Page 1 of 1: seven sister material part 5

sajida · Credits: 106680 My Scrapbook My Reading List 6 Books

Q.66 a patient is planned for operation for ingrown toe nail. You performed routine FBC, and found out MCV to be high, and suspect alcoholism. Take alcohol history.
Introduction, then you may start by saying: “You may remember that we ran some tests. Well we have got them back and there is something we just need to check before we go any further. Do you mind if I ask you few questions about your daily routine. What you eat, drink, and such questions?
What did you have for breakfast today? Is it your usual breakfast? What do you have for lunch? Do you enjoy anything with your meals? Do you drink at all?
Go through average day of drinking. Ask about type of drink. Amount, ask if the patient mixes drinks, and ask about drink in weekends.
Where do usually drink? With whom? How long can you go without having something to drink? Have you ever considered cutting down? Are you annoyed by people comments on your drinking? Have you ever felt bad or guilty about drinking? Have you ever had a drink the first thing in the morning to get rid of hang over? (Eye opener).
Cutting down, Annoyed, Guilt, Eye opener (CAGE), if the patient has 2 or more it means he/she has an alcohol problem.
Ask the patient: Can you always control your drinking? Has alcohol led you to neglect your family? Have you been in trouble with law? At what age did you start drinking? Did you seek help to stop drinking? Dou you have any disease? Do you use any medication? Is there any disease in the family?

Q.67 a patient with running nose. You suspect morphine addiction. Take history and explain complications.
Introduction, then you may say: “As far as I know, you have running nose. I would like to ask you few questions about your condition.
For how long have you had this? Is it the first time or you had this before? Did you notice anything that brings on the running nose? Do you have any other complaints? If no response, then:
Do you smoke? Do you drink? Do you take anything else besides drinking to enhance your mood? Do you inject any drug? How long have you been using this drug? Is it continuous or you stop from time to time? How do you use drugs? Injection? Sniffing? Where do you usually use drugs? Do you share needles? Do you have a partner? Does she/he use drugs? How do you finance your drugs? Any problem at home? At work? With law?
Well Mr. (the patient), Drugs can cause many problems and can affect health:
1. There are the complications of the drug itself: as feeling sick, being sick, constipation, sleepiness, it also affect respiration, and in high dose it may cause the respiration to stop. And it may cause problems with vision. And difficulty in passing water.
2. There is another problem, when you use the drug for long time, you get what we call dependence; that when you do not use the drug you get irritable, and feel craving for it and also get running nose, running eyes, tummy pain, loose motion, yawning, disturbed sleep and muscular pain.
3. Then there is the problem of injections, if the drug user shares needles he/she may catch disease such as AIDS, liver disease, also chest infection, and infection of the heart lining.
4. Finally, using drugs can cause you financial problems, and problem with law.

Q.68 A patient with lymphoma. Complaining of pain not relieved by Ibuprofen. You are going to put her on morphine. Tell her.
Introduction, and then: “As you know you have lymphoma and we have been treating you with Ibuprofen, for pain relief. But you still have pain so we are going to put you on morphine, which is stronger.
I would like to tell you few things about this drug. Morphine is very good analgesic and we will start to give you one tablet every 4 hours until you get complete relief of pain. Then we will change to one tablet twice daily with the same dose of a longer acting medicine. (Sustained release).
In some cases, Morphine cannot be taken by mouth, then we can give it by muscle injection or injection into blood (IV injection) or can be given underneath the skin injection by syringe driver.
Like any medication, Morphine has some side effects, such as feeling sick, being sick, should this happen we can give you drugs to overcome it. Other side effects, like dry mouth, and this is overcome by artificial saliva. Constipation is another side effect, to avoid it we advice you to eat lot of vegetables and fruits especially those with high fibers, and even we can give you some laxatives. Other side effects are sleepiness, and respiratory depression, which occurs only in high doses.
Also this medication may cause difficulty to pass water and should this happen try to go to toilet and turn on the tap, relax and you may pass water. But if it did work you should come to hospital.
Is everything clear? Are there any questions in your mind you want to ask?

