European.MD

I T P
Immune mediated thrombocytopenia (ITP) is a common explanation for spontaneous bruising in children.
As the name suggests it is caused by the dysfunction in the unman system which causes platelets to be damaged/destroyed. Symptoms include bruising, mucosal bleeding and haemetemsis/haematuria.
Diagnosis is via blood tests which will show low platelets and low Hb.
With children it is always better to be suspicious of bruising and they should be investigated thoroughly!

A D E M
Acute disseminated encephalomyelitis (ADEM) is caused by acute inflammation of the brain and spinal cord potentially damaging and destroying the myelin sheath surrounding neurones.
Patients can presented with sudden onset pathology including broad based gait, clonus (UMN) and cerebellum signs such as pass pointing and diadochokiensia.
Symptoms can mimic multiple sclerosis. Distinguish factors include a single flare vs MS where multiple flare ups occur.
ADEM is quite rare with incidence of 8 per 1,000,000 patients and they are concentrated in the age range of 5-8.
Treatment methods include methylprednisolone as well as intensive therapy work with physiotherapists (PT) and speech and language therapists (SaLT)

V I R A L I N D U C E D W H E E Z E
We are now getting an influx of wheezy children as the weather has shifted and children are back at school passing nurses along.
In paediatrics we are super hesitant to give a diagnosis of ‘asthma’ in those under 2 years of age.
We treat viral induced wheelers with salbutamol inhalers +/- atrovent inhalers. Nebulisers are only used if children require oxygen. There are further escalations in management including IV salbutamol, magnesium sulphate and aminophylline if required.
Remember to check the wheezy children regularly, they can deteriorate quite quickly!

ST A Y I N G A C T I V E

You may hear different advice about how much often you should be exercising per week and this is because this space is rapidly evolving, currently NHS England recommends that 19-64 year olds spend 150 minutes of their week doing a form of moderate aerobic exercise as well as strength/resistance based exercises twice per week!
Maintaining muscle mass is extremely important especially in the elderly who can become deconditioned within days of not exercising. Elderly patient can lose more than 10% of their muscle mass within a few days of being in a hospital bed!

If you have any concerns with your weekly activities, swing by in our DMs and we can help you out.

V P S H U N T S
Ventriculo-peritoneal shunts can be inserted in newborns with hydrocephalus to alleviate symptoms. Although many drain into the peritoneum, they can also be sited to drain into the pleural cavity or right atrium.
Common complications include infection if the shunt, blockage and migration. Babies can oreeenf with crying, irritability, headache, vomiting or fevers. Physically they may have a sunken or enlarged anterior fontanelle.
In this image the tube has migrated from below the diaphrgam and was nestled next to the right middle lobe of the lung.

E V O L U T I O N O F A S T E M I
-
A STEMI is caused by total occlusion of a coronary vessel most commonly the result of plaques rupture. This causes transmural ischemia with subsequent elevation of cardiac markers. Within minutes hyper-acute T waves not usually visible by the time ECG is performed . If they are visible remember to distinguish from hyperkalemua. So ST elevation will be visible first in certain leads depending on which area of the myocardium has been infarcted. After hours there may be some T wave changes such as inversions, which will resolve and within days-weeks-month pathological Q waves may form indicating scarring of the myocardium 💔

G L A S G O W C R I T E R I A F O R A C U T E P A N C R E A T I T I S

P E A
The rhythm you see above normally gives you comfort when you’re asked to review an ECG. It’s often called sinus rhythm, however in a certain situation it could be more sinister.
In the setting of a crash call it is often pulseless electrical activity (PEA.) In this situation the heart is maintaining its electrical activity but this is not resulting in any output.
If you see this rhythm in an emergency make sure you do a three point pulse check! It’s advised to check both femoral pulses and a carport pulse before assuming the patient is ok.

NIGHT SHIFT SNACKING 🌗
-
Being on-call overnight can be extremely gruelling and tiring. The bleep never seems to stop going of and it can be hard to fit in a long enough break as times. Most food in the hospital is not great nutritionally and most of the time places that sell food with be shut overnight. For this reason it is super important to ensure you have plenty of food with you and you stay hydrated throughout the shift to perform optimally. The worst combination is being dehydrated, hungry and tired. I like to take lots of snacks and spread them out throughout my shift. For protein I usually go for protein powder, bars and Greek yogurt (+ berries). For carbs I usually just stick to rice cakes to snack on or bagels with some PB. All these sources are easy to eat, require minimal prepping so you can just have them on the go and of course help hit protein goals for the day to make more gains! 💪

