Counselling: Trial of Scar

1. Introduce yourself
   
2. Confirm the patient's name and problem
   
3. Inform the patient that it is good to have her husband together during the discussion
   
4. Ask patient whether she knows about her condition, any preference in her option
   
5. Inform the patient of the options that she has:
   
   • vaginal delivery --> Trial of Scar 
   • LSCS
     
6. Tell patient that we need to assess the patient condition first whether the condition is favourable for:
   • any short stature -->CPD 
   • pelvic cavity size 
   • exclude placenta previa 
   • exclude other contraindication
     
7. Explain that there is risk in every procedure
   • risk of scar dehiscence 0.5% (if use oxytocin 0.8%, if use prostaglandin 2.45%)--> Therefore need to deliver in tertiary hospital where OT ,NICU and blood bank available
   •  we will monitor her closely (baby and vital sign to see sign of uterine rupture ie tachycardia, hypotension, vaginal bleeding, sudden loss of contraction, scar tenderness, continuous abdominal pain in between uterine contraction) 
   • can give option to patient for epidural 
   • however there is still risk of failed TOS --> need to proceed to LSCS
     
     
8. Explain pro and con TOS
   • fast recovery 
   • but we don’t know exact time for delivery, need to see progress of labour
     
9. Explained another option (LSCS), also explained pro and con
   • risk of adhesion lead to difficult surgery 
   • risk of injury to bowel and bladder 
   • risk of bleeding and blood transfusion 
   • the advantage is operation is done in planned environment 
   • explain that 2nd LSCS will limit family size 
   • if want to do BTL, can do together 
   • explained that the next pregnancy should be manage by LSCS
     
10. Give opportunity to patient to ask any further questions
    
11. Ask patient preference whether have decided or not
    
12. If can’t answer question from patient, get an appointment to refer patient to senior colleague or consultant for better picture
    
13. Provide patient pamphlet for any further information

Source: Teaching with dr nasir (this is one of osce question for pro exam last year,2010)

Hanisah A115275

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Counsel for blood transfusion

1. Introduction

-To patient and verify patients identity

-Include husband if husband is around

1. Ensure privacy

2. Explain current condition and indication

-Pre-existing anaemia

-Primary PPH

-Post-partum Hb 6g/dL

-She got symptomatic anaemia

3. Explain procedure

- Cross match blood

- Infection screening of blood product : HIV, HepB, HepC

- Transfuse 2 pints of pack cells

- Duration 6 hours/pint

- Diuretic in between to prevent fluid overload

- Repeat FBC after transfusion

4. Explain complication

- acute transfusion reaction

-blood-borne disease : HIV, HepB, HepC

- ABO incompatibility

-volume overload

- need for further transfuse if Hb level not satisfy

5. If patient refuse???

- ask the reason why?

-re-explain and convince the patient

- explain the complication of anaemia : heart failure

- if patient still refuse --> refer to other doctor / specialist

source: workshop

hanisah A115275

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Counsel for pap smear

1. Introduction

2. Ask patient if she know what we will do

3. Explain indication

-screening tool for cervical Ca

-yearly for two years,if normal then three yearly

- age 20-65 / once sexually active

4. Explain procedure

- duration is about 5-10 minutes

-no analgesia/ LA/ sedation given

- patient will feel uncomfortable during the procedure

-this is sterile procedure, wash hand,do aseptic technique, wear sterile gloves

- in dorsal position with open leg

- clean the perineum first with sterile water

- do bimanual palpation to know the position of cervix

- insert the Cusco speculum

-visualize if there is any lesion or abnormality if vulva/vagina/cervix

-use Ayre’s spatula to take sample

- rotate the spatula 360⁰

-put the smear on the slide

-make sure the slide have name and RN

- fix the slide with cytofix/ alcohol

-send the slide to lab

-then remove the speculum

-the procedure is finish

5. Explain complication of procedure

-spotting

-if having heavy bleeding come to hospital ASAP

-infection

6. Result

- ready in 1-2 weeks

- if normal, we don’t call. But if abnormal,we will call

- futher management will be done if any abnormalities detected

7. Ask patient if any question

source: workshop and dr. nasir

hanisah A115275

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Consent for Dilatation & curettage

1. Introduction

2. Confirm the diagnosis

3. Tell the patient indication for the procedure – to remove retained POC

4. Explain the procedure

- this is aseptic procedure

- duration 15-30 minutes

- NBM at least 6 hours before procedure (ask last meal)

- give patient IV drip

- anaesthetist will review patient before operation to choose mode of GA/ regional

