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Clinical Skills
| Question | Answer |
|---|---|
| Comprehensive adult history | • Identifying Data and Source of the History; Reliability • Chief Complaint(s) • Present Illness • Past History • Family History • Personal and Social History • Review of Systems |
| Physical examination techniques | • Inspection • Palpation • Percussion • Auscultation |
| Sensitivity & specificity | • Sensitivity is the ability to detect true positives • Specificity is the ability to detect true negatives • No test has 100% sensitivity and specificity! |
| Cognitive biases | • Subconscious errors leading to perceptual distortion, inaccurate judgement and illogical interpretation of information • The human factor |
| 4 Cognitive biases: | Social biases Memory biases Decision making biases Probability/ belief biases |
| The patient’s perspective (F-I-F-E) | • The patient’s F eelings, including fears or concerns. • The patient’s I deas about the nature of the problem • The effect of the problem on the patient’s F unction • The patient’s E xpectations of the disease, of the clinician, or of health care |
| The Seven Attributes of a Symptom | 1. Location 2. Quality 3. Quantity or severity 4. Timing 5. Setting in which it occurs 6. Remitting or exacerbating factors 7. Associated manifestations |
| Cultural context: Cultural humility | • Self-awareness: Learn about your own biases • Respectful communication: Eliminate assumptions about what is “normal.” • Collaborative partnerships: Build your patient relationships on respect and mutually acceptable plans |
| Common and concerning symptoms | -Fatigue and weakness -Fever -Weight changes -Pain |
| Fatigue | -Common symptom -Non specific -Sense of weariness and loss of energy |
| Weakness | -Loss of muscle power -Different from fatigue -Neurological symptom |
| Fatigue causes | Hard work -Anxiety / depression - Infections - Endocrine disorders - Chronic lung, liver or kidney diseases - Electrolyte imbalances - Nutritional deficits - Anemia - Malignancies - Medications |
| Fever | Fever = abnormal elevation of body temperature -Rise of temperature - Feeling cold - Goosebumps - Shivering - Drop of temperature - Feeling hot - Sweating |
| BMI | Weight (kg) / Height (m)^2 - <18,4 underweight - 18,5 – 24: normal - 25-29: overweight - >30 obese - >40 morbid obesity |
| Weight changes | Waist circumference Measure if BMI > 35 -Risk for diabetes, hypertension, and cardiovascular disease - waist circumference >90 cm (35 inches) in women - Waist circumference >101,6 cm (40 inches) in men |
| Health promotion and counseling | Optimal weight, nutrition and diet 1. Measure BMU and assess risk factors 2. Assess dietary intake 3. Assess motivation to change 4. Provide counselling about nutrition and exercise -Physical exercise |
| Acute and chronic pain | Chronic pain -Pain that persists for more than 3-6 months - Lasting >1 month beyond the course of an acute illness or injury - Recurring pain |
| Acute and chronic pain | Nociceptive (somatic pain) -Neuropathic pain - Central sensitization - Psychogenic and idiopathic pain |
| Pain assessment | Pain measurement scales - Visual analog scale - Numeric rating scale - Wong-Baker FACES Pain rating scale |
| General appearance | - Apparent state of health -Level of consciousness - Signs of distress (respiratory, pain, anxiety) - Skin colour |
| Vital signs | -Heart rate and rhythm -Respiratory rate and rhythm - Temperature - Blood pressure |
| Heart rate and rhythm | Palpation of radial pulse Normal 60 – 100 / min Regular |
| Respiratory rate | Observation Breaths per minute Primary vs accessory respiratory muscles Posture |
| Temperature | Core temperature vs skin temperature Axillary (-1 oC) vs Oral vs rectal vs tympanic membrane temp (+0,8 oC) Normal temperature: 36,5 – 37,5 oC |
| Temperature | Hypothermia <35 oC Fever (>37,5 oC or >38,5 oC) Hyperthermia Hyperpyrexia |
| SOAP notes | Subjective Objective Assessment treatment Plan |
| Early recognition of deteriorating patient | -hypoxia -hypotension |
| ABCDE | Airway Breathing Circulation Disability Exposure |
| Causes of airway obstruction: | -CNS depression -blood -vomit -foreign body -trauma -infection -inflammation -laryngospasm & bronchospasm |
| Recognition of airway obstruction: | Talking difficulty breathing, distressing, choking shortness of breath noisy breathing see-saw respiratory pattern, accessory muscles |
