Intro to clinical skills Flashcards
Pulse depends on
Intermittent injection of blood from the heart into the aorta which alternately increases and decreases the pressure
Flexibility of the arterial wall which allows expansion with each injection of the blood and then recoil
Importance of the pulse
Can tell us about the heart through the force of contraction
the rate of heart contraction
Gives us clues to any outflow problems
Tells us circulating blood volume
Occasionally indicates state of blood vessels
When can a pulse be felt
Wherever an artery lies near the surface and over a bone or other firm background
Limb pulses
Brachial artery Radial artery Femoral artery Popliteal artery Posterior Tibial artery Dorsalis Pedis artery
Brachial artery
At the bend of the elbow along the inner margin of biceps muscle, used to measure bp
Radial artery
At the outer aspect of the wrist, base of thumb
Brachial artery
Inner aspect of the wrist, equivalent to brachial
Popliteal artery
Behind the knee
Posterior Tibial artery
Behind medial malleolus
Dorsalis Pedis artery
On the dorsum of the foot along the line between 1st and 2nd toes
Head and Neck pulses
Common Carotid artery
Temporal artery
Facial artery
Examination of the pulse
Rate Rhythm Character Auscultation Strength Volume
Normal heart rates
New-born: 70-120 bpm
Infant: 80-160 bpm
Preschool child: 75-120 bpm
School child: 70-100 bpm
Reasons for fluctuation of temp
Diurnally
Exercise and eating
W/ menstruation
NOT w/ environment
Temp measuring sites
Oral Axillary Rectal Tympanic Temporal
Hyperthermia/ pyrexia causes
Infection Drugs Heat stroke Stroke Autonomic and infl diseases Malignancy and Gout
Hypothermia causes
Multifactorial Alcohol, drugs Hypoglycaemia, hypoadrenalism Infections (paradoxical - associated w/ poor prognosis) Post-op
Method of taking bp
Apply cuff
Inflate cuff while palpating brachial artery
Deflate cuff while auscultating artery
Record systolic and diastolic to nearest 2 mmHg and debrief patient
Apply cuff
Expose arm and choose correct size
Centre cuff over brachial artery, 2-3 cm above pulse point
Tubes should be superior or slightly off centre
Inflate cuff
Close valve
Place finger on pulse (brachial or radial)
Pump air until pulse disappears
Pump another 20-30 mmHg
Deflate cuff
Replace fingers w/ stethoscope over pulse position
Listen for Korotkov sounds
Korotkov phases
Tapping starts - systolic Tapping softer and swishing - auscultatory gap Tapping louder, sharper, clearer Tapping muffled Tapping disappears - diastolic
Taking history
Presenting complaint History of presenting complaint Past medical history Drug history Allergies Social history Family history
Intro before taking history
Introduce yourself (name and role) Check patients name and dob Explain what you want to do and gain consent
Systemic enquiry
Are you otherwise well?
Have you got any other symptoms
Problems w/ SAWTEM
SAWTEM
Sleep Appetite Weight Temp Energy Mood
Presentation of MSK disease
Pain Stiffness Deformity Swelling Paraesthesia Numbness
Principles of MSK examination
Look
Feel
Move
Assess do normal side first for comparison
Hip examination - Look
Leg length discrepancy - measure true then apparent Muscle wasting Flexion deformity ---> OA Scars overlying hips Lumbar lordosis Stance - straight or no Pelvic tilt - looking at iliac crests
Hip examination - Feel
Bony landmarks incl: Iliac crest ASIS Greater trochanter Pubic tubercle
ASIS
Anterior Superior Iliac Spine
Hip examination - Move
Abduction Adduction Flexion Extension Internal rotation External rotation Move leg against your hand w/ resistance - soft tissue injury if only pain w/ Trendelburg's test Thomas test
True leg length
ASIS to medial malleolus
Foot and ankle examination - Look
Observe feet, comparing for symmetry
Look at forefoot for nail changes or skin rashes
Look for alignment of the toes - hallux valgus of big toes or sublimation of joints
Callus formation
Patients footwear - asymmetrical wearing of the sole or upper
Foot and ankle examination - Look (w/ weight-bearing)
Toe alignment and whether in contact w/ ground
Foot arch position - look at midpoint (low arch resolves when on tip toes)
Achilles tendon thickening or swelling - hindfoot
Normal alignment of the hindfoot - varus/ valgus deformity
Foot and ankle examination - Feel
Bony landmarks
Palpate for tenderness
Squeeze MTP joints - discomfort?
