Category 1

"Doctor I have a headache - am I going to die?"

 "Well... eventually..."

As a doctor you have to try and give useful answers to fairly important questions, like, better than this. Differential diagnoses are one of the most useful tools when it comes to diagnosing symptoms and it's important to ensure you've thought of as many of the potential causes as possible. Here's a weird way to remember the key causes of a headache in an emergency situation.





Typical Day in A&E


You are on duty in the emergency department and you're feeling incredibly tense, as someone has just fired off a cluster grenade somewhere in the hospital. You've just been called in to see a patient who has a very bad headache, who says he has a history of migraines. 

 As you enter the room, you notice he's holding a cricket bat and smoking a huge joint. Next to him a washing machine is spinning out of control, pouring smoke all over the room.

 You notice a weird tingling stiffness in your neck, when suddenly his head catches fire.

 The man stands up and says "To Be Honest mate I'm just gonna go home", but his head begins to expand and he starts grinding his jaw. 

 You don't see what happens next because you go blind and pass out.



  • Tension headache
  • Cluster headache
  • Migraine
  • Subarachnoid (feels like being hit with a bat)
  • Drugs
  • CO poisoning 
  • Meningitis
  • Encephalitis
  • TBH - Tumour, TB, Haematoma
  • Temporal arteritis
  • Glaucoma




Step 1: Take a history

 RED FLAGS:

  • First and worst headache ever
  • Sudden onset and really bad
  • Unilateral with eye pain
  • Worse on coughing
  • Scalp tenderness
  • Decrease in GCS


- Any trauma?
- Any neck pain?
- Any fever?
- Any loss of consciousness?
- Any decrease in consciousness?
- Any warning signs?
- Any fitting/biting of tongue?
- Any other medical conditions?
- Any changes in vision?
- Any drugs?
- Sudden or gradual onset?
- How severe?

Two crucial questions:
- "Have you been away?"
- "Could you be pregnant?"

Step 2: Do a neuro exam

Step 3: Look in their eyes

Step 4: Get thinking


DDx:

No signs on examination:
- Tension headache
- Migraine
- Cluster
- Post-trauma
- Drugs - particularly nitrates and calcium channel blockers
- CO poisoning

 Signs of meningism:
- Meningitis
- Subarachnoid haemorrhage

 Decreased consciousness:
- Encephalitis
- Meningitis
- Stroke
- Cerebral abscess
- Subarachnoid haemorrage
- Tumour
- Haematoma
- TB meningitis

 Papilloedema:
- Tumour
- Malignant hypertension
- Benign intracranial hypertension
- CNS infection of >2weeks

 Painful jaw/temple:
- Temporal arteritis

 Changes in vision:
- Glaucoma

 Other:
- Paget's disease
- Sinusitis
- Altitude sickness
- Cervical spondylosis
- Venous sinus occlusion
- Vertebral artery dissection



All of the above information is from the Oxford Handbook of Clinical Medicine 7th Edition
byUnknown
in , , ,
08:42:00

Headache DDX

"Doctor I have a headache - am I going to die?" "Well... eventually..." As a doctor you have to try and give usefu...
Read More
Falls are bad. Most people recognise this fact. However they're particularly bad in the elderly for a number of reasons, making them the leading cause of mortality in those over 75. Preventing them is a damn sight better than trying to deal with the consequences.

Reasons why falls are bad:

  • They hurt
      • fear of falling and loss of quality of life
      • loss of independence
      • residential home admittance
  • They cause damage
      • osteoporosis and co-morbidities make fractures more likely
      • Fractures lead to immobility, pain, and risky operations
      • They also cost a lot (£5 million a week)
  • They can cause much more damage
    • If on the ground for a long time
      • This can lead to muscle breakdown and kidney damage (rhabdomyolysis)
      • They may not be able to take their medication while on the floor (comorbidities)
      • They may be bleeding, and if they're on Warfarin, this is going to be worse 


Risk factors for a fall are important, and need to be ruled out, or at least acknowledged before letting someone go home, especially if they live alone:

