Professional Documents
Culture Documents
Communication Skills MRCS
Communication Skills MRCS
tion Skills
Introductio
n
Communication Skills = Sharing information
General Manner 1. Picks up& responds to the patient concerns, anxieties and doubts
2. Listens actively
3. empathy
4. Offers support
5. Presents information non-judgmentally
6. Uses language patient understands
7. Uses appropriate body language
Questioning style - Open/closed questions used appropriately
Control of interview - Allows control of interview to: - alternate between doctor and patient
- Signposts change of direction
Information giving - Give the information & ensure that pt understanding
Summarizing - Summaries / next steps
The rules of preferred body language:
1. Sitting while speaking, + open posture + eye contact apply
2. Privacy may be less than optimal, in a busy clinic. Every attempt should be made to
provide a separate, quiet space. Asking the patient to quiet their personal communication
technology prior to the conversation can also minimize distraction.
3. Reducing or eliminating body signals that illustrate nervousness is very important in
establishing rapport with the patient. Simply placing your feet flat on the floor with your ankles
together and putting your hands, palms downward, on your lap is a successful neutral
position. Maintaining eye contact with your patient will help ensure your attentiveness.
Assessment of candidates:
1- Sensitivity to - Great & respect the patient , smile , be gentle & be polite
needs to patient / - Empathize & sympathize but be clear, honest & Professional
relative - Taking into account ethnicity, cultural, age & disability factors
- Responding appropriately to verbal and non-verbal ( body) language
- Listen to patients account
2- Professional Emotion/ social element
Dealing With - Variable emotional responses by the patient / relatives
- Variable cultural / religious backgrounds and ethnic backgrounds
Medical element
- Complaints appropriately
- Variable questions& situations that are beyond level of competence of candiciate
Time element - Time constraints
3- communication accurate information in an appropriate manner
Ability Informatio - To the patient / relatives
n Giving 1. Obtaining informed consent
2. Breaking bad news
3. Explain risk/benefits& possible impact of investigations in clinical situation
4. Explaining diagnosis or differential diagnosis
5. Explain options available and option not to treat
6. Explain uncertain diagnosis, outcome or prognosis
Ability to use background information to formulate an appropriate
response
- Checking for understanding and summarizing at appropriate intervals
- Involving the patient in decision making to the level that they wish
- Offer opportunities available for further information e.g. 2nd opinion
- Using feedback to regulate pace and content of consultation
- To colleagues/ other Healthcare professionals
1. Verbal communications
2. Written communications
- Clinical letters to medical colleagues - Investigation request forms
3. Telephone communication
Informatio - To the patient / relatives
n - Brief H/O from patient in OPD / ward
Gathering - Consultation with relative of patient
Ability to use background information& that gathered to formulate an
appropriate response
Discussion of management plan
Ability to summarize information appropriately
) ( ) (
Information Giving
Information Gathering
(
.1 = Breaking bad news
- Brief H/O from patient in Dealing with .2 = Angery patient or relative
OPD / ward
- Consultation with relative of .3 Explaining diagnosis or differential diagnosis
patient Explain risk/benefits& possible impact of investigations
.4 Explain options available of treatment
Explain outcome or prognosis
.5 + Obtaining informed consent
.6 + Organ transplant consent
(
- = Verbal communications
-2 = Written communications
Clinical letters to medical colleagues - Investigation request forms -
-2 Telephone communication
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Presentation of H/o taking
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Verbal communications
I- In The waiting area (5 min) ( Read, Record data & Mapping)
INFORMATION GIVING INFORMATION GATHERING
I- Read the scenario > time
II- Record Data important Items
You Name if given , & Job position (CT , SHO, Registrar).
Patient Name , Age , Venue ( hospital/ department, ER, OPD, Ward )
.Social prepare yourself about The Social point/s you should offer help for it
offer this in a question Ex:-
.Psychological prepare yourself about the Psychological points you should offer help for it
offer this in a question Ex:-
II- In Actor Area (10 min)= Actor Interview ( introduce & greeting Open Interview - Close)
INFORMATION GIVING INFORMATION GATHERING
INTERODUCE 1. Greeting the patient, smile, check hands
2. Introduce yourself - Same
3. Check patient identity
Is it Mr. / Mrs..?
OPEN INTERVIEW OPEN Differ according each situation
QUESTION
THE INTERVIEW Actor Interview ( 10 min), 1. Actor Interview ( 10 min)= 1st bay
- Task - Take H/O & Systemic review is focused on
- Scenario may go beyond - you are not allowed to write notes important points
scope of junior doctor, you The examiners will not talk to or discuss you - you are allowed to write notes regarding H/o
must recognize & should only they will assess your communication skills of the condition as you will present Later after
refer matter upwards; that should cover critical items within the taking The patient (= Actor) but take
. Ask consultant to provide interview, & how you Begin & end the interview permission.
further details The examiners will not talk to or discuss you
. Assistance from other only they will assess your communication skills
members of the team Rules :-
- You Should Cover The following items: Rules :- - Same
- Should deal with aspects 1. Medical - You should say that you will now speak to
of situation of patients 2. Social your consultant
condition as they emerge in 3. Psychological
conversation 3. Present the case ( 5 min) = 2nd bay
1. Medical Should be logical, structured,& in clinical
- Simple language (no medical terms, language
& no abbreviations) Presentation Skills
- Simple sentence & in a small chunk. - Simple language
- A fetal mistake = To give wrong medical - Methodical approach
information - Comprehensive
+ Ensure that the patient under standing you. - Succinct (keep to 5 minute limit)
Do you have any questions? - Emphasis and significance - keep appropriate
- Medical plan. to surgical context
2. Social:- offer help for it - Interpretation of ideas and concerns
3. Psychological:- The examiners will discuss you about
- empathize & sympathy but be 1. What DD would you suggest at this stage
honest & tell the truth .e.g. cancer based on the history?
