Wk 11: Clinical Reasoning Flashcards
how do we ascertain patient sings & symptoms ?
- history taking (subjective exam)
- physical assessment (objective exam)
SUBJECTIVE EXAM
what do you consider ?
patients status
e.g.
- pre-op, post op
- inpatient, outpatient
- planned admission, via ambulance/ ED
SUBJECTIVE EXAM
What do the details depend on?
information obtainable from other sources, e.g. medical records, admission notes etc
SUBJECTIVE EXAM
components
HPC, PMHx, Soc Hx, Meds, Ex tol, etc
SUBJECTIVE EXAM
what are you questionning for?
cardioresp symptoms
OBJECTIVE EXAMINATION
components
– (Nursing/bedside charts)
– Observation
– Palpation
– Auscultation
– Cough
– Spirometry (if appropriate)
– CXR (review CXR + read report if available)
– Interpret investigations/other information
Investigations that inform our CR
- Thoracic imaging – CXR, CT, MRI, CTPA
- Pulmonary function testing
- Arterial Blood Gases
- Blood tests
- Sputum culture (+ nasopharyngeal aspirates)
- Bronchoscopy
- Respiratory muscle strength
- Exercise testing
- Sleep studies
what are other cardiac investigations?
12 lead ECG
myocardial perfusions scans, exercise stress testing
other neurological investigations?
- EEG (measures electrical activity in the brain)
- nerve conduction testing
- intracranial pressure (ICP)
other skeletal investigations
PET scans , BMD scans
what does a sputum M/C/S identify?
pathological organisms in sputum in order to direct appropriate therapy
what are some examples of pathological organisms in sputum?
– Bacterial pathogen causing infection
* Pneumonia
* Cystic fibrosis & bronchiectasis
– Fungal infection
– Tuberculosis (TB)
* 3 consecutive samples to be negative for acid fast bacilli
what does “M/C/S” stand for?
microbiology, culture, and sensitivity
how do you induce sputum?
- Inhale hypertonic saline to 7% in order to facilitate
the production of a sputum sample
what is induced sputum used for?
diagnosis of TB or Pneumocystis Carinii Pneumonia (PCP)
what are naso-pharyngeal samples used to identify?
– Influenza types (influenza A, H1N1)
– Respiratory Syncytial Virus (RSV), or
– Bordetella pertussis (whooping cough)
what is a bronchoscopy test
invasive test done under GA / sedation
how is a bronchoscopy conducted?
Bronchoscope is passed down the trachea into the
large airways
how can a bronchoscopy be used?
- diagnostically
- therapeutically
how can a bronchoscopy help with diagnosis?
– Visualise airway anatomy
– Look for airway inflammation, malignancy, secretion
retention, reasons for unexplained, chronic cough
– Enable fine needle biopsy
what is Bronchoscopic alveolar lavage (BAL)?
a procedure done during a bronchoscopy for therapeutic purposes. (saline washes the airway and is then sucked in by the tube)
what meds for asthma
bronchodilators
COPD meds
bronchodilators + steroids (inhaled, IV)
CF meds
drugs that change rheology of sputum, hypertonic saline
(can also fit onto some airway clearance devices)
post-op patients: meds
analgesics
how do you measure a patient’s participation restriction (ICF)?
QoL measures
how do you measure a patient’s ICF activity limitations
activity measures
how do you measure a patient’s ICF impairments?
o Reduced Gas Movement
* O2 movement +/- CO2 movement
o Reduced Secretion Movement
* MCC +/- Cough (air flow clearance)
treatment goals
- Reversal of impairment
– Eg, to increase O2
gas movement to the left lower lobe - Signs and symptoms (compensatory)
– Eg, to reduce breathlessness - Prophylactic
– Eg to prevent postoperative pulmonary complications
Rx options to improve gas movement
– Deep breathing exercises
– Positioning (specific and upright)
– Exercise/mobilisation
Rx options to improve secretion movement
– GAD / MGAD
– Percussion/vibration/shaking
– PEP & OPEP devices
– FET, ACBT
– Cough/huff (+/- wound support/overpressure)
– Exercise/mobilisation
Rx options to relieve dyspnoea/improve respiratory muscle function
– Relaxed breathing
– Positioning (eg LFP, upper limb bracing)
– Purse Lips Breathing
patient & carer education with Rx
– Pre-operative education
– Discharge planning
– Exercise prescription
what do you assess in Rx?
- effectiveness of Rx (reversal of impairments)
- other patient problems e.g. participation restriction/ activity limitation
