Antedates

Ice antidotes

||Ecstasy poisoning #

@Ecstasy is a semi-synthetic, hallucinogenic substance =(MDMA, 3,4-methylenedioxymethamphetamine). @Its effects range from= nausea, muscle pain, blurred vision, amnesia, fever, confusion, and ataxia to tachyarrhythmias, hyperthermia, hyper/hypotension, water intoxication, DIC, K+↑, acute renal failure, hepatocellular and muscle necrosis, cardiovascular collapse, and ARDS. @There is no antidote and treatment is supportive. Management depends on clinical and lab findings, but may include:=

 Administration of activated charcoal and monitoring of BP, ECG, and temperature for at least 12h (rapid cooling may be needed).  Monitor urine output and U&E (renal failure p293), LFT, CK, FBC, and coagulation (DIC p336). Metabolic acidosis may benefit from treatment with bicarbonate.  Anxiety: diazepam 0.1-0.3mg/kg PO. Max IV does over 2min.  Narrow complex tachycardias in adults: consider metoprolol 5-10mg IV.  Hypertension can be treated with nifedipine 5-10mg PO or phentolamine 2-5mg IV. Treat hypotension conventionally (p778).

JVP

Jugular venous pressure (pulse)
Causes of an elevated central venous pressure
Right ventricular failure
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
Superior vena caval obstruction
Fluid overload
Hyperdynamic circulation
Wave form
Causes of a dominant a wave
Tricuspid stenosis (also causing a slow y descent)
Pulmonary stenosis
Pulmonary hypertension
Causes of cannon a waves
Complete heart block
Paroxysmal nodal tachycardia with retrograde atrial conduction
Ventricular tachycardia with retrograde atrial conduction or atrioventricular dissociation
Cause of a dominant v wave
Tricuspid regurgitation
x descent
Absent: atrial fibrillation
Exaggerated: acute cardiac tamponade, constrictive pericarditis
y descent
Sharp: severe tricuspid regurgitation, constrictive pericarditis
Slow: tricuspid stenosis, right atrial myxoma

Causes of postural hypotension

Causes of postural hypotension


Hypovolaemia (e.g. dehydration, bleeding)
Drugs (e.g. vasodilators and other anti-hypertensives, tricyclic antidepressants, diuretics, antipsychotics)
Addison's* diseaseHypopituitarismAutonomic neuropathy (e.g. diabetes mellitus), amyloidosis, Shy-Drager syndrome)Idiopathic orthostatic hypotension (rare progressive degeneration of the autonomic nervous system, usually inelderly men)

During is a synonym for as

As the novel pandemic influenza A (H1N1) virus spread around the world
in late spring 2009 with a well-matched pandemic vaccine not immediately
available, the question of partial protection afforded by seasonal influenza
vaccine arose.

answer is b. During spring 2009 not c. after spring 2009

Mix or swith idea make false statement

which statement is false:
a. Participating in how one's own country is run should be left to the alert and educated.
c. People being required to vote, to participate in the decision making process, is a good idea

Of those who do take the time to register and vote, few are sufficiently alert and/or educated to vote with intelligence, thought, and compassion. Requiring participation in the governance of one's own country is not a bad idea.

a -> false. both statement are talking about governing.

Vaccination edu

When a healthy person becomes infected with a virus, eg. measles, the body recognises the virus as an invader, produces antibodies which eventually destroy the virus and recovery occurs. If contact with the measles virus occurs again in the future, the body’s immune system ‘remembers’ the measles virus and produces an increase in antibodies to destroy the virus.

Vaccination is the process that is used to stimulate the body’s immune system in the same way as the real disease would, but without causing the symptoms of the disease. Most vaccines provide the body with ‘memory’ so that an individual doesn’t get the disease if exposed to it.

Vaccination conveys immunity to diseases by a process called active immunity, which can be achieved by administration of either inactivated (ie. not live) or live attenuated organisms or their products. Live vaccines are attenuated, or weakened, by growing the organism through serial culturing (or passaging) steps in various tissue culture media. Inactivation is usually done using heat or formalin (sometimes both). Inactivated vaccines may include the whole organism (such as oral cholera vaccine), the toxin produced by the organism (such as tetanus and diphtheria vaccines), or specific antigens (such as Hib and pneumococcal vaccines). In some cases, the antigen is conjugated (ie. chemically linked) with proteins to facilitate the immune response. Inactivated viral vaccines may include whole viruses (such as IPV and hepatitis A vaccines) or specific antigens (such as influenza and hepatitis B vaccines). Live attenuated viral vaccines include MMR, rubella, varicella and yellow fever vaccines.