If anyone is going to fall, it's Marjorie. She's 80, and a very thin little lady who's had a lot of health problems in the past. She fell down the stairs last year and has since become dependent on her daughter to help look after her at home. She gets terribly confused about her medications because there are so many, and she worries about falling over because she has to keep rushing to the toilet every so often. Her son bought her some crocs for her birthday, which made her very sad, but the whiskey made it a little better...
  • Over 80
  • Female
  • Low BMI
  • Previous fall
  • Already dependent
  • Polypharmacy
  • Confusion
  • Other illness
  • Urinary incontinence
  • Inappropriate footwear
  • Home hazards
  • Depression
  • Alcohol abuse 

When someone presents with a fall, you should try and figure out why they fell, as this will affect your management significantly. Furthermore, patients will often hide the fact that they're falling as they're aware this increases the chance of admission to a care home. Make it clear that you want to help them maintain as much independence as possible, and by telling you what's causing it, you might be able to help!
  • I tripped over the rug - Occupational Therapy help make homes safer
  • I stood up and everything went fuzzy - Orthostatic hypotension 
  • I leant my head back and fell - balance issues
  • I forgot to take my diabetes medications - hypoglycaemia
  • I got up straight away and felt fine - less worrying than 'I was on the floor for five days'
  • I found it difficult to talk afterwards - stroke/TIA
  • I can't find my glasses - eyesight problems
One of the best ways to figure out what happened is a collateral history - ask the patient if anyone else saw what happened.
  • Did they shake/bite their tongue


Bone health is also an important factor to consider, as fractures are more likely to occur in the elderly due to:
  • Osteoporosis
  • Osteomalacia
  • Paget's disease of bone
  • Metastasis and malignancy


Two simple tests:

  • Timed up and go - ask the patient to stand up without using their hands, walk three metres and turn around and sit down again
    • If they can do this without wobbling then they are low risk
  • Turn 180 - ask the patient to turn so they're facing the other way
    • If this requires more than four steps then further investigation is warranted

Preventing falls in the future:
  • The house
    • reduce risky obstacles, rugs, exposed wiring, furniture etc
    • wet floors
    • handholds and railings
  • The patient
    • ensure a good diet
    • encourage mobility and exercise
    • pilates and yoga to improve balance are best
    • encourage socialising and group activities to ensure independence and to allow others to check they are alright
  • The treatment
    • always review and query any medications and whether they are indicated
  • The fall
    • ensure that if the patient does fall, they are able to call for help quickly - pendant alarms etc

My general rule - If this person were my grandmother, would I be happy with her living on her own?
byUnknown
in , , , , , ,
07:19:00

Falls

Falls are bad. Most people recognise this fact. However they're particularly bad in the elderly for a number of reasons, making them the...
Read More
Cystic Fibrosis is a common explaining station in OSCEs, so I've put together some things to say about it to parents/lay people/bus drivers who may be interested.


1. Introduction

As always:

  • Wash hands
  • Introduce yourself
  • Explain why you're there 
  • Check you've got the right patient
  • Check they're happy to talk to you

2. What do they know?   (See OSCE communication checklist top 5 post)
  • Ask what they understand so far
  • Ask what particular concerns they have
  • Make sure you know what they want from the consultation

3. Answering specific questions:

  • What is it?
Cystic Fibrosis or CF is a genetic condition, where the body isn't able to make the secretions it makes watery enough. This means that any body part that makes these secretions, such as the lungs, the pancreas and the intestines can run into trouble with thick, sticky mucus. This is why people with CF often have recurrent chest infections, and tummy problems.
  • How common is it?
In short, not very. Around 1 in 2500 people are affected. Because you receive a copy of DNA from your mum, and a copy from your dad, both of these copies have to be defective for CF to occur. This means your parents are both 'carriers' - they have one defective gene, but they don't have symptoms because the other copy is working fine. Approximately 1 in every 25 people is one of these 'carriers' of the defective gene.

