PCP Flashcards
1
Q
Cardinal Features
A
Site Quality Severity Time Course Context Relieving Factors Aggravating Factors Associated Features -------------------------------- Medical History & Risk Factors Family History Alcohol Smoking Social & Occupational History
2
Q
Cardiovascular Exam
A
- Prepare patient (explain procedure, undress, check comfort)
- Hand hygiene
- General Inspection (mental state, alertness, resp. effort)
- Inspect hands (nicotine, clubbing, anaemia)
- Measure radial pulse (HR 60-100 and rhythm)
- Measure BP (120/80)
- Face, Head (conjunctiva -pallor, tongue, lips - cyanosis)
- JVP (<3cm)
- Carotid Pulse (Both sides, separate)
- Inspect chest (scars)
- Palpate chest (apex beat)
- Auscultate (bell then diaphragm) MTPA
- Posterior Chest (Lung Bases)
- Lower Limbs (oedema, pulse - dorsalis pedis and posterior tibial)
- Completion
3
Q
Respiratory Exam
A
- Prepare Patient (sit 90degrees)
- Hand Hygiene
- General Inspection (mental state, resp effort, sputum cup, coughing, wheezing)
- Inspection of hands (nails, smoking, clubbing, anaemia)
- Pulse & resp rate measurement
- Head and Neck (conjunctiva, lips, tongue, TRACHEA!)
- Inspection of Anterior and Lateral chest walls
- Measure Anterior Chest Expansion (x2)
- Percussion of Anterior and Lateral Chest (start clavicle then every 2nd space)
- Auscultate Anterior and Lateral (Diaphragm - bell if hairy)
- breath in and out through open mouth
- ninety-nine - Examination of Posterior Chest
- chest expansion
(rotate scapulae)
- percussion (4 sites)
- auscultation (breathe & ninety nine) - Measure Peak Flow
- End of Examination
4
Q
Points of Auscultation (Heart)
A
- 5th ICS - Mitral - Apex
- 5th ICS - Tricuspid - Lower left sternal edge
- 2nd ICS - Pulmonary Valve - Upper left sternal edge
- 2nd ICS - Aortic Valve - Upper right sternal edge
5
Q
Heart Borders
A
SUPERIOR BORDER
2nd CC left
3rd CC right
RIGHT BORDER
3rd CC right
6th CC right
LEFT BORDER
2nd CC left
5th ICS left
INFERIOR BORDER
5th ICS left
6th CC right
CC = 2cm from sternal edge
VALVES - PAMT (diagonal)
2nd CC left
6th CC right
ASCULTATION - APTM (Z shape)
6
Q
Lung Borders
A
ANTERIOR Apex - 2.5cm above medial 1/3rd of clavicle Sternoclavicular joint 4th CC 6th mid-clavicular 8th mid-axillary 10th adjacent spine
POSTERIOR
C7
T10
4cm from midline
OBLIQUE FISSURE
T2 spinous process
6th mid clavicular
HORIZONTAL FISSURE
4th CC
Intersect oblique mid-axillary
7
Q
Lung Pleura Borders
A
2.5cm above medial 1/3rd of clavicle 6th CC (right) 4th CC (left - cardiac notch) 8th mid-clavicular 10th mid-axillary 12th paravertebral
8
Q
Syncope Features
VASOVAGAL (Faint)
A
Sudden loss of consciousness and postural tone
PRODROME - light headed, wobbly, dim vision, distant sounds
SITE - not relevant
QUALITY - convulsive movements can occur
SEVERITY - unquantified
TIME COURSE - less than 30 seconds
CONTEXT - usually doesn’t occur while sitting or lying
PRECIPITATING FACTORS - fasting, pain, emotional events, prolonged standing, straining
RELIEVING FACTORS - Lying flat
ASSOCIATED FEATURES - Sweaty, pallor, no-frothing
PERIOD AFTER - Rapid recovery, rarely confused, no injury (protective mechanism)
PAST HISTORY - None
9
Q
Smoking Questions
A
Signpost before asking smoking questions
“Do you smoke / have you ever smoked?”
“What do you smoke?”
Duration & average consumption (pack-years)
“How do you feel if you don’t smoke?”
Nicotine withdrawal - restless, anxiety, insomnia, difficulty sleeping
“Do you need a cigarette after waking?”
“Are there any circumstances where you feel the need to smoke?”
“Are there any circumstances where you would not be inclined to smoke?”
“Have you tried quitting?” What techniques and what success?
Assess current motivation to quit.
10
Q
Asthma Questions
A
SITE - n/a
QUALITY -n/a
SEVERITY - frequency of symptoms (day&night)- wheezing, cough, attacks, hospital, usage of inhalers, peak flow
TIME COURSE - onset (childhood?), episodic, current activity of the disease
CONTEXT - see psychosocial.
AGGRAVATING FACTORS - not using glucocorticoids, illness, exercise, pollens, smoke, dust, cold air, stress.
RELIEVING FACTORS - how frequently bronchodilators are used
ASSOCIATED FEATURES - eczema, hay fever, hives
PSYCHOSOCIAL CONTEXT - how does the disease impact the patients life, how does life impact the disease?
