Osce Basil.

Content

Medicine

CVS

Ankle swelling

Calf pain

Hypertension

MI

Palpitation

Syncope

RS

Asthma

Cough, Acute

Cough, Chronic

Hemoptysis

SOB

SOB – Post Surgery

Hematology

High MCV

Wrong blood transfusion

Ophthalmology

Loss of vision

Diabetes

DKA

Tiredness

GI

Abnormal LFT

Acute abdomen

Diarrhea

Dysphagia

GERD

Mesenteric Iscemia

GU

Introduction

Dark urine

Geriatric wets himself

Difficulty to pass urine

HIV

Breaking news – HIV

Fever and tiredness

Headache – HIV complications

HIV test request

Needle stick injury

Tiredness for 6 weeks

Neurology

Approach to

Headache, acute

Headache, environmental

Headache, primary

Headache, subacute

Headache, template

Multiple Sclerosis

Neuropathic pain

Weakness in arm

Otolaryngology

Allergic rhinitis

Lump in neck

Counselling

Abortion

Ante-natal counselling

Breast Feeding

Diabetic daughter

Domestic violance

Endometrial cancer

Epilepsy

Fall

Febrile seizure

HRT

Lump in breast

Obesity

OCP

Pregnancy

Smoking Cessation

Warfarin Counseling

Pap Smear

OCP 3

Breast feeding 5

Ante-natal 7

HIV 9

Needle stick 10

IUGR 11

Abortion 12

Sexual abuse 14

Epilepsy 15

Drug seeker 17

Smoking cessation 18

Alcohol cessation 20

Imptence 21

HRT 22

Obesity 24

Paediatrics

Introduction

Anaphylactic Shock

Cough

Cry

Diarrhea

Diabetic daughter

Febrile seizure

Fever

Marijuana counseling

Osgood Schlatter

Pale

Phone cases

Post-concussion

Vomiting

Yellow discoloration

Immunization

IUGR

Child abuse

Enuresis

FTT 1

Child abuse 2

Speech delay 3

Vomiting in newborn 4

Enuresis 5

Febrile seizures 6

Jaundice child 7

Joint pain 8

Child with ADHD 9

Child with chronic cough 10

Child with abdominal pain 11

Well-baby visit 12

Child with fever 14

Yellow baby 16

Vomiting baby 17

Baby with diarrhea 18

Pallor baby 19

Child with chronic cough 20

Child with abdominal pain 21

Child abuse 22

Enuresis 26

Hyperactive child 27

History taking format 28

Vomiting child 30

Anemia in a child 32

Diarrhea in a child 34

Enuresis 36

Breast feeding 37

Delayed speech 39

ADHD 40

FTT 41

Child abuse 43

Anorexia nervosa 44

Vaccination 46

OBGYN

Introduction

Amenorrhea

Ask for file after C/S

HRT

Infertility

Pre-eclampsia

Request for C/S

Vaginal bleeding

Vaginal discharge

First trimester bleeding 1

Third trimester bleed 2

Pre-eclampsia

3

High risk pregnancy 4

Counseling breast feed

5

Vaginal bleeding

6

Vaginal discharge

7

Amenorrhea

8

OCPs

9

Counseling HRT 10

Screen for Breast Ca 11

Pap smear

12

Ethics

Decision to forgo treat 3

Delivering bad news 4

Woman abuse

5

Telling the truth

6

Death before arrival 7

Pharmacist refusal 8

Organ retrieval

9

Confidentiality 10

Decision maker 11

Substitute Decision M 12

(Admition) notes 13

Psychiatry

Psychiatry Introduction

Anorexia Nervosa

Bipolar Disorder

Delusions – contamination

Delusions – persecutory

Depression

Forms

Insomnia

Mania

Marijuana in the bag

MMSE

MMSE-Delirium

MSE-Psychosis

Panic Attack

Personality disorders

Psychiatric assessment

Req. admit (Delusion)

Req. Admit (Borderline)

Request to stop Lithium

Somatization disorder

Suicide Attempt

Depression 21

Manic episode 24

Sleep hygiene 26

Delusional disorder 35

Schizophrenia 36

Panic disorder 39

MMSE 42

MSE 43

Dementia 44

Delirium 46

Suicidal attempt 48

Competency=Capacity 50

Alcohol abuse 55

Borderline personality D. 57

Physical Exam / Manage

Introduction to Physical Exam

Acute and acute on chronic

abdomen

Back

Blood transfusion

Cranial Nerves

CVS

Diabetic Foot

ER: Trauma and Non-Trauma

Hand-Laceration

Hand - CTS

Hematemesis

Hip

Knee

Neck

PVD

Respiratory system

Secondary Hypertension

Shoulder

Unconscious Patient

Volume Status

MI

GI Bleeding 3

DKA 5

Asthmatic attack 7

TCA Overdose 8

Seizure 9

Anaphylaxis 11

Acute aortic dissection 12

Subarachnoid hemorrhage 14

Tool

Setting

Meaning

OCD

PQRSTUV

COCA-B

MOAPS

HEAADDDSSSS

Dating, Drugs, Sexual activity, Stress, Sleep, Suicide,

MGOS

MI PASS ECG

M

I

P

A

S

S

E

C

G

SAD PERSONS

Sex: male; Age: >60; Depressed; Previus attempts; Ethanol/drugs; Rational thinking loss; Suicide in family; Organized plan; No support; Serious illness/pain

DIG FAST

D

I

G

F

A

S

T

ABCD

A

_D

B

C

ABCDE

STIs), Dysmenorrhea decreased, Ectopic pregnancy/ pregnancy reduced.

SPIKE

BINDE

Environment

AMPLE

menstruation/meal/tetanus shot, Event

CAGE

Ever felt the need to Cut down on drinking? Ever felt Annoyed at criticism of your drinking? Ever feel Guilty about your drinking?