A D V A N C E D L I F E S U P P O R T
-
ALS algorithm is linked to an established cardiac arrest. The ALS interventions are instituted after BLS has started. Once a cardiac arrest has been confirmed CPR should be started, compressions can be periodically stopped to check the rhythm. Heart rhythms are divided into shockable (VT/VF) and non-shockable (Asystole/PEA). The main difference between the two is the need for defibrillation in those with VT/VF. Reversible causes should be treated: the 4 H’s (hypovolemia, hypoxia, hypothermia, hypo K/Ca/glc) and the 4 T’s (thrombosis, tension pneumothorax, cardiac tamponade, toxins)

A T R I A L F I B R I L L A T I O N
-
AF is an abnormal heart rhythm caused by irregular beating of the atria. The atrial rate is 300-600BPM. The AV nodes subsequently responds with an irregular ventricular rhythm. CO can drop causing a clinical picture of palpitations, dyspnea, chest pain and an irregularly irregular pulse. The main risk is the formation of a thrombus on the atria due to stasis of blood which can embolism. AF can be caused by: HF, HTN, IHD, valvular disease, pneumonia, hyperthyroidism and excessive alcohol consumption (so-called holiday heart syndrome). An ECG must be done on any patient suspected of having AF. It will show absent p-waves and irregular QRS complexes. Also bloods tests: U&E’s, TFT’s, Mg, Ca, cardiac enzymes. AF is managed in the acute setting where there are adverse signs with DC cardioversion. Chronic AF is a managed with anticoagulation and drugs to control rate or rhythm. Rate control is achieved using a B-blocker or a rate limiting CCB. Rhythm control can be achieved with an elective DC cardioversion, or pharmacological cardioversion using a drug such as flecanide.

C O N S T I P A T I O N
-
No matter what ward you are rotating on, constipation is something we deal with on a daily basis. Commonly it is a result of prescribing opioids which effect the myenteric plexus in the intestinal tract, reducing gut motility, causing constipation. Laxatives should be prescribed on the PRN side of the drug chart in any patient who is taking opioids for analgesia. CCB’s, anticholinergics and antacids can also constipate. Other non pharmacological causes are bowel obstruction, bowel/ovarian malignancy, paralytic ileus, functional bowel disease, hypothyroidism and structures. It’s important to consider constipation as a cause of new onset agitation in the context of an elderly patient. Look for distension, tenderness, absent/tinkling bowel sounds and always check the stool chart for the consistency and last bowel opening. Physical examination may be unremarkable so do a PR exam to check re**al tone, masses and the presence of stool in the re**al vault. Also note the consistency of the stool. If any doubt about the presence of bowel obstruction order an AXR. Constipation can be treated pharmacological with laxatives (bulk, osmotic, stimulant) or enemas.

G A R D E N C L A S S I F I C A T I O N
-
The Garden classification is a system of categorizing intracapsular hip fractures of the femoral neck:

1. Incomplete fracture, minimally displaced with impaction in valgus
2. Complete fracture but non displaced
3. Complete fracture, partially displaced
4. Completely displaced with no contact between the fracture fragments

Hope everybody is having a great bank holiday weekend!
We would like to briefly introduce ourselves. Both of us are Doctors who were trained at Charles Unversity (Cz) and are currently working in the UK. Dr Kishan Patel (left) is an FY1 working in North West London and Dr. Kapil VIj (right) is an GPST1 working in Wolverhampton. If you have any questions about med school, working as a doctor or anything else please feel free to message us! We hope you are enjoying the content we are posting, keep your eyes peeled for more 💉👀

C H O L E L I T H I A S I S
-
Gallstones can be formed in the biliary tract, they are derived from bile complements. Stones can be dark pigmented (bilirubin), yellow/green (cholesterol) or mixed. Risk factors are age, obesity, female s*x and hemolytic anemia to name a few. Biliary colic occurs when the cystic duct is obstructed or stones pass into the CBD. Patients present with RUQ pain and jaundice. Acute cholecystitis follow stone/sludge impact ion in the the GB neck causing RUQ or epigastric pain. This differs from biliary colic as there is an inflammatory component (fever, vomiting, peritonism). The stone may travel to the CBD causing obstructive jaundice. A sensitive sign for choelcystits is Murphy sign where 2 fingers are placed below the right cost margin, the patient is asked to breath in and will cease respiration as an inflamed GB hit your fingers. Cholecystits can be diagnosed by increasing WCC and CRP, US will show a thick walled GB with pericholecystic fluid, stones or a dilated CBD (>6mm) and MRCP. Treatment is keeping patient NBM, give IV fluids, IV ABX, ERCP or an laparoscopic/open cholecystectomy. Ascending cholangitis affects the bile ducts and occurs when they become inflamed usually due to obstruction by gallstones. This is classically characterised by charcots triad: RUQ pain, fever and jaundice. Additional adverse signs are chartised by Reynolds Pentax: charcots triad + altered mental status and shock.

Today I sat in during a paediatric clinic for children who were overweight. I was amazed at seeing children who had no idea about the repercussions of their diets!

