Bell’s Palsy
Reassurance about stroke à Patient will feel much better
Ask questions which help diagnosis
- Have you been unwell?
- Were you alright the night before?
- Find s/s: flu?
- Do you have DM or high blood pressure?
- Have you had it before?
- No need to ask stoke questions à already diagnosed
Explain pathogenesis
· This is Bell’s palsy, the nerve that supplies the face is paralyzed.
· It’s self-limiting 75%, >90% recovery in 3-6 weeks
Why it happens?
Draw a diagram, cause is infection, autoimmune.
Use the word ‘might have’.
Any treatment?
If due to HZ, give Acyclovir
Examine the ears to see blister.
If patient comes in 3 days à Steroid may help
General treatment
- Diet, water
- Take care of face by
· Use glasses
· Artificial tear
· Ointment or ABO eye drop if infection occurs - Refer to PT à facial exercise advice
- Analgesic for pain
Questions in the real exam
Do you think it is stroke?
Why it happens?
Will I have it forever?
How can I do in front of others?
Hepatitis C
Breaking a bad news or reassurance
- Is it alright if I go ahead?
- Do you want someone to stay with you?
Ask for risk factors
- She was an IV user à IV drug might be the cause of hepatitis C
Management
General
· Notify the authority and blood bank
· Test the partners and children
Specific
· Refer to gastroenterogist
· Anti-viral treatment
Information sheet, support group
Ask feed back from the patient: What do you understand?
Review the test to partner à make an appointment
Inform that ‘You’re not able to donate blood’.
Liver might become cirrhosis, cancer à regular blood test for LFT
It is unlikely to transmit by sexual intercourse.
Vertical transmission à if not sure, refer to O&G
Herpes Zoster (Shingles)
Questions to ask:
- Immunosuppressive history? DM?
- Are there any children at home? (child might get chickenpox)
Treatment:
· Acyclovir in 72 hours: 800 mg 5 times a day X 7 days
· Calamine lotion or soothing lotion
· Anti-histamine: ask for occupation, drowsy or non-drowsy drug
· Steroid in really bad case but not proven
Complication:
· Post-herpatic neuralgia if last beyond 1 month à see you in 2 weeks if analgesic cannot control.
· Herpes opthalmaticus à can cause corneal scar
ADHD
What’s been bothering you?
How’s his performance at school?
Does it happen recently? Or on going?
How is his grade and how was before?
Notice any changes at school? Concentration span?
What is his relation to school mates and teacher? How about family?
What do you do? How many children?
How much time you spend with your kids?
Does he sleep? (never look tired)
FH?
How bad was it?
Do you drink alcohol? Smoke? Recreational drugs?
Does he behave like this at home?
Is anything going on at home?
DDX: ADHD
Conduct disorder
Anti-social personality
Depression (if not eating well)
Treatment:
· Counseling
· Child psychiatrist
· Imipramine (stimulant)
Mental State Examination (MSE)
General appearance
Mood: Objective
Affect: Subjective
Though: Delusion à Grandiosity
Suicidal
Perception: Hallucination
Cognition
Insight
In psychiatric patient, have to exclude
· Thyroid
· Menopause
Can say psychotic illness, instead of schizophrenia
PTSD & Depression
Always think about thyrotoxicosis and other medical conditions
Psychiatry: Good history
Counseling
Differential diagnosis
PTSD (Post-traumatic stress disorder)
· Nightmares: Had it happened before? When?
· Flashbacks:
- Do you think about that quite often?
- Have you been to the place it happened?
- Does anything remind you of that? (trigger)
Precipitating factor
Trigger
Avoidance
S/S associated with it: Panic attack
Impact
a. How does it effect your social life?
b. Personal life? Work?
c. Relationship?
Coping: How are you coping?
d. Coping skill: Drug & alcohol or social support (?)
Medical problems
e. Do you have medical problems esp. thyroid?
f. What do you do? Have you had any mental/emotional problem?
g. Is there any FH of emotional problem?
Depression questions
· How is your mood?
· How is your energy?
· How is your sleep?
· How is your appetite?
Some people, when they go through this experience, they start drinking or use elicit drugs. Have you been using them?
Have you had any thoughts of ending your life? (harming yourself?)
Do you have anyone to talk about it?
Would you like to talk to someone?
Find whether she need psychotherapy or urgent treatment.
Identify risk of harming herself or others
Do you have a feeling of worthlessness?
Have you been feeling guilty? Can you enjoy what you used to?
You really need treatment at this stage.
If suicidal idea à admit & consult psychiatrist
If you don’t want, I have to use law.
Be safe, non-judgment and low-tone voice
Ask menstrual history to exclude thyroid.
OTD
Guest
Miss Howe is a 22 years old woman with two children and would like to be sterilized. Obtain informed consent for tubal sterilization.
More history:2 children
Partner, father of second child
No work, partner is also unemployed
She doesn’t like the pill
Management
Explore relationship: stable?
Talk about other contraception:
Male sterilization: easier
IUD (Mirena): carry risk of infection esp. this case; more chance of having more than one partner and unstable relationship
Implantation: last about 3 years (Implanon)
Explain pros and cons of sterilization
If fail, increase risk of ectopic pregnancy
reverse rate is very poor: 25-70% and still increase ectopic pregnancy after reverse
reverse procedure is not cover by medicare
long waiting list
Explain about laparoscopy and surgery of tubal ligation
Give another contraception before she leaves as she has to be on contraception while she is in the waiting list
(Hello Mrs. Howe, I’m Dr……., I understand that you come to see me today because you want to do permanent sterilization. I would like to ask you a few questions and the condition related to you, is that alright?
You are 22? Do you have children? How many? Are you sure that you don’t want to have any more children in the future?
Do you have a partner? Does he know about your decision? Does he agree?
Why do you want to be sterilized?
Do you know about other contraception methods such as oral contraceptive pills, coils, condoms, diaphragm and cups? There is also an implantation for contraception that is very effective and can be used for about 3 years each time. Have you heard about that? Are you interested in considering that?
What do you know about female sterilization?
Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked (draw diaphragm). This stops eggs moving down to meet sperms.
The operation can be done in several ways, the most common method is by laparoscopy or a key hold surgery. This is usually done under general anesthesia, where you will be put to sleep. A doctor will make 2 tiny cuts, one just below your nevel and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope, it is a thin telescope-like instrument with lense to look at your reproductive organs.
Another common way is by mini-surgery, usually you will be put to sleep as well. A doctor will make a small cut in your tummy, just below the bikini line to reach the tubes.
You need to stay in the hospital, usually a couple of days, depending on types of anesthesia and operation. After operation, if you have general anesthesia, you might feel unwell for few days and may have some bleeding and pain, which is slight.
You must consider sterilization as permanent method of contraception. However, there is an operation to reverse it but it is complicated and may not work, Medicare doesn’t cover for that either.
The failure rate of female sterilization is 0.1-0.3%. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy, which is very dangerous.
The advantage is that it does not interfere with sex, your womb and ovaries will remain in place. Ovaries will still release an egg every month and your sex drive and enjoyment will not be affected. Actually, they may improve as fear of pregnancy is no more an issue. Occasionally, some women might find their period becomes heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as you feel comfortable.
You must continue contraception until time of operation as now you are put in a waiting list. If you use IUCD, it should be left until the next period. You should contact your doctor if you think that you are pregnant or if you miss a period and especially if it is accompanied with tummy pain.)