUS/PUS
CLEAN PATIENT
Thank patient
23
Q
Resp exam
A
INSPECT
- end of bed- difficulty breathing? Bedside O2? Cachexic? Pursed lip breathing? Audible noises? Wheeze? Stridor?
- hands for finger club, CO2 retention, nicotine staining, peripherla cyanosis, tremor (salbutamol)
- pulse and RR (bounding pulse in CO2 retention)
- face- central cyanosis, anaemia,
- CHEST- pectus excavatum/carinatum, spider naevi. BACK- lateral thoracotomy scar, pleural effusion scar is anywhere, chest drain scar is lower chest wall vs armpit is pneumothorax drain
PALPATION
- lymph nodes
- apex heart
- trachea (deviation) or decreased below 3 finger breadths due to COPD
- chest expansion - decreased unilaterally in pneumothorax or atelectasis
PERCUSSION
- all areas comapre right to left (rememver supraclavicular)
- avoid scapulae in posterior chest
- axillae at least 2 areas each side
- describe percussion note- resonant, dull, stony dull (pleural effusion), hyper resonant (pneumothorax)
AUSCULTATION
- all areas through open mouth
- say 99- increased vocal resonance is infection
- breath sounds present/absent—> nature of sounds (bronchial=higher pitch and louder vs normal=vesicular= lower pitch and softer), bilateral equal inspiration, extra noises- fine crepitations- sounds like velcro- fibrosis/fluid- constant in inspiration and expiration vs pneumonia/effusion only in inspiration vs coarse crepitations is big mucous infection/bronchiectasis- disappear on coughing. Wheeze? Pleural rub?
Fibrosis= progressive SOB (3-5yr mortality from diagnosis) diarrhoea if on. Ask about arthristis, occupation
24
Q
Cardiovascular exam
A
INSPECTION
- general/scars/colour
- hand signs
- peripheral pulses
- JVP
- BP
- face signs
PALPATE
- apex beat (check other side- reasons for not finding- body hiatus, emphysema, dextracardia)
- heaves (from RVH) and thrills (palpable murmurs)
AUSCULTATE
-diaphragm in mitral, tricuspid, pulmonary, aortic
-bell in mitral and tricuspid
-patient sits forward -listen to aortic and tricuspid at end of expiration
-carotids while holding breath
REMEMBER TO PALPATE CAROTIDS WHILE LISTENING
PERIPHERAL OEDEMA
Think: scar- valve ? Bypass?
Not: murmur? AF? Arrhythmia?
-murmur old is aortic stenosis or mitral regurg
-can’t feel apex go to other side
25
Eye exam
GENERAL
-eyelids, eyelashes, sclera, pupils
VISUAL FIELDS
(Each quadrant for both eyes)
EYE MOVEMENTS
-ask about double vision
LIGHT
- pupillary and consensual response
- accomodation
- swinging flashlight for relative afferent pupillary defect
FUNDSCOPY
-red reflex (if absent- cataracts/infective endopthalmitis/vitreous haemorrhage)
-cup (cup:disc =0.3, increased in glaucoma/ICP)
-colour- yellow is normal vs white atrophic optic nerve
-contour- unclear edges= neuritis/papilloedema
-macula- drusen? If cherry red spot= central retinal artery occlusion
Other findings= dot and blot haemorrhages and cotton wool spots
-temporal and nasal arcs
VISUAL ACUITY
6/60= you can see at 6m what most people can see at 60m
-best corrected w pinhole
-if can’t see then step forward then finger counting
- vitreous haemorrhage
- diabetic retinopathy
26
Ear exam
INSPECT
-scars, swelling, discharge, hearing aid
PALPATE
- lymph nodes
- external ear
WHISPER TEST
-68 for high freq vs 100 low freq
RINNES TEST
-512Hz tuning fork place on mastoid until unheard then place in front of ear, if can hear= +ve rinnes as air conduction>bone conduction (ie in sensorineural hearing loss or normal hearing) if -ve then conductive hearing loss
WEBERS
- sound equal= normal
- sounds lateralises to abnormal ear in conductive vs to normal in sensorineural
AUROSCOPE
- rest finger against face
- should be pearly grey and see malleus, transparent- if infected then non transparent, inflamed BV and bulging. If glue ear= transparent but bulging. Comment on discharge/perforation/wax/cholestoma- crust in the attic? Otosclerosis?
