PLAS THIER (3) in a ine Date Booked _ TS e PSS Be tlo™ Joue > _ Plame of Fust name ‘Sumame a” ey hy Mt oats | PeaNA® A@D! viv Ligh | (eamimone cau Tel Number 7 ae ~ 4p DA Pe) CLE OIBNES1OV ny Zainabtatimaabel’ © Yohoo: _ an [ Cowuntry of Unf origin Rakishan PLAB 2 test a \a* Det How did you heat: sbout us Friends. 4 . Course date | yp MRO Sey caw . xy (Sie Oe "hy ‘Wock test | Full Mock | Ral eck pee [tee A dates Mock a bamonarpard J . Lrref a, fe thn o& Booked by + Soke Diwa She en be spits ha ely; ey mii de Spt il cao d 4 iene LEB IEC carey rs O whar [oka / Madera 29 “@ Pow Chie. B lecouers” 3 wee oF fa) o: A De ey ’ ate Co) crm oes a WorphJ Oe Oe Ve OO, rr bee abe Yr t thal we TY Ke, m2 FO vale QA tye kame de bit (Po fa Bes vis 1. Or \ ‘ BO Nae WD j roy cervort wr lis a. <4 to, V@ep He Am 29 Car) BAK | 62. Wher Beonmntef 4b VYron'’« Oe ON aig PRE PSone pale pee (Seni meePLA SWAMY }2 GUIDE A COMPLETE UPTODATE GUIDE FOR YOUR SUCCESS IN PLAB 11 EXAM WRITTEN BY THE EXPERIENCED AND GREAT TEACHERS OF PLABTRAINER. ye ‘tiny AG ADDRESS: Balfour House : 390-398 High Road _« ford, Essex IG11TLPLAB TRAINER, (SWAMY) HANDOUTS for PLAB 2 Please note that this is only a handout to help you in passing the PLAB 2 exam. Contents of this may not be authenticated to use in the hospitals. Candidates are Strongly advised to refer to the standard text books and follow hospital protocols once you start working in the NHS Course organiser ; Mr K S Ramaswamy, FRCS (UK ) Address : 390 -398 High Road, Tel: 020 8478 6100 (from within UK) Ilford, 0044.20 8478 6100 (from outside UK) Essex. Email: plabtrainer@google.com (may change. Please verify by phoning us.) 1G] 1TL PrefaceIn the recent years the General Medical Council exams have changed in different manners. To meet these changes and challenges, we decided to design a course to help the doctors to the PLAB 2 exam and named it as PLAB TRAINER course. In this course we guide and teach foreign graduates to meet the criteria of GMC exam. In Ten days all the topics related to PLAB II exam; History & Counselling, Clinical Examination, Advanced Trauma Life Support, Manikins, Dose Calculation and Viva Stations will be taught. To really help you get a feel of GMC before your actual exam, right here in PLAB trainer we conduct Full Mock, Manikin Mock and which will make your training complete. At the end of it all we hope that you will be ready to face the real test and walk down the rest of the path to success. We strongly suggest candidates to use this book only along with other standard PLAB 2 books and not depend entirely on this book. This book will constantly be updated according to GMC exam. We advise candidates to use the latest handouts. We sincerely hope that this handout will prove to be straightforward and readable and will provide the necessary knowledge in an integrated form that a foreign graduate requires for passing the PLAB 2 exam. We wish you all the very best of luck in your exam and future endeavour. QoS ia PLABTRAINER TEAM.Acknowledgments This handout has been prepared by the teachers who have taught at PLABTRAINER in the past and has been kept up-to-date by the current teachers and myself, The information in this handouts is mainly gathered from the candidates who appeared in the PLAB exam, without their help this would have been a impossible task. This handout has been the most popular guide for the PLAB 2 test where even the candidates doing the other PLAB courses too depend heavily on this handout to pass in their exam. We are extremely grateful to all those who have contributed for the preparation of this handout. Ht is very difficult to mention each and every name of contributors. But special thanks to all of those teachers who were and are teaching in PLAB TRAINER. Their contributions in PLAB TRAINER management and teaching deserve the best, because they are the best. And we da remember them, they were and they are part of PLAB TRAINER Team and Family. ‘A special thanks to Dr Sagib Siddiq and Dr. Atif who helped a lot in compiling this notes. c tact oboae ah, ee batt chronce Ay PLAB TRAINER (SWAMY)CONTE: ‘No Topics Page numbers Past GMC questions 10 days of course is divided into 2 paris of 5 days each. | PARTI 1 | Introduction ATES 7 | Oe ne Manikin teaching = section-1 a ea G Manikin teaching - section ~2 & Dose calculation 3 History and Counselling PART2 f —_——— 1 | Medicine _ For4 |__| OFTHE [2 _| Surgery and Orthopaedics a | days eae course {3_|OBG = (Days) |4 diatrics — } - — 5 [Psychiatry 6 | VIVA, Drug prescriptions, MRSA, and other 1 day | Ltopies. a PLAB TRAINER PAST OSCE STATIONSas a | MEDICINE (H&C means combination of history taking and then counselling HISTORY rT COUNSELLING Diagnoses which were in kept in the past GMC exam were written within the brackets: T | ANEAMIA (Bowel Ca, ete) 1 | ASTHMA —14 yr oid boy smokes — explain risks of smoking and advice to quit smoking. (boy said his grand dad has been smoking for yrs | and had no heath problems #0) 2 | ABNORMALTFT (H&C) 2 | ALCOHOLISM(H &C) ( Pt. posted for Herjorthaphy or ingrowing Toe nail removal- blood test shows Low Hb and high MCV ) 3 | BREATHLESSNESS (ASTHMA) 3. TBLOGD TRANSFUSION 4 | CHEST PAIN ova PE, Pneumonia) 4 | Chronic renal Failure (Low Hb, High Urea and Creatinine) | 5 | CHRONIC FATIGUE SYNDROME 5 | Diabetes Mellicus. Importance of maintaining Diabetic Dairy. 6 | CONSTIPATION (Pts on codeive or 6 ‘Morphine ~ drug induced) ) 7 | Young pt. chronic (3 months)DRY 7 | DIABETIC RETINOPATHY (pt is worried about COUGH, BREATHLESSNESS,WT ‘going blind) LOSS (PT is homosexual boy friend is FIV +), sek for rereatioal drags eee sizing) RCP) 160 yr oldman with cough with sputum 8 | EPILEPSY — young lady bas been diagnosed a (Ca Lang, Bronchiectasis) idiopathic epilepsy one week ago started on treatment — she goes to university) 9 | DIARRHOEA & VOMITING (H&C) EPILEPSY (POORLY CONTROLLED) —-H&C_ (food poisoning ) Tig. DOPLOPIX To FOOD POISONING [ir BzaNEss TI | Post Stroke Advice T2 [ EARACHE (ARO TRAUMA (eave i, 12 [ HEADACHE: (pasthist. ofmigraine now demands ‘OMS EXTERNA, Otis media) CT scan or MRI scan) 13 | FEVER (MALARIA PNEUMONIA, TB, PCP) | 13 | Pe wants HIV TEST 4 i4 iS /HEMOPTYSIS (1 & C ) (7B, PE.Ca, 15 | MESOTHELIOMA (BREAKING BAD NEWS ) Brower) 16 | HEADACHE (Ai) Explain 16 | NON PHARMACOLOGICAL TREATMENT OF mahagement to patient. HYPERTENSION 17_| HOARSENESS OF VOICE, T7_ | MULTIPLE SCLEROSIS (weakness in Ie eg and aa had loss of vision 4 yrs ago) 18 TR | MORPHINE FOR SPqNAL SECONDARIES | Hlas side effects — what to do 2?19 | HYPOTHERMIA IN ELDERLY 19 | TERMINAL CARE ~PT.DOESN'T WANT LADY. Take history ftom her son and MORPHINE (ASK HIM WHY HE DOESN'T counsel WANT AND ALLAY HIS CONCERN ) (2? Elderly abuse) cE 20 | LOSS OF CONCIOUSNESS 20 | PT.ON MORHINE FOR SECONDARIES, BUT PAIN NOT CONTROLLED WITH MORPHINE. 21 | PALPITATION 21 | Consultant stated pt. on morphine for secondaries athis back ~ pt. isa teacher ~ worried about work ~ can I teach ? ~ won’t be silly infront of kids 72) 22 | PANIC ATTACK 22 | PEFR - EXPLAIN THE CHART and plot the reading on the chart 23 | RED EYE - (Glaucoma, Ankylosing 23 spondil 24 RISK FACTORS FOR CVA 24 | Elderly lady came to hospital with ankle injury — no x-ray was done in her first visit — pt. came back again with pain ~ x ray done second time revealed facture in ankle. Pt. is very upset that X ray was not done — counsel. Pt. just needed POP cast as ‘treatment. Ths tests your communication skis for revealing hospital eror. 35 | WEIGHT GAIN ‘GUM clinic — urethral discharge (Gonortheoa) ins (HYPORTHYROIDISM) male after unprotected intercourse. (H &C ) 26 | WEIGHT LOSS (Hyperthyroidism) Post Mortem counselling 27 | SORE THROAT (Infectious ‘SMOKING explain risks and advice to quit Mononucleosis, Tonsillitis.) 28 Gaint cell (temporal) arteritis 30 | STD -You are in sexual health elinie - take history from a man who is anxious about contracting STD (only history no counselling) SURGERY aac HISTORY COUNSELLING 7] | HEMETEMESIS ] | APPENDICECTOMY (Ifthe patient has been vomiting dehydration should be corrected before the surgery) 2. | HEMATURIA 2. | HEMICOLECTOMY & COLOSTOMY 3__| PR BLEEDING 3 ‘| MALEANA (elderly lady with maleana—ptis | | 4 | LADY POSTED FOR NEPHRECTOMY FOR taking voltarol(diclofenac for rheumatoid RENAL TUMOUR — COULSEL HUSBAND arthritis) 5 | TESTICULAR PAIN 5 | VASECTOMY 6 | SCROTAL SWELLING [6 | HERNIORRHAPAY -GA ORLA (ANEASTHETIST DECIDED GA - CONSULTANT IS ON WARD ROUND — HE WILL COME LATER AND TAKE CONSENT FROM PT.— YOU COUNSEL FOR OPERATION & FOR GA ) 7 | DYSPHAGIA 7] POST HERNIORRHAPHY WOUND INFECTION 8 | DYSURIA (ENLARGED PROSTATE) 8 | POST HERNORRHAPHY PAIN HIST & MANAGEMENT MANAGEMENT9. | PAIN ABDOMEN (APPENDICITIS, 9. | HERNIORRHAPAY CANCELLED DUE TO ‘TWISTED OVARIAN CYST), ANEAMIA (PT. ON ASPIRIN) (MAY HAVE (THINK OF MIIN ELDERLY MAN WITH. ‘TO TAKE LITTLE BIT OF HISTORY) EPIGASTRIC PAIN EVEN IF HE IS ON TRIPLE ‘THERAPY FOR PEPTIC ULCER DISEASE) 10 | PRE - ASSESSMENT FOR OPERATION 10 | POST MASTECTOMY 1] | PRE- ASSESSMENT FOR OPERATION— || 1] | POST OPERATIVE PAIN MANAGEMENT ASSESS SUIATABILITY FOR DAY CASE ‘SURGERY (PLANNED FOR PIN REMOVAL FROM ANKLE) eer 12 165 YR OLD MAN WITH Lif PAIN 12 | ENDOSCOPY (ELECTIVE AND (DIVERTICULOSIS) EMERGENCY FOR HEMETEMESIS) ‘Chronic ulcer on the back history B | NA CHILD AFTER TEA (EEA FEMUR discuss DD and further management Reis An COUNT NG eae with the patient 14 | PROSTATIC HYPERTROPHY WITH UTI (MANAGEMENT OF UTI AND PROSTATECTOMY) Telephone conversation- Xray ofa patient was | | 15 | MOLE REMOVAL ket inside the cubicle. Patient had CVP line for total parenteral nutrition early that morning, Patient developed shoriness of breath by evening. Chest XRay was done. Discuss the XRay finding and management of this patient with e examiner 16 | ULCER OVER THE BACK - GP THINKS SINISTER (HEC) 17 | POST HEMICOLECTOMY COLLAPSE ~ TEL CONVERSATION 18 | POST HYSTERECTOMY — UNSTABLE VITALS - TEL CONVERSATION 19 | OBSTRUCTED INGUINAL HERNIA — TEL CONVERSATION PAIN ABDOMEN - ALL INVESTIGATION | LIKE BARIUM MEAL, COLONOSCOPY | ‘NORMAL (IBS) (HIS UNCLE DIED OF BOWEL CA) - COUNSEL (7? Irritable bowel mdrome) ‘LOCAL ANAESTHESIA 22 ‘Spinal Anaesthesia TOOTH EXTRACTION CANCELLED DUE TO OBESITY - BIOCHEMISTRY RESULTS ‘NORMAL - COUNSEL ORTHOPAEDICS HISTORY COUNSELLING 1_| KNEE PAIN (Reiter's syndrome) 1_| ANKLE SPRAIN 2__| BACK PAIN: 2 | RHEUMATIOD ARTHRITIS 3 | CARPEL TUNNEL SYNDROME 3. | GOUT (PT. ALCOHOLIC AND THIAZIDE (TINGLING AND NUMBNESS IN HAND) DIURETIC FOR HTN) | OSTEOPOROSIS F_T OSTEOPOROSIS 3 ELDERLY LADY HAS PAIN INKNEE— '5_ | TOTAL HiP REPLACEMENTPHOSPHORUS - HISTORY ONLY (OSTEOMALACIA, OTHERS 7OSTEOPORORIS, RHEUMATOID ARTHRITIS, OSTEO ARTHRITIS) BLOOD TESTS SHOWS — HIGH ALKALINE PHOSPHATSE, LOW CALCIUM AND LOW 6 |/55 year old fady with tingling numbness 6 | TOTAL KNEE REPLACEMENT in her hand. (Is a typist for 6 years - ? Repeated stress syndrome) i 7 7 | HEMI-ARTHROPLASTY OF HIP. PAIN MANGT ALREADY BEEN DISCUSSED. TALK TOT. _ | oF OTHER MANAGEMENT. i OBSTETRICS AND GYNEACOLOGY | HIsTORY [ COUNSELLING 1 | HYPEREMESIS (HIST & MANGT) ]__ | ANTEPARTUM HEAMORRHAGE, | 2_| URINARY INCONTINENCE 2 __| GA CERVIX— BREAKING BAD NEWS 3 | IRREGULAR 7HEAVY MENSTRUAL, 3_| DMINPREGNANCY : BLEEDING 7) ANENORRTOER F_| DOWN SYNDROME 5. | PREMATURED RUPTURE OF 5 | DYKARIOSIS - ADVICE COLFOSCOPY MEMBRANE _ 6 | LADY WITH STD GUM CLINI) 6 | DYMENORRHEOA [7 WAGINAT BLEEDING 7 [ECLAMPSIATEL WITH CONSULTANT 8 | ABDOMINAL PAIN 18 | ECLAMPSIA-TALK TO HUSBAND FOR. LSCS 9 | OCP SUITABILITY 9 [ECTOPIC PREGNACY - PATIENT WANTS TO ATTEND INTERVEIW IN THE NEXT ONE HOUR. [To [Pee accaersa gr eCy ECLAMPSIA.) (PT-HAD SEVERE HEADACHE AND BLURRING ‘OF VISION BP -160/110 ~ SEVERE PRE — 10 | GONORRHOEA POSITIVE—REFER TO GUM | CLINIC PRE MATURE MENOPAUSE |-GIOF FLUSHES WIGHT SWEATS). i HRT 123 HYSTERECTOMY CONSENT ll B LAPAROSCOPIC STERILIZATION | 14 ‘MISCARRIAGE 15 EMERGENCY CONTRACEPTION 16 ‘TERMINATION OF PREGNANCY [ 7 PAIN RELIEF INLABOUR 18 HUSBAND HAD SEX WITH PROSTITUTE — COUNSEL WIFE 19 STILL BIRTH 20 [PELVIC INFLAMMATORY DISEASE 21 [OVARIAN CYSTECTOMY 22 IDDM lady wants to be pregnant - counsel Jt Lady diagnosed to be having DVT. She has been commenced on warfarin. She is on OCP, Advise her for alternative methods of contraception. (Barrier methods, safe period method, may be progesterone only pills. JUD may be‘contraindicated when she is on warfarin ) PEADIATRICS HISTORY COUNSELLING ‘BREATHLLESSNESS (ASTHMA) 1 | INCONSOLABLE CRY we CONVULSIONS 2 COELIAC DISEASE (FEBRILE, HYPOGLYCAEMIC, MENINGITIS, EPILEPSY) 3 | DIARRHOEA (H&C) (Tel) PASSED [3TARRITABLE HIP URINE WHILE CHANGING NAPPY 4 | FEVER (UTI also discuss magt with mom) | +4 | DOWNS SYNDROME. 5 | VAGINAL DISCHARGE FB ASPIRATION H&G) 6 | COLLAPSE (VASOVAGAL) 6 | SWALLOWED BLEACHIOCP 7 | DELAYED WALKING (H&G) 7 | MENINGOCOCCAL SEPTICEAMIA 8 | INFANTILE COLIC H&G) C97] MMR - AUTISM 9° | VOMITING (H&C) ‘| NEEDLE STICK INJURY - MOM WORRIED ABOUT HIV INFECTION ‘Mom does not know whether the needle i rested ornot ~ 10 | WEIGHT Loss 10 | PHYSIOLOGICAL JAUNDICE (H&C) 1] | CHILD HAD COUGH 10 DAYS AGO. TL | INTUSSCEPTION NOW LETHARGIC, NOT EATING FOOD BUT DRINKING PLENTY OF WATER. 12 | URT-NOW NOT WELL (mum [12> PEA NUT ALLERGY WORRIED ABOUT MENINGITIS) 14 | HEAD INJURY (H&C) [447 OBESETY — GROWTH CHART chiidhood obesity, (NAD) 13y 01d BM 32kg/sam, about to be cischarged, Talkto Imether about testy and gietary modifiations, growth chart provided, NAT (FRACTURE FEMER/SCALD) NAI(TEL CONVERSATION WITH THE CONSULTANT) = (YOU ARE IN ARE DEPARTWENT,6 YR OLD BABY WAS BROUGHT BY HER MOTHER BABY HAS BRUISE ON RIGHT ARM MOTHER SAYS, ‘BABY FELL FROM COUGH. (Baby hes fracture humerus and rile os facies on bs —X RAYS kept on the table. Mom es agit cut boy fend takes care of avy, 15 [EAR INFECTION— GP GIVEN ABX. MOM WORRIED ABOUT MENINGITIS (TEL) 16 | PR BLEED (Biood in the nappy in Himonth | | 16 | CHILD WITH RASH— MOM WORRIED old child — Intussuseeption) ABOUT MENINGITIS (TEL) 17 | Child with potyarea, polydypsia, cough and | | 17 | Child swallowed one tablet of Tamoxifen (H& C) drowsy ) hist, 2? meningitis, 27 DM ~ Should say you will refer TOBASE or take advise from Poison information centre. Then ‘examiner gave Information about Tamoxifen overdose including complications and treatment). 18 | Child consumed 240mg Paracetamol 78) 2 YEAR OLD CHILD WITH Heo HYPOGLYCAEMIC COMA. TALK TO MOM ABOUT FURTHER MANAGEMENT Scabies 19 | IDDM COUNSEL MOM 1020 | Child with breathlessness — counsel dad ‘21 | Child with fracture ankle — take history from mom regarding assessment for anaesthesia, & tell her that anaesthetist will come and discuss about the anaesthesia ) (Child has IDDM) 22 | Unwell child ~ Dad says child had ear infection before and he thinks it could be the same this time asking you whether he can give the same antibiotics — tell him there is no ear infection — itis only URTI — there is no need for antibiotics. PSYCHIATRY HISTORY COUNSELLING 1_| ANOREXIA T_| PCM SUICIDE RISK 2__| DEPRESSION 2_ | DEPRESSION 3 | Insomnia without depression (pi. on 3. | ANXIETY - PTSD ‘methotrexate nd NSAIDS for Rhuematoid arthritis) history and management. 4_| INSOMNIA (SOMETIMES PT 4 _| DEPRESSED PT, READY TO BE DEPRESSED). (PT ON METHTREXATE DISCHARGED. ASSESS SUITABILITY TO BE AND NSAID FOR RHEUMATOID DISCHARGED HAND) 5__| OCD 35 _| MMSE 6 PSYCHOSIS 6 | MSE 77_| OPIUM ADDICTION | 7_| Obsessive compulsive disorder. <8. [ AMITRYPTILLINE, 8 PANIC ATTACK 97 | PAROXETINE 9 | SCHIZOPHRENIA (pt. brought in by 0 DRUG ABUSE (H & C) Heroin addict. Pi. wants police who has not committed amy crime but to quit. pi. thinks he has committed erime) | 10. | POST NATAL DEPRESSION (HIST & TI | Lady who took 20 OCPs (because she had "| MANGT) | unprotected sex - worried about pregnancy) also slashed her wrists. — assess suicide risk. Pt asked whether she can go home. IT | ALCOHOLHIST AND ADVICE HIMTO™["[I2 [SS QUIT ALCOHOL CLINICAL EXAMINATION MEDICINE 1 [cvs 8 12707 CRANIAL NERVE 2_|RS& PEFR 9_[ 8™ CRANIAL NERVE 3_| ALCOHOLIC FOOT 10 | DIPLOPIA 4 | DMLEG 11, VISUAL FIELD (PT. HAS VISION PROBLEM AFTER RTA) 5_| COMATOSE PATIENT [12 | LYMPHO RETICULAR SYSTEM - 6 | GCS & NEUROLOGICAL | 13 | MENINGITIS PT. EXAMINATION OF COMATOSE PT. (PRIMARY AND SECONDARY ratSURVEY HAS ALREADY BEEN DONE) 7 | LOWER LIMB SENSORY AND MOTOR | 174 | CEREBELLAR FUNCTION EXAMN, 8 15 | HEMIPLEGIA ORTHOPAEDICS SURGERY 1 [Hr | | UPPER ABDOMEN (MURPHY’S SIGN POSITIVE) ~ sometimes pt may have upper ‘midline incision sear. Do not check to look for incision hernia, epigastric hernia by asking the patient to lean forwards without support [Z_[ KNEE 2_| THYROID 3. | ELBOW 3 _| PERIPHERAL VASCULAR DISEASE 4_| WRIST 5 _| SHOULDER 6_| SPINE 77_ | FRACTURE HUMERUS Pis arm was on sling. Had severe pain. You can’t examine for movements or any tests involving movement as be is in severe pain. Don’t forget to check neuro-vascular deficits ~ | RHEUMATOID HAND. MANIKINS 1 | IVCANNULATION ~~ 9 | 36 WEEK PREGNANT (OBST EXAMN) ~~ —— 2 | BLOOD SAMPLING 10 | BREAST 1 3 | ABG w Ti | CERVICAL SMEAR L-7 [4] SUTURING [ * 12 | BIMANUAL EXAMN: 5 13 |-PERRECTAL — _-~ 6 14 OTOSCOPY. ee 7 15 | EUNDOSCOPY 8 16 | SPACER : MISCELLANEOUS 1 | ATLS 5 | SCRUBBING (PRIMARY SECONDARY SURVEY) 2 | NECR INJURY (WHIPLASH INTORY) HAND WASHING 3” | MRSA (LEG ULCER, CEASARIAN DOSE CALCULATION SECTION WOUND infection) 4 | LUMBAR PUNCTURE EXAPLAIN 8 | Medical negligence PROCEDURE TO PT. 12VIVA, DRUG PRESCRIPTION eee 4 T_, DIABETIC KETOACIDOSIS T_| DVT- WARFARIN 2 | Mi 2_| ASTHMA 3 | PARACETAMOL POISONING 3__| HIN- MEDICATION & S MODIFICATION DM~ MEDICATION &18 MODIFICATION | HEART FAILURE 6 6 | PAROXETINE “] -ANITRYPTILNE ~ _l 8 | POST MI g tyen loreal oa eee é fr tan Z Advanced Trauma And Life Support. Is a guideline to manage the patients met with high velocity trauma. Look for signs of injuries and diagnosis of injuries only. : TRAUMA TEA! B1) A&E Doctors & Nurses 2) Surgeons 3) Anaesthetists 4) Orthopaedicians Aim - Prionitise And To Save Time of Assessment Of The Trauma Victims To Save Life, ATLS Is Divided Into 2 Parts: 1. PRIMARY SURVEY: Look for immediately life threatening and Jinzb threatening injuries in the order of priority, manage them and stabilize the patient. 2. SECONDARY SURVEY: (Done after the primary survey once the patient is stabilized.) A) Take a detailed history B) Thorough head to toe examination, looking for delayed life threatening injuries and non life threatening injuries PRIMARY SURVEY: A Airway With Cervical Stabilization B Breathing With Ventilation C Circulation With Control Of Haemorrhage D Disability E_ Exposure ADJUNCTS IN PRIMARY SURVEY: 1) MONITORS : Cardiac Monitor, Pulse Oximeter, BP Apparatus 2) PRIMARY SERIES OF X RAYS A) Lateral View of The Cervical Spine B) Chest X Ray ©) Pelvic X Ray 3) TUBES A) NASOGASTRIC TUBE B) URINARY CATHETER (Urethral catheter if no urethral injury and Supra Pubic Cystotomy if urethral injury) ral AIRWAY: — Z2vucat zeit. + O - If the patient is able to speak in a normal speech there ean’t be any obstruction in their airway. Look at the mouth for any Jease dentures, eee See kn axa, sar had. , “ odes : pe abet Lis ree abetpation, (oO) cal Stabil [ Cenvi bilzation. (Loe) wy Assume all the major trauma vietims to be having neck injury and stabilize their neck to prevent any cord injury happening, if they already not had any cord injury. ‘Two Ways Of Stabilization Of The Neck D) Manual Intine Immalization 2) Triple Immobilization Hy Shouloert. olnd- aA Se eed bere! € a ee A) Neck Collar ~~ 7 he oy coven cJuerts B) Sand Bags (Head Blocks) : ree & ope oe ge Q) Tapes (Straps) De. 282 yy 4 oo Sey cad am ee BS ek aa SM Bo OL ene SoU “BREATHING; f'\o0% Hy too Wher can! Ceol 1. Tension Pneumothorax Signs d Symptoms : Side, Decreased Chest Wall Movement, Hyper-Resonance, Absent Breath Sound. Tachycardia, Hypotension, Hypoxia. ss , Engorged Neck Veins, Trachea Shifted To Opposite OF loreatty ‘Management : Emergency Needle Thoracacentesis To Decompress The Chest. Insert wide bore needle in the 2 intercostal space, mid clavicular line on the affected side and leave the cannula in situ. Listen for hissing sound of gush of air coming out. ‘Then reassess.) Defintive Management : Intercostal chest drain in the 5* intercostal space which is connected to the underwater sealed bottle. 1) Open Pneumothorax Signs & Symptoms : Breathlessness, no engorged neck veins or tracheal shift, decreased chest wall movement, open wound over the chest, hyper-resonance, diminished breath sounds. Management Cover the wound with a bandage which is stuck on three sides only which allows the air to escape out, but prevents air getting sucked in, Definitive Management; Intercostal Chest Drain. 2) Flail Chest Fracture of two or more ribs at two or more sites. Causes pulmonary contusion causing hypoxia, Pain — shallow breathing — hypoxia. May have associated injuries like pneumothorax or heamothorax. Management Oxygen, analgesics, fluid resuscitation, strapping the segment, IPPV 3) Massive Heamothorax Has double problem : Blood Loss And Lung Compression —> py, 15Signs & Symptoms Decreased level of consciousness, pallor, cold periphery, Breathlessness, tracheal shift, collapsed neck veins, Decreased chest wall movement, bruises, dullness on percussion, absent or diminished breath sounds. Management Resuscitate ; Oxygen, Iv Access, Blood Testing, IV Fluids, Chest Drain (if more than one and ahalf litre blood drained or more then 200 ml blood draining per hour , needs thoracotomy.) 9 Cardiac Tamponade po) g\ver Bho« Can die of reduced cardiac output. Signs & Symptoms Decreased level of conciousness, cold peripheries, Becks? triad -engorged neck veins, hypotension, muffled heart sounds) Exclude left sided tension pneumothorax or massive heamothorax to diagnose cardiac tamponade. Management Oxygen, Iv Access, Maintenance Fluid, Attach Cardiac Monitor, Defibrillator should be available, Perform — Pericardiocentesis Insert long, wide bore needle below the xiphisternum pointing towards left shoulder, keep looking at the ECG monitor. When there is changes in the ECG rhythm withdraw the needle little bit to make sure the tip of the needle is in the pericardial cavity, and then aspirate about 20 to 25ml of blood. Then reasse CIRCULATION PL [acs — GA External Bleeding : ‘wound and sumounding area, ~ Look forobvious blee: Management Direct Pressure Bandage, Internal Bleeding: Chest, Abdomen, Pelvis and Thigh Intra Abdominal Bleeding - Signs & Symptoms Distension, bruises, wounds, tendemess, rigidity, guarding, flank dullness, absent or sluggish bowel sounds. Mariagement . Resuscitate. Investigation : Ultrasound Or Doppler, Call for surgeons and make arrangements to shift the patient to theatre for urgent laparatomy Pelvie Bleeding— 16Signs & Symptoms Bruises, pelvic deformity, blood at the external urithral meatus, scrotal or perineal heamatoma Spring Test Spring test can dislodge clot or rupture more pelvic vessels so do it only if necessary to do it And should be done only once and should be documented in the notes. Management Resuscitate Apply pelvic binder, call for orthopeadicians for external pelvic fixators and for further management. THIGH; fracture of shaft of femur can cause internal bleeding upto about 2 litres on one side itself. Signs & Symptoms LOOK - swelling, bruises, deformity. FEEL - distal pulses MOVE — Do not ry to move if there is a sweeling or bandage seen over the thigh also do not, try the move his legs if he had pain on his pelvis(ie — if the spring test was positive). Management Resuscitate, Thomas splint, call for Orthopaedicians. Look for swelling or deformity in any other part of the limbs, and if any check distal pulse. DISABILITY: check level of consciousness with AVPU scale se. ches “Also check the pupils. a EXPOSURE: expose the patient completely but keep him covered with warm blankets to prevent hypothermia, Once the patient is stabilised then I will do the secondary survey. 11) Diagnosis and Management. PRIMARY SURVEY (How to do it the exam :-) ‘Mr Jonathan Ross is a 38 year old man has met with RTA and has been brought into the hospital A&E Department. His pulse is 110/min and BP is 100/70. Do the primary survey. Greet the examiner. Assume you have taken all universal precautions. (gloves, gown and goggles). Assume the Trauma team is present with you. Ask examiner for full exposure of patient. (Ideally dress should be cut with scissors) 17Ensure privacy, heweehapeuane I Airway Sa. , possible, a) If the patient is lying down without collar Infipei ization and check patient response simultaneously. If patient speaks — introduce yourself to patient ” - verbalize to the examiner that he is conscious and his airway is patent since he is speaking, at foe ~ instruct pt. notte move head, - leave hand and apply neck collar. eo . triple immobilization a ae ~ high flow oxygen. _ r Beene ~ , NOUR inanatowsahe oo. ert Pe lone b) If patient lying down with collar a eee ge ea, i here ty No need of in-line immobilization '"*y ctbtLa5 Check response. Yeo! wy potyrcs Es haem tep pee If patient is speaking - — introduce yourself to the patient >'- rner.,. ee hoy - verbalize to the examiner that he is conscious and hi airway patent since he is speaking ‘ = triple immobilization ~ high flow oxygen. > ca A) Request assistant to connect all the monitors (cardiac monitor, BP apparatus, and pulse oxymeter) B) Also request him to arrange for primary series of X-Ray! hest, Pelvis, and neck) iil Breathing. Inspection — Breathlessness, Neck — engorged neck veins, tracheal shift, surgical emphysema ~~ Chest = bruises, open Wounds, Hail chest, asynmetiy Of movement. ~~ Paipation - Expansion “COm you pir boke =) dla2ew poo oft Percussion — Hyper-resonance and dullness. ju! rep on por CLeAL wen teh ng ‘Ausoultation~ Absent or diminished breath sounds and fled hed counds Ayes IV_ Circulation. Pulse and BP (either it is mentioned in the task or may be put on the wall as a chart — mention the reading to the examiner. If it is not seen on the wall or not given in the task then ask the examiner for the vital signs) External bleeding, Pallor and cold peripheries 2 Large bore IV Cannulae, Blood testing (FBC, U/E, Group and X-match 4 units, sugar,ABG, Toxicology screen, clotting screen,) Rush with LV Fluids (2 litres of warm Hartman’s soh n if hypotensive and tachycardic.) 18Internal bleeding Abdomen: Inspection — bruises, distension, wounds, Palpation - Tendemess, rigidity, Guarding, Percussion ~ Flank dullness, Auscultation ~ Sluggish or absent breath sounds, Pelvis: Inspection — bruises, deformity, scrotal or perineal hematorna or blood x at the external urethral meatus. If there are no inspectory findings then you can do the spring test. ( In the exam since the patient will still be wearing the undergarments even if you had asked for full exposure, you will not see any inspectory findings $0 do the spring test in the exam. Spring test. First warn the patient that you will squeezing his hips and if it hurts ¢ ts. sven = aaJ to let you know. Gently press on his pelvis either trying to open it ot se 20) to close it In the exam if they keep Pelvic fracture as the diagnosis patient will scream with pain. Apologise to him and tell the examiner that since the patient has pain in pelvis he may be having” pelvic fracture and you will resuscitate him and then stabilize the pelvis with a pelvic strap and Yeon! tare = | ay, eall'the Orthapaedicians for external pelvic fixator and for further management. (we vy” “strongly advise you to mention the diagnosis and management as soon as you find it instead of 7 Ley leaving it later to mention it ). Atleast try to reach upto pelvis in the exam. 7 S v where Bares. Le Thigh: Inspection ses, Swell and deformity, Hoe Ralpation- Sst pulses 4 Boats -y , 7 Moverent. ee mere Puce ‘Sne’ ApAt Check distal pulses of other limbs if swelling or deformity in the other limbs. V)_ Disability. a Since he has been speaking he is fully conscious (alert) aa Ideally I will check the pupits just mention). _-—-VD)-Exposure: aad ‘Cover him with warm blankets to prevent hypothermia VIL) Tubes. pee noe \ eeNG tube and urinary catheter.) 2 oD Lae [ Thank your pt, and the Examiner.’ , 11 points to remember 1) A~do not forget to verbalize to examiner of airway patency 2)B- do not jump from chest to abdomen 3) C- donot forget external bleeding 4) DD -D and E are usually completely forgotten. S)E 6) Triple immobilization 7) Oxygen 8) IV Access, blood testing, TV fluids. 9) X-Rays10) Tubes 11) Diagnosis & Management Secondary Survey ‘Mr David Atkinson is a 40 year old man who fell off the ladder about 2 fours a6cK.and fas Seen Grought into the A of department. Primary survey has been done. His pulse 98/min and BP is 110/70. Do the secondary survey. Greet the examiner. Tell him that : T assume I fave taken all the universal precautions, and ideally I would fully expose fim completely by cutting off all his dress. will Reep checking fis vitals. ‘ Greet the patient. Introduce yourself to the patient, If fis in severe pain tel him that you will give fim the pain Killers. ‘Take AMPLE history : A- Allergy ( Ask him what happened ? Past medical illness, is he on any regular medications, and is he allergic to any medications. Do not take long history. ) P —Past Medical History L = Last Meal E~ Events Leading 0 the Incident Warn the patient that you are going to examine him. Then do thorough head to toe examination. ‘Warn him that you are going to examine him and if it hurts anywhere to let you know Head - swelling lacerations Mastoid Area ~ bruising ( Baitle’s sign) (sign of middle cranial fossa fracture) Ears — otoscopy to look for foreign body, blood CSF. Forehead ~ swelling, lacerations ‘Supra Orbital Ridge ~ tenderness Eyes — swelling, bruises , foreign body, blood, contact lens, pupils, fundoscopy Nose — deformity, Foreign Body Mouth — broken teeth, mucosal lacerations. Cheeks, zygoma, mandible - tenderness Neck — swelling, wounds, engorged neck veins, tracheal shift Chest ( Supposed to for look for injuries like simple pneumothorax, small pneumothorax, ruptured tracheo— bronchial tree, ruptured oesophagus, ruptured diaphragm, fracture of ribs, clavicle & sternum — but do not mention any of these in the exam) 20Inspection Breathlessness, asymmetry of chest wall movement, cuts and bruises, Palpation — chest wall tendemess, surgical emphysema, Expansion Percussion — Hyper resonance or duliness. Auscultation - Diminished or absent breath sounds Abdomen : Inspection : Distension, bruises, wounds, Palpation Tenderness, Rigidity, Guarding Percussion ~ flank dullness Auscultation — sluggish or absent bowel sounds. Pelvis T will look for any signs of injury like bruises or deformity of the pel blood at the external urithral meatus. scrotal haematoma or Perineum — swelling, lacerations Limbs - swelling, bruises, deformity, wounds and bandages, If there is a bandage say that ideally you will remove the bandage and assess the wound — (examiner may not allow you to open the dressing in the exam). (assess for site, size, depth, foreign body, structural damages). _- Check distal putse: sensation and movements>~—~ Mention that you will do the complete neurological examination Also mention that ideally with the help of four other people you will log roll this patient and. examine the back for any spinal injury and also do the per rectal examination. You will also try to rule out the neck injury. Af the examiner asks you how will you rule ou neck in jury :— A patient who is fully conscious, orientated, sober complaining of no neck pain, ofe no neck tendemess and no neurological deficits suggesting neck injury and normal x-rays, most likely he has no neck injury and the collar can be removed. Otherwise leave the collar in situ and refer the patient to seniors to take a decision. In the exam if you see swelling over thigh — Diagnosis — Fracture femur ~ If you see bandage over thigh ~ you suspect open fracture femur- Management Of Fracture Femur : analgesia, IV fluids, splint, X Rays of the femur and refer to osthopaedics.Mention that you will check his Tetanus status and give him antibiotics if you see a bandage (because there must be a wound inside the bandage) Neck injury This question may vome in 3 ways: 1) Mrs, Nicola Adams is 35 year old lady has come to you complaining of pain in her neck since about a month, She had met with an accident one month ago and was diagnosed to be having whiplash injury. She suffers with low mood. ‘Take history from the patient and discuss with the examiner. (Depression station) 2) Mr. Jonathan Ross is a 40 year old man who has met with road traffic accident yesterday and has come to you today complaining of pain and stiffness in his neck. Take history from the patient and do the relevant examination. Pt. may be either sitting or lying down. isthe patient is sitting : ‘What happened? ‘When? What happened after the accident? Did he go home immediately after the accident or had he come to the hospital yesterday. If he has come to the hospital yesterday any X RAY taken? And what was told to him? Where is the pain and when did it start ~ immediately after the accident (may be fracture) or few hours after the accident (may be whiplash injury). Any radiation? Any weakness or tingling numbness in the upper limb? Has he banged his head to anything yesterday during the accident? any headache ? any loc ? any vomiting a Did he had any pain in his neck before the accident? Examination Expose atleast the neck area. Inspection — Bruises, swelling, wounds. —~Palpation=Spine for tenderness ( upto about T3 spine) (7 Bony injury Y ~ Paraspinal area for tenderness and spasm (? Whiplash) Brief Neurological examination of upper limbs if complaining of tingling and numbness or weakness in ‘upper limbs. Ideally I will apply a cervical collar, make him lie down and do the triple immobilization and send for XRAYS of his neck . If the XRAYS are normal I will remove the collar and check the movements of his, neck. P Ask him to move his neck and tell the examiner how much movement is restricted If the patient is tying down — Tell the examiner that you will stabilize his cervical spine first ‘Then Take history. For examination —tell the examiner that ideally you would log roll the patient with the help of 4 other people and examine the neck, ask him whether you can assume you are log rolling him 7 ‘Then ask the patient to turn to one side and examine the neck. 3) Mr Jonathan Ross is a 35 year old man who has met with a road traffic accident and has suffered a neck injury. He was diagnosed as having whiplash injury — Counsel the patient. Hello Mr. Ross how are you doing? As you know you have injured your neck during the accident. I am here to tell about the injury to your neck. ‘As you know we have examined you and done the XRAYS of your neck . The good news is that your have not broken any bones in your neck and your have not injured your spinal cord also.‘The pain and stiffness what you are having im your neck is due to what we call as whiplash injury. In simple terms we can call it as neck sprain. This is due to excessive movements of your neck during the accident and you have pulled al] the muscles and ligaments in your neck. This pain and stiffness may last for 2 t0 3 weeks, but in some people it may last for few months. For this you should take regular pain killers and ke@p moving your neck as much as possible. If the pain and stiffness does not subside in 2 to 3 weeks time you can see your GP and he will arrange physiotherapy for you. Doctor will you give me a collar to my neck? Well, Mr Ross we used to give neck collar previously to give some rest the neck in the initial one or two days of the injury. But the evidence has shown that immobilizing the neck with collar Will only worsen the condition, instead it is better to keep moving your neck as much as possible from the beginning, Can I drive doctor? Since you will have pain and stiffness in the neck for some time it may be dangerous to drive, so we strongly advice you not to drive until the pain and stiffness has subsided. Can I do my job? It depends on what kind of work you are doing. If you are doing office type job where you just have to sit, itis entirely upto you, if you think you will be comfortable at your work then you can do your job, but if it involves manual labour type job, itis better to take rest until your pain subsides. undoscopy All Manikin stations begin with RULE OF 8 1. Greet the patient 2. Introduce yourself 3. Check his/her identityExplain the procedure/purpose of visit. Exposure/Position Privacy & Chaperone Consent Check Trolley/ Instruments. PIAA Greet the Patient Introduce Yourself Cheek Identity called ophthalmoscope. For that I will be shining a bright light into your eyes. During the examination I will be coming very close to you and will be touching your cheek and face, 1 will be using some dilating drops which might dim or blur your vision; therefore you are advised not fo drive home along oro sign any important legel documents during the day : Zoe ree oe E xplain Procedure : I am here to examine the back of your eye with a special instrument xposure/Position: You can blink normally during the procedure but don’t move your “SS head and sit comfortably. I will be dimming the lights of the room and you should fix ‘your vision at a distant object. Privaey and Chaperon Take a Verbal Consent Check Instruments Check Power of lens Check light — BIG FULL MOON. Inspection —coming at eye level - a Both Eyes are at same level No Ptosis No Signs of inflammation Orbit and appendages are normal Do a RED REFLEX #~ same level as the eye. Look through the fundoscope for red reflex. (Seen in normal eye and it means media is clear) Media is clear therefore I proceed to Fundoscopy. In the exam you may have to examine for red reflex on a simulator(patient) and then proceed to the manikin for the rest of the examination. In real patient, I would have examined with fundoscope light on but in exam since there is a bright light shinning from back, I may have reflection or glare so I would like to examine now with fundoscope light switched off. 24ght eye of patient Left Eye Of Patient cht eye of examiner Left eye of examiner ight hand of examiner (Fundoscope) Left hand of examiner (Fundoscope) Do the procedure, approach at an angle of 30-45°, and follow the red reflex. ‘Ask to look into the instrument to visualize macula. Explain findings to the examiner. Description of Comment on Optic Disc © Colour © Margin © Contour Cup Disc Ratio (CD Ratio) Origin of Blood Vessels Periphery and Rest of Retina Macula NORMAL FUNDUS A. Optic Dise ~ Always Nasal i) Colour ~ Pinkish pale or pinkish yellow ii) Margins - Well Defined iii) Circular or rounded in contour iv) Cup Disc Ratio - 0.3 - 0.5 B, Blood Vessels - Originating from optic dse, straight not tortuous, normal calibre of ~ -—-vessels—A:V2:3 — — C. Periphery and rest of Retina ~ Healthy and normal —no exudates, no haemorrhages. D. Macula — Healthy and normal SLIDE OF NORMAL FUNDUS can see the OD (optic disk), pinkish pale or pink yellow in colour, well defined margins, circular in contour, CD ratio is normal. Vessels are originating from OD, straight not tortuous, normal in calibre. Periphery and rest of retina and macula appears healthy and normal ‘Therefore my diagnosis is this is a NORMAL FUNDUS. SLIDE OF OPTIC ATROPHY 25can see the OD, pale or chalky white in colour, margin well defined, and circular in contour. Cup cannot be appreciated. Origin of vessels not clear, they are straight and normal in calibre Macula and periphery and rest of retina appear healthy and normal. Therefore my diagnosis is optic atrophy SLIDE OF DISC CUPPING I can see OD, pinkish pale in colour, circular in contour, margins ill defined. CD ratio is increased in size Origin of vessels not clear, they are straight not tortuous, normal in calibre. Macula and periphery and rest of retina appear healthy and normal. Therefore my diagnosis is Disc cupping most probably due to glaucoma, SLIDE OF PAPILLEDEMA Tean see OD which is swollen, oedematous and bulging, margins are blurred or ill defined, and cup cannot be appreciated Origin of vessels not clear but vessels are engorged, tortuous and congested, Periphery and rest of retina appears hyperaemic ‘Therefore my diagnosis is papilledema. SLIDE OF CENTRAL RETINAL VEIN OCCLUSION I cannot appreciate the optic disc. Origin of vessels is not clear, but veins are engorged tortuous and congested. I can appreciate flame shaped haemorrhages and hard exudates Periphery and rest of retina appears hyperaemic and seems to be a stormy sunset or tomato splash appearance, therefore most probably diagnosis is CRVO. SLIDE. OF SENILE MACULAR DEGENERATIO! Tecan see the OD which is pale towards temporal side, margins well defined, circular in contour, cup cannot be appreciated. Origin of vessels not clear but they are straight and not tortuous, normal in calibre. Tcan appreciate macula, there are few unusual pigmentation around it and are also scattered around periphery of retina, Therefore my most probably diagnosis is senile macular or age related macular degeneration. SLIDE OF BACKGROUND DIABETIC RETINOPATHY. Optic disc is not so clear Origin of vessels not so clear by they are straight and not tortuous Can appreviate hard exudates which are numerous in number, discrete, having imegular surface, margins are ill defined. Can also appreciate dot and blot haemorrhages and few micro aneurysms ‘Therefore my most probably diagnosis is Background Diabetic Retinopathy SLIDE OF PRE-PROLIFERATIVE DIABETIC RETINOPATHY 26Initial description of background + can appreciate a single soft exudste in inferior arcade + few more in superior arcade, fluffy in appearance, soft surface and having well defined margins. Can also appreciate hard exudates, dot and blot haemorrhages and micro aneurysms. Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy. SLIDE OF PROLIFERATIVE DIABETIC RETINOPATHY Can appreciate neo vascularization around OD and in superior nasal quadrant. Can also appreciate hard exudates, dot and blot haemorrhages and micro aneurysms. Therefore my most probably diagnosis is Proliferative Diabetic Retinopathy. SLIDE OF SUB HYALOID HAEMORRHAGE Can appreciate massive extensive haemorthage in inferior cascade which is most probably a sub hyaloid haemorthage. Can also appreciate a few hard exudates, micro aneurysms and dot and blot haemorrhages. ‘Therefore my most probably diagnosis is pre proliferative diabetic retinopathy with pre retinal haemorthage. SLIDE OF LASER PHOTOCOAGULATION Can appreciate few sear marks at the periphery of retina, which are homogenously distributed throughout periphery and are most probably due to laser burns. Therefore my most probably diagnosis is diabetic retinopathy treated with laser photocoagulation. SLIDE OF HYPERTENSIVE RETINOPATHY Can see diffuse narrowing and tortuosity of arteries in superior as well as inferior arcade Can also appreciate AV nipping in both arcades and silver wire appearance seen running through arteries, Therefore my most probably diagnosis is Hypertensive Retinopathy. Patient ‘Thank the chaperone ‘Thank the examiner. Otoscopy All Manikin stations begin with RULE OF 8 9. Greet the patient 10. Introduce yourself 11. Check his/her identity 12. Explain the procedure/purpose of visit.13. Exposure/Position 14. Privacy & Chaperone 15, Consent = 16. Check Trolley/ Instruments. - : Exer Oie @, eWar ch By awd a Greet the Patient ~ ‘ Introduce Yourself Cheek Identity Explain Procedure : Iam here to examine the inside of your ear with a'special instrument called otoscope. During the examination I will be coming very close to you and will be touching your cheek and face. I will perform a special test with another instrument called the tuning fork’ Position : Sitting with head and neck slightly tilted to the other side. Privacy and Chaperone ike a Verbal Consent Check Instruments { . * Otoscope working "9! 7? ATuning fork — 512 Hz or 256 Hz PROCEDURE: Ideally I would do the examination of the normal ear first but for exam purpose I will only examine the affected side. Pre auricular Scar, sinus, discharge, redness, swelling, discharge, previous marks of surgery Auricular No swelling, obvious haematoma, no obvious deformity, vesicles, bleeding, discharge. Post auricular Same as preauricular + no mastoid bruises/discolouration. Palpation 9) Temperature ii) Tenderness —looking at patients face a. pre auriculai'— pulp of finger = no obvious swelling or tendemess b. auricular ~ thumb + index finger 28c. post auricular — pulp of finger ~no obvious swelling or mastoid tenderness. Tragus Test: ‘Tragus positive ~ contraindication to otoscopy, abandon the procedure at this moment and proceed to tuning fork test. ‘Tragus megative — proceed with otoscopic examination. iii) Lymph node examination, a, Sub mental >. Submandibular c.Presauricular 4, Post Auricular e. Cervical £. Occipital Check instrument ‘New sterile clear appropriate size ear speculum 3 sizes - Small - Medium - Large. Otoscope in pen holding position External auditory canal — Throw light Comment on ~ No discharge, bleeding, inflammation, wax, FB. Tympanic membrane Left hand on head, pull pinna upward + backwards with thumb and index finger. — N LOOK AT THE SLIDE, ‘Withdraw the instrument, Look at speculum, comment on bleeding, discharge or wax over speculum. Remove and dispose it in clinical waste bin ~~ DESCRIPTION OF SLIDE Comment on: a 1. Cone Of Light + 2. Handle Of Malleus “Se 3. Umbo 4. Annulus r 5. Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane) SLIDE OF TYMPANIC MEMBRANE (NORMAL) Cone Of light — Directed downwards and anteriorly Handle of Malleus — antero superior Umbo - Central portion which joins handle with cone of light Upper 134 Pars Flaccida Lower 1/34 Pars Tensa Aunulus outer fibrous ring around TM joining TM to surrounding bony 29eK mp ABS cles Fe (honge Tie gar structures} A. Pearly grey in colour ‘ B. Semi transparent eae C. Normal in lustre. Can appreciate cone of light in antero inferior quadrant, handle of malleus in antero superior quadrant and umbo at the junction of cone of light and handle of malleus Pars flaccida, Pars tensa and annulus appear normal No retraction, no bulging, no air fluid level, no perforation, no bleeding, no discharge, no wax over TM ‘Therefore diagnosis is Normal Tympanie Membrane. SLIDE OF WAX Ican see the TM, Dion ic' @ bet oy ergy vie x), Colour of was in transition from pale yellow — Solden yellow- yellow brown — finally brown, See Tm which is obscured by golden material Cone of light, handle of malleus and umbo cannot be appreciated. Can appreciate annulus. Therefore my diagnosis is was over TM. SLIDE OF ACUTE OTITIS MEDIA WITH EFFUSION | oD ° I can see the TM which is red, inflamed, congested, edematous, and tense CD ae Can appreciate an air fluid Jevel in antero superior and postero superior quadrants. 7 41 Cone of light, handle of mallets and umbo cannot be appreciated eng, - Annulus can be appreciated, "94 Ye 2 ows a es aa ‘Therefore diagnosis is AOM with effusion tog OS My arin SLIDE OF AOM WITHOUT EFFUSION I can see-the-TM which is-red, inflamed, congested, edematous, and tense. —— ‘There is no air fluid level Cone of light, handle of malleus and umbo cannot be appreciated Annulus can be appreciated. ‘Therefore diagnosis is AOM without effusion. SLIDE OF AOM WITH BULGING Ican see the TM which is red, inflamed, congested, edematous, and tense. Can appreciate a bulge in Tm which is in the postero inferior quadrant due to pus or fluid behind ™. Cone of light, handle of malleus and umbo cannot be appreciated - Annulus can be appreciated. Therefore diagnosis is AOM with bulging which may progress to perforation or it is an impending perforation. 30Sri ape a Ada SLIDE OF CENTRAL PERFORATION WITH TYMPAN' Can see TM Cone of light Umbo cannot be appreciated but can appreciate handle of malleus which is distorted. Can appreciate a large central perforation in anteroinferior and postero inferior quadrants. Can also appreciate few white calcified plaques over TM Therefore most probably diagnosis is central perforation with tympanosclerosis. SLIDE OF TYMPANOSCLEROSIS “7+, Can see TM ; Cone of light, handle of malleus and umbo cannot be appreciated * Annulus can be appreciate: ER Can appreciate white calcified plaque in antero superior quadrant‘ Most probably diagnosis is tympanosclerosis. SLIDE OF GROMMET Can see TM Cone of light, handle of malleus and umbo cannot be appreciated Annulus can be appreciated. Can appreciate a foreign body in postero inferior quadrant, most probably a grommet Most probably diagnosis is grommet in TM. SLIDE OF SECRETORY OTITIS MEDIA Tean see the TM which is red, inflamed, congested, edematous, and tense Cone of light, handle of malleus and umbo cannot be appreciated Annulus can be appreciated. No air fluid level, bulge ete seen Most probably diagnosis is secretory otitis media. TUNING FORK TESTS THs ce a Bunnie iste s Check tuning fork 512Hz or 256 Hz ‘ Do Rinne’s or modified Rinne’s test Interpretation of tests AC>BC Rinne’s Positive ~ Normal or sensori neural deafness BC>AC Rinne’s Negative - Conductive deafness Do Weber’s Interpretation cssO el Conductive Same side Sensorineural Opposite side Conductive - lateralized to SAME side ‘Sensorineural - lateralized to OPPOSITE side. Thank the patient ‘Thank the chaperone ‘Thank the examiner.Catheterisation All Mannikin stations begin with RULE OF 8 1. Greet the patient 2. Introduce yourself 3. Check his/her identity 4, Explain the procedure/purpose of visit. — 1 am here to introduce a rubber tube into your water pipe to facilitate/relieve your waterworks 5. Exposure/Position — For that you need to undress below waist and lie comfortably on your back 6. Privacy & Chaperone 7. Consent 8._Cheek Trolley/ Instruments.- 2 pairs of sterile gloves, 2 sterile forceps, adequate no of gauze and swabs, antiseptic solution, normal saline, prefilled syringe with Distilled water, prefilled syringe with anaesthetic jelly, appropriate size Foley’s catheter, urobag, sterile drape, kidney tray, sticking tape, clinical waste bin. Procedure: Wear Gloves Cleaning i. Clean dorsum with antiseptic solution from corona to shafi(one stroke only) with forceps ii, Hold shaft with gauze iii, Clean ventral surface of penis with antiseptic solution(one stroke only) iv. Clean 2 groins with 2 different swabs v. Clean Suprapubic area (one stroke) vi. Then clean glans with normal saline ~ meatus to periphery in a circumferential manner (In the exam - manikin may have prepuse — if so do not forget to mention that you will retract the prepuse (foreskin) before cleaning the glans vi... Repeat-the step with new swab. ss _ viii. Send the forcep for resterilisation cae ae ix. Keep a gauze on ventral surface ack for ole CMa x, Change gloves (3s D Chasse ta. troley xi. Drape the patient » ee | xii, Remove gauze from penis Wonsurre xiii, Hold it with a new gauze drape xiv. Clean the glans once more with normal saline (6) Cte. xv. Inject anaesthetic jelly —- Ideally wait for 3-5 minutes (=) 40x" Catheter insertion technique & ree gorrek Push catheter with ano touch technique (don’t touch the catherér with find) g oe Ss eho Keep a kidney tray Gen veo “St Push upto Y junction eee eer Connect to urobag Merce 6 gv 3 pore anol Inflate the bulb frst with See distilled water, look at patients face and then infate rest of the 94, yy, volume Tug it slightly to place ‘Tear the drape 32atau oa 4 f Vy Je yer ends. 7d LQ, pe gue et t Stick catheteto thigh * ty Ask the patient to redress No; ‘Thank the patient 7 CAIN Record the volume of urine orton If you do not finish the whole procedure by 4 and a half min — do not stop keep continuing your procedure but verbalise at the same time about the remaining progedure, . ke Ap rere If Only 5 swabs given for cleaning Soren (First ask for more swabs with the examiner ~ but if he says there are no more swabs then do the following) -4 Clean dorsum and Suprapubic area in a T manner ey nd UO ce -+ Clean ventral surface covering the scrotal region D Sr seo Ne +4 3 swabs are for cleaning glans with normal saline (2 before draping-afd ? after draping.) PPA Une Ifonly 3 swabs given for cleaning ;- will be taught in the clay oLo } youubde on BLOOD SAMPLING 1, Greet the patient , 2. Introduce yourself = yh» Onis. yO 3.” Check his/her identity 4, Explain the procedure/purpose of visit aad take verbal consent. I would tell the patient, that for the purpose of investigations I need to introduce needle in his forearm and he would feel a sharp scratch but I would be as gentle as possible. : 5. Ewill ask him for his and ask to roll up his sleeve and I would ensure adequate privacy <- * and I would ask for a chaperone. Sy 6. Check trolley/instruments: “ * Vacutainer holder, vacutainer needle, vacutainer # alcohol sterrets, gauze pieces, * tourniquet, * sharps bin-yellow, +_waste bin, a white plastic box. _ ees = - ‘T , Ensure that the sharps bin is close by and open. Bry Seo LT me Qoy Grd bee qo » PROCEDURE @ ove even ea du route 1, Ideally I would position the arm and identify a vein. 2. Weara clean pair of gloves, while GRIPS 3. Remove the correct end (Smaller) of the needle and load vacutainer holder with needle both! i Bama 4. explain that I would apply the tourniquet and recheck their identity 5. Palpate the vein 6. Wipe with alcohol sterrets, one stroke only then discard in the waste bin 7. Fasten tourniquet _ 8. Unsheathe needle and throw cap in clinical waste bin 19. Wam the patient before inserting needle that he will feel a sharp scratch 10. Stretch the skin and introduce needle. Stabilise vacutainer holder with left hand and yar insert vacutainer one by one. TEM __511. Loosen the tourniquet at the end of the last vacutainer to be filled. 12. Take gauze piece and press on needle and withdraw the needle.n H ore eq. Wows OI Qepue he choae Osea Go 1 2, JOW TO AVOID ‘0’ OR ‘ without bending the arm, peo, VD Saber 13. Discard the vacutainer holder in sharp’s bin with the needle. #_.14. Twould maintain adequate hemostasis by asking the patient to press ver the gauze 1 15. [would iabel tubes and rock the tubes gently and seen tubes to laboratory. 16. Remove the gloves and discard in clinical waste bin. 17. I would enquire how the patient feels and thank the patient for his cooperation and ask him dress up. 18. Then I will thank the examiner. * Ask for arm preference. * Open correct end of the needle Load the vacutainer initially. 4) IV CANNULATION }od morning I am Dr. (D Oper tayo OO Ur sires & ee Kona Se on or & Can Sto in front~ of conta WS Hop (a eoleone the, tors. Discard the vacutainer holder ath need needle into the sharps bin. Throne Tce 2 bat Ideally I would greet the patient introduce myself to patient and check identity of the patient, I would explain the procedure and take a verbal consent I would tell the patient that for purpose oafs giving medications and fluids I need to introduce cannula in his forearm, I ‘would inform that he will feel a sharp scratch but I will be as gentle as possible. Ideally 1 would ask for arm preference and ask him to roll up his sleeves, Maintain adequate privacy and ask for chaperone. I would check my trolley. ‘Trolley contains * Gloves-clean pair * cannula, +~aleohol sterrets, guaze pie 7 © tegaderm, tourniquet, + 2cc syringes filled with normal saline, © sharps bin-yellow clinical waste bin. 6. Make sure sharps bin is close by and open the sharps bin, PROCEDURE Task where is a sterile area and if there is a kidney tray thin I will use it. If there is none 1 NAYREN then I would assume. ‘Wear gloves while GRIPS take cannula tray. Check the site where you want to insert the cannula. Inform the patient. Apply tourniquet and recheck the site and the vein. ‘ean the area with alcohol sterrets in one direction. Remove cannula with no touch technique. 