catheterisation - points i tend to miss

- explain why to do it
- wash hands
- maintain dignity as far as possible.
- double gloving
- not 'dropping the penis in to the sterile field'
- retracting foreskin before and after
- cleaning clockwise from centre out, each time, from twelve, from 3, from 6 from 9
- making sure the catch tray is there at the end of the catheter to catch the urine
- asking the patient if they feel pain at any point in time- especially at point of distending the balloon to hold in bladder trigone area...cos if ur blowing it up in the middle of the urethra u'll end up with trouble and major pain - do not want that!!

-Note size of catheter and volume of water used for ballooning to document in notes.
- making sure that you wait for 2-3 mins for anaesthetic to work, some say hold tip closed/massage down, but im not sure how to do that effectively

- clean sterile trolly down maintain clean area with alcohol, then open up pack so not touching inner sterile area. Drop everything in inner sterile area.

- make sure that the sterile solution is in the sterile bit filled already by yourself

- tear up the main bit of paper for passing over the penis area..clear field

- clearing everything away
- waiting for 3-4 mins while bag fills, chekcing urine for discolouration, blood, general appearance, and remember to put bag on the end of the tube.

-document in the notes : date, size of catheter, patient name, amount of water used for blowing up balloon, for colour and appearance of urine, any probs etc. sign ur name.

Obs and Gynae pocket doctor template

this is the gynae history from the POCKET DOCTOR booklet:

INTRO

CHECK
Patient name and age

PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT

1. BLEEDING
menarche
period regularity
heavy? if yes: pad changing per day/flooding/clots/tiredness
LMP
IMB/PCB/PMB
Discharge: if yes: colour, smell

2. FERTILITY
Sexual contacts
STI's
contraception: barrier and birth control
HRT if post-menopause
Pregnancy attempts
Smears: last date and result
Breast screening

3. PAIN
Painful periods? at what part of cycle
Painful sex? On penetration/during

4. UROGYNAE
Prolapse: dragging sensation/something 'coming down'. Back pain.
Urinary: incontinence? relation to coughing/sneezing/straining
Urinary symptoms: freq, noct, dysuria, strangury, hameaturia, unable to interrupt stream.
Bowel habits: esp change in habits.

OBSTETRIC HISTORY
Pregnancies: date delivered, mode, weight, problems.
Miscarriages: gestation?
Termination: gestation, reason?
ectopics

PAST MEDICAL HISTORY
esp gynae operations

DRUG HISTORY

FAMILY HISTORY

SOCIAL HISTORY

summary
address pesky concerns

[Kindly written up by a friend]

'Explanations' Template for OSCE's or in life.

A friend of mine said:

real simple template:
egs are for endoscopy

1. WHAT it is and WHY we do it (camera test to look for ulcers/bleeding)
2. HOW we do it (spray at back of throat, thin camera tube in mouth)
3. SIDE effects and RISKS (sore throat and infection/perforation)
4. RESULTS: when and how you get them
5. PREPARATION and AFTER the procedure (eg starve 6hrs before endoscopy, have a lift home organised)

its quite basic, but covers most things!

In essence its, why what how, side effects, risks, complications, results, preparation, afterwards [immediate, short term, longterm]

INSPECTION OF THE EYE ; and some.

This is following on from the post about the Eye Exam - just some depth into what you're looking for on examination:

General - Looking for

Patient's general health and facial appearance
Eyebrows: hair loss in myxoedema
Eye sizes: can be different (bupthalmos)
Protrusion: eg thyrotoxicosis
Swelling: eg renal disease, allergy
Lax lids : ectropion (lid out), entropion (where lid turned in)
Bruising: Trauma (generally assault)

Eyelid
Eyelash position -pointing in can damage the cornea
Ptosis -autonomic damage or congenital
Lid retraction -thyroid eye disease
Fasciculation or tremor? thyrotoxicosis
Redness and swelling? infection
Lacrimal punctum

Conjuctiva
Colour -anaemia, infection etc
Blood vessels
Pterygium and pinguecula - benign growths of the conjuctiva
Lymph follicles - allergy

Cornea
Corneal arcus w/wo deposits
Cloudiness/opacities
Ulcer

Pupil
Size, shape, irregularity
Iris colour and shape

PALPATION
Check for tenderness over and around the closed eye,
Check for gross abnormality of intra-ocular pressue

Percussion not applicable
Auscultation = check for bruits if applicable eg over any unexplained swelling or proptosis