| Treatment of airway obstruction: | -Airway opening: head tilt, chin lift, jaw thrust -Simple adjuncts -Advanced techniques: LMA, Tracheal tube -O2 -Early caponography |
| Causes of breathing problems: | - Decreased respiratory drive: CNS depression -Decreased respiratory effort -Lung disorders: Pneumothorax Haemothorax Infection COPD Asthma Pulmonary Embolus ARDS |
| Primary causes of circulation problems: | Acute coronary syndromes arrhythmias hypertensive heart disease valve disease hereditary cardiac diseases drugs |
| Secondary circulation problems: | asphyxia hypoxaemia blood loss hypothermia septic shock drugs |
| Common and concerning symptoms | -Headache - Change in vision - Hearing loss - Vertigo - Nosebleed (epistaxis) - Sore throat / hoarseness - Tumefaction - Goiter |
| The head | Headache prevalence 30% |
| Primary causes of a headache | -Migraine -Cluster headache -Sinus -Tension - Chronic daily headache |
| Secondary cause of a headache | -Meningitis -Subarachnoid hemorrhage - Mass |
| The eyes – health history | - Blurred vision / visual loss - Unilateral vs bilateral - Pain - Location: Partial, Central, Peripheral -Light flashes / dark spots - Pain - Redness |
| The ears – health history | - Hearing loss: Conductive, Sensorial -Tinnitus (ringing) - Earache: Symptoms (fever, sore throat, cough…) -Medications - Discharge - Vertigo vs diziness |
| The nose and sinuses – health history | -Rhinorrhea (nose discharge) - Nasal congestion - Unilateral - Bilateral - Upper respiratory tract infection - Onset - Epistaxis (nose bleeding) |
| The mouth and neck– health history | - Sore throat / pharyngitis - Bleeding from gums - Hoarseness - Neck lumps - Lymph nodes - Thyroid gland / goiter |
| Thyroid function | - Temperature intolerance - Sweating - Palpitations - Weight change |
| Loss of vision | - 10% of adults over 60 - 50% correctable - Causes: Cataract, Glaucoma, Diabetes |
| Hearing loss | - 1/3 of adults over 65 - Largely unnoticed |
| Oral health | - Children / adults - Decayed, missing, filled teeth - Daily hygiene measures - Diet, tobacco, alcohol use |
| Physical examination of the head | Observe Palpate Percuss |
| Superficial anatomy of the head | Bones define areas Salivary glands Superficial temporal artery |
| Anatomy of the eyes | - The upper eyelid covers iris but nor pupil - Palpebral fissure = opening of eyelids -Sclera covered by conjunctiva: Bulbar conjuctiva, Palpebral conjunctiva, Limbus |
| Eyeball | Ciliary body Anterior and posterior chambers Aqueus humor Vitreous body |
| Visual pathway | Retina Optic nerve Chiasm Optic tract Optic radiation |
| The light reaction | Direct reaction to light Consensual reaction |
| Near reaction | Convergence of eyes Accommodation(= increased convexity of lenses) Pupil constriction |
| Extraocular movements | Six cardinal directions - 3 nerves - Oculomotor (III) - Trochlear (IV) - Abducens (VI) |
| Eye physical examination | - Visual acuity - Visual fields - Conjuctiva and sclera - Cornea lens and pupils - Extraocular movements - Fundoscopy |
| Visual acuity | Snellen chart |
| Visual Field Confrontation | Visual fields by confrontation |
| Conjuctiva and Sclera | Sclera Conjuctiva Eyelid eversion |
| External ear | -Auricle -Ear canal -Tympanic membrane |
| Middle ear | -Ossicles -Malleus -Incus -Stapes |
| Inner ear | Cochlea -Semicircular canals - Auditory nerve (VIII) |
| Ear physiology | Hearing pathways -Conductive phase -Sensorineural phase |
| Equilibrium | Labyrinth of three semicircular canals |
| Physical examination | Auricle Ear canal & drum Otoscopy Auditory acuity Whispered voice test Finger rub |
| Rinne test | Compare air and bone conduction AC>BC |
| Weber test | Test for lateralization |
| Oral cavity examination | Inspection -Lips - Oral mucosa - Gums and teeth - Tongue - Floor of mouth - Palpate lesions |
| The neck anatomy | Surface anatomy landmarks -Sternomastocleidoid m - Trapezius m - Omohyoid m - Manubrium |
| The neck anatomy | Great vessels Carotid artery Internal jugular v External jugular v |
| Midline Structures and Thyroid gland | -Hyoid bone -Thyroid cartilage - Cricoid cartilage - Trachea - Thyroid gland |
| Trachea and Thyroid gland | -Inspection -Swallowing -Tracheal deviation -Thyroid gland -Inspection -Palpation |
| Tumefaction: | an action or process of swelling or becoming tumorous |
| Goiter: | abnormal enlargement of thyroid gland |
| Migraine: | - recurrent headaches moderate to severe - affect one side of the head - pulsating in nature - last from a few hours to 3 days - 15–30% experience episodes with aura |
