Miki's Med Notes

Ultimate Finals List - Surgery

2010-06-15T16:01:00.000-07:00

Surgery

Surgery: A game in how to fail an osce. Guy had colostomy with parastomal hernia. So I looked, got told off for running commentary (don’t do it to a surgeon) did the abdo exam, thought I’d finished and spent the next minute with the examiner looking at me and saying come on then.. have you really finished? I was in such a state by then, couldn’t remember if I’d done all the exam and didn’t want to continue it if I had so kept deciding to re-examine then stopping like some demented jack in a box. Questions on the stoma, very brief. Asked about possible reasons for the stoma // Patient had a parastomal hernia. examine and present findings. Asked why patient has had a stoma (Hartmann's Vs AP resection), types of stoma and indications. Asked what i would examine next - i said perineum, hernial orifices and external genitalia. Examiner then asked me to examine hernial orifices - normal except for two tattoo marks from radiotherapy (which the examiner told me everybody else missed!) then asked to put it all together and say why patient has a stoma - colorectal cancer, surgery, stoma which hasn't been reversed and radiotherpy for malignancy! // patient with colostomy and scars. Was asked to examine groin – patient had rash on one side but not on the other and also a radiotherapy tattoo mark but was unable to put it all together.

Abdominal exam- stoma- colostomy. Asked why the gentleman may have it in place. Then what else I would like to check... when I mentioned that I would like to check the anus as it would differentiate between an abdomino-perineal resection and an anterior resection, the examiner then made me examine the perineum without gloves and made every student after me do it too, so know how to examine it!!! I can't remember much about this station, it was my first one and the perineum examination threw me a bit!! // "Examine this patient's abdomen" ...the patient had a stoma. I don't know why I was still panicking, I saw the stoma and focused too much on it. I completely forgot to check for bowel sounds or shifting dullness!!! The stoma was the main thing, the man had a midline laparotomy scar as well, so I was quizzed on what I thought the stoma was (a colostomy) and why (left sided etc etc) operation the patient had, I said Hartmann's because the examiner had told me the anal canal was patent. That was apparently correct, the examiner then asked me why this patient might have had Hartmann's I said colorectal carcinoma or acute diverticulitis which was also apparently fine. The examiner then asked what ELSE it could be, I then said an A-P but I would have expected the rectum to be over sewn (i.e. anal canal NOT PATENT). The examiner then said "REALLY?" and I said " YES" and then had a million other ways of saying the same thing, and the examiner started shaking his head....I'm still not sure what he wanted me to say!!!

GI - - abdo exam of patient with stoma, Urostomy bag / ileal conduit due to bladder cancer plus ascites

Surgical - Abdo examination - small bowel obstruction post op, nephrectomy scar present, asked on causes of SBO, different types of resection

Surgical exam- Lady with multiple scars including midline laparotomy, left subcostal, plus stoma in right iliac fossa. Couldn't find any other signs or think of explanation for scars. I mentioned I would test for hernias to complete the exam, was told to procced but bell went. Was told she had Crohn's and asked about its surgical treatment. Didn't get round to mentioning about stenosis, fistulae, perianal abscesses etc.

Breast examination, left upper outer quadrant mass, DDx, genetic counselling

Surgical exam - mastectomy and examination of other breast, followed by discussion about breast cancer, risk factors, treatment options etc.

Surgery - peripheral vascular exam of legs, arterial history, varicose veins (needed to be stood up) // Peripheral vascular examination of claudicant asked about Buerger's Test. Values for ABPI and how would do it Surg stations was peripheral vasc- this was difficult and bitty- buergers was positive but the reactive hyperaemia was mild and i think many students said it was negative. Useful to do this test on a real patient before the exam! Ques- what would you expect his ABPI to be? What is normal? Explain how to do it. // SURGERY I had a gentleman with and amputated foot, lots of weird pigmentation around his ankles, I was asked to do a vascular examination of the legs, so got to him to stand up looking for varicose veins, he had none, so went on to arterial, had to Buerger's test to, I made it up completely, I could not see the leg going pale at all, but there was and obvious hyperaemic reaction when he swung his leg round, he had obvious haemosiderin deposits too, I think I would've done better if I knew what type of amputation he had, he asked me why what is a positive Buerger's test, why do u get a hyperaemic reaction, what does it mean if he has haemosiderin deposits, what was an ABPI, what reading would indicate critical ischaemia, this station was never ending!!!

Vascular - gentleman with an aortofemoral bypass graft (scars) and claudication. Poor pulses. // surgery: peripheral vascular disease....he asked: there is a scar in right groin and on medial aspect of right knee put it together...femoro-popliteal bypass...then he said feel the bypass and it has a hard lump on it..then he said to present the lump and a lumo!!! duo station...sly... // Surgery - peripheral arterial examination on an Asian patient with an amputated foot and scars from a fem-pop bypass on the left hand side, but normal pulses on the right. Very nice examiner, I examined the patient and presented and then it was more an informal discussion rather than proper question and answer, I got a question wrong and the examiner just corrected me. // Surgery: Peripheral vascular examination, did not want me to perform burgers when I tried. No radial, femoral pulses on the left, Sternotomy scar. Turn out to have lots of scars which were very hard to spot, got asked about a scar...which vein and what it was for (CABG), also about another scar which was a fem-pop bygraft // Surgery – assess this patient’s vascular STATUS (means varicose veins AND arterial examination). Man had no varicosities but had absent pulses below femorals bilaterally, also had positive Buerger’s test in right leg, had to scars over upper thighs and midline abdomen, was an aorto-bifemoral bypass operation. I was then asked what other reasons he would have had this operation besides atherosclerosis, no idea.

Peripheral vascular examination - femoral atherosclerosis

The next patient I was told to "examine the legs", I did not know if it was a surgical, locomotor or neuro station so the examinrer just said "why don't you ask the patient to stand up." The patient had huge varicose veins. I was asked to examine this and the peripheral vascular system of the leg. Then asked about the pathogenesis and anatomy of varicose veins. // pvd, Qs asked-where do u suspect the prob to besuperficial femoral (needed basic anat knowledge), treatment

Peripheral Vascular Disease. Patient had cold white legs. Pulses difficult to find. His radial pulse on the left was weaker on the left than on the right. If you found this sign you were asked about the possible causes and in most cases ridiculed by the especially unpleasant examiner. Which was nice.

vasc- wasn’t sure if this was varicose veins or arterial I did arterial though there were tourniquets I didn’t touch them. bit ulcers and all sorts- not my best station! I said the patient had oedema- examiner asked what type, I said pitting. then I was asked to demonstrate this. it wasn’t pitting! so he said what is it called! I said dependent oedema? the examiner said 'LYPHOEDEMA' 'have you ever heard of lymphoedema?' yes I had thanks for making me feel thick! // Surgical – pls examine this pt’s legs – fat ulcer on lat malleolus. Did arterial exam and went with arterial ulcer but q’s on venous ulceration... // surgery - arterial examination. only question was why arterial on grounds of inspection? obvious discolouration and arterial ulcers etc //

Hernias - inguinal and incisional, keloid scars, direct hernia // Surgery : Examine this persons groin. Direct Inguinal hernia. Asked about treatment options. // Surgery: Guy with lump in the inner thigh- lipoma. Had to test for cough impulse, lying and standing, felt scrotum for masses, mentioned that I would like transilluminate th mass. Examiner was happy and asked me for differentials and to say why I thought it was not that: e.g. femoral artery aneurysm - NOT pulsatile, saphena varix - NO cough reflex, sebaceous cyst -NO punctum etc. This sounds a litte bit daunting but it really was a nice station, and the examiner was very encouraging throughout. For these 2 stations, students are given a list of the questions they will be asked well in advance on the revision courses and handouts. The mark sheets are also available online so it's a good idea to use them and make sure you can answer the questions about different scenarios.

surgical: the patient had two lumps. One on her right forehead and another of right forearm. I went through site, size, shape, colour...etc..and said findings were most consistent with lipomas. The examiner said that was correct but wanted other differentials..we talked about sebaceous cysts, lymph nodes, AV malformations, dermoid cysts and other weird and wonderful lumps and bumps.. at the end he asked if I would refer this lady ..I said 'the lesions appear benign on examination but I would refer to be safe'..examiner said 'good’. examiner then asked what my first line imaging modality would be ' I said ultrasound'..examiner said 'good'.

Surgery - incisional hernia (only seen when getting the patient to raise his head), bronze skin + ?hepatomegaly (mentioned haemochromatosis but not sure). Lots of people thought this patient was normal. Got asked lots of questions on scars, hernias and causes of hepatomegaly. // Abdo – no idea, lots of scars, 1 in RIF, I mentioned it could be appendicectomy (examiner looked pleased), instructions actually said, ‘examine this patient’s abdomen, who has a lump in the groin’. So you had to do abdo exam, and then examine his scrotum and hernial orifices. He also had a slight splenomegaly I thought, but others thought it was hepatomegaly, he could not lie flat so this made it difficult to palpate the abdomen. He was tender in the lower abdomen. No idea what was going on. Examiner then asked what the lump in the groin was, I said an inguinal hernia.

Abdominal exam- man had midline laparotomy and ?appendicectomy scar. Examiner walked off when my back was turned and was replaced by another guy. Maybe this meant he had no signs apart from his scars- I couldn't find any. Examiner said the scars were related. I suggested kidney transplant and he asked why would there be a laparotomy. I said it wasn't a kidney then, and he said he didn't say it wasn't a kidney. Confusing. I think he had an incisional hernia which I was meant to test for- getting him to lift head while lying down. // Surgery - Abdominal - laparotomy scar, AP resection scar, colostomy, urinary catheter but no abdo signs.

surgery: inguinal hernia AND abdo exam AND scrotum exam AND examine a strange lump on the back......... not sure i could find a connection between the 2.. i think he had massive hepatomegaly which i gave as a cause for the hernia although i dont think i examined the scrotum properly because i then was asked a lot about clinical findings in a hydrocele and what i would find in the scrotum of someone with an indirect hernia and a hydrocele ie patent processus vaginalis - ie would you be able to feel any discrete masses? // Examine hernia, expected to include scrotum, asked about whether I would refer the atient, to give differntials, then asked a bit about anatomy, lymphatic drainage of the groin and surrounding structures etc - and what a mesh is adn how it work, why heneeds op, risks, is the lump malignancy, can he drive and when after, and when he can go back to work,,,it was not consenting them.

Surgery - sebaceous cyst of scalp, a really awkward 10 mins, had finished the examination (where's the red desc lamp!) in about two mins, had to give a differential - lipoma, neurofibroma. Examiner asked me to list the structures of the scalp and then explain to the patient what she should have done about it.

Surgery - man with a ganglion on the back of his hand. Just exmaine a lump/bump and test median/ulnar nerve function (the guy was a dr himself.. maybe the hernia didnt show up)

Surgery - Lump in the neck. Assess lump to see if its a thyroid lump and then assess throid status. How would you Ix- TFT, FNA, USS, biopsy. Complications of throid surgery eg, bleeding, infection, damage to laryngeal nerve, damage to parathyroid glands- hypocalcaemia.

Ultimate Finals List - Neurology

2010-06-15T14:50:00.000-07:00

Neurology

CNS – During our five minutes rest before my next station (CNS) one of the patients asks to go to the loo. On his walking back I couldn’t help but notice – stooped posture, expressionless face, slow turning and a lovely pill rolling tremor of the right hand. Five minutes rest up – “please examine this man’s gait and then upper limbs” – differential and diagnosis and that’s it... // Neurology - PD with choreoform movements superimposed from drugs - I just homed in on the chorea even though I elicited all the signs of PD doh! // parkinsons disease ( was very well prepared for this after your course!!! ) - Guy with Parkinsons. Asked to examine upper limbs and gait. Obvious rigidity and tremor. Cogwheel rigidity on synkinesis. Demonstrated glabellar tap and asked by examiner to demonstrate bradykinesia. Examiner asked me most likely cause and then other possible causes. Then how I would manage the gentleman- drugs, MDT, palliative care, information, liaison with primary care etc. cranial nerves, bilateral weakness of the upper part of the face, give differentials // Neuro – The patient had an obvious unilateral pill rolling tremor. The examiner asked me to examine the patient's motor function in his upper limbs. I first got the patient to walk and he did have a shuffling gait. I then examined his arms (and used your scheme of examining roots C5-T1, which was very helpful thanks) and found signs consistent with Parkinson's disease in the arm which had the tremor. The examiner asked me my differentials. I said that all my findings would be consistent with a diagnosis of parkinson's and he said "well common things happen commonly" and then asked me questions about the treatment of parkinson's and the impact on a patient's life ("Are there any other questions you would like to ask this patient?")

Horners syndrome

Speech assessment - previous MCA and expressive dysphasia Assessing pt’s speech. Glass of water next to pt – I didn’t use it, although probably should have. She’d had a stroke – questions about which area of brain (expressive aphasia). // Speech Exam, woman had expressive dysphasia. Also had arm in flexed extrapyramidal position, which I noticed, but forgot to mention. Not sure if were meant to do writing/reading/ say would do mental state exam. I missed out all those things from my basic speech exam routine I’d learnt! Examiner quizzed me after I’d talked about testing for a conductive aphasia . When I left I heard him telling the actress that he’d never heard of it and needed to go look it up now and that you learn something new every day!! Bit annoying cos if he hadn’t quizzed me about it I would have had extra time to do more speech exam! I expect he passed me on the station though. // Assess speech of patient, expressive dysphasia // There was a actress with a simulated expressive dysphasia, she also had a 'stroke' arm and a deviated tongue,I assessed comprehension, repetition, reading and writing the examiner asked me if I'd like to do anything else, not quite sure what he wanted. // Was then asked where the lesion was in an expressive dysphasia // Speech examination- in actor with right sided arm flexion deformity, Broca's dysphasia (expressive) I forgot the bit about getting them to repeat "British constitution" "baby hippopotamus" "butter" etc. // Assess Speech – Broca’s aphasia // Speech assessment on an elderly lady with a stroke posture (flexed arm, extended leg). She can’t really say anything well (expressive dysphasia) but can understand commands. Begin by asking her a general open question to assess her general speech, i.e. ‘how did you get here today?’ Ask her to say bread, butter, baby hippopotamus, she says Yes, Yes, Yes, then move on to commands which she complies with. Then ask her to say, ‘no ifs ands or buts’ (which tests the connection between brocas and wernickes areas). Can also ask her to say’ka ka ka, la la la, ma ma ma to assess pharynx, tongue and palatial involvement in speech. Finally do not forget to do a mini-mental test, the examiner should stop you half way as the patient cannot answer any questions properly. Examiner then asked what is wrong? Expressive dysphasia due to stroke. Where is pathology? Broca’s area, in frontal left lobe (usually).

Neuro- Spastic paraparesis. I was asked about possible differentials. // Neuro - lower limb examination of man with "stiff legs" He had spastic paraparesis. Quite good upper motor neurone signs with pyramidal distribution of weakness. //Neuro was spinal cord lesion with bilat UMN signs in legs // Neuro: Pt had scissoring gait, increased tone, bilat brisk reflexes. I presented findings and said these were consistent with 'spastic paraparesis'. I talked about finding a sensory level but the examiner only wanted me to perform motor exam. I summarised cause of spinal lesion: demyelination, vascular, mitotic change. Examiner said ' well that seems very comprehensive' . // NEURO- my worst station! had a lovely lady with bilateral upper motor neuro signs in her legs, but the power in the legs varied, and sensation was normal I think, I didn’t get to complete my examination so he just asked me what I would do, he then asked me to present my findings and I went blank and could not remember what I had found! he calmed down and asked me what pattern I had found, I said upper motor neuron lesion, he smiled and said hats all he wanted. he then asked where I thought the lesion was considering both legs were effected, I just said a lesion in the spine, he wanted to know where exactly...the bell went, I ran out!

right sided hemiplegia - upper limb neuro // Neuro: upper limb examination: right sided weakness with UMNL signs...he asked what else wud u like to do.,. I said examine the leg to look for hemiplegia...indicating stroke..he asked where wud the lesion be...in the left lobe....then he said which one vessel wud u like to examine...carotid n listen for bruits....anything else you’d b interested in: ECG for AF or mitral stenosis embolic stroke, since she was bout 40yrs old. // Neuro: stroke, asked about what other systems I would exam...cranial nerves, cvs looking for risk factors, AF, Ix doppler of carotids, got asked about what gait I would expect the patient would have, I answered spastic, scissoring but examiner was after 'hemiplegic'.

Neuro- man who had car crash, with multiple cranial nerve palsies. Right IIblind(causes relative afferent pupillary defect), right III (part ptosis), left VII. Couldn't finish all 12- included Rinne, Weber, acuity test etc. // CNS: Multiple cranial nerve lesions in a 16 year old girl.(not corellating to any random syndrome i.e. Cavernous Sinus/Jugular Foramen). Decreased visual field on left temporal, left VI nerve palsy, sensorineural hearing loss on left and fasciculation of the tongue. I concluded that it could be due to meningitis. // Neuro cranial nerves exam - loss of smell, blind in one eye, sensorineual deafness, facial nerve palsy - a great learning case!

Neurological assessment of eyes, meningism, photophobia & headache, SAH & meningitis, obs chart (high BP & low pulse) - visual fields, eye movements, accommodation, Ex & signs - acuity & opthalmoscopy, Kernig's, DDx, Ix - CT/LP // Hx and Ex of headache and eye pain???? no one knew what that was about!! Examination of eyes - presenting complaint: acute onset severe headache, problem with eyes, high blood pressure. (on the table nxt to pt was a 'sensory neuro' set ie. cotton wool, tuning fork etc..?! also hatpin, pen torch) - asked by examiner to proceed - pt was covering eyes with hands (photophobia) - basically went through eye examination ie. acuity (told not to worry about that as there was another station that tested this), fields, light responses, extraocular eye movements... - then asked for what else I might expect to find on examination with his presenting complaints eg meningism sign - asked to perform tests to elicit this (i did kernigs) - asked about my differential diagnosis: SAH and Meningitis - asked investigations i'd do, CT, LP, bloods - then asked to look at the Blood pressure again and whether this is what i expected if DDx was SAH, it was a high bp so i said yes! (is that right!?!) Overall comment: the examiner really helped me along on this one, she definitely wanted to see what I could do, not what i couldnt. This station had come up either last year or the year before. // Examination station. Patient presents with sudden onset of severe headache. Told not to take a Hx or do a full neuro exam, so i exmained the eye movements. accomodation, pupil reflexes, acuity and fundoscopy. I also tested for neck stiffness, and signs of meningism. asked to present findings and give a differential diagosis. Asked what condition i wanted to exclude and what investigations i would order and what i would find if it was SAH. examiner was happy with that // Actor covering his eyes and shouting out that his head was in a lot of pain!!! Supposed to do all the eye exams but basically you picked up say, an ophthalmoscope, and examiner said 'very good, move on' I also did Kernigs and made him move his neck around. Diagnosis subarachnoid haem and questions on it. // A women with symptoms of a sub arachnoid - 'examine her eyes'

Neuro - glove and stocking sensory loss - DDx, hemiplegia, myotonic dystrophy // Peripheral neuropathy, very nice case!!! I was asked the differentials after I said peripheral neuropathy secondary to diabetes, I said I didn't know, then the examiner said B12...and then I realised he meant the differentials for the causes, I had a complete panic attack and said "I know these!!!!!!" and then literally machine gunned about 10 causes at the examiner who again smiled to himself. The examiner then asked me what I would prescribe if the patient had neuropathic pain. I said gabapentin and the examiner asked what would be my first line. I then said tricyclics which was apparently fine because the examiner didn't bother asking anymore

Neuro - post-ear op, VII nerve palsy

PNS – MS, MND, mixed UMN and LMN signs // Neuro – lower limbs motor. Middle aged gentleman with two walking sticks, wasting of calves, upgoing plantar on right, hyperreflexic on right. Reduced power bilaterally, more on right. Asked differentials and a diagnosis, I said motor neurone disease, to which the examiner asked, ‘what feature is NOT present which you would expect to be present in a patient with MND? I had no idea, examiner said ‘· fasciculation’. // Neuro- asked to perform an neuro exam of the lower limb. Still not sure what it was- mixed UMN and LMN on legs. Spasticity, Increased knee reflexes, decreased ankle reflexes and down going plantars! Normal sensation. She asked for my findings, then differential. She then asked if I thought it was UMN or LMN, I mentioned it was mixed signs. She asked me to pick one. I said UMN and then she asked no more questions!

Upper limbs neuro and advice for sensory loss over axilliary area - The scenario for the short case was a young man who had been in a car accident with a whiplash injury, all X-rays had come back normal, but several days later he represents with some concerns. On questioning he says he has pins and needles in a patch over the outer upper aspect of his right arm. However on examination he has no pain, no stiffness of his neck and a neurological examination was entirely normal. He then asked for advise about whether he could return to work as a secretary. My flatmate took the osce at another site, the same scenario but a different actor who had mildly reduced power and sensory loss in a C6-8 distribution. She was asked what investigations she might do.

There were several stations where I found your advice to be flexible particularly useful- e.g. you are a doc in A&E and a patient presents 3 days post whiplash injury. instructions were not clear as to whether we should examine neuro of arms, locomotor of neck, history or explanation re return to job and physio etc. Obviously time allowing we would have liked to do all of these and most of us squeezed in as much as we could. // Management of whiplash - tingling in neck - examine neck and UL neuro, and reassure pt - examine c-spine, neck movements (and does it cause any tingling) - Tx, Mx, exercise, can i go back to work?

Neuro - power loss in one leg and sensory loss below knees - struggled with putting the signs together. // The next patient again I was asked to "examine the legs". He had wasting, normal tone, 3/5 power, brisk reflexes and no co-ordination (due to decrease power) in the left leg and a normal right leg. he also had a glove and stocking peripheral neuropathy in both legs. I said he had a peripheral neuropathy and a LMN lesion, but didn't really know. I got asked about my differential for peripheral neuropathy.

Neuro - common peroneal nerve and median nerve palsy

Neuro - patient with neurofibromatosis type 1, asked to examine her skin and then the ulnar nerve and her reflexes, other features? - neuro- neurofibromatosis- patient had many neurofibromas and cafe au lait spots.. asked about differential .. then a bit about the condition, when we would chose to operate.. wheere the neurofibromas can grow and what other problems it may cause....she also had a scar on her forearm which was over the ulnar nerve....then i had to show the examiner how to test for ulnar nerve palsy (thanks to your course i was able to do this well) also asked about hypertension and why these patients get it-

Visual fields testing-homonymous hemianopia and questions about causes (Stroke, Cerebral tumour, trauma asked which most common) // Visual fields (given red and white pin - I only used the red but not sure) - bitemporal hemianopia but actor was unsure... // Neurology: Examine this patients visual fields. Patient had a bilateral left sided lower quadrantanopia. Asked about where lesion may be and causes. Right sided parietal lobe.

neuro - i gave him 0/0 power in the limbs because he wouldnt move them when i asked him to... but forgot i had just assessed his gait which was relatively normal....!!

Cranial nerves: unilateral LMN lesion

Neuro - obvious diagnoses of myasthenia (bilat ptosis) examiner asked me what I wanted to do next, all the stuff was there for cranial nerves so I did them and discovered a field defect on the Right. A lot of other people said they wanted to examine her for fatiguability and the examiner just let them carry on making her wave her arms around, he gave no indication of which examination you were expected to perform. I found it very useful to ask the examiner at the beginning of each station whether they wanted me to talk through, most said that it was up to me. One consultant told me to remain quiet so that I couldn't prompt myself(?) another said "thank you for asking me what I'd prefer, all of your colleagues rabbit on dreadfully, it's tiresome". Mind you he was about a hundred and ten.

neuro- cerebellar examination // Cerebellar syndrome secondary to phenytoin toxicity. In addition i performed sensory examination for peripheral neuropathy and examined for diplopia as these are also side effects. Note: scenario only tells you that patient has long standing epilepsy and now presents with a drunken gait please examine as appropriate. Examiner asked me to present findings, give him a Dx ( cerebellar syndrome secondary to phenytoin) // causes of a cerebellar syndrome.

Oh god - neuro! Said 'do lower limb exam'. Young man had obvious upper motor neurone signs in both legs as even I could get all the reflexes (never normally happens!)But I completely panicked and forgot to make him stand and walk-aargh!! So had lots of time left and started doing sensory exam – loss of sensation in both legs. Diagnosis was obviously MS

Neuro - this station was the worst station I have ever done in my life. We all felt it was incredibly unfair. We had to perform a cranial nerves examination on a really non-compliant patient. In the end she was so bad at following my instructions that I only managed to get to cranial nerve 5 in 7 minutes, although I think the examiner was aware of why this was because for students after me, he stopped them in their examination much earlier on and just grilled them instead because the patient was really not helpful. In the end she had a VP shunt running down her neck and frontal bossing, which although strictly speaking not part of a neuro exam, were how you were supposed to figure out that this patient has hydrocephalus. And then you had to answer questions on that. If the medschool have got half a brain, they will not use his patient again cos she is not compliant enough for exams.

NEURO-bilateral weakness one side worse than the other, I thought it was · unilateral with a semi-circular gait, Qs- could it be and what is Brown Sequard?

neuro, still don’t know what that was I was asked just to do sensory of lower limb patient said he felt everything so I didn’t find anything wrong. though I was asked to Romberg’s and patient was wobbly even though jps was normal so I don’t know! it wasn’t cerebellar either

Neuro - man with diplopia which miraculously disappeared as I was examining him - he said I was a magical Dr and that I had healed him - a good thing to happen in an OSCE. Had to work out which eye muscle was faulty etc.

