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.
* Patients are competent if they are able to:
o Understand information about their condition & Rx.
o Remember this information.
o Deliberate about the therapeutic choices posed by the information.
o Believe that the information applies to them.
* >16yo can give valid consent.
* If <18 & refusing life saving Rx, talk to parents & your senior as the law is unclear - may need to contact duty judge.
* Vast majority of patients with psychiatric illness are competent to consent to refuse Rx.
* If patients with severe psychiatric illness are incompetent to understand the nature & consequences of their illness, they will be unable to provide valid consent to Rx.
* 1983 Mental Health Act - mentally ill patient may be detained under this for further examination & Rx against their will.
* Incompetent in one respect does not entail incompetence in all respects.
* No one can consent for another adult - if the patient is incompetent, doctors must decided what is & what is not done in the best interests of the patient
Breaking bad news
* Choose a quiet place where you will not be disturbed.
* Find out what the patient already knows.
* Find out how much patient wants to know.
* Share information about Dx, Rx, prognosis & specifically list supportive people & institutions e.g. hospices.
* Ask whether there is anything they would like you to explain.
Patient education including delivering information about life style measures to influence health
* When information is given skilfully, patients are able to understand what is said & to remember & to find it helpful.
* Patients are more likely to adhere to clinical advice if they get comprehensible information, if it makes sense of their problems & if they can get easy access to more if they need it.
* Information must be related not only to the biomedical facts, but to the patients' ideas about their condition.
* Use logical sequence to explain cause & effect of condition in context of patient's symptoms.
* Talk about one thing at a time & make sure patient understands before you move onto next.
* Use simple language, translate unavoidable medical terms & write them down.
* Make your information & instructions direct, detailed & concrete.
* To achieve maximum adherence, the clinician's suggestion about Dx or Rx must be negotiated with the patient. This requires an explanation of the benefits & disadvantages & the risks of these suggestions & any alternatives, all with the aim of enlisting patients to take an active part in their own care.
* Patients adhere to suggestions about Ix & Rx when they are thus enlisted as partners as a result of:
o Frank exchange of information.
o A negotiation of options.
o Involving patients in decisions.
* Any possible misunderstanding will be greatly reduced if a brief summary is made 1st of the patient's agenda & then that of the clinician.
Principles & practice of rehabilitation, particularly in the elderly & post-operative patient
* Focus on patients' problems not the doctors' diseases.
* See it from the patient's perspective.
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* Patients adhere to suggestions about Ix & Rx when they are thus enlisted as partners as a result of:
o Frank exchange of information.
o A negotiation of options.
o Involving patients in decisions.
* Any possible misunderstanding will be greatly reduced if a brief summary is made 1st of the patient's agenda & then that of the clinician.
Principles & practice of rehabilitation, particularly in the elderly & post-operative patient
* Focus on patients' problems not the doctors' diseases.
* See it from the patient's perspective.
* 3 concepts help - impairment, disability, handicap.
* Impairment - loss/abnormality of psychological, physiological or anatomical structure/function.
* Disability - limitation in any activity of daily living.
* Handicap - inability to carry out social functions.
* Stages of management:
* Assessment of disability & handicap - use Barthel index.
* Who can help? - nurses, physios, OTs, speech therapists, social workers, GP, geriatrician, psychogeriatrician, self help groups.
* Generate solutions to problems - look at each disability, work out its origin & agree on goals. Renew, review & adapt goals.
Imaging methods including plain X-rays, CT scanning, MR imaging, constrast radiology, ultrasound, radio-isotope imaging
* X-rays - structures containing air will be black on the film, dense (bone) will be white & muscle, fat & fluid will appear as shades of grey. Metal & contrast media will appear bright white.
* CT scanning - gives a detailed picture of the inside of the body. Helpful in Dx of disease & damage to internal organs, vessels & fluids.
* MRI - non-invasive procedure that uses powerful magnets & radiowaves to construct pictures of the body.
* Contrast radiology - when a contrast medium is given to improve visibility of structures during radiography.
* Ultrasound - creates images that allow various organs in the body to be examined. Ultrasound machine sends out high frequency sound waves which reflect off body structures to create a picture.
* Radio-isotope imaging - radioisotopes are introduced into the body for the purpose of imaging, evaluating organ function or localising disease or tumours. Radiation originates from within radioisotope (gamma rays). Special detector cameras are placed close to the area of interest to localise where the isotope is. Does not provide detailed anatomical information, but correlation with other imaging, clinical information & lab results helps identify & confirm disease processes.
Microbiological testing of blood, sputum, stools, urine & other body samples
* Optimal time of collection of specimen collection - before starting antimicrobials, acute phase of illness.
* Specimen collection - collection of clinically relevant specimen, collection from proper site with minimal contamination of normal flora, adequate quantity & appropriate number of specimen, clearly labelled.
* Procedure for making microbioligical Dx - naked eye examination, microscopy, culture, serology, molecular techniques.
