PCP Flashcards
Cardinal Features
Site Quality Severity Time Course Context Relieving Factors Aggravating Factors Associated Features -------------------------------- Medical History & Risk Factors Family History Alcohol Smoking Social & Occupational History
Cardiovascular Exam
- Prepare patient (explain procedure, undress, check comfort)
- Hand hygiene
- General Inspection (mental state, alertness, resp. effort)
- Inspect hands (nicotine, clubbing, anaemia)
- Measure radial pulse (HR 60-100 and rhythm)
- Measure BP (120/80)
- Face, Head (conjunctiva -pallor, tongue, lips - cyanosis)
- JVP (<3cm)
- Carotid Pulse (Both sides, separate)
- Inspect chest (scars)
- Palpate chest (apex beat)
- Auscultate (bell then diaphragm) MTPA
- Posterior Chest (Lung Bases)
- Lower Limbs (oedema, pulse - dorsalis pedis and posterior tibial)
- Completion
Respiratory Exam
- Prepare Patient (sit 90degrees)
- Hand Hygiene
- General Inspection (mental state, resp effort, sputum cup, coughing, wheezing)
- Inspection of hands (nails, smoking, clubbing, anaemia)
- Pulse & resp rate measurement
- Head and Neck (conjunctiva, lips, tongue, TRACHEA!)
- Inspection of Anterior and Lateral chest walls
- Measure Anterior Chest Expansion (x2)
- Percussion of Anterior and Lateral Chest (start clavicle then every 2nd space)
- Auscultate Anterior and Lateral (Diaphragm - bell if hairy)
- breath in and out through open mouth
- ninety-nine - Examination of Posterior Chest
- chest expansion
(rotate scapulae)
- percussion (4 sites)
- auscultation (breathe & ninety nine) - Measure Peak Flow
- End of Examination
Points of Auscultation (Heart)
- 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
Heart Borders
SUPERIOR BORDER
2nd CC left
3rd CC right
RIGHT BORDER
3rd CC right
6th CC right
LEFT BORDER
2nd CC left
5th ICS left
INFERIOR BORDER
5th ICS left
6th CC right
CC = 2cm from sternal edge
VALVES - PAMT (diagonal)
2nd CC left
6th CC right
ASCULTATION - APTM (Z shape)
Lung Borders
ANTERIOR Apex - 2.5cm above medial 1/3rd of clavicle Sternoclavicular joint 4th CC 6th mid-clavicular 8th mid-axillary 10th adjacent spine
POSTERIOR
C7
T10
4cm from midline
OBLIQUE FISSURE
T2 spinous process
6th mid clavicular
HORIZONTAL FISSURE
4th CC
Intersect oblique mid-axillary
Lung Pleura Borders
2.5cm above medial 1/3rd of clavicle 6th CC (right) 4th CC (left - cardiac notch) 8th mid-clavicular 10th mid-axillary 12th paravertebral
Syncope Features
VASOVAGAL (Faint)
Sudden loss of consciousness and postural tone
PRODROME - light headed, wobbly, dim vision, distant sounds
SITE - not relevant
QUALITY - convulsive movements can occur
SEVERITY - unquantified
TIME COURSE - less than 30 seconds
CONTEXT - usually doesn’t occur while sitting or lying
PRECIPITATING FACTORS - fasting, pain, emotional events, prolonged standing, straining
RELIEVING FACTORS - Lying flat
ASSOCIATED FEATURES - Sweaty, pallor, no-frothing
PERIOD AFTER - Rapid recovery, rarely confused, no injury (protective mechanism)
PAST HISTORY - None
Smoking Questions
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.
Asthma Questions
SITE - n/a
QUALITY -n/a
SEVERITY - frequency of symptoms (day&night)- wheezing, cough, attacks, hospital, usage of inhalers, peak flow
TIME COURSE - onset (childhood?), episodic, current activity of the disease
CONTEXT - see psychosocial.
AGGRAVATING FACTORS - not using glucocorticoids, illness, exercise, pollens, smoke, dust, cold air, stress.
RELIEVING FACTORS - how frequently bronchodilators are used
ASSOCIATED FEATURES - eczema, hay fever, hives
PSYCHOSOCIAL CONTEXT - how does the disease impact the patients life, how does life impact the disease?
