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Clinical Skills

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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