erratic-emedicine

A place where I will make medical notes (I'm approaching finals at a UK medical school) with no real rational or coherence. If you find something useful or interesting, reblog it to spread the knowledge! Alternatively, if you are interested in something, or confused about something, feel free to send me a message and I'll see if can break it down and make it understandable!

[erratic-emedicine]

How to get a boner from the NHS

NHS prescriptions for:

sildenafil, tadalafil and vardenafil; apomorphine; alprostadil

are only given if:

You have a long term health condition:

Diabetes, MS, Parkinson’s, Polio, Prostate Ca, Severe pelvic injury, single gene neuro-disease, spina bifida, spinal cord injury

You are receiving dialysis

You have had pelvic or urological surgery

You have received such medications since 14/9/98

You are caused severe distress by the condition

Significant disruption to normal social/occupational activities, mood, behaviour

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Contraindications to Sildenafil (Viagra)

Patients taking Nitrates, or similar vasodilating drugs such as Nicorandil

Viagra is a PDE (Phosphodiesterase) type V inhibitor, with preference for penile vasculature

Phosphodiesterases come in various forms, the most clinically significant of which break down cyclic AMP and cyclic GMP

One of the effects of cGMP is to promote smooth muscle relaxation, which in blood vessels --> vasodilation and decreased BP

If PDE breaks cGMP down, but we inhibit the PDE, the concentration of cGMP remains higher. 

So concurrent use of Viagra and other nitrates risks profound hypotension

Hypotension with BP < 90/50

Recent stroke or MI

Unstable cardiac dysrhythmias

Poorly compensated heart failure

Severe hepatic impairment - metabolised by the liver

(Know retinal degeration - eg Retinitis Pigmentosa - some PDE sensitivity in these pts - rare)

NB - Most men with coronary heart disease can safely resume sexual intercourse, with the exception of those listed above

Side effects

(=vasodilatory effects)

visual disturbances e.g. blue discolouration, non-arteritic anterior ischaemic neuropathy

nasal congestion

flushing

gastrointestinal side-effects

headache

[erratic-emedicine]

Hello from doctor world

Firstly, sorrrry about the inactivity on this blog. I think that I should try to make an effort now to encourage you guys still studying that there is light at the end of the tunnel. So if I am to write blog posts, what do you think they should be on?

There's a lot of experience-based medblr blogs, so I was thinking sticking with a more tutorial/learning based theme, what do you guys think.

All suggestions welcome, and hello from the real world! 

(PS I'm placed on Obs and Gynae right now, so that is what i'll be able to post about in most detail.)

[erratic-emedicine]

I AM DOCTOR NOW, RECEIVE MY WISDOM WITH INCREASED VIGOUR!!! (I passed finals)

[erratic-emedicine]

Febrile Seizures/Convulsions are not uncommon - around 3% of children by the age of 6 years have had one.

As a parent they are one of the most terrifying events to witness - a lack of understanding, a lack of control of the situation and fear for the worst assures this.

Cause 

Febrile seizures normally happen when an infant with an minor infection has a temperature spike.

If the child appears severely unwell it is important to rule out more serious conditions such as pnuemonia, septicaemia, meningitis and malaria.

Most seizures (simple seizures) last less than 5 mins and have the following symptoms:

Stiffening of body, then twitching, or shaking

A dazed appearance

Eyes may roll backwards

Sleepiness afterwards - drowsiness lasting up to an hour

Seizures more rarely can also be 'complex' or occasionally can progress as far status epilepticus (as seen in epilepsy).

Action to take

Immediately

Note start time of seizure

Lie child on side with head on something soft

Try to lowertemperature - remove clothes

Give them a drink and some paracetamol (acetomorphin)

Stay with the child at night

After the seizure

Always try to see a doctor soon, they may need treatment for the infection.

Contact the ambulance/doctor immediately if:

The seizure lasts more than 5 mins

There is no improvement within an hour of the seizure ending

There is another seizure soon after the first

The child has difficultybreathing

There is suspicion of seriousillness

N.B.:

Febrile seizures are not normally dangerous, and usually result in no long term damage, or effects on intelligence etc.

