MS CRITICAL THINKING DRILLS

By: Josie Q. Udan

Critical Thinking Drills : Congestive Heart Failure

UDAN Concepts:
Right- sided CHF “VENOUS BACK- UP”
“SYSTEMIC MANIFESTATIONS”
Left- sided CHF “LEFT – LUNGS”
“CELLULAR HYPOXIA”
“RAAS ACTIVATION” (HPN, HypoK+)

Signs/Symptoms RSCHF LSCHF

1. Distended neck vein

2. Bipedal edema
3. Orthopnea
4. Rales/crackles
5. Ascites
6. Hemolytic anemia
7. Hypertension
8. Serum K+ = 3.0 mEq/ L
9. Clubbing of fingers
10. Hepatomegaly
11. Anorexia, weight loss, weakness due to
decreased metabolism
12. Polycythemia
13. Hemoptysis
14. Central Venous Pressure = 15 cm H2O
15. Pulmonary Artery Pressure = 25 mmHg
16. Splenomegaly
17. Oxygen saturation= 90%
18. Icteric sclerae
19. Internal hemorrhoids
20. Syncope
jqu
Critical Thinking Drills: Different Types of Anemia

1
Signs and Symptoms Iron Folate Perni- Aplas- Thalas-
Defi- Defi cious tic semia
ciency ciency

1. Macrocytic, Normochromic
anemia
2. Pancytopenia
3. Microcytic/
Hypochromic anemia
4. Cheilosis
5. Beefy red
Tongue
6. Koilonychia
7. Intrinsic factor deficiency
8. Abnormal hgb,
short lifespan of rbc
9. Cyanocobalamine deficiency
10. Vinson- Plummer’s
Syndome

11. Iron overload

jqu
Critical Thinking Drills: Arterial/ Venous insufficiency

UDAN Concepts
Arterial insufficiency: “Low/ No oxygen in the legs”
Venous insufficiency : “Blood pooling in the legs”

Signs/ Symptoms Arterial Venous

Insufficiency Insufficiency
1. Elevation of legs relieves edema
2. Absence of pulse
3. Thin, shiny , hypopigmented skin in the
legs
4. Thickened, hyperpigmented skin in the
legs

2
 5. Ulcers in the toes
6. Edema
7. Cold, cyanotic skin in the leg
8. Ulcers at the ankle
9. Warm, reddish skin in the leg
10. Leg pain on walking
11. Lowering of legs improves blood flow
12. Gangrene develops
13. Leg pain relieved by walking
14. Intermittent claudication
15. Calf pain (Homan’s sign)
16. Thrombophlebitis
17. Raynaud’s disease
18. Aneurysm

Jqu

Critical Thinking Drills: Breath Sounds

A. Vesicular E. Crackles
B. Bronchovesicular F. Rhonchi
C. Bronchial G. Stridor
D. Wheeze H. Pleural friction rub

Description Breath Sounds

1. Rustling like the sound of wind in the trees
2. Harsh, hollow, tubular
3. Heard over mainstem bronchi
4. Burst of popping bubbles
5. High- pitched hissing/ musical sound on
expiration
6. Heard over trachea
7. Low- pitched musical sound on inspiration

3
 8. Musical wheeze over trachea
9. Sounds like 2 pieces of sandpaper rubbing
together
10. Heard at the periphery, apex, and base of the
lungs
11. Inspiration longer than expiration
12. Inspiration equals expiration
13. Inspiration shorter than expiration
jqu
Critical Thinking Drills: SIADH/ Diabetes Insipidus (D.I.)

UDAN Concepts
SIADH (Syndrome of Inappropriate ADH)
“Water Retention”
“ Low Serum Sodium”
D.I. (Diabetes Insipidus)
“Water Loss”

Signs/ Symptoms SIADH D.I.

1. Urine output= 4 to 6 L/ day
2. Highly- colored urine
3. Urine specific gravity= 1.050
4. Weight gain
5. Weight loss
6. Dehydration
7. Serum sodium = 120 mEq/L
8. Constipation
9. Fluid intake= 4L/day
10. Low urine specific gravity
11. Hemoconcentration
12. Low hematocrit
13. Polydipsia
14. Hypertension
15. Pulmonary edema
16. Decreased blood osmolarity
17. Water intoxication

4
 18. Water- like urine
19. Growth retardation
20. Urine sp gr = 1.004

Jqu

Critical Thinking Drills: Hyperthyroidism/ Hypothyroidism

UDAN Concepts:

