Clinical Medical Sciences (CMS) Flashcards
Blood pressure why is it important to use the right size cuff
- Use a blood pressure cuff that is of proper size to minimize errors in blood pressure determinations. The arm cuff should be at least 10cm wide; for the thigh, a width of 18cm is preferable. The length of the blood pressure cuff’s bladder (the inflatable part) should encircle at least 80% of the arm’s circumference.
Incomplete Occlusion: A small cuff may not fully occlude (block) the artery during measurement. This can result in some blood continuing to flow through the partially compressed artery, leading to a falsely high reading.
**If the clamp (cuff) is too small, you’d need to apply more pressure to stop the flow of water (blood). This excessive pressure can lead to inaccurately high readings because it compresses the artery too much.
If the clamp is just the right size, you’d apply the correct amount of pressure to stop the flow without squeezing the hose too tightly or leaving it too loose. This is analogous to using a properly sized cuff for blood pressure measurement, which gives accurate readings.
Conversely, if the clamp is too big, you wouldn’t need to apply much pressure because it naturally fits around the hose without squeezing it much. However, this can also lead to inaccurate readings because the cuff might not fully occlude the artery.
Blood pressure what to screen for before taking
Screen the patient to identify if patient has avoided caffeine and smoking 30 minutes prior to measurement. Also be aware that anxiety, “white coat syndrome”, rushing to make the appointment on time, bladder distension, chronic alcoholism, recent cigarette smoking and caffeine consumption can contribute to temporarily raised blood pressure in the absence of disease.
- The patient’s arm should be bare, free of clothing, and have no scarring, lymphedema, or arteriovenous (AV) fistulas. Keep the patients arm at the level of the heart.
Easy to remember if you understand to double for hypertension
Blood pressure what is normal, what are the different stages
Hypotension = low blood pressure (> 90/60 mm Hg)
Common Causes of hypo/hypertension
Clinical manifestations of low blood pressure can include fatigue, shortness of breath (SOB)/dyspnea on exertion (DOE), and light-headedness, especially on assuming an upright posture (orthostatic hypotension).
- The most common causes of low blood pressure are dehydration or decreased cardiac output.
- In patients with acute illness, hypotension with a systolic BP of <90 mm Hg can predict death in hospitalized patients in the intensive care unit (ICU) (LR+ 3.1) and in patients with bacteremia (LR+ 4.9) and pneumonia (LR+ 7.6); with a systolic BP of <80 mm Hg it can predict death in patients with myocardial infarction (LR+ 15.5). The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system, which predicts the risk of hospital mortality among patients in the ICU, assigns more points (and thus a higher risk) to severe hypotension than to any other vital sign or laboratory variable.
- Hypotension also predicts other adverse outcomes. In patients with myocardial infarction, a systolic blood pressure less than 80 mm Hg predicts a much higher incidence of congestive heart failure (CHF), ventricular tachycardia and fibrillation, and complete heart block. In hospitalized patients, hypotension greatly increases the risk of serious adverse outcomes in the next 24 hours (≤90 mm Hg, LR+ 4.7; ≤85 mm Hg, LR+ 9; ≤80 mm Hg, LR+ 16.7)
HYPERTENSION = High Blood Pressure (>130 / 80)
- Blood pressures that are too high may cause end-organ damage with equally disastrous consequences. Heart attack, stroke, hypertensive renal failure, and retinopathy are all too familiar in the hypertensive population.
- Essential hypertension is defined as three or more blood pressure readings taken over three visits separated by weeks
- Blood pressure should be measured in every person, even when asymptomatic, because essential hypertension is common and treatable and because treatment reduces cardiovascular morbidity and overall mortality rates.
For Patient Health Questionaire (PHQ-2) and (General Anxiety Disorder (GAD-2) remember the system is 0-3
The options for answering the following questions are:
Not at all - for a score of 0
Several days - for a score of 1
More than half the days - for a score of 2
Nearly every day - for a score of 3
FYI: It starts by asking, over the past/last 2 weeks… (It keeps up with the notion of of 2’s)
But what is the cutoff that lets you know to ask the rest of the questions?
3 is the cut off
PHQ-2
“Over the past 2 weeks, how often have you been bothered by the following problems?”
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
GAD 2
“Over the last 2 weeks, how often have you been bothered by the following problems? “
1. Feeling nervous, anxious or on edge.
2. Not being able to stop or control worrying
How is the ear exam performed?
Ear Exam-
Inspection & Palpation
Inspect the ears bilaterally for any asymmetry or prominence
Start the examination with the unaffected ear before assessing the affected ear.
Inspect the pinna and periauricular area –
Scars, masses, skin changes (such as erythema, desquamation, lesions), edema, and discharge
Palpate the pre- and post-auricular lymph nodes noting any tenderness or enlargement.