Many families said their child’s high BMI was due to lack of exercise, however we kept reinforcing that it was mainly due to the diet! You cannot out train a bad one.
In paediatrics we advise a plate ratio of 1/2 vegetables, 1/4 protein & 1/4 carbohydrates. The difficulty with managing children is that you often have to also treat the parents and help educate them too!

We mentioned in our previous post that looking after yourself is key to ensuring patient safety.
Having both done long 12 hour + shifts we will be the first to tell you that staying hydrated is important. It’s very easy to go that time without going to the toilet or drinking water. Foundation doctors are sitting ducks for AKIs and kidney stones.
Take a water bottle with you to work, keep it at your desk and sip on it whenever you can!

A C U T E P A N C R E A T I T I S
-
This is an unpredictable disease caused by pancreatic enzyme auto digestion, oedema, fluid sequestration and hypovolemia. This can present as a a life threatening emergency due to necrosis and haemorrhage. The causes are remembered by the mnemonic GET SMASHED (gall stones, ethanol, trauma, steroids, mumps, autoimmune, scorpion bites, hyperlipidemia/hypercalemia, ERCP and drugs. Patients usually presents with epigastric pain radiating to the back and there may be signs of shock, jaundice, peritonitism, rigidity, flank (Grey-Turner’s sign) or perimubillical haemorrhage (Cullen’s sign). It is usually diagnosed by a raised amylase and an abdominal/pelvic CT. Additional tests are usually ordered to aid in scoring the severity (Glasgow or Ranson score) or LFT’s/US (gallstones), AXR, CRP, ABG or ERCP. Management is mainly conservative: keep NBM, gives IV fluids, analgesia, and antibiotics. An intervention like ERCP may be done to relived a distal biliary obstruction causing gallstone pancreatitis. Fatal complications may arise such as AKI, shock, ARDS, DIC, sepsis. Chronic complications include pancreatic pseudocysts, abscesses, fistulae and splenic vein thrombosis.

D E E P V E I N T H R O M B O S I S (D V T)
-
As a junior doctor you should always be on the look out for signs and symptoms that indicate a medical emergency could be imminent, investigate accordingly and make sure a senior is aware. One of us is currently working in trauma and orthopaedics so DVT is something to always bear in mind as DVT occurs in 25-50% of surgical patients. DVT can lead to a PE which can be fatal. Moreover do not underestimate the potential of DVT occurring in an immobile non-surgical patient. Other causes are: malignancy, OCP and themobphillias. Signs of DVT are calf warmth/tenderness/swelling/erthymma, mild fever, pitting edema. The Wells score for DVT is a useful tool clinical probability scoring system. Based on the score you either do a D-dimer or US of the lower extremity veins. Patients should be anti-coagulated usually with LMWH, fondaprinux or DOAC (always check contraindications) and given thromboembolic deterrent stockings. PE is a preventable cause of mortality so always do proper risk stratification and ensure examination of the calves.

A - L E V E L S
Many of you guys will be receiving a-level results which will ‘determine’ what you’ll be doing come September. A lot of pressure is out on 18 year olds to fulfil their potential and choose a course that will ‘set them up for life. ’

Just remember, some ink printed on a piece of paper does not AND should not determine your future. If you really want something, work hard and stay focussed and eventually it’ll happen. Some people just take a detour to get to the same spot and this is perfectly ok.

Both of us missed out on our needs grades to study medicine in the UK. We are now both qualified doctors practicing in England.

If you want to discuss your results, hit us up in the DM and we will help where we can.

C L O S T R I D I U M D I F F I C I L E (C-D I F) I N F E C T I O N
-
C. difficile is a gram (+) spore-forming anaerobic bacillus. Risk factors for infection: use of broad spectrum antibiotics (fluoroquinolone, cephalosporins and clindamycin), hospitalisation and acid suppression therapy (H2 antagonists/PPi’s). Transmission is via the feaco-oral route, the spores are heat resistant and can remain dormant in the environment for long periods. New onset diarrhoea, more than 3 partially formed per 24-hour period (Bristol 5-7), distinctive foul odour, recent antibiotic use, abdominal pain and fever are suspicious for C-dif especially in a hospital sized patient. This infection can be diagnosed br ELISA for the A/B toxins, prior to these tests diagnosis was made by sigmoidoscopy/colonoscopy which revealed the finding of pseudomembranes. Treatment is with antibiotics such as vancomycin or metronidazole and giving fluids to replace any losses in the stool. In addition rigorous infections should be set in place to minimise the spread of infection.

P L S
You may have seen our previous post where we spoke about management of an adult cardiac arrest. Here we have the algorithm for our paediatric patients.
The main differences are that this starts with 5 rescue breaths because children usually have a respiratory focussed arrest rather than having a cardiac issue! This is also seen in the 15:2 ratio vs 30:2 in adults.

