TACS revision

Standard precautions

A group of infection prevention practices in any setting in which healthcare is delivered

5 moments of hand hygiene

1. Before touching a patient

2. Before carrying out a procedure

3. After body fluid exposure risk

4. After touching a patient

5. After touching patient surroundings

Temperature sites + average temperature

• Tympanic: 36.64C

• Oral: 36.57C

• Axillary: 35.97C

• Rectal: 37.04C

55-95bpm

Normal pulse rate

12-20 breaths per minute

Normal respiratory rate

>25 breaths per minute indicates

Tachypnoea

<8 breaths per minute indicates

Bradypnoea

Kortkoff sounds

sounds heard through the stethoscope when ausculating BP, caused by turbulent blood flow through a partially compressed artery

What causes HTN?

• Stress/ anxiety

• White coat HTN

• Stimulants e.g. caffiene, cocaine, nicotine, amphetamine

• Over-hydration/ full bladder

• Salt, baking soda, liquorice

• Cuff size too small

What do you do if BP is too high?

• Check cuff size (not too small) and correct placement

• Make sure patient is relaxed and arm supported

• Measure again after 5 minutes of rest

What causes hypotension?

• Relaxation/ prolonged bed rest

• Heat

• Recent meal

• Dehydration

• Serious illness

• Endocrine/ neurological conditions

• Cuff size too big

Location of aortic valve

2ics RSE

Location of pulmonary valve

2ics LSE

Location of tricuspid valve

4ics LSE

Location of mitral valve and apex beat

L5ics mcl

What does JVP assess?

Right atrial pressure

PPE that is part of standard precautions

• Non-sterile gloves

• Mask

• Eye protection

• Gown/ apron

Associated MSK symptoms

• Pain

• Discolouration

• Stiffness

• Joint swelling

• Heat

• Deformity

• Weakness

• Locking/ Instability

• Altered functional capacity

• Extra-articular symptoms

Associated CVS symptoms

• Chest pain

• Claudication

• Dyspnoea (orthopnoea and PND)

• Palpitations

• Syncope/ pre-syncope

• oedema

D

Sternal angle

C

Suprasternal notch

Why is the internal jugular vein used to assess R atrial P?

No valves and drains directly into SVC

Parts of a CV examination

1. Look (praecordium): scars, pacemaker box, apex beat, muscle bulk and symmetry, JVP

2. Feel: apex beat, peripheral pulses, ausculatation, capillary refill

Informed consent

Process to respect the patient’s right to be informed, make their own decision, and refuse or accept care offered to them

Standard precautions include

• Promoting safety climate

• Respiratory hygiene

• Hand hygiene

• Assessing risk of exposure to body fluid and PPE

• Patient care equipment

• Environment cleaning

Relative degrees of movemet: shoulder + knee

• Shoulder:

  • Flexion: 180°

  • Extension: 60°

  • Adduction: 50°

  • Abduction: 0-140°

• Knee:

  • Flexion + exetension: 0-180°

  • Hyperextension: 10°

  • MCL + LCL: up to 10mm movement (20-30°)

  • ACL + PCL: <5mm

Waves observed in JVP

a + v wave

How does the height of the JVP change with inspiration?

Falls with inspiration due to increased volume of thorax

Associated RESP symptoms

• Cough

  • Sputum

  • Haemoptysis

• Chest pain

• Wheeze

• Hoarseness

• Systemic symptoms

• Dyspnoea

Grading of dyspnoea

• Grade I: breathless when hurrying on flat or walking up slight hill

• Grade II: breathless when walking with other people of own age or on ground level

• Grade III: walks slower than peers, or stops when walking at own pace

• Grade IV: stops after 100m or few minutes on surface level

• Grade V: too breathless to wash/ dress

Normal amount of sputum produced per day

~100mL; clear

Assessment of sputum colour

• Clear/ grey: COPD

• White: asthma

• Dark yellow/ green: bronchopulmonary infection

  • Yellow = live neutrophils (acute)

  • Green = dead neutrophils (chronic)

• Yellow: RTI

• Clear/ water: beoncho-alveolar cancer

• Frothy + pink: pulmonary oedema

• Rusty: pneumococcal penumonia

Causes of hoarseness

Acute inflammation of vocal cords OR chronic tumour on vocal cord or recurrent nerve palsy