Insect Mastoid bone posterior to the pinna –
note any erythema, swelling, anterior displacement of the pinna, or loss of the post-auricular sulcus
Palpate the mastoid bone for any pain or tenderness which may also indicate mastoiditis. Gently tug on the pinna and palpate the tragus – pain on either of these tests indicate otitis externa
Otoscopic
Pencil grip – Left hand – resting on Px’s high cheek bone
Right hand displaces Ear – up, out and back
When performing an otoscopic exam, you should visualize and comment on the following:
• External ear canal
• Tympanic membrane – a tympanic membrane that is not perforated is often termed “intact”
• Cone of light
• Bony landmarks – manubrium of malleus
• Pars flaccida and pars tensa
why does conductive hearing loss lateralizes during the webers test?
During the Weber’s test, conductive hearing loss can often lead to lateralization, where the individual perceives the sound as louder in one ear compared to the other. This phenomenon occurs due to the way sound is conducted through the bones of the skull in cases of conductive hearing loss.
Here’s why conductive hearing loss can result in lateralization during the Weber’s test:
Bone Conduction Pathway:
In conductive hearing loss, the problem typically lies in the outer or middle ear, which hinders the transmission of sound waves through the air to the inner ear.
However, bone conduction, which involves the direct transmission of sound vibrations through the bones of the skull to the inner ear, can still occur relatively unaffected.
When a tuning fork is placed on the midline of the head during the Weber’s test, the sound vibrations are transmitted through the bones of the skull to both inner ears.
Unilateral Conductive Hearing Loss:
If an individual has unilateral conductive hearing loss (meaning the hearing loss affects only one ear), the affected ear may not receive the sound vibrations as efficiently through air conduction due to the conductive impairment in the outer or middle ear.
However, bone conduction, which is not affected by the conductive impairment, still transmits the sound vibrations to both inner ears equally.
Lateralization Effect:
Since the affected ear doesn’t receive the sound as well through air conduction but does receive it through bone conduction, the individual may perceive the sound as louder or more intense in the affected ear during the Weber’s test.
This leads to lateralization, where the individual localizes the sound to the ear with the conductive hearing loss, as it appears to be the source of the louder sound.
In summary, conductive hearing loss can cause lateralization during the Weber’s test because the impaired ear may not receive sound as effectively through air conduction but still receives it through bone conduction. This leads to the perception of the sound as louder in the affected ear, resulting in lateralization of the sound source.
More info
Yes, that’s another factor that can contribute to lateralization during the Weber’s test in cases of conductive hearing loss. Conductive hearing loss can result from various conditions that impede the efficient transmission of sound waves through the outer and middle ear. Here’s how this can lead to difficulties in sound leaving the ear and contribute to lateralization:
Conductive Hearing Loss and Sound Transmission:
Conductive hearing loss involves issues in the outer or middle ear that hinder the transmission of sound waves to the inner ear (cochlea). This can be due to factors like earwax buildup, ear infections, perforated eardrum, or problems with the middle ear bones (ossicles).
When sound waves encounter these barriers, they may not be transmitted as efficiently to the cochlea, leading to a reduction in perceived loudness and clarity of sounds.
Impaired Sound Exit:
In addition to hindering the transmission of sound into the ear (air conduction), conductive hearing loss can also affect how sound leaves the ear.
The impaired function of the middle ear structures, such as the ossicles (malleus, incus, stapes), can result in decreased efficiency in transmitting sound waves from the middle ear to the inner ear and further into the auditory pathway.
As a result, the sound may not exit the ear as effectively as it would in a normally functioning ear.
Weber’s Test and Lateralization:
During the Weber’s test, a tuning fork is placed on the midline of the head, and the individual is asked to determine where they perceive the sound.
In cases of conductive hearing loss, if the affected ear has difficulty transmitting sound out efficiently due to the conductive impairment, the sound may appear louder or more intense in that ear.
This can lead to the individual perceiving the sound as originating from the ear with conductive hearing loss, resulting in lateralization where the sound source is localized to that ear.
How to Introduce yourself before doing an exam. How to introduce yourself before doing a pelvic exam
“Hello, my name is Dr. _____ and I will be performing your pelvic examination today. The examination has 3 steps. The first is an external examination where I will be doing a visual and physical examination of the external structures/genitalia. The second is a speculum examination (show patient speculum) to visualize the cervix. This is where I will do any necessary swabs. The third part of the exam is the bimanual exam Which is partially internal and partially external. I will be inserting two fingers into the vaginal canal, and putting some pressure on your abdomen to assess the uterus and ovaries. If a any Lonny you feel discomfort please let me know, and if at any point you would like to stop the examination for whatever reason, please say “stop” and I will do so immediately.”
