Diagnostic Quest Outline

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5 Terms

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ECG

• The P-QRS-T components and what they mean

• The types of arrhythmias, the ectopies (PAC, PJC, PVC) and the AV Blocks

• How certain ECG profiles affect cardiac output

Waves in an ECG

P wave - atrial contraction/depolarization

QRS wave - ventricular contraction/depolarization + atria reset

T wave - ventricular reset/repolarization

U wave - not always present, ventricular repolarization

  • in a normal ECG

    • P follows 1 QRS

    • QRS complex

Arrhythmias

  • bradycardia - slow HR but normal rhythm

  • sinus arrest - missing cardiac complex, one or more, before returning (absence of PQRST) aka a brief flat line

  • arrhythmia - irregular rhythm, P precedes QRS (N) but gaps irregular

  • sinus tachycardia - high HR, P wave arrives quickly after T wave

  • atrial flutter - ‘flutter’ waves before each QRS (more atrial contractions before ventricles push blood out)

  • atrial fibrillation - no pronounced P wave (quivering), not immediately life threatening if Q (cardiac output) is consistent

  • ventricular tachycardia - 3 or more PVCs in a row, wide and bizarre QRS complexes that are life threatening, empty contractions

  • ventricular fibrillation - chaotic rhythm, no QRS complexes present, ‘coarse waves’

  • ventricular tachycardia - normal HR but no identifiable P waves, QRS waves are of varying widths

Ectopies

  • PAC - premature atrial contraction

    • absent P/P buried in T wave/abnormal P hidden in preceding T wave, distorting T wave making it pointier

    • signal to beat is happening somewhere else in atria other than SA node (sinoatrial)

  • PJC - premature junctional contraction

    • inverted P wave (bc conduction goes from junction to atrium not normal) or absent or after QRS

    • pacemaker in junction not SA node

    • normal QRS followed by pause

  • PVC - premature ventricular contraction

    • wide bizarre QRS

    • absent P

    • T is opposite to QRS (inverted)

AV blocks

  • first degree

    • all components in order BUT delay between P and QRS

  • second degree

    • P wave no relationship to QRS, hidden in QRS and T waves. 2 P for every QRS (more delay)

  • third degree

    • larger delay between P and QRS, atria fires again before ventricle

How certain ECG profiles affect cardiac output

  • if P absent or abnormal - low CO, blood is not pumped out of atria

  • ???

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Urinalysis

• Why it’s used as a diagnostic test

• What certain products indicate (glucose, casts, ketones, etc)

• How urine is analyzed

• Methods of collecting

• What the color, pH and odor of urine means

• What constitutes normal urine

• What constitutes diabetes, kidney failure, cancer, infection, dietary, etc changes in urine

  • why used - provides info on the kidney and urinary tract, metabolic or systemic (non kidney) disorders, reveal diseases that go unnoticed due to absence of symptoms, overall health of patient, urine composition

  • normal urine has around 96% water and 4% dissolved substances from food, waste products of metabolism

  • how - physical examination (colour, volume, odour, or specific gravity), chemical examination - (pH, blood, gluose, ketone), or microscopic (cells, bacteria, casts, crystals, WBC RBC etc)

  • methods of collection

    • random urine specimen - most common, taken at any time of the day, few ounces in cup

    • first morning urine specimen - greater [] of substances collected over time, also pretty common, collected after a nights sleep

    • clean catch mid stream urine specimen - or Mid Void, collected in the middle of a urination session, void a small amount before to flush normal flora

    • timed urine specimen - measuring urinary output or analyze substances found in urine, discard first specimen, and collect all urine for a specific time

    • 24-hour urine specimen - qualitative and quantitative analysis of one or more substances in urine released in urine sporadically, collected over 24-hours

  • urine

    • colour - fresh urine is clear/pale to deep yellow (yellow = urochrome, recycled RBC), dark yellow dehydrated, cloudy means infection

    • odour - fresh urine is slightly aromatic, if left to stand= ammonia smell as bacteria metabolize in urea solute, drugs/vegs can alter scent of urine

    • pH - normal is slightly acidic 5.0 - 8.0 on avg 6.0 but vary to diet, veggies/fruit/grain 8.5, high protein 4.0

  • products in urine

    • ketone bodies

      • intermediaries of fats and protein metabolism in body, indicate low carb diet or starvation or excessive vomiting, nail polish breath

      • when the body needs to break down fats and fatty acids to use as fuel. This is most likely to occur when the body does not get enough sugar or carbohydrates.