- relationships, pets, occupation, stress, hobbies, travel
Minimal Verbal Encouragers
"I see" "Yes" "Go on ..." "Sure" "Tell me more"
Body Language
Eye contact
Leaning in
Facial features (concern, interest)
Nodding
Palpitation Questions
Abnormal awareness of the heart beat
SITE - not typically useful
QUALITY - Rhythm (tap it out), Forcefulness (or a flutter)
SEVERITY - Speed
- How it affects daily activities
TIME - How long has it been there, onset/offset, sudden, duration
CONTEXT - what is happening when the palpitations occur
RELIEVING FACTORS
AGGRAVATING FACTORS (coffee, exercise, stress)
ASSOCIATED FEATURES - SoB, chest pain, fatigue, dizziness, blackouts, oedema
Past Medical History Questions
Past Serious Illness - Heart attack - Cancer - Blood Coagulopathies - Autoimmune - Infections Past Operations / Hospital Admissions Medications
Blood Pressure Measurement
- Prepare Patient
- Hand Hygiene
- Appropriate Sized Cuff
- Apply Cuff (2-3cm above brachial artery pulsation)
- Estimate Systolic pressure using palpation (radial)
- Steth (diaphragm) over brachial pulse, support elbow with right arm. +30mmHg
- Auscultatory Sounds
deflate 2-3mmHg per beat - Record Result (nearest 5mmHg)
BMI
weight (kg) / height squared (m^2)
<18.5 = Underweight 18.5-24.9 = Normal 25-29.9 = Overweight 30+ = Obese
Waist-to-hip Ratio
Waist Circumference / Hip Circumference
<0.9 Male
Syncope Features
CARDIAC (Blackout)
Sudden loss of consciousness and postural tone
PRODROME - not present
SITE - not relevant
QUALITY - convulsive movements can occur
SEVERITY - unquantified
TIME COURSE - less than 30 seconds
CONTEXT - can occur sitting or lying
PRECIPITATING FACTORS - usually doesn’t have any
RELIEVING FACTORS - Self limiting
ASSOCIATED FEATURES - Sweaty, pallor, no-frothing
PERIOD AFTER - Rapid recovery, rarely confused, injury may occur
PAST HISTORY - Cardiac Disease
Angina
Reversible myocardial ischaemia (70% occlusion)
Diffuse central chest pain Radiation to arms (left), neck, jaw Physical exertion makes it worse Relieved by rest (or nitroglycerin) Associated with dyspnoea, nausea, and sweating.
> 20minutes = Myocardial Infarction
Cardiovascular Risk Factors
Smoking High Blood Pressure (hypertension) High Cholesterol (Hyperlipidaemia) Diabetes Family History Age Gender
Claudication
Arterial narrowing causing ischaemic pain
Cramped feeling in calves
subsides with rest
intermittent
Family History
“Can you tell me about the health of your immediate family?”
- What age they died and cause
- What age they developed the condition
Oedema Causes
Increased Hydrostatic Pressure Decreased Osmotic Pressure Increased Permeability (inflammation) Obstruction of Lymphatic Drainage
Oedema Questions
Cardinal Features
Worse at end of day?
Relieved by elevating feet?
Bilateral? (unilateral indicates DVT)
Associated features (Dyspnoea on exertion & Orthopnoea indicate heart failure)
Dyspnoea questions
SITE - not important
QUALITY - heavy or shallow
SEVERITY - 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, episodic
CONTEXT - “when does the shortness of breath occur?”, recent travel
AGGRAVATING FACTORS
Orthopnoea (diffculty breathing worse lying down) - how many pillows required to sleep
RELIEVING FACTORS
ASSOCIATED FEATURES
Chest pain, cough, wheeze, swelling of ankles, fever, weight loss
Occupational History
Are you currently working?
Asbestos, Farmers Lung, Chemicals, Children
Stresses
Social History
Relationships & support systems Education and occupation Finances Ethnicity Religion and spirituality Hobbies & Exercise Pets Travel
Acute vs Chronic Cough
Acute < 2 weeks
Subacute 2-8 weeks
Chronic > 8 weeks
Cough Questions
SITE - chest or throat
QUALITY - sound, productive (characterise sputum separately)
SEVERITY - frequency
TIME COURSE - duration (acute, chronic)
CONTEXT - what were you doing when you first noticed the cough?
