Year 4

Satisified with passing my OSCE so next week I will be starting year 4!!! To be honest I was terribly worried about the outcome. Fortunately I have passed them, and apparently I only failed one station, passing 11/12 stations!

I was not sure how I managed to pass with "flying colours" but maybe it was the way I behaved. I probably had the same medical knowledge in my first one and my resit but what I probably did more of was acting in a more empathetic way. 

I'll make sure I do the same for the remainder of my medical career. Meanwhile, I am very much looking forward to new challenges!

I probably have spent too much of my summer on Youtube! Good thing I still spent some of my time earning the bucks as a student ambassador...

Exams and history taking

Provisional results of my OSCEs indicate that I was one station away from the pass mark. The stations I failed were also mostly just a few marks away from passing....

Generally they were not the results I had expected. I never really liked paediatrics.. (always seeing the same things over and over again... kids are OK, some cute too!) failing one of those stations - OK, but failing two... I was lost for words (in a bad way)... and I was in for a greater shock when I failed my cardiovascular exam...

I have always felt proficient in my CV exam but I guess the examiner did not really like me... or maybe it is just my excuse for failing. The feedback the examiner gave after was that I did not elicit manoeuvres for murmurs. I knew how to do it but the examiner never asked me to do so! Nor was I never taught to do them in CV exam other than if I thought something was abnormal.

I wonder what the future holds for me... maybe not so serious but it is the first exam I have ever failed in my life, and I wholeheartedly think I did not deserve it... to make matters worse, if the provisional results stay as it is, I will have to stay in UK..........................................

I guess life has ups and downs... and this is my first real challenge..............................

Anyways, on to history taking.

I must say... the one month of GP placement has given me much opportunity to practise history taking. I am very grateful for all the feedbacks my tutors have been giving me. They say my history taking is good but I know there is always room for improvement.

For example I met a patient today whose cousin has brain tumour (at the age of 30s). She herself complained about several months' history of earache, tinnitus, and throbbing headache. Both of which are worsening and wakes her up from sleep. Along with that she has occasional and new onset photophobia, nausea but no double vision.

I usually manage to get most out a patient... and I guess formulate some sort of differential... which I did. But for patients who have a complicated history like the above, I always seem have problem making it slick for the consultant to digest when I present the case.

The next time I hope to make my case presentation more concise, in line with my differentials!!!

Stroke

Now at the stroke ward... which seems interesting! Am glad that I managed to get that for my SSC!


TIA v Stroke

1) TIA: Focal neurological deficity that resolves <24 hours

• Transient ischaemic attack: a sign of impending stroke

2) Stroke: A focal neurological deficit of acute onset that persists >24 hours
The term CVA (cerebrovascular accident) is not a recommended term as it is avoidable.

To describe stroke, it is best to describe it as follows:
Side of stroke + Disability
(e.g. L. sided ischemic stroke with right hemiparesis, right homonymous hemianopia and expressive dysphasia

Stroke Classification (Bamford): TACS, PACS, LACS (lacuns) and POCS

• Total Anterior Circulation Stroke (TACS): 3 of the following: New higher cerebral dysfunction (eg dysphasia,  NOT dysarthria), homonymous visual field defect and ipsilateral motor and/or sensory deficit of at least two areas of face, arm and leg 

 (relating to the GCS: E - hemianopia V - dysphasia/higher cerebral M - hemiplegia)

• Partial Anterior Circulation Stroke (PACS): 2 of the above

• Posterior Circulation Stroke (POCS): Basically cerebellar dysfunction

1. D: Dysdiadokinesia
2. A: Ataxia
3. N: Nystagmus
4. I: Intentional tremor
5. S: Slurred speech
6. H: Heel shin test

Others worth mentioning...
Ipsilateral cranial nerve palsy
isolated homonymous visual field defect

• Lacunar Circulation Stroke (LACS): Internal capsule

1. Pure motor > 2/3 face, arm, leg 
2. Pure sensory > 2/3 face, arm, leg 
3. Mixed (motor and sensory) > 2/3 face, arm, leg 
4. Ataxic hemiparesis
5. No higher dysphasia or visuospatial or hemianopia or vertebrobasilar problems

Investigations

U&E and LFTs and Glucose
FBC (polycythemia)
Cholesterol levels
TFT (just to rule out reversible causes)
CXR and ECG
Coagulation screen – young and cryptogenic strokes
ESR, CRP - r/o temporal arteritis