Examination position of RESP assessment

patient lying on couch with bed head at maximal height

Causes of tracheal displacement towards side of lesion

Upper lobe collapse/ fibrosis; peneumonectomy

Casues of tracheal displacement away from side of lesion

massive pleural effusion or tension pneumothorax

Causes of tracheal displacement in either direction

upper mediastinal mass e.g. goitre, lymphoma, lung cancer

Sounds during lung field percussion

• Resonant: over normally inflated lung fields

• Dull: over solid structure e.g. liver, pulmonary consolidation, collapse, or fibrosis

• Stony-dull: over fluid-filled areas e.g. pleural efusion (or bone)

• Hyper-resonant: over completely hollow structures e.g. pneumothorax

Breath sounds on auscultation

• Vesicular: normal and louder on inspiration

• Bronchial: harsher and louder on expiration, audible gap between inspiration and expiration

Added sounds on auscultation

• Crackles

• Wheeze

• Pleural friction rub

Avoid ausculation within __ of the midline

3cm

Associated GI symptoms

• Mouth ulcers

• Dysphagia

• Indigestion/ heartburn/ GER

• Nausea

• Retching

• Vomiting

• Haematemesis

• Abdominal pain

• Melaena

• Jaundice

• Wind: belching or burping

• Change in bowel habits e.g. diarrhoea, constipation, overflow diarrhoea, recetal bleeding, tenesmus, steatorrhea

7 F’s of abdominal distension

• Fat

• Fluid

• Flatulence

• Foetus

• Faeces

• “Frightfully” big tumour

• “Phantom” pregnancy

Extra-abdominal organs assessed in GI assessment

• Hands: clubbing, tobacco staining, palmar erythema

• Face: jaundice, pallor, tobacco staining

• Eyes: conjuctive pallor, jaundice in sclera

• Mouth: dehydration, dentition

• Skin: bruising/ petechiae, sratch marks, spider navi

Extra-abdominal organs that require special permission in GI assessment

• Eyes

• Mouth

• Face (quizzes)

Gaurding

Contraction of the muscles in the abdomen, voluntary if the patient anticipates pain or involuntary in peritonitis

Rigidity

Constant involuntary contraction of the abdominal muscles associated with tenderness

Rebound tenderness

Tenderness elicitied by pressing firmly over an inflamed structure and suddenly withdrawing pressure

Borborygmi

Audible sounds madeby the GI tract (tummy rumbles)

Features of crackles (crepitations/ rales)

• Non-musical sounds

• Like velcro being pulled apart/ hair rubbed between fingers

• Common causes: infection, LHF, COPD, pulmonary fibrosis

Features of wheeze (rhonchi)

• Continuous muscial noises

• Caused by vibration of narrow airways

• Heard throughout lung fields, usualy in expiration

• Common causes: asthma, COPD

Features of pleural friction rub

• Like leather rubbed together/ creaking sound

• Due to thickened, inflamed surfaces rubbing together

• Associated w pleuritic pain

• Common causes: PE, pneumonia

Causes of reduced breath sounds

• Reduced conduction of sound (obesity, thickened chest wall, pleural effusion, pleural thickening, pneumothorax)

• Reduced airflow (COPD, collapse by foreign body/ cancer)

Causes of asymmetrical absent breath sounds

• Unilateral pleural effusion/ pneumothorax

• Collapse due to major obstruction of bronchus by foreign body or carcinoma

Parts of closing the session

1. Contracts

2. Safety nets

3. Summary

4. Final check

Associated neuro symptoms

• Pain (head, face, neck, back)

• Change in LoC, syncope

• Dizziness/ vertigo

• Seizures

• Weakness

• Nausea/ vomiting

• Motor impairment (gait, speech, dysphagia, involuntary movement, bladder/ bowel)

• Change in cognition

• Sensory impairment (loss, vision, hearing, smell, taste)

Normal chest expansion

>5cm normal

Causes of symmetrical reduced chest expansion

• Asthma

• Emphysema

Causes of unilateral reduced chest expansion

• Consolidation

• Pneumothorax

• Localised collapse

• Pleural effusion

Causes of back pain radiating to leg

• Disc prolapse

• Cauda Equina Syndrome

Characterstics of focal seizures

• Aura

• Motor features (e.g. limb jerking)

• Transient loss of awareness or responsiveness

Positive Romberg’s sign

Worsening balance when the eyes are closed (loss of proprioception)

Features of nominal dysphasia

• Cannot name objects

• Speech and lanuage normal, fluent

• Uses long phrases to descibe one word

Athetosis

Slow writhing movements often seen in cerebral palsy

Red flag features for headaches

• New headache in older person (>50yrs)

• History of trauma

• Sudden onset esp if no history of headache

• Severe debilitating pain (SAH)

