Podcast
Questions and Answers
What is the first step that the doctor who assesses the patient for the first time shall take?
What is the first step that the doctor who assesses the patient for the first time shall take?
Obtain History
What are the two types of hormones that affect blood Glucose levels?
What are the two types of hormones that affect blood Glucose levels?
Which of the following is NOT a recognized method for causing a pain stimulus during an AVPU assessment?
Which of the following is NOT a recognized method for causing a pain stimulus during an AVPU assessment?
The initial assessment of a ward patient shall be done within 30 minutes of the admission.
The initial assessment of a ward patient shall be done within 30 minutes of the admission.
Signup and view all the answers
What is the average length required to insert an NG tube into an adult patient's body?
What is the average length required to insert an NG tube into an adult patient's body?
Signup and view all the answers
What is the standard length of the Ryle's Tube?
What is the standard length of the Ryle's Tube?
Signup and view all the answers
What is the preferred vein to access in a patient experiencing shock or an emergency?
What is the preferred vein to access in a patient experiencing shock or an emergency?
Signup and view all the answers
What is the recommended infusion rate for a hypertonic saline solution?
What is the recommended infusion rate for a hypertonic saline solution?
Signup and view all the answers
What is the most common electrolyte disorder?
What is the most common electrolyte disorder?
Signup and view all the answers
Which of the following is NOT a complication of hyperkalemia?
Which of the following is NOT a complication of hyperkalemia?
Signup and view all the answers
Which of the following situations is NOT an indication for registering a patient as a Medico-legal case (MLC)?
Which of the following situations is NOT an indication for registering a patient as a Medico-legal case (MLC)?
Signup and view all the answers
What is the purpose of ID bands for patients?
What is the purpose of ID bands for patients?
Signup and view all the answers
Which of the following is a primary objective of triage?
Which of the following is a primary objective of triage?
Signup and view all the answers
What are the four categories of patients that the START triage method categorizes?
What are the four categories of patients that the START triage method categorizes?
Signup and view all the answers
The SBAR communication technique promotes clear, effective, and efficient communication.
The SBAR communication technique promotes clear, effective, and efficient communication.
Signup and view all the answers
Why is it important to ensure patient comfort?
Why is it important to ensure patient comfort?
Signup and view all the answers
Fasting blood sugar levels should be monitored every day in diabetic patients.
Fasting blood sugar levels should be monitored every day in diabetic patients.
Signup and view all the answers
Which of the following is NOT a common location for the development of pressure sores?
Which of the following is NOT a common location for the development of pressure sores?
Signup and view all the answers
What is the purpose of the FAST HUG technique?
What is the purpose of the FAST HUG technique?
Signup and view all the answers
According to the START triage method, which color band is assigned to a patient who has minor injuries and can wait for longer treatment?
According to the START triage method, which color band is assigned to a patient who has minor injuries and can wait for longer treatment?
Signup and view all the answers
What is the purpose of a handover book/form?
What is the purpose of a handover book/form?
Signup and view all the answers
The SBAR communication technique is a standard communication protocol that can only be used for informing consultants.
The SBAR communication technique is a standard communication protocol that can only be used for informing consultants.
Signup and view all the answers
What does the acronym 'DNR' stand for?
What does the acronym 'DNR' stand for?
Signup and view all the answers
The Glasgow Coma Scale (GCS) is used to measure the level of consciousness in patients with a brain injury, but not in patients before undergoing an operation or in patients who have experienced a trauma.
The Glasgow Coma Scale (GCS) is used to measure the level of consciousness in patients with a brain injury, but not in patients before undergoing an operation or in patients who have experienced a trauma.
Signup and view all the answers
The use of physical restraints on a patient is always prohibited.
The use of physical restraints on a patient is always prohibited.
Signup and view all the answers
Which of the following is NOT a primary objective of a good doctor-patient relationship?
Which of the following is NOT a primary objective of a good doctor-patient relationship?
Signup and view all the answers
What color band is used for identifying patients with allergies?
What color band is used for identifying patients with allergies?
Signup and view all the answers
It's okay to interrupt a patient to ask clarifying questions as long as it's done in a polite manner.
It's okay to interrupt a patient to ask clarifying questions as long as it's done in a polite manner.
Signup and view all the answers
The purpose of reporting medication errors is primarily to hold healthcare professionals accountable.
The purpose of reporting medication errors is primarily to hold healthcare professionals accountable.
Signup and view all the answers
Which of the following is NOT a common medication error?
Which of the following is NOT a common medication error?
Signup and view all the answers
It’s important to document the patient's medical history, diagnosis, and medications, but this information can be omitted if they are not directly related to their current complaint.
It’s important to document the patient's medical history, diagnosis, and medications, but this information can be omitted if they are not directly related to their current complaint.
Signup and view all the answers
It is appropriate to provide patient education brochures to relatives on admission to the Intensive Care Unit (ICU).
It is appropriate to provide patient education brochures to relatives on admission to the Intensive Care Unit (ICU).
Signup and view all the answers
In the SBAR communication technique, what does the 'A' stand for?
In the SBAR communication technique, what does the 'A' stand for?
Signup and view all the answers
What is generally considered a universal donor?
What is generally considered a universal donor?
Signup and view all the answers
Which of the following blood products is NOT usually given during a transfusion?
Which of the following blood products is NOT usually given during a transfusion?
