Clin Skills Pathologies Flashcards
resp: end of the bed
environment:
- inhalers
- oxygen
- walking aids
- sputum pots
- medications
patient:
- alert and comfortable at rest
- tachypnoeic or dyspnoeic
- obvious cyanosis
resp: hands
- clubbing
- peripheral cyanosis
- tar staining
- CO2 retention tremor
resp: face
eyes:
- conjunctival pallor
- Horner’s syndrome (anhydrosis, ptosis and miosis)
mouth:
- central cyanosis
resp: neck
- raised JVP
- tracheal deviation
- scars (tracheotomy etc)
resp: chest
- scars e.g. lateral thoracotomy or sternotomy
- chest wall movement (symmetrical?)
- chest wall deformities
resp: back
- exaggerated kyphosis
- scars
cardio: end of bed
environment:
- GTN spray and other medications
- oxygen
patient:
- alert and comfortable at rest
- pale, sweaty, flushed
- breathlessness
- mechanical ticking of a pacemaker
cardio: hands
- capillary refill
- tar staining
- bruising
- splinter haemorrhages
- other peripheral stigmata of endocarditis
- such as: jane way lesions (palms not painful) and osler’s nodes (fingers painful)
cardio: arms
- scars
- bruising
cardio: face
- malar flush
eyes:
- xanthelasma
- corneal arcus
- conjunctival pallor
mouth:
- central cyanosis
- good dentition
cardio: neck
- raised JVP
cardio: chest
- scars (e.g. lateral thoracotomy or sternotomy)
- pacemaker
- visible apex beat
abdo: end of bed
environment:
- nil by mouth signs
- feeding paraphenalia
- vomit bowls
patient:
- alert and comfortable at rest
- obvious abdominal distension
- obvious jaundice
- nasogastric tubes
abdo: hands
- dupuytren’s contracture
- palmar erythema
- bruising
- leukonychia
- koilonychia
- clubbing
- asterixis (liver flap)
abdo: arms
- AV fistula
- excoriations
abdo: face
eyes:
- jaundiced sclera
- conjunctival pallor
- keiser fleischer rings
- xanthelasma
mouth:
- oral hydration
- ulcers
- dentition
abdo: neck
- supraclavicular lymph nodes
abdo: chest
- gynaecomastia
- spider naevi
- excoriations
abdo: abdomen 😃
- abdominal distension
- caput medusa
- stoma
- scars
- grey turner’s/cullen’s signs
peripheral vascular: end of bed
environment:
- medications
- prosthesis
- waling aids/wheelchair
patient:
- alert and comfortable at rest
- amputations
- dressings
peripheral vascular: hands and arms
- colour
- hair loss
- ulcers
- gangrene
- scars
- shiny skin
- tar staining
CHUGSS + T
peripheral vascular: abdomen
- scars
- visible pulsation
peripheral vascular: lower limb
- colour
- hair loss
- ulcers
- gangrene
- shiny skin
- scars
- tar staining
CHUGSS + T
extras:
- varicose veins
- ‘no signs of venous insufficiencies’
DRE: inspection
anus and surrouding skin:
- skin tags
- external haemorrhoids
- fissures
- fistula
- abscess
- prolapse
- rash, excoriations
bear down:
- incontinence/leakage
- internal haemorrhoids
DRE: palpation (what to feel for)
anus:
- contraction and relaxation at the margin
- tone
- masses/ulceration/tenderness
rectum:
- masses (location, size, surface, consistency, mobility)
- stool
- tenderness
prostate:
- size (enlarged?)
- median sulcus (presence?)
- symmetry
- surface (smooth, irregular, masses?)
- consistency (hard, firm, soft?)
- tenderness
neck and thyroid: inspection
- scars
- swellings (e.g. goitre)
- pulsation (in goitre)
thyroid status: inspection of patient
- anxious/agitated or lethargic/slow
- clothing - appropriate for environment?
- voice - fast, slow, gravelly
thyroid status: questions + answers for hyper/hypo
1 = hypER
2 = hypO
skin + hair + nails
1. hair loss, sweaty
2. hair loss, brittle hair and nails
weight
1. loss
2. gain
energy levels + mood
1. high, anxious/agitation
2. low, depressed mood
appetite
1. increased
2. decreased
tremor
1. yes
2. no
intolerance to temperature
1. too hot
2. too cold
nervous system - palpitations
1. yes
2. no
GI + GU + Gynae
1. diarrhoea, amenorrhoea
2. constipation, menorrhagia
thyroid status: hands
- sweaty palms/cool dry
- palmar erythema
- acropachy (grave’s hypO)
- onycholysis
- tremor
thyroid status: face
- myxoedematous facies
- peaches and cream complexion
- eyebrow thinning
eyes:
- lid retraction
- lid lag
- exophthalmos/proptosis (grave’s hypO)
- opthalmoplegia (grave’s)
- chemosis (grave’s)
thyroid status: lower limb
- pre-tibial myxoedema
- generaised myxoedema
describing masses
- site
- size
- shape
- surface
- consistency
- contour
- thethering
- tenderness
- transillumination
phleb: things to think about/say
bottles:
- purple - FBC, reticulocytes, ESR
- blue - coagulation studies
- red - no additives (?)