There is little evidence to support the prevention of febrile seizures 

Febrile seizures are NOT a type of epilepsy

Febrile seizures are NOT  a reason to avoid vaccination

[cluelessmedic]

Measles - Subacute Sclerosing Pancencephalitis

a rare and fatal late complication of measles infection

due to an immune reaction to the virus, causing inflammation, swelling of the brain, it is always fatal

it may appear years after apparent recovery 

rarely seen now in countries with vaccination programmes 

[erratic-emedicine]

Taking Histories from specific patient groups - Gynae

As well as the basic medical history, there are some specific questions that you need to ask for a Gynaecological history:

Menses

1st day of last menstrual period (LMP)

Length and regularity (days bleeding, days between starts of bleed)

Unscheduled bleeding - Post menopausal, inter-menstrual (IMB - in between periods), post coital (PCB)

Excessive bleeding - clots, numerous pads, flooding of pads

Pain - Dysmenorrhoea (painful periods), cyclical, intermittent

Sex and Contraception

Sexually active (always ask, older ladies might surprise you!)

Any pain with sex (dyspareunia)? - deep or superficial

Using contraception? - what type, how long for

Cervical Smears

When was last smear? Normal?

Ever had abnormal smear?

Urogenital/Prolapse/GI

Urinary - dysuria, frequency, nocturia, urgency, 'any accidents, or leaks'

Any feeling of fullness in the vagina?

Any problems with bowel? - constipation, weight loss, appetite disturbance

Obstetric History

Gynae - previous preg.s ending < 24 weeks - miscarriage, ectopic, abortions, molar pregnancies

Obs - Previous preg.s delivered after 24 weeks, or live before 24 weeks

Dates and method of delivery

Any problems during pregnancy, delivery, or postnatally

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Red Flags by System

When you are taking a history based around a presenting complaint, it is very useful to eliminate 'red flags' that might indicate serious underlying pathology. 

Here are some red flags for a variety of systems:

Cardiovascular

Pain, Palpitations, SOB (on exertion, at rest, orthopnoea, PND) Ankle Swelling, Dizziness, Smoking, Exercise, Diet

Respiratory

Wheeze, SOB, cough, sputum, haemoptysis, chest pain, calf pain/swelling, Smoking

GI

Loss of appetite, Weight loss, nausea/vomit, dysphagia, reflux, pain, change in bowel habit, blood/mucus PR, blood in stool/vomit, jaundice, itching, darkened urine, pale stool

Urogenital

Frequency, Urgency, Pain/tingling, Haematuria, lower back pain, Discharge, Menstrual problems, last Sexual Health check 

Neurological

Collateral hx of GCS/Cognitive change, Visual Disturbance, Hearing Loss,  Speech/Swallowing probs, Headache, Neck/Back Pain, Weakness, Parasthesia, Balance/Coordination, Bowel/Bladder Control

Rheumatological

Morning stiffness, joint pain/swelling/stiffness, deformity, malaise/fatigue, weight loss, arthralgia, myalgia, rash, raynauds, hair loss, red/sore/dry eyes, dry mouth, Oral/Genital Ulcers

Diabetic/Endocrine

Polyuria, polydipsia, fatigue, weight loss, neck swelling/tenderness, tremor, heat/cold intolerance, sweating, changes in appearance – hair, skin, voice, hands, feet, pigmentation.

ENT

Ear Pain/Discharge, Nasal Discharge/Crusting, Sore Throat

General

Fever, sweats, fatigue/malaise, loss of appetite, weight loss, lumps

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paediatric Gait, Arms, Legs, Spine (or, pGALS)

pGALS is a screening tool designed to detect problems with the musculoskeletal system of school-aged children. 

NB - this tool is not appropriate for children younger than school age

There are two sections to the tool:

A specific and focussed history

A brief examination

As with any musculoskeletal examination, the key principles are detecting asymmetry and deformity, through a process of look, feel, move.

Key Questions:

Do you have any pain or difficulty in moving your arms, legs, neck or back?

When you get dressed, are you able to do this by yourself without any help?

Can you walk up and down stairs without any problems?

Examinaiton

Inspection - only takes a few seconds but is very important

Child should stand upright in only shorts, with a short sleeve top if a girl.