| Cluster headache: | -recurrent severe headaches on one side of the head -typically around the eye -eye watering, nasal congestion, or swelling around the eye on the affected side -last 15 minutes to 3 hours -pain is severe and disabling |
| Sinus (rhinosinusitis): | - inflammation of the mucous membranes that line the sinuses -thick nasal mucus, a plugged nose, and facial pain - fever, headaches, a poor sense of smell, sore throat, and a cough - Acute sinusitis : < 4 weeks - Chronic sinusitis : > 12 weeks |
| Tension (stress headache, or tension-type headache (TTH): | - the most common type of primary headache (90% of all headaches) - pain can radiate from the lower back of the head, the neck, eyes - typically affecting both sides of the head |
| Chronic daily headache: | - occur 15 days or more a month - longer than three months - True (primary) chronic daily headaches aren't caused by another condition - short-lasting and long-lasting chronic daily headaches - 4-5% |
| Meningitis: | - inflammation of fluid and meninges surrounding brain and spinal cord - triggers signs and symptoms headache, fever and a stiff neck - viral, bacterial, parasitic and fungal infections |
| Subarachnoid haemorrhage: | - bleeding into the subarachnoid space - area between the arachnoid membrane and the pia mater - surrounding the brain - severe headache of rapid onset, vomiting - decreased level of consciousness, fever, seizures |
| Mass: | - Benign or malignant - All types may produce symptoms - vary depending on the part of the brain involved - headaches, seizures, problems with vision - Vomiting, mental changes |
| Some Anatomists Like Freaking Out Poor Medical Students | Superior thyroid Ascending pharyngeal Lingual Facial Occipital Posterior auricular Maxillary Superficial temporal |
| sternal angle: | 2nd rib |
| tension pneumothorax: | 2nd intercostal space for needle insertion |
| chest tube insertion | 4th intercoastal space |
| Interviewing for chest pain: | Ask open-ended questions (Avoid fixation errors) “Do you have any discomfort on the chest? Where is the discomfort? Does it radiate anywhere? Ask the patient to locate the discomfort and navigate yourself anatomically Ask the seven attributes of pain |
| Interviewing about SOB | SOB can be either pulmonary or cardiac in origin Understand if SOB occurs at rest or exercise Understand the severity of SOB from patients physical activities (there is no scale for SOB) |
| Techniques of examination | Posterior thorax and lungs……… patient sitting Anterior thorax and lungs……….. patient supine |
| Initial Survey of Respiration | Assess ◦ Rate ◦ Rhythm ◦ Depth ◦ Effort ◦ Cyanosis |
| Tactile Fremitus: | Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall Use the ulnar surface of your hand Ask patient to say ninety nine. Use one hand then 2 hands to assess differences |
| Crackles - Rales | Like dots in time Intermittent, nonmusical and brief |
| Wheezes and Rhonci | like dashes in time relatively high pitched |
| The cardiac cycle | It all starts at the SA node Increasing heart rate, decreases duration of the cardiac cycle |
| S1 sound: | Closure of AV valves (long lasting vibration pitch) |
| S2 sound: | Closure of the semilunar valves (snap) |
| S3 sound: | In older adults pathologic change in ventricular compliance |
| S4 sound: | Atrial contraction and indicated pathologic changes in ventricular compliance |
| Normal S2 splitting | • Aortic valve closes before the pulmonary valve • Deep inspiration further delays the closure of pulmonary valve |
| Blood pressure | Normal: <120/80 mm Hg Prehypertension: 120-139/80-89 mm Hg Stage 1 Hypertension: 140-159/90-99 mm Hg Stage 2 Hypertension >160/>100 mm Hg If diabetes or kidney disease: <130/80 mm Hg |
| Midsystolic murmur | After S1 and stops before S2. Listen carefully for the gap before S2, it is heard more easily and if present it usually confirms the murmur as midsystolic not pansystolic |
| Pansystolic (holosystolic) murmur | starts with S1 and stops at S2, without a gap between murmur and heat sounds |
| Late systolic murmur | usually starts in mid or late systole and persists up to S2 |
| Early diastlic murmur | starts immediately after S2, and fades into silence before the next S1 |
| Middiastolic murmur | short time after S1 and it may fade or merge into a late diastolic murmur |
| Late diastolic (presystolic) murmur | stats late in diastole and typically continues up to S1 |
