Clinical skills - Secondary care Flashcards
Absorption of subcutaneous injections
Sustained and slow
How much fluid can you inject subcutaneously
1-2 ml
What is an example of a medicine given subcutaneously
Insulin as subcut is suitable for freq injections
Sites for subcutaneous injections
Lateral aspect of upper arms and thigh
Below umbilicus
What angle are s/c injections administered
45 degrees to optimise entry into s/c tissue
90 degrees if using shorter needles (5,6,8 mm)
Procedure of giving a s/c injection
Pinch the skin to elevate tissue from muscle
Why do we not aspirate with s/c injection
May form a haemotoma
Is skin cleaning pre-administration necessary for s/c injections
No unless the skin is visibly dirty
These injections usually have a lower chance of infection due to smaller needles used
Consideration for s/c injections
Rotation of sites of freq. injections
Avoid bruised, tender and scar tissue
Complications of s/c injections
Infection Incorrect location Bruising Pain Anaphylaxis
Absorption of intramuscular injections
Rapid and systemic
Volume of fluid given in IM injections
Up to 5ml in well perfused muscle
Sites for IM injections
Vastus Lateralis (Thigh) Deltoids (2mls)
Giving dorsogluteal injections
Map out an imaginary 2x2 grid over the gluteal area and and in the upper outer quadrant do the same and inject that spot
Upper outer, upper outer
Giving thigh injections
Land mark one palm from hip and one palm up from the knee
Divide the thigh in half and inject towards the outer edge of the lateral half
Note about giving dorsogluteal injections
High risk due to sciatic nerve; absorption hindered in obese patients
Giving ventrogluteal injections
Use opposite hand to leg being injected
Place hand and over greater trochanter and spread ring and middle finger
Inject at point in between two fingers
Giving deltoid injections
Place little finger on acromion
Split middle and ring finger
Inject at point in between two fingers
Procedure of giving IM injections
Z track
Pull skin taut with your opposite hand Open safety lock Inject pt with needle no more than 2/3 its length Aspirate Release skin whilst removing injection Close safety lock and dispose of needle
Why do we use the z track to give IM injections
Prevents escape of medicine by closing the point of needle entry on withdrawal
Why do we aspirate when giving IM injections
To make sure the needle hasn’t reached the blood vessels
Why can’t needles for IM injections be pushed all the way in
This makes removal easier in case of device failure/ breakage
Needle size and pain
Larger needles are less painful and smaller needles result in higher pressure –> discomfort
Note about pre-filled syringes
Some have an air bubble built into them to cover needle length ensuring pt receives full dose
DO NOT dispel this air
Do IM injections require skin cleaning
Yes as well-perfused muscle is being entered
Use every part of the clinell wipe, cleaning in diff directions and let dry for 30 secs
Procedure for loading syringes (plastic ampoules)
Open packet for syringe and blunt fill needle
Remove syringe and attach blunt fill needle before placing in blue box
Use clinell wipe to clean top of ampoule and twist open the top
Wait 30s for the ampoule to dry
Pick up syringe, remove cap from blunt fill needle and draw up desired volume of fluid
Ensure there are no air bubbles in the syringe
Open packet for needle w/ safety lock and swap needles, disposing of the blunt fill needle
Ensure you hear a click
Loading syringes using glass ampoules
Use blunt fill needle WITH a filter
Open ampoule by placing thumb on blue dot and fingers on other side, snapping the ampoule open
Procedure when approaching an unwell pt
Take brief history
ABCDE
Don’t move on without intervening if necessary
Handover to senior member of staff
Airway assessment for an unwell pt
Is the patient alert & speaking?
Any extra noises e.g. stridor, secretions?
Is the pt unconscious with an at-risk airway?
Airway management for an unwell pt
Consider airway manoevres
Do you need a definitive airway (and therefore an anaesthetist)
Is there anything you can see to suction or remove?