Look from:

The front, the side, behind of the whole body

The front and side of the face

Look for:

Asymmetry in muscle bulk, bone structure, joint swelling, shoulder/hip level

Deformity - Flexion, knock knee, scoliosis

Rashes

Gait

Ask child to walk to corner of room and back. Observe for:

Limping, gait rhythm, difficulty in turning around

Heel strike, stance phase, toeing off

Ask child about discomfort

Then ask child to walk on their heels and on their toes, ask about discomfort.

Arms

Sit child on couch - watch face for discomfort through exam

Inspect for: asymmetry, deformity, rashes

Manouvres

Supinate hands as much as possible

Make fists

Oppose thumb and each finger, repeat for other hand

Prayer sign, inverse prayer sign

Raise arms above head

Look up

Put hands behind head

Flex neck to each side

Ask child to put three of their own fingers into their mouth

Legs

Lie child flat on couch

Inspect for asymmetry of leg length and bulk, deformity rashes. Also check the bottom of feed for verucas or foreign bodies

Feel - see if knees are warm, and check for an effusion

Move

Check for full extension of the knee

Ask child to bring knee all the way to buttock 

Flex knee and hip to 90 degrees, then check internal and external rotation

Spine

Ask child to stand.

Ask child to bend forward and check that there is a consistent inline curvature of the spine from behind, and from the side.

Here is a link to the pGALS website. It has some great videos, so check it out!

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Taking Histories from Specific Patient Groups - Paediatrics

With all histories, it is important to cover the basics (see previous post). In specific patient groups there are extra questions to ask which are unique to the group:

Paediatrics

Birth History

Antenatal

Uncomplicated?

infections, IUGR, other events, drugs (prescribed or other), alcohol

Delivery

Vaginal, C-section,

Any complications of delivery?

Full term or preterm

Birthweight (<2.5kg = low birthweight)

Postnatal

Resus required?

Any infections

Feeding

What they are being fed - breast, formula milk, solids

Any new foods recently?

Are they drinking well/ as normal

Vaccinations

What have they had - are they missing any?

Developmental History

Gross motor

Fine Motor

Speech, language, hearing, - reaction to sound?

Social interaction - does child seem unreasonably scared or uninterested in play

Social 

Home - smokers, safety, house condition - damp?

School - Attendance, enjoyment, performance

Growth - not really a history question, but it is very important to plot the weight and height of all children on a growth chart (link), and the head circumference of infants.

Red Flags - make sure to ask about these:

Little or no urination

Are they drinking well?

Are they playing well?

Parental concern - a lot, or none is worrying

Crossing centiles on growth charts

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How to take a Medical History

Taking a good medical history is the most important skill to learn as a medical student, and is an art perfected over a whole career.

I am going to write about 3 things:

How to take a basic medical history

Things to include in histories from specific patient groups

Red Flags to ask about when taking a history from a particular system

Contents of a Basic Medical History

(and suggestions on how to gather the info)

Patient Identifiers - Name of patient, DOB, Job/Retired (if adult)

Presenting complaint (PC) - the single reason the patient has come to see a doctor/the hosptial eg. Shortness of Breath, vomiting blood etc.

Past Medical History (PMH) - All previous hosptial admissions, operations and chronic health conditions

Systematic Review - (I just want to run through a few systems, to make sure we haven't missed anything...)

Some people like to leave this until the end, but i think it helps to put this in with PMH as if you've missed anything (read - the patient forgets to mention it), you should be able to catch it here.

Cardiovascular - High BP, Heart Attack?

Respiratory - COPD, Asthma?

Gastrointestinal - Change in bowel habit?

Genitourinary - problems with waterworks?

Liver - ever become jaundiced or yellow at all?

Diabetes

Joints - Pain, stiffness or swelling?

Neuro - Altered sensation, vision, hearing, weakness?

Weight - unexpected gain or loss recently?

Psych - Had any mental health probs or experienced low mood?

Family History (FH) - any history of disease within the family?

Drug History (Drugs) - Take any regular medications for anything?

Again, this might reveal some more as yet unexplored PMH problems. Ask what each drug is for.

Ask: Name (generic if possible), Dose, Frequency, Route

Social History

Ever smoked? (how many per day, how many years)

It's amazing how many people just quit recently, or are 'cutting down'...