- done in operation theatre

- in lithotomy position

- clean and drape

- bladder catheterization

- vaginal examination to see os open/ close

- bimanual examination to know uterus size and position of cervix

- insert Sim’s speculum to visualize the cervix

-Use vulsellum to grab anterior lip of cervix

- insert uterine sound to measure length of uterocervical canal

- if os is closed, dilate with Hegar dilator – use from 3mm – 8mm

- ovum forceps is inserted to remove POC

- use blunt curate to remove POC

-Ask anaesthetist to give IV pitocin 40 unit to make sure uterus is contracted and hard so not easily perforated

- use sharp curate until gritty sensation is felt

- hemostasis secured

-remove vulsellum

-send POC for HPE

- count for estimated blood loss

5. Explain complication to the patient

Short term

- uterus perforate

-Bleeding

-infection

Long term

-adhesion,difficult to conceived

-Asherman syndrome

-placenta previa,placenta accrete

6. Ask patient is she has any enquiries

source: workshop

hanisah A115275

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Manual removal of placenta (MRP)

· Failure to deliver the placenta within 30 minutes after delivery of the fetus

· Management :

- monitor vital sign

-observe if there is sign of placental separation

-continue massage uterus

-if still no sign of separation , call MO

-insert large bore IV access (16-18 gauge)

-take blood and send for FBC & GXM

-do catheterization

- attempt control cord traction, if still failed, take verbal consent for MRP

· Preparation:

1. Give IV antibiotic Flagyl 500mg stat and 400mg TDS + Ampicillin 1 gm stat and 500mg QID for 1 day

2. Ensure adequate analgesia ( GA, epidural ,spinal)

3. If patient already on epidural, procedure can be carried out in LR

· Procedure:

1. Put patient in lithotomy position

2. Clean and drape

3. Scrub and wear MRP gloves

4. Put left hand on abdomen to encourage uterus to contract

5. Re-attempt CCT

6. If failed, the left hand should remain on abdomen

7. Insert right hand into uterine cavity by following direction of umbilical cord

8. If present of constriction ring at lower uterine segment, slowly dilate cervical ring until hand able pass to fundus ( forcefully dilate lead to vasovagal attack)

9. Plane of cleavage is identified

10. Assess degree of adherence and site of attachment of placenta

11. By moving fingers from side to side, this plane of cleavage is extended until whole placenta free from wall of uterus

12. Placenta is then removed

13. Re-explore cavity to make sure cavity is empty

14. Abandoned procedure if there is placenta accrete

15. Give IM syntometrine / IV pitocin to promote uterine contraction

16. Check placenta for completeness

17. Continuous iv pitocin 30units in 500mls NS at rate 125mls/hr infusion for 4-6 hours after procedure to maintain uterine contraction

· Complication

-post partum hemorrhage

-infection

-if placenta accrete --> risk of hysterectomy

source: workshop

hanisah A115275

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Counselling: Couple with Unexplained Infertility

1. Explain to the patient wait and see

- spontaneous conception can occur after – 1 year 85%

2 years 90 %

3 years 92-95%

2. Lifestyle modification

- no smoking

- reduced alcohol consumption – female 1-2 units/week

- male 2-3 units/week

3. Avoid stressful condition

- spacing sexual intercourse 2-3days to make sure increase sperm count and quality of sperm

4. Advice husband

- not taking hot bath or frequent sauna because this can reduced the sperm count

- do not wear tight underwear -->wear boxer

5. Advice wife on cleanliness and hygiene

- if having vaginal discharge,seek treatment ,need to treat infection first

6. Give folic acid supplement to prevent neural tube defect

7. Give other choice to patient if they don’t want wait and see..

- if still young --> can wait

- if getting older --> clomiphene -->IUI --> IVF

source : teaching with dr nasir

Hanisah A115275

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Consent for bilateral tubal ligation

1. Introduction

2. Explain indication

- 3 scar

-age more than 35 and completed family

3. Ask husband to join discussion if he is there

4. Ask patient what she knows regarding BTL

5. First of all, explain that this is permanent and irreversible procedure

6. If she understood and still want to proceed, continue to explain to her

7. If she did not agree,stop the discussion

8. Usually this procedure done together during LSCS, if done in daycare usually laparoscopic

9. Under GA/ CSE / epidural – anaest will review

10. Failure rate of BTL is 1 in 200 people (0.05%)

11. There is many type of BTL

- pomeroy method

-filshie clip/ hulka clip

- ring

-electocauterize

12. Advantage of doing this BTL

-no compliance issues anymore for contraception

-not disrupt in sexual intercourse

- no hormonal manipulation

13. Correct any myth

- patient always think that BTL = menopause : explain that we don’t remove ovary, so hormone still release as usual,and they will have period normally

