PCP - Semester One Flashcards
(112 cards)
1
Q
What are the Cardinal Features of Pain?
A
Site, Quality, Severity, Time Course, Context, Aggravating and Relieving factors and associated features.
2
Q
What are some types of Quality of Pain
A
Aching, Burning, THrobbing, Sharp, Pulsating, Dull, Tingling
3
Q
Two types of ways to gauge severity?
A
The 1 to 10 model or what does it stop you from doing?
4
Q
What is a symptom and what is a sign?
A
Symptom = something recognized by the patient Sign = Abnormality associated with a disease that is recognized or discovered by a doctor.
5
Q
What should you ask a patient about the site of the pain?
A
Get them to point to where it is the worst and if it travels/radiates anywhere else? eg: radiation to the arm or jaw in chest pain = indicates MI
6
Q
Quality of: Weight Loss? Cough? Temperature? Fatigue?
A
Weight Loss: do clothes still fit? how fast, intentional? Cough: Dry or productive Temperature: Shivering or sweating? Fatigue: last whole day without sleep? Fall asleep while doing a task?
7
Q
Types of Time Course of Pain?
A
Sudden and short Increasing crescendo pain Slow onset Dull aches Constant Progressive Pain Regular Frequency & regular episodes Regular Freq becoming more severe Episodic on a background of increasing intensity
8
Q
Ensure to ask about Time Course?
A
How it was at the start What happened over time (how often, for how long) Getting worse or more frequent? How did it end?/how is it now? Previous similar episode? - was it the same?
9
Q
What to ask about Context?
A
What was the patient doing when the symptom started? What medications were they taking? Had they eaten that day, drank enough water or had enough sleep?
10
Q
Questions about Relieving Factors?
A
Does anything make it better? Ask about specific interventions and if they helped?
11
Q
Questions about aggravating factors?
A
Have you noticed that anything seems to make it worse? Or a particular time or day?
12
Q
Asking about Associated Features?
A
Have you noticed anything else with the symptom? Direct specfic questions based on symptoms eg pain (swelling, redness, giving away, itch, rash, shortness of breath, nausea.
13
Q
Define Palpitation
A
An abnormal awareness of the heart beat. - skipping beat, irregular rhythm, faster or slower or stronger then usual
14
Q
What should you find out about Palpitations regarding: Site Quality Severity Time Course
A
Site: not that useful may feel in neck instead Quality: regular or irregular (ask patient to tap out) and feels forceful (slower) or like flutter (faster) Severity: difficult to establish Time Course: IMPORTANT! when do they start —-how long to they last —> how do they end. start and end suddenly more likely to be serious. Are they the same length all the time.
15
Q
What should you find out about Palpitations regarding: Context Relieving Factors Aggravating Factors Associated Features
A
Context: may be anxious, smoker how much caffeine? Relieving Factors: stops them? Aggravating Factors: coffee, exercise or stress Associated Features: SOB, Chest pain (ask more ?’s), fatigue, dizziness and blackouts (bad enough not to provide cerebral flow.
16
Q
What should you ask about Past medical history?
A
serious illness operations hospital admissions/have they ever been Medications allergies past complications with procedures
17
Q
What are the steps in taking a BP?
A
- Tell/ask the patient about what you are going to do 2. Hand hygiene 3. Good Sized Cuff (bladder = 80 circumference of arm) 4. Apply cuff to left arm - arrow pointing to brachial artery - lower border 2-3 cm above brachial artery pulsation 5. Palpate the radial pulse while inflating the cuff until the pulse disappears - estimate systolic blood pressure 6. Inflate cuff with steth over brachial pulse to 30mmHg over Palpated reading - cuff should be at heart level 7. Deflate cuff at 2-3 mmHg per beat. 8. Listen for start of Phase 1 sound as pressure drops below systolic. 9. Just before diastolic pressure is reached sounds become muffled Phase IV. then below sounds disappear Phase V. Report to nearest 5 mmHg.
18
Q
Normal Blood Pressure Ranges?
A
Systolic: 140 -100 = Ejection Diastolic: 90 - 60 = Filling
19
Q
Define Syncope?
A
Sudden loss of consciousness and postural tone due to insufficient blood supply to the brain.