RELIEVING FACTORS - what treatments have been tried
AGGRAVATING FACTORS - worse at night?
ASSOCIATED FEATURES - dyspnoea, wheeze, fever, haemoptysis, smoking, pain
Sputum Questions
Cover Cardinal signs
colour
(SEVERITY) volume (teaspoon)
thickness
odor
blood (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?
Vomiting Questions
SITE - n/a
QUALITY - Colour? (blood or bile stained?)
SEVERITY - frequency, volume
TIME COURSE - onset , episodic, relationship to meals, first thing in morning
CONTEXT - 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
Dysphagia Critical Reasoning
OROPHARYNGEAL DYSPHAGIA:
Difficulty initiating swallowing associated with CHOKING, COUGHING, NASAL REGURGITATION (stroke, parkinsons, ms)
OESOPHAGEAL DYSPHAGIA
Food sticks after initiation of a swallow
Mechanical Obstruction (e.g. cancer) - Solids only
Motility disorder (e.g. achalasia) - Solids & liquids
GI exam
- Prepare Patient (sit 90degrees)
- Hand Hygiene
- General Inspection (mental state, alertness, cachexia, jaundice, distressed, pain)
- Inspection of hands (leuconychia, palmar erythmea, pallor, dupuytren’s contracture), test for metabolic flap (15s)
- Head and Neck (conjunctiva jaundice or pallor)
- Examination of chest (spider naevi)
- Inspection of abdomen (Lay flat on one pillow) (scars, striae, distension, masses, caput medusae)
- Palpation of Abdomen (warm hands, palpate twice, check for discomfort)
- left inguinal, lumbar, hypochondrium
- epigastrium
- right hypochondrium, lumbar, inguinal
- suprapubic, umbilical - Palpate for liver from LRQ (firm pressure during inhilation, 2cm advances)
- percuss from LRQ and third rib mid clavicular
- measuring tape 12-13 cm - Palpate for Spleen from RLQ
- ballot (roll patient 45deg and place left hand behind) - Kidneys
- left hand posteriorly in loin region
- right hand under costal margin - End of Examination
Diarrhoea Questions
SITE - n/a (except for with abdominal pain)
QUALITY - Consistency (watery?) Colour (blood, mucous?)
SEVERITY - frequency, volume
TIME COURSE - onset , episodic, acute/chronic, worsening/improving
CONTEXT - Particular food, overseas travel
AGGRAVATING 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?
Acute, Persistant, Chronic Diarrhoea
Acute
- few days, due to infection, gastroenteritis, food poisining
Persistant
- 2 - 4 weeks
Chronic
- >4 weeks
Liver Surface Anatomy
Superior: between nipples
Inferior: costal margin
Gallbladder - mid-clavicular below costal margin
Appendix Surface Anatomy
McBurneys Point
1/3 distance from right anterior superior iliac spine to umbilicus
Kidney Surface Anatomy
Mid line (lateral to spine)
Left as high as rib 11
Right as high as rib 12
Extend to L3
(can identify L4 as midpoint between iliac crests)
Spleen Surface Anatomy
Posterior along line of 9th to 11th rib
Follows contour of 10th rib
lies antero-lateral to kidney extending around mid-axilliary line
Haematemesis
Vomiting Blood
Heam + Emesis
Haemoptysis
Coughing up blood
Common causes of vomiting
Gastroenteritis
Pregnancy
Medications (esp. chemo)
Acute MI
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?
Jaundice Questions
SITE / QUALITY / SEVERITY - Sclera and/or Skin? Colour (yellow vs green).
TIME COURSE - onset (abrupt?), episodic, acute/chronic, worsening/improving
CONTEXT - 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.
Causes of Jaundice
Overproduction of bilirubin
- heamolysis (malaria, drugs, sickle cell anaemia)
Impaired uptake or conjugation of bilirubin by liver
- rifampicin
- Gilbert’s
- Crigler–Najjar
Impaired bilirubin secretion
- Dubin-Johnson
- Primary biliary cirrhosis
Liver disease
- Viral or Alcoholic Hepatitis
Obstruction of bile ducts
- Gallstones
- Pancreatic cancer (head)
Pain Questions
SITE - Where is the pain? Radiation?
QUALITY - “Can you tell me what the pain feels like?”
