Anda di halaman 1dari 28

CTC Lecture Notes

2016-10-17
Orientation [Silas Taylor]
How do clinicians think? [Arvin Damodaran]

Hypothetico-deductive method

Limitations of hypothetico-deductive method


o Relies on the condition being on the list of probabilities
o Requires experience
o Need to be aware when back up is required
Inductive method
Tools to help avoid miss critical diagnoses
Murtaghs diagnostic strategy
Clinical decision-making needs to incorporate a number of factors:
o Probability that is modified by clinical characteristics and diagnostic
test
o Potential impact of disease
o Potential impact of diagnostic tests / treatment
o Disease trajectory
o Reliability of follow up
o Reliability of contingency plans

Patient with headache [Michael Bennett]

Theres a lot of info in how patients answer you as well as in the answers
themselves.

Case 1

2am, 35yo female presents to ED w 6-hr hx of headache, severity 9/10

Onset: over 1hr


Location: behind left eye
Character: throbbing
Severity: 9/10
Course
Exacerbating and relieving factors: worse with light, prefers dark and quiet
room
o DDx for photophobia subarachnoid haemorrhage, migraine,
meningitis
Associated symptoms: nausea and vomiting x1
PMH: similar headache every 2-3 months especially with stress. Not
usually this severe.
FHx: mother used to have weekly headaches.
Meds: COCP
Alcohol, smoking, caffeine, recreational drugs: 3std drinks ETOH per day.
Nil smoking, recreational drugs. 3-4 cups coffee and tea per day.
Social and occupational: works in caf, lives with partner, no children

DDx

Headaches
o Tension-type headache
Stress-induced
o Cluster headache
o Migraine
Common particularly in females of this age
Infections
o Meningitis
o Sinusitis
o Otitis media
Raised ICP
o SAH (subarachnoid haemorrhage)
o Intracerebral haemorrhage
Trauma
Intracerebral infarction
o Stroke
Trigeminal neuralgia
Temporal arteritis
Drugs
o Alcohol

Hx

HPC
o
o

o
o
o

S
O

Timing
Triggers

Focal neurological deficits, aura

C
R
A

o
o
o

Systemics
Meningitis: neck stiffness, rash

Clarify meaning
Progression

T
E
S

PMH/Surg
o Has it happened before
o Risk factors:
HTN
Meds/All
o
FHx
o
SHx
o Alcohol, smoking, recreational drugs
o Lifestyle
Sleep
Hydration
Diet
o Occupational

DDx #2

Include
o Red flags:
Intracranial mass
Subarachnoid some people might not have typical
thunderclap headache
o Migraine
But why late onset (first severe one now)
o Etc.
Exclude

Ix

Vitals
o Pulse
o Temperature
o Blood pressure
o RR
o Level of consciousness
Cranial nerve exam, especially:
o Slit lamp or fundoscopy (for ICP)
Dilated pupils
Papilloedema difficult to diagnose
Peripheral nerve exam or walking
o Stroke
Meningitis
o Kernig's sign, Brudzinski's sign
Lie down vs stand up

Exam

Gen Obs including LOC


Virals including temp, BP, PR, RR
Neurological system
o Neck stiffness, Kernigs (just next) and Burdzinskis signs (neck and
knees bent), photophobia
o CN (esp pupillary reflexes, fundi, extraocular movements)
o UL, LL exam including gait, cerebellar exam
Others
o Sinuses, cervical spine etc.

Exam findings

Alert, GCS 15
BP 151/86
o DDx: pain, stress (e.g. hospital environment)
Pulse 82/min
Nil significant photophobia
No neck stiffness
PEARL
No papilloedema
o Though it often takes hours to develop so does not rule out
intracranial mass
Rest of CN exam normal
Gait normal

Provisional and DDx

Provisional: migraine
Exclude: subarachnoid haemorrhage, stroke, malignancy

Red flags

Stroke, subarachnoid
Space-occupying lesion (not completely ruled out)
Meningitis

Management

Analgesia
Imaging
o CT?

The Murtagh diagnostic model

1.
2.
3.
4.
5.