20
Q
Two types of Syncope?
A
Cardiac and Vasovagal
21
Q
What Assoc Features should you ask about to rule out Seizures in a LOC?
A
Convulsing frothing at the mouth muscle aches confusion as to where they were and what happened Longer then 30 seconds
22
Q
Compare the: Prodrome Quality Time Course Context Precipitating factors Relieving factors Period after event In Cardiac and Vasovagal Syncope
A
Prodrome: Usually not present in Cardiac but in VV can get light-headed, wobbly legs, vision going dim, noises sounding distant, may remember start of collapse Quality: Both have loss of postural tone and may have only a few jerks —> more then seizure more likely Time Course: both usually less then 30s before, during, after Context: VV - usually don’t occur when sitting or lying. Cardiac can occur when sitting or lying down Precipitating factors: VV - often have specific pf eg fasting, pain, emotional events or prolonged standing. Cardiac = don’t usually have. Relieving factors: Cardiac = self limiting, VV= lying flat assists recovery. Period after event: both have rapid recovery and rearely confused after. Injury may occur in cardiac, not as common in vv as protective reflexes preserved.
23
Q
Associated Features and Past history for Cardiac and Vasovagal Syncope?
A
AF: Sweaty, Pallor, no frothing at mouth, incontinence may occur but not common Past Med history: Cardiac –> may have history Cardiac disease.
24
Q
Steps in Cardio Exam leading up to taking of BP?
A
- Prepare Patient: Reason for exam, what will happen, ask them to tell you to stop if there is any discomfort. Bed at 45 deg. 2. Hand hygiene 3. General inspection: supp oxygen? mental state? 4. Hands: Fingers for clubbing or nicotine stains. Palmar creases for evidence of anaemia 5. Measure radial pulse: count 15 seconds x 4 regular or irregular? 6. Measure BP.
25
Steps in Cardio Exam after you would take BP?
7. Head and Neck = conjunctivae, lips and tongue 8. Jugular venous pulse 9. Examine carotid artery pulse on both sides (not at same time) 10. Inspect chest 11. Palpate chest: 5th intercostal space then mid-clavicular line (Apex beat?) 12. Listen with bell to hear heart sounds and then diaphragm at four auscultation points apex, lower left sternal edge, upper left and right sternal edges. 13. Examine Posterior Chest - Listen lung bases for crackles 14. Examination of lower limbs - oedema, dorsalis pedis and posterior tibial pulses.
26
Associated Features of Chest pain?
Pale, SOB, Nausea/vomit, dizzy, collaspe. LOC, peripheral oedema (aka swelling in legs), radiation of pain (jaw, arms and back).
27
Three Life Threatening things that can present with Chest Pain?
MI, Aortic Dissection and Pulmonary Embolism
28
Define Myocardial ischaemia?
Pain caused by insufficient oxygenated blood flowing to the heart muscle because of an imbalance of supply and demand. Most common cause is the narrowing of coronary artery due to atherosclerosis.
29
What is Angina? stable vs unstable How does it present? When and how does it end? What are the Associated Features?
Def: reversible Myocadial ischaemia Presents: diffuse central chest pain --\> radiates to arms, neck, lower jaw and upper abdomen. Heavy or pressure pain When how? Often comes on with physical exertion, relieved by rest or specfic anti-angina drugs
30
Risk Factors For CV Disease that need to be asked about or considered?
Non Mod: Age, Gender, Family History or Personal Med History Mod: Smoking, Diabetes, Hypertension, Poor diet, Hyperlipidaemia, physical inactivity/obesity, depression/isolation.
31
Specific things to consider with Calf Pain?
- cramping feeling when patient walks (distance before pain starts = claudication distance) is this distance changing? - stops when patients rests - same risk factors as CAD - smoking, hyperlipidaemia, obesity, diabetes and inactivity.
32
Good ways to ask about Family History?
Could you tell me something about the health of your immediate family? Can you tell me about the health of your parents and siblings? Do your parents or siblings have any similar problems?
33
Which valves are the four hear auscultation points "looking" at?
Starting from Right Superior ( All Politicians take money) Atrial, Pulmonary, Tricuspid, Mitral (apex beat).
34
A person who is tall, thin and well with SOB?
