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MBBS - Year 1 > Clinical skills - Secondary care > Flashcards

Clinical skills - Secondary care Flashcards

1
Q

Absorption of subcutaneous injections

A

Sustained and slow

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2
Q

How much fluid can you inject subcutaneously

A

1-2 ml

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3
Q

What is an example of a medicine given subcutaneously

A

Insulin as subcut is suitable for freq injections

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4
Q

Sites for subcutaneous injections

A

Lateral aspect of upper arms and thigh

Below umbilicus

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5
Q

What angle are s/c injections administered

A

45 degrees to optimise entry into s/c tissue

90 degrees if using shorter needles (5,6,8 mm)

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6
Q

Procedure of giving a s/c injection

A

Pinch the skin to elevate tissue from muscle

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7
Q

Why do we not aspirate with s/c injection

A

May form a haemotoma

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8
Q

Is skin cleaning pre-administration necessary for s/c injections

A

No unless the skin is visibly dirty

These injections usually have a lower chance of infection due to smaller needles used

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9
Q

Consideration for s/c injections

A

Rotation of sites of freq. injections

Avoid bruised, tender and scar tissue

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10
Q

Complications of s/c injections

A 
Infection 
Incorrect location 
Bruising 
Pain 
Anaphylaxis
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11
Q

Absorption of intramuscular injections

A

Rapid and systemic

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12
Q

Volume of fluid given in IM injections

A

Up to 5ml in well perfused muscle

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13
Q

Sites for IM injections

A 
Vastus Lateralis (Thigh)
Deltoids (2mls)
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14
Q

Giving dorsogluteal injections

A

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

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15
Q

Giving thigh injections

A

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

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16
Q

Note about giving dorsogluteal injections

A

High risk due to sciatic nerve; absorption hindered in obese patients

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17
Q

Giving ventrogluteal injections

A

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

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18
Q

Giving deltoid injections

A

Place little finger on acromion
Split middle and ring finger
Inject at point in between two fingers

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19
Q

Procedure of giving IM injections

A

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
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20
Q

Why do we use the z track to give IM injections

A

Prevents escape of medicine by closing the point of needle entry on withdrawal

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21
Q

Why do we aspirate when giving IM injections

A

To make sure the needle hasn’t reached the blood vessels

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22
Q

Why can’t needles for IM injections be pushed all the way in

A

This makes removal easier in case of device failure/ breakage

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23
Q

Needle size and pain

A

Larger needles are less painful and smaller needles result in higher pressure –> discomfort

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24
Q

Note about pre-filled syringes

A

Some have an air bubble built into them to cover needle length ensuring pt receives full dose
DO NOT dispel this air