Constriction, Throbbing, Stabbing, Dull, Burning, Aching
SEVERITY - Rate / 10
- “does it stop you doing anything?”
- waking at night
TIME COURSE - Onset (sudden, gradual) Offset Duration Temporal profile (constant, fluctuating) Previous episodes? When does it occur?
CONTEXT - “What was happening when you first noticed the pain?”, recent travel, foods, sedentary, infections
RELIEVING FACTORS - “Does anything make it better?”
AGGRAVATING FACTORS - “Does anything make it worse?”
ASSOCIATED FEATURES -"Have you noticed anything else?" Headache Shortness of Breath Dizziness Tingling Heart Rate Nausea Acid taste in mouth Oedema Weight loss Sweating
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
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
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
Muscle Weakness Questions
SITE - Where is the weakness? Generalised/Localised? Asymmetric/Symmetric? Proximal/Distal?
True muscle weakness or just fatigue?
QUALITY - N/A
SEVERITY - What function remains?
Plegia or pareisis? Effect on day to day life? Muscle wasting?
TIME COURSE - Onset (sudden, gradual) Offset Duration Temporal 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?" Pain Sensory changes (numbness, visual, taste) Headache Fever Dizziness Tingling Nausea Weight loss Fatigue
PHx - autoimmune (diabetes, lupus, thyroid?)
CHD
LL Weakness Exam
- Prepare Patient
- Hand Hygiene
- Gait
- Inspection (lower back & while lying)
- Tone & Clonus (>5 beats abnormal)
- 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) - Deep tendon reflexes
- knee jerk (L2,L3,L4)
- ankle jerk (S1,S2)
- babinski (L5,S1,S2) - Coordination (heel-shin tests)
- Sensory examination (N/A)
- End of examination
Muscle Strength Grading 0-5
0 - Complete paralysis
1 - Flicker or trace of contraction
2 - Active movement with gravity eliminated
3 - Active movement against gravity
4 - Active movement against gravity and resisitance
5 - Normal power
Plegia vs Paresis
Plegia = paralysis Paresis = incomplete loss of strength
hemi - one side
mono - one limb
para - both lower limbs
quad - all four limbs
Reflex Grading 0-4
0 - Absent 1 - Hypoactive 2 - Normal 3 - Hyperactive w/o clonus 4 - Hyperactive w/ clonus
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 Duration Temporal 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?" Pain Other sensory changes (numbness, visual, taste) Gait/balance Injuries Bowel & bladder Headache Fever Dizziness, Imbalance Tingling Nausea Weight loss Palpitations
PHx - Diabetes, MS, Hypertension etc.
POSITIVE Parasthesia Hyperasthesia Dysaesthesia Hyperallgesia Allodynia
NEGATIVE
Hypoaesthesia
Anaesthesia
Analgesia
Parasthesia - abnormal sensation percieved without abnormal stimulus
Hyperasthesia - abnormal increase in sensitivity to a stimulus
Dysaesthesia - all positive sensory changes (including above two)
Hyperalgesia - heightened response to noxious stimulus
Allodynia - normal stimulus felt as pain
Hypoaesthesia - diminished ability to perceive pain
Anaesthesia - complete inability to percecive pain
Analgesia - complete insensitivity to pain
Responding to crying patient
Acknowledge crying is a legitimate response
Stop & put pen down
Encourage expression of feelings
Offer practical help (tissues? leave them alone?)