- they also think that this will decrease libido : explained that it is not related

14. Explain complication

-failure of BTL : ectopic pregnancy ( if missed period, come to check for UPT)

(due to recanalization and fistula formation)

-bleeding

-infection

-injury to bladder and ureter

source: ward round wad merah and dr nasir

hanisah A115275

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Consent for elective caeserian section

1. Introduction

2. Explain indication

- breech presentation

-previous scar

-placenta previa major

-macrosomic baby

-unstable lie

-fibroid / cyst obstructing the lower segment

3. Explain on procedure

- we will give admission form to admit to ward one day prior to operation

- ELSCS at 38 weeks

-fasting start at 12MN

-blood taking for FBC and GXM 2 pints pack cells

-also take consent for blood transfusion and hysterectomy in case anything happened

-CBD will be inserted in the morning before operation

-prophylaxis antibiotic will be given

- operation done by epidural/ CSE – anaest will review before operation

-duration 30-45 minutes

- lower abdomen will be cut for 10cm, baby out, placenta out, sutured

4. Explain complication

Early

- anaesthetic complication : nausea, vomiting, headache

-bleeding / PPH

- injury to bladder/ colon

-infection

Late

-decrease family size, limit to 3 lscs only

- adhesion

-next pregnancy LSCS

5. Postpartum

- 3 days monitoring in the ward for any bleeding

-give prophylaxis s/c heparin 5000iu thromboprophylaxis

-Wound inspection at day2

-monitor urine output, CBD will be romeved if patient can ambulate well

6. Advice patient on contraception

- need to have good spacing 2 years

- use contraceptive device that has good pearl index

-ensure patient compliance

-TCA 6 weeks at family planning clinic

7. Ask for any enquiries

sources: teaching with dr nasir

hanisah A115275

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CEREBELLAR DISORDER

COMMON CAUSES OF CEREBELLAR SYNDROMES

Acute (hours to days)
Cerebellar infarcts (Wallenberg / PICA syndrome)
Cerebellar hemorrhage
Encephalitis
Phenytoin toxicity

Subacute (weeks to month)
Alcohol abuse
Metastases
Paraneoplastic syndromes
Multiple sclerosis

Chronic (months to years)
Hereditary cerebellar degenaration (spinocerebellar ataxia)

=================
SHORTCASE
=================

UPPER LIMB (4)
1. arms outstretched and eyes closed --> limb of affected side DRIFT AWAY
2. arms outstretched, same level, quick push downward --> affected side REBOUND
3. finger-nose test --> INTENTIONAL TREMOR + DYSMETRIA
4. rapid alternating movement --> DYSDIADOCHOKINESIA

HEAD (3)
1. Eye --> HORIZONTAL NYSTAGMUS (> when look toward affected side)
2. Speech --> SCANNING/STACCATO
3. Head --> TITUBATION

TRUNK (1)
1. Sit patient up without support --> TRUNCAL ATAXIA

LOWER LIMBS (2)
1. Heel-shin test --> DYSMETRIA + INTENTIONAL TREMOR
2. Knee reflex --> PENDULAR KNEE JERK

GAIT (2)
1. Walk --> BROAD BASE + REEL TOWARD AFFECTED SIDE
2. Rombergs test --> NEGATIVE (in cerebellar disorders)

--------
Notes
--------

Unsteadiness + broadbase gait
= ?cerebellar OR ?vestibular OR ?proprioceptive

Vestibular
nystagmus; no other definite cerebellar signs; romberg negative

Proprioceptive
cerebellar sign may present; typically worse when eyes closed; romberg positive

Cerebellar
cerebellar signs; romberg negative

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Neuroleptic Malignant Syndrome

Mnemonic

FALTER

F - fever

A - autonomic instability

L - leucocytosis

T - tremor

E - elevated CPK

R - rigidity

medical emergency!!!but rare

and NOT an allergic reaction

those who take HIGH POTENCY antipsychotic (eg: Haloperidol, Fluphenazine, Pimozide)

How to manage?

1. DISCONTINUE treatment
2. Supportive therapy
3. Pharmocotherapy

- Benzodiazepines

- Bromocriptine

- Dantrolene

- Amantadine

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Cincinnati Stroke Scale

if 1 findings abnormal : probability having stroke >72%
if 3 findings abnormal : probability having stroke >85%

this scale usually use in prehospital setting.

Once the diagnosis of stroke is suspected, time in the field must be minimized.