*Here I would draw a diagram about recessive inheritence*

When two people conceive a child, that child receives one of the mother's genes, at random, and one of the father's. This means that there are four possible combinations for this gene - Fine/Fine, Fine/defective, defective/Fine, and defective/defective. CF occurs when both are defective, so there is a 25% chance that two carrier parents will have a child with CF.
  • What are the symptoms?
Usually CF is picked up quite early on, as the baby will have recurrent chest infections, and they may struggle to put on weight as well. They may also be wheezy or short of breath, and have diarrhoea. It is usually detected as part of a screening programme for all babies, though, called the heel prick test. We also have a 'sweat test' and genetic tests available to diagnose the condition in older children.
  • Could I have prevented it?
There was no way without both you and your partner being specifically genetically tested that you could have known you had the genes, and even then there was only a 25% that your child was affected. There was nothing that you could have done to make it more or less likely.
  • Is there a cure?
Currently there is no cure for the condition, so the main focus is on dealing with the problems that may arise. This includes using antibiotics to prevent chest infections, medicines to help open up the airways and shift the sticky mucus, and providing dietary advice and nutritional supplements to help their growth and development.
  • Is it going to kill my child?
The problem with the sticky mucus and the repeated infections is that it takes its toll on the lungs, and they become progressively more damaged over time, making CF a progressive condition. Currently the only treatment for this that we have is a lung transplant. Currently the life expectancy for people with CF is that over half will live beyond 40, however we anticipate that those children born with it now will live longer than this.
  • What can I do to help?
Ensuring your child eats well and does regular exercise is the best thing you can do, as they will need more calories and the exercise will help shift the mucus. Making sure nobody in the home is smoking, and generally reducing exposure to pollution and smoke will help reduce infections, as will making sure people at home are washing their hands regularly.
  • How can I prevent another child from having it?
Since you have had one child with CF, we know both you and your partner are carriers. This means any future child also has a 1/4 chance of the condition, however new techniques such as IVF allow us to select embryos that are not affected. Clearly that's another conversation to have on another day, but there are certainly options.
  • Where can I get more information?
I'll get you a leaflet with all the things we've discussed, and it also has some useful websites and contact information should you like more information. There are huge amounts of information online, as well as support groups including the Cystic Fibrosis Trust so it's definitely worth looking it up, and if you have any other questions do feel free to get in contact with us again and we'd be happy to help. 


4. Wrap it up

Make sure you end by checking the person's understanding:

"Before we finish, can I just check that I've explained it properly? Could you tell me the main points of what we've discussed?"

"Have I answered your questions? Please feel free to ask more"

5. Thank your patient and wash your hands
byUnknown
in , , ,
06:24:00

Explain Cystic Fibrosis

Cystic Fibrosis is a common explaining station in OSCEs, so I've put together some things to say about it to parents/lay people/bus driv...
Read More
This is how I remember the key points about antepartum haemorrhage:


Annie is a 25 year old lady who is 25 weeks pregnant. She doesn't know much, but she does know she's having twins. Her anomaly scan shows a low placenta with a clot behind it, and also some exposed vessels between the placenta and the baby.

She has had a number of STI's in the past, and recently hurt herself falling off her bike, which caused some bleeding from the groin.

The doctor goes to examine her but Annie slaps her hand away and says, "I have a placenta praevia, so you can't touch this"

Just at that moment, Annie starts bleeding torrentially, and goes very pale. She gets very hot, panics and collapses on the floor. She begins to urinate blood as well and the doctor sets up a transfusion to try and replace some of the blood, before she also puts on some TED stockings. The CTG shows marked foetal distress and very quickly the tiny foeti show no signs of life.




  • Affects 2-5% of pregnancies
  • Defined as haemorrhage after 24 weeks of pregnancy and before birth
  • Mainly idiopathic
  • Placenta usually the cause:
    • placenta praevia (more likely with twins)
    • placental abruption
    • vasa praevia
  • Genital causes:
    • cervicitis
    • trauma
    • vulvovaginal varicosity
  • Be sure to exclude a placenta praevia before performing a digital vaginal examination

  • Complications:
    • anaemia
    • consumptive coagulopathy (DIC)
      • can give 4 units of FFP and 10 units of cryoprecipitate
    • shock
    • psychological sequelae
    • renal tubular necrosis
    • transfusion and its complications
      • VTE risk
    • foetal hypoxia
    • iugr and sga
    • foetal death
byUnknown
in , ,
14:11:00

Antepartum Haemorrhage

This is how I remember the key points about antepartum haemorrhage: Annie is a 25 year old lady who is 25 weeks pregnant. She doesn't...
Read More
Tommy's Great Aunt June was disqualified from the Coeliac awards because she ate too much.


