More PCP Flashcards
1
Q
Cardinal Features
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SiteQualitySeverityTime CourseContextRelieving FactorsAggravating FactorsAssociated Features——————————–Medical History & Risk FactorsFamily HistoryAlcoholSmokingSocial & Occupational History
2
Q
Cardiovascular Exam
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- Prepare patient (explain procedure, undress, check comfort)2. Hand hygiene3. General Inspection (mental state, alertness, resp. effort)4. Inspect hands (nicotine, clubbing, anaemia)5. Measure radial pulse (HR 60-100 and rhythm)6. Measure BP (120/80)7. Face, Head (conjunctiva -pallor, tongue, lips - cyanosis)8. JVP (<3cm)9. Carotid Pulse (Both sides, separate)10. Inspect chest (scars)11. Palpate chest (apex beat)12. Auscultate (bell then diaphragm) MTPA13. Posterior Chest (Lung Bases)14. Lower Limbs (oedema, pulse - dorsalis pedis and posterior tibial)15. Completion
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Q
Respiratory Exam
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- Prepare Patient (sit 90degrees)2. Hand Hygiene3. General Inspection (mental state, resp effort, sputum cup, coughing, wheezing)4. Inspection of hands (nails, smoking, clubbing, anaemia)5. Pulse & resp rate measurement6. Head and Neck (conjunctiva, lips, tongue, TRACHEA!)7. Inspection of Anterior and Lateral chest walls8. Measure Anterior Chest Expansion (x2)9. Percussion of Anterior and Lateral Chest (start clavicle then every 2nd space)10. Auscultate Anterior and Lateral (Diaphragm - bell if hairy)- breath in and out through open mouth- ninety-nine11. Examination of Posterior Chest- chest expansion(rotate scapulae)- percussion (4 sites)- auscultation (breathe & ninety nine)12. Measure Peak Flow13. End of Examination
4
Q
Points of Auscultation (Heart)
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- 5th ICS - Mitral - Apex- 5th ICS - Tricuspid - Lower left sternal edge- 2nd ICS - Pulmonary Valve - Upper left sternal edge - 2nd ICS - Aortic Valve - Upper right sternal edge
5
Q
Heart Borders
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SUPERIOR BORDER2nd CC left 3rd CC right RIGHT BORDER3rd CC right6th CC right LEFT BORDER2nd CC left5th ICS leftINFERIOR BORDER5th ICS left6th CC rightCC = 2cm from sternal edgeVALVES - PAMT (diagonal)2nd CC left6th CC rightASCULTATION - APTM (Z shape)
6
Q
Lung Borders
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ANTERIORApex - 2.5cm above medial 1/3rd of clavicleSternoclavicular joint4th CC6th mid-clavicular8th mid-axillary10th adjacent spinePOSTERIORC7 T104cm from midlineOBLIQUE FISSURET2 spinous process6th mid clavicularHORIZONTAL FISSURE4th CCIntersect oblique mid-axillary
7
Q
Lung Pleura Borders
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2.5cm above medial 1/3rd of clavicle6th CC (right) 4th CC (left - cardiac notch)8th mid-clavicular10th mid-axillary12th paravertebral
8
Q
Syncope Features VASOVAGAL (Faint)
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Sudden loss of consciousness and postural tonePRODROME - light headed, wobbly, dim vision, distant soundsSITE - not relevantQUALITY - convulsive movements can occurSEVERITY - unquantifiedTIME COURSE - less than 30 secondsCONTEXT - usually doesn’t occur while sitting or lyingPRECIPITATING FACTORS - fasting, pain, emotional events, prolonged standing, strainingRELIEVING FACTORS - Lying flatASSOCIATED FEATURES - Sweaty, pallor, no-frothingPERIOD AFTER - Rapid recovery, rarely confused, no injury (protective mechanism)PAST HISTORY - None
9
Q
Smoking Questions
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Signpost before asking smoking questions”Do you smoke / have you ever smoked?”“What do you smoke?”Duration & average consumption (pack-years)”How do you feel if you don’t smoke?”Nicotine withdrawal - restless, anxiety, insomnia, difficulty sleeping”Do you need a cigarette after waking?”“Are there any circumstances where you feel the need to smoke?”“Are there any circumstances where you would not be inclined to smoke?”“Have you tried quitting?” What techniques and what success?Assess current motivation to quit.
