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MD3001 > CLINICAL SKILLS > Flashcards

CLINICAL SKILLS Flashcards

1
Q

Give the steps of the traditional medical model in order.

A

history –> examination –> investigation –> diagnosis –> treatment –> follow-up

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2
Q

Give the name of the author of The Inner Consultation (1987) and the 5 main points of the technique.

A

Roger Neighbour

  1. connecting
  2. summarizing
  3. handing over
  4. safety netting
  5. housekeeping
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3
Q

Explain what ‘handing over’ means in The Inner Consultation?

A
  • agreeing on doctor’s and patient’s agenda
  • negotiating, influencing and gift-wrapping
  • giving ownership & responsibility of management plan to patient
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4
Q

What structure should you follow to take a history?

A 
Presenting complaint + relevant systems inquiry
Past medical history 
Drug history and allergies
Family history
Social history
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5
Q

Name at least 3 things you should ask about when taking the past medical history.

A
  • medical conditions
  • visits to the GP/hospital
  • investigations
  • operations/procedures
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6
Q

When taking a past medical history, it is often advised to follow the acronym JAMTHREADS. What does this acronym stand for? What other conditions should you ask about in a cardiovascular history?

A 
JAMTHREADS
J - Jaundice
A - Anaemia & other haematological conditions
M - Myocardial infarction
T - Tuberculosis
H - Hypertension & heart disease
R - Rheumatic fever
E - Epilepsy
A - Asthma & COPD
D - Diabetes
S - Stroke

OTHER CONDITIONS:

  • vascular diseases (coronary artery, cerebrovascular, peripheral vascular…)
  • hyperthyroidism
  • renal disease
  • hypercholesterolaemia
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7
Q

Give 5 examples of themes of a social history.

A
  • upbringing
  • home life
  • occupation
  • finance
  • relationship & domestic circumstances
  • house
  • community support
  • sexual history
  • leisure activities
  • exercise
  • substance misuse
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8
Q

How do you calculate pack years of smoking?

A

(#cigs smoked per day x #years of smoking)/20

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9
Q

How many cigarettes make a pack?

A

20 cigarettes in a pack

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10
Q

What 6 things should you ask about in a cardiovascular system inquiry?

A
  • chest pain
  • breathlessness
  • palpitations
  • syncope/dizziness
  • oedema
  • peripheral vascular symptoms
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11
Q

What are the 4 non-modifiable factors of cardiovascular risk?

A
  • age
  • gender
  • genetic factors/family history
  • race & ethnicity
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12
Q

What are the 7 modifiable factors of cardiovascular risk?

A
  • hypertension
  • smoking
  • diabetes
  • physical inactivity
  • abdominal obesity
  • hypercholesterolaemia
  • psychosocial factors
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13
Q

Name 6 common cardiovascular symptoms.

A
  • chest pain
  • dyspnoea
  • palpitations
  • dizziness/syncope
  • oedema
  • fatigue
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14
Q

Name one type of medication that could cause dyspnoea.

A

beta-blockers

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15
Q

Name three types of medication that could cause oedema.

A
  • steroids
  • NSAIDs
  • calcium-channel antagonists
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16
Q

For chest pain, give 3 cardiovascular causes, and one respiratory, one GI, one musculoskeletal and one viral cause.

A

CARDIOVASCULAR

  • stable angina
  • acute coronary syndromes
  • pericarditis
  • aortic dissection

RESPIRATORY

  • PE
  • pneumothorax
  • pneumonia
  • lung cancer
  • mesothelioma

GI
- oesophageal disease

MUSCULOSKELETAL

  • trauma
  • costochondritis

VIRAL
- Herpes zoster

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17
Q

What is the usual distribution of chest pain in an MI?

A

along sternum, radiating down medial side of left arm

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18
Q

Define angina.

A

a clinical syndrome of chest pain or pressure precipitated by activities such as exercise or emotional stress which increase myocardial oxygen demand

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19
Q

Differentiate between stable and unstable angina.

