Clinical Skills and Reasoning Flashcards
Normal and abnormal cause of palmar erythema
Normal in pregnancy
Also found in liver disease
Symptoms of clubbing
nail hard, nail bed spongy, nail curvature and angle change
Causes of clubbing
CV: Congenital heart disease, Infective endocarditis, Atrial myxoma (tumour in atrium)
RS: Lung carcinoma, Pulmonary fibrosis, Cystic fibrosis, Bronchiectasis, Abscess, Empyema
What are osler’s nodes?
Red dots on the fingertips
What order do you examine the lymph nodes in? (11)
submental > submandibular > tonsillar > parotid > periauricular > postierior auricular > superficial cervical > deep cervical > supraclavicular > posterior cervical > occipital
What is the difference between marked and moderate hydration status?
Marked: loss of skin tension
Moderate: Tongue and eyes should be wet and glistening (fontanelle in babies)
Which 2 CAM therapies are statutory regulated?
Osteopathy and Chiropractice
Define the effectiveness gap
Clinical area where available treatments are not fully effective or satisfactory
3 main reasons for CAM use
Musculoskeletal/neuromuscular
Arthritis
Headaches
4 methods of chiropractic therapy
Mobilisation and manipulation (moving joints, relaxing muscles and modifying the pain gate)
Soft tissue therapies and massage
Guided movement
Rehabilitation exercises
What affects how well a treatment works? (5)
Relationship between patient and physician Treatment is patient centered Healthcare setting Patient education (complaince) Patient expectations
Why is acupuncture not in NICE guiedlines?
There is no significant difference between actual and sham acupuncture
What does NICE state about CAM therapies?
Used alongside other treatments such as drugs, psychological and exercise
Define dysponea
Is it a sign or a symptom
Breathlessness
Symptom
Why does giving oxygen not sure dysponea?
Not caused by reduced oxygen or poor respiratory rate
9 causes of cough hypersensitivity
Interstitial lung disease, Left heart failure, Lung cancer, Reflux
ACEi, Asthma, Aspiration, Infection, Pulmonary fibrosis
Define mucoid
Excess secretion of mucus
Define purulent
Green or yellow sputum from inflammation
When does mucus have a bad smell/taste? (3)
Anaerobic infection
Abscess
Cancer
What cardiac disease do you get haemoptysis in? (2)
PE or mitral stenosis
Define rhonchi
Wheeze: A musical noise produced by air moving through narrowed airways louder in expiration
Why does salbutamol not cure a severe asthma attack?
It does not cure every symptom of asthma
3 characteristics of pleuritic pain
Where does the pain come from?
3 causes
Sharp, stabbing and worse on inspiration
Parietal pleura
e.g. pneumonia, PE, pneumothorax
5 things which mimic pleuritic pain
What differentiates them from the lungs?
Reterosternal pain (trachea/mediastinum) Bony pain (e.g. metastases) Chest wall pain (trauma) Spinal root pain Shingles (often unrelated to exercise)
Define astrexis
Flapping tremor
Define intercostal indrawing
Skin between ribs pulled in
2 accessory muscles of respirtion
Pectoral
Sternomastoid
What causes mediastinal shift towards the affected side and away from the affected side?
Towards = reduced volume e.g. collapsed lung (penumothorax)
Away from = tumour, pleural effusion (fluid in pleural cavity)
What happens to the cricosternal distance when the patient is hyperinflated?
Reduces
Explain what causes the 4 noises on percussion
Stony dull = pleural effusion
Dull = pneumonia
Resonant = normal
Hyperresonant = pneumothorax
What is the technical term for normal breath sounds?
Vesicular
3 causes of diminished/absent breath sounds
Collapse, Effusion, Pneumothorax
Cause of bronchial breath sounds
What do they sound like
Why are they loud?
Consolidation
Harsh sounds with prolonged expiratory phase
Solidified alveoli transmits sound better than airy
Define crepitations
Crackles
Discontinuous non-musical sounds on inspiration due to explosive opening of occluded small airways
What does it mean if crackles clear with coughing
Secretions are in large airways rather than small ones
2 causes of coarse crackles
2 causes of fine crackles
Coarse: pneumonia, bronchiectasis
Fine: oedema, pulmonary fibrosis
Define whispering pectoriloquy
Whispered sounds are heard more clearly in consolidation
What does it mean if syllables are transmitted more/less clearly when testing vocal resonance?
More clear = consolidation
Less clear = collapse, pneumothorax, effusion
What are most deaths from CVD due to?
Smoking
9 symptoms of heart failure
SOB, Peripheral oedema, Cough with pink sputum, Reduced sleep, Reduced energy, Swollen abdomen,
Nocturia, Confusion, Memory loss
Difference between angina and MI?
