Clinical Skills

Question 1

Causes of peripheral cyanosis and how to check for it

Answer 1

Can be caused by central cyanosis or decrease in peripheral circulation. Check fingers for colour.

Question 2

Where is the supresternal notch?

Answer 2

Question 3

Examination for central cyanosis

Answer 3

Detected by blue discolouration of the tongue

Question 4

Surface anatomy for anterior borders of the lung upper lobes

Answer 4

The line of the 4th rib medio-laterally.

Question 5

Basic Activities of Daily Living

Answer 5

Dressing

Eating

Ambulating

Toileting

Hygiene

Question 6

ISBAR

Answer 6

For rapid communication regarding urgent care. Identification of self and pt Situation - quick Background Assessment - more details and why is the ddx Response - I need you to come and what should I do in the meantime

Question 7

Term for a sternum that is unusually convex

Answer 7

Pectus carinatum

Question 8

Surface landmarks for the boundaries of the right middle lobe of the lung.

Answer 8

The inferior borders are marked by the oblique fissure, which runs down from T3 and meets the 6th rib at the bid-clavicular line. The line along the 6th rib makes up the remainder of the inferior border. The superior border is marked by the 4th rib and travels laterally until it meets the oblique fissure in the axilla.

Question 9

Identify the costal angle

Question 10

Why might fremitus be decreased?

Answer 10

Soft voice, blockage of vibrations with tumour, fibrosis, thick chest wall

Question 11

Instrumental Activities of Daily Living

Answer 11

Shopping

House-keeping

Account

Food preparation

Transport/telephone

Question 12

Causes of peripheral cyanosis and how to check for it

Answer 12

Can be caused by central cyanosis or decrease in peripheral circulation. Check fingers for colour.

Question 13

How to identify C7 and why this is a useful surface anatomy marker

Answer 13

An alternate method of numbering the ribs posteriorly is to count down from C7. Lower your chin to your chest, please. With the patient’s neck flexed forward, find the most prominent spinous process, which is usually at C7. Then feel and count from C7 to T12. You can often palpate and count the processes below them, especially when the spine is flexed. This is one way to find the oblique fissue which runs from T5 down to the 6th rib anteriorly.

Question 14

ABCD

Answer 14

For assessing a patient’s status: Airways - speaking Breathing - RR Circulation - O2 sat Disability level - deterioration of condition

Question 15

CUS terms

Answer 15

I am concerned …. uncomfortable This is a safety issue

Question 16

Term for a sternum that is unusually concave

Answer 16

Pectus excavatum

Question 17

Normal respirtory rates for…

• newborn
• 1-12 months
• 1-5 yr
• 5-10 yr
• 10-16 yr
• adult

Answer 17

• Newborn: 30-60
• 1-12 months: 25-40
• 1-5 years: 20-30
• 5-10 years: 15-25
• 10-16 years: 15-20
• adult: 12-20

Question 18

Distinguish between the internal jugular pulsation snad carotid pulsations.

Answer 18

Internal Jugular Vein

•  Rarely palpable.
•  2 or 3 components (a, c, v waves).
•  Eliminated by light pressure on the vein just above the sternal end of the clavicle.
•  Pulsations vary with position.

Carotid Artery

•  Palpable.
•  Single component with vigorous thrust.
•  Pulsation not eliminated.
•  Pulsation not affected by position.

Question 19

How to locate the JVP

Answer 19

Extend the patient’s neck and slightly turn his head to the left (to examine the right internal jugular). Look for the pulsations of the internal jugular vein between the clavicular and sternal arms of the sternocleidomastoid. If necessary, raise or lower the bed so that the oscillation point of the internal jugular vein is visible.

Question 20

Why might fremitus be decreased?

Answer 20

Soft voice, blockage of vibrations with tumour, fibrosis, thick chest wall).

Question 21

Adventitious sounds

Answer 21

added sounds, indicating there may be something unusual/wrong in the lung. These include crackles (rales), wheezes (rhonchi), rubs and stridor.

Question 22

On percussion of the lungs from top to bottom posteriorly, you can detect dullness at the level of T8 on the left and T10 on the right. What may explain the differences between the two sides?

Question 23

common systems for defining regions of the abdomen:

Answer 23

Dividing the abdomen into 4 quadrants (right and left upper quadrants, and right and left lower quadrants) Epigastric, umbilical/periumbilical and hypogastric/suprapubic region.

Question 24

Ask the patient to push the abdomen out to the examiner’s hand or suck in the abdomen. WHY?

Answer 24

Understand that a patient who can do these manoeuvres is unlikely to have any acute inflammatory process in the abdominal cavity.

Question 25

the word for an abdomen that is curved in??

Answer 25

scaphoid

Question 26

word for abdomen that is curved out

Answer 26

protuberant

Question 27

Examination of the liver in an abdominal physical exam

Answer 27

Locate the upper border of the liver: Percuss downward in the midclavicular line, on the right side of the patient. Start over the lungs, and listen for the change from resonance to dullness as you move down.

Locate the lower border of the liver: Start in the right lower quadrant, in the midclavicular line. With your fingertips pointing toward the head of the patient, put your hand on the abdomen. Ask the patient to take a deep breath. As the patient inhales, hold your fingers still, and feel the liver edge coming down to meet your fingers. If you can’t feel the liver at this level, move your fingers closer to the ribcage, and repeat.

Once you have located the upper and lower borders of the liver, measure the distance between the two points – normal is 6-12 cm at the mid-clavicular line.

Question 28

Examination of the spleen in an abdominal physical exam

Answer 28

• If you suspect an enlarged spleen, with the patient supine, percuss in the lowest intercostal space in the left anterior axillary line. Continue to percuss while the patient takes a deep breath.
  
  • Normally this area is tympanic and remains tympanic with a deep breath. If the spleen is enlarged, it will move into this area during a deep breath, and the percussion note will change to dull. This is called “Castell’s sign”
  • Alternately, percuss in Traube’s space. Traube’s space is bordered the 6th rib superiorly, the mid-axillary line laterally, and the left costal margin inferiorly and medially. With the patient supine and breathing normally, percuss in several areas within Traube’s space.
  • Normal percussion yields a resonant or tympanic note, whereas the percussion note is dull in splenomegaly.
• Palpation for an enlarged spleen:
  
  • Stand on the patient’s right side. Place your left hand on the patient’s posterior costal margin to elevate the left rib cage. With the right hand, press very gently toward the costal margin, with your fingertips pointing toward the spleen, and starting at the umbilicus. Ask the patient to breathe in deeply while you hold your hand still and feel for the edge of the spleen as it comes down to meet your fingertips. Repeat, if necessary, after moving your hand toward the ribcage.
  • If you can feel the spleen, it may be enlarged.

Question 29

McBurney’s point

Answer 29

it is located maximally at a point ⅔ of the way from the umbilicus towards the anterior superior iliac spine. Used to detect appendicitis.