Erbs Palsy and Klumpke's palsy

Erb's palsy: C5,C6: associated with birth trauma/injury
Postion: waiter's tip - arm internaly rotated, forearm pronated, palm facing backwards
Sensory loss: Deltoid
Motor loss + wasting: Deltoid, most of rotators, biceps, brachioradialis
Special tests: absent biceps and supinator reflexes

Klumpke's palsy: T1 : associated with cervical rib/apical lung tumour -Pancoasts
Position: Clawed
Sensory loss: Inner aspect of arm and forearm
Motor loss + wasting: wasted hand
Special tests: ? Horner's syndrome

[see link for median, ulnar, radial nerve palsy]

Eye Examination - Safs notes

Remember AFRO

1. Snellen Chart - for visual Acuity - this is the distance from the chart at 6m/the last line read on the chart at 6m I think - eg 6/36 of 6/60 or 6/6 or 6/5,let them waer glasses, no glasses - pinprick hole in card. If worse that 6/60 - then bring to 3metres, if worse than 3/60, count fingers at 1metre, if not succesful, then Hand Movements, if not successful, Pen Torch at 1 metre.( record, CF, HM, PT) Also testing nearsightedness with newspaper/book - read. Test colour vision with Ishihara plates.

2. Fields - as in Visual Fields - if red pin doesnt work, waggling finger, map out presences of hemianopia, scotoma, enlarged blindspot. determine when pin disappears and reappears, moving laterally to horizontal within MID plane. Enlarged blind spot = papilloedema suggestive.

Inattentive test - visual neglect testd for with waggling finger, in pts left and right field, determing which finger, if not both, that the pt saw. Parietal lobe lesion - the finger that is ipsilateral to the lesion will be observed, but the finger on the opposite side will not be..., ie yes i see the right finger, no i dont see the left, means there is a lesion on the right side of the parietal lobe.



3. Reflex - as in direct and consensual light reflexes, swinging light reflexes, accomodation reflex. Swinging light reflex - looking for pupillary delayed constriction

Start of by observing size, shape - reg/irreg, of pupils,and also if presence of ptosis. - 3rd nerve palsy, Horner's.

For Direct and consensual - ask pt to fixate on distant object while testing.
For Swinging light reflex - swing a light from one eye to the next, observing for a sustained pupillary constriction suggestive of relative afferent pupillary defect {sign of Optic neuritis - think MS, other causes}
Accomodation - distant object, then my finger at 30cm from face, look for changes in pupillary size. Should constrict on accomodation, ie looking at near object.

4. SLOW PuRSUIT. The famous H - move horizontally, then vertically, then back to make the rest of the H, with your finger to cover all the eye movements. As the patient about : double vision & pain, watch for nystagmus.

Then From the top - hold 10 secs for fatiguability, and then move down slowly watching for lid lag - MG.

5.Double vision: Elicit whether the images are separated vertically or horizontally - and in which direction the separation is maximal.

'Tell me when you see double, okay so you see double now, can you close the right eye has one of the images disappeared? which one the outer or the inner, and now close the left eye...which one the outer or the inner disappeared?'

Here the issue is with the lateral or medial recti. The idea is that if when looking with the left eye, the outer object disappears when the right eye is covered , then the defect is in that right eye - which means that depending on if the direction we are looking to is to the left hand side - then it is a medial recti weakness, if we were looking to the right hand side when the right eye was covered, (and then it was still the outer image that disappeared), then we can say that it is a lateral recti problem of the right eye.

If in the scenario above the right eye was the problem, and the outer image disappeared on covering, then in the left eye when the test is switched, the inner image would have disappeared. Just a moot, side point.



Here is a link on diploplia http://www.jeffmann.net/NeuroGuidemaps/diploplia.html and I think some useful info on palsies.

Palsies to be aware of :

3rd (occulomotor)Nerve palsy: Ptosis, pupillary dilatation, eye is found 'down and out' (can be a posterior communicating artery aneurysm, or DM, vasculopathic infarction,trauma, meningeal inflammation, tumor, or ophthalmoplegic migraine).

the affected (pupil-dilated) right eye is abducted and tilted downwards (under
the unopposed influence of the 6th and 4th extraocular nerves) under the ptotic
upper eyelid on forward gaze (from link above)

4th (trochlear) Nerve Palsy:

The trochlear nerve (the fourth cranial nerve, also called the fourth nerve or
simply IV) is a motor nerve (a “somatic efferent” nerve) that innervates a
single muscle: the superior oblique muscle of the eye. An older name is pathetic
nerve, which refers to the dejected appearance (head bent forward) that is
characteristic of patients with fourth nerve palsies.