Q. 69 a patient, started recently on Dothiepin (TCA), is not feeling well. Counsel.
Introduction, then: “How can I help you? Do you take the medication regularly?”
As we have told you before, this medication takes sometimes to work, around 2-4 weeks. And as you take the drug regularly you will find improvement. The first thing you will notice, is that your sleep will be better, and then you will get improvement in appetite, mood, sex drive, concentration and so on. Just keep taking the medication and you will be much better.
Another thing is about the side effects, which we discussed before, but just I want to remind you that you may feel sick, or even been sick and in such case we can give you some medication to overcome that.
You may feel some dryness in your mouth, and to relief this we may give you artificial saliva. If you complain of constipation, I advice you to eat lot of vegetables and fruits containing fibers, and if this doesn’t work we can give you laxative. If you get blurring of vision, or sleepiness then you should avoid driving or being in high places. You may feel dizziness on standing, so try to stand up slowly from lying position. You may get difficulty with passing water, and in such case, turn on tap, and relax, should this not help, come to hospital.
There are some other side effects but rare, I need just to mention them to you: arrhythmia (disturbance of the electricity of the heart), and fits (convulsions).
Is everything clear? Do you want me to repeat anything for you?

Q.70 Examine the breast.
Introduction, and then you may say: “I would like to examine your breasts, is it ok with you?”. Ask for chaperon, ask to undress to the waist and draw the curtains to ensure privacy with the patient.
Inspection:
1. With both hands resting on the pages , look for asymmetry, swelling, skin dimple, change in colour, dilated veins, and nipple discharge or nipple retraction or in drawing.
2. With both hands pressing firmly on hips, check for any changes.
3. With both hands rose above head, check for any changes.
4. With patient leaning forward, check for any changes.
Palpation:
Ask the patient to lie on a couch with the head supported by one pillow, and the hand on the side to be examined under the head.
1. Start palpation from 1 o’clock till 11 o’clock then palpate the tissue under areola and nipple (start with normal breast).
2. Palpate the nipple between finger and thumb, and try to express discharge.
3. Palpate the axillary tail.
4. Repeat the same with the other breast.
5. If any mass appears, mention it then continue palpation then return to it to define its characteristics.
6. While the patient is lying, examine the abdomen for hepatomegaly, and ascites.
7. Ask the patient to sit on side of couch: support the right arm with your right arm and examine right axilla with left hand for lymph node or lumps.
8. Examine supra and infra clavicular lymph nodes.
Auscultation: The chest.
Percussion: the spine.

Q.71 a patient with Ca breast, depressed. Counsel.
Introduction, then you may start by saying: “I would like to have a word with you about your condition, as far as I know you have a nasty growth in your breast. How do you feel in yourself now?
I understand that this is not easy to come to terms with, but I can assure you that with modern treatment. Thousands of lives have been saved and made comfortable.
Fortunately, we have a good management plan for this condition; first we have to do surgery. That is we remove the growth together with your breast, this operation called mastectomy.
This operation is done under general Anaesthesia , where you will be put into sleep. It is a major operation, after which you may feel unwell for a few days. As for all operations, this one has some possible complications, like bleeding, pain, and infection. And for minimizing the chance of getting such complication we will give you medications.
You will, probably, be allowed up, the day after the operation. You should remain in the hospital for 5-7 days, and you can return to work in 6 weeks.
After the operation, we will give you a temporary breast form to wear under your exam preparations until the site of operation heals completely, then we can arrange for a more lasting breast forms.
Since mastectomy was introduced, this operation is carried out all over the world, and women underwent mastectomy are enjoying normal useful and happy lives. No one needs to know that they lost a breast. There is no reason what so ever why you shouldn’t be exactly the same. You probably met someone with mastectomy, without knowing it.
After the operation, you may need radiotherapy for 4-6 weeks daily in hospital; side effects are redness of skin, local hair loss, and local effect.
We may need to give you a type of medication called Tamoxifen that reduces the effect of female hormone called Oestrogen, or instead we may give you chemotherapy.
N.B: chemotherapy best for premenopausal. Tamoxifen for post menopausal.
You are not alone; it is a common condition affection 1/12 woman in the UK.