Ever need a drink first thing in the morning (Eye opener)

MUD PILES

HARD UP

ABCDEFGHI-M

Autoimmune hepatitis; Hepattis B; Hepatitis C; Drugs or toxins; Ethanol; Fatty liver; Growths (i.e. tumors); Hemodynamic disorders (CHF); Iron (hemochromatosis), copper (Wilson’s disease) or alph1-antitrypsin deficiency; Muscle injury

WARFARIN COUNSELLING

40 M came to clinic as he was informed by clinic to come as his INR result was 1. Next 10 mins take history & provide counselling

Divide into 2 parts: 1. History ---> 5 mins 2. Counselling ---> 5mins General scheme:

1. Event

2. Symptoms at the time of prescription 3. Compliance

4. Risk of bleeding from other sites 5. R/O relapse of DVT

6. Drugs and diet that interfere with warfarrin: Grapefruit, Antibiotics, NSAIDs, Antifungals, Restart INR (fresh person)

X3 dose of 10mg/d  change INR every day (change the warfarrin accordingly)

Check three time a week the INR if three consecutive are in the goal range  once aweek  than for every two weeks check once  than every month (or depend on the condition) If INR>10 or patient is bleeding  Vit. K (if active bleeding give FFP according to setting) Greeting: Good afternoon Mr.Hendricks,I’m Dr.X with you & will be your physician for today. As I understand, you’re here to discuss your blood reports.

1. Why was the blood test done?

[Pt had DVT x 5 wks ago,& was having regular checkups till last week when he decided to stop as he’d read some alarming information on the internet & did not like warfarin (or other scenario,his friend who was on warfarin had a stroke)]

2. When was DVT Diagnosed? 3. How was it diagnosed? 4. What was done??

5. WAS HE TREATED AS AN OUTPATIENT OR WAS HE ADMITTED?/If Yes: How many days? 6. What were the symptoms at that time?

7. Was there pain & swelling?

8. Was there SOB (lung involvement)

DO NOT LOOK FOR FACTORS THAT CAUSE DVT

9. Which medicines were you treated with? ---> Blopd thinners/Warfarin? 10. Is INR done on a regular basis?

11. What was the last time it ws done? 12. What was the target?

NOW BREAK THE NEWS

Your INR is ONE; do you know the reason why? IF Pt vague, give him options:

1...Do you take your medications on a regular basis? 1. Do you take your meds by yourself or do you need help? 2. Any chance you were skipping a dose?

3. Did you start any new medications or antibiotics? 4. Diet: Are you eating a lot of spinach?

5. Any Vit K supplements?

[If Pt expresses concern about bleeding S/e:Adress it & say it is a reasonable enough concern. I’ve to ensure that

you do not have any bleeding at that time.

Did you notice any blood from your gums,nose,bruises in body,coughing up blood?

Neuro Sx:...

Since you stopped the meds, I want to ensure that there is no Relapse of your DVT: Do you have: Swelling/Calf pain/SOB/Heart racing/Chest tightness?

2 Qns about PMH:

H/o long term illness or surgery

FH

COUNSELLING:

What is your understanding of DVT?....clot Why did it occur? ...

The concern about this clot is that if not treated, there is a chance of relapse, or it may recur & this chance is: 8%

To decrease this chance to 0.8% we use warfarin

If DVT occurs more than twice – take life time medication.

If not convinced: In addition to local recurrence there is damage to veins in the legs& valves& if this happens more than once warfarin has to be taken for a longer period

In addition these clots formed in your legs may dislodge & travel all the way to your heart,& This is serious. If large, can cause, sudden death. Can travel to lungs & can cause a condition called PE which again is a very serious condition

Of course the main side effect is bleeding which is very rare if properly monitored. As long as INR is in normal limits chances of bleeding are minimal i.e: 1%

We’ve to restart with Heparin & warfarin & monitor INR on a daily basis

EPILEPSY COUNSELLING

Young 16 yr old male for driving License counsel

Always ask Qn as to why he wants a driver’s license. Usually a Dr does not give such a note unless there is an underlying condition.

General scheme: 1. Intro

2. Event – before in and after the attack. When was the drug level checked? Any other medications that might interfere with epileptic drugs (e.g. OCPs). 3. If it is only seizure  go to secondary causes of seizures  refer to neurology 4. Which medication, and compliance

5. HEADDSSS –

6. Triggers – sleep deprivation 7. MOAPS

8. Counsel: needed to be seizure free for one year. Invite him again for f/u after one year. Risk behaviour: drivint, swimming, hicking, bath door open and don’t take bath but can take shower, no heavy machines

You have to take it for your whole life – if you have any attack let me know and we’ll discuss it. Talk with your physician about any new medication you want to take.

Valproic acid 500mg.

OCD:

1. Age of onset 2. When was the Ds 3. What was the Ds

4. How long does each attack last? 5. How frequently do the attacks occur? 6. +/- LOC

7. Aura prior to attack

8. How does she feel after the attack?

9. What meds is she on/Is she compliant/Were the drug levels checked? 10. Any other meds (if female ask about OCs)

11. When was last attack?

12. What happens during an attack? Does she shake/All over/Partly/roll up her eyes/bite her tongue?

System review:

CNS: Head trauma/HA/Vi CSx:

MOOD: Any chance you may hurt yourself? PMH: h/o Dm

HEAADDS

HOME: With whom do you live/How is your relationship with parents/siblings EDUCATION: How is school? How’re your grades? Any recent change in grades? ACTIVITIES: what are your hobbies?

ALCOHOL: Sometimes kids your age might smoke or take alcohol & experiment with drugs, any

of your friends do it? How about you? If YES: How much/How often?

DIET: How is your diet?

DATING: Are you dating? Are you sexually active? STIMULANT USE:

STRESS:

SLEEP: Do you have enough sleep?

MAKE SURE that he knows what a seizure is

What do you know about epilepsy?

It is a common condition due to increased electrical activity in the brain, some people lose consciousness, and some do not. It does not cause learning disability or damage the brain In those who have seizure attacks:

If lasts for a few minutes there is no brain damage If lasts for > 30 minutes, will cause brain damage

People with epilepsy should AVOID dangerous activities such as: 1. Driving 2. Mountain climbing 3. Swimming 4. Operate machinery 5. Boating 6. Chewing gum

7. Tub baths (have a shower bath & never lock bathroom door)

You can have a driver’s licence only after you’ve been seizure free for 1 year It is my duty as your physician to inform the Ministry of transportation

Mention TRIGGERS

 If you drink alcohol, it decreases the point at which ea seizure occurs and can cause an attack

 Sleep deprivation also can cause it  So also flashing lights

If you want to take any other meds, speak to your Dr

I will check the blood levels of your medications to see if it is at the therapeutic level If you want to get pregnant consult your Dr

There are support groups Regular F/u

Any Concerns?