The trochlear nerve is unique among the cranial nerves in several respects. It is the smallest nerve in terms of the number of axons it contains. It has the greatest intracranial
length. It is the only cranial nerve that decussates (crosses to the other side)
before innervating its target.

Finally, it is the only cranial nerve that exits from the dorsal aspect of the
brainstem.

It enters the cavernous sinus, where it is joined by the other two extraocular nerves (III and VI), the internal carotid artery, and portions of the trigeminal nerve (V). Finally, it enters the orbit through the superior orbital fissure and innervates the superior oblique muscle.

The superior oblique muscle ends in a tendon that passes through a fibrous loop, the trochlea, located anteriorly on the medial aspect of the orbit. Trochlea means “pulley” in Latin; the fourth nerve is named after this structure.

http://en.wikipedia.org/wiki/Trochlear_nerve

Diplopia (supposedly the commonest cause of vertical diploplia) with downward gaze - oblique muscle (SO4); orbital trauma, DM, HTN

Jeff Mann says, that the patient would typically have their head depressed slightly, chin down, and eyes looking upwards, I reckon to compensate for the fact that there is a downward gaze. He also says that they may have their head turned away from the side of the lesion, to compensate for the diploplia.

According to wilkinson, you get :
-incomplete depression of the affected eye in the adducted position
-some torsion of the eye in the orbit
-compensatory head tilt towards the opposite shoulder, may be present to obtain single vision whilst looking forward.

What I couldn't understand was why should have a downward gaze - hmm..when the muscle it self is important in that downward action. According to wilkinson, the 'SO' is important in looking down in the adducted position. Thus, when there is a palsy, this action is weakened if the patient tries to adduct the eye, so that it is slightly elevated. That's how you can see that specific problem of that supposed action of the SO.

Thus, on forward gaze, according to JM, the eye is slightly elevated, just slightly - its not looking up, but there is a slight space between the cornea the lower eye lid.

The reason for this is because of the opposing action of the fuctioning muscles. The lateral recti, medial recti, superior and inferior recti of the 3rd nerve and 6th nerve...work to elevate it slightly. I have no idea where 'downward gaze' comes from, other than that being a 'positioning of the head' rather than a placement of the eye itself. *SHIT*



6th Nerve Palsy: Abducens - Lateral recti :abducting abducens look laterally....lateral recti

There may be some inturning of the eye and double vision in the primary postion (because of weakness of eye abduction). There may be compensatory head turning (ie if right eye affected, head turns to right) to obtain a single vision whilst looking forward. No abduction of the eye. So the eye looks turned inwards basically.

This can be considered at times a false localising sign in patients with raised ICP;ms;small vascular lesions within the pons;pathology besides the cavernous sinus, in the superior orbital fissure, or orbit, adjacent nerves commonly inovled - 3/4/5a/2 if in the orbit.


4. Opthalmoscope/fundoscopy

-main things -
-explain what you are about to do - look with this opthalmoscope to check the back of the eye - this is basically like a torchlight with a magnifying glass attached to it - helps to illuminate and magnify the back of the eye - so I can look for any abnormalities or changes or just check to see if all is normal -it's a very simple procedure, that will not hurt, but may be a little uncomfortable - would that be okay?

-position paitnet so that they are seated with free acces to both sides of their chair

-BUT BEFORE THAT I'd JUST LIKE TO GENERALLY INSPECT YOUR EYE:
-start outer to inner - eyebrows - loss of hair, outer 1/3 indicative mostly of hypothyroidism, scares, check for periorbital oedema, any redness, swelling, discharge, foreign bodies, corneal abrasions or ulcerations, conjuctival changes or anaemia.

- know how to use fundoscope - ask pt to look at something in the distance and keep eye on it/fixated, switch on fundoscope make sure light is present by checking against hand, and set handle to zero if u dnt wear glasses. Turn down the lights. Hold fundscope in right hand - aiming to look at patient's right eye. Make sure u use your finger to focus - ie one finger at the front of the opthalmoscope - know how to hold it.

http://www.cornellsurgical.com/zWA11720.htm

Remember, the side with the horizontal dial is the side that faces the patient.

- Stand just in front of and to the right of the patient, asking them to look at a suitbale point a little above eye level and in the middle distance.
-Placing opthalmoscope to your right eye, place your left thumb on patient's eyebrow
-Bring head and opthamoscope slowly closer to the patients right eye. At about 30CM you need to check that you can see the red reflex. The absence of this suggests the presence of a a cataract.