10
Q
Asthma Questions
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SITE - n/aQUALITY -n/aSEVERITY - frequency of symptoms (day&night)- wheezing, cough, attacks, hospital, usage of inhalers, peak flowTIME COURSE - onset (childhood?), episodic, current activity of the diseaseCONTEXT - see psychosocial.AGGRAVATING FACTORS - not using glucocorticoids, illness, exercise, pollens, smoke, dust, cold air, stress.RELIEVING FACTORS - how frequently bronchodilators are usedASSOCIATED FEATURES - eczema, hay fever, hivesPSYCHOSOCIAL CONTEXT - how does the disease impact the patients life, how does life impact the disease?- relationships, pets, occupation, stress, hobbies, travel
11
Q
Minimal Verbal Encouragers
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“I see”“Yes”“Go on …"”Sure”“Tell me more”
12
Q
Body Language
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Eye contactLeaning inFacial features (concern, interest)Nodding
13
Q
Palpitation Questions
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Abnormal awareness of the heart beatSITE - not typically usefulQUALITY - Rhythm (tap it out), Forcefulness (or a flutter)SEVERITY - Speed- How it affects daily activitiesTIME - How long has it been there, onset/offset, sudden, durationCONTEXT - what is happening when the palpitations occurRELIEVING FACTORSAGGRAVATING FACTORS (coffee, exercise, stress)ASSOCIATED FEATURES - SoB, chest pain, fatigue, dizziness, blackouts, oedema
14
Q
Past Medical History Questions
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Past Serious Illness- Heart attack- Cancer- Blood Coagulopathies- Autoimmune- InfectionsPast Operations / Hospital AdmissionsMedications
15
Q
Blood Pressure Measurement
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- Prepare Patient2. Hand Hygiene3. Appropriate Sized Cuff4. Apply Cuff (2-3cm above brachial artery pulsation)5. Estimate Systolic pressure using palpation (radial)6. Steth (diaphragm) over brachial pulse, support elbow with right arm. +30mmHg7. Auscultatory Soundsdeflate 2-3mmHg per beat8. Record Result (nearest 5mmHg)
16
Q
BMI
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weight (kg) / height squared (m^2)<18.5 = Underweight18.5-24.9 = Normal25-29.9 = Overweight30+ = Obese
17
Q
Waist-to-hip Ratio
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Waist Circumference / Hip Circumference<0.9 Male
18
Q
Syncope FeaturesCARDIAC (Blackout)
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Sudden loss of consciousness and postural tonePRODROME - not presentSITE - not relevantQUALITY - convulsive movements can occurSEVERITY - unquantifiedTIME COURSE - less than 30 secondsCONTEXT - can occur sitting or lyingPRECIPITATING FACTORS - usually doesn’t have anyRELIEVING FACTORS - Self limitingASSOCIATED FEATURES - Sweaty, pallor, no-frothingPERIOD AFTER - Rapid recovery, rarely confused, injury may occurPAST HISTORY - Cardiac Disease
19
Q
Angina
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Reversible myocardial ischaemia (70% occlusion)Diffuse central chest pain Radiation to arms (left), neck, jawPhysical exertion makes it worseRelieved by rest (or nitroglycerin)Associated with dyspnoea, nausea, and sweating.>20minutes = Myocardial Infarction
20
Q
Cardiovascular Risk Factors
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SmokingHigh Blood Pressure (hypertension)High Cholesterol (Hyperlipidaemia)DiabetesFamily HistoryAgeGender
21
Q
Claudication
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Arterial narrowing causing ischaemic painCramped feeling in calvessubsides with restintermittent
22
Q
Family History
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“Can you tell me about the health of your immediate family?”- What age they died and cause- What age they developed the condition
23
Q
Oedema Causes
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Increased Hydrostatic PressureDecreased Osmotic PressureIncreased Permeability (inflammation)Obstruction of Lymphatic Drainage
24
Q
Oedema Questions
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Cardinal FeaturesWorse at end of day?Relieved by elevating feet?Bilateral? (unilateral indicates DVT)Associated features (Dyspnoea on exertion & Orthopnoea indicate heart failure)
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Dyspnoea questions
SITE - not importantQUALITY - heavy or shallowSEVERITY - exertion. "how far can you walk before you become short of breath?" "Is it present at rest?" / "does it wake you at night?"TIME COURSE - onset, offset, worsening, episodicCONTEXT - "when does the shortness of breath occur?", recent travelAGGRAVATING FACTORS Orthopnoea (diffculty breathing worse lying down) - how many pillows required to sleepRELIEVING FACTORSASSOCIATED FEATURESChest pain, cough, wheeze, swelling of ankles, fever, weight loss
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Occupational History
Are you currently working?Asbestos, Farmers Lung, Chemicals, ChildrenStresses
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Social History
Relationships & support systemsEducation and occupationFinancesEthnicityReligion and spiritualityHobbies & ExercisePetsTravel
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Acute vs Chronic Cough
Acute < 2 weeksSubacute 2-8 weeksChronic > 8 weeks
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Cough Questions
SITE - chest or throatQUALITY - sound, productive (characterise sputum separately)SEVERITY - frequencyTIME COURSE - duration (acute, chronic)CONTEXT - what were you doing when you first noticed the cough?RELIEVING FACTORS - what treatments have been triedAGGRAVATING FACTORS - worse at night?ASSOCIATED FEATURES - dyspnoea, wheeze, fever, haemoptysis, smoking, pain
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Sputum Questions
Cover Cardinal signscolour(SEVERITY) volume (teaspoon)thicknessodorblood (haemoptysis) - (SITE) prodrome (nausea & abdominal pain vs chest irritation)- colour (bright red & frothy = haemoptysis, dark red = haematemesis)- (SITE) associated pain (throat pain may indicate blood from URT)when did you first notice the blood?getting better or worse?