OCP COUNSELLING

21 F for OCPs Counsell x 10 mins

General scheme: Intro:

Good morning xxx,I’m Dr... As I understand,you’re here today because you want a prescription for Birth Control pills.

During the next few minutes, I will ask some questions that will help me

2 Questions here:

1. Have you ever used any form of contraception before ? 2. Why do you want to use it?

2.1. If in stable relationship 2.2. If sexually active

2.3. Do you practise safe sex?

2.4. How do you feel about this relationship?

2.5. Prior to this were you in any other relationship? 2.6. Whose idea was it/ Yours or His?

MGOS

MENSES:

MENSES Use the word ―period‖

1. When was your last period? 2. Are your periods regular / not 3. How often?

4. How many days or How long does it last? 5. How many pads do you use/change? 6. Are the pads full?

7. Are they heavy? 8. Do you see clots?

9. Between periods do you have spotting?

10. From your last menstrual period was your period different from the current one? 11. At what age did you start your periods?

12. Were they regular/irregular? 13. When did it become regular? 14. Are your periods painful / painless? 15. If irregular from beginning?

16. Discharge – ask if pregnant and when LMP

GYENECOLOGY

1. Any history of Gyn. Disease – polyps or cysts 2. History of pelvic surgery (if yes – when?) 3. Have you used any birth control?

5. Pap’s smear

OBSTETRICS:

Have you ever been pregnant?

Have you ever had an abortion or miscarriage?

SEXUAL HISTORY:

Any STIs? Any PIDs?

Any partner with STI?

CONTRAINDICATIONS:

To find out if you’re a suitable candidate,I need to ask a few more questions: ABCD (Active liver disease, Bleeding, Cancer, DVT)

1. Any abnormal vaginal bleeding? 2. Any active liver disease: (Ac & Ch)

3. CVS:Have you ever had clots in your calves/DVT/Very High blood pressure 4. H/o Migraine headaches?

5. FH of Ca breast/Uterine or Liver

AGREE to give if No CI EXPLAIN what are OCs

1. Combination of hormones Estrogen & Progesterone or sometimes only a progesterone 2. These come in packs of 21 or 28 pills

3. They prevent pregnancy by interfering with hormone signals in our body & prevent ovulation 4. Also make the inner lining of the womb & makes it hostile for conception

5. Thickens secretions at the mouth of the uterus & prevents conception

MISSED PILL;

To be taken at same time every day, so chances of forgetting is less & constant blood levels 1St pill on 1st Sunday of period, or 1st day of periods

1st month use back up method of Cx like a condom

In first 2 weeks:

If miss one pill: Take 2 pills next day & use condom x 1 week

If miss 2 pills: Take 2 pills same day + 2 pills day after + Condom x 7 days If miss 3 pills: Stop,use condom & restart new pack

In 3

week:

If you miss any pills restart new pack

Explain BENEFITS:

2. Will eliminate pain

3. Less blood loss during periods

4. Less chances of benign breast disease & ovarian Ca

But like any other medications, there are also the SIDE EFFECTS:  MILD

N/V,Wt gain (5lbs)breast heaviness,mood changes,Spotting may occur in the initial months If these occur,you can change brand

 SEVERE;

Severe Ha/SOB Chest pain ---> If these occur STOP the pill & sek urgent medical attentiomn

DRUG INTERACTIONS:

If takes any other medications,let her Dr know she s on the pill

SAFE Sex: PAP’s Smear

If Teenager: HEAADDS

Last any Concerns or qns?

ABORTION

1. Young woman 19 yrs asking for abortion x 10 mins counsel 2. Can be a teenager with a vague complain

a. Read body language & assure Confidentiality b. When did sexual contact occur?

c. Who was the partner?

d. Was she raped or was it against her will? e. Is she being regularly abused?

f. Do her parents know?

M (Signs of pregnancy: engorgement of breast, urine frequency, n&v) O G S PMH SHx: HEADDSSS:

Home enviorenment & parental attitude

MOOD & Interest SUICIDAL IDEATION NOW?

When pt tells outright she wants an abortion:

How do you feel about having an abortion?

If she says she feels there is no other option:

Explain that there are other options, Do you want to know them?

When did she find out she was pregnant?

Here be sensitive if she found out last night, she is probably in a panic, but if she has known it for a week, she has thought about it well, & is more decisive.

Before it can be done, I need to ask you some qns 1. How did she find out she was pregnant? 2. Was she using any contraception?

3. Has she spoken to her partner/family/friend? 4. Would she like to talk about it?

LMP: How was her LMP, was it similar to her previous LMP? Or was it shorter, lighter?

Is there Nx/V,visiting washroom more frequently? Breast engorgement?

O

Have you been pregnant before?

Have you ever had an abortion/miscarriage?

G

Has she ever used any kind of birth control before? Any Pelvic surgeries

Any Pap smear (depending on age)

H/O STIs

Since it is the first time I’m seeing you, I need to ask about

Any H/o HTN/Liver disease/DM? Surgeries/Anaesthesia complications Blood Group

Any Medications/Allergies

SOCIAL Hx:

With whom do you live?

How do you support yourself financially? If young teen: HEAADDS

Whatever you choose to decide, I will support you. Is she decides to go in for an

abortion:

I will refer you to an abortion clinic

However it is difficult to get an obstetrician who will do it after 20 weeks She has to make a decision fast

Also here ask about her own support system (family/boyfriend)

I will also get you connected with a support group, who are women who’ve had abortions before & will help you cope with it.

Now in addition to abortion there are OTHER OPTIONS: Would you like me to tell you about them?

1. If your concern is financial, you can carry on this pregnancy & there are a lot of support groups as well as the government who will help you.

2. You can carry on this pregnancy & give up the baby for adoption, a lot of people are looking for a child also nowadays you can have visitation rights in certain cases.

If Pt is still going for an abortion: For now, I will do

1. PAPs test

2. Blood tests: Sr B HCG & Blood group & Rh typing 3. USound

Once your pregnancy has been confirmed by us, I will send you to the abortion clinic From now, until the time you’ve the abortion, you’ve to;

Quit Smoking/Alcohol/Drugs

If you happen to see any dr during this time period, you’ve to inform him you’re pregnant

Smoking Cessation

According to the type of patients we will allocate the time: Neutral: Hx (4m), Why (3m), How (3m)

Willing: Hx (4m), Why (1m), How (5m) Unwilling: Hx (4m), Why (5m), How (1m) General scheme:

1. Intro (“Very good decision”) 2. Hx

2.1. Impact: breathing, coughing, phlegm 2.2. RF: HTN, DM, Hyperlipidemia,

Questions about target organs: heart, lung

2.3. Gain from quitting: what do you think you are going to gain from quitting 2.4. Hx from previous quit – what support do you need? What led to relapse?