- yellow - U+Es, lipids
sharps bin:
- position first in a convenient place
intro stuff:
- ask patient to confirm name + dob
- check wrist band
- check blood request form details match
- ask about pain!
- have you ever fainted after having your blood taken?
- are you on any blood thinning medications?
- have you got any allergies? latex?
- risks of procedure: small risk of infection but I will be wearing gloves and using an alcohol wipe to negate this, risk of bleeding but I will be applying pressure with some cotto wool afterwards
- consent for taking blood a second time in case the first is unsuccessful
other:
- ‘sharp scratch’
- release tourniquet!!
- in the event of a sharps injury: wash area with soap and running water without scrubbing, cover with plaster and allow natural bleeding, report immediately to OH or A&E out of hours for risk assessment and post exposure prophylaxis if needed
ear: outer ear
- scars
- swellings or lumps
- deformity
- inflammation
- skin condition e.g. eczema, lesions
- hearing aids
- discharge
ear: external auditory meatus using otoscope
- inflammation
- eczema
- furuncles
- vesicles
- wax or debris
- foreign bodies
- discharge
ear: tympanic membrane using otoscope
- handle of the malleus
- pars flaccida and attic (above malleus)
- pars tensa (below and around malleus)
sensory + motor: upper + lower limb
- skin changes
- scars
- dry skin from lack of sweating
- pale/cyanosed/red
- smooth shiny
- unreported injury or ulceration
- swelling or deformity (e.g. charcot’s joints)
motor: inspection of gait + stability
trunk when sitting:
- truncal ataxia
stance:
- ask pt if they are able to stand
- eyes closed - big difference between standing eyes closed and open = positive Romberg’s
gait:
- non-antalgic gait
- normal gait cycle
motor: upper + lower limb inspection
SWIFT
- scars
- wasting
- involuntary muscle movements
- fasiculations
- tremor
eye: general inspection and pupils
general:
- obvious abnormality or asymmetry of face or eyes
- glasses or contact lenses
pupils:
- irregularities in shape
- pupil size and symmetry
CN: general inspection
- obvious abnormality in head, face, eyes e.g:
- facial asymmetry
- eye related signs
- fasiculations (LMN)
- scard
- tracheostomy
- nasogastric tubes
CN: what to look for when testing CN IX+X
vagus and glossopharyngeal
tell pt to open mouth and say ahhh, use pen torch
- tongue retracts
- pharynx contracts
- palate rises symmetrically
- uvula remain in midline
CN: what to tell pt to do and look for when testing CN XII
hypoglossal
- open mouth but keep tongue inside - fasciculation and wasting
- stick out tongue - deviation (tongue points towards abnormality)
- wiggle tongue side to side - speed, difficulty, asymmetry
cognitive function: AMTS questions
- how old are you?
- what time is it?
remember the following address: 20 West Street, repeat it for me - who is that person (dr/nurse), what do they do?
- what year is it?
- what is the name of this place?
- what is your date of birth?
- what year did world war 1 start?
- who is the present monarch?
- count backwards from 20-1
- tell me the address I gave you earlier
7 or less = dementia/delerium
shoulder: look
environment:
- aids e.g. sling
- analgesia + other med
patient:
- alert and comfortable at rest
look:
- colour: bruising, erythema
- deformities
- wasting of deltoids (side), supraspinatus (behind), infraspinatus (behind)
- asymmetry of arms + acromioclavicular joints
- rashes
- fasiculations
- swelling + scars
DWARFS
shoulder: what to feel
- sternoclavicular joint
- clavicle
- acromioclavicular joint
- subacromial bursa
- glenohumeral joint anteriorly and posteriorly
- bicipital groove
- coracoid process
elbow: look
environment:
- aids e.g. sling
- analgesia + other meds
patient:
- alert and comfortable at rest
look:
- deformities
- wasting - biceps (ask to bend elbow), triceps (flex elbow)
- asymmetry - psoriatic rash, eczema
- rashes
- fasiculations
- scars (trauma, surgery) and swelling (rheumatoid nodules, gouty tophi)
- colour - bruising, erythema
DWARFS
elbow: what to feel
- olecranon
- medial epicondyle
- lateral epicondyle
- posterior border of the ulna for rheumatoid nodules
- temperature
hand and wrist: look - bedside
environment:
- walking aids
- eating/writing aids
- analgesia, steriods + other meds
patient:
- alert and comfortable at rest
- obvious tremor
hand and wrist: look - joints
swelling:
- soft tissue (inflammatory)
- bony hard nodes - heberden’s at DIPs, bouchard’s at PIPs
- firm nodules - rheumatoid arthritis subcutaneously mobile
- gouty tophi
deformities:
- ulnar deviation
- subluxation
- swan-neck deformity
- z-shaped deformity
- claw hand
