Random Flashcards
Needed to confirm death?
No response to sound No Pain response Absent corneal reflexes No Eye response (Fixed) No Carotid 1 minute No heart sounds 1 minute Absent breath sounds 3 minutes/effort
5 mins continuous no signs of life
When is “Time of death” ?
When you finish confirming death
Things to remember in notes when writing confirmation of death?
CONFIRM ID and DNACPR
Everything you did, was it expected? Time you wrote in notes
The patient had died also can include cause if known - coroner referral if relevant
The TIME OF DEATH
Name GMC and BLEEP
Reasons to refer to coroner?
No cause established Suicide or violent or accident Under a DOLS, Prison or Mental health act Within 24hrs in hospital Effects of anaesthetic Occupational/industrial
When can you not fill out a death certificate?
If not seen the patient within last 14 days you are not allowed to fill in the certificate
Must be a doctor
Must have a cause of death
No reason to coroner refer
Things to avoid on death certificate?
Modes of dying or failures for example “liver failure”
or “cardiac arrest”
Cremation form things to remember?
Hospital address not mine, use death certificate to fill in parts, examination part if you checking the body for a pacemaker etc
Units cross matched certain problems?
Upper GI bleed about 6
AAA 10 units
What is done in the A part of rrapid?
Airway check speech (how much can they speak) and or any obstruction in the airway could be anaphylaxis tongue swelling. Abnormal sounds and stridor due to obstruction any abnormal chest issues
B part of rrapid?
Inspection of patient are they looking unwell in terms of breathing
Chest movements, RESP RATE and SPO2
Visible signs of cyanosis? Attach monitoring and KEEP ATTACHED
Listen to chest, expansion and percussion. Consider ABG if felt needed
Interventions such as oxygen or nebulisers
What should we start COPD patients on 02 wise?
28% venturi
C of rrapid?
Do they look shocked, pale, sweaty and unwell?
Capillary refill time
Blood pressure and JVP
Heart rate and pulse thready or fast or slow
ECG
Cannulation and bloods if needed
Fluid challenge and urine output
? sepsis what to do/
BUFALO
Blood cultures, urine, fluids, abx, lactate and oxygen
Consider sepsis with which criteria?
> 2 of
SIRS Temp <36 >38
HR >90
Tachypnoe >20 or low CO2
White cells low or high
What should urine output be?
0.5ml/kg/hr
D part of rrapid?
GLUCOSE and pupil reactions
Consider GCS or AVPU
Neuro exam if needed
E for rrapid and acronym to remember?
BRACE Blood loss Rashes Abdominal - palpate percuss and auscultate Calves Everything else- Temp
Review charts- important of trends
Blood results from bleeding in upper GI tract?
High urea, can also be due to dehydration
Chest pain specific questions?
Worse when lying down? SOB/Exercise? Worse on inspiration? Leg swelling? Nausea/vomiting? Sweating? Palpitations? Relieving? GTN if so, how long and how many times?
Chest pain differentials?
ACS PE Pneumothorax GORD MSK
Palpitations important questions to ask?
Have they been persistent, or do they come and go?
How often? Duration?
Fast/slow? Tap it out?
Anything made worse- alcohol, caffeine, stress, recreational drugs, exercise?
LOC or faints? Dizziness?
Differentials palpitations?
Hyperthyroid AF/Flutter Ectopics Anxiety Hypoglycaemia Anaemia
Collapse syncope questions?
Pre- Intra- Post
Emotional stress, pain, anxiety? Prolonged periods of standing? Flashing or flickering of lights? Symptoms prior to event? Witnesses? Movement during? Tongue biting/incontinent? Head injury? Recovery time? Post ictal? Weakness? Medications, new?
Collapse differentials?
Vasovagal Medication Arrhythmia AS PE Postural hypotension Hypoglycaemia
Dysphagia Questions?
Where does food get stuck? Is swallowing itself difficult? Onset etc Solids or liquids? Progressive? Any systemic features such as weight loss and GORD? Voice changes or hoarseness?
Causes of dysphagia?