Pneomothorax
35
Young person, dry lips, SOB and ketones (on breath)
1st presentation of diabetes
36
Oedema: specific considerations? Site: Time Course: Associated Features
Site: Bilateral legs = Cardiac, Unilateral = DVT, General = increased capillary permeability. Time Course: often worse at end of day - resting with feet up can help Assoc Features: +dyspnoea and orthpnoea = cardiac failure with leg pain = DVT
37
Two main causes of dyspnoea?
Respiratory or Cardiac causes.
38
What type of phrases are used to described dyspnoea
out of puff, wheezy breathing, tightness in chest and can't get enough air? Wheezing is associated with diseases that primarlity affect the lungs- common cause of episodic wheeze is asthma
39
SOB: specific questions Quality: Severity Time Course Context Aggravatng Factors Relieving Factors Associated Features
Quality: heavy or shallow Severity: relate to exertion or at rest Time Course: sudden or slow onset, worsening with time or episodic? Context: certain environments --\> occupational lung disease. Agg: lying down = heart failure (how many pillows to sleep Rel: Esp important in asthma does usual medication help? Assoc: chest pain, cough, wheeze, swelling ankles. sweating, fatigue nausea.
40
Typical symptoms of asthma and how is it monitored/severity determined?
dyspnoea, cough, wheeze Severity: peak expiratory flow, spirometry and freq of symptoms, need of glucocorticoids and hospital admissions
41
Common triggers for asthma?
Smoking, pollen, viral illness, dust, cold air, exercise, stress
42
Important things to ask in asthma about? Time course? Severity? Relieving Factors Associated Symptoms
Time course: onset? How often have attacks (daily, episodic infrequenct) Severity: current level of activity freq sym during day and night. How often? how long? shouldn't need reliever without trigers Relieving Factors: bronchodilators Assoc Symptoms: other atopic diseases eczema, allergic rhinitis or hives.
43
Questions around occupational history?
Occupational lung diseases, back pain heavy lifting, hand washing and skin diseases. What type of work are you involved in? Have you had any other types of jobs in the past? Does anyone else at work have similar symptoms?
44
Asking about Social History?
relationships, hobbies, education and occupation, fiances, ethnicity, pets, travel. Recently been overseas? How lives with you?
45
What are the steps in Resp Exam before percussion?
1. Prepare Patient - sitting at 90 deg. 2. Hand hygiene 3. General inspection ask questions about sup O2 or sputum cup if there 4. Inspect hands - clubbing and nails 5. Measurement of pulse and RR 30 seconds. 6. Inspect anterior and lateral chest walls 7. Measure anterior chest expansion - hands over lower rib cage - thumbs together - upper anterior chest wall using flats of hands
46
What are the steps in a Resp Exam after measuring chest wall expansion?
8. Percussion of the anterior and lateral chest. Comparative tap twice. Clavicles to liver on right and cardiac dullness of left. 9. Auscultation of the anterior and lateral chest - ask patient to breath in and out - listen at sites of percussion - hands on hips for lateral chest - repeat with the 99's 10. Examination of posterior chest - readjust patient if necessary - Measure chest expansion - Ask patient to hug their chest - Percuss two positions in the upper zone and two in lower zone. - Auscultation same sites while patients brings in and out. - 99's at same site 12. Measure peak flow while standing, horizontal 3x.
47
Smoking History involves both a Quantitative and Qualitative assessment?
Quantitative: - smoker? if not check passive smoking or if they have ever smoked --\> time since cessation/pack years. - if yes -\> establish duration of smoking and average smoking at onset and now. - calculate pack years - have they ever stopped? Qualitative: - triggers - aka context social/occupational? - Signs of dependance - how often after waking do they need a cig. - can they tolerate times when they can't smoke eg flights, movies and work hours - Respiratory symptoms (SOB, cough?) - Attempted to smoke? why they were unsuccessful what techniques they used?
48
Signs of Dependance to cig?
- How soon after waking do you they need a cig? - Could they cope with any long term events that required them not to have a cig? eg plane, movie, work hours? - Do they avoid situations where they cannot smoke - is it hurting them financially? - Do they feel agitated with they can't have a smoke?