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Vomiting Questions
SITE - n/aQUALITY - Colour? (blood or bile stained?)SEVERITY - frequency, volumeTIME COURSE - onset , episodic, relationship to meals, first thing in morningCONTEXT - New medication, pregnancy, contact with others.AGGRAVATING FACTORS - does anything precipitate the vomiting?RELIEVING FACTORS - has anything made it better?ASSOCIATED FEATURES -abdominal pain, diarrhoea, fever, headache, vertigo, dehydration, weight-loss
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Dysphagia Critical Reasoning
OROPHARYNGEAL DYSPHAGIA:Difficulty initiating swallowing associated with CHOKING, COUGHING, NASAL REGURGITATION (stroke, parkinsons, ms)OESOPHAGEAL DYSPHAGIAFood sticks after initiation of a swallowMechanical Obstruction (e.g. cancer) - Solids only Motility disorder (e.g. achalasia) - Solids & liquids
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GI exam
1. Prepare Patient (sit 90degrees)2. Hand Hygiene3. General Inspection (mental state, alertness, cachexia, jaundice, distressed, pain)4. Inspection of hands (leuconychia, palmar erythmea, pallor, dupuytren's contracture), test for metabolic flap (15s)5. Head and Neck (conjunctiva jaundice or pallor)6. Examination of chest (spider naevi)7. Inspection of abdomen (Lay flat on one pillow) (scars, striae, distension, masses, caput medusae)8. Palpation of Abdomen (warm hands, palpate twice, check for discomfort)- left inguinal, lumbar, hypochondrium- epigastrium- right hypochondrium, lumbar, inguinal- suprapubic, umbilical9. Palpate for liver from LRQ (firm pressure during inhilation, 2cm advances)- percuss from LRQ and third rib mid clavicular- measuring tape 12-13 cm10. Palpate for Spleen from RLQ- ballot (roll patient 45deg and place left hand behind)11. Kidneys- left hand posteriorly in loin region- right hand under costal margin12. End of Examination
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Diarrhoea Questions
SITE - n/a (except for with abdominal pain)QUALITY - Consistency (watery?) Colour (blood, mucous?)SEVERITY - frequency, volumeTIME COURSE - onset , episodic, acute/chronic, worsening/improvingCONTEXT - Particular food, overseas travelAGGRAVATING FACTORS - does anything make it worse?RELIEVING FACTORS - has anything made it better? How effective?ASSOCIATED FEATURES - nausea, fever, vomiting, abdominal pain, weight loss. Any other people that have been affected?
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Acute, Persistant, Chronic Diarrhoea
Acute - few days, due to infection, gastroenteritis, food poisiningPersistant- 2 - 4 weeksChronic- >4 weeks
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Liver Surface Anatomy
Superior: between nipplesInferior: costal marginGallbladder - mid-clavicular below costal margin
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Appendix Surface Anatomy
McBurneys Point1/3 distance from right anterior superior iliac spine to umbilicus
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Kidney Surface Anatomy
Mid line (lateral to spine)Left as high as rib 11Right as high as rib 12Extend to L3(can identify L4 as midpoint between iliac crests)
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Spleen Surface Anatomy
Posterior along line of 9th to 11th ribFollows contour of 10th rib lies antero-lateral to kidney extending around mid-axilliary line
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Haematemesis
Vomiting BloodHeam + Emesis
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Haemoptysis
Coughing up blood
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Common causes of vomiting
GastroenteritisPregnancyMedications (esp. chemo)Acute MI
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Alcohol Questions
Do you drink alcohol (or have you ever)?How often do you have a drink containing alcohol?How much do you typically drink (and what type)?How often do you drink more than 4 STANDARD DRINKS?Do you have trouble STOPPING drinking once you start?Do you drink first thing in the MORNING?Is drinking stopping you from doing any ACTIVITIES/WORK?Do you ever feel GUILT/REMORSE after drinking?How often do you BLACKOUT?Have you or anyone else been INJURED?Has anyone been CONCERNED and suggested you cut down?Under what CIRCUMSTANCES(triggers/influences) do you drink?Have you ever tried to REDUCE your alcohol intake?Do you think you currently have a PROBLEM with drinking?How hard would it be for you to cut down or stop drinking?
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Jaundice Questions
SITE / QUALITY / SEVERITY - Sclera and/or Skin? Colour (yellow vs green).TIME COURSE - onset (abrupt?), episodic, acute/chronic, worsening/improvingCONTEXT - Particular food, overseas travel, illness (viral)AGGRAVATING FACTORS - does anything make it worse?RELIEVING FACTORS - has anything made it better? How effective?ASSOCIATED FEATURES - Dark Urine, Pale stools, Pruritis, Pain. PSYCHOSOCIAL - Alcohol consumption, recent travel, immunisations, tattoos, IV drug use, unprotected sex.