Don’t offer false hope
Don’t project feelings
LL Sensory Examination
- Prepare Patient
- Hand Hygiene
- Gait
- Pain (toothpicks)
L1 - Upper thigh
L2 - Lateral Thigh
L3 - Medial Knee
L4 - Medial Calf
L5 - Lateral Calf
S1 - Sole
S2 - Posterior Knee - Light touch (cotton wool)
- Thermal (only if pain abnormal)
- Vibration
- Proprioception (big toe)
Opthamology Examination
- Prepare Patient
- Visual Acuity
- Unaided (6/6, CF, HM, LP)
- With Pinhole
- With Glasses - Visual Field
- X quadrants - Eye Movements (H)
- Follow finger but don’t move head (any double vision?) - Examination of Pupils
- Darken room
- Symmetry
- Direct & Consensual response
- Relative Afferent response - Examination of Fundus
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 relevant
QUALITY - tonic - stiffening, clonic- contraction/relaxation
SEVERITY - unquantified
TIME COURSE - 1-2 minutes
CONTEXT - can occur sitting or lying or sleeping
PRECIPITATING FACTORS - , can be due to head injury, flashing lights, fatigue, fasting, stress
RELIEVING FACTORS - Self limiting
ASSOCIATED FEATURES - Tongue biting, head turning, cyanosis, cry or moan, frothing, incontinance
PERIOD AFTER - Slow recovery, confusion > 2 mins, injury common, exhaustion, muscle aches
PAST HISTORY - Seizures (recurrent = epileptic), changes to medication
UL Weakness Exam
- Prepare Patient
- Hand Hygiene
- Inspection (cervical spine & upper limb)
- Tone & Clonus (elbow and wrist)
- 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) - median - Deep tendon reflexes
- biceps jerk (C5,C6)
- brachioradialis jerk (C5,C6)
- triceps (C7,C8)
- finger jerk (C8) - Coordination (finger-nose, pronate-supinate)
- Sensory examination (N/A)
- End of examination
UL Sensory Exam
- Prepare Patient
- Hand Hygiene
- Inspection (cervical spine & upper limb)
- Pain (toothpicks)
C4 - shoulder
C5 - lateral bicep
C6 - thenar eminence (thumb)
C7 - palm
C8 - medial palm
T1 - medial forearm
T2 - medial bicep - Light touch (cotton wool)
- Thermal (only if pain abnormal)
- Vibration
- Proprioception (big toe)
CONTEXT
Exertion Recent travel Recent infection New medications Pregnancy Contact with others Trauma Lifestyle / Dietary changes Dehydration Immunisation Tattoo IV drug use Unprotected sex Stress/Anxiety/Depression
ASSOCIATED FEATURES
Dyspnea Pain Palpitations Fatigue Blackouts (loss of consciousness) Oedema Nausea / Vomiting Dizziness Headache Sweaty Pallor Fever Acid taste in mouth Cough Haemoptysis Wheeze Hay Fever Hives Eczema Swelling Redness Heat Sensory disturbances (photophobia) Other sensory changes (numbness, visual, taste) Tingling Weight loss / Appetite Diarrhoea Pee, Poo, Puritis, Pain Polydipsia (drinking more) Straining Anxiety (may be a cause of polydipsia) Loss of function (stiffness, locking, giving way, difficulty walking) Noises (popping, clicking) Gait/balance
Memory Questions
SITE - Sensory memory, short term, long term
Declarative
- Semantic (facts) - cortical association areas
- Episodic (events) - medial temporal lobe
Non-declarative (skills & habits)
QUALITY - N/A
SEVERITY - based on symptoms
TIME COURSE - Onset (sudden, gradual) Offset Duration Temporal profile (constant, fluctuating) Previous episodes?
CONTEXT - “What was happening when you first noticed the disturbance?” - medications, viruses, trauma, stress?
RELIEVING FACTORS - N/A
AGGRAVATING FACTORS - N/A
ASSOCIATED FEATURES -"Have you noticed anything else?" Aphasia Apraxia (performing tasks) Recognising people Bad planning Disorientation Losing things Unsafe behaviour Hygiene Incontinence Pain Fever
Headache Questions
Migraine vs Tension Type Headache
SITE - Unilateral (70% migraines) vs bilateral
QUALITY - Dull/Throbbing vs Band/Pressure
SEVERITY - How bad is it? Affect on daily activities
TIME 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 wanes
CONTEXT - “What was happening when you first noticed the headache(s)?” - medications, viruses, trauma, stress?
