Friday, November 6, 2009

EYE EXAM

Intro
-name
-CC

LOOK
-look at good eye 1st
-wash hands

FEEL
-bony prominences
-upper eyelid(jaundice) and lower eyelid(anemia)

TEST
1.Snellen (20ft/6m away)
2.Ishihara (arms length)
3.visual field
4.Blind spot
5.Accomodation
6.Pupillary light reflex
7.Ophtalmoscope

bye bye.

Upper Limb MSK

1) Introduction
2) Ask for Name
3) Privacy confidentality and Consent
4) Explain to patient the need for exposure, allow to stop if pain , and wash hands

5)Inspection!
Look for Sweats Signs + compare ( give a open commentary)

6) FEEL!
Jugular notch--->clavicle----> acromion---> superior border----> spine----> lateral border---> inferior angle---> medial border

coracoid process---> bicipital tendon--tenderness (ask patient to flex if you want)

7) MOVE!!
Place hand on acromio-clavicular joint when moving arm--> check for crepitus
ACTIVE FIRST, then passive

Flexion, extension
Abduction, adduction
Internal and external rotation

8) Painful arc syndrome - 60 degress to 120 degrees

Lower Limb MSK Examination

1) Introduce self, state purpose and ensure P&C
2) Ask patient's name & age
3) Short history- when and why?
4) Explain to patient about the examination about exposure
5) PLEASE TELL ME IF YOU FEEL ANY PAIN/ PLEASE STOP ME IF THERE IS ANY PAIN
6) WASH YOUR FREAKING HANDS

7) LOOK!!!!
SWEATS, Compare both sides

8) FEEL!!!
ASIS, pubic tubercle, (femoral pulse in between),
greater trochanter of femur,
tibial Tuberosity,
Feel for Baker's cyst
condyles,
patella, ( patella Tap, Bulge test-milk test)
medial and lateral malleolus

9)Movement (Active first , then passive)
Hip - Flexion/Extension , Abduction/Adduction, Internal/External R.
Knee - Flexion/Extension ,
Ankle - Plantarflex, Dorsiflex ; Eversion/Inversion

Specific Test
1) Tredenlenburg (double check this *)
2) Thomas Test *
3) Drawers Test
4) Lachman Test - ACL
5) Mcmurray Test - Medial Meniscus and Lateral Meniscus
6) Patella Apprehension *(during palpation)- move patella laterally, and extend your knee.
7) Bulge Test * (during palpation)- Milking
8) Semen Test - Squeeze your Calve muscles, if normal got plantarflexion
Measurement
1) True Length - asis to the medial malleolus
2) Apparent Length- belly button to medial malleolus

Thursday, November 5, 2009

Back Examination

1) Introduce self, state purpose and ensure P&C
2) Ask patient's name & age
3) Short history- when and why?
4) Explain to patient that the exam requires him to remove shirt
5) Ask patient to remove shirt while YOU WASH YOUR FREAKING HANDS

6) LOOK!!! - curvatures, SWEATS, fasciculations

7) FEEL!!!-
Protuberance, C2, C7, C6, T1 ,
spine of scapula----> sup. T2, inf. T7,
Illiac crest- L4,L5
Spinous process + Transverse process
Erector Spinae muscles0- wasting? fasciculations?

8) Measure lumbar extension- locate L5, 10cm up, 5 cm down----> more than 4cm= normal

9) MOVE!!!
Neck- flexion, extension, lateral rotation, lateral flexion
Thoracic- Rotation
Lumbar- flexion, extension, lateral flexion

10) Specific Tests
SLR----> BARRRHHH GADD's test (dorsiflex), LARRR SARGGHH's test (flex hip, extend leg)

11) Say your farewells to the patient, and thank patient.

History Taking!!!!!

CC
HPI
Systems Review
PMH
Past Surgical Hx
Obs & Gyn
Drugs & Medication
Allergy
Smoking & Alcohol
Fam Hx
Social Hx
Occupational & Travel Hx
Sexual Hx

OSCE BABY

Possible Stations:

1) History Taking
2) Dealing with emotion- angry/ depressed
3) MSE- 9 points- refer to aussie discussion board- questions to ask?
4) Suturing
5) Injection
6)MSK- UL, LL, Back
7)PNS- UL, LL,
8)HEP- Lifestyle advice- exercise/ stop smoking/ dietary
9)Ear examination
10) Eye examination
11) BP/ Vital signs

UNLIKELY THAT CPR WILL COME OUT

Thursday, October 22, 2009

SPina BIfida (Bowel,bladder control, sensation,dermatome)

Bladder and bowel problems in spina bifida

1. A person with spina bifida is usually born with an undamaged urinary system. Over time, paralysis leads to neurogenic bladder. It is caused by damage to the nerves in the sacral area:

- The bladder

- The urinary sphincter

- The muscular flap attached to the ureter.