348. Take out the stopper, place it on the table facing upwards. 9. Warn the patient that he may feel sharp scratch and fasten tourniquet. 10. Stretch the skin and insert cannula with bevel end upwards at 35 to 45° 11, When blood gushes back advance the cannula. 12, Release the tourniquet. 13. Remove the needle and discard into sharps bin. 14, Press over the vein around the tip of the cannula with the index finger of left hand. 15. position and stabilise the cannula with the thumb. 16, Take 2 ce syringe with normal saline and flush through third opening (Up), feel for the flow and see for patient’s comfort. 17, Inform the patient 19 please not move his arm. 18. Document the date and apply tegaderm and remove the paper around. 19. Thank the patient for cooperation and ask him to dress up 20. Document findings(what no. cannula inserted etc) 21. Thank the examiner. HOW TO AVQID ‘D’ or 'E” Ask for arm preference. Take out the stopper and keep it on the table. Don’t touch the proximal end of the cannula Stylet into the sharp’s bin. . ABG Good morning lam Dr 1. Ideally I would greet the patient, introduce myself to patient and check identity of patient. 2. [would explain the procedure and take a verbal consent. 3. would tell the patient that for purpose of investigations I need to draw some blood from his forearm by passing a needle but I would be as gentle as possible. Also] would inform that I would be repeating the procedure again if { fail in first attempt 4.—Ewould ask for arm preference, roll up his sleeves, maiiitaitt adequate privacy aiid ask for a chaperone. 5. I would check the trolley + ABG set (cork, bubble remover, syringe with needle with stopper), + apair of clean gloves, + adequate guaze pieces, alcohol! streets, «sharps bin-yellow © clinical waste bin, © adequate light. PROCEDURE ‘Wear gloves during GRIPS 1. Do Alllen’s test: to check the ulnar patency ‘dea\ty 1 WOvlbl clo fe Mle: . toy bl banca 4Ps: : Peres cre pomecncoin © Perform Allen’stest. br gasp i ; * Positive if less than 15 secands : + -Patentulnar artery 4 .odnare, cbiels toting. * Proceed with the task 2. If negative don’t do the ABG. If syringe is preloaded with heparin-flush the excess heparin before the procedure in clinical waste bin. 4, Palpate artery, clean with alcohol sterrets, discard in Take syringe, remove cap-discard it in clinical waste bin. 6. Insert needle in 90 degrees between two fingers of palpation, before inserting inform patient that he may feel a sharp scratch. 7. Collect 1 cc of blood-press gauze pieces and apply pressure and remove needle. I will tell my assistant to maintain adequate hemostasis, put the needle in cork and discard them in sharps bin. 8. Apply bubble remover-remove bubbles-discard it in clinical waste bin. (if there is no bubble remover first ask for it, if the examiner does not give it - then remove the needle and remove the bubble in air and apply the stopper). 9. Apply stopper, 10. thank the patient for cooperation and ask the patient to dress up 11. I will label the syringe and fill request form and take it personally do ABG immediately {@f aot working-send an ice bag to laboratory) 12. Iwill also check for temperature and oxygen concentration the patient ison , rayne , 13. Thank the examiner. Date ol- bw Hy ical waste bin HOW TO AVOID ‘D’ OR ‘E” © Inform about repeating the procedure * Arm preference © Do Allen’s test. © Sharps into sharps bin (aricheus to bo Forly Ore SUTURING Porcep is Aubin )V Mr. Johnson has sustained an injury (wound) to his forearm end has comdto the hospital. Hi __wound has been anaesthetised and consent taken, Clean the wound and put stitches. Good Morning I am Dr... KL 1. Ideally I would greet the patient, introduce myself to the patient, check the identity. 2. Iwill explain the procedure 3, Take written consent. 4. Iwill ask for adequate exposure and will maintain adequate privacy and ask for 2 chaperone. ( privacy and chaperone to be mentioned only if'it is appropriate ) Trolley- (after wearing two sterile pair of gloves ing © 3 forceps, { what if'you are given only one forceps ?? — will be taught in the class) « — I scissors, * I needle holder, © — suture material, pay 9 : hse antiseptic solution. —* © 10ce normal syringe with syringe, + alcohol sterets, 2. Kom one He © gauze piece, ove” pe pa = cL * Crepe Boe S PO Pie a dead t ‘ : ‘ & Citon Wyo sne 1 9. 10. ll. 12: 13. 14. 15, gloves, * clinical waste bin, sharps bin, 2 ce syringe with anaesthesia 2% lignocaine, DRAPE. If the task says assume you are gloved and wearing gown :- First check whether you have been provided with a assistant. If you are provided with an assistant then assume you are wearing gloves and gown after you greet the examiner. But do not touch anything unsterile. (You can ask your assistant to put everything into your assumed sterile area). But if you are not provided with any assistant then ~ first check the trolley and drop everything into your sterile area without touching the sterile area and then assume that you are wearing gloves and gown, PROCEDURE Wear two pairs of sterile gloves. Iwill be looking at the face of the patient and check for anaesthesia. Press with blunt forceps on both the sides-discard the forceps in unsterile area Take 10 ce syringe fill it with normal saline, part wound, flush it, If not clean then take more, ifsyringe not there-guaze piece with forceps (If syringes are not provided ask for ¢ 4 it with the examiner, but if he does not provide then you assume that you have one and Mv tell him that you will ideally flush the wound with sterile saline to clean it) : Antiseptic solution-dip the gauze piece and clean away from the edge and along the margins. Use 4 guaze pieces, discard 2" forceps. Remove one pair of gloves in clinical waste bin. If given 1 forceps-clean with hand and check anaesthesia with gauze. Now you can use the given forceps for suturing. Drape the ares Hold needle with needle holder(anterior 2/3" and posterior 1/3") Inform the patient that Lam about to take sutures he will feel it but there will be no pain. 3 anterior, 2 posterior. 1 anterior, lanterior = 7 knots. Cut thread by 1 cm with scissors. Discard forceps. Discard needle in sharps bin. I will apply sterile gauze piece on wound and put bandage on it. I will give adequate antibiotics and pain killers if required. I will be requesting the patient to come after 7 days for suture removal, I will be checking for tetanus immunization status Thank the patient for cooperation and ask him dress up. Thank the examiner. HOW TO AVOID ‘D’ AND ‘E's * Take written consent © Drape the wound * Don’t touch the needle with hand + One good tight suture * Discard needle into sharps bin ‘+ Try your best to finish the task by putting both the stitches. If you have not, finished by dand half min bell ~ do not stop but continue suturing and keep verbalising at the same time.( Tell the examiner that once you finish 37Suturing you will clean the area, discard sharps in the sharp bin, dress the wound, discharge him and advise him to go to GP for suture removal in 7 to 10 days time. When you hear the fifth min bell cut the suture and throw the needle in the sharp bin. Even if you are not able to throw the needle in the sharp bin do not worry, as long as have mentioned that you are going to throw that in the sharp bin. Blood Pressure Spor He POCEAIE- 1. Ask for the arm preference 2. Ask for soreness on thearm tee bysuk Sqverers Sevsation growls 3. Ask the patient to roll up his sleeves. ye Onsite Kay exedbse , cpfeg ‘COWL? <4. Check the size of the cuff, esc: ee eee 5. Palpate the radial and the brachial artery ao a a 6. Tie the cuff, 2 finger breadths above the cubital fossa and two fingers can be inserted A> o under the tied cuff 7. Measure the blood pressure by palpatory method first. Document your findings Do the auscultatory sitting, with the arm on the level of the heart. Document your findings 9. Tell the patient, that I am required to measure your blood pressure in the standing position as well and if you feel dizzy at any point of time, please feel free to sit down even without telling me. 10. Measure the auscultatory standing blood pressure keeping the arm at the level of the heart, with the ann completely extended, Documnent the readings on a piece of paper. 11. Thank the patient and the examiner, asks the patient to roll dawn his sleeves TS SPACER Counsel mom of the child who suffers with asthma about how to use the spacer. oye —— Tet 2rner \ eras ~ Prev d ted (Crepe! Pre mov} This is a volumetric spacer consisting of two halves which fit into each other to form a single plastic conical chamber. It has an opening on one side into which a metered dose inhaler fits. The clicking sound is from the other end which has a one way valve and a mouth piece around which your little one should make a tight seal with their mouth breathing in and out of it through thei mouth. Please note that one breath has 2 clicks i.e. one each for the inhalation and the exhalation of the single breath. The child should hold the spacer horizontally in a sitting or standing Position oye Roti cau ty ch If it’s the first time or it’s been a !ong timé since the inhalers been used then it needs to be primed by shaking it then uncapping to puff in the air away from her. Blue capped inhaler is a reliever ~ a bronchodilator that may cause racing of the heart i.e. palpitations. Brown capped inhaler is a steroid therefore her little one must rinse out his/her mouth after each use to prevent the growth of any bugs in the mouth called oral thrush. 38‘The spacer should be cleaned at least once a week and more depending on the frequency of use by taking it apart into two halves and place it’s inner compartments under running warm water. Please do not use any detergent nor scrub it’s inside to prevent any scratches or any residue. It needs to be replaced when there is obvious breakage, any staining inside it’s inner compartments and if there is no sound of clicking from the one way valve at the mouth piece end. If the mum does not have the RXN with her DO NOT PRESCRIBE but rather give an example making sure that she keeps in mind that one breath equals two clicks If her little one goes to school the schoo} RN should have a spacer also for ker little one and know regarding it’s use for child. Offer leaflets and websites. © onk new +9 VAR nse 3 | BREAST EXAMINATION | ey) Greet the patient : y 2 (Pi 26 o Introduce yourself to her Seca Ra Check the patient’s identity & g p My card tells me that you have felt a lump in the right breast and] have cometo 3 examine it. For the sake of examination I will be asking you to do some te manoeuvres. If you are uncomfortable, let me know. I will stop examination. For the sake of examination you will have to undress above your waist, for which 1 will ensure adequate privacy and a chaperone. Cant Tproceed (ie. verbaleonsent) Spon G5 * ' ‘i Ten perAtoyre :. COmpere. inspection: 3 Stn au (Allin sitting position, both the breast) ay - ade cos y eae — CLD bi Ask her to rest her hands on her thighs — - Both the breast are symmetrical = The level of nipple on the same line. - There are no skin changes or any pigmentation or peau de orange. - Ican not see any obvious lump. Ask her to raise her arms above her head — - Ican not see axillary fullness or supra-clavicular fullness. Ask her to place her hands on her waist and press (to tense her pectoralis major) - can not see any lump becoming obvious. 39Ask her to lift her breast ~ = There is no eczema in infra-mammary region. Ask her to squeeze her nipple with her two finger (you must not squeeze ) = There is no blood or discharge on squeezing. ‘Warn the patient that you will be touching her breast now. Ask her which part of the breast she has got the lump. ‘Tell the examiner that you will do the examination in 45 degree/reclining position. Tell the examiner that ideally you will start examine the normal breast, as there is time constraint. I would examine the affected breast first. Cheek for the local rise of temperature comparing with the opposite breast of each quadrant and say that there is no local rise in temperature. (finish all quadrants and then tell no rise in temperature) ‘Warn the patient that she might have pain as you are going to touch her breast. Start for the superficia) palpation — come to pathological site at the end. Do an ante clockwise palpation. Then do a deep palpation. Check for peri-areolar region for any swelling. If a lump present, describe the lump — + - Site = upper outer quadrant. we - Size-2x2 ems - Surface ~ smooth - Consistency ~ Firm - Check for tenderness by seeing the patient’s face. Skin overlying is not fixed. - Move it horizontally and vertically and comment if it is fixed to deeper structures or not. - Ask her to put her hands on her waist and press, again check for mobility ~horizontally/vertically. - Check for the axillary tail of Spence. Inform the patient that you will be exemining the few nodes in her. LYMPH NODES AXILLARY From Front 40,- Anterior - Medialocentral - Apical Inform I am going to examine from back From Back - Lateral - Posterior Ideally I will examine the other breast , the outer axillary group of lymph nodes. Ideally I will complete my examination by doing supra clavicular group of LN, cervical group of LN, spine, chest, abdomen, PV and PR. Thank the patient, ask her to get dressed and discuss your finding with the examiner. It can be a Fibroadenoma ~ single,young girls, firm in consistency Fibroadenosis — multiple, tender, premenstrual Cancer Breast — single, hard, irregular, fixed Never give the diagnosis, even if sure. Give only possibilities. Say you will discuss with the senior and give the complete diagnosis | __ BIMANUAL EXAMINATION Ideally Twill greet the patient, ce myself. Fil check the patient’s identity by asking her name. Ideally I will explain_the procedure that I am going to examine her front passage by means of 2 gloved lubricated fingers to find the cause of her symptoms. I will take a verbal consent before proceeding. Twill ask her to empty her water bag. (Imp) I will ask her to undress below her waist, for which I will ensure adequate privacy and ask for a chaperone. Lvill ask the patient to lie flat on her back on the couch with both thighs and knees flexed, ‘knees apart and ankle together, 44i will check for my trolley ~a pair of clean gloves, lubricating gel, few wipes, a clinical waste bin and a good source of light. For The Candidate Bimanual— Lower abdomen examination. - Inspection of external genitalia. - Digital examination. INSPECTION OF LOWER ABDOMEN (don’t take more then 1-2 min) Right lliac Fossa — Skin overlying the Rt ilise fossa appears to be nonmal. - No mass visible. Suprapubic Area— A mass is visible, which is about Sem from pubic Symphysis, surface is smooth, skin overlying is Normal. Leff Iliac Fossa ~ Skin is normal, no mass visible. PALPATION ‘Warn the patient that you axe going to touch her lower tummy. Place the hand on RIF, tell the examiner that I can not feel the for any Lump and I will check for tendemess, seeing the patient’s face Move your hand to suprapubic region, Tell the examiner that I have felt a swelling here, surface is smooth and consistency is firm and I will check for tenderness, seeing the patient’s face. As Tam not able to insinuate my fingers between swelling and pubic symphysis. feel the swelling must be pelvic in origin. 7 ” ™ Rolapse —) Shean Then wear gloves at this stage in doth hands. = nwa Nene’ > cory cn I will warn the patient that I am going to inspect her front passage. Ideally I will check for the hair distribution. I will check for labia majora, labia minora, clitoris, look for any scars, sinuses, bleeding, harge - : anaes 1 will check for Bartholins eyst at 5 0” clock and 7 ’clock position. I will ask the patient to strain to look for genital prolepses or stress incontinence. Now I will apply some lubricating gel. Warn the patient that I am going to introduce my lubricated gloved finger in to her front passage, if she feels any discomfort, she can let me know, I will stop the procedure. Part the labia with the left index and left thumb and then gently introduce the right index and right middle finger. When you are going in, tell the examiner, vaginal rugosities are normal. For The Candidate — ‘You have to comment on 42- Cervix - Uterus (Position and size) - 4 fornices - Cervical excitation test. I can palpate the cervix, itis firm in consistency, os is closed and circular. I can palpate any growth or any abnormality, Cervix is downward and backward, and I feel the cervix is normal, (Now move your left hand to the suprapubic region, as you will be describing about uterus.) Tcan palpate uterus through anterior Fomnix and it is anteverted in position, [ feel it’s like 16 weeks of size (with left hand ulnar border) Surface is smooth, firm in consistency, Check for tendemess, mobility to be checked. Right Lateral Fomix: Left hand over RT iliac fossa, Rt lateral Fornix is Free. Posterior Fornix: pouch of Douglas — 10 fullness, no tenderness. Left Lateral Fornix: Move left hand over Lt iliac fossa, Lt Lateral Fomix - Is free. Now I will warn the patient that I will remove the fingers. Check glove for bleeding, discharge I will offer tissue wipes to her. Ask her to dress up. ‘Thank the patient. Examination of a lady in third trimester of pregnancy GRIPS Greeting Identity check Introduction 43ory. SISSSy Vr ewe Rew ars ™ ye \ be “ina kor Thay : : CM Teneherinar$ Privacy . : : Hatt Src i Chaperon \ Upper BOQ al Soft. lbutveks Exposure Teg we eon | , , ¢ an lower poles lratat aotoviak s head es@R Oa, IEE: rae POGUE 4, rag nor Inspection ycl I \dbe des RR tore veollnceg Zh On inspection of HS ‘Pecks ‘there 181 Reese. ‘abdomen! "Reece epoad! cord = the ‘swelling of the tummy, consistent with the dates of amenorrhea. Sr 1am also able to see = ee cutaneous signs of pregnancy, such as striae gravidarum and linea nigra. There are no visible scars, veins, peristalsis, bruises; umbilicus seems to be inverted inside. . There is no edema of the abdominal wall 3. Ge ing ignern iS There are no obvious visible fetal movements. ik 4e ts Syne ° ary’? ata iw Palpation yg HOLY Ask mother if she is tender anywhere on abdomen betere fouching, and also ask if she. 2 feels discomfort or pain plz let you know 6. Semen Te | ive Place your hand on the tummy and comment about Prementet 941 Tone of abdominal muscles/ any uterine contractions/ any palpable fetal movements/ & anytenderness inpore 5 pss and _ a Snape ten ote bade. AA Comment about ower ool byyatraps Baby in vertex - or ‘head’ down position. 3. Assessing the height of the fundus (lower area of the baby) - seeing how many fingerbreadths below the xiphisternum (bottom of the woman's~ sternum bone) the baby is laying. | | 4. Assessing the size of baby and feeling [fe the baby's back and limbs. 45, Pawlik's grip - the lower part of the uterus is grasped by the midwife to determine the presenting part. | 6. Pelvic palpation to determine the position of the baby's head. 7. Measuring the height of the fundus which generally corresponds to the number of weeks of gestation 8. Listening to the baby's heartbeat 46We have to listen it by fetoscope Thank the patient ask her to dress up And tell the examiner that ideally you will confirm the fetal heart beats with the CTG machine. END OF EXAMINATION a | | PAP SMEAR Ideally I will greet the patient, introduce myself, and check the patient’s identity. Explain to her that, I will be taking few cells from the neck of the womb. Twill take the verbal consent. T would like to rule ouf the contraindications after which 1 will proceed. 441. 2 heyy (Active menstruation, active vaginal bleeding, recent use of spermicidal gel, recent 4 sexual intercourse) I will prepare the patient for the procedure, for which she will have to empty the water bag, ask her to undress below her waist for which I will ensure adequate privacy and a chaperone. * x1 will ask her to lie on her back with thighs and knees bent, knees apart and ankles together (imp). I will check for my troliey — Cuscos speculum, Ayer's spatula, prelabelled slides, and pair of clean gloves, a bowl of lukewarm normal saline, few wipes, clinical waste bin, fixator and a good seurce ef light. Wear the gloves. Warn the patient that you are going to start the procedure, Then I will sit in a chair, in front of her. On Inspection, there is no discharge or bleeding. Warn the patient that you are going to introduce the speculum/instrument in her front passage 47Cosviced 1 brush o | ‘Warm the speculum in lukewarm normal saline. wun I will apply the lubricant gels as per the hospital protocol. | Part the labia, introduce the speculum, rotate and open the blades. ‘When you visualise the cervix ~ self retain the speculum. I can see the vervix. There is no bleeding or discharge or any growth. The os is closed and there is no cervical erosion. Insert the spatula under direct vision. Rotate it to 360 degree and take the spatula out and apply it on the slide. Throw the spatula in the clinical waste bin and apply fixator to the slide. Insert the cytobrush under direct vision. Rotate it to 180 degree, take it out, roll it on the pre-labelled slide, discard the cytobrush in the clinical waste bin and apply fixator to the slide. Ose ohiel lotush tp use ¢ Warn the patient that you are going to remove the speculum, release the screw, unlock the blades, and remove it little outside (to make the cervix free), de-rotate the speculum. Keep the speculum for sterilization, remove your gloves and throw it in the clinical waste bin. Give wipes to the patient. Ask her to wipe herself. Ask her to get dressed. Inform her that she might experience spotting for few days. And she will get the results in two — three weeks time and it will be sent to her GP. ~—~ Ideally Twill thank her for her co-operation and thank the chaperon. ‘Vhank the examiner. \\Q ict trased (Okotete 5 Hmes we orep OF suk pall — CLOC Me, CANE This’ Prep oF Cinse in Pein pe XtO_ up hos, P PER RECTAL EXAMINATION (EXAMINATION OF PROSTATE) | I will greet the patient. Introduce myself Check the patient’s identity. 48Explain the patient that I am going to examine the gland situated at the base of the water bag by introducing my gloved and lubricated finger through his back passage. I will take a verbal consent before proceeding. I will prepare the patient for the procedure for which he will have to undress below his waist and will ensure adequate privacy and ask fora chaperone. meee HZ eprteci: Pann 42 Mo8 Lwill ask him to lie on his left side and fold his legs as close as possible to his chest and the buttocks at the edge of the table. I will need a clean pair of gloves, Jubricating gel, (KY — JEL), few wipes. Clinical waste bin and a good source of light. 1 will wear my gloves; warn the patient that I am going to touch his buttocks. (*\On Inspection — there is no scar, sinuses, anal fissures, external haemorthoids, any ~bleeding or discharge. DRS S Ideally I will ask the patient to strain, to check for any rectal prolapse. Warn the patient that ] am going to introduce my finger in his back passage. Place the pulp of your finger on his sphincter, giving some time for sphincter to relax and slowly introduce your finger. RB Mne oF Taoist In the lumen there is no a stool, or any mass. I will ask the patient to strain __ to feel for any growth touching my-finger.. —— — = The right lateral wall is normal and I can not feel for abnormality. The posterior wall is normal and I can not feel for any abnormality. The left lateral wall is normal eee T can not feel any ee ae Anteriorly [ean feel a gland, which feel: lobes, I can feel the median sulcus and its normal in size. The surface i is smooth, its firm in consistency. Anterior rectal mucosa is free. I will check for the tenderness.» by seeing the patient’s face, ha \3oe oS t lo Warn the patient that you are going to remove your finger, before which I will ask him to grip your finger (to check for anal tone) 49sae te Remove your finger; see the glove for any blood, mucosa or any faeces. Give him wipes, to wipe himself and ask him to get dressed, Thank the patient for his co-operation; tef{ him that you will get back to him after discussing your findings with your senior. Thank the chaperone and discuss your finding with the examiner. These are 5 Kinds ty ~ Normal prostate Suleue iS Mota! , Consistency 1s uae J - BPH — Bilateral Benign Enlargement Mediong Sulevs is olepress<. «larg ~ Unilateral benign enlargement (ORE in ; “ce \_ Bilateral carcinoma Comnot apereciake Re ryaction Sule ‘i : AS Vyadd Onc Re Qk mucds 18 Gxt, a ( Talk about the size > - Enlarged in all aspect normal e a Median sulcus 8 oo cS ~ Absent in bilateral carcinoma ee Surface eae - Smooth in all except carcinoma < - Firm inconsistency in all except Ca ~ hard za Anterior rectal Mucosa - Freely mobile — normal, BPH, unilateral benign enlargements. - Fixed—both CA TESTICULAR EXAMINATION i Good moming I am DR. ee aver 73'S gas 1. Ideally T will greet the patient, introduce myself and ‘clcck fdeitity, explain the procedure that I am here to examine his private parts down below and I need him to get undressed below the waist. I will maintain adequate privacy and ask for a chaperone. 2. would request the patient fo stand ” for the purpose of examination. I will request the “a, Patient 10 lift the water pip Lede vs Veen ure. wre BS UY anatom LOS tn Inspection ~$.,2°32 anotied 1. Tecan see left testis lower than right testis Lorna COTA) EBA O8eS 2. Tecan see normal skin rugosities, if no rugosities- = eR i 3. Ican not see any scars, sinuses, dilated veins, redness, thickening, vesicles, no scars of any previous surgery. 4. Iwill request the patient to cough-I cannot see any cough impulse. 5. I cannot see any peristalsis! > \ WALA AS SAW bey oy oa min ad 50gon en oe = 3n SAL oh Wy ee (ID) wif TEI AErOr moss > 2) ver ey OST 4 dnd) .s 6. Lwill also be looking fore surrounding area(thighs and penis)life scrotum aad {aspect the skin on the back. s eal 7. Iwill warn the patient that I will be touching his private parts is that ok with you,’ Tapdaedss bb Shee Otrove 6 Palpation fe shen os Each testis separately. Warn and warm, ask for any sore area. RON ok eee aren 1. Temperature. 3, dene. 2. Tenderness y 3. Spermatic cord, Epididymis (Epididymis- poster lateral part of testis) 4. Testis * Feel for increased temperature of the thigh, scrotum and compare(if ulcer-wear gloves and feel for temperature) + On superficial palpation gently feel the private parts and look at the patient's face for any discomfort(Tenderes © On deep palpation, I will feel for spermatic cord, epididymis and testis and will look for any abnormalities or swelling, If there is a swelling, describe it in terms of site, size, shape, surface, skin over the swelling, consistency, mobility, getting over the swelling. * — Ifitis acystic swelling, do in nh: 1. Transilh ation test with illuminoscope and a torch yerbes) |lhet, 2, Fluctuation test afier stabilising the testis. hanreatre JT, oH 3. PREHN’S SIGN — Lift testis up , improvement in pain if cngual ect +h epidydimitis(not in torsion) | CO 4% oy BR YO FE bis prutte tes‘ Iwill thank the patient and ask him to dress up. ‘yx’ <9 ve! "ts fern’ sign, jefe: 2! Will compiete the examination by doing lymph node examination — Superificial inguinal lymph nodes, Paraaortic nodes, supraclavicular nodes. I will also do Per rectal examination, abdominal examination, spine examination and chest examination. MY Shobbilize he buming iw I will thank the patient for cooperation and thank the examiner. 1. j3= 4 sm.) Ong, nord Ohare HOW TO AVOLD 4 © Ensure privecy ‘* _ Hold manniquin in correct position *~ Be gentle and professional in examination ~~ Have time to discuss DD with the examiner OR Adult Basic Life Support Adult CPR -——- > Puberty Safety +C spine (I will ensure that I am safe, patient is safe, environment is safe and there are no signs of cervical spine trauma or cervical spine is taken care of) Q StOe oo see Check Time (ree Ge FO, Hod ———_ u Check responsiveness (If no response) one Hand At the Shoulder Other Hand on The Head Or Both Hands On The Shoulders. g Shout for Help in 3 directions J Check Airway (For any Foreign Body) Check Breathing For 10 Sec, count loudly (With head tilt and chin lift---look- movement, listen at the victim's mout at the chest for for breathing sounds znd feel for air on your cheeks) F etn rae Pedersen Ifno breathing I] Go Se tt Tene A Team.) Tell the message -- Hello I am Dr XYZ. calling from XYZ place. I have found an unconscious man aged XYZ years, unresponsive who is not breathing. I have started CPR at — time. Could you please activate the Cardiac Arrest Team? (If calling from hospital)/ambulance (if calling from outside the hospital).Am I clear in my message? Do you want me to repeat? Could please reconfirm what I have told? Thank You. rescuers to place their hands in the centre of the chest) 30 Chest Compressions (Rate is 100/min, I 2 Rescue Breaths (Head tilt, chin lift and nose pinch and make a good seal around the mouth. Give each rescue breath over 1 second) 4 eid Continue with chest compressions and rescue breaths in a ratio of 30:2. 999 (From out side hospital for ambulance) / 2222 (If in the Hospital- call Cardiac Arrest 52 . )Continue until - Victim starts breathing normally ~ Qualified help arrives and takes over. - You become exhausted. No reassessment at any point. Stop to recheck the victim only if he starts breathing normally; otherwise don’t interrupt resuscitation [Paediatric Basic Life Support A child is between 1 year and puberty. \()Safety+C spine ({ will ensure that I am safe, patient is safe, environment is safe and there are signs of cervical spine trauma or cervical spine is taken care of) @ S Check Responsiveness (If'no response) Both Hands Check Time 7 ‘one Hand At the Shoulder Other Hand on The Head or mn the Shoulders. CG) Shout for Help in 3 Directions (es Airway (For any Foreign Bod’ < Check Breathing For 10 Sec, count loudly (With head tilt and chin lift-—look—at the chest for movement, listen at the victim’s mouth for breathing sounds and feel for air on your cheeks) J 2 2) 5 Rescue Breaths (While performing rescue breaths note any gag or cough response to your action, maintain Head tilt, chin lift and nose pinch and make a good seal around the mouth. Give each rescue breath and release nose pinch) 53@ Contd Pilge. \O See Check for signs of circulation (Signs of \ife) For 10 See (look for signs of circulation like any ‘movernent, coughing, or normal breathing {not agonal gasps-these are infrequent, imegular breaths}).If no pulse or <60/min = J ako 3 Nef (a) 15 chest compressions: 2 Rescue breaths (use one raat greta Here, GA) loninn far bnew On minh, After 1 minute cal} tesustation team_ Call 999 (From out side hospital for ambulance) /2222 (If in the Hospital- call Paediatric Arrest Team | Ppl the message -- Hello I am Dr XYZ calling from XYZ place. I have found an unconscious ) nam aged XYZ years, unresponsive who is not breathing. I have done 1 minute of CPR. Could ‘you please activate the Paediatric Arrest Team (if calling from hospital) / ambulance (if calling from outside the hospital).Am I clear in my message? Do you want me to repeat? Could please Salary | C- Spine reconfirm what I have told. Thank You 2+ Toned 2 een a8 Come back and tices 1 bi check for Orcas -signs of life F. Breseue Voreo hv -Airway B. Grol! Vise 1Osee -Breathing for 5 Sec (If no breathing) Bee Corns Ors x -Give 2 Rescue breaths 5. cay 24% ge: prow -ChedleFor signs of circulation for 5 sec (look for signs of circulation like any movement, coughing, or normal breathing {not agonal gasps-these are infrequent, irregular breaths}) If no Pulse We Aire -Continue CPR 1S: a Bo Scee p ln. ch fc "3, DL rescued sie ot, pulse is >60/ min, give 1 rescue breath for every 3 seeds. |. Cacstig! Ryne S yee, 7 £0 Sy Si compremor wr ewhowsind earer 2 i DOSE CALCULATION 1 FENTANYL Question. | Weight 25 kg ‘Required dose 4 mic gram/kg/hour inl = 500mic gram | Make a solution which you can run it @ 1 mV/hour for 24 hours and show how much normal saline is there in your solution ‘Answer 54‘ Lift the limb off the bed for and watch for any change of pink-calozation of great toe to white/blanching of great toe. 7 If the great toe blanches burger’s test is positive ; Note the angle at which blanching occurs. This angle is called burger’s angle. ~ v Pulses Dan 20 es Dorsalis pedis ~ Kus ke Posteriortibidl tty Popliteal ar cheek os Femoral ¥ Bruits Femoral bruit ‘© Ideally I would like to do Neurological examination W roaliod mmo tlectn vy PRExam v PV Exam (in females) ¥ Genital Exam « P/A Exam ’ ’ CVS Exam with peripheral pulsations RS Exam © Sensation — lateral and dorsal ¢ two ten Ooo aay erk ok, — Lelow Ae mip 94MEDICINE CENTRAL NERVOUS SYSTEM GRIPS ‘The purpose of my visit is to examine the nerves of your body. Position — Lying down Exposure— Complete © PICKLE first. Pallor Teterus Clubbing, cyanosis Koylonychia ‘Lyndenopathy Edema + HIGHER MENTAL FUNCTION Conscious, coherent, speech is normal. Ideally I would like to examine his Cranial nerves. * SENSORY EXAMINATION: v TOUCH: ok DERMATOMAL DISTRIBUTION Tie—C2 Till axilla~T1 Beneath the tie~ C3 Nipple ~T4 the tip of shoulder ~ C4 Umbilicus-T10 the Lat, aspect of elbow— C5 Belt—L1 the index finger ~ C6 Pockets ~L2 Middle finger - C7 Beneath the pockets over the knee cap~L3 Ring finger and Dorsum of foot — LS Medial aspect of elbow - C8 Lateral aspect of foot & sole~ S1 Sit on ~ $2, $3, S4 95Figure 12.11 Dermatomes. This map shows the approximate boundaries of the detmatomes, contest Thorac This is the wisp of cotton with which I will be touching you, please let me know whether you feel me touching u by saying yes. Please close your eyes. + = = Neuropins to check pain sensation (If you use sharps like this do not forget to throw it in the sharp bin. ¥ VIBRATION: —128Hz ‘+ This is the instrament which buzzes; I will be placing it on your body. Please let me know whether you feel the buzz or not. 96Shin of tibia, Medial malleolus, great toe, forehead, stermum & DIP of thumb. v JOINT POSITION: ~& Twill be placing your finger up or down, Please let me know whether it is up or down by closing your eyes. * MOTOR EXAMINATION: ¥ BULK: + Ideally I would like to examine bulk with a measuring tape. But on gross examination, there appears to be no wasting. v TONE: 4 I would like to see how smooth or stiff theymuscles around your joints & Tone at wrist, elbow, hip, knee and onxe( Pie “¢ Bey fe a ie) v POWER: s Could you cock your wrist up/down? ++ Could you pull your forearm inwards (flexion) / push outwards (extension)? *& Could you push your hands? Forwards (flexion) Backwards (extension) Outwards (abduction) Inwards (adduction) + Could you raise your leg straight? Press down + Could you pull your leg inwards (flexion)? Push outwards (extension)? + Cock your ankle up and press down? v REFLEXES; + This is medical hammer with which Lam gently tapping you. It will ~~~ disconifort or Pain: Please let nie kniow of any distomifor ¥ DOLL’ EYE MOVEMENT, NECK STIFFNESS: *} To be performed only if cervical injury has been ruled out and only if cervical collar is not there. 97CRANIAL NERVES | (Either Il to Vitor VII to X11) | GRIPS { would like to examine the nerves of your face. During my examination I will come closer 19 you Position — Sitting Exposure - Up to shoulder. No pickle. * CNI:Did you smell your coffee today morning? * NIE Inspection Periorbital swelling, Trauma, Contusion, Ptosis. Go behind the patient and look for proptosis ‘Acuity of vision - Do you wear glasses? Can you see clearly? Could you please close your Rt. Eye? Now count my fingers? Are they clear? Field of vision —I would like to examine the extent of your vision for that I want you to close your Rt. Eye first with Rt. hand. Try not to move your head please. Ideally I would like to do colour vision with ischiara chart. Direct eye reflex ‘Consensual reflex Accommodation reflex - I will be bringing my finger or torch towards your nose please follow that (convergence with meiosis +ve reflex eee & bee © CNIILIV &VI: -& Ocular movements — please follow my finger with your eyes. Try not to move your head. If you have any problem or y don’t see clearly or see any double please let me know. All ocular movements are normal and no lid lag. Ideally I would like to do a cornea) 1 This is wisp of cotton with which I will be touching your face. Please close your eyes and let me know if you feel me touching by saying yes. Touch his face on the angle of eye, mandible and maxilla. Could you please clench your teeth for me? Feel for temporallis & messeter. Ideatly { would like to do jaw jerk as well. + + © CNVIE Could you please look up and frown for me? Could you please tightly close your eyes when 1 am trying to open it? Could you puff your cheeks out for me? Check for nasolabial folds. Could you show me all your teeth and say eeeeeceece? Could you taste your breakfast in the morning? eee EE 98«© CNVII: bros on | utoid OAL, Can you hear properly? Do you have any ringing in your ears? Is there any pain in your ears? Inspect the ear for any preauricular swelling, discharge, bleeding, FB inthe ear. Modified RINNIE’s Test: This is instrument which buzzes. I will be placing it behind and in front of the ears. Please tell me where you hear it better. WEBER’S Test: I will be placing it on your forehead. Please tell me in which ear you hear better. Ideally I would like to do Caloric test, Hallpike’s manoeuvre and complete Otoscopic examination. -}- # & teeee * CNIX&x: + Could you please open your mouth and stick your tongue out and say AAH while I shine my torch into your mouth? ‘You look for movernent of uvula upwards and pharyngeal wall backwards. * CNX: ~& Could you please shrug your shoulder for me? * CNXI: ++ Could you please open your mouth and once more look for fasciculation in the tongue? st Could you please stick your tongue out and move your tongue side wards? + Could you please press against my finger with your tongue on your cheek? DIPLOPIA GRIPS. a The purpose of my visit is to check the cause of your double vision. Position: Sitting Exposure: Till the shoulders * INSPECTION: <4 Any signs of Periorbital swelling, Trauma, Contusion, Ptosis, subconjuctival haemorthages. Ge or ‘+ Go behind the patient and look for proptosis (ry ve. € ‘ s Do the Light reflex. Cn). 2eée 2rd. Cosel Do the Red reflex. Reco -cMoite thonve s+ Position of the head — Check for any abnormal position. drcard bei SO Fe vs Keiliny Whether you see double at any point, any part of the day? Are you injured in your eye? * Do you wear glasses? Do you see double all through the day? Does it worsen by the end of the day? Do you have headache? 99Tey OOS LD Cet : war COE GUL. ae ¥ a \ ve i Arse | Dl eae ON [deter keckw We Be Gala culere We see, AOU, are, Cole Fe pe +O Che One Oh ayer Akt cole LC ch ase) uN Sepenes Ob * Do you have any problems like high blood pressure, blood sugar? Cow Gee, + Have youlostweigh? IE BF Seb einer imag * Do you sweat when others are comfortable? eke Li ae © Do you have weakness in any part of your body? Re Vinkowk, ib Se * CAUSES: over We Ore “| — + Refractory errors ke ote | DP. & Lenticular dislocation te oltcete gl +—~ <& Retrorbital & intraocular tumours 7 ¢ + Extra ocular muscle palsy ~mYyasmenioy Grar. + Diabetes 7 TER ROFO KI AGA + Cover and uncover test + piece ct Raper va bone OF He ee & + Examine for ILIV & Vicranialneves Wyo ie cline. her Lateatng ke Cex . aos 6 Kae pr at Cock etradqub alt Cont Mee oor ecg CEREBELLUM. \ + GRIPS Ook Dr to i ARTI GH ae _ Tam here to examine that why he has problem with his balance. CON STITOTION ‘Appreciake my DE has Position: Lying down Comer 1 § Exposure: Complete eur Cpeecha © PICKLE first he pis Silting © Nystagmus - =a OK HOA | te ole tf TESTS OF COORDINATION: perce a Cages nore + Dysdiadokokinesis — Could you please flip flop the hand for me? ¢/ ; . dle He AOL L Rigernose eat LO Ey Cte to jeuton | JU OLE en, Gvr_AX. "sb Knee heel test- Could u please touch your right heel to your left knee and slide it _ yar on the left shin? + Tandem walking ~ Could you please walk in straight line with the heel touching your toes? st Rhomberg’s test with eyes open for cerebellum, + MOTOR EXAMINATION: v BULK: + Ideally I would like to examine bulk with a measuring tape. But on gross examination, there appears to be no wasting. v TONE: + I would like to see how smooth or stiff the muscles around your joints are. ‘Tone at wrist, elbow, hip, knee and ankle POWER: s Could you cock your wrist up/down? + Could you pull your forearm inwards (flexion) / push outwards (extension)? +4 Could you push your hands? Forwards (flexion) 100Backwards (extension) Outwards (abduction) Inwards (adduction) *& Could you raise your leg straight? Press down + Could you pull your leg inwards (flexion)? Push outwards (extension)? st Cock your ankle up and press down? v_ REFLEXES: +. This is medical hammer with which I am gently tapping you, It will not cause any discomfort or pain. Please let me know of any discomfort ¥ DOLL’S EYE MOVEMENT, NECK STIFFNESS: +& To be performed only if cervical injury has been ruled out and only if cervical collar is not there, VERTIGO Qaangs (2 64 ; ON Big te GRIPS > Tam here to examine why patient has got dizziness. ol Bleue WlerebeklLom Position — Sitting 9 Stemek, Exposure — Up to shoulders Scat » Ceorelsellent tea!” 4 + HISTORY: ee ark, sk Do you have dizziness? + Isitall the time? ~~-»rak-Do you have pain-in your ears, fever?-—- Have you been injured on your ears? Do you hear any ringing in your ears? Is there any discharge? Is there any headache? Do you have any problem in swallowing food? Do you have any weakness in any part of your body? Does it come in any situation like getting up or turning to the side where you feel dizzy? FER EERE sb Wax byqee ) SKE Se) S Taume + Infection, sce werye + BPV de yoo p L nina © “ a Meniere's disebse”, Fee! coy Gheener in a Cestoya postion $ Cerebellar tumour ¢~ 1 Ove 1 You enV + CPangle tumour STEP > , + Stoke Kyrj tenner inrfU lovel 1 101INSPECTION of ear Tragus test — if +ve, absolute CI for otoscopy. VIILV & VItth nerve examination TESTS OF COORDINATION: + Dysdiadokokinesis ~ Could you please flip flop the hand for me? sk Finger nose test ~ “+. Knee heel test - Could u please touch your right heel to your left knee and slide it n the left shin? s+ Tandem walking~ Could you please walk in straight line with the heel touching your toes? +4 Rhomberg’s test with eyes open for cerebellum UNCONSCIOUS PATIENT CAUSES: Loy + Epilepsy sb Overdose — Medication poisoning SS) + Trauma ; \y + Tumour ~ Bleed 4 £ Meningitis + Intracranial bleeding. Thave an unconscious patient. Is the cervical injury ruled out? His airway, breathing, circulation is normal or not? I would also like to take a brief history from the ambulance crew or relatives to find out the event that has occurred his past medical illnesses and the medications Assess the GCS of the patient. faintain the airway by protecting the airway and then call for your ser Privacy and ask for the chaperone. PICKLE first. HEAD to TOE oh Head : Any sign of injury or trauma on the scalp and behind ear & Eye: Per orbital contusions, Haematoma, Subconjuctival haemorrhage T would like to check the pupillary reflex and do fundoscopy. ch Ear: Look for discharge, foreign body, signs of trauma. Ideally ofoscopy as well s& Mouth and Nose: Any smell of alcohol, any drugs, open the mouth and look for any signs of bleeding. Loose denture, loose teeth. s& Neck: Look for any signs of strangulation. Abnormal pulsations in the neck. Non-pulsatile engorged vessels. Supraclavicular or infraclavicular hollowing or fullness. st Hand: Wrist bands for DM, Epilepsy or asthma, signs of TV drug abuse. Ros 4, st Ask for pulse and BP ‘& Chest: Look for dilated veins, scars, abnormal pulsations. Looking for any signs of pneumonia or infections in the chest Meno 102s+ Abdomen: Any distension, dilated veins, intra-abdominal pathology. My orthopaedic colleague will take care of the pelvis. *& Thighs: Signs of injection mark, signs of any abscesses. Elsewhere in the body. Distal pulses. GCS AND NEUROLOGICAL EXAMINATION. (PRIMARY AND SCONDARY SURVEY HAS BEEN DONE) GRADE THE PATIENT ON GCS chart . IT WILL BE GIVEN IN EXAMS. If not then ask the examiner for the card * GLASSGOW COMA SCALI BESTMOTORRESPONSE _| OBEYING COMMANDS | LOCALIZES PAIN WITHDRAWS S$ TO PAIN FLEXION TO PAIN (withdrawal in flexion) EXTENSOR TO PAIN (withdrawal in extension) _| NO RESPONSE. L BEST VERBAL RESPONSE ORIENTED 3 CONFUSED 4 | |APPROPRITE SPEECH eyes cclery at Can ok a 7O epen bil cues TIN RESPONSE TO PAIN 2 NONE 1 + Ifthe GCS is 8 or below 8 then tell the examiner that you will take care of his ABC first and then call the Anaesthetist immediately for Intubation, + (Inthe exam the GCS is usually between 8 to 10.) Cox oetene, Cone + NEUROLOGICAL EXAMINATION: enneteesi~ Com bwrtedo kr + Ifthe GCs is below 15 you cannot do the higher function, cranial nerve examin and sensory examination. Secor Sew * MOTOR SYSTEM: & a oF é) ~ Attitude of limbs(esp. for decerebrate or decorticate =e aul Roti Quer thy ae PK enw Fe bugs ALL DEEP TENDON JERKS do PR w chueks PEANTARS bedwsla, 5 Orin Canod to \omenn8 Offer) + Faby wetter Pecliedic, th ae ke UF 3 Degg is euice te nae Ohad 1S0mq [keg —4.% agency RE aA He be RB! we Ww OO PARACETAMOL POISONING Id, J | CPhis is a guidetine only. Follow the hospital protocol when you start working in NHS) ‘QUESTION ‘A young lady of 25 years old bas taken overdose of Paracetamol. Take history from the patient and discuss Cry] the management with the examiner (or may be with the patient). Do not take psychiatric history. HISTORY ‘What did she take ? ‘When? How much ? Did she vomit ? (Throw up) If vomited when ? (how Any pain abdomen much time after taking the tablet ?) If vomited within _| Do not ask why she took it about an hour — would have vomited some tablets also- in which case would be beneficial to the patient. Is she a high risk group ? Liver disease, Pts. taking enzyme inducer drugs (antiepileptics like Phenytoin, | phenobarbitone, carbamazepine)or Rifampicin, Malnourished (alcoholics) Management 1 tab of Paracetamol = If an adult has consumed more than 12 grams(24tabs) or 500mg. more than 150mg/kg~ FATAL eee If an adult has consumed more than 7.5 grams(1Stabs) — Dangerous (means starts damaging liver ) ‘Monitor patient for ABC. Gastric lavage If the patient presents within | hour of ingestion of Paracetamol a Activated charcoal If presented within 8 hours of ingestion of tablets (black coloured liquid) to Rowers, Bieri Wp io drink (50 grams) Adsorbs 3 L, Paracetamol —so helps in oa eens x A PEM G0 Herft | excreting paracetamol Blood tests FBC, U&E, Glucose( hypoglycaemia is complication), LFT, INR, ABG (may have metabolic acidosis). Do Paracetamol levels only after 4 hours has elapsed from the time of ingestion of Paracetamol tablets. Ifthe patient has consumed | Anti-dote is N-acetyle | Which is to be given as IV more than the dangerous level | cysteine. (Acts best if | Infusion which once started will | of Paracetamol (15 tabs or given within 15 hours of | go on for 20 hours and 15 mins. more) - itis better to ingestion of tablets) Hoos bea WC commence with antidote x En 1S he straight away without waiting vagy cn “ for the serum Paracetamol ; levels If the serum level is above both the treatment lines— needs anti dote whichever group the patient belong ‘Then do Serum Paracetamol | If the serum level is below both the treatment lines— does level after 4 hours of ingestion | not need anti dote whichever group the patient belongs. of tablets to decide whether to [If the serum level is between the treatment lines ~- then it 113,— molnouisra J’ hha YOu ‘of i \ recorHy ) Sedona ) ayy See = oobi - ote ocr ed tes alo woudl pnare | continue with the antidote or | matters whether she is a normal patient or belongs to the . to stop it. high risk group of patients. If the patient normal - does not need antidote because the level is below the treatment line 8 of normal patients, but if high risk group - needs antidote | > because the serum Paracetamol level is above the high risk § 9. & roup patient treatment line, & If the patient does not require treatment with antidote — then stop the antidote if already k been started and probably repeat the level again afler about another 4 hours andif still below 3 the treatment lines— does not require any medical treatment— but refer to psychiatric team Es yy? sO for psychiatric assessment. But if the serum Paracetamol level is above the treatment line — then continue with the antidote and monitor the patient for any liver or renal damage. Monitor for Liver damage | Clinical signs of liver damage (hepatic encephalopathy) — t Shif the yt dom A Ooh we ‘nreetewae ~~. Of PYRE ELO Reduced consciousness, irritability, flapping tremors, =| patient to [7 Bradycardia, Hypertension, Jaundice, Abnormal LFT (to ve 8 SITUit w repeated daily) , Raising INR (to be repeated 12 hourly) = * | liver or £5 sha aoe Renal damage | Reduced urinary output, high urea and creatinine. Keep monitoring U&Es, Sugar, ABGs Exercise _| Patient has taken 15 tab of Paracetamol 12 hours ago ‘No need of | Do alll the blood tests | Commence with antidote | Monitor patient and teite> @ gastric lavage | including serum and decide to continue or _ | to psychiatric assessment and activated | Paracetamol level. stop the antidote once the once medically charcoal. serum Paracetamol level is | improved in hand, {andidates are strongly advised fo talk about the management with the patien eto B| | >! ib lok 238 a Wap ges ie mo ds Tah ane, he exer nes ask dg mak OP ieadiclew HOkS oe ae CHEST PAIN(MD_ 5.71, CE eed pnd LEST i Question ‘A 55 year old man has presented to aa ‘A&E dept. 2 complaining of severe chest pain. How do you manage this patient. | Sit up patient in comfortable position and take care of ABC Onot 15 units/wk. 3. EXERCISE: exercise type shall depend on age. Middle aged and above should walk briskly for at Teast 45 mts/day at least 5 days/wk. 4. BRACELET: Wear bracelet containing type of diabetes, medication ptis taking, and his/her GP. 5. Pay particular attention to Feet and wear comfortable footwear. 6. Check eyes regularly 7. Avoid Over-The-Counter medications. 8. Regular follow up with treating doctor. DVT - WARFARIN ‘Que: Mrs. Katherine Jones 28yr old lady has been diagnosed as DVT. She is being discharged from the hospital today. Your consultant has commenced her on warfarin tablets. Talk to the patient and address her concerns. 1). Greet the examiner. 2) Check ‘a. Prescription chart for patient identity and for all the medications ‘Medicines for expiry date and strength of tablets Greet the patient. Congratulate the patient for getting discharged. we Explain the purpose of your visit. AW” Take some information from the patient. \o" A ert alley ae ey EDA b. Other ilinesses to know about contraindications 7? pC? (Liver disease, Peptic Ulcer, Sever HTN) Aa) e ©. Other medications to know about interactions C Ge a4 4. If the patient is female — pregnancy, breast feeding, OCP. \v-~ ened ‘ 4). Explain medicines to the patient ee Blood thinning tablets, should be taken regularly, everyday same time for about six months. Dosage will depend on the blood test what we do on you regularly. This is called as INR noes ‘come to the Hospital frequently and bring tie booklet with you aaa sr Side effects ~ Prone for bleeding. So if you notice any bruises on skin, bleeding from the nose, red x colour urine or dark coloured urine inform doctor immediately. If you notice and lesions (Skin ae necrosis and rashes) on skin also please inform your doctor. (other side effects ~ bair loss ) 5). General information regarding prescription a. Do not stop, alter the dose, or start taking any new medications without consulting her GP. Ifyou require pain killers you can take paracetamol but do not take anything = C1... containing Aspirin. roy b. Ifthe patient is on OCP ~ advice to stop OCP because it can precipitate DVT as well its\~2 effects may be reduced due to warfarin. For alternate methods of contraception they can ()C. f¢ consult their GP. 2 . Ifthe patient is female advise her not to become pregnant for the next six months. 5) Advice on illness. ; Wo You a. Wear pressure stockings. he conn. Avoid Tong journey figs 8 Sar ¢. Advice to siop smoking and drink slcohol only in moderate amounts-*~ C&O rn. o ! Repro. bkResackow4 ea ‘ jg)126 Awe pale ow. fMedierne eer wey Po Oa te) ad4. If they develop chest pain or shortness of breath (PE), advice to come to the hospital immediately. Heart Failure Mrs Lucy Williams, 58 Year old lady feels short of breath while climbing stairs, she has been diagnosed with Left Ventricular Failure. She is to be discharged. Talk to her about the management & address her concerns. GRIPS Disclose the condition — to the patient. ‘Mrs Williams, as you know you have come to us feeling short of breath & we did some tests on you. ‘Unfortunately it seems as though your heart is not beating as effectively as it should, and hence it needs some life-style modifications & medications to keep you comfortable. Let me talk about the medications first (ask for a prescription chart if available) ‘A range of medicines can be used to relieve the symptoms of heart failure and slow down any worsening of the condition. Any underlying cause will be treated first — drug treatment given to lower blood pressure, for example. The various drugs prescribed work in different ways: Diuretics, eg bendroflumethiazide ‘These increase the production of urine, and so help remove excess fluid from the body. This reduces leg swelling and removes fluid from the lings, which can improve symptoms such as breathlessness. There are some side-effects, Diuretics can upset the balance of salts in the body (especially potassium) and this cart cause muscle weakness, fatigue and abnormal heart rhythms. At the start of treatment with a diuretic, large amounts of urine may be produced, requiring frequent trips to the toilet. This will usually settle down within a day or so. ACE inhibitors, eg lisinopril ‘These drugs relax the walls of the blood vessels, reducing pressure and making it easier for blood to ‘cifculate: They're also good for reducing levels of the body's Own heart-stinmulating chemicals: Overall; ‘they can improve the performance of the heart. ACE inhibitors can reduce the symptoms of heart failure and in studies have been shown to reduce the risk of dying. Side-effects can include a persistent dry cough, low blood pressure and faintness. A group of drugs known as angiotensin II antagonists (eg losartan) works in a similar way to ACE inhibitors, but they tend not to cause a dry cough Digoxin This is used to teat irregularities inthe heartbeat and so is known as an antiarrythmic drug, Digoxin is particularly used for a condition known as atrial fibrillation, which is where the heart beats quickly but irregularly. Digoxin works to slow the heartbeat and so improves the heart muscle’s pumping ability. Side-effects can include a loss of appetite and nausea. Beta-blockers, eg atenolol Beta-blockers are very commonly used drugs for treating high blood pressure. They also steady the heartbeat and make the heart more able to cope with exercise. In the past they were thought to be ‘unsuitable for people with heart failure, but studies have shown that they may help prolong life. Beta blockers are not suitable for people who have asthma. 