Would perform audiogram for hearing loss, tympanogram for absorptive frequencies - glue ear flat, negative pressure is Eustachian tube dysfunction, and CT for otosclerosis and MRI for acoustic neuroma
27
Nasal exam
INSPECT
- basal cell carcinoma- telangiectasia, pearly
- sq cell
- fracture
- inflammed
- dry skin
- blood
PALPATE
- bones
- cartilage
- infraorbital edges
NASAL AIRFLOW
mist on glass or cover one nostril and feel for airflow
AUROSCOPE
- turbinates at edges
- septum
- TRAUMA- check for septum nasal haematoma= emergency
- nasal polyps pale
Nasoendoscopy
28
Hand, wrist, elbow exam
```
INSPECT
Dorsal- nail pitting/oncholysis/infarct.
-DIP- Herberdens node
-PIP-bouchards node
-nodules
-ulnar subluxation
-Z thumb
-swan neck/boutinerres deformity
-squaring of CMC jt
-skin thinning or bruising
-rashes
-small muscle wasting
PALM- erythema, duputyrens contracture, muscle wasting, ulnar styloid swelling, dactylitis, wrist scar for CT release
ELBOW- psoriatic plaques, carrying angle (5-15° if straight it’s gun stock deformity for supracondylar fracture of humerus)
```
PALPATE- TEMP, PULSES, JTS, MUSCLES, SENSATION
PALM
-thenar and hypothenar feel and sensation
-peripheral pulses
DORSAL
-temp on forearm, wrist, MCP
-squeeze MCP
-palpate MCP PIP DIP
-radial nerve sensation on thumb and webspace
-ulnar border to elbow, lateral and medial epicondyle, olecranon, radial head and ulnar groove, biceps tendon)
MOVE
- straighten fingers
- make a fist
- flex (prayer sign)
- extension (back of hands together- phalans test for CTS and CT tap test)
- spread fingers
- grip
- pinch
- pick up coin
- flex/ex pronate/supinate elbow
Special- tinnel’s and phalens test for CTS and golfers elbow -flex and palpate medial epicondyle while flexing wrist vs tennis ebow- flex and palpate lateral epicondyle whilst extending wrist)
-hand inspect -arthritis, skin changes, PALM- palm changes, muscles, duputyrens , anaemia crease
PALPATE- temp, squeeze, C thumb, DIP and PIP
ACTIONs-
MOTOR - thumb, press hands, press wrist
SENSORY
DIP spared is rheumatoid
29
Foot and ankle exam
GAIT-limp? Heel to toe cycle? Lean to one side? Foot arch?