-Keeping the reflex in view, continue to move in until your head is withint 1-2cm of your thumb and no closer!

-Keep the beam of light pointing slightly nasally so that you can keep focused on the disc when looking at the fundi....
-Improve the focus on the retina if need bee by alterning the setting of the lense with the dial.
- Tilt your head and opthalmoscope to follow the blood vessels towards the optic disc lying in the lower nasal quadrant of the retina.
-BEST TO START WITH OPTIC DISC THEN MOVE TO PERIPHERY but U USE THE VESSELS TO LEAD YOU TO OPTIC DISC

-so remember that the retina or back of the eye is split into 4 quadrants - lateral upper and lower, nasal upper and lower.

-CHANGES TO NOTE ON THE OPTIC DISC:
Margin - is it indistinct? - consider optic disc oedema, is there neovascularisation present (ie new blood vessel formation) - think Diabetic retinopathy
Colour - is it nice a pink = normal optic disc; are we looking at pallor of the optic disc? - in which case we are considering optic atrophy.

Contour - raised? - optic disc oedema.
CUP-DISC ratio: so the greater the inner cup, the more likely it is glaucoma - we calculate the ratio, measuring the diameter of the disc (the whole optic disc) and the cup, the inner aspect of the disc's diameter - the CUP/disc = ratio.

If this value is >0.5 = possible glaucoma, if 0.3-0.5 = normal, if CUP is absent : papilloedema!

So we've observed the optic disc - we want to have a good look at the periphery now:

-Avoid getting head or light into patient's line of sight
-Follow the blood vessles form the optic disc into the periphery (ie the area away from the disc, moving outwards). Then look at the 4 quads of the retina, and finally at the macula. The blood vessels - there are 4 - arteries and veins [superior/inferior, temporal/nasal].

- Remember that you're looking for microaneurysm, venous beading, dot and blot haemorraghes, ateriolar narrowing, AV nipping, copper or silver wiring, exudates -

please see following link for some really great images:
http://www.studentmess.com/index.php?d=163 (study carefully to get use to what you're seeing~)
http://studentmess.net/search_result.php?tid=19&title=retinopathy

Briefly on retinal changes:

Hypertensive retinopathy: (I-IV)
I minimal arteriolar narrowing - Silver wiring
II obvious arteriolar narrowing with focal irregularities: AV nipping, silver wiring
III previous changes, with haemorrhages (flame) and or hard exudates (retinal star) with or without cotton wool spots
IV Previous grade with papilloedema (malignant HTN)

Diabetic retinopathy (I-IV)
I Background (non proliferative) - dot (aneurysm), Blot (haemorrhage), hard exudates (yellow, lipid and fluid)
II Pre-proliferative (I with soft exudates and venous beading and oedema?)
III Proliferative - new vessels (neovascularisation, new friable vessels), tortuous fragile, and hence vitreous haemorrhages present, with fibrous growth into vitreous - getting floaters, can lead to increased ocular pressure, and painful glaucoma.
IV Maculopathy

These are the main things to be aware of above, tho there are other retinal changes (maybe talk about later)

- so having looked at all four quads, the retina and nasal and temporal areas, we want to ask the patient to look directly into the light to view the macula. Note its colour - pigmented - snile macular degeneration, and pink is normal) - then you say thank you and move to the left side to examine the left eye informing the patient that this is what you would like to do.

- repeat procedure
-turn of scope
- turn on lights
-thank the patient
-report and record your findings in the notes
-wash hands.

[Central retinal vein occlusion: blockage of retinal VEIN - common in DM and HTN pts. Fundus 'Stormy sunset' appearance.- with dilated engorged veings, dot and blot haems around them. Cotton wool spots and papilloedma may also be apparent.]

[Papilloedema: congested optic disc - in raised ICP, swollen disc and margins disappeared.
Optic atrophy: Retinal veins look congested, grey disc, pale, associated with loss of vision. Maybe 2ndry to glaucoma/retinal damage/ischaemia/poisoning]

Explanations: (from st.george's university handbook)

AV Nipping: when the arteriosclerotic arterial walls loose their transparency
and obscure the view of the underlying veing, on either side, this makes it look
as if the vein is 'nipped'
Haemorrhages: usually occuring in the most superficial nerve fibre layer of the retina, and because of the orientation of the fibres, they look linear or flame shaped
Hard exudate: yellowish white deposits in the deeper layers of the retina, they are accumulations of fats that have leaked out during retinal oedema
Cotton wool spots: retinal infarcts in the nerve fibre layer and are indicative of oedema. They are accumulations of degenerate axoplasm and are a grave prognostic sign. it happens in severe htn, which leads to obstruction of precapillary arterioles and hence cotton wool spot formation.
Narrowing: The primary response to systemic htn is narrowing. Older pts, vessels so stiff, may be minimal narrowing. Two sorts of narrowing; general along the lenght of vessel and Focal where vessels cross. Focal narrowing - likely that pt has htn.

