CluelessMedic

British Junior Doctor. Happy to answer questions...pop it in the ask box!

[pervocracy]

child handling for the childless nurse

My current job has me working with children, which is kind of a weird shock after years in environments where a “young” patient is 40 years old.  Here’s my impressions so far:

Birth - 1 year: Essentially a small cute animal.  Handle accordingly; gently and affectionately, but relying heavily on the caregivers and with no real expectation of cooperation.

Age 1 - 2: Hates you.  Hates you so much.  You can smile, you can coo, you can attempt to soothe; they hate you anyway, because you’re a stranger and you’re scary and you’re touching them.  There’s no winning this so just get it over with as quickly and non-traumatically as possible.

Age 3 - 5: Nervous around medical things, but possible to soothe.  Easily upset, but also easily distracted from the thing that upset them.  Smartphone cartoons and “who wants a sticker?!!?!?” are key management techniques.

Age 6 - 10: Really cool, actually.  I did not realize kids were this cool.  Around this age they tend to be fairly outgoing, and super curious and eager to learn.  Absolutely do not babytalk; instead, flatter them with how grown-up they are, teach them some Fun Gross Medical Facts, and introduce potentially frightening experiences with “hey, you want to see something really cool?”

Age 11 - 14: Extremely variable.  Can be very childish or very mature, or rapidly switch from one mode to the other.  At this point you can almost treat them as an adult, just… a really sensitive and unpredictable adult.  Do not, under any circumstances, offer stickers.  (But they might grab one out of the bin anyway.)

Age 15 - 18: Basically an adult with severely limited life experience.  Treat as an adult who needs a little extra education with their care.  Keep parents out of the room as much as possible, unless the kid wants them there.  At this point you can go ahead and offer stickers again, because they’ll probably think it’s funny.  And they’ll want one.  Deep down, everyone wants a sticker.

[mikkeneko]

This is also a pretty excellent guide to writing  kids of various ages

[cranquis]

TSK: Chief Complaint “2 y/o with fever and runny nose x6 hours”

Cranquis: … so this virus will probably stop causing fevers within the next 2 days, and as long as he keeps drinking liquids meanwhile, he’ll be just fine.

Mom: BUT YOU’RE GOING TO GIVE HIM ANTIBIOTICS FOR THE INFECTION RIGHT.

Cranquis: Well, if there were any signs of bacterial infection on his exam, I would definitely do that. But this is a viral infection, and viruses just giggle when they see antibiotics.

Mom: NO YOU GUYS HAVE STRONGER ANTIBIOTICS THAT KILL ALL THE VIRUSES TOO AND YOU’RE GOING TO GIVE HIM SOME BECAUSE I AM SICK AND TIRED OF HIM GETTING VIRUSES EVER SINCE HE STARTED DAYCARE 6 MONTHS AGO.

Cranquis: That’s the unfortunate nature of daycare – kids share all their viruses around a lot. On the plus side, he’ll have a much healthier immune system by the time he starts school and–

Mom: HE WON’T EVEN SURVIVE TO START SCHOOL AND WHEN HE DIES BECAUSE OF THIS VIRUS IT’S GOING TO BE YOUR FAULT FOR NOT GIVING HIM ANTIBIOTICS. THERE HAS TO BE SOMETHING YOU CAN DO TO KEEP HIM FROM GETTING VIRUSES.

Cranquis: Well, funny you should mention it, because I noticed he hasn’t had a flu shot yet, and the flu is a virus that could actually kill him, so a flu shot could help keep him from getting a deadly virus.

Mom: I’M NOT PUTTING THOSE CHEMICALS IN HIS BODY HE NEEDS TO FIGHT IT OFF ON HIS OWN.

…and some people say that if you put your ear up to the door of Urgent Care Exam Room 4 today, you can still hear this conversation taking place on an infinite loop until the eventual heat-death of the universe…

[cranquis]

TSK: Chief Complaint “2 y/o with fever and runny nose x6 hours”

Cranquis: … so this virus will probably stop causing fevers within the next 2 days, and as long as he keeps drinking liquids meanwhile, he’ll be just fine.

Mom: BUT YOU’RE GOING TO GIVE HIM ANTIBIOTICS FOR THE INFECTION RIGHT.

Cranquis: Well, if there were any signs of bacterial infection on his exam, I would definitely do that. But this is a viral infection, and viruses just giggle when they see antibiotics.

Mom: NO YOU GUYS HAVE STRONGER ANTIBIOTICS THAT KILL ALL THE VIRUSES TOO AND YOU’RE GOING TO GIVE HIM SOME BECAUSE I AM SICK AND TIRED OF HIM GETTING VIRUSES EVER SINCE HE STARTED DAYCARE 6 MONTHS AGO.