Withdrawal symptoms? What is the longest time you quitted? 2.5. In which situations you need to smoke?

2.6. SHx: do you smoke in front of your children? 3. Counseling

What is your motivation to stop smoking (scale 1 to 10)

Different people from different reasons…what is the reason for your smoking? 3.1. Why

3.1.1. Effects of the smoking on different of the body 3.1.2. Reduced risk for diseases – time frame

3.1.3. Influence on other household 3.1.4. Economical effect

3.2. How

3.2.1. Set a quit date within 2 weeks – reduce gradually within 2 weeks

3.2.2. The support you’ll need – tell your family. Found someone who wants to quit. 3.2.3. Diary

3.2.4. Exercise, healthy diet

3.2.5. Things you can do instead of smoking

3.2.6. If taking nicoting replacement – stop smoking.

3.2.7. Medication: Ziban (bupropion) 150mg (only in the morning for three days and than increase to bid to 7-12 weekly up to 6months)

S/E Insomnia and dry mouth C/I seizure, eating disorder, MAOI; Varenicline (Champex)

S/E nausea

Intro

Hello Mr./Ms. …..

As I understand you are here today to seek help to quit smoking. I am really happy to hear that – can you tell me what made you come to that decision?

What are your expectations from this visit?

Motivation can be assessed by asking the following two questions:

1. “Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most important thing to do right now, how important is it for you to quit smoking altogether?” 2. “Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most

confident you have felt about anything, how confident do you feel you will be able to quit smoking altogether?”

Ask about the smoking now – how long, how much, since when

Impact of smoking of his life: breathing and coughing, weakness, relationship and sex, CSx RF: HTn, DM, Cholesterol, FHx of CAD and Cancers,

In your opinion - what are the good things you will gain from quitiing? Have you tried to quit before?

What stopped you from quitting before? What support will you need in order to quit?

Smoking Hx

What is the reason that made you decide to smoke? How much you smoke, how long (More than 10pk/y -

Sleeping pills

Withdrwal symptoms

Heart racing, sweating, shakiness, Irritable What is the longest time you quit

smoking? (every time you quit you have a better chance of success.)

Because you have been smoking for long time I’d like to see how this smoking has affected your health:

Target organs: Heart, Lung, GI, PVD, Sexual, CHx

MOAPS

FHx (also addiction, cancer, suicide, depression) SHx

Do you smoke in front of your children?

Counselling

Why

Different people smoke from different reasons - what is the reason you smoke?

In your opinion – what are the advantages of smoking?

Do you know what the active components in cigarettes are? (It is Nicotine, and when you smoke it you have a sense of well being. To maintain the same effect you keep increasing the number of cigarettes and by that tolerance develops. So, when you stop you get withdrawal symptoms, and therefore it is habit forming and difficult to quit. In addition to the effect on our brain it causes narrowing of our blood vessels all over the body.

In the heart it causes heart attacks which are leading cause of death in our society. In the brain it causes stroke which is the third leading cause of death.

In the GI it causes peptic ulcers. It can cause erectile dysfunction.

In addition to nicotine, cigarettes can contain few thousands of other substances – some of these affect the lungs and cause COPD which is an irreversible condition which there is no treatment.

On top of that, smoking is associate with cancer in a lot of different organs of which lung cancer is the leading cause of death from cancer worldwide.

In addition to medical impact it affects also family members and expose them to most of the harmful effects mentioned previously.

It is expensive, staining and smelling, increases hazards (fire).

If you quit smoking you are taking the right step and can expect to gain the following:  After 1 year, the risk of coronary heart disease is cut in half

 After 5 years, the risk of stroke falls to the same as a non-smoker

 After 10 years, the risk of lung cancer is cut in half and the risk of other cancers decreases significantly

 After 15 years, the risk of coronary heart disease drops, usually to the level of a non-smoker

How

1. Set a quit date. It should be within the next two weeks. Avoid a time when you will be under stress.

2. Think about why you want to quit and all the good things that you expect as a result of quitting.

3. If you have tried to quit before, you have probably learned some valuable tips of what not to do this time. Think about what was most difficult last time and why you gave up trying. Think about the things you need to avoid this time.

4. Decide what kind of support will be most helpful over the next six months to a year. For example, you can join a smoking cessation group or plan to meet regularly with a health professional (such as a pharmacist, nurse or doctor).

5. Tell your family and friends that you are quitting. Ask them to help you to stick to your plan. If they smoke, ask them to respect your decision to quit and to not smoke in front of you. Think of things you can do to avoid smoking while with them.

6. Find someone you know who does not smoke and ask them to help you to quit. 7. Make a diary for a few days to keep track of when and why you smoke.

8. Think of ways to avoid situations when you usually smoke.

9. Buy a brand you don’t like. Buy one pack at a time. Increase the time of lighting it, and smoke only part of it.

10. Think of things you can do instead of smoking (for example, chewing gum, sipping water, holding a fake cigarette).

11. Most people gain weight while quitting. You can avoid this by healthy eating and increased activity. Keep healthy snacks around for times when you get the urge to nibble.

12. Keep busy with healthy activities like walking or an exercise program. Starting a new activity will help to break old habits connected with smoking.

13. If you are taking medication to help you to quit, be sure to follow the instructions carefully. 14. If you are taking nicotine replacement therapy, do not continue smoking, as this is very

OBESITY COUNSELLING

38 YOM 6 ft height,weight=260Ib 10 min.HX. and Education

Keys:

 Explore motivations for wt.loss.

 Provide information about the consequences of obesity (health and psychological well-being) and nutrition.

 Set realistic goals, target BMI

 Offer support/reinforcement throughout the weight-losing process.

Hx

DIET & EXERCISE:

Motivation for losing wt. now? Self –image,

Health concerns? ……… Can you tell me more.

Good decision to come today, I am glad you came.