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Causes of Jaundice
Overproduction of bilirubin- heamolysis (malaria, drugs, sickle cell anaemia)Impaired uptake or conjugation of bilirubin by liver- rifampicin- Gilbert's- Crigler–NajjarImpaired bilirubin secretion - Dubin-Johnson- Primary biliary cirrhosisLiver disease- Viral or Alcoholic HepatitisObstruction of bile ducts- Gallstones- Pancreatic cancer (head)
46
Pain Questions
SITE - Where is the pain? Radiation?QUALITY - "Can you tell me what the pain feels like?"Constriction, Throbbing, Stabbing, Dull, Burning, AchingSEVERITY - Rate / 10- "does it stop you doing anything?"- waking at nightTIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur?CONTEXT - "What was happening when you first noticed the pain?", recent travel, foods, sedentary, infectionsRELIEVING FACTORS - "Does anything make it better?"AGGRAVATING FACTORS - "Does anything make it worse?"ASSOCIATED FEATURES -"Have you noticed anything else?"HeadacheShortness of BreathDizzinessTinglingHeart RateNauseaAcid taste in mouthOedemaWeight lossSweating
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Cardiac (syncope) - Nail down the timeline of the collapse – before, during, after - Context of collapse is important to rule out vasovagal - dehydration, fatigue, stress, standing all day - Cardiac associated features (past issues) - chest pain, palpitations, dyspnea - Ask about cardiac risk factors – hypertension, dyslipidemia, diabetes, family history
n/a
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Respiratory (dyspnea) - Quantify the severity of the shortness of breath (how far they can walk, how many steps they can climb prior to onset) - Think about releveant dyspnea associated features: Respiratory – wheeze, cough (productive), fever (infective cause) Cardiac - orthopnea (ask about how many pillows), PND, peripheral edema, chest pain - Quick characterization of cough - sputum, colour, presence of blood Cough may also be from drugs (e.g. ACE-Inhibitors) or from heart failure (cardiac cause)
n/a
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Gastrointestinal (abdo pain) - Ask about any radiation of the pain - Characterization of jaundice - ask about the 4Ps (Piss, Poo, Pain, Pruritis) - Other notable associated features - fever, nausea, vomiting, diarrhea, loss of appetite
n/a
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Muscle Weakness Questions
SITE - Where is the weakness? Generalised/Localised? Asymmetric/Symmetric? Proximal/Distal?True muscle weakness or just fatigue?QUALITY - N/ASEVERITY - What function remains?Plegia or pareisis? Effect on day to day life? Muscle wasting?TIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur (activities)?CONTEXT - "What was happening when you first noticed the weakness?" - mediciations, viruses, trauma, stress?RELIEVING FACTORS - "Does anything make it better?"AGGRAVATING FACTORS - "Does anything make it worse?"ASSOCIATED FEATURES -"Have you noticed anything else?"PainSensory changes (numbness, visual, taste)HeadacheFeverDizzinessTinglingNauseaWeight lossFatiguePHx - autoimmune (diabetes, lupus, thyroid?)CHD
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LL Weakness Exam
1. Prepare Patient2. Hand Hygiene3. Gait4. Inspection (lower back & while lying)5. Tone & Clonus (>5 beats abnormal)6. Power- hip flexion (L2,L3)- hip extension (L4,L5,S1)- hip abduction (L4,L5,S1)- hip adduction (L2,L3,L4)- knee flexion (L5,S1)- knee extension (L2,L3,L4)- ankle dorsiflexion (L4,L5)- ankle plantarflexion (S1,S2)- inversion (L4,L5)- eversion (L5,S1)- big toe extension (L4,L5,S1)7. Deep tendon reflexes- knee jerk (L2,L3,L4)- ankle jerk (S1,S2)- babinski (L5,S1,S2)8. Coordination (heel-shin tests)9. Sensory examination (N/A)10. End of examination
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Muscle Strength Grading 0-5
0 - Complete paralysis1 - Flicker or trace of contraction2 - Active movement with gravity eliminated3 - Active movement against gravity4 - Active movement against gravity and resisitance5 - Normal power
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Plegia vs Paresis
Plegia = paralysisParesis = incomplete loss of strengthhemi - one sidemono - one limbpara - both lower limbsquad - all four limbs
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Reflex Grading 0-4
0 - Absent1 - Hypoactive2 - Normal3 - Hyperactive w/o clonus4 - Hyperactive w/ clonus
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Sensory Disturbance Questions
SITE - Where is the disturbance? Bilateral? Whole limb? Dermatomal? QUALITY - How does it feel? Positive or negative sensory symptoms?SEVERITY - Effect on day to day life? Injuries? Waking at night?TIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur (night)?CONTEXT - "What was happening when you first noticed the disturbance?" - mediciations, viruses, trauma, stress, rash?RELIEVING FACTORS - "Does anything make it better?"AGGRAVATING FACTORS - "Does anything make it worse?"ASSOCIATED FEATURES -"Have you noticed anything else?"PainOther sensory changes (numbness, visual, taste)Gait/balanceInjuriesBowel & bladderHeadacheFeverDizziness, ImbalanceTinglingNauseaWeight lossPalpitationsPHx - Diabetes, MS, Hypertension etc.