The presence of a patient with acute stroke is a “load and go”.

A more extensive examination or initiation of supportive therapies should be accomplished en route to the hospital.

another similar name :
FAST (facial, arm, speech test)

p/s : doctor in emergency department apply this scale during patient's arrival to ED during my oncall shift in Red Box. So i think we can also use this scale to quickly assess probability of having stroke so that we can decide our further management.

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6H's & 5T's

reversible causes associated with cardiac arrest

6H
Hypoxia
Hypovolemia
Hypothermia
Hypo/Hyperglycemia
Hypo/Hyperkalemia
H2 (acidosis)

5T
Tension pneumothorax
Tamponade (cardiac tamponade)
Thrombosis (pulmonary embolism / MI)
Trauma
Toxin

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SEVEN PRIMARY MASQUERADES

Seven Primary Masquerades (John Murthagh)

1. Depression
2. Diabetis Mellitus
3. Drugs
- iatrogenic
- self abuse (alcohol, narcotics, nicotine, others)
4. Anaemia
5. Thyroid and other endocrine disorders
- hyperthyroidism
- hypothyroidism
6. Spinal dysfunction
7. Urinary Tract Infection (UTI)

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Suicide Risk Assessment (SAD PERSONS) - UPDATED

Score >7 = high suicide risk

--------------------
MANNED OSCE
--------------------

1. Have you attempted suicide?
# A : No --> low risk
# B : Yes --> higher risk

2. Have you thought about dead?

3. Have you thought about suicidal (suicidal ideation)?
# No : lower risk
# Yes : higher risk

4. If yes to questions (3) :
# what kind of thought?
# method? (> serious/dangerous method, > higher risk)
# how often you thought of it?
# any specific plan?
# have you told others about the plan?
# have you actually ever attempted? (to reconfirm back with patient)
# what stop you from attempt suicide? (protective factors)
# have you make any suicidal note?
# have you make the will?
# conditions
***if patient method is to drink paraquat, have he bought the paraquat?
***if patient want to jump from high places, ask him whether he live in terrace, condo, apartment

5. ask this to patient who had attempt suicide previously (additional)
# what is the method? evaluate how dangerous is the method
# what is the chance of dying? (lock door, nobody at home, alone, etc...)
# what is the chance of rescue? (anybody at home? has tell others? etc..)
# intention of attempt? (very high? not really want to attempt?)
# what is his/her feeling after being rescued? (relief? angry to the rescuer? etc..)

6. ask to all (other factors)
# psychotic illness?
# severe depression
# alcoholism / substance abuse
# physical illness
# severe stressor
# no support
# live alone
# others.......

So evaluate this patient suicide risk subjectively based on the answers you get prof the patients.
Use logical thinking. ^_^

Teaching from Prof Maniam.
A115262.

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FOOT CARE IN DIABETIC PATIENT

Keep diabetis under good control and do not smoke.

Check your feet daily. Report any sores, infection, or unusual signs.

Wash your feet daily.
Use lukewarm water (beware of scalds)
Dry thoroughly, especially between toes
soften dry skin, especially around the heels, with ?lanoline
apply methylated spirits between toes to help stop dampness

attend to toenails regularly
clip them straight cross
do not cut them deep into the corners or too short across

wear clean cotton or wool socks daily; avoid socks with tight elastic tops

exercise the feet each day to help the circulation in them

avoid injury to the foot
wear good-fitting, comfortable leather shoes
shoes must not be too tight
do not walk barefoot, especially ot of doors
do not cut your own toenails if you have difficulty reaching them or have poor eyesight
avoid home treatments and corn pads that contain acids
be careful when you walk
do not use hot water bottles or heating pads on feet
do not test the temperature of water with your feet
take extra care when sitting in front of an open fire or heater

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Causes of unilateral leg swelling:

Vessel - Artery - acute limb ischemia
Vein - Chronic venous insufficiency (varicose vein), DVT, post-phlebitic leg synd
Lymph - lymphedema (non pitting)
Bone - # , tibia osteomyelitis
Soft tissue - swelling (post-trauma - knee sprain/injury, gastrocnemius muscle tear/haematoma, cruciate knee ligament tear)
Skin - cellulitis
Tumor - osteosarcoma (compression of large veins by tumor)
infection eg filariasis
others:
necrotising fascitis
compartment synd
Ruptured baker's cyst

find it easier to rmb based on the anatomical structure thr:)
Hope it helps:)

Posted by CP,
feel free to comment if i am wrong and if thr's any additional info pls feel free to add:) TQ!

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