- relationships, pets, occupation, stress, hobbies, travel
11
Q
Minimal Verbal Encouragers
A
"I see" "Yes" "Go on ..." "Sure" "Tell me more"
12
Q
Body Language
A
Eye contact
Leaning in
Facial features (concern, interest)
Nodding
13
Q
Palpitation Questions
A
Abnormal awareness of the heart beat
SITE - not typically useful
QUALITY - Rhythm (tap it out), Forcefulness (or a flutter)
SEVERITY - Speed
- How it affects daily activities
TIME - How long has it been there, onset/offset, sudden, duration
CONTEXT - what is happening when the palpitations occur
RELIEVING FACTORS
AGGRAVATING FACTORS (coffee, exercise, stress)
ASSOCIATED FEATURES - SoB, chest pain, fatigue, dizziness, blackouts, oedema
14
Q
Past Medical History Questions
A
Past Serious Illness - Heart attack - Cancer - Blood Coagulopathies - Autoimmune - Infections Past Operations / Hospital Admissions Medications
15
Q
Blood Pressure Measurement
A
- Prepare Patient
- Hand Hygiene
- Appropriate Sized Cuff
- Apply Cuff (2-3cm above brachial artery pulsation)
- Estimate Systolic pressure using palpation (radial)
- Steth (diaphragm) over brachial pulse, support elbow with right arm. +30mmHg
- Auscultatory Sounds
deflate 2-3mmHg per beat - Record Result (nearest 5mmHg)
16
Q
BMI
A
weight (kg) / height squared (m^2)
<18.5 = Underweight 18.5-24.9 = Normal 25-29.9 = Overweight 30+ = Obese
17
Q
Waist-to-hip Ratio
A
Waist Circumference / Hip Circumference
<0.9 Male
18
Q
Syncope Features
CARDIAC (Blackout)
A
Sudden loss of consciousness and postural tone
PRODROME - not present
SITE - not relevant
QUALITY - convulsive movements can occur
SEVERITY - unquantified
TIME COURSE - less than 30 seconds
CONTEXT - can occur sitting or lying
PRECIPITATING FACTORS - usually doesn’t have any
RELIEVING FACTORS - Self limiting
ASSOCIATED FEATURES - Sweaty, pallor, no-frothing
PERIOD AFTER - Rapid recovery, rarely confused, injury may occur
PAST HISTORY - Cardiac Disease
19
Q
Angina
A
Reversible myocardial ischaemia (70% occlusion)
Diffuse central chest pain Radiation to arms (left), neck, jaw Physical exertion makes it worse Relieved by rest (or nitroglycerin) Associated with dyspnoea, nausea, and sweating.
> 20minutes = Myocardial Infarction
20
Q
Cardiovascular Risk Factors
A
Smoking High Blood Pressure (hypertension) High Cholesterol (Hyperlipidaemia) Diabetes Family History Age Gender
21
Q
Claudication
A
Arterial narrowing causing ischaemic pain
Cramped feeling in calves
subsides with rest
intermittent
22
Q
Family History
A
“Can you tell me about the health of your immediate family?”
- What age they died and cause
- What age they developed the condition
23
Q
Oedema Causes
A
Increased Hydrostatic Pressure Decreased Osmotic Pressure Increased Permeability (inflammation) Obstruction of Lymphatic Drainage
24
Q
Oedema Questions
A
Cardinal Features
Worse at end of day?
Relieved by elevating feet?
Bilateral? (unilateral indicates DVT)
Associated features (Dyspnoea on exertion & Orthopnoea indicate heart failure)
25
Dyspnoea questions
SITE - not important
QUALITY - heavy or shallow
SEVERITY - exertion. "how far can you walk before you become short of breath?"
"Is it present at rest?" / "does it wake you at night?"
TIME COURSE - onset, offset, worsening, episodic
CONTEXT - "when does the shortness of breath occur?", recent travel
AGGRAVATING FACTORS
Orthopnoea (diffculty breathing worse lying down) - how many pillows required to sleep
RELIEVING FACTORS
ASSOCIATED FEATURES
Chest pain, cough, wheeze, swelling of ankles, fever, weight loss
26
Occupational History
Are you currently working?
Asbestos, Farmers Lung, Chemicals, Children
Stresses
27
Social History
```
Relationships & support systems
Education and occupation
Finances
Ethnicity
Religion and spirituality
Hobbies & Exercise
Pets
Travel
```
28
Acute vs Chronic Cough
Acute < 2 weeks
Subacute 2-8 weeks
Chronic > 8 weeks
29
Cough Questions
SITE - chest or throat
QUALITY - sound, productive (characterise sputum separately)
SEVERITY - frequency
TIME COURSE - duration (acute, chronic)
CONTEXT - what were you doing when you first noticed the cough?
RELIEVING FACTORS - what treatments have been tried
AGGRAVATING FACTORS - worse at night?
ASSOCIATED FEATURES - dyspnoea, wheeze, fever, haemoptysis, smoking, pain
30
Sputum Questions
Cover Cardinal signs
colour
(SEVERITY) volume (teaspoon)
thickness
odor
blood (haemoptysis)
- (SITE) prodrome (nausea & abdominal pain vs chest irritation)
- colour (bright red & frothy = haemoptysis, dark red = haematemesis)
- (SITE) associated pain (throat pain may indicate blood from URT)
when did you first notice the blood?
getting better or worse?