Alcohol - how much per week on average- work out units later

Living situation - alone, with family, mobility difficult? - stairs, any help around the house?

This is important information when it comes to discharge if the patient will need social support.

On Examination - Findings of relevant system examination.

Right, so that's a good basic history, which you can adapt as you see fit in the context of each individual patient.

The most important thing when taking a history is to be nice. If the patient likes you, they will divulge key information much eagerly. On the other hand, if they feel like you are judging them, the 62 year old man with a persistent cough may tell you he doesn't smoke much, and you may miss his cancer - disaster!

I'll write about Red Flags and specific patient groups in another post, that's all for now!

[erratic-emedicine]

Starting Atypical Antipsychotics

Antipsychotics are often prescribed for people with Schizophrenia, Bipolar Disorder, Major Depressive Disorder and Mania, as they can be very effective at reducing the intrusive symptoms experienced.

First line are 'Atypical Antipsychotics'

Second line are 'Typical Antipsychotics'

Atypical Anitpsychotics

Olanzapine

Quetiapine

Rispiridone (can be given as 1-4 weekly depot injection)

Aripiprazole

Atypicals need monitoring for some well recognised side effects:

Metabolic Syndrome

Weight gain

Sexual characteristic dysfunction - Impotence, Gynacomastia, Menstrual Disturbances

Cardiovascular changes

Extrapyramidal SEs

Monitoring needs to be done before initiation of medication, then every 3 months for the first year, then as a yearly medication review. The monitoring is as follows:

Metabolic - glucose, HbA1c, Lipids

CVS - ECG, BP

Clincial - BMI, Waist circumference, dyskinesia assessment

Other general advice to be given before starting:

Take at same time each day - if one is missed take it when remembered, or skip if close to next dose

Don't stop suddenly due to withdrawal effects

Enhances effects of alcohol

Driving is legal, but medication can cause drowsiness - take before bed if finding sedation a problem

NB - Side effects vary a lot between individual Atypicals, so trying more than one may be worth it.

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Post Partum Haemorrhage (PPH)

PPH is the leading worldwide mortality of maternal death after giving birth, caused by:

80% of cases - Uterine Atony, Retained Placental matter

Other:

Perineal/vaginal trauma

Uterine rupture

Coagulopathy

Infection

Gestational trophoblastic disease

After birth the uterus should contract to prevent excessive blood loss, failure to do so is Uterine Atony.

There is huge capacity to lose blood, so it is essential to activate a Massive Transfusion Protocol and call specialist help (ITU/anaesthetics, obstetrician, haematologist) as soon as you become concerned.

Principles of Management

Resuscitate using usual ABCDE (link) approach

Stop bleeding

Encourage contraction of uterus

Repair or remove uterus

Definitive management

Specific Management

Empty Uterus

Remove placenta, or any retained tissue

Massage Uterus - can stimulate contraction

Increase uterine contraction medically

Oxytocin infusuion IV

Ergometrine IV or IM

Misoprostol (Prostaglandin) Rectally

Carboprost (Prostoglandin) IM, thigh or in uterus

Apply bimanual compression

Repair perineal/vaginal trauma, including tears

Uterine Tamponade

Balloon inserted into uterus and filled with warm saline

left in situ for 12-24 hours

Surgery - arterial ligation, sometimes proceeding to hysterectomy is needed.

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Does my patient need an X-ray?

With ankle or foot injuries, the need for an X-ray can be determined by applying the Ottawa Ankle Rules.

The patient with foot/ankle pain needs an X-ray only if there is at least one of the following:

An inability to weight-bear both immediately after injury, and in emergency department

Bony tenderness at the posterior of the medial or lateral malleolus

Bony tenderness at the base of the 5th metatarsal

Bony tenderness over the navicular bone

NB - if swelling is too large to palpate, or the patient has diminished sensation, or is drunk, the rules do not apply

If none of these criteria are fulfilled, you can discharge your patient with advising RICE, and follow up in 5-7 days if no improvement. The Ottawa Ankle rules are accurate in predicting the absence of a fracture in 98.6% of cases - pretty good eh!

