Yr6 PACES Flashcards
What are important points of any cardio px you have to say?
On general insp: well + not tachypnoeic
O/e of hands: nad, pulse, BP
O/e of H+N: no pallor, carotid artery character, JVP
On insp of chest: no scars
On palpation: apex beat not displaced + no heave or thrills
On auscultation: HS 1+2 audible w no added sounds
Lung bases, peripheral oedema, obs chart
JVP
Check all the way up to the ear lobes, biphasic, impalpable
Systolic Murmurs
Aortic Stenosis
Mitral Regurg
Tricuspid Regurg
Aortic Stenosis
Loudest in the aortic area
Radiates to the neck
A/w narrow pulse pressure, slow rising carotid pulse, thrill in the aortic area
Mitral Regurg
Quiet S1, pansystolic murmur loudest in the apex best heard on inspiration, S3
Radiates to the axilla
A/w displaced apex beat and apical thrill
What does mitral valve prolapse sound like?
MR but w a mid-systolic click
Tricuspid Regurg
Loudest in the tricuspid area
Best heard on INSpiration
A/w elevated JVP, left parasternal heave, palpable liver
Diastolic Murmurs
Aortic Regurg
Mitral Stenosis
Tricuspid Stenosis
Aortic Regurg
Early diastolic murmur loudest at the left lower sternal edge when sitting forward
Best heard held in EXpiration
A/w eponymous signs, collapsing pulse, dynamic apex
Mitral Stenosis
Loud S1 and audible S2 followed by an opening snap and MDM
A/w AF, malar flush, tapping non-displaced apex beat, left parasternal heave
What causes a loud S2?
HTN + Pulm HTN (will also have a left parasternal heave)
What is a left parasternal heave a sign of?
Right ventricular hypertrophy
What are S3 and S4 due to?
S3: rapid ventricular filling
S4: atrial contraction against stiff ventricles
What are the stages of clubbing?
1: inc fluctuancy of bed
2: loss of angle b/w nail and bed
3: inc curvature of nail
4: expansion of terminal phalanx
Wheeze Ddx
Asthma COPD Pulm Oedema Anaphylaxis Malignancy
Fine Crepitations Ddx
Fibrosis + HF
Coarse Crepitations Ddx
Bronchiectasis + Pneumonia NB: may change w cough and should ask to sample sputum
Proximal Myopathy Ddx
Polymyositis, Dermatomyositis, Cushing’s Disease Plus working through surg seize: MG/LEMS, HIV, hereditary, sarcoidosis, paraneoplastic, drugs eg statins
Peripheral Neuropathy Ddx
Diabetes, Alcohol, B12 Deficiency Plus working through surg seize: GBS/CIDP, HIV, hereditary, sarcoidosis, paraneoplastic, drugs eg metronidazole
What are the headlines for treating acute asthma/copd?
Oxygen, Bronchodilators, Steroids
What are the headlines for treating PE?
Oxygen, Anticoagulation, Analgesia
What reflexes do you want to offer as part of the CN exam?
Jaw Corneal Gag
Pneumothorax O/E
Trachea - deviated away Expansion - reduced Fremitus - decreased Percussion - resonant Auscultation - absent Added - occasional click
Pleural Effusion O/E
Trachea - deviated away Expansion - reduced Fremitus - decreased Percussion - stoney dull Auscultation - absent Added - occasional rub
Pneumonia O/E
Trachea - central Expansion - reduced Fremitus - increased Percussion - dull Auscultation - bronchial Added - crackles
Collapse/Lobectomy/Pneumonectomy O/E
Trachea - towards Expansion - reduced Fremitus - decreased Percussion - dull Auscultation - absent Added - none
Rheumatoid ILD vs Bronchiectasis
O/e: if there’s a sputum pot nearby + quality of crackles Ix: PFTs inc spirometry, lung volumes, gas transfer (restrictive vs obstructive) + HRCT (honeycombing and ground glass vs dilatation and mucus plugging)
Bronchiectasis Px
Clubbed Bilateral coarse insp crackles which alter but do not fully clear w coughing Findings consistent w bronchiectasis Ddx: pneumonia + ILD
Asthma Px
Salbutamol Inhaler Resonant and symmetrical percussion w equal air entry and no added sounds Findings consistent w controlled asthma Ddx: physiological normal chest + COPD Ascertain if any prev ITU admissions or night sx
ILD Px
Sup O2 at 2L/min via nasal cannula w RR of 20 Features of rheumatoid hands w/o clubbing, characteristic find end insp crackles, peripheral oedema Findings consistent w pulmonary fibrosis perhaps 2° to RA w pulm HTN leading to RHF requiring LTOT
COPD Px
Prolonged exp phase and pursed lip breathing Signs of hyperinflation specifically red cricosternal distance, loss of cardiac dullness and displaced liver edge No features of pulm htn or cushings Findings consistent w COPD
Ddx for Collapsing Pulse (3)
AR Normal psychological state eg pyrexic or pregnant High output state eg anaemia or thyrotoxicosis
What are the signs of hyperinflation? (3)
Red cricosternal distance, loss of cardiac dullness, displaced liver edge
What are the signs of portal HTN? (4)
SAVE Splenomegaly Ascites Varices Enlarged Abdo Veins
What are the signs of CLD? (4)
PDGS Palmar Erythema Dupuytren’s Contracture Gynaecomastia Spider Naevi
Workup for Acute Abdomen
NBM Fluids Analgesia Antiemetics Antibiotics Bleeding Risk Allergies Airway Difficulty Refer to Surgeons Monitor Vitals
What should you say if you don’t know the abx?