A

STABLE –> pain predictable according to activities

UNSTABLE –> pain unpredictable

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20
Q

To which spectrum do MI and angina both belong? What is the main pathophysiological difference between the two conditions?

A

acute myocardial ischaemia

MI = ischaemia with necrosis of cardiac tissue
angina = ischaemia without necrosis of cardiac tissue
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21
Q

How would you differentiate between MI and angina when taking a history?

A

MI often spontaneous VS angina precipitated by exercise or emotion

angina relieved by nitrates and rest, not MI

MI: severe anxiety, increased sympathetic activity, nausea and vomiting common VS angina: none or mild and uncommon

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22
Q

Which type of 999 call would chest pain be classified as? What about breathing problems?

A

Chest pain - red 2

Breathing problem - green 1

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23
Q

What is the cause of most pericarditis (80-90%)?

A

idiopathic (probably viral)

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24
Q

What eases pain of pericarditis?

A

sitting up and leaning forward

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25
Q

Describe the pain of aortic dissection in 5 points.

A
  • sudden
  • severe
  • deep
  • tearing
  • radiating to left shoulder and back
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26
Q

What syndrome involves a higher risk of aortic dissection?

A

Marfan syndrome

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27
Q

Define dyspnoea.

A

shortness of breath

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28
Q

What is the most likely system in cause for dyspnoea relieved by diuretics?

A

cardiac

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29
Q

Give 3 cardiac, 3 respiratory and 3 other causes of dyspnoea.

A

CARDIAC

  • cardiac failure
  • angina
  • MI

RESPIRATORY

  • asthma
  • COPD
  • pneumothorax
  • pneumonia
  • bronchitis
  • bronchiectasis
  • pulmonary fibrosis

OTHER

  • anaemia
  • obesity
  • hyperventilation
  • anxiety
  • metabolic acidosis
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30
Q

Define paroxysmal nocturnal dyspnea (PND).

A

= sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.

usually associated with cardiac failure as fluids fill the lungs

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31
Q

Define orthopnea.

A

= sensation of breathlessness in the recumbent position, relieved by sitting or standing

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32
Q

Define palpitations. What features are you looking for?

A

= unexpected awareness of heart beating in chest

  • fast or slow
  • regular or irregular
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33
Q

What 6 questions should you ask a patient presenting with palpitations?

A
  • tap out the rhythm
  • onset and termination
  • precipitating and relieving factors
  • frequency and duration
  • associated symptoms: chest pain, collapse, sweating, dyspnea
  • past medical history of cardiovascular or thyroid disease
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34
Q

What are the 4 categories of causes for dizziness and syncope?

A
  • cardiac
  • ENT
  • neurological
  • hypoglycaemia
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35
Q

What are 4 cardiac causes of dizziness and syncope?

A
  • postural hypotension
  • vasovagal (neurocardiogenic)
  • micturition syncope
  • cardiac arrhythmias
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36
Q

Distinguish between of pitting and non-pitting oedema.

A

PITTING
pressure applied over a bony surface will cause the skin to stay indented at the point of pressure

NON-PITTING
no indentation in skin following pressure applied over a bony surface

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37
Q

Give 3 causes of bilateral oedema.

A
  • congestive cardiac failure
  • cor pulmonale
  • cirrhosis
  • acute renal failure
  • calcium channel blockers
  • sepsis
  • hypothyroidism (myxoedema)
  • pregnancy
  • idiopathic
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38
Q

Give 3 causes of unilateral oedema.

A
  • DVT
  • chronic venous insufficiency
  • compartment syndrome
  • retroperitoneal mass
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39
Q

What causes cardiac failure in cor pulmonale? Which side of the heart fails?

A

stiff arteries in lungs

Right side

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40
Q

How would you recognise a vein with DVT using ultrasound?

A

normal vein can be visibly compressed

VS vein with DVT cannot be compressed as the clot is solid

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41
Q

Give 2 cardiac causes of fatigue.

A
  • cardiac failure

- side-effects of beta-blockers

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42
Q

Give 3 major signs of each of left-sided and right-sided heart failure.