If patient request first surgery, tell him that sound reasonable however, surgery is not the first line can be done based on BMI if >40

If you like I can calculate it for you; kg/m2. I need > information about your condition:

WEIGHT:

1. What is your weight today? 2. Highest weight.

3. When started to gain wt? 4. When started to be concerned? 5. Have you tried any wt- loss programs? 6. Which one?

7. How long? 8. Did you lose wt? 9. Why did you stop?

I am going to ask you Qs to see

WHY YOU’RE GAINING WEIGHT:

Do you calculate your calorie intake?

How many meals do you take/day including snacks? Tell me more about your DIET:

 What do you eat?

 How much fat, fruit, veg bread? Eat while watching TV,

Breakfast daily,

Ever eat to relax or when stressed? Binge eating?

Do you feel guilty about your eating? Do you induce vomiting/purging?

ALCOHOL

How about your ACTIVITY, Do you exercise?

IMPACT:

I am going to ask you how this Affects your life? 1. Difficulty sleeping,

2. Tiredness, 3. Heart burn, 4. Nausea, vomiting,

5. GB stones, bowel motion, 6. Back pain,

7. Jt pain.

PMH: HTN, DM,

Medications: anti-psychotic, OTC, steroids, thyroid disease, OCP. Social Hx: With whom do you live? Any change in sexual desire?

How it affects your self esteem,mood and interest?

Do you smoke? Drink? Recreational drugs?

FHx : obesity

Education:

There are some genetic factors that influence wt. We can’t modify these but we can modify our diet and exercise. In some people, diseases are the underlying cause for obesity.

Give patient their ideal wt. for ht. >20% ideal wt is obesity. Being overwt increases the risk of

Hypertension,CVD,CAD,GB disease,DM,fatty liver,cancers(breast,bowel),OA,sleep apnea,spinal dysfunction.

 We recommend to lose 10% of your body wt.over 6 months (gradually).guidance is BMI There are 2 methods to lose wt: Decrease intake or Exercising more.

If you like I can refer you to a dietician.

We also recommend dividing your meals into 3 small and in between snacks ( carrot, veg.or fruit) 55% CHO, 15% protein,30% fat

Avoid saturated fat, cheese, alcohol Give patient a target caloric intake:

to lose 1 Ib/week,should take 300-500 kcal less 1g fat-9kcal, 1g CHO-4kcal, 1g protein-4kcal

Do not recommend diet medications and fad diet, these may be harmful and are of no long-term benefit.

If BMI>27 + RF (DM, Htn...) or BMI > 30 start pharmacotherapy:

Xenical=increase bulk of stools, leakage, decrease absorption of fat sol.Vit. Meridia (sibutramine) = suppress appetite, cause heart racing, hypertension.

Exercise:begin with walking,regularly 30 min,4-5 times per week Reach 60-80% maximum heart rate (220-age)

Self-monitoring, group support

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70 yr old female with H/o fall at home .Brought in by ambulance

personell to the ER.

She is medicaly cleared;

In the next 20 minutes take history & Counsel;

1. When did the fall occur? 2. Where did it occur? 3. Were you alone?

4. Could you get up by yourself or did you need help? 5. How long before you got help?

6. Did you trip or just feel your legs give way?

7. If there was a witness around ask permission to speak to witness after you finish talking to Pt to obtain collateral history

3 parts of history relating to the EVENT: A.Before fall

B.During the Fall C.After the fall

Events assoc with the Fall:

A.Before:

1. Did you feel

2. Light headed/ Spinning/ Hungry/ Heart racing & Sweating --- HYPOGLYCEMIA 3. Chest pain/ Palpitations/ Shortness of breath----CVS

4. Lights flashing/ Strange smell/ Strange feeling in body--Seizure

5. Weakness/Numbness/Dificulty finding words/Visual disturbances --CNS/STROKE 6. Was the lighting good?

7. How is your vision

B.During the Fall:

1. Did your wife mention that you were shaking or making jerky movts? 2. Did you wet yourself?

3. Turn blue & were stiff? 4. Bite your tongue?

C.After the fall:

1. Nausea/Vomiting 2. Weaknes

3. Difficulty finding words 4. Any vision difficulties

5. Loss of sensation in the arms or legs 6. Ringing in ears

Has this ever happened before

1. When & where

2. Did you seek medical help then 3. What were you advised?

CONSTITUTIONAL SYMPTOMS:

 Fever & Chills & Night sweats  Wt loss & Loss of appetite  Lumps & Bumps

Sx related to CVS:

Chest pain/SOB/Palpitations

Sx of CNS:

Weakness/Numbness/Loss of vision/LOC

Past Medical History;

1. Are you taking any medications?

2. Can you take them by yourself or does your caregiver give them to you? 3. Do you take them regularly as prescribed?

4. Can I see them please? Please see the meds

Was there a recent change in the meds

5. Besides these do you take any additional OTC products or herbal medications? 6. Do you take alcohol? ...

 How much do you take regularly?  Did you take alcohol prior to the fall? 7. Do you have high blood pressure?

 What did your doctor have to say about it? 8. Do you have high blood sugar or Diabetes?

 When was it last checked?

 What did your doctor have to say about it?

9. Did you ever have a stroke or heart attack? 10. Were you ever diagnosed with Cancer

11. Were you hospitalized at any time in your life?

I need to ask a few more questions concerning your

lifestyle

1. With whom do you live?

2. Are you happy living with XXXXX 3. Who prepares your meals? 4. Do you do your own shopping? 5. Do you manage your own finances?

6. Do you go out of the house & meet up with friends & have your own social life? 7. Do you get into arguments with XXXX?

8. Have you ever been hit or yelled at or threatened by XXXX?

COUNSELLING FOR POLYPHARMACY (Orthostatic Hypotension)

Based on what you’ve told me most likely the reason of your fall is a condition called “Orthoststic Hypotension”.Have you ever heard about it?...

When you change position from lying to sitting or standing blood pools to the legs & Bld vessels narrow to maintain BP.

In pts with OH because of Age,Medications,DM or a combination of these condts body might fail to react,& blood pools in the legs & thus BP drops & there is not enough bld reaching the brain.

There is a possibility that this might happen again & from now on whenever you change your posn from lying get up slowly,sit at edge of bed & slowly get up.

I need to get in touch with your doctor & modify the dosage of your meds or change them. Is it alright with you?

