Pérdidas por calcinación 10.6 Curva de gresificación

1. Take hx. From man with acute urinary retention. Pep: most likely dx, ddx, investigations 2. Take hx. From mom of child with febrile seizure

pep: dx, tell mom risk of recurrence, tell mom how to manage a future seizure 3. Take hx. From man with dysphagia

pep: shown barium swallow, describe xray finding, give dx, give workup 4. Examine young man with acute hip pain

pep: ddx, key hx points, investigation 5. Examine young woman with purpura and epistaxis

pep: hx, dx, investigations

6. Examine 20 y.o female with hypertension

pep: ddx, investigations, what to do if your investigations are normal 7. Take history from mother of child with chronic cough unresponsive to abx

pep:ddx, key hx. Elements, investigations 8. Examine young woman with llq pain

pep: ddx, key hx. Elements, investigations 9. Take hx. From woman with menorrhagia

pep: ddx, key hx elements, investigations 10. Examine man with calf claudication

pep: interpret ekg, risk factors, investigations 11. Take history from man with sob and sputum

pep: er rx, investigations, advice re: prevention 10 minute stations

1. Counsel young woman with unwanted pregnancy (mostly re: abortion) 2. Head to toe neuro exam for a confused lady already seen by another md 3. Counsel young woman re: oral contraceptive pill

4. Manage an epigastric stabbing in er with a nurse

5. Woman with "abdominal blockage" seen and cleared by another md q1-describe pt's appearance without looking, q2-dx 6. Take hx from woman with sleep disturbance

q1- dx, q2- management

1. Man with ankle sprain. Counsel re: rehab, care, followup 2. Manage acute mi in er with nurse

3. Take hx. From parent of child with language delay q1-dx

4. Examine man with low back pain

q1- dx (disk prolapse) q2- what level

1997

1. First year university student, 9 weeks pregnant, considering abortion. Take a history and counsel. Findings: tearful, guilty, sleep disturbance, has not engaged social supports.

History: combine a pregnancy history with a social history and a screen for depression.

Pregnancy: Patient ID (name, age, occupation). GTPAL (number of gestations, term pregnancies, premature births, abortions, live children), history of problems, if any, with previous pregnancies. Current pregnancy, establish gestational age (GA) by last menstrual period (LMP) if regular periods and sure dates (if unsure a dating ultrasound would be needed). The GA is the number of weeks from the first day of the LMP. The EDC is first day of LMP + 7 days – 3 months. Ask about use of alcohol, smoking, drugs, domestic violence (50% begins in pregnancy), maternal illnesses during the pregnancy (particularly diabetes, rubella, toxoplasmosis, herpes, CMV, thyroid dysfunction, HTN, hypercoagulation). Use of birth control, if any. Past medical history, family history of pregnancy related problems, medications.

Social: Status of any relationships at present including relationship with the child’s father. Social supports (family, friends, boyfriend), do they know? Are they helping? Employment/financial/educational status of the patient, does the patient feel prepared to raise a child? Psychiatric: How does the patient feel about this decision? How is she coping? Cover mnemonic for major depression. MSIGECAPS: mood (depressed), sleep (increased or decreased…if decreased, often early morning awakening), interest (decreased), guilt/worthlessness, energy (decreased or fatigued), concentration/difficulty making decisions, appetite and/or weight increase or decrease, psychomotor activity (increased or decreased), suicidal ideation – positive diagnosis of major depression requires five of these over a 2 week period, one of the five must be loss of interest or depressed mood. Symptoms do not meet criteria for mixed episode, significant social/occupational impairment, exclude substance or GMC, not bereavement.

Counseling: Make empathetic statements, e.g. “This must be very hard for you.”

Health while pregnant: recommend abstinence from harmful agents (alcohol, smoking, drugs) while pregnant and use of medications only after consulting with a physician, treatment for pregnancy-related illnesses as above, and healthy eating habits.

Social supports: Discuss the importance of engaging social supports, and consider a visit with both the patient and her partner or other supporting person.

Abortion: Provide information on local abortion services. Make the patient aware that the gestational age limit after which many

practitioners will not perform an elective abortion in Canada is 20 weeks, but that this is a late limit and her decision should be made sooner, before 16 weeks would be best. Inform the patient that further advice is available from private gynecologists who perform abortions and counselors at elective abortion centers. Offer to refer the patient if she wishes.

Depression management: Normalize the patient’s depressed mood in view of her circumstances. If there is evidence of major clinical depression, arrange close follow up to monitor for suicidal ideation, refer to psychiatry. Do not prescribe medications at this time (because of the pregnancy).

2. 20 year old female wants an oral contraceptive. Take a history and counsel.

History: Name, age occupation/school level. Why does patient want an OCP? Has she been on it before or other forms of contraception? If so, why was it stopped? How long has the patient been sexually active? How many partners? Current contraception used. Is there a possibility that the patient could be pregnant? Obtain the date of last menstrual period.

Pregnancy history: GTPAL (number of gestations, term pregnancies, premature births, abortions, live children), history of problems, if any, with previous pregnancies.

Gynecological history: Ask about sexually transmitted disease (STDs), PID, migraine, fibroids, diabetes, thromboembolic disease, heart problems, cancer, liver disease. Date of last Pap smear, history of abnormal Pap smear and follow-up/treatment? When did the patient start menstruating? Menstrual history: regularity and length of cycle and duration of periods, heaviness of flow (number of pads required), cramping, associated discomfort/pain, bloating, mood swings (PMS). Medications, drugs, alcohol, smoking, past medical history (especially breast cancer), family history, review of systems.