Neuro - evil station, 'this man has problems with his vision, please examine his cranial nerves'. I was made to perform fundoscopy, test his visual acuity (which was all normal) I got to CN 7 and the bell went, so had to present my findings of my half finished exam! I found his left eye was unable to abduct and he had nystagmus on all aspects of eye movements - so presented my findings. Gave some differentials as cavernous sinus thrombosis, false localising sign of raised intracranial pressure, mononeuritis multiplex from Diabetes and MS and was pressed for more and more diagnoses, which I was then blank! Asked about management - I suggested tests for DM and for MS, but the examiner wanted something else and kept pressing me...and asked 'if you could give his man one thing what would it be...' at which point the bell went and I went tot he next station - turns out the answer was an eye patch as we saw the patient coming out of the room at the end! // Neuro – HORRIBLE!! Missed the lateral rectus palsy and got thoroughly humiliated // Neuro - cranial nerves - 6th CN palsy. Causes, treatment, what to expect on fundoscopy // Neuro – cranial nerves – asked about course of 6th nerve. At that point she said I was doing well and not to worry as my mind went blank. Don’t think I ever knew that!

Neuro- The worst station. Everything about it was dreadful. Were told the lady had problems swallowing and chewing and asked to examine her cranial nerves. I clarified with the examiner who told me to examine whichever ones I wanted, and so I started with 9-12 thinking I had an idea of what was wrong, only to not pick up any signs. I then for some reason decided to examine the rest of them but in a sporadic, unstructured manner, rather than starting at 1 and working through them. In my defence I think I did this as I was aware of the time constraints but it meant my examination looked unpractised and unstructured and I forgot things. On top of that, the lady had very obscure signs and no-one had a clue what was going on with her.

... and just for fun...

Neuro lower limb (motor and sensory) (my patient fell asleep after 3 mins and kept snoring then)

Ultimate Finals List - Locomotor

2010-06-15T14:03:00.000-07:00

Locomotor

Gals and knee - nice, patient looked like he wanted to sleep. Pain in all his joints, lots of OA. Also had Pagets. I thought his legs looked Bowed, but didn’t mention it, had to have the examiner point it out later! Note, if you think something say it! He had big lumpy thing below his knee.. not sure if that’s an osteosarcoma. Questions on tests for Pagets, eg bloods what would be high and low and who and how and why to treat. Straightforward. // GALS on a patient who was actually half asleep. I forgot all my gals questions and half the examination but this doesn't seem to matter too much (!). I examined the knee after doing GALS because the man had a scar on his knee. The examiner then asked why the man had a scar on his knee. It was a knee replacement scar so I said so. He then asked why this patient might have had a knee replacement. I said osteoarthritis or rheumatoid. He then asked me if this patient had rheumatoid, I said no. He then asked what investigations I would do. After all the bloods etc etc, I got to bone scan and he asked apart from rheumatoid and osteoarthritis ...what else could show on a bone scan. I finally saw the light and said Paget’s. He also asked me look at the patient's legs again and pointed out (I quote) "there is subtle bowing of the tibia." He then asked me about blood tests for Pagets, I said alk phos, he asked what I would see. I said it was raised, and he asked me about calcium and phosphate which I said would both be normal. He then asked about the treatment of Pagets, I said bisphosphonates, although most patients are usually symptomatic. He nodded and said "yeess" so I think I made up for missing the diagnosis! He then made me answer questions about osteoarthritis and rheumatoid arthritis, about the investigations, and the treatment and the WHO analgesic ladder.

Knee exam on med student pretending to have a gait disorder. Just examined and told to explain actions. I even had to do the Mcmurray test // Knee exam – football injury. Was medial collateral ligament. // examination - anterior cruciate ligament tear

Please perform the GALS and the examine this lady’s hands. UNIlateral MCP subluxation, Z thumb, flexion deformity of the MCPs, Boutonniere’s – the works except the unilateral bit. Examiner didn’t know why either but rheumatoid was the answer. // GALS screen - rheumatoid hands and feet, DDx and Ix // details of DMARD side effects // asked about how long I thought the patient had had the condition, asked differentials and which other joint would be improtant to examine, then had to examine it, I picked the neck // Musculoskeletal- Do GALS and then examine hip of a young man with RA. He had one leg shorter than the other. // locomotor- I performed GALS. The patient said he had pain in his arms and could not dress himself. On inspection there was obvious subluxation at wrists and ulnar deviation at MCPs. I went on to perform Rheum hand exam. I gave the differentials of RA, Psoriatic arthropathy, SLE (had pt been young and female). Once I had presented the examiner asked me about the reasons for patient having leg and foot bandages. I didn’t have a clue but I said 'pt may have had operation to fix deformity caused by rheumatoid arthritis', or patient may have ulcers due to systemic effect of connective tissue disease. Not sure what examiner was getting at. // GALS + hands - RA - asked what else I would examine and I said "feet" and he made me do a foot exam!! // rheumatoid hands. good station but they hid a medic alert bracelet under the patients watch so only saw it if looking very closely

Locomotor exam- "GALS of just the arm" plus hand exam. She had osteoarthritic changes- Heberden's nodes (forgot to call them this), Bouchard's nodes (forgot to call them this), no rheumatoid nodules, no vasculitic lesions, marked DIP involvement.

GALS in a lady who could not lie on the bed due to pain, so slightly pointless. she had had a knee replacement, and the examiner just asked questions on that. // Mention would complete examination by examining neurovascular status of legs and examine joint above and below (hip and feet).

GALS – Patient with scleroderma. She had a waddling gait and sclerodactyly. Scleroderma seems to be a common thing in exams. Might want to imprint that to students, so they dun get caught out (which i am sure a lot did) // MSK - scleroderma - only signs were painful joints and raynauds phenomenon - had to do GALS then examine the hands // GALS and MSS - did a GALS screen on a lady who had very limited signs! I thought she had limited internal rotation of her hips, so presented my GALS screen and said 'I would further like to formally examine this lady's hips'...to which the examiner suggested I examined her hands...oops! On examination her hands were near normal, with some slight redness and thickening of her skin from her PIPJ's distally. I was almost ready to present her a normal case (and was slightly panicking now!) but with 1 min to spare the examiner said 'if you want to ask her a few questions go ahead' - so I asked the lady if she had any pain or stiffness at any time of day, she replied 'not time of day, but time of year...Finally! I then asked the questions you suggested on your course 'do you notice they change colour at all? (yes..they did!) and she had some difficulty in swallowing too!) She had scleroderma (although really didn't have the typical facial features I've seen before! - then presented her case, discussed a little re scleroderma what investigations I would like etc etc.

Locomotor - hip examination. right sided restricted movement due to pain, DDx, ?OA secondary to trauma, RA vs OA

GALS screen, ank spond and psoriatic arthritis I think. // MSK - ank spond - did GALS then stood there looking at the woman for ages That station was run by a fairly.. shall i say..notorious rheum consultant. She wouldn’t let me talk to her till 7 mins was up (which is fair enough). The instructions were that this young man had a problem with his neck and I was to do a GALS screen and anything else necessary to make an assessment. So I did the GALS screen - he basically had severely limited ROM in the cervical, lumbar and thoracic spine and stiffness on internal and external rotation of the hips, otherwise all normal. Having done full inspection, palpation and movement of the spine i couldnt think of anything else to do. There was a box of neuro 'toys' - vibration, orange sticks, etc so i tested his sensation in broad terms and the power, but i was done within about 4 and half minutes. so i just waited. The questions were 'so tell me what you found' and she shook her head all the way through it, which was a little off putting. Then she said what was my main differential - so i said ank spond. and she asked for any other possibilities.. and I couldn’t think of anything else. so I said lupus (hahah) which is the answer to everything along with HIV, TB and idiopathic. then the bell went. // Asked me to present, asked differential, then extra articular manifestations of ank spond and lastly, the available treatment

Orthopaedics - examine back and hip in 6 mins. Ank Spond, Hip Replacement (scar), OA of other hip.

Knee examination - osteoarthritis // Knee examination (he then asked me to examine the neurovasculature of the foot) // GALS I had to a gals screen and then I focussed examination depending on what I found, this lady had a very bad knee, every time I touched her she would yelp. I did the best I could, the examiner was quite sympathetic, even when the time to examine was up, she gave me an extra minute to complete my examination, I presented, and said I thought she had osteoarthritis, she asked what else could she have, I wasn’t too sure what she was getting at, I said an atypical presentation of rheumatoid or septic arthritis although I would expected more redness, I think that’s what she wanted me to say, she then said considering what u found in her back what is the most likely diagnosis, I then realised I hadn’t tested flexion of the back in my gals screen but obviously thought I had, just goes to show, if you act confident they wont even realise that you've missed anything out! it was OA of back and knee

A hip examination. The patient had undergone arthrodesis of the right hip and the left hip had severe osteoarthritis and almost no range of movement. He had scars EVERYWHERE from previous orthopeadic surgery. I don't know about the history of this patient but he had deep sinuses in his lower spine which looked like some kind of neural tube defect. V confusing. I’d never seen anything like it and it really distracted me. I’m sure they just wanted us to mention it and then focus on the hip but it was difficult not getting distracted. // He couldn't flex hip past 20 degrees so i was unable to test int and ext rotation in flexion so instead did it in extension. Quest- management of OA (worth having a spiel for that one i think- my friends and I prepared OA pretty well as it seems to come up most of the time).

Musculoskeletal – I think I was just asked to examine the patient's joints so I did the GALS screen. The only abnormalities I found were bony swellings over the PIPs and DIPs and that the patient had had some knee pain in the past when I asked the 3 questions. When I reported this to the examiner and said that this would be consistent with a diagnosis of OA he said "What about his spine?" I had found forward flexion of the patient's spine to be normal during the GALS screen but the one movement I had forgotten to test in the GALS screen was lateral flexion of the spine! I remembered when the examiner prompted me, tested this and sure enough it was markedly reduced. The examiner then asked me to look at the patient's hands which were erythematous. He asked me what this could be and led me towards saying Raynaud's. I had trouble putting this all together but then the time was up.

Patient had congenital kyphoscoliosis // Klingon syndrome or something similar?!!

GALS - this was ridiculous. You were asked only to perform a gals screen. We all offered to examine another joint to help with the diagnosis, but the examiner wouldn't let us, so instead we all finished the station in 2 minutes and twiddled our thumbs for 5 minutes not knowing what to do until the examiner starting asking questions. None of us have any idea what was wrong with this patient. I am pretty sure she had scelrodactyly because when I offered this to the examiner, she seemed to think I was on the right tracks, but then she kept asking me what sclerodactlyly was called, even though I'd already told her. I said I thought it was scleroderma and she asked me for another diagnosis seeing as that was so rare.

MSK: knee exam....again which was nice...massive swollen left knee on an elderly lady in pain! wasn’t sure but he told me its a tense effusion....then he waned to make sure that we know what to do when we see a swollen single joint!!! so septic arthritis 1st differential and aspirate with broad spectrum antibiotic n he was happy with that answer... then he said how to investigate: FBC, ESR., CRP (inflammatory markers) // Musc skeletal: Examination of a hot red swollen knee, too painful to do special tests asked about differentials, what is important to rule out, what I think it could be...I said pre patella bursa, Then asked about Ix

do gals then examine the spine. patient had scoliosis had to give a differential and why I didn’t think this was ank spond.

... and for fun...

GALS screen - my examiner knocked over the cubicle walls and spent about 5 mins rebuilding them! I just carried on blissfully, afterwards the examiner apologised and said that I had passed, which was nice!

Blood Transfusion

2010-06-12T13:18:00.000-07:00

Order Blood

Patient ID
Name
DOB
Gender
HN

Background Info
Why?
What type?
How much?
Special requirements eg CMV -ve
Needed when?
Needed where?

Legal
Requesting doctor
Bleep
Signature

Sample
Confirm ID
Name
DOB
Gender
HN

Checks
Verbally confirm with patient
Confirms matches wristband
Matches requesting form
Label tube
NO PRE-PRINTED LABELS on TUBE

Send sample to blood bank

Pre-transfusion Checks
Match ID on blood pack to any form of patient ID
Sign out blood

Check pack
Record patient obs before transfusion
Verbal check with patient
Check with wristband
Check with compatibility form
Check form with blood pack

Record
Why transfusion
Date and time
Sign pre-transfusion checks

Transfusing...
Blood
- within 4hrs from ridge
- within 30mins from out of fridge
- over 3-4hrs
- after platelets

Platelets
- ASAP
- over 30-40mins

Reactions
Symptoms?
Stop and get help
Obs
- Temp <1.5 degrees, slow transfusion and give paracetamol
- Mild urticaria - chlorphenamine 10mg IV and slow transfusion
- ABO incompatibility - stop, return to blood bank, IV fluids, urine output, furosemide if necess
- Severe allergy - stop, return, IV chlorphenamine 10mg, O2, salb nebs, adrenaline
- ?bact - blood cultures, BSp antibiotics

LA Vs GA, Closed Vs Open

2010-06-12T12:51:00.001-07:00

The advantages of local anaesthetic are:
1. Quicker recovery time allowing for earlier discharge.
2. The local injection will act as pain relief over the hernia area for a period of time after the operation has finished
3. Less risks associated if you have any other concurrent illnesses eg:lungs or heart

The disadvantages of local:
1. The patient will be awake
2. The patiemt may flee pressure over that over during the operation
3. there is increased liklihood of local structure damage

Laparoscopic:
advantages are:
*less painful
*earlier discharge
*smaller incisional site

disadvantages are:
*more expensive
*risk of conversion to open
*always need a general anast
*unsuitable for some hernias

Open surgery
advantages are:
*can be done under local or general
*has been performed by more surgeons for a longer period of time
*suitable for alll types of hernias

disadvantages:
*longer hospital stay
*more painful post op

IV Drug Administration

2010-06-12T12:47:00.000-07:00

WIPERNA

Wash hands

Hello____
My name is______
I'm a _____

Explain
I was wondering if I could give you some medication - would that be alright? I believe you have a cannula already in site, so we don't need to use an injection and we can use that.

Check name/nameband/prescription chart/allergies

Check infusion site
?redness
?swelling
?pain

Ex/Nm/Nb/Pc/All/Cann

Equipment
Clean tray
2 sterile needles
2 alco swabs
2 syringes

Saline
Drug
Dilutent - sterile water

Sharps bin

& Assemble

Reconstitute
Check prescription chart with drug name, dose, strength, volume, route, time, date, signature - if not signed, not legal to give - therefore find doctor who prescribed it

Check with leaflet or trust drug administration policy

Check name, strength, volume of drug

Check expiry dates x3 - saline/dilutent/drug

Double check with another person

Pc/Lt/Dg/ExpD/x2P

Reconstitute according to guidelines

What you want / Got x What's it in

Wash hands

Glove

Needle + syringe

Flip cap off ampoule

Wipe wth alc swab

Aspirate sterile water

Inject into ampoule

Agitate

Draw up drug

Draw up flush

Distinguish CAREFULLY

WH/Gl/N&S/FpCp/Wp/SW/Amp/Agit/Flh/Dist

Patient

Recheck name, nameband, prescription chart, allergies

Wash hands

Change gloves

Remove port cap

CLEAN BUNG with alco swab and allow to dry

Flush with 5ml saline

?resistence, pain, swelling, leakage around cannula, back flow of blood on aspiration

Inject drug - over recommended time

1ml

Feeling ok? Watch for adverse effects - flushing, resp difficulties, tachycardia

... if occurs...

Stop injection

W/D back into syringe

Get help

Stay with patient

... if added to IV infusion

Fill in additive label and stick onto bag

Date/Time/Drug/Signature

Finish flush

Replace bung/cap

Rc-N/Nb/Pc/All
WH/Gl/Bg/CB/Fs/Dg/AE/Fs/Bg

Thank you

Tidy away

Wash hands
Complete prescription chart and fluid chart - sign

Inform nurse if delayed reaction

Venepuncture

2010-06-12T12:32:00.000-07:00

WIPERNA

Hello ______
My name is_______
How are you?

Explain
I was wondering if I could take some blood from you, just so we can do some tests on it, and hopefully help with your care. Have you had this done before? It's not painful, but you will feel a sharp scratch - but I'll warn you, and let you know when it's all over. You don't have to look. Are you okay with needles? Any questions?

Check nameband
I'm just going to get the equipment

Prepare Equipment
Clean tray inside and outside

Tourniquet
Alco swab
Needle
Vacutainer
Blood Bottles
Gauze/cotton wool
Plaster

Wash hands
Assemble equipment
- attach needle to vacutainer

Prepare Patient
Pt comfortable
Arm exposed from elbow
Lying next to them

Wrap tourniquet
Select vein
Alco swab skin

Cm/Ex/Re/Tq/V/Alc

Gloves
Stabilise vein
Sharp scratch!
Angle - 45 degrees
Reduce angle

Swap hands if necess
Grab bottles

Collect blood
Fill bottle
Remove bottle

Removes tourniquet
Remove needle
Flip back top if attached vacutainer
Sharps bin

Gl/SV/SS!/45/Bt/xTq/xN/Shp

Pressure
Plaster
Invert bottles

Pr/Pl/IB

Thank you
Are you okay?

Label bottles

Suturing

2010-06-12T12:22:00.000-07:00

WIPERNA

Hello, I'm________
I'm a_________
How are you?

Explain
Okay, I understand you had an accident. It seems that you'll need a few stitches for your wound, just to help it heal properly, and reduce scar formation, hopefully. This involves using a small needle and special thread, and we'll use LA to help ensure that you're not in pain. Does that sound okay? You're happy for us to go ahead? Are you alright with needles?

I'll just get my equipment.

... Wash hands...
Equipment
Sterile gloves

Lignocaine 1% LA (max 3mg/kg)
Syringe
Green needle

Orange needle

Sterile water/Saline
Gauze
Syringe
Suture pack
-tray
-needle holder
-scissors
-curved scissors
-toothed forceps (skin only)
-non-toothed forceps (needle only)
Suture Needle

Sharps box

Prepare Equipment
Wash hands

Open suture pack with sterile technique

Drop pair of gloves, syringes, sutures and needles into field

Put antiseptic solution into bowl

Sterile gloves on

WH/SF/SW/Gl

Prepare Patient
Questions - tetanus, allergy, LA ?
Inspect wound for debris/dirt - clean and debride if present
X-ray - potential of foreign body
Cleanse/irrigate wound and surrounding skin

0.9% saline soaked gauze/in syringe or with chlorhexidine/betadine (high risk contamination)

Swab held with forceps/hand

Centre outwards

Postion pt so they're comfortable

Cover wound with drape with hole in it - sterile field

Q/Insp/Clean/SF

Anaesthetic
Select syringe and attach the 21G green needle
Draw up 10ml of 1% lignocaine
Dispose of green needle
Attach orange needle

Inject LA into skin encompassing wound approx 0.5-1cm from its edge
Aspirate needle on inserting to ensure a vessel has not been entered
Fan shape around wound

Wait 5-10mins for anaesthetic to work - test area
Ask pts after signs of LA toxicity eg tingling in mouth, metallic taste, dizziness or light headaches, ringing in ears or difficulty in focusing eyes

Max lignocaine = 3mg/kg
Lasts approx 30 mins

Lg/Fan/Wt

Suturing
Mount needle
Grasp curved needle with needle holder (short. blunt forceps with straight jaw)
Hold needle 2/3 along shaft from tip
Perpendicular to needle holder
Hold needle holder with thumb and ring finger, with index to stabilise

Pass through skin about 0.5cm wound edge at middle of wound
Use forceps to pick up skin (toothed) - above hand
Pass N perpendicularly
Full thickness through skin to the base of the wound - xbacteria
Pull suture threat through hole, leaving 2-3cm tail behind
Pass N through opposite skin edge using forceps to hold the skin
Not too tight or loose
Make sure exit hole opposute insertion hole, and 0.5cm from edge
Put needle in sterile tray

Tie knot
- double throw
- needle holder parallel to wound
- wind two loops of long end of suture in a clockwise motion around the needle holder
- needle holder to 12 o'clock
- pull short end of stitch through the loops using the mouth of the needle holder
down to 6 o'clock
- pull knot gently down to the skin, opposing the two sides of wound at the same time

- tighten so skin edges are apposed but without tension

2nd throw - single

3rd throw - single
- single throws in opposite direction
Suture material can then be cut to complete the stitch
- 1cm
- ensure the knots created are everted and spaced 5-10mm apart
- knots on same size
- good opposition - no pie crust or puckering

Halves
- offer to place the next suture (rule of halves) half-way between the present suture and the distal, medial end of the wound. Repeat until the wound closed

Mount/SgKn/Hvs

Tidy Up
Dressing
- dry dressing
- Tetanus immunity if wound contaminated / pt has not had booster in last 10years

Document
- detail of sutures
- polypropelene

Dispose of waste
inform pt that sutures can be removed in 10days

Tell the patient to attend GP
- if any worries (red, oozing wound, stitches come out etc)
- and to in about 7-10 days time for stitches removal./or come back to A&E

Dr/Tt/Doc/Disp/GP

Thank you
Any questions?

Sutures
- scalp
3/0, non absorbable
7 days

- trunk
3/0, non absorbable
10 days

- limbs
4/0, non absorbable
10 days

- hands
5/0, non absorbable
10days

- face
6/0 non absobable
3-5days

Deep wounds
Absorbable eg monocryl, vicryl, dexon
Superficial wounds
Monofilament non-absprbable
eg Nylon (Ethilon) or Prolene

Male Catheterisation

2010-06-12T11:58:00.000-07:00

WIPERNA

Hello________
My name is_______________
I'm a doctor
How are you feeling?

I was wondering whether I could catheterise you? Do you know what a catheter is?
We insert a small plastic tube to reach your bladder through your penis, so we can collect the urine into a bag. It helps us monitor how you are doing, and means you won't have to get up to go to the loo. We'll use local anaesthetic so it won't be painful, but it might be uncomfortable at first. Any concerns? Okay - so you're happy with us to go ahead?

I'll just go get my equipment ready

Equipment
Catheter pack
Foley catheter 16/18 - smallest cath poss

Catheter bag

Trolley
Sterile gloves x2
Lignocaine gel 2%
Sterile water/saline
Syringe x2
Bin

Prepare Trolley
Wash hands - 7 stage
Put on apron
Clean trolley - top & bottom
Open cath pack and slide onto trolley, preparing sterile field

Place equipment into sterile field

Attach yellow disposable bag onto side of trolley/move bin nearby

Pour sterile water into small bowl with swabs

Fill syringe with 10mls and place outside sterile field if not already within pack

Put on sterile gloves

Put on disposable gloves

WH/Ap/CT/CP/SF/SW/GL/GL

Prepare Patient
Expose + reposition
Make hole in drape and place onto pt - 2nd sterile field
Wrap gauze around shaft and keep in sling, with left hand raised
Retract foreskin
Clean penis - holding swabs in right hand/with forceps and wipe out from meatus x2
Dispose
Warn anaesthetic
Insert LA (lignocaine 2%) - squeeze 5ml into urethra
Hold for 3-5mins to give time for the anesthetic to work
Discard top gloves

E+R/SF/SL/FSK/x2Cl/LA/Wait/xGl

Catheter
Place receiver dish inbetween legs/attach catheter to bag
Open catheter
Insert catheter into urethra - ANTT
- touch plastic only
- massage out and into urethra
- if necess when negotiating prostate, lower penis
- if resistance ask pt to breathe deeply
- move till bifurcation
- by now urine should start emptying into plastic/kidney dish
Inflate balloon - 1ml of sterile water
Any pain?
Continue to fill with remaining 9ml
Withdraw catheter to make sure balloon becomes lodged into neck of bladder
Attach catheter bag if not yet attached

Dish/Cath/Ball/WD/Bag

Finishing Off
Restore foreskin/ask pt to (avoid paraphimosis)
Thank pt

Cover them up

Throw away remaining waste

Document:
A) date & time
B) size and type of catheter
C) amount of water in balloon
D) ?problems

E) residual volume of urine intially collected

Tests - dipstick & MSU
10ml from sampling port

Fsk!!/TY/Cov/Cl/DocRV/Ix

Making Errors

2010-06-12T10:03:00.000-07:00

Digoxin Side Effect
Excessive/ppt by hypokalaemia: anorexia, nausea, vomiting, diarrhoea, abdominal pain, visual disturbances, headache, fatigue, drowsiness, confusion, dizziness, delirium, hallucinations, depression, arrhythmias, heart block
Tx: Potassium-sparing diuretics, potassium supplements, digoxin-specific antibody fragments

Mx: blood levels, cardiac monitoring

Methotrexate

Toxicity: anorexia, diarrhoea, toxic megacolon, hepatotoxicity, pulmonary oedema, dizziness, blood disorders (sore throat, bruising, mouth ulcers), liver toxicity (nausea, vomiting, abdominal discomfort, dark urine), respiratory effects (shortness of breath)

Mx: FBCs, LFTs, Obs

Insulin
OD: hypoglycaemia

Tx: 50% dextrose, IM glucagon, sugary drink

Mx: Blood glucose

Warfarin
OD: haemorrhage

Mx: INR, withhold warfarin, Vitamin K

Penicillin Allergy
Anaphylactic Reaction: urticaria, angiooedemam, fever, inflammation

Mx: Stop antibiotic, adrenaline, chlorphenamine, steroids, fluid

Communications:
- Apologise

- ?Admit responsibility- Explain carefully what has happened
- Short-term effects
- Long-term effects
- "This shouldn't have happened and we will do everything we can to make sure it does not happen again
- There are many checks and balances"- Notify senior
- Will make an inquiry/Fill in incident form
- Direct to PALS (Patient Advice and Liaison Services)

- Independent Complaints Advocacy Service (ICAS)
- Complaints can be made to Trust Complaints Manager

- Can talk to consultant

- Write to ward manager
- Give name and bleep number

Alzheimer's Counselling

2010-06-12T09:34:00.000-07:00

Alzheimer’s

Normal

- lose memory, brain cells, difficult to retain information

Alzheimer’s

- more pronounced

- changes in brain structure (plaques, tangles, loss of mass) and reduced chemicals involved in transmission of signals

How?