Consult local guidelines and microbiology for a suitable course of action
Where is the best place to look for jaundice?
Sclera + under the tongue
How do you elicit Quincke’s sign?
Ask the pt to push their finger into the table and observe for the border b/w red and pale move to pulse
Mx of OA
Confirm dx w hx, exam, ix Take an MDT approach w PT, OT, podiatrist Consrv: manage RFs ie optimise weight, diet, low impact exercise, ensure other medical conditions are well controlled + applying warm/ice packs Med: analgesia up WHO pain ladder + intra-articular steroid injections Surg: referral to ortho for osteotomy, arthrodesis and more likely arthroplasty
Mx of Open Fracture
ATLS NV Status Photograph Soaked Gauze Abx + Tetanus Restrict Xrays Theatre Rehab
Mx of NOF#
Upon admission MMSE, seen by orthogeris, operate within 36hrs Intracapsular: 1,2,Screw + 3,4,Austin-Moore Extracapsular: inter DHS + sub nail Mobilise early w physio and minimise risk of future falls and osteoporosis
Mx of Bronchiectasis
Ix: Obstrc Spirometry, Sputum Cultures, HRCT, Immunoglobulins, Sweat Test, Aspergillus Markers Tx: MDT, Smoking Cessation, Pulm Rehabilitation Plus: physio, abx, correct underlying cause
Mx of ILD
Ix: Drug Hx, Complement, Autoantibodies, Precipitins, CXR, HRCT, PFTs, BAL, Echo Tx: MDT, Smoking Cessation, Pulm Rehabilitation Plus: ambulatory O2, LTOT, antifibrotics for IPF, immunosuppressives for CTD/sarcoid related, transplant workup
Mx of HF
Acute: 1. Sit Up & Call Help 2. Diamorphine 1.25mg 3. Furosemide 40mg 4. GTN Spray x2 SL Chronic: 1. CAGES, Dec RFs, Vaccines 2. ACEi/ARB/Hydralazine + BB 3. Add MRA 4. Specialist
Mx of Pneumonia
Calculate CURB-65: confusion, urea >7, RR >30, SBP <90, Age >65 If 0-1: home - PO amoxicillin 500mg/8h If >=2: hosp - PO amoxicillin 500mg/8h AND clarithromycin 500mg/12h If >=3: ICU - IV augmentin 1.2g/8h AND clarithromycin 500mg/12h F/U @ 6wks
AF
Ix: Hx (ETOH/Caffeine), Obs (Pulse/HTN), Bloods (TFTs/BNP/D-dimer), ECG, Echo (IHD/RHD) Unstable Tx: DCCV +/- Amiodarone Stable Tx: Rate (BB/CCB +/- Digoxin), Rhythm (DCCV or Flecainide/Amiodarone), Anticoag (CHA2DS2-VASc vs HAS-BLED)
STEMI
Atypical px in elderly + women Anteroseptal - LAD: V1-4 Lateral - LCX: V5-6, I, aVL Inferior - RCA: II, III, aVF Tx: MONAT + PCI/Thrombolysis Comps: FAM ie Failure, Arrhythmias, Murmurs
What are the signs of decompensation? (4)
JBAE Jaundice Bruising Asterixis Encephalopathy
What causes massive splenomegaly? (4)
MF CML Malaria Leishmaniasis
Ddx for RIF Pain
GI: appendicitis, mesenteric adenitis, terminal ileitis GY: ectopic, tubo-ovarian, endometriosis GU: stone, UTI, cystitis
Hepatomegaly Causes
Hepatic: hepatitis, cirrhosis, budd-chiari, NAFLD, hereditary haemochromatosis Cardiac: cor pulmonale, right valvular disease, right heart failure Other: infection, malignancy, myeloproliferative
Splenomegaly Causes
Vascular: haemolysis, leukaemia, lymphoma, CML, MF, portal HTN Infective: malaria, leishmaniasis, hydatid disease, EBV, CMV, HIV, TB, IE, chlamydia psittaci Inflam: sarcoid, amyloid, pancreatitis, RA, SLE, sjogrens
What are the causes of HF?
LHF: HTN, IHD, L Side Valves RHF: LHF, Cor Pulmonale, R Side Valves
How do you px normal auscultation of the lungs?
There was equal air entry and symmetrical vesicular breathing in all zones bilaterally
What are you looking for in the hands?
Gen: clubbing, tar staining, colour/temp Cardio: evidence of IE + CRT Resp: evidence of steroid use + RA GI: evidence of CLD + koilonychia/leukonychia
Why do you look at the armpits in the abdo exam?
Acanthosis Nigricans - benign, T2DM, stomach malignancy Hair Loss - shaven, IDA, malnutrition
Stridor Ddx
Quinsy Epiglottitis Foreign Body Anaphylaxis Malignancy
How should you describe any ABG?
Met/Resp Acid/Alk AND T1RF/T2RF
How should you categorise your ix?
Bedside
Bloods
Imaging
How would you counsel someone w chest pain to go to the hospital?