I need to talk now to your wife & do an ECG to check your heart

HA DOMESTIC VIOLENCE

Domestic Violence common presentations: 1. HA 2. Abd Pain 3. Ac Abd 4. Insomnia 5. Sleeping pills 6. Vaginal Bleeding Sx

1. No good eye contact 2. Vague complaints 3. Non communicative

OCD/PQRST

CONSTITUTIONAL Sx:

R/o Migraine & Tension HA

RISK FCTS:

Smoke/Alcohol/Recreational drugs

PMH:Are you on any meds/OTC/Herbal meds?

Were you hospitalized at any time?

FH:

SOCIAL HISTORY: Important**

All information you give here is entirely confidential & will not be released unless you authorize it

Who lives with you?

Any recent changes/Stress in your relationship

SCREEN FOR DOMESTIC VILOENCE:

Does your Partner: 1. Hit you?

2. What happens during an argument? 3. when he is angry,does he :

4. Shout/Swear & call you names or demean you?

5. Has your partner ever ridiculed you or cut you off from other relationships with friends/family?

6. Have you ever sought help from others in health care?

ABUSE RISK FCTS:

1. Drink alcohol,drink more now than before? 2. Does he have access to firearms?

3. Does he ever get angry to the point where he gets physical & hits you?Did you ever have to go to the ER? Was there a serious consequence?

5. Does he get more angry now,& How has all this affected your self esteem? 6. How does it make you feel?

7. Does he ever force you to have sex against your will? 8. Who controls the finances & spending?

9. Has he ever mistreated you in front of the children?- If yes: it is emotional abuseto children & has to be reported to CAS

10. Has he ever misRxed th children?

11. Have you ever thought of putting an end to your life or his life? Have you spoken to anybody abt this?

Do you have some support?

COUNSELLING: Empowering & Education

3 kinds of Pt: 1.She wants Help

2.She might Consider getting help

3.She does not want to get help & thinks he is right

I’d like you to know that what you’re experiencing is called “Domestic Violence “or Spousal abuse. It is a crime against the law & not acceptable.

It is not your fault & you should not accept it & feel guilty It can get out of hand & you can get harmed seriously Call Police (Never Call Police from your office)

Contact Social worker, who will help you with housing, finding a job & finances & child support If she is considering

Escape Plan

Keep a bag with important documents,change of clothes & hide it

DOCUMENT

Fup x 3 days

Diabetic Daughter 2y, Counsel

Either she is not doing well in school Not seeing well

Not playing well, tired DKA

Is it regular f/u or something special you wanted to discuss? When was the last f/u?

How was she diagnosed? What happen then?

What were the symptoms? Is there any pain / vomiting?

Are you feeling eating/drinking/peeing more? Is there any weight loss or blurred vision?

From the last f/u till now have you had DKA? How about before? Have you had low blood sugar?

Talk with the father: which medication does she take? How does she take? When was the last time?

Do you take insulin or somebody else gave it to you? Do you take it all the time? DO you skip dose? Does she need any help to take insulin? DO you measure blood sugar regularly? When was the last time? Do you record them in the machine? (The glucometer should be used by only one patient).

There is a blood work called ―Hemoglobin A1C‖ it is done every three month – did you do it? Did you start new medication? How about your diet?

DO you have your log book? What do you eat?

Have you ever seen by a dietician? PMHx

FHx Counseling

A lot of people have diabetes and she is not the only one. What’s your understanding of diabetes?

Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and from there to different parts of our body. Sugar act in our body like a fuel, in order for our body to use this energy it needs insulin. Patients having diabetes have not enough insulin. Sugar will be built up in your blood. The body tries to get rid or it, by peeing extra sugar – this will lead to thirsty and tiredness.

This can be avoided by controlling the blood sugar. If you control your blood sugar you’ll be able to play again. If not controlled – may end in DKA, hypoglycaemia and serious

consequences.

Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry. Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will clarify your situation.

Medical Error, Wrong blood transfused

When there is a mistake, always there is a kind of unintentional medical error.

(to the nurse) when informed about wrong blood – ask: ―did you stop the blood?‖ say: ―Well done!‖ If she asks not to tell the patient...ask her what her believe she may loose her job, and it is too early to determine who is responsible. Errors take place in medical practice. We don’t know what exactly happened. We will stabilize patient and ensure he’s fine and later deal with this issue.

(to the patient) Intro: I am the doctor in charge, and it looks like it was an unintentional medical error took place. We need to make sure you are stable. We don’t know who is responsible, there are at least 15 steps and in each step could have been an error. We will fill an incident report and as soon as we get result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize you.

ABCD

A – Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing),

Oxygen saturation. Normal air entry. Normal S1, S2 Vitals again

Remove blood unit and keep cannula. Start new IV line.

Once new line, don’t give fluids if stable.

Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria

Unit to be sent to blood bank for cross matching.

Ask nurse to call the blood bank and keep original blood. D

D1 – I’d like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my finger, wriggle...wriggle...

D2 – (if febrile) give tylanol

Please prepare for me benedril (Diphenhydramine) 50mg. Steroids (Hydrocortisone) and Epinephrine

Secondary survey

Hx (two parts:) condition (how is he feeling now) and the other is: ―Why blood was given?‖ Condition: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in lips / fingers? Hives?

Before transfusion did you have fever?

Check for haemolytic reaction – any back or flank pain? P/E – no oozing at IV line

Then press on flank and back – no pain for haemolytic reaction. Is it the first time?

Why did you receive blood?

If received blood before – was there any complications? Any long term diseases?

Counseling

Mr. X what do you know about blood transfusion?

It is a life saving measure, and a lot of measures are taken to make sure it is safe. However, like any other medication with blood transfusion there could be side effects, and these side effects could be serious.

The most common side effect is febrile reaction (3%), usually it is self limited and can happen again. Next time you receive blood we will give you tylanol.

Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict it. However, we have good measures to deal with it, and your symptoms make it less likely that you have had an anaphylactic reaction.

The yhird reaction reaction is more serious and called haemolytic reaction. Usually happens when patients receive blood belonging to another blood group. The fact that this blood is same as your blood group, and the symptoms are not consistent with haemolytic anemia make it less likely that this is not the case here. The blood is sent to the blood bank and once results are back we will get final confirmation, we will able to reassure you.

Febrile Seizure

A child brought to the ER because of febrile seizure. Next 10m counsel him.

He is stable. During the next few minutes I’ll ask you few questions, and after that I’ll go with you to see him.