2. Can be either flaccid or spastic:

- Flaccid - limp and cannot contract completely to force urine out. When the flaccid bladder becomes full, excess urine spills over and flows out of the body through the urethra. Urine dribbles out continually and when excess pressure is put on the bladder (laughing or crying), this dribbling becomes more severe. However, the bladder never empties completely and some (residual) urine always remains.

- Spastic - Does not store urine at all. The muscles that line this type of bladder are extremely sensitive and irritable. They contract and expel urine immediately after it enters the bladder.

3. Damage to the sphincter muscle can be either too tight or too loose. When the sphincter muscle is tight, urine becomes trapped in the bladder and is often forced back up the ureters to the kidney. If the sphincter muscle is too loose, however, urine continually leaks out of the body.

4. This backward flow of urine can be very damaging to the urinary system and especially the kidneys. Normally, a muscular flap on the ureters closes and once the urine flows out of the kidneys, it cannot flow back. However, the muscles that control this flap are often damaged and instead of following the path from the kidneys to the bladder and outside of the body, the urine flows back up the ureters to the kidney.

5. Urine infection - A person with spina bifida who has paralysis in the lower extremities should monitor the appearance of their urine carefully since they may not be able to feel the first warning signs — pain while urinating, for example — of a urinary tract infection.

Lack of sensation

For lower lesions, it is not so straightforward. Children who are able to walk fairly well seem only to lack some movement in the feet, but loss of sensation will usually be in some areas of the feet, right up the leg, and also the buttocks.

1. Possible problems

a. Burns

- Sunburn on legs and feet (especially if shoes and socks are usually worn).

- Wheelchair left in hot sun. The child transferring back into a hot wheelchair may burn buttocks, legs and feet.

- Hot drinks/chips held on lap.

- Hot car/bus seat.

b. Scrapes (Child crawling on rough ground (especially pool surrounds) may scrape knees, ankles and toes)

c. Pressure - Pressure areas are red areas of skin caused by prolonged pressure on one area. Any red area that disappears within 30 minutes is no problem, but one which persists from day to day needs attention. Pressure areas can develop into very nasty sores if they are not treated early and effectively. They can in some cases take months or years to heal.

Gait

General gait features include overall limb hypotonicity, flexed posturing of the lower limbs, decreased velocity in an attempt to conserve energy and significant foot deformities.



Possible OSCE Station- HEP/ Lifestyle Station

The following is the stem we were given for our end of year OSCE last year -


You are a doctor in a GP clinic. Arif Asri, a 36-year-old sales manager, has come to your clinic because he is very concerned about his health and wants to know what he can do to improve it. He has recently been diagnosed as having diabetes mellitus. Apart from this, he has gained a lot of weight in the past two years, and also smokes about 20 cigarettes a day. On examination his BP is 130/90 mm Hg and his BMI is 30.

Tasks:

You are required to:

a) Take a brief history of his lifestyle based on the ESSENCE model (4 mins.)

b) Suggest a plan for changing any one aspect of his lifestyle (diet, exercise, or smoking), using a behaviour change strategy e.g. Prochaska Diclemente cycle of behaviour change, and a model for target setting (4 mins).



Approaching this Station -

  1. Introduce yourself, consent, explain what you'll be doing -

'Hi, my name is ______, how are you? I understand that you've come in today because you're concerned about your health?'

  1. Much of the information you would normally gain from a history has been provided in the stem, so don't spend too much time going over it – remember you only have 8 minutes (sounds like ages – it's not always!)
  2. “So you're looking at improving your health, and that's fantastic. Acknowledging that you want to change is the first step so it's great that you've come in to see me.” Positive reinforcement is always useful and very helpful in developing rapport.
  3. Before we start discussing the changes that we would like to implement, first I'd like to find out a bit more about your current lifestyle – so tell me, are you getting much exercise at the moment?
  4. Then just move systematically through the ESSENCE model – or whichever plan works best for you. Personally I find that starting with Exercise is a good question to start off with as people will expect it and (initially at least – while you're still developing rapport) it's easier to answer than “where do you get a sense of meaning from.
  5. So, working through the acronym, just have a general question in mind for each aspect -

E – Education – 'what do you know about how your habits affect your health?'

S – Stress Management – 'do you ever feel stressed about work/relationships? How do you deal with this?'

S – Spirituality – 'do you get a sense of meaning from somewhere in particular? Do you attend church?'

E – Exercise – 'what sort of exercise do you do? How much would you do in a week?'

N – Nutrition – 'what would you eat for each meal in an average day?'

C – Connectedness – 'do you feel close to your friends or family? How much time do you spend with them/how often do you see them?'

E - Environment – 'who are you living with? Are you happy living with them? Do you think they would support your new lifestyle changes?'


  1. And then, using BASK or Prochaska DiClemente, set up a plan for the patient to begin these lifestyle changes. Personally I find smoking to be the easiest as there is generally just the one aspect – needing to cut down as much as possible. Nutrition and Exercise are both good ones to look at though (remembering that this stem has only asked you to look at one.)