Imaging:
CT Head / MRI - more detailed
Cardiac echo
Carotid ultrasound: Stenosis
ECG: rule out AF
 

Acute Stroke Management

• Aspirin 300 mg initially and then 75 mg od
• Consider Thrombolysis within 3 hours of witnessed symptom onset (ie. if you wake up with a stroke, you won't get it) using alteplase

Thrombolysis - Inclusion Criteria

• Clinical signs and symptoms of acute stroke
• Clear time of onset
• Presentation within 3 hours
• Hemorrhage excluded by CT
• NIHSS<25
• Consent to treat (every effort made to contact next of kin)

Thrombolysis – Exclusion Criteria

• Rapidly improving neurological signs
• Systolic blood pressure (SBP) greater than 185 or diastolic blood pressure (DBP) greater than 110
• Seizure at stroke onset
• Symptoms suggestive of subarachnoid haemorrhage
• Suspected acute pericarditis
• Stroke or serious head trauma within 3 months
• Major surgery or serious bodily trauma within 2 weeks
• History of a prior ICH
• Intracranial neoplasm
• Arteriovenous malformation or aneurysm
• GI or urinary tract hemorrhage within 21 days
• Arterial puncture at a noncompressible site or lumbar puncture within 1 week
• Concomitant oral anticoagulant (INR>1.7)
• Platelet count <100 x 109/L
• Prothrombin time (PT) >15 (INR >1.7)
• Activated partial thromboplastin time (aPTT) elevated beyond reference range
• Glucose <50 mg/dL or >400 mg/dL
• Positive pregnancy test (in woman of childbearing age)
• Blood should be sent for type and screen in case transfusions are required

Thrombolysis - Scanning

• Non contrast head CT scan
• An immediate head CT scan is imperative.
• Any Haemorrhage is an absolute contraindication to thrombolysis.
• Early signs of major infarction on initial CT scan (eg, mass effect, oedema, hypodensity
involving more than one third of the middle cerebral artery territory) are a reason for caution in the use of thrombolytic therapy, because the risk of haemorrhage is increased.

Thrombolysis – Practical Aspects

1. Arrange for an emergency head CT scan and laboratory studies.
2. Monitor BP at least every 15 minutes before tPA. If high, intravenous labetalol bolus (or other suitable agent). BP must be under these parameters to administer tPA.
3. Establish intravenous access for hydration and thrombolytic therapy.
4. Mix tPA as soon as the patient is deemed to be a potential candidate for treatment
5. Monitor for improvement of neurological deficits.
6. Place a Foley indwelling catheter and nasogastric tube, if necessary, prior to starting tPA.
7. During and after tPA infusion, monitor BP at least every 15 minutes for 2 hours.

Complications – Intracerebral Haemorrhage

ICH may be signaled by acute hypertension, headache, neurological deterioration, and
nausea or vomiting.

If ICH is suspected, obtain an emergent head CT scan and obtain PT, aPTT, platelet count, and fibrinogen.

If ICH is present on CT scan, evaluate lab studies and administer, if needed, 6-8 units of
cryoprecipitate containing fibrinogen and factor VIII, 6-8 units of platelets, and/or fresh frozen plasma.

Swallowing

– Nil orally initially
– SALT assessment + IV fluids
– Temporary NG feed if appropriate
– PEG placement if appropriate
– Try to ensure nutrition in all patients


Secondary prevention
Medications: Aspirin (300mg for two weeks, then 75mg for life) (/clopidogrel if allergy) and dipyridimole, statin
Lifestyle advice: exercise, stop smoking, lose weight, don't drive for at least one month.
Endarterectomy if carotid dopplers show stenosis (the stenosis is cleaned out by vascular surgeons)

Virtually all patients with atrial fibrillation who have a history of stroke or TIA should be
treated with warfarin in the absence of contraindications


Source: MedRevise.co.uk, DOK.org.uk

Pediatrics -> Geriatrics

Now in my final unit of the academic year, I finally finish with the geriatrics block (big change from the pediatrics as I was about to find!). Although just 2 weeks into it, I am beginning to think that geriatrics is not as intriguing as I had hoped. When I worked as a volunteer, I loved chatting with the elderly. You had all the time in the world to speak to them.