| Continuous murmur | begins in systole and extends into all or part of diastole |
| Transpyloric line | • Fundus of gallbladder • Pylorus • Neck of pancreas • Kidney hilum • SMA origin |
| Abdominal pain | • Visceral • abdominal organs • distention or forceful contraction • poorly localized • Parietal • inflammation of parietal peritoneum • strong, aching, well localized, aggravated by movements • Referred • from distant sites – innervation pattern) |
| Abdominal symptoms: mechanisms | • Musculo-skeletal disorders • Gastrointestinal disorders • Renal and urinary disorders |
| Symptoms from gastrointestinal disorders | • Pain, acute/chronic • Nausea, vomiting • Indigestion, early satiety, loss of appetite • Dysphagia, odynophagia • Diarrhea, constipation • Jaundice |
| Symptoms from renal and urinary disorders | • Pain: • Kidney or flank pain • Ureteral colic • Suprapubic pain • Dysuria, urgency, or frequency • Polyuria or nocturia • Urinary incontinence • Hematuria |
| Symptoms from renal and urinary disorders | • Acute kidney injury • ↑ Serum creatinine (↓ GFR) • ↓ Urine output • Chronic kidney failure • >3 months duration • ↓ GFR |
| Physical examination of the abdomen | 1. Inspection 2. Auscultation => bowel sounds unaffected 3. Percussion 4. Palpation |
| Physical examination of the abdomen | • Expose from xiphoid process to symphysis pubis • Warm hands and stethoscope • Avoid quick, unexpected movements • Distract patient with conversation or questions • Watch patient’s face for pain or discomfort • Examine painful areas last |
| Inspection | • Symmetry and shape: • Asymmetry • enlarged organ or mass • Local bulges • hernia • Bulging flanks • ascites • Suprapubic bulge • distended bladder • pregnant uterus • ovarian cyst |
| Inspection (2) | • Symmetry and shape • Visible peristalsis • partial bowel obstruction • Pulsatile mass • aortic aneurysm • Scars • surgery • Dilated veins • liver insufficiency – portal hypertension • Rashes |
| Epigastric hernia | a small midline portrusion trough a deect in the linea alba, btween the xiphoid procss and the umbilicus |
| incisional hernia | protusion through an operative scar. |
| Inspection – groin hernias | • Inguinal hernia • Direct • Indirect • Femoral hernia |
| Auscultation | • Bowel sounds • 4 – 12 / min • increased (borborygmi) or decreased • Bruits • abdominal aorta • renal arteries |
| Percussion | • Tympany • gas • Dullness • solid organ • fluid • feces • underlying mass • Rebound tenderness • Guides palpation on areas of potential pathology |
| Palpation | • Light palpation • Deep palpation • Organ palpation • Liver • Spleen |
| Light palpation | • Hand & forearm on horizontal plane, fingers together & flat on abdominal wall • Palpate with light, gentle, dipping motion • Raise hand just off skin to move to next quadrant • Palpate all four quadrants |
| Light palpation | • Look for: • Tenderness • Muscular resistance (spasm) • Superficial organs and masses |
| Deep palpation | • Palmar surfaces of fingers • Press down in all four quadrants • Identify masses • Note location, size, shape, consistency, tenderness, pulsations, and mobility |
| Acute abdomen | • Positive cough test • Percussion tenderness • Guarding • Rigidity • Rebound tenderness |
| Bladder examination | • Percussion: dullness above symphysis pubis • Palpation: dome of distended bladder/ tenderness |
| Digital Rectal Examination | Palpation: • Anus & Rectum • Prostate & seminal vesicles (male) • Uterus & ovaries (female) |
| Urine dipstick | • Quick bedside analysis of 10 factors • Kidney, liver, metabolic diseases, infection |
| Kidney: not just a waste disposer | • Excretion of metabolic waste & chemicals • Regulation of water and electrolyte balance • Regulation of acid base balance • Regulation of arterial blood pressure • Regulation of erythrocytes production • Vitamin D activation • Gluconeogenesis |
| Glomerular filtration rate (GFR) | The volume of fluid filtered by the kidney per unit of time • Calculated from estimation of Creatinine Clearance |
| Dysuria | = pain or discomfort during urination (UTI) |
| Acute kidney injury causes | • Prerenal = volume depletion • Renal = kidney pathology • Postrenal = obstruction |
| Acute kidney injury | • Definition • Increase of serum creatinine (>50%) • Decrease of urine output (<0,5 ml/kg/h) • RIFLE classification system. |
| Chronic kidney disease | • End-stage renal disease • Dialysis • Renal transplantation |
| Azotemia | = increased serum urea (BUN) and creatinine |