Extra luminal- Masses goitre maligancy
Intraluminal- Spasm, achalasia
Luminal, oesophagitis, candida, strictures tumour
Myasthenia gravis or stroke or parkinsons
Questions for haematemesis?
Volume? Colour? How many times, what happened before? Prolonged retching and straining? Alcohol or liver disease? Bowel habits or changes any malaena or fatigue? Weight loss? Medications such as NSAIDS or steroids?
Haematemesis differentials?
Oesophagitis, variceal bleeding, ulcers, gastritis, mallory weiss, malignancy
Abdo pain questions?
Site, onset? Timing? Colicky? Character? Mouth ulcers? Vomiting? Weight loss? Fever? Change in bowel habit? Change in the stool? Relieved by defecation? Pregnancy? Jaundice? Urine colour?
Abdo differentials?
Gallbladder Obstruction Appendix AAA Pancreas Pregnancy problems Diverticular Ulcers Colic (renal)
Rectal bleeding questions?
Onset? When and how quickly? Duration? How many times? Intermittent or continuous? Colour? Quantity? Mixed in? on paper? Steatorrhoea? Mucous? Urgency, Incontinence and tenesmus? Anal pain? Weight loss? Fevers? Travel? Takeaway? Constipation?
Rectal bleeding causes ?
Malignancy Gastroenteritis Peptic ulcer Varices Diverticular Ischaemic colitis/mesenteric Haemorrhoids Fissure
Nausea and vomiting questions?
Onset? Duration? How many times? Volume? Was it forceful? Colour and consistency? Fever and diarrhoea? Chest pain? Abdominal pain? Headache? Weight loss? Recent travel? Takeaway or eaten out? Contact with others/anyone else ill?
Nausea and vomiting differentials?
Gastro Obstruction Appendix Peptic ulcer Renal colic pancreas DKA Raised ICP Inner ear or migraine
Back pain important questions?
Worse at night? Analgesia used? Sudden or insidious? Where is it? Paraesthesia, or weakness? Thoracic pain? Cancer history? When did you last go to the toilet? Saddle anaesthesia? Persistent pain? Steroid use? Activity? Precipitating factors?
Back pain differentials?
Mechanical Myeloma Spinal cord compression Cauda Equina Osteoarthritis Wedge fracture Sciatica Disciitis Psoas abscess
Headache questions?
SOCRATES Episodic, diurnal night time? Worse in any position ie laying down? Worse in morning and betetr when awake? Progressively getting worse? Any vision or sensory loss? Prodromal? Smoking, alcohol medication ? Neck stiffness and Photophobia? Phonophobia? Watering of eye?
Headache differentials?
Migraine Tension Cluster SAH Meningitis Temporal arteritis Angle closure glaucoma
Confusion questions?
Onset? Progressive or suddenly worse? Memory loss? Depressive or psychiatric? Sleep? Change in behaviour? Hallucinations or personality change?
Confusion causes?
Dementia Delirium Infection Malignancy Depression Head injury
Shortness of breath questions?
Episodic? Triggers- dust, pollen, exercise, cold air? Change in exercise tolerance? Problems with sleep? Haemoptysis? Wheeze? Fever? Weight loss? Ankle swelling? Smoking? Travel? Recent surgery? Chest pain?
Shortness of breath Differentials?
Asthma/COPD Fibrosis PE.Pneumothorax MI HEar failure Arrhythmia Anaemia Anxiety
Cough Questions?
Onset? Chronic >2months. Timing- diurnal, seasonal? Sputum? Colour, frequency? Exercise? Made worse? Haemoptysis? Wheeze? Weight loss? Chest pain? Ankle swelling? Hoarse voice? Travel history? Smoking? Occupation? Pets?
Cough differentials?
Asthma COPD Bronchiectasis Heart failure Lung malignancy PE Pneumonia URTI
Joint pain questions to ask?
Onset? Activity? Morning Stiffness? >1 hr for RA or ank spon? Constant? Radiation? Activity better? Associated signs at all? Joint involvement? Symmetrical or not? Family history? EYE signs? How is it affecting life? Nail changes or rashes?