Originated from general practice, but useful because it provides a safe


diagnostic model in settings of higher uncertainty
What is the probable diagnosis?
What serious disorder/s must not be missed?
What conditions can be missed in this situation?
Could the patient have one of the masquerades commonly encountered?
Is the patient trying to tell me something?
o May be somatisation of another problem that is worrying them

Case 2

43 yo man presents to GP w 1 month hx of headache

Headache is dull and all over the head


Severity 2-3/10
Headache lasts between few hours to couple of days
Occurs every 3-4 days
Pain is better w paracetamol or NSAID
Not had nausea or vomiting
Similar headaches in the past
PHx unremarkable
No significant FHx
No smoking, alcohol or drug
Alart, GCS 15/15
BP 125/70
Pulse 68
Nil neck stiffness or photophobia
PEARL
Normal EOM
Fundi NAD
Rest of CN exam NAD
Gait NAD

DDx

Tension-type headache
Medication-related
Red flag: intracranial mass

Management

Do we need CT?
Inform and educate
o Chances of tumour
o Symptoms and signs to note, upon which pt should re-present
o Risk of finding an incidental-oma w unnecessary testing; chance of
finding cause of headache is low, but chance of finding another
abnormality is high; cascade of ensuing consequences e.g.
investigations and management and exposure to further risks
o Discuss all these w pt so that they can make an informed decision
whether to do a CT scan, to delay considering the scan, or to do it
now.

Px request

Pt worried about a brain tumour and is requesting (assertively) a scan. His


friend was recently diagnosed w brain tumour and was missed by the
doctor although he went to see him several times w a headache.

Ordering brain imaging

Neuroimaging is usually not needed unless the pre-test probability is


raised
In populations where there is low pre-test probability (e.g. in GP setting),
this is assessed using the red flag system
If all the red flags are negative then there is only a very small chance of
the condition being present

Exposure to ionising radiation from a single head CT scan is estimated to


significantly increase the average lifetime attributable risk of death from
cancer. For a 45-year-old person, NNH is 1 in 20,000.
A 2005 report found that Australian GPs ordered a CT of the brain or head
in around 1 in 10 headache problems
Significant problem at population level
o UK study: 0.6% of cumulative cancer risk by age 75 years thought
to be due to diagnostic imaging

Case 3

83 yo female w 2 day hx of headache


Dull ache on left side of head
8/10
Had headaches in past but usually all over the head and not as severe
Feels unwell appetite has been off
o DDx: malignancy, infection etc
Red flags:
o 2 day hx and first time
o Very severe
o Loss of appetite
Nil other neurological or visual symptoms
Nil jaw claudication
Pain and stiffness in particularly the left shoulder the past 12 months
Does not take aspirin, clopidogrel, warfarin or NOAC
History of osteoarthritis, hypertension, GORD, nil other

DDx

Malignancy (red flag)


o Metastases!!!
o Likely not gonna do much to clinical course due to age and risks of
intervention
SAH!!!, intracerebral haemorrhage (red flag)
o Traumatic (small unnoticed trauma)
o Non-traumatic
Giant cell arteritis
Trauma
Otitis media

Additional questions

Neurological syptoms
Hx of trauma
Symptoms of GCA
o Scalp tenderness
o Visual
o Jaw claudication
o Fever
Symptoms of polymyalgia rheumatic
o Pain and stiffness of shoulder and pelvic girdle muscles over past
few weeks to months
o Fatigue

o Weight loss
Medications (especially blood thinners)
PMH including past haemorrhage, PMR, cancer

DDx

Metastases
Subdural
Intracerebral haemorrhage
Exclude: stroke

Exam

2016-10-21
Approach to a patient with a fluid balance problem
[Rohan Gett]

Recipe of 8-hrly bags


o 2 x [4% d (dextrose) + n/5 (ie 1/5 n/s) with 30 mmol K Q8h (ie over
8 hours)]
o + Hartmans solution (physiological form of normal saline, ie
crystalloid) 1L per 8 hour at 125ml/hr
This is maintenance.
Avoid consecutive n/s over many days drives towards
acidosis hyponatremic
To maintain K homeostasis, 1mg/kg/day is required. Ie 70kg man needs
70mmol K daily.
o 3.5-5mmol/L is eukalaemic. Better hypo than hyperkalaemic
o Renal impairment excess K removed through dialysis
10-hrly bags
o 1ml/kg/hr urine output is accepted for surgical pts who are fasting
o 0.5ml/kg/hr (or less) is acceptable for post-operative pts
Resuscitation
o Remembering that maintenance is 125 ml/hr
o Resuscitation may be 500 ml/hr or even litres depending on volume
of fluid (e.g. blood) lost
o Monitoring: central venous pressures or urine output