* Urine - naked eye examination, dipstick, microscopy, culture of midstream urine, quantitative colony count for significant bacteruria, antibiotic sensitivity testing.
* Sputum - naked eye examination, microscopy, culture, special culture (TB, legionella, nocardia, aspergillus).
* CSF - naked eye examination, gram stain, ZN/Auramine staining, antigen detection, cultures & sensitivities, PCR.
* Blood - Aerobic cultures, anaerobic cultures, microaerophilic, carbon dioxide culture, sensitivity testing, extended cultures (TB, fungal, brucella, bacterial endocarditis), antigen detection.
* Stools - naked eye, microscopy, culture, toxin detection, special staining, special culture.
Tissue biopsy procedures
* Most biopsy procedures are minor & do not require sedation & many require no anaesthesia or only local anaesthesia.
* Aspiration/FNA biopsy.
* Cone biopsy.
* Core needle biopsy.
* Suction assisted core biopsy.
* Endoscopic biopsy
* Punch biopsy
* Surface biopsy
* Surgical/Excisional biopsy.
Use of oxygen & arterial blood gas analysis
* Arterial blood gas analysis - heparinized blood is taken from radial, femoral or brachial artery & pH, PaCO2 & PaO2 are measured. It assesses the acid-base balance, oxygenation, ventilatory efficiency. It is measured when there is unexpected deterioration in a patient, anyone with acute exacerbation of chronic chest conditions, anyone with impaired consciousness, anyone with respiratory effort, when there are signs of CO2 retention or hypoxia, to monitor the Rx of respiratory failure, anyone ventilated in ITU, after major surgery & major trauma & to validate measurements from transcutaneous pulse oximetry.
* Oxygen is administered therapeutically in various conditions in which the tissues are unable to obtain an adequate supply through the lungs.
Pulmonary function testing
* Spirometry measures functional lung volumes.
* Forced expiratory volume in 1 sec & forced vital capacity are measured from a full forced expiration into a spirometer. Ratio gives a good estimate of severity of airflow obstruction. 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.
Holter ECG recording (ambulatory ECG monitoring) & temporary cardiac pacing
* Continuous ECG monitoring for 24hrs may be used to try & pick up paroxysmal arrhythmias.
* >70% patients will not have symptoms during monitoring.
* 20% will have normal ECG during symptoms.
* Only 10% will have arrhythmia coinciding with symptoms.
* Give these patients a recorder they can activate themselves during episode.
* Recorders may be programmed to detect ST segment depression, either symptomatic (to prove angina) or to reveal silent ischaemia.
* Indications for temporary pacing:
* Complete AV block with inferior MI (R coronary artery occlusion), with anterior MI (massive septal infarction).
* 2nd degree block.
* 1st degree block.
* Bundle branch block.
* Sinoatrial disease & serious symptoms.
* Pre-op
* Drug poisoning
* Symptomatic bradycardia
* Suppression of drug resistant VT or SVT.
* Asystolic cardiac arrest with P wave activity.
* During or after cardiac standstill.
* Complications of temporary pacing - infection, air embolism.
Central venous catheterisation & pressure measurement
* Indications of central venous catheterisation:
* Measurement of CVP.
* Infusion of substances irritant to small veins & tissues e.g. dopamine.
* Difficulty obtaining peripheral access.
* Administration of drugs during cardiac arrest.
* Modified central venous lines are used for administration of intravenous feeding, insertions of Swan-Ganz catheter & temporary transvenous cardiac pacing.
* There are no absolute contraindications but cannula is placed away from area of skin sepsis if possible.
* Aim of central venous cannulation is to place tip of cannula in the R atrium or superior vena cava. This is achieved by percutaneous puncture or R internal jugular or subclavian vein.
* Complications - puncture of major arteries, pleura, thoracic, duct, air & catheter embolism, catheter-related sepsis, venous thrombosis.
* Measurement of CVP - the pressure in the R atrium & may be measured continuously with a pressure transducer or intermittently with a manometer.
* Normal value is between 0-4 & 3-7 cm H2O measured from the sternal angle & mid axillary line.
Multiple symptomatology
* Several disease processes may coincide.
* One problem may have many causes - all need to be treated for recovery.
Primary & secondary cardiovascular disease prevention & management of high risk cardiovascular patient - diabetes, hypertension, smoking, prothrombotic states
Primary education:
Education
Tobacco avoidance
Diet - aim for healthy weight
Exercise daily
Lower High BP
Reduce high blood cholesterol
Stop excessive alcohol intake.
Manage diabetes
Secondary education:
Promote risk reduction - diet, smoking, exercise, weight.
Active management of existing disease.
Use of specific drug regimens.
* Patients classified as being at very high risk (>20%) of cardiovascular disease should be considered for Rx with a statin or other appropriate medication begun concurrently with intensive dietary Rx.