Signup and view all the answers
If a patient is experiencing a transfusion reaction, what should be the immediate action?
If a patient is experiencing a transfusion reaction, what should be the immediate action?
Signup and view all the answers
An increase in heart rate is an indicator of potential complications in patients with a recent history of myocardial infarction.
An increase in heart rate is an indicator of potential complications in patients with a recent history of myocardial infarction.
Signup and view all the answers
In a patient with a suspected neurological event, it's important to obtain a detailed history, including the exact time of onset of the symptoms.
In a patient with a suspected neurological event, it's important to obtain a detailed history, including the exact time of onset of the symptoms.
Signup and view all the answers
Which of the following is NOT a common cause of hypokalemia?
Which of the following is NOT a common cause of hypokalemia?
Signup and view all the answers
It is generally considered safe to administer Potassium Chloride intravenously, in a concentrated form through a peripheral line.
It is generally considered safe to administer Potassium Chloride intravenously, in a concentrated form through a peripheral line.
Signup and view all the answers
What color band is used for identifying patients who are considered vulnerable?
What color band is used for identifying patients who are considered vulnerable?
Signup and view all the answers
The 5 Rights of Medication Administration are designed to help reduce the risk of medication errors.
The 5 Rights of Medication Administration are designed to help reduce the risk of medication errors.
Signup and view all the answers
What is the primary purpose of reporting medication errors?
What is the primary purpose of reporting medication errors?
Signup and view all the answers
It is acceptable to use short forms when documenting patient consents.
It is acceptable to use short forms when documenting patient consents.
Signup and view all the answers
It's generally recommended to use the ‘SBAR’ communication technique when reporting the findings of an unconscious or disoriented patient.
It's generally recommended to use the ‘SBAR’ communication technique when reporting the findings of an unconscious or disoriented patient.
Signup and view all the answers
Which of the following is NOT typically included in a handover report during a shift change?
Which of the following is NOT typically included in a handover report during a shift change?
Signup and view all the answers
It's a good practice to use a penlight to assess pupillary reflexes in a dark environment without any external distractions.
It's a good practice to use a penlight to assess pupillary reflexes in a dark environment without any external distractions.
Signup and view all the answers
When assessing the motor system, what are the five key areas to focus on?
When assessing the motor system, what are the five key areas to focus on?
Signup and view all the answers
It's considered safe to administer IV Potassium chloride in its undiluted form via a central line.
It's considered safe to administer IV Potassium chloride in its undiluted form via a central line.
Signup and view all the answers
What is the purpose of the 'FAST HUG' mnemonic?
What is the purpose of the 'FAST HUG' mnemonic?
Signup and view all the answers
What is the primary purpose of the 'READ BACK' technique in medication administration?
What is the primary purpose of the 'READ BACK' technique in medication administration?
Signup and view all the answers
Which of the following situations is NOT a common reason for a patient to be considered 'vulnerable' and require special care?
Which of the following situations is NOT a common reason for a patient to be considered 'vulnerable' and require special care?
Signup and view all the answers
Study Notes
Patient Admission Processes
- Various locations have different admission pathways (Deccan, Nagar Road, Hadapsar; Kothrud, Bibwewadi, Surya, Nashik, Karad)
- Planned admissions and walk-in/emergency admissions are distinguished.
- A doctor assesses patients, obtaining medical history and performing initial assessments.
- The consultant and Care Plan are then used.
Doctor Responsibilities (Initial Assessment)
- Obtain the patient's history.
- Do an initial assessment.
- Inform the consultant.
- Document and follow the Care plan.
Lab Investigations
- Consultant/Resident orders the investigations.
- Doctors document the IPD file and fill the Lab requisition form.
- Online requisition forms are available.
- Samples can be collected by a Phlebotomist or Staff nurse.
- Lab samples will be collected for ABG and Blood Culture & Sensitivity.
- Specific preparations are needed (e.g., 14 hours NBM for lipid profile).
- Doctors follow up on the reports (HMIS).
- Doctors document the report and inform the consultant.
Radio-Diagnostic Investigations
- Consultant/Resident orders the investigations.
- Doctors complete the radiology requisition form and contact Radiology/Diagnostics .
- Doctors obtain history and indication, and take preparation instructions (e.g., NBM status/full bladder).
- Specific preparation is required (e.g., creatinine before contrast, rule out metal implants before MRI).
- Unstable patients are accompanied by a nurse and doctor.
- Doctors follow up on & document the reports and inform consultant.
History Taking
- Effective history taking requires patient attention.
- A good rapport is required with the patient.
- Introduce yourself, be respectful and comfortable with the patient.
- Communicate with the patient in their preferred language (mother tongue).
Initial Assessment of Ward Patients
- Ward patient assessment within 30 minutes of admission, and within 10 minutes for critical care.
- The doctor documents a complete history sheet for all columns.
- CMO fills out the history for casualty, ward/ICU patients.
- CMO/doctor fills out history for planned admissions to wards/ICU directly.
- The patient/relative signs the history for verification.
Chief Complaints
- Obtain information in the patient's own language.
- Avoid medical terminology when asking questions (e.g., avoid burning micturition = hematuria).
- Ask open-ended questions like "Tell me about your stomach pain."
- Ask leading questions like “Was the vomitus red, yellow or black, coffee ground?”
- Use medical terms during documentation on the case sheet.