INSPECT
- front for scars, toe clawing, varum valgus (evert feet) vs varus (invert feet)
- side
- posterior -achilles tendon, symmetrical, tip toes
- psoriasis, alignment of toes,
- underside- callus, shoes for fit
- arch
FEEL
- temp at 3 points
- squeeze MTP
- palpate ankle, subtalar
- sensation
- pulses
MOVE
- plantar and dorsiflexion at foot and big tow
- inversion and eversion
- ACTIVE AND PASSIVE (remember to fix heel)
30
Knee exam
INSPECT
- gait
- all sides -varus/valgus
- lying down- scars, swelling, psoriasis
PALPATE
- temp
- margins (only one side at a time so you know which side gives the patient pain), tibial tuberosity, 2 joint lines, bakers cyst
- jt effusion- bulge test, patellar tap for bigger effusions
ACTIVE AND PASSIVE FLEXION
SPECIAL TESTS
- medial and lateral collaterals
- drawer test ant and pos cruciate- relax hamstrings
Differentials: OA/RA/psoriatic
- meniscal tear
- gout/pseudogout
- bakers cyst
- bursistis
- patellar tendonitis
- chondrimalacia patella- exercise overuse
- osteochondritis dessicans- clunking and locking and x ray lesions- repetitive minor damage
- ant cruciate tear
31
Hip exam
INSPECT
- gait
- front, side, back
- lying down- scars, discreptinces leg length, muscle wasting
PALPATE
- temp
- greater trochanter and inguinal area
MEASURE
-apparent and true leg length
PASSIVE MOVEMENT
- abduction
- adduction -stabilise pelvis
- flexion (knee to stomach)
- internal and external rotation (bend leg in)
SPECIAL TESTS
- trendelenberg- hip drop, fix pelvis and raise leg
- thomas test- hand under back, knee to chest, if other knee moves up- fixed flexion deformity
Further investigations:
- examine joint above and below
- neurological exam
- x ray
- aspirate?
- CT
- MRI
Differentials:
OA/RA/ank spond/malignancy/infection/fracture/perthes/developmental dysplasia/transient synovitis/slipped upper femoral disc/pagets disease/ trochanteric bursitis/labral tear/ femoral acetabular impingement
32
Shoulder ezam
INSPECT
-all sides- swelling, scars, muscle wasting, erythema
PALPATE
- temp
- bones- sternoclavicular jt, acromioclavicular jt, acromion, coracoid process, humeral head, spine of scapula
- muscles- trapezius, supra and infraspinatous, deltoid
MOVEMENTS- ACTIVE AND PASSIVE
- flexion
- extension
- abduction (fix scapula)
- adduction
- internal
- external rotation
SPECIAL
- arms above head
- thumbs up back
33
Spine exam
INSPECT
- gait
- muscle bulk, scars etc
- front, side (normal cervical lordosis, thoracic kyphosis, lumbar lordosis), back (scoliosis)
MOVEMENTS
- cervical flexion and extension
- turn head to each side
- touch ear to shoulder on each side
- touch toes-flex
- hyperextend (w support)
- arm down each side
- fix thoracolumbar spine and rotate turn round each side
SPECIAL TESTS
- Schobers- posterior superior iliac spines and mark midline- 10cm above and 5cm below- measure as they touch toes- should be more than 21cm
- Straight leg raise
34
Peripheral pulses
RADIAL-rate, rhythm (regular?) volume, character, symmetry
- radio radial delay- due to coarction of aorta/blockage
- radio femoral delay
- waterhammer pulse (rapid rising and falling- aortic regurg)
BRACHIAL
CAROTID
- volume/character- slow rising= aortic stenosis
- bruits
POPLITEAL
POSTERIOR TIBIAL
DORSALIS PEDIS
35
Neck exam
INSPECT
-lumps/scars/swelling/erythema
PALPATE
- submental
- submandibular
- parotid
- preauricular
- post auricular
- occipital
- posterior chain
- supraclavicular
- anterior chain
LUMP
- size
- consistency
- edges
- fixed/mobile
- colour
- temp
- site
- shape
36
Cranial nerves exam
CN1- OLFACTORY
smell to separate nostrils
CN II OPTIC
pupillary reflexes, fundoscopy, visual fields, acuity- eg 2 wrong letters on 6/6 line would be 6/6 (-2) if more than 2 letters wrong acuity is recorded as previous line. UA- unadided. PH- pinhole.