Immunity can also be acquired passively by the administration of immunoglobulins. Such immunity is immediate and is dose-related and transient. For example, measles or hepatitis B immunoglobulin can be used promptly after exposure in an unimmunised person to help reduce the chance of catching measles or hepatitis B from the exposure.

Similar condition follow initial presentation

Otherwise well apart from, unremarkable other than ...

I am writing to refer Mrs. Starkovic, a patient of mine to you. Mrs Starkovic is married with two children and is currently suffering from cholelithiasis. She is otherwise well apart from a history of migraines.

Mrs. Starkovic initially presented on 20/01/07 with a ten-day-history of radiating epigastric pain to the right side after dinner and nausea. The previous night, 19/01/07, she had similar pains but more severe which lasted for two hours. She also vomited once. Her physical examination was unremarkable, other than the mild tenderness on the right upper quadrant of the abdomen.. Liver function tests and a biliary ultrasound were carried out.

On review today, the patient reported that she had not experienced any further attacks.. Her investigations showed mildly elevated alkaline phosphate, a small contracted gallbladder and multiple gallstones. Please note, Mrs. Starkovic is anxious about the possibility of cancer about which she was reassured.

I would appreciate your assessment and management in view of a possible cholecystotomy.

Relavant history following initial presentation

I am referring Mrs Howard who is suffering from an early bowel obstruction due to possible diverticulitis or carcinoma. She has a past history of an ovarian cystectomy and an appendicectomy, as well as a possible spontaneous abortion on 09/01/07.

Mrs Howard initially presented with a two-day history of lower abdominal pain on 20/01/07. This sharp and constant pain came on suddenly and was worsened by changing position but relieved by Valium. An examination found tenderness in the left lower quadrant of the abdomen and a palpable vague mass. Mrs Howard reported a similar pain occurred in December last year, and her last period was in October 2006. Consequently, a pregnancy test and blood tests were carried out. One day later, Mrs Howard reported passing a hard stool coated with bright red blood after three days of constipation.

On review today, Mrs Howard reported worsened symptoms after meals and a failure to pass flatus and stools. Bowel sounds were absent on examination, and the blood tests showed anaemia (haemoglobin 9.3 g/dl, mild left shift).

I consider Mrs Howard is suffering from an early bowel obstruction possibly due to diverticulitis or carcinoma and needs specialist assessment. I would be grateful if you could take over Mrs Howard’s case for surgical management.

Sciatica

Sciatica...sciatic nerve...Sciatica can be brought on by sitting on a hard seat...into the back of the thigh and leg...prolapsed or 'slipped' discs tend to bulge and press on the intervertebral nerve...by narrowing of the nerve tunnel between discs due to osteoarthritis...

Hot pain in the buttock ...

Aching in the buttock...

Pins and needles ...

Lumbar vertebrae are vulnerable to injury ...

Sleeping on a mattress that is neither too soft, nor too hard ...

Ergonomic furniture, such as chairs with lumbar support ...

Traction...

Manipulative therapies such as chiropractic or osteopathy ...

Chemonucleolysis injection of a special enzyme...

Alternative therapies including acupuncture ...

'partial discectomy'...

Tertiary students - healthy eating

Your food cupboard

•     Soups- easy to make and nutritious, especially if you add lots of vegetables, beans or
lentils. You can use canned or packet soup as a base and add your own herbs, spices and
leftovers.
•     Pasta- quick and easy to prepare. Keep pasta sauces in your cupboard and add your own
variations and flavours.
•     Rice- try making fried rice or risotto, or mix cooked rice with leftover vegetables and meat.
•     Beans and lentils - canned varieties can make a quick and nutritious addition to soups
and stews. Lentils and beans can be used as a main meal with vegetables added.
•     Vegetables and fruit- make vegetable curries, stir-fries and vegetable patties and soups.
Canned and frozen vegetables make a handy addition to last minute meals. Fruit is good
for a quick nutritious snack.
•     Meat and fish- tinned tuna is a great cupboard stand-by. Shop for cheap cuts of meat for
stews and casseroles.
•     Condiments- add flavour and interest to your cooking. Keep a selection of dried herbs,
spices, curry powder, vinegars, tomato sauce, soy sauce and stock cubes in your cupboard.

Writing - Which comes first? First presentation or Past history

If past history and general info are short and simple, write them first.
I am referring this patient, a widower, who is presenting with symptoms consistent with a bilateral inguinal hernia. He has been suffering from hypertension for 5 years for which he takes Noten, Aspirin and multivitamins. He is allergic to penicillin.