49
Describe the cough reflex:
cough receptors activated by stimules leading to deep inspiration, closure of the glottis, muscle contraction against it, leading to forceful release of air from the lungs and characteristic sound.
50
How are coughs classified by duration?
Acute: 8 weeks
51
What important pathologies are likely in these types of cough: barking? Whooping?
Barking = croup Whooping = Pertussis
52
Common causes of acute cough? Serious?
viral infections of lungs bacterial infections of lungs serious = pulmonary embolism
53
Common causes of chronic cough?
asthma, post nasal drip and gastro-oesphageal disease.
54
What factors should you find out about the sputum of a productive cough?
colour volume thickness odour purulent? blood stained?
55
What is the medical term for coughing up blood from the lower respiratory tract, with our without sputum?
Haemoptysis
56
What do you need to know about? Site Quality Severity Time Course Context Relieving Factors Aggravating Factors
Site: not useful Quality: bark, hack - dry or productive if there is sputum needs to be separately characterized. Severity = frequency Time Course: greater or less then 3 weeks Context: context of onset of cough Relieving Factors: any treatments? Aggravating Factors? Precipitating? aka allergies, exercise, lying down? Worse at night, day or morning?
57
Associated Features to ask about for a cough?
SOB, wheeze, fever, haemoptysis, smoking, acid reflux.
58
What is blood call if it is cough/vomited up from the GI track?
Haematemesis
59
What features are used to distinguish haematemesis and haemoptysis? aka site
Prodrome: GI: nausea and abdo discomfort Resp: irritation in chest or throat follwed by desire to cough. Colour GI: Dark red not frothy RESP: Bright Red Frothy
60
Possible causes of hemoptysis?
bronchitis lung cancer trauma TB pulmonary infarction long term pulmonary hypertension clotting problems + trauma pulmonary embolism
61
How to find out about the: Severity Time Course context Associated symptoms. Of Haemoptysis.
Severity: how much: massive \> 200mL in 24 hrs, teaspoon? Time Course: when did it start, how often is it still going Context: allergies, better in morning night lying standing Associated symptoms: Respiratory or Gi symptoms, smoking, alcohol etc
62
How does regurgitation differ from vomiting?
It is the passive flow of oesophageal contents into the mouth without: nausea, muscular activity normally occurs when associated with gastro-oesophagel reflux disease.
63
Associated Symptoms with vomiting
Nausea Dry retching: muscle contractions with no expulsions Haematemesis: vomiting blood
64
What to ask about Site Quality Severity Time Course Context Relieving Factors Aggravating Factors of vomiting?
Site: not helpful Quality: ask it's colour, taste?, contains blood or bile stained (yellow and bitter) Severity: how many times and how much Time Course: Onset, duration and if there is a pattern? Morning or timed with meals Context: medications, preg, alcohol, food intake, contact with others who have vomited or diarrhoea. Relieving Factors: tried anything to stop? Aggravating Factors precipitaes vomiting
65
Associated Features of vomiting?
pain, diarrhoea, fever, headache, vertigo, symptoms of dehydration and weight loss.
66
What is dysphagia? What is odynophagia
Dysphagia is difficulty swallowing: sensation that food is becoming stuck as it passes through the pharynx or oesophagus. Odynophagia is pain on swallowing
67
What are the two main types of dysphagia? One of them has two causes?
Oropharyngeal dysphagia: difficulty with the initiation of the swallowing process. Oesophageal dysphagia: passage of food or liquid through the oesophagus to the stomach is hindered. Symptoms after initiation of swallowing. -\> Motility disorder: difficulty swallowing both solids and liquids from onset -\> Mechanical obstruction: initially difficulty swallowing solids may progress to difficulty swallowing liquids.
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Site, Associated Features of Oropharyngeal dysphagia? Site, Associated features of Oesophageal dysphagia?
Oro = Cervical region: coughing, chocking or nasal regurgitation Oeso = retrosternal area:
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Causes of dysphagia
Oropharyngeal dysphagia: stroke, Parkinson's disease and MS Oesophageal dysphagia: -\> Motility disorder: neuromuscular, achalasia -\> Mechanical obstruction: cancer of the oesophagus.