31
Vomiting Questions
SITE - n/a
QUALITY - Colour? (blood or bile stained?)
SEVERITY - frequency, volume
TIME COURSE - onset , episodic, relationship to meals, first thing in morning
CONTEXT - New medication, pregnancy, contact with others.
AGGRAVATING FACTORS - does anything precipitate the vomiting?
RELIEVING FACTORS - has anything made it better?
ASSOCIATED FEATURES -abdominal pain, diarrhoea, fever, headache, vertigo, dehydration, weight-loss
32
Dysphagia Critical Reasoning
OROPHARYNGEAL DYSPHAGIA:
Difficulty initiating swallowing associated with CHOKING, COUGHING, NASAL REGURGITATION (stroke, parkinsons, ms)
OESOPHAGEAL DYSPHAGIA
Food sticks after initiation of a swallow
Mechanical Obstruction (e.g. cancer) - Solids only
Motility disorder (e.g. achalasia) - Solids & liquids
33
GI exam
1. Prepare Patient (sit 90degrees)
2. Hand Hygiene
3. General Inspection (mental state, alertness, cachexia, jaundice, distressed, pain)
4. Inspection of hands (leuconychia, palmar erythmea, pallor, dupuytren's contracture), test for metabolic flap (15s)
5. Head and Neck (conjunctiva jaundice or pallor)
6. Examination of chest (spider naevi)
7. Inspection of abdomen (Lay flat on one pillow) (scars, striae, distension, masses, caput medusae)
8. Palpation of Abdomen (warm hands, palpate twice, check for discomfort)
- left inguinal, lumbar, hypochondrium
- epigastrium
- right hypochondrium, lumbar, inguinal
- suprapubic, umbilical
9. Palpate for liver from LRQ (firm pressure during inhilation, 2cm advances)
- percuss from LRQ and third rib mid clavicular
- measuring tape 12-13 cm
10. Palpate for Spleen from RLQ
- ballot (roll patient 45deg and place left hand behind)
11. Kidneys
- left hand posteriorly in loin region
- right hand under costal margin
12. End of Examination
34
Diarrhoea Questions
SITE - n/a (except for with abdominal pain)
QUALITY - Consistency (watery?) Colour (blood, mucous?)
SEVERITY - frequency, volume
TIME COURSE - onset , episodic, acute/chronic, worsening/improving
CONTEXT - Particular food, overseas travel
AGGRAVATING FACTORS - does anything make it worse?
RELIEVING FACTORS - has anything made it better? How effective?
ASSOCIATED FEATURES - nausea, fever, vomiting, abdominal pain, weight loss. Any other people that have been affected?
35
Acute, Persistant, Chronic Diarrhoea
Acute
- few days, due to infection, gastroenteritis, food poisining
Persistant
- 2 - 4 weeks
Chronic
- >4 weeks
36
Liver Surface Anatomy
Superior: between nipples
Inferior: costal margin
Gallbladder - mid-clavicular below costal margin
37
Appendix Surface Anatomy
McBurneys Point
| 1/3 distance from right anterior superior iliac spine to umbilicus
38
Kidney Surface Anatomy
Mid line (lateral to spine)
Left as high as rib 11
Right as high as rib 12
Extend to L3
(can identify L4 as midpoint between iliac crests)
39
Spleen Surface Anatomy
Posterior along line of 9th to 11th rib
Follows contour of 10th rib
lies antero-lateral to kidney extending around mid-axilliary line
40
Haematemesis
Vomiting Blood
| Heam + Emesis
41
Haemoptysis
Coughing up blood
42
Common causes of vomiting
Gastroenteritis
Pregnancy
Medications (esp. chemo)
Acute MI
43
Alcohol Questions
Do you drink alcohol (or have you ever)?
How often do you have a drink containing alcohol?
How much do you typically drink (and what type)?
How often do you drink more than 4 STANDARD DRINKS?
Do you have trouble STOPPING drinking once you start?
Do you drink first thing in the MORNING?
Is drinking stopping you from doing any ACTIVITIES/WORK?
Do you ever feel GUILT/REMORSE after drinking?
How often do you BLACKOUT?
Have you or anyone else been INJURED?
Has anyone been CONCERNED and suggested you cut down?
Under what CIRCUMSTANCES(triggers/influences) do you drink?
Have you ever tried to REDUCE your alcohol intake?
Do you think you currently have a PROBLEM with drinking?
How hard would it be for you to cut down or stop drinking?
44
Jaundice Questions
SITE / QUALITY / SEVERITY - Sclera and/or Skin? Colour (yellow vs green).
TIME COURSE - onset (abrupt?), episodic, acute/chronic, worsening/improving
CONTEXT - Particular food, overseas travel, illness (viral)
AGGRAVATING FACTORS - does anything make it worse?
RELIEVING FACTORS - has anything made it better? How effective?
ASSOCIATED FEATURES - Dark Urine, Pale stools, Pruritis, Pain.
PSYCHOSOCIAL - Alcohol consumption, recent travel, immunisations, tattoos, IV drug use, unprotected sex.