CN III IV VI
eye movements
III palsy will be ptosis, dilation, horizontal diplopia and in general difficulty with a lot of movements
IV will be tilt to normal side and rotational/vertical diplopia, cant look down
VI will be horizontal diplopia, cant abduct
Pause for horizontal nystagmus
CN V TRIGEMINAL
- sensation in opthalmic, maxillary, mandibular,
- corneal and jaw reflex - corneal absent in MS
- temporomanibular joint
- temporalis and massetee muscle bulk assess and palpate when contracted
- try close the open mouth
CN VII FACIAL
- symmetry of muslces, blinking, nasolabial folds and mouth
- raise eyebrows
- close eyes tightly against resistance
- blow out cheeks
- purse lips
- show me your teeth
- anterior 2/3 tongue- change in taste?
CN VIII ACOUSTIC
change in hearing
CN IX GPN and VAGUS X
- change in speech?
- cough
- position of uvula (lower motor neurone lesion of vagus causes uvula to move to unaffected side vs UMN vagus to affected side)
- observe soft palate rise on “ah”
- gag reflex on each side
- swallow
ACCESSORY CN XI
- assess muscle bulk and symmetry
- try push down shoulders (trapeziys)
- try turn head (sternocleidonastoid)
HYPOGLOSSAL CN XII
- muscle bulk symmetry fasicicukations of muscle bulk
- protrude tongue (deviation to affected side in tumour)
- tongue move side to side
- push tongue against cheek
37
Upper limb motor exam
INSPECT
- scars
- UMN: disuse atrophy, pose
- LMN: muscle wasting, fasciculation’s,
- scapular winging (long thoracic nerve)
- tremor
- face: hypomimia, Ptosis, opthalmoplegia
- tardive dyskinesia, pseudoathetosis (writhing), chorea, myoclonus
- speech
- GAIT
- PRONATOR DRIFT- close eyes and palms up
TONE
- move in random fashion
- hypertonic=umn vs hypotonia=LMN
- Spasticity= stroke, velocity dependent- worsens as velocity increases, associated with weakness, clasp knife spascity- increased then suddenly gives
- rigidity- movement disorders- cogwheel is Parkinson’s vs lead pipe=neuroleptic malignant syndrome with antipsychotics
POWER
- push down on shoulders (abduction)-C5 axillary deltoid
- push up on shoulders (adduction)- C6/7 thoracodorsal
- push in elbows- C7 radial triceps
- pull out arms (elbow flex ion) -C5/6 musculocuraneous BBC
- push down wrists while flexed (flex ion C6/7 median)
- push up wrists while extended (C6 radial)
- fingers spread (thumb abduction is median vs finger abduction is ulnar)
- grip
- UMN- weak arm extensors and weak leg flexors
- LMN- specific
CO ORDINATION
- finger from nose to my finger
- dysdiadochokinesis
REFLEXES
-biceps C5-6
Supinator c5-6
Triceps C7 C8
```
MRC MUSCLE POWER GRADING
0 total paralysis
1 flicker movement
2 movement w gravity eliminatex
3 movement against gravity, no res
4 movement against resistance, but incomplete
5 full movement
```
Reflexes: ++ brisk normal + just present +- present w reinforcement
38
Lower limb motor exam
INSPECT -pes cavus etc
WIFT- wasting, involuntary movement, fasocukations, tremor
GAIT - cerebellar- wide ataxic gait, difficulty turning vs parkinsons no arm swing, stooped, shuffling many little steps to turn. High steeping gait- foot drop- can’t use heels. Hemiparetic gait associated w stroke one leg stiffly and swings round in arc. Spastic paraparesis- both legs stiff and circumducting
ROMBERGS- positive if they fall. Shows ataxia is not due to cerebrllar dysfunction.
