Physical Exam Cardiac - murmur, AD Extremity - look for signs of chronic peripheral vascular disease Neurological - sensory and motor loss Vascular - grade peripheral pulses ABPI
Amputations are more common with thrombotic occlusions. Emboli are different - and most often from the heart and comprised of platelets. They can also come from aneurysms - and will be made of atheroma. Vasculitis, iatrogenic, compartment syndrome, aortic dissection are also risk factors.
Upper arm emboli are less common. Thoracic outlset syndrome may masquerade - pressure on the subclavian artery from a cervical rib or abnormal soft tissue band may lead to a dilatation lined with thrombus, predisposing to occlusion or embolisatoin. Popliteal aneurysms are very likely to be dislodged.
PAIN - worse on movement, and relieved by hanging your legs over the edge. Tenderness on examination is often due to muscle death. PALLOR - limbs are often white. Chronically ischaemic limbs may turn sunset pink due to compensatory response. Dry gangrene is black, and a sign of chronic ischaemia for more than two weeks. PARAESTHESIA- PERISHINGLY COLD - compare PULSELESSNESS - use dopplers
Check bloods including a creatinine kinase.
Treatment: Analgesia, Oxygen, 5000 units IV heparin, heparin infusion, IV fluids Unless bleeding, pregnant, CVA/TIA, tumour, previous GI bleed, trauma
As a presentation to ED, I don't think sexual assault is that common, and the brief mention in the curriculum probably supports that. Sexual assault is maybe underrepresented and more common than we think.
Sexual Assault - Examine carefully including in the mouth and treat any injuries - consider liasing with SARC for forensic samples to be taken before irrigating wounds if appropriate. - Advise patient not to wash or bathe, eat or drink - as it will affect samples - Refer to SARC if patient wishes to attend. The investigations may take three hours. DNA can be gathered for up to seven days after vaginal penetration, up to two days in oral penetration and for up to three days in anal/penile penetration irrespective of washing or bathing - Offer emergency contraception - Safeguarding referrals -Accelerated Hep B - one now, one month, two month If high risk Hep B immunoglobulin - Bloods 3 months after exposure - Consider PEPSE - STI prophylaxis - Cefixime 400mg + Azithromycin 1g + Metronidazole 2g as single oral stat (pregnant or breastfeeding women Cefixime 400mg + Azithromycin 1g).
Domestic Violence SAFE Questions S tress/Safety Do you feel safe in your relationship? A fraid/Abused Have you ever been in a relationship where you were threatened, hurt, or afraid? F riend/Family Are your friends aware you have been hurt? E mergency Plan Do you have a safe place to go and the resources you need in an emergency?
Sexually Transmitted Infections Reactive Arthritis aka Wegener's 2-6 weeks following infection (Chlamydia, salmonella, shigella, yersinia, campylobcater) Symmetrical arthritis, knees, ankles, feet and heels Conjunctivitis or uveitis Dactylitis NSAIDs
Gonococcal Arthritis often causes septic arthritis
Other STIs Our curriculum says we need to know the main types. I think that seems sensible...although actually, all we really need to know I think is test test test. And secondary syphilis is making a come back.
Herpes Zoster Significant exposure - infected people with exposed or disseminated lesions, or those with compromised immunity are more likely to shed the virus. Low risk of contracting the virus from the zozster rash under clothing. - Infectious 48hrs before until crusts. - Closeness and duration of the contact - face to face or contact in the same room for >15minutes.
I wrote a summary of what each common competency involved to make sure I linked properly. Here's my summary:
CC1 - History Taking - Risk Factors, Communication Barriers, Time Management, Questionnaire, conflicting family, assimilate, non-verbal queues, mechanism of injury, no bias in re-attenders, children, interpretor, third parties, notes review
CC2 - Clinical Examination - constraints to overcome them, limitations, targeted, DSH, interpet, mental state, clinical, psychologial, religious, social and cultural factors, adjunctive examinations, ECG, spirometry, ABPI, joints, FAST, echo
CC3 - Therapeutics and safe prescribing Indications, contraindications, SEs, drug interaction, dose of commonly used drugs, adverse drug reactions, complementary meds, tools for patient safety and prescribing including ID, effects of age, body size, organ dysfunction, concurrent illness on drug distribution and metabolism, regulatory agencies, review long term meds, anticipate and avoid interactions, appropriate drug dose, adjustments, monitoring, concordane, explainations, minimise risk, non-medical prescribers, formulary, info sharing, therapeutic alert Methadone Meds from overseas, and translate into UK equivalent, Children, rapid chemical tranq. Empathetic for pain. PGD. Drug prescribing audits. Reviews stock. Introduces new drugs.