Relevant Questions About Pain
- Question the patient about site, onset, character, radiation, associations, timing, duration, exacerbating, alleviating factors, and severity.
- Use a numerical pain score ranging from 0 to 10.
- Document & act accordingly.
Cardio-Respiratory Symptoms
- Chest pain
- Dyspnea (shortness of breath, at rest or exertion)
- Orthopnea (shortness of breath when lying down)
- Edema (swelling)
- Palpitations (rapid heart beat)
- Cough
- Wheeze
- Sputum
- Hemoptysis (coughing up blood)
- Weight loss
GI Symptoms
- Pain in the abdomen
- Nausea
- Vomiting – color, quantity, frequency
- Hematemesis – blood in vomitus
- Diarrhea
- Constipation
- Altered bowel movements
- Pain while defecation
- Blood in stools
Genitourinary Symptoms
- Incontinence (urge to urinate)
- Dysuria (painful urination)
- Hematuria (bloody urine)
- Nocturia (need to urinate at night)
- Polyuria (frequent urination)
- Hesitancy (difficulty starting urination)
- Terminal dribbling
- Pain in the flanks
Neurological Symptoms
- Senses (sight, hearing, smell, taste, touch)
- Headache - location, type.
- Numbness of limbs
- Weakness of limbs
- Higher mental function
Musculoskeletal Symptoms
- Pain, stiffness, swelling of joints
- Diurnal variation
- Functional deficit
Thyroid Symptoms (Hyperthyroidism)
- Prefers cold weather
- Bad tempered
- Sweaty
- Diarrhoea
- Oligomenorrhoea
- Weight loss, increased appetite
- Tremors
- Palpitations
- Visual problems
Thyroid Symptoms (Hypothyroidism)
- Depressed
- Slow, tired
- Thin hair
- Croaky voice
- Heavy periods
- Constipation
- Dry skin
- Prefers warm weather
Associated Complaints
- Headache - nausea, vomiting
- Chest pain - jaw pain, shoulder pain
- Neck pain - numbness in arms
- Long standing productive cough - nigh sweats, weight loss, anorexia.
Drug History
- Current medication – name, dose, route, frequency, duration.
- Allergies to any past medication
Past History
- Ask about HTN/DM/TB/IHD.
- If yes, ask about the medication's details and previous surgical history.
Family History
- Details about family members including - HTN/DM/TB/Epilepsy/Cancer
- Ask about the age of onset of diseases/illnesses,
- prognosis, tendency for hyperlipidemia, obesity, HTN
Personal History
- Smoking, Alcohol, Drug Use / Tobacco use
- Details about diet habits.
- Social life (to get an understanding about the above parameters)
- Occupational history.
Menstrual History
- Menstrual Cycle (MC: 4/28 - bleeding for 4 days every 28 days)
- Regular, moderate, painless menstrual periods (RMP)
- Heavy bleeding (Menorrhagia)
- Painful menses (Dysmenorrhea)
- Painful intercourse (Dyspareunia)
- Last Menstrual Period (LMP)
- Date of Menarche
Obstetric History
- Obstetric codes for patients with two living children and one abortion
Obstetric History (Details)
- Gravida – number of pregnancies
- Para – number of births
- Parity – number of viable fetuses born
- Multipara
- Primipara
Concluding the History
- Ask the patient's ideas, concerns, and expectations.
- Summarize the history and ensure understanding. Collect patient's signature for verification.
Important Considerations During History Collection
- Don't get disturbed/irritated/carried away
- Maintain composure while patients are arguing, confused, weepy or violent.
What is Pain?
- An unpleasant sensory and emotional experience associated with actual or potential tissue damage.
- The body's response to pain has both physiological and psychological aspects.
- Effective pain management is crucial for patient care, and plays a key role in patient satisfaction and overall hospital experience.
Pain Causes Issues
- Pain can lead to tachycardia and sweating due to sympathetic nervous response.
- The person may hold their breath, have shallow breathing which can lower circulating oxygen and increase cardiac load.
- Pain can interfere with sleep, appetite and lower overall quality of life.
- The body will naturally respond to pain, stopping activity, tensing muscles and withdrawing from the pain.
- Untreated pain can lead to fatigue, anxiety, confusion and depression. It also leads to increased risk of falls, and decreased physical functioning.
Good Pain Management
- Conduct pain assessment.
- Obtain detailed history.
- Regularly monitor pain scores.
- Develop a pain management plan including drug and non-drug interventions.
- Monitor patient response to treatment.
Common Failures in Pain Assessment
- Neglect (overlooked area)
- Poor documentation (lack of detailed assessment.)
- Unimportant (treatment given without pain assessment)
- Confusion, about how to assess / measure pain
- Myth that assessment is unnecessary once treatment is given.
Pain Assessment Is Not...
- Relying on changes in vital signs
- Deciding patient 'looks in pain.'
- Knowing how much a procedure should hurt.
- Assuming a sleeping patient does not have pain.
Pain History Considerations
- Pain characteristics (onset, duration, location, quality, intensity, associated symptoms, exacerbating/relieving factors).
- Past and current pain management therapies
- Medical and family history
- Psychosocial history
- Impact of pain on daily life (work, activities, personal relationships, sleep, appetite, emotional state).