You should r/o meningitis. Educate, and what to do next time.

Did you see him? (Started to shake. All over his body? Bite his tongue / roling up his etes / wet himself). After the seizure does he have any neurologic deficits.

How long did it last, or did you come on your by his own or medcial staff. Did he stop seizing on his own or after medical interv.

Is it the 1st time?

Ask about fever? (if it started a week ago – did you seek medical assistance? Discharge? Did they give you any treatment? Did they give it to him or no?)

Why! Some studies show you can treat OM without antibiotics. You should look for the reason not to give the antibiotics (negligence?). Is he having any vomiting? Skin rash? Coughing? Head to toe... If you find nothing – ask when he got his last shot? (up to 72 hours he can have fever).

R/O meningitis, pneumonia.

Any family history of febrile seizures, epilepsy BINDE (especially immunization).

Counseling:

Your child has condition called febrile seizure (FS).

It is a condition that might happen from 6m to 60m. We don’t know exactly why – we believe it is a sudden change in the temp. This might lead to the seizure. This condition might happen again. Any time your child has fever – seek medical admition. Give tylanol and sponge to decrease his temp. Most of the children will outgrow this condition by the 6th year.

They don’t recommend Diazepam because it might make him drowsy.

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately. Brochure.

“This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER. I am calling that your child swallow medication. I know you are stressed, I need to take your phone number and address, and how far it is from the hospital.”

Stay calm. Your son needs you, I am going to give you some instructions and you need to follow them. Is your son is alert or not? Is he conscious? Can he talk to you? Can he recognize you? If he doesn’t – do you know how to do CPR and start with that.

He’s crying. What is colour? Pink. Hold him and try to calm and sooth him. If he his conscious – try to hold him and check his mouth. Is he breathing? We’ll send the ambulance for you. When did it happen? How long was he alone? Which medications did he take? Do you have the container? (don’t go to the next room to bring them). Do you know what condition your father have (was it vitamins, sleeping pills, or any other?) how much the amount? Don’t use any ippecak?

Is it happened before? What is the weight of the child? BINDE (was it full date, did he needed special attention after term, does he have any special conditions). Weight for two reasons – antidote and estimate neglect.

Post encounter Q: what are the first four steps you do when he arrives? (ABC, Monitor vitals, IV line, NG, Foley as needed, Blood works – CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen – blood and urine).

List three risk factors for this child.

What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate). CAS and Poisoning centre.

Second scenario – while he is seizing just put him on the side, and not start any CPR. Before I proceed I’d like to take your phone number and address. Is it the same time or happened before. If it is the second time – more than 15m he needs intervention.

Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than the lt.). Observe him. What is his colour? Is he still shaking? You send the ambulance. Can you tap on his shoulder? If he is not responding – can you do CPR? Can you feel his pulse? Is he alert? Can he talk to you? Can he move his legs? Was he shaking? Does your child have fever? Did you seek medical attention? What prevented you from giving the medication?

Post Concussion.

2 scenarios (Osgood schlatter and Post-concussion)

Decision will based whether the child can tolerate pain or not? #1 About to see the father of 14yom with Osgood Schlatter.

Make sure that the child best interest are preserved. What was done to diagnose the child? OCD PQRST compare to the other knee, is the first time or not, was any trauma.

What is the child wish? (Don’t go for HEADDSSS since it is the father). Counseling

What is your understanding of OS.

Let me explain to you what is the mechanism for OS.

Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The rule is that he can continue up to his limit of his pain.

54 year old female comes to clinic concerning about using

HRT.

.

When a patient has concern about any subject, address it very soon. Don't wait to the end. Dr: As far as I understand you're here as you have concern about using HRT.

Patient: yes Dr. I feel I am confused about using HRT.

Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT. Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT.

Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time.

Serious side effects are Cancer,

Heart attacks and Strokes.

For that reason the routine use of HRT was stopped.

Nowadays we have a better understanding and have better guidelines. Not only that we do it on the individualized basis.

We use it only for short time, they don't exceed five years. So using HRT within five years is safe.

So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not.

Dr: What makes you interested in HRT? Patient: because of hot flushes.

At this stage if the patient gives you the symptom, it is your chief complaint. But if patient doesn't give you any symptoms, you should start with her LMP

If she starts with the symptom of hot flushes, ask the patient 1. When did hot flushes start,

2. Is it all the time, 3. On & off or continues, 4. How many attacks, 5. Day or night,

6. How do you feel that you have it.

7. Night episodes, you have any night sweating, does it wake you up.

Asked patient if the hot flushes wake her up during the night and if she needs to change her gown of night’s sweats.

1. Affect your sleep and how does it affect your concentration.

2. Change in your mood, anybody has told you that your short tempered, and if you 3. feel tired.

4. Some women with the same symptoms may notice some change in their sexual life. a) So the doctor should ask with whom do you live?

b) Are you sexually active?

c) Any dryness or pain during the intercourse? 5. Any change in your urination?

6. Have you ever lost control? 7. Last period?

 Are you periods regular or not?

 If it's irregular, when did it start to become irregular?  Are your periods heavy or not?

 Any clots?

 *Any bleeding or spotting between periods?This is a very important point. 8. Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will

discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.

MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation, surgeries.

Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects? Also you should ask about her last smear.

Because she is 50+ you should ask about her mammogram.

At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient pass 65 you should add bone density.

You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you have been pregnant?

Now use the transition...

Because this is the first time I met you, I would like to ask you about your past medical and social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history of allergy, and the medication she takes.

ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT

For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool?

For B you should ask about any vaginal Bleeding? ... You have already asked these question before For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer).

For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke.

Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how does this affect her life and ask about osteoporosis.

Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT. However as I told you it is an important information to tell you to make your decision.

As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between person to person.

At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches.

As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers

depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease.

So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better.

To get rid off the hot flushes that are other measures like exercise or herbal supplements that you can try to improve the symptoms.

The HRTs are the same as OCP's but in this smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time.

This serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spottings.

If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both.

Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium

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CARDIO

1.45 yr old Chest Pain x 45 mins ER History x 5 mins (MI)

1. When did it start?

2. What were you doing at that time? 3. How did you get here today?

4. If you came in by Ambulance, did the paramedics give you a tablet to be kept under your tongue?

Course:

Was it sudden or gradual?

Position:

Where exactly is it hurting you the most?