A

LEFT-SIDED

  • paroxysmal nocturnal dyspnea
  • orthopnea
  • pulmonary congestion

RIGHT-SIDED

  • increased peripheral venous pressure
  • distended jugular veins
  • ascites
  • enlarged liver/spleen
  • dependent oedema
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43
Q

Give the steps of cardiovascular examination.

A
  • introduction and explanation
  • inspection
  • palpation
  • auscultation
  • other areas
  • conclusion
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44
Q

How should the patient be installed on the couch in a cardiovascular examination?

A

at 45 degrees with chest adequately exposed

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45
Q

What are you assessing for in close inspection of the hands (9 things)?

A
  • warmth
  • cap refill
  • peripheral cyanosis
  • tar staining
  • clubbing
  • splinter haemorrhages
  • Janeway lesions
  • Osler’s nodes
  • koilonychia
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46
Q

What are you assessing for in close inspection of the head (6 things)?

A
  • malar flush
  • pallor
  • clinical anaemia
  • xanthelasthmata
  • corneal arcus
  • central cyanosis
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47
Q

How would you quantify cyanosis in g/dL deoxyhaemoglobin?

A

more than 5g/dL deoxyhaemoglobin

48
Q

Define malar flush. What cardiac condition is it a sign of?

A

= a high colour over the cheekbones, with a bluish tinge caused by reduced oxygen concentration in the blood

sign of mitral valve disease

49
Q

Define butterfly rash. What condition is it characteristic of? Give one differential diagnosis.

A

= erythema in a butterfly distribution on the cheeks of the face and across the bridge of the nose

characteristic of systemic lupus erythematosus

dd= acne rosacea

50
Q

Define koilonychia. What is it a manifestation of?

A

= abnormality of the nails that causes them to be spoon-shaped (concave)

chronic iron deficiency

51
Q

What are the three changes in the area under and around nails that occur with clubbing?

A
  • softened nail beds
  • last part of finger is large, bulging, red and warm
  • convex nail shape
52
Q

What is the most common cause of clubbing?

A

lung cancer

53
Q

What are two signs of infective endocarditis seen in more than 85% of patients?

A
  • fever

- heart murmurs

54
Q

Give 5 classic signs of infective endocarditis.

A
  • petechiae
  • sublingual splinter haemorrhages
  • Osler’s nodes
  • Janeway lesions
  • Roth spots
55
Q

Name 4 main types of rash.

A
  • erythematous
  • maculopapular
  • petechial/purpuric
  • vesiculobullous
56
Q

Define Osler’s nodes. What are their usual location?

A

painful erythematous nodules associated with bacterial endocarditis

finger and toe tips, thenar and hypothenar eminences

57
Q

Where would you find Janeway lesions? What do they look like?

A

soles, palms, thenar and hypothenar eminences, plantar surface of the toe

macule of variable size and irregular shape

58
Q

Describe Roth’s spots and explain what each part corresponds to.

A

Red spot - haemorrhage

pale white center - fibrin-platelet plug

59
Q

What is the most common cause of Roth’s spots?

A

acute bacterial endocarditis

60
Q

Give one other name for a Roth’s spot.

A

A Litten sign

61
Q

Explain the workings of Duke criteria for endocarditis diagnosis.

A

Either 2 major signs, 1 major + 2 minor or 5minor signs.

MAJOR SIGNS

  • 2 positive blood cultures
  • new regurgitant murmurs
  • positive echo

MINOR SIGNS

  • predisposing condition (congenital heart disease, prosthetic valve…)
  • fever
  • immunologic signs
  • one positive blood culture
  • positive echo that doesn’t meet major criteria
62
Q

Which behavior puts the tricuspid valve at increased risk of endocarditis?

A

IV drug use

63
Q

Define xanthelasma. Which condition is it an indicator of?

A

= sharply demarcated yellowish flat plaques on upper and lower eyelids

atherosclerosis (with disturbed lipid metabolism)

64
Q

What are the two main causes for corneal arcus?

