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osce > Osce Fall 2018 > Flashcards

Osce Fall 2018 Flashcards

1
Q

What woudl you include on auscultation from a respiratory perspecitve?

A
  • breath sounds = comment on quality (vesicular, bronchial, intensity) - take deep breaths through an OPEN mouth
  • added sounds - wheeze, crepitations,
  • vocal resonance (say 99 over and over as you listen to the lung fields) -in consolidation, this would be increased
    *
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2
Q

how should a patient be exposed for a peripheral venous examination

A
  • exposed in shorts that able to still examine the femoral pulse
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3
Q

What should you include on your inspection from a peripheral venous examination perspective?

A
  • varicose veins
  • signs of progressive chronic venous insufficiency
    • oedema
    • venous eczema
    • ulceration
      *
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4
Q

Intro for any exam

A
  1. wash hands
  2. introduce yourself
  3. position
  4. expose
  5. explain the procedure
  6. ask if they are sore anywhere
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5
Q

how should you expose a patient for a respiratory examination?

A

45 degrees - shirt off

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6
Q

Inspect the chest from a cardiovascular perspective

A
  • visible heave (apical= left ventricular hypertrophy, or parasternal = right ventricular hypertrophy)
  • scars: pacemaker/ICD - under either clavicles - may be an obvious underlying lump
    • midline sternotopy (cabg, or valve replacement)
    • left submamammy (mitral valvotomy, pericardial window)
    • legs (vein harvesting)
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7
Q

Auscultate from a cardiovascular perspective

A
  • 4 primary valve areas
  • areas of murmur radiation (axilla, carotid)
  • manoeuvers to amplify diagnostic murmurs (inspiration, lean forward etc)
  • auscultate lung bases for crepitations (left heart failure
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8
Q

what should you include on palpation from a respiratory perspective?

A
  • chest expansion (symmetry)
  • apex beat (paricularly lateral/medial displacement) -may be due to mediastinal shift in pneumothorax, tension pneumothoraxis, or big pleural effusion
  • RV heave (cor pulmonale)
  • Tactile vocal fremitus (anterior and posterior chest)
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9
Q

what should you palpate for in a peripheral venous exam?

A
  • skin texture for lipodermatosclerosis - hard/woody texture
  • calf tenderness (DVT)
  • varicose veins: tenderness, temperature (warm)
  • saphenofemoral incompetence: locate pubic tubercle, approximately 2 cm inferior/lateral- feel for hernia
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10
Q

how would you conclude a cardiovascular examination

A
  • wash hands
  • review observation chart- HR, BP, RR, SpO2, temp
  • review abdomen for AAA and ascites
  • examine peripheral pulses
  • investigations = ECG, CXR, echocardiogram, urinalysis
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11
Q

assess Pulses from peripheral vascular disease perspective

A

always move from proximal to distal

assess rate, rhythm, character, and symmetry - move from side to side

  1. femoral- half way between ASIS and pubic symphysis, below inguinal ligament
  2. popliteal - flex knee to 30 degrees and grasp with both hands, thumbs in front
  3. posterior tibial = behind medial maleolus
  4. dorsalis pedis = between bases of 1st and 2nd metatarsals
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12
Q

Perform a close inspection from a cardiovascular perspective

A
  • hands:
    • temperature and cap refill (should be 1-2 s)
    • peripheral cyanosis (PVD, Raynaud’s, CCF or central cyanosis)
    • Tendon xanthomata (hypercholesterolaemia)
    • osler’s nodes, janewau lesions or roth spots (infective endocarditis )
  • Nails:
    • finger clubbing (IE, Congenital heart disease, atrial myxoma)
    • koilonychia ‘spoon nails’ (iron deficiency anaemia)
    • splinter haemorrhages (IE, splinters…)
    • nailfold infarcts (vasculitis, RA)
  • Wrist:
    • radial pulse (rate, rhythm, volume character)
    • collapsing pulse
    • radial-radial delay (aortic coarctation/dissection)
    • radial- femoral delay (aortic coarctation/dissection)
  • Arms:
    • blood pressure
  • face :
    • malar flush of cheeks - (mitral stenosis)
  • Eyes:
    • corneal arcus and xanthelasma (hypercholesterolaemia)
    • conjunctival palor (anaemia)
  • Mouth
    • central cyanosis (lung disease, cardiac shunt, abnormal Hb)
    • poor dentition (risk factor for IE)
  • Neck
    • carotid pulse - look for exaggerated pulsation (aortic insufficiency)
    • JVP - right heart failure
  • sacrum
    • inspect for sacral oedema = right heart failure
  • ankles
    • oedema RHF
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13
Q

Exposure for peripheral arterial exam

A

shorts - and ability to expose groin for femoral pulse

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14
Q

How should the patient be positioned for a cardiovascular exam?

A

45 degrees

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15
Q

what would you include in percussion from a respiratory perspective?

A
  • assess percussion note (hperresonant, resonant, dull?)
  • start in supraclavicular fossae and work down chest - compare each side as you go
  • dont forget the axillae
  • posterior chest wall = ask them to “hug yourself” to get scapulae out of the way
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16
Q

what should you include in your general inspection from a respiratory perspective?