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25
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
26
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
27
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
28
Procedure when approaching an unwell pt
Take brief history ABCDE Don't move on without intervening if necessary Handover to senior member of staff
29
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?
30
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?
31
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 ```
32
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
33
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 ```
34
Cause of arrhythmia - circulation in an unwell pt
Tachycardia or bradycardia
35
Cause of hypotension- circulation in an unwell pt
Could be fluid depletion, sepsis, blood loss | Low bp causes tachycardia, prolonged CRT & weak pulses
36
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
37
Normal saline soution %
0.9%
38
Fluids that can be given via cannula
Saline - salty Hartmans - more balanced ions Dextrose Blood
39
Disability assessment for an unwell pt
``` DEFG GCS Temp Neuro assessment PEARL Pain AVPU ```
40
DEFG
Don't ever forget glucose
41
Neuro assessment
Asking pt to raise both arms and legs and wriggle toes and fingers
42
PEARL
Pupils equal and reacting to light Shining a bright light into the pupils
43
AVPU
Alert - awake and aware of environment Verbal - responds to verbal stimuli Pain - responds to a pain stimulus Unresponsive - unresponsive to any stimuli
44
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
45
Everything else assessment for an unwell pt
Expose and assess for injuries, rashes, oedema Examine other systems (abdomen, ENT, neurological MSK) Manage other abnormalities
46
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
47
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 ```
48
Describing displacement on a X-ray
Undisplaced Mildly Severely
49
100% translation on an X-ray
Diameter has moved fully
50
STAR on X-rays
Shortening (offended) Translation (measured in %) Angulation Rotation
51
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
52
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 ```
53
Main investigations used during blood tests
``` FBC Infl markers Renal function tets Liver function tests Bne profile Muscle enzymes ```
54
What does FBC incl
RBC WBC (neutrophils, lymphocytes, eosinophils, monocytes, basophils) Platelets
55
What to check after identifying low Fe
MCV
56
Types of anaemia
Microcytic and hypochromic | Macrocytic and hyper chromic
57
Biggest source of iron in body
RBCs as iron is recycled from old RBC's back in into bone marrow
58
Fe deficiency causing microcytic anaemia
Bleeding e.g. menstruation | Bowel - peptic ulcers, Crohn's, ulcerative colitis, cancer
59
Peptic ulcers
Stomach or duodenal ulcers | Can be caused by NSAIDs
60
Endoscopy vs colonoscopy
Endoscopy is for upper GI tract and colonoscopy is for lower GI
61
Causes of increased MCV
Low B12 or folic acid
62
When do we see normocytic anaemia
Anaemia of chronic disease | Acute bleeding e.g. stab wounds
63
When do we see neutrophilia
Infl e.g. gout | Phagocytosis for bacterial infection
64
Neutropenia
Low levels of neutrophil
65
Lymphocytosis
High level of lymphocytes
66
Lymphopenia
Low levels of lymphocytes | Seen in viral infections e.g. infectious mononucleosis
67
When do we see eosinphils
Allergies Hay fever Parasitic infections Asthma
68
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 ```
69
Enzymes in the liver
ALT | ALP
70
Where is ALT found
Produced in hepatocytes
71
When is ALT increased
Liver damage from hepatitis Infection Cirrhosis Drugs
72
Where is ALP found
Biliary epithelium
73
When is ALP increased
Infl Sepsis Bone disorders
74
Hepatic jaundice
High ALT | Normal ALP
75
Obstructive jaundice
High ALP Normal ALT Caused by pancreatitis or gallstones
76
Function of albumin
Increases osmotic pressure so when dc teases fluid leaves blood vessels and causes swelling
77
Albumin as a -ve acute reactant
Decreases in infection and infl due to higher levels of globulins
78
Renal blood tests
U&E's Urea and creatinine Sodium, potassium
79
Hepcidin
+ve aceite phase reactant
80
How does fibrinogen affect ESR
Leads to increase
81
Causes of +ve RhF
``` Bacterial endocarditis Osteomyelitis TB Syphilis Hepatitis Mononucleosis Diffuse interstitial pulmonary fibrosis Liver cirrhosis Sarcoidosis ```
82
Investigation results seen in MM
``` Anaemia Lytic lesions High globulin Renal failure High infl marker ```
83
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 ```
84
Serum levels in osteoporosis
No change ion phosphate and calcium levels | High ALP when fracture occurs
85