Numbers

3L of fluid/day
1ml of urine/kg/hr
1-2 mmol Na/kf/day
1 mmol K/kg/day
4:2:1 = 70kg 110ml/hr
o 4 ml of fluid for first 10 kg
o 2 ml of fluid for next 10 kg
o 1 ml of fluid for remaining kg
3L fluid 125mL/hr
o Use crystalloid (cheap, effective)

Vs. colloid expands intravascular volume more rapidly and for


more sustained period of time
Vs intravascular fluid or hartmans fluid leaves intracellular
space very quickly oedema?
Replace the fluid lost, 3:1
Monitor pt response to fluid
If 2-3 L do not resuscitate pt, ICU and inotropes may be required
May have difficulty moving fluid around body
Inotropes stronger cardiac output to reduce shock

o
o
o

Continuing

Serum K gives a very indirect measurement of total volume K


Urine collection
o Urine that sits in collection starts to degrade and gets a deep hue
o Urine in tubing however is more useful to indicate pt condition
Appearance of urine in tubing
o Dark dehydration
o Etc
K is the single most important cation
o Profoundly hyperkalaemic pts require acute action
Crystalloids or colloids?

Beware not to overload pts with too much fluid as well

Serum magnesium

Persistently hypokalaemic pt is often more easily managed if theyre


also hypomagnesaemic. These often run together. When corrected
hypomagnesaemia, hypokalaemia becomes easier to manage

Improved tissue perfusion acid-base balance improves more neutral


pH K levels improve

Resuscitation

o
o
o
o

If pts need IV fluid resus, use crystalloids that contain Na in the


range 130-154 mmol/L, w a bolus of 500 ml over less than 15 min.
Do not use tetrastarch for fluid resus
Consider human albumin solution 4-5% for fluid resus only in pts w
severe sepsis.
Extra notes
Pts in response to stress of surgery secretes cortisol, ADH etc
these secretions tend to preserve volume and decrease
urine output
Giving pt albumin will reduce urine output

Hartmanns is a surrogate n/s


o Has potassium but not enough to maintain K homeostasis on its
own
o Consecutive hartmans drives towards base; Consecutive n/s
drive toward acidosis; good for balancing out
o Not enough to use for Ca replacement
Dextrose
o Not used consecutively after dextrose metabolised only water
oedema

Approach to a patient with a rash [Vanessa Paddon]


See slides

Approach to a patient with shock [John-Paul Favero]


Case study

39yo pt at 37 wks gestation is booked for elective caesarean section in 1


wks time. She is otherwise well, weighs 80kg, and has a hx of 4 previous
caesarean sections. Her ultrasound scan shows an anterior placenta
praevia w additional features strongly indicative of placenta accreta.

One big concern of delivery for placenta accreta PPH


(haemorrhage)

Definitions

Normal = placental vessels not beyond decidua basalis or uterine


endometrium
Placenta previa
Accreta: villi attached to myometrium
Increta: villi extending into myometrium
Percreta: villi penetrating myometrial wall

Diagnosis of placenta accreta

Increased clinical suspicion based on risk factors


o In case: age, multiple caesarean sessions (and any form of uterine
surgeries)
Pre-delivery ultrasonography transvaginal (TV) u/s improved resolution
and diagnostic yield; risk for closer to term pregnancies
Recent studies looked at use of MRI but utility not confirmed

Assessment

History
o Previous deliveries, anaesthetics, bleeding, ICU
o Specific complications
o Medical records
Examination
o Heart and lungs
o Signs of failure
o Pre-eclampsia
o Other
Investigations
o Bloods including FBC, Group and Hold, Coags, functional clotting
and platelet function
o MRI

Major concerns in this case

2 patients
Bleeding
Specialised resources
o Environment tertiary centre
o Equipment cell saver, rapid infusor, access
o Staff obstetrics, neonatology, anaesthetics, haematology, often
gynae-oncology / general surgeons
Avoid:
o Shock
Secondary to, potentially: anaesthesia, haemorrhage, spinal
cord hypoperfusion (and other forms of
neurogenic/cardiogenic/iatrogenic obstructions)

