Psychiatry is hard

3 weeks of placement at an Eating disorder unit was an eye-opening experience. All had their own cause of this mental illness... biological, psychological and social.

And I think that is what makes psychiatry hard, especially history taking because you had to encompass all that - not only the causes, but also the consequences.

A long enduring experience for me because my history taking skills is not too good but I have learnt a lot in this process.... and found out that psych is definitely not for me.

I love Medicine!

Just had the urge to post this....

Studying medicine has its ups and downs... Becoming a doctor without having have the best of memories worries me; without sounding too nerdy though, sometimes there are times, especially little things that when they come together make sense, which make you light up and say "I love Medicine!!!" What a timely post on Valentines day...

For me today, it is heart murmurs and ECG!!!

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