Presence of a peripheral pulse - dorsalis pedis
Integrity of Achilles tendon - calf squeeze test
Bony landmarks in foot and ankle
Lateral/ medial malleolus Calcaneus 5th metatarsal bone Medial longitudinal arch Joints
Foot and ankle examination -Move
Inversion and eversion at the subtalar joint
Dorsi and plantar flexion at big toe and ankle joint - restriction and/or crepitus
Passively invert and evert forefoot w/ heel fixed
Knee examination - Look
Compare knees for symmetry and alignment Look at back of knees Normal posture Muscle wasting of quadriceps Gait Swelling and redness --> infl/infection
Valgus deformity
Leg deviated laterally
Varus deformity
Leg deviated medially
Types of swelling
Effusion
Soft tissue
Bony
Knee examination - Feel
Bony landmarks
Use resistance and look at dflexion and extension
Feel skin temp using back of hand, mid-thigh vs over knee
Palpate for tenderness along borders of patella
Feel behind knee for popliteal cyst
Sweep/ bulge test
Patellar tap
Ballotement test
Follow up w/ hip exam - hip arthritis can present as knee pain
Knee examination - Move
Active movement - full extension
Passive movement
Flex knee to 90 degrees and check stability of ligaments
Anterior draw test and posterior draw test
Asess medial and lateral collateral ligament stability
How do deaths occurs after an accident
Trimodal death distribution
Peaks in trimodal death distribution
1st peak - within seconds to minutes at accident site
2nd peak - within minutes to hours at Hosp
3rd peak - days to weeks in hosp icu
1st peak of trimodal death distribution
Death due to laceration of the brain Laceration of the brainstem Rupture of major vessels e.g. aorta Laceration of the spinal cord Rupture of heart
2nd peak of trimodal death distribution
Brain haemorrhage such as extradural and subdural
Haemothorax, tension pneumothorax, open pneumothorax
Pelvic fracture
Long bone fractures
Abdominal injuries e.g ruptured liver and spleen
Golden hour principles
Save life
Save limb
Save joint
3rd peak of trimodal death distribution
ARDS MODS Renal failure Pneumonia Sepsis
ATLS
Advanced Trauma Life Support A - airway w/ cervical spine control B - breathing w/ ventilation C - control of haemorrhage D - disability brain protection E - exposure
SIRS
Systemic Infl response
Leads to leaky vessels –> multiple organ failure
Can last a few days or a few weeks
IL-6 is a proven marker
CARS
Counter-regulatory anti-infl response
After trauma there’s a balance between SIRS and CARS
Terrible triad
Acidosis
Coagulopathy (platelet count <90,000)
Hypothermia (<32 degrees)
MODS
Multiple organ dysfunction syndrome
Can be fatal
ARDS
Adult respiratory distress syndrome
Can be fatal
Joint injections
Injecting steroid into a joint to reduce infl but also reduces function of immune system
Shingles
Reactivation of chicken pox virus, presents as v. red rash (blistering) and stays in one dermatome
Treatment of shingles
Aciclovir
Pneumonia
Infection of lung
Alveoli gets filled w/ WBCs and becomes consolidated
Can be fatal if suffering from other illnesses
Amoxicillin
Dosage of 250/300 mg TDS for a week to treat a chest infection
Tendonitis
Infl of tendons
Glucose in urine
Diabetes
Pregnancy
Leaky kidney
HBA 1C in urine (glycated hb)
If found do a blood test
Indicates sugar levels over last 3 months
Bilirubin in urine
Jaundice
Liver issues
Life cycle of RBC’s
120 days
Ketones in urine
Product of glycogen breakdown –> starvation
V dangerous if diabetic –> coma
Proteinuria
Leaky kidney
Kidney problems
Would do a 24hr protein collection
Blood in urine
Infection
Bladder and kidney/ ureter cancer
Trauma (internal damage to surface of kidney)
Kidney stones
Nitrites in urine
Bacterial infection (usually Gram -ve)
High pH of urine
Infection stones
Low pH of urine
Uric acid stones
Leucocytes in urine
Infection and cancers
Bradycardia
Less than or equal to 50 bpm
Tachycardia
More than 100 bpm
Addn trauma associated w/ fractures
Soft tissue injuries
Central pulses
Carotid artery (neck) Femoral
Peripheral pulses
Radial
Brachial
Types of reasons for heart rate increase
Pathological
Physiological
Pathological reasons for hr increase
Shock
Anaemia
Hypoxia
Hyperparathyroidism
Physiological reasons for hr increase
Exercise
Pregnancy
Apnoea
Absence of breathing - respiratory arrest
Dyspnoea
Symptom of difficulty in breathing
Tachypnoea
An increased rate of breathing from any cause. Diff to hyperventilation
Depth of breaths is increased in ..