RELIEVING FACTORS - Analgesia, dark room
AGGRAVATING FACTORS - Physical activity, stress, contraceptives, fatigue, food, wine, cheese, head movements, bright lights, noise
ASSOCIATED FEATURES -"Have you noticed anything else?" Neck pain / muscle tenderness Nausea Vomiting Photophobia Aura (prodrome) Visual/speech disturbance Motor weakness Sensory changes Loss of consciousness Seizures
PHx - CVD, history of cancer
Ear/Hearing Examination
Whispered voice test
- stand 60cm behind patient
- occlude/rub external auditory meatus
- 66 - high frequency
- 100 - low frequency
Otoscope
- pull auricle up and back
- diect speculum down and forward
- inspect while inserting
- colour, consistency, cone of light
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 disease
Non-specific
- ‘light headed’ / ‘woozy’
- cause: hyperventilation, idiopathic, anxiety
Dizziness Questions
SITE - N/A
QUALITY - Type of dizziness (Vertigo, Presyncope, Disequilibrium, Non-specific) -> not loss of consciousness
SEVERITY - Affect on daily activities, injuries
TIME COURSE - Onset (sudden, gradual) Offset Duration Temporal 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 room
AGGRAVATING FACTORS - head movements, standing up quickly
ASSOCIATED FEATURES -"Have you noticed anything else?" Illness Nausea Vomiting Fever Weight loss Cardiovascular risk factors hearing changes Syncope prodrome Muscle weakness / decreased control
PHx - CVD, anxiety, fainting / seizures
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 Duration Temporal 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) appetite Pain / trouble swallowing Nausea Vomiting Diarrhoea Urine Fatigue Fever Tremors, Sweating, Palpitations Anxiety/depression Temperature intolerance Masculinisation (acne, hair) Change in bowel (diarrhoea)
PHx Hyperthyroid Cancer Diabetes Cardiovascular diseases
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, malodorous
SEVERITY - How is it affecting your life? pain scale 0-10? Do you wake up and need to urinate?
TIME COURSE - Onset (sudden, gradual) Offset Duration Temporal 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) Pain Fatigue (esp w/ nocturia) Vision changes Straining Increased / decreased appetite Nausea Vomiting Diarrhoea Fever Anxiety (may be a cause of polydipsia)
PHx
Pregnancy
Diabetes
Cardiovascular diseases
Definitions:
- Micturition
- Dysuria
- Polyuria
- Urgency
- Frequency
- Irritative Voiding Symptoms
- Obstructive Voiding Symptoms
MICTURITION - urination
DYSURIA - 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 irritation
IRRITATIVE VOIDING SYMPTOMS - dysuria, frequency, and urgency - usually due to UTI
OBSTRUCTIVE VOIDING SYMPTOMS - hesitancy, straining, dribbling - can lead to irritative symptoms due to detrusor hypertrophy
complete obstruction can lead to urinary retention
(BPH, stones, tumor, scar tissue, neuromuscular disorder)
Causes of Knee Pain (INJURY vs NON INJURY)
INJURY
- ligaments
- menisci
- tendons
- bone
- chondromalacia patellae
- bursitis
- referred from hip/groin/back
NON-INJRY
- osteoarthritis (cartilage) / rheumatitis (inflammation)
- haemorrhage
- sepsis
- gout
- referred from hip/groin/back
Knee Pain Questions
SITE - One knee? other joints?
Anterior -> osteoarthritis, patella
Lateral/Medial -> ligament sprain, meniscal tear
Posterior -> hamstring strain, bursitis, baker’s cyst, DVT
Other -> rheumatoid/arthritic/gout
QUALITY - 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
Duration
Temporal 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?" Swelling Redness Heat Loss of function (stiffness, locking, giving way, difficulty walking) Noises (popping, clicking) Pain Other sensory changes (numbness, visual, taste) Gait/balance Headache Fever Nausea
PHx - Osteoporosis, gout, arthritis, autoimmune etc.
Knee Exam
- Prepare Patient - it will involve both knees
- Hand Hygiene
- Inspection Standing (knee alignment, gait, muscle wasting)
- valgus (knocked-knee)
- varus (cowboy) - Inspection Lying (scars, inflammation)
- Anterior Palpation
- temperature (back of hand)
- swelling - milking w/ patella tap
- effusions - up-medial, down-lateral
- palpate (patella, tendon, quad) - Lateral and Posterior Palpation
- 30degree flexion - lateral/medial joint
- straight - posterior - Testing Movements
- normal 0-135degrees - ACL & PCL
- 90 degree flexion - Collateral Ligaments
- slight flexion - End of examination
Shoulder Pain Questions
SITE - One shoulder? other joints? referred? movement?
intrinsic = joint, bursae, muscle, tendon
extrinsic = spine, diaphragm, heart
QUALITY - How does it feel? Burning, stabbing, grinding?
SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROM
TIME COURSE - Onset Offset Duration Temporal 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?" Swelling Redness Heat Loss of function (stiffness, locking, giving way, difficulty walking) Noises (popping, clicking) Pain Headache Fever Nausea
PHx - Heart disease
- Autoimmune
Shoulder Exam
- Prepare Patient - it will involve both shoulders
- Hand Hygiene
- Inspection
- anterior, lateral, posterior
- scars, swelling, redness, muscle wasting - Palpation
- sternoclavicular
- clavicle -> acromioclavicular joint
- coracoid
- anterior glenohumeral
- head of biceps tendon
- supraspinatus insertion
- spine of scapula
- inferior pole of scapula - Active Movement
- abduction & adduction (180degrees)
- flexion & extension (180 & 70 degrees)
- internal & external rotation (90 degrees & T7) - Fixed scapula (detectable between 45-90degrres)
- End of examination
Back Pain Questions
SITE - Specific? Non-specific? ? other joints? referred? movement?
L1-S5 = degenerative
L5/S1 = sciatica
buttocks&back of legs = central stenosis
QUALITY - How does it feel? Burning, stabbing, grinding, numbness?
SEVERITY - How bad is it? 1-10? Effect on day to day life? Waking at night? ROM
TIME COURSE - Onset Offset Duration Temporal 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?" Swelling Redness Heat Loss of function (stiffness, locking, giving way, difficulty walking) Noises (popping, clicking) Joint pain Headache Fever Sweats Nausea Blood in urine Weightloss Loss of appetite Bladder/bowel/motor/sensory
PHx - History/suspicion of cancer
IV drug use
glucocorticoids
Back Pain Red Flags
Age > 50 or < 20 History or suspicion of cancer IV drug use fevers, sweats, weightloss glucocorticoids Sciatica Pain not relieved by rest Pain over 1 months duration
Menstrual Cycle Questions
SITE - N/A
QUALITY - Colour? Clots? Changes over period?
SEVERITY - Volume (pads & changing)
- spotting
- change from normal
TIME COURSE - length of cycle
- length of period
- frequency of menstruation
- regular / irregular
- date of last menstrual cycle
- age of onset
- change over time
CONTEXT - “What was happening when you first noticed the change?” - illness, contraceptives, pregnancy, peri-menopause
RELIEVING FACTORS - “Does anything make it better?”
AGGRAVATING FACTORS - “Does anything make it worse?” stress? weightloss?
ASSOCIATED FEATURES -"Have you noticed anything else?" Pelvic pain Post-coital bleeding Anaemia Fatigue Hot flushes Headache Fever Sweats Nausea Weightloss Cold intolerance Masculinisation (acne, hair)
PHx - Menopause
- Thyroid
- Hormonal
Menopause Definitions
- Frequency
- Duration
- Amount
- Primary amenorrhoea
- Secondary amenorrhoea
- Oligomenorrhoea
- Polymenorrhoea
- Primary dysmenorrhoea
FREQUENCY
between 21-35 days
Duration
4-5 days
Amount
20-60mL (>80 = abnormal)
PRIMARY AMENORRHOEA
never menstruated
SECONDARY AMENORRHOEA
pregnancy, weightloss, stress, menopause
OLIGOMENNORRHOEA
4-9 periods per year or light flow
POLYMENORRHOEA
more frequent than 21 days
PRIMARY DYSMENORRHOEA
first & all periods are painful
Vaginal Discharge Questions
SITE - N/A
QUALITY - Colour? Consistency? Odor? Blood?
Candidiasis = white, clumped, itchy
Bact Vaginosis = white-grey, fishy
Trichomonas = Green-yellow, frothy, itch
SEVERITY - 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?" Itch Change in menstruation Pain with urination Pelvic pain Post-coital bleeding Anaemia Fatigue Headache Fever Sweats Nausea
PHx - UTIs, STIs
Erectile Dysfunction Questions
SITE - N/A
QUALITY - 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?" Libido Orgasm & Ejaculation Cardiovascular Proteinuria (diabetes)
PHx - CHD, alcohol, smoking, diabetes, operations
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?
Recreational Drug Questions
Signpost & Confidentiality Open Question & Tell me more Which drugs? - cannabis - cocaine - amphetamines/ice - ecstacy - ice - legal medications (benzodiazepines, codeine)
Quantity
- type / route
- how much (grams, cones, money)
- how often
Context
- 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)