The pain is sometimes a sign of the body telling us the heart isn’t getting enough blood
I wouldn’t want you to go away and for something more serious to happen
Explore dislike of hospital and suggest you can call ahead to reduce the wait time when they get there
Cardio SRV
Chest Pain Dyspnea Orthopnea PND Syncope Palpitations Leg Swelling
GI SRV
Dysphagia Odynophagia Nausea + Vomiting Haematemesis Abdo Pain Bowel Habit Blood + Mucus Mouth Ulcers Itchy Eyes Rashes Jaundice
MSK SRV
Pain ROM Swelling Stiffness Crepitus Locking Giving Way Instability Trauma Fever Diabetes Smoking
Chest Pain: SOCRATES + ECG
Site Onset Character Radiation Timing Exacerbation Severity
SOB: NOTEP + ABG
Nature Onset Timing Exacerbation Progression
Neuro SRV
Headaches Seizures Blackouts Vision Speech Strength Sensation Face/Arms/Legs
Resp SRV
Chest Pain Dyspnea Cough Sputum Haemoptysis Wheeze Triggers Leg Pain
Gen SRV
ICE FLAWS Prev Ep Recent Illness Close Contacts
Cardiac RFs
HTN Cholesterol Diabetes Stroke Smoker
Resp RFs
Pets Allergies Smoking Travel Occupation
GU SRV
LUTS: FUND HIPS
Storage - freq, urgency, nocturia, dysuria
Voiding - hesitancy, intermittency, poor stream, straining/incomplete emptying/terminal dribbling
Plus: haematuria, polyuria, polydipsia, vaginal bleeding/discharge, MOSS
What are the cardiac causes of clubbing?
CIA: congenital cyanotic heart disease, infective endocarditis, atrial myxoma
What are the respiratory causes of clubbing?
Newly Sprouted Fingers:
Neoplasia - bronchogenic carcinoma + mesothelioma
Suppurative - abscess, bronchiectasis, cystic fibrosis, don’t say copd, empyema
Fibrotic - cryptogenic fibrosing alveolitis + connective tissue disease
What are the GI causes of clubbing?
The 3 C’s: cirrhosis, coeliac disease, crohn’s/UC
Liver Screen
Sx: Jaundice Itchiness Dark Urine Pale Stool
RFs: Tattoos IVDU UPSI Travel
What do you want to investigate most abdominal pathology?
FBC U+E LFT Clotting Amylase Lactate USS
Charcot’s Triad
Fever
Jaundice
Abdo Pain
Reynold’s Pentad
Fever Jaundice Abdo Pain Shock AMS
Courvoisier Law
The presence of a palpably enlarged gallbladder with accompanying jaundice is unlikely to be due to gallstones
Mx of Cholecystitis
Tbc
Mx of Ascending Cholangitis
Tbc
What should you establish if the patient is a diabetic?
The type and therefore whether they are at risk of DKA/HHS
Ddx of Palpitations
Must ask about chest pain, sob, blackouts
AF Arrhythmias Anxiety Panic Attacks Medications Substances Caffeine Hyperthyroid Hypoglycaemia Pregnancy Menopause
Headache Red Flags
Papilledema Seizures Focal Neuro Cancer/HIV Visual Disturbance Postural Change Pregnancy N+V Vasculitis Diabetes Worsening AM Sx
Headache Qs
SOCRATES
Sinister: red flags, trauma, first and worst, unilateral, meningism
Non-Sinister: triggers, lacrimation, electric shock sensation, dhx, stress
Kidney vs Spleen
Kidney: ballotable, resonant, moves down on insp
Spleen: can’t get above, dull, moves to RIF on insp
Which inguinal hernia is more common?
Indirect
Def of a Hernia
An abnormal protrusion of a viscus through a defect in it’s containing compartment
Where is the deep inguinal ring located?
The midpoint of the inguinal ligament ie ASIS to PT
Where are inguinal and femoral hernias found in relation to the pubic tubercle?
Inguinal: superior + medially
Femoral: inferior + laterally
Tx of Groin Hernia
Open (Lichtenstein repair - can be done under LA day case) vs Lap (either TEP or TAP - both require GA)
What do you look for next after identifying a midline sternotomy scar? Why?
Ddx: CABG, valve repair, congenital heart disease, pacemakers, ICD
Leg scars for vein harvest
Arm scars for arterial harvest
Pacemaker vs ICD
An ICD will have thick coils on CXR
What do relatively small scars on the top, bottom and left side of the chest indicate?
S/C ICD
No leads within the heart
Smaller risk of infection and vasc comps
But cannot place in thin individuals nor do advanced pacing
Ddx for splinter haemorrhages and nail fold infarcts (3)
Infective endocarditis, Rheumatoid vasculitis, systemic sclerosis
What can you do if you’re struggling to feel the apex beat?
Try in held expiration and in left lateral decubitus position
How would you finish your cardiac exam?
Full hx PLUS check temp (endocarditis), dipstick urine (diabetes, HTN, glomerulonephritis), ECG (rhythm disturbance)
What should you do if a young woman presents cyanotic?
O/E: clubbing, scars underneath the breasts, signs of right heart strain
Ix: bloods (polycythaemia, IDA, liver function, uric acid levels), ECG (AF, p pulmonale, RVH), echo (right heart catheterisation)
Rx: oxygen, diuretics, consider referral to PH centre for vasodilators, avoid pregnancy
What are the signs of right heart strain? (5)
Loud and palpable P2, systolic V waves in an elevated JVP (raised venous pressure), parasternal heave (RV hypertrophy), pulm regurg, tricuspid regurg +/- pulsatile liver
What are the possible cardiac causes to consider in the cyanotic pt? (2)
Shunt + Pulmonary HTN
NB: they are linked as you could get PH secondary to an old shunt
If you hear a murmur on the left sternal edge what is it most likely going to be?
VSD > Tricuspid Regurg
What is the sign called when a murmur is louder in inspiration?
Carvallo’s Sign
What is Eisenmenger’s syndrome?
L-R shunt -> R-L shunt
What are the three most common causes of Eisenmenger’s in order?
VSD
ASD
PDA
Why do cyanotic pts get IDA?