45
Causes of Jaundice
Overproduction of bilirubin
- heamolysis (malaria, drugs, sickle cell anaemia)
Impaired uptake or conjugation of bilirubin by liver
- rifampicin
- Gilbert's
- Crigler–Najjar
Impaired bilirubin secretion
- Dubin-Johnson
- Primary biliary cirrhosis
Liver disease
- Viral or Alcoholic Hepatitis
Obstruction of bile ducts
- Gallstones
- Pancreatic cancer (head)
46
Pain Questions
SITE - Where is the pain? Radiation?
QUALITY - "Can you tell me what the pain feels like?"
Constriction, Throbbing, Stabbing, Dull, Burning, Aching
SEVERITY - Rate / 10
- "does it stop you doing anything?"
- waking at night
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur?
```
CONTEXT - "What was happening when you first noticed the pain?", recent travel, foods, sedentary, infections
RELIEVING FACTORS - "Does anything make it better?"
AGGRAVATING FACTORS - "Does anything make it worse?"
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Headache
Shortness of Breath
Dizziness
Tingling
Heart Rate
Nausea
Acid taste in mouth
Oedema
Weight loss
Sweating
```
47
Cardiac (syncope)
- Nail down the timeline of the collapse – before, during, after
- Context of collapse is important to rule out vasovagal
- dehydration, fatigue, stress, standing all day
- Cardiac associated features (past issues)
- chest pain, palpitations, dyspnea
- Ask about cardiac risk factors – hypertension, dyslipidemia, diabetes, family history
n/a
48
Respiratory (dyspnea)
- Quantify the severity of the shortness of breath (how far they can walk, how many steps they can climb prior to onset)
- Think about releveant dyspnea associated features: Respiratory – wheeze, cough (productive), fever (infective cause) Cardiac
- orthopnea (ask about how many pillows), PND, peripheral edema, chest pain
- Quick characterization of cough
- sputum, colour, presence of blood Cough may also be from drugs (e.g. ACE-Inhibitors)
or from heart failure (cardiac cause)
n/a
49
Gastrointestinal (abdo pain)
- Ask about any radiation of the pain
- Characterization of jaundice
- ask about the 4Ps (Piss, Poo, Pain, Pruritis)
- Other notable associated features
- fever, nausea, vomiting, diarrhea, loss of appetite
n/a
50
Muscle Weakness Questions
SITE - Where is the weakness? Generalised/Localised? Asymmetric/Symmetric? Proximal/Distal?
True muscle weakness or just fatigue?
QUALITY - N/A
SEVERITY - What function remains?
Plegia or pareisis? Effect on day to day life? Muscle wasting?
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur (activities)?
```
CONTEXT - "What was happening when you first noticed the weakness?" - mediciations, viruses, trauma, stress?
RELIEVING FACTORS - "Does anything make it better?"
AGGRAVATING FACTORS - "Does anything make it worse?"
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Pain
Sensory changes (numbness, visual, taste)
Headache
Fever
Dizziness
Tingling
Nausea
Weight loss
Fatigue
```
PHx - autoimmune (diabetes, lupus, thyroid?)
CHD
51
LL Weakness Exam
1. Prepare Patient
2. Hand Hygiene
3. Gait
4. Inspection (lower back & while lying)
5. Tone & Clonus (>5 beats abnormal)
6. Power
- hip flexion (L2,L3)
- hip extension (L4,L5,S1)
- hip abduction (L4,L5,S1)
- hip adduction (L2,L3,L4)
- knee flexion (L5,S1)
- knee extension (L2,L3,L4)
- ankle dorsiflexion (L4,L5)
- ankle plantarflexion (S1,S2)
- inversion (L4,L5)
- eversion (L5,S1)
- big toe extension (L4,L5,S1)
7. Deep tendon reflexes
- knee jerk (L2,L3,L4)
- ankle jerk (S1,S2)
- babinski (L5,S1,S2)
8. Coordination (heel-shin tests)
9. Sensory examination (N/A)
10. End of examination
52
Muscle Strength Grading 0-5
0 - Complete paralysis
1 - Flicker or trace of contraction
2 - Active movement with gravity eliminated
3 - Active movement against gravity
4 - Active movement against gravity and resisitance
5 - Normal power
53
Plegia vs Paresis
```
Plegia = paralysis
Paresis = incomplete loss of strength
```
hemi - one side
mono - one limb
para - both lower limbs
quad - all four limbs
54
Reflex Grading 0-4
```
0 - Absent
1 - Hypoactive
2 - Normal
3 - Hyperactive w/o clonus
4 - Hyperactive w/ clonus
```
55
Sensory Disturbance Questions
SITE - Where is the disturbance? Bilateral? Whole limb? Dermatomal?
QUALITY - How does it feel? Positive or negative sensory symptoms?
SEVERITY - Effect on day to day life? Injuries? Waking at night?
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur (night)?
```
CONTEXT - "What was happening when you first noticed the disturbance?" - mediciations, viruses, trauma, stress, rash?
RELIEVING FACTORS - "Does anything make it better?"
AGGRAVATING FACTORS - "Does anything make it worse?"