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POSITIVEParasthesiaHyperasthesiaDysaesthesiaHyperallgesiaAllodyniaNEGATIVEHypoaesthesiaAnaesthesiaAnalgesia
Parasthesia - abnormal sensation percieved without abnormal stimulusHyperasthesia - abnormal increase in sensitivity to a stimulusDysaesthesia - all positive sensory changes (including above two)Hyperalgesia - heightened response to noxious stimulusAllodynia - normal stimulus felt as painHypoaesthesia - diminished ability to perceive painAnaesthesia - complete inability to percecive painAnalgesia - complete insensitivity to pain
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Responding to crying patient
Acknowledge crying is a legitimate responseStop & put pen downEncourage expression of feelingsOffer practical help (tissues? leave them alone?)Don't offer false hopeDon't project feelings
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LL Sensory Examination
1. Prepare Patient2. Hand Hygiene3. Gait4. Pain (toothpicks)L1 - Upper thighL2 - Lateral ThighL3 - Medial KneeL4 - Medial CalfL5 - Lateral CalfS1 - SoleS2 - Posterior Knee5. Light touch (cotton wool)6. Thermal (only if pain abnormal)7. Vibration8. Proprioception (big toe)
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Opthamology Examination
1. Prepare Patient2. Visual Acuity- Unaided (6/6, CF, HM, LP)- With Pinhole- With Glasses3. Visual Field- X quadrants4. Eye Movements (H)- Follow finger but don't move head (any double vision?)5. Examination of Pupils- Darken room- Symmetry- Direct & Consensual response- Relative Afferent response6. Examination of Fundus
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Seizure Features
Sudden loss of consciousness w/ increased tone - Grand Mal Seizure(Focal may have no LOC)PRODROME - Aura (depends on origination in brain)SITE - not relevantQUALITY - tonic - stiffening, clonic- contraction/relaxationSEVERITY - unquantifiedTIME COURSE - 1-2 minutesCONTEXT - can occur sitting or lying or sleepingPRECIPITATING FACTORS - , can be due to head injury, flashing lights, fatigue, fasting, stressRELIEVING FACTORS - Self limitingASSOCIATED FEATURES - Tongue biting, head turning, cyanosis, cry or moan, frothing, incontinancePERIOD AFTER - Slow recovery, confusion > 2 mins, injury common, exhaustion, muscle achesPAST HISTORY - Seizures (recurrent = epileptic), changes to medication
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UL Weakness Exam
1. Prepare Patient2. Hand Hygiene3. Inspection (cervical spine & upper limb)4. Tone & Clonus (elbow and wrist)5. Power- pronator drift (palms up)- shoulder abduction (C4,C5,C6)- elbow flexion (C5,C6)- elbow extension (C7,C8)- wrist extension (C6,C7)- wrist flexion (C6,C7,C8)- finger extension (C7,C8)- finger flexion (C7,C8)- finger abduction (C8,T1) - ulnar- finger adduction (T1) - ulnar- thumb abduction (T1) - median6. Deep tendon reflexes- biceps jerk (C5,C6)- brachioradialis jerk (C5,C6)- triceps (C7,C8)- finger jerk (C8)7. Coordination (finger-nose, pronate-supinate)8. Sensory examination (N/A)9. End of examination
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UL Sensory Exam
1. Prepare Patient2. Hand Hygiene3. Inspection (cervical spine & upper limb)4. Pain (toothpicks)C4 - shoulderC5 - lateral bicepC6 - thenar eminence (thumb)C7 - palmC8 - medial palmT1 - medial forearm T2 - medial bicep5. Light touch (cotton wool)6. Thermal (only if pain abnormal)7. Vibration8. Proprioception (big toe)
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CONTEXT
ExertionRecent travelRecent infectionNew medicationsPregnancyContact with othersTraumaLifestyle / Dietary changesDehydrationImmunisationTattooIV drug useUnprotected sexStress/Anxiety/Depression
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ASSOCIATED FEATURES
DyspneaPainPalpitationsFatigueBlackouts (loss of consciousness)OedemaNausea / VomitingDizzinessHeadacheSweatyPallorFeverAcid taste in mouthCoughHaemoptysisWheezeHay FeverHivesEczemaSwellingRednessHeatSensory disturbances (photophobia)Other sensory changes (numbness, visual, taste)TinglingWeight loss / AppetiteDiarrhoeaPee, Poo, Puritis, PainPolydipsia (drinking more)StrainingAnxiety (may be a cause of polydipsia)Loss of function (stiffness, locking, giving way, difficulty walking)Noises (popping, clicking)Gait/balance
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Memory Questions
SITE - Sensory memory, short term, long termDeclarative- Semantic (facts) - cortical association areas- Episodic (events) - medial temporal lobeNon-declarative (skills & habits)QUALITY - N/A SEVERITY - based on symptomsTIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?CONTEXT - "What was happening when you first noticed the disturbance?" - medications, viruses, trauma, stress?RELIEVING FACTORS - N/AAGGRAVATING FACTORS - N/AASSOCIATED FEATURES -"Have you noticed anything else?"AphasiaApraxia (performing tasks)Recognising peopleBad planningDisorientationLosing thingsUnsafe behaviourHygieneIncontinencePainFever