Q.72 a young female patient presenting with palpitation. Take history.
Introduction, then you may say: “How can I help you? What do you mean by palpitation? Can you describe it for me, please? Is it fast or slow? Regular or irregular? Can you tap it on table for me please? Where and when do you usually feel it? How long does it last? Do you have any chest pain, shortness of breath, fainting?
Do you have any stress at home or in job? Did you notice any change in your weight? How is your appetite? How is your bowel motion? How is your period? Is it heavy? Do you prefer hot, or cold weather? Any recent changes? Any tremor? Sweating more than usual? Do feel any new easy irritability? Any change in your voice? Do you have any disease? Any anaemia? Are you on any medication? Any disease in the family?
Do you drink coffee, tea? Do you smoke? How many cigarettes? Do you drink? How much? What do you do for living?

Q.73 Examine a patient with suspected thyroid disease.
Introduction, then: “I would like to examine your neck gland”.
Start by inspecting the:
1. Hands: nail changes, check for sweaty, hot, coarse or dry skin. Ask the patient to outstretch both arms and fan fingers and look for fine tremor. To check that, you can put a paper on the hands and watch for tremors. Take pulses and mention about blood pressure.
2. Face: check for any hair changes, excessive sweating. Eye: examine from front: for lid retraction and chemosis. Ask the patient to follow finger up and down not too slowly. And look for lid lag (Von Graafe’s sign). Ask the patient to follow finger up, down, right, left as it moves towards point. And look for ophthalmoplagia. Ask the patient to tilt head down and to look upward, look for absence of forehead wrinkling (Joffroy’s sign). From back: tilt the head back and support it with right hand and remove the hair with left hand. Look for ptosis (Nafzinger method of examination).
3. Neck:
a. Inspection: for any mass (goitre) or lymph nodes. Ask the patient to take a sip of water and look, and ask to protrude tongue and look for any thyroglossal cyst.
b. Palpate: (from behind) ask the patient for permission to stand behind and palpate, for lymph nodes. And for the gland: first palpate both lobes, then stabilize one lobe and palpate the other. Ask the patient to take a sip of water and continue. Then ask to breathe in deeply and palpate (check for stridor), check the position of trachea. Percuss over the suprasternal notch. Auscultate for bruit.
4. Lower limbs: check reflexes of knee and ankle. Look for pretibial myxoedema.

Q.75 a mother with 3-4 years old child with polyuria, polydipsia, lethargy. Take history.
Introduction, then: “I would like to ask you a few questions about your child’s condition”.
When did you notice that she pass water more than usual? How many times does she pass water? Day or night? Is it just increase in frequency or is it also increase in the amount of urine? Any change in colour of urine? Any burning sensation while passing water?
Any tummy pain? Does she drink water more than usual? Has she lost weight recently? How is her appetite? Does she seem to be dry? Her mouth? Does she cry without tears? Does she seem to be feverish? Any recurrent infection?
Any whitish discharge or itch from down below? Any injury to the head? Any change in vision? Does she seem to be sleepy? Does she seem to be tried? Does she have any illness? Is she on any medication? Any family history of DM ? Any disease?

Q.76 a mother bringing her 8 months old child crying all night. Take history.
Introduction, then you may start by saying: “What seems to be the trouble? How long has he been crying? Is he crying all the time or with periods of rest? Does he draw the legs to the tummy? (Signs of pain)
How is his feeding? Did you introduce any new type of food? Has he been sick? Did you notice any lump in his tummy? Any visible movement? How many times did he open his bowel? Is it normal motion? Any changes in stool consistency? Any changes in stool colour?
Does he seem to be dry? His mouth, tongue? Does he cry without tears? Does he have any fever (temperature)? How is his water works? Is he active, tired, sleepy? How is his breathing?
Well Mrs. (the mother), from what you have said it seems likely that your child has a condition what we call intussusception, it is a condition where part of your child’s gut is telescoped, i.e. has folded back in on itself, just like my sleeve. So first, I would like to examine him, and then we need to run some tests. The important one is to do what we call barium enema where we put tube in the back passage and push a contrast material which will make the condition appear on x-ray, and may treat it as well (cause the folded part to unfold). And if doesn’t unfold by this method, we will need to do operation which allow to look at that part of intestine, and if still healthy, we return it back to its original position. And if not, then we will cut that unhealthy part and re-join the ends.

