qSkills Flashcards
Four Frames
Onset – When did the symptom start? / Was the onset acute or gradual?
Duration – Minutes / hours / days / weeks / months / years
Severity – i.e. If the symptom was frequency – how many times a day?
Course – Is the symptom worsening, improving, or continuing to fluctuate?
Intermittent or continuous? – Is the symptom always present or does it come and go?
Precipitating factors – Are there any obvious triggers for the symptom?
Relieving factors – Does anything appear to improve the symptoms?
Previous episodes – Has the patient experienced this symptom previously?
Systems R/V
Fits/Faints/Funny turns
Coughs/colds
SOB
N/V
Change in bowel habit
change in water works
Any pain anywhere
Have you lost any weight
hows your appetite been
Cardiovascular Red Flags
Chest pain
Palpitations (heart racing or thumping)
Shortness of breath (dyspnoea): tolerance
PND and Orthopnoea
Peripheral oedema
Pain in legs on walking, cold limbs (PVD)
Respiratory Red flags
Shortness of breath (dyspnoea): tolerance
Cough: duration, haemoptysis
Sputum: amount, character, blood, pink
Chest pain on breathing (pleuritic pain)
Wheeze, stridor, snoring
Gastro Red Flags
Difficulty/Pain chewing or swallowing, ulcers
Nausea, vomiting, ? blood
Indigestion or heartburn or abdo pain/mass
Change in appetite, weight loss, weight gain
Bowel habit: changes, blood, mucous, melaena, pale stools or floating (steatorrhoea)
Neurological and Psychiatric Red flags
Headache, fits, faints, dizzy, blackouts
Numbness ( or any change in sensation), weakness or clumsiness in arms or legs
Changes in vision, double vision, hearing (deafness, tinnitus), speech, taste, smell
Change in mood, stress levels, thoughts
Genito-Urinary Red Flags
Pain or discomfort urination
Difficulty starting or stopping
Are you finding you’re going more often
Noticing you’re waking up at night to go to the loo
sudden urge to pee
any accidents
Fever/rigors
N&V
weight loss
Uraemic Symptoms
Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
Urinary frequency: commonly associated with UTIs.
Urinary urgency: may be associated with UTIs or detrusor instability.
Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hypertrophy).
Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hypertrophy).
Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
Fevers and rigors: typically associated with pyelonephritis.
Nausea and vomiting: typically associated with pyelonephritis.
Weight loss: associated with malignancy and uraemia.
Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.
Pain or difficulty passing urine, ? dribbling
Day urination versus nocturia
? Amount ? need to drink fluids overnight
Vaginal or penile discharge, lesions
Periods: last one, changes, usual pattern,
Diabetes and Endocrinology Red flags
Polyuria, polydipsia, weight loss/gain, , blurred vision, thrush
Heat or cold intolerance, neck swelling.
Change in appearance, sweating, hirsutism, periods, energy, libido, ED
Surgical Sieve
GCS
Glasgow coma scale (GCS) scores are generally expressed in the following format ‘GCS = 13, M5 V4 E4 at 21:30’.7
Intubate if GCS <8 (eg cuffed endotracheal tube)
Musco-skeletal and derm Red Flags
Pain, stiffness in joints ? circadian rhythm
Pain, stiffness in muscles
Tingling/weakness in hand eg CTS
Falls, difficulty walking or dressing or ADL
Any skin lesions: rash, ulcer, blisters, heat bruising, itching, bleeding, colour change
Rash specific: itching/pain
Notes Mneumonic
REDCOAT
Resus Status
EDD
Drugs Chart r/v
Cannula
Oxygen
Abx
Thrombolytis
Post Operative Assessment
IMPOTENCE
Introduction
- What surgery & when?*
- How many days post op? Anaesthetic type? +/- sedation*
- Intra-operative complications?*
Mental State
Alert & orientated? GCS/AVPU? Consider AMT10
Pain
Where is the pain?- SOCRATES Is analgesia effective?
PONV - antiemetic Laxatives
Observations
EWS - BP/HR/SPOZ/RESPS/TEMP
+/- CVS/RESP EXAM +/- glucose measurement
Thromboprophylaxis
Calves soft & non-tender?-DVT Compression stockings Foot pumps LMWH
Consider chest - PE Mobile ASAP
Eating and Drinking
Diet & fluids
IV fluids / oral input fluid chart
PU/catheter - why catheterised? Colour/amount?
Bowels open?
Passed flatus/bowel sounds/Abdo SNT
Neurovascular
Check distal neurovascular status & document - take into consideration, surgical positioning/anaesthetic /surgery
Cut
Surgical wound site - is it clean dry & intact? Why has the dressing been changed? Any drains?