```
TONE
-lift leg and drop
-roll
- heel will lift off bed in increaased tone
ANKLE CLONUS
```
POWER
- press down on thigh (straight leg)- hip flexion, L1/2
- under thigh and resist me lifting leg- hip extension
- try bend knee (straight leg) -S1 hamstrings
- pull knee out (knee at 90°)- quadriceps knee extension L3/4
- press foot down - L4/5 ribialis ant
- pull foot up- S1/2
- big toe (2)
CO ORDINATION
-herl to shin
REFLEXES
- knee L3-4
- ankle S1-2
- babinski
39
Upper limb sensory exam
INSPECT - WIFT
LIGHT TOUCH -cotton wool
-demonstrate on sternum
CLOSE EYES
SHARP AND DULL
TEMP
PROPRIOCEPTION
VIBRATION 128 HZ tuning fork
DIP- when it stops vibrating
- peripheral neuropathy (diabetes alcohol) glove and stocking
- myopathy- only muscle weakness
- contralateral sensory loss- thalmic stroke lesions
40
Lower limb sensory exam
INSPECT
LIGHT TOUCH -cotton wool
-demonstrate on sternum
CLOSE EYES/ dorsal and spinothalmic
SHARP AND DULL- spinothalmic
TEMP-
PROPRIOCEPTION - dorsal
VIBRATION 128 HZ tuning fork- dorsal
DIP- when it stops vibrating
41
Full thyroid exam
INSPECT
- front and side
- swallow
- protrude tongue (if moves on tongue = thyroglossal cyst)
PALPATE
- behind- size, symmetry, consistency, masses, thrill (graves) (Adam’s apple to cricoid cartilage), separately and while swallowing- asymmetry may indicate unilateral mass) GOITRE- diffuse, uninodular, multi modular
- during swallowing (lump disappear into thorax?)
PERCUSS sternum for retrosternal extension
AUSCULTATE both lobes
PERIPHERAL SIDES
- hands- temp, tremor, erythema- HYPER, acropachy- periosteal thickening- GRAVE’s,
- pulse
- skin and hair- dry- hypo, Peaches and cream?, hyper- sweating, eyebrow loss hypo
- eyes-lid lag- delay on descent of upper eyelid, , exopthalmus from behind and side and front, lid retraction if sclera visible
- power
- reflexes
- pre tibial myxoedema- waxy discolouration graves
- proximal myopathy- hyper- stand from sitting with arms crossed
42
Examination for vertigo
EAR EXAM (peripheral causes of vertigo can cause hearing loss such as labyrinthitis and menieres can cause tinnitus)
CARDIO EXAM- rule out arrhthmias etc
```
NEURO EXAM
Dysdiadokinesis
Ataxia
Nystagymus
Intention tremor
Slurred speech
Heel shin test
(Central causes such as MS/posterior circulation stroke/cerebellum tumours/vestibular migraine)
```
SPECIAL TESTS
HINTS-distinguish peripheral vs central vertigo
HI- Head impulse test- eyes fixed on nose, jerk head to one side- if eyes saccade back to nose then vertigo = peripheral
Nystagymus- unilateral horizontal = peripheral vs bilateral vertical = central
TS- test of skew- alternately cover eyes and remain fixed on nose- if one eye drifts up or down to focus on nose= central vertigo
DIX HALL PIKE manouver will trigger nystagymus in BPPV
ROMBERG TEST OF BALANCE- stand with eyes closed
43
Varicose vein exam
INSPECT
- gait
- front and back
- lying down- colour/ankle swelling/ signs of venous insufficency- venous eczema, haemosidern deposits, lipodermatosclerosis, venous ulcers, atrophie blanche- varicose vein distribution (long saphenous =medial vs short saphenois= lateral)
PALPATE
- pulses
- varicose- phlebitis =hard and tender meaning inflammation is in superficial vein.
- saphenofemoral junction- ask to cough and if you feel it varicose is present
- DVT tenderness
SPECIAL TESTS
- elevate leg to 15° and notice rate of elptying
- perthes test= tourniquet and do heel raises- if superficial veins disappear then deep veins are functioning
- trendelenberg test- elevate leg and milk veins until empty- pressure over SFJ and make patient stand- if veins refill then incompetent valve is below SCJ
- chevriers sign- pressure on SFJ and tap vein- if thrill felt then its a varicose
Investigations
-venous duplex USS and colour doppler- 2 whooses for reflux
Surgery
- vein ligation
- foam sclerotherapy
- thermal ablation
44
Hernia exam
INSPECT
- scars (incisional hernia?)