BASK model for behavior change

Behaviors

Attitudes

Skills

Knowledge



SAME model for goal setting

Specific

Attainable

Measurable

Enjoyable


Prochaska DiClemente Cycle for change

Precontemplation

Contemplation

Preparation

Action

Maintenance

Relapse (relapse is not failure)


8. For this I would probably talk to patient through Prochaska (I find it easy to explain) – although stick with whichever you are most comfortable/familiar with.

Eg - “Are you familiar with the Prochaska DiClemente cycle? It's a system that is used for helping people initiate behaviour change. Most importantly, we need to identify the stage as which you are at. The first stage is Precontemplation, but by coming in to see me I recognise that you have already begun thinking about the changes we need to make. The next stage is contemplation, and this is where you begin to weigh up the benefits of embracing a healthier lifestyle, and it's great to see that you've done that. The next phase is Preparation, and this is what I'd like to work with you to do today... Proper preparation is very important etc... You've mentioned that you'd like to cut down on smoking -

- reduce number of cigarettes

- have you ever heard of nicotine patches?

- reward yourself when you resist a cigarette

- remove yourself from/reduce the number of situations where you want to smoke – high stress, 'smoko' at work etc

When you leave today I'd like you to begin to put this into Action... After this it is important to Maintain these changes... if you do move into Relapse, where the lifestyle changes we discuss are not upheld, remember that this is not a 'failure' as such... You can try again etc...

Hydrocephalus

Hydrocephalus - "water on the brain," the "water" is actually cerebrospinal fluid (CSF). It is a condition in which the primary characteristic is excessive accumulation of fluid in the brain.

Sign and symptoms

-Symptoms of hydrocephalus vary with age, disease progression, and individual differences in tolerance to the condition. For example, an infant's ability to compensate for increased CSF pressure and enlargement of the ventricles differs from an adult's. The infant skull can expand to accommodate the buildup of CSF because the sutures (the fibrous joints that connect the bones of the skull) have not yet closed.

Symptoms in infants

* Poor feeding
* Irritability
* Reduced activity
* Vomiting

Symptoms in children

* Slowing of mental capacity
* Headaches (initially in the morning) that are more significant than in infants
because of skull rigidity
* Neck pain suggesting tonsillar herniation
* Vomiting, more significant in the morning
* Blurred vision: This is a consequence of papilledema(optic disc swelling that
is caused by increased intracranial pressure. ) and later of optic atrophy
* Double vision: This is related to unilateral or bilateral sixth nerve palsy
* Stunted growth and sexual maturation from third ventricle dilatation: This can lead to obesity and to precocious puberty or delayed onset of puberty.
* Difficulty in walking secondary to spasticity: This affects the lower
limbs preferentially because the periventricular pyramidal tract is stretched
by the hydrocephalus.
* Drowsiness

Sore Foot Infection

How it Happens?
Occurs when there is pressure on the feet followed by contamination by foreign materials or colonization by bacteria. Normally, this restricts flow of blood, oxygen, and nutrients to the area. Subsequently the skin cells die. A person with spina bifida has areas of skin which do not have any feeling and often have partial or complete paralysis, and so does not receive these messages. If the pressure continues the blood supply is cut off, causing pressure sores.

Prevention
-Regular Visual Checks
-Suitable wheelchairs, footwear, and braces must be fitted.
-Wearing loose clothing can help prevent rubbing. Tight clothing can reduce circulation
-Ensuring the skin is kept clean and dry will help protect from rashes and bacteria.
-Exercising regularly may improve circulation considerably lessening the risk of pressure sores.

Grade
Grade 1 – skin discolouration, usually red, blue, purple or black.
Grade 2 – some skin loss or damage involving the top-most skin layers.
Grade 3 – necrosis (death) or damage to the skin patch, limited to the skin layers.
Grade 4 – necrosis (death) or damage to the skin patch and underlying structures, such as tendon, joint or bone

Treatment
Grade 1 and 2 only need pressure relieve and daily check up of the foot. if there is any open wound, clean and dressing to avoid infection. The goals are to provide a moist wound environment, encourage drainage, avoid build-up of necrotic tissue, and keep the bacterial count low.

For infection, the most frequently used medications for foot infections are first-generation cephalosporins, clindamycin (for patients allergic to penicillin), amoxicillin, clavulanate (Augmentin), and levofloxacin (Levaquin) and are directed toward the most common organisms, including S aureus, S epidermidis, and Streptococcus species.

Severe limb-threatening foot infections require aggressive treatment with a combination of local wound care, intravenous antibiotics, and surgical debridement. Infections with open wounds, usually are inoculated with a combination of gram-positive and gram-negative aerobes and anaerobes. These should be treated with broad-spectrum antimicrobials such as ampicillin and sulbactam (Unasyn), ticarcillin and clavulanate (Timentin), or piperacillin and tazobactam (Zosyn) In the patient who is allergic to penicillin, intravenous clindamycin in combination with oral ciprofloxacin, levofloxacin, or gatifloxacin may be used.Wounds that are suspected of containing very aggressive gram-negative organisms should be covered additionally with an aminoglycoside.