  • Tissue transglutaminase IgA antibody (TGA)
  • Jejunal biopsy
  • HLA - DQ2 or DQ8





byUnknown
in ,
09:31:00

Disqualified Coeliac

T ommy's G reat A unt June was d is q ualified from the Coeliac awards because she ate too much. Tissue transglutaminase IgA antib...
Read More
Someone has collapsed. You must fix it.

Go!

Before you go in:

 Read the vignette before you enter the station and think about these:

  • What's the patient's name? This is quite important
  • What are you (other than sweating)? Does it say you're a doctor, student, or passer by? This is what you're going to have to introduce yourself as.
  • Where are you? On a ward? On the street? What equipment are you likely to have?
    • is there likely to be any danger?
    • bag valve mask (instead of rescue breaths)?
    • auto defibrillator?
    • call 999 or 2222?
    • have you got someone to help you?
    • is it likely trauma was involved?
    • What are your four Hs and Ts of Cardiac arrest?
      • Hypoxia
      • Hypovolaemia
      • Hyper/po kalaemia (metabolic disturbance)
      • Hypothermia
      • Tamponade
      • Tension pneumothorax
      • Thromboembolism
      • Toxins
Deep breath. Check your own pulse so you know whether you're feeling yours or theirs. Chill. It's going to be just fine.




As you go in:

 Grab a tiny squirt of hand gel and some gloves. Stick them on as you start talking to the patient.

DR CAB2

  • Danger
  • Response
    • call their name
    • shake their shoulders
    • squeeze trapezius
  • Call for help
    • If in a bed, lower it in case of needing to do CPR, and drag the bed clear of the wall, to ensure people can access both arms and the head
  • Airway
    • look in their mouth
    • head tilt, chin lift
    • jaw thrust if gurgling noises or risk of spinal injury
  • Breathing
    • listen for ten seconds, while watching their chest and feeling for carotid pulse
    • don't let hair/necklace/dreads dangling into patient's mouth
  • 2222 (or 999 if outside)
    • ask assistant to do this
    • "Please could you call 2222, adult cardiac arrest in the Plastic Dummies Ward, and on your way back could you bring the crash trolley, and let me know when it's done"

CPR

  • Chest compressions - it's all in the hips
    • heel of the right hand on patient's sternum, 
    • fingers extended, wrists extended, elbows extended
    • left hand on top of right
    • 30 compressions, 5-6cm (1/3 of patient's chest depth) at 100-120bpm
      • pretty much all house/electro music is 128bpm so if you have that in your head while you do it you won't be far off
      • count the compressions out loud
    • 2 breaths
      • preferably with bag valve
      • watch the chest rise
      • preferably done by assistant if they've returned
        • they might hold mask on face and you use left hand to do the breaths (hence right hand on the bottom for compressions)
    • repeat until crash trolley and/or help arrives

HELP ARRIVES

Your first priority is to tag someone else in - ask them if they can take over compressions, and say you'll count them in, and they should take over after the 2 breaths. Count on alternate compressions: 

"3...press...2...press...1...press" ---- 2 breaths ---- they begin.


Now you're clear to think. If there's only 2 of you, you can take over airway.

DEFIBRILLATOR

 Pads, pacemaker and piercings

  • one over apex, other just below right clavicle
  • >8cm from pacemakers
  • away from piercings and jewellery (doesn't need removing, just move away)
  • one on the back if needed

Select, stop, shock?
  • select the 'pads' option for trace monitoring on the defibrillator
  • call to stop CPR and check the rhythm
    • you have 5 seconds to assess the rhythm, the first 3 are needed to let the rhythm settle after CPR stops
      • if it looks like a normal or vaguely organised trace, check for pulse 
        • if pulse, stop cpr
        • if no pulse, back on the chest
      • if not normal, decide if shockable
        • shockable - VF, pulseless VT
        • non-shockable - PEA, Asystole

Continue, Charge, Clear
  • While CPR is happening, say:
    • "Continue CPR, everyone else clear, oxygen away, I'm charging" and press charge 
      • (150J biphasic)
  • Once charged:
    • "Stand clear, shocking"
    • CHECK EVERYONE IS CLEAR
    • Shock
    • Back on the chest

Time, think, treat

Ideally you would have these jobs delegated, with a system running like clockwork, allowing you to think.