- familial (early position)

- basically unknown

Does it get better?

- progressive

- starts with forgetfulness/wandering

- problems with cooking, cleaning, dressing

- speech

- difficulty recognising people

- no cure

- just slow progression of disease, reduce anxiety and memory loss

- Donepezil, rivastigmine, galantamine (Ach-esterase inhibitors)

Side Effects (resolve within few weeks)

- sleep disturbance

- nausea

- loss of appetite

- diarrhoea

- muscle cramps

ECG before & regular review

Support

- community nurses

- home carer

- social worker

- occupational therapist

- respite care

- Day Hospital – group Tx

- Alzheimer’s society

- Dementia Relief Trust

Steroid Counselling

2010-06-12T06:11:00.000-07:00

Hello_____
My name is ________
I'm a __________

Find The Problem
I understand that you've been recently been put on steroids. How do you feel about that? What do you know about steroids? You understand what it is for? Do you have any understanding of the side effects?

Information

Steroids are naturally produced in the body and help reduce inflammation and swelling. Steroids are often used synthetically to help with health problems characterised by inflammation. They are very different from the kind that you hear about in the news that athletes take - those are known as anabolic steroids and act differently on the body.

However, steroids aren't used unless they have to as they have these side effects, but these usually only occur after prolonged use and with higher doses, and we monitor carefully to see if any of these occur.

These include:
Infection - immunosuppression
Higher blood pressure - monitored regularly
DM - can happen go to GP if feeling tired/going to the toilet more
Osteoporosis - thinning of bones - supplements of Ca and Vit D/bisphosphonates/HRT
WG - fullness of face
Increase in appetite
Skin thinning - bruising
Mood change - irritable/depressed
Dyspepsia - indigestion/stomach upsets

General Advice
Blue steroid card - keep with and inform doctors so they can prescribe safely for you. You can also wear a bracelet to let paramedics know.

You musn't stop suddenly as while you take this medication the body produces less of its own steroids, adn stopping suddenly can cause your body to react badly - for example causing confusion, abdomoinal pain, and can require you to go to hospital.

Avoid smoking/drinking
Avoid ibuprofen
as they can increase the likelihood of indigestion

PMHx
Do you suffer from epilepsy/osteoporosis/diabetes/hypotension/excessive bleeding/tuberculous/chicken pox/stomach ulcers?

DHx
Do you take NSAIDs/any other medication?
Allergies?

SHx
Smoke/Drink

Is that all clear? How do you feel about that? We can arrange a follow-upappontment with GP if you have any further questions you want to ask. What have you taken away from this?

I can give you some leaflets. Steroid cards also carry a lot of info, so don't worry if you forget.

Peak Flow

2010-06-12T06:02:00.000-07:00

WIPER

Hi, my name is _______, I'm a doctor here. It's very nice to meet you.

Find the Problem
I understand you have symptoms that might suggest asthma. In order to rule help us to rule in or rule out the diagnosis we do a test called the Peak Flow test. Have you had this test before? Are you happy with your understanding of asthma? Are you happy with doing this test?

This is a peak flow meter. It's just a simple tube that measures how well the air flows out of your lungs, and whether you have any difficulty pushing it out. If you have asthma this shows as being less than normal for a person of your height, sex and age.

Demonstrate
I'll show you how to use it, to help you understand how to do it.
First we reset the pointer to make sure that it's one zero.
We stand up for the test. We put a fresh mouthpiece into the meter.
Breathe in fully deeply, as much as you can. Hold the meter level in front of you making sure your fingers don't cover over the pointer. Make a tight seal with your mouth on the mouthpiece. Blow as hard as you can and as fast as you can, like blowing out the candles on a cake. We're not concerned about how long or how much you blow out. Okay? Like so.

We'll do the test 3 times, and take the highest reading as your score.

General Advice

We record like thus and if we record it in a diary we can keep of track of how your breathing is throughout the day. Asthma tends to vary quite characteristically through the day, and can help us make a diagnosis and see how you are doing on medication.

The best time to take a peak flow are first thing in the morning, and before you go to bed. Also take it when you are experiencing symptoms such as coughing or wheezing.

Repeat Relevant Parts

Would you like to have a go?

ICE
Do you have any questions, concerns or expectations?

We'll need to follow-up to see how you've coped with the medication and if your symptoms have improved.

What factors affect PEFR?
- height
- age
- sex
- acute and chronic resp disease
- smoking

Using Inhalers

2010-06-12T05:57:00.000-07:00

Hi, my name is______
I'm a final year student.
How are you today?

Find the Problem
Okay, from your symptoms and peak flow recording we believe you might have asthma. What do you know about asthma? How do you feel about it?

Asthma is a condition of the lung where you can get difficulty breathing. We find sensitive airways, that react by narrowing when they become irritated, making it difficult for air to move in or out. It's this narrowing that causes the chest tightness and wheezing that you've been experienced.

We can do something to help with these symptoms. To help with this condition we can prescribe you salbutamol, which is given in a blue inhaler. It works by opening up the airways so air can move more freely. By being given in an inhaler we can deliver the medicine exactly where it needs to be. Is that okay?

What do you know about inhalers? Have you ever used one before?

Demonstrate
Okay, I'm going to show you how to use the inhaler, because technique is very important in ensuring you get the most out of it and to help your lungs as much as possible. Use it when you art feeling wheezy or tightness of the chest.
First we shake the inhaler with the cap on to mix the medicine properly. We remove the cap from the mouthpiece and hold the inhaler like so, between your thumb and index finger, with your index finger on the canister.
Take a big breath in and fully breathe out. Put the mouthpiece in your mouth. At the same time as you breath in push down on the top of the inhaler. Hold your breath for ten seconds afterwards.

Repeat if necessary after 1 minutes.
Gargle/rinse out your mouth if you are using a steroid inhaler.

Mild side-effects of salbutamol include fast heart rate, shakiness and headaches. If they are worrying you should again come back to us.
Salbutamol can be taken 2 puffs as needed, up to 4 times a day, as the maximum. If you need more than that you should return to us, as we might need to try something else, perhaps combining it with another inhaler.

Does that sound okay to you?

Repeat Relevant Parts
Can you show me know how you would use it?
Can you tell me when should you use it?

General Advice
There may be some leaflets I can give you to help your understanding, and to take home with you.

ICE
Do you have any questions, ideas, concerns, expectations?

We'll review you in a while to see how you are doing with it, and if your symptoms have improved.
Does that sound okay?

Thank you!

Using A Spacer

2010-06-12T05:04:00.000-07:00

Hello, my name is....
I'm one of the doctors here.
How are you feeling today?

Find the problem
I understand that you've been having some problems in using an inhaler - tell me a bit about that.
How are your symptoms? You understand that it's important to use - for your asthma? Can you show me you trying to use it?

It's really important that you're able to take your inhaler if you need it but I can see that you're having problems with it. This isn't an uncommon issue for people, it can be fiddly, so there is a device we can use to help you called a spacer. The spacer makes it easier to deliver the medicine to your lungs.

Demonstrate
I'll demonstrate what to do...

The spacer is made up of two parts which slot together easily.

On one end you can attach the inhaler, and on the other side you have the mouthpiece
Shake your inhaler well and attach it to the far end
Release 1 puff into the spacer
Don't worry the medicine stays inside
Make tight with your mouth on the mouthpiece
Breathe deeply in and hold for 10s
Breathe out slowly all the while keeping your mouth attached

Wait 30s before next dose
Do this for three or four times
This should be enough to get the medicine into your lungs

Repeat Relevant Parts
Can you show me how you would use this?

General Advice
In caring for the spacer wash it once a week warm water, and leave it to drip dry
Don't use any detergents as this can cause static inside the spacer, which makes it less effective
Store the device in its box in a cool area to prevent scratches
We should relace the device every 6-12months of use to make sure you have optimum delivery of the drugs

ICE
How does that sound?
Do you have any ideas? concerns? expectations?

We'll follow you up to see how you're doing

Thank you!

Cannulation

2010-06-12T04:59:00.000-07:00

WIPERNA

Hello my name is _______
I'm a __________
How are you doing?

Is it alright if I put a cannula in your arm? Have you ever had one before?
It's a small plastic sterile tube that we insert into a vein, that acts like a port, that we leave there.
We use it to transport the fluids through.it's not painful, but you probably feel a small scratch. Do you have a problem with needles? Are you fine with me to go ahead?

Checks:
Nameband/dob/name/hospital number

I'm just going to get my equipment.

Equipment
Tray

Gloves

Tourniquet

Alco swab

Cannula (16G grey - 18G green - 20G pink)

10ml syringe

Saline 0.9%
Green needle

Bung
Tegiderm
Sharps bin

Prepare Equipment
Clean tray inside & out
Wash hands
Open cannula
Open bung
Draw up saline

CT/WH/Eq/Flu

Prepare Patient
Roll up sleeve
Pt comfortable?
Tourniquet (clench fist - promote venous filling)
Select vein and direction (distal to proximal)
Clean area with swab

Put on gloves/alcohol gel gloves/change gloves

Tq/V/Alc/W+G

Cannula Bit
Stabilise vein
'sharp scratch'!!!
Cannula - shallow angle 25-35
Flashback?
Lower cannula
Advance by 2mm
Withdraw needle slightly watch blood track along cannula
Advance plastic sheathing
Take off tourniquet
Press over vein above cannula
Remove needle
Bung over cannula

SS!/25-35/FBl/AdvPl/xTq/OutN/Bung/Flush

Secure
Needle into sharps bin
Apply tegiderm over cannula
Flush!

Sec/Sharps/Saline

Finishing Off
Thank pt, make sure they're comfortable

Document:
Cannula gauge
Location
Operator
Site

Dispose waste

Resite immed if signs of inf/phlebitis
Otherwise ev. 72hrs

T/Doc/Disp/Resite

MSK Cases

2010-06-12T04:49:00.000-07:00

X-ray

Normal

OA
- narrow joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes

RA
- soft-tissue swelling
- ill-defined marginal erosions
- loss of joint space
- periarticular osteoporosis

Gout
- assymetrical soft tissue swelling
- well-defined periarticular erosions
- bony 'hooks'

MSK Investigations

2010-06-12T04:46:00.000-07:00

Ix

Bloods
ESR
CRP
Serum uric
Autoantibodies
Blood cultures

Synovial Fluid Aspirate

Imaging
XR
MRI
CT
Bone Scans
DEXA

Spine Examination - Revision Card

2010-06-12T04:41:00.000-07:00

WIPER

... Standing...
Look
Sides, behind - asymmetry, wasting, scoliosis, lordosis, kyphosis

Feel
Spinal processes
Paraspinal muscles

Move
Lumbar
- Flexion - fingers in spinous processes
- Extension
- Lateral flexion - arm down sides
Cervical
- Flexion, extension, lateral flexion, rotation

... Sit on couch, arms crossed...
Thoracic
- rotation

... Lying on couch...
Straight leg raise
Dorsiflexion of foot, and big toe
Limb reflexes

Knee Examination - Revision Card

2010-06-12T04:35:00.000-07:00

WIPER

... Standing...
Gait

Look
Valgus/varus deformity
Popliteal swellings

... Couch...
Look
Varus/valgus deformity
Muscle wasting
Scars/Swellings/Erythema/Rash
Side - fixed flexion deformity

Feel
Skin temperature
Patellar tap and crossfluctuation (bulge sign)
Knee slightly flexed - joint line and borders of patella, femoral condyles, tibial tuberosity
Popliteal fossa

Move
Flexion and extension - active & passive
With crepitus
Posterior sag (PCL)
Medial and lateral collateral - 15 degrees
Anterior draw test (ACL)

Hip Examination - Revision Card

2010-06-12T04:27:00.000-07:00

WIPER

....Standing....

Move

Assess gait - antalgic/Trendelburg

Trendelenberg test

Look
Gluteal muscle bulk

...Couch...
Look
Fixed Flexion deformity
Leg length
- ALL - xiphisternum - MM
- TLL - ASIS - MM
Scars

Feel
Greater trochanter for tenderness

Move
Flexion - knee flexed
Internal rotation
External rotation
Thomas' test - FFD - loss of pelvic tilt

Shoulder Examination - Revision Card

2010-06-12T04:17:00.000-07:00

WIPER

Look
Shoulders - front, side, behind
- symmetry, posture, wasting scars

Feel
Temperature
Palpate bony landmarks - SCJ, ACJ, Acromion process, scapula
Joint lines
Surrounding muscles - supraspinatus, infraspinatus, deltoid muscles

Move
Hands behind head (ext rotation)
Hands behind back (int rotation)
Elbow flexed at 90 degrees
- external rotation
Raise arm
- flexion
Hand behind
- extension
Abduct
- 10 to 120 degrees
- passive
Push against wall
- scapular movement

Function
Hands behind head and back

REMS - General Principle

2010-06-12T04:10:00.000-07:00

WIPER

Look
Scars
Swellings
Rashes
Muscle wasting

Feel
Temprature
Swellings
Tenderness

Move
Full range of movement - active and passive
Restriction - mild/moderate/severe

Function

Elbow Examination - Revision Card

2010-06-12T04:09:00.000-07:00

WIPER

Look
Scars
Swellings
Rashes

Feel (at 90 degrees)
Skin Temperature
Head of radius
Joint line
Medial & lateral epicondyles

Move
Full flexion & extension - compare
Pronation & supination
Crepitus
Function - hand to mouth or nose

Hand Examination - Revision Card

2010-06-12T03:46:00.000-07:00

WIPER

Look
Inspect dorsum of hands for muscle wasting, skin and nail changes/swelling
Can you turn your hands over for me?
Check wrist for carpal tunnel release
Put hands on shoulders? - check elbows

Okay - you can put them back on the pillow

Feel
Skin
- Temperature
- Presence of nodules/plaques at elbows
- Tendon thickening

Joints/Bone
Pain in your hands?
- Squeeze MCPs
- Bimanually palpate swollen/painful joints, incluiding wrist

Nerves
- Radial Nerve - pulse, first web-space
Turn your hands over?
- Median Nerve - thenar eminence bulk, lateral index finger sensation
- Ulnar Nerve - hypothenar eminence bulk, medial aspect of medial fingers
*tendon thickening

Move
Wrist flexion and extension (prayer and inverse prayer sign)
Thumb opposition/abduction
Full finger extension and full finger tuck (extensor tendon ramage, joint damae, neuro damage
Finger adduction/abduction

Function
- grip power
- pincer grip
- pick up small object

Carpel Tunnel Syndrome?
Tinel's Test
Phalen's Test (60s)
Old Synovitis
Thick, rubbery, non-tender
Active synovitis
Thick, rubbery, effusion, warm, swollen, tender

Confirming a Death

2010-06-12T03:29:00.000-07:00

Before approaching the patient...
I would ask the nurse for a brief history of the background to the death - find out who discovered him/witnessed it
I am checking that full attempts at reversal of any contributing factors have been made
I would also confirm that the patient was not for resuscitation
I would also like to read the patient's medical notes and drug chart and recent diagnosis and past medical history

At the patient's side...
Draw the curtain around the model to ensure privacy
I am confirming the patient's identity by checking the wristband with the name and hospital number
I am exposing the patient adequately, and inspecting
I am looking to see if there is any increased muscle tone (rigor mortis)
I am commenting on the absence of respiratory movements
I am looking at the colour and lack of physical movement

Response...
I am seeing whether the patient is responsive to pain eg trapezius squeeze, sternal rub, pressure on orbits

Eyes...
I am inspecting the eyes with a pen torch to see if the pupils are fixed and dilated
Checking for a light response, direct and consensual reflex and noting their absence
I am inspecting the fundi with an ophthalmoscope to see if there is segmentation of the retinal blood columns (only present in 30%), also looking for tracking/rail roading of the retinal veins

Pulses...
I am palpaing the major pulses - confirm that no pulses can be palpated - check on both sides for a minute
I am palpating the carotid pulse on either side
I am palpating both femoral pulses on either side

Precordium...
Look for pacemaker scar
I am auscultating the praecordium for heart sounds for 1 minute, and commenting on their absence.
I am auscultating the chest for any breath sounds for 3 minutes, and commenting on their absence.

Finishing Off...
I am washing my hands
I am documenting in the notes my findings, and the date and time of death
e.g.
Pupils fixed and dilated
No spont resp effort
No response to deep stimuli
Absent heart and breath sounds for 3mins
Time of death: 0000
Date of death 12/12/12

NOTE pt has pacemaker - therefore cannot cremate

Plan

a) fill out death certificate/contact coroner

b) contact family

c) arrange for patient to be moved to morgue

d) contact GP

Signature and date
Printing it with designation and bleep number
I am asking the nurses to contact the deceased's next of kin

NB!!

Conditions that can mimic death
- hypothermia
- hypoglycaemia
- alcohol/drug overdose
- adrenaline use at cardiac arrest can cause dilated pupils
- rigor mortis does not appear until 3hrs after death

Ultimate Finals List - Writtens

2010-05-31T04:13:00.000-07:00

1st paper (SBA path +)*
* Picture of ECG: was difficult choices were ectopic (supraventricular or
ventricular), capture or fusion beat
* X-ray pictures:
- ARDS in pancreatitis
- Mantoux test +ve/-ve
- Gram stain: group B strep, campylobacter
- Knee X ray: fractured? compound?
- Lumbar X ray: ank spond
- Hand X ray: rheumatoid hand
* Path pictures (mostly from Utah path site)
- mesothelioma
- pneumonia
- CLL or CML
- adeno/squamous oesophageal ca
- myeloma
- PE
- question on focal segmental glomerulonephritis
* Epidemiology questions: do questions on LAPT lite as these are very
similar and some have been transferred from T/F to SBA format.
* Picture of eyes: bilateral ptosis (hx consistent with myasthenia)
* Diagram of blood levels of antigens/antibodies in HIV (it's in baby Kumar
and Clarke) and ask to label one of the lines (although they ended up
withdrawing this question as wasn't printed well).
* Slide of giardia
* Picture of psoriasis and question surprisingly on pathophysiology of
psoriasis
* Detailed question about high dose/low dose dexamethasone suppression test,
length of test
* Question on gallstones and knowing significance that colour of gallstones
is yellow
* Many questions on interpreting sodium/potassium, ALP, Ca

*2nd paper*
* Do and know all questions from Moodle, 2 came up (question on hyoscine for
dying patient and question on lung function)
* AF management
* Scleritis
* Chronic supparative otitis media
* Pleomorphic adenoma
* CSF changes with viral encephalitis
* Polycythaemia - primary or secondary? Few questions on this.
* Paralytic ileus, causes
* Rx of hyponatremia: water restriction?
* Anal fissure
* Haemorrhoids
* Ulcerative colitis treatment
* Vomiting in adult: pyloric stenosis
* Lateral medullary syndrome
* Headache: cavernous sinus thrombosis
* Acute glomerulonephritis
* Carpal tunnel syndrome: hand pain in man with DM
* 1st thing would do in anaphylactic shock
* Acne treatment
* Woman with sores around mouth
* Breathlessness in GP setting: would give salbutamol?

Ultimate Finals List - Cardiology

2010-05-31T02:07:00.000-07:00

Cardiology Stations

CABG, heard no heart sounds initially, then listened again and again, then thought dextracardia, then got asked what sternotomy scar could indicate
CABG, aortic valve replacement and systolic murmur, all due to alcoholic liver disease (?) // Gentleman with a very impressive nicotine stained beard! Plus AF, a raised JVP, midline CABG scar, clicking valve replacement and graft scars on his leg. We had to examine, report our findings and then state what drugs we would expect him to be on
Cardiology st: Pt looked well. Had midline sternotomy scar and click THUD which I could hear from end of bed. Pt had no other leg or arm scars. I said it was aortic valve replacement and talked about infective endo.Then time was up. I wish there had been time to recite the causes of AF!
Cardio - prosthetic at S2, midline sternotomy. Asked about how I knew it was aortic. When I would replace the valve. Porcine vs prosthetic
Cardiovascular- Patient with sternotomy scar. I couldn’t hear a metallic click (in fact he had incredibly quiet heart sounds) and started to panic when I looked for a scar on the upper thigh but couldn’t see one. So I presented and said if it was a CABG I would expect a scar which was not present. At that point the examiner pointed out a scar near the guy’s ankle! It turned out he had had a CABG and valve replacement (biological) and I was asked what valve was most likely to have been replaced and why. I didn’t know and guessed the mitral- wrong! I didn’t mind this station as it all seemed to make sense and the examiner was lovely.
CVS – Aortic valve replacement, had collapsing pulse, asked for BP, examiner said 160/60 (wide pulse pressure). Auscultation revealed a click at S2, midline sternotomy scar also. Also a diastolic murmur heard with patient sat forwards in expiration. Asked for diagnosis and reasons for my thinking it is aortic regurgitation.
CVS - Not 100% certain, CABG scar, and ankle scar, loud 2nd sound, but not metallic, I gave CABG and aortic (porcine) valve replacement (examiner said I did really really well). Unable to hear the mitral heart sounds (everyone found this).
The patient had a large sternotomy scar and metallic sounding S2 and some people also heard a murmur and he had AF. I only mentioned the prosthetic valves and said it was a aortic valve replacement because of the position of the scar and because I heard it loudest in the aortic area. He seemed happy enough with that cos I saw him tick the pass box.

Mitral valve replacement in a Marfans patient - then asked about JVP waves
CVS - young afro-Caribbean lady with a midline sternotomy scar - when palpating for her apex beat I could hear the clicking sound of a valve replacement without even my stethoscope! Nice straightforward station - presented my case and gave some differentials as to the type of valve (mitral/aortic etc), examiner asked what else I would consider giving the patient (warfarin with INR between 3-4) and that was about it // Cardio – MVR – mechanical, heard from bedside!! Q’s on likely causes, warfarin

CV - lady had clubbing and a metallic valve with massive midline sternotomy, which I thought was aortic valve replacement but now I think was pulm secondary to Fallot's. Asked about what I thought she had and why, and complications of valve replacement

Cardiology – Radial scar with sternotomy scar and mechanical aortic valve!! Patient had a CABG replacement with the radial artery, and an AV replacement. REMEMBER if there is a scar on the radial side and NO pulse use the other hand, many people made the pulse up!!// CARDIO- the lead in was this lady has high cholesterol and hypertension, please do an cardiovascular examination. I had done a specialist module in cardiology so I was pretty confident with my murmurs, however, this lady had no murmurs, the only things I could find were quiet heart sounds in the aortic and pulmonary regions, and a very weak left radial, I presented my findings and was asked about the causes of a weak left radial, I started going through a list of things I had learnt and then I said possibly cardiac catheterisation via the right radial artery for angioplasty/stent insertion, I think that’s what he wanted as he didn’t ask me any more

Cardio - difficult, very loud systolic murmur and obvious artifical valve sound (? ball and cage) loudest at left sternal edge, no radiation. Pt had massive sternotomy scar which looked like it had been re-opened at least once. Also thought she had a waterhammer pulse. Examiner asked me which valve, we had been told by numerous consultants that it would be either a mitral or an aortic pathology so I guessed aortic. Examiner didn't seem too bothered but asked me to look at her abdomen and arms, covered in what looked like multiple biopsy or cigarette burns - had no idea. Turns out pt was a former IVDU and thus it was tricuspid valve replacement - haven't met anybody else who got it yet, most people said mitral though

Congenital cyanotic heart disease with a right-left shunt. I was asked about causes of central cyanosis.

Cardio exam - irregular pulse in thin old man with rheumatoid hands, no peripheral oedema. JVP very elevated. Thrill over mitral valve. Systolic murmur, louder on expiration and leaning forward, radiated to carotids not to axilla. I said it was aortic stenosis, examiner guided me to mitral valve prolapse.
Patient had AF and mitral prolaspe, I thought it was Aortic stenosis but the examiner was very nice and led me round to describing mitral prolapse. He then asked me about the pathogenesis of mitral regurg and how it caused LVF

Some thought it was aortic stenosis but others thought it was mitral regurgitation. He had subconjunctival haemorrhage which they also wanted you to note and this tied in with his being on Warfarin

CVS - AF and aortic stenosis. Causes, investigations and managament of aortic stenosis and asked about pulse deficit in AF

Cardio – gentleman with a beautiful pansystolic murmur also heard at the apex but NOWHERE else. Almost too good to be true. Anyway he also had a pacemaker so had to discuss reasons why – big MI I suggested as likely although he was quite thin and the examiner seemed to enjoy taking a few of us along the HOCM route...
cardio: excellent station...MR murmur, but apex was undisplaced, examiner asked: give me differentials of just systolic murmurs: MR, VSD, TR, AS, A sclerosis, PS....then he said one investigation: ECHO......y is his JVP raised if he doesn’t have oedema or crackles or other signs of HF....the bell went and I said not sure n he said ur right its difficult to say why!:)
This was quite straight forward until the questioning. Examiner was again ridiculously nice. The case was mitral regurgitation. The examiner asked me to name the causes (which was fun!). When I said Marfan’s, the examiner asked me what valve is more commonly affected with Marfan’s, I said aortic and he nodded and smiled (see..nice!!!). Then when I said mitral valve prolapse, he also asked me the causes of mitral valve prolapse. He then asked what I would hear with a mitral valve prolapse, I said a mid systolic click and he nodded again. Then he asked me the clinical features of mitral valve prolapse, I think he was getting at signs of left ventricular failure. Then he asked me how many cusps the mitral valve has. I had a moment of madness when I said 2..er no 3....er no 2......about twenty times. He then asked me which cusp more commonly prolapses with mitral valve prolapse, I do believe the answer was anterior (because he told me) but I'm not repeating my answer here because I had a REAL moment of madness!!! Still passed though (despite the examiner laughing in my face).