Vascular permeability causes oedema, haemorrhages, exudates

Upper Limb Nerves Lesions: Examinations; median, radial, ulnar nerve specific

Upper Limb Nerves Lesions: Examinations (by Dr.J Archer, notes of sheer gold)

1. Complete the normal peripheral nervous system expiation of the upper limb
2.What nerves do this test? -- Median Ulnar radial
3.How do you know which one is being tested?

Ulnar Nerve: C8-T1

Remember the route that this nerve follows - Here are some good tricks to remember:

1. Remember the dermatomal pattern of sensory loss for the ulnar nerve.
2. Flexor digitorum profundus (FDP) C8 - flexes the DIP of the ring and little finger
3. Lumbricals C8 - flexes the PIP of the ring and little finger
4. Interossei (PAD - Palmar interossoi adduct - hold this between your fingers, DAB - doral interossoi abduct - push out against my finger)

Ulnar nerve lesion signs:
- general wasting (dorsal guttering, hollowing of the web space) - thenar eminence sparing
- LOW LESIONS - Will result in a CLAW HAND : the MCP of the ring and little finger are hyperextended and the IP are flexed, (FDP intact). Weakness of abduction and adduction of the fingers and thumb. Sensory loss over the medial side of the hand and little finger + medial border of the ring finger. (Use Froments sign - paper between thumb and finger- testing adductor pollicis of thumb against finger). Low lesions occur at the wrist.

- HIGH LESIONS - FDPs are also paralysed and so the DIPs are not flexed and the clawing is less obvious.Called the ULNAR PARADOX. High lesions occur at the elbow - OA and RA.

Median Nerve : C6-T1

Remember the route that this nerve follows -

Good tricks to remember (LOAF muscles)

1. Lateral two lumbricals (flexes at the PIP of index and middle)
2. Oppenens pollicis - thumb to little finger
3. Abductor pollicis brevis - palms up, lift thumb toward the ceiling
4. Flexor pollicis brevis - touch your palms with your thumb
5. Think about the pattern of sensory loss
6. Lastly, another imp muscle: median part of FDP of index and middle fingers - flexes at the DIP....

Median nerve lesions- eg carpal tunnel syndrome

- Thenar wasting
- Weaknes of LOAF muscles
- Reduced sensation over the palmar side of the hand to lateral side of ring finger
- percussion over the wrist produces tingling (Tinel's sign)
- flexing the wrist causes tingling (phalen's sign) - for one minute

Causes - CTS (idiopathic most common, then RA, pregnanct, OA), in addition to wrist lacerations, foream fracture #, elbow #

Radial Nerve : C6-8

Signs:

- wrist drop, confirm intrinsic muscles of the hand intact - (therefore not an ulnar or median nerve palsy) - by lying hand on a pillow, unable to straighten fingers; (because the action of the radial nerve is to extend those fingers and extend at the wrist)
-Sensory loss over the first dorsal interosseous
- high or low lesion - test the triceps reflex (C7) - if present lesion is below the spiral groove of humerous. If it is absent, it implies the lesion, is high, up in the axilla -[ saturday night palsy.]

Median & ulnar nerve TIPS: things to help u remember - :
Remember just two muscles - Abductor Poll Brevis(median) and 1st Dorsal Interossei (ulnar)

Remember that if they cannot lift their thumb - but can push 1st finger our against your hands (holding back the other three) = median nerve problem
If they are able to lift thumb, but first finger test is weak = ulnar lesion/problem.

And finally if there are no problems with thumb or finger test - consider radial problem.

Neurological Examination of the Arms : General stuff

We carry out neuro exams of the arms for two main reasons : 1. to find the site of the lesion, 2. to form a list of differential diagnoses.

Types of lesions - they may be MOTOR / SENSORY / MIXED

Remember one motor neuron pathway- has two components - the Upper motor neurone [from cells in the precentral gyrus of the frontal cortex, through the internal capsule, brainstem, cord, anterior horn cells in the cord] and the lower motor neurone [nerve roots, plexi, peripheral nerves] .