Q.77 a mother worried that her child may have meningitis. You diagnosed upper respiratory tract infection. Reassure the mother.
Introduction, and then you may say: “I can understand how worried you have been, because I have heard from the nurse that you thought that your child might have meningitis.
You don’t need to be worried, because we examined him and we found that he has no signs of meningitis. He has some fever, but his temperature is 37.5؛C, which is mild fever (temperature), while in meningitis we have high fever. A child with meningitis usually has severe headache, whereas your child has just mild headache. And a patient with meningitis becomes so tired and sleepy, but your child can move and walk around. Besides, a child with meningitis can even develop fit. And becomes sick many times and doesn’t like food and as you know your child just has been sick once and he can eat.
Someone with meningitis usually dislikes light, shy away from light. And your child can look nicely to light. Also a patient with meningitis finds it difficult to move his neck, which may be painful, but your child can move his neck freely with no problem. Your child has no skin rash, as might occur in children with meningitis. And besides, after examining your child, we are pretty sure that he has pharyngitis that is inflammation of the throat. It is a good idea to be careful and to keep a careful eye on him, but as I have told you, there is nothing to worry about.

Q.78 a mother is on the phone, worrying about her child how has fever and his GP thinks it is ear infection. And gave him antibiotics. Reassure the mother.
Hello this is Dr (you), How can I help you?
How long he has been like this? Is it there all the time or does it come and go? Is it the first time? Any associated chills, sweating? Any fits? Any joint pain? Any headache? Are his hands or feet cold? Is he active, walking, playing or drowsy, sleepy all the time?
How is his appetite? Has he been sick? Did you notice that he would shy away form light, dislikes bright lights? Can he move his head freely? Any pain when moving the neck? Any skin rash (tell about the glass test)? Has he had any contact with other children who developed the same features? How are your other children?
Features to ask about in meningitis:
1. Fever with cold hands and feet.
2. Fits.
3. Headache, joint pain.
4. Tiredness and drowsiness.
5. Being sick, dislikes of food.
6. Neck stiffness.
7. Photophobia
8. Skin rash.

Q.79 A mother is seeking advice, over the phone, for her child with diarrhoea.
Hello, this is .Dr (you), how can I help you?
How long has he been like this?
How many times does he open his bowel? Is it watery, loose or semi formed? Any blood, mucous, pus? (mucous = slippery).
Any tummy pain or lump? Has he been sick? Any fever (temperature)? How is he feeding?
Ask about signs of dehydration:
How is his mouth? His tongue, is it dry or moist? Or cry without tears? His eyes seem to be depressed? Does he pass water as usual? How is his breathing?
Then if the dehydration is mild, give him ORS; if not available, teach the mother how to prepare one. 1 L of water (2pints of water), boil and let to cool, then add 10 TSF of sugar and TSF of salt. And give the child by spoons as much as he accepts. Don’t give ORS if breastfeeding continues.

Q.80 a mother is worried about her boy who had a needle stick injury. Take history and give advice.
Introduction, then you may say: “How can I help you?”.
How old is your boy? When did this happen? Were you with him? Did he bleed after that? Did you clean the area? Did you bring the needle with you? Was it clean or dirty? What about his immunization? Is it complete?
If he is fully immunized, and the needle was clean, there is no need for any tetanus toxoid booster.
If the boy is fully immunized, and the needle is dirty, give the boy a booster of tetanus toxoid.
If the boy is not immunized and the needle is clean, start immunization.
If the boy is not immunized and the needle is dirty, give tetanus IG, and start immunization.
For HIV and Hepatitis B, take blood sample for baseline then follow up:
For Hepatitis B the incubation period is 2-6 months.
For HIV, take blood sample after 3, 6, and 8 months.
Check needle stick in the hospital in OHCM 4th ed. Page 216.

sepplabber · Credits: 9585 My Scrapbook

gr8 work thanks

Guest · Credits: 81560 My Scrapbook

great work it will surely help us a lot in preperation.thanx a lot!

keep it going....

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