My CVS station was AS. Nothing much to say. maybe transoesophageal vs transthroracic echo, and when to have surgery
Cardiovascular exam: Young Patient with audible clicking and midline sternotomy scar. Ejection systolic murmur radiating to the carotids. Asked about causes of aortic stenosis (marfan’s?)

Blalock shunts

Examine pulse, JVP, precordium of Harvey, mitral stenosis & tricuspid regurg // With Harvey, we were told that 'the patient has ankle oedema and bibasal crackles, please examine his precordium' .the murmur was pansystolic, radiating to axilla and was associated with S3 and S4. I said mitral regurg but the examiner kept pressing me saying 'but it can't just be mitral regurg, what is it?' I didn't understand and didn't get the answer, but after my time was up I asked what he meant and the answer he wanted was biventricular failure. causes of mitral regurgitation
Harvey – cardiac murmur simulator – told to inspect and auscultate the precordium only without talking and then to present our findings. Was mitral regurgitation. Displaced apex beat, Pansystolic murmur @ apex radiating to axilla – s1 obliterated, s3 present giving short diastolic sound. Normal splitting in Pulmonary area, Normal in Aortic area and Tricuspid regurgitation at the tricuspid region - Asked Dx (chronic MR with TR due to R sided dilation). Ask what would do – look for signs RH Failure and do an echo. Asked re causes (I said Rheumatic heart disease, SBE, MV Prolapse and Pap muscle Rupture (although said last would be acute so no displ apex). Told under ECHO that the valve was normal – what is the cause ? No idea I guessed must have been cardiomyopathy. Bell went and as I was leaving I was asked what I would look for on Examination – I said signs of alcohol use?! No idea what he wanted there as I had already mentioned RH failure signs>?
HARVEY cardiac patient simulator. He had dilated cardiomyopathy but most people said mitral regurgiation.

CVS - aortic stenosis and mitral regurgitation

There was a soft ejection systolic murmur which I said was a flow murmur, and he asked the other possible reasons that there could be a flow murmur but I didn't know so he moved on.

HARVEY (mitral regurg and 3rd heart sound)

2 murmurs to trick me! mitral regurg and aortic stenosis both radiating loudly... everywhere, in a really talkative patient making it rather difficult to auscultate the pracordium!

CVS: VSD

Tetrallogy of fallot!!

cardio - was asked to explain my understanding of pulmonary hypertension and right sided heart failure and how this might fit with the murmur

cardio- great my cardio patient must of been ill so I got a normal medical student! no murmurs after all those hours of learning! however his intro led u to believe it may be hocm, however examination was normal. I was then asked why else he may have collapsed while playing football on a hot summers day. duh dehydration- I forgot to do cap refill!

Ultimate Finals List - History Stations

2010-05-31T01:12:00.000-07:00

History Stations

Take a history of abdo pain...he had renal colic and told me when the bell went his urine was pink! You had to specifically ask if there was blood in the urine/changed colour- otherwise he said it was all normal.
... next station was a follow on...u had to ring up the hospital and on the phone refer ur patient n the doc on the line asks u why u referring and what management plan do u propose...pt had a family history of gout so I said to screen for that, analgesia and further investigations cos he was male // Telephone referral of the case - not sure what they wanted. Finished way early. Looked like an idiot again as asked to speak to the med registrar, so the examiner hiding behind the screen said he was the surgical reg.. oh I said.. no, I want you!! :S // Talk to a Dr on a fake phone, I didn't check who I was talking to - so I gave all of the info to the man who picked up the phone, which could have been anyone- so check! // He then asked you for a differential and what tests you wanted to do. They provided you with urine analysis results and examination results, which confirmed renal stones - no signs of inf, but haematuria, plus tenderness in the loins

Cough hx, due to ACEi, so never omit the drug history. Was even asked about why ACEI give you cough and ATR blockers don’t. I discussed a chemical building up in body, normally broken down, some people mentioned bradykinin specifically. I’m not sure how much technical info a patient would want to hear // but u must say at the end that well change ur antihypertensive medication and see if cough improves n if it doesn’t well call u back in for more tests. cos they waned u to discuss a management plan with the pt in the quest // Smoking history with 40 pack year history, hence differentials are ACEi cough and maybe some underlying cancer of the lung.

History - diabetes history from knowledgeable patient, asked about complications. Had no differential diagnosis to make.
Hx Diabetes Mellitus in 19 yo girl with abdo pain and weight loss

Splenectomy + pancreatectomy, HCV + HIV etc.

Hx - Rheumatoid Arthritis. You get 5 minutes before you start but no info. So just wrote down headings and surreptitiously studied the patient for clues! History taking was fine, but I missed the clue about TB in the family - he didn’t want to go on biologicals because of the risk of TB reactivation. Also re chronic conditions make sure you ask about previous medications patient have been on rather than just the current ones. Presented a differential diagnosis at the end. I also forgot smoking and alcohol till I heard my neighbour ask about it swiftly followed by the next door cubicle too! Questions on how to monitor RA (Esr/ Crp I think) How to diagnose, Dmards, how to protect vs possible Tb reactivation. Cjd from biologicals possibility? Should people with RA have joint replacements? Was straightforward I think. // rheum arthritis, also going through MJ THREADS was important as patients had TB in the past and lots of people didn’t pick that up. Asked to present the hx then asked about differentials, what the drugs were Anti TNF therapy what it was, Ix I would do...I mentioned anti ccp and the examiner seemed very impressed. // History for 20 mins from pt then 10 mins of qus from examiner. Lovely patient with rheum arthritis and kidney failure. Then she went out and I was asked about her meds etc and differentials for her kidney failure. I then asked examiner what the cause of it actually was- he didn't know! So I think as long as you gave a differential, it was fine. // Others histories that came up: stroke, scleroderma examiner asked me about RA so known ur stuff about chronic conditions in particular!! she waned to know all the drugs she was on and their side effects especially steroids and she was also on etanercept so u must say u give it when 2 DMARDS including methotrexate have failed hence don’t forget to ask patient if they’ve been on methotrexate ever like I did!!

Hx Adhesions

History - guy with MS. Needed to elicit that his main problem was urinary dysfunction

Peripheral vascular disease in a man who smokes and drinks a lot!!!! Take a good social history because most of his problem list was to do with this and I spent most of my time discussing his drinking and smoking with the examiner as opposed to his PVD. General questions I got asked about PVD was investigations and management (conservative, medical and surgical). In terms of his drinking, she asked me how I would know that he has problem drinking - eye openers, interference with work and social/family life, putting alcohol above all other priorities and if he's ever been admitted into hospital with an alcohol related illness. It turns out he's on iron tablets. You are asked how this relates to his drinking - GI bleeds?
hx - 25year history or arterial and venous disease. Discussion of all surgical options and complications of such disease

SAH history (Know Cushing’s response)

Ankle swelling history - patient was on amlodipine

Focused history - Chest pain - given a short case scenario of a woman who presented with epigastric pain radiating round both sides 'like a strap' worse when hungry, not on any medication. ECG and cardiac enzymes show no features of MI. - take a history and then answer examiners questions - patient had no CVS symptoms other than the chest pain, but had features suggestive of peptic ulcer disease/GORD. - examiner asked: whats ur differential diagnosis (GORD/PUD/DUD); what further investigations could you do; and what the management would be if patient had PUD (examiner stressed MEDICAL management, didnt want any conservative management! hurried me along!) Overall comment: you don't have very long to do the history so it's important to focus in on the really important things eg. does patient smoke/drink lots of alcohol/use of NSAIDS important if suspecting PUD etc.. Triple therapy for treating H Pylori
answer questions about PUD and its aetiology/risk factors/diagnosis/management - had to ask if taking any medication over counter cos only then she said NSAIDS and paracetomol.... . // As I was leaving I was asked what it was important to rule out – said cancer and that I should have asked the patient about weight loss. The examiner asked how I would investigate this possibility and I said endoscopy.

Patient had rectal bleeding and history of aortic dissection, bladder cancer and angina. Asked about bladder cancer.
Hx - Bleeding episodes PR twice yesterday on background of weight loss and increased diarrhoea with mucous in a 59 year old lady with an aunt who has just been diagnosed with colorectal carcinoma.
... Writing a referral letter to hospital re: PR bleed - write referral letter to Med Reg on call regarding an urgent referral for this woman – quite tight for time.

Hx lady with Marfans - presented with 12 year hx of back pain. Asked diff dx, then why you get lens dislocation and mx of patients with marfans. Examiner was impressed when I said genetic counselling.

history - a man with hypothyroid, this was annoying - presenting complaint was just increasing tiredness. eventually got to the fact that he had carpel tunnel as well. // TATT - History of tiredness...pt is only tired absolutely no other symptom...okay this comes up yearly n we figured that last year she had a change in her diet so you had to ask in particular have you changed ur diet...but this yr when I asked that she said no...so I asked r u a veg and she goes yes for 20 yrs she’s been a veg!!! only other problem was weight gain in past 5 months...so hypothyroid??? but examiner didn’t ask any questions so still not sure what her prob was exactly.
History station – tiredness. She was a vegetarian, taking vitamin tablets, recent weight gain, slightly depressed. Take a full focused history, and then give differentials (main were anemia, depression and hypothyroidism), then mention to patient you will take some blood tests looking for anemia and thyroid problems and will review her later at GP // Hx - tiredness (vegetarian and swollen glands and sore throat: ?infectious mononucleosis) - told her I would ix her for anaemia, TFTs, EBV, depression hx- tiredness. // Young girl with tiredness for 2 months, some bowel problems, a viral infection a few months ago, vegetarian (but had been all her life). No heat/cold intolerance or menstrual changes. No idea. He asked what bloods I would do at the end and I said Fbc but it wasn’t until I was on the tube home that I thought of TFTs! and to keep a food diary for review

Some weird skin condition where the patient had what looked like multiple skin tags for a history taking station (not neurofibromatosis - it was really random, but the friend of mine who had this didn't know what either of these things was and still got a distinction, so I don't think they really care that much about you getting the correct diagnosis).

Had to take a history from a guy who had been vomiting small amounts of blood for the past two days and who had a family history of gastric cancer which he was worried about but no other symptoms. He was taking shed loads of ibuprofen for a sprained ankle. Learning point: make time for the drug history!!!
... 10) Referral letter for above patient. This was a strange station, we had to refer the patient we had taken a history from for further investigation, the main issue here was time and getting all the patient details down.
History station on Gastrointestinal stromal tumour. Viva mainly on upper GI bleeds, differentials, emergency treatment etc.

Hx – Chronic Pancreatitis – asked differential, problem list, summary etc. + causes, Ix, differences between chronic and acute
Hx - BPH
... Referral for patient above via telephone - examiner kept asking what else??

Hx - Acute shortness of breath. O/E legs for swelling - signs of tension pneumothorax and P.E management.

Hx station - Stevens Johnsons syndrome (doesn't really matter what the Dx is - just have to take a thorough Hx and then summarise, give DDx, problem list, management plan)

History - IHD

Hx - crohn's disease - Dx, Rx, prognosis, aetiology etc

Hx - perianal abscess in lady with nonspecific colitis - causes, crohns, diabetes, COPD, Qs on diabetic Cx and Ix of colitis

My history was really hard as the patient was jaundiced, but had left abdo pain, urinary frequency and a hx of diverticulitis. I couldn't put it together but stuck to my format for the history and it must have gone OK because my score was good in the end

History of feeling odd with frothy urine and a rash - SLE // History of gentleman with recently diagnosed hypertension (i.e. that day) and urine dip showing nephritic syndrome. Nice history of two months increasing tiredness and joint aches and spotty red rash over legs and gluteals ... Can you guess what it is yet... Two questions – most likely diagnosis and which investigations // History from a person with hypertension, with protein and blood in urine. Does not have any cardiovascular risk factors...was kinda stuck because secondary causes such as phaechromocytoma and coarctation of aorta could not be ruled out. Turned out infact patient had a rash and diffuse joint ache. Other students said the patient had SLE?? Asked what 2 investigations would you do? Answer depended on what you got out of the history, I went for renal ultrasound and ECG. // Urinalysis with nephrotic syndrome picture - history taking of hypertension, haematuria and proteinuria. - You are a GP and a patient who has just moved house had just registered- has a urine dipstick and u get given the result - ++++proteinuria and ++blood He had swollen ankles and face and a rash on shine 2/52 agon ? Nephritic sx? Asked 3 Ix would do. .
Think most people like me fumbled around with renal failure as most likely diagnosis and said we'd like to do U&E, FBC, glucose, creatinine clearence... and prayed for the bell to go... I said SLE, although other people think it might have been IgA - who knows? // history of (i think) glomerolonephritis secondary to SLE. He didn't question my diagnosis anyway like he did with other people who said things like pyelonephritis, nephrotic syndrome. Asked to name three tests you would do eg urine culture, microscopy, U and Es, autoantibodies for SLE

History station - obstructive jaundice

Hx station: very long and complicated UC history from a real patient but they just wanted to see hoe you cope with taking a complicated history.

I had a stable patient with diabetes brought on by steroids she was on for Crohn's. Quite straightforward Others had diabetes, SLE, and there was one with gauler's disease which noone had heard of!!

Liver transplant history

Hx - pt with lymphoedema and median nerve compression post-radiotherapy for breast cancer
History of a 79 year old woman with a history of breast cancer. “Please talk to this woman regarding any problems she had with this diagnosis”. More psychological rather than medical but still talked briefly (in the history and with the examiner afterwards) about triple assessment, oestrogen receptor inhibitors, staging and grading and non-medical treatments for breast cancer.

I got SLE (I almost cried). the patient had recently been discharged from hospital with heart failure, but I asked her every question under the sun (systems review in the best!) and she was feeling very well and had no rashes or anything. She mentioned that she sometimes gets "cold fingers" and the penny dropped after that. The examiner was really nice and asked me to present my findings as a problem list. I was then asked about the features of SLE and why this patient had heart failure. I said cardiomyopathy (which I think might have been wrong) and then pericarditis/pericardial effusion (which I think made more sense). I was asked about investigations for the patient and how often I would review this patient in clinic. I said monthly for the first six months then perhaps six months. I actually was making it up.

History: (20 mins observed + 10 mins questions) This was ridiculous. My young patient was referred to clinic with recurrent shoulder dislocations and stretchy skin. She had long complicated history involving hyperextendible joints and operations for shoulder and broken tibia, fundoplication for GORD, arthroscopies. She had osteoporosis and secondary amenorrhea because of a pituitary adenoma. On many meds - remember to ask about doses and any side effects. Diagnosis was Ehler Danlos. Differentials include osteogenesis imperfecta, Marfans, pseudoxantha elasticum. Examiner then asked questions about ED - what type of collagen affected? how would you treat? referrals? At the end the examiner said he would never have expected to see an Ehler Danlos patient in finals and that he did not feel it was fair. I did ok though!

History – 30 minutes station, 17 minutes history, rest of time questioning by examiner. I had history of elderly man with chronic fatigue and episodes of melaena. Main differential was colon cancer. Take a FULL history, you have 5 minutes before station starts to read the scenario and write whatever questions you may want to ask so use this time efficiently to write down differentials etc before you have even taken the history. Examiner then asks you to present the history briefly and then asks for differentials, investigations and a management plan.

Other people had a scleroderma history (shortness of breath and skin changes so know that inside out).

Remember they like chronic diseases for histories, like HIV (nasty one as you need to know about anti retrovirals and their side effects etc), rheumatoid, SLE, IBD (UC and Crohn’s is world famous history to come up). // Hx - HIV clinic please take Hx of lady with known HIV. Turns out she has a cough, so disuses differential/management afterwards with

hx of woman who had lung ca 4 yrs ago, had to find out how this affected her life. I was only asked questions about things I brought up. for example, when asked what investigations I would do I said fbc to start looking for high calcium - I was asked how having cancer may raise your calcium. and how on a scan they may differentiate cancer from fibrosis due to previous radiotherapy

long hx- Mine was on thyroid cancer- initially hypothyroid, then developed thyroid cancer & Mx. A nice history in comparison to what other people got. The questioning was relatively difficult, but the doctor was very nice and there's not much you can do to prepare for it anyway

History – took history from patient with history of several valve replacements and infective endocarditis more recently. Then asked questions by examiner on infective endocarditis and valves etc.

Long History station - was a little baffled by this at first, the instructions were just to take a full med history from this lady, who when I asked for her presenting complaint, said 'I don't know dear, I've come in today because I always come in for exams and the doctors asked me to'. But just moved onto her PMH etc and she had a lot to go through, to which I really had to rush by the end to get a complete history! But then the 10 min discussion I just presented my case (who had diabetes, AF, OA, cancer of the breast and skin, a stroke and a few other chronic problems) and then was asked how I would manage these different parts as a GP. Again

Hx - Patient is new to GP practice. Please take her medical history. My patient just would not stop talking and kept going off on tangents. At 17mins, I was still on HPC. Had to rush through social hx. Moral: feel free to interrupt patients!!

History of acute cord compression and a linked station with the next one being a telephone referral (which was actually really fun!)

MI & Liver Enzymes

2010-05-14T07:11:00.000-07:00

Remember - does the investigation rule out/in? Dx

MI Enzymes

CK
- rises 3-6hrs after event
- only 50% pts show rise > ULofN @ 4hrs
- CK rises by over 50% over 12 hrs

CK-MB
- rises earlier than CK
- 3% CK-MB in skeletal muscle
- rhabdomyolysis = raised absolute levels
- better test = CK-MB/CK

+
Sys + ECG
CK-MB to confirm CK

Troponin

Myofibrillar protein fr damaged cells
- subtypes inc trop-T/trop-I
Measured at 12hrs post onset
Elevation persistent up to 10 days
Can indicate low-grade myocardial damage before infarction, requiring acute treatment
Good specificity

Liver Enzymes

ALT - cytosolic enzyme

ALP - biliary brush border enzyme
GGT - ribosomal test, x liver specificity

Enzymes

2010-05-14T07:05:00.000-07:00

Raised Levels
*most significant finding
- increased synthesis/cell proliferation
- cell membrane damage
- cell death
- defective/slow blood clearance
Level increased can = extent of injury
Isoenzyme = greater tiss specificity

Enzyme profiles

1) tissue of origin
2) isoenz pattern in tiss
3) timing in relation to disease
4) lab availability

Normal variations of enzyme levels

1) Age/sex variation in reference range (ALP higher in adolescents)
2) Race (CK higher in afro-Caribbean)
3) Analytical interference (transaminases & LDH - haemolysis from red cells)
4) Renal failure (Amylase increased, as excreted renal-ly)
5) 'Macro enzymes' - binding of enzyme to immunoglobulin - lowers rate of degradation
- primary protein (immunoglobulin) disease eg myeloma
- temp
- *CK & AMY
- = req alt of Ix w/ documentation

MI
CK & CK-MB
troponin (non-enzyme)

x transamimases/LDH

Liver
ALT
ALP
GGT

Pancreatitis
Amy

Skeletal

CK for muscles
ALP for bone

Osteoporosis

2010-05-14T06:58:00.000-07:00

Reduction in bone mass via loss of matrix
Excessive bone loss
Normal mineral:matrix ratio

Causes
Old age (post-menopause)
Endocrine
- premature ovarian failure (early menopause)
- Cushings
- thyrotoxicosis
Drugs
Steroids
Heparin

Ix
pl Bone profile = normal
DEXA
- Identify fast bone losers
- Monitor therapy (HRT, bisphosphonates)

Osteomalacia

2010-05-14T06:56:00.000-07:00

...aka rickets in children

Defective mineralisation of bone (calcium deficiency) + Increased osteoid

Causes
Dietary/Malab - Ca/vit D def
x Exp to sunlight
Disordered vit D metabolism
- renal Dis (decreased 1-hydroxylation)
- vit D-dep rickets (1alpha-hydroxylase def)
- a-convulsive therapy (induces metabolism)
Low phosphate (Renal Tubular Leak)

Ix
low sCa & PO4
high ALP (osteoblastic response) - interpret with age-related ref range
low circulating 25-OH cholecalciferol (?diet def)
elev sPTH (2ry HPThm)

Hypocalcaemia

2010-05-14T06:51:00.000-07:00

Hypocalcaemia

Sy & Si
MSK - numbness, parasthesia, muscle cramps, convulsions
+ve Chvostek's & Trousseau's signs

Bone - myopathy & bone pain (low vit D)

Eyes - cataracts (chronic)
Brain - behav disturbances

ECG = Prolonged QT

Causes (NB hypoalbuminaemia)
Low vit D
Disordered vit D metabolismm (eg Renal Failure)
hPTH (congenital, AI, post Thyroid Sx, infiltrations)
PseudohPTH (PTH resistance)
Mg depletion (impaired PTH synthesis/release)
Acute pancreatitis
Neonatal
Massive blood transfusion (citrated blood)
Artefactual ( Blood sample collected into EDTA/citrate)

hCa + low/undetectable PTH = hPTm

hCA+elevated PTH = non-PT causes (except pseudo hPT)

Hypercalcaemia

2010-05-14T06:43:00.000-07:00

"Bones, Stones, Abdo Groans & Moans"

Si&Sy
GI - Anorexia, N&V, Abdo pain & Constipation, Peptic ulceration & Acute pancreatitis
Renal - Polyuria & polydipsia, calculi & nephrocalcinosis, renal failure
CVS - HTN, heart arrhythmias
MSK - weakness, lassitude
Eyes - corneal calcification
Mental changes
Underlying Disease

Causes
*
1ry HPTH (1/1000)
Malignancy (*myeloma)
- Bony mets
- Tumour - PTH related peptide
- Tumour - HCa agonists
Other
Sarcoidosis (increased calcitriol synth)
Vit D intox
3ry HPTH (eg CRF - post Tx)
Immobilisation (Paget's, Adolescents)
Thyrotoxicosis (severe)
Tz diuretics
Familial hypocalciuric HCa (v rare)

HCa + supp PTH = non-PTH Cause
HCa + raised/detectable PTH = PTH-mediated cause

Calcium Haemostasis

2010-05-12T14:56:00.000-07:00

Haemostasis
Skeleton = 1kg/25000mmol/99% body Ca
Dietary Intake of Ca = 25mmol/day
Exchange between ECF and bone = 10mmol/day
*renal (imp in regulation)
GIT... also involved

Pathology
... occus with...
- Gut, renal, skeletal problems
- Parathyroid disorders
- Abnormal Vitamin D metabolism

Ix
*Total plasma calcium
plCa = alb-bound 40%, complexed 10%, free ionised fractions 50%
Ionised Ca = active fraction - roles in bone, teeth, neuromuscular activity, coagulation (enzyme co-factor)

Corrected Ca = Ca + 0.02(40-Albumin)

Parathyroid Hormone
Increase in PTH - stim by
- low Ca
- raised PO4 (Chronic effect only)
Only intact PTH is active
...act on...
Kidneys
- incrs Ca reabsorption
- decrs PO4 reabsorption
- decrs HCO3 reabsorption
- incrs 1-alpha-hydroxylation of vit D (activated)
Bone
- incrs osteolclastic resorption

Vit D
Dermal synthesis & Diet
Liver = 25-OH cholecalciferol - 'inactive'
Renal = 1,25 dihydroxycholecalciferol (calcitriol - 'active')
Calcitriol stim by...
- low ionised Ca (via PTH)
- low PO4
- low vit D
Calcitriol acts on...
- gut = incrs Ca & PO4 absorption
- renal = incrs Ca & PO4 reabsorption
- bone - incrs resorption/mineralisation, remodelling

Calcitonin (Thyroid 'C' Cells)
hCa actions
- stim by increased Ca ions

Septicaemia

2010-05-12T10:14:00.000-07:00

Bacteraemia = "presence of bacteria in blood"

Aet
- N flora - access to bloodstream
eg dental & soft tissue abscesses/cholecystitis/appendicitis/diverticulitis/upper renal tract infection
- **prosthetic surgery (orthop, CVS, neuro) - prosth can be 'seeded' by organism & infect irrev
- Pneumonia - S pneum
- Skin - S pyogenes/S aureus

Sy&Si

Asy (pray that it's not)
or
Severely ill
Fever (absent with child/eld)
Shock (later presentation)
Depressed consciousness (confused/drowsy)
?GN-ve vs G+ve - cannot clinically differentiate

h/e signs poss...
- N meningitidis - purpura
- S Aureus - embolic lesions
- N Gonorrhoeae - arthritis

Dx
x2 peripheral blood cultures b4 Tx
Septic screen
- blood cultures

- urine cult

- sputum cult

- CSF

- skin swabs

- CXR/AXR
- abdo US

Tx
1) empirical DO NOT WAIT!!! - BSp

Empirical Therapies

Skin - strep & staph
-Flucloxacillin
Abdo sepsis - enterobacteriaceae & obligate anerobes
-Ceftazidime & metronidazole/meropenem
Prosthetic devices - staphylococci
-Fluclox/vanc
Urinary Tract - enterobacteriaceae & enterococci
-Piperacillin/tazobactam (init if Hosp acq & sev)
Meninges - N Meningitidis, S pneumoniae, H influenzae
-Benzyl penicillin/Cefotaxime

Line-related septicaemia
- increased risk with time
- S aureus, S epidermidis, Klebsiella
- look for inflammation - remove if susp infection

- Ix - blood cultures from peripherally through cannula
- Tx - ABs, Glycopeptide (MRSA)

- Prevention - ANTT, device w/o dead space/side ports, good dressing, staff hygiene, regular inspection, periph resited every 48hrs, central & tunnelled lines - inspection changed with evidence of infection

- Cx - septicaemia, endocarditis, metastatic infection (eg OMyelitis)

Puerperal Fever
Sev
*bacteraemic infection
Entry of pathogens throo placental bed/cervix following delivery
*w/i 7d of deliv

Sy
Fever
Back pain
Offensive lochia
Shock

Fever - if in early puerperium = Ix! - bl/ur cult/endocervical swabs

Tx
Empirical
3rd gen cephalosporin & metronidazole
Remove any retained products of contraception
Intensive care if necess