UPPER MOTOR NEURONE lesion (affects groups of muscles not individual muscles):

• no fasciculations



• wasting after some times



• increased tone (spasticity - arm flexors, leg extensors ; manifested as resistance to passive movment that can suddenly be overcome - 'clasp-knife' feel)



• weakness



• increased reflexes



• upgoing plantars(+babinski) +/- clonus (rapidly dorsiflexing the foot; < or =" 3">

LOWER MOTOR NEURONE lesion:

• yes fasciculations (spontaneous involuntary twitching)



• wasting



• decreased tone ''HYPOTONICITY''/Flaccidity (soft and floppy, little resistance to passive stretch)



• weakness



• decreased reflexes/reduced or absent

MYOTOMES

Shoulder joint: c5 abduction and lateral rotation; C7 abduction and medial rotation

Elbow joint: C5-6: flexion; C7-8: extension

Wrist joint: C6-7: Flexion/extension

Fingers: C7-8: Flexion/Extension; T1: Abduction/Adduction (small muscles of the hand)

POWER GRADES:

0;complete paralysis

1; a flicker of movement only

2;able to move when gravity is eliminated

3;just able to move against gravity

4;able to move against gravity with some resistance

5; normal



REFLEXES

Biceps jerk : C5,6

Triceps Jerk: C7,8

Supinator jerk; C6,7



Recording reflexes:



+ hyporeflexia; +/- present with reinforcement; ++ normal; +++hypereflexia



Sensory:



dermatomal

peripheral



sensory modalities:

pain&temp (spinothalamic) (spinster...spino pinprick)

Light touch, vibration, proprioception (dorsal columns)

Myotome effect:
C3,4 and 5 supply the diaphragm (the large muscle between the chest and the belly that we use to breath).
C5 also supplies the shoulder muscles and the muscle that we use to bend our elbow .
C6 is for bending the wrist back.
C7 is for straightening the elbow.
C8 bends the fingers.
T1 spreads the fingers.
T1 –T12 supplies the chest wall & abdominal muscles.
L2 bends the hip.
L3 straightens the knee.
L4 pulls the foot up.
L5 wiggles the toes.
S1 pulls the foot down.
S3,4 and 5 supply the bladder. bowel and sex organs and the anal and other pelvic muscles.

[http://www.apparelyzed.com/myo-dermatomes.html
can get a relatively okay dermatome map here]

http://en.wikipedia.org/wiki/Image:Dermatoms.svg

Spine Examination : Rough Marking Schedule

This isn't the official way to do a spinal exam, but rather a rough checklist of an OSCE-like marking sheet...

1. Introduces self to patient (full name and role) 2/1/0
2.Explains purpose of examination and obtains consent 2/1/0

Examination

3. Exposes the patient and comments on exposing patient adequately 1/0
4. Inspects spine, back and side, looking for scoliosis and normal [cervical, lumbar] lordosis, and [thoracic] kyphosis 2/1/0
5. Identifies C7 correctly (may be prompted) - 1/0
6. Palpates spinous processes 1/0
7. Palpates para-spinal muscles for tenderness 1/0
8. Tests cervical flexion and extension 1/0 (so chin to chest, head up to ceilin)
9. Tests lateral cervical flexion 1/0 (ear to shoulder, ear to shoulder)
10. Tests cervical rotation 1/0 (look left, look right)
11. Tests lateral lumbar flexion 1/0 (slide hand down side to the feet, and now the other side)
12. Tests lumbar flexion and extension 1/0 (bend forward, okay, and now bend as far back as you can, I'll help support you)
13. Performs Schoeber's test (2) or places fingers on spine (1), 2/1/0

Schoeber’s test – measures the degree of back stiffness by measuring
spinous process separation on forward flexion of the spine. Ensure
movement is within the spinal column rather than just the hips! Schober’s test ( > 5cm lumbar flexion)

http://www.yoracle.com/index.php?option=com_content&task=section=4&id=0&Itemid=15&limit=9&limitstart=81

14. Tests thoracic rotation stabilising pelvis 1/0 (cross your arms each hand touching the opposite shoulders, and I'm going to place my hand on your hips, now turn to the right, and then left. Alternatively, sit down, cross your arms, and turn to the right, and now to the left.)
15. Demonstrates straight leg raise 1/0 (lie down for me, I'd like to hold down one side of your hip, lift your leg up, and now vice versa) ??
16. States would like to perform full neuro - vascular examination 2/1/0
17. Demonstrates adequate hand hygiene 1/0

Total (out of 23)
Global rating fail/borderline/pass/clear pass/excellent

Wegener's and Goodpastures

Wegener's : onset over time, stiffness...before sudden presentation

Goodpastures: immediate onset, go down

both, best treated with dialysis and pred, if possible, especially Goodpastures;

Breaking Bad News

The process of breaking bad news to a patient may feel like a complicated one, and the idea of it daunting. But there are a few basic structure points to take into consideration to help one through it. In essence, it can sometimes turn into the unexpected but by the same token, you can expect the same thing to happen.