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Pain
Other sensory changes (numbness, visual, taste)
Gait/balance
Injuries
Bowel & bladder
Headache
Fever
Dizziness, Imbalance
Tingling
Nausea
Weight loss
Palpitations
```
PHx - Diabetes, MS, Hypertension etc.
56
```
POSITIVE
Parasthesia
Hyperasthesia
Dysaesthesia
Hyperallgesia
Allodynia
```
NEGATIVE
Hypoaesthesia
Anaesthesia
Analgesia
Parasthesia - abnormal sensation percieved without abnormal stimulus
Hyperasthesia - abnormal increase in sensitivity to a stimulus
Dysaesthesia - all positive sensory changes (including above two)
Hyperalgesia - heightened response to noxious stimulus
Allodynia - normal stimulus felt as pain
Hypoaesthesia - diminished ability to perceive pain
Anaesthesia - complete inability to percecive pain
Analgesia - complete insensitivity to pain
57
Responding to crying patient
Acknowledge crying is a legitimate response
Stop & put pen down
Encourage expression of feelings
Offer practical help (tissues? leave them alone?)
Don't offer false hope
Don't project feelings
58
LL Sensory Examination
1. Prepare Patient
2. Hand Hygiene
3. Gait
4. Pain (toothpicks)
L1 - Upper thigh
L2 - Lateral Thigh
L3 - Medial Knee
L4 - Medial Calf
L5 - Lateral Calf
S1 - Sole
S2 - Posterior Knee
5. Light touch (cotton wool)
6. Thermal (only if pain abnormal)
7. Vibration
8. Proprioception (big toe)
59
Opthamology Examination
1. Prepare Patient
2. Visual Acuity
- Unaided (6/6, CF, HM, LP)
- With Pinhole
- With Glasses
3. Visual Field
- X quadrants
4. Eye Movements (H)
- Follow finger but don't move head (any double vision?)
5. Examination of Pupils
- Darken room
- Symmetry
- Direct & Consensual response
- Relative Afferent response
6. Examination of Fundus
60
Seizure Features
Sudden loss of consciousness w/ increased tone - Grand Mal Seizure
(Focal may have no LOC)
PRODROME - Aura (depends on origination in brain)
SITE - not relevant
QUALITY - tonic - stiffening, clonic- contraction/relaxation
SEVERITY - unquantified
TIME COURSE - 1-2 minutes
CONTEXT - can occur sitting or lying or sleeping
PRECIPITATING FACTORS - , can be due to head injury, flashing lights, fatigue, fasting, stress
RELIEVING FACTORS - Self limiting
ASSOCIATED FEATURES - Tongue biting, head turning, cyanosis, cry or moan, frothing, incontinance
PERIOD AFTER - Slow recovery, confusion > 2 mins, injury common, exhaustion, muscle aches
PAST HISTORY - Seizures (recurrent = epileptic), changes to medication
61
UL Weakness Exam
1. Prepare Patient
2. Hand Hygiene
3. Inspection (cervical spine & upper limb)
4. Tone & Clonus (elbow and wrist)
5. Power
- pronator drift (palms up)
- shoulder abduction (C4,C5,C6)
- elbow flexion (C5,C6)
- elbow extension (C7,C8)
- wrist extension (C6,C7)
- wrist flexion (C6,C7,C8)
- finger extension (C7,C8)
- finger flexion (C7,C8)
- finger abduction (C8,T1) - ulnar
- finger adduction (T1) - ulnar
- thumb abduction (T1) - median
6. Deep tendon reflexes
- biceps jerk (C5,C6)
- brachioradialis jerk (C5,C6)
- triceps (C7,C8)
- finger jerk (C8)
7. Coordination (finger-nose, pronate-supinate)
8. Sensory examination (N/A)
9. End of examination
62
UL Sensory Exam
1. Prepare Patient
2. Hand Hygiene
3. Inspection (cervical spine & upper limb)
4. Pain (toothpicks)
C4 - shoulder
C5 - lateral bicep
C6 - thenar eminence (thumb)
C7 - palm
C8 - medial palm
T1 - medial forearm
T2 - medial bicep
5. Light touch (cotton wool)
6. Thermal (only if pain abnormal)
7. Vibration
8. Proprioception (big toe)
63
CONTEXT
```
Exertion
Recent travel
Recent infection
New medications
Pregnancy
Contact with others
Trauma
Lifestyle / Dietary changes
Dehydration
Immunisation
Tattoo
IV drug use
Unprotected sex
Stress/Anxiety/Depression
```
64
ASSOCIATED FEATURES
```
Dyspnea
Pain
Palpitations
Fatigue
Blackouts (loss of consciousness)
Oedema
Nausea / Vomiting
Dizziness
Headache
Sweaty
Pallor
Fever
Acid taste in mouth
Cough
Haemoptysis
Wheeze
Hay Fever
Hives
Eczema
Swelling
Redness
Heat
Sensory disturbances (photophobia)
Other sensory changes (numbness, visual, taste)
Tingling
Weight loss / Appetite
Diarrhoea
Pee, Poo, Puritis, Pain
Polydipsia (drinking more)
Straining
Anxiety (may be a cause of polydipsia)
Loss of function (stiffness, locking, giving way, difficulty walking)
Noises (popping, clicking)
Gait/balance
```
65
Memory Questions
SITE - Sensory memory, short term, long term
Declarative
- Semantic (facts) - cortical association areas
- Episodic (events) - medial temporal lobe
Non-declarative (skills & habits)
QUALITY - N/A
SEVERITY - based on symptoms
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
```
CONTEXT - "What was happening when you first noticed the disturbance?" - medications, viruses, trauma, stress?