Cx
DIC

Systemic Causes of Haematological Changes #3

2010-05-12T09:48:00.000-07:00

Liver Disease

Bleeding
- deficiency of vitamin K factors (II, VII, IX, X), Factor V, fibrinogen
- functional abnormalities of fibrinogen
- increased fibrinolytic activity
- decreased plts (Hsplen, direct alcohol effect)
- portal HT - varices

Anaemia
- bleeding & iron deficiency
- alcohol - direct toxic effect
- folate def (megaloblastic An)

- Hsplen
- Hlysis - alcohol, Copper (Wilson's), AI (a/w hepatitis)

Red cell changes (macrocytosis, target cells, spur cells)

Chronic Renal Failure

Bleeding

- abn plt function
- thrombocytopenia (AI, HUS)

Anaemia
- decrsd erythropoetin production
- Fe def (dialysis, venesection, poor plt function)
- aluminium toxicity
- folate def (chr dialysis)
- Hlysis (HUS)
- anaemia of chronic disease

Red cell changes (Burr cells, fragmented cells in HUS)

Anaemia
- chronic disease
- Fe deficiency (Chronic bleeding, *GI tract tumours)
- immune haemolytic anaemia *NHL
- pure RC aplasia a/w/ thymoma
- BM infiltration (extensive)
- folate deficiency (anorexia, drugs)

Polycythaemia
- erythropoietin-producing tumours eg kidney, cerebellum, liver

Platelets & coagulation
- thrombocytosis - eg GI bleeding, reactive
- DIC - eg mucin-secreting carcinoma
- coagulation factor aB - eg to factor VIII

Hsplenism
Incrsd pooling, sequestration, destruction

Causes An, Leucop, Tbcytop

Hyposplenism

- splenectomy
- sickle cell dis

- essential thrombocythaemia
- adult coeliac dis

Splenic function impaired by
- corticosteroids
- radiation

Haematological changes
RCCs:
- Target cells

- Howell-Jolly bodies (DNA remnants)

- siderotic granules (iron-containing)

- nucleated RBCs

WCCs:
- early after splenectomy = Nphilia
- ltr = lymphocytosis, monocytosis

Plts:

- early post-splen = marked tbcytosis
- ltr = plts slightly elevated

Cxs:
Increased risk of fulminant infection (*encapsulated bact, malaria)
- S Pneumoniae
- N meningitidis
- H influenzae

Tx

Life-long prophylactic penicillin/erythromycin (prior to splenectomy if poss)
Immunisation - pneumococcus, HiB, meningococcus

Systemic Causes of Haematological Changes #2

2010-05-12T08:30:00.000-07:00

Acute Phase Reactants
- general indication of inflammatory resp
eg
Fibrinogen
Complement
CRP
Haptoglobin
Ferritin
Serum amyloid protein

Ix
Presence & extent of inflamation + resp to Tx

ESR
Red cell sedimentation through plasma in 1hr
- cheap
- dependant on plasma concentration of large proteins - immglob/fibrinogen
- raised - chronic infection/myeloma/dissem malig/AI
- aff by red cell concentration - low in polycythaemia & high in An

Normal range
Men < 5mm/hr
Females < 15mm/hr
Increases with age

Plasma Viscosity
n(1.5-1.7 mPa/s)
15min test
Slight increase with age
Unaffected by red cell changes

CRP
Rapid increase to tiss inj (4-6hrs)
Highly sens
Unaff by RC Changes

?poss - paraproteinaemias

Systemic Causes of Haematological Changes #1

2010-05-12T08:21:00.000-07:00

White Cell Changes

Neutrophilia
> 7.5
- Bacterial infection - localised (eg abscess), disseminated (eg septicaemia)
- Inflammation/necrosis - eg MI, vasculitis
- Malignant disease
- Myeloprofilerative disease - eg CML
- Metabolic disease eg uraemia, gout
- Corticosteroid Tx

Leukaemoid reaction
WBC > 50 nt fr leukaemia
Lymphocytes/Neutrophils +/- immature forms
- Severe infections - bacterial eg pneumonia
- Viral - eg infectious mononucleosis
- Severe haemorrhage/haemolysis
- Malignant disease
- Intoxications - eg burns, eclampsia

Ix
BM aspirate/trephine Bp
BM cytogenetics
BM film - Np Granulocytes/Myelocytes
(NB identical to CML, therefore test for Philadelphia chromosone)

Leukoerythroblastic change
Blood shows - nucleated RBCs & primitive WBCs
- Marrow invasion - eg metastatic tumour, Hm malignancy (eg myeloma/lymphoma), fibrosis
- Severe illness - eg trauma, septicaemia, massive haemolysis

Ix
BM trephine biopsy

Neutropenia
< 2
Isolated/pancytopenia

Isolated
- Drugs eg phenylbutazone, co-trimoxazole, carbimazole, anti-psychotics
- Racial
- Congenital eg Kostmann's syndrome, cyclic
- Infections eg hepatitis, typhoid, TB, malaria
- AI eg Felty's, SLE, idiopath

Pancytopenia
- MF - any cause (aplastic anaemia, megaloblastic anaemia, irradiation, malignant infiltration)
- Hypersplenism

Eosinophilia
> 0.5
- Allergies eg asthma, drugs, hayfever
- Parasites eg ankylostoma, ascaris, filaria
- Skin eg eczema, psoriasis, dermatitis herpetiformis
- Malignancy eg Hodgkin's disease
- Inflammatory disease eg sarcoidosis, PAN
- Hypereosinophilic syndrome
- Eosinophilic leukaemia

Hx - for travel, Dx, allerg
Ex - skin, lungs, joints
Ix - as above, stool examination (parasites), RhF, CXR

Lymphocytosis
> 3.5
- Acute infection - *viral eg rubella, mumps, infectious mononucleosis
- Chronic infection - TB, brucellosis, hepatitis
- Thyrotoxicosis
- CLL
- Other Leuks & Lymphomas

Hx - viral illness/night sweats/WL
Ex - throat, LNs, liver, spleen

Viral serology - EBV

Marrow Failure - Myelodysplasia

2010-05-12T06:48:00.000-07:00

MDS (myelodysplastic sydromes/myelodysplasia)

Acquired clonal d/o fr haemopoetic stem cells

Epid
Pts *> 70 yrs

Ix & Path
Cytopenias - *An

Morphological evid of dysplasia in blood & BM cells
BM - cellular/Hcellular (NB difference to AA)

Aet
*idiopath
Prev cytotoxic CTx/RTx

Dx
Typical dysplastic changes of Blood & BM
+ Clonal cytogenetic abnormalities on chromosomal examination of BM cells

Prognosis
3 variables
- % immat blast cells in BM (low blast = best)
- cytogen abnorms
- no of cytopenias

Tx

- Supportive - red cell transfusion, iron chelation Tx after multiple transfusions, recombinant erythropoetin therapy
- Cytotoxic CTx - for AML, h/e poor response rate
- Differentiation therapy eg 5-azacytidine (accelerates differentiation of MDS clone, so normal stem cells can regain dominance)
- StC transplantion - definitive cure; only poss 4 small fraction of younger pts

MDS - *AML

Marrow Failure - Aplastic Anaemia

2010-05-12T06:36:00.000-07:00

Features:
- Pancytopenia
- Hypoplastic marrow
- Low reticulocyte count

Si&Sy
Infection/bleeding/anaemia

Causes:
Congenital
Fanconi's (not*)
Acquired
Idiopathic - *AI reaction to BM Stem Cells - eg T suppressor lymphocytes
Radiation - RTx/Occ
Chem - Benzene TNT, DDT
Drugs - Cytotoxic Dx (requires frequent FBCs), other
Viruses

Viral Causes

- Hepatitis

- EBV

- ParvoV

Non-cytotoxic Drug Reactions

- Chloamphenicol

- Zidovudine

- Gold

- Phenylbutazone

Remove cause

Supportive - red cell transfusion, ABs, plt transfusion

Stim BM Stem Cells - anabolic steroids

Severe AA
- Np < 0.5
- Plts < 20
- Transfusion-dependant Hb

Tx
BM transplant
- <45yrs
- with HLA matched donor avail
ATG/ALG (anti-thymocyte globulin)
- removes inhibitory T-cells
- H/e SE: temp thrombocytopenia & serum sickness
Immsupp
- cyclosporin
- HD steroids

Marrow Failure - Thrombocytopenia

2010-05-12T06:08:00.000-07:00

Thrombocytopenia

Decrease in plts prolongs bleeding

(>50 is still okay)
Important to know in case of invasive procedures eg LP

Sy
Purpura/mucosal bleeding

Tx
Plts < 10 = daily transfusion of plt concentrate obtained w/i last 72 hours

Relatives/HLA-matched donors - plt-pheresed on cell separator
Short life-span, so in 24h = x sustained increase in no.

Plt count unreliable mesr of effectiveness

Effective transfusion?
1) Cessation of bleeding
2) Incrs in plt count >20 over baseline, after 1 hr-post transfusion

Problems

HLA aBs in pt (if not matched)

Continued plt consumption at bleeding sites

Marrow Failure - Leucopenia

2010-05-12T05:53:00.000-07:00

***Neutrophil count !!!

<1.0 = pyogenic infection
<0.5 = severe risk

FNEs (Febrile Neutropenic Episodes)

Temp = 38.5 x1 or 38x2 w/i 1hr

Ix
Clin exam - severe infection poss from minor inj
Blood M,C&S
Throat sub

MSU

Tx
BSp ABs + change according to sensitivities/if unresponsive to BSpectrum ABs
Continuing fever after ABs = admin of IV anti-fungal agents (amphotericin)

Prophylaxis in Np patients

Barrier Isolation (filtered air & sterile food) = Severely Immunocompromised
Alternatives = Compromise isolation/Home
Compromise isolation = xVisitors with active infections, xFood with bacteria eg cheese, glove & gown

Oral anti-fungals eg nystatin/amphotericin (against oral candida)
x prophylactic ABs except poss LD co-trimoxazole for post-transplant and AIDs pts (against PCP)

Leucocyte Transfusion - from - normal donor treated with G-CSF/pts with chronic granulocytic leukaemia (due to higher no of circulating Nps)

Lymphopenia
Increased risk of viral infections/pneumocystis

Prophylactic aciclovir (against herpes) until T-lymphocyte count > 0.2
Marrow transplant causes immunosuppression * with GVHD
CTx (nucleoside analogues eg fludarabine) also cause immunosuppression

Marrow Failure - Anaemia

2010-05-09T02:48:00.000-07:00

Symptoms
Tiredness
Dyspnoea
Angina

Ex
Pale mucous membranes eg eyes

Tx
Transfusion = Packed cells/plasma reduced red cells (NB vol overload)
Adult = 1 unit of blood : 1g/dl in Hb
Aim in-patient = Hb 9-10g/dl
Severe An (Hcrit<.30) = Prolonged BT & can worsen Tbcytopenia

Transfusion reactions
Prev transfusions = antibodies against blood components
eg
- HLA Ag (found on WC & plts)
therefore can = NHFTRs (non-haemolytic febrile transfusion reactions) - from dead WC&Plts in red cells units

Immunocompromised
Require CMV-ve (found dormant in lymphocytes) blood
40% UK donors CMV-ve
Patient CMV aB+ve status useful to establish

Cx
Heart failure

Bone Marrow Failure

2010-05-09T02:29:00.000-07:00

Marrow Failure
=
Pancytopenia i.e.
Anaemia
Leucopenia

Thrombocytopenia

2 types

- Hypocellular (empty)

- Infiltrated (competes with normal marrow & normal haemopoetic cells)

Hypocellular
Aplastic Anaemia
Myelodysplasia (can be cellular)
CTx
RTx

Infiltrated
2ry causes (lung/prostate/breast/thyroid/kidney)
Acute leukaemias
Lymphomas
Myeloma

Differentials of Chest Pain

2010-05-08T10:14:00.000-07:00

Cardiac
- Angina
- MI
- Myocarditis/Pericarditis (pleuritic)
Pulmonary
- Pneumonia
- Pleurisy
- PE
- Pneumothorax
Gastrointestinal
- GORD
- Oesophageal Spasm
- Peptic Ulcer Disease
Musculoskeletal
- Muscular Strain
- Costochondritis
- Rib Fracture
Other
Anxiety

Infectious Diseases - Empirical Therapies

2010-05-04T13:53:00.000-07:00

Skin

Cellulitis

Strep. pyogenes
± Staph. aureus

Mild/Moderate (oral)
Penicillin V + flucloxacillin
or Co-amoxyclav alone
or Erythromycin alone (if penicillin allergic)

Severe (IV)
Benzylpenicillin + flucloxacillin
or Co-amoxyclav alone

Bones & Joints

Osteomyelitis & Septic Arthritis
Staph. Aureus

Streptococci

Staph Epidermidis

ALL CASES ARE SEVERE
IV Flucloxacillin (+ fusidic acid for osteomyelitis)
or Clindamycin alone

ENT Infections

Sinusitis & Otitis Media

Viruses
Strep. pneumoniae

Haemophilus influenzae

Nothing
or Amoxycillin
or Erythromycin

Throat Infections

Viruses

Strep. pyogenes

Nothing

or Penicillin V

or Erythromycin

Respiratory Infections

Community Acquired Pneumonia
Pneumococcus (Strep. pneumoniae)
‘Atypicals’

- Mycoplasma pneumoniae

- Chlamydia pneumoniae

- Legionella

Mild/Moderate (oral)
Amoxycillin

+ Erythromycin (if ‘atypical suspected’)

or Erythromycin alone

Severe (IV)
Co-amoxiclav

or 2nd/3rdgen. cephalosporin + Macrolide

Pulmonary tuberculosis

Mycobacterium tuberculosis

Rifampicin + Isoniazid + Pyrazinamide + Ethambutol (2 months)
Rifampicin + Isoniazid (4 months)

Acute Exacerbations of COPD
Pneumococcus (Strep. pneumoniae)

Haemophilus influenzae

Moraxella catarrhalis

Amoxycillin + Clarithromycin

or Tetracycline (if penicillin allergic)

Urinary Tract

Urinary Tract Infection
E. Coli (60-90%)
Proteus (10%)
Klebsiella

Mild/Moderate (oral)
Trimethoprim (unless pregnant)
or Amoxycillin

or Nitrofurantoin

or Ciprofloxacin
(A 3-day course is usually sufficient)

Severe (IV)

Co-amoxiclav

or 2nd/3rd gen. cephalosporin ± gentamicin

GI Tract Infections

Gastro-enteritis
Often viral and self-limiting
No antibiotic usually indicated

Campylobacter
Ciprofloxacin

Salmonella
Ciprofloxacin

Typhoid fever
Ciprofloxacin

Pseudomembranous colitis
Oral metronidazole

or Oral Vancomycin

GI Tract Surgery & Peritonitis - Antibiotic Prophylaxis and Treatment

Staph. aureus (wounds)
Mixed faecal flora including anaerobe

2nd/3rd gen. cephalosporin + metronidazole

or Co-amoxyclav alone

Meningitis

Meningococcus (N. meningitidis)

Pneumococcus (Strep. pneumoniae)

Haemophilus influenzae

ALL CASES ARE SEVERE

Ceftriaxone IV

Prophylaxis for Meningococcal contacts

Rifampicin

or Ciprofloxacin

Septicaemia

Many possible causes

‘Blind therapy’ is broad spectrum + additional cover for strong clinical suspicion
Definitive therapy based on culture results

Community Acquired

Ceftriaxone ± gentamicin
Add Metronidazole if anaerobes suspected
Add Flucloxacillin is Staph. aureus suspected
Add Vancomycin if MRSA suspected

Infectious Diseases - Antibiotics Profiles

2010-05-04T13:28:00.000-07:00

General Principles

Empirical Therapy

Likely organisms

Severity of infection

Investigations
Microbiological:
Swabs
Fluids e.g. sputum, urine, aspirates
Blood culture
Serology

Bloods

FBC

Inflammatory markers

Radiology

Review Progress

Clinical

Cultures & Sensitivity

Adverse Effects

Penicillins
Inhibit bacterial cell wall synthesis
Well tolerated:

Rash (common)

Anaphylaxis (rare)
Excreted in urine
‘Safe’ in pregnancy
Destroyed by beta-lactamase (S. aureus and some anaerobes)

Except:

Flucloxacillin - beta-lactamase resistant

Amoxycillin & clavulinic acid - beta-lactamase inhibitor, may cause jaundice

Benzylpenicillin (IV) or Penicillin V (oral)
Gram +ve (strep)
Meningococcos
Gram +ve Clostridia species of Anaerobes

Ampicillin/Amoxycillin
Gram +ve (strep)
Gram -ve

Flucloxacillin

1st choice - S. aureus

Co-amoxyclav (amox & clavulinic acid)
Gram +ve (strep)
S. aureus
Gram -ve
Anaerobes

Cephalosporins

Inhibit bacterial cell wall synthesis
Broad spectrum
Well tolerated, though 10% cross-over with penicillin allergy
Excreted in urine
‘Safe’ in pregnancy
Resistant to beta-lactamase (S. aureus and some anaerobes)
x cover Enterococci

Cefuroxime (‘2nd generation’)
Gram +ve
S. aureus (not 1st choice)
Gram -ve

Ceftriaxone (‘3rd generation’)
Gram +ve
S. aureus (not 1st choice)
Meningococcus
Gram -ve

Ceftazidime (‘anti-pseudomonal’)
Gram +ve
S. aureus
Gram -ve
Some Pseudomonas

Aminoglycosides

e.g. Gentamicin

Inhibit bacterial protein synthesis
Reserved for severe Gram –ve infections
IV only
Excreted in urine
Important adverse effects:

Nephrotoxic

Ototoxic
Monitor blood levels
Only use in pregnancy if benefit outweighs risk

Aminoglycosides
Gram -ve

Pseudomonas
Mycobacteria - some, not 1st line

Macrolides

e.g. erythromycin, clarithromycin

Inhibit bacterial protein synthesis
Atypical pneumonias
Patients allergic to penicillins
Well tolerated

GI upset (common)

Jaundice (rare)
Erythromycin inhibits cytochrome P450

Macrolides
Gram +ve

S. aureus

Atypicals

Tetracyclines

Inhibit bacterial protein synthesis
Broad spectrum including most atypicals
Over-used in the ‘60s and ‘70s - widespread resistance
Deposits in bone and teeth - grey staining
Avoid in pregnancy and children < 12 years
May exacerbate renal impairment

Tetracyclines

Gram +ve (Used as empirical alternatives to penicillin in mild/moderate URTI, also used for acne)
Gram -ve
Atypicals (Treatment of choice for microbiologically proven Chlamydia, Rickettsia, Brucella, Borrelia)

Trimethoprim

Bacterial dihydrofolate reductase inhibitor
Broad spectrum, some resistance
Well tolerated
Excreted in urine
Avoid in pregnancy
Useful for empirical treatment of UTI and respiratory infections

Trimethoprim

Gram +ve
Gram -ve

Quinolones

e.g. ciprofloxacin

Inhibits DNA gyrase

Mainly Gram –ve aerobes inc some pseudomonas
Over-used in the ‘80s - widespread resistance
Rarely = seizures or tendon inflammation/rupture
Excreted in urine
Avoid in pregnancy

Quinolones

Meningococcus - Prophylaxis only
Gram -ve
Some Pseudomonas

Glycopeptides

e.g. vancomycin, teicoplanin

Inhibit cell wall synthesis

Severe Gram +ve infections resistant to penicillins
Inc. MRSA (resistant to flucloxacillin)
Vancomycin:

Nephrotoxicity

Ototoxicity

‘Red man’ syndrome
Requires blood levels

Glycopeptides

Gram +ve
S. aureus
Anaerobes - Clostridia species

Metronidazole

Inhibits bacterial DNA synthesis
Anaerobic bacteria and protozoal infections only
Very low resistance
Well tolerated but can cause metallic taste
Avoid if possible in pregnancy

Metronidazole

Anaerobes

Chronic Kidney Disease

2010-05-04T11:41:00.000-07:00

Chronic Kidney Disease

Not that you can possibly care...
GFR (ml/min/1.73 m2) = 186* x
{[Serum creatinine (mmol/l)/88.4] -1.154}
x age (years) -0.203
x 0.742 if female
x 1.21 if African American
(* correction factor depends on creatinine assay)

Stages of Chronic Kidney Disease & GFR (ml/min)

Stage 1
Normal GFR with another abnormality
> 90

Stage 2
Mild reduction in GFR with another abnormality
60-89

Stage 3
Moderate reduction in GFR
30-59

Stage 4
Severe reduction in GFR
15-29

Stage 5
End-stage renal disease
<15 or dialysis

Kidney Damage
•Proteinuria (albuminuria)
•Haematuria (microscopic, macroscopic)
•Abnormalities on imaging studies
•Histological abnormalities on biopsy

Causes of Chronic Kidney Disease
•Diabetes mellitus
•Glomerulonephritis
•Chronic pyelonephritis
•Prostatic hypertrophy
•Renovascular disease

•Multisystem diseases
•Genetic diseases

Management of CKD
Establish a diagnosis
Avoid nephrotoxic drugs
Treat hypertension
Treat complications
Monitor kidney function
Prepare for dialysis and transplantation

The “Uraemic Emergency”
•Pulmonary Oedema
•Peripheral Oedema
•Metabolic acidosis
•Hyperkalaemia
•Uraemic Pericarditis

Acute Kidney Injury

2010-05-04T11:32:00.000-07:00

Acute Kidney Injury

3 Types:

1) Pre-renal i.e. renal hypoperfusion

- Dehydration

- Haemorrhage
- Clamps

- “Shock”
- Low cardiac output

2) Intrinsic renal i.e. tubular, glomerular or interstitial injury
- Acute tubular necrosis
- Acute glomerulonephritis
- Acute interstitial nephritis

3) Post-renal

- Renal tract obstruction
- Ureteric stone(s)
- Bladder outflow problems

- Surgical ties
- Retroperitoneal disease

Pre-renal:

•Urinary sodium < 20 mmol/l
•Urinary plasma:urea ratio > 10:1

Intrinsic renal:
•Urinary sodium > 20 mmol/l
•Urinary plasma:urea ratio < 10:1

US scan:
Are there two kidneys?
How big are they?
Are they “bright”?
Are they obstructed?

Management of AKI
- Fluid: Match urine output + 500 ml
- Nutrition: Restrict only potassium
- Monitor and treat sepsis
- Reduce gastric acid production
- DVT prophylaxis

Renal Failure

2010-05-04T11:11:00.000-07:00

Kidney Functions

- Produces EPO - acts on bone marrow - which produces RBCs
- Vitamin D absorbed from skin/gut (cholecalciferol) - converted in liver to 25(OH)2D3 - converted in kidney to 1,25(OH)2D3 (calcitriol)

Dysfunction results in accumulation of toxic waste products:
- Fluid retention
- Hypertension
- Metabolic acidosis
- Hormonal disturbances

- Normochromic normocytic anaemia
- Secondary hyperparathyroidism and bone disease
(high phosphate & low calcium & low 1,25(OH)2D3 stims PTH)

Biomarkers of “kidney failure”
•Elevated blood urea and creatinine
•Reduced estimated GFR (eGFR)
•High blood potassium and phosphate
•Reduced blood pH and low bicarbonate
•Normochromic normocytic anaemia
•Reduced blood 1,25(OH)2vitamin D3
•Elevated blood parathyroid hormone levels

Prescribing Safely

2010-05-04T10:59:00.000-07:00

Know a lot about drugs
Only prescribe for a narrow list of drugs that you know really well
Use more established drugs, and avoid new drugs unless they really are an advance
Be careful prescribing drugs to young women
Use low doses in the elderly
Double check with the BNF if you are prescribing a drug

–For the first time
–To someone on lots of other drugs
–To someone with liver or kidney disease

ALWAYS WRITE
–Name

–Date of birth

–Hospital Identity number

–Allergies

–Date of admission

–Consultant’s name

–Prescriber’s name and bleep no.

Avoid decimal points

Units

–g: grams

–mg: milligrams

–mcg: micrograms

–ng: nanograms

–U: units

Formulation of the drugs:

-tabs (tablets)

-caps (capsules)

Frequency:

–od–once a day

–bd–twice a day

–tds–three times a day

–qds–four times a day

–PRN(still need to give maximum dose)

–1º-1 hourly

Route of Administration

–po-orally

–iv -intravenously

–im-intramuscularly

–top–topical (state where)

–s/c-subcutaneously

Special instructions

e.g. take before food

Finally

SIGN and DATE

Ultimate Finals List - Clinical Skills, Prescribing & Pharmacology

2010-05-04T10:37:00.000-07:00

Clinical Skills, Prescribing & Pharmacology

Fluid balance – standard every year station. Mention looking around bed for drugs, drips, lines, catheters in situ, cannulae, central lines. Then feel peripheries (?warm), cap refill (examiner asked for normal time <2s), check pulse. There is a blood pressure cuff, he asks you to measure the BP, so do it fast, other students spent ages fiddling with the cuff and wasted time, the examiner will not let you proceed until you get the BP. Then check JVP, examiner asks for normal height (=2cm). Then assess skin turgor, auscultate heart and lungs especially lung bases for crackles (?pulmonary oedema), check for sacral and ankle oedema // I asked if patient had had a fever, recent surgry, diarrhoea or vomitting // How to do a lying and standing BP and the time interval between measuring both. // Examiner then wants to know what else, so mention all of your charts:

- fluid balance chart, examiner asks what is on it so you say: inputs (IV fluids, oral intake) and outputs (urine, stool, drains, stoma bags etc)
- obs chart (temperature, BP, O2 sats, pulse, RR).
- Urine output chart.
- Drug chart – is patient on any diuretics?
- Further Ix i.e. U&Es, FBC, central line monitoring

Spacer - Explain spacer and demonstrate its use with a MDT. Woman was on bd inhaler of salbutamol, I don’t know why it wasn’t prn. I started discussing this before the bell went. Asked about why should use a spacer, had to assemble and demonstrate technique. Should have been a very straightforward station. Actress was very pleasant and trying to help. // Inhaler with spacer – advise newly diagnosed asthmatic woman on how to use it. Assemble it in front of her and tell her to rinse it with warm water and leave to dry without drying manually. Replace spacers every 6 months or so for optimum delivery of drugs. I offered to explain other things like side effects of salbutamol, but she stated that she already knew these things and only wanted to know about the spacer device and its advantages over using only an inhaler.// make sure you check his actual technique with the spacer and inhaler provided!