Have someone timing (using the clock on the defibrillator) and counting the number of cycles


  • rhythm and shock check every 2 minutes

    • Think about your Hs and Ts and what might be causing this, and how you might treat it

    • Look at their drug chart
      • opiate painkillers
      • potassium sparing/losing diuretics
    • Listen to the chest
      • equal air entry? Tension pneumothorax? Tamponade?
    Treat

    TEST BLOOD GLUCOSE
    • during CPR:
      • establish a definitive airway
        • cuffed endotracheal tube in the trachea with the cuff inflated is the only secure airway
      • get IV access
        • if you can't, get IO access
        • take bloods and send them off
          • FBC
          • U&E
          • Group and Save
          • VBG
      • have drugs at the ready
        • ADRENALINE 1mg IV - 10ml 1:10 000 pre-loaded syringe 
          • every other cycle (3-5 mins)
        • AMIODARONE 300mg IV - after 3 shocks
          • if needed again, 150mg
          • infusion if still required


    •  Treat the cause:
      • Tamponade - pericardiocentesis
      • Tension pneumothorax - thoracocentesis (2 ICS Mid clavicular line)
      • Toxin - remove toxin/give antidote
      • Thrombus - thrombolysis
      • Hypothermia - warm patient
      • Hypoxia - 15l 100% oxygen
      • Hyper/po kalaemia - fix abnormal electrolytes
      • Hypovolaemia - IV fluid challenge




    Continue until one of the following happens:
    • return of cardiac output
    • rhythm is no longer shockable, and a senior member of staff calls it

    RETURN OF CARDIAC OUTPUT

    • ABCDE assessment
    • Oxygen (sats >94%)
    • consider therapeutic cooling 


  • Thank your team!

    • CXR
    • 12 lead ECG
    • Echo
    • Blood pressure
    • Bloods
    • Transfer to ITU
    • Write everything down
    • Go talk to relatives





    Things to remember:



    ALWAYS DO CLOSED LOOP COMMUNICATION 
    If you ask someone to do something, make sure you tell them to tell you when it's done, to avoid confusion and help your thought process along. 



    byUnknown
    in , , , ,
    09:32:00

    OSCE - BLS/Auto Defibrillator

    Someone has collapsed. You must fix it. Go! Before you go in: Read the vignette before you enter the station and think about these: ...
    Read More
    Trichomonas vaginalis is a common infection of the female genital tract that you might have to explain to a patient during your career/OSCEs/particularly awkward bus journey. Here are the main points and how you might want to go about explaining them to a lay person.


    What is it?

     TV is an infection caused by a parasite that sits in the vagina in women, and the water pipe in both men and women.


     How did I get it?

     It's passed along through sexual contact, possibly by sharing sex toys as well, and it can also be transferred from a pregnant mother to her baby. You can't get it from oral sex, anal sex, kissing, other physical contact or sharing (external) cutlery/seats/xbox controllers


     How do I know if I've got it?

     Half the time both men and women can be completely symptom-free, but usually symptoms will show themselves within a month of the infection occurring. Women might notice abnormal vaginal discharge with a strong smell, burning when you pee and sore itchiness around the vagina. Men might notice a thin white discharge from the penis and a burning sensation when peeing.


     Can I be tested for it?

     Yes. We offer the test to people with symptoms of TV or whose sexual partner has TV. Note that even if your partner tests negative you may still have it. It is often worth checking for other infections while you're at it, as multiple ones can be transmitted at once. For women, we take a swab sample from the inside of the vagina, and we might ask for a urine sample too. For men we take a swab sample from the entrance to the water pipe and again, may require a urine sample. It might be a little uncomfortable but it doesn't hurt.


    When should I get the test?

     As soon as you can, usually TV will show up within a few days of transmission. You can go to a genitourinary medicine (GUM) clinic, your GP or a sexual health clinic.


    When will I get the results?

     The results may be available immediately, if they can be looked at under the microscope straight away, otherwise it can take up to ten days.