Head injuries, ketoacidosis
Depth of breaths in decreased in …
Opiate overdose, chest injury and disease
Temp can be increased by
Fever/ illness/ infections etc
Brain injuries
Heat stroke/ exhaustion
W/ some drugs
Temp can be decreased by
Hypothermia
Some drugs
Giving cold IV fluids quickly
Casts
Tiny particles of ‘debris’ found when examine urine under microscope
MSU
Mid stream urine
Assumes 1st part of voiding is contaminated w/ bacteria around genitalia and perineum
Pyuria
Pus in urine
Voiding
Passing urine
Why we analyse urine
Detection of systemic diseases or pathology
Detection of renal disease/ injury
Detection of pregnancy
Screening for certain diseases
Urinalysis stages
Macroscopic examination
Chemical examination
Microscopic examination
Other ways to collect urine
24 hr urine collection
Catheter sample
Bag urine collection
Suprapubic bladder puncture
If the sp gravity of the urine is high (> 1.02) …
The patient may be dehydrated - glycosuria
Diuretic use
Diabetes insipidus
Adrenal insufficiency
Common bacterial organisms causing UTI’s
E. coli - most common, Gram -ve
Profeus Mirabillis - Gram -ve
Staphylococcus - Gram +ve
Pseudomonas - Gram -ve
Management of UTIs
Trimethropin 300mg QDS OD/ 3 days
Co-amoxiclav 250/125 mg TDS/ 3 days
Ciprofloxacin 250-500 mg BDS/ 3 days
Nitrofurantoin
Official name of green prescription
Fp10
Meaning of prn on a prescription
As required
Meaning of ud on a prescription
As directed
Omeprazole
Prescribed by acid reflux disease
20 mg OD
Features of an anaphylactic reaction
Circulatory collapse
Airways obstruct
Fast heartbeat
Clammy skin
1 in every million suffer from immunisations
Drugs administered for anaphylaxis
Adrenaline
Steroids
Anti-histamine
Oxygen
Febrile convulsion
When a baby has a fit in response to having a fever
Diseases vaccinated against at 2 months
Diptheria Tetanus Pertuses Polio H. Influenza type B Hep B Menigococcal B Rotavirus gastroenteritis
Side effects of immunisations
Local infl
Myalgia
Fever
Rigors
Myalgia
Pain in muscle
Rigors
Episodes where temp rises v quickly whilst you have severe shivering
General principles of look - examination
Positioning is key Undress Give them space Look from anteriorly, posteriorly and laterally at: Skin Posture and symmetry Bony structures Muscle bulk
Examples of emergency conditions
Life-threatening injuries e.g multiple injuries
Limb-threatening injury e.g compartment syndrome
Problems that cause irreparable damage
Examples of urgent conditions
Malignant tumours
Uncontrolled pain
Systemically unwell
Fractures – that aren’t life-threatening nor limb-threatening
Pain history
SOCRATES
Site Onset Character Radiation Associated symptoms Exacerbated/ relieved Scale
Soft tissue history (tendons, ligaments)
Precipitated by Swelling Crepitus Temp - higher over area Loss of function Description of occupation/ recreational activity
Trauma history
When How What was done at time What is it like now Ay other injuries Soft tissue symptoms NAI Classification
Joints (non-traumatic) history
Pain - usally in more than one joint Stiffness Deformity/ swelling Duration and evolution of symptoms Pattern of joints affected Aggravating and relieving factors Loss of function Systemic features
Infl history
Pain, swelling, stiffen NSAIDs Pattern Onset Risk factors Sero-ve/ connective tissue disease symptoms
Concepts of being professional
Personal space Dignity Signposting and consent Practice makes perfect Responsiveness and reflexivity Cultural awareness
Personal space
Approx. 1.2m
Varies w/ context, culture, gender, age and from individual to individual
Dignity
Appropriate exposure
Gowns/ curtains/ screens
Signposting and consent
‘If it is ok with you, I’d like to examine you now’
‘Would you be able to lie on the bed and remove …?’