• Features of raised ICP

Red flag symptoms for headaches

• Change in LoC

• Fever, nausea, vomiting, photophobia, neck stffness

• Weight loss

• Changes in mood or personality

• Focal neurological deficit

• Changes in cognitive function

Causes of true vertigo

• Acue labrynthitis (inflammation of inner ear)

• Benign paroxysmal positional vertigo (short-lived intense vertigo)

• Meniere’s disease (acute attacks of vertigo, fluctuating tinnitus, increasing deafness, pressure in inner ear)

• Acoustic neuroma (benign slow growing tumour)

Parts of cognitive examination

Orientation to person, place, and time (date)

Eye response in GCS

4 = spontaneous

3 = to sound

2 = to pressure

1 = no response

Verbal response in GCS

5 = orientated

4 = confused

3 = words

2 = sounds

1 = no response

Motor response in GCS

6 = obeys commands

5 = localising

4 = normal flexion

3 = abnormal flexion (decorticate)

2 = extension (decerebrate)

1 = no response

Features of decorticate response (abnormal flexion)

• Slow sterotyped movement

• Elbows flexed and forearms across chest

• Hands pronated

• Thumb and fingers flexed

• Legs extended

• Feet plantarflexed

Features of decerebrate response (extension)

• Elbows extended

• Arms adducted and internally rotated

• Wrist, thumbs and fingers flexed

• Legs extended

Interpreting GCS severity

13-15: mild head injury

9-12: moderate head injury

3-8: severe head injury

Pressure points in GSC exam

• Supraorbital notch pressure

• Trapezius squeeze

Upper limb reflex locations

• Biceps (C5, C6)

• Triceps (C7, C8)

• Brachioradialis (C5, C6)

Lower limb reflex locations

• Knee jerk/ patllar reflex (L3, L4)

• Ankle jerk/ achilles reflex (L5, S1)

• Plantar reflex (S1, S2)

Lesions in the brain which can cause sensory disturbances

• Brainstem

• Thalamus

• Sensory cortex

Vibration sense positions moving proximally

1. End of great toe/ toenail

2. MTP of big toe

3. Medial malleolus

4. Tibial tuberosity

5. Anterior iliac spine

Parts of CN V examination

• Sensation

• Corneal reflex

• Motor (jaw opening)

• Jaw reflex

Parts of CN IX, X, XII examination

• Cough

• Speech/ articulation

• Uvula movement

• Gag reflex (if indicated)

• Tongue appearance and movement

Conductive deafness

Abnormal conduction of sound anywhere from the external auditory meatus to stapes (includes blockage from otitis media and earwax)

Sensorineural deafness

Abnormal conduction of acoustic vibration and neural impulses by the cochlear and vesitbulocochlear nerve to the brain

Normal (+ve) Rinne’s test

Air conduction better than bone conduction

Abnormal (-ve) Rinne’s test usually indicates

Conductive hearing loss (bone conduction greater than air conduction)

Weber’s test in conductive hearing loss

Sound localises to affected ear

Weber’s test in sensorineural hearing loss

Sound localises to normal ear

Why is the weber’s test louder in the affected ear in conductive hearing loss?

• Masking (no masking effect from environmental noise)

• Occlusion (sound cannot dissipate out of auditory canal which increases cochlear stimulation)

‘Lowest line read’ in visual acquity test

The last line that can be read with 2 errors or less

The finger should be held approximately __cm from the patient when testing eye movement

30cm

The torch should intially be held __cm away from the face when testing the light reflex

10cm

Hand positioning when testing orbicularis oculi (CN VII)

• Left hand: fingers and thumb at the eyebrow

• RIght hand: fingers and thumb just below the eye

Hand positioning when testing buccinator (CN VII)

3 fingers on each cheek, length of fingers (rather than fingertips)

Types of tuning forks used in CN VIII exam

256Hz or 512Hz

Abnormal Rinne’s test suggesting severe sensorineural hearing loss

• Cannot hear both bone and air conduction

• Patient does not hear tuning fork when placed on mastoid AND beside external auditory meatus

Cough heard in laryngeal nerve problem (CN X)

Non-explosive/ bovine cough

Wheeze

High-pitched squeek caused by turbulent flow of air through constricted airways, heard louder on expiration

Stridor

Inspiratory wheeze which may indicate upper airway obstruction

Process of assessing tracheal position

Right middle finger above suprasternal notch

Right index finger and ring finger to right and left of trachea

Hand positioning during chest expansion

Fingers towards mid-axillary line

Fingers firmly and gently applied to lateral chest wall

Thumbs towards the spine, almost meeting and midline and hovering slightly off chest