Hyperthyroidism Hypothyroidism
“Everything is high, fast, and “Everything is low, slow, and
wet ” dry”
“Hypocalcemia” “Hypercalcemia”
“Eye manifestations”

Signs/ Symptoms Hyperthyroidism Hypothyroidism

1. Anorexia
2. Cold intolerance
3. Diarrhea
4. Fatigue
5. Obesity
6. Exophthalmos
7. Thin
8. Restlessness,
Nervousness
9. Fine, oily hair
10. Dry, sparse hair
11. Serum Calcium= 12 mg/ dL
12. Serum Calcium= 3.5 mEq/ L
13. Fine tremors
14. Lid lag
15. Pulse rate= 55 to 60 bpm
16. BP= 140/90 to 159/ 94 mmHg
17. Serum cholesterol= 280 mg/dL

5
 18. Thickened, hyperpigmented
skin in the pretibial area
19. Dry, scaly skin
20. Diarrhea
21. Sweaty skin
22. Tachycardia
23. Slow physical and mental reaction
24. Hypercalcemia
25. Elevated body temperature
26. BMR = (-)30 %
27. Treated with Synthroid
28. Treated with Tapazole
29.Treated with PTU
30. Treated with Lugol’s solution
31. Dull look
32. Exophthalmos
33. Von Graefe’s sign
34. Jeffrey’s sign
35. Dalyrimple’s sign
36. Treated with Cytomel
37. Requires high calorie diet
38. Requires low fiber diet
39. Requires cool, quiet
Environment
40. Requires warm environment
during cold climate
41. Tendon of Achilles
Reflex (+1)
Jqu

“How are you at this point? Keep on working towards your BRIGHT
FUTURE!”

Critical Thinking Drills:

6
Hyperparathyroidism/ Hypoparathyroidism

UDAN Concepts
Hyperparathyroidism
“Everything is low and slow Except BP ” (BP is high)
“Hypercalcemia, Hypophosphatemia”

Hypoparathyroidism
“Everything is high and fast Except BP” (BP is low)
“Hypocalcemia, Hyperphosphatemia

Signs/Symptoms Hyperparathy- Hypoparathy-

roidism roidism
1. Hypercalcemia
2. Hypocalcemia
3. Dry, scaly skin
4. Dry, brittle hair and nails
5. Muscle cramps
6. Muscle weakness
7. Hypophosphatemia
8. Low BP
9. Seizures
10. Increased urine output
11. Polydipsia
12. Tingling lips, fingers, toes
13. Fracture of long bones
14. + Chvostek’s
15. + Trousseau’s
16. Hypertension
17. Laryngospasm
Jqu

Critical Thinking Drills: Types of Diabetes

7
Signs/Symptoms Type I Type II
1. Non- insulin dependent
2. Associated with obesity
3. Thin
4. Prone to HHNC
5. Onset after age 30 years
6. Lifelong insulin therapy
7. Brittle DM
8. Associated with heredity
9. Treated with Oral Hypoglycemic Agents (OHA)
10. Occurs among children
11. Prone to DKA
12. Pancreas secretes insulin but demands are
Increased
13. Absence of Islets of Langerhans
14. Ketosis- resistant
15. Onset before age 30 years
16. Associated with autoimmune disorders
17. Obese
18. Insulin- dependent DM
19. Best managed with diet, activity, exercise, insulin
jqu

You’re doing great, nurses!

Critical Thinking Drills: Hyperglycemia/ Hypoglycemia

8
UDAN Concepts
Hypoglycemia
“Decreased glucose supply to the brain”
“SNS stimulation”
“Feeling hungry”

Hyperglycemia
“3 P’s”
“Dehydration”
“Ketoacidosis”

Signs/ Symptoms Hypoglycemia Hyperglycemia

1. Blurred vision
2. Headache, dizziness
3. Pallor, diaphoresis
4. Urine output 300mls/hour
5. Acetone odor of breath
6. Fluid intake 4L/ day
7. Kussmaul’s breathing
8. Cold, clammy skin
9. Sunken eyeballs
10. Restlessness
11. Excessive hunger
12. Weakness, shakiness
13. Faintness
14. Urine (+) for glucose and ketones
15. pH =7.31, HCO3= 18
16. Hunger pangs

Hypoglycemia Hyperglycemia

9
 17. Yawning
18. Blood glucose = 50 mg/ dL
19. Warm, flushed, dry skin
20. Inability to concentrate
21. Hypokalemia
22. Needs insulin
23. Needs glucose
24. Memory lapses
25. Urine (+) for glucose and ketones
26. Fruity odor of breath
27. Polydipsia
28. Polyphagia
jqu