Certifying death. Nurse bleeps you, says thinks pt has died, you come on over and do your thing. Look at the notes, signs of death (look, listen, pupils etc). // Told patient died expectantly. Had to demonstrate what would do on a very dead plastic dummy! eg. Test pain, check pupils, listen to heart sounds and lung sounds. Then had to document appropriate things in the notes. the examiner asked if there was anything else I’d like to write that I missed things out. Hmm, maybe I forgot to write down about pacemakers? // do the basics: check for pain, shine light in eyes to check pupils r dilated...no response to pain..no breath sounds...no heart sounds...apnoeic....CHECK for PACEMAKER!!! then write ur finding in notes... // Write the date and time etc and who is doing the ward round, then mention findings and I also wrote a management plan, which included: a) fill out death certificate, b) contact family, c) arrange for patient to be moved to morgue etc

Bladder catheterisation - No one expected this to come up as we all thought UCL would be too stingy to provide catheters for everyone! We were right about them being stingy - the catheters were reused. This was to test our comm skills and catheterisation, there was a guy sitting on a bed with a plastic penis between his legs - hilarious

Insert cannula

Suturing - double station. Was my last station, by which time I was a blithering idiot and managed to take 3 minutes to discuss a sterile field! The examiner kept asking me what I needed to do to clean the wound, and I just said sterile water and lignocaine 5 times till he pointed at the green sheet and I got the message! The girl pretending to be drunk saw I was a wreck and didn’t even chat to me, which I think they were meant to do to put you off. I did my stitches competently enough. Chuck sharps! Questions on advice to patient re wound care and max dose of lignocaine. // suturing...10 min station!!! u had to suture wound of an alcoholic n I had this annoying patient who was acting drunk and completely overacting and trying to disturb me...which was the whole point of the station since it was a mixed communication skills station // she kept asking things like do u love ur job??? r u happy being a doc???? and she wouldn’t be quiet...so after about 6 minutes I thought lets put her out of her misery and I replied " yes I love myself, and I love my job and my university is the best university in the world. being a doctor is the best job in the world and I wouldn’t trade it for anything" and hooray I made the examiner smile! // apparently on the second day they asked people what kind of dressing they would use // Remember your lignocaine dose, 3mg/kg maximum, I was asked this. Also remember to arrange a safety et, tell the patient to attend GP if any worries (red, oozing wound, stitches come out etc) and to attend GP in about 7-10 days time for stitches removal. // Consent, check wound, tetanus, allergy, LA etc then x3 // I think marks may have been given for attempting to make small talk. Also patient had fear of needles so had to give counselling prior. // Examiner was nice enough but a bit annoying as kept saying ‘pretend I’m not here’ and then proceeded to talk to me or to keep telling me to ‘pretend’ he wasn’t there.

Written station (true/false mcqs), fluid balance chart, massive haematemesis

Venepuncture

IV drugs administration (2 stations)- one to prepare the drugs and the second one to adminster it. Have to talk through what one would look for in the drug information leaflet and drug chart // Look at drugs chart for pt with severe asthma – need to give IV Hydrocortisone 100mg Look at drug chart- cherk allergies, correct drug, dose, route, time,date, not yet given and that it has been signed for (IT WASN’T SIGNED) // explain how u calculate drug dose- look @ sheet to see how slow to give as IV - glove up and go to next station to give the drug Give the drug having checked pt name, dob etc ad that no signs inflammation- flush, give according to sheet, flush and discuss re what would do if anaphylaxis

Filling in crossmatch form, checks before administering blood - asked what ANTT stood for and no one could work it out!! Aseptic Non-Touch Technique!! What you would do if you dropped a syringe before taking blood // most of the marks for this section seemed to be concerned with triplechecking the identity of the patient and filling in forms and blood bottle labels to send correct bloods off for the right tests. // The examiner gives the candidate a set of labels with the patients details on to use on the blood form but this is a trick!!! You have to hand write the patient's details on the blood form!!

Prescribing - Given drug chart. Mr X is on paracetamol post-op, has kidney failure, and is in pain, about 4/10. Prescribe him something – you’re given a BNF if you need it. Some people went with morphine, and the things that go with it: laxative and anti-emetic. I just went one step up the ladder and gave co-codamol. // Think I should have put in something in the stat section too, but I forgot and just did the regular section. I had to ask the examiner the date, he told me but looked at me like I was a muppet! Stress does curious things, I tell you //You do not write up morphine as it is too strong for pain of 4/10. Other people I spoke to wrote up NSAIDs, he was already on paracetamol so DO NOT OVERDOSE HIM by giving paracetamol as well. I wrote up co-codamol and mentioned that I would stop the existing paracetamol. Remember to fill in the patient details, ward, consultant, date etc first as these are the main marks. // Had renal failure too so went with co-codamol // in the end I wrote up paracetamol, NSAIDS regularly and some opiates and metoclopramide in the PRN section.

Prescribing - Given ABGs for acute exacerbation of COPD. Asked to write up meds on a prescription chart.
then...TTA Letter - I found this station very confusing we had to fill out a TTA form for a lady who had had an exacerbation of COPD. There was a BNF there as well. I hardly filled anything in - it was unclear whether we had to list the drugs for the acute episode or prescribe her regular meds as written out in the scenario.

Discharge form - Write a discharge letter for a post-MI patient // Writing up TTOs // Explaining to a patient about drugs post MI, side effects and implications (statin, aspirin, atenolol etc.. with questions from patient about DVLA regulations on driving after an MI) - taxi driver, Heparin – explain will stop, Aspirin - lifelong, Atenolol - lifelong, Atorvastatin - lifelong nocte, Temazepam – didn’t sleep ion hosp 2 nights – not chronic used so can stop, Last Q had to explain cannot drive for a month (although examiner kept saying do I want to change my answer- though was that long but would check with colleagues, DVLA etc

Discharge summary - a LONG instructions page followed by a LONG history - patient had been diagnosed with temporal arteritis, needed to be placed on steroids and bisphosphanates. - needed to fill out the discharge summary form. Everything on it!
then... Talking to the patient whose discharge summary you filled in. She is on Prednisolone and bisphosphonate after first presentation of temporal arteritis. Explain side effects of both, steroid card. // Advise lady who needs to be on steroids because of temporal arteritis. Tell her the side effects of steroids - i couldn't remember any initially and finally blurted out 'you might go psychotic' (don't do this!)Also show her steroid card and advise her to keep it on her at all times. She asks when she can come off them - I said when her ESR was back to normal and all her symptoms had gone.

Read notes-style information about the admission of a man for asthma attack after exposure to a neighbour's dog. Fill in discharge summary with patient details, take home medications, instructions to the GP to review spacer technique and then sign and date form (there wasn't enough time to do all of this properly).
then... Meet the man (actor) whose discharge summary you've just filled out. He is worried that he was only on PRN salbutamol before admission and that now he is on 2 inhalers and oral steroids. He has heard about bad side effects for oral steroids so isn't happy about this. You needed to find out what his worries are – he thinks he has to stay on the oral pred indefinitely but is only on a 7 day course, talk to him about this, about his inhalers and demonstrate use of a spacer. // Write TTA for patient after being admitted with exacerbation of asthma - everyone found it difficult to do in 5 mins but it was easy enough, just copying info off discharge summary

Ultimate Finals List - Abdominal Stations

2010-05-03T12:05:00.000-07:00

Abdominal

GI: multiple abdo scars // Abdo - This guy was strange. He had a long midline scar that was a bit strange (didn't look much like a laparotomy scar and yet did as well) and an incisional hernia in the scar. He also had a midline sternotomy scar (which I missed and looked like a complete idiot when I said "there are no scars in the chest." It's okay though because I passed and apparently some people also missed the hernia and they still passed! It was quite subtle). The examiner was really very nice and asked me why this man had a midline sternotomy scar (abdo station no?) and then why his laparotomy scar looked a bit strange. Apparently it was because it was the old fashioned way of performing a laparotomy. I also thought this guy had hepatomegaly, but I completely forgot to mention this when I was presenting. I was then told this man had a congenital problem. The only thing I could think of at the time was Marfan’s, with a valve replacement and aortic repair

Gentleman with splenomegaly and anaemia, although I couldn't feel the spleen as the abdo was pretty distended! This examiner was a bit mean and told me I was digging myself a hole by examining the JVP! // Splenomegaly in a young afrocarribean girl // Abdo: Felty's RA and spleen got asked to present my findings, how I could differentiate the mass, is spleen from kidney

Abdo - PCKD with transplant, av fistula, cushingoid from steroids & hydrocoele - Fx of Cushings // rather large woman I thought I felt fullness in flanks, I was happy with myself for noticing little scar in bellybutton, however as I presented the examiner separated a role of her fat to reveal a large flank scar! oops. asked me what I thought had gone on I said possibly kidney transplant due to pcos, he said - why else may she have this scar if she was well but her family member was ill...it was cos she had donated a kidney. this was a little mean.

Hepatomegaly secondary to CLD, with spider naevi // Abdo - the yellowest man I've ever seen! He glowed! He also looked far too ill to be a patient for our exams and I hated moving him. No other signs apart from hepatomegaly. I think diagnosis was pancreatic cancer. // Oh and my abdominal examination pt was a gentleman with telangiectasia and a MASSIVE liver. Examiner asked for differentials, I said the 3cs : cirrhosis, congestive cardiac failure, carcinoma..then I talked about other causes: hepatitis, lymphoproliferative, myeloproliferative, endocrine etc. and time was up // Very long gentleman with pectus excavatum and palmar erythema and a whopping Mercedes scar across the abdomen – oh and two Medicalert bracelets with ‘liver transplant’ written on the back... // Guy with most of the classic liver disease signs: jaundice and yellow sclera, palmar erythema, bilateral Dupuytren's, mild ascites, spider naevi, venous engorgement, hepatomegaly. I said Alcoholic Liver Disease (alcoholic cos of the Dupytren's) and examiner was impressed. Patient also had a upper paramedian surgical scar. // Abdo - Amazing alcoholic liver disease from the ward. Ascites with old tap wound, jaundice, FLAP!!!! Hepatomegaly.

Elderly man with anaemia. He had hepatosplenomegaly. We were expected to discuss the likely diagnosis which I think was a myeloproliferative disorder. I was asked why a person with PRV would be cyanotic and didn't have time to think about my answer and give it – really annoying as I’m sure it was a point-scorer // Abdo station - patient with bronze discolouration, duypytren's contracture and apparently hepatosplenomegaly, which I couldn't feel. I did not get the diagnosis in the exam, although when I write this all down now I can see that it was haemochromatosis, but it didn't matter anyway.

Abdo: incisional hernia, urostomy. questions about what stoma was and why, what kind of metabolic abnormalities happen in a patient with a urostomy... i gave retroperitoneal fibrosis as a reason for needing a urostomy and was quizzed as to the potential drug causes of retroperitoneal fibrosis

Abdo - guidance said patient had long term lyphoma but I could find no abnormailty on examination apart from subcutaneous lipomas.

suprapubic mass - spoke about the bladder and uterus // differential, so I said fibroids, a mass in the bladder, and I would like o rule out pregnancy even though the lady was over 50... he was very impressed when I said that, he then said how would u manage someone with a fibroid, I said if it wasn’t causing any symptoms you could leave it alone, if there were symptom, there was medical management to control menorrhagia and pain, or surgical management was to remove it, and then we sat in silence, I think the examiner was very bored!// n a 50-ish year old woman with a hard pelvic mass - which really confused me, at first but just carried on my examination, presented my findings and we discussed some differentials for pelvic masses - I said fibroids, pregnancy (unlikely in a woman her age), calcified bladder, tumour and discussed how I would manage this patient (full history, basic bloods, tumour markers, dip the urine etc etc, maybe a pelvic ultrasound), then the bell went!

Gastro-divarification of recti and a sebaceous cyst, also Dupuytren’s contracture which I missed. Asked about causes of Dupuytren’s and management. Also asked to describe the seb cyst and why I thought it was one etc.

Ultimate Finals List - Respiratory Stations

2010-05-03T11:46:00.000-07:00

Respiratory

Suppurative lung disease. I was asked about possible differentials. // Hyperexpanded chest, clubbing (I missed this). Empty sputum pot by bed. Coarse crackles. Bronchiectasis (I said COPD, but examiner guided me, asked for causes e.g. obstruction of bronchi, severe childhood infection like pertussis, secondary infection of tuberculosis lung, cystic fibrosis, Ix // The blindness and madness continued here. The patient had the most obvious clubbing I'd ever seen, proper drumsticks!!! He had COPD which was apparently unrelated to his clubbing I swear the left lung base was dull to percussion but again I had a moment of complete madness and said resonance was normal throughout. Afterwards the examiner made me go back and look at a plaster mark on the patient's back that revealed a needle sized hole!!! The examiner then asked me what this patient had had done, I said pleural aspiration. I was then asked why, I said pleural effusion. He then asked me if percussion was resonant and for some crazy reason I still said YES! (?!?!?!?!?!?!).

Middle aged gentleman – ulnar deviation at MCP joints, rheumatoid nodules, hyperexpanded chest, no shortness of breath, fine inspiratory crackles more on left than right also heard at apices of lungs. Peculiar pulse. Examiner was grilling me for causes which although I said obviously secondary to rheumatoid or possibly methotrexate. he was looking for something to cause unilateral fibrosis. Only thing I could come up with was radiotherapy but with hindsight perhaps recurrent pericarditis and reactive effusions? //Peak flow at the side so use it to test peak flow // Gentleman with bilateral inspiratory crackles, decreased expansion - ?fibrosis. Asked about causes of fibrosis and then if there were any signs of any drugs patient had been on; I only noticed steroid induced "buffalo hump" when examiner pointed it out! A man with mixed connective tissue disease and lung fibrosis (I got him to do a prayer sign) // RESP- very obvious fibrosis of the lungs, I was asked about a differential but started giving causes of fibrosis..oops! she asked again about the differential, I was a little stuck, I said it may be consolidation but I would expect to hear coarse crepitations, she agreed and then said what else can we rule out, I felt a little silly saying the trachea was central so there no pneumothorax or collapse of the lung, the percussion not is resonant throughout so again rule out pneumothorax or consolidation and so on, but it what she wanted, we spent the last few minutes discussing how tired the patient must be getting, I saw her give me an A on the mark sheet

Questions ask on different between obstructive and restrictive

RS - Asthma - normal Examination poss! // my patient had low PEFR but normal Examination so just gave differentials - forgot to mention sputum pot I saw next to bed though!!

Resp - lateral thoracotomy scar-lobectomy for bronchial carcinoma

Actress with pleuritic chest pain – asked to examine her chest from behind as young female actress- 1st give 02 and reassure // followed by discussion re Diff Dx. Pneumothorax, PE, Pneumonia etc and how would treat a pneumothorax, Obs Chart with questions

Respiratory - cryptogenic fibrosing alveolitis - questions on differentials, investigations, treatment options and criteria for home oxygen

Respiratory: Nothing obvious on examination. Possibly hyperressonance on percussion. Peak flow was very low. When asked for differential I said COPD (hyperexpanded chest??). That was my last station, so the consultant asked the patient to stand up and made me comment on inspection. She had a marked Kyphosis and a bit of a scoliosis which was the causing a restrictive airway pattern.

Migratory crackles in a woman with mild clubbing, no other signs, apart from dowagers hump (elderly lady with osteoporosis), I think diagnosis was bronchiectasis but I also mentioned pulmonary fibrosis.

Resp: palmar erythema, Dupuytren’s but chest signs were not clear, end inspiratory crackles=fibrosis??, I wasn’t sure so I said its unlikely to be COPD as there was no wheeze etc, other students all came out with different differentials but the examiners was just interested in the reasoning.

Ultimate Finals List - GP, Public Health & Epidemiology

2010-05-03T11:32:00.000-07:00

Epidemiology

Read short summary of a prospective cohort study looking at the effect on breast cancer risk of eating fruit and vegetables. Non-significant findings. Asked to think of potential confounders - e.g. obese person eating less fruit causes confounding because real cause of increased cancer risk is earlier onset puberty and more oestrogen produced by peripheral fatty tissue

Evaluation of evidence - trial abstract, case-control study, strengths & weaknesses, odds ratio, confidence intervals meant, bias, confounding & public health - benefits of exercise - individual, local and national level

Evaluation of evidence - cross sectional studies

Public health questions related to alcohol and MI

Evaluation of evidence: Randomised Controlled Trial on exercise. Asked about study design and how to promote exercise at a National, Local and Individual level. // The woman kept banging on about what we would do if we could not double blind the patient...I went on about standardisation and randomisation but apparently this WAS ALL WRONG!

Evaluation of evidence station - meta-analysis

Epidemiology - Cohort study

Epidemiology - ecological study - a topic we had been told not to learn so I said 'ermm' for ten minutes. Really annoying!!!

Evaluation of Evidence and Public health: Shown a summary for a meta-analysis into the effectiveness of statins preventing cardiovascular events. Also a forrest plot. Asked what a meta-analysis is and what a Randomised control trial is. Discuss the forest plot. And the second part involves discussing how to implement the statins to the UK: eg Health needs assessment.

All about what smr meant and what an smr of 244 meant. I didn’t know.

Diabetic foot check, stocking sensory loss, implications of sensory loss, controlling diabetes & risk factors

Death certificate, causes of death, when you can actually certify as a HO, refer to coroner? We had been given a lecture on death certification in our revision week which had covered all of this and explained the pitfalls of e.g. putting 'heart failure' or 'old age', as, well as the relevant details and the importance of completing them accurately - 1) Cerebral haemorrhage, Hypertension, Could sign this certificate without any problems 2) I studied this second scenario for a long time (too long to be honest) and I could not find any good reason to refer to the coroner - I was the doctor who had clerked the patient in but he wasn’t actually under my care – I explained this to the examiner and when pressured for an answer at the bell I blurted out “yes!” Think that was wrong in reflection and I should have listened to myself when I was thinking “why can I not sign this?” just rang my friend (the clever girl who wins all the prizes yet thinks she fails…we all have them) and she said she didn’t send either to the coroner. // Death certificates 1) Adenocarcinoma of the prostate for ~ 5 years who developed bony mets and ?secondary to immobility developed bronchopneumonia // One was someone you had clerked in but not under your care since then. I said you could do it as the rules are unclear what "attended" means, apart from that you have see them 14 days before death, but that you would check with the consultant or the coroner to be sure. // all info from the lecture given in revision week. Can you respiratory failure type I & II but not heart/ kidney etc failure.

Public Health

Needlestick injury - counselling a junior colleague and instructing him on what to do following a needlestick injury. Question about how risk of transmission of infectious diseases is assessed and the rates of transmission of Hepatitis B, C and HIV. - Tx for all ie Anti Rets HIV PEP <72hrs HB booster and HB immuneglobulin Don’t do anything for the Hep C

Health promotion - alcoholic in hypertension clinic - discuss with him about alcohol, and assess motivation for change and all that stuff

Health Promotion - encouraging pt to take BP medication

Health Promotion - woman newly diagnosed with type 2 DM and placed on metformin (noted 'not keen') and given diet regulation advice. At her last check her HbA1c was 6 but this time it has gone up to 10 or so. You need to elicit that she is not taking her metformin but rather tries to control the illness with diet alone. She isn't keen on taking a pill for the rest of her life etc. The point ot this one was to recognise that she has made significant changes to her lifestyle and should be encouraged and congratulated but also needs to know that Metformin is essential etc.

Health promotion: Asthmatic lady with worsening asthma not taking brown inhaler (because if you dig a bit you find out that she is worried about taking steroids). Still smoking. Asthma worsening. Came to practice nurse for review, and nurse refers on to you (the FY1 Foundation Dr at the practice). Had find out about symptoms and effect on her life, work etc, how she felt, what inhalers she was taking and why not takling brown one, and also smoking cessation advice.

Health promotion - advice lady with aortic stenosis to stop smoking, and need for surgery, discuss her fears and prognosis etc. Given sheet to read at beginning with all facts on so didn't have to know anything! // A bit tricky because in the information we were given we were told that if the patient did not have valve replacement when her aortic stenosis became severe she would have a lower life expectancy. The patient kept pushing me to say that she had no choice but to have the surgery and to say if she would die if she didn't have it but although I said this in the terms mentioned on the card I wasn't keen to state this any more bluntly for fear of upsetting her too much in 10 minutes. Besides it said on the card that she was about to meet with the consultant who surely would be better qualified than an FY1 to deal with this difficult discussion of risk/benefit balance?!

Ultimate Finals List - DR WHO

2010-05-03T11:20:00.000-07:00

DR WHO

ALS & defib, VT, reversible causes

Mx of anaphylactic reaction to antibiotic infusion

Dr WHO - ABCDE Pt with Meningitis - Emergency medicine. Run-through scenario with a resus-Annie type thing but you talk through what you would do (DR ABCDE Look Listen Feel Measure Treat routine) The patient was "A" in AVPU, in shock with warm peripheries and you were shown a picture of his legs which had meningococcal rash questions on the management of which filled in the remaining 2 mins - of course he was allergic to penicillin as all patients in finals suddenly turn out to be...

Airway station with anaesthetist – alcoholic comes in… gurgling sounds – ABC, talk through airway adjuncts (Guedel->Nasopharyngeal etc and asked how would use and measure for each) Shown obs chart sats still low – high flow 02 etc etc – doesn’t improve – bag valve

DRWHO - DKA

Dr ABCDE- a patient acute chest pain. Go through airway-breathing-circulation, look/feel/listen/measure/treat for each as appropriate. Shown an ECG which conforms to thrombolysis criteria, expected to talk through basic management.

DR WHO - a UCL thing. Diagnosis hypoglycaemia. Said would give IV dextrose. Then made idiot of myself. Examiner said 'if patient was conscious what could you give him?' I said a sugary drink. He said 'or...' I said 'a Mars Bar' He said 'or..' I said 'Or a Snickers' (Why was I naming chocolate bars!!!???) He then spoke to me like I was very simple and said 'Yes, but we're doctors and doctors like to use drugs so what could you prescribe?' Answer (which I got what felt like 8 hours later was IM glucagon!!!) - hypostop gel (oral), 50mls 50% iv dextrose, im glucagon.

Airway Management- fairly straightforward scenario regarding a patient on the ward who’s obs had dropped. Seemed to be anaphylaxis as swollen tongue etc. Had to site a nasopharyngeal airway. Examiner then told you the pt has now stopped breathing. I had a moment of panic at this point and wanted to start cpr until examiner kindly informed me the patient had a pulse!!!! I suddenly looked at the equipment in front of me and had a flash of inspiration and told the examiner I would use the bag-valve-mask. She was very happy about this and said most people had struggled with remembering the bag-valve-mask!

Ultimate Finals List - Communication & Ethics

2010-05-03T11:15:00.000-07:00

Communications

Apologise to woman to whose mum you had given ten times too much digoxin to and explain about PALS. Her mum now had slow heart beat. I said we would just monitor it as digoxin effect would wear off but think you were supposed to say something like atropine to counterbalance effects. // Explanation to a patient's daughter that she had been given 10 times dose of digoxin because you had not made decimal point clear on drug chart - ability to admit mistakes and comm skills // talk about effects of Digoxin, antidotes, what will happen to mother now (blood levels, cardiac monitoring), can see consultant if she wishes, incident form has been filled in and so situation will be investigated. She talks about wanting to make formal complaint, you have to tell her about, PALS, independent complaints advocacy service, procedure….generally be as informative and helpful as possible.

METHOTREXATE overdose which I thought was really unfair as other people got insulin and warfarin. Never mind. We just had to explain it to the angry patient and say we were very sorry and talk about pals. // Given BNF, but looking at it with the patient I thought I’d freak her out more. That drug can cause most nasty side effects. Had to apologise, admit responsibility, explain the complaints procedure and produce a plan of action. // just apologise lots, refer to PALS, say you've filled out a serious incidents form and informed your consultant etc //

Angry patient. Came to pick up her mum after discharge for uncomplicated UTI over previous week. She arrived to find her mother sweaty and almost unconscious. Turns out you (student)are the doctor responsible for having mis-read her drug chart and given her the wrong kind of insulin lets call it 'X-tard' instead of her usual 'Y-tard'...Unfortunately - wouldn't you just believe it - 'X-tard' is stronger than 'Y-tard' ...oh dear... So you have to adopt a suitably remorseful, crestfalle manner and talk about how sorry you are, PALS and complaints procedures, incident forms... // Have to admit mistake and apologize and mention that a serious incident report form has filled in and it is being investigated and also provide information to patient about how to complain (PALS, writing to ward manager etc..)

u prescribe penicillin on drug chart and on drug chart it says no allergies. but he is allergic to penicillin in the notes. so daughter is angry n I said it was my fault because I gave penicillin and im sorry etc PALS help and complain to trust complaints manager..speak to consultant and reassure her uve documented an incidents report form to ensure it doesn’t happen again...some people said it wasn’t their fault because they followed the drug chart n u didn’t fill in the drug chart...but don’t know..

Woman whose husband died four hours ago and she wishes to talk to someone. Perfect station to end on. Lots of sympathy and suggestions for getting help from family / chaplain. Bit stumped really...