CC4 - Time management and decision making Organisation, prioritisation, delegation, techniques for time management, prompt investigation, diagnosis + treatment. Estimate time. Workload. Work to deadline. Calm in stress. Manages multiple patients. Quick disposal decisions, CTR... Staff allocation. Team management. Teaching during low demand. Rota vs patient attendances
CC6 - Patient central focus of case Recall health needs to deal with diverse patient groups - learning disabled, elderly, refugees and non-English speaking. Gives time. Answers questions honestly. Self-management plan. Voice preferences. Acts as advocate. Time off work. GP letters. Gillick-competent adolescent. Assess capacity. Alternative management options. Worried well. DNAR + end of life decisions Complaints Patient survey + local patient groups
CC7 - Patient safety Safe working environment. Hazards of medical equipment. Med side effects. Risk assessment + management. Safe working practice. Local procedures for optimal practice. NHS and regulatory procedures where concern about performance of team. Recognise failure to response. Use medical equipment carefully, report faults. Improve understanding of SEs and CIs. Sensitively cousel a collegue following SE or near miss. Root cause analysis. High risk patients - nonEnglish speaking, agressive, un-cooperative, clinically brittle Supports trainees + nursing staff after SUIs Handover
CC8- Team working _ patient safety Effective collaboration. Roles + responsibilities. Factors adversely affecting a Drs performance. Note keeping. Patient lists. Handover. Leadership and management in education & training, deteriorating performance of collegues (stress fatigue), high quality care, effective handover. Interdisciplinary team meetings. Supervision. Encourage open environment. Second opinion. Induction. Information sharing. Debrief.
CC9 - Quality and Safety Improvement Clinical governance, local and national significant event reporting, EBP, local health + safety protocols (fire and manual handling), risk - biohazards, patient early warning systems, national patient safety initiatives - NPSA, NCEPOD, NICE Surgical checklits. Quality improvement process eg. audit, errors/ discrepancy meetings, critical incident reporting, unit mortality and morbidity, local and national databases. Reflect regulalrly No-blame culture. Audit
CC10 - Infection Control Prevent infection in high risk groups. Notification in UK. HPA / CCDC / LA in infection control. Potential for infecition. Counsel patients on risk. Local infection control procedures. Antibiotics according to local guidelines. Cross - infection. Aseptic technique. Atypical common infections. Not eating on shop floor Blood cultures, sepsis 6
CC11 - Long term conditions + patient self care Natural history of diseases that run a chronic course, rehab and MDT, QoL, medical and social models of disability, social services, carers, information, patient advocate. Feedback on referrals. Patient notes. Self-help groups,
CC12 - Patients + Communication Structure an interview, understand importance of patient's background, rapport, sensitive, manage communication barriers, deliver information compassionately, use and refer to other sources, check understanding, notes, follow up. Language line, anxious patients. Acutely disturbed psych patient. Safe and lawful restraint.
CC13 -Breaking Bad news Stressful. Honest, factual, realistic, empathetic. Organ donation. Lead resuscitation with relatives present.
CC14: Complaints and Medical error Local complaints procedure. Factors likely to lead to complaints. Deal with disasatisfied patients. Honest. Apologise. Review. Support junior ED staff in responding.
CC15: Communication with collegues + cooperation MDT + team dynamics. Inter-professional collaboration. Communicate accurately, clearly, promptly. Use whole MDT. Hospital at night. Behavioural management skills with collegues. Healthy work / life balance for whole team. Confidentiality. Accept additional duties. Handover. Manages shift to ensure breaks. Respect for nursing staff.
CC16: Health promotion and public health Incidence and prevalence of communication conditions - biological, social, cultural and economic. Lifestyle on health. Screening. Smoking, obseity. Globalisation. Substance misuse, gambling. Ill health and disease. Lifestyle changes. Registered with Dr. Encourages alcohol, drug, smoking. Discourages high risk. Display local information.