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Headache QuestionsMigraine vs Tension Type Headache
SITE - Unilateral (70% migraines) vs bilateralQUALITY - Dull/Throbbing vs Band/PressureSEVERITY - How bad is it? Affect on daily activitiesTIME COURSE - Onset (sudden, gradual)Time of day (mornings - migraine)Offset Duration (3 days - migraine)Temporal profile (constant, fluctuating)Previous episodes?Migraine crescendo, TTN waxes and wanesCONTEXT - "What was happening when you first noticed the headache(s)?" - medications, viruses, trauma, stress?RELIEVING FACTORS - Analgesia, dark roomAGGRAVATING FACTORS - Physical activity, stress, contraceptives, fatigue, food, wine, cheese, head movements, bright lights, noiseASSOCIATED FEATURES -"Have you noticed anything else?"Neck pain / muscle tendernessNauseaVomitingPhotophobiaAura (prodrome)Visual/speech disturbanceMotor weaknessSensory changesLoss of consciousnessSeizuresPHx - CVD, history of cancer
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Ear/Hearing Examination
Whispered voice test- stand 60cm behind patient- occlude/rub external auditory meatus- 66 - high frequency- 100 - low frequencyOtoscope - pull auricle up and back- diect speculum down and forward- inspect while inserting- colour, consistency, cone of light
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Dizziness Types
Pre-syncope- decreased BF to brain- 'feeling faint'- causes same as syncope (dehydration, infection, fatigue, fasting, CVD, stress)Vertigo- 'environment spinning'- nausea/vomiting- cause: disturbance of vestibular system (viral, stroke, tumor, trauma), Benign Paroxysmal Positional Vertigo (calcium crystals settle in posterior semicircular canal)Disequilibrium- gait ataxia- 'wobbly' / 'leaning'- occurs only while walking- cause: muscle, nerve, cerebellar diseaseNon-specific- 'light headed' / 'woozy'- cause: hyperventilation, idiopathic, anxiety
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Dizziness Questions
SITE - N/AQUALITY - Type of dizziness (Vertigo, Presyncope, Disequilibrium, Non-specific) -> not loss of consciousnessSEVERITY - Affect on daily activities, injuriesTIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?CONTEXT - "What was happening when you first noticed the dizziness?" - walking, medications, illness, trauma, stress, fatigue, sudden head movement, hyperventilation, anxiety?RELIEVING FACTORS - Analgesia, dark roomAGGRAVATING FACTORS - head movements, standing up quicklyASSOCIATED FEATURES -"Have you noticed anything else?"IllnessNauseaVomitingFeverWeight lossCardiovascular risk factorshearing changesSyncope prodromeMuscle weakness / decreased control PHx - CVD, anxiety, fainting / seizures
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Weightloss Questions
SITE - Local or general?QUALITY - Intentional or unintentional? Changes in appetite?SEVERITY - Amount lost (>5% significant), clothing fit.TIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?CONTEXT - "What was happening when you first noticed the weightloss?" - lifestyle/diet changes, exercise, medications, illness, trauma, stress, fatigue, overseas travel?RELIEVING FACTORS - "anything halt/limit the weightloss?"AGGRAVATING FACTORS - "anything make the weightloss worse?"ASSOCIATED FEATURES -"Have you noticed anything else?"Increased (hyperthyroid) / decreased (cancer,meds,anorexia) appetitePain / trouble swallowingNauseaVomitingDiarrhoeaUrineFatigueFeverTremors, Sweating, PalpitationsAnxiety/depressionTemperature intoleranceMasculinisation (acne, hair)Change in bowel (diarrhoea)PHxHyperthyroid CancerDiabetesCardiovascular diseases
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Urination Questions
SITE - Location of pain when urinating (if any)QUALITY - dysuria (pain, burning, discomfort), polyuria (volume), frequency, urgency, nocturia, hesitancy, straining, dribbling, blood (haematuria), cloudy, malodorousSEVERITY - How is it affecting your life? pain scale 0-10? Do you wake up and need to urinate?TIME COURSE - Onset (sudden, gradual)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?CONTEXT - "What was happening when you first noticed the urinary problems?" - lifestyle/diet changes, medications, illness, trauma, stress, fatigue?RELIEVING FACTORS - "anything halt/limit the urinary problems?"AGGRAVATING FACTORS - "anything make the urinary problems worse?" Drinking (fluids, diuretics - coffee&alcohol)ASSOCIATED FEATURES -"Have you noticed anything else?"Polydipsia (drinking more)PainFatigue (esp w/ nocturia)Vision changesStrainingIncreased / decreased appetiteNauseaVomitingDiarrhoeaFeverAnxiety (may be a cause of polydipsia)PHxPregnancyDiabetesCardiovascular diseases
