Intro practical clinical skills

Normal BG

4-5.9 mmol/L

Fasting blood glucose >7 mmol

It is abnormal but further testing is required

How to use peak flow

Practise explaining…

1. Pull the counter (the red arrow) back as far as it will go to the top.

2. Stand or sit upright

3. Take the deepest breath you can.

4. Make sure your mouth makes a tight seal around the mouthpiece.

5. Blow as hard and fast as you possibly can into the meter.

6. Write down your score

7. Do this three times in a row, with a short rest in between.

8. Use the highest of these scores to fill in your peak flow diary.

Which parameters are important for peak flow

Height, age, sex

always measure best of 3 to compare baseline

What else do we use to support asthma diagnosis

Peak expiratory flow variability

Amplitude percentage >= 20%

What does BTS/NICE/SIGN say about monitoring

Do not use regular peak expiratory flow to assess asthma control

What would should a patient do if they have a best-of-three result that is:

•80% of personal best

•70% of personal best

•≤50% of personal best ? call ambulance, give treatment

blood glucose kit

Contains lancet and cotton wool/gauze

Gloves

Sharps bin nearby

Stages in taking blood glucose reading

wash with warm water to promote blood flow

‘milk the finger’ to increase blood flow

What do we do with fingerprick test

We don’t diagnose diabetes based on test

But it can prompt further investigation

Can be used for self-monitoring e.g. hypoglycemic episodes, driving, operating, pregnant, planning pregnancy

Urinalysis

What is the normal color range of urine?

Colourless to dark yellow.

What are some pathological causes of brown urine?

Bile pigments, myoglobin.

What are some food and drug causes of brown urine?

Levodopa, metronidazole, nitrofurantoin, some antimalarial agents, fava beans.

What are some pathological causes of brownish-black urine?

Bile pigments, melanin, methaemoglobin.

What are some food and drug causes of brownish-black urine?

Cascara, levodopa, methyldopa, senna.

What are some pathological causes of green or blue urine?

Pseudomonal urinary tract infection (UTI), biliverdin.

What are some food and drug causes of green or blue urine?

Amitriptyline, indigo carmine, IV cimetidine, IV promethazine, methylthioninium chloride, triamterene.

What are some pathological causes of orange urine?

Bile pigments.

What are some food and drug causes of orange urine?

Phenothiazines, phenazopyridine, rifampicin, hydroxocobalamin.

What are some pathological causes of red urine?

Haematuria, haemoglobinuria, myoglobinuria, porphyria.

What are some food and drug causes of red urine?

Beetroot, blackberries, rhubarb, phenolphthalein, rifampicin.

What are some causes of yellow urine?

Concentrated urine (orange to gold in dehydration), carrots, cascara.

What are some possible causes of cloudy urine?

Contamination with vaginal mucus or epithelial cells, excess phosphate crystals in alkaline urine, pyuria due to infection, chyluria (secondary to filariasis), hyperuricosuria from a purine-rich diet, lipiduria, hyperoxaluria.

What is the normal odour of urine?

Described as urinoid.

What conditions cause urine to have an abnormal odour?

Alkaline fermentation (ammoniacal smell), diabetic ketoacidosis (sweet or fruity odour), cystine decomposition (sulphuric smell), gastrointestinal-bladder fistulae (faecal smell), medications (e.g., vitamin B6), diet (e.g., asparagus).

Signs of uti

Who do we not use dipsticks for

in older people they have asymptomatic bacteriuria that doesn’t need treatment so don’t use it

•Men <65 years

•do not use urine dipsticks to rule out UTI in men

•Children

•Pregnant women

•People with catheters

•Recurrent UTIs

what can be present in urine

Haematuria

GLucose

Ketones

Visible and non-visible haematuria

Visible (macroscopic) haematuria: Pink, red, or rusty/cola colour.

Non-visible (microscopic) haematuria: Reagent detects: red blood cells, haemoglobin, myoglobin.

but also consider contamination with menstrual blood

Glucosuria

Glucose in urine

Indicates diabetes, renal tubular disease, SGLT2i

Ketones

Breakdown product of fatty acid metabolism

Usually absent

Indicates lack of carbohydrates e.g. ED

Poorly controlled diabetes

RED FLAG: Diabetes, glucose, ketones

Diabetic ketoacidosis

Cause: Insulin deficiency, lipolysis, ketones, metabolic acidosis

Symptoms: Thirst, frequent urination, abdominal pain, nausea, diarrhoea, acetone breath

If you find ketones doesn’t mean DKA but do further investigation

Vaccinations: Who should not have vaccines

Anyone with previous anaphylactic reaction to the vaccine

Acutely unwell

Live vaccines: contraindicated if pregnant or immunosuppressed

Intranasal

Live attenuated flu vaccine for children

Subcutaneous and intradermal

Subcutaneous: 45 degrees

Intradermal: 15 degrees

Bleeding disordor

For people with bleeding disorders, vaccines are given by deep subcutaneous injection not intramuscular.

Needle kit

What dangers

Deltoid muscle prefered site

If you touch shoulder risk of injury

Lift arm, feel for dimple = acronium process

Too high risk : sciatic nerve

Too low risk of nerve damage axillary or radial nerve

Don’t inject buttock