- distension, pallor, cachexia, hernia
- COUGH IMPULSE
- POSITION- inguinal (above and medial to pubic tubercle vs femoral below and lateral) umbilical, parastomal, incisional- strangulated?
PALPATE
- irreducable/reducable
- cough impulse
- direct vs indirect inguinal hernia - compress laterally towards deep inguinal ring and hand over deep ring and ask to cough- if it reappears its direct
AUSCULTATE bowel sounds
STAND UP cough
45
Genitalia exam
INSPECT
SCARS SWELLING ERYTHEMA
-scars/swelling/warts/chancre/erythema/necrosis/lymphadenopathy
-phimosis/paraphimosis/hypospadias/varocele/hydrocele/fournieres gangrene
-on standing
PALPATE
- penis- retract foreskin, open urethral meatus to assess patency, inspect glans
- testicles- immobilise and palpate and posterolateral epidiymus- mass? (Can you get above it- if not then it may be bowel from an inguinal hernia. Is it cystic- transillumates and bulges on palpation? Solid?
- spermatic cord to deep inguinal ring
- HERNIA
Test for testicular torsion vs epipidymitis
- prehns test- elevate testes will improve pain in epididymitis
- loss of cremasteric reflex on stroking inner thigh in torsion
- transillumination
- hernia?
Chlamydia is discharge and joint pain
Gonorrhoea is atypical discharge
SWAB and
46
Breast exam
Inteo and explain and chaperone
INSPECT
- relaxed
- hands on hips (does mass move with muscle? Then its tethered)
- hands behind head
- asseymtry, scars, implants, nipple inversion, lump, discharge, erytgema, pagets disease, peau dorange
PALPATE-patient at 45°, hand above head
- one hand supports breast and other in all 4 quadrants, subareolae, tail of spence, axilla
- lymph
47
Examination of a rash/lesion
RASH
1) LOCATION- generalised/extensors/folds/flexors
2) 1° RASH- flat (macule if smal vs patch if large). Raised and no filling then papule if small and plaque if large. Raised and pus = pustule. Raised and clear filling is vesicle is small and bulla if large. Petechiae vs pupura.
SHAPE- discrete/confluent/discoid/target/annular
3) 2° features- erosions/ulcerations/scaling/lichenification/fissuring/crusting
4) symmetrical?
5) colour?
6) well or ill defined edges?
7) SOCRATES pain
8) change in rash
9)PALPATE
10) SYSTEMIC SIGNS- nails, scalp, mucosa, fever, wheeze, confusion, abdo,
```
PIGMENTED LESION
Asymmtry
Borders
Colour (more than 2 melanoma)
Diameter (<6mm melanoma)
Evolved over time
```
Differentials:
- precancerz
- cancers
- infection
- autoimmue (pemphigus/herpetiformjs)
- granulomatous (sarcoidosis/granuloma annulare/necrobiosis lipoidica)
- inflammatory (erythema nodosum associated with diseases such as bechets, erythema multiforme associated with infections sucj as hsv, lupus, dermatomyositis, psoraisis, atopic ezcema)
- non melanocytic lesions- cut cyst, seborrhoeic keratosis, sq papilloma, pyogenic granuloma, pilonidal sinus etc etc etc
Look at geeky medics
48
ECG- perform and interpret
Intro and consent
Place earth leads (red (RA) yellow (LA) green (LL) black (RL)
Place chest leads
```
V1 fourth ICS
V2
V3 between
V4 5th ICS mid clavicular
V5 ant axillary line 5th ICS
V6 mid axillary line 5th ICS
```
```
INTERPRET
1) is patient sick
2) rate (300/no. Large sqs)
3) rhythm (regular/irregular irregulat= AF vs flutter is regularly iregular)
4) P waves
5) PR interval should be 0.2 one large sqaure
6) QRS shluld be 0.1seconds half square
STEMI
QT -2 large squares
7) T waves
8) summarise abnormalities
```
Diffferentials:
- bradycardia/tachy
- sinus
- extrinsiic cause like hypoThyroidism
- inteinsic cause like sick sinus syndrome
- AV block (primary prolonged PR) secondary ( mobitz one is a dropped QRS vs II is progressively longer then dropped QRS) tertiary is random
- bune branch block
- AF
- VF
- STEMI/NSTEMI- SAY TERRITORIES. NSTEMI vs POSTERIOR STEMI? - turn ECG upside down and if it looks like STEMI it is.
