CLINICAL SKILLS Flashcards
Give the steps of the traditional medical model in order.
history –> examination –> investigation –> diagnosis –> treatment –> follow-up
Give the name of the author of The Inner Consultation (1987) and the 5 main points of the technique.
Roger Neighbour
- connecting
- summarizing
- handing over
- safety netting
- housekeeping
Explain what ‘handing over’ means in The Inner Consultation?
- agreeing on doctor’s and patient’s agenda
- negotiating, influencing and gift-wrapping
- giving ownership & responsibility of management plan to patient
What structure should you follow to take a history?
Presenting complaint + relevant systems inquiry Past medical history Drug history and allergies Family history Social history
Name at least 3 things you should ask about when taking the past medical history.
- medical conditions
- visits to the GP/hospital
- investigations
- operations/procedures
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?
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
Give 5 examples of themes of a social history.
- upbringing
- home life
- occupation
- finance
- relationship & domestic circumstances
- house
- community support
- sexual history
- leisure activities
- exercise
- substance misuse
How do you calculate pack years of smoking?
(#cigs smoked per day x #years of smoking)/20
How many cigarettes make a pack?
20 cigarettes in a pack
What 6 things should you ask about in a cardiovascular system inquiry?
- chest pain
- breathlessness
- palpitations
- syncope/dizziness
- oedema
- peripheral vascular symptoms
What are the 4 non-modifiable factors of cardiovascular risk?
- age
- gender
- genetic factors/family history
- race & ethnicity
What are the 7 modifiable factors of cardiovascular risk?
- hypertension
- smoking
- diabetes
- physical inactivity
- abdominal obesity
- hypercholesterolaemia
- psychosocial factors
Name 6 common cardiovascular symptoms.
- chest pain
- dyspnoea
- palpitations
- dizziness/syncope
- oedema
- fatigue
Name one type of medication that could cause dyspnoea.
beta-blockers
Name three types of medication that could cause oedema.
- steroids
- NSAIDs
- calcium-channel antagonists
For chest pain, give 3 cardiovascular causes, and one respiratory, one GI, one musculoskeletal and one viral cause.
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
What is the usual distribution of chest pain in an MI?
along sternum, radiating down medial side of left arm
Define angina.
a clinical syndrome of chest pain or pressure precipitated by activities such as exercise or emotional stress which increase myocardial oxygen demand
Differentiate between stable and unstable angina.
STABLE –> pain predictable according to activities
UNSTABLE –> pain unpredictable
To which spectrum do MI and angina both belong? What is the main pathophysiological difference between the two conditions?
acute myocardial ischaemia
MI = ischaemia with necrosis of cardiac tissue angina = ischaemia without necrosis of cardiac tissue
How would you differentiate between MI and angina when taking a history?
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
Which type of 999 call would chest pain be classified as? What about breathing problems?
Chest pain - red 2
Breathing problem - green 1
What is the cause of most pericarditis (80-90%)?
idiopathic (probably viral)
What eases pain of pericarditis?
sitting up and leaning forward
Describe the pain of aortic dissection in 5 points.
- sudden
- severe
- deep
- tearing
- radiating to left shoulder and back
What syndrome involves a higher risk of aortic dissection?
Marfan syndrome
Define dyspnoea.
shortness of breath
What is the most likely system in cause for dyspnoea relieved by diuretics?
cardiac
Give 3 cardiac, 3 respiratory and 3 other causes of dyspnoea.
CARDIAC
- cardiac failure
- angina
- MI
RESPIRATORY
- asthma
- COPD
- pneumothorax
- pneumonia
- bronchitis
- bronchiectasis
- pulmonary fibrosis
OTHER
- anaemia
- obesity
- hyperventilation
- anxiety
- metabolic acidosis
Define paroxysmal nocturnal dyspnea (PND).
= 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
Define orthopnea.
= sensation of breathlessness in the recumbent position, relieved by sitting or standing
Define palpitations. What features are you looking for?
= unexpected awareness of heart beating in chest
- fast or slow
- regular or irregular
What 6 questions should you ask a patient presenting with palpitations?
- 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
What are the 4 categories of causes for dizziness and syncope?
- cardiac
- ENT
- neurological
- hypoglycaemia
What are 4 cardiac causes of dizziness and syncope?
- postural hypotension
- vasovagal (neurocardiogenic)
- micturition syncope
- cardiac arrhythmias
Distinguish between of pitting and non-pitting oedema.