CC17: Medical ethics + confidentiality GMC on confidentiality. Data Protection Act + FOI Act. Caldicott Guardian. Caldicott approval. Patient consent - desirable but not required eg. communicable diseases. Consent. Confidentiality following death. Problems by disclosure in public interest. Factors influencing ethical decision making. DNR. MCA. Confidential waste, no password sharing, doesn't take notes home, anonymisation, DNAR
CC18: Valid Consent Consent is a process that may culminate in a consent form. Consider understanding and mental state. Balanced view. Autonoy. Scope of authority. Don't withold information. Seek advance directives. 2nd opinion. STEMI/ stroke thrombolysis Patient advocacy
CC19: Legal framework Best interest of the patient. Legislative framework - death certification and role of coroner/ procurator fiscal. Safeguarding children. Mental health legislation. Advanced directives. Living Wills. Withdrawaing and witholding treatment. Resus decisions. Surrogate decision making - organi donation + retention. Communicable disease notification. Medical risk + driving. Data protection + FOI Act, continuing care. Differences in legislation in 4 countries of UK. Disciplinatry processes. Role of medical practitioner in relation to personal health + substance misue including what to do ?abuse. Report to Coroner.
CC20: Ethical Research Good practice in research. Audit vs research. Understand how guidelines produced. Knowledge of research principles. Formulate research question. Comprehend principal qualitative, quantitative, bio-statistical and epidemiological research methods. Funding. Critical appraisal skills Write scientific paper. Ethical research, literature databases, good verbal + written presentation skills Popuation based assessment + unit-based studies and evaluate outcomes. Complete a BestBET. CTR.
CC21: Evidence and Guidelines Application of statistics in scientific medical practice. Different style methodologies. Critical appraisal. Level of evidence + quality. Advantages and disadvantages of guidelines. NICE and SIGN process. Search medical literature. Address clinical question. Limits of research.
CC22: Audit Data for audit. Role + steps. Local + national. Local / national audit meetings.
CC23: Teaching and training Adult learning principles, identification of learning methods. Educational objectives. Questinoning tecnhiques. Teaching format and stimulus. Literature. Appraisal interview. Bodies in med ed. Appraisal vs assessment. WBPA knowledge. Define learning objectives and outcomes. Failing trainee. Vary teaching format and stimulus. Feedback. Appraisal. Demonstrate effective lecture, presentation, small group + bedside teaching sessions. Career advice. Improve patient education. Departmental teaching programmes, failing trainee. Has discussion. Formal tuition in medical education. Personal development as a role model. PowerPoint. Small group teaching. Simple feedback. Supevision. WBPA.Teaces med students. Supervises things. Medical student programme.
CC24: Personal Behaviour Inappropriate patient and family behaviour. Respect rights of children, elderly, physical, mental, learning or communication difficulties. Eliminate discrimination. Honesty and probity. Honesty and sensitivity. Ethical reasoning. Value-based practice. Royal Colleges, JRCPTB, GMC, Postgraduate Dean, BMA, specialist societies, medical defence organisations Practice with integrity, compassion, altruism, continuous improvement, excellence, respect for cultural and ethnic diversity, equity Rotas. Utilise resources. Specialist support. Press + media. Clinical leadership + management Mentor, educator and role model. Accept mentoring. 360 feedback. Annual departmental stragetic vision.
CC25: Management and NHS Structure GMC management guidelines. Understand local NHS structure. Structure and function of healthcare systems. Understand NHS debates and changes in the NHS. Local demographic data. Clinical coding, EWTD, NSF, health regulatory agencies, NHS structure + relationships, NHS finance and budgeting, consultant contract + contracting process, resource allocation, independent sector. Managerial meetings. Technology.
TIAs Isolated vertigo is rare in posterior circulation TIAs. They may be hard to diagnose.
There is little benefit from further aspirin if patients are already on aspirin. If patients present late, they should be treated as lower risk of stroke.
For risk assessment, RCP guidelines say investigate all urgently without further risk stratification, and all patients need to be seen within 24hours. No imaging unless to exclude haemorrhage - in patients taking an anticoagulant.
TIAs need aspirin (for 2 weeks), clopidogrel, statins, and BP lowering therapy.
Confusion, memory problems, faintless or syncope, generalised weakness or numbness and incontinence are NOT TIA symptoms.
Always assess the carotid as part of your TIA assessment.
Stroke Anatomy Anterior circulation is served by the internal carotids which branch into the MCA, ACA. - weakness or sensory loss affecting the contra-lateral arm, leg or face - mostly leg. Dysphasia or dysarthria. Monocular visual loss. - Middle cerebral - contra-lateral face and arm more than leg. - Internal capsule often affects the face, arm, and leg equally.