RELIEVING FACTORS - N/A
AGGRAVATING FACTORS - N/A
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Aphasia
Apraxia (performing tasks)
Recognising people
Bad planning
Disorientation
Losing things
Unsafe behaviour
Hygiene
Incontinence
Pain
Fever
```
66
Headache Questions
| Migraine vs Tension Type Headache
SITE - Unilateral (70% migraines) vs bilateral
QUALITY - Dull/Throbbing vs Band/Pressure
SEVERITY - How bad is it? Affect on daily activities
```
TIME COURSE - Onset (sudden, gradual)
Time of day (mornings - migraine)
Offset
Duration (3 days - migraine)
Temporal profile (constant, fluctuating)
Previous episodes?
Migraine crescendo, TTN waxes and wanes
```
CONTEXT - "What was happening when you first noticed the headache(s)?" - medications, viruses, trauma, stress?
RELIEVING FACTORS - Analgesia, dark room
AGGRAVATING FACTORS - Physical activity, stress, contraceptives, fatigue, food, wine, cheese, head movements, bright lights, noise
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Neck pain / muscle tenderness
Nausea
Vomiting
Photophobia
Aura (prodrome)
Visual/speech disturbance
Motor weakness
Sensory changes
Loss of consciousness
Seizures
```
PHx - CVD, history of cancer
67
Ear/Hearing Examination
Whispered voice test
- stand 60cm behind patient
- occlude/rub external auditory meatus
- 66 - high frequency
- 100 - low frequency
Otoscope
- pull auricle up and back
- diect speculum down and forward
- inspect while inserting
- colour, consistency, cone of light
68
Dizziness Types
Pre-syncope
- decreased BF to brain
- 'feeling faint'
- causes same as syncope (dehydration, infection, fatigue, fasting, CVD, stress)
Vertigo
- 'environment spinning'
- nausea/vomiting
- cause: disturbance of vestibular system (viral, stroke, tumor, trauma), Benign Paroxysmal Positional Vertigo (calcium crystals settle in posterior semicircular canal)
Disequilibrium
- gait ataxia
- 'wobbly' / 'leaning'
- occurs only while walking
- cause: muscle, nerve, cerebellar disease
Non-specific
- 'light headed' / 'woozy'
- cause: hyperventilation, idiopathic, anxiety
69
Dizziness Questions
SITE - N/A
QUALITY - Type of dizziness (Vertigo, Presyncope, Disequilibrium, Non-specific) -> not loss of consciousness
SEVERITY - Affect on daily activities, injuries
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
```
CONTEXT - "What was happening when you first noticed the dizziness?" - walking, medications, illness, trauma, stress, fatigue, sudden head movement, hyperventilation, anxiety?
RELIEVING FACTORS - Analgesia, dark room
AGGRAVATING FACTORS - head movements, standing up quickly
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Illness
Nausea
Vomiting
Fever
Weight loss
Cardiovascular risk factors
hearing changes
Syncope prodrome
Muscle weakness / decreased control
```
PHx - CVD, anxiety, fainting / seizures
70
Weightloss Questions
SITE - Local or general?
QUALITY - Intentional or unintentional? Changes in appetite?
SEVERITY - Amount lost (>5% significant), clothing fit.
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
```
CONTEXT - "What was happening when you first noticed the weightloss?" - lifestyle/diet changes, exercise, medications, illness, trauma, stress, fatigue, overseas travel?
RELIEVING FACTORS - "anything halt/limit the weightloss?"
AGGRAVATING FACTORS - "anything make the weightloss worse?"
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Increased (hyperthyroid) / decreased (cancer,meds,anorexia) appetite
Pain / trouble swallowing
Nausea
Vomiting
Diarrhoea
Urine
Fatigue
Fever
Tremors, Sweating, Palpitations
Anxiety/depression
Temperature intolerance
Masculinisation (acne, hair)
Change in bowel (diarrhoea)
```
```
PHx
Hyperthyroid
Cancer
Diabetes
Cardiovascular diseases
```
71
Urination Questions
SITE - Location of pain when urinating (if any)
QUALITY - dysuria (pain, burning, discomfort), polyuria (volume), frequency, urgency, nocturia, hesitancy, straining, dribbling, blood (haematuria), cloudy, malodorous
SEVERITY - How is it affecting your life? pain scale 0-10? Do you wake up and need to urinate?
```
TIME COURSE - Onset (sudden, gradual)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
```
CONTEXT - "What was happening when you first noticed the urinary problems?" - lifestyle/diet changes, medications, illness, trauma, stress, fatigue?
RELIEVING FACTORS - "anything halt/limit the urinary problems?"