* Patients at high risk (15-20%) should receive 6-12 weeks of dietary intervention prior to being considered for Rx with statins or other appropriate medication. Dietary intervention should be continued indefinitely.
* Patients at moderate risk (10-15%) - clinical judgement is needed with probably only lifestyle intervention & dietary advice.
* Diabetic patients with high triglycerides & low HDL should be considered for Rx known to improve this lipid profile - diet, physical activity, fish oils, drug Rx including fibrate.
* Diabetic patients with elevated total cholesterol or LDL cholesterol should be considered for statin therapy.
Ascites & abdominal paracentesis
* Ascites - accumulation of fluid in the peritoneal cavity causing abdominal swelling. Causes include infection, heart failure, portal hypertension, cirrhosis, ovarian & liver cancer, obstruction to lymph drainage.
* Abdominal paracentesis - procedure where needle is inserted through abdominal wall to remove fluid that has accumulated in peritoneal cavity. Sample of the fluid can then be analysed.
Initiation & monitoring of anticoagulants
* Indications for anticoagulants - DVT, pulmonary emboli, stroke prevention - AF or prosthetic heart valves.
* Initiation - give heparin IV (5000-10000iu in 5 min).
* Add 0.9% saline in a syringe pump.
* Give IV infusion & check APTT at 6 hours.
* Institute 5 day sliding scale, measuring APTT every 10hours (every 4hours if APTT>7 & stop infusion).
* Start warfarin 10mg PO on day 1 at 6pm. Do INR 16 hours later.
* If INR<1.8, 2nd dose warfarin 10mg at 5pm (24hours after 1st dose). If INR >1.8 give 0.5mg warfarin at 6pm.
* Use sliding scale to keep INR in target range.
* Do INR daily for 5 days, then alternate days until stable, then weekly or less often.
* Stop heparin when INR>3.
Bone marrow aspiration
* Bone marrow is the tissue that manufactures the blood cells & is in the hollow part of most bones.
* Test is done by suctioning some of the bone marrow for examination.
* Used to Dx leukaemia & other disorders affecting the blood.
* May help to determine whether cancers have spread.
* Can Dx types of anaemia & infections.
Transfusion of blood & blood products
* Whole blood rarely used - indications: Exchange transfusion, grave exsanguinations. Blood more than 2 days old has no effective platelets.
* Complications of massive transfusion - fall in platelets, calcium, clotting factors, increase in K, hypothermia.
* Red cells - used to correct anaemia or blood loss. Complications - bacterial contamination or ABO incompatibility with/without anaphylaxis, heart failure, transfer of virus, bacteria
* Platelet transfusion - not usually needed if not bleeding.
* Fresh frozen plasma - used to correct clotting defects, warfarin OD, liver disease, thrombotic thrombocytopenic purpura.
* Human albumin solution - no compatibility requirements. Used in hypoproteinaemic people (liver disease, nephrotic) who are fluid overloaded.
* Cryoprecipitate - source of fibrinogen.
* Coagulation concentrates - self injected in haemophilia.
* Immunoglobulin.
* Blood should only be given if strictly necessary.
You will be aware of:
Masked & non-specific presentation of disease in elderly
* Some presentations are common in the elderly.
* Geriatric giants - incontinence, immobility, instability, dementia/confusion.
* Virtually any disease may present with these.
* Typical signs & symptoms may be absent.
DC cardioversion/defibribillation
* Indications - VF/tachycardia, fast AF, SVT.
* Aim - to completely depolarise the heart using a direct current.
* Unless critically unwell, conscious patients, require general anaesthesia.
* After shock monitor ECG rhythm.
* Consider anticoagulation as the risk of emboli has increased.
Cardiac catheterisation, coronary angiography & angioplasty
* Cardiac catheterisation - insertion of catheter into heart via femoral artery or vein. Used to measure pressures, sample blood to assess oxygen saturation, inject radiopaque contrast medium to image anatomy & flow, perform angioplasty, valvuloplasty, cardiac biopsies, perform intravascular ultrasound.
* Indications - congenital heart disease, coronary artery disease, valve disease.
* Complications - haemorrhage, contrast reaction, loss of peripheral pulse, angina, arrhythmias, pericardial tamponade, infection.
* Mortality <1/1000.
* Coronary angiography - X-ray examination of blood vessels. Contrast medium injected into artery & rapid series of X-ray recordings made.
* Angioplasty - balloon dilatation of stenotic vessels.
* Indications - poor response/intolerance to medical therapy, refractory angina in patients not suitable for CABG, post-thrombolysis in patients with severe stenoses, symptoms, positive stress test.
* Complications - re-stenosis, emergency CABG, MI, death.
Cardiac & respiratory exercise testing
* Patient undergoes graduated, treadmill exercise test with continuous 12 lead ECG & BP monitoring.
* Indications - to help confirm Dx of IHD, assessment of cardiac function & exercise tolerance, prognosis following MI, evaluation of response to Rx, assessment of exercise induced arrhythmias.
* 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