Poster circulation: CN palsy + contralateral deficiency or bilateral. 20% dead, 20% dependent, 60% independent Lacunar: pure motor or pure sensory. Dependent 30%, independent 60% TACS: cortical dysfunction and field deficit and contralateral weakness in 2 areas. 60% dead. PACS: 2/3 of TACS.
The posterior circulation is served by the vertebrobasilar arteries - which supply to the posterior 2/5 of the cerebrum, and the basilar arteries.
Anterior and posterior circulations are linked by the posterior communicating arteries, forming the circle of Willis.
Malignant MCA infarcts cause a lot of brain oedema, which may lead to herniation and early death. Young patients are particularly at risk because they don't have any spare brain space. A decompressive hemicraniectomy may be considered if pre-stroke rankin <2, defects indicate MCA, NIHSS >15, not alert, signs on CT of at least 50% of the MCA. Refer to neurosurgery. Likely fatal, and early senior neurosurgical involvement is necessary.
Stroke Assessment Consider a ROSIER score - negative score for LOC/ syncope or seizures, with positive for weakness, speech and visual fields. NIH score Perfusion scan if diagnosis in doubt, or >4 hours including wake up stroke
Stroke Treatment - Very high BP is a contraindication to thrombolysis so stick on a GTN patch on the way
Hypertensive encephalopathy or nephropathy Hypertensive cardiac failure/myocardial infarction Aortic dissection Pre-eclampsia/eclampsia Intracerebral haemorrhage with systolic blood pressure over 200 mmHg. In patients being considered for thrombolysis, a blood pressure target of less than 185/110 mmHg should be achieved
- ASPECT score to see if for thrombolysis - determined from CT findings >7 = thrombolyse. - Alteplase is the preferred option. 19/20 stay the same, 1/20 get worse. - If on NOAC (not dabigatran) no thrombolysis. Consider if clotting normal.
A tear in the vertebral artery, is a common cause of stroke in young people. The tear has a clot and causes a false blockage - causing an ischaemic stroke. It can happen spontaneously or after minor trauma to the neck, including yoga and chiropractice.
A recent respiratory tract infection may also predispose - making vertebral artery dissection seasonal.
There are two types: Infarction - ischaemia of the vertebrobasillar circulation due to arterial narrowing and thromboembolism Haemorrhagic type - presents as a SAH
They may not present with problems, because of the contralateral vessel. Acutely ruptured dissections have a high mortality, and may rebleed (mostly in the month immediately after).
Clinical Symptoms Severe neck pain, followed later by neurological symptoms May get a spinal cord infarction Maybe with a headache and horners syndrome
We think of spondaneous coronary artery dissection as being a cause of peripartum myocardial infarction - but about 90% of cases are not pregnant. It can be precipitated by valsalva type manoeuvres. There is an association with exercise, especially in male users. There are case reports linking SCAD with drugs, and emotional stressors.
Thrombolysis is considered safe and apparently effective but generally avoided, because can cause rupture leading to tamponade. Dual antiplatelet therapy probably indicated - but may cause menorrhagia as is used for women of child bearing age.
Transient ischaemia of the basilar circulation system. Dizziness, vertigo, headaches, vomit, diplopia, blindness, ataxia, imbalance and weakness are all possible symptoms.
Ear symptoms may also cause ischaemia of the inner ear. Posterior circulation imbalance rarely causes only one symptom. Isolated dizziness is rarely VBI. Standard artherosclerotic risk factors. May be associated with facial pain - sharp single stabs or jolts of pain.
Wallenberg Syndrome - lateral medullary syndrome, caused by a vertebral artery stroke. May be facial pain with a contralateral hyperanalgesia.
2. Erysipelas is a superficial cellulitis, with similar risk factors. It looks a lot worse than cellulitis with ruptured bullae and vivid bright red erythema. Almost all erysipelas is caused by group A beta haemolytic strep. It can recur due to persistence of risk factors and lymphatic drainage. Complications can include abscesses, gangrene, chronic leg swelling
Signs and symptoms are normally abrupt, affecting predominantly the lower limb and face. It has a sharp raised border, and is bright red and swollen. The swelling may lead to dimpling, blistering, and even necrosis.
3. Cellulitis Cellulitis is very rarely bilateral. 35-50% of patients will have a leukocytosis, 60-92% will have an elevated ESR, and 75-95% will have an elevated CRP. Blood cultures are unlikely to be helpful. Orals are very bioavailable so most of the time are just as good as IVs.