Joint pain differentials?
RA Osteoarthritis Reactive arthritis Gout Ank Spon Septic arthritis Osteomyelitis
Febrile traveller questions?
Where visited and why? Vaccinations? Prophylaxis taken? Sexual contacts, and food drink animal exposure? Swimming? Any healthcare received? Air conditioning, where did they stay? Bottled water? Any symptoms whilst there? Contact with infected persons? Any bites? IVDU or tattoos or piercings? Rashes/fever/diarrhoea and vomiting?
Febrile traveller differentials?
Malaria
Thyphoid
E-coli, giardia - watery
Bloody diarrhoea- Campylobacter, salmonell and shigella
Giardia - prolonged .3 weeks diarrhoea
Fatigue history?
What do they mean tired? Are they weak? Low mood or energy? Sleep? SOB? Pallor? Weight gain or loss? Menstruation? Polyuria or dipsia? Appetitie? Hair loss? palpitations? Lymph nodes? ADLs? Recurrent infections?
Fatigue causes?
Hypothyroid Anaemia Depression Diabetes Malignancy- Myeloma/Leukaemia/Lymphoma CKD
Causes of bitemporal hemianiopia?
Pituitary tumour, craniopharyngioma
Homonymous hemianopia causes?
Stroke, migraine tumour, trauma
Important points for blood transfusion?
Cross match if you want the blood doesn’t mean you have to have that many units though only those prescribed
Write in pen on bottles
Process for eye examiantion? mnemonic?
AFRO
ACUITY, FIELDS, REFLEX and OPTIC DISC
How to test acuity?
Snellen charts, Near vision charts and ishihara plates
Testing fields of vision?
Ask if wears glasses
Inattention- Hold fists out ask to point to ones which are opening could be contralateral lesion if inattention present
Sit patient 1 metre in front both close the eye in front of each other use the WHITE PIN to test the quadrants of vision
Cerebellar signs?
DANISH Dysdido Ataxia Nystagmus Intention/past pointing Speech Hypotonia/heel shin test
Video signs of parkinson’s?
Loss of arm swing Rigidity Mask facies Shuffling gait High stepping Speech problems (slurring) Intention tremor (unilateral) Slow to get up from chair
Parkinsons disease differentials?
Multisystem atrophy (autonomic dysfunction)
Parkinsonism from lewy body dementia
Induced parkinsonism from antipsychotics/metoclopramide
ABCD2 score?
Age >60 BP Clinical (weakness and speech 2 or one =1) Duration 0-1hr (1) 1hr more (2) Diabetes -1
Driving after TIA?
Don’t have to tell DVLA if not disabled but shouldn’t drive for 4 weeks
CXR interpretation?
Rotation(clavicles) Inspiration(6 anterior ribs) Projection(PA AP) Exposure (can i see behind heart)
AXR?
Projection AP, supine or erect
Bowel and other organs
Bones
Calcification and artefact
How do you know its small bowel?
Valvulae conniventes, all the way across
How do you know it’s large bowel?
Haustra
What xray for Perforation?
Erect chest get them to sit up for 15 mins
Sizes for the bowel on AXR?
3 6 9
Small large caecum
Bone Xray ABCS?
Allignment, Bone, Cartilage, soft tissue
Osteoarthritis Xray signs?
Loss of joint space Asymmetrical
Osteophytosis
Sclerosis
Subchondral cysts
Rheumatoid xray signs?
Soft tissue, symmetrical loss, periarticular erosion no osteophytes, subluxed joints
When to involve senior in RRAPID?
If don’t know what to do? Mention reassess then senior input
RRAPID cheat sheet?
Constant monitoring ?nasal of vomit Bedside clues How talking for airway Senior review and reassess Drug chart
Blood loss, rash, calves, abdo
Crossmatch and bloods
ABG nuggets?
Allen’s, anaesthetic
Sterile gloves
Day type of resp failure first
Things to remember for skills stations?
Keep sterile! CONFIRM CONFIRM CONFIRM
Confirm expiry dates too
Can ask examiner to be patient etc
Aortic stenosis examination findings?