- Patient (and family's) expected goals for treatment
Nonverbal Pain Indicators
- Facial expressions (e.g., grimacing, rapid blinking, sadness, or fear)
- Vocalizations (e.g., crying, moaning, groaning, grunting, chanting, calling out, or noisy breathing)
- Body movements (e.g., guarding, rigidity, tense posture, fidgeting, pacing, rocking, or limping)
Using Pain Scales (Examples)
- Numerical Pain Scale (0–10) Patient rates own pain.
- Faces Pain Scale - Facial expressions, to correlate with patient pain levels.
Pain Management - Drugs
- Analgesics are used to relieve pain without eliminating sensation (different from anaesthetics).
- Systemic analgesics categories : Oral, Intravenous, Intramuscular, Transdermal patch
- Topical analgesics: Cream, ointments, gels.
- Other analgesics categories: NSAIDS, COX-2 inhibitors, Opioids, combinations, Atypical analgesics
NSAID - Non Steroidal Anti-Inflammatory Drugs
- Analgesics and antipyretics
- Anti-inflammatory effects in larger doses.
- Non-narcotic and non-addictive
NSAID - Examples
- Salicylates (Aspirin)
- Propionic acid derivatives (Ibuprofen, Dexibuprofen, Dexketoprofen, Naproxen)
- Acetic acid derivatives (Indomethacin, Etodolac, Ketorolac, Diclofenac, Aceclofenac)
- Enolic acid derivatives (Piroxicam, Meloxicam, Lornoxicam).
- Anthranilic acid derivatives (Mefenamic acid)
NSAID - Sulfonanilides
- Nimesulide
- Banned for some countries due to risk of hepatotoxicity.
- Not indicated in children below 12.
- Prolonged use can cause side effects such as diarrhea, vomiting, skin rash, itching & dizziness.
Paracetamol/Acetaminophen
- Not an NSAID.
- Low anti-inflammatory activity.
- Analgesic and Antipyretic.
- Maximum combination with other analgesics (e.g., Dicyclomine + Paracetamol, Mefenamic Acid + Paracetamol, Dextropropoxyphene+Paracetamol etc.).
COX-2 inhibitors
- Controversial due to cardiovascular risks.
- Rofecoxib and Valdecoxib are banned in India.
- Available in India: Celecoxib, Etoricoxib (Ezact, Etoshine, Lorfit, Celact).
Adverse Effects of Pain Medications
- Paracetamol: Liver failure with overdose
- NSAIDS: Dyspepsia, nausea, vomiting & gastric erosion/bleeding; kidney/liver failure in high doses.
- COX-2 inhibitors: Increased risk of MI & stroke.
Opioids
- Act on opioid receptors to produce analgesia
- Mechanisms: decreased pain perception, lowered pain reaction and increased pain tolerance.
- Types: Mild (e.g., tramadol, codeine) and Strong (e.g., morphine, fentanyl)
Mild Opioids
- Tramadol (Injection, Cap/Tab/Suppository, 50mg/100mg)
- Often combined with Paracetamol
- Ultracet/Urgendol P
- Codeine Sulphate (Tab Codeine, Syp Phensedyl, Mit's Codeine Linctus)
Strong Opioids
- Morphine Sulphate (Tab / Inj 10mg)
- Fentanyl Citrate (Inj/Patch)
Opioids Adverse Effects
- Nausea, Vomiting
- Constipation
- Sedation
- Respiratory Depression
- Cough suppression
Strong Opioid Considerations
- Euphoria.
- Physical dependence: Patient relies on medication to avoid symptoms of withdrawal.
- Drug Tolerance: Larger doses may be needed to achieve the same effect over time.
Atypical Analgesics
- For chronic/neuropathic pain
- Categories: Tricyclic antidepressants (e.g., Amitriptyline) and Anti-epileptic drugs (e.g. Carbamazepine, Gabapentin, Pregabalin)
WHO 3-Step Pain Ladder (Cancer Pain)
- Strong opioids (e.g., morphine, fentanyl) - for pain severity 8+/10
- Mild opioids (e.g., codeine, dihydrocodeine, co-codamol) - for pain severity 5-8/10
- Non-opioids (e.g., paracetamol +/- NSAID) - for pain severity 2-5/10
Choice of Analgesic
- Considerations: Severity & cause of pain, earlier drug treatment, patient's age & comorbidities.
Non-Pharmaceutical Pain Management
- Rest and immobilization
- Manipulation, Mobilization, Physiotherapy
- Correction of posture
- Traction
- Local heat application
- Cryotherapy (cold therapy, e.g., icepacks)
- Transcutaneous electrical nerve stimulation (TENS)
Clinical Examination
- Privacy & dignity.
- Proper draping, only expose area being examined
- Accompany female patients with a female attendent
- Use Systematic approach to examination
- Vital signs (e.g., temperature, pulse, respiration, blood pressure, Sp02)
- General examination (e.g., posture, nutritional status, consciousness, responsiveness, pallor, edema, lymph node assessment , icterus, cyanosis, skin, dehydration
- Inspection: (e.g., cleanliness, appearance, posture (e.g., forced supine, fetal))
- Palpation (e.g., tender, masses, normal lymph nodes are not palpable
- Others (e.g., systemic examination)
Nutritional Status (Patient Assessment)
- One of the most important factors impacting health and disease.
- Evaluated through assessing skin, hair, muscle, and subcutaneous fat.
- Measurable parameters include body weight, height, BMI, arm circumference, and skinfold thickness
- Patient classification: Normal/Average Nutrition, Under-nutrition or Over nutrition( overweight or obese).