- widespread changes is not stemi- saddle ST elevation is pericarditis
- wolff parkinson white Delta wave is SVT- young, fainting when exercising
- hypokalaemia U waves of vomiting or diarrhoea
49
Cardiovascular history
- chest pain
- Dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
- ankle swelling
- syncope
- intermittant claudication
50
Respiratory history
- chest pain
- cough
- haemoptysis
- sputum
- dyspnoea
- wheeze
51
Urological history
- frequency
- nocturia
- volume-polyuria/oliguria
- dysuria
- urgency
- incontinence
- terminal dribbling
- hesistency
- incomplete bladder emptying
- poor stream
- odour
- appearance
- blood
- loin or back pain
- fever
- nausea/vomiting
- change in weight
- bowel movements
- appetite
Sexual history- sexually active? STI? Discharge?
Obsteteric
Menstruation
52
Musculoskeletal history
-stiffness
-swelling
-pain
-fever
-fatigue
-eye problems
-weight loss
-recent illness
-
53
GI history
- energy levels
- cjange in weight
- change in appetite
- difficukty swallowing
- heartburn
- nausea
- distenzion
- bloating
- vomiting
- constipation/diarrhoea
- blood
- pain
- masses
- tenesmus
- fever
- jaundice etc
Urinary
Gyane
54
Headache history
Site, onset, frequency, duration, intermittant, character, radiation, secerity, exacerbating or relieving factors, associated symptoms: nahsea/vission/vomit/tired/fever/weakness/watery eyes or runny nose/rash
Special times-stress/morning/eat/menses
Change in mood
Change in speech
Lost consciousness
Seizures
55
Collapse history
BEFORE
- when where what
- prodrome- chest pain/SOB/palpitations, lightheaded, sleepy, pins and needles, nausea, photophobia, neck stiffness
- trigger? Coughing, not sleeping, dehydration, emotion, standing
DURING
- lose conscioyness
- injury
- tomgue biting, incontinence
- jerky movements
- change in colour
AFTER
- how long to recover
- confused/drowsy/ nausea/sweat/SOB/weakness
PMH- epilepsy/pacemaker/diabetes
56
Thyroid history
- lump in your neck
- SOB/didficukty swallowing/change in voice/hoarseness
- appetite
- weight
- heat and cold intolerance
- change in skin or hair or nails
- change in mood
- energy levels
- bowels
- menstruation
- tremor
- eye
- pins and needles
PMH- autoimmune diabetes coeliac RA
57
Gynae history
- duration of symptoms
- date of last period
- menarche
- duration and freq of normal periods
- bormal bloodnloss
- bleeding between oeriods
- pain associated with periods
- PMS/perimenopausal symtpms
- sexuakly active
- contraception
- pain or bleeding on sex
- discharge
Obstetric history
Smear history
PMH- thyroid/hormone problems/PCOS
58
Examination of a swollen limb
59
Explanation of how to use inhaled meds
General overview of inhaler and mouthpiece and name and purpose
Explain when to use and how many times
Rinse mouth after use
Check their understanding
Check expiry date
```
Demonstrate
-hold uoright
-remove cap
-shake well
-sit uo and tilt chin up
-breathe out
-tight seal around inhaler
-breathe in slowly as you press canister
-remove and seal lips for 10 seconds
-breThe out gently
RINSE if inhaler had steroids in it
```
Watch patient technique
Spacer device?