Defining shock

No vital sign or laboratory test can diagnose shock


o Usually diagnosed by MODS (multiorgan doctors)

Initial diagnosis
o Based on clinical recognition of inadequate perfusion and ?????
Types of shock
o Septic delayed treatment, unrecognised infecton
o Hypovolaemic e.g. haemorrhagic
o Obstructive tension PTx (pneumothorax), cardiac tamponade
o Cardiogenic coronary artery thrombus
o Neurogenic upper thoracic and higher SCI (spinal cord injury)

Haemorrhage

Definition
o A rate of loss >150ml/hr
o Paeds >20 to 40ml/kg
Classes of haemorrhagic shock
o Blood loss tennis scores

Large number of confounding factors affect the usefulness of this guide


o Pain
o Anxiety
o Athletes
o Pregnancy
o Drugs
o Obesity
o Many more
Most common presentations
o Obstetric haemorrhage

o Cancer surgery major gynae-oncology


o Trauma
o GI bleeders
o Abdominal/thoracic surgery
o Cardiac surgery
o Vascular surgery
Adult blood volume
o Approx. 70ml/kg or 5-6L
The lethal triad
o Acidosis, hypothermia, coagulopathy death
Complications of massive transfusion
o Haemorrhage hypotension/acidosis resuscitation
haemodilution coagulopathy hypothermia haemorrhage (cycle)
Massive transfusion
o Replacement of blood volume within 24hrs
o Transfusion of
>10 unites within 24hrs
>4 unites in 1hr
50% of blood volume in 3hrs
o With broader implications for mortality and management (eg
intensive care)

Methods of stopping external bleeding

Compression
o E.g. direct (at the site) or aortic
Packing
Realign / reposition
o E.g. fractures
Tourniquet
Haemostatic agents
Etc.

Methods of stopping internal bleeding

Balloon tamponade
o Bakri intrauterine
o REBOA resuscitative endovascular balloon occlusion of the aorta
Embolization / interventional radiology
Surgical ligation
o Cautery, diathermy, topical agents
Etc.

Methods of stopping obstetric bleeding

Uterotonic drugs (in order of commonality of use)


o Oxytocin
Carbetocin
o Ergometrine
o Misoprostol
o F2 Alpha
= carboprost
o Other drugs

Physical measures
o Bimanual pressures (uterine fundus and cervix)
o Aortic compression
o Uterine balloons
o Compression sutures
o Arterial ligation
o Embolization
o Hysterectomy

Estimating blood loss

Kidney dish (900mls)


Bluey (650mls)

Tests for assessing hypovolaemia

Blood gas (arterial vs venous)


o pH, lactate, iCa (ionised calcium)
FBC (full blood count)
Coags (coagulation studies)
ROTEM or TEG (point of care testing)
o ROTEM (rotational thromboelastometry)
Rotational cup/pin placed in blood sample into a tube with
citrate to stop blood clotting citrate removed lotting
resumes measures how quickly blood forms, how strong it
is and other associated characteristics to indicate how
effectively the patient is clotting
o TEM (thromboelastography)
o Advantages of POCT
Faster useful info
Etc.
Bedside haemacue (venous vs skinprick)
UEC (urea electrolytes creatinine)
o Indirect measure of hypovolaemia or haemodilution

Returning to case study

HR 101, ABP 112/89, SpO2 93%, RR7


Surrogate for hypoperfusion: diminishing End Tidal Carbon Dioxide Trace
(CO2 diminishing over few breaths)
o Indicates perfusion to lungs and gas exchange is reduced

People needed

2 anaesthetists
Surgeons / obstetricians
o Most experienced available
Assistants
o Anaesthetic technicians / nurse
Theatre nurses
Orderlies
o Transporting blood products and tests

Equipment needed

Large bore venous access devices

o Large IVs, CVC +/- Swan sheath, etc.


o Ultrasound (to help place these)
Fluid warmers / rapid infusion devices
Forced air warmers (to avoid hypothermia which will worsen coagulopathy)
Invasive monitoring equipment