127Anticoagulants, eg warfarin These drugs thin the blood. Tf the heart is not working properly, some blood may remain in the heart chambers at the end of the pumping action. This tends to make blood clots more likely to form. These clots can be carried in the blood and then block a narrow blood vessel. A stroke occurs if this happens in the brain. Thinner blood is less likely to clot. Taking warfarin requires careful monitoring, with regular blood tests. Thinning the blood too much, for example, can mean that an injury causes bleeding that is, 4ifficult to control. Life style modifications Diet: A regular low salt & balanced diet. Maintain optimal weight & nutrition. Regular gentle exercise without stressing yourself. Keep yourself stress free. We would refer you to the dietitician. Stnoking & Alcohol: Quit smoking & take alcohol in moderation Referral to Cardiac Rehabilitation Team Leaflets & Websites DIGOXINE: Description: increases the force of heart Cautions: Recent Ml, Thyroid disease, Pregnancy Contraindication: none at this level ‘SIE: related to over dose: Nausea & vomiting, GI effects, Headache, Visual disturbances. Dose: 125-250 mg daily FUROSEMIDE: Description: Water tablet Cautions: Pregnancy and lactation, Hypotension, liver Failure, BPH, Gout, Contrairdication: Renal Fallure with anuria, S/E: Postural HyTN, Gl effects, hypo-Na/K, uric acid, Dose: Oedema 40mg morning PO ACE |: _Cautions: Initiated with care in pt receiving diuretic, (night dose), Lactation, rene impairment, (monitoring). Contraindication: Hypersensitivity, Reno-vascular disease, Pregnancy ‘SIE: HyTN, dry cough, rash and Angioedema, Gl effects Dose: As prescribed ASPRINE Description: Blood thinner Cautions: Asthma, hepatic and renal impairment, Contraindication: PUD, Lactation, Bleeding disorders, Gout SIE: Gl effects, Bleeding, Tinnitus, Dose: Once @ day, PO, after food. BETA BLOCKERS Description: Siows the heart and protects it Cautions: Diabetes Pregnancy and lactation, hepatic and renal impaltment, Avoid abrupt withdrawal, \Verapamit interaction. Contraindication: Asthma, 0.A Dis. 128SIE: Postural HyTN, Gl effects, Sleep disturbances, Bradycardia Dose : HTN 50 mg moming PO ‘THIAZIDE DIURETICS Description: Water tablet Cautions: Diabetes, Gout, pregnancy and lactation, hepatic and renal impairment Contraindication: hepatic and renal Failure, Addison, hypo-Na/K, hyper Ca SIE: Postural HyTN, Gl effects, Dose : HTN 2.5 mg PO: Early in the momning=>not to interfere with sleep MRSA Siper bug Mrs. Katherine Jones is a 28 year old lady who had a caesarean section for foetal distress about 2 weeks ago was very upset that her operated wound wasn’t showing any signs of healing. Swab done on her wound showed that MRSA is growing in her wound. Disclose the diagnosis to the patient and address her concems. Hello Mrs. Jones, How are you doing today? Lam Dr, ... Working in the department of OBG and I am here to talk about the test result which was done on your operated wound. ‘Well Jones as you know your operated wound wasn't showing any signs of healing and there was some discharge from the wound. So we had done a special test, that is we took a swab from that wound. Results have come back now and unfortunately results aren’t that good Mrs. Jones. The results shows that there is a bug growing in your wound which is called as MRSA which is otherwise called as Super bug. Super bug ??? Where did I get this from doctor ? ‘Well Mrs Jones I wish I knew the answer for this. Unfortunately we do not know where you got this from at the moment, but our infection control team is looking into this. So what is going to happen to me doctor? Well Mrs: Jones; as you nay know it is very difficult to treat theses bugs; because they are resistant to most of the antibiotics. But fortunately we do have some type of antibiotics which may work against these bugs. So we will start treating you with these antibiotics and see how it goes. It may take a bit longer time to get rid of these bugs and I ai afraid you may have to stay a bit longer time in the hospital. As well, as ‘we may have to keep you in a separate room until you have been treated completely off these bugs. So what about my baby doctor? Will my baby also have these bugs? hope your baby hasn’t been infected with these bugs. Our specialist Paediatric doctors are looking into this issue, but you don’t need to worry about this much we will take a good care of your baby. ‘What about feeding my baby doctor? Unfortunately you should not cuddle your baby as the bugs may be transmitted from you to your baby, so you cannot breast feed your baby. And also it may not be advisable to give your expressed breast milk also because the strong antibiotics what we are giving you may flow through your breast milk to your baby. Again as Isaid you do not need to worry about your baby as we have specialist nurses who will take care of your baby including feeding of your baby. Ke Nesp Me MD Oy TAY Vor uoMycin Veiminn Ze tonee, o fbe 4 a 129MRSA (Methicillin Resistant Staphylococcal Aureus) Mr Alan Border is a 55 year old gentle man has an ulcer over his right leg. ‘Wound is suspected to be positive for MRSA. Examine the wound by taking all aseptic precautions. (PS: questions may come as just remove the dressing or change the dressing- in which case does not examine the wound). Greet the examiner and tell him that ideally this patient would have been isolated in aseparate room and you would have washed your hands and taken alf the precautions before you would have entered patient's room. Then go to the dressing table. Ask assistant to help you wear the gown and wear it. Wear the mask. Then open the dressing pack (or tell the assistant to open) kept on the table (pack contains gauze pieces, bowl and a yellow bag). Take the yellow bag from inside the pack and stick on the side of the dressing table. If there is no dressing table, stick it to the wall, but mention to the examiner that ideally you will stick on the side of the dressing table. Then wear the sterile gloves. ‘Then greet the patient. Take his permission to open the dressing and examine the wound. Then ‘open the dressing and throw it into the yellow bag. Then change the gloves (verbally). Examine the wound (only verbally) (PS: There is only an artificial wound). (Examine the wound only if asked in the task.) Inspection; site, size depth, Edge (sloping, undermined, punched out, raised), Floor— covered with granulation tissue, slough, pus or blood Surrounding area ~ colour changes, eczematous changes, varicose veins Palpation: (only verbally). Tenderness, Induration and fixity of the base Then 1 will examine peripheral pulses, sensations, lymph nodes, chestand abdomen. ‘Then mention ideally you will take a swab and send for culture and sensitivity, clean the wound and redress the wound. (Redress if task mentions it.) Then take the yellow bag close the mouth with the glue side of the bag and discard in the dinical waste bin, alsa. discard gloves, gown and.mask into the clinical waste bin and tell the examiner ically the clinical waste bin would be discarded separately. ‘Then mention that you would thoroughly wash your hands. Then thank the patient and the examiner. Lumbar Puncture Hello Mrs.__. How are you doing? I'm Dr. ‘one of the SHO in the Medical Department. ‘As you know thai you have been having headaches and fever we would like to do a special test called Lumbar Puncture, otherwise known as spinal tap. This wil! help us to find out what exactly is happening with you like meningitis or bleeding around your brain, For this test we'll have to remove a small amount of fluid called Cerebrospinal fluid that surrounds your brain and spinal cord. We can take this fluid by inserting a needle in your lower back. Before we do this we'll do a special scan called the CT scan of your head to make sure there is no increase in pressure of this fluid inside the brain or the spinal cord. 130\ ‘When we do this procedure you'll have to lit on your side with your knees drawn up to your chest. We will inject a local anaesthetic at your lower back to numb the area so that you do not feel any pain or discomfort. If you feel any tingling or numbness on your feet while we insert the needle you should let us now. We'll collect some fluid and send it to the lab for testing, The procedure may take around 20 to 30 ‘min. Once the procedure is complete you'll need to lie down for about an hour. You should not do any strenuous activity for the first 24 hours. You should drink plenty of fluids after the procedure. This will reduce the incidences of headaches. Indications: Meningitis pe Vee rie Coma And axanue the Sat oe ee Pe, ey be, De entrnst or Eooepialide Tear wr? dit ets core Yrerdink ‘Anaesthesia (epidural) YUcd Gono ow cl + Infections around puncture site. ( ‘ ani Dr worse Thee ICP ce Degenerative intra-vertebral joint disease Co Complications: Headache (10% - 30% of patients) 26 PDR ) Bleeding, infections (very rare) Risk to life (due to coning) is rare as we are doing a CT scan before we do this procedure. ‘Treatment. : Bed rest Fluids: Analgesics Pay weer Berra ta ruts home. nvtipetor Gorm ein? nurse Teteprems COonuelSabrin - dip. whe do yo mene tof COdspe on bene in baw BD Vow Rep) pede Sabor y parr Ls 3a IT) | (3) has he heel, asi boro shyote Pen (FE) Om endinat OC TY frecet Petty eon t Khe cust, AtDnel, omy Hh at. Sop wredicardiny © Cee, te el 2 trove bona! in het Ca,» Chemge 1s boned nhshs, oom few ped winba A 1 Property : 1310 —— DmgHigion we Rogue Bap , any Ongoing Problem Reon Te \eEd) Pre operative assessment. Object is to make sure whether the patientis suitable for the elective operation as well as for anaesthesia and to optimise his condition for the operation. In some cases surgery may need to be postponed until the patient is optimised. Assessment consist of taking a full history, examining to see whether any new changes has happened since his operation was decided. To do necessary investigations to help in anaesthesia and to prescribe some pre op medications if needed. Also patient needs to be explained about the procedure and the need for operafon and to take his consent, History. ‘Ask about his condition. Does he know he has been posted for operation and what operation and the time and date of operation. Past Hx : Have you ever been in the hospital before ? M-~Myocardial Infarction ‘A> Asthma, Chronic Obstructive airway disease. EE Rheumatic fever, One row S.; Sicke cell anaemia, stroke @.5 ee; 8 6-42. ~Ows Keele H{— Hypertension/ hemophilia/Hepatitis/Hypo- Hyperthyroidism ae Sows ~ Epilepsy/Embolism D- Diabetes mellitus LzIsheamic heart disease. Boe Abo LEIP SPS, % Wane: Steriods, antihypertensives, for diabetes, Thyroid mediSids, Glood Fianers 0¢ Pg Abiieoegilanis, Antibioties. Oral conteaceptivepills(chouldbe stopped six weeks before surgery and alternative contraception should be prescribed) i general anaesthesia, any problem with anaesthesia before, any allergy to anaesthetic Sexual habbits, Recreational drugs (High risk for HIVand Hepatitis) Social Lx 'o find whether anyone to look after him after the surgery. = —— Systemic enquiry In order to make sure you do not miss any new acute symptoms, you may want to go through the following list of symptoms with your patient. (Just ask few questions from each system whatever you can remember in the exam ) a . Ty. 7 A X > have toate aq Tentechignh Oy tecennna Laed 132Tam are WON Te commended for } 2. wae Soule gee Ae. ~ np wagtr We Con? Rocopd ¢« of Care sarees POU Cardiovascular: chest pain, shortness of breath, paroxysmal noc] “er esbnoe, oedema, palpitations \~.5 Guact [4 AO, AO CO-motladivg Respiratory: cough, sputum, haemoptysis, Gastrointestinal: nausea, vomiting, dysphagia, acid-reflux, haematemesis, abdominal pa he > abdominal swelling, altered bowel habit, melacna/rectal bleed, weight loss, appetite. {_/ Genitourinary: dysuria, haematuria, dribbling, voiding difficulties, incontinence, noctyria Neurological: fits or seizures, faints, funny tums, loss of power, vision, or sensation. Any problems in the neck. Investigation; Recommended tests before an operation Gust a g wheeze, stridor @yy of t= bo eps “aA ide) {Test Patients Full blood count All patients over 40 Urea and electrolytes | Patients over 60 having major surgery Diuretic therapy, high blood pressure, congestive cardiac failure, renal | failure, gut/urology surgery, dehydrated Electrocardiogram All patients over 50 Coagulation studies. | -—_—Patients on warfarin, alcohol excess, hepatobiliary disease Glucose Diabetes, arteriopathies Liver function Liver disease, alcohol excess, hepatitis, | —|Chestxray Patients over 60 having major surgery | ‘Congestive cardiac failure and chronic obstructive airways diseas with localising signs, high blood pressure, malignancy Arrange Cross matched Depends on operation blood May need DVT prophylaxis. ecfic patients and problems Diabetes using - Insulin sliding scales, patients on steroids requires more steroid cover, alcohol dependent patients requires vitamin supplementation and sedation, and jaundiced patients requires Vitamin K. Consent (Ideally the person who operates should take the consent). . 133,Questiol Patient posted for removal pins from his ankle. Assess the suitabi for daycase surgery. Take relevant history like any Pre op assessment and then decide, This is a minor procedure. Can be done under general anaesthesia as a day case surgery provided no serious problems. If the patient is Insulin dependent Diabetic, if the sugar well controlled (ask him is he monitoring his sugar), (check his Diabetic dairy) can be done as a daycase surgery. Should come on empty stomach, omit morning dose of Insulin. Anaesthetist will check his sugar in the hospital on the day of surgery. He has his food in the hospital later in the evening and has his usual dose of insulin and then goes home. Someone should be there to keep an eye on him. Oral hypoglyceamics ~ No chlopropamide 24 hour pre op.(has long half life ) Hypertensive patient - No need to omit his medication. Fracture ankle 22 6f-.§ + AT 7 ~Mrs; Margaret Anderson is «78 year old lady had injured-her ankie-3 days ago and had visited — your hospital at the time of injury. One of your colleagues had seen her and told her that she has ankle sprain without doing any X Rays, and told her to take rest. But since the accident, pain had not settied and she returned to your hospital. You did the X Rays this time, but the patient overheard the Radiographer saying that there is a fracture seen in her X-ray. Address medical negligence issue and tell her that she only needs bandage to her ankle. Patient may be very annoyed and upset with you. Approach very sympathetically. Hello Mrs. Anderson How are you doing? Lam Dr. ----- and J am one of the doctors working in the department of A&E. ‘Mrs. Anderson I understand that you have injured your ankle 3 days ago and you have visited us at that time and one of our doctor told you that you have sprained your ankle, is that right ? That is right doctor, but at that time he did not do any X Rays and told me I just have a fracture and I had this severe pain so { came back and the nurses did the X rays and I heard that there isa fracture seen in the ‘X Ray 7? deni Well Mrs Anderson first of lam very sorry that the X Rays shows # smalf fracture in your ankle. And I do On ago rm apologise for not doing the X Rays in your first visit. I do appreciate that you came back to us now. Se, 134However this is gspall farture in your ane, so Mis. Andersen you donthavs to worry much ve aze hereto uke cae TOTES YOUROW, Wae nr) ar 0d $9 oon a need _ will art Wd pa ytd ke LD a PO oie 40 Well why didn't you people do the X Rays when came here frst time? “£2. yl" oo ten As L already told you itis a mistake which happened and I sincerely apologise for this. Unfortunately we receive many patients every day with ankle injury because this is a very common type of injury. So we usually do not do X Rays on every one. We normally do the X Rays only when we suspect that there could be a fracture, We normally press on the bones and see whether the patients feel any sore on the bone which usually signifies thet there is a fracture. In such cases we definitely do the X Rays. But if we find that there is no soreness over the bones then we usually think jt is just asprain and we usually do not X Rays, As well as X Rays has its own complications like you will be exposed to radiations which is harmful the people, that it can cause cancers. So we avoid doing unnecessary X Rays. But in your case unfortunately the doctor who examined on that day must have felt that there is no soreness on your bones and must have felt that i is not necessary to do the X Rays. [once again apologise for what happened. raf ue bo, mie Je ™ role Hebe yy ale. ee pete eh reese 2 tee oe oa Dodior hat woul Mee hopped if] didnt come DaEk? haere leer ecaatt” ye, te Well Mis, Anderson iis very dificult o say what woold have happened to you, but Iam very glad that ‘came back to us so that we can treat you properly, However the good news is that it is not a very serious injury what you need is only a bandage over the ankle which we will give you now and I will arrange an ¢¥ > appointment for you with the bone. ne specialist doctors and thy will akeya proper case of yousiom now Ate. 8(. "ey. a, ee peo Col band prdariie on ee 49 rachael” vider borer & ay tag, eed eer ‘wily Sou ‘fbr the fisture 30 that ad will not happen again? I do appreciate your concern. 1 will inform this incident to my consultant and I am sure he will take all the measures needed so that such incidents don’t happen again. Is there any other concerns Mrs. Anderson. Thank you very much. hoa +P po no caret Aiph 'l worpeed- > Needle stick injury Nurse accidentally pricked her finger while drawing blood from a patient. Counsel her. G Ae OF Vow murs S Syed - ee Dubs & Ly Yor H® ‘Sayre Ask few questions about ‘What happened ? When happened? What did she do after the incident ? Has she been properly immunised against Tetanus and Hepatits B (Ail hospital staff: should oe. oes be immunised before they can start working in the hospital). What is her concerns, 2 ® Loan Rar Does she know anything about the patient. (?? patient was suspected to beTiaving oy meningitis) or? bance Tell her she should squeez out the blood, wash it soap, do not suck or —, in bleach. eat Note name address and clinical details of the patient (Donor), eyree, Ay paisa heap bos &) v2 your ‘olaad wed Gab ckheal neden= Fon 4 wisod 2 3, Po. € Felten OCU BOS rare st mn . 7 ©, dispose. atoy Behbiee Soap OP Ay IA Dev colleO32 7 contioins2 Be MOM CSO Cay © doe han Medic“you +R & od OL, - a honk i She co WA) Oe Porm? 4 ctor rE) ar Pres Tell her that she should inform the occupational health department-and fill in an accident (critical incident) form. ‘You will store blood from her as well as from the patient. (If possible ascertain the HIV and HBs of both). AL? Lea ture ) a aye OMe aes Y Se 7 : ude hapa need ee | hes 5 ~ eh / sed), 1 needles Le Ve | whol otct . oO nbaee. * L e as hey voce sony ge » Immunize (active and passive) against Hep B at once if required.(most probably it to will not be required in this case as she would have been immunised (9), 5.0%, co Reassure that the risk of she getting the FIV is very low (less than 0.5% ff donor Bx HIV positive) and test her (recipient) at 3, 6 and 8 months. Tell that we (You and her) can speak to the Infection control team who may advise her about the prophylaxis medication (Has severe side effects), (make sure she is not pregnant). Prophylaxis should be given urgently ie- within one hour of inoculum(injury) if the risk is higher (Deep injury, Large inoculum). Prophylactic medications are usually kept in the Accident and Emergency department. Also tell her that you may give her some antibiotics (Rifampicin) as ves after going through the patient (donor) proper!; going through Pati (donor) properly. | cede ae ner aK a AS “J tow) Lin eAI® 58, s\ my 30 year old man collapsed outside the pub, Take history and discs, La 8 the management with the examiner, Hx _ What happened? Did anyone tell you how long you were unconscious ? Did you hurt [ a nak wes uk ut oor Or coe no ae 4ov yourself any where? Have you lost consciousness before this? aD Sy (oc Is ibe You evil nove oo tel D/Ds ~~ | alcohol Alcohol excess or ypoglycaem | Recreational drugs ‘| Have you been taking recreational drugs aa eRe BO ESR Posse [Head injury | Cardiac Arrhythmia Epilepsy to — = Hypoglycaemia due to DM Do you remember hitting your head to anythin Are you a Diabetic Did you feel your heart racing before | | you fell unconscious ~ | Did you feel that you are going to faint before you lost consciousness ?, Did you bite your tongue ?, Did you wet ‘your pants ? Do you suffer with epilepsy ye R Re suse & weg). stile Kory os pod(Asthma ‘Were you short of breath before you | became unconscious, Are you an | asthmatic ? Medications ‘Are you on any regular medications? & Overdose Have you taken any medications in excess? Ifanyone lost consciousness for more than 2 min try to find out the cause instead of just blaming it on Vaso-vagal !! ‘Management — Check blood sugar, Toxicology screen, cardiac monitoring for arrhythmia and 12 Lead ECG, CT scan of Head. If the examiner says all the results were normal — say that you will keep the patient in the hospital atleast for 24 hours for observation so that you can keep him in cardiac monitor for 24 hours to pick any missed arrhythmias or to redo CT scan if the head injury signs develops later. If the examiner does not agree - then say that you may discharge him after discussing with your senior colleagues - if there is someone to take care of him at his home for the next 24 hours, after giving head injury instructions and also you will fix up an appointment with the medical outpatient clinic to do EEG if required. POST MORTEM CONSENT: Indications: Accidents, Suspicious death, Some questions regarding the death. > Introduce yourself: Hello: | am Dr. > Feel you are sorry. No more talking about why you are sorry. Directly tell the PURPOSE 1 of interview. Purpose 1: am sonry to inform you that Mr. / Mrs. X is no longer with us. lam here to explain what happened to her. PAUSE.. er — = Check that how much they know about his / her condition = Involve them as much as possible but take the control of the situation. = Give bad news layer by layer: Positive (explain what the primary condition was and how good you did and the patient improved) + then negative (then sudden deterioration) + Positive (how much you tried) + Negative (Sorry that we were unsuccessful) > Assure the pt. was comfortable and not in pain when she / he died PAUSE. : eet aerate © COMFORT THE ATTENDANTS..... TISSUE, SOMETHING TO DRINK, © (Empathy) Show you understand why/how the pt is important to them. © If they are well tolerant tell the second purpose. To know exactly what was wrong with him / her we need to do a post mortem examination for which we need your permission, PAUSE. eect cere (BODY LANGUAGE, USE A LOW, CONFIDENT, SORRY TONE, SPEAK ARTICULATELY-NO HURRY) 137(pen you second task clearly while you show your empathy. Say that “To know what was really wrong with the pl. you need their permission to do a post mortem examination” Say thal Without clarifying the actual cause, you can not issue a death certificate" Explain the mutual benefit. (You and the attendants will know the cause ) Explain the procedure Assure there will be no external damage to the face. Do not guaranty that we will understand the cause. ‘Address their concerns and acknowledge their emotions + Ifany resistance summarise the subject address their feelings again and logicaly insist. Show that definitely it must be done, + 77? Offer another appointment if needed = Thank the attendants. BREAKING BAD NEWS: + Grips + Position of counselling, + Eye contact, body language, listening + Good opening, + Give enough time to pt + Give bad news layer by layer, + Let the patient to respond, reciprocate with the patient's feelings, and check if he understands, + Reassuré that you are not going to leave him alone + Give real simple information about treatment options, other modalities to improve quality of life and prognosis,=> (No jargons), avoid false hope, but leave a room for hope (+ <=> -) Eye contact if pt does not make it ask "Does any thing makes you worried, ask met I'll let you know." ‘A SAMPLE FOR BREAKING BAD NEWS: Chid with Fractured Femur and splenic injury Grips + How is he? _At the moment he is in ertical situation. Do not say “He is fine” + Is he alive? _Yes, yes of course -l understand itis 6 terible time; | have come here to talk about it. Do you feel like talking? Alter the accident we found he had fracture in his rt. Thighbons, but i's nothing to be worried about. We have involved our Orthopaedic surgeons. They can manage it. There are some bruises on his tummy that seems he has injured his spleen. Do you know what is it? __ tis one of the organs helps to fight against infection and contains a lot of blood. Any injury can cause a lot of biood loos. Its important fe stop bleeding. The whole team is busy to make him comfortable. We have giveri him 2, Pain killers, aid Fluids but he needs an operation, We will put him to sleep. Then have a good look inside the tummy to know where the exact ste of bleeding is. We will do our best to fix it but if the damage is severe we have to remove it Concerns about the infection: 138Alter loosing the spleen the pts will be more susceptible to infection, but we are not leaving him alone. We willbe giving him jabs and good antibiotic. ‘Ask if the ptis up to date with the jabs? Yes=: and will make sure. 1s he allergic ta any medicine? Penicillin? We want to give him penicilin for very long time, make sure do not skip it before counselling your GP. __ Make sure you do not travel to Malaria area. admire it NO=> no problem, we will refer to red book 139HISTORY & COUNSELLING MEDICINE HEADACHE GRIPS OFFER PAIN KILLERS AND DIM THE LIGHTS IF THE PATIENT IS NOT COMFORTABLE — OTHERWISE PATIENT MAY NOT COOPERATE WITH YOU (EVEN IN HISTORY TAKING STATIONS YOU SHOULD CARE FOR THE COMFORT OF THE PATIENT) Ask the patient how the symptoms started.(trauma, Spontaneous or he had the feeling that the headache is going to come as in migraine) ‘Ask her to grade the severity of the pain ona scale from I-10. Ask for the progression if it is same, increased, decreased or initial increase followed by gridual decrease. Where is the location of the pain? What makes the pain worse or make him feel comfortable Associated symptoms like vomiting (without nausea in CNS), photophobia, any visual complaints, weakness in limbs, unconsciousness, any fits. Rule out the differentials: Subarachnoid haemorrhage: occipital headache. The most severe headache the pt ever has experienced. Ask for any preceded trauma or waming headaches in the preceding 2 weeks. Associated with projectile vomiting (without nausea), photophobia, loss of consciousness. Giant cell arteritis: pain in the temporal region. Associated with combing the hair, Ask for any impairment in vision. More common in females. Cluster headache: severe headache associated with redness in’ thé - Occurs in clusters each lasting for more than an hr stays there for 6 months duration then goes for remission. Affects the same side always. Acute congestive glaucoma: Ask for previous problems with the eye. Any medications being used. Presence of coloured haloes when looking into light. Migraine: Ask the pt whether she was previously diagnosed with it, Any long term use of pain killers. Associated vomiting, problems with vision. Headache can me hemicranial. Meningitis: fever, rash, vomiting, photophobia Complete the history format by asking: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma. ‘Treatment hx: any surgical or medical ailments for which admission of warranted. ‘Medication bx: ask the pt whether she is on any tablets. Allergic hx: any known drug allergies Personal hx: ask for smoking and drinking habits. Bowel and bladder and menstrual hx. Travel hx, occupation bx, social hx 140RED EYE J GRIPS Ask the pt how the symptoms started. Ask about the condition of other eye or any problem anytime in the other eye. Ask if the symptoms are worsening, improving or same since onset. Ask for associated symptoms like headache, vomiting, impairment in vision. (loss of vision) ‘Ask the pt whether it’s involving either the eyes or just one eye. Rule out the differentials. Foreign body: ask the pt whether there is a gritty sensation in the eye. ‘Trauma: ask the pt whether she/he hurt the eye. Conjunetivitis: usually involves both the eyes. Ask for matting of the eye lids in the morning. Excessive watering in the eyes with photophobia. Foreign body sensation, Cluster headache: ask the pt whether there is associated headache which is very severe in nature, ask for associated lid swelling. Headache will be unilateral and will always will affect the ipsilateral eye. Acute congestive glaucoma/uveitis: these conditions characteristically cause circum corneal congestion and will not be good DD’s for red eye. (had come in the exam) Subconjuctival haemorrhage: ask whether there is pain, which is ideally not a symptom of this, condition, SYSTEMIC ILLNESS CAUSING RED EYE Rheumatoid arthritis- symmetrical joint pain of smaller joints with early moming stiffness, residual deformi Reiter’s syndrome- UTI, conjunctivitis, arthritis Inflammatory Bowel Disease- altered bowel habits more commonly diarrhoea, Fever, Blood in stools, joint pain. ‘Systemic lupus erythematosus. Buller fly rash over face, Complete the hx format by asking for: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma. ‘Treatment hx: any surgical or medical ailments for which admission of warranted. Medication hx: ask the pt whether she is on any tablets. Allergic hx: any known drug allergies. Personal hx: ask for smoking and drinking habits. Bowel and bladder and menstrual hx. ‘Travel hx, occupation hx, social hx Ankylosing Spondylitis - Young man having back pain. Painful Red eye is Uveitis.(had come in the exam) Pains, serositis, fever due to 142Weight g: GRIPS Ask the pt how the problem started. How much weight gain if she has measured. Ask the pt whether she noticed any other associated changes with this weight gain.( this might g give you a clue towards the diagnosis) Rule out the differentials: \ ‘Hypothyroidism: ask the pt whether she feels cold when others are comfortable. Constipation, menstrual irregularities. Ask for any swelling in the neck, ‘Cushings: ask the pt whether she has recently noticed any bluish marks on her tummy. Ask for excessive growth of facial hair. (Hirsutism) Poly cystic ovarian disease: ask the pt whether she is anxious to conceive. Ask whether she has noticed a gssive ice hair growth, Menstrual irregularities will be also being a feature. Ack Suk freae otal Drug induced: ask the pt whether she i$ on any long term steroid use. ‘Habitual: ask the pt whether she has recently changed her diet pattern and preference. If yes ask her whether she prefers eating food items like pizzas, fries, chocolates. Acromegaly: this could be a cause of weight gain. ask the pt whether there is any change in her shoe or ring size. Ask her whether she has noticed any change in her appearance compared to her previous photos. Complete the hx format by asking for: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma, ‘Treatment bx: any surgical or medical ailments for which admission of warranted. Medication hx: ask the pt whether she is on any tablets. Allergic hx: any known drug allergies. Personal bx: ask for smoking and drinking habits. Bowel and bladder and menstrual hx. ——Trayel hx, occupation hx, social hx ——-—— a -_— HOARSENESS OF VOICE Mea you GRPS Ask the pt how everything started.(ODPARA) Rule out the differentials: Laryngitis. ask the pt whether he/she is running a temperature. Ask for pain in the throat.) Vocal abuse: ask the pt about his/her occupation. Ask whether the problem started afer excessive voice abuse. Instrumentation: ask the pt whether he/she any procedures done for the throat. Surgery bx: ask for any thyroid surgeries. Recurrent laryngeal nerve injury. Carcinoma of the larynx: this is common in elderly pts. Ask for weight loss, halitosis, swelling in the neck (nodes). Hypothyroidism 142_the bowels. One of the commonest causes in elderly. Complete the hx format: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma. ‘Treatment bx: any surgical or medical ailments for which admission of warranted. ‘Medication bx: ask the pt whether she is on any tablets. Allergic hx: any known drug allergies. Personal hx: ask for smoking and drinking habits. Bowel and bladder and menstrual lx. ‘Travel hx, occupation ie, socialhx 4 x yw Foal A ae ‘40: + 'AD NSE EM sory who DIARRHOEA Gres — Colewect ad PresOn ie, Ask the pt how the problem started. (ODPARA) - oh POR 494 ism Acute usually infectious, chronic usually non infectious t N Assess severity by asking for thirst, urine output, dry mouth and tongue. ‘Ask forthe frequency, presence of fever, consisteney of stools, and presence of blood in stools Ask for any alternating constipation. : Rule out differentials: Gastroenteritis: ask the pt whether he/she had food outside. Ask whether she/he is running temperature. Food poisoning: ask whether the pt had canned food, or mushrooms recently. Ask for associated vomiting. , Irritable bowel syndrome: ask the pt whether she/he needs to empty the bowels very often, associated with meals. Feeling of incomplete emptying. Inflammatory bowel disease: ask the pt whether he/she noticed blood on passing stools. Duration of the problem will be chronic. Symptoms will be Interrupted with periods of remission, Laxative abuse: ask the pt whether he/she has the habit of using any medications to help open Complete the hx format: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma Treatment hx: any surgical or medical ailments for which admission of warranted. Medication hx: ask the pt whether she is on any tablets. Allergic hx: any known drig allergies Personal hx: ask for smoking and drinking habits. Bowel and bladder and menstrual hx. ‘Travel hx, occupation hx, social bx, a th aan ye [oman reales Y Carer LOSS OF CONSCIOUSNESS |_05-Linig.ca) Canter GRIPS Pare siers ots ody Ask the pt to brief you about the events preceding the loss of consciousness. How long didittast © bf and post episode amnesia, ‘4. ‘\- 20a mo pprree! ‘sete > Jon When doubt exists about whelber blackouts epileptic or cardiovascular in origin, acourate recall 9)" 1*/ of events immediately preceding the blackout, absence of headaches or other symptoms after the event and the rapid and complete recovery all strongly favour a non epileptic origin. Ask specifically about these features to aid the diagnosis. 19a whe jy wires Of ey Enquire whether the pt experienced any previous episodes. y ol ( ~ 143Wo. A ioscvane 3 hugo tegen ol 4 epks an Reon A Rule out differentials: Arrhythmias: H/O palpitations prior to or with the episode ask the pt whether he/she is been diagnosed to have any cardiac problems, > me ng TIA: ask the pt whether he/she is having weakness in any part of the body. Characteristically pt will completely recover within 24 hrs. > Ad a0, Hypoglycaemia: ask when the pt had his/her last meal. Ask whether the attack followed a acca prolonged period of fasting, — Hypotension: ask whether the pt is a hypertensive and whether he/she is on any medications for the same. For postural hypotension ask whether the attack followed after a prolonged period of standing. Complete the hx format by asking for: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma. ‘Treatment hx: any surgical or medica! ailments for which admission of warranted. Medication hx: ask the pt whether she is on any tablets. Allergic hx: any known drug allergies. Personal hx: ask for smoking and drinking habits. Bowel and bladder and menstrual bx. ‘Travel bx, occupation hx, social hx HAEMETEMESIS GRIPS Ask the pt how the symptoms started. (ODPARA) How many episodes and duration between each and the amount of blood loss each time. If the problem is increases. Associated with vomiting or coughing (to differentiate with haemoptysis) Grade the severity of the problem. Ask for easy fatigue, shortness of breath on exertion. Ask for the colour of the vomitus. Is it coffee ground or fresh red blood? Rule out the differentials: Oesophageal varices: ask whether pt was diagnosed to have any liver problems in the past. ‘Medications: ask whether the pt is on any anticoagulants. Tustrumentation: ask whether the pt underwent any procedures in the throat preceding this problem. APD: ask whether pt has any tummy pain associated with meals. Ask whether he/she is on any medications like NSAID. Carcinoma: ask the pt for hx of weight loss and loss of appetite, Complete the hx format by asking for: Past history: diabetes mellitus, hypertension, stroke, epilepsy, asthma, Treatment hx: any surgical or medical ailments for which admission of warranted, Medication hx: ask the pt whether she is on any tablets. Allergic lux: any known drug allergi sk for smoking and drinking habits. Bowel and bladder and menstrual hx Travel hx, occupation hx, social hx (not that very imp in this case). 144CHEST PAIN Offer pain killers (just say that you will tell your nurse to get the painkillers for him). Start with ODPARA. Was the patient fine before this episode?” How did it start/appear (any trauma). What was the patient doing? Is it the same when it started ad if any change, what’s the change. More frequent/ severe of longer duration, precipitated by less exertion than before (esp. for anginal pain) How long does the pain last after it comes? ‘Try to establish pleuritic type or anginal type Pleuritic type ‘Anginal type Localised (finger pointing) band like pain Pricking, stabbing, cutting, heaviness, compression, —_ oppression, squitezing vf Does not radiate relieved by sleeping on same side radiates to left arm, jaw to umbilicus 4) AGGRAVATING FACTORS (what brings it on) AGGRAVATING FACTORS Deep breathing walking, running or any exertion = PE Cove vos #4 RELIEVING FACTORS (what helps him to get comfort) RELIEVING FACTORS Lying down on same side rest, sublingual nitrates ASSOCIATED SYMPTOMS ASSOCIATED SYMPTOMS, Bree. Cough, breathlessness, wheezing, breathlessness, palpitations, sprees Haemoptysis, sweating (diaphoresis) nausea, Pirccal te vomiting BEWARE OF COSTOCHONDRITIS AND SKIN INFECTION waren may {fntie® PLEURITIC CHEST PAIN, WHERE THE PAIN IS LOCALISED BUT INCREASES ON LOCAL PRESSURE. fouoy PERICARDITIS IS RELEIVED BY BENDING FORWARDS. Aortic dissection: pain in between the shoulder blades, but can be retrosternal. Oesophageal spzsm or GERD pain increases on lying down after food, heart brash or with reflux, Acute coronary syndromes or stable angina @nginal type) Pleuritic type ~ Pneumonia, Pulmonary Infarction, Rib fracture Pericarditis Oesophageal spasm Aortic dissection Severe inter-scapular pain, PE (Travel history is important.) DRY COUGH When it did start? Was the patient fine before this episode or any complaints? ODPARA Type of cough BRASSY (hard and metallic) pressure on trachea BOVINE (prolonged and deep pitch) vocal cord paralysis. Any associated’ change in voice. Associated symptoms Chest pain, breathlessness, wheezing, fever ‘Ask for post nasal drip, or GERD as a cause. (Related to posture appears on lying down) 145 epsAny particular time of the day, early morning in COPD, cardiac asthma, or immediately on lying If accompanying breathlessness ask what is more distressing Rule out infectious cause as initially it could be dry in nature. Smoking history in detail DIFFFERENTIALS Pressure on trachea- intrathoracic lymph node, any ca., cardiomegly Post nasal drip Cardiac asthma- pre-existing cardiac illness, SOB Bronchial Asthma (Young man chronic dry cough - ”? PCP (Ree drugs and, sexual habbits important (May be sharing needles, May be homosexual) S2xva! Qh@nhehor > EAR ACHE When did it start? Was the patient fine before this or any complaints beforehand? Start ODPARA. Character of pain (throbbing, dull aching) has the pain changed in severity since its appearance. Any new symptoms like Any ear discharge, trauma or foreign body inside, tinnitus (ringing bells), vertigo (difficulty in balancing), headache, any neurnlogical symptoms like visual complaints (for orbitl ceffulites), weakness in limbs for brain abscess. FEVER, ALL ENT SYMPTOMS (nasal discharge, sore throat, post né drip, sinusitis- early moming headaches, pain over the face) — DIFFFERENTIALS ‘Acute otitis media ( severe pain, fever, yellowish discharge, headache) Acute on chronic otitis media ‘Basa trays (had come in the Exam).(Ask him whether he has travelled by flight recently). EPILEPSY Ask the patient or witness to describe in detail about the event or mimic if possible. Try to distinguish between focal (no toss of consciousness, motor movements start and limited to one side of body, note the jacksonian march where the movements start from thumb, toe and progresses to involve one side of the body) and generalised tonic clonic movements involving all the four limbs simultaneously or partial onset of generalised seizures where it starts from one part later to involve the whole body to genstalised nie clonic movements. Ask the patient (before the event) > For any prodrome which may be lasting from hours to days. > For aura (a strange feeling in the gut, or a disturbing sense of familiarity) or strange smells 6r flashing lights. 146S 8 > Ask for tongue bite (proves organicity but absence does not rule out epilepsy.) and faecal incontinence. > Ask if anything brings it on?( alcohol , TV) ‘Ask for (after the event) > How much the patient remembers of the event( amnesia common with tonic clonic, complex seizures) > Any post-ietal paralysis, confusion or loss of consciousness. Other questions to rule out (in case of children) petit mal epilepsy 1) Drop attacks- sudden weakness of legs causes the patient to fall on ground. There is no waming, no LOC and no confusion.( usual in older woman). 2) Anxiety —Hyperventilation, tremor, sweating, tachycardia but no LOC. Detailed neurological history for any change in smell, visual complaints, weakness in any part of body, any difficulty in balancing or any movement, headache to rule out Space occupying Jesion.(BUT only after detailed history of seizures) DJFFFERENTIALS Epilepsy Pseudo seizures ThA § “Stokes Adams syndrome (only for drop attacks and not generalised tonic clonic or pseudo) s -» Stokes Adams syndror © ilepsy Lifestyle Changes Counselting Ms Kimberly Yates is a 21 year old Student who has recently been diagnosed with Epilepsy. She has moved to a new city as she is about to start a new Course in University. Advise her on Lifestyle change she neods to make and adress her cones ers do po know @ ying MDP 245! psy > As you know Ms Yates, You have | bean diagnosed with Epilepsy whichis a condition in which __you have abnormal electrical activity in the brain. The reason as to why this happens is usually _ mknown. You can have a normal life, i's good to take some precautions though and make some Tifestyle changes which will be very helpful. I am here to talk to you about them. Is that all right with you? If you have any concems please ask me and I will address them. © Diet - 1's important for you to eat regular meals. Its good to eat at shorter intervals in small Quantities. Do not skip meals or go fasting for prolonged periods as this couté cause the Sugars in your body to go low and cause you fo have a ft. Eat a balanced diet. Ifyou need more advice I will refer you to a dietician. ~~ _ (3) Alcohol-[Ask her if she drinks?] It is better to avoid Alcohol, but if you do wish to drink, please drink in moderation.1-2 units of alcohol only is generally recommended for people with epilepsy Half a pint of beer on tap or 1 small glass of wine = I unit) Some people with epilepsy find that drinking any alcohol can trigger seizures; but not always while they're actually drinking. Often it’s later during a hangover when your brain is dehydrated that seizures happen. Drinking water in between alcoholic drinks is one way to keep your body hydrated and can help you feel less rough in the morning. Alcohol can make some medications less effective ~ the information leaflet that comes with your medications is likely to say if alcohol is not recommended. You could ask your doctor if you are unsure. hyadalycansion = Tagan OE Qe eee We PD dagba ton aledlaglayy ViizdK 2 , i HOOT EM py ” FIN 2Wwar SO Fh pe pee y ue ae - Lop M RUg ead iC yeas £ 4 y p ‘i Teorey = jiQteaications- Pease take your medications on time as prescribed to you. Do not take any other medications, even if itis ‘over the counter’ medications. Always check with your Gp. [Ask about any OCP intake] If Yes- Please use Barrier methods as well because the Anti epileptic, medications could interact with them and make them less effective. Your Gp will give you more .advice on other methods of contraception. / exercise Start with some light exercises and inform somebody nearby if possible about your condition, Avoid Rough Sports. If you go swimming, inform the Lifeguard about your condition (+r. 02+ ‘or go with someone who is an experienced swimmer.'«Jo. C>.- O33 ~ Eee )Home- While cooking informs someone at home, Take shallow baths; do not spend much time before a Tv or'a computer as these could precipitate an attack. When you go out, avoid places with flashy lights like a discotheque. Work Inform people around you about your condition a [if you work!] .Always wear an alert bracelet which will inform people about your condition. Inform your family, Colleagues, ____ Register with @ Gp and let him know about your condition. .s\ Driving — There are important regulations about driving. Please contact the DVLA regarding \) more advice, - 2) Will [have to take medications for life? YY) ~~ We will review you from time to time and there is a possibility that you could be taken off medications if you remain fit free for 3 years, but my senior will be able to give you more advice on that. Cam 1 go on Holiday? Yes You Certainly Can, Simply inform your companion, your insurance company and the place where you stay about your condition, Why Me? -I’s a difficult question-to answer, as-[-said earlier the reasons.are unknown, but che good part is that you are here and with regular follow up, we hope to keep your condition under control Lwill give you addresses of Support Groups, some leaflets and websites about this condition. Any Questions? —— —_ Thank you [ __ ¢ = Counsellin; me) Helio Mr How R U doing today? R U comfortable? Lam Dr. SHO in the dept. of As you know you came to us having been suffering with heatlaches, We did some investigations and the results are with us now. I am here to discuss with you what exactly is happening with you, what is causing this problems, what problems you can have because of this, what investigations we did. I will also tell u all the treatment options available for this condition, Is that ok Mr. _. Well Mr. Ail the investigations what we did on you show that you are having a condition called giant cell arteritis. Giant cell arteritis (GCA) is an inflammation of the lining of your arteries — the blood vessels that carry oxygen-rich blood from your heart to the rest of your 148,body. Although GCA can affect the arteries in your neck, upper body and arms, it occurs most often in the arteries in your head and especially those in your temples. For that reason, the disorder is sometimes called temporal arteritis or cranial arteritis. GCA frequently causes headaches, jaw pain, and blurred or double vision, but the most serious potential complications are blindness and, less often, chest pain and stroke. These problems can ‘occur when swelling in the arteries impairs blood flow to your eyes, heart of brain, (Older adults are at greatest risk of GCA. The disorder affects about 200 of every 100,000 people older than 50.) The exact cause isn't known. Although we have done some blood tests (ESR and CRP) now, we may have to do some more special tests like biopsy ie.take a small sample from your cranial arteries to confirm the diagnosis which we can do later. Unfortunately there is no cure for this condition but we can prevent the symptoms and complications of these conditions with some medications. One of the major and complication which can happen is that you may lose your vision suddenly. Unfortunately this may be permanent. To prevent this happening we will start treating you with some medications even before we confirm the diagnosis with the biopsy test. This medication is called as steroids. Initially we will give you bit higher doses (40 to 60 mg).You should start feeling better in just a few days, but you may need to continue taking medication for two years or longer. Afier the first month, we may gradually begin to lower the dosage until you reach the lowest dose of corticosteroids needed to control inflammation, Some of your symptoms may retum during this tapering period. Anyhow we will keep monitoring you throughout and we will take care of you. What are corticosteroids? Corticosteroids are powerful anti-inflammatory drugs whose effects mimic those of hormones produced by your adrenal glands. The drugs can effectively relieve pain, but prolonged use— especially at high doses —- can lead to a number of serious side effects ‘These include: ~ Thinning of sama bones( Osteoporosis) ~~ . High blood pressure a + Muscle weakness + Cataracts ( = Other possible side effects of cortisone therapy include: + Weight gain + Increased blood sugar levels, sometimes leading to diabetes + Thinning skin and increased bruising + Decreased immune systern function = Mood changes + Your symptoms should improve within just a few hours or days of beginning corticosteroid treatment, and your vision isn't likely to be affected. However if you develop any side effects from this ssedication please do not hesitate to contact us. 1 also suggest you to eat healthy diet and exercise regularly to prevent any problems like bone Joss, diabetes and high blood pressure. ‘New treatments One drug under investigation is methotrexate, 449‘Multiple sclerosis Counselling. Hello Mrs, Johnson How are you doing? Tam Dr. Khan, one of the doctors working in the department of medicine, Mrs Johnson I understand that you have been diagnosed as having multiple sclerosis. Tam Very sorry about this. Well Mrs Johnson { am here to explain about this condition and how to cope with this condition, Dr. I don’t know much about this. Well Mrs. Johnson although this condition does not pose any immediate risk to life, this may makegign disabled in some.parts of jeer body. This is usually a slow and progressive illness Which can affect your brain and the spinal cord. Fe ne blr De We think this is due to an auto immune disease, means that your immune system attacks the part of your body as if it’s a foreign substance. The antibodies are formed in your body which can damage the myelin sheath which is a fatty substance which surrounds the nerves just like insulation shield electric wires. This may block the nerve signals that control your muscle coordination, strength, sensation and vision. Unfortunately we do not know what triggers this process, although we think that heredity and environmental factors has a role. Unfortunately lot of people have been affected by this condition in this country. This illness is very unpredictable in severity, that means some may have only mild problems but in some others it may cause permanent disability like weakness in arms and legs, blurringor loss of vision, forgetfulness, problems with bowel and bladder and sexual function. This illness may have flare ups and a period of remission initially and later may become continuously progressive. Dr. Are you sure about the diagnosis? Could you be wrong? ‘Well we wish we are wrong. Mrs. Johnson, we have examined you and we have done investigations fike MRI scans on you if you remember, all these investigations say that you do have this condition Dr what are you going to do for me now? ‘Well Mrs Johnson, unfortunately though there is no cure for this condition, we can always modify the progress of this condition and relive the symptoms with some medications and life style adjustments. Main thing is that you should remain cool and calm and continue in you. without losing confidence in yourself. There are some medi ores can regulate immune system in your body and reduce the flafe ups. Unfortunately they do not reverse any damage which has already occurred nor does it prevert any damage which may 150happen. My consultant will decide whether you are suitable to this type of treatment or not given this medication, xou-are-suppascd to inject yourself to your body. We may give you some other medications like corticosteroids, muscle relaxants to relieve your symptoms. In addition to medications, we can help you in other ways: Physical and occupational therapy a physical or occupational therapist can teach you strengthening exercises and show you how to use devices that can ease daly tasks. This can help preserve your independence. — Counselling: Individual or group therapy may help you cope with MS and relieve emotional stress. Yout family members or caregivers may also benefit from seeing a counsellor. Self-care These steps may help relieve some symptoms. Get enough rest so that you will not get fatigued Exercise Reguiar aerobic exercise and swimming may help in improving the strength of your muscles. Be careful with heat. Extreme heat may cause extreme muscle weakness. Don't getinto a hot tub or sauna unless there's someone nearby who can pull you out if necessary. Cool down, Ifyou live in a hot and humid area, consider having air conditioning in your home. Eating a healthy diet and taking the recommended daily dose of vitamins can help keep_your___.. immune system strong. ‘Maintain normal daily activities as best you can. Stay connected with fiends and family. Continue to pursue hobbies that you enjoy and are able to do. Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Dr Will I be wheel chair bound? ‘Well Mrs Johnson it is a difficult question to answer at the moment, because as I said the severity of this illness may vary in different people. It may take along time before you may be wheel chair bound. But as I already advised you~ do not lose your heart and continue with your life as usual. We will support you as much as we can. 151Doctor will my children get it? Well it’s a difficult question to answer, but it has some genetic links, but there is no apparent pattern of transmission in a given family. Hopefully your children shouldn’t get it. Doctor will I get blind? Well Mrs Johnson it is a difficult question to answer at the moment, because as I said the severity of this illness may vary in different people. Hopefully it is a temporary phenomenon, but there are chances that your vision may get permanently affected. But as I already advised you~ do not lose your heart and continue with your life as usual. We will support you as much as we can. Theard Cannabis helps this condition? Well yes, there is an interesting research going on as to whether cannabinoids really help in this, condition. This is a powerful drug with a risk to abuse it & presently it’s at the experimental stage. Hopefully we'll get a medicinal preparation with guidelines to prescribe it sooner. We'll keep you informed of any latest developments. Will it affect my job & family? How will I cope with that? We completely understand your concer, you may be entitled to variety of benefits which includes the Disability Living Allowance. Home adaptation & Specialist equipment may be provided to you to help your work; this can be arranged by the Social Services & Occupational Therapy Services. They may help you to get a suitable placement within your abilities as well. __.._ @ ‘Mr. Martin Crow has been diagnosed to be having diabetic Retinopathy. Talk to him and address his concerns. ‘DIABETIC RETINOPATHY Hello Mr. Crowe How are you doing ? Iam Dr. John one of the doctors in the dept of medicine I understand that you have been diagnosed to be ‘having diabetes which has affected your eyes. I am here to discuss this condition with you and answer any ‘concerns you may have regarding this condition Mr Crowe do you know any thing about what is happening with your eyes ? NO doctor. Tell me. ‘Well Mr. Crowe as know you have been suffering with Diabetes for some years now, it has affected yours eyes now. am sorry to say this, ‘What exactly is.wrong with my eyes doctor? 