Talk to wife of stroke patient who has died recently. Be sympathetic and state that nurse was with him when he died and he did not regain consciousness (as says in scenario). mention consultant will see her to discuss death certificate. There was a lot of spare time on this one.

There was a gentleman actor who had come to the doctors as he felt he wasn't coping with a very difficult situation at home - his wife had cancer. Wasn't entirely sure what they wanted, think this was about listening, showing sympathy and offering some appropriate help. Again, the revision lecture was good // don't miss he was depressed

My lead-in was 'take a history from this 69 year old lady with urinary diversion and recurrent UTI (Great, I thought - lucky Urinary Diversion Surgery is forms such a massive component of the medical degree...) For 6 months she had been receiving increasingly unpleasant UTI's with rigors fever etc. They were becoming more frequent and becoming less and less responsive to antibiotics. She also has severe osteoarthritis of the knee and needs replacement surgery but these problems are delaying her surgery. She had had her urostomy for 15 years post bladder cancer. Three stoma re-fashionings since October due to parastomal hernia problems. Also lurking away in her past was a nephrectomy following renal cancer, a recent cataract operation and depression secondary to the recent death of her husband but her three adult children all live locally and take good care of her. She started crying when I asked about her mood of late (having noted 'Fluoxetine' on the prescription she gave me when I was taking a drug history) - potential OSCE nightmare!! but in fact it was amazing how quickly you forget the OSCE and recognize that you're dealing with a real human and real human life. Luckily it brought the real human out in me and for those two minutes or so I forgot about the OSCE, the examiner and everything. The examiner mentioned being impressed at the end so it wasn't as big a disaster as I thought it was going to be.

Talk to a son about his father being diagnosed with Alzheimers. All the medical information is given it was just to see how you communicate and show empathy // how long before the patient will no longer be able to take care of himself, are there drugs available etc. All the information you need to tell the son will be given to you so its not about testing your knowledge at all // Explaining Parkinson’s to a son (all information given, testing communications skills)

Ethics

Ethics also straightforward, dying man, wanted LPAs explained and if the Dr could commit euthanasia and how to go about writing an advance decision. Just go to the revision lecture, straightforward. // assisted suicide scenario and discussion. one doctor wants to help, the other refuses - what is the basis of their decision? // Case of man who is going to die who wants to know about options for his care. Wants to know if you can kill him with opioid (nope) and then about advance decisions and lasting power of attorney. // Ethics – counsel daughter re father who wants to be left to die i.e. DNR. Q from daughter who had clearly been to ethics school. Is he competent? If not who makes decisions? Can I? Discuss AD / AS. All in revision session. // Patient has mets liver ca. He refuses chemo but daughter wants him to have it. Assess competence. Also he wants you to end his life - refuse!! He's worried about dying in pain. Explain PCA and role of palliative care team. Give lots of counselling, reassure. Advise him to talk to his daughter and you will be willing to meet // man with cancer, 6 months to live wants help to die, say NO. Then he asks if you can give him morphine to relieve his pain, you say YES, but may kill him. Then he asks about advanced decisions, advanced statements and lasting power of attorney. Easy stuff, use the revision handouts.

Man with HIV doesn’t use condoms, talk about confidentiality. I just asked him what he thought, he said I wasn’t allowed to tell anyone right? I talked on about how I’d have to tell the partner as she was at risk of getting aids, discussed his reasons for not wanting to tell her himself, explained I’d try to persuade him and wouldn’t tell her before alerting him I was about to, arranged a meeting with a counsellor to discuss the best way to tell partner of HIV status. Bit short on time here. // I also mentioned offering anonymous counselling to the wife, using condoms and ensuring he had time to think about what we'd discussed and setting a time to meet a week later.

Epileptic telling her doc she was still driving. Legal issues etc. Will tell the DVLA if she doesn’t.

Regarding breast cancer treatment of 49 year old woman with Down syndrome. Sister and consultant favoured palliation, while registrar favoured discussing intensive potentially curative treatment with her. Asked about mental capacity act (i.e. give patient best chance to demonstrate competence, if they are not competent act in their best wishes, choosing option least restrictive of their freedoms), the criteria of competence (can retain information, can understand proposed treatment, weight up pros and cons, communicate their wishes), case law: Tony Bland.

Talk to daughter of competent 80 year old with an aortic aneurysm. Healthcare professional daughter had been present at ultrasound scan. Mother just gone to toilet and daughter wanted to know if it was an aneurysm she saw - 4cm diameter, which you were told in scenario was not large enough to merit operating on. Some students didn't tell her anything at all owing to confidentiality wanted written permission from her mum. I told her that surgery would not be required. Then she asked me not to mention anything to her mum as she would worry. I said this would not be possible, but said we would be sensitive to her concerns // Not sure if this station was meant to have you say “confidential – need permission from mum to discuss it” or if there was implied consent to talk as she had been in all the scans. If you spoke to her (as I did) she asked you not to tell her mother the diagnosis so as not to upset her (and you were meant to say you would find out the level she wanted to know but that you needed to tell her etc.. Lots of people did not realise this was a law station) // it was your job to assert that it was up to the patient how much information she wanted and that the team would be having full discussions with the patient as they were her choices to make

Ethics - Again this was very fair, given a case of a woman who was making an unwise decision not to have ehr leg cut off even though it was gangrenous! Basically about competence. Its all in the lecture handout. // ethics - discussion around consent (woman with critical ischaemia refusing amputation), had to discuss the differing views of 2 doctors

Ethics - longstanding MS, didn't want to go in to hospital for treatment when she had a heart attack, and pointed to a living will when the gp on call came to see her, he agreed to treat her as best he could at home. the next day her own gp said he thought it was ridiculous and told her she should go to hospital just for some investigations but that she wouldn't be admitted (he was fibbing) and so she agreed to go on that basis. she was then admitted. Qs - what makes consent valid, and was the consent valid in this case, when do you not need consent, what does the law say about competence, what is a living will and is it relevant in this case, which doctor do you think was acting most in line with current law/guidelines, what is the essence of their disagreement fact or value? what positions are each adopting, in your opinion could the other gp ever be right? Examples from your own clinical experience where you might be worried about the validity of consent. // I was also asked about paternalistic ideas and patient autonomy and my own experience of patients not being fully informed/consented and the reasons why a doctor might do this and the consequences of unethical practice.

Ethics and Law - scenario. 92 year old man with dementia and depression stabs himself at nursing home. Taken to hospital and given (expensive) surgery. Patient continues to decare that he wants to die (stabbing himself with needles etc at hospital). Some doctors say he should be left to die, others say the (now necessary further) surgery should continue. Asked questions about withdrawing care vs withdrawing support, circumstances where treating a patient against their will is legal. Competence and its assessment. We were asked what issues are at stake (I think he meant values versus facts etc) // Ethics and Law - patient in a nursing home has dementia and depression. He tries to kill himself by slitting himself with a knife one night from the kitchen of the nursing home. When he is first bought into A&E he is resuscitated and undergoes a very expensive surgery to stop the bleeding. His sister arrives later and says that he's been depressed for years, ever since his wife died and no longer wishes to live and shouldn't be kept alive. The consultant and registrar have a disagreement about what should be done in his treatment. The first question I was asked was how the law applies in this situation - very vague so you just have to pick an avenue and go with it. Asked lots of questions, about consent and competence, what to do if a patient is non-competent, lasting power of attorney and whether it is written down and needs to be witnessed, who makes the decision in this case, should money ever be a consideration in such cases

Ethics - Patient who had metastatic renal cell Ca, signed a DNR when competent, gets infection, doctor gives ABx, does not improve, debate as to whether 2nd round of Abx should be given. Family says yes. Consultant decides they should, Registrar disagrees. Questions about why they disagree and whether DNR is relevant to the Abx treatment etc.

Scenario about consultant telling poor prognosis of an elderly patient to her daughter first and the 2 of them deciding it is better NOT to tell the patient. GP tells daughter that is not on, and tells the patient. Questions on confidentiality: law? GMC guidelines? Who acted correctly and why? Why did the 2 doctors differ in their actions. disagreements about facts or disagreements about values? Examples of cases of breach of confidentiality that I have witnessed in everyday clinical practice.

Ethics - Giving drugs with a therapeutic benefit that might shorten life

Ethics and Law – Shown case: patient refuses treatment but sons want father treated and say that he is depressed. One doctor wants to treat, the other doesn’t. Talk about Mental Capacity Act and values of each of the doctors.

Explaining Procedures

Explain endoscopy for dysphagia, presumed oesophageal ca, answer concerns

Hernia - explanation to patient of hernia operation- will be done under local anaesthesia. Good to know some stats beforehand e.g. 2% recurrence risk. Have to mention risks such as testicular ischaemia, haemorrhage etc. Advise not to drive until comfortable with emergency stop (can be 1 month), advise re time off work (can be 2 weeks, depends on job and how well they recover) // Answering Pts questions about a inguinal hernia repair - local anaesthetic or general anaesthetic is better, Man asks questions about returning to work, how painful it will be, whether it will ever come back what the operation involves etc // When discussing his concerns about the operation it became apparent that he was worried he would be able to see everything that was going on if he opts for an LA and was also concerned that an inguinal hernia could mean he has cancer/a higher risk of cancer. You needed to talk to him about these concerns. // wanted to know lots about the mesh we'd use (infection risks?was it permanent? and other things i cant remember), if he would have stitches and if/when he had to have them taken out // Overall comment: This station said it tested consultation skills, and asked candidates to answer questions specifically that he had. It helped having gone over 'explaining a hernia op' the day before with a friend, but still i was not expecting the questions to be as specific as some of them were. Where i didnt know the answer, i said I'd have to double check with a senior to avoid giving him the wrong information and I'd get back to him as soon as possible with the answer. I didn’t want to risk giving patients the wrong information as we were told always to be safe by being honest with what we dont know. The questions about mesh complications threw me a little because all i could really think of at the time were the general ones that come with any procedure eg infection. It may be a good idea for future candidates to go over all the common ops that patients have and go through explaining what the procedure involves/what happens pre and post op including drinking/eating/work/driving/sex if appropriate for operation, day case vs admitted to hospital for days, main complications /risks. // Most students forgot to ask about occupation and recreational activities. (patient was a solicitor but did weight training, so tell him to stop the latter)

Communication skills - tell bloke about two different operations for hip osteoarthritis. Lots of information on sheet for me to read so I just handed it to him and we went through it together. Arrange follow up appt etc. Hard to know how it was going, but I just answered concerns etc.

Ultimate Finals List - Opthalmology

2010-05-03T10:44:00.000-07:00

Opthalmology

Visual acuity with a snellen chart, and ophthalmoscopy

- Snellen chart was already placed about 3 m away from the patient (i think it was 3!)
- asked by examiner to read instructions and proceed.
- instruments available: the pinhole instrument u need to eliminate refractive error, plastic head with one slide in each eye, and then 3 pictures of fundi.
- told not to bother with the 'browny points' bits (introducing myself etc..) when got to fundoscopy but rather to just get straight to using the opthalmoscope. Then asked to present what i could see.
- asked for my diagnosis

On a real patient – I saw black pigmentation on the retina especially around the periphery – possibly retinitis pigmentosa but this was very tricky and I did not get the diagnosis in the exam.

Scarring from from photocoagulation therapy. I wasn't very sure at first what was going on but the examiner told me she had diabetes.

Proliferative diabetic retinopathy

Two of the images had lots of cotton wool spots, one had papilloedema

Eye station - Snellen and ophthalmoscope and four pictures - i think diabetic, optic atrophy, laser burns, papilloedema

Senile macular degeneration and glaucoma in the other eye. Then shown other picture, papilloedema

Hypertensive eye disease and one other.central retinal vein occlusion, diabetic background, retinopathy, maculopathy...

Adverse Drug Reactions

2010-05-02T16:45:00.000-07:00

Drugs with low therapeutic ratio:
Anticoagulants
Antidiabetic drugs
Anticonvulsants
Digoxin
Cancer drugs

Patient Fx:
Elderly
Polypharmacy
Co-existing liver/kidney disease
Young women with child-bearing potential
IV drugs

Drug Reaction Classifications:
Type A - common, dose related, low mortality
Type B - uncommon, not dose related, high mortality
Type C - uncommon, dose and time related eg cumulative dose

Statins
AE
Myositis
Measure CK & LFTs before and 1-3 months after
If CK >x10 normal = stop drug (risk of rhabdomyolysis)
If Transaminases rise >x3 normal = stop drug

Erythema Nodosum
...from...
- oestrogens
- sulphonamides
- phenytoin
- penicillins

Stevens-Johnson Syndrome (toxic epidermal necrolysis)
Immune response to drug in skin and mucous membranes
- sulphonamides (including sulphasalazine)

- co-trimoxazole
- penicillins
- lamotrigine & phenytoin
- barbiturates

Yellow Card scheme
- intensive event monitoring
- doctors, pharmacists and pharm industry
- report suspected AE in newly licensed drugs as well as in older medicines
- cards in back of BNF
- new drugs highlighted in BNF, MIMS and ABPI by black triangle

NB More difficult to identify common adverse events

Acute Poisoning - TCAs, Lithium & Digoxin

2010-05-02T16:10:00.000-07:00

Tricyclic Antidepressants

2.5-3.5g of amitriptyline

Anticholinergic effects = Neuro & Cardio problems
Usually w/i 6 hrs = severe effects:
- Ventricular arrhythmias
- Seizures
- Hypotension
- Respiratory depression

Lithium

Different forms:

- liquid peaks at 30mins
- tablets peaks at 4-5hrs
1/2 life = 8 - 45hrs

Higher toxicity - in HT, DM, CCF

Digoxin

Plasma = >10ng/mL

Toxicity

Fatigue, blurred vision, disturbed colour perception (Van Gogh's halos)

Anorexia, nausea, vomiting, diarrhoea, abdominal pain

Headache, dizziness, confusion, delirium, and occasionally hallucinations

Cardiac arrhythmias - most common cause of mortality & most common pattern = SVT + AV Block

Hypokalaemia predisposes
Hyperkalaemia a consequence

Ix
Upper normal limit = 2ng/mL (without predisposing factors)
Measure plasma levels 6hrs after last dose

Tx
Activated charcoal (within 6-8hrs) or cholestyramine
Correct electrolyte abnormalities - careful replacement of potassium (too rapid can increase AV block)
Hyperkalaemic = glucose, insuline and sodium bicarbonate
Digoxin-specific antibody Fab fragments - binds to circulating digoxin
if >10mg ingested in adults
if >4mg ingested in children
or plasma concentration >10ng/mL
or >5mmol/L with life-threatening arrhythmia - VT, VF, progressive bradycardia/high-degree AV nodal block

Partial response/resistance
Underlying heart disease/late administration/ too small a dose

NB dramatic hypokalaemia can occur after digibind threapy at 1-4hrs therefore MONITOR!!

Extracorporeal techniques

Haemodialysis/haemoperfusion
- helps with hyperkalaemia/volume overload with renal failure
h/e less helpful due to digoxin's large distribution and binding to tissue

Acute Poisoning - Paracetamol & Salicylates

2010-05-02T15:53:00.000-07:00

Paracetamol

Overwhelming of body's glutathione, in its inactivation of paracetamol's toxic metabolite
Safe up to 150mg/kg
>350mg/kg = extensive damage
Hepatotoxic
Nephrotoxic
High risk - malnourished, immunocompromised, anti-epileptics, anti-TB medication, alcohol excess

Ix
Levels
Standardised Treatment Graph - normal and high risk treatment lines

Tx

N-acetylcysteine - supplies glutathione
Side-effects - wheezing, flushing hypotension, bronchospasm, anaphylactoid reation

Alternative is methionine PO (<12hrs)

Salicylates

1 tube of bonjela cream = 970mg

Levels at every 4 hrs

>500mg/L Moderate-Severe

>700mg/L Lethal

Tx
Activated charcoal
Rehydrate
>500mg/L alkaline diuresis
>700mg/L haemodialysis

Alkaline diuresis - elimination of salicylate ions increased in alkaline urine
- Optimum urine pH = 7.5-8.5
- Serum pH = upper limit at 7.6
Correct any hypokalaemia

Acute Poisoning - Carbon Monoxide & Alcohols

2010-05-02T15:33:00.000-07:00

Carbon Monoxide

Children more susceptible - higher rate of intake

Ix
CarboxyHb
- higher in smokers, urban joggers
- not suitable for LEVEL of exposure, only to confirm exposure
- if not high still doesn't rule out CO poisoning
ECG - non-specific ischaemia
CXR - inhalation injury
CoHb/ABGs - metabolic acidosis, hypokalaemia, increased anion gap
Increased CK - from rhabdomyolysis

Tx
HbO
Hyperbaric oxygen

Alcohols
Ethanol
Methanol
Ethylene glycol
Isopropyl alcohol

Ix

Specific levels only useful is raised - not good indicator of outcome

Anion gap
- difference b/w plasma concentrations of cations and anions
- increased anion gap = increased presence of unmeasured anions

eg alcohols/overproduction of organic acids/decreased excretion eg in renal failure

- can be used to monitor progress

[Na+ + K+] - [HCO3- + Cl-]

>20mmol/L = lactate, formate, oxalate

Osmolar gap

- difference b/w measured and calculated osmolality

- osmolar gap in metabolic acidosis = presence of unmeasure osmoles ie methanol, ethanol, ethylene glycol

2(Na+ + K+) + Urea + Glucose

Tx

Methylpyrazole
- inhibits alcohol dehydrogenase
- predictable elimination, no CNS depression

- expensive

Fatal dose of ethanol:
- Adults = 6-10ml/kg
- Children = 4ml/kg

Acute Poisoning - General Principles

2010-05-02T15:15:00.000-07:00

Hx
Can be very unreliable
What, when, how much was taken?
?empty bottles
?witness reports
?emesis

Ex
DR ABCDEs as usual
Pay special attention to:

- Odours
- Mucous membranes
- Eyes

Ix
Temperature
Blood glucose
Toxicology - blood & urine
ALWAYS - paracetamol and salicylate levels

Other tests...
U&Es, LFTs, Clotting, Bicarbonate, ABGs
Osmolality, Osmolar gap, Anion gap
ECG, CXR, AXR
etc

Pills seen on AXR

ATE CHIPS

Arsenic
Theophylline
Enteric Coated Pills

Chloral Hydrate
Heavy Metals
Iron

Phenothiazines
Salicylates

Principles

- Supportive
- Correct abnormal electrolytes and obs (hypoxia, hypotension, dehydration, hypo/hyperthermia, acidosis)

1) Reduce absorption
2) Increase elimination
3) Give antidotes
- Monitor - TPR, BP, ECG, Oxygenation, GCS

Elimination

Emesis
- Activated Charcoal
(good for organic compounds, not lithium/iron/alcohol, 1G/kg or x10 ingested dose, C-I corrosive ingestion)
- Gastric Lavage
- Whole Bowel Irrigation
(Klean Prep, polyethylene glycol, up to 12hrs p-ingestion, poss use in lithium/arsenic/iron/lead oxide/body packers)

Enhanced Emesis
- Forced Diuresis
- Chelation
- HBO
- Haemodialysis
- Haemoperfusion

Predisposing factors to toxicity
- Old age
- Cardiac disease - myocarditis, active ischaemia
- Metabolic abnormalities - hypokalaemia, hypomagnesaemia

GALS Examination - Revision Card

2010-04-25T03:41:00.000-07:00

WIPER

GAIT
Observe gait (3)
Observe patient in anatomical position (8)

SPINE
Inspect spine (3)
Assess lateral flexion of neck (1)
Assess lumbar spine movement (2)

ARMS
Observe shoulder movement (3)
Observe back of hands and wrists (2)
Observe palms (2)
Assess power grip & grip strength (4)
Assess fine precision pinch (1)
Squeeze MCPs (1)

LEGS
Assess full flexion and extension (3)
Assess internal rotation of hip (1)
Patellar tap (1)
Inspect feet (3)
Squeeze MTPs (1)

GALS Examination

2010-04-25T03:35:00.000-07:00

- Screening examination
- Examines Gait, Arms, Legs and Spine
... but we usually examine them in the order of Gait, Spine, Arms, Legs, for simplicity.
... however, 'GSAL' is less catchy.

WIPER

"Hi, my name is Anamika Basu, I'm a final year student.

- Is it alright if I do a quick examination of your joints and general movement?

- For this examination we need to have in your underwear, is that okay?

- And we'll need to have you standing up at the start of it."

GAIT

"Can you walk a few steps away from me, turn around and walk back to me?"

I'm observing the patient's gait for symmetry, smoothness and the ability to turn quickly.

"Can you stand like this (imitate anatomical position)?"

I'm looking from

- behind, from the sides, and from the front,

all the time assessing for

- the bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles,

- limb alignment,

- alignment of the spine,

- level of iliac crests,

- ability to extend elbows and knees,

- any popliteal swelling,

- and any abnormalities of feet.

SPINE

As the patient is standing, I am also inspecting the spine

- behind for scoliosis

- and from the side to observe any lordosis or kyphosis

"Can you tilt you head to each side, with the ear towards the shoulder?"

I'm assessing the lateral flexion of the neck

"Can you bend down to touch your toes, as much as you can?"

I'm assessing functional movement

"Okay, now I'm just placing two fingers on your back. Can you straighten up for me?"

I placed my fingers on the lumbar vertebrae to see if they move apart on flexion and back together on extension. This also helps to distinguish the patient's movement from compensatory hip flexion.

ARMS

"Would you like to sit on the couch?

- Can you put you hands behind your head?"

I'm assessing

- shoulder abduction,

- external rotation

- and elbow flexion

"Okay, relax, now can you put you hands out like this, with the palm face down, and fingers outstretched?"

I'm looking for any

- joint swelling

- or deformity

"Can you turn your hands over?"

I'm assessing the palms for

- muscle bulk

- and any abnormalities

"Can you make a fist for me?"

I'm assessing

- power grip,

- hand and wrist function

- and range of movement in fingers

"Can you squeeze my fingers for me?"

I'm assessing grip strength

"Can you bring each finger in turn to meet the thumb?"

I'm assessing fine precision pinch, which has functional importance

"Do you have any pain in your hands?"

I'm gently squeezing across the MCP joints to check for tenderness, which might suggest inflammatory joint disease, remembering to look at the patient's face for discomfort.

LEGS

"Can you lie down on the couch for me? Are you comfortable? Do you have any pain in your legs? I'm just going to have a feel of your knee joints."

I'm assessing for

- full flexion and extension of the knees

- and feeling for ant crepitus

- x2

I'm flexing the hip and knee to 90 degrees, holding the knee and ankle. This is to assess the

- internal rotation of each hip in flexion

- x2

"I'm going to tap on your knee."

I'm performing a patella tap on each knee to check for patellar effusion

This involves me sliding down my hand down the thigh and push over the suprapatellar pouch, forcing any effusion behind the patella. Keeping the pressure on that hand, I use the first two fingers of my other hand to push the patella down gently. If the patellar bounces and 'taps' this is positive for the present of an effusion.
- x2

I'm inspecting the feet for

- swelling,

- deformity

- and calloses on the soles

"Is there any pain in your toes?"

I am squeezing across the MTP joints to check for tenderness

GALS is written down a column with two additional columns headed appearance and movement.

A tick is given for normal findings, and a cross for abnormal ones, with extra notes noting the details.