Other resources needed

Theatre adequate staffing and skill mix


Laboratory / blood bank
o Haematologist
o Special products including off site (antibody, platelets, more
blood)
Radiology
o Diagnostic
o Interventional (are they onsite?)
ICU / HDU postop
o HDU = high-dependency unit

Plan (anaesthetic perspective)

Multi-D (multidisciplinary) discussion and reviews prior


Consent for caesarean hysterectomy
Confirm ICU bed available
Cross match 4 units, MTP (massive transfusion protocol) standby
Full team present
Timeout and outline plans in event of specific scenarios - >2L, HD
instability
Epidural, GA (general anaesthetic), ETT (endotracheal tube)
Art line, 2x14G cannulas, CVC
Cell saver, rapid infusor, relevant drugs

Key resuscitation goals

Maintain vital organ & tissue oxygenation


Avoid / correct coagulopathy
Minimise adverse effects of treatments

Assessing (efficacy of) treatment of shock

Assessing therapy in haemorrhagic shock


o Clinical assessment, bedside, lab tests
o Peripheral perfusion
o Vital signs plus > central venous pressure, arterial line swing,
cardiac output monitors
Arterial line swing differences in intrathoracic pressure
affect heart swing
o Measuring actual blood loss
E.g. suction volume, weigh swabs, etc.
o pH, Base Excess, Lactate, Haemoglobin

Guiding principles of blood component therapy


Physiological
parameter

Critical physiological
derangement

Temperature
Acid-base status
Ionised calcium
Haemoglobin
Platelet count
PT / INR
APTT
Fibrinogen

< 35
pH < 7.2, BE > -6, lactate > 4
mmol/L
< 1.1 mmol/L
< 70 g/L
< 50 x 109 /L
> 1.5 x normal
> 1.5 x normal
< 1.0 g/L

Additional measure to be considered for this patient and case

Preoperatively
o Emergency contingency plan
o Patient close to planned hospital of confinement for duration of third
trimester
Estimated date of confinement (EDC)
o Optimisation of maternal Hb and iron stress
E.g. through transfusion or oral supplementation
o Antifibrinolytics
Associated with some pro-coagulant thrombotic risk
o Consideration of ureteric stenting
Prophylaxis to protect them e.g. leading to iatrogenic renal
failure
o Interventional radiology salvage device placement / preembolisation
o Team training and simulation
o Multidisciplinary care in a specialised centre
Intraoperatively
o Rapidly available blood products
o Point of care testing and targeted therapy (ROTEM) tranexamic
acid (TXA), fibrinogen, recombinant factor VIIa
o Ability to deliver and manage high volume transfusion team work,
rapid infusor
o Cell salvage appropriate draping
o One more!
Postoperatively
o Ongoing transfusion management as required
o Intensive care with capacity for all organ supports
o Multidisciplinary specialised care
o Debriefing, reporting, critical analysis and research

Writing up medical records, presenting to clinical peers


[Monique Akouri]
Patient
care

Written
- Specific concerns
- Progress notes
- Discharge summaries
- 1x results
- Information booklets
- Referrals to allied health/
other HCPs

Oral
- Calling consults
- Handovers between diff
HCP / departments
- Multi-disciplinary meetings
- Families
- Getting advice / second
opinions

Educatio
n

Admission notes
Operation reports
Student assignments
Case reports
Research
Audits

Discuss w GP for urgent care


Corridor/informal consult
Grand rounds
Conferences
Presentations on ward
rounds
VIVAs & other assessments

A medical history
As a senior medical student quickly present the case to a busy ED staff
specialist for advice about who to call.

Patient notes: write up the hospital admission so the team on in the morning
has an accurate record of your assessment and plan

PC
o
o
o
o
o
o
o
o

o
HPC
o
PMHx
o
Surg
o
o
Meds
o
All
o
FHx
o
SHx
o

o
o
o

Pain
Site: in stomach, under ribcage
Onset: Last night, woke him up & cannot go back to sleep
Character: Colicky
Radiation:
Associated Sx: nausea
Timing:
Exacerbating: nothing makes it best or worse, tried
quickies/aspirin/panadol
Severity: 8-9/10 (last night), 6/10 (now)
Never happened
Asthma as a child and now only wheezy cough upon sickness
Fractured ankle (at 14)
Projectile vomit as a baby
Tetracyclines
Parents dead; father: stroke (87), mother: AMI (70 something)
Diet:
Pizza and cake at sons birthday last night
Pretty good otherwise
A lot of take-away lately (more fatty foods than usual
Exercise:
Smoke: 30 per day for 30 years
Alcohol: 5-6 beers on the weekend and around one here and there

o
o
o

Married, 4 children (17-9yo)