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
Give 3 causes of bilateral oedema.
- congestive cardiac failure
- cor pulmonale
- cirrhosis
- acute renal failure
- calcium channel blockers
- sepsis
- hypothyroidism (myxoedema)
- pregnancy
- idiopathic
Give 3 causes of unilateral oedema.
- DVT
- chronic venous insufficiency
- compartment syndrome
- retroperitoneal mass
What causes cardiac failure in cor pulmonale? Which side of the heart fails?
stiff arteries in lungs
Right side
How would you recognise a vein with DVT using ultrasound?
normal vein can be visibly compressed
VS vein with DVT cannot be compressed as the clot is solid
Give 2 cardiac causes of fatigue.
- cardiac failure
- side-effects of beta-blockers
Give 3 major signs of each of left-sided and right-sided heart failure.
LEFT-SIDED
- paroxysmal nocturnal dyspnea
- orthopnea
- pulmonary congestion
RIGHT-SIDED
- increased peripheral venous pressure
- distended jugular veins
- ascites
- enlarged liver/spleen
- dependent oedema
Give the steps of cardiovascular examination.
- introduction and explanation
- inspection
- palpation
- auscultation
- other areas
- conclusion
How should the patient be installed on the couch in a cardiovascular examination?
at 45 degrees with chest adequately exposed
What are you assessing for in close inspection of the hands (9 things)?
- warmth
- cap refill
- peripheral cyanosis
- tar staining
- clubbing
- splinter haemorrhages
- Janeway lesions
- Osler’s nodes
- koilonychia
What are you assessing for in close inspection of the head (6 things)?
- malar flush
- pallor
- clinical anaemia
- xanthelasthmata
- corneal arcus
- central cyanosis
How would you quantify cyanosis in g/dL deoxyhaemoglobin?
more than 5g/dL deoxyhaemoglobin
Define malar flush. What cardiac condition is it a sign of?
= a high colour over the cheekbones, with a bluish tinge caused by reduced oxygen concentration in the blood
sign of mitral valve disease
Define butterfly rash. What condition is it characteristic of? Give one differential diagnosis.
= 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
Define koilonychia. What is it a manifestation of?
= abnormality of the nails that causes them to be spoon-shaped (concave)
chronic iron deficiency
What are the three changes in the area under and around nails that occur with clubbing?
- softened nail beds
- last part of finger is large, bulging, red and warm
- convex nail shape
What is the most common cause of clubbing?
lung cancer
What are two signs of infective endocarditis seen in more than 85% of patients?
- fever
- heart murmurs
Give 5 classic signs of infective endocarditis.
- petechiae
- sublingual splinter haemorrhages
- Osler’s nodes
- Janeway lesions
- Roth spots
Name 4 main types of rash.
- erythematous
- maculopapular
- petechial/purpuric
- vesiculobullous
Define Osler’s nodes. What are their usual location?
painful erythematous nodules associated with bacterial endocarditis
finger and toe tips, thenar and hypothenar eminences
Where would you find Janeway lesions? What do they look like?
soles, palms, thenar and hypothenar eminences, plantar surface of the toe
macule of variable size and irregular shape
Describe Roth’s spots and explain what each part corresponds to.
Red spot - haemorrhage
pale white center - fibrin-platelet plug
What is the most common cause of Roth’s spots?
acute bacterial endocarditis
Give one other name for a Roth’s spot.
A Litten sign
Explain the workings of Duke criteria for endocarditis diagnosis.
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
Which behavior puts the tricuspid valve at increased risk of endocarditis?
IV drug use
Define xanthelasma. Which condition is it an indicator of?
= sharply demarcated yellowish flat plaques on upper and lower eyelids
atherosclerosis (with disturbed lipid metabolism)
What are the two main causes for corneal arcus?
- age
- hypercholesterolaemia
Give the normal mean arterial blood pressure range.
85-100mmHg
Where are the most important arterial baroreceptors located?
- left and right carotid sinuses
- aortic arch
Give 5 different rate and rhythm abnormalities of pulse and one explanation for each.
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
Give 4 different volume and character abnormalities of pulse and one explanation for each.
LOW VOLUME
hypovolaemia, left ventricular failure
INCREASED VOLUME
anaemia, fever, thyrotoxicosis
SLOW RISING
aortic stenosis
COLLAPSING
aortic regurgitation
Up to what value of heart rate would be normal for a newborn?