152Diabetes affects your body from head to toes. This includes your eyes. The most common and most serious eye complication of diabetes is diabetic retinopathy, which may result in poor vision or even blindness aa This is due to the damage to the tiny blood vessels which supplies blood to the tissue at the back of your eyes. These blood vessels are often affected by the high blood sugar. Some times new blood vessels grow in the tissues at the back of your eyes and can leak blood into the surrounding tissues affecting your vision. Blurred vision cant be brought on by rapid fluctuations in blood sugar. ‘The longer you have diabetes, the more likely itis you'll develop diabetic retinopathy. Initially, most ‘people with diabetic retinopathy experience only mild vision problems. But the condition can worsen and ‘threaten your vision. Do you mean I may lose my vision? Well Mr Crowe, as I said there is a risk of you losing your vision, but you do not need to worry we are here to take care of you. Doctor do you mean I may lose my vision permanently? Unfortunately if this happens it will be permanent. Can’t you do some thing doctor? Yes Mr. Crowe, ifyou do whatever we advice you fo da, then the risk of you losing your vision is very small. Yo can take steps to slow the progression of diabetic retinopathy: + Control your blood sugar. Tight control of blood sugar slows the onset and progression of retinopathy and lessens the need for surgery. You should take your insulin or other medications regularly, monitor blood sugar levels, follow a healthy eating plan, exercise regularly and maintain ‘a healthy weight. “And remember that better control lowers but doesn't efiminate-your risk of developing retinopathy. + —Keepran eye on vision changes. In addition to getting an annual eye exam, be alert to any sudden changes in your vision. Have your eyes checked promptly if you experience vision changes that last more than a few days or aren't associated with a change in blood sugar, or if your vision becomes blurry, spotty or hazy. (In addition, if you have diabetes and become pregnant, you eye examination as soon as possible. Additional exams may be recommended throughout your Pregnancy.) * "Keep your btood pressure down. Tight blood pressure control slows the progression of diabetic retinopathy. To reduce your blood pressure, you may need to make lifestyle changes and. take medications. * Control your cholesterol. High cholesterol levels in the blood are associated with a significantl isk of vision loss. As with high blood pressure, treatments to improve your blood cholesterol may include lifestyle changes and medications. * Stop smoking. Smoking is especially bad for people with diabetes because it promotes the closure of blood vessels. * Control stress. (Stress can cause swings in blood sugar levels in people with diabetes. may affect your ability to control your blood sugar. 153‘Treatment ‘The two main treatments for diabetic retinopathy are photocoagulation that is laser treatment and a small operation inside your eye (vitrectomy). In many cases, these treatments are effective and slow or stop the progression of the disease for some time. But they're not a cure. Because diabetes continues to affect your body, you may experience further retinal damage and vision loss at a later Your eye doctor can tell you more about the operation if you like to know more about it. BLOOD TRANSFUSION ‘You have planned to transfuse 4 units of blood to an elderly man for severe aneamia.( may be for myelofibrosis) Address his concerns. Hello, Mr. john, how are you doing? I am Dr. -—- working in the department of medicine. As you know you are severely anaemic (je you have very low red cells in your blood which helps in carrying oxygen), we have planned to transfuse some blood to you. So T am going to tell you about how we are going to transfuse and also you tell you what problems we may face while we are doing this and also clear any doubts you may have regarding thi: First of all can you tell me do you have any restrictions for receiving bloai, I mean are you a Jehovah’s Witness? No doctor ~ I am not If the patient is Jehovah's witness — Tell him that you do respect his believes and then make him understand the importance of having blood transfusion saying that this is the only option treat the severe anaemia. If he still does not agree you can tell him that you will make an arrangement for him to speak to hospital Priests or counsellors to talk to him.) As I told you that you are severely anaemic we have planned to transfuse about 4 units (bags) of blood to you Each unit will take about 4: hours to transfuse; So-you may have to stay oveight — as it may take about 16 hours or more to transfuse all these biood. How are you going to do this doctor? ‘Well first of all we are going to put a small tube in your blood channels and give blood through, that, While we are transfusing we will keep observing you closely by connecting some monitors to you. You can eat and drink waile you are having the transfusion if you want to as well as you can move around a little bit inside the ward if you wish to. Dol have to come on empty stomach? ‘No. You can have a light breakfast before you come to the hospital. Is it safe doctor? It is quite safe. You don’t need to worry much about this, because we take blood from healthy human donors only and we cross match to see whether it matches with your blood and.we also sereen the blood thoroughly for all possible bugs which can be transmitted through the blood (hepatitis B, C , HIV, Syphilis, CMV } before we transfiuse the blood to you. 154Qs We also make sure that you will not get any other problems because of this transfusion, like we always double check the products before we give this blood to you as well as we keep on monitoring you so that if at all you develop any problems we will take care of you. If at all you develop any allergic reactions we will stop the transfusion immediately and take appropriate actions immediately. There could be some problems because of the transfusion like some chemical changes (hypocalcaemia, hyperkaleamia, increased iron load) but again we will keep checking your blood regularly and if there is any problems we will take care of that, Also since wwe are transfusing about 4 units of blood this may increase the volume of fluid inside yourbody, we may give you some water tablets to get rid of the excessive fluid out of your body. Your body temperature also may go down a little bit but again this can happen only if we transfuse it very fast and without warming the blood . We will make sure such problems will not happen. © SMOKING Mrs Joan Thomas is «lady who has been planned for Angioplasty She is a Chronic Smoker. Advise her to quit smoking ‘and address her concerns. rips Mrs Thomas as you know, you we have planned to do an angioplasty operation. We have been quite concemed about your smoking habit and I am here to talk to you about it. Could I ask First of all...What do you smoke/How much do you smoke and how long have you been smoking for? ‘Mrs Thomas,| want to tell you a little bit about the harmful effects of Smoking. I don’t mean to fiighten you but there are some real risks involved when you smoke. ‘Smoking hardens and narrows the blood channels in your body. It starts earlier in smokers and blood clots are two to four times more likely than in non smokers. ‘Smoking can also cause clots in the body, cancers jlung disease, heart attacks and stroke. Each Cigarette contains harmful substances a + tar, a substance-that causes cancer + nicotine is addictive and increases bad fat[cholesterol] levels in your “pody + carbon monoxide reduces oxygen in the body and Emotional i There are also some Social,Einanci Social Polluting the air with Cancer causing substances [carcinogens] Children at higher risk of asthma, cot-death, bronchitis and glue ear + Nicotine stains your walls as well as your fingers. + Increased risk of fire in the home 155’ + To help you further and to deal with any craving you may develop when you try to stop, \ fi = oo year's time. | \= Support Programme: There are self help groups to help you to stop~ smoking. We will be with you at each stage to help you and advice. = GS “To join Together all you need to do is decide on a stop date, then you need 7s to register with them. aes ~ _Y Financial At today’s rates, a 20-a-day smoker will spend £31,025 over the next 20 years. You could have used this money for the Holidays you could have enjoyed; savings you could have built up; a home, car or important Possessions you could have owned. Emotional Emouar + Being a tum off to potential pariners and the possibility of missing out on relationships + Ever present, nagging sense of guilt that you should give up + Increasing pressure from a society that doesn't want to be subjected to smoke Thave given you quite some information and I hope it will be useful for you to consider giving up smoking. there are Nicotine Replacement treatment [NRT]) in the form of gum, skin es or nasal spray am ” ‘patches or nasal spray ¥ + There is a medication [bupropion] that's licensed to help stop smoking + behaviour modification programmes + Alternative therapies such as acupuncture and hypnosis. If you are interested I will refer you to the smoking cessation Clinics where you will be given more advice and a suitable plan. new What Happens when you stop Smoking? - Giving up smoking can reduce the risk of developing many smoking related illnesses. Within 10-15 years of giving up, an ex-smokers' risk of developing J 5 lung cancer is only slightly greater than someone who has never smoked. = “3, [1] The circulation improves in 2 to 12 weeks. {2] Coughs, wheezing and breathing problems improve in about 3 to 9 months time, [3] The risk of having a heart attack falls to half as that of a smoker in a } I will give you more leaflets, websites and support mN ikMr Phil Dyson is a 14 year old who has recently started Soncking He says his granddad has been stoking for years and tas had no heals problems, Advise bim to quit ooking The approach is the same to phil dyson the 14 year old who has started smoking [See question on Page1].There are a few questions relevant to his age dealt with below- My granddad smokes and doesn’t have any problems, Why should I Quit? I don’t mean to scare you but Research has shown that smoking reduces life expectancy by seven to eight years.On average each cigarette shortens a smoker's life by around 11 minutes. Smoking also causes coughs and increased phlegm, wheeziness and shortness of breath in the young age group than those who do not smoke. Consequently, young smokers take more time off school than non-smokers. The earlier children become regular smokers and persist in the habit as adults, the greater the risk of developing lung cancer or heart disease. Smokers are also less fit than non-smokers. —/ OBESITY ‘Mrs Pauline Gibson was scheduled for dental extraction which was cancelled as she was found to be obese with a body mass index of 32. Counsel the patient about her obesity and address her concerns. GRIPS its Gibson,as you know you came to have your tooth removed. For this procedure we have decided that it would be necessary for us to put you to sleep. Unfortunately, we had to cancel it as we found that a comparison of your height and your weight is a bit higher which means that your-weightis on the higher side. - [Pause] J will tell you how it could affect the outcome of this procedure. Firstly as far as putting you to sleep for the procedure is concerned, there is a greater chance of some complications. ray and make it more likely to collapse - Fat deposits in the neck tissue compress the ai and excess ‘Weight in the abdomen makes the breathing muscles operate inefficiently, which contributes to breathing difficulty and can complicate the process of putting you to sleep. - When your weight is on the higher side, there are also more chances of developing a wide range of conditions, including high blood pressure, gallstones, cancerand, most clearly, high blood sugarftype 2 adult-onset diabetes.] I don’t mean to frighten you but I am duty bound to tell you the risks involved... ‘There is also the risk of heart disease, stroke and arth But does not worry, with some appropriate life style changes; you can bring your weight under control and reduce the chances of developing these conditions. 1387- It is important for you to take a low fat diet with good amounts of fruit daily and drink lots of water. Also consume plenty of vegetables and salads. Avoid fatty snacks, Junk foods, Carbonated drinks, Red meat. Eat lean meat preferably grilled. I will refer you to thedietician who will give you more appropriate advice. Exercise- It is also very important for you to exercise daily. Ithas been found that regular exercise is very helpful to controlling your weight and maintaining a healthy lifestyle. Please do not start any heavy exercises as it is important to have an exercise training programme for which our physiotherapist will give you appropriate advice. It is also good to go on some brisk walks to start with. Alcohol- It is better to avoid alcohol or if necessary to drink in moderation, Stress- Do indulge in some stress relieving exercises like aromatherapy, yoga, acupuncture as i will help you remain focused. Naturally, weight loss is just a generally very healthy thing. I will also give you Addresses of Support Groups, Leaflets and Websites that will be helpfal Bo thronic Fatigue Syndrome The main symptom of CFS is a new, severe fatigue that lasts for over six months and does not improve after rest. Itis disabling all or most of the time. Even normal physical activity exacerbates the feeling of tiredness. People who have CFS may also have other symptoms such as; + forgetfulness, memory loss, confusion, or difficulty concentrating, + sore throat, + tender lymph nodes in the neck or armpits, + _.musele pain, . — + joint pain without redness or swelling, + headaches, + unrefleeting sleep (waking up feeling tired or untested) or trouble getting tosleep, + Fatigue that lasts more than 24 hours after exercise or exertion at a level that the person ‘was previously able to manage without fatigue. Other symptoms may include: + feeling hot or feverish even though temperature may be normal, * sensitivity to light or sound, + orthostatic hypotension, which causes lightheadedness or dizziness as a result ofa drop in blood pressure when standing or sitting up from a reclining position. Diagnosis When a doctor examines someone with CES, they usually find no physical abnormalities. Diagnosis of CFS is made by taking a medical history, and by ruling out other possible 158ia Hee {PRN We conditions. Blood tests may help to rule out other illnesses, and in people with CFS the results will be negative. There is no specific test for diagnosing CFS. Treatment Often, simply making the diagnosis of CFS and explaining what this means will help the person affected greatly. It is important to be aware that the cause of CFS remains a mystery and that there is no simple cure. Recovery may take months, or even years, but most people do recover. People with CFS need a regular review every couple of months by either a specialist or their gencral practitioner. If any new symptoms appear, treatment will need to be reassessed. People ‘with CFS who do not respond to these treatments may be referred to a team including a doctor, psychiatrist, psychologist, occupational therapist, physiotherapist and liaison nurse. With chronic fatigue syndrome, treating both physical and psychological factors is important. To c help with the physical aspects, the following may be beneficial: , Gentle exercise Getting regular gentle exercise helps relieve and control symptoms. Most people with CFS can only tolerate light exercise, so it’s best to follow a "graded exercise programme", which means starting with an activity that can be done comfortably, and increasing the level of activity every few days. Getting too much exercise or increasing the level of exercise too quickly can make symptoms worse. Painkillers Pain relievers such as ibuprofen, aspirin or Paracetamol may help relieve muscle and joint pain, headaches, and other physical symptoms. Some prescribed painkillers can become addictive and should only be used in the most severe cases on a short-term basis. Long-term use of any ~ -- medication shouldbe under the supervision of a doctor (Daily routine Adjusting the daily schedule to improve sleep habits may help. To help with the psychological aspects, the following may help: Cognitive behavioural therapy (CBT) This is the most successful treatment for chronic fatigue syndrome. CBT helps people identify how their thoughts affect their behaviour. It can help people to develop ways to cope more successfillly with fatigue and other symptoms of CFS. Referrai to a psychiatrist for thistreatment does not mean that the doctor believes it is "all in the mind”, Antidepressants These may be beneficial for some people with CFS where depression is a significant symptom. 159(Young man he been feeling weak and tired for about six months. No other positive symptoms. May had some viral infections in the past.— Think of chronic fatigue syndrome.) CFS came as history taking station also.) Q Post Mortem Counselling 63 Year old Mrs Marianne Turner underwent a Hysterectomy six days ago and was recovering well. She was to be discharged in a couple of days. She suddenly developed complications in the ward, Resuscitation failed and she died. The Cause of Death is unknown. Explain to her Son Mr Jim Turner about the situation and take consent from him for a post mortem examination. GRIPS, EMPATHY, SYMPATHY, BODY LANGUAGE Lam sorry about your mother Mrs Turner .{ really understand her death must be really distressing to you as it was totally unexpected at this time. Pause [Allow the /e to express his thoughts| ‘As you know she was admitted for an operation to remove her womb , She was recovering quite well as we were even planning on discharging her in a couple of days. Unfortunately, she suddenly developed complications and in spite of our best efforts to save her, she passed away. Lam really sorry about this. Why did it happen? As you know, my colleague would have mentioned to you about some complications associated with this operation. Death is quite rare with this procedure and honestly speaking, it certainly was not something we. - were expecting. We really do not know why this happened, ‘Wait for few seconds! Ask if its all right for you to proceed! As I said, we do not know the actual cause of herdeath and we wish to find out what really went ‘wrong. For this purpose we need to do a post mortem examination and I am here to explain to you about it and seek your consent as well. In this examination a specialist Doctor will have a look outside and inside the body. The purpose as I said earlier is to look for the cause of the sudden deterioration that leads to her death. ‘Small tissue blocks [tissue samples] and slides, photographs and X-rays will be made and may be kept as part of the medical record. Her face, hands and feet will not normally be affected by the examination and you should be able to see the body afterwards if you desire. She is already dead Doctor, so what’s the point? Tunderstand how you fee! Mr Turner, doing this examination may help us to know the cause of death which may allow you to come to terms with your grief. 1603 i eo (Dvn pila - bay Ob we ois in Hebe Sits \ ved [ear une. ena "Re “eh, ear BO, Sud UY CB -~b4 on ae 7 Rader Vater oh eta Shorts ot no tage Lye LE Qt a Sa nt sp Stee “Wwovelling by bony li teree Da i" Ceteaty (Dru fradkuing YX , an ores , Liscodos tebe ake Son aoa end: care a Bete yep ak Tee a) wher Plt, len ef Ounn % % seg og in @ eek OF ves yg ® a KOvo eeeppente db ( eal babes| COT rey Rein elroy oa a a Fain eete : Seq cWe could leam more about her condition and it would help in preventing it from happening in the future in other patients. You might feel good that you have participative in medical education and research, Moreover, it may help us diagnose and treat conditions that might affect other members of the family. Without the post-mortem report we won't be able to Issue a death certificate which may delay the funeral procedures, as well it may delay in obtaining insurance benefits. ‘The final results of the examination will usually be available in 21 days and a copy will be sent to the GP as well. Won't the body be disfigured doctor? No. At the end of an autopsy, the incisions made in the body are sewn closed. Performance of an autopsy does not interfere with an open casket funeral service, as none of the incisions made are apparent after embalming and dressing of the body by the mortician. IF Patient Consents: ‘Thank you for your patience at this difficult time Mr Turner. ‘If Patient Refuses Consent Ido understand that this is « very difficult time for you. You can discuss this with your family members and take a decision about it.I will come back later and discuss it with you. Suggest Bereavement help groups before ending the station POINTS TO REMEMBER: + This is not a breaking bad news station but it requires and sympathy. __* Don’t get into the trap of suggesting the death maybe due to a pulmonary embolism —____ or DVT. Maintain that the cause of death is unknown! jimilar amount of empathy S) HYPOTHERMIA Mr Gordon Ramsay is 77 years old and has been brought to the A&E by his Son Mr Robert. His Core body temperature has been found to be 35 degree centigrade. Talk to the Son and advice accordingly. Consent has been obtained from the father to talk to his son. GRIPS Express Confidentiality before proceeding ‘+ Mr Robert, on examination of your father we found that his body temperature is low, which means that if itis left untreated, it could affect all the organs of the body and could harm his life. It can also cause sluggishness, mild confusion, shivering and loss of control of fine finger movements. I don’t mean to scare you but I need to ask you a few questions to try and find out why this happened. Is that all right with you? 161ey Sp Is this the first time this has happened? Is Mr Ramsay a bit forgetful? Does he leave windows open or forget to turn on the heater? Does he find it difficult to move about? Dees he wear Warm Clothes? Is there heating in the house/ Is it working properly? Is he on any Long Term medi Does anything make him drowsy? Does he drink Alcohol? Does he have any illnesses? ‘Thank You for answering my questions Mr Robert ‘There are a few things that I would like to advise you about + [will refer Mr Ramsay to the social services Department who will suggest any changes to be made in the house that will help make him comfortable. * It would be good for you or his neighbours to go around and see if he is all right everyday. * We will write to his GP to review any medications and cut down on any if necessary. + It’s important for him to eat weli and dress warmly. = Since a quarter of Body heat is lost from the head, its important for him to keep his head covered when its cold, = It’s important to avoid Alcohol before going out in the cold as Alcohol lowers the body’s tolerance to cold. * Iwill give you some leaflets on this condition and some website addresses. * Any Concems Could you tell me if your partner is male or female? [Ask this question if only by this stage, there is no indication of the sex of the partner!] > What type of sexual intereourse did you have [oral, anal or vaginal]? 180Why do you ask me Doctor? Well Mr Palmer, it would help us to know the areas from where we need to take samples to test for any bugs that cause different conditions, Do you have any medical conditions or have you had any surgeries in the past? [This is to know if he has any conditions with associations to sexually transmitted diseases] Do you take any recreational drugs? If yes, do you share needles, syringes or drug preparation equipment? [Ascertaining usage of illicit drugs is part of sexual history as risk for HIV is increased in this route of usage] Have you travelled abroad recently? If Yes “Ask if he had unprotected sex abroad with anyone besides his travelling partner?[This is to identify partners who are at a higher risk of sexually transmitted infections than thos: in the UK] + Did you have any medical treatment abroad including blood transfusions? [Incidence of spread of HIV through blood products is extremely rare in the UK, think about blood borne viruses causing syphilis, HIV or Hep B if blood transfusion abroad] Is there any other concern that you would like to tell me about Mr Palmer? Thank you for answering my questions. Present your observations to the examiner. If your patient is a Lady, ask the following questions as well: Menstrual history with any changes in the cycle, or imegular bleeding? | Any lower tummy pain? When was the last menstrual period? Do you use any contraceptives? | Has she had any previous pregnancies? If the Lady is over 25 years old, has she had a cervical smear and if so wa: abnormal? feeeee norma or 181[ Causes of palpitations Anxiety Fear Stress Caffeine (coffee) Excessive alcohol, Arrhythmias | Heart problems Hypoglycaemia, hyper ventilation | Hyper thyroidism Causes of sore throat y ‘Mumps: | ‘Swelling and redness over Viral cheks —_ measles. Rashes on body Chicken pox “Rashes on body , --[Glandular fever __| Painful lumps U—1 (infectious (GlandsOon neck, mononucleosis) armpit and braved Can f ‘ever, headache, thse «| weakness Bacterial Streptococcus A | Sever pain on (Tonsillitis ) ‘swallowing, Redness in the throat, high fever. Trritants Pollens, dust, | Could be 7 change of| recurrent weather. smoking | Allergic conditians | Hay fever [Excessive use of —| Singers, teachers voice tumours ] Back of toungue, | Loss of weight and — throat, vocat appetite. cords, |SURGERY HISTORY STATIONS PROFORMA OF GENERAL HISTORY TAKING GRIPS HO PRESENTING COMPLAINS Onset, Duration, Intensity, Progress, Aggravating Factors, Relieving factors Associated Complains NEGATIVE HISTORY Discuss all your DDs here PAST HISTORY H/o simitar complains in the past H/o hospitalization Hlo HT, DM, Asthma, Fits, Stroke FAMILY HISTORY H/o similar problem with anyone in the family PERSONAL HISTORY Hlo Sleep, Appetite, Bowel habits, Bladder habits H/o Smoking, Alcohol, Recreational Drugs H/o Allergies H/o Medications MENSTRUAL H/O OCCUPATIONAL H/O SOCIAL HIO CHILDREN: Birth H/o, Developmental H/o, Immunisation H/o should be asked. 183DYSPHAGIA: Differential Diagnosis, Achalasia Cardia Oesophageal Carcinoma Oesophageal Stricture Pharyngeal Pouch Myasthenia Gravis Globus Hysterious Post Procedural (endoscopy) H/o difficulty with swallowing liquids more than solids (Achalasia Cardia) H/o difficulty with swallowing solids more than liquids (Ca Oesophagus) Hlo drinking hot liquids or corrosives, H/o passing any instrument/tube through your mouth into the tummy (Qesophageal Strictures) Hlo difficulty in swallowing worsening as day progresses with drooping of eyelids and undue weaknessitiredness (Myasthenia Gravis) H/o difficulty in swallowing with persistent halitosis with food stuff left on pillow when u gets up in the morning (Pharyngeal Pouch) H/o persistent sensation of difficulty in swallowing for which many tests performed but no caused found (Globus Hystericus) ABDOMINAL PAIN RIGHT UPPER QUADRANT PAIN: ~ Differential Diagnosis — Acute Cholecystitis Acute Hepatitis viral/alcoholic Acute Pancreatitis Right Basal Pneumonitis, Fracture Rib Gastric Ulcer Duodenal Ulcer Renal Calculi H/o pain increases on fatty foods (Acute Cholecystitis) H/o yellow discolouration of hands, eyes, high coloured urine, H/o blood transfusion (Acute Hepatitis viral/alcoholic) H/o pain radiating to the back (Acute Pancreatitis) H/o pain radiating to arm and jaw with severe sweating (Myocardial Infarction) Hio fever with cough with expectoration/phlegm with pain increasing with cough (Right Basal Pneumonitis) 184H/o trauma on the chest following which pain started (Fracture Rib) H/o pain increasing by food, even sight and smell of food increases pain (Gastric Ulcer) H/o pain relieved by food (Duodenal Ulcer) H/o pain midway in the back and unrelieved by any measure (Renal Calculi) LOWER ABDOMINAL PAIN: Differential Diagnosis ‘Male causes) + Testicular Torsion * Acute Epididymo-Orchitis (Female causes} * Ectopic Pregnancy + Pelvic Inflammatory Disease * Torsion of Ovaries (Common causes) * Acute Appendicitis Obstructed Hernia Acute Diverticulosis Irritable Bowel Syndrome Ureteric Calculi Urinary Bladder Calculi Urinary Tract Infection H/o pain in scrotum, unrelieved by any measure, pain increases on lifting the testicles (Testicular Torsion) Hio pain swelling in the scrotum with fever (Acute Epididymo-Orchitis) Hio amenorrhoea, severe abdominal pain, are u pregnant?, any contraceptives? (Ectopic Pregnancy) fates oar oleh Hlo fever with Severe back pain, discharge per urethra (Peh Hio severe pain in lower tummy, H/o ovarian cyst previously pain unrelieved by any measure in a young female patient (Torsion of Ovaries) Hlo severe pain beginning around the belly button and then radiating to the right lower quadrant and staying there (Acute Appendicitis) Hio hernia/groin swelling which use to disappear but now does not disappear and has become tender to touch (Obstructed Hernia) H/o sever pain in the left flank, pain disappears with passing stools and bleeding from back passage (Acute Diverticulosis) Hilo tummy pain with altemating bowel habits, pain relieved upon passing stools in a young patient (Irritable Bowel Syndrome) Hlo severe tummy pain with pain starting midway in the back and traveling from the sides of the tummy going deep down in the tummy (Ureteric Calcul) Hio haematuria, passing small stones, stream of urine suddenly stops followed by sever gripping pain in the private parts (Urinary Bladder Calculi) Hio Fever with shakes, with burning sensation while passing peeing, H/o sexual contact Hio instrumentation through water pipe (Urinary Tract Infection) 185BLEEDING PER RECTUM: Differential Diagnosis Haemorthoids Fiseure in Ano Rectal Prolapse Rectal Carcinoma Colonic Carcinoma Ulcerative Colitis Acute Diverticulosis Post Procedural (proctoscopy/sigmoidoscopy/colonoscopy) Drug induced (warfarin) ( H/o constipation and painless bleeding as drops / splash in the pan (Haemorrhoids) H/o constipation and painful bleeding with streak of blood on stools (Fissure in Ano) H/o feeling of something coming down from back passage whenever u strain (Rectal Prolapse) Hilo weight loss, loss of appetite, stools mixed with blood, H/o incomplete evacuation (Rectal carcinoma / Colonic carcinoma) H/o painless bleeding from back passage, with skin changes and eye changes (Ulcerative Colitis) H/o severe pain in the left flank with pain relieved by passing stools and bleeding through back passage (Acute Diverticulosis) H/o any medication eg blood thinners H/o any —_ procedure undergone —through_~sthe_~=—sback ~——passage (proctoscopy/sigmoidoscopy/colonoscopy) MATURI Differential Diagnosis Renal Caiculi Ureteric Calculi Urinary Bladder Calcul Urinary Tract Infection Renal Carcinoma Urinary Bladder Carcinoma Schistosomiasis - Drug induced (warfarin/cyclophosphamide) Post Procedural (Urethral dilators/catheters) Post Surgery (TURP) H/o pain midway in the back and unrelieved by any measure (Renal Calculi) H/o severe tummy pain with pain starting midway in the back and traveling from the sides of the tummy going deep down in the tummy (Ureteric Calculi) 186H/o haematuria, passing small stones, stream of urine suddenly stops followed by sever gripping pain in the private parts (Urinary Bladder Calculi) H/o fever with shakes, with burning sensation while passing peeing, H/o sexual contact H/o instrumentation through water pipe (Urinary Tract infection) H/o Hematuria wt loss, fullness in the loin area /midway in the back (Renal Carcinoma) Hio painless haematuria, wt loss, H/o working in dye industry (U.Bladder Carcinoma) H/o swimming in the lakes after which haematuria started (Schistosomiasis) H/o medication like blood thinners (warfarin) or medication for sinister problem (cyclophosphamide) URINARY OBSTRUCTION: Differential Diagnosis Benign Prostatic Hypertrophy Urinary Bladder Calculi Urinary Tract Infection Prostatic Carcinoma Drug Induced (anticholinergic/antidepressant) Post Procedural (catheter) Hlo frequent passage of urine (Frequency) H/o urgent need to pass urine (Urgency) H/o urgent need to pass urine, and u reach toilet but have to wait for long time before starting to pass urine (Hesitancy) H/o passing urine upon lifting weights/coughing (Stress Incontinence) H/o passing urine even at rest (True Incontinence) H/o haematuria, passing small stones, and stream of urine suddenly stops followed by sever gripping pain in the private parts (Urinary Bladder Calculi) Hio fever with shakes, with burning sensation while passing peeing, H/o sexual contact H/o instrumentation through water pipe (Urinary Tract Infection) Hlo weight loss, loss Of appetite and back pain (Prostatic Carcinoma) Hlo medications for any eye problem / antidepressant (Drug-induced) TESTICULAR PAIN ; Differential Diagnosis Epididymo-Orchitis Torsion of Testis Urinary Bladder Calcul Urinary Tract Infection Obstructed Inguinal Hernia H/o pain in scrotum, unrelieved by any measure, pain increases on lifting the testicles (Testicular Torsion) H/o pain swelling in the scrotum with fever (Acute Epididymo-Orchitis) 187H/o fever with shakes, with burning sensation while passing peeing, H/o sexual contact H/o instrumentation through water pipe (Urinary Tract Infection) H/o haematuria, passing small stones, stream of urine suddenly stops followed by sever gripping pain in the private parts (Urinary Bladder Calcul) H/o hemia/groin swelling which use to disappear but now does not disappear and has become tender to touch (Obstructed Hernia) SURGERY COUNCELLING UPPER G.I. ENDOSCOPY GRIPS it is a simple camera test, wherein we will pass a tube having a camera from your mouth into your tummy to visualise your tummy from inside. We can also take small piece of tissue from any problem areas we see inside. This will help us in diagnosing more accurately and provide appropriate treatment. You will have to be fasting 6-8 hrs, We give spray a local numbing agent in your mouth and so you will not feel much discomfort when we pass the tube through your mouth. Rarely we might give you some mild sleep medications through your blood channels, so that you can co-operate better. The procedure will last for 15-20 mins. After procedure if you are comfortable and we are assured you are completely alright, then we will send you home immediately. Someone has to accompany/ drive you home, and look after you for first 24 hrs. You can resume all your activities after 24 hrs, if you are comfortable. Complications: Pain _Sofe Throat__ Bleeding Perforation/ Puncture: Small ones- heal on their own Large ones- will treat with Antibiotics (rarely needs surgery) COLONOSCOPY GRIPS tis a simple camera test where we will be passing the tube having a camera, up through your back passage into your bowels & visualise your bowels from within. We may need to take pieces of tissue from the problem areas which we will be able to see: We will push gas into your bowel to see things more clearly. The procedure lasts for 15 — 20 mins minutes. After the procedure once you are comfortable, we will send you home immediately. Someone has to accompany you home & look after you for the first 24 hours. Then if you are comfortable, you can resume all your routine work and activities Complications: 188Pain in Abdomen Bleeding (rare) Perforation /Puncture Small-heal on its own + antibiotics (Very rare) —_Large-surgery (colonic over sewing with defunctioning colostomy) APPENDICECTOMY GRIPS: There is a small organ called appendix which is of the size of a matchstick located lower down in your tummy on the right side at the junction of your large bowel and small bowel. This organ is diseased from inside. We do not know why this has happened to you. The only treatment for this problem is removal of this appendix by an operation. This organ does not have any function in your body and therefore it will not affect your body function in any way afer its removal by surgery. Why Surgery? Because it is the only definitive treatment Any Medication? 1 out of every 4 patients come back with bigger complication later on which sometimes may be life threatening. Surety of the diagnosis? It is a clinical diagnosis ‘We will keep you fasting from now onwards Anaesthesia? We take you to operation theatre and put you to sleep, detail of which my anaesthetic colleague will talk to you. Operation: Assmall skin nick about 4 inch in your tummy wall above your bikini line and remove the diseased appendix and close the skin. The surgery takes about 30 to 45 mins. Atter Surgery: Hospital stays for about 2-3 days. We will monitor your recovery and then will send you home once you have recovered fully Recovery: At Home: Res! for 2-3 days After 1 weeks simple household work After 2 weeks driving and sex after 2 weeks (whenever comfortable) After 4 weeks all office works. After 6 weeks all laborious activity Wound care? Sutures Sutures will heal on their own in 5 days time Don't rub the wound Don't use detergent on the wound Sponge bath for about 4 to 5 days then shower bath Swimming after 2 weeks Complications 1. Pain - pain killers 2. Infections- antibiotics 1893. Bleeding-very rare 4. Paralytic lleus - NG tube and fluids till bowel starts moving. 5. Damage to surrounding structures, (If the patient has been dehydrated because of vomiting — dehydration need to be corrected before the operation) Ask for any concerns, if no concerns take the consent for surgery. LAPAROSCOPIC GHOLECYSTECTOMY GRIPS Explain need for surgery. You have been diagnosed of having stones in the gall bladder it is actually a small sac underneath your liver. Which stores bile which helps in digestion of fats in your diet? It is due to these stones you experience pain. We have decided to remove your gall bladder so you don't have recurrent pain. Why surgery? It is the only definitive treatment Why not medications? It will not cure your problem and also it is unpredictable ‘Surgery! Operation: Overnight fasting (6- 8 hrs) - Key hole surgery where we will make a small hole in your tummy and pass harmless gas inside your tummy. We will make 2 more holes ‘smaller than first one. Through one hole we will pass a camera which will enable us to see your tummy from inside and through the other hole we will pass our instruments with which we will operate and remove the diseased gall bladder. After this we will remove our instruments tren camera and then gas. Benefits: Very small scar Faster Recovery time ~ Surgery takes 30 to'45 mins ~~ In patient: will stay in hospital for 2-3 days and sent home, After 1 weeks simple household work After 2 weeks driving and sex after 2 weeks (whenever comfortable) After 4 weeks all office works, After 6 weeks all laborious activity Complications: Bleeding-if uncontrollable by this technique then will have to open your tummy. Injury to other organs and gut Shoulder tip pain. Anaesthetic complication (Nausea & Vomiting) NEPHRECTOMY 19040 yr old lady admitted to iT'S with ARF. Incidentally was diagnosed with Renal Cell Carcinoma. Decision to perform Nephrectomy has been taken. Counsel the patient's husband. GRIPS with the husband Explain to him that her wife is in a critical state. Enquire how much does he knows about her problems. Ask the patient whether he wants to be with someone before you break the news about her being suffering from cancer. Break the news gently but empathetically. Give a pause; let the diagnosis sink into the patient. Handle the patient depending on the way he reacts. Reactions: Pt upset and sits quiet —-ask him whether he is alright? Does he want you to continue? Pt starts crying—offer tissues to him Pt says, is she going fo die?? ... Difficult question to answer NEPHRECTOMY GRIPS Inquire how much the pt knows. (can't say whether it is a bad news breaking station). Explain the problem to the pt. Break news of cancer empathically. (If talking to relatives then maintain pt condition to be critical all through the station). Give a pause; let the diagnosis sink into the patient. Handle the patient depending on the way he reacts. Possible Reactions: Pt upset and sits quiet —-ask him whether he is alright? Does he want you to continue? Pt starts crying-—offer tissues to him Pt says, is she going to die?? ... Difficult question to answer. Explain surgery (nephrectomy) as the only and the best treatment option at present. Explain Surgery: NBM for 8 hrs, will shift to OT, will put to sleep, will open her tummy from behind, remove the diseased kidney and then close the tummy with sutures. irgery will shift you to ITU and then once he-recovers will send. to. wards, and if 9 goes smooth then will send you home soon, At home pt. will have to drink plenty of water to keep the other kidney flushed. She will lead a normal life, but can't do athletic activities. Will keep regular follow-up, will keep reviewing medicines, addresses of cancer societies, leaflets and support groups. Complications? Yes they do occur sometimes. Bleeding, Pain, Infection, Damage to surrounding structures, Risk of Death (may succumb to his own problems and may never recover at all). Any concems? If No, Take consent (Mrs. Anderson has been posted for Radical Nephrectomy for Renal cancer. Talk to her husband. 191Approach same as above. What do you remove doctor ? A radical nephrectomy is a procedure to removecancer in and around one of the kidneys. In this procedure we will be removing the kidney, ureter (the tube connecting the kidney to the bladder), and surrounding connective tissue, lymph nodes, and adrenal gland. What happens during the procedure? She will be given a general anesthetic. The surgeon makes a cut (incision) either in the front or on the side of her tummy. Then surgeon removes the kidney and the othet affected parts. The procedure may take 2 to 3 hours. What happens after the procedure? She may have to stay in the hospital for about 4 to 7 days. A catheter (tube) remains in your Viadder for about a week to allow urine to drain and relieve the pressure. ( During the first 2 weeks after the operation, she should do light activity, such as walking, and avoid all heavy activity for the first 6 weeks, including lifting. What are the benefits of this procedure? jon will be slowed. Even when cure is not, The cancer may be cured or the progress of the con possible, she may feel more comfortable. What are the risks associated with this procedure? + There are some risks when you have general anesthesia which my Anaesthetic collkague swill tell you later. a - + Rarely there could be some damage to the surrounding organs, + Wemay not be able to remove all of the cancer or the cancer may come back. + She may have infection or bleeding. HEMICOLECTOMY (possibility of Colostomy) GRIPS Inquire how much the pt knows. (Can't say whether it is a bad news breaking station) Explain the problem to the pt. Break news of cancer empathically. (\f talking to relatives then maintain pt condition to be critical all through the station). Explain surgery (hemicolectomy) as the only treatment option at present. Explain Surgery: NBM for 8 hrs then wilt stift to OT and then will put to sleep (details of which my anaesthetic colleague will discuss with you), will open your tummy, and remove the diseased part of large bowel and then join the cut ends of the bowel together. 192Also explain, in case we need to remove large part of the bowel and joining the cut ends is not possible then we will have to make a hole in the tummy wall and join the first part of the bowel to this hole so that he can pass stool from this hole, as after this surgery he will no longer pass stools through his back passage at all. Explain that we will provide colostomy nurse to him to take care of the wound, and that u vill have all her contact details. After Surgery will shift you to ITU and then once he recovers will send to wards, and if everything goes smooth then will send you home soon. Complications? Yes they do occur sometimes. Bleeding, Pain, Infection, Damage to surrounding structures, Risk of Death (may succumb to his own problems and may never recover at all). Maintain they occur rarely. Any concems? If No.Take consent COLOSTOMY You can lead almost a normal life after ostomy. It takes time to become comfortable with your body after ostomy surgery. You can still do many of the activities you enjoyed before surgery. You can eat whatever you want if you have an ostomy ‘Some foods may give more odour than other, but remember ostomy bags are odour proof. If you wish you can try to avoid foods which gives strong odour. Drinking cranberry juices will reduce the odour. Certain foods are more likely to cause gas, diarthea, constipation, incomplete digestion or urine _ ‘odour. You can participate in sports if you have an ostomy but try to avoid contact sports with potential for injury You can go for running, swimming (Special ostomy swim suits may be available) or other athletic activity but use a special belt or binder to hold your ostomy bag in place. You can go back to work if you have an ostomy Consider going back to work once you're feeling well. Don't let your nerves get the best of you. Working again can make you feel good about yourself You can tell — or not tell — whomever you want about your ostomy You can hide your ostomy . Most people won't notice your ostomy unless you tell them about it, As you get used fo your ostomy, you'll figure out tips and tricks to keep the bag hidden and the noises to a minimum. 193It will take some pre-trip planning, but having an ostomy shouldn't prevent you from traveling. Bring extra ostomy supplies and pack them in both your carry-on and checked bags You can have sex and intimate relationships if you have an ostomy You may experience some temporary sexual side effects, such as erectile dysfunction and vaginal dryness. But sexual intimacy can continue if you have an ostomy. Discuss this with your partner.. Your partner can help make you feel more comfortable and reassure you that you are just as attractive with an ostomy. Talk to others with ostomies BREAST LUMP \ GRIPS Ask about concerns with the breast. Listen to her story carefully. Assure the pt. Explain not all lumps are sinister. Advice tests like X-ray of Chest for any undue opacity. May need Mammography in case chest X-ray fails to show the lump, as it will diagnose even small lumps missed out on simple X-rays, and also it is safer. Once lump found then will have to do more tests to see what it is made up of. Will do Biopsy (needle test in which we will have to remove a piece of tissue by needle and ‘send it to lab for further tests). If we find any cancer cells it's only then we have diagnosis in our hands. If Ca then we has to remove the lump through surgery will also treat with X-ray therapy and Medication (chemotherapy) Ifno.Ca, then.will treat as per cause as guided by biopsy. Any concerns?? Thank the pt. BREAST CARCINOMA (post-op options, GRIPS t Console pt first Options: A) SURGICAL OPTION: a) Time reinflation technique b) Silicon Implants (may take 2-4 surgeries) ©) Reconstuction using skin and muscles flaps (may take 4-8 surgeries) B) EXERCISE REGIME: a) Perform action of combing your hair b) Perform action of scratching your own back ©) Perform action of climbing wall with hands (move your hands in full range) C) Self Breast Examination of other breast. 194Will also provide stronger pain killers, physiotherapy reference, leaflets, support groups, and will keep regular follow up. HERNIORRHAPHY GRIPS Mr. John, as you know that you came to us with a swelling in your groin region and we had examined you and we have diagnosed you to be suffering from Hernia, Hernia? There is a weakness in your tummy wall through which contents of your tummy comes out whenever you strain. This swelling is called a “Hernia” You will need to undergo an operation to treat it, as surgery is the only definite treatment of this problem. This surgery is called Herniorthaphy ‘We will keep you fasting for 6-8 hours before surgery. Then will take you to operation theatre. We will put you to sleep, and make a small nick in the skin of your tummy over the swelling area, open the tummy walll & push the contents of the swelling back into the tummy & close the gap. Rarely may we have to use an artificial material called mesh for strengthening your tummy wall muscles. Surgery will last for about 30 to 45 mins Recovery: Day care: will go home on the same day once we are accursed he is fully recovered In patient: will stay in hospital for 2-3 days and sent home (if everything goes smooth) After 1 weeks simple household work allowed After 2 weeks driving allowed, sex allowed after 2 weeks (as and when comfortable) After 4 weeks all office works (as and when comfortable) After 6 weeks all laborious activity (as and when comfortable) Complications: Though it is a routine procedure there are certain seen & unforeseen complications that may occur about which I'm duty bound to tell u. 1. Feeling of sickness (due to recovery from sleep medications) 2. Bleeding (which we will control during surgery) 3. Pain-(which-we-will control with-pain Killers) 4. Infection (which we will control with antibiotics) 5. Damage to surrounding structures (we will take due care) These are very rare complications and usually do not happen. 6. Failure of the procedure. Ask for any concerns?? If no concerns... then Take consent for the procedure. Patient refuses surgery: Then ask patient's fears and clear them if possible. Explain it is a routine procedure. If the surgery is not done then you may experience a complication later where the bowels might get twisted around it and if might create a life threatening situation for you and you might have to undergo a bigger operation. We do not want this to happen to you and so in your best interest and benefit we advice you to undergo this surgery. 195ANAEMIA (Herniorrhaphy cancelled) GRIPS Ask the pt. what are his concerns? Apologise for trouble caused due to cancellation of the planned surgery. Explain Anemia, Tell him that amount of blood in his body has lessened. Explain effects of Anaemia on his Surgery. Tell him about poor wound healing, risk of infection and dangers to life with sleep medication Explain that we have to first find out the cause of such sudden drop in Hb in his case. Will carry on some investigations to find the cause first, and then treat accordingly. Explain that in the mean time you will treat him with Iron Tablets, if needed then Iron Injections, Vitamin Injections Folic Acid tablets and also adjust his diet (green leafy vegetables) to build up blood in the body to adequate levels. Explain that in rare instances of emergency only, we might transfuse blood to him. Immediately inquire that is he is Jehovah's Witness?? If yes, then say we respect your views but then he will have to discuss with his priest regarding blood transfusion, if at all it becomes the issue later on. Tell him that you will keep him informed about his progress and once we find you fit for surgery again, we will take you up for surgery immediately. Any concems?? Apologise once again for the inconvenience. Thank the patient. POST OPERATIVE WOUND INFECTION Patient underwent hernia 7 days back, now the wound is open / oozing. He is angry and anxious Calm the patient down. Listen to his problems empathetically. Please calm down and relax. Help us out so that we can help you out Empathize with the patient and offer immediate pain relief Explain the situation — Explain that he is suffering from wound infectior Bugs entered the wound, we don’t know from where camé from? Patient — Why wasn't | told? Explain that the patient had signed the consent form (I am quite sure that some doctors must have told you about these unfortunate unforeseen complications, but it is more important to see how we can help you out now) How can you help me now? — Admit you right away, Pain killers, Blood tests, Blood Culture, Wound ‘swab culture to identify the bug, start Antibiotic treatment immediately. — Wound cleaning and dressing with clean bandages, with the help of specialist. Patient: Will | be cured? With the specificity as which is given by the bug, mostly it should be cured by the antibiotics. However | can arrange an appointment with my consultant. If the wound is open secondary suturing should be done after the infection is controlled. 196PROSTATECTOMY (T P) GRIPS: Prostate problem: It's a small gland located iow down in your tummy below your water bag close to the neck of your water bag. This gland has enlarged in size and now it is pressing upon your water pipe. This is causing you difficulty in passing the waters. Anaesthesia: Spinal Fasting 6 to 8 hrs Surgery: We will pass a tube through your water pipe up towards your water bag and shave the enlarged part of the gland to relieve the obstruction so that you will be able to pass water without any problems this procedure will last for about 45 minutes. After surgery you will fund a tube in your water pipe which will be kept there for 2 ~ 3 days to prevent any blood clot which may block the tube again. After 2 days the tube will be removed and if you are able to pass waters normally then we will send you home once you are comfortable. You may experience some amount of bleeding while peeing for up to 2-3 weeks. Recovery: In patient: will stay in hospital for 2-3 days and sent home. After 1 weeks simple household work After 2 weeks driving and sex after 2 weeks (whenever comfortable) After 4 weeks all office works. After 6 weeks all laborious activity Complication: 1. Bleeding 2. Pain —pain killers 3. Infection — antibiotics 4, Retrograde ejaculation (dry ejaculations) TESTICULAR LUMP GRIPS: \ have come to talk to your about the swelling you have down below. On examination of your testicle, we found a lump which does not appear separate from your testicle, clinically. We will be performing an USG / TV scan for your scrotum, to confirm our clinical suspicion, also hormonal tests like AFP, beta HCG. Ifon USG, the lump is a part of your testicles, then Mr.. it may be a sinister, but may also be a cancer. To confirm this we will have to remove your diseased testicle along with the [ump and send it for laboratory examination. That is the only way to confirm whether this is a cancer / no. If the cancer is localised, then cure rate is very high. But we will have to remove the testis and provide X-ray treatment to lower tummy region. 