- Patient conditions: Emaciation, Marasmus, Cachexia
Cachexia
- Severe form of malnutrition characterized by weight loss, muscle atrophy, fatigue, weakness, and poor appetite.
- Conditions associated include malignancy, AIDS, chronic obstructive lung disease, and tuberculosis.
Consciousness & Responsiveness (Patient Examination)
- Memory Deficit
- Confusion
- Disorientation
- Language disturbance
- Delayed responses
- Emotional status
- Restlessness
- Aggressive, Rowdy, or Delirious
- Depressed, indifferent
- Drowsy, stuporous, or comatose
Assess Responses (AVPU)
A - Alert (fully awake, may not be well oriented) V - Responsive to voice (eyes, voice, or motor response) P - Responsive to pain (eyes, voice, or motor response) U - Unresponsive (no eye, voice, or motor response)
Pallor
- Paleness of the skin and mucous membranes.
- Causes include: reduced oxyhaemoglobin amount due to decreased blood supply (e.g., cold, fainting, shock, hypoglycemia), or decreased red blood cell numbers (e.g., anemia)
- Checking locations: face, lips, oral mucous membrane, tongue, palate, conjunctiva, palmer crease, and nailbeds.
- Good lighting is important.
- Pallor can develop suddenly or gradually.
Raynaud's Phenomenon - Pallor (Details)
- A cause of pallor.
- A condition in which blood vessels narrow, reducing blood supply to the extremities (fingers, toes).
Possible Causes of Pallor (Acute/Chronis)
- Acute: Emotional response (fear, embarrassment, grief, panic attacks), Frostbite, reaction to alcohol/drugs, migraine attack, shock or hypoglycemia.
- Chronic: Anemia( blood loss, malnutrition ), Vitamin D Deficiency, Osteoporosis, Scurvy, Hypothyroidism, Hypo-pituitarism, Cancer, Leukemia.
Icterus
- Yellowish pigmentation of the skin and mucous membranes, (especially conjunctiva over sclera) caused by hyperbilirubinemia.
- Normal serum bilirubin level is typically less than 1 mg/dL
- 1.8 mg/dL or higher, this leads to jaundice/icterus
Prehepatic Icterus (Mechanism)
High rate of hemolysis beyond liver's ability to conjugate, so there's an accumulation of unconjugated (indirect) bilirubin in blood. • Conditions associated: Hemolytic anemia, Sickle cell anemia, Thalassemia, Malaria, HUS
Intrahepatic Icterus (Mechanism)
Problems in the liver itself - liver cirrhosis and alcohol liver disease, infections of the liver (e.g., viral, Leptospirosis) or inflammation.
Extrahepatic Icterus (Mechanism)
• Blockages in the biliary tree(e.g., gall stones, or stricture causing increased level of conjugated(direct) bilirubin) • Other conditions : Obstructive Gall stones, Pancreatitis, cyst or cancer in the head of pancreas.
Cyanosis
- Bluish discoloration of skin and mucous membranes caused by oxygen deficiency in blood (lack of oxygen or increased levels of deoxygenated hemoglobin).
- A more severe level of hypoxia is needed for cyanosis to be seen in anemic patients (e.g., Hb of 6 g/dL need oxygen saturation to fall as low as 60% before cyanosis is clinically apparent).
- The central sites (e.g. tongue, lips) will show cyanosis before the extremities.
Oedema
- Abnormal fluid accumulation under the skin or tissues (general or localised)
- Pitting oedema - More common, resulted by water retention (pregnancy, heart/kidney failure, and local conditions like varicose veins/thrombophlebitis, insect bites or dermatitis.
- Non-pitting oedema (Lymphedema & myxoedema): more common with various types of hypothyroidism and in other conditions like Graves' disease
Pathophysiology of Oedema
- Filtration depends on hydrostatic pressure in the blood
- Increased permeability of capillaries can be caused by inflammation, sepsis, thrombophlebitis, stings / bites and allergic reaction.
- The reabsorption of fluid and protein in blood depends upon oncotic pressure
- Conditions leading to reduced albumin synthesis (e.g., liver cirrhosis, malnutrition) increase the risk for oedema formation.
Lymphadenopathy
- Enlarged lymph nodes
- Causes include localised infections (e.g., flu) or generalised infections (e.g., influenza) and other conditions like Tuberculosis (TB), Tumors.
- Includes primary tumours (e.g., Hodgkin's and non-Hodgkin lymphomas) and secondary tumours (e.g., metastases), autoimmune conditions (e.g., SLE, rheumatic arthritis). or immunocompromised status
- Clinical Presentation: may be localised/generalised
Palpation : Lymphadenopathy (Details)
- Normal lymph nodes are not palpable
- Assessment notes
- Location of lymph nodes (e.g., head, neck, axilla, inguinal)
- Size (in centimeters)
- Degree of tenderness
- Fixation to the underlying tissue
- Texture (e.g., hard, soft, etc).
Skin
- General examination
- Eruptions, Rash, Erythema
- Pigmentation, Scars (physical or healed from surgical procedures)
- Observe for moisture & elasticity
- Observe for capillary refill
- Skin conditions indicate generalized health
- Including hydration status
Dehydration Clinical Classification (Table)
- Patient classification
- Includes mental status and descriptions of heart rate, breathing, pulse, capillary refill, perferusion, blood pressure, eyes, tears and mucous membrane, skin turgor and urine output for the patient classification.