Chronic hypoxaemia, activation of hepcidin, same mechanism as ACD
What is the gold standard to look at right heart pressures?
Right heart catheterisation
What ix do you perform in pts w chronic cyanotic cardiac disease?
CT chest for ILD causing the pulm HTN + V/Q scan for thromboembolic disease in lungs
What rx should you give pulm HTN pts? (2)
Warfarin + Digoxin
What is the most common cause of pulm HTN?
Systemic HTN
What are the signs of CO2 retention? (3)
Bounding pulse, flapping tremor, red palms
COPD O/E
Obstructive Picture
Inspection: big chest, breathless at rest, leaning forward, use of accessory muscles, cough
Key Signs: plethoric, CO2 retention, tar staining, hyperinflation, prolonged maximal exhalation, pursed lip breathing, cor pulmonale
Bronchiectasis O/E
Obstructive Picture
Inspection: clubbing, lots of sputum, cachexia
Key Signs: insp click, early to mid insp creps that DO shift w coughing, yellow curved nails and lymphoedema in legs
What does a pt w COPD who gets clubbing suggest?
Developed bronchogenic carcinoma
Fibrosis O/E
Restrictive Picture
Inspection: clubbing, cyanosis, on oxygen, steroid signs, Rheumatic hands, CREST, ank spond, thoracotomy scars, cachexia
Key Signs: dull percussion note + fine end resp creps that DON’T shift w coughing
Why are pts w bronchiectasis cachexic?
The recurrent chest infections put the pt in a hyperinflammatory state throughout the year
How would you finish your resp exam?
- Full hx PLUS check temp, sputum, peak flow/bedside spirometry, bloods, ABG, CXR/CT
- Any evidence the pt is on tx such as oxygen therapy
- Closing statement regarding associations and causation
What are the relevant resp negatives? (5)
Breathless at rest, clubbing, tar staining, LNs, pulm HTN/RHF
What is a/w secondary polycythaemia?
Gout
.’. If a pt presents w gout check their haemoglobin
What’s a reduced cricoid-sternal distance?
Less than three fingers
How long does a maximal exhale that is suggestive of an obstructive defect take?
> 6s
What bloods do you want to do for ILD?
FBC - secondary polycythaemia + raised eosinophil count
Inflam Markers - ESR, RF, cANCA, pANCA, anti-GBM
PLUS: ACE and Ca (sarcoidosis), precipitins (hypersensitivity pneumonitis), CK (polymyositis)
What bloods do you want to do for bronchiectasis?
Serum immunoglobulin levels + Aspergillus serology
What does the sputum look like during a pseudomonas infection?
Blackish Green
What does PESTO stand for in resp histories?
Pets Exercise Smoking Travel Occupation
What do you look for next after identifying a Rutherford-Morrison scar? Why?
Look to the neck for a parathyroidectomy scar hidden in the neck crease
Px of CKD
On general insp: well, not tachypnoeic, also notably not Cushingoid
O/e of hands: AV fistula in the left arm w signs of recent use + BP was elevated at 150/90 in keeping w renal impairment
O/e of H+N and chest: nad
On insp of abdo: scar in LIF w a firm underlying mass which was smooth and non-tender w/o overlying erythema consistent w a kidney transplant
The rest of abdo was SNT, no organomegaly, BS were present
The current mode of RRT is likely to be adequate as the pt is euvolemic w/o signs of pedal oedema
The cause of the pts ESRF is not readily apparent and I would like to enquire about RFs for chronic kidney disease such as diabetes and HTN
I would also like to dipstick the urine to look for glucosuria and blood or protein which may indicate an underlying glomerulonephritis
Px of CLD
On general insp: cachectic
O/e of hands: clubbing + palmar erythema
O/e of H+N: conjunctival pallor + elevated JVP
On insp of chest: multiple spider naevi in the distribution of the SVC
On insp of abdo: distended with dilated veins which fill away from the umbilicus suggestive of caput medusae
On palpation: I noted eight finger breadths of smooth non-tender hepatomegaly extending below the right costal margin w no associated splenomegaly
On percussion: I noted a distended abdomen with shifting dullness in keeping w ascites which is non-tense
On auscultation: BS were present
There was peripheral oedema likely from hypoalbuminaemia
These findings would be most consistent w a dx of cirrhotic liver disease w some evidence of decompensation
Valuable ix would inc a liver US to confirm the cirrhosis and blood screen looking for causes and signs of liver dysfunction
Signs of uraemia
1st Sign: hiccups -> pruritus
PLUS loss of appetite, malaise, pericarditis w pericardial rub
Signs of fluid overload
Unable to lie flat, breathless, on oxygen
Raised JVP + pedal oedema
Signs of immunosuppression
Violacious striae, other steroid signs, inc risk of chronic infection, reactivation of herpes, ca esp skin
Cyclosporin - gum hypertrophy + tremor
Tacrolimus - diabetes mellitus + tremor
Azathioprine - anaemia + liver fibrosis
How do you assess graft function?
Failure: anaemic, fluid overload, uraemic, active RRT methods
Rejection: tenderness and heat over the graft
Ddx RIF Masses (3)
Caecal malignancy, crohns, adenopathy
What bloods do you do for pts w CKD?
Assuming chronic: bicarbonate, potassium, urea, Cr, Hb, PTH, calcium, phosphate
PLUS urine PCR
Why would you check for parotid swelling in an abdomen exam?
A/w alcoholic liver disease
How long do you need to check for liver flap?
30secs
What is key to accurately stating the pt has hepatomegaly?
Percuss for the top edge as well
How would you finish your abdo exam?