Often caused by strep and staph. Atypicals are common: Cat bites can have pasteurella, sea water Vibrio vulnificus, fresh water Aeromonas hydrophila, fish farms Streptococcus iniae. These atypicals can cause a rapidly progressive cellulitis.
Class I: No signs of systemic toxicity or co-morbidities. Can be managed on POs. Class II: 2 or more SIRS, but no organ dysfunction, or have a co-morbidity. May need IV outpatient management. Class III: Sepsis and organ dysfunction, or unstable co-morbidities normally require admission. Class IV: Severe life threatening infection.
Later Pregnancy https://www.rcemlearning.co.uk/modules/bleeding-in-pregnancy/
Antepartum Haemorrhage >24 weeks gestation Placenta praevia - stage depends how much of the os is covered by the placenta. Bright red and painless bleeding. Placental abruption - complete or partial separation of the placenta. Causes lots of bleeding which may be concealed. Normally associated with continuous abdominal pain. Vasa praevia - the fetal blood vessels run everywhere, not protected by the placenta. They may run over the cervix. High perinatal mortality - easy to rupture the fetal blood vessels. Can cause painless bleeding. AntiD may be needed after a potentially sensitising event.
Hopefully all of these will be identified by screening, and hopefully these patients will present to the maternity assessment unit, not the ED!
PostPartum Haemorrhage Primary PPH - in first 24hours. Secondary PPH - up to six weeks. Again, hopefully these patients will present to MAU not ED.
In pregnancy, problems are the 4Ts Tone, trauma, tissue, thrombin. Tone: uterine massage, bimanual compression, catheterise, give syntrometrin
Bleeding should slowly stop after a 12 weeks. It's often significantly less after the first few hours, and should change from bright red to brown (lochia). The commonest cause is endometritis. There may be retained products - start IVs, get an USS. If there's no RPOC, there could still be endometritis. The uterus in endometritis will remain palpable after 14days after delivery. Endometritis is a clinical diagnosis. I think bleeding persistently after delivery needs to see O&G. Bleeding that stops and starts again is probably "new" bleeding.
B12 deficiency, cobalamin deficiency or pernicious anaemia is also knon as Biermer's anaemia, Addison's or Addison-Biermer anaemia. It's one of the megaloblastic anaemias.
Pathophysiology Normally, B12 is absorbed through the ileum with the help of intinsic factor which is secreted by the parietal cells. Various things can stop this happening - antibiodies to parietal cells, like in atrophic gastritis, antibodies to intrinsic factor like in pernicious anaemia, lack of a terminal ileum, or disease of the ileum - like Crohn's disease, and reduced b12 intake. It takes a while for the disease to become apparent as there's 3-5 years worth of reserves in the liver. Lack of B12 means that DNA replication is slow, so cells divide less but grow bigger. This gives you your macrocytic or megaloblastic anaemia. Lack of B12 means the conversion of homocysteine to methionine is reduced, so there are high levels of homocysteine - causing things like atherosclerosis, thromboembolism and osteoporosis. More importantly, B12 is a cofactor in the conversion of methylmalonic acid into succinyl CoA. Without this, the dorsal and lateral spinal columns are demyelinated, through an unknown mechanism, so you get neurological symptoms.
Investigation FBC will show macrocytic anaemia, and maybe neutropaenia and thrombocytopenia. A blood film will show anisocytosis and poikilocytosis. Bilirubin may be increased because of haemolysis. Then you can look for autoantibiodies, and maybe an absorption test like the Schilling test.
Symptoms Symmetrical, legs > arms Ataxia Loss of position sense Loss of vibration sense
Low grade pyrexia, weight loss, diarrhoea, jaundice due to haemolysis, pallor due to anaemia, premature greying of the hair.
Treatment If B12 levels are low, then patients need intramuscular B12 and a haematology referal. If there is neurological involvement, 5 - 6 loading doses of 1000mcg, followed by maintainence of 1000mcg every three months. If B12 levels are borderline, then oral B12 may have a reponse and be diagnostic. Patients often feel better within 24hours of starting treatment. If patients are asymptomatic, there is debate about their treatment- monitoring seems preferred.
B12 is naturally found in animal products - fish, meet, eggs, milk. It's not generally present in plant foods, but is in fortified cereals. It's worth mentioning that pabrinex doesn't contain B12!