Ejection systolic murmur
Radiates carotids
Slow rising pulse
Aortic thrill
Mitral regurg examination findings?
Pansystolic murmur
Radiates to the axilla
ECG findings for aortic stenosis?
LVH big R waves lateral leads and S waves anterior leads
Can get bifid P wave
Mitral regurg ECG?
Prior infarction or arrhythmia
Echo valve size Aortic stenosis?
<1 cm
Metallic heart valve signs?
Irregular pulse, flow murmur
Jaundice or haemolysis due to the RBC destruction
Respiratory exam findings fibrosis?
clubbing, tachypnoeic, find end-inspiratory/expiratory crackles that do not clear on coughing
Cyanosis
Spirometry for fibrosis?
Reduced FEV1 and FVC normal or increased ratio >0.7
Spirometry obstructive?
Fev1 reduced ratio <0.7
Signs of bronchiectaiss examination and station?
Crackles that clear with a cough.
Sputum pot with lots in
if young could be CF
ABG bronchiectasis and fibrosis?
Bronch and COPD, obesity neuromuscular is or near fatal asthma type 2
Fibrosis is type 1, ARDS pneumonia, Oedema
CXR fibrosis?
Tram lines, ground glass and interstitial shadowing
CT result for fibrosis?
Honeycombing
CT for Bronchiectasis?
Signet ring
GI transplanted kidney signs?
RIF scar, may have previous fistula scars
Dialysis patient examination?
Fistula, tunneled lines, dialysis catheter
Signs of ank spon?
loss of lumbar lordosis and fixed thoracic kyphosis,
hypertension of cervical spine to maintain horizontal gaze.
Tenderness at the sacroiliac joints. Decreased range of movement.
Shober’s test (10cm above dimples and 5cm below, bend forward a positive result
Principles of rheum exam? LOOK
Look, feel, move
DIP spared. Guttering of the interossei. Subluxation and ulnar deviation at the MCP. Swan neck, boutonnieres, Z thumb deformity. Any scars- carpal tunnel release
Rheum exam Feel?
- Palpate all the joints, test for carpal tunnel, feel the pulse.
Rheum exam move?
straighten fingers, prayer sign, make a fist, squeeze my fingers,
pincer grip (don’t let me break ring),
assess function i.e. pick up a coin/do up a button, both hands behind head
Bilateral cerebellar causes?
= MS, bilateral posterior stroke, alcohol, multisystem atrophy
Unilateral causes cerebellar?
MS, posterior circulation infarction, haemorrhagic stroke, space occupying lesion in posterior fossa (tumour/abscess)
Stroke video signs?
- increased tone, increased reflexes, no cerebellar signs, sensory loss,
UMN facial weakness (forehead sparing), dysphasia, homonymous hemianopia.
Examination in stroke?
Perform fundoscopy (diabetes and hypertension), full cranial nerve examination, cardiovascular exam, speech and swallow assessment, BP, capillary blood glucose. CT head, 12 lead ECG
Within how long for stroke thrombo?
4.5hrs of the stroke starting
Driving and stroke/TIA?
If non disabling then 4 weeks don’t tell dvla
management of stroke/TIA with AF?
If stroke get aspirin for 2 weeks before anticoag if TIA immediately
What not to forget on the drug chart ?
VTE SECTION
Treatment of hypoglycaemia ?
10-20g oral glucose or
75ml of 20% glucose IV
Glucagon IM 1mg (if not malnourished or alcoholic)
Hypothyroid symptoms?
weakness, tiredness, cold sensitivity, constipation, weight gain, depression, menstrual irregularity, dry coarse skin, goitre.
Intermittent claudication symptoms?
Pain and burning on walking usually in calves and behind knees, thighs buttocks subsides on rest
History of vascular problems diabetes etc big smokers and drinkers
Ulcers and mottled skin
ABPI measurements?
Ankle (tibialis and dorsalis)/brachial to get ratio
1-1.2 normal
> 0.8 is mild claudication
<0.5 critical