70
Steps in GI Exam before palpation
1. Preparing Patient. Who you are what you would like to do? 2. Hand hygiene 3. General Inspection 4. Examination of the hands: - leuconychia (white nail), - palmar erythema (redness) - pallor of palmar creases. - Feel palms for Dupuytren's contracture. - metabloic flap: check 15s 5. Eyes - jaundice in whites of eyes & pallor which may indicate anaemia 6. Examination of Chest - spider naevi front and back gynaecomastia - glandular tissue in male breast -\> both signs of chronic liver disease. 7. Inspection of abdomen: Get patient to lie flat. - look for scars, distension or masses - caput medusae -\>collateral vessels around umbilicus = cirrhosis - distended abdo wall viens - obstruction of IVC.
71
After inspection of the abdomen?
8. Palpation of the abdomen -ask if they are tender anywhere -\> start further away from pain. Use right-hand lightly first then more deeply. Watch patients face while you palpate 9. Examine & Measure Liver - palpate right lower quad with flat of hand on abdomen parallel to costal margin. Get patient to breathe. Advance hand during Expiration. Feel for lower border. -percus from right lower quadrant to right costal margin. - put patients hand on lower boarder. resonant to dull - Define upper border of the liver percuss along midclavicular line from third rib down. - measure along midclavicular line 12-13 cm. 10. Examine Spleen - Right hand parallel to costal margin. Palpate as patient inspires. across to left upper quandrant. advance during expiration. - Patient at 45deg, advance right hand same way on expiration. 11. Examination of the kidneys - Right hand under costal margin - Left hand is placed posterioly in loin region
72
Features of a normal bowel habit?
Varies in general population. From every 2-3 days to several times a day. Consistent. Not changing.
73
Classifications of Diarrhea by time period?
Acute: abrupt onset and lasts few days Persistent: lasting between 2 and 4 weeks Chronic: slow to develop and have long duration \> 4 weeks.
74
Applying Cardinal Features to Diarrhea: Site Quality Severity Time Course Context Relieving Factors Aggravating factors
Site: of assoc abdo pain Quality: watery? any blood? or mucus in it? Severity: frequency of bowel actin and volume of stools Time Course: distinguish acute from chronic, worsening or improvement. How it was. Now how it is? Context: food associated? overseas travel, new medications or infective contacts Relieving Factors: not eating makes osmotic diarrhea stop Aggravating factors:
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Associated Features of Diarrhea:
nausea, fever, vomiting. Abdo pain, dehydration, weight loss, dizzy. Crohn's Disease: joint pain, clubbing and red bumps on shins.
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Symptoms patients will report when Constipated? What could it be?
excessively hard stools, incomplete evacuation of bowels, patients need to strain to pass stools. Could be caused by low fibre diet, medications (eg codeine), bowel cancer, immobility and hypothyroidism.
77
Cardinal Features of Rectal Bleeding: Site Quality Severity Time Course Context Relieving Factors Aggravating factors
Site: could be from lower or upper GI Quality: Colour, spots, clots? Severity: spots ---\> anaemia Time Course: When did it start? Has it stopped? Context: Family history of bowel cancer Relieving Factors Aggravating factors
78
How does the colour of blood indicate site or origin?
bright red -\> close to the anus darker or maroon-coloured blood that is more likely to be mixed in with stools = first parts or large intestine. Upper GI -\> stools usually appear black and tarry and called melaena
79
Why do the stools look black or tarry called melaena?
Oxidised by bacteria as it passes through the intestines.
80
Organs in right upper quadrant of abdomen?
Liver and gallbladder
81
What quandrant is the stomach in?
The left upper quandrant
82
What is in the right lower quadrant?
Caecum and appendix
83
What is in left lower quadrant?
Descending colon and sigmoid colon
84
How do you locate McBurney's point?
One third of the way along a line from anterior superior iliac spine (ASIS) to the umbilicus - base of the appendix and site of incision to remove.
85
Which kidney sits higher? What rib does each superior pole reach? Inferior poles of both?
Left kidney is higher -\> rib 11 Right kidney reach rib 12. Inferior poles of both extend to approx L3
86
Alcohol contributes to a number of diseases?
Chronic liver disease, heartburn, hypertension an depression.
87
What percentage of deaths in 20-39 yo are attributable to EtOH
25%
88
How do you start EtOH history
Do they drink EtOH? If no, did they use to and have stopped? If no can end. If yes need to get further history.