A
  • general appearance : well/unwell/dyspnoeic/ cough/wheeze/cyanosis/stridor/fidgety?
  • accessory muscle use/pursed lip breathing (lower airway obstruction usually COPD)
  • nutritional status/cachexia
  • oxygen, fluid and medications (inhalers, nebulisers)
17
Q

palpate from a cardiovascular perspective

A
  • apex beat = should be 5th ICS midclavicle - if unable to locate consider increased adiposity or enlarged heart
  • left parasternal heave = right ventricular hypertrophy
  • thrills = palpable murmurs (grade 4 or above by definition)
18
Q

what should you include on inspection from a respiratory perspective?

A
  • hands:
    • peripheral cyanosis (PVD, Raynaud’s)
    • feel temperature (central cyanosis= warm, pure peripheral cyanosis= cold),
    • dilated veins (hypercapnia)
    • tar staining/coal dust tattoos (smoking/ mining)
    • web space wasting (T1 lesion with pancoast tumour)
    • pallor of palmar creases (iron deficiency anaemia causes SOB)
    • palmar arythema (CF)
  • nails
    • clubbing (CF, Ca, interstitial lung disease, suppurative lung disease)
    • koilonychia (iron deficiency)
  • wrist
    • flapping tremor= asterxis = CO2 retention, hepatic, renal failure
    • fine physiological tremor - could be side effect of beta 2 agonist
    • respiratory rate = count over 15 s. while pretending to take pulse
    • radial pulse - rate, tachycardia if unwell or on b2 agonist
  • face
    • cushingoid = moon face, plethora, acne - due to long term steroid use
  • eyes
    • conjunctival pallor (anaemia causes SOB)
    • horner’s syndrome (ptosis, miosis, anhydrosis) due to pancoast tumor
    • chemosis
  • nose
    • septal devation
    • polyps
    • congenital abnormalities
  • mouth
    • central cyanosis (hypoxic lung disease, abnoraml haemoglobbin)
    • candida infection (steroid inhalers, immunocompromised
    • tonsilitis, pharyngitis
    • tooth dentition
  • neck
    • JVP- elevated in right heart failure, PE, SVC obstruction,
    • trachea deviation (deviates towars collapse, away from tension/big effussion)
    • lymph nodes = tender = infection, non-tender = suspicious of malignancy
19
Q

Inspect from peripheral arterial exam point of view

A
  • colour
    • pallor = ischaemia especially acute
    • redness= chronic ischeamia
    • Black = tissue necrosis
  • peripheral oedema - venous incompetency
  • trophic changes
    • pale skin, hair loss, fungal infections of nail/skin
  • ulcers - site, ege, exudate
  • scars- fem-pop bypass
20
Q

How do you conclude a peripheral vascular disease examination?

A
  • wash hands and thank the patient
  • measure Blood pressure
  • measure ankle-brachial pressure index
  • assess for risk factors for peripheral arterial disease (tar staining, hypercholesterolaemia)
  • further investigations - doppler USS, MRA
21
Q

palpate from peripheral arterial disease point of view

A

a. temperature
b. capillary refil time
- should be between 1-2 s

if increased = PVD ischaemia

if decreased = blood pooling

22
Q

what should you include on chest inspection from a respiratory perspective?

A
  • AP diameter - hyperinflation= COPD
  • scars (check carefully around sides and back)= thoracotomy, old chest drain sites
  • deformity of chest/spine - pectus excavatum, pectus carinatum, kyphoscloiosis
  • intercostal indrawing (hoover’s sign)
    *
23
Q

What should you include on general observation in the cardiovascular exam?

A
  • General appearance: well/unwell, pain or no pain, struggling to breath? fidgety?
  • patient surroundings? O2, fluids, medication
24
Q

what special tests would you perform in a peripheral venous exam?

A
  • Trendelenberg test = identifies level of venous incompetence - have patient lie flat, perform straight leg raise and ‘milk’ the blood out of the veins. - once empty, apply tourniquet tightly at upper thigh and ask patient to stnad up - look for refilling
  • if varicose veins refil with tourniquet in place = NOT due to femoral/sapheno insufficiency
  • if varicose veins do not refil with tourniquete in place = due to insufficiency of sapheno-femoral valve
25
Q

perform special tests for peripheral vascular disease

A

Burger’s Test = lie patient flat, normal side first, slowly perform straight leg raise, note the point at which the leg goes pale - angle between the horizontal at this point is burger’s angle

Burger’s sign = after patient’s leg goes pale, drop to the side of the bed - compare the color to the other leg - if vascular disease present, the ischaemic leg should turn bright red in comparison indicating reactive hyperaemia

26
Q

what should you include in your conclusion of a venous examination?

A
  1. examine lower limg neurology - ulcers may be multi-factorial
  2. doppler ultrasound to identify sites of incompetence
27
Q

how would you conclude a respiratory exmaination?

A
  • ask to look for periphearl/sacral oedema
  • wash hands and thank patient
  • review observation chart (HR, BP, RR, SpO2, and temp)
  • investigations: Peak flow, PFT, CXR, ABG

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