- anomalous deformities from traumatic injuries
hand and wrist: look - muscle
- in pronation - interossei muscle wasting
- in supination - thenar and hypothenar eminences for wasting
hand and wrist: look - nails
- clubbing
- pitting
- onycholysis
- ragged nail folds,
- dermatomyositis
- splinter haemorrhages
hand and wrist: look - elbows
- psoriatic rashes
- rheumatoid nodules
- gouty tophi
hand and wrist: what to feel
- temperature wrist and hand
pronation:
- distal radius and radial styloid
- distal ulna and ulnar styloid
- joint line of wrist
- MCP PIP DIP
half supinated:
- CMC MCP IP thumb
fully supinated:
- palmar fascia + dupuytren’s contracture
- along flexor tendons
hip: look
environment:
- walking aids
- analgesia + other meds
patient:
- alert and comfortable at rest
look:
- deformity - tilted pelvis, exaggerated lordosis, abnormal leg positioning, leg length discrepancy
- wasting - difficult to assess
- asymmetry
- rashes
- fasiculations
- swellings/scars - make sure to look at back
- colour - bruising
DWARFS
AND:
- gait
- trendelenburg
hip: what to feel
- greater trochanter
- ASIS
- mid inguinal point
- temperature
knee: look
environment:
- walking aids
- analgesia + other meds
patient:
- alert and comfortable at rest
gait:
- non-antalgic gait
- normal gait cycle
look:
- deformity - valgus/varus, hyperextension, fixed flexion
- wasting - quads particularly
- asymmetry
- rashes - psoriatic
- fasiculations
- swelling
- scars
- colour - bruising, erythema
knee: what to feel
- patellar margins
- patellar tendon
- tibial tuberosity
- fibular head
- medial & lateral joint lines
- swelling in popliteal fossa
- patella apprehension
- effusion
ankle: look
environment:
- walking aids
- analgesia + other meds
patient:
- alert and comfortable at rest
gait:
- non-antalgic gait
- normal gait cycle
look:
- Deformities
- Wasting
- Asymmetry
- Rashes
- Fasciculations
- Scars
- Swelling
- Colour - bruising, erythema
ankle: what to feel
- Temp
- Medial tibia
- Head & shaft of fibula
- Both malleoli
- Base of 5th metatarsal
- Ligament - ATF, PTF, CF, deltoid (medial)
- Tendons: achilles, peroneus brevis
spine: look
environment:
- walking aids
- analgesia + other meds
patient:
- alert and comfortable at rest
look:
- deformities
- wasting
- asymmetry - normal/pathological lordosis/kyphosis, scoliosis
- rashes
- fasiculations
- swelling + scars e.g. laminectomies
posture specifically;
- head - balanced centrally
- shoulders - balanced centrally, relaxed
- cervical spine - gentle lordosis
- thoracic spine - gentle kyphosis
- lumbar spine - gentle lordosis
- pelvis - normal slight downwards anterior tilt
- hip - 0 degree angle
- knee - straight not hyperextended
- abdomen - flat, not portruding
- feet - vertical turned out at 10 degrees
spine: what to feel
in prone position
- spinour processes
- facet joints
- sacroiliac joints
gynae: inspection of vulva, perineum, pubic area
- warts, ulcers
- lumps
- vulvitis, vulval atrophy
- eczema, psoriases, excoriations, infestations
- swelling, erythema
- discharge
- obvious prolapse
gynae: inspection using speculum
vagina:
- discharge - colour, odour, amount
- warts
- masses
- irregular areas
cervix:
- polyps
- ectropian
- warts
- nabothian cysts
- discharge
- ulcers
- bleeding
- irregular areas
- masses
- products of conception if appropriate ?
- nulli/multi parous
male genital: inspection
standing:
- general - comfortable alert, pain, skin (excoriations of scabies etc), joints (inflammation), eyes (conjunctivitis, uveitis)
- lower abdo + pubic area - swellings, lumps, ulcers, scars, erythema, rashes, excoriations, infestations
- inguinal + femoral region - bear down to see swellings, lymphadenopathy, scars
- scrotum - lumps, swellings, skin abnromalities, bear down to see varicocoele
lying down (inspection parts only):
- penis - inspect all aspects for hypospadias, ulcers, nodules, rash, masses (only palpate if indicated)
- drawback foreskin to inspect for phimosis
- urethral meatus - position, discharge
- frenulum
- corona - warts, inflammation, rashes, ulcers
antenatal: end of the bed + peripheral
patient:
- gait (when they walked into room) and sitting - pain, discomfort
- pallor
- breathlessness
peripheral:
- finger oedema
- ankle oedema
antenatal: abdo
- degree of abdominal distension
- striae gravidarum
- linea nigra
- everted umbilicus
- scars e.g. previous caesarean section
- visible foetal movements
breast: inspection with patient sitting on edge of bed, arms by sides
- symmetry
- smooth/distorted contour, obvious masses
- erythema
- tethering/dimpling
- peau d’orange
- ulceration
- scars
- nipples and areola - symmetry, inversion or distortion, discharge, blood, signs of Paget’s disease