1.Preparation ( for you, for the disease or outcome of the patient concerned, what you know about it, what you want to say to them, what they need to know at the time, the room, the seating, the place and the day or time, the people around also listening.)

2. What does patient know? Could I ask you what you know so far about your condition, what have you been informed of /told so far?

3. Is more information wanted? ie, if they don't know, they need more information about what they need...this is to gauge their knowledge.

4. Give a warning shot... Mr.X I'm afraid to say its bad news, or I'm sorry to inform you that I have some bad news...or I'm sorry Mrs X, we tried everything we could, but he passed away, or I'm afraid I do not have good news to tell you...

5. Allow denial - if they deny, or cry - give them time for their grief - don't patronize them by saying anything during this time, silence is golden, especially where either rage or sorrow is concerned...eg in case of tears, saying anything more may encourage that emotion further, which may not be good if there is more to discuss with them. but don't rush them either.

6. Explain if requested - in layman's terms....explain results.condition.disease. whatever questions they have...ask if they have any qs.

7. Listen to their concerns - ask them how they are feeling if necesssary...

8. Encourage breathing -

9. Summary and plan

10. Offer availability (ie of ur service your bleep, nurse bleep, senior's contact bleep or whatever)


PART II:

Will I die doctor/do you mean I'm going to die doctor?
'It is true, that as your body gets weaker, it will not be able to sustain your life, and death will be the final outcome, as treatment is no longer sufficient to help you recover from this illness.'

~How long do I have doctor?
'I cannot really give you a specific known time frame, but based on what we know, that you are suffering with certain symptoms eg tiredness and sickness, in addition to what the results of the CT scan show, our best case scenario is between a couple of weeks and a couple of months, I very sorry to say - please note this is our best estimate'

'I'm sorry to have to tell you that the results are not good. ....'

Warfarin

Just some important points about warfarin:
(image taken from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html and some of the notes supplemented with quotes from http://www.pharmacy-and-drugs.com/reviews/Warfarin.html in addition to my own personal notes)

1. 1mg (brown), 3mg (blue), 5mg (pink) tablets

2.That they inhibit F 10, 9, 7, 2

3.That PE/DVT aim INR 2-3 ; recurrent 3.5
4.That AF : 2-3; or cautious and no risk factors (no stroke/dm/ht/tia/under 65) then 2.5-3.5
5.That prosthetic valves : 3-4.9; higher risk valves (cage and ball;tilting disc/mitral and aortic valves) aim for 4-4.9; lower risk ~3

Monitoring

everyday for first week
every week for next 3 weeks
every month for next 6months
then every 8 weeks?

Vit K regenerating reductase enzyme inhibitor - therefore - state is like vit K deficiency :
patients should avoid VIT K containing foods : LIVER AND GREEN VEGETABLES -- stops anticoagulant effect of Warfarin.

Patient to be aware of menstruation - heavier/longer than normal
Patient to be aware of DENTAL WORK/SURGERIES - to always inform both the doctor, surgeon, dentist.

Pregnant women and breastfeeding women to avoid warfarin -- query first and last tri avoid?
(note also, NSAIDS, aspirin DO NOT GIVE TO PREG LADIES -- paracet only ok)

Always to inform docs about the fact that you are on warfarin --!! very very important, never shy away from that, never forget to inform them. - alters treatment /drug interactions

Remind them of dangers of alchol, binge drinking and they are allowed moderate etoh, but good idea to tell them to stop etoh.

Tell your doctor immediately if you are, or become pregnant, or are
breastfeeding, as Warfarin may cause birth defects.

Also tell your doctor of any other medications you are taking, including vitamins and herbal /supplements, and any medical conditions you may have.

So vitamins - which vits?

Herbal supplements : st.John's wort - interaction -? lessen or worsen anticoag effect?

Medical conditions : note our contraindications - also screening questions

1. have you ever had a stroke or tia
2. are you pregnant or breastfeeding
3. do you have an ulcer?
4. do you have high blood pressure?
5. do you have endocarditis -bacterial endocarditis
6. do you have any bleeding disorders
7. have you ever had any major head trauma or cerebral aneurysms?
8. ???? recent surgery?