Examination of Respiratory System
- Respiratory Rate (Normal: 12-18 breaths/min).
- Pattern of respiration (bilateral chest movement assessment)
- Auscultation (assessing air entry for all lobes, anteriorly and posteriorly (e.g. wheezes, rhonchi, creptus, and rales)
- Check for abnormal breath sounds (e.g. wheezes, rhonchi, crackles, or rales)
- Check for decreased air entry and percussion note
- Check for use of accessory muscles
Examination of Cardiovascular System
- Palpate the apex beat (at 5th intercostal space in midclavicular line).
- Auscultate the heart sounds (at the apex or mitral area).
- Turn to left lateral position and listen during expiration (for any murmur, e.g., mid diastolic murmur for mitral stenosis and pansystolic murmur for mitral regurgitation).
Examination of Abdomen
- Assess 9 abdominal areas; light and deep palpation (e.g., assess for guarding).
- Palpate abdomen for Masses
- Liver (using radial border of index finger)
- Spleen (start below umbilicus, moving towards left costal margin, ask patient to breathe deeply)
- Specific abdominal quadrants
- Use of 9 abdominalquadrants.
Examination of Neurology
- Walk – gait assessment (e.g., Romberg's test, heel walking, tandem walking).
- Speech – assessed for content and articulation.
- Vision – assessed visually for acuity, temporal fields, and眼 fundus.
- Face – assessed for eye closure, mouth deviation/opening, facial sensation.
- Upper Limbs - Pronator Drift, shoulder abduction against resistance, biceps/triceps/finger-to-nose test, fine movements of the hand, sensation.
- Lower Limbs – Hip flexion & knee extension against resistance, deep tendon reflexes (knee and ankle), and plantar reflex.
- Others – assessed for neck stiffness and checked cranial & spine.
Vital Signs
- Temperature
- Respiratory rate
- Pulse rate
- Blood pressure
When to Assess Vital Signs?
- On admission
- Every 4-6 hours in wards & continuous in the critical care areas.
- Changes to symptoms or appearance of new symptoms.
- Before, during & after any surgery or invasive procedure
- Before & after medication administration, (especially high risk medication/procedures like blood transfusions).
- Before, during & after Blood transfusion.
- Vulnerable/high-risk patients require more frequent monitoring.
Vital Signs Linked to MEWS Scoring
- Patients shifted from ICU to wards.
- Immediate post-operative patients in wards.
- Patients with GCS score < 13
- Patients with 2+ comorbidities
- Known case of Diabetes, Hypertension, or Ischemic/heart disease.
- Known case Hypothyroidism/COPD/renal failure.
Temperature
- Measures the balance of heat produced and heat lost by the body.
- Types include core temperature, oral temperature, rectal temperature & surface temperature.
- Variations may occur within 1°C.
- Factors affecting include diurnal variation/environmental temperature/age/basal metabolic rate/muscle activity/sympathetic stimulation / response to stress.
- Alterations like hypothermia(<35.0 °C)
- fever/pyrexia (36.5-37.5 °C)
- hyperpyrexia (>40 °C)
- Risk Factors -Age, Poor clothing, Hypoglycemia.
- Common reasons -Exposure to cold for prolonged, diving etc.
- Clinical setup–Intra-operative, immediate postoperative, critically ill patients, sepsis
Hypothermia (Signs & Symptoms)
- Shivering (may cease in severe hypothermia)
- Slurred speech
- Memory loss
- Confusion
- Drowsiness
- Mild Hypothermia: Tachycardia, rise in BP.
- Moderate to Severe Hypothermia: Bradycardia, arrhythmias (AF), hypotension, VF, asystole.
- J wave (Osborn wave) in ECG
Hypothermia (Treatment)
- Protect from cold/wet surfaces/wind.
- Remove wet clothes.
- Warm the center of the body (chest, neck, head, and groin.)
- Use electric warm blankets (avoid hot.)
- Give warm drinks if alert and allowed.
- Use warm gastric lavage through Ryle's tube (for unconscious patients unable to drink)
- Monitor the patient.
- CPR and defibrillation as needed
Pyrexia / Fever (Causes)
- Infection (acute or chronic. e.g. sepsis.
- Inflammatory conditions. e.g. boils, abscess.
- Immunological diseases, e.g. SLE, inflammatory bowel disease.
- Tissue destruction, e.g., trauma, surgery, hemorrhage, or reaction to incompatible blood products.
- Cancers (leukemia, lymphoma)
- Metabolic disorders (gout).
- Thrombo-embolism (e.g., PE or DVT)
- Fever of unknown origin.
Pyrexia / Fever (Actions)
- Do not cover patient during heat phase
- Tepid sponging.
- Covered ice packs for armpits and groin
- If patient has RT, do a cold water lavage (especially if possible complication)
- Give fluid replacement (oral or IV)
- Monitor patient carefully and use antipyretics.
Patient's Respiratory Status (Assessment)
- Respiratory Rate – Normal RR: 12 – 18 per minute
- Tachypnea : abnormally fast respirations
- Bradypnea: abnormally slow respirations
- Apnea: absence of breathing
- Assess for pattern/rhythm
- Assess depth (normal, deep, shallow, hyperventilation/hypoventilation.)