    • glucose

      • glycosuria, common in patients with diabetes, excess glucose in urine

    • nitrite

      • means bacterial infection

      • best test for this is FIRST MORNING

    • WBC

      • in UTI infections or renal infections

      • leukocyte esterase = chemical seen when WBC present

    • pregnancy tests

      • based on hormone CHORIONIC GONADOTROPIN

    • STDs

      • 15-25yrs old females check annually for chlamydia

      • affected have nucleic acid in urine

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Blood Testing

• components and percentages of normal blood

• purpose of a blood smear and what it can reveal

• 6 primary blood counts and what the high and low values may indicate

• how RBC, Hct, and Hgb are related and what their counts reveal

• purpose of blood testing and sample collection

normal blood

  • plasma 55%, RBC 45%, WBC and platelets <1% (buffy coat)

  • plasma is ~90% water containing nutrients, proteins, etc

    • RBC - carry oxygen as hemoglobin carries and releases oxygen to tissues

    • WBC - fight infection

  • a blood smear can determine overall patient health, and are done at the time of a patient’s best body condition, detect disease and diagnose and treat disease

6 primary blood counts - a CBC is the most common blood test incl. 6 test:

  • RBC - total # of RBC

    • low anemia high polycythemia

  • Hct - % of RBC in blood

    • low anemia, blood loss ,high dehydration, burns, shock

  • Hg - amt of hemoglobin in blood

    • low anemia

  • WBC - total # of WBC

    • low bone marrow issue high infection

  • Plt - # of platelets in sample

    • low thrombocytopenia

  • Diff - number of each type of WBC in first leukocyte of sample

    • high infection, cancer athritis

    • low lymph - aids

    • high mono - bacterial infections

    • high eosin - allergies

    • immature WBC - leukemia

  • RBC, Hct, and Hgb are related since #/% of RBC and amt of hemoglobin in sample. Hgb carried by RBC, determines O2 sats etc.

  • purpose of blood sampling + collection - how well organs such as your kidneys, liver, heart, or thyroid are working. Help diagnose diseases such as cancer, diabetes, coronary heart disease, and HIV/AIDS

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Other Diagnostic testing and imaging package

• know the major reasons why certain tests are undertaken (i.e. mammograms, CTs, cholangiograms etc)

mammogram - for breast cancer, cysts, small tumours

lumbar spine MRI - herniated disc, fractured vertebrae, back pain, shows all hard and soft tissue

dental xrays - impacted teeth, tooth decay, cavities

barium enema xray - polyps, IBS, colon cancer

knee xray - knee pain, arthritis, osgood schlatter's disease

hand xray - breaks or dislocation of bones in hand (phalanges, metacarpals), reduction - realigning bones

bone scan - if cancer has trasferred to an are, diagnose bone pain or broken bones or damage, usage of tracers to find hot spots

head ct scan - indicates bleeding and brain tissue damage indicating stroke

intravenous pyelorogram - obstructions in urinary tract or kidney

intraoperative cholangiogram - shows billary duct system/gall bladder and blockages within the system, using a particular dye

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Miscellaneous

• how a history and diagnostic testing are linked

• the entire Taking a History note and the Vitals note (and skills)

  • outpatient - less detail, inpatient - more detail (admitted into hospital)

10 elements of a Hx

  1. Hx of cardiorespiratory disease

  2. Occupation (exposure to things, or second hand smoke)

  3. smoking

    a. 8 pack years magic #, where dmg to lung becomes irreversible and chance of lung cancer increases

    b. X packs per day times Y years smoking = Z pack-year

  4. hoarseness - how long? chronic can be sign of tumour

  5. social Hx - lifestyle/eating/exercise, family support, education

  6. dypsnea - constant or intermittent? when?

    a. sudden onset SOB = cardiac issue or sudden lung collapse

    b. gradual SOB = slow progressing disease

    c. orthopnea = SOB lying down measured by pillows

    d. paroxysmal nocturnal dypsnea - awakens from sleep with SOB suddenly

    d. embolism - blockage of an artery

  7. cough - dry or wet/productive? if wet, is there blood or colour?

    a. sputum colour: yellow is infection/inflammation, green is active infection, clear is usually good or can be in excess cardiac issue, brown is old blood, red is fresh blood, frothy pink is heart failure

  8. pain - where? why is it happening? what makes it better?

    a. Borg (6-10)and VAS(0-10) scale are both SUBJECTIVE scales (effort and pain)

  9. peripheral edema - swelling in extremities (blood accumalates in tissue)

  10. appetite and weight loss

percussion - tapping the body to elicit sounds and determining whether the sounds are appropriate for a particular organ or area of the body, diagnose a number of lung abnormalities

sign - objective and measureable e. temp

symptom - subjective and not measureable ex. hot and flushed

apnea - cessation of breathing