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Definitions:- Micturition- Dysuria- Polyuria- Urgency- Frequency- Irritative Voiding Symptoms- Obstructive Voiding Symptoms
MICTURITION - urinationDYSURIA - pain, burning, discomfort (infection/prostate/bladder)POLYURIA - excessive volume (2.5-3.5L -normal 1.5L)(increased intake, diabetes mellitis, diabetes insipidus)URGENCY - compelling need to empty (even if not full)FREQUENCY - increase usually due to infection or irritationIRRITATIVE VOIDING SYMPTOMS - dysuria, frequency, and urgency - usually due to UTIOBSTRUCTIVE VOIDING SYMPTOMS - hesitancy, straining, dribbling - can lead to irritative symptoms due to detrusor hypertrophycomplete obstruction can lead to urinary retention(BPH, stones, tumor, scar tissue, neuromuscular disorder)
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Causes of Knee Pain (INJURY vs NON INJURY)
INJURY- ligaments- menisci- tendons- bone- chondromalacia patellae- bursitis- referred from hip/groin/backNON-INJRY- osteoarthritis (cartilage) / rheumatitis (inflammation)- haemorrhage - sepsis- gout- referred from hip/groin/back
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Knee Pain Questions
SITE - One knee? other joints?Anterior -> osteoarthritis, patellaLateral/Medial -> ligament sprain, meniscal tearPosterior -> hamstring strain, bursitis, baker's cyst, DVTOther -> rheumatoid/arthritic/goutQUALITY - How does it feel? Burning, stabbing, grinding?SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night?TIME COURSE - Onset (acute = trauma/haemorrhage)Offset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur (night, morning, exercise)?CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, knee position, 'popping' noise?), illness?RELIEVING FACTORS - "Does anything make it better?", rest, analgesics?AGGRAVATING FACTORS - "Does anything make it worse?" specific movements?ASSOCIATED FEATURES -"Have you noticed anything else?"SwellingRednessHeatLoss of function (stiffness, locking, giving way, difficulty walking)Noises (popping, clicking)PainOther sensory changes (numbness, visual, taste)Gait/balanceHeadacheFeverNauseaPHx - Osteoporosis, gout, arthritis, autoimmune etc.
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Knee Exam
1. Prepare Patient - it will involve both knees2. Hand Hygiene3. Inspection Standing (knee alignment, gait, muscle wasting)- valgus (knocked-knee)- varus (cowboy)4. Inspection Lying (scars, inflammation)5. Anterior Palpation- temperature (back of hand)- swelling - milking w/ patella tap- effusions - up-medial, down-lateral- palpate (patella, tendon, quad)6. Lateral and Posterior Palpation- 30degree flexion - lateral/medial joint- straight - posterior7. Testing Movements- normal 0-135degrees8. ACL & PCL- 90 degree flexion9. Collateral Ligaments- slight flexion10. End of examination
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Shoulder Pain Questions
SITE - One shoulder? other joints? referred? movement?intrinsic = joint, bursae, muscle, tendonextrinsic = spine, diaphragm, heartQUALITY - How does it feel? Burning, stabbing, grinding?SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROMTIME COURSE - OnsetOffset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur (night, morning, exercise)?CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, ROM, 'popping' noise?), illness?RELIEVING FACTORS - "Does anything make it better?", rest, analgesics?AGGRAVATING FACTORS - "Does anything make it worse?" specific movements?ASSOCIATED FEATURES -"Have you noticed anything else?"SwellingRednessHeatLoss of function (stiffness, locking, giving way, difficulty walking)Noises (popping, clicking)PainHeadacheFeverNauseaPHx - Heart disease- Autoimmune
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Shoulder Exam
1. Prepare Patient - it will involve both shoulders2. Hand Hygiene3. Inspection- anterior, lateral, posterior- scars, swelling, redness, muscle wasting4. Palpation- sternoclavicular- clavicle -> acromioclavicular joint- coracoid- anterior glenohumeral- head of biceps tendon- supraspinatus insertion- spine of scapula- inferior pole of scapula5. Active Movement- abduction & adduction (180degrees)- flexion & extension (180 & 70 degrees)- internal & external rotation (90 degrees & T7)6. Fixed scapula (detectable between 45-90degrres)7. End of examination
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Back Pain Questions
SITE - Specific? Non-specific? ? other joints? referred? movement?L1-S5 = degenerativeL5/S1 = sciaticabuttocks&back of legs = central stenosisQUALITY - How does it feel? Burning, stabbing, grinding, numbness?SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROMTIME COURSE - OnsetOffset DurationTemporal profile (constant, fluctuating)Previous episodes?When does it occur (night, morning, exercise)?CONTEXT - "What was happening when you first noticed the disturbance?" - trauma (mechanism, ROM, 'popping' noise?), illness?RELIEVING FACTORS - "Does anything make it better?", rest, analgesics, bending forwards, therapies?AGGRAVATING FACTORS - "Does anything make it worse?" specific movements? walking?ASSOCIATED FEATURES -"Have you noticed anything else?"SwellingRednessHeatLoss of function (stiffness, locking, giving way, difficulty walking)Noises (popping, clicking)Joint painHeadacheFeverSweatsNauseaBlood in urineWeightlossLoss of appetiteBladder/bowel/motor/sensoryPHx - History/suspicion of cancerIV drug useglucocorticoids