- Assess quality (e.g., usually does not require effort/dyspnoea/labored breathing/gasping respiration)
- Check auscultation for abnormal sounds, e.g. wheezes (if any), rhonchi, crepts / rales and cyanosis.
- Assess for accessory muscle use
- Check SpO2
- Check for any associated complaints. Confirm with CXR, ABG, ECG
Dyspnea (Symptomatic Treatment)
- Propped-up position.
- Oxygen supplementation (limited flow in COPD).
- Nebulization
- Bronchodilator (e.g., salbutamol, ipratropium)
- Steroids (e.g. Budesonide, Beclomethasone, Fluticasone)
- Mucolytic (e.g., Acetylcysteine)
- For COPD or Asthma give Inj. Steroid, after assessment by consultant (e.g. dexamethasone/hydrocortisone/methyl prednisolone).
- For LVF/CCF with Pulmonary edema: Diuretics
- Inform senior and consultant.
Oxygen Therapy
- Nasal prongs (2–5 LPM, O2 concentration 24–35%)
- Face mask (6–12 LPM, O2 concentration 28–50%)
- Venturi mask (predetermined O2 concentration 24-60%)
- Rebreather mask (5−15 LPM, concentration 40−70%)
- Non-rebreather mask (with valve, delivering high O2 concentration upto 90%)
- Assisted ventilation (mask with ambu bag ventilation with O2).
Identify Impending Respiratory Emergency
- Tachypnea (rapid breathing)
- Shallow or short breaths.
- Use of accessory muscles.
- Gasping respiration
- Respiratory distress
- Fatigue
- Low SpO2
- Central cyanosis
- Confused, lethargic, or drowsy mental status
- ABG showing hypercapnia or hypoxia.
Pulse
- Rate - Tachycardia ( > 100 bpm) and Bradycardia ( < 60 bpm)
- Rhythm - Regular/Irregular
- Force/Volume - Weak or thready, Full or bounding, Absent/Imperceptible
- Central Pulse (carotid/femoral)
- Peripheral Pulse (radial, brachial, popliteal, dorsalis pedis, posterior tibial)
- Factors affecting pulse - Age (Newborn, Infant, Children, Adults), Gender, Weight, Medication
Abnormal Pulse Rate (Assessment)
- Check whether the rhythm is regular or irregular.
- Assess the patient's temperature
- Respiratory rate
- Pattern of respiration & SpO2
- Blood pressure
- Associated complaints like chest pain etc
- ECG must be done.
Sinus Tachycardia
- Heart rate above 100 bpm, regular rhythm.
- Normal physiological response to exercise, stress, fear, anger, anxiety
- Other causes include hyperthyroidism, sepsis, hypovolemia (blood loss or shock), dehydration, anemia and heart failure.
- Caffeine, nicotine, and smoking.
Sinus Bradycardia
- Heart rate below 60 bpm, regular rhythm.
- Physiological response in trained athletes/healthy individuals.
- Other causes include hypothermia, hypothyroidism, intrinsic SA node disorders.
- Drugs like digitalis, beta-blockers, quinidine, Calcium channel blocker, secondary to infections (e.g., diphtheria) or viral myocarditis
- Increased intracranial pressure
Blood Pressure
- A measurement of the force exerted by blood against the walls of the arteries
- To measure, the brachial artery in the upper arm is usually used. However, the following should be avoided : Arm with plaster cast / Arm with AV fistula/ Arm on side of mastectomy (e.g. right mastectomy on right arm).
- Other locations include the thigh on popliteal artery, or on the ankle (posterior tibial & dorsalis pedis)
- Normal ranges are usually Systolic 110 – 140 mm Hg and Diastolic 60 – 90 mm Hg.
- Values below this indicate hypotension & above this indicate hypertension.
Hypotension (Signs & Symptoms)
- Fainting, lightheadedness, dizziness
- Profound fatigue.
- Temporary bluring of vision
- Headache
- Seizures
- Loss of Consciousness
- Chest pain
- Shortness of breath
- Irregular Heart beat
- Fever higher than 38.3°C
- Prolonged diarrhoea or vomiting.
Hypotension (Examination, Search, Treatment)
- Confirm BP accuracy using a palpatory method if unable to use an auditory one.
- Note airway & breathing pattern, note all vitals including SpO2 and level of consciousness (alertness).
- Note blood sugar level.
- Search for cause (patient's history, comorbidities, recent BP recordings, leading events like giddiness after standing or during physiotherapy/post-drug administration/blood transfusion; rule out allergic/drug reactions, or anaphylaxis).
- Rule out hypotension due to hypovolemia, cardiac causes (ACS), or septic shock- Establish IV access of Large Bore (18/16 French size). Recheck blood pressure after the fluid has been given.
Hypotension (Due to Probable Medication Error / Adverse Drug reaction / Anaphylaxis - Emergency Actions)
- Assess vitals signs and SpO2, check level of consciousness (alertness)
- Check for associated symptoms such as chest pain/vomiting/dyspnoea
- Note leading event of hypotension
- Stop any drugs administration that's started newly.
- Give oxygen via mask (6-8 Lit / min)
- Establish good IV access
- Hold the anti-hypertensive medicine
- Recheck Blood pressure after fluids administration (IV NS 250-500 ml, fast drip).
- Immediately inform the consultant
- Use prescribed SOS Inj. Hydrocortisone 100 mg IV stat.
(In cases of bleeding into vital organs, or those suspected for severe cases of blood loss)
- Establish IV access
- Do BSL R.