197Removal of one testis does not affect his fertility if the other testis is healthy. If on USG, the lump appears separate from the testicles then, we may need to operate and remove the lump only if itis causing any discomfort to you. vaseEcTOMY GRIPS: 1. Explain that it is a permanent procedure and if asked for reversal later on — he will have to undergo another operation for which the NHS will not fund for it. 2. Has he consented or informed his partner. 3. Completed his family or not. Explain Procedure: ‘This procedure will be done under LA. A small part of skin will be made numbs on both sides of root of your water pipe. A small nick will be made in the skin and we identify your sperm tube. We will cut it and tie the cut ends separately and then close the skin. Complication: ( 1. Pain — Analgesic, 2. Haematoma- Analgesic. 3. Infection- Antibiotics. 4, Failure or surgery. Recovery: Procedure will take 30 mins (15 mins on each side). Once we are assured that you are comfortable and recovered fully we send you home, Someone have to drive you home and look after you for first 24 hours. In case of any problem you can always come back to us or visit your GP, After 24 hours can start moving around in the house (as per comfort level) resume all routine activities (Driving, Sex, and Office) after 1 week, as per comfort level? ‘Advice: - Immediately after vasectomy surgery the patient is not sterile, two smear tests will be done first 12" week and second at 16" week. f second test comes negative then we will declare you sterile, till then you will have to use a barrier contraception e.g. ( Condom ULCER OVER BACK / MALE REMOVAL Db: Pressure Sores Diabetic Ulcers Post Traumatic Ulcers Malignant Melanoma Squamous Cell Carcinoma Basai Cell Carcinoma Tuberculosis Uicers GRIPS NOMPEN= 198Ask detailed History Explain the pt that it could be a sinister problem. Will have to perform some tests on the ulcer in that ‘we are going to remove it (excision biopsy) and then send it to laboratory for detail examination, after the results we will provide you the treatment according to the diagnosis. If Ca, then will treat with remove the ulcer by surgery and then will give medications (chemotherapy) and if needed X-ray therapy In future will do skin grafting Ifo Ca, then will treat as per the cause ABDOMINAL PAIN Patient have pain in the abdomen but Alll the investigations are normal including barium studies, talk to patient GRIPS Ask the patient: may | know your concerns Ask him is any one else suffering from this condition in his family Explain the patient that all the series of investigation have been done and none of them was conclusive or suggestive of any abnormality Tell the patient that we have given his case a very careful consideration, keeping in mind the time and comfort. We do respect and regard your concern and we are going to treat the symptoms If the patient says may be the results are not correct: There is a very less or no chance for this but as you know we have run many investigation on you they are in them it self a cross check to each other so taking it in consideration will not be a beneficial thing. If the patient asks for admission in hospital: ae Tell him that at this moment he might nof néed this but we are going to keep in close eye and keep in regular follow up with the GP. Again ask for any other concern: Thank the patient and thank the examiner PAIN MANAGEMENT For terminally ill patient Simple pain killers NSAIDs Stronger NSAIDs Tramadol Oral morphine Dermal patch of morphine \V morphine Higher doses of morphine 199PCA OBSTRUCTED HERNIA (Tel. Conversation) Check on the phone whom u talking to. Apologise to him for disturbing him. Explain the urgency. Details about the patient you just saw. Explain the problem, that he came with so and so complains. Then tell him your impression that u feel this is an obstructed hernia. Describe what all u have done after sensing the problem. U started the patient on Oxygen, sent blood for investigations like CBC, SE, BUN, FPBS, removed ECG, sent Tell him, u also taken Abdominal X-ray in erect position and u found dilated bowel loops and air fluid levels, which has confirmed your diagnosis of intestinal obstruction, U have informed the registrar about this problem and he has advised u to do all these investigation and inform u directly (as the registrar is busy operating an emergency case, and he will join u as soon as he finishes that case). Tell him that u has informed the OT staff about a possible emergency surgery case and the OT is made available to us. U has also informed the Anaesthetic and even he is available to us. ( U has also informed the relatives of the patient and has told them about the possible surgery. Ask him, is there anything else he wants u to do. Request him to come to the hospital and decide about further lines of management. Thank him Orthopaedic. Total Hip Replacement GRIPS Pré op ~ Admission ~ When? ~ The day before surgery ~ Fasting from previous night. Anaesthesia — i. Epidural ii, GA ( iii. Spinal Our anaesthetic colleague will come and discuss with you the type of anaesthesia required. Preparation for the part Operation Incision: Cut 4-6 inches, may need to extend, on the side of thigh. Duration of operation — 1 %-2 hrs. Pain: Anaesthesia Artificial joint — Ball and socket joint, metal or plastic type of Joint, last for 10 — 15 years Immediate post op — Will find him in the recovery room where he will find tubes attached to his body for medicines. Also, a tube will be coming out from the outer 200part of his thigh to drain the blood; the drain will be removed in a couple of days depending on the amount of blood drained. Pain ~ shall feel no pain — will be covered by pain killers Finding — when he is advised to — bowel sounds may not disappear. Can start feeding once he is not drowsy. Transfer to ward Rest for 2 days Physiotherapy after 2 days — gentle exercise Graded, supervised exercises should follow We hope that you will able to walk with the help of Zimmer frame/crutches Discharge Usually after 7 ~ 10 days Suture removal in 14 days Precautions Do not use low chairs Should not squat Do not cross legs Should not over stretch the joint — jumping/jogging Follow up 3-4 weeks Complications Infection DVT Dislocation; stiffness, May have to undergo the surgery again after 10-15 years Patient’s Concerns Driving — refer to occupational therapists ~ a seat raise on the car Work ~ 6-8 weeks, desk job If manual labour or heavy work, convince to stop Sex —as and when comfortable, prefer to wait for 3 weeks. TKR SIMILAR TO THR, HAS 4 CHANGES, COMPARED TO THR. Prepare the limb from groin to toe, Incision — over the front of the knee Contraindicated movements- squatting only. Sports allowed- golf and ail styles of swimming. 201ANKLE SPRAIN Grips X-ray has come back as normal. We believe it’s an ankle sprain. Do you know what an ankle sprain is? Injury to the ligaments Pain __: First 3-5 days as prescribed, then as and when required Rest: 1 wk NWB, 2nd and 3" wk PWB, can walk subsequently Ice itial 24 to 48 hrs, 5-10 minutes every 11/2 2 hours in a handkerchief Compression Bandage: Toes to thigh — help by partial support and Reduces oedema, can remove at night, 10 to 14 days Elevation: whole leg with pillow at night. GOUT Grips ‘Address and complaints Ask whether the patient know about the complaint Natural tendency to accumulate chemicals like uric acid in your blood when it reaches a particular level, it may become deposited as crystals in your joint, causes pain Management Medicines to relieve pain and control uric acid levels, Lifestyle changes Diet=Noredmeat - No tomatoes No Rhubarb Diet should be advised by dietician. r Alcobol - STOP Weight reduction Avoid stress ‘Avoid dehydration Ifyou fall sick, take the opinion of your GP Recently have you been started on any medication? Stress as follow up Websites, Leaflets 2022% OBSTETRICS AND GYNAECOLOGY Menstrual history ¢ When was your LNMP? How many days do they last? * Are they regular? » How many weeks between each period? © Do you get pain? (pain ~primary- is good because it indicates ovulation) * Any bleeding between your periods? Or after intercourse @ (intermenstrual bleeding can be a sign of; ovulation i Hormonal imbalance ii, Cervical polyp i. PID iv. Cervical erosion Breakthrough bleeding after using the COC Obstetric history © Have you ever been pregnant? * How many children do you have? © Any miscarriages or abortions? © Duration: of pregnancy? © Mode of delivery? © Any complications before, during or after pregnancy? Sexual history © Are you sexually active? * Do you use condoms? * Are you on any contraception? * Soty to ask you this but do you have any other partners? Taking a sexual history Core sexual history components (Note based on BASSH Guidelines,® developed for use in GUM clinics) Reasons for attendance ‘Symptom review Last sexual intercourse (LSI) - date, patient gender, sites of exposure, condom use Previous sexual partners - as for LSI Previous STIs, For women - LMP, contraceptive and cytology history HIV, Hepatitis B & C risk assessment Establish mode of giving results© Sexual history should cover all partners within the last 3 months. Ifno partners are reported during this time, then the last time the patient was sexually active should be noted. © Ifthe patient is symptomatic, the sexual history should cover all partners during the incubation period of STIs that may cause current symptoms. * Where no unprotected penetrative oral, vaginal or anal sex is reported during this period, ask the last time that this took place.® History taking and Counselling 25 year old lady Miss Linda Carlson has come to Gynae OPD requesting OCP. You are the SHO in the department. Talk to the patient, assess her suitability and give her necessary advice. ‘Take consent from the patient and assure confidentiality What brings you to the hospital today? Pt-l want to start the pill ican help you with that just need to ask you a few questions to assess if you are suitable to use the pill TAKE A MENSTRUAL HISTORY 7 _ Rule out contraindications; 1) Have you ever had any clots in your lungs or legs? 2) Any family history of clots in legs or lungs? 3) Sorry to ask you this but have you or any family member been diagnosed with cancer of the breast? 4) Have you ever experienced a migraine or a one-sided severe headache? 5) Do you have any liver disease? 6), Do you smoke? a) What do you smoke? b) How many do you smoke? ©) Since when have you been smoking? 7) Are you on any medication? 8) Are you allergic to anything? a) What happened? ( tight chest, wheezing, rash, itchy eyes) Miss Carlson from the information | gathered from you it seems you are suitable person for the pill. Do you know anything about the pill?ie ! ae ne x! i : ‘ The pill contains 2 hormones which are the same that your egg-producing glands make. The pill stops the production of the egg so it makes it difficult to get pregnant. Any Advantages doctor? Miss Carison these are very effective forms of contraception and apart from then it will make your periods lighter and less painful Also reduced incidence of. + benign breast disease + endometrial cancer + ovarian cancer Side effects?? Miss Carlson as you know every medicine has got some side effects, it may make you feel a sick or give you a headache. It does increase the risk of getting cancer of the breast or neck of womb but since you do not have a family history and we will be regularly following you up with pap smears and we will teach you how to self-examine your breasts so you don’t need to worry about it you may get some acne or some bleeding between your periods. It also increases the risk of getting clots in the legs so if you get any pain in your calf or any sudden shortness of breath contact your GP immediately How do | take the pill? Miss. Carison there-are 2+ tablets inthe pack you've to take, 1 tablet per day and preferably at the time. Start from the first day of your next period and continue taking it for the next 21 days en give a break of 1 week before you start the next pack. During this week you will experience (bleeding much like your period What If I miss a pill? No nied to worry if you miss one pill you take the pill at once What If | miss 2 pills? Ifyou miss 2 pills, you've to take last missed pill at once, you've got to use some other contraception for 7 days and you've to look at the pack and check how many tables are left if there are less than 7 tablets left, you've to start the next pack after finishing pack without giving a chance for withdrawal bleeding. You will not have bleeding during this time please do not worry.£.g. > 7 tablets left you've to take it as usual, give gap of 7 days and next pack.Additional contraception for next 7 days.Ms Carison | need to warn you that the pill is a very effective form of contraception but itis a 100% and there may still be a chance that you could get pregnant so if you miss a period take a pregnancy test or contact your GP. It also does protect against STI's so if you feel a burning sensation or itch in your private parts with a’discharge make an appointment with your GP. lf you need to take any other medication even if i's over-the-counter consult your GP and inform him that you are on the pill. If you develop a fever the effectiveness of the pill is reduced so use extra precaution during that time Offer Leaflets 25 year old Miss Laura Davis had an unprotected intercourse 48 hours back, she is in OPD. You are the SHO in the clinic. She is worried that she could be pregnant because of that. Talk to the patient and discuss with her the alternate methods of contraception. Miss Davis, | assure u whatever we talk will be strictly confidential What brings you to the hospital today? Pt- | had unprotected sex and I'm worried | could be pregnant Doc- | understand you must be very anxious, once again let me assure you confidentiality, but | need to ask you some personal questions. 1) When was the episode of unprotected intercourse? 2) Were there any other episodes before or after this one? $)_ When was your LMP? 4) Have you had any ischarge down below? There are two options available depending on the duration of the unprotected intercourse WITHIN 72 HRS The morning after pill contains a hormone known as progesterone which is one of the same hormones that your egg-producing gland produces. It makes the lining of the womb thicker making it unfavourable to get pregnant. It's just one or two tablets that you take now but if you throw up within 3 hrs you may have to come back and take another one. It may make you feel nauseous or sick and it will not protect you from pregnancy in the remainder of your cycle, so you will need to use some form of contraception for the future. WITHIN 5 DAYS You can use an IUD, Which is a small coil that is fitted into your womb by a trained doctor. It prevents the sperm from travelling up to your tubes and thus makes it difficult for the sperm to fertilise the egg, It can be fitted now and you can use it for future contraception, if you do not want 9 °at y ¥ y pe ie 3 sexuaily transmitted infection before inserting it because it cannot be used if you have an infection down below. Ihave to warn you that despite these methods there is still a possibility that could get pregnant so if you miss your period if they are at least ten days late or feel nauseous, have any inexplicable 's you Should consult your GP or take a home pregnancy test. fatigue, sore breast or headac! Pt. If get pregnant will this affect my pregnancy? Doc- neither the pill nor the coil will affect your baby if you do get pregnant. (Although if she had any unprotected intercourse before this episode it's possible that she could already be pregnant and in that case the IUD will be a contra-indication, therefore it is very portant to ask the precise time of the unprotected intercaurse) Iwill give you some leaflets so you can read about them as well. 27 year old Ms Grey has come to you with pain in her tummy. You are the SHO in the clinic take history from the patient and give D/D What brings you to the hospital today? Pt have this pain in my tummy. 1) Where is the pain? 2) When did it start? 3) Where did it start from? 4) How did it start? What were you doing when it started? 5) Does the pain go anywhere else? an Have you tried anything to make it better? Did it work? 1) Have you noticed anything that makes it worse? 8) When was your LMP? 9) Are you on any contraception? 10)Any fever? 11)Any nausea? 12)Any vomiting? 13)Any bleeding or passage of clots through your front passage? 14)Burning while you pass water? 15)Discharge from your front passage? 16)Any lumps in your lower tummy? Continue with history format. Ie. MAFTOSA DD * Ectopic pregnancy * PID © Miscarriage«ull Acute appendicitis 35 year old lady Mrs. Williams is complaining of amenorrhoea for 6 months. Take a history from the patient and give DD. What brings you to the hospital today? Pt- I've missed my periods for... months * Take a menstrual history * Take an obstetric history( few brief questions to exclude Sheehan's or ashermans syndromes) Sheehan syndrome, also known as postpartum hypopituitarism is due to decreased functioning of the pituitary sland caused by necrosis due to blood loss and hypovolemic shock during and after childbirth Asherman's syndrome, also called "uterine svnechiae" or intrauterine adhesions, presents a condition characterized by the presence of scars within the uterine cavity. The history of a pregnancy event followed by a D&C leading to secondary amenorrhea is typical. Hysteroscopyis the gold standard for diagnosis ® Are you on any contraception?(post-pill amenorrhea may last up till 6 months and is usually treated by waiting for spontaneous remission and spontaneous occurrence of periods. If the patient is anxious to get her periods back treated can be started with clomiphene citrate after waiting for 3 months of amenorrhea) * Have you noticed any growth of hair in unusual site © Are you anxious to get pregnant? * Have you felt any hot flushes or night sweats? * . Have any of your family member's alfained menopause ata younger age? * Are you on any medications? + Have you noticed a change in your weight? ( if weight is decreased it can a possibility of either anorexia, stress or hyperthyroidism) (if weight is increased exclude Cushing's) * Do you have any weather preference? Or do you ever feel warmer as compared to others such as on your face? in the same room? * Have any of your friends or family recently commented about your weight? © How are things at home or work? Any stresses? 2 Have you noticed any biuish marks on your tummy? © Any particular part of your body you feel you may have put more weight on? “truncal obesity in Cushing's) * Have you noticed any milky discharge from your breast?( galactorrhea is a sign of prolactinoma, other signs include low libido, vaginal dryness and discomfort during intercourse, larger tumours can cause headache, visual disturbance) * Continue with a medical history, ie. MAFTOSA. DD 1. Pregnancy 2. PCOS: eal Endocrine causes — Cushing's Premature ovarian failure. Prolactinoma Sheehan's Asherman's Anorexia Stress 10. Post pill amenorrhea, ©2NOTAY 21 year old Miss Simpson is admitted for lower abdominal pain and an US diagnosed a left sided ovarian cyst. Decision has been taken to doa Laparoscopic ovarian cystectomy on the patient, you are the SHO, talk te her and take consent. iRIPS. How much do you know about what's going on? Mrs. Simpson, after the necessary investigations the result shows that you have a fluid-filled sac in your egg-producing gland Pt- what's going to happen now? My consultant has decided to perform an operation to remove this sac. Pt- why do you have fo do an operation? Well the sac is a potentially dangerous and life-threatening condition, if it is not removed now then it can continue to grow in that case it might rupture, bleed or twist on itself creating a situation in which we will have to remove it by an emergency operation, Since you aré here how we can plan ~ ead to avoid that situation. Pt- what kind of operation will you do? First of all it is known as ovarian cystectomy, you will be admitted a day before and kept fasting for at least 8hrs so that you can be given anaesthesia, which my anaesthetic colleague will come and chat to you about later and answer any of your concems regarding that. We are planning to do a key-hole surgery in which the surgeon will make a small nick below your belly-bution to insert a harmless gas. This gas will distend your tummy and help the surgeon s inside better. The gas will be removed after the operation. Next the surgeon will make a further two nicks on the sides of your bikini line to insert the camera tube and instruments. Ft-how big will the scars be? If the operation is done laparascopically then the incisions are quite small, that's why it's called a key-hole surgery. However during the operation if the surgeon is unable to remove the cystthrough these small cuts it's possible that he may have to open up your tummy, in that case you may have a sear about 3-4 inches on your lower tummy. Ptwill you be removing my ovary too? |! understand you must be very concerned, until now we are planning to remove only the cyst, however once the surgery starts and the surgeon sees that the cyst is occupying a large portion of the ovary , then there is a possibility that the surgeon may have to remove that egg-producing gland.im sorry. Pt-will | still be able to have children?? As fong as your other egg-producing gland is working fine you will be able to get pregnant and have children like any other woman. Pt- how long is the operation? a It's about half an hour to 45 min. a Pt-how long do | have to stay in the hospital? After the operation you'll be taken to the recovery room. And we may keep you in for a day just to make sure that your feeling ok. However provided that everything goes smoothly you may be able to go back home either on the same day or the next if you have someone to take you home. Pt-are there any complications? As with any surgery there are certain complications such as bleeding, infection or damage to surrounding structures. However these are quite rare and we are ready to treat them in case something should happen. Pt-when can | go back to work? Well, that depends on what type of work you do. If it's not too heavy then you can go back to work after a week. However if its heavy work | suggest you take some rest for at least 2 weeks before retuming ( Pt-when can | have sex again? Well it's advisable to avoid intercourse for up to 2-3 weeks after a laparoscopic surgery. Pt-what about stitches? There are no stitches in a key-hole surgery because the incisions that are made are very small. 1 leave this consent form for you to read and sign. Thank you. 45 year old lady Mrs Brown has come for sterilization. You are the SHO. Talk to the patient What brings you to the hospital today?Pt- }’d like to get sterilization done. Do you know anything about it? I need to ask you a few questions before | explain about the procedure, is that ok with you? © Have you completed your family? Are you on any contraception? Or do you know about other forms of contraception? ® Do you know anything about male sterilization? it’s a fairly simple procedure with fewer complications as compared to female sterilization. It can be done as a day case in which your partner can come as an out patient, be given local anaesthesia and 2 small nicks will be made around the area of the tubes that carry the sperm, the tubes are identified and cut, then the ends are tied separately. ( If patient does not want to know about male sterilization, then explain about female sterilization. I need you to consider it as a permanent or irreversible procedure Pt. My friend has had it done and reversed! | appreciate your knowledge but | need you to consider it as irreversible because the operation that actually reverses it is another surgery which in most cases is unsuccessful. However even if it successful and you do get pregnant there is a high possibility that your pregnancy may occur with complications (such as ectopic} “MALE STERILIZATION © Key-hole surgery ie. laparoscopically. + Usually day-case but can keép at most for a total of 2 nights. * General anaesthetic is required * If operation is done during the 2" half of the monthly cycle and the woman has had unprotected intercourse since het-last period there is a risk of pregnancy occurring. * Contraception should be continued until the operation © Ittakes about half an hour to 45 mins. © Assmall nick is made in the belly-button through which a telescope is inserted and the surgeon can see the tubes clearly. Another tiny incision is made in the lower tummy and a thin instrument is introduced designed to insert either clastic clips or rings around the tubes. Which the surgeon sees through the telescope. + Insome cases if the tubes may not be clearly seen an open operation is done then the tubes may be cut and tied. In this case the operation and the hospital stay will be longer. Any complications? The risks with the key-hole surgery are small and involve sometimes injury to the bowel: ‘Some women feel pain for months that have had clips or rings on the tubes. But this is rare. Some women notice heavier periods after the operation and is usually because they have been using the contraceptive pill before sterilisation. Péwill | still get my periods? Your Periods will continue unless your ovaries or womb have been removed. Pt-how soon after can | have sex? Intercourse can be resumed as soon as desired. (if the patient is taking COC advise her to continue unti! her next period and if she has a coil then this can be removed during the operation if it is during the first half of the monthly cycle otherwise it will need to be left in until the next period.) 32 years old Mrs. Helen Goodman is due to have her delivery in a few days time and would like to know the various options for pain relief. You are the SHO in labour ward. Talk to the patient and address her concerns. i {ello Ms, Goodman congratulations so much on your baby. | understand you would like to know about the various types of pain relief available during labour. First I'd like to tell you that it is your right to ask for pain relief, we want this to be a happy time for you to experience so piease do not feel guilty about it(if she says she feels guilty about it) Before I tell you about them I'd like to know if you; ® Attended your birthing classes? * Have you chosen your birthing partner? © Do you know about the breathing exercises? (if she says no, then tell her, don't worry, one of the mid-wives will be going through with them with you tater) ~~ * We also have the facility of a birthing pool, should you wish to have your delivery there? (it's when there is delivery in a small pool, the benefit is that the delivery can be done at home, it can have a seothing and relaxing effect for the pain in the back for some women). ( The different types of pain relief are: TENS- transcutaneous electrical nerve stimulation. It's a small device which is attached to the belt of your gown and it has a few leads which are attached around your tummy and back. It sends out electrical stimulation to the tummy and prevents the pain signals from reaching your brain and also stimulates your body to release your own feel good hormones( the endorphins). ‘The advantage is that you can use it early on in your labour, it does not affect your baby but cannot use it once your labour has actively started. However, it takes an hour to become effective and in most cases does not effectively relieve labour pain. It cannot be used if you choose a poo! delivery. ENTONOX. is a mixture of 50% O2 and 50% NO. {t's also known as laughing gas and is completely harmless for you and your baby. You can simply breathe it in through a face-mask, and wocan use it whenever you want it and however much you want, It's quite effective although if taken too much it can make you feel a bit dizzy or sick. PETHIDINE- is a synthetic version of the medication morphine so it's a very strong pain-killer. It’s given as an injection into your muscle and it acts rapidly. It is only given during the early part of your labour (the cervix should be at least 3cm dilated) and is quite effective, it wears off as your labour progresses and it cannot be given again because it can cross the membranes surrounding your baby and can cause some breathing problems. In case that happens a doctor from the neoriatal feam will be here to deal with that and involves giving your baby an injection but don't worry we will be monitoring your baby even during your labour. Another disadvantage is that it can make you feel quite sick so another anti-sickness medication will be given to you along with the njection, and it may make you dizzy or sleepy. EPIDURAL- is a special form of anaesthesia in which the anaesthetist will pass a narrow tube rough a special needle in the small of your back. The needle will be removed and the medication . passed through the tube. It's quite effective in relieving pain and you may feel some numbness in your lower tummy and legs. It can cause a drop in your blood pressure so it's advised that you don't walk around too much although if you feel the need to you can with some help. You may not be able to feel the urge when u want to pass water so a plastic tube will put into your water bag to relieve your water works, During labour you may not feel your baby coming down and someone next to you will be asking you to push as hard as you can, In some instances if you are unable to push as hard as is required we may need to use some instruments to help bring your baby out Itcan also leave you with a headache afterwards. LSCS- although this is not an option for pain relief and is done either electively if there is some difficulty with NVD or as an emergency. If despite instrumentation delivery is uifficult then we might need to do a CS, in that case an epidural will suffice will give you some leaflets so you can read about them and discuss with your partner. The choice yours to decide. 37 year old patient Mrs. Margaret Johnson has come to the ANC, 12 weeks pregnant, she is worried that she might have a Down’s baby, you are the SHO in the clinic, talk to the patient and counsel her. GRIPS How can | help you Mrs. Johnson? Pt- well doator I'm worried that ! might have a down’s baby. lunderstand you must be anxious but would you mind if | asked you why are you worried? Pt- well | read its quite common in women getting pregnant after a certain age. | appreciate your knowledge and | would like to ask you a few questions if that’s ok with you. aDo you have any children? * How are they? Anyone in your family who has Down's syndrome? Well there are a number of tests available which can help find out if your pregnancy is affecied. We can do some screening tests which are non-invasive and involve taking a simple blood sample in which certain markers can be identified that are particular to downs syndrome or do an US in. Which the thickness of fluid behind the babies neck is measured. These can be done following 11 weeks of pregnancy up till the 14" week. The results can be known immediately and it only takes a short time to perform them. However, they do not completely diagnose the conditicn, if the results show that there is a possibility then we can move on to the diagnostic tests. These include two tests: Chorionic villous sampling- in this test a consultant will take a tissue sample of the membranes that surround your baby by using a needle which is inserted either through your tummy or your front passage. This test is done at 10-13 weeks. The test takes about 30 minutes to perform and the results are ready in 2-3 weeks because the sample is sent to the lab for testing the chromosomes which takes a bit long (i.e. karyotyping). (transabdominal approach after 12" week or if transcervical access is impeded) Amniocentesis- is a similar procedure but in this a sample of the fluid surrounding your baby is taken under US guidance. And this can be performed after 15weeks | must warn you that there is a risk of miscarriage and infection with both these procedures and the results are not always reliable \ can give you some leaflets and some website addresses fo you can have a read about them. ( If patient asks which one? It depends on the date of gestation and risk factors. NOTES FOR SCREENING TESTS Sennn screening for Down's syndrome + ablood sample is taken at the appropriate gestation and tested for various proteins and hormones, usually in combination + biochemical screening undertaken during the first trimester of pregnancy (between 10 and 14 weeks), uses a combination of free beta-hCG and placenta associated plasma protein A (PAPP-A). This test should be combined with nuchal translucency (N1 + the following tests meet current standards: © from 11 to 13 weeks 6 days - the combined test (NT, hCG and PAPP-A) © from 15 to 20 weeks - the quadruple test (4CG, AFP, uE3, inhibin A) o from 11 to 13 weeks 6 days and 15 to 20 weeks + the integrated test (NT, PAPP-A + hCG, AFP, uE3, inhibin A)+ the serum integrated test (PAPP-A + hCG, AFP, uE3, inhibin A) 73 year old lady Mrs. Green has been complaining of urinary incontinence. You are the SHO in the clinic, Take history and give DD’s. Hello Mrs. Green Can you tell me what is happening to you? What were you doing when that happened? c!'as it ever happened before? (“low many times and was it the same? Urge: when you feel like you need to use the loo can you hold it till you get to the toilet? Stress- Do you leak whenever you cough, lift weight, run? UTE -, Do you have any pain/burning Do you get up during the nig! How many times? True - Do you leak continuously? DM - Have you ever gotten your blood glucose checked? Drugs - Are you on any medications? _ a ~ , you take lots of tea and coffee?? {_ ve you had any instrumentation procedures done down below? Prolapse - Have you noticed any lump down below? Neurological - Do you have any past major medical illness? Do you have any children? How many? Were there any problems during delivery? ‘When was your LMP? Ave you taking HRT? Your DD's * stress incontinenceae eay * urge incontinence + mixed( stress and urge) * uTl © Prolapsed © Overactive bladder (+/-urgency, frequency, nocturia- wet if urge UI is present and dry if no urge Ul) © Atrophic vaginitis Investigations * Urine dipstick * MSU © Bladder diary « Urodynamic tests * Bladder scan Management © Reduce intake of caffeine/fluids in OAB © Pelvic floor exercises for stress/ mixed © Bladder training for urge/mixed. There are certain bladder training programmes, if the patient is unsatisfied then medication can be added. * Vaginal estrogen for atrophic vaginitis © Medications surgery 28 year old-lady Mrs. Hillary Clinton has.come to ANC. The midwife has.checked her BP, Its 160/100 and a Urine sample shows protein in it. She is 32 weeks pregnant. You are the SHO in the clinic talk to the patient. GRIPS How much do you know about what's going on? Well your BP is quite high and | need to ask you a few questions * Have you been attending your ANC? + What was your booking BP? + Were you told that you have high BP at any point of your pregnancy? + Have you noticed any tummy pain? * Blurring of vision? * Headache? + Puffiness in hands or face? Change in you waterworks? (oliguria) * Change in your baby’s kicks?From what you have told me you may have a condition known as pre-eclampsia Do you know anything about it? It's a condition also known as pregnancy induced hypertension, in which the BP is raised. Itis a potentially serious condition because if the BP is not controlled then it can lead to eclampsia in Which you can have a fit. And that is dangerous to bath you and your baby. We need to admit you and give you some medicine to control your BP. You and your baby need to be continuously monitored and we need to do some tests to ascertain the severity of your condition. We'll do an US on your tummy and with the help of a special machine called a CTG we can find out how your baby is doing 1y consultant will come and review your Case. And in the event that if your blood pressure remains high it may lead to a fit, in that case we may have to deliver your baby. Pt. will my BP always be high now? After delivery your BP will return to normal, but you are at an increased risk of developing high BP later on in life and also in your subsequent pregnancies. Mrs Elizabeth Martin 28 years old is 34 weeks gestation with uncontrolled BP has been admitted with eclampsia. She has been taken to the theatre for emergency delivery, talk to her husband, explain to him his wife's condition and answer his concerns. GRIPS ‘e you Mr.martin? M- yes Ive come to talk to you about your wife's condition. M- what's going 0n?? Is she ok? Is the baby ok?? How much do you know about your wife’s condition? M- well she said'she was not feeling well so i brought her to the hospital. Well, your wife's BP is very high and she had a fit, im afraid she is in a critical condition right now. The only way to ensure the safety of your wife and child is by delivering the baby now otherwise it can endanger both of their lives. M- but the baby is not due yet??!7! lunderstand this is a very difficult time for you and we're all here to help, at the moment we have given your wife some medication to control the blood pressure and the fit, your baby’s condition is wEra . cab) goa. ihe also being continuously monitored and i know that the baby is not due yet, but the only way to help them both is to do an emergency caesarean section operation now. Your baby will be in good hands when delivered, a special team has been notified of the urgency of this situation M- what kind of operation? Is it dangerous? As this will be an emergency operation the risks involved are slightly higher, she will be given anaesthesia but because she has not been prepared for it there is a possibility that she could vomit and choke on it, because her BP is high there is increased chances of bleeding, for that i need to ask you if you have any restriction to a blood transfusion should we need to give her some blood and with every other operation there is always a risk of infection. But she will be given antibiotics for that M- is she going to be ok? We are doing all that we can, the theatre staff, the anaesthetist and the pediatric team have all been informed. We are currently giving her some fluids and medications . after the operation, the baby will be taken to the neonatology unit where premature babies are given extra care. And your wife will be taken to the recovery room. | have to warn you that when you see her there might a tube coming out from the site of the operation. , this is to avoid any blood collecting inside the body. There might be a tube from her front passage to help her water works as well. Everything has been explained to your wife as well, if you have any more questions or concerns thats what im here for. | need to ask your consent to go ahead with the operation. clampsia- Telephonic conversation with consultan' 32 yrs Old primigravida admitted in hospital with 32 weeks pregnancy. B.P. 160/110 mm ‘ Hg. fits after admission. FHS are regular on CTG. You are the SHO- discuss the condition of your patient with the on-call consultant Mr. Thurston on telephone. 1. Am talking to Mr. Thurston 2. I want to speak to you about the patient (give details) 3. Ihave put her on oxygen 4. Ihave started Magnesium Sulphate as per hospital protocol. 5. B.P. 160/110, so | have started Hydralazine and asked midwife to check BP every five minutes. Also, monitoring her respiration, pulse and deep reflexes every 5 minutes. | have put a catheter and monitoring an hourly urine output. 8. Sent her blood for FBC, group and save, urea, electrolytes, LFT, coagulation profile, uric acid. 9. Ihave checked FHS and they are regular and have put her on continuous CT6. xo10.Also informed anaesthetist, theatre staff, paediatrician and special baby care unit. 11.1 have discussed about patients condition with the partner, 12.Would you like me to do anything else Mr. Thurston? Ifyou don’t mind would please come and see the patient and decide the further Management. Rormone Replacement Therapy * 54 years old mrs.cole is complaining of hot flashes and mood swings, her LMP was 12 months ago and she knows she has menopause. “GRIPS What brings you to the hospital today? Pt- well ive been getting these horrible hot flushes lately and i feel like i get annoyed at the slightest things that never used fo bother me beforel! Its quite frustrating. im so sorry about that, When was your LMP? Pt- well my periods stopped about a year ago. There is a medication to control the symptoms your having, its called the hormone replacement therapy. Do you know anything about it? Pt-i have heard about it but i don't really know what it is. Ata certain age the egg-producing glands stop producing eggs and the menstrual cycle ceases, re hormones involved in this cycle are also reduced and that's what can cause these hot flushes and cestain mood swings. | need to ask you a few questions if thats ok with you? Pt ofcourse Are you having night sweats? Palpitations? Headache? How is your sleep and concentration? Sony to ask you this but have you ever had any lumps in your breasts or ever béen diagnosed vith cancer of the breast or the womb? vou have any known liver disease? ‘ou ever had any ciots in your legs or lungs?x tesuirs ae hee Op, ee ene, OGR PSeo < Corhidlersi ain, 2) Concesvwv ¢ Organs oeBe EWG Hs eae ds aH aE Ee Have you had a hysterectomy i.e. your womb removed? ( if a hysterectomy hi an estrogen only HRT can be given) Are you prone to falls? Have you had any fractures? Anyone in your family with a condition called osteoporosis, that is thinning of the bones? Thank you for answering my questions, it seems thal you are suitable for the HRT. I's quite similar to the oral contraceptive in the sense that it replaces the hormones estrogen and progesterone that the body has stopped making. It helps with the mood swings and hot flushes. Pt- are there are any side effects? © Nausea and breast tenderness © Weight gain and fluid retention * Headaches and leg cramps (estrogen) * Increased risk of endometrial and breast carcinoma ( will be doing a pap smear regularly and teaching self-examination of breast) * Increased risk of clots in legs and lungs: © Spotting for a while ( if lasts more than a few months need to inform) * Increase in BP ses if HRT is used for more than 5 yrs) (the risk for breast carcinoma i The loss of hormones can also affect your bones and cause them to thin, HRT does not prevent this from happening bul can delay it. | will be referring you to a physiotherapist and a nutritionist who can guide you more about a special diet and exercise to help strengthen your bones. prescribe calcium, exercise and (if she has a family history of osteoporosis but no signs hers: diet) ~ "she has had fractures and/or is prone to falls — prescribe medication- if axial fracture then -commended medication is bisphosphonates and if peripheral fractures then raloxifene) Advise about r ites if she asks, oral, transdermal and implants. {can give you some leaflets and some websites, you can have a read about them. Dyskaryosi 25 years old Miss.Lilly Peterson, has been diagnosed with Dyskaryosis on routine cervical smear examination. You are SHO in Obs & Gynae department. Talk to the lady regarding further management. Hello mrs.petersan how are you doing today? Pt ok, just a bit anxious. | understand you must be, i understand you had a smear test done. Is this your first smear? 18e Pt- yes this is my first smear Well i have the results with me and they show that you have a condition called dyskaryosis Do you know anything about it? Pt- no, it sounds serious. Dyskaryosis means that there are certain abnormal cells. It is not serious but is potentially serious as these abnormal cells can regress back to normal or they can become more Olona Dees Te nese oD he onal | abnormal Pt- do you mean its a cancer? No, it is not a cancer. As i said its called dyskaryosis which means that the cells are only just abnormal. Pt- whats going to happen now? 5 Ioqess +o Ca'pascep Since this was your first smear and the results show that it is a amikdtebrormality we will repeatthe-test ifi'3-6 ronths-time Pt-What if they are still abnormal? if they are still abnormal then my consultant will do a special lens test called colposcopy You will be in the same position as a smear test anda dye will be injected into your fromt passage which will highlight the abnormal cells when seen with the magnifying lens of the colposcope: Pt- im scared doctor what if the cells are still abnormal does that mean im going to get cancer? It does not necessarily mean that you will get cancer, even if there is a risk it depends on the level abnormality of the cells at that time. However, don’t worry, if the cells are still abnormal after the colposcopy they can be removed by a special operation called LLETZ —— (long loop excision of transformation zone) don’t be alarmed by the long name. it means that the area where the abnormal cells grow will be removed by a hot loop of wire while you are put to sleep so that you don’t feel any pain. "4 ‘a feos sre fral- ee Pt- can it happen again?? S2mOUs - 2Onoti Nol ser After the operation you will be called for regular follow-up after 6 months and then annually for atleast the next 5 yrs. Cantar | oni Pokenk ol eS >be Bw bop (if patient asks about sex, then avoid it for 1 week after colposcopy and 4 weeks after LWETZ) Cancer of Cervix: (Breaking Bad News) @ 54 yrs old Mrs. Katherine Patrick has come to Gynae OPD. Diagnosed as terminal stage of cancer cervix. SHO, talk to patient. Mrs.Patrick | have the results with me and | am here to discuss those results with you. Are you comfortable? Do you want somebody with you? _!Infortunately I don’t have good news for you, results of test suggest that you have cancer { the neck of the womb and it is in the advanced stage. Q. I don’t believe your result? A.| can understand your state of mind, | know this has come to you as a shock, but we have double checked the results and discussed with seniors. | wish they were wrong, but unfortunately they are not. If Crying: Mrs.Patrick | can understand what you are passing through but this is not the end of the road. Although we cannot cure you but we can do many things to make your life comfortable Are you comfortable? Do youneed a glass of water? -~ ~ ease don’t think that you are alone, we are here to help you out. If any problem, you can discuss with us, we need your cooperation, without which we will not be able to do anything. Q. What can you do for me? We breve & Mrultecleec pliatany seer Mle man nurses A. We can refer you to oncologists; they are specialists who deal with these sorts of cases ica Yes ay We have excellent pain control teams in our hospital that can take care of your pain. We can refer you to dietician who will take care of your diet. We will give you leaflets, address of cancer society and support groups where you can find people with similar problem and can share your concerns with them. Q. How long will | survive?223 A. Difficult to answer, every person reacts differently to the disease and treatment. 35 Yrs old Mrs. Hawkins came to the gynae OPD complaining of a change in her baby’s kicks. You have done an US and a CTG and she is asking you what is wrong because she can not feel her baby’s kicks any longer. Talk to the patient about intra-uterine death. Mrs, Hawkins, how are you feeling right now? Pt- im scared, what is going on doctor? Why can’t i feel my baby’s kicks?? lunderstand you must be very scared right now, for that reason would you iike me to call someone for you so that you are not alone? . ‘ Pt. no, its fine, please tell me what is wrong? Can i just ask you what you think it could be? Pt- i don’t know! We did the US and the CTG, which is a special instrument to measure a baby's heart rate but according to both the tests and what you are telling us that you can not feel your baby’s kicks, it all means that your baby’s heart is not beating any more Pt- (crying) does that mean he is dead? No.....this cant be true!! tater | wish it was‘nt, im so sorry. (offer tissues once and then a giass of water if she does not respond) Pt-cani ge home right now?? | need to go home. A , oe pou CB ase wed ty olediver Yeo \neday Gfeoucse you can, boule tke me to Catt amyone for you? nDAD ). Baaagl wu» ahe R etinb gd Ror dow Pt-Yes please. : C But mrs.hawkins you need to come back to the hospital as soon as possible because we will have to deliver your baby by inducing labour. After the delivery you can hold your baby, you can even take foot prints or take a fock of his hair. You can take pictures if you wish Ifit’s too difficult for you right now, the hospital can even arrange for a small funeral for you.i yh 1g 5 eed ~ @ ee Pt-why did this happen doctor? SO < wo Ws “Dt o few avery J Did you have any high blood pressure during yout pregnancy? High blood sugar? Any kidney disease? Did you hurt your tummy during your pregnancy (placental abruption)? Pt- no We will be taking a blood sample from you and your baby, and also a few swabs from your front passage. We can perform an autopsy on your baby to find out the cause but sometimes the cause can not be found. We will however be keeping a close eye on you in your future pregnancies. can give you the number of a bereavement councillor who may be able to help you cope ~ ith the difficulty and the still birth and neonatal death society, there are other people who are going through the same thing as you. “.""" “SQ We cani~ ony bute an Somre ! pre Keaep 4. pyun tyel os 27 years old Ms Johnson presented with vaginal bleeding, she is 28 weeks pregnant and this is her second pregnancy. Take relevant history and discuss the management with the patient. @ Antepartum haemorrhage the patient Approach should be to take history to reach a diagnosis (or DDx) and to ass circulation, History: © What brought you to the hospital today? What were you doing when it started? oe Colour, amount, clots, pain, contraction, change in fetal movement! Discharge and fever? —~ ——-* —— Trauma, HTN, smoking Any dizziness, palpitation? Obstetric history, including previous pregnancy? DDx: 2 Poirier MOM HN BIWKH, Is iF secon oX, oe 1. Placenta praevia {the afterbirth is planted on or near by the opening of your womb) \ i 2. Placental abruption (pat of the alerbith has separated from the womb prematurely, this causes that area to bleed insideyRaing x. L 3. Local causes (cervical infection, trauma) > P ; ws Counselling: oO * Admission Pe * Circulatory support and fetal monitoring * Urgent USS (avoid vaginal examination till placenta previa is ruled out) t ‘, © Take blood for Hb, X-match, blood group (Anti-D) g * For any APH if both the mother and the baby are stable, blood loss less than 500ml, and ¢ no retro placental clots the discharge after 24 hours and deliver at 37 weeks "Nak os + We se* Otherwise delivery either by induction of labour or caesarean section depending on clinical judgement of seniors. ee : » Con@icavons oF PB Pelvic inflammatory Diseases: Ms Osborne is 25 years old was diagnosed to have PID, she has been on treatment, for 7 days and doing well. Talk to her ye anit ed ered ——e ee ee tor, Rom OOF Sry Introduce yourself and insure privacy, OCP. » ebhas ot os testure =! Ask the patient for her concern end respond accordingly: 4 Bee hse Use fo 7 Infertility: “| am afraid that there is a risk but you are doing well with treatment which will reduce the risk” © Ectopic: " there’is a risk and again treating the infection can help, you can also contact your GP if your period is delayed or you experience unusual bleeding” * The partner: “he or she need to be treated to eliminate the bug and prevent reinfection, ¢ avoid intercourse during the period of treatment” C * N.B. explain partner notification programme if she does not want to tell the partner” ¢ Other complications: dysmenorrhoea can ease up with time but sometimes persist, if it is disturbing you then there areyolenty of opliogs.on how ty de ajn killers, OCPs) © _Any other concems? Poe. rea: on “eb Ae encom eso 4o8 Oweq PE Uae oS cath & ST tem vies ond Heal He porlner © Menorthagia: sey ne © eS > he Lee $ Men ie yah ove Tels Were Go Bn have he Mrs Stevens is 37 years old, has been suffering from heavy periods for 6 monthstoné>. take history and give your examiner a diagnosis. “Te — History must cover: ~ Qnset, duration; color; amount, clots,associated discharge? ¥ aur. ~~ Full menstrual history starting from menarche and including Pap smears Obstetric history Contraception and Medications Family history of similar complain DDx: 1. Fibroids (heavy bleeding, intermenstrual bleed, miscarriages or infertility) 2. Ectropion (on OCPs, post coital bleed, clear discharge w/out local irritation) 3. Endometrial or cervical CA (offensive, family history or on oestrogen only, might have wt loss 4. Polyp (posteoital or intermenstrual) 5. If symptom of chronically irregular periods with hirsutism then the diagnosis is carcinoma or b hyperplasia of the endometrium due to PCOS igo g NES, MOS olrer places Lwhie You ote Pouing mane, Investigations: \4 . Mee EPSOM DS Enrol ASH USS, Pap smeat and endometrial sampling yuo be ‘ee 9. Deer Fe rote. & POOLEY cog a cece | aoe om % vot, 5 wa ay IAT >i é © Diabetes and gestational diabetes: Scenario 1 Preconception counselling for a diabetic female Fe Craquen’ Fars Drone etavs Bath @ pe be Badass © First of all reassure that many diabetic s get pregnant and have healthy babies ¢ Ask if'she is concemed about anything before you explain further . th fe rae ng hove You ‘eee olinbe eneral information that you can o er) ore you! Fein g ad) td Bi High blood sugar is associated with most of the complicati8ns of pregnancy, so it must be well controlled 2. Ish OHAs thi lin will be st ted 2) bor Coger (acy: Fee she's on OHAs then insulin will be starte as oma ~ 3. More frequent ANC visits will be scheduled, “CE ne \aatze’ chee 4, Before: Folic acid 3 months before pie eas ro ee . 5. T1: is the most critical as the baby's body parts are ‘armed a3 it's siniSortant 7 Keep an eye on the blood sugar, also there is a risk of miscarriage." Fe USr 4 ro 6. T2: anomaly scan, the baby start moving , any change in the movement'must be reported 7 T3: diabetes might cause growth restriction, or a big baby in some cases CIS is the mode of delivery, there is a chance of IUFD Reassure by mentioning that she will be fooked after all through her pregnancy 8 9. After delivery the baby is at risk of hypoglycaemia but, again, that will be managed. N.B: it's not @ must to mention all these information, the main thing is to address the patient's questions and concerns wesc at { beter en bow babe, 5 5 ir Mipos| Lseadee? > Scenario 2 ~ re 5 & 5 ¥ A patient who is 26 weeks pregnant found to be hyperglycaemic in her ANC visit.