     How accurate are the results?

     The tests are very good, but no test is 100% accurate, so sometimes you might get a negative result when you actually do have TV. This may be why people get different results from different clinics or why a partner may show as negative when you show as positive. It is very unlikely that it will say that you do have the infection when you don't, however.

     What's the treatment? 

    The treatment is either a single dose or week course of antibiotic tablets. If you take it as prescribed it's 95% effective. Don't drink alcohol for the duration of the treatment and for 48 hours afterwards. We might give you the antibiotics before the results are back if it looks clinically like it is TV. Your symptoms should go away within a few days.


    When should I come back?
    • If you notice pain in your tummy, then it may be something else causing the problem and we'll need to check it out
    • If you think you may have been infected again, or had unprotected sex before the course of antibiotics is finished
    • If you vomited after taking the tablets
    • If the symptoms don't go away after a few days
    • If your test was negative but you start to get symptoms



    Can I treat it without antibiotics?

     In short, no. If you don't treat it you have a greater risk of contracting HIV and it can cause problems with pregnancy. In men if left untreated it can increase the risk of prostate cancer. Complimentary therapies have not been shown to work, and it doesn't tend to go away by itself.


    Can I have sex?

     Avoid sex of any kind until you and your partner have completed a course of antibiotics. If you have to have sex, use a condom, but know that you can still pass on the infection.

    Do I need to tell my partner?

     It is very important that your current and/or recent sexual partners are informed so that they can get tested. If you are uncomfortable about contacting them yourself, the clinic can do it for you, anonymously. It is not a legal requirement to tell them, but it is very strongly advised, and I imagine you'd prefer to be told?

    Will it affect my fertility?

     There is no evidence to suggest that it affects your fertility, however it can affect a pregnancy. Some evidence suggests it can cause a premature birth, or a small baby. The baby can also be born with the infection.


    How do I avoid it in future?


    • Use condoms
    • Avoid sharing sex toys, or use a new condom each time 

    What if I'm really nervous?
    • You won't be judged at the clinic
    • Everything is kept confidential
    • All tests are optional, and under your control, you can change your mind at any time
    • You can ask as many questions as you like
    • You can find more information online, and I'll give you a leaflet with everything we've just talked about and some contact information as well



    Trichomoniasis Vaginalis

    • Organism
      • protozoan
      • produces mechanical stress on cells and ingests fragments after cell death
    • Symptoms usually 5-30 days after infection
      • asymptomatic
      • dysuria
      • vaginitis
      • urethritis
      • dyspareunia
      • fishy vaginal discharge
    • Tests
      • Saline microscopy - 60-70% sensitive
      • Culture - 70-89%
      • NAATs - 80-90% 
    • Prevention
      • condoms
    • Treatment
      • Metronidazole PO single dose/week
      • Week course better for women with HIV


    byUnknown
    in
    10:13:00

    Explain Trichomonas

    Trichomonas vaginalis is a common infection of the female genital tract that you might have to explain to a patient during your career/OSCEs...
    Read More
    "A group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progressive disturbances of the foetal or infant brain"

    Here I've mocked up a fake case history for the 'typical' cerebral palsy patient, which is how I remember the key features:

    Charlie Babinski and his twin brother were born on the 2nd of November 2000 at 28 weeks gestation. He weighed 1499g, and his brother was a much bigger 2300g.


    • Babinski - often have persistent primitive reflexes
    • More common in multiple births
    • 2.11/1000 live births affected
    • Much higher incidence below 28 weeks
    • Much higher incidence below 1500g
    • Associated with IUGR, and CP patients usually small as their bones aren't able to grow to their full potential


    During the pregnancy, he'd suffered many infections, including toxoplasmosis and rubella. His mother had also been ill, and had very high blood pressure, for which she took ACE inhibitors. During the pregnancy she was involved in a plane crash, which she survived, but at the reassurance scan they noticed congenital abnormalities.