Treatment of uric acid levels during gout attack
Wait until attack has subsided as uric acid levels usually normal
86
Malignancy and calcium
Malignancy pushes up Ca level
87
When do we see thrombocytosis
In infl conditions like vasculitis
88
Look in examinations
Deformity Scars/ redness Swelling Muscle wasting
89
Feel in examination
Bony landmarks Effusion Swelling Temp (back of hand)
90
Move in examination
All possible movements at joint: Active Passive Resisted
91
Bony landmarks in hip
ASIS Iliac crest SI joint Greater trochanter
92
Indentifying SI joint
Dimples of Venus
93
Abnormal Trendelenburg test result
``` Gluteus medius (abductor) weakness Superior gluteal nerve weakness ```
94
Testing resisted flexion of hip
Place hand near hip and ask pt to bring knees close to chest
95
Testing abduction of hip
Hold ASIS tp stabilise pelvis
96
External rotation of hip
For move in
97
Pain when internally rotating
OA
98
Why do we ask the pt to fully flex during the Thomas test
Removes lumbar lordosis
99
Bony landmarks of knee
``` Patella Patella tendon Tibial tuberosity Joint margin Femoral condyles Head of fibula ```
100
Feel in knee exams
BPEST ``` Bony landmarks arks Popliteal fossa/ pulse Effusion Swelling (bursa) Temp ```
101
What is Baker's cyst a sign of
OA
102
Testing effusion in knee exam
Patellar tap (testing for bounce)
103
What is key in both anterior and posterior drawer test
Making sure the hamstring is relaxed
104
What to do if you find leukocytes and nitrates in urine
Microscopy and culture to identify pathogenic organism
105
What to do if you find glucose in urine
Capillary blood glucose and serum HBA1C
106
What to do if you find glucose, ketones and low pH in urine
Admission (diabetic ketoacidosis)
107
What to do if you find raised SG and proteinuria in urine
U&Es and microscopy & culture (nephrotic syndrome and UTI)
108
What to do if you find blood in urine
FBC, U&Es
109
Adequacy of film
Views - minimum 2 views required Image joint above and below Rotation Penetration
110
ABCS of radiographs
A - alignments and joint space B - bone texture C - cortices S - soft tissues
111
What can cause thrombocytosis
Infl
112
Cervical spine exam - look
Do whole exam seated Deformity - lordosis Scars Swelling Muscle wasting
113
Cervical spine exam - feel
Bony landmarks - C7 and count up, parapsinal muscles, trapezius, deltoid Swelling Temp - compare w/ shoulder
114
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
115
Neurological part of spine exam
Sensation on dermatomes - cotton tip, neurotip (do both limbs) Reflexes Myotomes - resisted movement's
116
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)
117
Testing reflexes in spine exam
Wait for response, hit at enthesis (max 2x) | Hit tendon at perpendicular angle
118
Cervical spine dermatomes
``` C5 - deltoid C6 - thumb C7 - middle finger C8 - pinky C1 - axilla ```
119
Thoracic spine dermatomes
T4 - nipple T8 - diploid T10 - umbilicus T12 - symphysis
120
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
121
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
122
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
123
Lumbar spine - Look
Deformity - scoliosis, lordosis, kyphosis Swelling Scars Muscle wasting
124
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
125
Lumbar spine - move
Flexion - touch toes Extension - lean back (stand behind pt) Lateral flexion - hand down leg Schober test - use fingers
126
What does Schober test look for
AS
127
Neurological aspect of lumbar spine exam
Do lying down | ``` Straight leg raise/ sciatic stretch Dermatomes Reflexes Myotomes Femoral nerve test ```
128
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
129
Lumbar dermatomes
``` L1 - upper thigh L2 - middle thigh L3 - lower thigh L4 - knee joint and big toe L5 - middle toe S1 - pinky toe ```
130
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
131
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 ```
132
Testing lumbar myotomes
Hip - push hand down into bed and up Knee - push hand back and forward Ankle - " " Hallux - " "
133
Shoulder exam - look
Deformity (asymmetry/ winging) Swelling Scarrs Muscle wasting
134
Shoulder exam - feel
SCJ, clavicle, ACJ, acromion, spine of scapula, medial border, tip of scapula, lateral border, greater tubeoritu, coracoid process Effusion Swelling Temp
135
Posterior shoulder dislocation
V rare Caused by electrocution or electric seizure See lightbulb sign in X-ray
136
Anterior shoulder dislocation
Common Caused by trauma Head of humerus not in glenoid fossa
137
Detcting AC OA during shoulder exam
Tenderness of ACJ | Pain in high arc
138
Injury hx
Mechanism of injury Dominant hand Occupation/ hobbies Any previous injuries

MBBS - Year 1 (93 decks)

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