Signal your wishes and establish consent
Things to avoid when examining
Keyhole examinations Making friends Engaging mouth before engaging brain Dirty clothes and equipment Bad breath and BO
Active vs passive movement in an examination
Pain on passive suggests intra-articular pathology
Painful active movements which are less painful of passive movements suggests articular pain
Painful resisted movements may originate from the soft tissues e.g muscle/ tendon
Types of gait
Antalgic gait - pain, don’t spend long on one leg
Trendelenburg gait
Waddling
What does a Trendelenburg gait indicate
Weakness of abductors
What does waddling suggest
Proximal muscle wasting
What are you looking for in skin in an examination
Rashes Redness Bruising Muscle wasting Scar Deformity
Testing flexion in a hip examination
Flexing knee to 90 degrees
Passively flex and then push knee to chest
Testing adduction in a hip examination
Bring leg over the other
Testing extension in a hip examination
Place hand under ankle and ask patient to push your hand into the bed
Testing rotation in a hip examination
With knee flexed, invert the knee (internal) and then evert the knee (external)
Thomas’ test
Place your opposite hand under back of patient and flex knee until its at the chest - should feel hand being squashed if normal
Testing abduction in a hip examination
Ask patient to abduct leg - hold pelvis still with opposite hand when doing passively
What does the Thomas’ test identify
Fixed flexion deformity
Apparent leg length
Umbilicus to medial malleolus
What is the medial malleolus connected to
Tibia
What is the lateral malleolus connected to
Fibula
Sweep test
Empty the suprapatellar pouch
Stroke the medial side of the knee joint to move any excess fluid across to the lateral side of the joint then do the lateral side
Patellar tap
Empty supra patellar pouch
Tap patella
How to empty the suprapatellar pouch
By sliding your left hand down the thigh to the upper border of the patella
Ballotement test
Force fluid out of suprapatellar pouch
Push patellar down into femur using two hands
Hyperextension of knee
Pushing hand under knee into bed
How do you examine the integrity of the MCL and LCL
Place your hand under the knee and the other on the ankle and move L and R
Looking for hard end point
How do you examine the integrity of the ACL and PCL
Anterior and Posterior draw test
Sit on foot and place hands under hamstrings and pull knee forward/ backwards
Hallux valgus
Bunions
Big toe drifting laterally
Bony landmarks in knee
Femoral condyles Joint line Patella Tibial tuberosity Tibial plateau Head of fibula
Examination of Ankle and Wrist - Look
Muscle bulk Scars Redness Position of wrist Swelling and deformity of joints Thenar and hypothenar eminences
Examination of Ankle and wrist - Feel
Heat Joint swelling Wrist joints Radius and ulnar styloid processes Psiform Scaphoid Finger joints: MCP, PIP, DIP
Examination of Ankle and Wrist - Move
Flexion and extension Abduction and adduction Finger extension and flexion Flexion and Extension of individual fingers at MCP, DIP, PIP Abduction and adduction of fingers Same for thumbs and opposition
Tachypnoea
Rapid breathing, 20+ breaths/min
Hyperventilation
Inappropriate, rapid breathing
Types of sites pulse can be measured at
Peripheral e.g. brachial
Core e.g. temporal
Examples of causes of tachycardia
Exercise
Hypertension
Anaemia
Hyperthyroidism
Examples of causes of bradycardia
Drugs e.g. beta blockers
Sleep
Hypothyroidism
Hypothermia
Diagnostic parameter for chronic hypertension
Bp over 140/90 in 3 consecutive readings taken sitting down and 30 mins apart
EWS and NEWS2
Looks at: Airway Breathing Circulation Disability (consciousness ) Exposure (temp)
Urine output should also be considered
Things to look at in a respiratory assessment aside from respiratory rate
Chest expansion
Oxygen sats
Sternum/ intercostal muscle recession
Examples of causes of increased respiratory rate
Exercise Stress/ anxiety Shock Hypoxia Diabetic ketoacidosis
Measuring oxygen sats
Place finger probe on opposite hand use total bp
Can also use earlobe probe if patient has nail polish
Where do the most accurate temp values come from
Oral and tympanic