Always remember that children’s medications are dose adjust for weight/age. Here the joules for the defibrillator are significantly different for the defibrillator as are the doses for adrenaline and amiodarone.

N E W S S C O R E
-
The national early warning score is based on the measurement of a set of physiological parameters which generally tend to deteriorate when the patient becomes more unwell. These include: RR, HR, BP, Sats, Temp and level of consciousness. A score is allocated to each parameter, the greater the deviation of that parameter from the norm the hereafter the score. The values for each physiologic parameter are added together, if the total score reaches the a ‘threshold’ value (>5, or any individual parameter > 3) nursing staff should increase the frequency of observations and alert a doctor to review the patient (depending on local guidelines).

B R E A S T M A S S E S
-
Breast lumps have a range of different causes and most are harmless, however some can be a sign of something serious such as a malignancy. Breast lumps should be worked up if there are unusual changes suspicious for malignancy such as: ni**le inversion, dimpled skin, increasing size of the lump, axillary lymphadenopathy or discharge (blood streaked). In an effort to prevent deaths from breast cancer, mammography is offered in the UK to all women aged 47-73 every 3 years. The triple is a diagnostic tool for examining potentially cancerous breasts and involves: physical examination, mammography and needle biopsy.

S P I K I N G T E M P E R A T U R E
This is one of the things you’ll be bleeped about the most when you’re oncall and you should definitely be comfortable managing someone who is febrile. The main thing you want to rule out here is sepsis so stick to our plan and you’ll cover all bases.
This scenario makes the patient a priority, the time period in which the patient should receive antibiotics is 60 minutes (the golden hour).
Do an A-E assessment of the patient and then undertake the sepsis 6, 3 IN and 3 OUT.
IN: Oxygen, Fluids & Antibiotics
OUT: Blood cultures, Bloods (including lactate) & Urine (+measure output)

There are other signs of sepsis apart from a spiking temperature and you should consider these too; hypotension, tachycardia, tachypnea, hypothermia, high lactate.

C O M P A R T E N T S Y N D R O M E
-
Compartment syndrome is a condition that presents when the pressure within one of the body’s compartments increases to levels that prevent venous drainage and arterial perfusion of muscular and nervous structures. In Orthopaedics, this is usually caused by a fracture, crush injury, reperfusion injury or vascular injury. Excessive fluid builds up causes oedema and compression of tissues within a given compartment. This ultimately leads of ischemia and if the pressure is not relieved, tissue necrosis and subsequent contractures (e.g volkmann contracture associated with the supracondylar fracture of the humerus). Another complication is rhabdomyolysis subsequently causing AKI. Compartment syndrome can be recognised by the 5 P’s: Pain, Paresthesia, Pallor, Pulslessness and Paralysis. Treatment is a fasicotomy, where the fascia is cut to relieve pressure within the given compartment 🔪

C A R D I A C A R R E S T
At some point in the coming weeks and months as an FY1 you will be on call and inevitably get the dreaded cardiac arrest call (crash call). It’s daunting just to think about! Just remember you’ll never be expected to lead the arrest call. Don’t worry, the arrest call will get a lot of people coming (quickly!) and you won’t be alone for too long if you get their first.
At most you’ll be expected to exercise those arms and put in good quality compressions or chip in finding some more IV access.
Algorithm taken from the Resus council (UK)

It’s recently been announced that England may reduce the time it takes to become a doctor post-brexit. The main reason behind this move is to try and plug gaps in the health service.

We both really believe that shortening training could be catostrophic for patient safety in the future. We feel that much of our knowledge comes with experience and exposure to clinical situations and reducing this by a year would decrease our knowledge.

What do you guys think about this propose move? (Full link in bio)

C O P D 🌪
-
Chronic obstructive pulmonary disease (COPD) is an obstructive disease of the airways in the lungs. It includes chronic bronchitis (defined clinically as cough and sputum production for 3 months of 2 consecutive years) and emphysema (dilation of airways distal to the seminal bronchioles with destruction of alveolar walls). Patients usually present with dyspnea, wheezing, sputum production. COPD is a chronic, progressive disease and has a strong correlation with to***co smoking and air pollution, these irritants produce an inflammatory reaction which destroys the tissue within the alveoli of the lungs. Patients can be diagnosed with COPD on the grounds of abnormal imaging (CXR/CT), spirometry measurements and ABG’s. Treatment is undertaken using a stepwise approach based on severity of obstruction which can be determined by the patients measurements on spirometery such as the patients FEV1. Advanced COPD can lead to high pressure in the arteries of the lungs causing the right ventricle to fail, this is known as cor pulmonale. COPD patients are prone to exacerbations usually triggered by an infection. Thus it is essential they are given prophylactic vaccinations (influenza, Hib and pneuomococcal) to try and minimise this.

The FY1 Doctor Essentials 💉👨🏽‍⚕️