A
  • age

- hypercholesterolaemia

65
Q

Give the normal mean arterial blood pressure range.

A

85-100mmHg

66
Q

Where are the most important arterial baroreceptors located?

A
  • left and right carotid sinuses

- aortic arch

67
Q

Give 5 different rate and rhythm abnormalities of pulse and one explanation for each.

A

FAST REGULAR
exercise, anxiety, pain, fever, medication, hyperthyroidism

REGULARLY IRREGULAR
ectopic beat

IRREGULARLY IRREGULAR
atrial fibrillation

SLOW REGULAR
athletic training, hypothyroidism, medication

SLOW IRREGULAR
sick sinus syndrome, 2nd degree heart block, complete heart block

68
Q

Give 4 different volume and character abnormalities of pulse and one explanation for each.

A

LOW VOLUME
hypovolaemia, left ventricular failure

INCREASED VOLUME
anaemia, fever, thyrotoxicosis

SLOW RISING
aortic stenosis

COLLAPSING
aortic regurgitation

69
Q

Up to what value of heart rate would be normal for a newborn?

A

205 beat/min

70
Q

What is the normal level of the upper limit of the venous column in jugular venous pulse assessment?

A

behind right sternoclavicular joint, at level of sternal angle

71
Q

Where is the normal apex beat positioned?

A

left mid-clavicular line and 5th intercostal space

72
Q

How many landmarks are there for a praecordial exam?

A

4

73
Q

Which 7 exams would you offer to do at the end of a cardiovascular exam?

A
  • auscultate lung bases
  • check for ankle and sacral oedema
  • abdominal examination
  • peripheral vascular examination
  • take BP
  • fundoscopy
  • urinalysis
74
Q

What are the 2 main aims of a drug kardex?

A
  • to ensure safe, effective and patient-centred prescribing

- to maintain accurate records

75
Q

In which 4 instances should brand prescribing be used?

A
  • insulins
  • combination inhalers
  • modified-release preparations
  • epilepsy drugs
76
Q

How would you write oral, sublingual, topical, milligrams and nanograms in a kardex?

A 
ORAL
SL
TOP
mg
nanograms
77
Q

How many health professionals have to sign for a controlled drug to be administered to a patient?

A

2

78
Q

What is the info that MUST appear on a prescription for a pharmacist to be able to supply controlled drugs to a patient outside of the hospital?

A
  • name and address of patient
  • name of medication
  • form of medication
  • dose and directions of administration
  • strength to be supplied
  • total quantity to be supplied in words and figures
  • signed and dated by doctor
79
Q

How would you record that a patient has no drug allergies in a kardex?

A

NKDA -no known drug allergies

80
Q

How would you check that the patient is not rotated on a chest X-ray?

A

measure the distance between the medial end of each clavicle to the spinous process line

81
Q

Name each part of the ABC approach to chest X-ray.

A 
Airway
Breathing
Cardiac
Diaphragm
External structures & equipment
Fat & soft tissues
Great vessels
Hidden areas
82
Q

In the right lung collapses, which side would the trachea deviate towards?

A

left lung

83
Q

Give one feature of the carina that you should check for on a chest X-ray.

A

angle of the bronchi may be affected by pathologies

84
Q

What level would you expect the right hemidiaphragm to be at on a chest X-ray?

A

6th rib anteriorly

85
Q

Where would TB characteristically place itself in the lung?

A

apical zone

86
Q

Give 2 common diagnoses of enlarged heart on chest X-ray.

A
  • heart failure

- hypertension

87
Q

What would a stomach bubble in the left chest indicate on an X-ray?

A

diaphragmatic rupture

88
Q

Name 5 types of bones that are visible on a chest X-ray.

A
  • ribs
  • thoracic vertebrae
  • clavicles
  • scapulae
  • heads of humeri
89
Q

What are you screening for when examining fat and soft tissues in a chest X-ray?

A

emphysema

90
Q

What deposits should you look out for on a chest X-ray in the elderly?

A

calcium deposits

91
Q

Where would you find lingular pneumonia on a chest X-ray?