Occupation: full-time car sales
Stress:
Wife started job, they are not getting along
Teenage daughter not behaving well at school

Learning

AMPLE
o A: allergies
o M: medication
o P: past history (med, surg)
o L: last ate and drank
o E: events
SNAPPS
o Mnemonic for a learner-centered model for case
o S: summarize briefly the history and findings
o N: narrow the differential to two or three relevant possibilities
o A: analyse the differential by comparing and contrasting the
possibilities
o P: probe the preceptor by asking questions about uncertainties,
difficulties

A patient with fever


Case 1

33 yo male
5 day history of feeling hot & cold, headache, generalised myalgia, nausea
At the onset of his illness, he also had a sore throat for two days but this
settled
The headache and nausea has been gradually worsening which prompted
his presentation
o Common: sinusitis
o Red flag: meningitis
DDx (in order of likelihood):
o ILI
o Meningitis (ask about neck stiffness, photophobia, rash; primary
symptom is bad headache)
o STIs
o LRTI lower on list
Past health
o Appendicectomy age 10
o Idiopathic epilepsy diagnosed at age 16
Controlled w carbamazepine for past 10 yrs
Social history:
o Married, 2 children
Family well except 3yo daughter who had 3 day illness with
fever, sore throat and irritability just prior to the onset of the
patients illness
^ very helpful!!!
o Financial advisor
o Travelled to Bali with family two months ago.

Well apart from mild diarrhoeal illness while there.


Examination
o PR 108, BP 120/75, RR 14, T 38.8
o No neck stiffness
Frequently see people with meningitis WITHOUT neck
stiffness doesnt rule out meningitis
o Rash discrete, erythematous macules eon chest and abdomen
Could be a heat rash from having a fever
o Throat pharyngeal injection
I.e. red throat not much help
o Soft, systolic ejection murmur in aortic area
Most common: hyperdynamic circulation (flow murmur)
Often can hear a normally inaudible flow murmur when
someone is febrile
o Palpable non-tender lymph nodes (1cm) in both inguinal regions
May not be pathological
Most common in cause of (widespread?) lymphadenopathy in
young people: glandular fever
Provisional Dx: viral ILI
o Most likely enterovirus which is often passed from young child
(especially if diarrhoea) to parents
o Often this is actually a little bit of meningitis and will show on
lumbar puncture

Working through

Immediate DDx
o ILI (influenza-like illness)
o Meningitis
Screen with headache! If no headache then dont need to ask
other symptoms
o Skin
o UTI
o STIs
o Gastro
o Resp
Age
o <65 more likely virus
o 65 or more more likely bacteria, more likely respiratory/skin
Gender
o Female more likely UTI
o Male

Case 2

19 yo male
One week hx of sore throat, headache, fever, generalised myalgia and
arthralgia, tiredness
On the day prior to presenting he notices a rash over his trunk
o May be due to antibiotics (EBV and taken amoxicillin; this specific
combination)
o Red blotches on chest and back, slightly itchy
DDx:

o Meningitis
o EBV most likely thus far
o RRV/Barmah forest
o ILI
o Influenza
o HIV
o STIs
o Malaria
o SLE
o Dengue
o Zica
Sexual
Past health
o Hep C diagnosed one year ago; has mild abnormality of LFTs
Social history
o Single, gay male, frequent unprotected sex with casual partners
o Works in engineering company
o Occasional use of cocaine, including injecting
Physical examination
o Bilateral inflamed tonsils
o Tender cervical lymphadenopathy
o Tender splenomegaly (2-3cm)
o Rash erythematous, maculopapular lesions on trunk
Initial investigations
o Normal Hb and platelets
o Total WCC 21,000; 40% lymphocytes; atypical lymphocytes
o Mild mixed LFT abnormalities (cholestatic enzymes raised unlike
past LFTs)
DDx:
o EBV still much more common despite his history;
o HIV - 1 in 100 for gays and only 20% will present with
seroconversion illness