89
What do you need to find out about EtOH history?
How much, what and how often? Time-line: when did they start drinking? Context: what situation do they drink, with people or along? Symptoms of Depndence: morning drinking, inter with work Have they tried quitting? Alcohol related harm?
90
Signs of Dependence?
C: cut down? A: peole annoyed you by criticing drinking G: guilty about drinking or things they have done while drinking E: eye opener -\> drink in morning?
91
Current guidelines for drinking?
no more then two standard drinks on any day no more than four standard drinks on any single occasion.
92
How is bilirubin produced?
pigment produced by metabolism of haemoglobin released during the destruction of RBC at end of life span.
93
In what form does bilirubin circulate in teh blood stream?
Unconjugated form bound to albumin
94
How does bilirubin end up in the intestines?
Conjugated in hepatocytes in the liver --\> make it water soluable -\> secreted into bile then into intestines.
95
How does bilirubin exit the body?
Excreted in faeces -\> steroglobin = normal dark colour of faeces Or metabolised to urobilinogen (bacteria) which is reabsorbed and excreted via the kidneys.
96
Two major categories of jaundice?
- unconjugated hyperbilirubinamia - mixed unconjugated and conjugated hyperbilirubinaemia
97
Two types of unconjugated hyperbilirubinamia:
1. over-production of bilirubin (pre-hepatic jaundice), increased destruction of RBCs. 2. Impaired uptake or conjugation of bilirubin by liver eg Gilberts syndrme
98
Three types of mixed hyperbilirubinamia:
1. Impaired secretion into bile cannalicuil - Dubin Johnson syndrome, or by destruction of the intrahepatic bile ducts 2. Liver disease: damge to hepatocytes conjugated bilirubin predominates as excretion is rate limiting steps. Viral and alcoholic hepatitis 3. Obstruction of the bile ducts (post-hepatic jaundice) - gall stones in common bile duct and cancer of head of pancreas --\> primarily conjugated bilirubin builds up.
99
Four Symptoms associated with jaundice?
1. Dark urine - excretion of water soluable conjugated bilirubin - post hepatic and hepatic
2. Pale or clay coloured stools - lack of steroglobin - post hepatic
3. Pruritus - itching - build up of bile salts - esp in post hepatic jaundice
4. Pain
100
Levels of urobiligin in urine, conjugated bilirubin in urine, steroglobin in stools in pre, post and hepatic jaundice
101
Things to find out about cardinal features of jaundice:
Site: eyes or just skin
Quality: not importnat
Severity: higher levels of bilirubin for both skin and sclerae. green = oxidation
Time Course: Come on rapidly? (gall stones or acute hepatitis) come on over weeks and months = neoplasm or chronic cirrhosis more likely.
Context: travel? infection? intermittant/mild from fasting and viral illness = Gilberts
Associated: Dark urine, pale stools, pruitus and pain
Alcohol consumption, recent travel, immunisations, tattoos, IV drug use and unprotected sex
102
Associated Features for Palpitations?
SOB, chest pain, fatigue, dizziness blackouts, caffiene consumption, smoking, anxiety, stress
103
BMI ranges: for underweight, normal weight, overweight and obese?
normal: less then 18.5
Normal weight: 18.5 - 24.9
Overweight: 25 - 29.9
Obese: \>30
104
Normal pulse rate?
60 to 100
105
What heigh of JVP from sternal notch is tolerated before indicating raised pressure in the right side of the heart
3 cm.
106
Where do you find the apex beat?
Fifth intercostal space in the mid-clavicular line.
107
Prolonged angina pain greater then how many minutes suggest MI
20 minutes -\> ischaemia is severe enough to cause permanent heart msucle damage (necrosis).
108
Location of Auscultation of Mitral Valve
Apex - 5th intercostal space in mid-clavicular line
109
Location of Auscultation of tricuspid valve?
Left side of the sternum at the level of the 5th costal cartilage (T)
110
Location of auscultation of aortic valve
Just to the RIGHT of the sternum in the second intercostal space (A)
111
Location of Auscultation of Pulmonary valve?
Just to the left of the sternum in the second intercostal space (P)
112