Critical Thinking Drills: Addison’s Disease/ Cushing’s Disease

UDAN Concepts
Addison’s Disease
“Everything is low EXCEPT K+ , Ca+ ,Pulse rate”
“Dark skin”

Cushing’s Disease
“Everything is high EXCEPT K+ , Ca+” ,Pulse rate”

Signs/ Symptoms Addison’s Cushing’s

1. Moon face
2. Hyperglycemia
3. Edema
4. Hypertension
Addison’s Cushing’s
5. Delayed wound healing
6. Hypotension.

10
 7. Hyponatremia
8. Thinning of scalp hair

9. Osteoporosis
10. Bradycardia
11. Eternal tan appearance of the skin
12. Hirsutism
13. . Dehydration
14. Obesed trunk, thin arm and legs
15. Hyperkalemia
16. Purple striae on the abdomen

17. Hypoglycemia
18. Hirsutism in females
18. Loss of appetite to eat
19. Hypocalcemia
20. Fatigue
21. Nausea, vomiting
22. Poor wound healing
23. Gynecomastia in males
24. Depression
25. Buffalo hump
26. Hypernatremia
27. Hyponatremia
28. Weight loss
29. Muscle weakness
30. Increased virilism in females
jqu

Critical Thinking Drills: Cranial Nerves

Cranial Nerves B. b. Optic

A. a. Olfactory C. c. Oculomotor

11
 D. d. Trochlear I. Glossopharyngeal
E. e. Trigeminal J. Vagus nerve
F. f. Abducens K. Spinal Accesory
G. Facial L. Hypoglossal
H. Acoustic

Signs/Symptoms/Tests Cranial Nerves

1. Blurred vision
2. Protrusion of the tongue
3. Tic douloureux
4. Vertigo
5. Unequal pupils
6. Papilledema
7. Rolling of the eyeballs
8. Loss of sense of taste , anterior 2/3 of the
Tongue
9. Inability to shrug shoulders
10. Loss of hearing
11. Parasympathetic stimulation
12. Loss of sense of smell
13. Dysphonia
14. Ptosis of the eyelids, diplopia
15. Bell’s palsy
16. Inability to smile and show the teeth
17. Inability to stick out the tongue
18. Loss of gag reflex
19. Scotoma (Blind spots in the visual field)
20. Slowing and slurring of speech (dysarthria)
jqu

Critical Thinking Drills: Neuromuscular Disorders

UDAN Concepts
a. Parkinson’s disease

12
 “Tremors, rigidity”
b. Myasthenia gravis (MG)
“Muscle weakness”
c. Multiple sclerosis (MS)
“Demyelination of CNS”
d. Guilain Barre’ syndrome (GBS)
“Demyelination of the peripheral nervous system

Signs/Symptoms Disorders
1. Pillrolling tremors
2. Muscle weakness associated with activity
3. Ascending paralysis
4. Tiptoe walking
5. Ataxic gait
6. Shuffling gait
7. Ptosis, strabismus, diplopia
8. Treated with Levodopa
9. Treated with Mestinon
10. Treated with Cogentin
11. Bradykinesia
12. Cogwheel rigidity
13. Decreased dopamine production
14. Decreased acetylcholine receptor sites
15. Resting tremors
16. Intention tremors
17. Sticky skin
18. Positive Tensilon test
19. Soft, monotonous voice
20. Scanning speech
21. Treated with Baclofen
22. Treated with cholinergic
23. Treated with anticholinergic
24. Flattened affect

13
 25. Stooped posture
26. Small, shaky handwriting
27. Associated with swine flu vaccine
28. Bladder and bowel dysfunction
29. Charcot’s triad
30. Absence of arm swing when walking
31. Lhermitte’s sign
jqu

Critical Thinking Drills: Different Types of Arthritis

Rheumatoid Arthritis (RA)

Osteoarthritis (OA)
Gout

Signs/ Symptoms RA OA Gout

1. Degenerative disorder
2. Metabolic disorder
3. Autoimmune disorder
4. Males more commonly affected
5. Females more commonly affected
6. Obese elderly commonly affected
7. Subcutaneous nodules
8. Localized inflammation
9. Cartilage of joints wear off
10. Synovial membrane affected
11. Joints of fingers commonly affected
12. Weight- bearing joints most commonly affected
13. Big toe commonly affected
14. Tophi
15. Bouchard’s nodes
16. Heberden’s nodes
17. Ulnar drift of the hand
18. Cock- up toe
19. Crepitus
20. Morning stiffness
21. Pain-on-use of joints
22. Pain-on-nonuse of joints