Breathing assessment for unwell pt
Measure respiratory rate Pulse oximetry (oxygen sats) ‘Work of Breathing’ Examine the chest Listen to the lungs in 3 diff positions
Breathing management for an unwell pt
Sit up
Give oxygen if sats <94% via a reservoir mask
Treat any underlying cause eg. in asthma give inhaler
Circulation assessment for an unwell pt
Heart rate (HS I + II + 0) Blood pressure Capillary refill time Feel pulses Listen to the heart Fluid balance Place a cannula & take bloods
Cause of arrhythmia - circulation in an unwell pt
Tachycardia or bradycardia
Cause of hypotension- circulation in an unwell pt
Could be fluid depletion, sepsis, blood loss
Low bp causes tachycardia, prolonged CRT & weak pulses
Initial treatment for circulation in an unwell pt
Cannulate
Give 500ml of normal saline as a fluid challenge, monitor pt. Give 250ml in pt w/ heart failure
Further boluses can be given if the pt responds
Blood loss ideally replaced w/ blood
Escalate to ITU if you’ve given >2L fluids or pt is overloaded
Normal saline soution %
0.9%
Fluids that can be given via cannula
Saline - salty
Hartmans - more balanced ions
Dextrose
Blood
Disability assessment for an unwell pt
DEFG GCS Temp Neuro assessment PEARL Pain AVPU
DEFG
Don’t ever forget glucose
Neuro assessment
Asking pt to raise both arms and legs and wriggle toes and fingers
PEARL
Pupils equal and reacting to light
Shining a bright light into the pupils
AVPU
Alert - awake and aware of environment
Verbal - responds to verbal stimuli
Pain - responds to a pain stimulus
Unresponsive - unresponsive to any stimuli
Disability management for an unwell pt
Correct low blood sugars with buccal/ oral / IV glucose
Check for DKA if blood glucose is high
If temperature is raised, consider infection and treat
Consider causes for altered neurology (e.g. stroke)
Manage pain
Everything else assessment for an unwell pt
Expose and assess for injuries, rashes, oedema
Examine other systems (abdomen, ENT, neurological MSK)
Manage other abnormalities
Handing over an unwell pt after treating initially
SBAR
Situation - brief history
Background - PMH, DH, HPC
Assessment - findings and interventions
Recommendation - what you’d like the member of staff to do next
Describing X-rays
Say name, dob, hosp no and date X-ray taken Say where it is Describe view e/g lateral, posterior Describe displacement Mention any artefacts Translation STAR Extra-articular or intra-articular
Describing displacement on a X-ray
Undisplaced
Mildly
Severely
100% translation on an X-ray
Diameter has moved fully
STAR on X-rays
Shortening (offended)
Translation (measured in %)
Angulation
Rotation
Taking a drug hx
Routes
Dosage, freq, indication, compliance, side effects, day of the week taken, monitoring e.g. blood tests
How long they’ve been taking it for
OTC, illicit drugs and herbal remedies
Allergies and adverse reaction, intolerance - incl description
For pt’s who forgot drug hx
At least 2 other sources
Summary of care record Next of kin Dusset box MAR chart Calling GP
Main investigations used during blood tests
FBC Infl markers Renal function tets Liver function tests Bne profile Muscle enzymes
What does FBC incl
RBC
WBC (neutrophils, lymphocytes, eosinophils, monocytes, basophils)
Platelets
What to check after identifying low Fe
MCV
Types of anaemia
Microcytic and hypochromic
Macrocytic and hyper chromic
Biggest source of iron in body
RBCs as iron is recycled from old RBC’s back in into bone marrow
Fe deficiency causing microcytic anaemia
Bleeding e.g. menstruation
Bowel - peptic ulcers, Crohn’s, ulcerative colitis, cancer
Peptic ulcers
Stomach or duodenal ulcers
Can be caused by NSAIDs
Endoscopy vs colonoscopy
Endoscopy is for upper GI tract and colonoscopy is for lower GI
Causes of increased MCV
Low B12 or folic acid
When do we see normocytic anaemia