Full hx +/-:
- Urine dip to look for nitrites and leucocytes which may indicate infection as a cause of decompensation AND glucosuria as diabetes is a RF for NASH
- Perform a DRE to look for melaena as a cause of decompensation
- Examine external genitalia looking for signs of loss of secondary sexual characteristics
- Examine CVS to look for underlying valvular heart disease
- Examine neuro to look for signs of chronic alcohol use such as cerebellar ataxia and peripheral neuropathy
What are the causes of decompensation? (3)
Infection, Constipation, Alcohol
PLUS meds (sedatives, NSAIDs, XS diruetics), any source of inc protein/nitrogen (GI bleed + renal failure), HCC
How do you px hepatomegaly?
Describe: size, smooth, irregular, tender, pulsatile
Causes: cirrhosis, cancer, congestion, infiltrative, inflam, riedel’s lobe
Why do liver pts get palmar erythema, spider naevi, gynaecomastia, lack of body hair, testicular atrophy?
Inc in relative oestradiol:testosterone ratio as a result of dec production of albumin and sex hormone binding globulin
What bloods would you do for a CLD pt?
Gen: Hb, MCV, Pl, LFTs, U+Es, coag screen, albumin
Viral: Hep A IgM, Hep B sAg, Hep C Ab
AI: serum Igs, anti smooth muscle, ANA
What are the signs of portal HTN? (4)
SAVE
Splenomegaly
Ascites
Varices
Encephalopathy
What is the consequence of splenomegaly?
Hypersplenism - sequestration of the platelets - thrombocytopenia
Why are varices in liver pts so catastrophic?
They’re already thrombocytopenic and have an elevated INR
How many of all pts w portal HTN have gastric varices?
20%
What is the mortality of a varices haemorrhage?
20%
Tx to relieve pressure on the portal vein
TIPSS
How is decompensation defined?
It describes the comps of advanced liver disease: any of ascites, jaundice, encephalopathy
How does XS diuretics lead to decompensation?
The hypoK results in dec renal ammonia clearance
What are the signs of hepatic encephalopathy?
1st Sign: diurnal sleeping pattern disturbance
Asterixis -> Bradykinesia -> Areflexia -> Decerebrate -> Coma
What should you always think about adding to your conservative mx?
MDT, Referrals, Pt Education
CVS RFs
HTN Diabetes Cholesterol Strokes Smoker
What are you inspecting for in neuro examinations?
DWARFS: deformity, wasting, asymmetry, rashes, fasciculations, swelling and scars
What may small scars inferiorly to a midline sternotomy represent?
Drains
What are the cardinal signs of hyperinflation?
- Red Cricosternal Distance
- Loss of Cardiac Dullness
- Displaced Liver Edge
Examining a skin lesion
Intro: chaperone, full exposure, any pain
General insp: number, location, distribution, objects, equipment
Closer insp: size, outline, discrete/confluent, colour, shape
Palpate: surface (texture, elevation, crust, temp) + deep (consistency, fluctuance, mobility, tenderness)
Systemic: hands and elbows, hair and scalp, mucous membranes
Complete: swab/scrap, dermatoscopy, biopsy
What are the different distributions of skin lesions?
Acral - hands and feet
Extensor - elbows and knees
Flexural - axillae, cubital fossae, genitals
Follicular - face, chest, axillae
Dermatomal - confined and don’t cross the midline
Seborrhoeic - face and scalp
What is the different morphology of skin lesions?
Macule - flat <1.5cm diameter
Patch - flat >1.5cm diameter
Papule - raised <0.5cm diameter
Nodule - raised >0.5cm diameter
Vesicle - clear fluid filled <0.5cm diameter
Bulla - clear fluid filled >0.5cm diameter
Pustule - pus contained lesion <0.5cm diameter
Abscess - pus contained lesion >0.5cm diameter
Furuncle - staph infection around or within a hair follicle
Carbuncle - above plus adjacent hair follicles
How do you assess a pigmented lesion?
ABCDEF
Asymmetry
Border
Colour
Diameter
Elevation + Evolution
Finally look for other suspicious lesions and examine the regional lymph nodes
Long Term Central Venous Line
The remnant of the line is tunnelled s/c which dec incidence of infection Indicated for longterm parenteral nutrition, longterm IV abx or chemo
Nasopharyngeal Airway
What: Nasopharyngeal Airway Why: provide a non-def airway for pts who are semi conscious and unable to tolerate a guedel or have a clenched jaw Sized: diameter of the pts little finger How: by using a rotational action up to the flared end which prevents it becoming irretrievable CIs: base of skull # and facial trauma/surg Comps: damage to nasopharynx, intracranial placement, laryngospasm, vomiting
How do you structure your answer for any instrument?
What? Why? Size? How? CIs? Comps?
What are the two definitive airways?
