Foundation Clinical Skills Flashcards
Summary of things to ask about in a psychiatric history
- Introduction
- History of Presenting Complaint
- Past Psychiatric History
- Family History
- Personal History
- Past Medical History
- Use of Medication / Drugs / Alcohol
- Forensic History
- Mental State Examination
- Relevant Physical Examination
- Risk Assessment
Components to consider in a personal history
Birth
Early development
School - social / academic
Home environment
Qualifications
Relationships and children
Work
Things to discuss when asking for Drug Hx
Current Medication
Allergies
Illicit Drug use
- How much?
- What?
Alcohol Consumption
- How much and how often?
- How long?
Also consider what age they started at
Things to consider for Forensic history
juvenile crime
court appearances
convictions
length of sentence
against person / property
experience of prison
Important risks to consider in psychiatry
Self neglect
Harm to self
Suicide
Harm to others
Vulnerability to exploitation
Child risk
Risk assessment
- How likely is it that an event will occur?
- Past behaviour can help predict future risk
- Risk can change over time and depending on the situation
- When is it expected to occur?
- How bad will it be?
Risk should be identified based on information from the history + other information the patient has communicated
Components of the Mental State Exam
Appearance and behaviour
Speech
Mood
Thoughts
Perceptions
Cognition
Insight
Mood vs Affect
Mood -refers to emotion over a prolonged period of time.
Affect - refers to immediate emotion
3 examples of thought disorders
Flight of ideas: thoughts are moving so quickly that one chain of thought is not completed before the next one starts. Can be linked by obscure references, rhymes or puns etc.
Loosening of associations: lack of logical connection between a sequence of thoughts
Perseveration: persistent and inappropriate repetition of the same thought
What is the qSOFA score for
sensitive test for assessing organ dysfunction + sepsis
Components of the qSOFA score + associated mortality risk of each score
- change in mental state
- Systolic BP <100mmHg
- RR >22
0-1 = 3% risk of mortality
2 or more = 24% risk of mortality
Parameters of the NEWS2 score
- Respiration rate
- Oxygen saturation
- Are they on air or oxygen
- Systolic BP (diastolic is not usually included)
- Pulse
- Consciousness (Alert, Voice, Pain or Unresponsive)
- Temperature
What is the suggested NEWS2 score cut-off for escalating to a Dr
- Overall score of 5
- a score of 3 in just one of the parameters
Key markers to check for deterioration in a patient
Cardiopulmonary:
- Respiratory Rate
- Oxygen Saturations
- Supplemental oxygen
- Heart Rate
- Systolic and Diastolic Blood Pressure
Markers of End Organ Dysfunction:
- Consciousness or new confusion
- Urine Output
Other:
- Temperature
- Pain
Ones in bold are not included in the NEWS score but are still important
Alveolar ventilation equation + what it means
Alveolar Ventilation (VA) = 1/PaCO2
An issue with ventilation would therefore cause a drop in oxygen delivery and reduction in carbon dioxide removal i.e. high CO2 and low O2 in the alveoli
Equation for minute ventilation
Minute Ventilation = Tidal Volume (TV) × Respiratory Rate (RR)
What is the normal range of Resp Rate
12-20 bpm
Characteristic findings of heart failure on examination
JVP
Ankle oedema
Crackles in lungs
3rd/ 4th heart sound
Displaced apex
MR
Potential presentations of IHD
Corneal arcus and xanthelasmata
Tendon xanthomata
High blood pressure
Arterial bruits and peripheral vascular disease
Retinal arteriolar changes (common in diabetic and hypertensive patients with IHD)
- typically entirely normal
Diff types of murmurs to check for on examination
- turbulance if stenosed/regurgitation
- Systolic murmurs
- ejection systolic, pansystolic?
