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Medicine - Additional

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Introduction

MEDICINE - ADDITIONAL Demonstrate familiarity with: Problems faced by patients & relatives in coping with illness * It is important to deal with the illness on a physical, emotional & spiritual level. Compliance with Rx * Problems identified as causing failure of adherence to clinical advice: o No named doctor being in charge of patients care. o No named nurse being in charge of patients care. o Being in pain most or all of the time. o Not being told on discharge when to resume their normal activities. * Factors in communication which improve patients' adherence to clinical advice: o Clinician understands the patient. o Clinician's tone of voice. o Clinician elicits all the patient's health concerns. o Patient is comfortable asking questions. o Patient perceives that sufficient time is spent with the clinician. * Health outcomes depend on the extent to which patients adhere to their clinical advice. * Correctable factors are all matters of communication: letting patients know why their Rx is being given & what benefits they stand to gain, what pros & cons there may be, what options exist, & doing so in a ways which builds trust & collaboration. Adjustment to loss & bereavement * Phases of bereavement - shock, distress, adjustment, moving on. Legal & ethical issues relating to consent to Rx * Doctors seeking consent for a particular procedure must be competent in the knowledge of how the procedure is performed & its problems. * For agreement to Rx to be legally accepted it must meet 3 conditions: o Consent must be informed to an adequate standard. o Patients must be competent to consent to Rx. o Patients must not be coerced into accepting Rx against their wishes. * It is unlawful battery to intentionally touch a competent patient without their consent. * Rx can be given legally to adult patients without consent if they are temporarily or permanently incompetent to provide it & Rx is necessary to save their life, or to prevent them from incurring serious & permanent injury. ...read more.

Middle

Normal ratio is 80%. * Obstructive defect e.g. asthma, COPD - FEV1 reduced more than FVC so the ratio is <80% * Restructive defect e.g. lung fibrosis - FVC reduced & ratio >80% * Peak expiratory flow rate is measured by maximal forced expiration through peak flow meter. Used to estimate air flow calibre. * Total lung capacity & residual volume are measured by inspiring a known volume of inert gas. They are increased in obstructive airways disease & reduced in restrictive lung disease & musculoskeletal abnormalities. * Gas transfer across alveoli is calculated by measuring carbon monoxide uptake from single inspiration in standard time. * Transfer factor is the gas transfer corrected for alveolar volume. * Flow volume loop measures flow rates at various lung volumes. Pleural aspiration & insertion of chest drain * Pleural aspiration is a procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest. * Indications - large pleural effusion or bile pleural effusion, when pleural effusion is thought to be haemorrhagic or infected, acute pulmonary oedema, persistant pleural effusion inspite of antitubercular therapy. * There are no contraindications. * Complications - pleural shock due to vagal stimulation, air embolism, pulmonary oedema, circulatory collapse due to high negative intrapleural pressure, injury to intercostals vessels, pneumothorax, haemoptysis, infection. * Insertion of chest drain - inserted to drain blood, fluid or air & allow full expansion of lungs. It is placed into the pleural space. The area where the tube will be inserted is numbed with local anaesthesia & chest drain is inserted between the ribs & connected to a bottle of sterile water. Suction is attached to encourage drainage. Sutures & adhesive tape are used to keep it in place. * Indications - conditions causing lung to collapse including pneumothorax, haemothorax, empyema. * Risks - breathing problems, bleeding, infection. ...read more.

Conclusion

* Contraindications - unstable angina, recent Q wave MI (<5 days), severe aortic stenosis, uncontrolled arrhythmia, hypertension or heart failure. * Tests that will be hard to interpret - complete heart block, pacemaker patients, osteoarthritis, COPD, stroke, other limitations to exercise. * Stop the test if chest pain or dyspnoea occurs, patient feels faint exhausted or is in danger of falling, ST segment elevation/detection, atrial or ventricular arrhythmia, fall in BP, failure of heart rate or BP to rise with effort or excessive rise in BP, development of AV block or LBBB, maximal or 90% heart rate for age is achieved. * A positive test only allows one to assess the probability that the patient has ischaemic heart disease. * 24/100,000 morbidity, 10/100,000 mortality. Fibreoptic bronchoscopy, mediastiniscopy & thoracoscopy for obtaining biopsy material in the chest * Fibreoptic bronchoscopy - diagnostic procedure in which a tube with a tiny camera on the end is inserted through nose or mouth & into lungs. Provides view of lungs & allows collection of lung secretions & to biopsy tissue specimens. * Diagnostic indications - hilar mass, slow resolving pneumonia, pneumonia in immunosuppressed, interstitial lung disease. * Therapeutic indications - aspiration of mucus plugs causing lobar collapse or removal of foreign bodies. * Mediastiniscopy - procedure where lighted instrument is inserted through a neck incision to visually examine structures in the top of the chest cavity. Most commonly used to examine lymph nodes in patient with lung cancer for disease staging. * Thoracoscopy - endoscopic procedure to inspect the pleural cavity. Allows examination & biopsy of pleural lesions, drainage of pleural effusions & talc pleurocesis. Indications for mechanical ventilation of patients with respiratory failure * Significant respiratory acidosis resulting from increased PaCO2. * Arterial hypoxaemia that is refractory to supplemental oxygen via an aerosol mask. Domiciliary oxygen & nebuliser therapy in lung disease * Domiciliary oxygen - home oxygen therapy. * Nebulisers - instrument used to apply liquid in form of fine spray. Additional therapies for cancer * Immunotherapy - BCG inoculation & monoclonal Ab * Hyperthermia * Sensitisers ...read more.

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