Quality:

Can you describe the pain? Is it crushing? Knifelike?...

Radiation:

1. Does it move anywhere else in your body 2. Does it move to the back?

Severity:

On a scale of 1 to 10 where one is minimum & 10 is highest, where would you place this pain?

Associated symptoms:

CVS:

 N/V,Sweating?  Heart racing?

 SOB/Orthopnoea/PND?

 Have you been under stress recently?  Cough with blood tainted sputum?

GI

 Acid taste in mouth?  Heart burn?

 Dysphagia  Pud?

MSK

 Have you had any trauma to the chest  Are there any blisters on chest?

RS

 Did you have any flu recently?  Cough with Phglem?

CONSTITUNIOL Sx

 Do you have night sweats  Loss of appetite & Loss of wt?

Alleviating Fcts:

What makes you feel better? 1. Rest? 2. GTN? 3. Antacid? 4. Sitting forward? Aggravating Factors: 1. Exercise/exertion? 2. Movements? 3. Deep inspiration? 4. Lying down? 5. Eating? RISK FCTS:

I need to know additional information that could be related to your pain right now, and need to ask some further questions...

1. Do you have a high Blood pressure?

 When,& what did your doctor have to say about it?  Were you put on medicatn?

2. Were you diagnosed at any time with an elevated Blood Sugar or were told you had diabetes?

 When,& what did your doctor have to say about it?  Were you put on medication?

3. Have you ever had your cholesterol checked? If yes:

 When,& what did your doctor have to say about it?  Were you put on medication?

4. Do you smoke? If Yes;

How many & Since how long? 5. Do you take alcohol

6. Have you used recreational drugs? Cocaine?

7. .Do you find time for regular physical activity? 8. Do you eat a lot fast food?

9. In your family has anyone had a heart attack under the age of 50?

CAUSES/Consequences & Symptoms:

2. Did you have a weakness or numbness?

Past Medical History:

1. Do you take any medications?/OTC or herbal products? 2. Are you allergic to anything?

3. Were you hospitalized at any time? 4. Did you ever undergo any surgery? 5. Were you ever diagnosed with Cancer? 6. Do you have a bleeding disorder?

7. Did you have any head/facial trauma since last 3 mo?

I need some more information about your family HTN/DM/MI/Stroke

Social History:

1. With whom do you live? 2. How do you support yourself? MANAGEMENT:

 Rapid, targeted history and physical examination, with particular attention to onset of symptoms, contraindications to use of thrombolytic agents

Absolute contraindications

4. Ischemic stroke within 3 mo EXCEPT acute stroke within 3 h; 5. Suspected aortic dissection;

6. Active bleeding or bleeding diathesis (excluding menses); 7. Significant closed head or facial trauma within 3 mo.

Relative contraindications:

1. History of chronic severe, poorly controlled HTN, 2. Severe uncontrolled HTN (BP > 180/110 mm Hg)c;

3. Prior CVA greater than 3 mo or known intracerebral pathology not covered above; 4. Traumatic or prolonged (> 10 min) CPR or

5. Major surgery (< 3 wk);

6. Noncompressible venous punctures;

7. recent (2–4 wk) internal bleeding; pregnancy; 8. active peptic ulcer;

and evidence of high-risk features (tachycardia, hypotension, congestive heart failure)

Management

1. ECG STAT, then every 8 hours for the first 24 hours, then daily for 3 days. a. In addition, repeat the ECG with each recurrence of chest pain

2. Baseline troponin STAT, (creatine kinase if troponin is unavailable) and then every 8 hours until enzymatic confirmation of the diagnosis

3. CBC to rule out the presence of anemia, 4. Baseline electrolytes,

5. Creatinine,

6. Fasting lipid profile (within 24 hours of presentation) 7. Liver function tests

8. Portable chest x-ray (CXR) STAT

9. Echocardiography to assess LV function after stabilization and treatment.

Echocardiography is also used emergently when there is suspicion of acute mechanical complications post-MI

Therapeutic Tips

 The goal for thrombolytic treatment is a door-to-needle time of 30 minutes or less.

 The goal for primary PCI is a door-to-dilatation time of 90 minutes or less.

 Careful attention to maximum pain relief is important.

 In patients with right ventricular infarcts:

o avoid nitrates and diuretics

o use fluids and inotropes to treat hypotension

 Administer beta-blockers early to all patients without contraindications. Increase the dose every 12 hours (every 24 hours for once-daily beta-blockers), if tolerated (monitor blood pressure and heart rate), until the patient has reached adequate beta-blockade (HR ≤ 55-65 BPM).

 Start ACE inhibitors early. The choice of agent can depend on practitioner preference, hospital formulary or financial constraints for the individual patient.

 In smokers, the need to quit smoking should be reinforced early (within 24 hours) and frequently.

 Stool softeners are often used in the immediate post-MI period to prevent straining with bowel movements.

 Anxiolytics are often used on an as-needed basis in the immediate post-MI period.

Hx OCD

PQRST (if it is suspected to be ACS - stop at R and start primary survey)

Primary Survey (If patient talks – Airway preserved, take Oxygen saturation and start Oxygen Stat – 4L/m through nasal prongs)

Vitals

Auscultation: normal air entry and normal S1, S2

IV lines (normal NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic., Alcohol, Lipids; and finger prick for Glucose) ECG 12 leads and continue monitoring

Ask about Allergy and Viagra (if negative) Give ASA chewable (325mg)

Non-ST elevation: give Nitro x3 (S.L) if there is no benefit – give Morphine. Contin

PQRST AA&A

How do you feel now?

Ask Hx on CVS and GI (especially peptic ulcer) CSx

RS DVT

ST Elevation: do not go for DDx, Vitals (again) RF Nitro (2nd dose) Examination: JVP Listen to heart Base of lung

Compare BP in both Upper extremities to r/o coarctation of Ao CXR

Once there is no Aortic Dissection  Thrombolytics (should be clear to r/o: Peptic ulcer, recent surgery, pericarditis, aortic dissection, brain tumor, and stroke)

Based on ECG – counselling Counseling

Based on your ECG it is most likely you are having an heart attack. If stable – BP and HR are stable, but it is a serious condition, however it is treatable. Heart attack means that greater than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic dissection you are a good candidate for treatment. It is an effective medication, needs consent. 1% chance of stroke and we can start heparin.