Endotracheal Tube + Tracheostomy
Drains: Open vs Closed
Open - fluid collect in stoma or guaze - inc risk of infection
Closed - tubes into bag or bottle - dec risk of infection
Instrument
What: Oropharyngeal Airway Why: provide a non-def airway for pt w impaired level of consciousness at risk of upper airway collapse or if the manual manoeuvres are unsuccessful Sized: distance b/w maxillary incisors to angle of mandible How: in adults inserted upside down and rotated within the oral cavity + in children inserted the correct way up CIs: a conscious person w intact gag reflex + foreign body obstrcing airway Comps: damage to teeth, palate, oropharynx + improper sizing can lead to bleeding
What are the signs of a base of skull #? (4)
Racoon eyes w tarsal plate sparing, postauricular ecchymosis, haemotympanum, CSF otorrhoea
Image
What: iGel - buccal cavity stabiliser, epiglottic rest, gastric channel Why: a supraglottic airway used as a step prior to intubation esp for short elective procedures <4hrs, cardiac arrests, prehosp airway mx Sized: according to the pts weight How: use K-Y jelly, insert w the number facing towards you when behind the pt who is in the ‘sniffing the morning air’ position, glide downwards and backwards along the hard palate until the tip is in the oesophageal opening, taped down CIs: non fasted, trismus, >40cm H2O ventilation pressure Comps: leak + aspiration
Endotracheal Tube
What: Endotracheal Tube Why: def airway thus preventing aspiration used commonly in trauma cases, long surg w general anaesthetics and pts w GCS <8 Sized: age, sex, height - position checked by looking for symmetrical rising of chest on ventilation, bilateral breath sounds, no gurgling over epigastrium How: inserted into trachea via oropharynx using a laryngoscope and Eschmann Tracheal Tube Introducer by anaesthetist, tape to secure tube in airway, inflate balloon w air below vocal cords to maintain position and protect from aspiration CIs: Mallampati score of >=3 + sev airway obstrc where a cricothyrotomy might instead be indicated Comps: inappropriate placing, injury to larynx esp vocal cords, pneumothorax, atelectasis, infection, sore throat, tracheal stenosis
Tracheostomy
What: Temporary Tracheostomy Why: def airway thus preventing aspiration used acutely in maxillofacial surgery or electively in ITU pts for more efficient ventilation w dec dead space Sized: How: via transverse incision made 1cm above sternal notch CIs: Comps: injury to oesophagus or recurrent laryngeal nerve, haemorrhage, pneumothorax, sore throat, tracheal stenosis
Laryngoscope
What: Laryngoscope - if blades are curved it’s McKintosh va straight it’s Miller Why: aids intubation + dx of vocal problems and stricture Comps: soft tissue injury, pharynx/larynx scarring, ulceration, abscess
Nasal Cannula
What: Nasal Cannula Why: Comps: nasal sores + epistaxis therefore encourage use of water based creams
What is a key principle of administering oxygen via venturi or high flow nasals?
You can give an exact FiO2 as air flow > PIFR
What is the avg peak insp flow rate in a healthy individual?
20L/min
What are examples of variable devices ie the FiO2 is dependent on PIFR? (3)
Nasal Cannula, Hudson Mask, NRB
How do you measure PIFR?
Spirometry
Tesio vs Hickman
Tesio - doesn’t have a dacron cuff, buried deeper, used for haemodialysis therefore double lumen Hickman - dacron cuff, tunnelled s/c, used for long term parental nutrition/abx/chemo therefore single lumen
Venturi
What: Venturi - uses Bernouli principle to mix oxygen w room air Why: deliver b/w 2-15L/min at a fixed FiO2 Comps
NRB
What: Non-Rebreather Mask - ensure the bag in full before placing Why: deliver up to 15L/min and ~85% FiO2 Comps:
Self-Inflatable Bag-Valve-Mask
What: Self-Inflatable Bag-Valve-Mask Why: Comps: barotrauma from lung inflation + aspiration/vomiting from gastric insufflation
NIV
CIs: drowsiness + pneumothorax
LMA vs iGel
Ultimately that would be the anaesthetists decision: The LMA-Protector provides a better airway seal The iGel is faster to insert, a/w less mucosal injury, allows for easier gastric tube insertion
Uncuffed ET
Used in children <8yo as the smallest diameter of the airway is the cricoid ring However may have to place again if the sizing is wrong, doesn’t allow for as high ventilation pressures or protect against aspiration as well
Drains: Active vs Passive
Active - maintained under suction - eg redivac following mastectomy, neck dissection, joint replacement
Passive - drains by pressure differentials, overflow, gravity - eg stoma, NGT, robinsons, foleys
What are the different types of venturi valves?
Blue: 2-4L/min = 24% O2 White: 4-6L/min = 28% O2 Yellow: 8-10L/min = 35% O2 Red: 10-12L/min = 40% O2 Green: 12-15L/min = 60% O2
Devers Retractor
This is a Devers retractor. I have used it in open abdominal surgery to allow the surgeon to operate.
Self-Retaining Retractor
This is a self-retaining retractor. I have seen this used to hold wounds open during an appendicectomy and hernia repairs.
Forceps
These are the two common types of forceps: toothed for skin + nontoothed for inside the peritoneal cavity
Scalpels
These are the two common types of scalpels: disposable and non-disposable
Feeding NG Tube
What: Feeding NGT - fine bore w radio-opaque guide wire Why: long term enteral nutrition for pts post op, ITU, unsafe swallow Sized: tip of nose round ear to epigastrium How: consent pt, place aqua gel on tip, go along the floor of the nasal passage, ask pt to keep swallowing as you advance, confirm correct placement CIs: base of skull # and facial trauma/surg Comps: NGT+feeding ie nasal trauma, misplacement, blockage, refeeding syndrome, electrolyte imbalance, feed intolerance
Ryles Tube
What: Ryle’s Tube - wide bore w metal tip, clear, stiff Why: part of the drip and suck tx for bowel obstrc to decompress + insert drugs or contrast into the GIT Comps: the larger diameter inc risk of nasal trauma + misplacement and blockage
How do you ensure the NGT is in the correct place?
Document: the pH aspirate is <5.5, bubbling upon epigastrium auscultation following air insertion, on CXR bisects the carina and tip sits below the diaphragm in the gastric bubble
High-Flow Nasals
Humidified and well tolerated V high flow can be achieved
Describe bubbling and swinging wrt chest drains?