Working through

HIV
o

EBV
o

Seroconversion illness: flu-like first presentation, rash on hands and


feet but also anywhere
Mononucleosis (EBV, CMV, HIV)

Patient with cough []


What is cough

Inhale
Recurrent laryngeal nerve close epiglottis
Increase intrathoracic pressure (abdominal muscles etc.)
Explosive release of air

Classification

Acute resolves under 2 weeks


Chronic unresolved after 8 weeks

Subacute? 2 to 8 weeks

Case 1

Robyn, started about 3 wks ago and getting worse in past few days
Wakes her up at night and too tired to work

History you want:

Onset (trigger/timing)
o Night waking them up: could be manifestation of PND
o Medications: ACEI (5% of people with cough are due to ACEI)
Characteristics
o Moist vs dry
o Blood
Tuberculosis, carcinoma
o Sputum quantity and quality
clear: non-infective
Purulent (browny, yellowy, greeny): infections often bacterial
Assoc Sx
o Pain
Pleuritic vs non-pleuritic
o Fever
Allergies
o Perhaps asthma-related (e.g. pollen), cats
Smoking Hx
Exposure to asbestos, dust etc.

Further history

Initial sore throat [ie pharyngitis] and feeling generally unwell about 10
days ago. Hurt to swallow for a few days
She does not own a thermometer so does not know if she had a fever
Still coughing and feeling unwell
Has tried OTC cough medicine
o Cough medicine OTC often does not have much effect
Usually well
No known allergies
Takes only propranolol 10 mg daily for migraine
Never smoked
Married w two adult children (live away)
Husband is an architect
Owns a cockatiel

Hypotheses

Viral infection: bronchitis pneumonia


Pneumonia:
o Strep pneumoniae (group B)
o Klebsiella
o H influenza
Pulmonary fibrosis

Red flags

Haemoptysis

Dyspnoea: at night or oat rest


Smoker >20 pack year history
Smoker age 45+ with new cough
Substantial sputum production
Systemic symptoms
Feeding difficulties
Complicated GORD (weight loss, anaemia)

Investigations

Robyns Peak flow: 350L/min


o Predicted (420L/min)
o Highly related to height
o Reduced air flow consistent with airway obstruction
o See if responsive to bronchodilator (Ventolin, salbutamol):
permanent (chronic bronchitis), reversible (asthma)
Spirometry
o Flow-volume curve: measures amount of air going in and out
o Reversible airway disease
o Someone with restrictive lung volume can still have normal peak
flow (e.g. pulmonary fibrosis)

Provisional diagnosis

Asthma
Explaining to patient:

Suggested management

Mild to moderate asthma


Inhaled beta agonist
o Device and advice
Acute flare-up
o Oral steroids
Side effects: bruising, cushingoid, increase blood pressure,
predispose to diabetes etc.
Longer term? preventative
o Long-acting beta 2 agonist
o Inhaled glucocorticoids
Alter migraine medication

Management of other likely diagnoses

Rhinosinusitis (+ nasal polyps)


o Intra nasal steroid
o Saline irrigation
Rhinosinusitis (- nasal polyps)
o Saline irrigation
o +/- Antihistamine
o +/- Intranasal steroids
GORD
o Behavioural management
o Alginate/antacid
o PPI

Probability-based diagnosis of chronic cough

Adults
o Asthma
o Rhinosinusitis
o ?? reflex??
Etc.

Remediable conditions: not to be missed

Protracted bronchitis (chronic)


Asthma
GORD
Bronchiectasis
o In people with chronic lung infections
ACEI
Infection TB, abscess, rhinosinusitis

Look out for

Neoplasia
o Even in non-smokers, esp. small cell
Parenchymal disease
o COPD, fibrosis, bronchiectasis, sarcoid
Infection
o TB, pertussis
Cardiovascular disease
o LVF, thromboembolism

Cough

Is common
Chronic persistent cough >8 weeks
Explore causes
Retain a list of worrying symptoms
Think of medication reactions
Keep an open mind

ANTT, Wound Care and Hand Hygiene


Wound Care
Principles of aseptic technique

Planning (ensure logical and safe sequence)