Cranquis: That’s the unfortunate nature of daycare – kids share all their viruses around a lot. On the plus side, he’ll have a much healthier immune system by the time he starts school and–

Mom: HE WON’T EVEN SURVIVE TO START SCHOOL AND WHEN HE DIES BECAUSE OF THIS VIRUS IT’S GOING TO BE YOUR FAULT FOR NOT GIVING HIM ANTIBIOTICS. THERE HAS TO BE SOMETHING YOU CAN DO TO KEEP HIM FROM GETTING VIRUSES.

Cranquis: Well, funny you should mention it, because I noticed he hasn’t had a flu shot yet, and the flu is a virus that could actually kill him, so a flu shot could help keep him from getting a deadly virus.

Mom: I’M NOT PUTTING THOSE CHEMICALS IN HIS BODY HE NEEDS TO FIGHT IT OFF ON HIS OWN.

…and some people say that if you put your ear up to the door of Urgent Care Exam Room 4 today, you can still hear this conversation taking place on an infinite loop until the eventual heat-death of the universe…

[cluelessmedic]

Lhermitte’s Sign

Tingling in hands which is brought on by flexion of the neck. This indicates disease near the dorsal column nuclei of the cervical cord. Causes include; trauma, space occupying lesions, multiple sclerosis and cervical stenosis.

[cluelessmedic]

Incorrectly Placed Nasogastric Tube

[cluelessmedic]

Please don’t feed.

Should bisect carina, tip below the diaphragm and moving towards the patients left side.

Because even if it appears to be below the diaphragm but moves to the right could be in the lung bsse.

[cluelessmedic]

Important for all you new doctors starting soon!

[cluelessmedic]

Horner’s Syndrome

A rare condition arising from damage to nerves from the sympathetic trunk supplying the eye. Symptoms are ipsilateral to the damage, and is characterised by; (1) miosis (constricted pupil), (2) ptosis (drooping eyelid) and (3) anhidrosis (loss of sweating). There may also be an apparent enopthalmos (sunken eye). 

Various causes best divided in to; Congenital (look for heterochromia), Central (stroke, MS, tumours, syringomyelia), Pre-ganglionic (pancoast tumour, cervical rib, trauma, thyroidectomy) and Post-ganglionic (carotid dissection/aneurysm, cavernous sinus thrombosis)

[cluelessmedic]

Aspergilloma

A growth of fungus within an already pre-formed cavity, occuring in adults with cavitating lung disease e.g. TB, sarcoidosis, bronchiectasis. Most are asymptomatic but may present with haemoptysis which can be life-threatening if associated with erosion in to bronchial artery. Radiological features of a intracavitary mass, surrounded by a crescent of air.

Sources: 

(1) http://www.nejm.org/doi/full/10.1056/NEJMicm980601#t=article 

(2) http://pathhsw5m54.ucsf.edu/case16/aspergilloma.html

(3) https://radiopaedia.org/articles/aspergilloma

[cluelessmedic]

Thread Worm: Enterobius vermicularis

Sometimes known as Pinworm, commonly found in children. Infection is asymptomatic in 90%, but may cause perianal itching particularly at night, girls may present with vulval symptoms. 

Usually treated empirically, entire family single dose anti-helminthic agent e.g. mebendazole and hygiene advice.

[dxmedstudent]

The Smallest Things...

We all go into medicine with a strong desire to help people. Or at least, I hope we do. Somewhere inside, there’s a pride that what we do can make a difference. We tell ourselves that giving up our youth to studying and walking dark corridors armed with nothing more than a stethoscope and our wits, will be totally worth it because we’ll make a difference. But it’s not that simple. Every doctor has a secret; deep down, each one of us sometimes fears that we’re not really helping anybody. That what we do is insignificant. And that we are too, by extension. If you wonder how doctors can feel like they don’t help anyone, it’s pretty simple. Real medicine isn’t like on TV. It’s not all action sequences and heroics. There’s a lot of paperwork, and sometimes a lot of doing things that it feels like nobody cares or appreciates. A lot of your decisions are made as part of a team, and quite often the individual part you play in any patient’s journey can feel, and be, quite small. So of course you minimise it further. I didn’t really do that much for Mrs Smith, you tell yourself. I barely did anything for Mr Jones, really. And it goes on. After all, it’s just everyday work for you and your colleagues. Perhaps your seniors, team mates and even patients don’t really seem to notice how much effort you put in. At any rate, it never really seems to be enough. You’re always fire fighting, always dealing with less resources than you should have, and always apologising for not doing more, and not doing it sooner. Sometimes it feels like all you do is apologise. And sometimes it feels like you never know enough. And sometimes it feels like you can never do enough. It’s easy to feel like a tiny, insignificant pawn trapped in a colossal system far bigger than yourself. But just at the moment when it feels like that the little flame is about to go out, something happens. A woman points you out to her husband and tells him you were there when they did CPR on him. You spotted the diagnosis your seniors nearly missed; you referred Mrs Smith to the right team and now we finally know how to help her. Your depressed patient meets you for their tenth appointment, but this time they haven’t needed a tissue once. They smile; you didn’t realise that the tiniest, tiniest smile could look so radiant. You hear back about Mr Jones’ operation; they got all the cancer. A patient’s mum thanks you for takng time to take bloods; their child is nonverbal, and finds hospital very stressful but your brief time with them was the first time in a long while that she felt her child was treated with respect. You get to see the kid who was brought in looking sick as a dog, skip out of the hospital because of the tiny little things that you did. Why do I write here? Because I can’t shut up. But really, it’s because every so often, I hear a little voice that tells me ‘something you said helped me’, and whenever my own voice falters, I think of them. Why do I draw? Because I feel compelled to, of course, but why draw this? Because if even one person feels less alone, then imagine what kind of a contribution to the world it is. Perhaps it is only a small contribution, but I bet every person you do something for, even if it’s small and insignificant, will remember that action very differently than you do. We have a tendency to minimise the good we do, just as our fears make us amplify the bad. Sometimes, I think of how amazing it is to be able to help someone in even the smallest way. You don’t even need to be a doctor to do it, and sometimes even when you are a doctor, the moments when you feel you really helped people, weren’t the dramatic ones at all. You just need to take a chance, any chance, to make someone feel better.