14
 23. Excessive dryness of eyes, mouth, and vagina
(Sjogren’s syndrome)
24. Leukopenia, splenomegaly (Felty’s syndrome)
25. Hemolytic anemia
26. Elevated urine and serum uric acid
27. Unilateral affectation of joints
28. Inflammation affects both side of the body

jqu

Critical Thinking Drills: SNS/ PNS

UDAN Concepts
Sympathetic Nervous System (SNS)
“Everything is high and fast, EXCEPT GI and GU”

Parasympathetic Nervous System (PNS)

“ Everything is low and slow, Except GI and GU”
____________________________________________________________________________________________

 SNS PNS

DILATE: PUPILS CONSTRICT: PUPILS

BRONCHIAL TREE BRONCHIAL TREE
CORONARY BLOOD VESSELS CORONARY BLOOD VESSELS
CONSTRICT: PERIPHERAL BLOOD DILATE: PERIPHERAL BLOOD
VESSELS VESSELS

Signs and Symptoms SNS PNS

1. Restlessness
2. Tachycardia
3. Peripheral vasodilatation
4. Peripheral vasoconstriction
5. Hypotension
6. Hypertension
7. Bradycardia
8. Bronchoconstriction
9. Bronchodilatation

15
 10. Dilatation of pupils
11. Constriction of pupils
12. Diarrhea
13. Constipation
14. Urinary retention
15. Urinary frequency
16. Dryness of mouth, thirst
17. Increased salivation
18. Diaphoresis
19. Pallor
20. Cold, clammy skin
21. Hypoglycemia
22. Hyperglycemia
23. Increased gastric acid secretion
24. Decreased peristalsis
25. Wheezing
26. Diminished bowel sounds
27. Increased heart rate
28. Increased respiratory rate
29. Slow respiration
30. Abdominal distention
31. Elevated body temperature
32. Flushed skin
33. Coronary vasodilatation
34. Increased force of myocardial contraction
35. Decreased cardiac output
jqu

SNS: Anticholinergic
Beta Agonists (e.g., Bronchodilators)

PNS: Cholinergic
Beta Adrenergic Blockers (e.g., Antihypertensives)

Critical Thinking Drills: Antidotes

Answers Drugs/ Conditions Antidotes
(in
letters)

16
 1. Morphine A. Mucomyst
(acetylcystein)
2. Magnesium Sulfate B. Calcium gluconate

3. Hyperkalemia C. Digibind
4. Beta adrenergic blockers D. Glucagon
5. Calcium channel blockers E. EDTA
6. Acetaminophen poisoning F. Methadone
7. Lead Poisoning G. Disulfiram
8. Heparin H. Vitamin K
9. Coumadin I. Protamine sulfate
10. Opiate addiction J. Cholinergic
11. Digitalis toxicity K. Naloxone
12. Alcohol abuse L. At SO4
13. Myasthenic crisis M. Desferal
14. Cholinergic crisis N. Romazicon
15. Diazepam
16. hemosiderosis
jqu

Critical Thinking Drills: Positions

Situations/ Conditions Positions
After thoracentesis, left lung Right side- lying
After right modified radical mastectomy Semi- Fowler’s, right arm
abducted, elevated
Patient with COPD Upright, leaning forward
(othopneic position)
During liver biopsy Left side- lying
After liver biopsy Right side- lying
Patient with increased ICP Semi- Fowler’s, HOB elevated at
15- 30 degree,maximum of 45
degree
After kidney biopsy Supine
After tonsillectomy Lateral
After pantopaque (oil-based) myelography Flat/ supine
After metrizamide (water-based) Semi- Fowler’s

17
myelography
After UGI endoscopy Lateral/ side- lying
During colonoscopy Left lateral
After incisional cholecystectomy Semi- Fowler’s
Patient with MI Semi- Fowler’s
Patient with CHF High Fowler’s
Patient who had supratentorial craniotomy Semi- Fowler’s
Patient who had infratentorial craniotomy Flat
During gastrostomy feeding Semi- Fowler’s
During change of IV tubing Trendelenburg

During insertion of TPN catheter into the Tendelenburg

subclavian vein
Patient with arterial insufficiency Legs lower than level of the heart
Patient with leg varicosities Legs higher than the level of the
heart
Patient with autonomic hyperreflexia Upright/ Sitting
Patient with spinal cord injury Flat
Patient who had lumbar laminectomy Flat
During enema (adult) Left lateral
Catheterization of female patient Dorsal recumbent
Woman in labor with prolapsed umbilical Trendelenburg
cord
During cystoscopy Lithotomy
jqu

18