Otherwise, put current urgent thing first like emergency:

Thank you for seeing my patient, Margaret Leon, who has been very concerned about blood in her stools. She has seen blood in the toilet bowl on two occasions after bowel motion. She is very anxious and as well as that depressed because her father died of bowel cancer and she feels she may have the same condition.

Margaret has otherwise been quite healthy. She does not drink or smoke and is not taking any medication. She was slightly overweight six months ago with borderline high blood pressure.

or mixed history with initial presentation

I am writing to refer this patient, a 40 year old married man with two sons aged 3 and 5, who requires screening for prostate cancer.

Initial examination on 09/07/09 revealed a strong family history of related illness as elderly father was diagnosed with prostate cancer and mother was diagnosed as hypertensive.

referal ectopic pregnancy.

17.02.09

Patient History

Miss Cathy Jones - 25 year old single woman
Occupation - receptionist
Family history of deep vein thrombosis
On progesterone-only pill (POP) for contraception
No previous pregnancies

15.02.09
Subjective  

Presents to GP surgery at 7 pm, after work
Complains of lower abdominal pain since the evening before, worse in right iliac fossa
Unsure of last menstrual period, has had irregular bleeding since  starting 
POP 2 months ago,  New partner for past 2 months
No bladder or bowel symptoms

Objective      

Mild right iliac fossa tenderness, no rebound / guarding

Apyrexial, pulse 88, BP 110/70                                
Vaginal examination - quite tender in right fornix. No masses

Assessment

Non-specific abdo pain

Plan: Asks her to return in morning for blood test and reassessment

16.02.09

Subjective

Pain has worsened overnight. Now severe constant pain.
Some slight vaginal bleeding overnight also.
Felt faint while waiting in reception.
On questioning, has left shoulder-tip pain also.

Objective     

Very tender in the right iliac fossa, with guarding and rebound tenderness
Apyrexial, Pulse 96, BP 110/70
On vaginal examination, has cervical excitation and markedly tender in  the right fornix.
Pregnancy test result positive
Urine dipstick clear

Assessment    

Suspected ectopic pregnancy

letter:

Thank you for seeing this 25 year old woman who I suspect has an ectopic pregnancy.

This is her first pregnancy. She presented to the surgery yesterday evening with vague lower abdominal pain. She started the progesterone-only pill for contraception two months ago, when she started a new relationship, and has had some irregular bleeding since then. Therefore she is unsure of her exact last menstrual period. Yesterday, she was mildly tender only and her observations were normal.

However, on review this morning her pain had worsened overnight, she is very tender in the right iliac fossa, with rebound and guarding, and on vaginal examination there is cervical excitation, and marked tenderness in the right fornix. Her pregnancy test is positive.

I am concerned that she may have an ectopic pregnancy, and would appreciate your urgent assessment.

Please keep me informed of the outcome.

History taking

Autistic Disorder

Table 84.2 A guide to the diagnosis of autistic disorder (after Tonge)⁸

1 Onset during infancy and early childhood.

2 An impairment of social interactions shown by at least two of the following:

• lack of awareness of the feelings of others

• absent or abnormal comfort seeking in response to distress

• lack of imitation

• absent or abnormal social play

• impaired ability to socialise, which may include gaze avoidance

3 Impairment in communication as shown by at least one of the following:

• lack of babbling, gesture, mime or spoken language

• absent or abnormal non-verbal communication

• abnormalities in the form or content of speech

• poor ability to initiate or sustain conversation

• abnormal speech production

4 Restricted or repetitive range of activities, interests and imaginative development, shown in at least one of the following:

• stereotyped body movements

• persistent and unusual preoccupations and rituals with objects or activities

• severe distress over changes in routine or environment

• an absence of imaginative and symbolic play

5 Behavioural problems:

• tantrums

• hyperactivity

• destructiveness

• risk-taking activity

 

 

The earliest signs of autistic spectrum disorder in infancy include:⁷

• excessive crying
• no response to cuddling if crying
• failure to mould the body in anticipation of being picked up
• stiffening the body or resisting when being held
• no babbling by 1 year
• resistance to a change in routine
• appearing to be deaf
• failing to respond or overacting to sensory stimuli
• persistent failure to imitate, such as waving goodbye
• a need for minimal sleep
• no single words by 16 months

The diagnosis remains difficult before the age of 2 years.

Latter features:

• fascination with certain toys/objects
• poor interaction with other children
• not pointing to objects, e.g. grabs parent's hands to show things

Second

2

I want to be