Angina: worse on exertion and cold; relieved by rest and GTN, 2-10 mins
MI: worse at rest, no relief, breathless, sweaty, nausea, fear, 30 mins +
What are the 4 classifications of angina
- Angina with prolonged exertion
- Slight limitation of normal activity (stairs, hill, cold)
- Marked limitation or normal physical activity
- Angina at rest / can’t do any physical activity
2 characteristics of pericarditis pain
2 things that make it worse 1 thing which makes it better Duration Cause 2 ECG changes
Sharp, stabbing
Worse with inspiration and lying flat Eased by sitting Hours > Days Viral illness ST elevation and PR depression
4 characteristics of aortic dissection pain
2 places it radiates to
Sudden, tearing, knifetlike, excrutiating
Radiates to back/abdomen
2 characteristics of pulmonary embolism pain
What is it associated with?
Pain over infarcted area
Pleuritic rub
SOB
Define tachypnoea
More than 20bpm
What is it called when patients have to sleep on more pillows?
Orthopnoea
What is PND?
Explain what happens during an episode and how long it lasts
2 causes
Paroxysmal Nocturnal Dysponea
Wake up and have to sit up and go to the window
Cough and wheeze for 20 mins
Frightening
Reduced respiratory drive, Reduced heart adrenergic activity at night
Define palpitation
Unpleasant awareness of heart beat
Define syncope
Brief transient loss of consciousness and postural tone with rapid spontaneous recovery
6 characteristics of a cardiac syncope
Sudden onset No aura No jerks/incontinence Injury common Immediate recovery Very pale
4 characteristics of a neurological syncope
Convulsive movement
Confusion after
Incontinence
Tongue biting
Explain vasodepressor syndrome
Faint after prolonged standing
Gradual faintness and greying vision
Response to stress
Explain carotid sinus hypersensitivity
Diagnosis and treatment
Syncope when pressure is put in the carotid artery
Diagnosed by rubbing carotid with ECG
Fitted with a pacemaker
3 drugs which cause peripheral oedema
NSAIDs, Fluorocortisone (retain Na)
Amlodipine (increased capillary permeability)
5 causes of fatigue in cardiac patients
Reduced cardiac output or blood pressure
Excessive diuresis (causing reduced K)
Drugs e.g. beta blockers
3 causes of splinter haemorrhages
SLE, gardening, rheumatoid
What causes clubbing of the toes?
Patent ductus artriosus
What are the 2 lipid signs around the eye?
Orbital xanthelasma
Corneal arcus
What is the cause of a slow rising pulse and collapsing pulse?
Slow rising = Aortic stenosis
Collapsing = Aortic regurgitation
Where do you measure the JVP from?
Manubrum-sternal joint
What are the 5 parts of the JVP wave?
A: atrial systole
X decent: after atrial contraaction
C: rapid increase in R ventricle pressure before tricuspid valve closes
V wave: venous return fills RA during ventricle systole
Y decent: Tricuspid valve opens
6 causes of an elevated JVP
Cardiac tamponade Constrictive pericarditis Heart failure Increased arterial pressure Renal disease SVC obstruction (cancer or mediastinal mass)
3 causes of large A waves on the JVP
Pulmonary hypertension, Tricuspid stenosis, Cannon waves
1 cause of giant V waves
Tricuspid regurgetation
1 cause of a steep Y descent
What sign is also seen?
Constrictive pericarditis
Freidreict’s sign - rapid increase and slow decrease in JVP
What causes the 1st and 2nd heart sound?
1st: Tricuspid and mitral valve CLOSE
2nd: Aortic and pulmonary valve CLOSE
What does it mean if the apex beat is:
- Normal bit shifted
- Impalpable
- Tapping
- Heaving
- Volume loaded
- Double impulse
- Dyskinetic
- Normal bit shifted: Pneumothorax
- Impalpable: High BMI, COPD, Cardiac tamponade
- Tapping: Mitral stenosis
- Heaving: Increased bp, Aortic stenosis
- Volume loaded: Aortic regurgitation, Bigger LV
- Double impulse: Hypertrophy cardiomyopathy
- Dyskinetic: Previous MI/LV aneurysm
What does splitting of the 2nd heart sound indicate?
What does reverse splitting indicate?
Atrial septal defect
Pulmonary heard before atrial in severe aortic stenosis
3rd heart sound:
What does it sound like?
When is it?
How can you hear it?
3 causes
Ken-tuc-KY After S2 (start of diastole) Low pitch (bell)
Normal in young adults and athletes
Failing LV/ Movement of blood between atrial walls
4th heart sound:
What does it sound like?
When is it?
1 cause
TENN-es-see Before S1 (end of diastole)
Failing LV
What increases the sound of a cardiac hypertrophy murmur and a mitral stenosis murmur?
Cardiac hypertrophy = squatting
Mitral stenosis = rolling to the left
When are heart murmurs not important? (4)
Short systolic murmurs around the left sternum (pregnancy/anaemia)
Normal heart sounds, normal ECG, asymptomatic
What murmurs are found with prosthetic valves?
Aortic valve prosthesis = systolic ejection murmur
Mitral valve prosthesis = diastolic flow murmur
What happens to the heart sounds in stenosis?
What changes to the pulse and ECG?
2nd heart sound is soft (calcified valve)
Slow rising carotid pulse
ECG = left ventricular hypertrophy
What happens to the heart sounds in sclerosis?
What changes to the pulse and ECG?
Normal/loud 2nd sound
Carotid pulse is brisk/normal
No LVH on ECG unless severely hypertensive
