PCP Flashcards
Cardinal Features
Site Quality Severity Time Course Context Relieving Factors Aggravating Factors Associated Features -------------------------------- Medical History & Risk Factors Family History Alcohol Smoking Social & Occupational History
Cardiovascular Exam
- 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
Respiratory Exam
- 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
Points of Auscultation (Heart)
- 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
Heart Borders
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)
Lung Borders
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
Lung Pleura Borders
2.5cm above medial 1/3rd of clavicle 6th CC (right) 4th CC (left - cardiac notch) 8th mid-clavicular 10th mid-axillary 12th paravertebral
Syncope Features
VASOVAGAL (Faint)
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
Smoking Questions
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.
Asthma Questions
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
Minimal Verbal Encouragers
"I see" "Yes" "Go on ..." "Sure" "Tell me more"
Body Language
Eye contact
Leaning in
Facial features (concern, interest)
Nodding
Palpitation Questions
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
Past Medical History Questions
Past Serious Illness - Heart attack - Cancer - Blood Coagulopathies - Autoimmune - Infections Past Operations / Hospital Admissions Medications
Blood Pressure Measurement
- 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)
BMI
weight (kg) / height squared (m^2)
<18.5 = Underweight 18.5-24.9 = Normal 25-29.9 = Overweight 30+ = Obese
Waist-to-hip Ratio
Waist Circumference / Hip Circumference
<0.9 Male
Syncope Features
CARDIAC (Blackout)
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
Angina
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
Cardiovascular Risk Factors
Smoking High Blood Pressure (hypertension) High Cholesterol (Hyperlipidaemia) Diabetes Family History Age Gender
Claudication
Arterial narrowing causing ischaemic pain
Cramped feeling in calves
subsides with rest
intermittent
Family History
“Can you tell me about the health of your immediate family?”
- What age they died and cause
- What age they developed the condition
Oedema Causes
Increased Hydrostatic Pressure Decreased Osmotic Pressure Increased Permeability (inflammation) Obstruction of Lymphatic Drainage
Oedema Questions
Cardinal Features
Worse at end of day?
Relieved by elevating feet?
Bilateral? (unilateral indicates DVT)
Associated features (Dyspnoea on exertion & Orthopnoea indicate heart failure)
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
Occupational History
Are you currently working?
Asbestos, Farmers Lung, Chemicals, Children
Stresses
Social History
Relationships & support systems Education and occupation Finances Ethnicity Religion and spirituality Hobbies & Exercise Pets Travel
Acute vs Chronic Cough
Acute < 2 weeks
Subacute 2-8 weeks
Chronic > 8 weeks
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
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?
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
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
GI exam
- Prepare Patient (sit 90degrees)
- Hand Hygiene
- General Inspection (mental state, alertness, cachexia, jaundice, distressed, pain)
- Inspection of hands (leuconychia, palmar erythmea, pallor, dupuytren’s contracture), test for metabolic flap (15s)
- Head and Neck (conjunctiva jaundice or pallor)
- Examination of chest (spider naevi)
- Inspection of abdomen (Lay flat on one pillow) (scars, striae, distension, masses, caput medusae)
- Palpation of Abdomen (warm hands, palpate twice, check for discomfort)
- left inguinal, lumbar, hypochondrium
- epigastrium
- right hypochondrium, lumbar, inguinal
- suprapubic, umbilical - Palpate for liver from LRQ (firm pressure during inhilation, 2cm advances)
- percuss from LRQ and third rib mid clavicular
- measuring tape 12-13 cm - Palpate for Spleen from RLQ
- ballot (roll patient 45deg and place left hand behind) - Kidneys
- left hand posteriorly in loin region
- right hand under costal margin - End of Examination
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?