| Uremia | = Azotemia with symptoms & signs of renal failure |
| Physical examination | • General appearance • Extremities • Face • Skin |
| Fluid overload | • General appearance • Blood pressure • Jugular venous pressure • Chest auscultation (crackles) • Peripheral oedema • Weight gain • Fluid input / output |
| Kidney examination | • Inspection • Auscultation • Palpation |
| The legs veins | • Deep veins: corresponding to arteries • Superficial veins: • Great saphenous v • Small saphenous v • Perforating veins |
| Common presenting symptoms from arteries | Lower (upper) Extremities • Asymptomatic ischemia • Intermittent claudication • Night pain / Rest pain • Tissue loss (ulceration / gangrene) • Acute limb ischemia • Digital ischemia Abdomen • Mesenteric ischemia • Abdominal aortic aneurysm |
| Common presenting symptoms from veins | • Varicose veins • Deep vein thrombosis • Chronic venous insufficiency & ulceration • Superficial thrombophlebitis |
| Risk factors for peripheral vascular disease | • Personal medical history • Drug history • Lifestyle • Family history |
| Allen test | • Evaluation of arterial supply to hand (radial & ulnar arteries) • Ensure patency of both ulnar artery before puncturing radial artery |
| Bruits | Epigastric bruits confined to systole are normal |
| 6P of acute limb ischemia | • Pain • Pulselessness • Pallor • Paresthesia • Paralysis • Poikilothermia (cold temperature) |
| Pitting edema | Firm gentle pressure for at least 2 sec. Persistent pitting (depression caused by pressure) |
| “Red flags” for lower extremity PAD | • Known atherosclerotic coronary, carotid, or renal artery disease • Age 70 years or older • Younger with atherosclerosis risk factor (diabetes, smoking, dyslipidemia, hypertension) • Leg symptoms • Abnormal pulses |
| “Red flags” for renal artery disease | • Hypertension in young age (≤30 years) • Severe or resistant hypertension • Renal function worsening, particularly after use of ACEi or ARB • Unexplained small kidney • Sudden unexplained pulmonary edema, especially with worsening renal function |
| “Red flags” for abdominal aorta aneurysm (AAA) | • Abdominal, flank or back pain = rapidly enlarging aneurysm or aneurysm rupture • Pulsatile abdominal mass • Increased aorta width |
| i.v. cannula selec,on | • 14G • 16G • 18G • 20G • 22G • 24G • Large volume replacement • Rapid transfusion of whole blood or blood components • IV maintenance, NBM patients • IV analgesia • Paediatrics, elderly, chemotherapy patients • Paediatrics, neonates |
| Preparing vein | Warm veins by •Rubbing •Washing patient’s hands under warm water •Apply warmed towel •If limb is warm ask the patient to gently clench and unclench their hand •Or gently rub up and down the vein |
| Potential complications | • Extravasation • Hematoma • Thrombophlebitis • Venous Spasm • Infection • Nerve damage • Occlusion |
| Order of draw | Cultures – Aerobic – Anaerobic • Blue tube • Red tube (chemistry panel, serum) no gel or addi>ve or silica clot ac>vator • Purple tube |
| Common Complains- male reproductive | Sexual Orientation • Penile discharge or lesions • Scrotal pain, swelling or lesions • Sexually Transmitted diseases or infections |
| ABC approach for sexual health | Abstinence Be Faithful Condom use |
| Menarche | Age at onset of menstruation (9-16) |
| Amenorrhea | Absence of menses |
| Primary Amenorrhea | Absence of ever initiating menses |
| Secondary Amenorrhea | Cessation of menses after they have been started |
| Physiologic forms | Pregnancy, lactation , menopause |
| Polymenorrhea | <21 day intervals between menses |
| Oligomenorrhea | ; Infrequent bleeding |
| Dysmenorrhea | Pain during menses |
| Menorrhagia | Excessive flow |
| Premenstrual Syndrome: | Cluster of emotional and physical symptoms (anger, irritability, depression) <= 5 days before menses for 3 consecutive cycles |
| Gravida Para notation system: | Gravida (G): total number of pregnancies Para (P): outcomes of pregnancies F: full-term, P: premature, A: abortion, L: living chld eg G2, PF1, PP0, PA1, PL1 |
| Pelvic Pain | Acute: PID Ovulation pain (middle cycle),ruptured ovarian cyst Life threatening conditions : ectopic pregnancy, ovarian torsion, acute appendicitis |
| Breast cancer factors | -Familial breast cancer - BRCA1 / BRCA2 mutations - Risk by age 70 57% and 49% - In Situ breast disorders - DCIS - LCIS - Dense breast tissue |
Created by:
elenatz
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