Bubbles - air is being expelled during expiration Swinging - the fluid going up and down the tube during insp/exp Swinging w/o bubbles shows all the air from the pneumothorax is out
If the drain doesn’t stop bubbling what does this suggest? And what should you do?
There’s a fistula -> requires specialist intervention
TED Stockings
What: TED Stockings Why: mechanical VTE prophylaxis usually used in conjunction w pharmacological eg LMWH to prevent DVTs CIs: pts w arterial disease
Two-Way Catheter
What: Two-Way Urinary Catheter - Male v Female Why: therapeutic ie retention and immobile pts + diagnostic ie measure UO and collect sterile sample Sized: inc Charrière inc circumference usually 12-14Ch for adults How: consent pt, clean w saline and anaesthetise w instillagel, use ANTT, wait until urine starts to drain, inflate the ballon w 10ml of water, attach bag, ensure foreskin repositioned, document CIs: consider suprapubic access if urethral injury, high riding prostate, pelvic fracture, scrotal haematoma Comps:
Three-Way Catheter
What: Three-Way Irrigation Catheter Why: allows for bladder irrigation in pts w haematuria at risk of clot formation Comps:
Foley vs Long-Term Urinary Catheter
Foley: <28d + latex Long-Term: <3m + silicone
Approach to Chest Radiograph
Pt+Image Details, RIPE, Most Obv Abnormality, A-F, Ddx
Approach to Abdominal Radiograph
Pt+Image Details, RPE, Most Obv Abnormality
- Bowel Gas Pattern 2. Extraluminal Gas 3. Soft Tissues 4. Calcification 5. Masses 6. Bones
Approach to MSK Radiograph
Pt+Image Details, Most Obv Abnormality, JOAST, Ddx
Trachea Deviation
Ipsilateral: collapse, fibrosis, surgery Contralateral: tension pneumothorax + pleural effusion
Bowel: Small vs Large
Small: valvulae conniventes vs Large: haustral folds
The 3-6-9 Rule: small, large, caecum PLUS appendix <6mm
Insert Image (EDH)
Extradural Haematoma: lentiform ie lens shaped + biconvex ~ Day Lucid Interval
Insert Image (SDH)
Subdural Haematoma: crescentic ie moon shaped + concave ~ Wk Lucid Interval
Insert Image (SAH)
Subarachnoid Haemorrhage: the star sign ie presence of blood within the basal cisterns and sulci
Hickman
What Why: the dacron cuff prevents back tracking of infection and forms a bond w surrounding tissue to prevent line migration Sized How CIs Comps
Approach to CT Head
Midline Shift + Symmetry
Rigler’s Triad
SBO Pneumobilia Ectopic Calcified GS
What does JOAST stand for?
Joint Outline Attitude Soft Tissues Texture
What does RIPE stand for?
Rotation Inspiration Penetration Exposure
CT vs MRI
CT - more detailed bony structures, white bone, black water unless contrast MRI - more detailed soft tissues, T1 black water, T2 white water
What layers do you pass through during an epidural?
Skin S/c Fat Supraspinous Interspinous Ligamentum Flavum
What is the composition of the crystalloids?
0.9% Sodium Chloride: 154 Na, 154 Cl, 300 OsmolaLity Hartmann’s: 131 Na, 112 Cl, 5 K, 4 Ca, 29 HCO3, 281 OsmolaLity 5% Dextrose: 50g Dextrose + 278 OsmolaLity
Where outlines the mediastinum on a chest radiograph?
Right atrium, ascending aorta, SVC, aortic arch, main pulmonary artery, left ventricle
Where does one tend to aspirate and why?
Right lower lobe as the right bronchus is more vertically oriented
What does the majority of the hila consist of?
The lower lobe pulmonary arteries
Where do you first see a pleural effusion?
Obscured CP angles
What places opacification in the right middle lobe?
Up to the horizontal fissure and loss of right heart border
What is the radiological sign of consolidation?
Air Bronchograms Plus inc density and no volume loss
Ddx for Consolidation
Pus - Pneumonia Fluid - Oedema/Haemorrhage Cancer - Adenocarcinoma
Bronchopneumonia vs Pulm Oedema
If there’s NOT bilateral perihilar appearance, blunting of the CP angles, enlarged upper lobe veins think bronchopneumonia > oedema
Bronchopneumonia vs Multifocal Adenocarcinoma
If there’s NO raised WCC and the pt is systemically well think cancer or bleed > pneumonia
How do you work through A-F of a CXR?
A: Trachea B: Hila C: Mediastinum D: Diaphragm E: 🔼 Bones + Lines F: 🔽 Fields + Pleura
What are the signs of COVID pneumonitis?
Patchy peripheral areas of ground glass opacification and consolidation w a mid/lower zone predominance
Left Lower Lobe Collapse
Mediastinal shift towards ie volume loss in hemithorax, ‘sail sign’ triangular opacity behind heart, obscured diaphragm, unable to visualise the descending thoracic aorta, depression of left hilum
What are the sinister underlying causes of lobar collapse?
Central obstructing cancer + FB aspiration
What are the signs of emphysema?
Inc anterior ribs + flattened diaphragm
Left Upper Lobe Collapse
Mediastinal shift towards ie volume loss in hemithorax, veil-like opacity in upper zone, obscured heart border, still able to visualise the descending thoracic aorta, elevation of left hilum
Where does the oblique fissure run in a lateral view?
Ant CP angle to T4
What is the sail sign indicative of?