AGGRAVATING FACTORS - "anything make the urinary problems worse?" Drinking (fluids, diuretics - coffee&alcohol)
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Polydipsia (drinking more)
Pain
Fatigue (esp w/ nocturia)
Vision changes
Straining
Increased / decreased appetite
Nausea
Vomiting
Diarrhoea
Fever
Anxiety (may be a cause of polydipsia)
```
PHx
Pregnancy
Diabetes
Cardiovascular diseases
72
Definitions:
- Micturition
- Dysuria
- Polyuria
- Urgency
- Frequency
- Irritative Voiding Symptoms
- Obstructive Voiding Symptoms
MICTURITION - urination
DYSURIA - pain, burning, discomfort (infection/prostate/bladder)
POLYURIA - excessive volume (2.5-3.5L -normal 1.5L)
(increased intake, diabetes mellitis, diabetes insipidus)
URGENCY - compelling need to empty (even if not full)
FREQUENCY - increase usually due to infection or irritation
IRRITATIVE VOIDING SYMPTOMS - dysuria, frequency, and urgency - usually due to UTI
OBSTRUCTIVE VOIDING SYMPTOMS - hesitancy, straining, dribbling - can lead to irritative symptoms due to detrusor hypertrophy
complete obstruction can lead to urinary retention
(BPH, stones, tumor, scar tissue, neuromuscular disorder)
73
Causes of Knee Pain (INJURY vs NON INJURY)
INJURY
- ligaments
- menisci
- tendons
- bone
- chondromalacia patellae
- bursitis
- referred from hip/groin/back
NON-INJRY
- osteoarthritis (cartilage) / rheumatitis (inflammation)
- haemorrhage
- sepsis
- gout
- referred from hip/groin/back
74
Knee Pain Questions
SITE - One knee? other joints?
Anterior -> osteoarthritis, patella
Lateral/Medial -> ligament sprain, meniscal tear
Posterior -> hamstring strain, bursitis, baker's cyst, DVT
Other -> rheumatoid/arthritic/gout
QUALITY - How does it feel? Burning, stabbing, grinding?
SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night?
TIME COURSE - Onset (acute = trauma/haemorrhage)
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur (night, morning, exercise)?
CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, knee position, 'popping' noise?), illness?
RELIEVING FACTORS - "Does anything make it better?", rest, analgesics?
AGGRAVATING FACTORS - "Does anything make it worse?" specific movements?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Swelling
Redness
Heat
Loss of function (stiffness, locking, giving way, difficulty walking)
Noises (popping, clicking)
Pain
Other sensory changes (numbness, visual, taste)
Gait/balance
Headache
Fever
Nausea
```
PHx - Osteoporosis, gout, arthritis, autoimmune etc.
75
Knee Exam
1. Prepare Patient - it will involve both knees
2. Hand Hygiene
3. Inspection Standing (knee alignment, gait, muscle wasting)
- valgus (knocked-knee)
- varus (cowboy)
4. Inspection Lying (scars, inflammation)
5. Anterior Palpation
- temperature (back of hand)
- swelling - milking w/ patella tap
- effusions - up-medial, down-lateral
- palpate (patella, tendon, quad)
6. Lateral and Posterior Palpation
- 30degree flexion - lateral/medial joint
- straight - posterior
7. Testing Movements
- normal 0-135degrees
8. ACL & PCL
- 90 degree flexion
9. Collateral Ligaments
- slight flexion
10. End of examination
76
Shoulder Pain Questions
SITE - One shoulder? other joints? referred? movement?
intrinsic = joint, bursae, muscle, tendon
extrinsic = spine, diaphragm, heart
QUALITY - How does it feel? Burning, stabbing, grinding?
SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROM
```
TIME COURSE - Onset
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur (night, morning, exercise)?
```
CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, ROM, 'popping' noise?), illness?
RELIEVING FACTORS - "Does anything make it better?", rest, analgesics?
AGGRAVATING FACTORS - "Does anything make it worse?" specific movements?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Swelling
Redness
Heat
Loss of function (stiffness, locking, giving way, difficulty walking)
Noises (popping, clicking)
Pain
Headache
Fever
Nausea
```
PHx - Heart disease
- Autoimmune
77
Shoulder Exam
1. Prepare Patient - it will involve both shoulders
2. Hand Hygiene
3. Inspection
- anterior, lateral, posterior
- scars, swelling, redness, muscle wasting
4. Palpation
- sternoclavicular
- clavicle -> acromioclavicular joint
- coracoid
- anterior glenohumeral
- head of biceps tendon
- supraspinatus insertion
- spine of scapula
- inferior pole of scapula
5. Active Movement
- abduction & adduction (180degrees)
- flexion & extension (180 & 70 degrees)
- internal & external rotation (90 degrees & T7)
6. Fixed scapula (detectable between 45-90degrres)
7. End of examination
78
Back Pain Questions
SITE - Specific? Non-specific? ? other joints? referred? movement?
L1-S5 = degenerative
L5/S1 = sciatica
buttocks&back of legs = central stenosis
QUALITY - How does it feel? Burning, stabbing, grinding, numbness?
SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROM
```
TIME COURSE - Onset
Offset
Duration
Temporal profile (constant, fluctuating)
Previous episodes?
When does it occur (night, morning, exercise)?
```
CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, ROM, 'popping' noise?), illness?
RELIEVING FACTORS - "Does anything make it better?", rest, analgesics, bending forwards, therapies?