[cluelessmedic]

Hereditary Haemorrhagic Telangiectasia 

An autosomal dominant condition also known as Osler-Weber-Rendu Disease. It causes abnormal blood vessel formation and often presents with multiple telangiectasia (see above) and bleeding e.g. nasal, rectal. 20% of cases occur spontaneously without any family history.

4 Diagnostic Criteria: (1) Spontaneous recurrent nose bleeds, (2) telangiectasia, (3) visceral lesions e.g. GI, aterio-venous malformations, (4) family history

[cluelessmedic]

Koplik Spots

Associated with measles, occurring a few days before the rash, small white spots, like “grains of salt” affecting buccal mucosa.

[cluelessmedic]

Return...

So I had taken a bit of a break from this. But exams coming up so I may be posting a bit more stuff that may be educational!

[caringintensely]

When you see it…..

–Via “23 at the lip” on Facebook

[cluelessmedic]

Emergency Criteria for Dialysis

refractory pulmonary oedema or fluid overload

persistent hyperkalaemia (>7)

severe metabolic acidosis (pH <7.2 or BE <10)

symptoms of uraemia e.g. pericarditis, encephalopathy

[medicineisnotmerchandise]

JUST TO REMEMBER

[cluelessmedic]

GCS - best motor response

1 - no response

2 - extensor response to pain (decerebrate posture)

3 - abnormal flexor response to pain (decorticate posture) - to remember think it is “better” as the body is being covered/protected

4 - withdraws to pain

5- localises to pain

6 - obeying commands

[cluelessmedic]

PFO - Pissed, Fell Over

The pattern of injury depends on blood alcohol concentration. If concentration is above 2.5g/L you are probably too drunk to put your hands out - hence the head injury.

[erratic-emedicine]

This diagram shows how the mechanics of the heart co-ordinate with the heart sounds and the ECG (EKG).

By keeping this diagram in mind, it can make identifying murmurs much easier, by taking the pulse whilst auscultating.  

The pulse represents the maximum arterial pressure, which as you can see in the diagram occurs in between heart sounds 1 and 2. Once you have identified which heart sound is which, you can more easily identify systole, and diastole, and describe with greater accuracy the nature of a murmur if present. 

[erratic-emedicine]

Murmur Murmur

Here’s some causes of murmur patterns:

Ejection Systolic Murmurs

AorticStenosis - Ejection systolic murmur, radiates to carotids (In Aortic Sclerosis, there is no carotid radiation)

Pulmonary Stenosis  - Ejection systolic murmur which radiates to back/left scapula (may obscure second heart sound)

Atrial Septal Defect - sounds like pulmonary stenosis

Hypertrophic Cardiomyopathy - Harsh Ejection systolic murmur, palpable

Pansystolic Murmurs

Mitral Regurgitation - Best heard at apex, radiates to axilla

Tricuspid Regurgitation - Best heard at left lower sternal edge (tricuspid region) 

Ventricular Septal Defect - Best heard at left sternal edge

Early Diastolic Murmurs

Aortic Regurgitation - best heart at left sternal edge, in expiration, with patient leaning forward

(Rarely) Pulmonary Regurgitation

Mid-Diastolic Murmurs

Usually Mitral Stenosis - Best heard with Bell of stethescope at apex, with patient rolled to left

Rarely Tricuspid stenosis - sounds simliar to Mitral Stenosis

Continuous Murmur - referred to as a ‘machinery murmur’, although I don’t think anyone knows what machine it sounds like.

Patent Ductus Arteriosus - rare in adults. Best heard over upper left sternal border, radiates to back/left scapula