Anaemia of chronic disease
Acute bleeding e.g. stab wounds
When do we see neutrophilia
Infl e.g. gout
Phagocytosis for bacterial infection
Neutropenia
Low levels of neutrophil
Lymphocytosis
High level of lymphocytes
Lymphopenia
Low levels of lymphocytes
Seen in viral infections e.g. infectious mononucleosis
When do we see eosinphils
Allergies
Hay fever
Parasitic infections
Asthma
Function of liver
Clears toxins Bile products Production of proteins e.g. albumin, globulins, clotting factors Metabolism of sugar and fat Conversion from harm to bilirubin
Enzymes in the liver
ALT
ALP
Where is ALT found
Produced in hepatocytes
When is ALT increased
Liver damage from hepatitis
Infection
Cirrhosis
Drugs
Where is ALP found
Biliary epithelium
When is ALP increased
Infl
Sepsis
Bone disorders
Hepatic jaundice
High ALT
Normal ALP
Obstructive jaundice
High ALP
Normal ALT
Caused by pancreatitis or gallstones
Function of albumin
Increases osmotic pressure so when dc teases fluid leaves blood vessels and causes swelling
Albumin as a -ve acute reactant
Decreases in infection and infl due to higher levels of globulins
Renal blood tests
U&E’s
Urea and creatinine
Sodium, potassium
Hepcidin
+ve aceite phase reactant
How does fibrinogen affect ESR
Leads to increase
Causes of +ve RhF
Bacterial endocarditis Osteomyelitis TB Syphilis Hepatitis Mononucleosis Diffuse interstitial pulmonary fibrosis Liver cirrhosis Sarcoidosis
Investigation results seen in MM
Anaemia Lytic lesions High globulin Renal failure High infl marker
Causes of high globulins
Chronic in sections e.g. HIV, TB Liver disease (billiard cirrhosis, obstructive jaundice) RhA Ulcerative colitis MM, leukaemias, macroglobulinemia Autoimmunity (lupus, Sjorgen's) Kidney dysfunction
Serum levels in osteoporosis
No change ion phosphate and calcium levels
High ALP when fracture occurs
Treatment of uric acid levels during gout attack
Wait until attack has subsided as uric acid levels usually normal
Malignancy and calcium
Malignancy pushes up Ca level
When do we see thrombocytosis
In infl conditions like vasculitis
Look in examinations
Deformity
Scars/ redness
Swelling
Muscle wasting
Feel in examination
Bony landmarks
Effusion
Swelling
Temp (back of hand)
Move in examination
All possible movements at joint:
Active
Passive
Resisted
Bony landmarks in hip
ASIS
Iliac crest
SI joint
Greater trochanter
Indentifying SI joint
Dimples of Venus
Abnormal Trendelenburg test result
Gluteus medius (abductor) weakness Superior gluteal nerve weakness
Testing resisted flexion of hip
Place hand near hip and ask pt to bring knees close to chest
Testing abduction of hip
Hold ASIS tp stabilise pelvis
External rotation of hip
For move in
Pain when internally rotating
OA
Why do we ask the pt to fully flex during the Thomas test
Removes lumbar lordosis
Bony landmarks of knee
Patella Patella tendon Tibial tuberosity Joint margin Femoral condyles Head of fibula
Feel in knee exams
BPEST
Bony landmarks arks Popliteal fossa/ pulse Effusion Swelling (bursa) Temp
What is Baker’s cyst a sign of
OA
Testing effusion in knee exam
Patellar tap (testing for bounce)
What is key in both anterior and posterior drawer test
Making sure the hamstring is relaxed
What to do if you find leukocytes and nitrates in urine
Microscopy and culture to identify pathogenic organism
What to do if you find glucose in urine
Capillary blood glucose and serum HBA1C
What to do if you find glucose, ketones and low pH in urine
Admission (diabetic ketoacidosis)
What to do if you find raised SG and proteinuria in urine
U&Es and microscopy & culture (nephrotic syndrome and UTI)
What to do if you find blood in urine
FBC, U&Es
Adequacy of film
Views - minimum 2 views required
Image joint above and below
Rotation
Penetration
ABCS of radiographs
A - alignments and joint space
B - bone texture
C - cortices