\7_ yr —— an a. > —~ Confirm the Dx of gestational diabetes Se A 4. Before your pregnancy were you diabetic, or have you had high blood sugar? \ i 2. In your previous ANC visits were you told that you had high blood sugar? C3 * Explain that she has Gestational diabetes, which mean the her body is not able to utilize on the way it did before she was pregnant + + It’s a common condition that occurs at this time of pregnancy, mostly it resolves soon atter > =, 9 delivery. But it might persist as diabetes or she might become diabetic after e It's not caused by the baby or due fo pregnancy alone, in addition there are other pre ptans e : (genetics, environment) 4 2 No risk of congenital anomalies as the baby completed body building, (so you only need to c - mention T3 complications from above) * Management: 1. More frequent ANC visits 2. Keep an eye on blood sugar and babies movement 3, We will try to control the condition by diet if not the by insulin (injection with the hormot that utilize sugar) ( Hyperemesis Gravidarum:OGRE S 4 Con clarke ™ Be nauseous or feeling sick is very common in pregnancy, but when it disturbs eating and causes dehydration it becomes hyperemesis gravidarum itis related to one of the hormones that the afferbirth secretes (HCG) if fact that's why it also common with twins We need to admit you, run some blood test and do USS scan to double check on you and your baby, We wil give fluids though your veins as you are a bit dry ‘Once you can eat and drink you can go home oe This condition will resolve by time and here are some advices ai inagvenk must Shyer yt Drink and eat litle and offen“ e.2) 2. Meals high in carbohydrate and ower in fat are betior ; 3. Cold meals reduce smell-related nausea Lb eS 4. Avoid caffeine and alcohol as these enhance dehydration ZB OT: 5. Ginger can reduce the nausea and the vomiting Zoro 8. “if symptoms persists medications (Antihistamine like promthazine) _ oe ot 7. NO metoclopramide ata (he. Aue pee oo hype erneit in A girl around 20-25 yrs of age has dysmenorrhoea and wants something for it. Discuss management options with her e.g. O' Ps, NSAIDS, progestogens.* ocr's - Benefits--makes your periods lighter-and-less painful (his is the progesterone effect in the.coc.__ pill.) ‘ Disadvantages- — oestrogen- H ° * Heavy periods 4 + Ectopy ae bw Oo eng, tig. , C + Breast fullness en Iyer + Nausea Cot FT te © taom er * Bloating Chath of (Diiifenn Cai' eet - Progesterone- re ® NORTON Freese Coe ih) Lighter periods + Breast tenderness + Leucorrhoea * Increased appetite Leg cramps Acne, greasy hair> por Co. 4 muse Coby gay 9 Riqne reg ck COM gud. 4 90 ce aS Mone Tuy Soe NSAID'S e.g, aspirin, ibuprofen, naproxen. me, ade Olt Heese Advantages- available over- the counter, effective pain Telief.- \ DG, Dis-advantages- can increase risk of gastric ulceration, Gl bleeding, C} in women with bleeding disorders. ‘Po rwad Slee! are @ Miscarriage: (BBN 5 “ss 7 27 yrs Old pregnant lady Mrs.White presented to the hospital with bleeding from her front passage.you have done an US and it shows a miscarriage. you are the SHO- Talk to the patient Oke o \one® ‘steed Wor uabicwe ete aia He i Hello mrs.white, how are you doing right now? —> 8 you know that you had some bleeding from your fropt passage, what do you think is going on? ee ae Pt- i don’t know doctor. Im worried. SEG Ses use a nab te dra unles How many weeks into your pregnancy are you? Lads. =. Tes 007 Derk ny wose FICK 1%) Pt-about 7 week airs wakes ween thes iop Well we have just done an US, and iwas wondering if ybu WOuld like to have someone with you before i tell you the news. Pt- what do you mean, what is it doctor? aineSO Ly Im so sorry but your pregnancy is no longer viable’ Uo derdeingh weer su Tees a on So soe Brak Sab be be the rh Pt- (starts erying) why did this happen? Is hi Geese of something idid?,, +m yp. a4 ~ sase don't blame yourself, it is not your fault, there is nothing you could have done to prevent it. Pt- but then why did it happen? {t fs not an uncommon condition, mostly affecting first pregnancies. Sometimes it is due an abnormality in the building blocks of the baby but in most cases the cause is unknown. Pt- what’ s going to happen now? we need to make sure you have not lost a lot of blood and take a sample of your blood to check your blood group, are you still bleeding? How much did you bleed? Did you notice any clots or products? Do you have tummy pain? Pt- what are you planning for me? Well, you can go home provided someone is there to take you and you will have some bleeding for the next few days. Or we can give you some medication that you can either take by mouth or insert in your front passage, this will help clear your womb. You need to come back after a few days so that we can do an US nad check if your womb is empty, if it is not then we might have to 26F wk i 4) i do an operation called dilaton and suction, in which you will be admitted and put to sleep. Then with a sterile suction tube the contents of your womb can be removed. Medical management- less than 7 weeks and more than 12 weeks. One dose of mifepristone taken orally in the hospital. Patient admitted for 4 hrs after this dose. Patient can go home but she has to come back after 24-48 hrs. No later than 3 days. She will be given a second medication , prostaglandins either orally or per vaginum. If she wants to go home, she can, so explain to her to insert the tablets as high up in her front passage as she can, warn her that she will experience bleeding and passing of clots so wear pads and not tampons. If you feel the need to admit her depending on her condition or what the patient answers. Then you explain to her that the second medication is not help clear out the womb and we will be inserting it into your front passage. Up till 5 tablets can be inserted every 3 hrs. Surgical management- D&°S for cases that indicate remaining products of conception or - gestational age 7-12 weeks, although up till 9 weeks medical management can also be done is ( actually preferable. But depends on patients choice and also her condition. @ermination of Pregnane 23 yrs, Old Ms Remington has come to you requesting TOP. 9 wks. Pregnancy. SHO- talk to patient. Hello ms.remington, how can i help you today? | assure you whatever we talk about will be kept confidential Pt- well i want fo get an abortion. When was-your-LMP? = = a Ifyou don’t mind me asking why do you want to do this? It is a decision you will have to live with for the rest of your life. If it is a financial reason, social services can help you. Are you sure about this? Pt yes doctor i am sure about this. Well, we will need to carry out a few tests, a pregnancy test and an US to confirm the date of gestation, and your blood group. We need to do a test to check for any infection down below. Treatment: same as miscarriage, depending on the age of gestation. Contraception- Further appointment Ectopic Pregnancy: @ 2724259104 Or cal & oh = 28 yrs old Ms. Jones has come to the hospital with pain injher leftliliac fossa, her LMP was 6 weeks ago, you have done an US and it shows ectopic pregnancy. She wants to go back home. SHO- talk to the patient == Hello ms.jones i'm dr...... , how are you doing right now? pre, , ow 9 Pt- i've got this awful pain in my tummy. ! juuict sh a Im so sorry about that, do you need any pain-killers at the moment? When was your LMP? Pt- what's going on doctor? ‘According to your pain, and the US that has been done, it shows that you have an ectopic { egnancy, which means that pregnancy is not in the usual place and it is in the tubes that connect \e ovaries to your womb, Because there is no place for the pregnancy to grow here it can rupture the tube, bleed or twist on itself creating an emergency Pt- i want to go home!!! \understand this must be a difficult time for you, but we need to admit you to the hospital right now. Pt- no, you don’t understand doctor i need to get out of here right now. Can i just ask where you need you need to go, because if you leave the hospital right now and your tube ruptures it will be life-threatening. In that case we may not be able to help you if your a distance away from the hospital Pt- but i need to attend this interview, it's. once in a life-time opportunity!!! - derstand getting interviews is really hard, but at this stage your life is in danger. We can write you a medical letter stating the seriousness of this situation that you can present tg firm you have your interview with, YO Ube $6 9224 ves bey Ot oye clancaree hx (400 oo Waite MAD nen? ) Pt- no, i still need to go. IV be back within a few hours. I'm sure i'll be fine I'm afraid none of us know when the real danger might strike. But we need to be ready for it. The tube could burst now as soon as you leave the hospital or it could happen when your al the interview. | would strictly advice you to stay here as you need strict constant medical supervision Pt- j need to go. I'll come back. i promise. I'm sorry i have not been able to convince you, i'll fix an appointment with my senior who might be more successful than me. INFERTILITY @ 32 YRS OLD Mrs.Wilson has come to the infertility clinic. You are the SHO in the clinic, Talk to the patient and address her concerns.Ensure confidentiality nd Determine if tis primary or secondary? -—<—T, Detailed sexual history? How often do you practice intercourse? ie hn Does = ildren? aa joes your partner have any children’ Be. one, Has ever been diagnosed with a condition called undescended testes? Or has he ever had mumps? TCO, Wa at Sten 2) Wearing tight underwear can affect a man’s fertity, does your husband wigar tight underwear? ase aut ao $ Have you ever been pregnant before? 3 Tes [not Ohyt yp are . a7 Ae . 7 oy veoh s R070 FV cots Thox Any abortions or miscarriages? Detailed menstrual history? Any infections down below? Have you ever been diagnosed with PID? Endometriosis? Hepatitis b/c or have you ever tested for Hiv? Sorry to ask you this but have you ever done any recreational drugs? Are you on any medications? Any over-the-counter medications? Have you noticed any leaking from your breasts? ( galactorthoea is a sign of prolactinoma which can cause menstrual irregularities and thereforé lead to difficult pregnancy) others are comfortable? Any shaking of your hands? Racing of your Do you feel warm whi heart? a Have you had any operations or instrumentation done down below? Investigations Male- semen test- if the first is abnormal repeat after 3 months. Female- blood tests- progesterone( 21 day), oestragen, FSH, LH. Chlamydia screen Hysterosalpingogram or HSCS- fluid injected through the neck of the womb and examined by an US. Hysteroscopy. Management Depends on the cause. Sexually transmitted infection » 29 (222 = The correct term in UK is STI and not STD's. 25 yrs old Miss Winslet presented in the gynae OPD with complains of a whitish discharge from her front passage for the last 14 days.and a burning sensation while passing water. Take relevant history from the patient and discuss diagnosis and management with the patient. GRIPS Ensure confidentiality Joneaes His 4 How can i help you miss winslet? SS Pathos Pt. doctor ive been getting this discharge from my front passage. ow long? Wihat colour is it? Any blood? Conorvee Any foul smell? LMP? = Jeans! ite Dai Ay gir Burning while passing water? Ps per Rela rs cin Red eyes? Joint pain? er creas Red eyes’ f. Hes fe ove Any ulcers in your private parts? : a - 4 quicey Any lumps around your private parts or anywhere else on your body? — Saphl s —VU "i Are you sexuaily active? When was your last intercourse? Did you use a condom? es your partner have any of the same symptoms? Have you recently changed your partner? Sorry to ask you this but do you have more than one partner? From the symptoms that you are giving its possible that you could have an infection down below. We will need to do some investigations such as smear test or a urine test to make sure Pt- what kind of infection? Most likely a sexually transmitted infection which can lead to the symptoms you have described Pt- is it dangerous or treatable? itis a treatable condition with antibiotics (azithromycin (single dose) or doxycycline (bd for a week). But your partner needs to be treated aswell because in most cases the infection remains symptomless and can reappear later when it has done potential damage. That is why we have a partner notification programme. We can inform your partners and encourage them to seek 30238 treatment that they might need anonymously if you provide their details your name will not be mentioned at all Pt-does the infection have any complications? There is a high risk of re-infection if you have any intercourse during the period of treatment and also if your partner is not treated. If re-infection does occur it can infect your womb and make periods irregular, it can infect your tubes and make it difficult for you to get pregnant in the future, So it is very important that you and your partner get treated now. [conte Lee to Svs Dy eae os Fae Botan? ' 5 Ore ca od Cony 3 al ere J 16 Combate, de 31courhel Kern and E pvt B ALTERNATIVE FORM OF CONTRACEPTION FOR PT HAVING DVT Hello I’m doctor ..... what brings you to the hospital today? Pt. Doctor i have been sent to you regarding contraception. can help you with that but before I tel! you more I would like to tell you that whatever we discuss will remain highly confidential, is that ok. Pt. yes ‘Well mrs/miss ..... from my notes { understand you have a condition called DVT are you taking tabs. PL yes doc Well mrs.... Syne u r having dis condition its not advisable for you to take OCPs anymore. Pt. but why doc Ican understand ur concern I will be telling u about alternative forms of contraception more suitable for u 80 u don’t need to worry but u have to stop OCP bez u know it contains 2 hormones oestrogen and progesterone.The oestrogen hormone increases clotting factors so increases chance of clots, so nt advisable in ur condition, do u want to know abt other methods which r safer fer u? Pt. yes doc Before I tell u abt those id like to ask few qs.... 4 PS Ok ill tell u diffrnt options its upto u to decide which one u want k-Feel free to stop me at any point if u don’t understand ok. Pr. ok doc.thank you 1. Barrier Method: condoms ete Advantages: No hormones , decrease chance of STI but nt very reliable 2.POP... mini pill .contains only progesterone Any history of liver dx? Ady : doesn’t contain oestrogen so suitable in pt CI to OCP e.g DVT, migrane high BP pts Disadv: Imegular periods, spotting between periods CI: "fiver dx , breast cancer How to take: Take I pill each day at same tym and no break ,finish one pack and start a new one ‘Mirena Coil: plastic coil inserted chru front passage protects in 2 ways , prevents sperm from reaching egg and contains progesterone hormone making womb line thinjjer and less favourable fr implantation. Adv: Good fr forgetful ppl who cant remember pills , and there ff 5 yrs Disadv: irregular periods CT : liver disease , breast cancer Trained doc or nurse will insert that , do u have any discharge frm down below@ PSYCHIATRY NOTES ~ DEPRE: SSION Q 1 A 32 yr old female, with low mood, lost her husband a few months back. Take history & counsel her. Q2 + Gonly common cond hory— Whenever Peeple mr! BASICIDEA oh toy and MH aot wing Hn | (om oie ee es *Tell her about the diagnosis. *Do not commit yourself to it. sh Can yg ID knows aiee abo*Tell her about investigations. *Psychotherapy and counselling. *Help-line, support groups, self-help groups. *Anti-depressants. “Encourage her and reassure her. ¥+** IF SUICIDAL RISK PRESENT..... ADMIT PATIENT!! DD *Depression *Manic depressive psychosis *Dysthymia *Cyclothymia *Hypothyroidism *Cushings disease * Addisons disease *Drug and alcohol abuse How antidepressant increase risk of suicide in initial treatment Depressed patient Has plans for suicide but too tired and upset to carry it out Anti depressant given Patient feels better, is more active but still depressed ‘The restriction for carrying out the plan vanishes He acts upon it © COUNSELLING FOR AMITRIPTYLINE. © Tell her that you have come to know that she has been prescribed amitriptyline for her low moods( or chronic pain or migraine... whatever the indication is as given in the question) Ask her if she knows anything about the drug. ‘Then tell her what the drug is for, how it works and what the side effects may be, Tell her not to get alarmed with the side effects and that all drugs cause these to some extent and that it is not necessary that it should happen to all people anyway.Moreover, if “= they do occur, there is a possibility that they may wear off quickly but if ee do penis troublesome, Ne sanige in the class of drug could be the solution. ee Of oo sot one Then tell her you would keep her on the drug/ medication Tor “6 weeks at maximum dose to see if she benefits from itlf not, then she could expect a change in the medication.Butif she responds well to it, the protocol eo, suggest its continuation, for, 6-8 <- months thereafter to sustain the beneficial effects, ><" qou donor feel Many ob Me Ren ce Bre You oO any ater mmedicabOors? MEP ee = el er tle 3 ang? yh a 2 Bo yor ennokd > eee ty Oe ep tom one anedical eo See Hobe te ting Ne nk aaa ina chacns* Wind off the session by telling her that you would be providing her with leaflets that give her more information on the drug and it is entircly upon her to choose if she wants to start on the medication. ‘+ Ask her if she has and medical condition especially a heart condition because amitriptyline prolongs cardiac conduction and can be fatal if given in heart blocks. Arrthymias,ete, ‘* Ask about a seizure history.Amitryptyline lowers seizure threshold.So avoid in such patients. ‘+ Ask about any other medication like esp MAOI, SSRI ete because this drug interacts with them. ‘+ Tell her that if she is to be placed on any medication at any point of time, she is to inform ‘the doctor concerned about the drug she is on. © Tell her to quit smoking and drinking alcohol during the time she is on amitriptyline will interact with them. Tel) her that investigation of her blood will be carried out, along with assessments of her heart and liver during the time she is on the drug to see that she is doing fine. « Ask her if she has any suicidal tendencies. If she has it is better to AVIOD amitriptyline 1 or if absolutely necessary, to use with caution. AD will make the person feel better and his psychomotor retardation will vanish, so that during the initial period of treatment his suicidal risk is more, as he may now actually carry out his plan which earlier he was not able to, ae SBF RIERA cll ly owing pelt 9 i " Jib te ple bef ou bie < bey INFORMATION ON AMITRYPTILINE: ‘5 ' ae ae © It acts on the reception for SHT, NA and DA and bits them resulting in an increase in ab the level of these in the bedy. This has an antidepressant affect on the body ( inhibition of DA ,*~’Y receptake) Ye ge taker 2? re © Side Effect- ve ol . > Anti-M1 ( anti-cholinergic) came! Poor memory Confusion : p Bluredvision > Meany. ened OFF 2 Drymouh = i exe SalOeA One: rth tit Urinary retention . Constipation Si At vem Ser drt lent. Anti-ccl (anti-adrenergic ) ae ols ale “ oe Postural hypotension“) BUlOn le Nn, a Sexual dysfunction * Lower seizure threshold—do not use 42.2.4. presc fitgo ‘* Increase suicidal risk esp. during initial treatment. os ‘Interest with alcohol, smoking, anticonvulsants, SSRIs, MAOL, ‘i \ nee @ Investigation to be carried during long term therapy She COTE chutes - FBC Set DU ia feen toF ohh = Liver function ert om — “py ee COUNSELLING FOR PAROXETINE inet libs € fu, ~ OSE «GRIPS oe —— OD halp yes - an ~% Vv« Ask her if she knows anything about Paroxetine and tell her what it is and why she has been placed on it (may be 0.C.D Generalised Anxiety Phobia Depression) * Tell her about side effects and counsel as you did with Amitryptiline . «Tell her again like Amitryptiline what the management strategy is that the algorithm. ‘+ Ask her about medication used currently. Avoid if MAO inhibitors are used. Ask her about psychiatric illness its contraindicated in Mania, * Tell her specifically about withdrawal symptoms and she should not forget to take tablets and not stop it on her own, © Quit alcohol and smoking. *# Cheek suicidal risk. INFORMATION ABOUT PAROXETINEG. ) Its an SSRI Side effects: - headache ~ nausea - Glupset = Sexual dysfunetion Withdrawal symptoms ~ dizziness - vertigo - lightheadedness - gait instability - flue like symptoms - suicidal thoughts Withdrawal symptoms develop 2-5 days after dose reduetion or discontinuation. ‘Management of the withdrawal ~ Reintroduce the drug - Educate the patient about the problems - Ifiithas to be stopped, very gradually taper off - Manage specific problems while tapering drug off. POST TRAUMATIC STRESS SYNDROME &) Pneumonic- DREAMS, D- disinterest in life, detached and emotionally numb R- re-living the incident trough intrusive flashbacks, nightmares or vivid memories rca xtreme nature of the event always, a1 voed tke Someday Holl Dans. a A- avoidance of similar circumstances a abwayh “on Ay 2 ‘Ppt M- months <6 months ¥ ) S- sympathetic hyperarousal like hypervigilance, on the edge, ete. * Start by asking him to describe the incident if possible. - How has he been feeling since?= Does he feel detached , numb, ete ne - Ihe having flashbacks and ee x = Does he avoid similar situations? 1 Does be felon the edge all ine ine? - How does he cope? tere fer os ce Lyon = pr’ ~ How does he see the future? _— F joltg = Hows his sleep and appetite? a. de aed = Cn = Does he have suicidai tendencies? lap Ad wt BR fear ~ Are his friends and family supportive? - Does he drink alcohol,smoke or do drugs? - _ Is this incident driving him to drink? = Does he go to work? - Isit stressful ? - Any medical, mental illness and is he on any medications? COUNSELLING © We = Psychotherapy (systematic desensitisation) far fe = Medication to contol depressionamsicny yy. ey | ee ‘wT - Leaflets i | rg! = Support groups and selfhelp groups “O~C2 > On Wi et Vat a DRUG ABUSE rd - your wll 5 & t Q- A young man comes to you with the intent of stopping drug use- history and counsel Q- A young man comes in ( brought by the police) and you have to assess him for drug abuse / dependency. \- eheager Cobre! oily ap wedici-€ - GRIPS = Depending on how he comes to you, on his own or brought by the police, you have ¢o talk likewise. - Ifhe comes on his own, he is going to be very receptive to you but if not, you will have to.calm_ him down, reassure and make him understand that the quegions you are asking are for his own good. Questions 5 heGle + = youde dnt nae you ever hace! hocetle haat-you 7 Whattypeofdrugdoyouuse? = > ye! (ay? aha is ile port tag. 7 Howlong have you been using it - Hews roc, Fine ay crx sreg, Taw, do You met Do you we nee toa? Do you know ofthe Nese Exchangs : toreag 442 Programme? jou Sukh seuys Leal How much do you use in a day? eal ae myech oF YO (How often do you use it? Do you need to use more of it to get the same effect as time passes? v oe *» ‘What happens if you do not use it for a day or two?Do you have any problems ? What % tar AR are they? | Where do you work ? How much do you spend in a day on drugs?If not sufficient, how do you procure the money for the drugs? FAMISH CAGE - Deperctence alteehs soned Che shat yas teyal ob + eee at lured ed wat Low Ton, t je TF am! Wee tou bet ne Genel wire § Oe c _ PAA + hae. Berenice . Weimeilay rad, eee MY pe N28 rp!WO Dee Pye, My tmiay ee redrt Ome wel hw allow © Peo auetoes Faw we earldecicle - F-Do you live alone? D_ 0 your friends and family know of your dependency? If he has come 10 you for help-~-- are they going to stand by you as you go in for a de- addiction programme? - How are your finances? - Have you any trouble with the law? - A-Do you smoke or consume alcohol? - M-,Medical illness and medications - |- interest in life - Is there any particular event in your life that forced you into this? = Do you feel better when you indulge in your habit? ~ How do you see your future? - Do you suffer from low moods? - Any thought of self harm? = S-Is there any stress at home or work? - _H- Any voices commenting on you or any buzzing/ ringing ni beliefs you hold that others do not agree with. -s in your ears? Any COUNSELLING SUICIDAL RISK ASSESSMEN’ \ - Commend him on his intent to quit drugs and encourage him - If he is irritable ( brought by the police), tell him that drugs are notorious for making a person dependent on them,thereby creating problems. This is his chance to try and stop this habit and that the entire hospital team would support him on it. - It would not be easy initially and very frequently withdrawal symptoms will develop but medications are available for them. - He has to develop the determinativis te keep away from drags - Self help groups = Support groups - Needle exchange prog - Leaflets on drugs, their problems ands support - Counselling/ Psychotherapy sessions if necessary = Sekine “stertan iyo cre. Asebarting sh. GRIPS Conbelenral [ aan 1 [ee Se yt ad AEF - “ Howare you atiow? ee NSE ne Pg = Why did you try to harm yourself? 8 ee - Was there any particular event that pushed you into it? £ - How long have you been planning? ~ Pave catrome ~ Did you understand the fatality ofthe method used by you? Rj : = Have you tried this before? Wd SIG PF OM plannine - Do you keep having thoughts or keep making plans? — Ad nol Loue AY - Did you prepare yourself for this incident?Did you make arrangements und take vare of —_okagr your affairs? WD DIA ns - Did you write a suicide note? Who did you address it to? What did you write on it? hy j-— 2h A = Where did you commit the incident? 4 = Can you describe the place for me? SOmne one cpu of = Were you alone? What time of the day was it? Orme, in - Do you normally consume alcohol? Were you intoxicated just before committing the act? a J i Risk. Ponred! cue er dinky its qu fi +o olive now yoo ae Geelne four wortd youu t Pe cna 8 t aeeven VE doy ere Prove ples A Jew Hsic (as anak Iochere ws: baton coer ke admi- os P COnsle hr naan _? ae “+ 9 Who brought you to the hospital? a Paak y ; fer from How does it feel to be alive? . ¥ ores P LED Would you try it again? _— jae ge Gohet ina, How do you see the future? A) eo ouLob OBSSESSIVE COMPULSIVE pisonpad 6) UG. coat 1-9 RIPSOUR, — Cea ee - R-Repititive - Intrusive - P- Persistent S- Senseless O- derived from his own thoughts UR- Unable to resist QA lady who washes her hands excessively. Ask about her presenting problems ‘What exactly is her problem? When did it start? Is there any particular event you remember that triggered it off? Is it repetitive? How many times do you wash your hands a day? Do you think these thoughts are your own? Do they intrude upon your flow of thoughts normally and hamper daily activities? Do yau feel they are senseless? Have you tried resisting them? Do you get anxious when you try resisting them? Do you have any other problems like checking on the locks aif the time,ID cards? Do you fear crowds, open spaces or talking to people? Are you otherwise a rather neat and_clean person who is very meticulous and finds it very difficult to complete tasks at times after beginning them? Has this made you depressed? Hows your sieep and appetite? \ Any tendencies to self harm? How about alcohol, smoking, drugs? Is this problem driving you to drink? Are your friends and family supportive? ‘Any medical problems and medications? ‘Stress at work Hallucinations and delusions? COUNSELLING Tell her that what ever she has said makes you feel she suffers from OCD Offer her support and encourage her Counselling and Psychotherapy Behavioural therapy and relaxation therapies Medications if necessary Leaflets on the problems and its management- ocD - Phobias - - Panic attacks / <. Generalised Anxiety Disorder Features - Tremors - Breathing difficulty and tachycardia - Tingling and numbness in hands and feet = Dryness of the mouth - Palpitations - Choking sensation n throat - Feeling of impending doom - Butterflies in the stomach GRIPS: QI. How long have you been having problems? 2. What happens to you ? Do you have drumming in your chest, feel dizzy and numb, have breathing problems and have a sense of impending doom? Q3. What brings it on? How long has this been going on? Q4. Does it occur only when you are faced with such a situation or at any time? he He -- h/o presenting complaints Q5. Can you ai all yo out ofthe house? eo! 70 Q6. Are you affaid of crowds and peopie? ~ dusol a eaecee Q7. Any special fears? asrmet > QB.ls this hampering your daily life? eo heel Q9. What do you do to have them subside them? , QUO. Is your family and friends supportive? § —~ Clout QI. Is there stress at work / family? QI2. Do you enjoy your daily activities / interest / otherwise? Q13. Is this problem making you suicidal? QI4. Any other medical / mental condition you wish us to know of? And any medications? DDs: 1) Panie attacks 2) Generalized anxiety disorder 3) Hyperthyroidism 4) Pheochromocytoma 5) Alcohol and substance abuse. MANAGEMENT: My 1) CBT 2). Rebreathing into a paper bag. . eg: 3) Medications 92 awe Cornet Seataie 4) Counselling in psychotherapy a rare necessary. nt ce? Arent 4 ry, 5) Leaflets. yCDOT ein que Peele (pots Ce Boe Se Tein nse Uae asi we me ar w unh Upre : MENTAL STATE EXAMINATION. _/ 1) Appearance a) apparent age and ethnic origin ») style of dress and level of cleanliness eg: Mr. Johnson appears to be a white gentleman of around 27 years , dressed appropriately and cleanly / but shabbily. 2) Behaviour a) appropriateness of behaviour b) level of motor activity Cv Xi wd (ouel ejeye contact PH mig ewe houtlueinatesd faeban gor d) anxiety levels ) rapport eg: Mr. Johnson’s behaviour is appropriate and he maintained proper eye contact during the interview / did not maintain proper eye contact. He is suffering from psychomotor agitation and appeared to be anxious and I could not develop a good rapport with him. O4HN the pes Oo TOnee a rt Pousti a) subjective --- ask him b) objective --- comment. AKON ned ~ Blade hata Pr -3 Eg: Upon being asked he said his mood was fine but objectively he seemed to be rather : under the weather / irritated. g 6 ha llerete auls , who is 2 eT eee Cw is hatteina et ) Fauci =D nT, how a cael 1003 f 4) Spedch * (Srey a) volume “Melk: “t ary? fs iS Coming Pot pou b)rate Oday ? “ ae A 22 ©) Tone eR Sik 2 olsen ful 6 4) flight of ideas St i bt Pharaely— itil LAL. As his speech is normal in rate, volumd, tone ., To Hight of ideas a S TIM Souk Yo" Ped ary — 5) Risk of suicide . \ ©) Thought do you Hains Prok noel 's thes, s afom San . : Le b)eontent YOY Inger Pr 7) Perception mind — Read Pr LaAx 4) a Eee ‘i om PR Unt vertigo ‘yor We pseudo hallucinations c) delusions vad cant! s 8) Cognition oo 402 See Pang (ihe Hers = What date is today ae iil © pl 7 - which place are you in? — hf ot IM See ~can urepeat the word WORLD in the reverse manner, POyce! WHO + aS - can youepeat the phrase NO IFS ANDS OR BUTS \_ ~ can you repeat three objects DD. befkee M2 & ~y thot 9) Insight ~ Do you think you have a problem? NO 2 can tag peMENTAL STATE EXAMINATION -Calm the patient down if agitated and build rapport - talk about confidentiality = may ask { or 2 questions about alcohol or the present illness. 1) How’s your mood? 2) Bo you have any ideas of self harm? 3) Do you hear voices / ringing in your ears? 4) Do you have any thoughts that you firmly believe in but others do not at all?” 5) Task you a few questions that may seem silly but are actually important to assess if your memory is doing fine. ~ what is today’s date - which place is this - WORLD backwards 6) Do you feel you are suffering from any problem at present? ‘Now comment on it (MSE) to the examiner , tell the patient that you will speak to the examiner - appearance - behaviour - speech - mood a) subjective ) objective ~ thought - perception = suicidal risk - anxiety level MINI MENTAL STATE EXAMINATION +5 ascess ghebB urn OX Cement o aA 7 Py 1) Orientaon —-j0points _ © bie dom, Bs Dawing 2) Registration /Conceiitration / recall — Ji poinjs. *"* nag ro 3) Lang fds ~9 points a a ree ae . token ADD muh Orientation: OPH ane) is tor cak; aan im hese HO ok Yu oo Ce Day of week AAEMTOV gre cot ELy yas Date ¥ bk Sear ND Season Silay -ountry City, Area / street Street / building Floor Registration / concentration / recall:- 3words ~~ table , apple, penny. s+ 3 points make him repeat uptil three tries in case he doesn’t remember. Ask him to remember , then you will ask him later. - concentratioy WORLD backwards -- 5 points -recal! words table, apple, penny. 4 Language and drawing, \\ - close your eyes a meani “write a compete sentence Cow yy cove lew corde ‘= - repeat NO ANDS IFS OR BUTS ea. for mt “wh2, pe name two objects -— pen, Watch on = piece of paper, fold, and give back CBULa! f° hae a piece of Lor * copy the drawing. ae ra pa) Binge henner Coed i , ia bel. beak” +9 meaty ey bo PSYCHOSIS LaMar mm 2 ‘2 * ae DS i Siew ewot talco Q1.A voilent man - -- where you are assessed on how you present yourself and handte yourself. 2. A calmer but psychotic man who is responding to hallucinations! delusions. \ yy eee a VOILENT; Site or r ~ keep yourself nearer to the door. cop tf for = Observe from a distance ~ Try to calm the patient down and reassure. = Offer inj / or oral wanyuilliser. May agree or may not — reassure him, tel! him that the medicine would cal_ him down and make him feel better. - if ke calms down, start asking him questions - if he continues to remain voilent, continue in your efforts. CALMER PERSON RESPONDING TO HALLUCINATIONS: ------— ~ Reassure him and calm him down. QL. Does anybody keep repeating your thoughts? 2. Do you have the sensation of someone taking out your thoughts or someone putting any into your mind. Q3. Do you hear anyone discussing about you , arguing about you or continuously commenting on your actions or thoughts. Q4. Do you smell strange smells or see strange things that other people don’t, Q5. Do you beffeve in something that other people do not with at all, Q6. Have you been finding it difficult to socialise lately, Q7. How long have you been experiencing these problems Q8. Do you hear someone asking you to do things for him Q9. Do you feel someone is commanding or influencing you, Q1O0. Do you feel you are on a special mission.POSTNATAL DEPRESSION (PND) GRIPS, tassiecongemntatinger onde brirsthasnesiiaby. Sc : 1 gathered from your notes that you are feeling a bit low. vey te Fen ee ~ ca Can you tell me more about your mood? tee ed 1d. Are you having this low mood since the birth of you baby? vor wate her Was it a planned pregnancy? Did you see your GP regularly during your Pregnancy? ‘Were there any problems during your pregnancy? ‘Was the childbirth difficult? Ask about antenatal , intranatal, postnatal problems. How is your sleep and appetite? How many children do you have? How do you feel about your baby? Do you breastfeed the baby? Whom do you live with? Are your family and friends supportive? DO YOU HAVE ANY THOUGHTS OF HARMING THE BABY OR YOURSELF? Do you drink at all or take other illicit drugs? Ss okineg & oll eget Do you have any other medical illness? | Have you ever seen a psychiatrist before? Does anyone in your family suffer from mental illness? Have you ever heard any voices or noises or seen any visions when you were all alone in the room? ‘+ How do you see your future? FAMISH COUNSELLING Reassure her and tell her to confide in people whom she trusts and seek help from herfamily and social services.Tell her to pursue her hobbies, Keep some time for herself. MANAGEMENT Counselling Support Groups and Social groups Helplines and Crises lines Friends and families Drugs when needed Baby blues * PND ‘© Post partum psychosis ANOREXIA NERVOSA GRIPS + Howare you doing? * Do you know why you have been brought here? * Have you lost weight recently? * How much are you weighing? aX© What was your weight earlier? © What do you do you eat far your breakfast lunch and dinner? * Do you exercise or take any medications to reduce weight? * How do you perceive yourself in the mirror? . atk wv © Who are your role models? Oo 4e V houk, oO a «What type of clothes do you wear? tole nwo dels |? ‘© What do your family and friends say about your weight? © How are your periods? Are they regular? how do . * Do you have habit of binge eating? in * Do you induce vomiting? © Howis your apetite? * Howis her mood? ‘How does she see her future? + Has she ever thought of harming herself? 2 a AB A fi a Cee ‘¢ Have you ever visited a psychiatrist before?) = WAU 4M, ea ie re ¢ History of mental illness in the family? moore & O ny pote ear MANAGEMENT: aor ‘penal Ory (Zin Jane, from what you have told me you do not have sufficient amay fiosd Tike you eel OS 5 1,9 well and Lam sure you are doing well but sometimes when you tend to eat Iess and when this Ay.) 5) goes on for sometimes there is a condition called Anorexia Nervosa that people suffer.They tend emi to eat less to lose weight. Would you like to have a leaflet to read about it? : ‘We will fix an appointment with our dietician .this will help you to maintain your figure as well "O** shan as give sufficieut wutvitional support. "4R5E ore We feel you are exercising a Jot .we will fi< anappointment with our gym instructor who would C2o"m Sarto) advise you. = ‘You may go home now but if there is any problem like pain , dizziness come to us. Infections. ee «Diabetes mellitus + Malignancy © Malabsorpti Hyperthyroidism Insomnia Mrs Marie Clarke 65 yrs old C/O inability to sleep for more than 4 months duration, Iritability / Confusion. She has been on medication for atleast 7 yrs since she was diagnosed of Rh. Arithritis. Take a detailed history and council her (pts don’t take amedicine history — put up sometime) GRIPS Confidentiality ‘Empathy / eye contact / make the pt talk ‘Ask about sleeping pattern or sleeping scheduleDiSs Shift worker Living environment Depression Mania / anxiety Grief Nocturia (BPH), (DM) Noctural cough (asthma) Medication Pain (joint problems) Negative history ( questions for ) Panic attack ocD PTSD Psychosis Insight Past history of any psychiatric illness Family history of any psychiatric illness Social history ‘What do you do for your living? Are your family and friends supportive? + Personal history ‘Smoking Drinking Drug abuse + Any problem with police ot law * Suicidal risk * Counselling bio / psycho / social Effective plan but need your co-operation Advice Pls don’t go to bed unless you feel sleepy Pls don't have coffee / alcohol before you go to sleep Pls don’t watch TV for late hours at night Pls have a warm water bath before going to bed Pls have a glass of milk or listen to any kind of music which makes you fee! We would also like to mark your sleep on a diary called ‘sleep diary’ at least for a week and pls bring it back to us so that we have a fair idea about your sleep + Even though these measures are not helping you we would like to put you on medication which would help you to go to sleep, which will be decided by my team if required later oon : + Any questions? TA donk teke colfemie. Leora @ Or Crnfope tie Keo! ch feo Hopes|-Wow + nko, | Coraly Ars. ok 6 HISTORY _AND COUNSELING 2. HISTORY TAKING FORMAT: Okese tea Conplaly >(opPara) + Chief complaints D Gam Uk proce OF ire, Rot) History of presenting illness (ODPARA) Pos abe y ante nov Rule out the differential diagnosis erred + Essential questions in Paediatries(4) Severo ia Ax + Past history @: Senosl PrOYenr + Personal history On nu + Family history exsonet >< = Travel history Tremonton Hx + Allergy hi : a een Medicator Hy HISTORY OF PRESENTING ILLNESS: (ODPARA) (\) A at = @ Yo \eslicat Ay Progression a .. dsgrovaing fctors (D eas. 4 omy slell lieth Relieving factors (9%. orenrdd Ob FOC OUP fy. Associated symptoms yt Wr 5 DIFFERENTIAL DIAGNOSIS © Faw! ‘t QL Per po i) LON onl ox OVS ef seporake Lowe More than one diagnosis C ta Te ih Prioritise the Diagnosis oO Cocos ae + Consider life threatening conditions followed by common conditions oO Sus tenes «Rare diseases are rare Lore FOUR ESSENTIAL QUESTIONS IN PAEDIATRICS: 1. Birth history (Antenatal, Natal and Postnatal) 2, Development history 3. Immunisation history4. Personal history (Bladder, Bowel, Feeding) UNCONTROLLED EPILEPSY A child aged 4 has come with uncontrolled epilepsy. Talk to mum. Good Moming doctor, I am Doctor.... Are you Mrs.,.? How should | address you? Mum. You can call me by my name Dr-Would it b ok if call you mum Mum- Yeah sure Dr-from your case sheet I have come to know that your child has epilepsy, am on medication since some time and have increased fits now days, can you please tell me more about it. Mum- Yes doctor I don’t know watt is wrong with my little Tommy, he was doing fine with the medication, but from the past four weeks, he has increased fits. Dr-Could you tell me about few things. ‘Has Tommy been taking medications regularly, who supervises him, Does he take the proper dose of medication? 1s he having excessive vomiting? Has Tommy’s wt been checked recently, because if little Tommy has gained wt then the dose of the medication needs to b increased? 1s he having same type of fits that he was having in the past? Has little boy been prescribed other medications, does he have adequate sleep at night, does he swatch try for long time. ‘Mum T would advice you to— Check if your child is receiving correct dose of medication If your child has gained weight, then the dose needs to be adjusted accordingly. If he is throwing up or passing loose stools, we would like to do some investigations to find out the cause, in the meantime we will try to make sure that he is receiving proper dose of medication. He should be given shallow baths If he has started with some other medication, please contact your GP, because that medication might be affecting the working of this medication, Make sure that he gats adequate sleep. He should not watch TV for long hours. He should not with computer for long hours. ‘Make sure that he wears his epilepsy bracelet all the time.(ithe as older child then tell mum, that child should avoid adventurous sports, should avoid going to disco’s, because flickering light can precipitate the attack, also he should not spend jong hours in cinema. RUPTURE SPLEEN AND FRACTURE Fi A child has had a trauma, after doing necessary investigation you found out that the child has ruptured spleen and a fracture femur, your are the SHO in the paediatric department, talk to ‘ mur, Dr. Good moming Mrs... 5 am Dr... One of the doctors in the paediatric department, I am here to talk to you. As you know little Johnny unfortunately had an accident, but do not worry we have an expert team who are taking care of them, we assure you that we will give him the best possible treatment, We have done some investigations such as X-rays and TV scan, unfortunately Johnny has fractured one of his bone in the leg what we call as femur bone, but do not worry we have given ‘him pain kiters and he is not in pain at the moment, and also we have called the orthopaedic, team, Are you with me, Is there anything that you need to ask. Also we did a TV scan of the abdomen and we have out that his spleen has ruptured as well. But you need not worry, we have an expert team of surgeons, they will look inside bis tummy and if required might remove his spleen. But de not worry, after removing the spleen we will give him ~~ - some jabs to protect him from bugs entering his body. - Also we will give him some medications called as antibiotics for a couple of yeas; these too will help him from bugs. Dr- If you travel abroad to topical countries, Johnny must be given medication to protect him from malaria Do you have any other concerns, Is there anything that u wish to ask. NEEDLE STICK INJURYWhile taking sample from little Tommy, you pierced yourself, Now you need to talk to mum and te her that you need to take a blood sample from Tommy to check for communicable diseases. Dr- Good morning, I am doctor ....one of the doctors in the paediatric department, how should I address you, can Teall you mum, Mum-Yes Dr-Mum as you know that I had to take a small amount of blood from Tommy’s blood channels today and send for tests, But while doing so I pricked myself, when such a thing happens, what wwe need to do is to take small amount of blood of the patient and send it laboratory to check for any communicable diseases, So we need to take some blood just a fem mis, from little Tommy’s blood channels. ‘Mum- What do you mean? You will prick my little baby again, Are you in your senses? Why should [ let you prick my little Tommy again? Dr- Mum please, does not be upset, | know this is hard for you but the thing is that we need to know if little Tommy has any communicable disease. Mum. What do you mean? Why would my baby have communicable disease? You must be out ‘of your mind Dr- No [am not saying that little Tommy has communicable diseases, but what Tam trying to say is that there might be a possibility of him having a communicable disease and dnce I am the doctor in charge of taking care of many other little ones, like Tommy. I may transfer a communicable disease to other children, if little Tommy is been infected. So just for the safety of the other little ones, we are bound to do so. Also this is our hospital protocol, that if a doctor is pricked by a patient’s needle, then the Patients blood has to be checked for the communicable diseases, so that if the patient has one, the doctor can be given prompt treatment, so that he does not spread itto other children. So you lam bound to follow the hospital protocol. Also, you need not worry because it will be done quickly and only a small amount of blood will be taken from this purpose. Mum- Doctor how much blood you will take. Doctor: It will-be not more that-few mls; Hhope I am able to-convince you. Mum- No I am not convinced yet. Doctor- Ok Mum I am very sorry that I am not able to convince you, but do not worry I will fix your meeting with one of my seniors, and they will address your concerns. NEEDLE STICK INJURY - I While playing in his friend’s garden little John got pricked by a needle lying on the ground. Mother is very worried that he might HIV and / or Hepatitis B. talk to her and addresses her concerns. GRIPS Ask about the concern Mum: I am worried because little John has been pricked himself with a needle. I have heard that onecan acquire HIV and Hepatitis B by a needle pick. I am very scared for my little baby. Dr: Mum, [ understand your concem and do respect them but before answering this I would like to ask few questions. What did you do immediately after this event? Mum: I immediately washed his finger with soap Dr: Did you squeeze his finger as well? Mum: yes, I did Dr: well, that was really good, Has your child received all jabs up till now? Mum: yes Dr: Wonderful Mom: But you know the needle lying on the ground can have HIV Virus on it, will my child have AIDS? Dr: Oh no, you need not worried about it become. It is very unlikely that the AIDS virus will survive outside a human body Mum: But please you must check my child for HIV Virus and Hepatitis B Virus Dr: As I told you its highly unlikely for this virus to survive outside human body but if you want us to cheek hitn for HIV and Hepatitis B. let me tell you something. After exposure to an HIV virus there are certain antibodies produced in the blood. But these will not be formed until 3 months after the exposure. Same is with Hepatitis B virus. After the exposure to virus, antibodies are formed after 130 to 150 days. So even if we check little John’s blood, it might not be of any use. So, what we can do is, to call after sometime and do these blood tests. INFANTILE COLIC Mrs, Jean has come to you with the complain that little Tommy, 3 months old is crying excessively since 2 days. She is very worried about her little baby. You are an SHO in Paediatric department. Talk to her and address her comers oO aa bak Soedinl honse 4) Deora aesion Gal. Ctarning, env GRIPS 7 Dr: As far as I know you are here because your child is crying excessively. I am glad to say that, we have done all the necessary investigation and all the tests have come back to normal. Before I proceed I would like to ask you few questions, is it alright. wre gq» waren cLid cried Mum: Ok. nn oe wn Cegr & Uo Is there any possibility that your child might b hungry? ahes ole oe a Mum: No I feed him regularly ° rAQ, Dr: Do you check your baby’s nappy’s regularly, is there any chance that they elute b wet. ‘Mum: No doc, I check quite frequently, ony dt) psrive. Dr. atMedacak0or .. On Hee is NO kno Caine MO medica Vrere ase % Wiol + Qore IK Oey sien hllwiv ng E ® bowd eno cAKo | ja corona VA ora AGO, orche d 1S breas Mey ta d ee ie eee ree : It is condition seen in children less then One year ofage, ) ys a ate It usually happen when the small air inside baby’s tummy causes dstension and discomfort, Nie 7 et ean! to which baby cries tot Foun a re bop Dalley 4, Do you burp your baby after feeding? Because if the swallowed air remains inside baby’s tummy-torn. ft a, will cause the same thing as your baby is having. And also, do not put baby to sleep immediately ~ after feeding. One Wk oF Lactose bro py If the baby crieSin spite of being burped regularly, please try to distract his attention by sounds like that of fan. iS) oy Pe w aker p Also, you can but a new toy for the baby or take the baby for a drive or also you can give a warm bath to the baby in evening ‘You can also but ‘infacol’ which is very helpful in relfeving these symptoms. Please don’t worry, this is nothing serious. Do you have any other concern? ASTHMA IN CHILD I \ it \. Little Tommy has been diagnosed asthma, talk to mother. Normal bronchiole Asta GRIPS Dr: As you know that little Tommy came to us with difficulty in breathing after doing some tests we have found out that he has a condition called ‘asthma’. Do you know about it? ‘Well, it is a condition in which the airway get narrowed because of an allergic response to a few things. But do not worry; we will give him certain medication to relieve his condition. There are two types of medication one is called reliever. This is of blue colour andthe other is called preventer, which is of brown in colour, Anyway after using the preventer, little Tommy should raise his mouth so that he does not acquire a fungal infection, Our nurse will teach you how Tommy should take these inhalers, But there are certain measures which need to be done, May I ask you few questions? Do you have pets in your home? It would be advised that if you have pets, please they should not be allowed inside the house Do you smoke? It would be advised that you do not smoke in front of him or near him 26 aAlso, please make sure that he is well protected with warm clothes, when he goes out in child ‘You must carry his medications when ever you are travelling Please inform the school nurse and your GP about his condition Also we will provide a bracelet, which little Tommy should wear all the time. ‘We will keep him in follow up Is there anything you should need to ask? T'll give you leaflets and will tell you about certain websites so that you can read about this matter on your own Inspite of these medications, if you feel that little Tommy has difficulty in breathing, please bring him back to us immediately. IRRITABLE MIP > 1945 DIA A A evclsiqn | Wad inbectray or ns nd A child has come to you with difficulty in walking. You did all investigation and did not find tren’, anything sinister. Talk to mother . Km dehcabe Hyena trabk Wisicoty -b jor coud GRIPS nome d os Called ynor unpied n tet ean odeo fey 5 bub plod 200 IA Penn tine conde, 2 AO As you know thal Fouf ¢hild Kas difficulty and pain while walking. We did all investigation and” 2~ didn’t find anything sinister. Its most probably a condition called ‘irritable hip’ Mother: What's that? Dr: In this a little amount of fluid collects in the joint space and it is most likely due to reaction to some bug. But don’t worry. It’s not a condition which will be there for a long time, neither will it cause any permanent disability. We have given him some pain killer. But your litle boy must take rest for at least two weeks Get taatin gYOrrie 7 FB ree Mum: what if he has to goto Loo? tones PRI KIS ECan plete Cae Ey eh Dr: Yes, he can go to the Lu with someone assisting him. Mum: when catt he go back to school? Dr: He can go back to school after 2 weeks ‘Mum: when can start playing football, he is fond of it Dr: Yes, he can do so after a month ‘Mum: it will be very difficulty to make him rest for 2 weeks Dr: I know but you can buy him some DVD’s. Also you can buy him some video games Mum: would you like to call him after sometime? Dr: Yes, we will call him after 6 weeks to have a review X-Ray. Mum: Can this happen again? Dr: Usually it does not reoccur there is no recurrence Review va da aatkks Hwa, R Srored nee Sere dA nap Whie redtng postion 8b Up] buy do OO rods ba of toe bade SE tee J Nee oe oe othe ed sob, — ouhtucrl - I choy We oe bape forORO SG AE Reuclerea, 11900 belies in UK 4 evpackaney 6 ee Refer ty SVP vind Brera BpEAB ky ton} Fe" P DOWN'S SYNDROME | ¢ Waki cae Ale audiolory chieHod wee odaplnity healH- cree poorker CAN 7 WOYKeNs, wees hes. lene Taw Spade aie yh Child has been diagnosed to have Down’s syndrome. Tatk to mother OF otha ae eh OD: Grips Poy «: mitt yt Ae eet ws tee ‘We did some test on your child and we have found out that your child has ‘down’s syndrome’ Mom: what's that? T Ordlersten~d ts om Ghovle Dr: Well our body is made up of many cells and each cel] has building blocks called chromosomes. In your child there is an extra chromosome 9% O Cir ne900 172 1 F~ bhi ; meet Can tang ed 9 Mom: What will happen to my baby? Wows aro den) & Dr: Well, your child will be mentally challenged. He will be fun loving and music loving child!” Mom: what do you mean by mentally chafienged? (Prygaad Crakooe - le Lyre. tic’ Dr: It means that IQ of your chiid will be less than the other children of his age. But, doesn’t t worry he would be send to special school and also occupational therapist will be there to help him. We will also provide the ph. numbers and address of “down syndrome society” which include parents of the babies with Down syndrome Mum: Will my child have any problem other then a low IQ? Dr: your child might have some heart problem but that we will confirm after doing Echo- cardiogram. ‘Mum: How long will my baby live? , Dr: Well, the life span of these children are not predicted Mum: What other care my baby needs? Dr: some home adaptation and special equipments may be needed in the house to protect the child from house hold accident and especially for those who are ovemctive, like arranging windows locks, provision of safe space in home, toughened glass in the bed room. This can be done by social services. ‘Also he would require health checks frequently in which we will do growth monitoring we will check eyes and hearing hear function. Cob af tee Stacie no 2uw hor ee Vl give you ieaflets and web site address so that you can read about thid condition in your child more. Bomnercr2, Yese Co) Woleeme tye tp tees , cet nant tp yor r ‘ ree : we 7 a ee , mn yee — \ : a ~ aps ae aba & hace pe! Weve Ore Sek O'G, Gmacin’y ane dat —TS keow YOO vst be Wey Ta When What manome accord glu \ FOREIGN BODY INGEST Vite? Ad Ye chug nae DO cous? Hire bis op? Kee Gov Gume he Sia JS Ondy Ore? ¢ \nan he beers Chern 22 did Wo etron dehtdu+? ron se \neppene before (tp vole oul- Chitd has swallowed a coin talk to mother a0 \¢ ch) Ne GRIPS iy ‘As you know that your child has swallowed ¢ coin please do not worry. We will give him the possible management We will do an X-Ray of neck which will be a lateral view to find out whether the coin is in food pipe or wind pips. If it is in wind pipe, we will remove it by a telescopic instrument called bronchoscope. If itis in the food pipe we will do series of X-Rays to make sure that it crosses the lower end of food pipe. If it is at the lower end of food pipe, called lower oesophageal sprinter we will remove it with telescopic instrument called endoscope. If the coin passes the lower oesophageal sprinter, then there are very less chances that it will get stuck in any other part of intestine. ‘What you will have to do is to make him pass poo on a closet which should be covered with cloth. After the child passes poo, pour water on the poo so that the poo stains out and if the child passes out the coin it will be left behind on the cloth ‘Please do not be worried. If the child has the coin in food pipe then there are more chances that he will pass it out in poo. Is there anything that you need to ask me? 42 aD WIme 0 dagke COORG ge LON be Sa Surg, tel: Aga ral Dinos to a 2Lousaket yan yarn dn . peas As you know that you came fo us with ....... Problem, while examining the child we found out that his weight is above to what is expected of a child of this age. If the same continues till he reaches adult hood he might have some problems like high blood pressure, high blood sugar can explain you his growth on the growth chart ar Me ouseda Oe be era) Cae bart Jnl \ finals" Howr tid is Roo bulk cue Syxeb Seles - lee aks = iy a. mM z , wad vil ( eae ¥ Pag has ade ’ . We ca, veless Lin a Pro D Aspe cAr . t aa FO mre 40 explou, Oy on Bie AIF Lk are Be Onn a) wae uv Malu “yt fe va, aL. aK Pn Ourtse brtanice that 9 cae IND ch chow AG are etOLD PRA pant. Aad mb 2sBirth 3 18 1B 21 24 yo 8, tA [AGE (MONTHS! Seto, Check fa a of Se on aime Z4ozmr 4zo-ms ‘AGE (MONTHS) ie His te fort pea fort +30 Fas. 0 Gastatnnal Lie. —_| he: woake Langit [wad Ore, - +14. 