AGGRAVATING FACTORS - "Does anything make it worse?" specific movements? walking?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Swelling
Redness
Heat
Loss of function (stiffness, locking, giving way, difficulty walking)
Noises (popping, clicking)
Joint pain
Headache
Fever
Sweats
Nausea
Blood in urine
Weightloss
Loss of appetite
Bladder/bowel/motor/sensory
```
PHx - History/suspicion of cancer
IV drug use
glucocorticoids
79
Back Pain Red Flags
```
Age > 50 or < 20
History or suspicion of cancer
IV drug use
fevers, sweats, weightloss
glucocorticoids
Sciatica
Pain not relieved by rest
Pain over 1 months duration
```
80
Menstrual Cycle Questions
SITE - N/A
QUALITY - Colour? Clots? Changes over period?
SEVERITY - Volume (pads & changing)
- spotting
- change from normal
TIME COURSE - length of cycle
- length of period
- frequency of menstruation
- regular / irregular
- date of last menstrual cycle
- age of onset
- change over time
CONTEXT - "What was happening when you first noticed the change?" - illness, contraceptives, pregnancy, peri-menopause
RELIEVING FACTORS - "Does anything make it better?"
AGGRAVATING FACTORS - "Does anything make it worse?" stress? weightloss?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Pelvic pain
Post-coital bleeding
Anaemia
Fatigue
Hot flushes
Headache
Fever
Sweats
Nausea
Weightloss
Cold intolerance
Masculinisation (acne, hair)
```
PHx - Menopause
- Thyroid
- Hormonal
81
Menopause Definitions
- Frequency
- Duration
- Amount
- Primary amenorrhoea
- Secondary amenorrhoea
- Oligomenorrhoea
- Polymenorrhoea
- Primary dysmenorrhoea
FREQUENCY
between 21-35 days
Duration
4-5 days
Amount
20-60mL (>80 = abnormal)
PRIMARY AMENORRHOEA
never menstruated
SECONDARY AMENORRHOEA
pregnancy, weightloss, stress, menopause
OLIGOMENNORRHOEA
4-9 periods per year or light flow
POLYMENORRHOEA
more frequent than 21 days
PRIMARY DYSMENORRHOEA
first & all periods are painful
82
Vaginal Discharge Questions
SITE - N/A
QUALITY - Colour? Consistency? Odor? Blood?
Candidiasis = white, clumped, itchy
Bact Vaginosis = white-grey, fishy
Trichomonas = Green-yellow, frothy, itch
SEVERITY - Volume (pads?)
TIME COURSE - Onset
- Offset
- Duration
- Temporal profile (constant, fluctuating)
- Previous episodes?
CONTEXT - "What was happening when you first noticed the change?" - illness, antibiotics, sexual activity (partners, genders, protection, STIs)?
RELIEVING FACTORS - "Does anything make it better?" Anti-thrush treatments?
AGGRAVATING FACTORS - "Does anything make it worse?" contraceptive pill?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Itch
Change in menstruation
Pain with urination
Pelvic pain
Post-coital bleeding
Anaemia
Fatigue
Headache
Fever
Sweats
Nausea
```
PHx - UTIs, STIs
83
Erectile Dysfunction Questions
SITE - N/A
QUALITY - Erectile dysfunction? Libido? Inability to reach orgasm? Difficulty with ejaculation?
SEVERITY - Degree of rigidity,
- time to achieve erection,
- duration of erection,
- prevent intercourse,
- affect on relationship?
- masturbation?
- early morning erections?
TIME COURSE - Onset (sudden = psychological)
- Offset
- Duration
- Temporal profile (constant, fluctuating)
- Previous episodes?
- Always present?
CONTEXT - "What was happening when you first noticed the change?" - illness, trauma, anxiety, libido, sexual activity (partners, genders, protection, STIs)?
RELIEVING FACTORS - "Does anything make it better?" medication?
AGGRAVATING FACTORS - "Does anything make it worse?" anxiety, alcohol, medications?
```
ASSOCIATED FEATURES -"Have you noticed anything else?"
Libido
Orgasm & Ejaculation
Cardiovascular
Proteinuria (diabetes)
```
PHx - CHD, alcohol, smoking, diabetes, operations
84
Medications Questions
- Amount / Dose
- Route
- Frequency
- Adherence
- ADR's (sides, allergies, intolerance)
- Is disease well controlled?
- Prescribed, OTC's, Alternative meds
- Recently ceased (why?)
- Any drug allergies?
85
Recreational Drug Questions
```
Signpost & Confidentiality
Open Question & Tell me more
Which drugs?
- cannabis
- cocaine
- amphetamines/ice
- ecstacy
- ice
- legal medications (benzodiazepines, codeine)
```
Quantity
- type / route
- how much (grams, cones, money)
- how often
Context
- when did you start?
- what occasions do you take the drugs?
Dependancy
- do you need it through the day?
- what happens if you don't have it?
- how long can you go without?
- changed life to accomodate habit?
Quitting
- tried before? worked?
- considering quitting?
Damage
- Blackouts / regrets
- harm to self or others
- kids / job (work next day)
- financial responsibilities
- health (weightloss, asthma)