    • Antenatal causes of cerebral palsy:
      • infection
        • toxoplasmosis
        • rubella
      • maternal illness
      • teratogenic insult
      • abdominal trauma
      • plane - flight - DVT risk - coagulopathy
      • congenital malformations

    At the time of his birth, he had got stuck during the delivery for several minutes, and suffered severe hypoxia as a result. He was then delivered forcefully with forceps and was very floppy when he was delivered. Because he was bright yellow, they did a scan and found he had significant intraventricular haemorrhage and periventricular leukomalacia.

    • Intrapartum/neonatal causes:
      • hypoxia
      • trauma
      • hyperbilirubinaemia - kernicterus
      • intraventricular haemorrhage
      • periventricular leukomalacia
    • children with CP may be hypo or hypertonic depending on the severity and location of the insult



    Charlie is now a very happy child, and whizzes around at high speed in his four-wheeled electronic wheelchair. His eyesight isn't very good and his joints are stiff so he regularly crashes into things. Sometimes these crashes trigger him to have a seizure, but his muscles are very short and stiff so he doesn't move much when they occur, and he doesn't ever talk about them. He gets very upset when his brother tip-toes past him with a pair of scissors and snips his homework into little pieces.

    • Mobilises with electronic wheelchair - Gross Motor Function Classification System (GMFCS)
      • level 4 impairment
    • Associated impairments:
      • emotional disturbances
      • poor vision
      • seizures
      • poor communication
    • Secondary motor impairments:
      • muscle shortening
      • arthritis
    • Tip-toes - toe walking seen in CP patients as they have very short calves
    • Scissors - 'scissor legs' seen due to shortened adductors
    • Learning difficulties


    Charlie comes to see you for help. You decide to manage his condition in two stages; Temporarily, and Permanently.

    Permanent management requires you to call the neurosurgeons, and in the meantime, you'd like to control his seizures, reduce his urinary incontinence and relax his stiff muscles. To do so you give him some oral medications and then tell him to take off his shoes and lie down on his front. You then give him a massage from his head, down his spine, to his toes, and insert a needle into his spine, which gets him all in a tizz.


    • Managment:
      • Temporary
        • Oral
          • Anticonvulsants
          • Antimuscarinics
          • Muscle relaxants
            • central - benzodiazepines
            • spinal - baclofen/tizamidine
            • peripheral - dantrolene
        • Intrathecal
          • baclofen
        • Orthotics
      • Permanent
        • Neurosurgery
        • Selective dorzal rhizotomy
        • Deep brain stimulation
        • Orthopaedic surgery
    byUnknown
    in
    11:22:00

    Cerebral Palsy - an example

    "A group of permanent disorders of the development of movement and posture causing activity limitation that are attributed to non-progr...
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    I met a patient today who was pregnant and had hypothyroidism, so I read up a little about how pregnancy affects the thyroid and vice versa.


    What normally happens

     The way I think about it is that as the baby grows, the mum's liver is going to have to work harder, and so it starts producing more globulins that can bind to thyroid hormone. These globulins then start mopping up free thyroid hormone in the blood, and the thyroid has to start making more to restore the right levels.

    Thus several things happen:

    • Levels of total T3 and T4 increase
    • Levels of free hormone remain roughly the same
    • Levels of TSH remain the same

    Next, it might be that the body notices the thyroid starting to grow, and gets wary - so it might start producing antibodies against various components of thyroid tissue. Probably the most important are anti-thyroid peroxidase antibodies. This happens in 1/10 women, usually around 14 weeks.

    These antibodies can lead to:
    • loss of pregnancy
    • gestational thyroid disease
    • post partum thyroiditis

    Too low?
    Around 2.5% of pregnant women can be classed as hypothyroid, however only about 0.3% are actually affected by it.

    How I remember causes of hypothyroidism in pregnancy: Acid will rip your thyroid to shreds

    • Autoimmune
    • Congenital
    • Iodine deficiency
    • Drugs - lithium, amiodarone
    • Radioactive contrast
    • Infiltrative disease
    • Pituitary or hypothalamic dysfunction

    How I remember presentation of hypothyroidism in pregnancy:

    I threw a dry yellow ball at Mrs Hypothyroid, but her reflexes were so slow that it smacked her in the eye and knocked all her hair out. She then started shivering and her neck started to swell, and then she said in a really hoarse voice that she couldn't sleep. Then she tried to go to the loo but couldn't stand up and started bleeding all over the floor.