10- 4zo-ms 8 6 2 Ib-Ekg Bim 3 6 The weight of your child is above the .... Centile, which if not controlled now can cause problem latter in life May I know what does he normally eat during the day? 20 orMum: well he takes a lot of chips, drinks and chocolates Dr: do you cook anything for him? Mum: yes, I give him potatoes fries Dr: well it is advisable that you give him healthy food like vegetables and salads; you can also give him adequate amount of proteins. Also please see that he takes his food on proper time and not whenever he feels like eating Mum: what can I cook for my boy? Dr: | will refer you to dietician and they will tell you and guide you about it Dr: does your child go to school? Mum: yes Dr: is the school at walking distance? Mum: yes somewhat but not exactly Dr: if he can ride a bicycle than it’s advisable to ask him to ride bieyele for school Initially you all have to eat the same diet as he eats so that he doesn’t feel left out Is there any thing else that you need to ask me? NEONATAL JAUNDICE 34-4)... 5 => 18 He eal Ge dino ! On rans Crowne eral PH cdnn.a) Nene Vo FD Dot Yor Maanan tf wovwt4 _ ea voneencred terial ae yellowish discolouration of eye and skin o » oleli vedy > Mat [ ask a few question? Since how long does he have this yellowish discolouration? le \ Mum: Since 2 days OY Loe abid bof Dr: Did child thrown fits Corer / Roan Mum: No henge iv wet Dr: Did someone check his temperature Onerlye in Oy) Mum: No eo Wow: Ld Belg, Ste Dr: Ishe taking feeds well? Is he active? teh ove Mum: Yes ~ ee Dr: Did he vomit feeds? ‘Mum: no Dr: Was the child fine before 2 days was he active and taking feeds? Mum: yes Ge: ~ d eae o eG ec ee \ . fi yy pd tp ea Fd Lh. PF ‘Dr: Well from what you told me | think this is physiological jaundice ‘Mum: what's that? zo) | Sealer on a Dr: When a child is bor the liver of the child is Rdt Rinctiining Sshould’ aii aeuites Panu the pigment which colour the body like this. 5 Jooak a. Cay tev lows &, Hk adi Mum: What will you do now? wrk Ng 280 ins ve ou “eo Dr: We will do a blood test, if we find that it is below a certain level we will send the baby home Potter but please bring the baby immediately back to us if you find that baby is not feeding well or not active. After blood test if we find that the level is high above a certain, level we will do phototherapy. w4 uI® Cou cnt ees be win Re gale a sade sn In this the child is kept under a special light. All his clothes would be removed. Only eyes will be gg j.'s, covered so that the light does not have a harmful effect on eyes. 2 gir te thn This light will convert the harmfui pigment in a soluble form, which can be removed by the! | ~ kidney, While giving phototherapy, child will be given to you from time to time so that you can breast feed your baby, We will again do blood test after giving him phototherapy. If we find that the kvel of harmful pigment is still high, we will do a procedure called exchange transfusion, In this procedure we will replace blood with harmful pigments by blood which does not contain this pigment. ‘ww ohaas- Ae Apo Do you need to ask anything else? we U3 repeat Yayo) ) aes hope m4 ~ ny Wed oO Or ee BA Ba HYPOGLYCAEMIC FIT ar ny ae = Ms Fe ony Chowne, oe olard ee oe Feet Phi ee a copter onytooty rae hed tare bas he Seer vist Ree Telose 5 Tyr old Tommy, who is diabetic, threw fits; mum brought him to the hospital, ‘ats to mum. Dr. Good moming I m doctor . please tell me what happened? .. one of the doctors in the paediatric department, could you vote Mum: My son has diabetes. About half an hour back, be suddenly started throwing ft, his sets Whole body was jerking, han ne Lgl cle Tecan. a Dr: Can you please answer my few questions if you don’t mind. Vn oh cor + How long has he been diabetic? 60 > hia mva'd Mum: 2 yrs wD voved oe Wal x Who give him the medication (Insulin?) Was he someone else who gave him today? ee aly aah [| Vom, 2 Mum: No | gave him insulin myself. 7 BO We LDA oe Dr: Has the dose of insulin been changed recently? oN Sera oad fe >} Mum: No| ee ae roehvn Yay doo Chane ts ond alwys = DBE GS Seen ands bs oi one Dr: Did child eat anything after taking insulin ‘Mum: No he could not eat anything as today I got late in preparing meals. Dr: Well, I see, According to the history that u have given me, most probably your child had fits because of low blood sugar levels. Please see that this does not happen again and make sure that when ever he takes insulin, he eats something soon after taking it. Dr: Do you have a device called glucometer at home to check blood sugar levels regularly. Mum: No I don’t have tha Dr: Ok don’t worry we will teach you how to check bloed sugar levels at home by a glucometer. Dr: Were you given hypoglycaemia demonstration at the time when little Tommy was prescribed nae insulin? Sr Wi On Mum: Yes i mi Bay the OTe a Les, Dr: Ok, fine, when ever you feel that child has become hypoglycaemic give him a sweet or sugar drink so that he does not develop a fit \ Does your GP and the school nurse knows about little Tommy’s condition? ( Mum: Yes Dr: Little Tommy must be given a bracelet to wear, please make sure that he wears the bracelet at all time. [will give you some leaflet and websites so that you can read about the condition more.. Do youhave any other concerns? "o'r clay $ Bho. B30 awe Mum: No 5 maya s food Thank you very much. , nb. } your Cha’ ¢ ‘dood DIABETES MELLITUS A Child is diagnosed to have IDDM, Talk to mum and address her concerns. Dr. Good Moming, I am doctor ....one of the doctors in this department (Paeds). You brought your child to us with complains of excessive thirst, excessive eating, and going to the toilet again and again We did some tests and found that your child has a condition called Diabetes Mellitus. In this a protein called insulin is not formed by the. body cells, s0.the. level of blood sugar rises, due to which child goes to loo and passes water very frequently. Also he feels very thirsty and hungry most of the time ‘We will put him on a medication called as insulin, Please make sure that whenever you take your little boy outside, you always keep something sweet or sugary drink with you. Please make sure that his school nurse and GP are also informed about the condition that your son is suffering from. Twill also give you some leaflets and addresses of some websites so that you can come to know more about the condition. Ask concerns also in between, qeAS yr child brought to A and E with complains of itching, face swelling and breathlessness All this happened affer eating peanuts, you are the SHO in the department, talk to the mum... mne of the doctors in the Paeds department. Dr: Good Morning Doctor, I am doctor. Mum: How is my child now? Dr: Do not worry my colleagues are taking care of him, Could you please tell me mum what exactly happened, Mum: Ye little John took peanuts about half an hour back, after 15 min he started to complain of itching all over his body and then he developed shortness of breath, we rushed him to A and E. Dr: Well mum, what ever history you have given me so far indicates that most probably your child has developed allergy to some proteins in the peanuts. Please make sure that he doesn’t eats peanuts later or anything that contains peanuts such as cakes and other bakery products. Mum: Dr what if I boil them, can my child have peanuts if boil them or wash them properly. Dr: No the allergy can not be destroyed by washing or boiling it. ‘Mum: What if child eats peanuts or some bakery products when he is not at home. Dr: Please see that this does not happen, but at all if that happens, you will come to know, because after half an hour or 6 hours he will develop the same symptoms to the peanuts ¢s you have seen just now. ‘You must always keep adrenaline nasal spray with you and use it as soon as the child starts developing allergic symptoms, and bring the child to hospital assoon as you could. Pea nut allergy (Other points Mrs. Nicola Anderson has brought her 6 year old son jack Anderson to the A &E department when she noticed that he developed rashes over his skin, itching and shortness of breath immediately after eating Pea nuts. Talk to her and allay her concerns. Hello Mrs Anderson, How are you ? Well you must be worried about your son but he is fine now, you need not worry about him. Can you tell me what really happened to him before you brought him to the hospital ? Doctor he developed all theses rashes itching and shortness of breath after eating pea nuts. I got ‘worried and brought him here. Haas this happened before ? No.. Well Mrs. Anderson, it looks like your son has developed an allergic reaction to the pea nuts It is very good that you brought him immediately to the hospital. Actually he could have developed a serious life threatening reaction to theses nuts. So what should I do now doctor ? Well you need not worry about this. We are going to tell you what youshould do in the future, ee 7mr as 3 APN be ae foes se a Itis likely that he is going to develop these reaction to the pea nuts as well as to other nuts also( ifhe is almonds, brazil nuts, cashew nuts, hazel nuts, pistacio nuts, walnuts and pecan nuts exposed to these. You should avoid him getting exposed to these nuts. Do not give these nuts to him to eat . Make sure you buy only such food items which are free from nuts. We will give you a medication which you should give your child at once if he is exposed to any nuts and starts showing allergic symptoms and then call the ambulance and bring him to the tal. This is called as epinephrine and this is given as injection. This is otherwise called as Epipen. This is an automatic injection device, which one of our my nurse will teach you how to use this. (only explain if patient asks you how to use this) + Hold the device firmly in your fist with the black tip pointing down. Do not touch the black tip; hold oniy the cylinder. + Remove the gray activation cap. + Keep the black tip is near the child's outer thigh. * Press the black tip firmly onto your child's outer thigh at a 90-degree angle, You may inject the needle through clothing that is covering thigh. + Keep the device firmly in this position for about 10 seconds, + Remove the device from the thigh and rub the area with your fingers, ‘+ Look at the black tip to see if the needle is showing. If the needle is not showing, repeat steps 3- 6 + Ifthe needle is showing, then your child received the full dose of epinephrine. You will notice that ‘most of the liquid remains in the device. This is extra liquid that cannot be used. Press the needle against a hard surface. Replace the device in the carrying tube (without the activation cap) and cover with the cap. ‘You must call the ambulance immediately after this and come to the hospital. Make sure any one else who takes care of your child also knows about your child's problem and let them too know how to use this medication. Rememetr this medicine should be available wherever your child goes. ‘These medication may cause some side effects which are not very serious to worry about. (vomiting, sweating, dizziness, pale skin, headache, shaking hands) Keep this medication in the plastic carrying tube it came in, tightly closed, and out of reach of children, Store it in a dark place at room temperature. Can twash the pea nuts or boilit and then giveit?’ ©. GLa Ae ° Sater ab aig Unfortunately there is no use asitcan stil cause allergic reaction. | \ ; nae Bt ass he Will my child grow out of nut allergy ? we yo) rhe . contd cak, Unfortunately this is may remain forthe rest of his lif. yy, . 5 i . Can this be cured doctor ? aD Beg Desensitising injections have been tested but they are still in experimental stage. Can my other children also may have this problem ? It runs in family. Unfortunately allergy tests are not very conclusive. My consultant will decide whether to give any epinephrine pump for your other children also or not. Can my child eat in the restaurant ? We strongly advice you not to. Ifat all your child is going to have food outside you must have the epinephrine pump with you. We oecescera te} 2s per aye pt Bean & 4 Seed yo. lowsDo you have any other concems; I will give you some leaflets and websites, which will provide you more information about this condition. Pea nut allergy (other points Mrs. Nicola Anderson has brought her 6 year old son jack Anderson to theA &E department when she noticed that he developed rashes over his skin, i¢ehing and shortness of breath immediately after eating Pea nuts. Talk to her and allay her concerns. Hello Mrs Anderson, How are you? ‘Well you must be worried about your son but he is fine now, you need not worry about him. Can you tell me what really happened to him before you brought him to the hospital ? Doctor he developed ai! theses rashes itching and shortness of breath after eating pea nuts. I got worried and brought him here. Has this happened before ? ( No.. ‘Well Mrs. Anderson, it looks like your son has developed an allergic reaction to the pea nuts. It is very good that you brought him immediately to the hospital. Actually he could have developed a serious life threatening reaction to theses nuts. So what should I do now doctor 2 ‘Well you need not worry about this . We are going to tell you what you should do in the future, Its likely that he is going to develop these reaction to the pea nuts as well as to other nuts abo ( almonds, brazil nuts, cashew nuts, hazel nuts, pistacio nuts, walnuts and pecan nuts)if he is exposed to these. ‘You should avoid him getting exposed to these nuts. Do not give these nuts to him to eat . Make sure you buy only such food items which are free from nuts. We will give you a medication which you should give your child at once if he is exposed to any nuts and starts showing allergic symptoms and then call the ambulance and bring him to the hospital. This is called as epinephrine and this is given as injection. This is otherwise called as “Epipen. This is an aiitomatic injection device, which one of our my nurse will teach you how to use this. (only explain if patient asks you how to use this) Hold the device firmly in your fist with the black tip pointing down. Do not touch the black tip: hold only the cylinder. Reimove the gray activation cap. Keep the black tip is near the child's outer thigh. Press the black tip firiy onto your chile’s outer thigh at a 90-degree angle, You may inject the needle through clothing that is covering thigh. Keep the device firmly n this position for about 10 seconds. Remove the device from the thigh and rub the area with your fingers. Look at the black tip to see if the needle is showing, If the needle is not showing, repeat steps 3- 6. * Ifthe needle is showing, then your child received the full dose of epinephrine. You will notice that ‘most of the liquid remains in the device. This is extra liquid that cannot be used, * Press the needle against a hard surface. * Replace the device in the carrying tube (without the activation cap) and cover with the cap. * You must call the ambulance immediately after this and come to the hospital.™M act iL Ve pagtmer AS cae. ney jo OO 7 YOO ATA AY ae met? bp oor clita = wen my ole here V6 in Sent ~o Marb B GED Cod TOYA Ladd RTP orl Me can! pO ay Me : hy VIP bas, | “4 ob Make sure any one else who takes care of your child also knows about your child's problem and let ~ \/* 3 tar kno ow oe i eteaon Remereb he mene sdb evade ea {ev ae erie of ony ‘These medication may cause some side effects which are not very serious to worry about. f ley (vomiting, sweating, dizziness, pale skin, headache, shaking hands) aa Keep this medication in the plastic carrying tube it came in, tightly closed, and out of reach of children. Se tis oda ple at com onpercie See en ee clot Rae Can | wash the pea nuts or boil it and then give it ? ob ose A= CAG A £6 RG Soke Yon Untriay teiono etcetera AL, Sra SEPLOC Pale Will my chit of nut allergy ? Kr estelAte Tad Sane, Ad “ee my child grow out of nut allergy Vesa Nolet oe mat seem arg Unfortunately this is may remain for the rest ofhis life. “© ©° 2 ¢ ba Avann \ Can this be cured doctor ? at lod Podbiichev trout mame be Desenstsing injections have boon ested but they re stil n experimental $988-0. Stroy gh in. ley 2} Can my other children also may have this problem ? ol- cabeb a Itruns in family. Unfortunately allergy tests are not very conclusive. My consultant will decic 2 whether to give any epinephrine pump for your other children also or not. Cox SC. Nace zed Can my child eat in the restaurant 2 Cees Lice Cece Cin IG We strongly advice you not to. If at all your child is going to have food outside you must have the “Seal ine ma we YOU CAm 1 Bug ram @ Sef, ok aw youn - ND Fay ove, pore eMtedA bade, 2 ahok ihe “ : . MMR VACCINATION (oe Wore two i Og Fonury 5 . . Urhe 4Ur Pitaciton, he nowy low & mak Wp Cotter Ook ot el aban tng, + . be. ¢ Child is 5 months of age. Father has come to you. He has read an article which was published S years back. It related MMR with autism. He is worried about him. And address his concern. seprerinkhe Yor Weal se Abate bole sake Le GRIPS > GK Ged Spre Ves Leon vewre Guole Athor | Father: I have read an article which was published 5 year back according to this article, MMR, ~"7-2_ he might have autism. Pion Dr: yes, there was an article which related autism to MMR vaccine but many articles were “ published after that according to which there is no relation between autism and MMR. ‘As MMR is given around 15 months of age and this is the same age around which autism is diagnosed, so there was a fake impression that autism is caused by MMR. <2. “me "A g5 1 G MMR Vaccine can cause mild reaction like indurations and pain at the site of injection and fever. - for sometime. Fijog tla, tm: DIY 0 B INGESTION OF BLEACH Dy ferel. > tw Ont § crothip OF hide Ont dee! on Treen inieroA 2 year old child ingested about £00 ml of bleach. Mum is worried. Talk to her ( GRIPS Dr: Do not worry. My colleagues are taking care of the baby. Could you please answer a few questions? When did this incident happen? Te One uf ol : Mum: About half an hour back Seem toe es Dr: how much bleach did the child drink. Can you give me an average idéa? |” oe Mum: Not much because [have checked the bottle of bleach. ut Oy s fre heen Ann Dr: Did the child vomit immediately after that? ae hosp Mum: Yes, < 24 erdescspy Ay ; SHB 5 iow t Dr: Did the child had any difficulty in breathing? oe win eh Mum: Well, I don’t think so PPO, TOR tent~ Chie 1 Meyae Dr: Well, don’t worry from. what you have told me hopefully. The child will be a soon, We will admit the child for at Teast the ¢24 hours. We will observe him for any breathing difficulty. DR ORI. Ifable to take by mouth we will; give him fluids and milk. Ans yo {par nee oie HY If we find that the child has severed symptoms, we will do endoscopy and give sastigy . decompression. roche fink. UO0 Mum: Are there any long term problem for my child? op tie kee Dr: From the quantity of bleach that your child has taken itis unlike ‘ar Keeedabe my of | complication later Bee CD Ae ade O28 Do you want to ask any thing else? Ve - P Dalkey, CHILD WITH UTIon > turin a ¢ eT A Waesed — heuer ex os! see ee [Jeon areca Jeatby Wh uae wr tee re teed ee Pte test as \ dato 7l t oy Cen AO cue need! +9 tea i. A child of 5 years has been diagnosed to have UTI. Talk to mum. a hand = Tayrent abied 9 MeO Mad 6 GRIPS t Sern As you know your child cries while passing urine. We sent a urine sample for culture and we have found that bugs are growing in your child’s urine. We will give him certain medication called antibiotics. These would be given up to seven days. If the child has recurrent infections then we will do some further investigation like a TV scan or another scan called micturations eystomethrogram. By the way, I need to ask few questions to sort out the risk factors. Do you give bubble bath to your child? 5 L Does he pass urine regularly or not? ;/“” mlQT ASE Somer Is the chiid properly toilet trained? If the child is not properly toilet trained then please do so because it is one of the reason of developing a UTI Please see that child does not wear tight under garments. Also the child should pass urine regularly; otherwise this will predispose him to UT. 5335) g lao. Is there anything that you need to ask me? 7 Twill give you leaflets and website, so that you can read about it on your own as wel JEHOVAH'S WITNESS Child is jaundiced. You have planned exchange transfusion but parents are ‘Jehovah's witness’ they are not giving permission, talk to them GRIP: As u knows your child has jaundice and he needs exchange transfusion. Dad: Iam sorry, but my religion doesn’t permit DR: yes,but this is to save the life of your little one. Dad: yes, but there has to b some other way of treating my child "See ask Wav Polhete Yo m0 Hovis \ = help ole Yams ee eohno mM Dean lying FS tly oe Ye ag wet Soy see ened CO orvakSennen IDIOPATHIC THROMBOCYTOPENIC PURPURA vo Do) Vache 38Qar 7 We D 7 { ute og gees hy he In g ( 6 Dr: I am afraid, this is the best possible management, which is required, because of the level of ‘harmful pigment has reached to a level where there is no ofer treatment option than this. We need to replace the baby’s blood which contains the harmful pigments. ‘an the body for 24 hours and after that bath should os taken. For a day or two after the treatment . \we will give you medication and ealamine lotion, (2 oO be ge Ae Is there anything you would like to ask any thing? Ke Permobr WD, angoid af: teat dese ley WOR ON Wand syou OMe oe We yao 7G FD 4 Orde co »\) “ASSESSMENT FOR ANAESTHESIA IN A CHILD WITH IDDM 22.2 | Ragen ee oR Siw AO! PP “names. A child 5 year of age has IDDM. He has come with fracture of ankle and a surgery has been planned. Assess his fitness for anaesthesia by talking to Mum, ars ytd yo ever rrewr Aseo! & ong thar rredical condtiars (pre you child’have come 1o'us Sih Rachure of ankle and we have planned surgery. Could you please answer a few questions? Recut 7 aduenton > How longhas litle Tom been diabetic? 6 ey Ae area io Has he Been taking insulin regularly? Keet#@F> a Does he have any fever? & MOY in TIME ie “ny Did he have any illness in the past few days? yo BAL ie bac! sur Did he have vomiting? Oey be gt? ne Ishe passing loose poo? § ae Does he have any cough? ice Does he have any other illness that you woutd ke to tell Me about? : From what you have told me, I feel that little Tom is suitable for anaesthesia Details of anaesthesia will be told to you by my anaesthetic colleague. TE pe ones abget insulbin. Wa rou ved 12 Ado Lorne so WS kin Gar to wher. ( (ei S(mpPpb re AO ft ANIM OL HASWAAL InAs —— i FA ~~ We Mens ere ed wn atrecd Cub Bees opie a> Oareiongttc A 10 EPO 3e @ oy x pe ot HDi be eyepe 4 Beir SE One oho cla EAR INFECTION /URTI noced 1 EAR INFECTION / URTI he F a, & then, A child 5 year old has came to you with fever. Father thinks that it &s ari ed infection as he’ 2p hhad an ear infection previously and insisting you to give antibiotics, Talk to him and address © ~FeC#E 14 Ais concerns, a [rote 4 Dr: may I know what your concems are? Dad: My child has fever since past 4 days and I think that he has ear infection, so please give antibiotics to my son, so that he can be well soon. Dr: What makes you think that this is an ear infection? Dad: He had fever about four months back and he was diagnosed to have ear infection, so | have a feeling that it is again an ear infection. Dr: Could you please answer my few questions? 7 5 ees a Dad; yes sure \aub con Ppreeiobe 49 Kr ovuleds, i You a Dr: Have you checked temperature of your child? Nee Auer nal Leah dy u Dad: Yes, its not high grade fever cbisebrorse Vso oy Lote wml it af Cerner tine Burg ok ears | ‘Dr: Does he have cough and is he sneezing? ‘ Ax nN i Dad: Yes HAAN Or EN on ster Dr: From what you have told me my assessment is that your child has an Upper Respiratory Tract Infection not an ear infection. Sneerins Cb Its usually because ofa bug called virus and no antibiotic is required for this. <5. ws y RT, Don’t worry; your child will be well soon. I will give him Paracetamol for fever. ( If you feel that child’s condition is not improving, bring him back to us. Sunes ) (oe ode Conor _Do you have anything else to ask? Bb OF oa ved VAGINAL DISCHARGE IN A CHILD AGED 6 YEARS PI Looe sruttter Ascher assure, Conntidontofty socal) sa | 0 NAN Servo a Obs Dr: Does he complain of any discharge form the ear? Dad: No neither he have any pain belen. Ly. ra 3 Coc bined 7 See AD medication Sor Vaginal discharge in a6 year old child (9 VT! A child has come with vaginal discharge. She is 6 years old. Take history and discuss the differentials with the examiner.wv Yona yar Ou = OY GR in Or Ant Conde 2 ooo. wis he On cme f Yee { g Uno 8) heer sour Lh in token core Ober ? Dr: Good moming. I am Dr. XYZ one of the doctors in the paediatrics department. I am here to ask a few things about your child’s condition. Can you please tell me since how long has your child been having discharge? Does it have a foul smell? Is there any bleeding? Was the child hurt down below? Is your child toilet trained? Is the child diabetic? Is the child on any medication called steroids? ‘Mrs ABC I need to ask a few more questions. Who takes care of your child at home? Is your child acting strangely nowadays? Does a she seem unfriendly or scared? Mom: why do you ask so? Dr: I have something in my mind that I need to rule out. Is there any staining of her undergarments? Have you noticed anything in her front passage? Has she had anything similar in the past? Was everything fine at the time when she was born and just after she was born? Are you happy with the child’s red book? Is your child up to date with jabs? Is there any problem with wee and poo? Ts anyone diabetic in the family? Thank you mom for your cooperation T will talk to the examiner now. ‘Tuming to the examiner From the history that mom has given me my most probable diagnosi imy differential diagnosis is However I would like to take a more detailed history and does a rdevant clinical examination discuss with my seniors and do relevant investigations before confirming or ruling out a diagnosis. DIFFERENTIAL DIAGNOSI: OF VAGINAL DISCHARGE: . Vaginal Candidiasis © Diabetes Mettitus — Past history © Long term steroids — Past history © Hygiene—Is the child toilet trained awForeign body — Has the mother noticed anything abnormal in the front passage Sexual Abuse — Any staining of the Undergarments, any possibility of fowl play HEAD INJURY IN A CHILD 5 year old child has come with head injury. Talk to mom and discuss management with her. ( Good moming I am Dr XYZ. I am here to talk to you about your child’s condition, May I know what happened? iy 30 SomTY 40 hear bab Did your child become unconscious? fm reer ® eyes then orhow long? Wig agar urites inn Couitbne sy) Did the child have fits? aan Covitne in Oh ape ¢ r Did the child vornit? ° OPRG u fod Did the child bleed? If the child was unconscious then what happened after the child became conscious? . Isthe child diabetic? hay bre COrnplasn 2 oh haa athe. Is he epileptic? Mom we will admit your child and keep him under observation for 24hours We will do an X-ray of the skull to see | fihere is any fractpre. ji Mom: -Dr-why-don’t-youdo.a CT sean? . 8. ge a arse ~A9r- Dr: we will do it if necessary. ——¢ bre / , We will give him medication ifrequied, ( %€ 7 to Fae gi requiet But mom do not worry your child is in safe hands and we will give the best possible management. is there anything that you need to askme mom?, (2!) Let 2G cane, PCCP yything that y WR haters om ey vie 4 mes baad Elaborate the incidence (witness) Anyvomiting bon Jeo. 2 \ taal! Unconsciousness Any fits ve ni et ad qe Duration of Unconsciousness Condition of the child prior to the incident fh) + What happen at recovery? Past history of diabetes or epilepsy — Aree, Ifpresent elaborate ~1 ro it Any signs of extemal bleeding raul a A wsVOMITING IN A CHILD: (dows Vomiting in a child 1 ‘A.2 month old chifd has been brought differential diagnosis with the examiner. mn Sex ard o vomiting. Take history and discuss fo 4 j kee DD Dore 4yA00 by Over feeding ~ ode ycon.r) UTI LF) Pyloric stenosis Ove ceed ns Duodenal atresia a H Good morning , I am Dr. XYZ 1 am here to talk about your child’s cond)tion. eh From the case sheet I gather that your child has been vomiting. | Fed Could you please tell me, since how long has the child been throwing uf lao What is the colour? ( Do you think that the child is being fed too much? mee Does the child cry while passing wee? ob . Does the vomit go over the far end of the cot? Prey foe ah a Do you see any lump in his tummy while feeing fed? Sve doen 4 i Was everything fine when he was born and right after that? ore ba Has the child been fine up till now? Sure nM Is there any problem with the wee and poo? ‘Thank you mom you have been very cooperative IN OLDER CHILDRE! A year old Tommy has come with vomiting. Take history from mom and discuss D/D with the examiner. o*DID Gastroenteritis Meningitis URTI Head injury Diabetic ketoacidosis Intestinal obstruction Accidental poisoning Good morning I am Dr XYZ one of the doctors in this department. Thave come to talk to you about your child’s condition Could you please answer a few questions? Since how long has tommy been throwing up? What is the colour? Is there any loose poo? Is there any fever? Is there headache? ( Does he shy away from light? Does he feel any neck stiffness? Does he complain of any burning while passing wee? Does he have any cough or running nose? Did he have any head injury? Does he complain of any tummy pain? Could he have ingested something harmful by accident? How is the activity of your child? Do you find him very lethargic? Is your child passing we? Mum I need to ask you a few more questions? Was everything fine at the time of birth and just after that? Are you happy with the red book of your child? ild developing normally? jabs until now? Did you travel abroad recently? ‘Mum thank you. You have been very cooperative. I need to tali: o my exam may I do so? What else to consider in Vomiting’ ‘Assess level of dehydration = Activity + Passing urineDID al Wood bso — BH39045 BON a Oia Dy . wryssv 4 Qe Isle. foe HSP,HUS nots offecke d) ® “ites OBSTRUCTION - INTUSSUSCEPTION ORevdors a LMS Op \ “ Pos cespatig, | blood supply of Se Foc Iv) Orjeckels . \oave! sen ate ig BM hy diver ole’ Gnd SpechaGil Guaeor vy Dad Se lay Whe rN ! “ Place ale in- A eeac 6months old johnny has come with episodie cry and red coloured stools. Talk to mom and discuss the management with her, o Fee hy § earue Good moming I am Dr XYZ one of the doctor in the department of paediatrics. Tam here to talk to you about your child’s condition, Could you please tell me since how long is Johnny erying like this? i Since when is he passing red stools? AQ@> - Canng. on kap, Of Psale Oh Is there any associated vomiting? sve 8 Hyg Have you noticed a lump in his tummy? Is there any drawing up of legs while crying? . : Is there anything that you want totellme? “ f Siva.ae t Say drake ie From what you have told me I think your child has a condition called Intussusception. Do you know what that is? This is a condition in which there is telescoping of 1 segment of bowel into another,”? Dy dy lege We will do an X-ray andaTV scan.booe 4 \ike & Wybe Od pos) We will put a dye in the back passage and try to relieve the condition. Ongn 4 Wh iP, If the condition is not relieved by this we will do a surgery. ae In this we will open the tummy of your little one and have a look inside. If we find volley > b that part of the bowel has been damaged we will remove the part and join the 2 ends ° of the bowel. Moi, you need not worry as we have an éxpert team of doctors and we will give him the best treatment possible. Nin ay aha 4 ot dl PeSking iscussing management: Explaining the condition Barium enema (Dye through the back passage Ultrasound guided air reduction Ultrasound guided air reduction Telescoping of the bowel Surgery (Reduce and examine) Overiding of the bowel Remove damaged segment and join the ends‘Letha: getting tired easily Not playing as before Polyurea — Passing water more than usual and more frequently Feeling thirsty and drinking plenty of water Vomiting may be presenting feature Severe dehydration with dry mouth is present Ketone breath smell — Fruit like 5 year old tommy has come with lethargy, polyuria and polydipsia. Take history and discuss the diagnosis with the examiner. Good morning mom, I am here to talk to you about your child’s condition. ( From tommy’s case sheet I have come to know that he is thirsty most of the time, and going to the loo frequently and eating most of the time. Could you tell me more about it? te luo SIN Since how long has this been happening. mod anche Sow, Is there any vomiting? Is there any tummy pain? modo ted Brph Is there anything that you want to tell me about? R Did he become unconscious at any time? Does he have a fruity smell in his breath yorogric oe | “pte a Was he fine previously? ‘Was everything fine at the time of birth? Are you happy with his development? welt Has he received all his jabs until now? Noctis Does he have any problem with the wee and poo? — - Do you have anyone in the family with diabetes? ‘Thank you mom, you have been very cooperative. I will talk to the examiner. May I do so? MENINGOCOCCAL SEPTICAEMIA: Infection of the coverings of the brain now spread all over the body through bloodA Se rhealt RotechOr opr Cormac Hong, 5 year old Tommy has Meningococcal Septicaemia. Talk to mother GRIPS I am here to talk to you about your child’s condition. 1 am afraid | don’t have encouraging news. Do you want to be with someone? We have done some test and we have found out that your child has a condition called Meningococcal Septicaemia, Do you know any thing about it? In this condition certain bugs have infected the covering of some blood channels. We have started certain medication called antibiotics. Mom: will my child be fine? Dr: Nothing can be said at this moment, But we will give him the best possible management Mom: Can I see my child? And can [ hold him in my arms? Dr: [ am afraid it is not possible because we have kept him in room called isolation room. But you can see your child from the glass window of the room. Mom: But doctor, I want to touch my baby? Dr: [understand your feeling mom, but it is not possible at the moment I need to ask you something mom. Are there other people, living in the same house? We need to give them some medication to prevent them from developing the same condition Mom: Will my child have any long term complication because of this illness? Dr: After recovery the child may develop difficulty in hearing ‘Monit: will my child die-doctor? - Dr: It is very difficult to say anything at the moment. We are giving him the best possible management. URTLIN CHILD MOTHER WORRIED OF MENINGITIS Ask for reasons why mother thinks so and asses if reasonable “b Fox (Upper Respiratory Infection Meningitis Moderate temperature Very high temperature Active Drowsy or Lethargic Comfortable in bright light Shying away from bright light Vomiting always preceded by cough _| Vomiting not preceded by cough Rash not present / if present is Non blanching rash blanching jducate on Tumbler test reokon Cahn boonReassure and advice not to hesitate to get back if any symptoms of meningitis occur ‘Tommy aged 5 years has fever with rash Mrs. Brown his mom is worried and she thinks that Tommy has meningitis. She has called you. Talk to her GRIPS Mom: My son Tommy has fever and rash and I think that he has meningitis. ‘ould you please tell me that what is the age of Tommy? ince how long does he have this fever? Did you check the temperature? Is it high? How is the activity of the child? Does he look lethargic? Does he have any vomiting? Is it preceded by cough? Does he have headache? Does he shy away from light? Since how long he have the rash? Do you know about the ‘tumbler’ test? Press a glass gently on the rash. If the rash blanches then the chances are that it is not meningitis, - Mum from what you have told me I feel that your child simply has an upper respiratory tract infection and not meningitis Please, take your child to the GP for medication. If you feel that at any point the child is getting worse contact us immediately , Is there any thing that you need to ask? So Wey tue ae saa “hn aghe a? D Continn te Conteet etal! — introcluce Grips GOoxdere — Berne 9H home AAbdTEy « ATE Ore HOP QIC Or OD PARA ¢ 7 Mom: my child has loose poo and I am worried about it Dr: could you tell me since how long does your child have loose poo? How many loose poo doers he passin a day? ei » weds oh ceprse Is there any blood in the poo? or WWE 'UaWwhh §S a cyeny . Dr: Does he have vomiting or tummy pain? ax ony fon ov Cpa DIARRHOEA:— 4 tre chid ackue or no —s more PATSIY hon Udyot> — Pasins eee on 4 tye? paces MO Wen — bo Ys the child 2 WO nous Yor Cronged m off Isheable to drink? On Dania ‘ee i 7 beta 1s he rhe Does he have fever? \ ay 9. ye heey any Tey ¢ i ned { “ shack, Panag 2 (Viral Diarrhoea Bacterial Diarrhoea Protozoal Diarrhoea Loose stools Water stools Loose stools Ae tar] jade ws Usually no fever Fever No fever oid 2 ‘t eh No vomiting Vomiting may be present No vomiting | ta No abdominal pain Abdominal pain present | Abdominal pain relieved "|" bree on defecation Blood and ‘aes Be resent \ Needs in ese eG No blood or mucus in stools Blood and mucus may ye present Tove Ch ‘Usually Teads to dehydration and needs __| treatment intervention> 0 Laser Vintec ds BCOHS (medicine ndvee Food porsoina @ lavakuL abure CY: Self limiting usually does not require intervention Management; a Adequate pain killers Insisting on admission Inform orthopaedic team if required Arrange for skeletal survey Arrange to check Child Protection Register Request consultant to come and see to. confirm and ‘ * Decide on Social services ‘A 6 month old child has been brought to A@E. On examination you suspected a facture of right humerus, which has been confirmed on X-Ray. X-ray also shows callus formation in some of the ribs —_ brepna 4 You also noticed some bruises on buttocks erat ees ie Ate so. aa Mom has given you a history that child fell from a sofa. Also she has told you that her it partner takes care ofthe child and that this was an unplanned pregnaney — ‘x. 36 Ne PREDIGUN eden sQnr a> From the history, examination and investigation you are suspecting a non-eccidental injury Talk to your consultant. lake, Drobo, . Regarding this on telephone and discuss your plan of management ~ dk a ‘oe’ OY ml BOA Hello I am Dr... SHO in the department, may I speak to Dr... Rl~ ler Coe DU rep c ‘bel 1 am sorry to disturb you. I need to talk about a child who has come to A&E, his Poodeiny mother has given a history that he fell ftom a sofa, Also according to het history her of partner takes care of the child and this was an unplanned pregnancy-kyyv Olof o> HQ PrOv-& X-Ray shows fracture of the right humerus and callus formation in few ribs. pipe D- 3 eok4 ca). [feel that this is a case of non-accidental injury. — 43 )©C2>_, My plans to admit the child, I have already given pain killer to the child, T want to do G5) co skeletal survey. Also wish to involve orthopaedics team. I want to look up child's name in child protection register. Can you please come and see the child and tell me 949; Q- about further management and so decide stow ivaling social services. be Oa ay ae sade PO : Non Accidental It i A child has come to you with a history that he fell from sofa. On examination you notice few bruises on child’s body Talk to mom and discuss management with her and then with examiner GRIPS (. i A t Would you please tell me what had happen Codd Dy ae SMA I Pas Shatios Dr: could you please tell me more about it? What happen after that? Did he loose 0 5 ine? consciousness any external bleeding? \ 4 4.9 egyol~ c Mom: he was fine afierthat 4) 00 0 se | ‘Mom: little Johnny has hurt himself. He fell from a sofa 4 days back Dr: who takes care of child at home? " ; Mom: my partner Re stony dow ol-eomucke CK EEF Beg oo we Dr: was this is a planned pregnancy? o(— Mom: No -Dr:T have noticed some burses on-young one. When did they appear? - ‘Mom: the same day when he fall Dr: I would like to admit your child. I will give him pain killers. Also I would like to ‘ do certain imaging called skeletal survey. I also want to involve orthopaedics team Mom: why you are admitting him? Why don’t you give him treatment and discharge him today? Dr: am afraid this is not possible and for his treatment we need to admit him Turing to examiner | find that history is not correlating with the child’s injury. Also the partner is taking care of the child and this was unplanned pregnancy mother is reluctant for hospital admission. I think that this is a case of non-accidental injury. 1 want to give pain killers to the child. I want to admit him. T want to do sutyey and to involve the orthopaedics team. Also I want to look of child's name on child protection register 4,4 Wigod ter fy 2vrakse leo My Ss ) “o 7 Aico dos —T oat’ also eheetle & Seal Sevars) iC- Vee % ; a. AOE A NOUR docia) Soruicen nol & One we a Fant Sl ot anbe 4 os OM OSS PLEA OE a GEL’ went tp BOCHRONIC DIARRHOEA/WEIGHT LOS! Differential Diagnosis stools) + Long Star medicafions A 3 year old child has come with a history of chronic diarthoea take history from mother and discuss D/Ds with examiner GRIPS Could you tell me please that since how long has your child been having loose poo? How many times in a day he pass the loose poo? Is there any blood in it? Does he have fever? Or vomiting Did the loose poo started after your child was put on weaning diet? Is the child on any medication? Does the child have any breathing difficulty? Did he have loose poo in the past? Was everything fine at the time of birth and after birth? Are you happy with child’s development? Has your child received all jabs up till now? Is the child feeding well? Is there any other person in the family. who has loose poo? ADC SIA ide catoyr - 2n9f Oi Prete | actin wren tows Veheues * Malabsorption (Food and vegetable * Chronic infections(Protozoul infections) howe material in © Coeliac Disease (Diarthoea on consumption of bakery products) © Cystic fibrosis (Recurrent respi a tod A dntection 3 ox hnao. fee as jr 7 Bowesvan fueling ie ean sai for Duek ou eet a oo —— On Wim ele on adi Differential Diagnosi G ] « Acute © Tranma/Septic Arthritis + Chronic Cerebral palsy (All mile stones delayed) © Congenital Dislocation of Hip (Lump in the buttock region) o Malnutrition © Chronic infections © Constitutional Delay (Running in family) © Dochene Mugutar Sens, Bibiten 4 Obickiy Gourd. uve cl orp a i Has child attained other milestones? to Bnd ovk cosether Was everything fine during pregnancy, during birth and after birth? 1, 0 £,'g) baa Has the child resuscitated after birth? Did he require any oxygen? Ging y cache ous ad Was the child put on ventilator after birth, due to breathing difficulty? » Was he diagnosed to have developmental dysplasia of hip? , OY 4s Did he had any trauma in the past FORO WR Dor sieald na, Did the child receive all the jabs up till now? itd MA Me ede J Does he take appropriate feeds? ne one Is there any problem with the wee or poo? +a. a Is there any person in the family who had delayed walking? 2? 493 dow W2 recor “py on Ppl tne Lia TOUS CHIL ‘doen re Se, I Differential Diagnosis: = NAL Mon, mayhs y = Epilepsy =" Diabetic ketoacidosis * Head Injury Accidental Poisoning Vasovagal syncope Cynotic heart disea: Cormaner- 10 Clylater is the 4, wake 8 GRIPS Could you please tell me what had happened? ~ 4 henge \ 0 cole Since how long is the child unconscious? Did he hurt himself? Did he have any fits? Did he have any fever or headache? Did he have vomiting or loose poo? Does he have diabetes? Ishe epileptic? Did he accidentally ingest something? Rr 2 Lok,spot Dew GI ade. t Foye bn hoes . F 5 vos . Any past history of unconseious previously Birth history COELIAC DISEASE: + Explain Diagnosis (Hyper reaction one particular content of food containing gluten. Gluten free food (Dietician) Availability of Gluten free food Growth monitoring Will other child be involved Challenged diet Complications (Skin lesions, Bowel cancers) Consider when time comes to cross the bridge A.2 year old child had chronic diarrhoea and is diagnosed as having celiac disease talk to mother cars Wheat | 240 / Barlon , ‘As you know we have done somte test on your chi reports have come back and according to it your child has a condition called celiac disease. Itis a condition in which your child’s intestine are allergic to a portion in a diet called Gluten.$9 wreneucd ie iS erpuse co! by ke he will Koue ene, We will keep him on Gluten free diet for some time. After that we will again add i gluten to his diet for 3-6 months. Then we will do a biopsy. After it if we find that the gluten has not harmed the intestine, we will keep the young one on normal diet. But if we find that gluten has harmed him then we will keep him on gluten free diet may be for life. We will refer him to a dietician who will advise about gluten free diet. Also gluten free diet is freely available in the market. We will keep monitoring the growth of child and will keep calling him for repeat followup.) Coo )0- hui be x uot fom: Are there any ong term complication? Dr: yes, but it’s too early to talk about it, At the moment I'll give you leaflets and website-akiress 50 That you can read about it on your own 100. Sopa, ese DeOlsLemaA a oe Cons Gp FEBRILE CONVULSIONS: Vous + Ae * Common condition (6 months to 5 years) * Admission for 24 hours observation first time "Preceded by temperature and does not last for more than five minutes Temperature control Stock of Paracetamol syrup Avoid excess clothing Improve ventilation Tepid sponging Inform school nurse and GP During an attack (Safety) Per rectal diazepam (Nurse) ‘Need not become an epileptic No specific reason ai eyOIE WI, Ase Alaa. Jo ; eer. yeuyl. bee 2a bet . SF, hie ROE Or alates 4 conabtg. \owd? ty problen. GAD Stuy We hart 4 alm HLS Steg of o i 6 990 reine op oA ® i 7 ferrera our woduhy us | Ra oe yout Steans au NJ} Ue . an Hand washing shoutd take . 15-30 seronds : abana Patios. ryourhands* ‘capyse 2007 288573 1p te Sep? 4 from World Health Organization Guiefias on HaccTO! Glocleter graney — Ce Ponere ary > lomps f Bop, bban om _ Steal Cirrheorrs — Pimory Celeroring Chala - Ser eae ae oF Ty \G arinws Civglery def | jaurot Coal te Pate gyolsy — We coved be surnis Te TOE On yr Yue orf ovr Ki ak rors Vices 0GCenwlor pry 3 ance om hep Ate mre dca ki Onn Tain A Abnormal Liver Function tests ___ a | Indirect Bilirubin (unconjugated) increased in — Pre hepatic canses — heemalysis, Check reticulocyte count, blood film, haptogiobins, LDH and may need direct Coomb's test. Liaise with haematologist., Drugs, Gilbert's syndrome, Crigler-Najjar syndrome Direct (conjugated) bilirubi increased in Hepatic of post ‘hepatic ceuses- Hepatitis, Obstruction ( gall stones, Ca head Bilimbin (@ -Vimicromols/L z of Pancreas) Albumin (30 -50g/L) . [Peer ‘in Cicthosis, Inflammation, malmutrition, | regnancy, AST (3-35iwL), ALT (3- ALT more specific to liver than AST. \ 35i0/L) AST elso found in Cardize and Skeletal muscle and RBC. Very high levels (1000 TU/) suggest drug induced hepatitis (e.g. paracetamol), acute viral hepatitis (A or B) , ischaemic or rarely autoimmune hepatitis. ‘The ratio of AST to ALT can give some extra clues-as to the : cause: i In chronic liver disease ALT > AST, once cirthosis established AST > ALT. The extremes of the ratio of | AST:ALT ean also be helpful: >2 suggests alcoholic liver disease, and a ratio of <1.0 suggests non-alcoholic liver disease. Jucreased iz Obstruction, Alcohol Bone disease(especially Poget’s), Pregnancy (placenta produces ALP) ‘Alkaline phosphatase (ALP) - comes maizly fiom the cells Jining bile ducts but also in bone. Marked elevation is typical of cholestasis (often with elevated GGT) or bone disorders (usually nommal GGT). Isoenzymes analysis may helps: identify source. Itis physiologically increased when there is increased bone tumnover (c.g. adolescence) and is elevated in ‘the third trimester (produced by the placenta). GGT is raised. ALP may be normal. AST>ALT_ I Rise in ALP and GGT more than AST and ALT. This may be intrahepatic or extrahepatic (bilirubin will also be raised), ‘ALP (Aléaline Phosphatase) (40-1205wE) GGT (10-53iwL} Tn alcoholic liver disease Obstructive Pictu Intrahepatic -Gallstone in common bile duct Head of pancreas neoplasia Dings eg. exvthromyuin, tricyelic antidepressants, Busloxecillin, oral contraceptive pill and ic steroids Cerdine failure - improves with trestment ue te ig - commoner in women and frst sign | isanisein ALP 2 . . Neoplasm ~ primsry (rarely) and secondaries Femiliel (benign) — ‘ise in AST end ALT more then ALF and GGT: Alcoho) - fatty infiltration and acute alcaholio hepatiti (usually aseocisted with markedly deranged fiver funeticn). Cicchosis of any cause - eleohol being ane of the commonest," ‘ Medications ¢.g. Phsnytoin, carbamazepine, isoniazid, statins, metholrexate, paracetamol overdose, amiodarone. (Transaminases may be >1000 101M). ~~ Hepatitie piemre Chronic hepatitis B and C. Acute viral hepatitis e.g. hepatitis A, B and C and CMV Autoimenune hepatitis, ‘Neoplasms - primiry ar seconderice, ‘Haemochromatosis. ote ‘Metabolic - Glycogen storage disorders, Wilson's disease.@ Tschaemic liver injury e-g, severe hypotension Fatty liver disease (mild elevation in transaminases <100 TA). Non-hepatic canses:. Coeliac disease, haemolysis and -— Hoygertirrrfctise J Management plan. Any liver sbnonmalities with evidence of hepatic dysfunction e.g, low albumin, raised INR should be referred to a specialist? 1. Ifslightly abnormal rise in fiver fanction tests (ie. less than twice upper ‘ limit of normal): © Repeat liver fimetion tests in 6 months time. © IE you suspect the cause to be alcohol related then inform the patient and ask them to abstain and repeat the tests. Other lifestyle changes may help e.g. good DM control and weight loss. ‘J still abnormal perform further tests e.g. viral serology or ‘ultrasonography. Hfremain abnormal for longer than six months then consider referral to a specialist. If the patient is unwell despite slightly abnormal LT's then they may need to be referred more urgently. 2. Very abnormal liver function tests (Le, more than twice upper limit of abnormal): _ se = imaging. ae © Organisé further blood tests ©. Referto out-patients - if you suspect the conse may be malignancy then an urgent cancer referral should be made.* Consider urgent referral for hospital admission if patient unwell, for example + Severe jaundice + Sovere ascites ¢ Encephalopathy Septic Otherwise out-patient referral for anyone less ill if indicated - but try to determine cause.eee — Hels Mi... As may may know=we had dane SoniB Samet the result ows back which shows that some of the tests done to look at your liver Show some abnormality. f need to ask few questions to find out what exactly is wrong ? Do you feel unwell at all if so what 7 Any jaundice now or recently, Weakness, Fever (Hepatitis) (Iavta ~ viral serology) Tested for anaemia ~ Hemolysis (may be due to drugs too) Jaundice, fever, pain abdomen right side (Cholecystitis) Jaundice, Itching, pain abdomen, pale stolls , dark urine - gail stones, (Uitrasound ERCP). Jaundice, itching, pain andomen, we lois ant osg-of appetite, diahoea, constitpation — ca head of pancreas (Ultrasound, CT scan ) Distended abdomen, Weakness, Heametemesis ~ drinking excess alcohol — alcoholic diver disease. = Travel — (diarrhoea — hepatitis) Hospitalisation in underdeveloped countries —Nepal ~ Unsterilised needle use, Blood transfusions there) Tattoos — hepatitis Prracetorn! Drugs ~ Paracetamol over dose _ Are 492 on pig y abc O~ anna piephs Unprotected sex hepatitis a. Corb hekot y MOI Pla Parnes Family history (Any liver disease in fimuily) — Gilberts syiidtome, heamochromdtosis, wilson's disease- ( Serum copper, ceruloplasmin levels) DM, Hyper lipideamia ~ amyloidosis ( fatty liver) ¥ obstructive picture tell m we may have to do other tesis like USG, CT sea, Camera test (ERCP). Aloholie - advise to ext down. (CAGE)Pain Control ia Terminal Care Pain is easier to prevent than it is to relieve and drugs should be prescribed on prophylactic besis with no other consideration than maintaining the patient's quality of life. "Specialist palliative care teams (hospital or hospice based) (Maorillan teams, -——----—- GPs with special interest-in-palliative tare) — —— = * . Adequate psychological support is critical as removing the fear of pain in itself will help to optimise pain comtrol. A patient who is fearful, withdrawn and depressed often appears to have a lower pain threshold than one who is still actively engaged in enjoying what is left of their lives, even though they may have same siage disease. ~ Principles of pain control in terminal care ‘ + Use the WHO analgesic ladder to guide systematic pain-relief but remember other treatments (surgery, nerve blocks, radiotherapy ete) aud non-drug treatments may also have azole. WHO analgesic ladder Step 1 Non-opioid+/-adjuvant Pain persisting or increasing? Step 2 Opioid for mild to moderate pain +/-non-opioid +/-adjuvant Pain persisting or increasing? Step 3 Opioid for moderate to severe pain+/-non-opioid +/-adjuvant Objective: Freedom from pain Beso the choice of drag on the severity of pain aad not the stage of disease. : Step up to strong opioids when step 1 and 2 analgesics have failed. Adjuvant analgesics may be usefully edded at any stage. Common adjuvzint analgesics for cancer pain £ Drogs Indications Bone pain Sofft tissue infiltration © Hepatomegaly ‘Nor-steroidal anti- inflammatories @ Raised intracranial pressure ° Soft tissue infiltration ° Nerve compression ° Hepatomegaly Nerve compression ar Antidepressants end infiliretion anticonvulsants ° Paraneoplastic neuropathies° Bone pain Bisphosphonztes Regalar review is essential to ensure that treatment goals are being met, side- effects avoided ete. Analgesia Nou-opinids » Paracetamol is a weal analgesic with very few side effects, + NSAIDs ate particularly useful for bone pain that is often poorly controlled by opioids. Their main side effect is GI bleeding - often a PPI is co-prescribed to counter this risk, ‘Weak opioids ‘These are used when non-opioids ate ineffective. These include codeine phosphate and dihydrocodeine tartrate and are often used in combination with pararetamol. ‘This forms the backbone of first-line therapy. Patients and family are comment -—————~— concesmed at the outset aad it needs to be explained that morphine is an effective analgesic, conferring overal) benefit and does not imply imminent death. Other ; common myths and misunderstandings include: tf It is not normally addictive. Patients commonly reduce their dose if other measures counter the cause of the paiv. + Respiratory depression is nof usually @ problem. Pein tends to counteract ‘tis effect even in those with respiratory disease and itis useful for symptomatic relief of dyspnoea. Significant tolerance to morphine does mot usually develop. Patients are nonnally maintained for several weeks on a constant dose end this is only ‘increased because of advancing disease, + Morphine is not stupetying. At the correct dose patients can continue with sosmal activities. Always warn patients that initial sedation may occur but that it usually setiles within 48 hours. Comuuon side-effects ‘Use the lowest necessary dose for full anslgesic effect to minimise side-effects. »enaliy subsides within e few days.