Exercise
Has the patient been up & mobilising? Walking aids used?
Heart Rate
6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96
102
108
114
120
126
142
148
Hand Measurements
Thumb edge : 4.5cm
Index to thumb base: 12cm
Index inside edge: 8cm
Pinky to wrist: 15cm
FBC range
HaemoglobinMen: 135-180 g/l Women: 115-160 g/l
Mean cell volume82-100 fl
Platelets150-400 * 109/l
White blood cells4.0-11.0 * 109/l
Neutrophils2.0-7.0 * 109/l
Lymphocytes1.0-3.0 * 109/l
U&Es range
Sodium135-145 mmol/l
Potassium3.5 - 5.0 mmol/l
Urea2.0-7 mmol/l
Creatinine55-120 umol/l
Bicarbonate22-28 mmol/l
Chloride95-105 mmol/l
LFTs range
Bilirubin3-17 umol/l
Alanine transferase (ALT)3-40 iu/l
Aspartate transaminase (AST)3-30 iu/l
Alkaline phosphatase (ALP)30-100 umol/l
Gamma glutamyl transferase (yGT)8-60 u/l
Total protein60-80 g/l
ISBAR
Introduce
This is Luke an FY1 calling from ED. Who am I talking to?
Situation (reason)
Current problem
I am calling about Mr Brown who was admitted with severe pneumonia, he has sats of 90% despite high flow oxygen and I am very worried about him.
“The problem appears to be cardiac/respiratory/neurological/sepsis”
“I’m not sure what the problem is but the patient is deteriorating”
“The patient is unstable, getting worse and I need help”
Background (Story)
reason for admission and past medical hx
“He is 55 and previously fit and well. He has a 2 day hx of cough and fever and arrived an hour ago by ambulance”
Assessment (vital signs)
go through ABCDE approach
He looks very unwell and is tiring. Airway: . . . .. . Breathing . . . .. .
Recommendation (Plan)
State explicitally what you want to caller to do - WHAT AND WHEN
I have given him IV abx that you presecribed and he has had 1 litre of IV saline. I am worried he is getting worse. I need help, please can you come and see him right away?
“I am going to start the following tx, is there anything else that you suggest?”
“I am going to do the following ix, is there anything else you can suggest?”
“If they do not improve when would you like to be called?”
“I don’t think I can do any more: I would like you to see the patient urgently”
ECG red flags
Other Haem Range
Erythrocyte sedimentation rate (ESR)Men: < (age / 2) mm/hr Women: < ((age + 10) / 2) mm/hr
Prothrombin time (PT)10-14 secs
Activated partial thromboplastin time (APTT)25-35 secs
Ferritin20-230 ng/ml
Vitamin B12200-900 ng/l
Folate3.0 nmol/l
Reticulocytes0.5-1.5%
D-Dimer< 400 ng/ml
Other Biochemistry Ranges
Calcium2.1-2.6 mmol/l
Phosphate0.8-1.4 mmol/l
CRP< 10 mg/l
Thyroid stimulating hormone (TSH)0.5-5.5 mu/l
Free thyroxine (T4)9-18 pmol/l
Total thyroxine (T4)70-140 nmol/l
Amylase70-300 u/l
Uric acid0.18-0.48 mmol/l
Creatine kinase35-250 u/l
Innervation
Upper limb Motor
Shoulder Abduction (C5, C6) and Adduction (C6, C7, C8)
Elbow Flexion (C5, C6) and Extension (C7, C8)
Wrist Extension (dorsiflexion, C5, C6, C7) and Flexion (palmar flexion, C6, C7, C8)
Grip: use your index and middle finger (C8, T1)
Fingers out straight, “stop me bending them” C7 Radial N.
Upper Limb Sensation
o C4 = shoulder tip
o C5 = deltoid
C6 = Thumb
o C7 = middle finger
o C8 = little finger
o T1 = elbow
Upper limb reflexes
Test biceps (C5, C6) ? Jendrassik Manoeuvre to re-inforce
Supinator (C5,6)
Triceps (C7,8) also finger jerk (C8,T1)
Lower limb Motor
- Hip Flexion (L1, L2) and Extension (L5, S1)
- Hip Adduction (L2, L3, L4) and Abduction (L4, L5, S1)
- Knee Extension (L3, L4) and Flexion (S1)
- Dorsiflexion of Foot (L4, L5), Plantarflexion (S1, S2)
- Inversion of foot (L4, L5) and Eversion (L5, S1)
- Toe Extension (L5) and Flexion (S1)
Lower Limb Sensation
Light touch: L1 = hip L2 = outer thigh L3 = Inner Thigh L4 = big toe L5 = middle toe or outer calf, s1 = little toe or outer foot
Paeds Red Flags
Have they been eating and drinkning normaly?