Lung Tumours

2010-04-20T13:11:00.000-07:00

Normal Respiratory Epithelium

- Ciliated columnar cells
- Goblet mucin-producing cells
- Kulchitsky cells (diffuse/dispersed endocrine system)
- Reserve Cells (stem cells)

Tumour-Like Lesions
Pulmonary Hamartoma
Developmental disorder of cell growth - excessive growth of normal cells & tissues at a site

1ry Tumours
Lymphoid
Lymphoma
Epithelial
Benign - Bronchial Adenoma
Borderline - Carcinoid
Malignant - Bronchogenic Carcinoma
Connective Tissue

Benign - Leiomyoma/Lipoma
Malignant - Leiomyosarcoma/Liposarcoma

2ry tumours
Metastasis

Epithelial
Connective Tissue
Lymphoid

Benign Tumours
Well-circumscribed
*single masses of 1 cell type

Well-differentiated
Little cytological atypia

Interstitial Lung Disease - Goodpasture's Syndrome & Wegener's Granulomatosis

2010-04-20T12:38:00.000-07:00

Interstitial Lung Disease

Goodpasture's Syndrome
Autoantibodies to alveolar basement membrane
= pulmonary Hg & fibrosis

Autoantibodies to glomerular basement membrane
= proliferative, crescentic glomerulonephritis

Ix
serum anti-BM (basement membrane) antibodies

Wegener's Granulomatosis
Systemic vasculitis
Necrotising, granulomatous inflammation in upper and lower respiratory tract
= pulmonary Hg & fibrosis

*assoc/ w/ proliferative, crescentic glomerulonephritis

Ix
serum C-ANCA (anti-neutrophil cytoplasmic antibody)

Composition of the Normal Respiratory Tract

2010-04-20T12:30:00.000-07:00

Trachea
C-shaped plates of cartilage anteriorly & smooth muscle posteriorly
Pseudo-stratified, columnar 'respiratory' epithelium

Mucous glands

Bronchus
Discontinuous foci of cartilage and continuous smooth muscle
Pseudo-stratified, columnar 'respiratory' epithelium
Mucous glands

Non-respiratory Bronchiole
No cartilage
Continuous smooth muscle
Pseudo-stratified, columnar 'respiratory' epithelium
No mucous glands

Respiratory Bronchiole & Alveolar Ducts
No cartilage
Discontinuous smooth muscle
Flat single layer epithelium
No mucous glands/goblet cells

Alveoli

Flat single layer epithelium
Type I & Type II pneumocytes

Interstitial Lung Disease - Pneumoconiosis

2010-04-20T12:09:00.000-07:00

Pneumoconiosis

Inorg/org/chemical fumes

Inorganic = direct interstitial fibrosis

Organic = inflammation = fibrosis

Fumes = ARDS = fibrosis

NB Org & fumes also = asthma

Inorganic Pneumoconiosis

*clinically insignificant
Progressive massive fibrosis when significant respiratory compromise
Caplan's syndrome if assoc/ w/ RA

*Coal dust - anthracosis (coal-mining, *hard coal)
*Silica - silicosis (foundry work, sandblasting, stone cutting, hardrock mining)
Asbestos - asbestosis (mining, milling & fabrication, insulation - NB also causes non-isttl pulm & extra-pulm diseases)
Beryllium - Beryllium granulomatosis (mining, fabrication)
Iron Oxide - Siderosis (welding)
Barium Sulphate - Baritosis (mining)
Tin Oxide - Stannosis (mining)

Pathology

Nodules of fibrosis & chronic inflammation in Isttm

Organic Pneumoconiosis
aka extrinsic allergic alveolitis/hypersensitivity pneumonitis
Sensitisation to organic inhaled antigen
Init - Type III reaction

Late - Type IV reaction

Farmer's lung - actinomycetes in mouldy hay
Bird fancier's lung - animal proteins from faeces
Bagassosis - bagasse & paper (manufacturing of wallboard)

Pathology
Isttl inflammation by lymphocytes & granulomata
Later = fibrosis

Tx
Stop exposure = stop progression
Any damage irreversible

Organic pneumoconioses that produce asthma
Byssinosis - cotton, flax, hemp (textile manufacturing)
'Asthma' - red cedar dust, nitrous oxide, sulphur dioxide (lumbering, carpentry)
'Asthma' - ammonia, benzene, insecticides exposure (occupational/accidental)

Interstitial Lung Disease - Sarcoidosis & Idiopathic Pulmonary Fibrosis

2010-04-20T11:51:00.000-07:00

Interstitial Lung Disease

Group of diseases
Med by immune mechanisms
Interstitial inflammation & fibrosis
Defined by lung function tests
Restrictive pattern (reduced lung compliancy & gas exchange)

Causes
Pneumoconiosis
Systemic CT (autoimm) disease
Sarcoidosis
Wegener's granulomatosis
Goodpasture's Syndrome
Post-RTx/CTx
Post ARDS
Idiopathic pulmonary fibrosis

Sarcoidosis
Systemic disease of unknown aetiology
F>M
Black>>White>>Asian
Prob response to Ag
Activated T-Cells & macrophages
Hilar LN/lung involvement in 90%
Skin/LN/Kidney involvement*
Raised serum ACE
*High calcium
Pathology
Granulomatous inflammation w/o necrosis

Idiopathic Pulmonary Fibrosis
aka
cryptogenic fibrosing alveolitis/usual interstitial pneumonitis/Hamman-Rich syndrome when rapidly progressive
M>F
60+ yrs
Interstitial pneumonitis & fibrosis
?cause
Pathology
End stage 'Honeycomb' lung (cystic air-spaces from interstitial fibrosis)
Extensive interstitial fibrosis with alveolar distortion & interstitial expansion

Tx
Steroid/further imm-supp
Variable response
*Progress to significant fibrosis

Cx
Respiratory failure
Cor pulmonale
Pulmonary HT

Tuberculosis

2010-04-20T11:07:00.000-07:00

Mycobacterium tuberculosis

Atypical mycobacteria produce different disease
Course dependant on host immunity & organism virulence
Histology always same

- Worldwide epidemic
- Incidence rising (w/ HIV & drug resistance)
- 1ry infection *lung
- Gut/skin/lymph nodes rare 1ry sites

Classification
1ry Pulm TB
2ry Pulm TB
Progressive Pulm TB
- cavitatory fibrocaseous TB
- tuberculous bronchopneumonia
Extra-Pulm TB
- single organ TB
- miliary TB

1ry Pulmonary TB
1st contact with bacillus

Initial lesion parenchymal & sub-pleural
Involvement of draining hilar lymph nodes

Usually asymptomatic

Most cases heal by scar formation

Occ progression - * infants/imm-supp

Pathology

Ghon complex - yellow, necrotic areas in parenchyma & nodes

2ry pulmonary TB
Occurs in 5% of 1ry TB cases
Usu due to reactivation

Assoc/ with debilitation
Occ re-inf/post-BCG

Apices due to high O2 tension

Often symptomatic
May heal by scar formation

Progression more common than 1r TB

Pathology

Assmann focus - more ext parenchymal involvement of upper lobes

Progressive pulmonary TB

Cavitatory fibrocaseous TB
Usu seen with 2ry TB

Drainage into bronchus/bronchiole
Formation of cavity
Extension of local inflammation
Spread of inflammation w/i lungs
Spread into upper airways & gut = open TB

Gd prognosis w/ Tx

Pathology
Large parenchymal lesion
W/ central cavity & surrounding necrosis

Tuberculous bronchopneumonia
Usu seen with 2ry TB

Rapid parenchymal spread via airways = open TB

Rare with Tx h/e prognosis poor

Pathology
Scattered but ext parenchymal inflammation

Extra-pulmonary TB

Single organ TB

Usu seen with 2ry TB

Single episode of Hg spread
*Bone/kidney/adrenals/memnges/genital tract

Prognosis gd with Tx

Pathology
Single focus of destruction
eg spine = pott's disease

Miliary TB
Usu seen with 1ry TB

Widespread Hg spread
Assoc/ w/ reduced immunity
*Lungs/spleen/bone marrow/liver

Prognosis poor despite Tx

Pathology
Widespread small necrotic foci

Histology
Epitheloid cell granulomata with central necrosis & Langhans giant cells
Lymphocytes & plasma cells
Coalescence of granuloma w/ extensive central caseous necrosis
Use of ZN (Ziehl-Neelsen)staining

COPD

2010-04-20T09:59:00.000-07:00

Chronic obstructive airways/pulmonary disease

Defined by lung function tests
Combination of bronchitis & empysema
2ry to smoking
Most = mixture of function, h/e 'pure' disease at each end of spectrum

Treatment & Prognosis

Prevention & supportive therapy
5-10% of all deaths in UK

Pneumothorax
Polycythaemia
Cor pulmonale
Pneumonia
Resp failure
Pulmonary hypertension

Pure empysema

'pink puffer'
Middle-aged to elderly
Dyspnoea early & severe
Cough minimal with scanty sputum
Infections rare
Hyperinflation as low recoil
O2 and CO2 maintained at muscular cost
Type I resp failure & cor pulmonale = terminal events

Pure chronic bronchitis
'blue bloater'

Middle-aged
Dyspnoea mild
Cough productive
Infections common
Increased airways resistance
Low O2 & CO2 levels tolerated
Repeated type II resp failure & cor pulmonale

Emphysema

2010-04-20T09:45:00.000-07:00

Emphysema

Definition

- Abnormal permanent increase in the size of air spaces beyond the terminal bronchioles

- With destruction of their walls
- Without fibrosis

Pathogenesis
Imbalance between protease & anti-protease activity

... leads to...

Neutrophils & macrophages = released proteases

Alpha-1-antitrypsin most common protease inhibitor
h/e...
Neutrophils = also release O2 free radicals

+ oxidants from cigarette smoke
Leads to inhibition of alpha-1-antitrypsin

Classification

Centriacinar emphysema
- assoc with cig smoking & CB
- increased protease activity
- affects upper zone of lungs
- 2ry to airway inflammation

Panacinar emphysema
- assoc with alpha-1-antitrypsin deficiency

- decreased anti-protease activity
- affects lower zones of lungs
- homozygotes (PiZZ) = emphysema <40
- heterozygotes = emphysema if they smoke

Pathology
Macro
Cystic alveolar spaces (end-stage emphysema)
Micro
Destruction & dilatation of alveolar walls

Effects
Functional obstruction
- loss of elastic recoil
- premature closure of small airways

Chronic Bronchitis

2010-04-20T09:11:00.000-07:00

Definition:
- Chronic sputum production, usually accompanied by chronic cough
- Most days for 3 months of year
- 2/more consecutive years
(when not due to a specific disease e.g. TB)

Pathogenesis:
Chronic irritation
Cigarette smoke & air pollution
= Death of ciliated cells
= Reduced mucociliary action

= Increased mucous production
= 2ry infection

= Inflammation & fibrosis

Partially reversible on x Smoking

Classification
1) Simple chronic bronchitis

- cough, no obstruction
2) Chronic asthmatic bronchitis

- bronchospasm & wheezing
3) Obstructive chronic bronchitis

- COPD

Pathology

Thickened walls, increased size in mucous glands & fibrosis

Increased no of goblet cells = increased mucin production

Squamous metaplasia of respiratory epithelium

Effects
Physical obstruction

Thickened wall

Submucous gland hyperplasia
Measured in Reid index
Normal = 0.14 - 0.36 (mean = 0.26)
Chronic Bronchitis = 0.41 - 0.79 (mean = 0.59)

Mucus accumulation

Increased production

- From increased goblet cells & mucous gland size
Impaired clearance

- From loss of ciliated epithelium & thicker mucus

Obstructive Airway Disease

2010-04-20T08:46:00.000-07:00

Obstructive Airways Disease

Acute
- Bronchiolitis
- Foreign Body

Recurrent acute
- Asthma

Chronic
- Chronic Bronchitis
- Emphysema
- Bronchiectasis

Ultimate Finals List - Advice

2010-04-18T04:16:00.000-07:00

Ultimate Finals List

Random advice garnered from the askdoctorclarke website

Writtens
- They are all RANDOM but not too bad. For instance we had this questions on J curves on an ECG, apparently re Hypothermia. I’d just happened to see it in the Cheese and Onion that morning, very lucky. Some questions were ok, eg. practical things like how long someone should fast before an operation etc

- The med school repeat questions they have put up on Moodle, so learn those well and do them the day before exams for easy marks. I also think they use questions that are similar to the commercial SBA question books and websites out there, so it is worth doing those. I didn’t do many SBA books, although I did pastest and onexam websites religiously- not sure if they helped much. My friend who I revised with kept asking me questions she had struggled with from books and lots of similar questions came up- although in the exam I could never quite remember what the answer was! Either question setters are unable to be original, or they are purposefully copying questions cos they are lazy or want to give us a better chance of passing. Another possible explanation is that maybe its just core curriculum that examiners set questions on which is somewhat limited! It really helps to speed through questions if you have seen similar situations before as they are often assessing principles rather than factual recall.

- There were lots of data interpretation questions and a fair bit of orthopaedics. Pharm was generally ok. Microbiology was horrible, especially the pictures but it wasn’t worthwhile revising all of communicable diseases for a few picture questions. I’d also ignore the pathology books and read a decent path book with colour photos as they are very dull and you won’t remember anything from them anyway. I studied mine for weeks and it didn’t seem to help at all, I would have been better off reading the cheese and onion. Some pictures, an ecg, an x-ray come up although we did have one text definition of what chronic inflammation in the stomach looks like which was lifted directly from the pathology book but that was really just common sense re the inflammatory cell types expected.

- The pictures in the exam were pretty impossible. One slide was nicked off UTAH path quizzes. That’s it, the rest were just random guess work! Some questions were really tricky, perhaps relying on epidemiology? Stats came up, more easy marks.

- My recommendations for the writtens would be check the common conditions in the log book, rare conditions are not just small print but barely feature AT ALL, so don't waste your time, and don't forget to look at common ENT and ophthalmology.

OSCEs
- The exam in no way tested the depth of my knowledge, it just wanted to check I had the basics needed to be an FY1, ie. Simple practical stuff like filling in drugs charts or giving a referral!! I must have done ok with these as I passed but it wasn’t because I’d prepared well for them, I just had to adlib in the exam, which made me believe my answers were incorrect. Examiners also give you clues. Ie. If they repeat a question, its not cos they are hard of hearing, its due to them giving you a second chance to change your answer which is Wrong! Also, they try to help and will say “are you sure there is nothing else you want to add.” This makes you feel like a wally if you know you’ve missed something, but can’t remember what it is- but you will still probably pass the station, so don’t get disheartened. It might even jog your memory.

- My advice would be to complete your history and examinations fully and then look the examiner in the eye and tell him/her what you think without making anything up. Then you have most of the marks and it doesn't matter if you have got the diagnosis wrong.

- Got told off for running commentary - don’t do it to a surgeon.

- The neuro / MSK stations had a box of neuro based toys in them which i didn’t think i needed to use.

- Time was very short on most of them so by the time you'd finished the examination you barely had time to present and that was it. One thing that is quite odd about the long stations is that some examiners let you talk through the exam, and in fact encourage it because you're short of time, and others absolutely refuse to let you. This can be very off-putting as it's not standardised and everyone seems to make up their own rules... Hmm.

- Take a FULL history, you have 5 minutes before station starts to read the scenario and write whatever questions you may want to ask so use this time efficiently to write down differentials etc before you have even taken the history.

- The examiner jumped over and covered the patient when I had finished and was washing my hands - I felt really bad as I was going to do it in about 10 seconds, but he got there first and gave me a raised eyebrow so I just apologised to the patient.

Causes of Hyperthyroidism

2010-04-14T10:46:00.000-07:00

Graves' disease (thyroid-stimulating autoantibodies)
Toxic adenoma
Toxic multinodular goitre
Amiodarone
Viral (de Quervain's) thyroiditis
Postpartum thyroiditis
T4 overdose
Pituitary TSH-secreting adenoma (rare)

Let us bid adieu to de Quervain,

As he is lowered into the pit of his grave.
Post the tears, we'll nod amid beers,
Over pity he couldn't be saved.

Let us bid adieu (toxic adenoma) to de Quervain (viral de Quervain's thyroiditis),

As he is lowered into the pit (pituitary TSH-secreting adenoma) of his grave (Graves' disease).
Post (postpartum thyroiditis) the tears, we'll nod (toxic multinodular goitre) amid (amiodarone) beers,
Over (T4 overdose) pity he couldn't be saved.

Bone Scans

2010-04-14T00:39:00.000-07:00

Bone Scans or Skeletal Scintigraphy

We start with a bone-loving agent - Tc99, a radioactive tracer which is followed by 007, our special gamma camera that can trace our tracer, no matter where it hides.

Indications
Spread of cancer
Unexplained bone pain/musculoskeletal pain

How to Read a Bone Scan
"This is a bone scan of [NAME], date of birth [DOB], taken on [DATE]. It shows increased uptake in [HOT AREAS], while osteopenic, or reduced uptake in [COLD AREAS]. This is suggestive of [DIAGNOSIS]."

Dark or "cold" spots
- areas that absorb little or no amount of tracer
Lack of blood supply to the bone/bone infarction
Certain types of cancer eg multiple myeloma

Bright or "hot" spots
- areas that absorb increased amounts of tracer
Rapid bone growth or repair/abnormal bone metabolism eg Paget's disease
Arthritis
Tumour
Fracture eg hip fractures, stress fractures - poorly seen on X-Ray
Infection eg osteomyelitis
Malignancy

Contra-indications
Pregnancy, due to possible radiation exposure to foetus

Contamination/Artefacts
Urinary contamination - the kidneys clear the radioisotope. If patient wets themselves, or urine spots leak onto clothing or the body, these can be recorded as false positives. Can be confirmed as contamination on removal of hospital gowns and a second scan
Injection sites, where the radioisotope can 'leak'
Barium - bone scans should be performed before the use of any barium
Patient motion
Full bladder, which blocks the view of the pelvic bones
Jewellery/Metal accessories

Other Ix necessary for Dx

- as bone scans cannot distinguish between different pathology
X-ray tests
CTs
MRIs
Blood tests
Biopsy

Thrombocytosis

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Plts > 500
1ry vs 2ry

1ry
'Essential thrombocythaemia'
Myeloproliferative D/O
Dx of exclusion
25% prolonged BT with abn plt function
25% vascular thromboses (thrombotic and bleeding probs)

Tx
Cytotoxic agents = decreases plt count
(hydroxyurea/radioactive 32P)

2ry
Rarely plt count >1000

Chronic bleeding
Low Fe
Trauma
Inflammation - neoplasm/chronic infection (TB)/Chronic collagen disorders (RA)

Abnormal Platelet Function

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Platelets count = normal
BT = prolonged

CFx
Purpura/bleeding mucosa

Aetiology
Congenital
Acquired

Acquired
1) *Drugs (asp/NSAIDS) - NB - stop for 2 weeks and repeat BT
2) Membrane defects (CRF/polycythaemia/raised FDPs)
3) Acquired storage pool disease (myeloproliferative D/Os eg essential thrombocythaemia)

Congenital
Rare
1) Membrane abnormal (Bernard-Soulier Syndrome = deficiency in glycoprotein Ib)
2) Glanzmann's Thromboasthenia (deficiency of gp IIb/IIIa)
3) Arachadonic acid metabolism enzyme defects (cycloxygenase deficiency)
4) Storage Pool Disease (Abn/decreased alpha &/ dense granules)

Ix
i) Plt aggregation studies (ristocetin, ADP, collagen)
ii) ADP & ATP (contents of alpha and dense granules) release post max-stim
iii) Quantify specific membrane protein receptors (*gp Ib & gp IIb/IIIa)
iv) Ix arachadonic acid pathway & Ca flux
v) exclude immunological destruction (plt a/ Ig)

Tx
1) Underlying cause
2) Congenital = plt concentrates (operations/bleeding)
OR DDAVP infusion *storage PD
3) ITP
- Steroids (pred) - suppress immune reaction & inhibit splenic sequestration
- Splenectomy - decrease plt destruction
- HD IV human gammaglobulin (temporary ret-endothelial blockade)
Clinical Course
Post-splen = 60% remission
NB Proph. pneumococc. vacc & long-term penicillin
If splenectomy/steroidx ineffective - other immune suppressants eg azathioprine

Thrombocytopenia

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Low Platelet Count

1) Decreased production from bone marrow

2) Peripheral destruction/consumption

- autoimmune (reticuloendothelial system)

- massive clotting process (DIC)

Ix of Choice
Bone marrow examination

Underproduction
1) BM infiltration - leukaemia/secondary malignancy
2) Decrease in megakaryocyte numbers/abnormal differentiation - aplastic anaemia/severe megaloblastic anaemia/excess alcoholism

Peripheral Destruction/Consumption
BM: megakarocytes no. normal or raised

1) Raised peripheral destruction

Pathology
Immunological
aB adh to Plt membranes
Premature ret-end Plt clearance

Aetiology
*ITP (idiopathic thrombocytopenia purpura)
2ry -
SLE
Lymphoid malignancies (B cell chronic lymphocytic leukaemias)
Drugs (quinine, rifampicin)

Ix
Plt a/ Ig (aBs bound to plt surface antigen)

2) Increased consumption

Haemostasis

DIC
Tcytopen assoc with consumption of all clotting Fx
Prolonged coag time
Intravascular haemolytic An
RBCs chopped up by fibrin strands

3) Pooling

1/3 plts pooled in normal spleen
Mod-severe splenomegaly = 'circulating thrombocytopenia'
eg myelofibrosis + mass spleen

4) Massive Transfusion
Bank blood = no functional platelets
Clumps of dead WCCs + plts = microaggregates
Plt adh (before ret-end/lung filtration)
Solution: microaggregate filter in giving set

NB + plt consumption in bleeding site/wound loss

Platelets & Investigations

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Platelets
Fragments of megakaryocyte cytoplasm

Megakaryocytes
- giant cells
- multilobulated nuclei
- fr red bone marrow

Platelet Structure
Discus with surface openings on the membrane that connect to the canalicular system
Contains 2 granules
- dense (rich in ADP)
- alpha (contain fibrinogen/factor V, vWF & PA1-1)
and lysosomes
Cytoplasm = Coag Fx - a/w/ the surf membranes

Normal function
BV damage
Plts attach to exposed collagen (underneath endothelial vessel lining)
Plts shape change & degranulate
= ADP release
= activates nearby Plts
Phospholipid released from plts = coagulation system

Defects - can be in no. or function

Tests
Test of number
Electronic particle counters
Blood film

Function test
Bleeding time
- cuff and cut
Norm <10minutes
New: In-vitro BTs

or

Lab aggregating agents (ADP/collagen) + light transmittance through plasma

Two Basic Initial Tests
1) Plt Count (n = 150-400)
NB if init. low - *artefactual, clot in sample therefore repeat
2) Bleeding Time (n = 2-10 minutes)

The Bleeding Patient

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Haemostasis
1) BV constriction
2) Plt adh/activation/aggregation
3) Coagulation factors, leading to a fibrin clot

Bleeding D/Os
2 Types

Platelet Dysf
- superficial bruising
- skin/mucous membrane purpura

Coag Fx Dysfunction
- Deep muscular haemotomas
- Haemarthroses

GIT Viral Infections

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Virus types
RotaV (2/RNA)
AdenoV (2/DNA)
AstroV
SRSVs/CaliciV

With Non-GI Symptoms
HepA
EnteroVs (polioV)

Characteristics
ALL unsegmented 1 stranded/RNA
Except...
RotaV - segmented 2-stranded/RNA
AdenoV 2-stranded/DNA

Signs and symptoms
D/N/Vg
Abdo cramps
Fever
D&V = severe dehydration & hypoNa

Epidemiology
*infant mortality in developing world
*children (also more severe)
a/w/ overcrowding/poor sanitation/poverty

Transmission
* F/O
Contaminated food/H20
Vomitus - SRSV-a/ GE (caliciV)

Dx
Stool samples
E-Micro/ELISA/Latex agglutination
*Useful in outbreaks
PCR
Research only
Tissue Culture
Not helpful (Viruses fastidious)

Tx
Symptomatic
Rehydration
Replace Na loss

Prevention
Hygiene
Food preparation
Clean H20
Good sewage disposal
Hospitals - hand washing, source isolation
Vaccines - polio, hep A

Food Infections of the GIT

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Food Poisoning

Beware! > 50% food-related infections come from chicken

GI Defences
Acid (biocide)
Motility
Normal flora (colonisation resistance)
MALT - Peyers patches - sample lumen Ags - seed LProp with T & B cells
B Cells pass through enterocytes & attach to glycoprotein called the secretory piece
Mature secretory IgA = immune exclusion = pathological binding

Organisms

Ingestion of Toxins
Tx + receptor (GIT)

V&D

Central absoption = CNS symptoms

Staph aureus

Vomiting
2-6h
Creams
Cold meats

Bacillus Cereus
V&D
1-10h
Contam rice

Clostridium perfringens
Abdo pain & D
10-20 h
Contam meat stews

Clostridium botulinum
Paralysis
1-3d
Canned foods
Yoghurts

Enterotoxic Organisms
Organism + receptor (GIT)
Secrete Txs

Disrupt enterocyte cell signalling

Loss of Na and H20 from cell

Vibrio cholera

Water-spread

Cholera

Large volume fluid loss

Rapid dehydration

Enterotoxigenic E. coli

Food

Toxin similar to cholera

Not as severe

E. coli O157

Poorly cooked meats
Verotoxin - similar to Shigella

Toxins spread to blood stream

Affects platelets and kidneys
Haemolytic-uraemic sydrome
Enterocyte necrosis = dysentry

Enteroinvasive Bacteria

Invasive organisms = cell necrosis/apoptosis

Txs = binding/penetration/membrane damage/cell death

Erosion and ulceration = dysentry & 'bystander damage'

(acute inflamm = accumulated polymorphs in LPp = releases pore-forming toxins)

Campylobacter jejuni

Chicken

Dysentry

Salmonella enteritidis

Meat & eggs

Diarrhoea

Enteroinvasive E. coli

Dysentry

Shigella sp

Dysentry

F/O

Food/water

Enteroinvasive Viral/Protozoa

Transmitted by water

Watery diarrhoea

Protozoa

Giardia

Cryptosporidia

Entamoeba histolytica (dys)

Virus

RotaV

SRSV

Norwalk

Organisms transmitted by food/water, but without GI symptoms

Listeria

Most foods

*Cheese

Septicaemia

Meningitis

Salmonella typhi

Water-sp

Systemic illness

Some GI symptoms

Polio

Water-sp

Neuro Sys

Hepatitis A

Water

Reaction/Tx

LHA

Prevention

Adequate food preparation

Safe portable water supplies

Good sewage disposal

Vaccination - polio/typhoid

Small Bowel Tumours

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Benign
Lipoma
Leiomyoma
Adenoma

Malignant
Carcinoid tumours
Carcinoma
Lymphoma
Sarcoma (GI stromal tumours)

Carcinoid Tumours
Neuroendocrine cells
Secrete gastrin/5HT/somatostatin/VIP/Insulin/other endocrine things

Site
Malignancy depends on site of origin
Appendix/Rectum
Locally invasive
Resectable
SmI/St/Col
Highly invasive
Metastatic

NB - also occur in lungs

Symptoms and Cx - Carcinoid Syndrome
Flushing
Diarrhoea
Wheezing
Abdo fibrosis
Cardiac valve fibrosis/stenosis/regurgitation

If metastasises to liver:
5HT bypasses portal system = CS
- otherwise metab in first past metabolism
NB therefore lung tumours drain directly into system = CS

Gastrointestinal Stromal Tumours
*Stomach/SmI
SmM/neural differentiation
Ben/Malig
Malignant = higher mitotic rate/necrosis/neural differentiation

Gastrointestinal Tract Lymphomas
*GIT extranodal lymphoma

1) MALT lymphoma
2) Enteropathy-associated lymphomas
3) Other B Cell lymphomas (mantle cell Lys & follicular Lys)

1) MALT
B Cell neoplasm
Fr mucosa associated lymphoid tissue
*SmI & Col - Tx difficult
St with H.Py
H.Py = chronic inflammation = chronic inflammatory cell infiltrate
Tx of H.Py can Tx Lymphoma (therefore ABs)

2) Enteropathy-associated Lymphomas
eg a/w/ Coeliac disease
* T cell