+ Nausea and vomiting - common in opicid-naive patients. Usually settles within a few days but can be prevented using anti-emetics (eg metocloprami 10 mg tds or haloperidol 1.5 mg or nocte). Constipation - very common and laxatives should be prescribed prophylacticall Dry mouth ~ adh quent. sips-of iced strinks, destal floss;—— © Pruritis - related to histamine release. Try oral antitistamine to control itch. + Bronchoconstriction - again related to histamine release. Use iv fim. antihistamine and bronchodilators end switch to a pharmacologically distinct opioid such as methadone. + Toxicity - appears as agitation, hallucinations, confusion, vivid dreams and sayoclonic jerks, Worsening renal or hepatic function will alter the metabolism - of morphine and may.cause accummlation and toxicity. Consider adjusting dose downwards or increasing dose interval. Parenteral routes Syringe drivers If vomiting, dysphagia or increasing weakness prevent patients ftom taking oral morphine, then usual practice is io convert to a subeutaneous infusion of opioid via a device such 28 a syringe driver. Injection site should be changed every 2-3 days. + Diamorphine is approximately 3 times as powerful as oral morphine as an ‘thalgesic. Subcutaneous morphine can be used in its place when diamorphine is not available and is twice the potency of oral morphine. ‘Transdermal fentanyl An alternative to both oral morphine and s.c. diamorphine is transdermal fentanyl patches. They cau be useful in ambulatory patients where: Problems with the oral route, intractable constipation, Morphine intolerance Fentanyl is « very powerful synthetic opioid (150x potency of oral morphine). Other options include: Psychological techniques eg cognitive behavioural therapy, simple relaxation, hypnosis Local nerve blocks and epidurals 7 © Acupuncture ‘Transcutancous eléctrical nerve stioralation (TENS) ° Counselling Access t6 spiritual advisors Antidepressants or anxiolytios Complementary therapiesPatient-Controlled Anaigesia System (PCA) What is patient-controlied analgesia? Pain tehief io called an revontrolled-analgesia (PCA) is type of pain relief youzoay get at the hospital or sometimes at home. when and how often you get pain medicine. When you begin to feel pain, you press a button onthe PCA pump to inject a dose of medicine through an IV tube in your. vein. When is it usec? PCA may be used at the hospital when you have pain after an accident or surgery. It moay also be used at the hospital or at home if you have chronic (long-term) pain, such as cancer pain. How does it work? ‘Your health care provider sets up the PCA pump and chooses a pain mediaine to use inthe pump. A staal] tube is placed in one of your veins so the medicine can be given into the bloodstream. If your pain gets worse, You can press @ button on the machine and the medicias is pumped throngh the TV tube. The machine may also be set to give you medicine slowly all the time. If you continually get medicine from the machine, _.. YOU ean, get extra medicine by pushing the tion, Narcotic medicines that may be used include: “ihorpiine ~~~ * meperidine @emerel) fe «_hydromorphone (Dilaudid). ‘You need to push the button whenever you start feeling mare pais. Do not wait for thé pain to get severe before pushing the button. After you press the button, the medicine ‘will start working to relieve your pain Within minutes, Only the person receiving the medicirie should push the button. It can be very dangerous for anyone else to push the button. Your health care provider will meke suré that your family members know this. Also, always make sure the hospital staff checks your hospital bracelet before they add medicine to the PCA. This helps to anake su you are-getting the right medicines. You may not always get extra medicine when you yush the bution. How much medicine you can get depends on how much your provider thinks you should get in a certain amount of time. This decision is based on your condition, other medicines you may be taking, and your weight. The PCA machine will record each time you push the button even if medicine is not given. This can help you and your ptovider decide ‘how well your pain is being controlled. Nurses and others caring for you will check ‘you end the pump. often and ask about your pain level at those times. Rein hard to awaken and having very slow breathing may be sigus tha you are oe ee eemay be uncomfortable and restless. Make sure that you tell your provider if you are still uncomfortable a few minutes after you push the button. Your provider can change ‘the medicine, its dose, or its timing if you are still having pain. ‘The pump may be battery operated. You may be able to carry the pump around with you when you are walking. Place the pump outside the.tub.or shower stall wher-you— _batbe-nr-shower:~ ‘Your health care provider will decide how long you will need the pump. What are the benefits? + You do not have to wait for someone to give you more pain medicine. You can get pain relief faster, The medicine gets into your bloodstream faster ‘than if you took it by mouth or were given a shot. You will not have to have repeated shots of pain medicine with aneedle. + Youmay need ess pain medicine. ‘You may not feel as sleepy as with other medicines and there may be fewer side effects. PCA pumps have several safety features to help prevent your getting too much medicine. What are the risks or disadvantages? © Despite the safety features of the PCA pump, care must be taken when giving narcotic pain medicines. The pump must be carefully programmed by your health care provider. If someone other than you pushes the button for more medicine, you could get. t00 much medicine, which could cause serious harm © Narcotic medicine can cause you to breathe too slowly. Because of this, you may not get as much oxygen as you need. To make sure you get enough oxygea, you will be checked often while you are receiving PCA. +. Nercotic medicine say make you very sleepy too much of the time. Ifyou are very sleepy, your provider may advise that you wait a while before you push ~ the button again. Some people may not be able to use PCA because of their age, mental state, or level of consciousness. When should you calf your health care provider? Call your provider right away if 2 You become very sleepy and still have @ lot of pain. + You have nausea, vomiting, or itching © The place where the tube is in your skin is red, swollen, painful, wann, or bleeding. © The pump's alarm goes off, Ifyou are going te have PCA after surgery, be sure ta talk to your health care provider about it before your surgery.‘Your Consultant has started morhine to a patient who is having Lymphoma. ‘Tal aot Mr. _~ How are you? ‘Well Mr. -- as you ere Aaving severe pain with your medical condition zay consultant has devided to put you on @ very good pain killers so that you will not suffer vrith pain and you will be comfortable. Before I talk about this I wouls like to know fiom you whether you are allergic to any motifcations or you are eny other medications 7 ‘These medications is called Morhine, Iam sure you would have heard about this, This is'a very strong and good pain Killer. You cen take this by mouth. Initially you may have to take it 4 times a day Tater on we Will adjust the dose to twice a lay 0 that you don’t need to keep taking this medication very often. Like any medications these too have some side effects however we will keep 2nenitoring you ell the tims and we will sort out any problems if you develo. ‘You may fee! sick or be sick if this happens we can give some medications to overcome this. This also can cange drowsiness so you should-not drive and work, ‘bear any heavy machinery. If you get dryness of mouth we can give some —* ~* artificial saliva. Constipation is another problem with this medication but if you ~~ Batot af vegetables and fruits with high fibres then this may not be a big problem. We cam also give some laxmives. Sometimes we may-be able to adjust overcome this problem. At high doses you may feel very sleepy orit may youto breath very slowly but as I ssid we will be monitoring you regularly so that ‘You won’thave any such serious side effects. When you are on this medications if you take any over the counter medications like cough medications (entibistaminits) it may cause more droway. So please do talk to your doctor before you take eny other medications inefuding over the counter or herbal medications. E This can also cause difficulty in passing water and if this happens try to go tot the “EES toilet and tum on the tap, and you may be able to pass water. But if this does not help you can come to the hospital. Doctor] am a school teacher. Won’t I look stupid in front of my students 7 Why do you say so ? ‘Well we teach our students not to take such drags. ‘Ido understand how you feel, but Mr. - you need not wory about this, You are Tot taking thiledrug for recreational purposes, but you axe taking this as a eemedication to control your pein, I am sure everyone Will understand this and they respectthis, Will I look silly feeling drowsy in front of my students? - Well in.. if you take the medications at the right dose and the right time you shonld not have this problemi as well es drowsiness usually wears off after few days. _Patiznt is on. morhine but he-does notw: Ask him why he does uat want. - If be says any of the coutplications above ~ tell ‘him how you and him can manage and cope with that. As*well as dose may need to be reviewed and adjusted if he tias developed side effects, Tell him that morphine is the best medication to control pain. Also ask him how is the pain. Other adjuvants may required along with moshine such as corticosteroids, antidepressants, anticonvulsans. But if the mothine is not controlling pain next option may be Fentanyl patches. Won't I get addicted ? - At the right dose it will not cause addiction as I said we ‘will be monitoring you so thet you will not exceed the necessary dose. Other options are Norve blocks, Radiottvrepy, counselling, psychotherapy, aoupunctire, Relaxation, electrical stimulations(TENS) may help. Daughter worried about her mother having terzninal illness suffering with pain. Ido understand you concems to your mom, But you need not worry. We have lot of specialist who is going to be involved in managing her pain like cancer ‘specialists, pain contol tem, Palliative team, McMBillan nurses, Psychiatric _ doctors for counselling and also there are different modes to controlling pain. So ‘we vill keep a5 as comfortable s possible. ‘We do have good pain killers and otber type of medicaticrs to control her pain, ‘We do have other modes of treating the pain like radiotherapy (radiation to the painfil area), some sort operations, we can block nerves which carries pain sensation to the brain, First of all she needs ber family support to keep her cheerful. If she is left alone and if she is inactive she is more likely to suffer with pain. Regarding the pain killers — we will start her on some mild pain killers like paracetamo} and codeine initialiy and see how it goes, If that is not enough then ‘we will commence her on stronger medications like morphine until she is completely pain free. ‘Then talk abowt morhine (various routes — oral, intravenous (should be in the ‘hospital initially until dose titrated and changed to oral medications), PCA(can be given at home too). Talk about side effects and how to overcome them.mua ([ERGATRE ] esophaatls Preumonia \N- Hepatic euouy Hepatic abscess Billary colic Hepatitis ») Croangitis Cholecystitis Fyeloneptts Sf Renal cole Renal Infarction Retrocaccal appendicitis aneurysm Meckets eenalcole 1 ett Intussusception Crohn's disease Acute appendicitis Ovarian cyst Salpingltis Ectopic pregnancy Diverticultis Pele Uterine rr appendicitis, aes pen (3 Ovarian cyst ED : Salpingitis = . Cystitis [wa] Pneumonia Splenic infarction Pancreatitis Pyelonephritis Renal colic Renal infarction Oiaranyst ~ I Salpingitis Ectople pregnancy uF 28 Clinical presentationsat a glanceExamination of the unconscious patient Twill take all the Universal precantions before approaching the patient and ensure privacy end have 2 chaperone. Ifyou see patient iying with the cervical collar just say ~ “since the patient is on collar. essume that neck injury-hasn*t- been ruled ows”. (if no collar seen — say I will do the Triple immobilization of his neck) Asses if the patient is responding by Look, end verbal command and gently shaking the Patient. If not responding — open mouth and look for obstruction and then look for breathing {say - [can eve the patient is not responding but breathing , I will take care of ABC and protect the airway and call for senior help immediately). Assess the GOS of the patient. (May be eround 9). (IF8 or below 8 needs intubation so Twill call Anaesthetist immediately), > Iwill check the vital signs Pulse, BP, Oxygen saturation, Tempereture (Hyperthermia septicaemia, cerebral malasia, Hypothermia ) Expose the patient and then do fill examination. —-Pruacy amel Comment on posture of the patient f eny abnormal postare (Decerebrate, Decartioate, One side paralysis) HEAD to TOR ‘+ Head : Any sign of injury ortreuma on the scelp and behind ear (bruises over ae “& Bar: Lovie for discharge Gnfection)(CSE), foreign body, signs of trauma, Ideally sk Uk ese mastoid for Battle's sign) (There may be bruises an the forehead — head Snjury) sk Bye: Raccoon eyes, Subcaujuctival haemomhage-I would like to check the comeal __- — — reflex, papillary size, reflex end do the fiuidoscopy. & otoscupy #s weil + Mouth and Nose: Any smell of alcohol, hepatic fetor, ketosis, uraemia, Open the end month end look for bleeding, Loose teeth or denture, Cyanosis, pallor. ++ Facial palsy (mouith deviated to one side (Stroke) »& Neck: Since the neck injury is not riled oot Twill not check for n. Eine or “) of Dolle’s eye movenient at this stage. 4 Hand: Wrist bands for DM, Epilepsy or astlune, signs of IV drug abuse. ey sb Chest: (Do only inspectian) Respiratory rate and type. Look for dilated veins, scars, abnomesl pulsations, Rashes, Spider neevi. Iwill do « fill chest examination to Ioak for any signs infections, heact'mummurs. 2 aunesegeil ~k Abdomen: (do only inspection) Distension (ascitis), bruising (tramma, Ac eget pancreatitis) dilated veins, Organomegaly, intra-abdomignl pathology. 7° “SE Thighs: Sign’ of injection merk, signs of any abscesses. Elsewhere in the body: > Distal pulses (Leaking aortic aneurysm, dissection of aorta) + Since the GCS i low — do ‘a complete newrologital examination — ( Higher _fuuetion, Sensory system and power exmnot he;aséessed'as the GCS is Tow. Check “Yor bulk, tone and reflexes including plantar reflex.- sk Then I will examine the back and do per rectal examination sh [time left start doing chest and abdozien examination sk Cover the patient.GCS AND NEUROLOGICAL EXAMINATIO! (Pationt met with trauma, Primary and Secondary survey has been done, now do the GCS and the neurological examination) [vvil take all the Universal precentions before approaching tho patient aud ensure privacy and have a chaperona. Lf you seo patient lying with the cervical collar just eay —* since the patient is on collar I ‘assume that neck injury hasn't been raled ou”. : “Since the Primary and Secondary Survey has beem done Taseume the ABC has been takza, care of © Assess the GCS of the patimnt. (May be around 9). (IF GCS is 8 or below 8 needs intubation so Iwill call Anaesthetist immediately). (fn the exam the GCS is usually between'8 to 10.) (GLASSGOW COMA SCALE: BEST MOTOR RESPONSE Obeying tommands 6 Localizes pain 5 Withdraws to pain 4 7 Flexion pain BO —~ oO 1 EXTENSOR TO PAIN 2 (Qecerebrate: Tigidity) — No 1 BEST VERBAL RESPONSE. Oriented a | Confused 4 j incapptopsiate spench [3 [n= ible sounds 2 ‘None i EYE OPENING Spontaneous 4 Opens to verbal stimulus 3 Opens to painful stimulus 2 ‘None fa ° Iwill check the vital signs for Pulse, BP, Oxygen saturation, Ternperature. ° Expose the patient and then do Neurological examination. Since the GCS is low—do a complete neurological examination — (Higher fimetion, Sensory system and power cannot be assessed as the GCS is low) ok Head : Any sign of injury or trauma on the scalp end behind ear (bruises over rmastniil for Battle’s sin) (There may be bmnises on the forehead —head injury)+ Bye: Raccoon eyes, Subconjuctival bacmorhage.I would like to check the cores rellex, papillary size, retlex and do the fimdoscopy. 4 Ear Look for discharge (infection (CSF), foreign body, signs of trauma, Ideally ctnscopy as well 4. Neck: Since the neck injury is not ruled out I wifl not check for neck stiftiiess or Delle’s eye movement at this stage. (Gxamine Chest and abdomen afier neurological examination) _° MOTOR SYSTEM: . sh Attitade of limbs(esp. for decerebrate or decorticate posturing) 4. TONE in all limbs =} RELEXES ALL DEEP TENDON JERKS PLANTAR, POWER if possible Iwill also check his back for spinal injuries aid do the per rectal exanaination fix anal tone. Iwill also do the fll examination of the patient incinding skin, chest and abdomen. Cover the patient. » DISCUSS THE MANAGEMENT WITH THE EXAMINER - IF-ASKED.Cranial nerves examination Mr. John Atkins is SB years old male has come to the ophthalmology department with compliance of visual disturbance; you're a SHO in this department. Please examine the patient. (CN I! to CN Vil) Hello, Mr Atkin, Fn Dr one ofthe doctors in this department, as have gathered from your — notes, you have got some difficulties in your vision. I'm here to examine that and the nerves in your face. Is that alright with you? For the purpose of this examination | have to ask you to sit strait on the chair and your neck area should widely expose, therefore I'll ensure you privacy. Is that fine? During my examination | may come close to you, touch your face and may ask you to do certain manoeuvres, if you do feel any discomfort please let me know otherwise Ill be gentle as possible, Is it O.K with you? Thank youl = © Instrument needed CN I~ Optic nerve 1. Inspection. (Front}- Ptis looking at you. 1. Head position. 2. Redness. -Scleritis or Conjuneti 3. Swellings. 4. Discharge. 5. Ptosis (Norrowing the gop between upper & lower eyelids). 6. Trauma. 7. Haemorthages. 8. Visible foreign bodies. 9. Excessive lacrimation. Picture 01 —oQQeVwowewaeoSSSE]ESSE(From behind) Pt’s head tlt back and upward glaze. 1. Proptosis. 2. Reflexes a) Red eye. - with fund scope/ ophthalmoscope (media clearance) b) Direct eye reflex and consensual reflex- (pupil reaction on light) ¢) Accommodation reflex- convergent of the both eyes and constriction of the pupils. 3. Visual Acuity (VA\ Ideally 1 would like to use a Snellen chart at 6 meter distance or 20 feet distance, but at present ll use finger counting method. (Both pt and the doctor should sit on chairs with arms length distance in face to face direction.) Y Askthe ptf he/she can see properly & are they wear any glasses or contact lenses. ¥ VAis typically measured monocular _—father than binocularly with the ald | of the pt hand or an occluder to cover the eye not being tested. Ask the pt count your fingers held in line with your body. 4. colour Vision Ideally | would check the colour vision by using an fshihara Chart, ‘Mudeiasis — popilary dilation coused by contraction ofthe dlotor of, the ris — sa normal response to decreased light, song emotional stimuli, and topical administration of mydriatic and eyloplegic drugs. can ako result from ocular and neurologic disorders, eye troumo, and alizorders that decrease level of consciousness (LOC). Mydriasis may be an adverse effet of antihistamines or other drugs. 20/200 |20/100 I \20/70 |20/s0 20740 jzores Sseovoup GN + Ishihara Chart.5. Field of vision Examine peripheral visual field oniy!tH! Visual fields are assessed by confrontation, ie. the examiner compares the patients visual field to their own and assumes that theirs is normal. ¥ The examiner places himself approximately arms length away from the patient and advises the patient to look directly at the examiner's eye for monocular testing. The test object (either a wiggling fingers, or a white pin head) is presented equidistant from the patient’s and examiner's eye and the patient is asked to say "yes" when they first see a moving finger or white het pin. ¥ Ideally | would like to use Amsler Grid to identify defect in the central vision ~ central scotomas A Peripheral visual ld 1 (0) wiggling fingers (0) white pin B. Central visual field (@) red pin ‘Normal Response: The normal monocular visual field ae extends approximately 100 degrees laterally, 60 degrees medially, 60 degrees superiorly and 75 degrees inferiorly. 1s divided into nasal and temporal halves and superior and inferior altitudinal halves. A Blind spot is located 15 degrees temporal to fixation and just below the horizontal meridian. Cause for reduced field of vision Y Cataract. Y Central Visual Field defects i) Lesions of the macula —Central Scotomas. Central Scotoma, Lesions of the Peripheral retina- Ring Scotomas. ill) Lesions of the optic Horizontal or Arcuate Scotomas. Bilateral arcuate scotoma Lesions of the optic nerve -with in the orbit cause Central Seotoma that differ from those of macular orgin in that red desaturation (red colour appear as orange or pink). Y Other lesions- refer Picture 01 /page1CN Ill Oculomotor, CN IV ‘Trochlear, CN VI Abducens Extra ocular movements: Examination Technique: 1) The examiner places themselves approximately arms length distance in front of the patient. 2) Ask the patient to look to each side, up and down following an “A” pattern, 3) Pursuit: ask the patient to follow a target such as your finger or a pen with their eyes without moving their head,pause at the ends of each direction of gaze to observe for nystagmus (Cross) 4) Assess Saccadic Eye Movements by having the patient make quick horizontal and vertical eve movements.(Hiand & Fist) 5) Ideally | would like to examine Optokinetic nystagmus by using an Optokinatic Drum (is performed by having the patient follow a series of ‘moving horizontal or vertical stripes and observing for nystagmus). CNV Trigeminal Nerve ‘a}_{deally would ike to examine the.—_ comeal reflex. b) Ught Touch With a cotton wisp, itis advisabfe to perform side to side comparisons m from the impaired side to the normal side. Touch a cotton wisp to the forehead; cheek and chin (avoid the angle of the jaw which is innervated by upper cervical roots}. ©) Trigeminal Nerve - Motor ‘The moter component ofthe trigeminal nerve (V3) supplies the muscles of ‘mastication. The largest ofthese include the temporalis and masseter muscles. Oculomotor Nerve Medial rectus - Adduct eye Inferior rectus - Adduct, lower and laterally rotate eve Superior rectus. -Adduct, raise and mediatly rotate eye Inferior oblique -Abduct, raise and laterally rotate eye, ‘Abducens Nerve Superior oblique -Abduct, lower and medially rotate eye Trochlear Nerve Lateral rectus - Abducteye Optokinatic Orum -@ SSL RR AE sate) ‘The Sth cranial nerve, trigeminal, consists of three sensory (V1, \V2.and V3) and a motor component, V3. 71. Palpate the temporalis and. masseter muscles on either side when the patient clenches their teeth. 4) Ideally | would fike to examine the Jaw jerk reflex - (i reflex is elicited by the examiner placing their index finger over the middle of the patient's chin with the mouth slightly open and the jaw relaxed. The index finger is then topped with a reflex hammer, delivering a downward stroke. The offerent impulse for this reflex is the sensory portion of the trigeminal nerve. The efferent limb is through the motor (V3) branch of the trigeminal nerve} e) Ask the patient can they feel food in thelr mouth when eating. CN Vil Facial Nerve The maior role of the facial nerve is to innervate the muscles of facial expression. Examination Technique: 1. Observe for asymmetry — widening of the palpebral fissure or flattening of the nasolabial fold. 2. Observe for involuntary facial movements {e. hemifacial spasm, orofacial dyskinesia, myokymia, or synkinesis). 4. Ask the patient to wrinkle their forehead by raising thelr eyebrows. 5. Close their eyes tightly. Observe for asymmetry of ability to burry the eyelashes and palpate for differences of ability to resist eye opening. 6. Ask the patient to show their teeth, puff out their cheeks and appose their lips. 7, Askthe patient can they taste their food without any problem. Normal Response: 1. The jaw should not deviate to either side. 2. The jaw-jerk is usually absent ar weakly present. ‘Abnormal Response: 1. The jaw deviates towards the side of weakness. 2. The jaw-jerk is exaggerated and pathologically brisk with lesions affecting the pyramidal pathways above the Sth nerve motor nucleus, especialy ifthe lesions are bilateral. Normal Response: Y Although patients may have an asymmetric face, there should be no {faciol weakness. ‘Abnormal Response: Lower motor neuron lesions causes weakness ofthe entire side of the face with equal involvement of upper and lower facial muscles. Y-_Anvupper motor neuron lesion of the contralateral supranuclear ‘pathway resufts in weakness primarily of lower muscles of facial ‘expression, Y The upper muscles of facial expression frontalis and orbicularis ‘cul are much less affected because the facia! nucleus that innervates them receives partial input from the ipsilateral hemisphere. TExaminati ‘ial Nerves VIII gle = Li qeee , Vode Ae + Mr, Binderenkov Bunanuchchey comes to the ENT clinic complains with “ringing” in his ears. You are a SHO in this department please examine the patient. Exposure: - Up to the mid arm patient can be in his. Positic Sitting CN VilVestibulocochlear Nerve 1. Inspection of the ears Redness. ‘Swellings. Haemorthages. csr. Discharge. Trauma, Visible foreign bodies. Vesicles. Pre auricular area Auricular area Post auricular area px geen 2. Palpation of the ear. Y Localize raise of Pre auricular area temperature. Y Look for tenderness by Auricular area looking at patients face. Post auricular area 3. Tragus test Just gently put pressure on tragus to look for tenderness. (+ Tragus Test — absolute contraindication for otoscopy) Y Ideally | would like to do otoscopy to check the ear. 4. Auditory Acuity Rub fingers each other near to each ear -First rub fingers ~~ simataneausly frontof the both ears, then individual ear ~ separately. Ask the patient which ear he/she hears better? 5. Rinne’s test (Compare air conduction with bone conduction) Apply the vibrating fork against the mastoid process then place it In front of the ear. Ask the patient which place they heard well? Is. it front or back of the ear? 6. Weber's Test (This is to identify lateralization of the sound) Apply the vibrating tuning fork to the center of the forehead and ask the patient where they hear it. Rinne - air conduction (perceiving the sound] of the tuning fork in front of the ear} is greater ‘than bone conduction (with the tuning fork held against the mastoid process). AC > BC Weber — normally, patients will either hear it ‘equally from bath ears or respond that they are not sure. Abnormal Response: Rinne: 1) In gonductive hearing Joss, bone conduction is greater than air conduction. BC > AC 2) In Sensorineural deatness, air conduction is greater than bone conduction. AC >BC ‘The Weber: Is abnormal if the patient clearly lateralizes it tooneear. 1) Witha conductive hearing loss, the patient lateralizes the sound to the affected ear. 2) With sensorineural deafness the sound is best heard by the non-involved ear. = ae ek wage 8 (2 aT eee a.’ eee ea eee lz BEE EPS 245 ei eg Fat Ho £ 7 3 FE QO[tine et tance cls peer ERA, Caen a te! Fand cow tommtred Chie Precblt Las tcnes Vestibular Function: Compl Seo, coer {the vestibular component of the auditory nerve i tested by ,. | Dix-Hallpike Test ‘observing for nystagmus when extraocular movements are 3... assessed) Le on Ideally 1 would like to perform following test on my patient ¥_ Dix-Hallpike Test (Noting positional nystagmus). is the definitive diagnostic test for Benign Paroxysmal Positional Vertigo (sappy) VK estore ten ere Neppepire ciel im ont OO Abe € set Y Calorie Test, PGES SE Ae Cae cor cet cores eh Y Rombers's Test, COE FC CLEC YSER is used to assess the dorsal columns of the spinal cord, which are essential for joint position sense (proprioception). Ask the patient to stand erect with feet together and eyes closed. Stand close by as a precaution in order to stop the person from falling over and hurting themselves. A positive sign is noted when a swaying, sometimes irregular swaying and even toppling over ‘occurs. The essential feature is that the patient is unsteadier than with open eyes, ‘The essential features of the test are as follows: 11. The patient stands with feet together, eyes open and hands by the sides. 2. The patient closes the eyes while the examiner observes, for a full minute. Because the examiner is trying to elicit whether the patient falls when the eyes are ciosed, itis advisable to stand ready to catch the falling patient. For large patients, a strong assistant is recommended. Romberg's test is positive if, and only if, the following two conditions are both met: 1. The patient can stand with the eyes open; and the patient falls when the eyes are closed. Patients with a positive result are said to demonstrate Romberg's sign or Rombergism. They can also be described as Romberg’s positive. a) A positive Romberg test suggests that ataxia is sensory in nature, i.e. depending on loss of proprioception. Za”. ‘Aperson is brought from sitting toa supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. Once supine, the ‘eyes are typically observed for about 30 seconds. If no nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other side is tested. if the person has arthritis in their neck, the ‘maneuver may be performed in side-lying position.) (isa test which uses differences in temperature to diagnose ear nerve damage). ‘This test stimulates the inner ear and nearby nerves by delivering cold and warm water to the ear canal at different times. Sometimes, the test is done using air instead of water. One ear is tested at a time. a) When cold water enters the ear, it should cause rapid, side-to-side eye movements called nystagmus. b) Anegative Romberg test suggests that ataxia is cerebellar in nature, i.e. depending on localised cerebellar dysfunction instead. b)_ Tho eyes should move away from the cold water and slowly back. ©) Warm waters placed into the ear. The ‘eyes should now move towards the warm. water then slowly away. 4) Patches called electrodes, placed around the eyes, detect the movements. A ‘computer records all the results. diplo pies tered Recto Yoo Gn NreHex stn Chee € { fest fean Conv bee lOve rata fay te Vain!1X Glossopharyngeal and X Vagus 1. Check palatial elevation by having the patient sustain an ‘When observing palatal moverent, look at the palate rather than the uvula. 2. Ideally | would like to do the gag reflex by gentling touching the posterior pharynx with a tongue depressor. Look for symmetric elevation of the palate. 3. I would like to ask you to take a sip of water. (Swallowing can be assessed by giving the patient a sip of water and observing them swallow.) 4. Listen to the patient's speech. Is there a nasal quality? XI Spinal Accessory Nerve (The spinal accessory supplies the trapezius and | stemnocleidomastold muscles.) a) Observe for atrophy or asymmetry of the muscles. b). Observe for quickness of shoulder shrug and ask the patient to, shrug their shoulders against resistance. ©). Ask the patient to turn their head to the opposite side against resistance, both watch and palpate the sternocleidomastoid muscle. (The 9th and 10th nerves are tested together. They are responsible for swallowing, phonation, guttural and palatal articulation (the 7th nerve has a component for labial articulation). The glossopharyngeal nerve ‘also subserves taste to the posterior one-third of the tongue but this is rarely tested.) Normal Respons ‘The palate should elevate symmetrically, both ‘when sustaining an “AH” and in response to stimulation on either side. Some patients however do not have a gag response and this ‘can be normal ifit is absent bilaterally. Patients should also be asked if they feel the stimulus. Abnormal Response: With unilateral palatal weakness, the palate fails to elevate on the weak side and the gag reflex will be absent on that side.Xi Hypoglossal Nerve (The hypoglossal nerve is motor to the tongue). ‘Normal Response: a) Observe for tongue atrophy or enlargement. Y The tongue should be able to protrude relatively straight. Minimal degrees of bb) Look for tongue fasciculations. Do not overcall tongue deviation (i.e. only millimeters) affecting fasciculations. tts very difficult to relax the tongue. only the tip are insignificant. €)_Askthe patient to protrude the tongue. ‘Abnormal Response: 4) Ask the patient to push the tongue into each cheek or with tongue weakness, the tongue alternatively to protrude the tongue and push it laterally deviates towards the weak side against a tongue depressor. ) Ask the patient to move the tongue quickly from side to side. If there is facial weakness, correct this by supporting the upper lip on the side of weakness, otherwise there may appear to be deviation of the tongue but once the facial weakness is corrected for, the tongue will no longer appear to deviate. Location of brainstem lesions Effected Cranial Nerve ~~ a)_ Lateral Brainstem lesions. CNS=IV, VI Vili, IX, X, and XI b) Medial Brainstem lesions. CNs~ 1, I, Viand Xt ©) Midbrain lesions. CNs=II, 1, Or IV 4) Pontine lesions. CNs~V, Vi, Vil OF Vill a) Medullary lesions. CNS—1X,X, XI Or Ximin: Ovtion 1 ion of Central Mr George Guidegen 76 years old man present with left arm and leg weakness to Medicine ward. You are a SHO in this department please examine the patient. Qotion 2 Mr. Vadimir Negovski, 50 years old transvestite man come to the A&E with compliance of left leg weakness please ‘examine the patient. You are @ SHO in this department please examine the patient. Ser Examination Examination Technique: ¥ Patients should be sufficiently undressed but draped to preserve modesty. Y Compare right to left. When necessary assess for a sensory level, peripheral nerve or dermatomal sensory Impairment. 1. Components of the sensory examination: a) Light touch Y Usea cotton wisp. Apply a gentle touch {do not drag the stimulus). Ask the patient to close their eyes and report "yes" every time they perceive the stimulus. b) Vibration sense Y Use a 128 hertz vibration fork. -Y~Apply the stimulus over the distal phalanx of the index finger/ thumb or large toe. Ask the patient to report whether they feet vibration sense. c) Position sense Y Demonstrate to the patient intially with eyes open that you will be moving their digit, up (towards their head) or down (towards their feet). ‘Ask the patient to close their eyes. Stabilize the distal interphalangeal joint of the upper extremity and make minimal movements upwards or downwards and ask the patient to report after each movement KN WE. Dermatomal Distribution Dermatomes ‘Corresponding Nerve —— "Cervical Segment | a) Tie c2 b) Beneath the tie 3 ©) Tipofthe shoulder C4 d) Anterior aspect ofthe C5 arm ( Biceps Muscles) e) Thumb 6 f) Middle finger co 8) Little finger cy Thoracic Segments hy Tillaxialla (Armpit) 71 D Nipple 14 i) _Umbilicus T10 SSSa the direction of movement. Similarly in the lower extremities, stabilize the interphalangeal joint and move the large toe up or down. Pain? Y Use a disposable pin. Y Ask the patient to close their eyes and report whether they feel sharp or dull. Y Be sure to apply the sharp stimulus to all sites since if only the dull stimulus is applied, in sensation has not been assessed. Abnormal Involuntary Movements. ‘Muscle Bulk Ideally | would like to use measuring tape to ‘measure the muscle bulk, but on gross ‘examination bulk appears to be normal. Tone Ensure the patient is relaxed. For assessment in the upper extremities, the patient may be lying or sitting, In the lower extremities, tone is best assessed with the patient lying down. Explain the examination technique to the patient before proceeding Spasticity (clasp knife) is velocity dependent and should be assessed by a quick lexion/extension of the knee or the elbow or quick supination/pronation of the arm. Rigidity (lead pipe) is continuous and not velocity dependent and the movement should be performed slowiy. "Activated" rigidity; minor degrees of rigidity may be enhanced by having the patient activate the opposite limb. rigidity n the neck can be assessed by slow ‘lumbar Segments ky Belt u 1) Pockets 2 m) Overtheknee cap 3 1) Medial aspect of the La st ©) Dorsum ofthefoot LS (Not big & litte toes) p) Sole sa @) Sitting & perianal sLss Tone Normal Response: Normally minimal, if any resistance to passive movement is encountered. ‘Abnormal Response: Y Spasticty is a feature of an upper motor neuron lesion and maybe minor such as a spastic catch ora very stiff limb that cannot be moved passively. Accompanying features may include spasms, clonus, increased deep tendon reflexes and an extensor plantar response. Y Rigidity isa continuous resistance to passive ‘movement and is seen in extrapyramidal disorders such as Parkinson’s disease. Rigidity may be continuous or ratchety (cogwheeling). Cogwheeling is typically seen at the wrists5. Brak flexion, extension and rotation movements Power. Power or strength is tested by comparing the patient's strength against your own. Compare one side to the other. Deep Tendon Reflexes Biceps. Triceps. radial Knee or patellar (quadriceps). Ankle, The patient should be relaxed. Explain to the patient the examination technique. Before concluding that reflexes are absent, have the patient re-enforce by performing an isometric contraction of other muscles (e.g. clench teeth or opposite limb for upper extremity reflexes or pull hooked fingers apart for lower extremity reflexes). Before concluding that ankle reflexes are absent, position the patient in a chair by having them kneel where one would normally sit, squeeze the back of the chair for reinforcement, on your count of three, just as you deliver the strike to the Achilles’ tendon which should be gently stretched by passive dorsiflexion of the ankle. Y Hypotonia (flaccidity) or decreased tone is more difficult to appreciate but s seen with lower motor neuron or cerebellar lesions. Deep tendon reflexes tested: Upper extremities: biceps (C5, C6), brachioradialis (C5, C6), triceps (C6, C7), finger flexors (C6-11) Y Lower extremities: knee or patellar (L2, 3, 4), ankle (S41, $2) Superficial reflexes: Abdominal - above umbilicus (18, 19, T10) and below umbil 712). tus (T10, 711, =: ‘Make a solution which you can run it @ 1 nnilhoar fr 24 hows and show how much normal saline is there in your solutionStep 1 | Weight x RDA ‘Dose required for this 10 kg x 15 mic gram / hour patient per hour 2. | patient ner 30 hours Step 2 (05 milligram )= 500 mic gram drug=iml | 450021 “| 4500 mie gram drug=?ml_ | 500 = 9 ml Step3 Drag + Normal saline = Sulution ~ [30m 9 ml | om + 2 30 ml =2ml Smt + 2hmt 0 ml Iwill diseard 6 ml from 30mi of solution and the remaining 24 ml solution I will run @ Im} /nour for 24 hours. Step 4) ‘Normal saline in 30m solution is 21 ml 24X21 ——— = 16.8ml Normal saline in 24 ral solution =? (Normal saline in 24 x2 solution is Question Weight 10k Required dose | 5 mie our _ Imi = mili gram ‘Make a solution whick you can run it @ 1 mV/hour for 24 hours ind show how much normal saline is there in your solution Answer | Step 1 [ —J Dose required for this Weight x RDAT patient per hour 10 kgx 5 mic gram / hour = 50 mic gram Dose required for this | 50 mie gram x30 hour pationt per 30hours = 1,00 mic prams = Step 2 (milligram) = 1000 maie gram drug = tal S00 x1 =15 ml TENN in ero deme=?rnt | 40002m of drug (2000microgram) + 2m normal saline = 4ml solution (contains 2000 micrograms) Take 3ml of this sohution(number 1) which contains 1500 micrograms +27 ml of normal saline = 30 ml solution (number 2). Discard 6ml and remaining 24ml run @1ml/hour for 24 hours. Normal saline in dial solution is: — 2ml So normal saline in 3 ml solution will be~_1.5ml 3X2 i ‘Normal saline in 30m solution is:— 27ml + L5m1=28.5ml Normal saline in 30m solution is — 285ml 24X28.5 So normal saline in 24 ml solution will be 22.8 ml ‘Normal saline in 24m solution is — 22.8ml. 6 Midazolam - 1 Question Weight kg Reguired dose | 20 mic gram/kg/hour ml = 1 milli gram Make a solution which you can run it @ 1 ml/hour for 24 hours and show how much normal saline is there in your solution Answer Step 1 Dose required for this i patient per hour 40 kg x 20 mic gram /hour = 800 mic gram Dose required for this 800 mie gram x 25 hour | patient per 25hours = 20,000mic grams = 20milligram | Step 2 1 milli gram drag = Iml 20x1 20milli gram drag? ml 1 =20ml Step 3 Drug + Normal saline 25iml—20 ml 20ml + 7 =Sml 20ml + Sml I will discard 1 ml from 25ml of solution and the remaining 24 ml solution I will ran @ Im} /hour for 24 hours. 25ml solution is 5 ml 24X5 25 (19.2 mt = 192m) ‘Normal saline in 24 ml solution is(Midazolam -2 Required dose | 20 mic gram/kg/hour 7 iml= Hi ‘Make a solution which you ean run it @ 1 mlfhour for 24 hours is there in your solution | Answer Step ‘Dose required for this | Weight x RD Patient per hour 36 kg x20 mic gram / hour 226 mie gram Slee cues Dose required for this 720 mic gram x25 hour patient per 25hours = 18,000 mic grams =18 milli gram Step 2 Trailli gram drug = Tal I8mlxi 18 milli gram drug =? mi 1 =18imt Step 3 - Drug + Normal saline = Solution - ml-mt 8m +P = 25m. Trad. zi 18ml + Tm = 25m) Twill discard I ml from 25m of solution and the remaining 24 ml solution I will. run @ 1m /hour for 24 hours. Step 4) ‘Normal saline in 25m solution is 7 tal 2X7 Normal saline in 24 ml solution = ? wo 17.28) 25 Normal saline in 24 snl solution is 17.28 mal - —_ 8 Midazolam -3 Question Weight 38k Required dose 0 mie gram/kg/hour Iml= Till gram ‘Make a solution which you can run if @ 1 mllhour for 24 hours and show how much normal saline is there in your solution’ =Dose required for this | Weight x RD/L patient per hour 38 kg x20 mic gram / hour = 760 mic gram a ‘Dose required for this 760 mic gram x 25 hour | patient per 25hours = 19,000 mic grams =19 milli grant | Step 2 i Tombs 1 =19 ml Drug + Normal saline = Solution 225ml — 19 ml =6ml 19m + ? = 25m ml + 6m = 25m [7 will discard 1 mal from 25ml of solution and the remaining 24 mil solution Fw run @ Im hour for 24 hours. - Step 4) (yee ae Ga 2 solution is Gm ‘Normal saline in 24 ml solution = Normal saline im 24 ml solution is [576 mt Midazolam -4 az kg _ 20- mie gram/kg/hour—— aos 'Limilli gram Make a solution which you can run it @ Imil/hour for 24 hours and show how much normal saline is there in your solution ‘Answer Step Dose required for this | Weight x RD/HT patient per hour 42 kg x 20 mic gram / hour = 840 mic gram Dose required for this 840 mic gram x 25hour | patient per 25hours =21,000 mic grams =21 milli gram imix i 21 milli gram drug =? ml 1 =21 mail Step 3 Drug + Normal saline = Solution 25m] —2iml 2m + ? = 25 ml = 4m 2iml_+ _4mi = 24mi Twill discard 1 ml from 25ml of solution and the remaining 24 ml solution T will,ie MEDAZOLAM - 5 _ Question Weight akg _ - = Required dose | 0.02 milli gram/kg/hour. ml = S.mili gram Matce a solution which you can run it @ 1 ml/hour for 24 hours Ind show how much normal saline is there im your solution Answer Step 1 Dose required for this | Weight x RD/A patient per hour 4 keg x 0.02 milli gram /hour = 0.08 railli gram Dose required for this | 0.08 milli gram x25 hour patient per 2Shours | =2 milli grams {5 milligram drag = imi 2 milli gram drug =? m) ‘Sial of drug (5 milligram) + 4ml normal saline | milligrams) : - Take 2m of this solution(aiauber 1) (which contains 2milligramsdrug) +23.ml-.|—.——__ of normal saline = 25 ml solution (numbey 2). Discard Imi and remaining 24m1 run @1mYhour for 24 hours. ‘Normal saline in Smal solutiow is: — ral 4X2 So normal saline in 2 ml solution will be ~ a = Ll 16 ml 5 Normal sahine in 25m sotution is: 23m + 1.6m] = 24.6m)_ Normal saline in 25ml soludion is — 24.6m1 24X 24.6 a = 23.616 mal So normal saline in 24 ml solution will be 25, ‘Normal saline in 24ml solution is— 23.616 mal. (but I will take 23.62ml sine we cannot take 3 decimals in any syringe). Ui _[- Morphine 1 Question Weight TikeRequired dese [25 mic gram/kefhour tml = Limilli gram - Make a solution which you can ran it @ 1 inl/hour for 24 hours and show how much normal saline is there in your solution ‘Answer - step 1 Dose requited for this | Weight x RD/HL patient per hour 4 kg x25 mie gram /hour L =100 micgram ‘Dose required for this 100 mic gram x30 hour |_patient per 30hours = 3,000 mic grams =3 milli gram Step 2 Tmilli gram drug = al 3x 3 milli gram drag =? ml 1 =3m) Step 3 ‘Drug + Normal saline = Solution 130ml — 3 mi 3ml + 7? = 30 mi =27 mi 3ml + 27m = 30m Twill diseard 6 ml from 30ml of solution and the remaining 24 mil solution I will run @ Iml /hour for 24 hours. | Step4) _ are Normal saline in 30ul solution is 27 mal 24X27 Normal saline in 24 ml solution a = 21.6mt 30 oat Normal saline in 24 ml sotation is 2.6m 2 Morphine -2_ _ Question Weight Akg Required dose | 30 mie gram/kg/hour im{ = 10 milli gram Make a solution which you can ran it @ 1 ml/hour for 24 hours ind show how much normal saline is there in your solution Answer Step 1 I Dose required for this | Weight x RD/L patient per hour 4g x30 mic gram / hour = 120 mie gram ‘Dose required for this | 120 mic gram x 25 hour patient per 24hours _| = 3,000 mic grams =Smilli gramStep 2 — ml of drug (1Omilligram) + 9m normal saline = 10m solution (contains 10 milligrams) Take 3ml of this solution(aumber 1) (Which contains 3milligrams drug) + 22 ml of normal saline = 25 ml solutiois (aumber 2). Discard Iml and remaining 24ml 01 ‘Normal saline in 10m solution is: — 9mi So normal saline in 3 ml solution will be— 1.5ml 222ml + 2.7ml = 24.7ad Normal saline in 25ml solution is :~ Normal saline in 25tal solution is - 24.7ml 24X24.7 80 normal saline in 24 mi solution will be Normal 24m solution is— 23.712 ml. (but I will fal cannot take 3 decimals in any syringe). 13 Morphine -3 Question - — Weight | Ske : Reguired dose _/20 mie gram/igjhour 7 ‘hal = 10 milli gram Make a solution which you can run it @ 1 mM/hour for 24 hours ind show how much normal saline is there in your solution Answer Step 1 Dose required for this | Weight x RD/H patient per hour 3 kg x20 mic gram / hour = 60mie gram Dose required for this | 60 aie gram x25 hour | patient per 24hours = 1,500 mic grams ~= 1.5 milli gram Step2 10 milligrara drug = imi [4 xt 1.5 milli grem drag =? ml 10 = 0.15 ml Ina of drug (10milligram) + [inl normal saline = 20m solution (contsins milligrams) ‘Take 3ml of this solation(anmber 1) (which contains 1,5 milligrams drug) + 22tal of normal saline = 25 ml solution (umber 2), Discard Iml and remaining 24ml rim @ln/hour for 24 hours. Normal saline in 20m! solution 19m) 9X3 2.85 ml‘Normal saline in 25mal solution iy -— 22m] + 2.85ml = 24.85inl ‘Normal saline in 25ml solution is — 24.7m1 24K 24.85 So normal saline in 24 ml solution will be ————- = 23.856 ml : _ L 25 Normal salize in 24ial solution is ~ 23.86 ual. (but I will take 23. 72ml since we cannot take 3 decimals in any syringe). 14 _.__| Heparin Patient requires 30,000 units of heparin for 24 hours. Make a 48mi solution to ran for 24 hours. im] = 25,000 units. | Answer: a T 25,000 units = ml "30,00051 30,000 units =? | 25,000 =1.2ml Drug + normal saline = solution 48 -1.2= 46.8 12m +? = 48ml 1.2m + 46.8 =48 ml = Normal saline in 48ml solution is - 46.8ml is INSULIN - 1 Question_ ‘Weight | 40kg Required dose | 0.05 Units/kg/kour a 10 m= | 1000 wints ‘Make a solution which you can run it @ 1 ml/hour for 24 hours ind show haw nich normal satine is there in your solution ‘Answer Step1 ‘Dose required for this | Weight x RDAZ ~ patient per hour 40 kg x0.05 winits/ hour =2 units Dose required for this {2 units x 24 hour patient per 24hours =-48 units Step 2 [7,000 units = 10ml AB xi | 48.uints = ml 1000. = 0.48 mi ‘Drag + Normal saline = Solution 24nd — 0.48 ml —T 0.48 + ? = 24ml = 23,52 ml048ml + 23.52mb = 24 ml [ Normal saline in 24 ml solution is 23.52m1 16 INSULIN - 2 Question - _— Weight | 30 ke [Required dose | 0.05 Uniisikghhour 10 ml= 11000 wings _—— ‘Make a solution which you can ran it @ 1 mi/hour for 24 hours jna show how much normal saline is there in your solution — Answer z Step 1 Dose required for this | Weight x RDAT patient per hour 30 kg x0.05 uinits/ hour = =1.5 units a Dose required for this [1.5 units x 24 hour patient per 24hours =36 units _ ~}Stepa—-———. | an man fia _ 1,000 units = 10mi 36. x1 36uints = ? ml 1000 = 0.36mi Drug + Normal saline = Solution ‘24m — 0.36 ml 036ml + 7 = 24 ml = 23.64 ml 0.36 m + 23.64mi = 24 ml | Normal saline in 24m solution is - 23.64m) 2 a 17 INSULIN 3 . Start an Insulin infusion @1 unit/hour in a solution of 100mi/hour for 5 hours. Do the calculation , prepare and demonstrate. _ Given in the station | 500ml ‘Syringes provided : normal 0.5m), iaal,2ra),Sm},1 0ml,20ml and Som! saline bag. (note ; 0.5m and 1 ml syringes are Insulin Insulir-vial | syringes) _ 10m = 1000 unitsIx 5=Sunits Tnsulin required for 1 hour is So Insulin required for 5 hours is 1000units = 10ml 5 units = 0.05ra1 = 0.05m1 T will take 0.05mai(Sunits) of Insulin and insert into 500ml aormal saline bag and run it @100mi/hour (Iasulin @1unit/hour) for 5 hours. Preparation Ideally I will do this with a witness. Take all sterile precautions. Cheelc the name and expiry date of Insulin, Normal Saline, syringes and needle, Check on the table for the drugs, Normal Saline, appropriate syringes (should be inside an unopened pack), needles(needle is attached to syringe in Insulin syringes), sharp bin, sterets and gloves(may not he kept). _ Demonstration aa ¥lip open the metal cap (if present) on the Insulin syringe, but ifthe cap is already opened (means it was used already before) then clean the rubber cap with the steret, Take 5 units(0.0Sml) accurately in a 0.Sml Insulin syringe. Clean the surface of the small port( yellow cap) of 500ml normal saline bag with the steret, Insert the drug through that port (insert the needle of the syringe ~ no need to open the cap on the bag). Discard the needle and the syringe in the sharp bin. ‘Then label the bag and run it @100ml for 5 hours {Label Patient name DOB _ ‘Hospital ntunber ‘Name of the Drug Concentration of the drug Rate of Infusion Date —— ‘Time started ——— Prepared by (name and sign) _| Checked by —-(name and sign of the witness) 18 INSULIN 4 Start an Insulin infusion @2 units/hour im a solution of 100mY/hour for 5 hours. Do the ‘calewlation , preparé atid deimonstite. Given in the station | 500ml Syringes provided : normal 0.5ml,ml,2m},Smi,10ml,20ml and 50mm, saline hag (note: Ami and 1 ml syringes are Insulin[a9 [Diazepam Answer 7 Insulin required for J hour ls =2units. a5 = 1Ounits So Insulin required for 5 hours is = 1units. 1000units = Omi idz10 10 units = 0.iml 1000 = 0.2m) ~ Twill take 0.Lml(10units) of Insulin and insert into 500mi normal saline bag and'run it _@100myhour (Insulin @2units/hour) for 5 hours. Preparation l L Tideally I will do this with a witness, ‘Take all sterile precautions. Check the name and expiry date of Insulin, Normal Saling, syringes and needle, Cheek on the table for the drugs, Normal Saline, appropriate syringes (should be inside au unopened pack), needles(needle is attached ta syringe in Insulin syringes), sharp bin, streets aud gloves(may not be kept). Demonstration Flip opea the cap (if present) on ihe insulin syringe, hut if the cap is already opened (means it was used already before) then clean the rubber cop with the steret. ‘Take 10 units(0.1ml) accurately in a 0.5ml or Ll Insulin syringe. Cleau the surface of the small port( yellow cap) of $00m) normal saline bag with the steret. HInsert the drug through that port (insert the needle of the syringe —no need to open the cap on the bag). Discard the needle and the syringe in the sharp hin. ‘Then label the bag and run it @100ml for 5 hours Label Date (Patient name DOB “Hospitelmumber |e [Name oftheDrag ‘Concentration of the drug Rate of Infusion ‘Time started Checked by —(name and sign of [the witness)_ Make a 50m solution at a concentration of 0.2mg/ml of Diazepam. Prepare and‘ Given in the station_| 1) 50ml normal saline bag. 2) Diazepam (2 ampules) Each ampule is Iml containing Smg of Diazepam. _| 3) 50 Syringe provided Twill take 2mls(10mgs)(ie Iml from each ampule) of Diazepam in 2 50ml syringe and | then I will tale 48m of normal saline into the same bag. Preparation i Lideally I wil do this with a witness. ‘Take all sterile precautions. Check the name and expiry date of Diazepam, Normal Saline, syringes and needle. Check on the table for the drugs, Normal Saline, appropriate syringes (should be inside an unopened pack), needles, file to eut open the ampule, sharp bin, streets and | gloves(may not be kept). Demonstration ‘Cut open the cap of the Diazepam ampules, (@2 ampules) ‘Take Im] from each ampule in a 50 ml syringe and the withdraw 48 ml of normal saline into the same bag after cleaning the small (yellow coloured) port on the normal saline bag, Diseard the needle and the syringe in the sharp bin. ‘Then label the bag. Label Date Patient name DOB a Z Hospitalnuimber Name of the Drug Diazepam Concentration of the drug 0.2mg/mal | Rate of Infusion Date-—— ‘Time started ——- Prepared by -—-(aame and sign) | Checked by —(name and sign of the witness) —_} aoe Answer 1 wl of solution shonld contain =0.2mg of Diazepam | 0.2x50= 10mg | So 50zul of solution should contain = 10mg of Diazepam. 1 Smgs = Iml {toxi 10 mgs =2 ml 5 =2ml [Drag + Normal saline = solution 50-2=48 2ml +? =50ml 2ml__+48ml 50my Dv ge ee ure 2A c * py Bo \ vo \ Stable > ; ae P1EF 8 Look bbe merked in sted quate \4y ayo WwW OD wrorce J v jouypar 2 fo aw rimsdos BNCR Nm eee dlngu " becaationad Avan — Semvod ier opie, eae ae bow Ris Th Becela> - BWeorod) ner “Dow oe one. WOE mato Atlant on ape W.. Unprotected bey aryorer 4 cerynt Perkrwre > fle few paw) mas ms 1 @ bot. aes pena mai eu) “eng! bin, Ma egy? - Se abo? 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