- Diastolic murmurs
- early diastolic AR (or PR)
- mid-diastolic MS
- Pericardial friction rub or bruit (more common in renal patients)
Heart sounds to check for
- 1st heart sound - MV and TV closure; usually single but may be split
- 2nd heart sound – AV and PV closure; pulmonary sound delayed on inspiration causing audible splitting (physiological); fixed splitting occurs with atrial septal defect
- 3rd heart sound – abnormal in adults over 40, LV overload
- 4th heart sound – increased ventricular stiffness
factors affecting the rate of gas exchange in the lungs
- Alveolar surface area (e.g. COPD)
- Blood-gas membrane thickness (lung fibrosis)
- Protein-gas binding (determined by the oxygen-Haemoglobin dissociation curve) - (pH, temperature, PaCO2)
- Capillary transit time (V/Q mismatch) - MC
- Diffusion coefficient of gases themselves
- Partial pressure gradients of the individual gases across the alveolus and capillary (altitude, ventilation, acid-base balance)
2 types of V/Q mismatch
- Alveolar Dead-Space Ventilation - lots of ventilated alveoli but no, or limited blood flow to them i.e. V>Q
- Physiological Shunt - lots of blood flow to the alveoli but no, or limited ventilation i.e. Q>V
At what O2 sat should supplemental O2 be given in an individual without COPD
If O2 sat falls below 94%
What is the target O2 sat for patients with chronic type 2 resp failure + examples
88-92%
COPD, MND
Physiology of why chronic type 2 resp failure patients require lower oxygen
- If PaCO2 and subsequently CSF pH is raised chronically, bicarb is transported into the CSF to normalise it so central chemoreceptors can no longer recognise the patient is hypercapnic
- The patient then becomes dependant on peripheral chemoreceptors for resp drive
- This requires them to be hypoxic so giving higher levels of O2 can stop their resp drive
Normal resp rate
12-16 bpm
Normal minute ventilation
5-8L per min
Minute ventilation =
tidal volume x resp rate
Where is the central resp pacemaker located
In the medulla
Equation defining flow of blood
Poiseuille’s law:
Q = πΔPr^4 / 8ηl
In the context of Poiseulle’s law: Mean Arterial Pressure (MAP) =
Cardiac Output (CO) × Total Peripheral Resistance (TPR)
- used as a surrogate marker of tissue perfusion as the components of poiseulle’s law that are the most variable are pressure gradient and vessel diameter (r^4)
Mean Arterial pressure equation in the context of it being the average pressure in the arterial system
MAP = Diastolic Blood Pressure + (Pulse Pressure/3)
How can tissue perfusion be measured
- best = MAP
- if MAP not available e.g. in emergancy clinical setting -> Systolic BP
Which 3 factors determine stroke volume and what do they each mean
- preload i.e. the myofibril stretch at the end of diastole
- contractility i.e. the innate contractility of the myocardium irrespective of pre/afterload
- afterload i.e. the pressure the ventricle has to overcome during ejection of blood
Frank-Stirling Mechanism
- The higher the preload, the larger the end-diastolic volume/ventricular pressure.
- This leads to increas stretch of myofibrils in the ventricular walls leading to more forceful contraciton.
i.e. higher preload = higher stroke volume + Cardiac output
Clinical measures to increase preload and improve cardiac output
- raise patient’s legs if they’re lying down
- give fluid boluses (oral or iv)
- give venoconstrictors (veins can hold a lot of blood when at high capacitance)
How is malignant/accelerated hypertension defined
SBP >180mmHg or DBP >120mmHg
AND End organ damage - e.g.:
- Eyes - papilloedema, flame haemorrhages on fundoscopy
- Kidneys - impaired renal function or haematuria
- Brain - confusion or encephalopathy
Triad of Cushing’s reflex
Hypertension
Bradycardia (+ wide pulse pressure)
Deranged breathing
Causes of bradyarryhthmias
- usually due to disease of conductiong tissues of heart (congenital or traumatic/acquired)
- RCA infarcts damaging the SA node
- Electrolyte disturbances e.g. Hyperkalaemia, if left untreated can cause cardiac arrest and so should be treated swiftly - it is a medical emergency.
- Hypothermia
- Severe Hypothyroidism
- Hypoxia
(remember congenital, MI and 4 H’s)
Deinition of fever and hypothermia
Fever = >37.5
Hypothermia = <35
SBAR framework
- Situation
- Background
- Assessment (including what you have already done to try and manage)
- REcommendation
What are the things you need to do before starting any physical examination
- Make sure you are in a private area
- Wash hands
- Introduce yourself + confirm patient’s identity
- Explain examination + gain consent
- Ask if they are experiencing any pain (start examining at area furthest away from pain etc)
- Position the patient correctly and make sure the relevant areas of their body is exposed (make sure they are comfortable though)
What are the 5 categories tested in a neuro examination of the upper + lower limbs
- Tone
- Power
- Reflexes
- Sensation
- Coordination
What tings need to be included when writing up patient notes after an examination
- Name, age + occupation
- Presenting complaints
- Positive findings
- Important negative findings
- Differential diagnosis + Management plan that has already been put in place, if appropriate
What are the categories you need to cover in a mental state exam
- Appearance + behaviour
- Speech
- Mood + Affect
- Thoughts (delusions included in this category)
- Perceptions (hallucinations included in this)
- Cognition (how connected are they with time, the world and themselves)
- Insight into their condition
General steps of any MSK examination
Look, Feel, Move
General steps of any organ system examination
Inspect, Palpate, Percuss, Auscultate
(Look, feel, tap, listen)