Left Lower Lobe Collapse
Collapse vs Surgery
You’d expect to see clips following surgery and the main bronchus would be cut near the carina
What is the usual cause of an entire lung collapse?
Cancer obstructing the main bronchus
Ddx for White Hemithorax
Lung Collapse Pleural Effusion
What does lobulated pleural thickening suggest?
Malignant Mesothelioma
What does pulmonary TB look like on CXR?
Typically affects the upper lobes giving mixture of consolidation, nodular shadowing and cavitation
Which cancers cause miliary metastases?
Thyroid + Renal
Miliary TB vs Metastases
The pt will be septic if it’s TB
Where do inhalational and haematogenous disease tend to occur?
Inhalational - Upper Zones Haematogenous - Lower Zones
Pulmonary Nodule vs Mass
> 3cm
What is characteristic of lung cancer on CXR?
Solitary mass w spiculated edge
Ddx for Dark Hemithorax
Pneumothorax
What are the causes of pneumomediastinum? (3)
Spontaneous A/W Pneumothorax Oesophageal Rupture
What should you be worried about if the pt is SOB and they have a normal CXR?
PE
What is pathognomonic for pulm oedema?
Septal ie Kerley B Lines
What are causes of non-cardiogenic pulm oedema?
Altered Permeability > Inc Osmotic Pressure Neurogenic, ARDS, TRALI, RAS, heroin induced, near drowning, high altitude
Which part of the colon is fixed/variable?
Fixed ascending/descending/rectum as they’re retroperitoneal Variable transverse/sigmoid as they have mesentery
What causes the bowel to dilate? (3)
Distal mechanical obstruction, ischaemia, sick bowel
What is the Rigler sign?
A sign of pneumoperitoneum when gas outlines both sides of the bowel wall
What is the sign of a sigmoid volvulus?
Coffee bean sign: distended loop of colon arising from the pelvis
What are the two types of caecal volvulus?
- Axial Torsion 2. Caecal Bascule
+/- Small Bowel Obstruction
What is the 10 day rule for women of child bearing age?
Imaging of abdomen/pelvis using ionising radiation should be restricted to the first 10 days following onset of menstruation
How can you tell if an AXR is adequate in terms of both penetration and coverage?
You can see the vertebrae, edges of the pelvis and down to the greater trochanters
What causes cavitary lung lesions?
Infectious: strep, klebsiella, mycobacterium, aspergillosis, parasites Non-Infectious: cancer, GPA, congenital
What do you need if the CXR does not show a rib fracture or splenic injury but there’s clinical suspicion?
CT
CVC vs PICC
Length + Lumen
MRI: T1 vs T2
We commonly use T1 to visualise anatomy and T2 to visualise disease: look at the water which will be black in T1 and white in T2
What is Chilaiditi’s sign?
An incidental finding where gas containing bowel is positioned between the right diaphragm and the liver which is often misdiagnosed as pneumoperitoneum
What sign is pathognomonic of SBO?
The presence of a ladder pattern on an erect film showing fluid air levels within each loop of bowel
What does a diaphragmatic hernia look like on a CXR?
The diaphragmatic border is lost and the hemidiaphragm is elevated with a fluid level in the gastric buddle and absence of lung markings
Mx of SBO
‘Drip and Suck’
Gain IV access to take bloods inc vbg for lactate and immediate electrolytes then start IV fluids and place a catheter to monitor fluid balance
Place a NG tube to decompress the distended stomach, give analgesia and antiemetics, keep NBM and discuss w surg team, CT AP to determine level of obstrc and cause, monitor obs closely
Abdo: Stoma Qs
Define a stoma
Indications for a stoma
Ileostomy vs Colostomy
Why would you do a colostomy
How do you know it’s functioning
Indications for an emerg Hartmanns
Complications of a stoma
How much fluid would be normal to lose from a stoma
When do you remove it
Abdo: Pancreatitis Qs
What would be possible ddx
List the causes of acute pancreatitis
Why do you get Cullens, Grey Turners, Foxs
What ix would you perform
What are the three reasons you’d get an AXR
Difference b/w MRCP + ERCP
What scoring system is used
How does this affect mx
General mx principles
Abdo: Upper GI Bleeding Qs
What would be possible ddx
What is the Mackler triad of Boerhaave syndrome
Which ix would you perform
What is the difference b/w XM + G&S
What scoring system is used
How does this affect mx
General mx principles
Abdo: Stoma Examination
Site Lumen Sprout Effluent Surrounding Comps
Listen for bowel sounds + pt cough
Look for scars + abdo exam if indicated
SVR: Scar Examination
Location Orientation Size ?Well Healed ?Incisional Hernia
.’. Consistent w _ op for _ condition
I+I: What are the three indications for an AXR?
Obstrc/volvulus, UC toxic megalon/lead pipe, foreign body
NEVER CONSTIPATION
I+I: What should you say if they show you an xray of a limb in one plane?
Ask for another view to ascertain if there is a fracture
T+O: Mx of Fracture
ATLS, Assess NV Status, 4R’s
Closed: once stable non-op document NV status, analgesia, activity modification, reduce, casts, splints, traction + operative fixation
Open: photograph, cover w saline soaked gauze, give IV abx + tetanus, splint and xray, debride + washout +/- fixation
If GA3b require plastics input for graft
If GA3c require vasc surgeons for shunt bypass before exfix, vasc repair, debridement, dressing, def fixation
Finally physio would be involved for rehabilitation: use, move, strengthen, WB
What are the usual things to forget in examinations?
Core Three: cap refill, flap, JVP, lymph nodes, sacral/peripheral oedema
CN: insp | UL: pronator drift | LL: rombergs + gait