NOTE that use with caution in the elderly and in those with past GI bleeds!
Don't ever give warfarin and NSAIDS together!

It is very important that you take this medicine exactly as your
doctor tells you to.

At the same time every evening -- once only in the
evening!!

Do not take more or less medicine than directed, and
never stop taking Warfarin without discussing it with your doctor first.

If you miss a
dose of this medicine, take it as soon as you remember, unless
it is almost time for your next
dose. Do NOT double doses.

Recall warfarin drug interactions (to be added later):

LIVER ENZYME INHIBITORS FECKIN COB(inging on alcohol) SCAM
So in this case they would potentiate/increase the effect of warfarin - ie more prone to bleeding, increase the INR, because the available warfarin is increased and not being broken down due to inhibited liver enzymes.

liver enzyme inducers CRAP GPS (chronic alcohol)
The opposite is the case here, where the individual is more likely to form clots, the anticoagulant effect of warfarin is decreased, less warfarin is available in the body because is has been eliminated or is being eliminated faster by the liver enzymes of the body induced by the respective drug.

check with doctor if :

Check with your doctor immediately if any of the following symptoms occur:
bleeding from gums when brushing teeth; blood in urine; nosebleeds; pinpoint red
spots on skin; unusual bleeding or bruising; unusually heavy bleeding or oozing
from cuts or wounds; unusually heavy or unexpected menstrual bleeding; abdominal
or stomach pain or swelling; back pain or backaches; black, tarry stools;
bleeding in eye; blood in stools; blood in vomit or vomit that looks like coffee
grounds; blood in urine; blurred vision; chest pain; confusion; constipation;
coughing up blood; severe diarrhea; dizziness or fainting; joint pain,
stiffness, or swelling; loss of appetite; continuing nausea and vomiting;
nervousness; numbness or tingling of hands, feet, or face; paralysis; shortness
of breath; or sudden weakness.

The Diabetic Foot

The other day, whilst perusing whatever book it was that I was reading, I came across something called - neuropathic ulcers. This was linked with peripheral neuropathy. It just so happened that in my week off I was faced once again with diabetes. Such is the topic of diabetes that people either get bogged down by this big topic...or they embrace it whole-heartedly.

The diabetic foot, I reckon is a term either for the diabetic person with a foot or a condition that can develop in diabetics resulting in a specific foot problem or problems of the feet that are particular to those that suffer with diabetes. Any complications that develop are probably in the late stage of diabetes, but as many will say, many complications can be prevented overall or at least greatly delayed.

The problem with diabetes is the effect it has on the nervous system within the body. Sugar or sweet blood, which the diabetic individual aims to control with either insulin or diet, has overtime, in cases where there is poor control especially, has the effect of damaging the delicate structure of the nerve.

We know that nerves, have in essence many main functions.

That of light touch, pressure, pain, temperature and joint position and vibration sense, in addition to power, tone and movement.

In a diabetic individual, any one of these functions may fail if the nerve that is affected that carries out that particular function.

Often, what tends to happen is that there is what is called a peripheral neuropathy. Ie the nerves that have left the spine, travelling out to the respective organ or skin or muscle - is damaged. The process of this damage is rather complicated and has much to do with glycated proteins and maybe even free radical formation...but i'd rather not say...and this is where my revision is nonsense and needs me to look over it again....suffice to say that damage occurs.

So the diabetic foot - neuropathic ulcers...develop as a result of the individual not feeling their feet or pain in their foot or the pressure applied to their foot.

The management of an unaffected foot of a diabetic individual is beyond crucial. Managing it well can be the difference between preventing the formation of an ulcer or damage to bone or ligaments or blistering of the skin, to all of these things and the long term complications and difficulties in its healing.

Edited:

I was talking the other day to someone about this....and I've come across terms - 'neuroischaemic ulcers'

I learnt the following. That not only are the nerves affected : proprioception (hence joint injury or over usage of joints beyond what they are normally capable of..particularly the over-flexion or over extension of a joint - contributes to Charcots joints, which themselves im not sure .. get painful, poor healing due to poor microvasculature - infection>?)

But on the microvasculature : this is perhaps where the term neuroischaemic comes along -- poor healing of the skin - be that from a small injury, or to the tissue, or poor healing in infection due to poor blood supply.

And then high glucose levels too - encourage infections and generally affects or reduces the effectiveness of the immune system or inhibits the immune system...

Little nitty gritty things like this annoy me...when I don't know specifics...REALLY annoys me. But so far, this i believe is the general gist of things.

I need this to be clarified though.