Hand hygiene
Gloves (sterile/non-sterile)
Personal protective equipment (gown/apron, mask and eye protection)
Environment management (procedure area/equipment are clean)

Two types of aseptic technique

Surgical aseptic non-touch technique (surgical ANTT)


o Used when performing invasive or complexed clinical procedures
whereby involves large open key sites or large or numerous key
parts
o Use sterile gloves

Where any contact with sterile items, sterile tips etc. is unavoidable
or inevitable
Standard aseptic non-touch technique (standard ANTT)
o Used when performing simple, short and uninterrupted procedure
o Requires non sterile glove and aseptic field
o Procedures where contact with critical sterile points is evitable
o

Types of wound

Epithelial = pink
Granulation = red
Slough = yellow
Infected = green
Ascar? = black

Signs & symptoms of wound infection

Acute
o Local inflammation
o Increased exudate
o Pus formation
o Pain
o Heat
o Systemic: increased temp, malaise
o Increased WCC
o Culture?
Chronic
o ??

Collecting a wound swab

Clean & debride prior


Non touch technique
Swab centre of wound for 30s
Swab clean exposed granulation tissue if possible

Infection Control

Sources of information
o Policies see intranet
o Infection control communication sheets
o Flagging system of patient front sheet - Alert box on CR1
Majority of hospital acquired infections are preventable
Infection control breaking the chain
o infectious agent reservoirs portal of exit means of
transmission portal of entry susceptible host infectious
agent (cycle)
o infectious agent e.g. MRSA (methicillin resistant staph aureus)
o reservoir e.g. flagged patient
o means of transmission e.g. hands, environment, equipment
o portal of entry e.g. wounds, basic dermoses (cannulas, catheters)
o susceptible host e.g. immunosuppressed, most of patients in
hospital
Infection control process
o Two-tiered approach

1st tier Standard Precautions includes those precautions


designed for the care of all patients, regardless of their
diagnosis or presumed infection status
2nd tier Additional Precautions that are applicable only to the
care of specific patients
Standard Precautions
o Apply to all patients regardless of their diagnosis or presumed
immune status
o For blood, all body substances, excretions, secretions except sweat,

o Etc.
Hand hygiene 5 moments

Assessments in Phase 3 [Anthony OSullivan]

To graduate, you must pass:


o All courses
o Phase 3 biomed
o Phase 3 ICE in all disciplines
o Phase 3 portfolio
Phase 3 assessments
o Course assessments
Learning plans
Combination learning contract and supervisors
assessment
Mini-CEXs, T-Mex
Courses specific assessments
o Phase assessments
QUM assignment: during Medicine Course
Indigenous assignment by TP1 year 6
Primary Care Teamwork project
Completion of the Clinical Skills Log Book
National Prescribing Curriculum modules
o Major assessments
Biomed Viva end of year 5
Phase 3 Integrated Clinical examination
Phase 3 Portfolio examination

Biomed viva

Overview:
o 4 stations
o Scientist and clinical examiner
o Questions about specific discipline in a clinical context
o Scans, x-rays, histology
Station types
o A: Campus-based Anatomist + Hospital-based clinician
o B: Examines knowledge gained from hospital diagnostic laboratory
visits and laboratory medicine. Staffed by any Campus-based
Biomedical Scientist + Hospital-based Haematologist/Clinical
Chemist/ Microbiologist/ Immunologist/ Anatomical Pathologist

C: Examines knowledge gained from macroscopic Pathology


demonstrations and Pathology. Staffed by a Campus-Based
Pathologist + Hospital-based clinician
D: Pharmacologist + Hospital-based clinician

Phase 3 ICE

Three components
Etc.

Approach to a patient with palpitations [Terry Campbell]

History
o Describe
o Tap out
Words mean different things to different people
Correlation between palpitations and arrhythmia not good
Examination
o Pulse
Irregularity may be normal in quite a few children and
young people. With age, irregularity increasingly becomes a
sign of abnormality.

o JVP
o Auscultation
o BP
Investigations
o ECG
o Holter
o Longer-term recording options
o Assessment of co-morbidities (echo, angiography etc)
Management
o Reassurance
o First do no harm
o Anticoagulation issue
o Beta-blockers
o AAD
o Interventional EP