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Back Pain Red Flags
Age > 50 or < 20History or suspicion of cancerIV drug usefevers, sweats, weightlossglucocorticoidsSciatica Pain not relieved by restPain over 1 months duration
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Menstrual Cycle Questions
SITE - N/AQUALITY - Colour? Clots? Changes over period?SEVERITY - Volume (pads & changing)- spotting- change from normalTIME COURSE - length of cycle- length of period- frequency of menstruation- regular / irregular- date of last menstrual cycle- age of onset- change over timeCONTEXT - "What was happening when you first noticed the change?" - illness, contraceptives, pregnancy, peri-menopauseRELIEVING FACTORS - "Does anything make it better?"AGGRAVATING FACTORS - "Does anything make it worse?" stress? weightloss?ASSOCIATED FEATURES -"Have you noticed anything else?"Pelvic painPost-coital bleedingAnaemiaFatigueHot flushesHeadacheFeverSweatsNauseaWeightlossCold intoleranceMasculinisation (acne, hair)PHx - Menopause- Thyroid- Hormonal
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Menopause Definitions- Frequency- Duration- Amount- Primary amenorrhoea- Secondary amenorrhoea- Oligomenorrhoea- Polymenorrhoea- Primary dysmenorrhoea
FREQUENCYbetween 21-35 daysDuration 4-5 daysAmount20-60mL (>80 = abnormal)PRIMARY AMENORRHOEAnever menstruatedSECONDARY AMENORRHOEApregnancy, weightloss, stress, menopauseOLIGOMENNORRHOEA4-9 periods per year or light flowPOLYMENORRHOEAmore frequent than 21 daysPRIMARY DYSMENORRHOEAfirst & all periods are painful
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Vaginal Discharge Questions
SITE - N/AQUALITY - Colour? Consistency? Odor? Blood?Candidiasis = white, clumped, itchyBact Vaginosis = white-grey, fishyTrichomonas = Green-yellow, frothy, itchSEVERITY - Volume (pads?)TIME COURSE - Onset- Offset - Duration- Temporal profile (constant, fluctuating)- Previous episodes?CONTEXT - "What was happening when you first noticed the change?" - illness, antibiotics, sexual activity (partners, genders, protection, STIs)?RELIEVING FACTORS - "Does anything make it better?" Anti-thrush treatments?AGGRAVATING FACTORS - "Does anything make it worse?" contraceptive pill?ASSOCIATED FEATURES -"Have you noticed anything else?"ItchChange in menstruationPain with urinationPelvic painPost-coital bleedingAnaemiaFatigueHeadacheFeverSweatsNauseaPHx - UTIs, STIs
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Erectile Dysfunction Questions
SITE - N/AQUALITY - Erectile dysfunction? Libido? Inability to reach orgasm? Difficulty with ejaculation?SEVERITY - Degree of rigidity, - time to achieve erection, - duration of erection, - prevent intercourse, - affect on relationship?- masturbation?- early morning erections?TIME COURSE - Onset (sudden = psychological)- Offset - Duration- Temporal profile (constant, fluctuating)- Previous episodes?- Always present?CONTEXT - "What was happening when you first noticed the change?" - illness, trauma, anxiety, libido, sexual activity (partners, genders, protection, STIs)?RELIEVING FACTORS - "Does anything make it better?" medication?AGGRAVATING FACTORS - "Does anything make it worse?" anxiety, alcohol, medications?ASSOCIATED FEATURES -"Have you noticed anything else?"LibidoOrgasm & EjaculationCardiovascularProteinuria (diabetes)PHx - CHD, alcohol, smoking, diabetes, operations
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Medications Questions
- Amount / Dose- Route- Frequency- Adherence- ADR's (sides, allergies, intolerance)- Is disease well controlled?- Prescribed, OTC's, Alternative meds- Recently ceased (why?)- Any drug allergies?
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Recreational Drug Questions
Signpost & ConfidentialityOpen Question & Tell me moreWhich drugs?- cannabis- cocaine- amphetamines/ice- ecstacy- ice- legal medications (benzodiazepines, codeine)Quantity- type / route- how much (grams, cones, money)- how oftenContext- when did you start?- what occasions do you take the drugs?Dependancy- do you need it through the day?- what happens if you don't have it?- how long can you go without?- changed life to accomodate habit?Quitting- tried before? worked?- considering quitting?Damage- Blackouts / regrets- harm to self or others- kids / job (work next day)- financial responsibilities- health (weightloss, asthma)