[cluelessmedic]

Paracetamol Toxicity Normogram

~40% of self-inflicted poisoning is due to paracetamol

can cause severe liver damage if >150mg/kg is taken (>12g or 24 tablets)

damage is from accumulation of NAPQI (metabolite of paracetamol)—> liver and renal damage 

"High Risk Patients" = alcoholics, malnutrition, HIV, enzyme inducing medications, cystic fibrosis (lower threshold for Rx)

Symptoms - nausea, vomiting, abdominal pain + hepatic tenderness, jaundice

Treatment - plot plasma paracetamol on graph, if above treatment line —> N-acetylcysteine, initially rapid infusion 150mg/kg, then 50mg/kg over 4hrs, and 100mg/kg over 16hrs

INR = most sensitive measure of liver damage

Monitor U&Es and urine dip as risk of acute tubular necrosis 

?Transplantation - use the Kings College Criteria (pH, INR, Creatinine, encephalopathy)

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Cardiotocography (CTG)

CTGs are used to monitor the fetus in the mother's womb. They are important for picking up signs of fetal distress.

The top trace is the fetal heartrate, the bottom indicates uterine contraction.

A useful mnemonic for assessing a CTG is DR C BRAVADO

DR  - Define risk - any cause for concern - fever, IUGR, maternal medical issues?

C - Contractions - > 5 per minute?

BRA - Baseline rate - should be 110-160 bpm. Sustained >160 bpm indicates fetal infection or hypoxia

V - Variability of Baseline rate - should be >5 bpm. Sustained reduced variability suggests fetal hypoxia

A - Accelerations - accelerations with fetal movement, or uterine contraction is reassuring

D - Decelerations - the timing, not the depth of decelerations is important:

Early Decelerations - occur with contractions - normal

Variable Decelerations - occur with cord compression, can --> hypoxia

Late Decelerations - Persist after contraction - suggest hypoxia

O - Overall assessment

Subsequent actions:

If sustained bradycardia --> deliver

If other abnormalities --> fetal blood sampling

If Fetal blood sampling abnormal --> deliver by quickest route

[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

[erratic-emedicine]

Management of Atrial Fibrillation (AF)

There are two main aims in the management of AF:

Control ventricular rate, or attempt to restore sinus rhythm

Assess for risk of stroke and thromboemobolism

Acute Management

If haemodynamically unstable -->

DC cardioversion

If known permanent AF --> Beta Blockers, Verapamil or Amiodarone

If non-life threatening, alternative is IV Amiodarone (300mg, IV central line, 60 mins), or Flecainide, which is preferred in WPW syndrome.

NB, flecainide should be avoided in Ischaemic Heart Disease, or Left Ventricle Dysfunction

If urgent ventricular rate control is needed - Beta Blocker, Verapamil, or Amiodarone can be give IV.

If haemodynamically stable --> different management

Restoration of of sinus rhythm

If onset of AF definitely <48 hours, administer Heparin, then:

DC cardioversion or

IV  or oral cardioversion with flecainide, amiodarone

No need for anticoagulation if definitely <48 hours since onset

If onset of AF >48 hours

Anticoagulate for at least 3 weeks (if this is not possible use LMWH, and rule out atrial left thrombus)

Electrical cardioversion preferred to IV

Anti-coagulate for at least 4 weeks, and assess long term risk - follow up at 1 month

Success of procedure can be increased by 4 weeks of oral sotalol or amiodarone

Chronic Management

AF can be caused by non-cardiac events such as pneumonia, so this step is only necessary in cases where such a precipitating factor exists.

Maintenance of sinus rhythm

Beta blocker

Flecainide, propafenone or Sotalol (preferred with CAD)

Amiodarone

If rhythm control has failed --> Rate Control

Rate Control - for Persistent/Permenant AF

Beta-Blocker or Verapamil

If more rate control needed:

During exercise - Verapamil and Digoxin

At rest - Beta blocker or Verapamil, and Digoxin

If further control needed refer --> Cardiologist

Thromboembolism Risk

As with most risk assessment, there's a calculation (and tool) for it. The CHA2DS2VASc (Link) score predicts the yearly risk of a thrombotic stroke in patients with AF. It can be used to stratify patients into groups to guide whether the anticoagulation, or anti-platelet medication is indicated.