But now as a medical student, it becomes a bit different. Your role is to gather a history, give some differential diagnosis, leaving you little time for a chat (if you want to get your work done)

I liked interacting with pediatric patients more... or maybe I just think too much about the few not-so-good experiences with dementia/delirious patients I met. However I think the pathology/diseases that present in the geriatrics ward are more interesting than the pedatric ones. There were tons more murmurs to hear (predominantly MR). It has also given me more opportunity to look out for abnormalities therefore systems examination become more relevant.

A patient with lung CA (maybe small cell?) had paraneoplastic syndrome. One of it being SIADH.
The syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH) is characterized by excessive release of antidiuretic hormone (ADH or vasopressin) from the posterior pituitary gland or another source. The result is hyponatremia and sometimes fluid overload. It is usually found in patients diagnosed with pneumonia, brain tumors, head trauma, strokes, meningitis, encephalitis, or small-cell carcinoma of the lung.

Suspect SIADH if all of the following diagnostic criteria are met:

• Hyponatraemia (serum sodium concentration less than 135 mmol/L).
• Decreased plasma osmolality (less than 280 mOsmol/kg).
• Increased urine osmolality (greater than 100 mOsmol/kg).
• Increased urinary sodium concentration (greater than 30mmol/L).
• No clinical or biochemical features of adrenal and thyroid dysfunction.
• No dehydration on clinical examination.
• No use or recent use of diuretic medication.

• Most people with hyponatraemia are asymptomatic, particularly if hyponatraemia is mild (serum sodium concentration of 130–135 mmol/L) and has developed slowly.
• When symptoms of hyponatraemia are present, they are often non-specific and are related to both the severity of the hyponatraemia and its rate of onset.
• Early symptoms
• Anorexia.
• Nausea.
• Lethargy and apathy (associated with slow-onset hyponatraemia).
• Late symptoms (associated with severe or rapid-onset hyponatraemia).
• Disorientation.
• Agitation.
• Seizures.
• Coma.

Treatment: Fluid restriction, hypertonic saline, demeclocycline (to induce DI)

With saline infusion: A rapid rise in the sodium level may cause central pontine myelinolysis.^[6] Avoid correction by more than 12 mEq/L/day

I hope to spend more time on this unit examining patients!

Source: Wikipedia and CKS NICE

Febrile seizure

Saw a 5 y/o child with seizure that lasted for 15 minutes. Temperature was 38.8 degrees.

Dx: Febrile seizure secondary to some URTI (apparently the child has prominent adenoids... he has been snoring throughout the entire consultation)

I asked if he had any rash but the parent said no.

Areas I need to improve on:

•  I guess I could have asked more symptoms to rule out meningitis (e.g. photophobia, neck stiffness) if the patient was able to give a response or test it on the patient (e.g. kernig's / brudzinski's sign). 
• I should also have asked more about the seizure itself: During - irregular breathing? pallor? After - is he back to his usual self?

Learning point:

• Parent getting reassurance from the doctor in that simple ones do not cause permanent brain injury and most children usually grow out of it by their 6th birthday.

On a side note, family history is also important. I remember clarking a patient before whose entire family had some form of febrile seizure.....

Anyways I think I have improved on my history taking skills... practice practice practice (unlike Allen Iverson :P)

History taking

The presenting complaint and HPC should be able to give you a differential diagnosis. It has taken me several months to realise that... only up till now have I had some sort of meaningful criticism of my case presentation.

I hope to engage more with case presentations so I can improve on the not so goods!

With the lessons learnt I hope I could go back in time and be able to interview the same patients I had interviewed... whereas before it just felt like a history taking exercise... now I think medicine makes a lot more sense to me!

I shall finish this post with a chest radiograph taken from oocities.org

Back from a year+ of Hiatus... (hernia)

 

Don't think anyone really looks at my blog... anyway I hope to use this blog more to share my frustrations of life on the net!

Recently: Had been on habbo... still was addicted to the typing game (Revenge) and also to miniclips but quitted them weeks ago because I felt it was dragging me behind in my studies. and Thankfully I also passed my mock exams(!).

Today: Nothing special really... but few days ago, I got grilled by a consultant about history taking - not detailed enough and not making sense. My take-home message: Make sense of what patient say to you and question if need be (the patient said the child vomited 3x/day for a week... not possible!). The exercise of history taking is not to repeat what they say to you but for you to make a differential diagnosis! 

I still have a long way to go on becoming a (good) doctor!!!