205 beat/min
What is the normal level of the upper limit of the venous column in jugular venous pulse assessment?
behind right sternoclavicular joint, at level of sternal angle
Where is the normal apex beat positioned?
left mid-clavicular line and 5th intercostal space
How many landmarks are there for a praecordial exam?
4
Which 7 exams would you offer to do at the end of a cardiovascular exam?
- auscultate lung bases
- check for ankle and sacral oedema
- abdominal examination
- peripheral vascular examination
- take BP
- fundoscopy
- urinalysis
What are the 2 main aims of a drug kardex?
- to ensure safe, effective and patient-centred prescribing
- to maintain accurate records
In which 4 instances should brand prescribing be used?
- insulins
- combination inhalers
- modified-release preparations
- epilepsy drugs
How would you write oral, sublingual, topical, milligrams and nanograms in a kardex?
ORAL SL TOP mg nanograms
How many health professionals have to sign for a controlled drug to be administered to a patient?
2
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?
- 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
How would you record that a patient has no drug allergies in a kardex?
NKDA -no known drug allergies
How would you check that the patient is not rotated on a chest X-ray?
measure the distance between the medial end of each clavicle to the spinous process line
Name each part of the ABC approach to chest X-ray.
Airway Breathing Cardiac Diaphragm External structures & equipment Fat & soft tissues Great vessels Hidden areas
In the right lung collapses, which side would the trachea deviate towards?
left lung
Give one feature of the carina that you should check for on a chest X-ray.
angle of the bronchi may be affected by pathologies
What level would you expect the right hemidiaphragm to be at on a chest X-ray?
6th rib anteriorly
Where would TB characteristically place itself in the lung?
apical zone
Give 2 common diagnoses of enlarged heart on chest X-ray.
- heart failure
- hypertension
What would a stomach bubble in the left chest indicate on an X-ray?
diaphragmatic rupture
Name 5 types of bones that are visible on a chest X-ray.
- ribs
- thoracic vertebrae
- clavicles
- scapulae
- heads of humeri
What are you screening for when examining fat and soft tissues in a chest X-ray?
emphysema
What deposits should you look out for on a chest X-ray in the elderly?
calcium deposits
Where would you find lingular pneumonia on a chest X-ray?
behind the heart
Define central line.
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
Give 5 reasons for using a central line.
- 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
Name the two most common sites for central line insertion.
- internal jugular vein
- subclavian vein
What is a normal central venous pressure? What would a high and low CVP respectively indicate?
normal: 0-8mmH20
low: hypovolaemic shock or dehydration
high: right heart failure
Give the 7 most common complications of central line insertion.
- 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
Give 4 examples of indications for a chest X-ray.
- acute deterioration in shortness of breath
- acute chest pain
- mesothelioma
- chronic lung disease
- suspected malignancy
- pneumonia
- peritonitis
- following an invasive procedure
What are the 5 rights of medicine administration?
- right patient
- right medicine
- right route
- right dose
- right time
Give 6 reasons for IV administration.
- 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
Give 6 disadvantages of IV administration.
- 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
Give four types of intravascular devices.
- peripheral venous catheter
- peripherally inserted central venous catheter
- skin-tunneled central venous catheter
- arterial catheters
Which method of IV administration would you follow for Dobutamine?
continuous infusion
Name the three methods for administration of IV drugs.
- continuous infusion
- bolus injection
- intermittent infusion
Give 5 examples of complication of IV drug administration?
- 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
What are the symptoms of red man syndrome?
- erythematous rash (face, neck, upper torso)
- diffuse burning
- itching
- generalised discomfort
Give 4 influencing factors that affect the stability of IV medicine.
- light
- temperature
- concentration
- pH
Give an example of a drug of zero order kinetic.
alcohol
What is first order kinetics?
the amount of drug eliminated per unit time is related to the concentration of drug in the plasma
Define clearance.
the volume of blood or plasma cleared of drug in a unit time
What 2 factors does the steady state concentration depend on?
- clearance
- volume of blood
How many half-lives of a drug are needed to reach the steady state concentration?
5
How do you calculate the half-life of a drug?
ln 2 x volume of distribution / clearance
How would you check for collapsing pulse?
hold the patient’s arm up above heart level and feel muscle belly of forearm
What is the normal right atrial pressure?
6mmHg or 8mmH2O
What is the waveform of the jugular venous pressure?
two visible peaks
On an ECG, which electrodes cannot be placed anatomically?
C3 and C5