S - soft tissues
What can cause thrombocytosis
Infl
Cervical spine exam - look
Do whole exam seated
Deformity - lordosis
Scars
Swelling
Muscle wasting
Cervical spine exam - feel
Bony landmarks - C7 and count up, parapsinal muscles, trapezius, deltoid
Swelling
Temp - compare w/ shoulder
Cervical spine exam - move
Explain in layman’s terms to pt, medical to examiner
Only do active movements
Flexion - touch neck w/ chin
Extension - look up
Rotation - look to the left/ right
Lateral flexion - bring ear to chest without moving neck
Neurological part of spine exam
Sensation on dermatomes - cotton tip, neurotip (do both limbs)
Reflexes
Myotomes - resisted movement’s
Cervical spine exam - reflexes
Ask pt to rest arm on knee
C5 - place 2 fingers over biceps tuberosity then hit fingers (biceps)
C6 - hit radial styloid processes (bracxhioradialis)
C7 - hit olecranon (triceps)
Testing reflexes in spine exam
Wait for response, hit at enthesis (max 2x)
Hit tendon at perpendicular angle
Cervical spine dermatomes
C5 - deltoid C6 - thumb C7 - middle finger C8 - pinky C1 - axilla
Thoracic spine dermatomes
T4 - nipple
T8 - diploid
T10 - umbilicus
T12 - symphysis
Testing myotomes in spinal exam
Only do resisted movements - testing muscle power
Place hand close to joint
Finish all movements at joint before moving on
Ask examiner whether or not to do both sides
Cervical myotomes
C5 - shoulder abduction (deltoid)
C6 - elbow flexion (biceps), wrist extension
C7 - elbow extension (triceps), wrist flexion, finger extension
C8 - finger flexion
T1 - finger abduction
Most common injury in spine
Slipped disc esp at (L4/5 or L5/S1)
Rarely happens at cervical spine (C6/C7)
Never happens in thoracic spine
Lumbar spine - Look
Deformity - scoliosis, lordosis, kyphosis
Swelling
Scars
Muscle wasting
Lumbar spine - feel
Bony landmarks - start at ASIS, round iliac wings, L5 and count up, lat doors, posterior iliac crest (level with L4), SI joint
Swelling
Temp
Lumbar spine - move
Flexion - touch toes
Extension - lean back (stand behind pt)
Lateral flexion - hand down leg
Schober test - use fingers
What does Schober test look for
AS
Neurological aspect of lumbar spine exam
Do lying down
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Straight leg raise/ sciatic stretch
Dermatomes
Reflexes
Myotomes
Femoral nerve test
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Straight leg raise test
Raise leg until painful and note approx angle
Drop leg slowly until pain is gone
Dorsiflex foot and abs for pain
Pain should be in back
Lumbar dermatomes
L1 - upper thigh L2 - middle thigh L3 - lower thigh L4 - knee joint and big toe L5 - middle toe S1 - pinky toe
Lumbar reflexes
Knee jerk - L3/4 - place arm under both knees, make sure quads are relaxed, flex nee slightly, hit just above tibial tuberosity
Ankle - S1 - flex knee and turn out, use hand to dorsiflex for, hit Achilles’ tendon before insertion in Os-Calcis
Lumbar myotomes
L2 - hip flexion L3/4 - knee extension L4 - nakle dorsiflexion L5 - hallux extension S1 - hip extension, ankle plantar flexion, hallux flexion S2 - knee flexion
Testing lumbar myotomes
Hip - push hand down into bed and up
Knee - push hand back and forward
Ankle - “ “
Hallux - “ “
Shoulder exam - look
Deformity (asymmetry/ winging)
Swelling
Scarrs
Muscle wasting
Shoulder exam - feel
SCJ, clavicle, ACJ, acromion, spine of scapula, medial border, tip of scapula, lateral border, greater tubeoritu, coracoid process
Effusion
Swelling
Temp
Posterior shoulder dislocation
V rare
Caused by electrocution or electric seizure
See lightbulb sign in X-ray
Anterior shoulder dislocation
Common
Caused by trauma
Head of humerus not in glenoid fossa
Detcting AC OA during shoulder exam
Tenderness of ACJ
Pain in high arc
Injury hx
Mechanism of injury
Dominant hand
Occupation/ hobbies
Any previous injuries