A

behind the heart

92
Q

Define central line.

A

large bore cannula or catheter inserted into one of the larger veins in the body in which the tip of the cannula may lie in either the superior or inferior vena cava or in the right atrium

93
Q

Give 5 reasons for using a central line.

A
  • taking CVP
  • administration of drugs or products that would damage smaller caliber veins
  • if peripheral veins are shut down
  • high-flow fluids administration
  • IV access needed for several days
94
Q

Name the two most common sites for central line insertion.

A
  • internal jugular vein

- subclavian vein

95
Q

What is a normal central venous pressure? What would a high and low CVP respectively indicate?

A

normal: 0-8mmH20

low: hypovolaemic shock or dehydration
high: right heart failure

96
Q

Give the 7 most common complications of central line insertion.

A
  • puncturing the apex of the lung
  • puncturing a major vessel
  • cannulating a large artery
  • damage to the thoracic duct (if line placed on left)
  • causing an air embolism
  • introducing infection into a major blood vessel and into the bloodstream
  • damage to anomalous valves
97
Q

Give 4 examples of indications for a chest X-ray.

A
  • acute deterioration in shortness of breath
  • acute chest pain
  • mesothelioma
  • chronic lung disease
  • suspected malignancy
  • pneumonia
  • peritonitis
  • following an invasive procedure
98
Q

What are the 5 rights of medicine administration?

A
  • right patient
  • right medicine
  • right route
  • right dose
  • right time
99
Q

Give 6 reasons for IV administration.

A
  • medicine not available in another form
  • patient cannot tolerate medication by another route
  • constant or high plasma medication concentration needed
  • rapid onset of effect needed
  • more effective as an IV
  • to ensure compliance
100
Q

Give 6 disadvantages of IV administration.

A
  • increased cost and time for administration of medicine
  • requires trained staff
  • rapid/immediate onset of action
  • volume of fluid needed to dilute the medicine
  • can cause discomfort/pain
  • health risks
101
Q

Give four types of intravascular devices.

A
  • peripheral venous catheter
  • peripherally inserted central venous catheter
  • skin-tunneled central venous catheter
  • arterial catheters
102
Q

Which method of IV administration would you follow for Dobutamine?

A

continuous infusion

103
Q

Name the three methods for administration of IV drugs.

A
  • continuous infusion
  • bolus injection
  • intermittent infusion
104
Q

Give 5 examples of complication of IV drug administration?

A
  • fear/phobia/pain
  • infection/sepsis
  • thrombophlebitis
  • extravasation/infiltration
  • emboli
  • anaphylaxis/hypersensitivity
  • overdose
  • insufficient mixing
  • stability of medicines in solution
  • interaction of medicine with bag or syringe
105
Q

What are the symptoms of red man syndrome?

A
  • erythematous rash (face, neck, upper torso)
  • diffuse burning
  • itching
  • generalised discomfort
106
Q

Give 4 influencing factors that affect the stability of IV medicine.

A
  • light
  • temperature
  • concentration
  • pH
107
Q

Give an example of a drug of zero order kinetic.

A

alcohol

108
Q

What is first order kinetics?

A

the amount of drug eliminated per unit time is related to the concentration of drug in the plasma

109
Q

Define clearance.

A

the volume of blood or plasma cleared of drug in a unit time

110
Q

What 2 factors does the steady state concentration depend on?

A
  • clearance

- volume of blood

111
Q

How many half-lives of a drug are needed to reach the steady state concentration?

A

5

112
Q

How do you calculate the half-life of a drug?

A

ln 2 x volume of distribution / clearance

113
Q

How would you check for collapsing pulse?

A

hold the patient’s arm up above heart level and feel muscle belly of forearm

114
Q

What is the normal right atrial pressure?

A

6mmHg or 8mmH2O

115
Q

What is the waveform of the jugular venous pressure?

A

two visible peaks

116
Q

On an ECG, which electrodes cannot be placed anatomically?

A

C3 and C5

MD3001 (9 decks)

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