Have they been having the normal amount of wet and dirty nappies for them?
Any nausea or vommitting?
Any Fevers?
Any Rahes?
Any coughs or runny noses?
any changes in weight?
Any pain?
Have you felt they’ve not been their normal self in any other way?
Dietary intake: clarify what the child’s baseline dietary intake is and, if relevant, how this has changed recently.
Fluid intake: calculate the child’s fluid intake over the last 24 hours.
Urine output: ask if there has been any change in the child’s urine output (in younger children, ask if there has been a change in the number of wet nappies).
Stool: ask about the recent frequency and form of the child’s stools.
Vomiting: if the child has been vomiting, determine the frequency, volume and consistency of the vomit (e.g. bilious, haematemesis). Ask specifically about projectile vomiting if considering pyloric stenosis as an underlying diagnosis.
Fever: ask if the child has had a fever recently and if this was confirmed with a thermometer.
Rash: ask if the child currently has a rash, including its location, whether it appears to be spreading and if it appears to be itchy.
Coryzal symptoms: ask if the child has recently had a runny nose, or sounded ‘sniffly’.
Cough: ask if the child has a cough and if they are bringing up any sputum with it. Gain further details about the frequency of the cough, including associations with particular triggers or times of the day (e.g. nocturnal cough).
Work of breathing: ask if the child’s breathing has appeared more laboured recently.
Weight change: ask if the child appears to be gaining weight at an appropriate rate and review growth charts if available.
Behaviour: ask if the child appears to be their usual self, including their level of activity, mood and social interaction.
Pain: ask if the child appears to be in pain and further explore this using the SOCRATES acronym.
Lipid Levels
Total cholesterol< 5 mmol/l
Triglycerides< 2 mmol/l
HDL cholesterol> 1 mmol/l
LDL cholesterol< 3 mmol/l
Blood Pressure
Home BP S1 = 135/85 mmHg
Home BP S2 = >= 150/95 mmHg
Clinic BP severe = >180/110
Sepsis
Common ECG patterns
Developmental Red Flags
- No smile by 8 weeks
- No eye contact by 3 months
- Not reaching for objects by 5 months
- Not sitting at 9 months
- Not walking at 18 months
- No speech at 18 months
- Hand preference below 12-18 months
- No 2-3 word sentences at 2½
Opthal Red Flags
vision changes/ double vision
Flashes/Floaters
Photophobia
Eye pain
Jaw/Temporal Pain
Headache/neuro changes
Trauma/Wear Contacts
LFT table
ALT 3-40 iu/l
AST 3-30 iu/l
ALP 30-100 umol/l
GGT 8-60 u/l
Bilirubin 3-17 umol/l
Albumin 35-50 g/l
PT 10-14 s/ 1
ALT>AST = chronic liver disease
AST>ALT = alcoholic hepatitis or cirhosis
ENT Red Flags
Ears
Hearing changes? Muffled? Uni/Bi?
Titinis
Discharge (ottorhea/purulent)
Blood per ear
Pain? - where? pulling/swallowing?
Vertigo
facial weakness
NOSE (unilateral things worse!)
Discharge? clear/purulent
Blood?
Breathing problems? snoring?
Pain/ Headaches(sinisitis)
Facial Pain
Buccal Swelling
Visual disturbances (cancer growth
Throat (ALARMS 55)
Anaemia
Loss of weight
Anorexia
Recent onset/rapid progression
Malaena
Swallowing difficulty
>55
AMT
Abbreviated Mental Test
AMT-4: (<4 = abnormal cognition)
Age
DoB
Place
Year
AMT-10 (7-8 cut off to ix further for dementia)
Age
Time (nearest hour)
Address to recall later (42 west street)
Year
Name of this place
Identification of two persons (eg doctor/nurse)
Date Of Birth
Year of First world war ended
Name of The Monarch
Count backwards from 20 -1
Recall the address
Anti-Muscarinic Side Effects
drowsiness
dry mouth
blurred vision
constipation
urinary retention
lengthening of QT interval
Musco-skeletal and derm Red Flags
Pain, stiffness in joints ? circadian rhythm
Pain, stiffness in muscles
Tingling/weakness in hand eg CTS
Falls, difficulty walking or dressing or ADL
Any skin lesions: rash, ulcer, blisters, heat bruising, itching, bleeding, colour change
Rash specific: itching/pain
Hand Measurements
Thumb edge : 4.5cm
Index to thumb base: 12cm
Index inside edge: 8cm
Pinky to wrist: 15cm
