T-minus 5 Flashcards
SBARR
Who
- Introduce yourself including your name and grade.*
- Clarify the name and grade of the person you are speaking to.*
- Provide the basic details of the patient you are calling about (e.g. name, gender, date of birth and hospital number).*
Where
Provide the patient’s location (e.g. “The patient is located on the haematology ward at the Royal Hospital”) and your own location if different.
When
Provide the timing of the current problem (e.g. “The patient began to deteriorate 15 minutes ago”)
What and why
- Make it very clear what aspect of the patient’s management you need advice on and explain your current working diagnosis if relevant (e.g. “I need your advice on how we should manage the intracerebral haemorrhage.”).*
- If there have been decisions about the escalation of care and resuscitation, these should also be discussed.*
SBARR
Background
Relevant medical details include:
- Admission reason
- Date of admission
- Current diagnosis
- Relevant past medical and surgical history
- Relevant medications (e.g. warfarin if the patient has presented with a bleed)
- Allergies (particularly if the allergy may impact the choice of treatment)
- Relevant investigation results
- Current management and the patient’s clinical response
SBARR
Assessment
The assessment part of SBARR involves communicating your objective clinical assessment of the patient including:
Vital signs: blood pressure, pulse, respiratory rate, SPO2 and temperature.
Clinical examination findings: in the context of an acutely unwell patient an ABCDE approach of reporting your findings can be useful to provide a coherent structure.
Overall clinical impression: this is your working diagnosis (e.g. “the patient appears septic” “the patient is neurologically deteriorating“).
SBARR
Recommendation
State the following
State your suspected diagnosis, what you think needs to happen and in what time frame you expect those things to happen.
“This lady has suffered an acute intracerebral haemorrhage and given the ongoing clinical deterioration she needs urgent review by the neurosurgical team.”
Ask the following
- Whether they can review the patient and in what time frame they would be able to do this.
- Whether there is anything further you could do (e.g. requesting investigations, administering treatments).
- Whether a transfer to another clinical environment is required (e.g. ward, theatre, ICU).
“Are you able to come and review the patient now? In the meantime is there any other treatments or investigations you’d suggest? Are you happy to accept this patient for transfer urgently to the neurosurgical high dependency unit?”
SBARR
Response and review
Check that they have accurately understood the current clinical situation and check if they have any further questions.
Clarify expectation of response (e.g. “So you’ll be coming within the next 5 minutes to review the patient?”).
Document the discussion in the patient’s notes, including the details of those involved in the discussion (name, grade, bleep, their advice and timings).
CAGE history
CXR
A
B
C
D
E
A
- trachea
- carina
- hilar enlargement
B
- lung fields
- pleura
C
- cardiac size
- cardiac borders
D
- diaphragm
- costophrenic angles
E
- mediastinal contours
- bones
- soft tissues
- tubes valves, pacemakers
Chemically mediated nausea treatment
Secondary to hypercalcaemia, opioids, or chemotherapy
- If possible, the chemical disturbance should be corrected first
- In the context of other chemically mediated syndromes, for example due to opioid medications, there are a number of suggested medications
- Key treatment options include ondansetron, haloperidol and levomepromazine
Urinary history
Pain: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).
Frequency: commonly associated with UTIs.
Urgency: may be associated with UTIs or detrusor instability.
Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hyperplasia).
Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hyperplasia).
Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).
Management of cow’s milk protein intolerance
Management if breastfed
- continue breastfeeding
- eliminate cow’s milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
- use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
Management if formula-fed
- extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
- amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
- around 10% of infants are also intolerant to soya milk
CMPI prognosis
CMPI usually resolves in most children
in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
a challenge is often performed in the hospital setting as anaphylaxis can occur.
Illicit Drug history
Diabetes Breaking bad news station
Osce station
Marrion (mum) wants to find out about her 16 year old daughter’s medical history
Hearing voices OSCE
(8)
Discharge from hospital osce station
Causes of AF
Week 6 screening tests
Gynae History
Obstetric History
Gynae History
- When did you first get your period?
- Are you currently sexually active?
- Have you ever had an STI before?