- Check Haemogram, PT, aPTT (report to blood bank).
- Send post-transfusion blood sample of patient, and the remaining untransfused blood bag to blood bank
- Patient will need shift to ICU.
Patient Transfer (Within/Outside Facility)
- Within Facility:
- Stable patients can be transferred with PCA on wheelchair or stretcher.
- Unstable patients must be accompanied by a nurse and doctor.
- Inform Consultant immediately
- Detailed shift out summary required inside ICU
- Outside facility Transfer :
- Stable patient accompanied by relative / Attendant.
- Obtain written consent in IPD file from patient and relative (if possible)
- Unstable patients must be accompanied by BLS/ACLS professionals.
- A transfer note (including treatment plan, patient condition)
Joint Care / Transfer to Another Consultant
- If a consultant requests joint care/transfer of a patient, ward doctor provides a note to change in HMIS and Face Sheet of IPD.
- The Medical Case Officer (MCO) will confirm with both consultants.
- Ensure joint care is not within the same speciality
- Authenticate the note for joint care/transfer.
- Note must be sent to IPD to correct HMIS and Face Sheet.
- Give all needed information to both consultants.
BSL Management
- Introduction: Glucose Metabolism
- Hypoglycemia (causes, symptoms, treatment/management)
- Hyperglycemia (causes, symptoms, treatment)
- Diabetic Ketoacidosis (DKA)(Causes ,symptoms, complications, diagnosis & management)
- Insulin (types & commonly used preparation and monitoring)
Introduction: Glucose Metabolism
- Blood glucose/plasma glucose level refers to the amount of glucose in the blood.
- Glucose is the body's primary energy source
- Hormones which impact blood glucose levels are catabolic hormones (glucagon, cortisol, and catecholamines -increase blood glucose) & anabolic hormones (insulin – decreases blood glucose).
Glucose Metabolism (Details)
- Insulin produced by the pancreas helps the body cells to absorb glucose and lower blood glucose levels.
- Blood glucose level fluctuates throughout the day; usually lowest in the morning (during fasting), and rises after the intake or meal.
Normal Blood Sugar Levels
- Fasting BSL(overnight or at least 8hrs) <100 mg/dL
- Post Prandial BSL (2hrs Post Meal) <140 mg/dL
- Random BSL <200 mg/dL
Type 1 Diabetes (IDDM)
- Patients depend on external insulin for their survival because the body no longer produces insulin internally.
Type 2 Diabetes (NIDDM)
- Patients body's cells become resistant to insulin, leading to a relative insulin deficiency,
- Body cells can't use glucose effectively, resulting in a rise in blood glucose levels.
Diagnosing Diabetes (Methods )
- Fasting Plasma Glucose (FPG) less than 100 mg/dl = Normal
- 100 mg/dl to 125 mg/dl = Prediabetes
- 126 mg/dl or more = Diabetes
Diagnosing Diabetes (Methods - FPG, HbA1c, Oral Glucose Tolerance Test (OGTT), and BSL Random)
- HbA1c less than 5.7% = Normal
- 5.7% to 6.4% = Prediabetes
- 6.5% or higher = Diabetes.
- OGTT less than 140 mg/dl = Normal
- 140 mg/dl to 199 mg/dl = Prediabetes
- 200 mg/dl or higher = Diabetes
What is HbA1c?
- Glycated hemoglobin measures average plasma glucose levels over the previous 3 months approximately.
- Lowering HbA1c to be around 6% is helpful in reducing microvascular and neuropathic complications associated with type 1 and type 2 diabetes.
- Elevated levels suggest poor control & is associated with Cardiovascular disease, Nephropathy, and Retinopathy.
Hypoglycemia (Causes)
- Diabetic patients:
- Prolonged fasting
- Overmedication (much insulin
- Non-Diabetic patients:
- Prolonged fasting
- Exercise (intense)
- Impaired glucose metabolism (e.g. hypoparathyroidism)
- Hypothyroidism
- Acidosis
Hypoglycemia (Signs & Symptoms)
- Sweating
- Blurry Vision
- Dizziness
- Anxiety
- Hunger
- Irritability
- Shaking
- Fast Heart rate
- Headache
- Weakness
- Fatigue
Hypoglycemia (Complications)
- Severe Hypoglycemia can lead to Seizures & altered levels of sensorium (coma)
Hypoglycemia (Treatment)
- Oral supplements (salty food/drinks, Electrolytes, and salt capsules)
- IV supplements (2ml/kg Bolus, repeat SOS, dextrose 10% (infants & Children), dextrose 25% (adults). Monitor blood sugar regularly
- Treatment of the cause
- Repeated episodes should be looked into for Insulinoma (rare endocrine tumor).
Hyperglycemia
- Uncontrolled Diabetes Mellitus
- Steroid-induced conditions
- Stress - related trauma or surgery
- Medical Conditions
- Stroke
- Infection, sepsis
Hyperglycemia (Signs & Symptoms)
- Classic symptoms: Polyuria, Polydipsia, Polyphagia)
- Dry mouth and skin
- Numbness
- Giddiness
- Blurred vision
- Drowsiness
- Weight loss.
- Chronic conditions: Recurrent infections, Poor healing, Diabetic Nephropathy, Diabetic Neuropathy, and Diabetic Retinopathy
DKA (Diabetic Ketoacidosis)
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