Potential sode effecfs- salbutamol palpitations and tremor vs steroids oral thrush
60
Glasgow coma scale
```
Best eye response
4 opens eyes spontaneously
3 response to speech
2 response to pain
1 none
```
```
Best verbal response
5 orientated
4 confused
3 inapproriate random single words
2 incomprehnesive sounds
1 none
```
Best motor respinse
6 obeys commands
5 localises pain (moves towards pain to remove it)
4 flexion withdrawal (moves away from pain)
3 abnormal flexion (decorticate- funeral position)
2 extension to pain (decerebate)
1 no response
61
Anaemia history
62
Joint injection
Inteoduce
Ezplain risks- infection bruisinh bleeding, 70% get good pain relief, watfarin ind must be >3
Halfway down patella from side inject underneath- lidocaine
Then aspirate
63
Cannulation
Intro and ask about allergies
Green is biggest, pink middle, blue small
Collect equipment (gloves, apron, tourniquet, cannula (purple small—yellow—dark blue), sterile dressing pack for sterile feild, cannula dressing, luer lock cannyla cap or extension set, gauze, 0.9% 10ml saline, 10ml syringe, alcohol swab, sharps box
Don gloves and open dressing pack- place cannula, dressing etc on feild
Prepare flush ensuring air is out
Choose vein- dorsum of hand usually
Tourniquet
Palpate vein
Clean area
Wash hands and don new gloves (DO NOT TOUCH VEIN AGAIN)
Reapply tourniquet if removed
Open cannula wings, withdraw and replace needle to allow easy movement, unscrew cal at back of cannula
Anchor vein by pulling distal to insertion site
Insert at 10-30° bevel upwards
Observe flashback
Lower cannula and insert further 2mm
Partially withdraw needle and carefully advance cannyla into vein and simultaneously withdraw introducer needle
Release tourniquet
Gauze underneath cannula to catch blood
Pressure to vein
Fully remove introducer needle
Attach luer lock to cannula
Apply adhesive strips to cannula wings
Flush and observe and palpate for swelling
Close cannuka port
Add dressing and sign dtae
64
Counselling station:
- steroid counselling
- on a new diagnosis (diabetes, PCOS, PCKS, )
- do they want a family member present
- check their understanding
- explain the condition briefly
- ask if they want to know more
- explain dangers/risks
- give advice
- give literature
65
Blood cultures
Same as taking blood except attach aerobic (blue) blood cultures bottle then anaerobic (pink)
66
NG Tube
67
ABCDE assessment
A- airway patent if talking. Open and look. Head tilt, chin lift or jaw thrust.
Oropharyngeal airway/NPA
B- RR, spo2, auscultation. ABG, CXR. Non rebreathe 15L O2 or if COPD or CO2 retention then Venturi mask.
C- pulse, blood pressure, fluid balance, cap refill. IV cannulation. Fluids.
D- AVPU. PEARL. Drugs. Glucose and ketones. CT head.
E- temp, extra exams eg PR,
68
BLS
RESPONSE- shake and ask if yes then ABCDE if no then continue
HELP
AIRWAY- on back- head tilt, chin lift and check for obstruction or jaw thrust if trauma
SIGNS OF LIFE- CAROTID PULSE, check for BREATHING- listen to mouth and look at chest, feel- 10 seconds
- pulse present but RR<12- bag valve mask 10 breaths/min
- Agonal/no breathing then
CALL RESUS OR CRASH TEAM 2222
CPR- unconscious and no breathing
30 compressions : 2 ventilations
DEFIB- attach (remove piercing£