- When was your last smear test?
Obstetric History
- Have you had any problems with your current pregnancy?
- Have you ever been pregnant before?
- Have you ever had a miscarriage?
- Headaches, swelling in legs, visual disturbances?
Respiratory system antibiotics
Urinary tract antibiotics
Skin infection antibiotics
Ear, nose & throat antibiotics
Genital system antibiotics
Gastrointestinal infection antibiotics
Types of laxative
Features of Klinefelter’s syndrome
Klinefelter’s syndrome is associated with karyotype 47, XXY
Features
- often taller than average
- lack of secondary sexual characteristics
- small, firm testes
- infertile
- gynaecomastia - increased incidence of breast cancer
- elevated gonadotrophin levels
Features of Kallman’s syndrome
Kallman’s syndrome is a recognised cause of delayed puberty secondary to hypogonadotrophic hypogonadism.
It is usually inherited as an X-linked recessive trait.
The clue given in many questions is lack of smell (anosmia) in a boy with delayed puberty
Features
- ‘delayed puberty’
- hypogonadism, cryptorchidism
- anosmia
- sex hormone levels are low
- LH, FSH levels are inappropriately low/normal
- patients are typically of normal or above average height
Androgen insensitivity syndrome features
Features
‘primary amenorrhoea’
undescended testes causing groin swellings
breast development may occur as a result of conversion of testosterone to oestradiol
Central cause of hypertonia
(4)
Causes of neonatal hypotonia include:
- neonatal sepsis
- Werdnig-Hoffman disease (spinal muscular atrophy type 1)
- hypothyroidism
- Prader-Willi
Maternal causes
- maternal drugs e.g. benzodiazepines
- maternal myasthenia gravis
Mcune Albirght syndrome
McCune-Albright syndrome is not inherited, it is due to a random, somatic mutation in the GNAS gene.
Features
- precocious puberty
- cafe-au-lait spots
- polyostotic fibrous dysplasia
- short stature
Meningitis in children: organisms
Neonatal to 3 months
- Group B Streptococcus: usually acquired from the mother at birth. More common in low birth weight babies and following prolonged rupture of the membranes
- E. coli and other Gram -ve organisms
- Listeria monocytogenes
1 month to 6 years
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
- Haemophilus influenzae
Greater than 6 years
- Neisseria meningitidis (meningococcus)
- Streptococcus pneumoniae (pneumococcus)
Paediatric foot conditions
Scarlet fever
Features
- fever: typically lasts 24 to 48 hours
- malaise, headache, nausea/vomiting
- sore throat
- ‘strawberry’ tongue
- rash
fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles
Management
- oral penicillin V for 10 days
Criteria for the use of therapeutic cooling in neonates:
(4)
Neonates with a gestational age ≥36 weeks and birth weight >1800g
History of acute perinatal event during delivery associated with period of hypoxia, and/or an Apgar score ≤5 at 10 minutes or at least 10 minutes of positive-pressure ventilation
Severe metabolic acidosis on cord gas, or blood gas taken within 1hr of birth
Evidence of moderate-severe HIE – demonstrated by onset of seizures, and/or on the basis of clinical assessment of consciousness level, spontaneous activity, posture, tone, primitive reflexes, and autonomic systems.
Undescended testis
Complications
Management
Complications of undescended testis
- infertility
- torsion
- testicular cancer
- psychological
Management
Unilateral undescended testis
- NICE CKS now recommend referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age
- Orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1 year of age
Bilateral undescended testes
- Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
The following conditions are inherited in a X-linked dominant fashion:
Alport’s syndrome (in around 85% of cases
Rett syndrome
Vitamin D resistant rickets
School exclusion for
Impetigo
Diarrhoea & vomiting
Mumps
Chickenpox
Rubella
Measles
Whooping cough
Impetigo - Until lesions are crusted and healed
Diarrhoea & vomiting - 48 hours
Mumps - 5 days from onset of swollen glands
Chickenpox - All lesions crusted over
Rubella - 5 days from onset of rash
Measles - 4 days from onset of rash
Whooping cough - 2 days after commencing antibiotics