    • dry skin
    • yellowing around the eyes
    • diminished tendon reflexes
    • thinning of hair
    • cold intolerance
    • goitre
    • hoarse voice
    • sleep disturbance
    • constipation
    • weakness
    • anaemia

    The way I manage complications of hypothyroidism in pregnancy:

    I asked Mrs Hypothyroid how she was feeling, she said it was complicated. Her heart hurts and she keeps craving salt. Then all of a sudden her abdomen started to swell and she began sweating and shaking. She said she was hearing voices and her shins began to swell up. Then she fell asleep. 

    • congestive heart failure
    • hyponatraemia
    • megacolon
    • adrenal crisis
    • psychosis
    • myxoedemal coma


    Management is pretty simple: supplement the thyroid hormone
    • if mum was on thyroxine before pregnancy, it will need a 30% boost during pregnancy
    • after birth, return to normal dose, and check TSH 6-8 weeks later
    • it's quite likely that women with auto-antibodies to the thyroid in pregnancy may develop post-partum thyroid dysfunction, so they need monitoring!
    Prognosis tends to be good, although recent research says that maternal hypothyroidism can lead to neurodevelopmental problems in the baby, even if the baby is euthyroid, as the maternal thyroid hormone helps govern neuronal development until 13 weeks gestation.
    byUnknown
    in ,
    11:31:00

    Pregnant and hypothyroid

    I met a patient today who was pregnant and had hypothyroidism, so I read up a little about how pregnancy affects the thyroid and vice versa....
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    Lots of drugs are a no-no in pregnancy. Here's my way of remembering the teratogenic ones.


    Pam is a very worried pregnant lady. She is sat at a cafe with her depressed parrot that suddenly has 3 seizures. She's having miso soup because she's on a low carb diet and he's eating carrots. 

    • pam - diazepam (anxiolytics)
    • paroxetine - antidepressants
    • seizures - carbamazepine, valproate, phenytoin
    • misoprostol
    • carbimazole
    • carrots - retinoids


    A man called Danny, who is a well-known meth addict with a lisp approaches on a bicycle, holding a pack of cards. He says;

    "Lithen clothely, I am going to perform a magic trick"

    Pam, remembering Danny's last trick, puts tha' lid on her soup and says, "It better not be a lame pencil trick again, that was just a fluke"

    • Androgen - danazol
    • methotrexate
    • cyclophosphamide
    • ace of spades - ace inhibitors
    • lithium
    • thalidomide
    • lame pencil - pencil-lame - penicillamine
    • fluconazole

    He suddenly starts bleeding from one of his injection sites, starts glowing, and then screams "DIE ETHYL!" before collapsing on the ground and lying completely static.

    • warfarin
    • radioactive contrast
    • diethylstilbestrol
    • statins






    Disclaimer: not all of them are listed here, and the evidence may change in the future! This paper:

    https://notendur.hi.is/magjoh/kennsla/medications%20in%20pregnancy%201.pdf

    describes how not all of them are absolutely contraindicated, but most of them are avoided if possible. Sometimes discontinuing the drug, such as psychotropics, is likely to lead to a worse outcome than continuing.










    Category X drugs in pregnancy:


    Known Teratogenic drugs:
    • ACE inhibitors
      • captopril
      • enalapril
      • lisinopril
    • Antidepressants
      • paroxetine
    • Antiepileptics
      • carbamazepine
      • phenytoin
      • valproate
    • Anxiolytics
      • diazepam
    • Alkylating agents
      • cyclophosphamide
    • Androgens
      • danazol
    • Antimetabolites
      • methotrexate
    • Carbimazole
    • Coumarins
      • warfarin
    • Oestrogens
      • diethylstilbestrol
    • Fluconazole
    • Lithium
    • Misoprostol
    • Oral contraceptives
    • Penicillamine
    • Retinoids
      • isotretinoin
    • Radioactive iodine
    • Thalidomide








    byUnknown
    in , , ,
    09:08:00

    Category X - contraindicated drugs in pregnancy

    Lots of drugs are a no-no in pregnancy. Here's my way of remembering the teratogenic ones. Pam is a very worried pregnant lady. She...
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