Counseling:

Contraindications to OCP: current pregnancy, undiagnosed vaginal bleeding, active cardiovascular/thromboembolic diseases (includes coronary and carotid disease, symptomatic mitral valve prolapse, cerebrovascular disease, moderate-severe HTN, active DVT), proliferative retinopathy, history of breast cancer or other estrogen dependent tumors (liver, breast, uterus), impaired liver function (obstructive jaundice in pregnancy), congenital hyperlipidemia, age > 35 and smoking, Wilson’s disease. Relative contraindications to OCP: smoker > 35 years old, diabetes, migraines, fibroids.

Mechanism of action of OCP: standard preparations contains estrogen and progesterone or just progesterone, prevents ovulation by interfering with feedback of hormone signaling, atrophic endometrium, change in cervical mucous (mucous plug…thought to be due to progesterone component).

Available preparations: 21 day vs. 28 day tablets (7 placebo days). Other preparations: Depo injections q3m (Depo-Provera – medroxyprogesterone, restoration of fertility may take up to 1-2 years, irregular menstrual bleeding), implants q5y (Norplant –

levonorgestrel, six capsules inserted subdermally in arm, irregular menstrual bleeding). Longer term preparations offer lower cost over the duration of action (but greater one-time cost) and greater convenience.

Benefits of all the hormonal contraceptives: ABCDEs: Anemia reduced, often clears Acne; Benign breast disease and cysts decreased; Cancer (ovarian decreased), Cycles regulated, Increased Cervical mucous which reduces STDs; Dysmenorrhea decreased, decreases Ectopic pregnancy rates and of course: virtually no chance of pregnancy when taken as directed (98-99.5%).

Risks of hormonal contraceptives: slight weight gain is usual (5 lbs), increases risk of DVT especially in combination with smoking, may stimulate estrogen-receptor positive breast cancers, but does not appear to cause them, may have to try two or three different preparations to arrive at the one for the patient. Also note that hormonal contraceptives do not provide as much protection against sexually transmitted diseases, compared to barrier methods.

Directions: Start OCP on the first day of the next menstrual period. Place package in an obvious location to help you to remember. Take at the same approximate time each day. Use additional contraception for the first two months, as OCP contraception is not reliable until then. If you miss a day, take two pills the next. If you miss two days, take two pills for the next two days and use an alternative method until the next period. Give prescription for OCP of choice…any family members (sisters/mother) on OCP? What works for them? Arrange follow up. 3. 16 year old boy with epilepsy documented by neurologist, comes to you because he does not want to see his parent’s family doctor. Wants a driver’s license. Take a history and counsel.

History of seizure disorder: Patient ID. Age of onset (primary generalized rarely begin < 3 or > 20 years old). Precipitants: Sleep deprivation, drugs, EtOH, TV screen, strobe, emotional upset. Describe seizures (Jacksonian march? Salivation, cyanosis, tongue biting, incontinence, automatisms, motor vs. visual/gustatory/olfactory), frequency, duration, what body parts affected and in what order (motor – frontal lobe, visual/olfactory/gustatory hallucinations = temporal lobe), promontory signs (presence of aura: implies focal attack), post-ictal state (decrease in level of consciousness, headache, sensory phenomena, tongue soreness, limb pains, Todd’s paralysis - hemiplegia), degree of control achieved with medications, at what dose and for how long, corroboration from family if possible. Was a CT scan done when seizures were first diagnosed? Number and description of recent seizures, are they different from previous seizures? Is the patient having any new symptoms such as headache, morning vomiting, new neurological deficits. If the drug worked in the past why does the patient believe it isn’t working now? Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias, peripheral

neuropathy, acne, nystagmus, dysarthria, hypertrichosis (excessive hairiness), gingival hypertrophy (phenytoin). Medications, drugs and alcohol, smoking, allergies, past medical history, family history, review of systems.

Compliance: Is the patient taking meds? Why not? Problems at school or home? Ask about relationship problems. Depression screen as in #19 above. Social supports.

Physical exam: neurologic exam including mini mental, cranial nerves, bulk, tone, power, sensation, cerebellar exam, deep tendon reflexes. Treatment: Discuss importance of compliance with medication and avoiding dangerous activities such as driving until good control is achieved. Ministry of Transportation regulations require 1 year seizure free before they will grant a driver’s license in Canada. Inform the MOT of the patient’s seizure disorder if you have not already done so and inform the patient that this is required by law.

If alcohol is an issue, inform the patient that chronic alcohol intake may decrease blood levels of antiepileptics (via increased liver metabolism), and excess alcohol intake can precipitate seizures by lowering the seizure threshold thereby precipitating a seizure. It is generally recommended that the patient not drink at all. Fatigue and concomitant illness can also lower seizure threshold. The patient should consult a physician before taking other medications, as they may also lower the seizure threshold. The same is also true of sedatives, cocaine, amphetamines and insulin. Fatigue and other illnesses can also lower seizure threshold, in addition to various other medications.

If patient is having stress management, anxiety issues, he may require further counseling. Outline a treatment plan consisting of: EEG, CT head, metabolic screen, medications (if not done already), and follow up appointments. Get the parents involved if possible.

Send blood for serum Dilantin (phenytoin) levels if patient is on this already. If Dilantin levels are therapeutic, but the patient is having severe side effects or poor seizure control, a second drug may be added (usually carbamazepine or valproic acid).

Discuss what to do in the event of seizure, counsel parents if possible. Bystanders are not to insert objects into the patient’s mouth. Turn patient on his side while seizing. Call ambulance or take to Emergency if seizure doesn’t stop in 5 minutes.

Arrange regular follow up to monitor progress and serum Dilantin levels.