- Listen to his concern & dont interrupt 2. What signs would you look for specifically in
offer help for it the examination
- Smile & use body language( nodding the 3. What investigations would you request for
head), this patient?
END INTERVIEW= - Close appropriately (check if has no further - Same
questions, and knows what will happen next)
- Summary all these in simple sentences
- End Question
Do you have any questions? Before we end
- Thanks & smile
Explaining diagnosis or DD Explaining Treatment options
Introduce
Raise your voice 1. Introduce yourself Hello, I am .
to make all listen Name if given , & Job position (CT , SHO, Registrar)
Be self confident Check hand & Smile, eye contact
Be warm/&sympathy 2. Check patient identity Is it Mr. / Mrs..( Family name of the patient)?
- Offer a chair...Do you have a chair Mr./ ?
If he has a chair Ask him to sit. .. Sit down please?
If no offer a chair
- Sit infront look at his face (don't give him your side), But dont give your back to the
examiners. stay calm relaxed
Explain why interview I am asked by Dr/.( Explain why interview I am asked by Dr/.( or
or team) to come to talk to you about you concern team) to come to talk to you about you concern and the
Open questions treatment options
1- Would you like someone to be with us in this Open questions
consultation? 1- Would you like someone to be with us in this
2- I would like to ask you, what do you know about consultation?
the problem? 2- I would like to ask you, what do you know about the
problem?
Medical:- = . Medical:- =
Inform the patient directly ( be clear & Inform the patient directly ( be clear & honest) - Scenario
honest) - Do you know what the treatment options for your may go
- Do you know Why this Diagnosis? concern mean? beyond
- Ok I will start to explain & if anything isnt - Ok I will start to explain & if anything isnt clear or scope of
junior
clear or if you have any Question please stop if you have any Question please stop me to re- doctor, you
me to re-explain clearly& answer your explain clearly& answer your questions. must
questions. recognize &
Social /psychological =Sympathy:- Social /psychological =Sympathy:- should refer
matter
upwards;
Medical:- = Medical:- = . Ask
Explain in brief(No much technical Explain in brief(No much technical information) consultant to
information) what is the diagnosis mean provide
further
What is this diagnosis mean What are the treatment options mean? details
what are possible other diagnosis what is What are the available a treatment options? . Assistance
the next plan in management = test or And indication for each from other
therapy What are the risks without treatment = members of
During the discussion Frequently establish complications of the disease the team
That the pt understands. Is it ok? Do you What are the risks/ benefits with each treatment
have any question? option what is the outcome = prognosis - Should
Social/psychological =Sympathy:- During the discussion Frequently establish That deal with
the pt understands. Is it ok? Do you have any aspects of
situation of
Listen to concern, idea& fear + offer question? patients
(Answer, sympathize & offer solving for any Social/psychological =Sympathy:- condition as
social Q). they emerge
Listen to concern, idea& fear + offer (Answer, in
sympathize & offer solving for any social Q). conversatio
n
Same - Summary all these in simple
sentences..
- End Question. Do you have any question, Before
we end?
- Offer contact?
- Thanks the patient ..Thank you Mr. /
Mrs..? & smile/ greeting/ check hand
.Know the medical facts and their implication before initiating the conversation -
:Stick to basic rules of interview: question-listen-hear-respond -
Informed consent= -Sufficient information giving to a patient (patient's right), by either the physician or their
representative, to allow the patient to make an informed decision regarding whether or
not to consent to a treatment or procedure.
(patient's right) -Sufficient information giving to allow the patient to make an informed decision
- To refuse medical care for any reason e.g. religious grounds any other personal, even if you
as physician consider their grounds to be in poor judgment.
Who give Consent - Adult> 16y ( organ donation >18y) Responsible with complete mental capacity
- If children or not fill that ( parent or legally responsible relative or persons)
Who Obtain Consent A health care provider who is reasonably involved with the patient's care.
Validity time 30 days. In cases where planned treatments in advance .e.g. chemotherapy 6 mo
If consent is not The patient has the right to sue for medical malpractice.
obtained Informed consent is necessary any time the physician is going to either touch the patient or
perform an invasive procedure
Type Consent? Written consent All cases performed in OR / invasive procedures/ Contrast Rad.
Oral consent Clinical exam/ simple treatment requirements e.g. canula/ Injections/ NGT
No Consent Only in life saving + pt unable to give (whatever the cause) or refuse.
What is Sufficient 1. Diagnosis 2. Treatment / procedure
information to be 3. Risks &benefits of treatment/ procedure. 4. Alternatives to treatment / procedure
giving 5. Risks of not receiving treatment / procedure
+
Obtaining Informed Medical Consent
Same with all
Explain why interview I am asked by Dr/..( or team) To come & talk to you about your
operation that is planned tomorrow / next week ?
Open questions 1st establish what he Know
- Do you know Why this operation/ surgery are planned for you?
-Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure
(operation/treatment). We want you to be informed about your choices to help you to be fully involved
in making any decisions and at the end if you are satisfied you will sign an informed consent for the
surgery.
- Please ask about anything you do not fully understand or wish to have explained in more detail -
Remember, you can change your mind about having the procedure at any time
Medical:- =
Inform the patient directly ( be clear & honest)
- Do you know Why this Operation? (= bec the Diagnosis)
- Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to re-
explain clearly& answer your questions.
Social/psychological =Sympathy:-
Medical:- =
Explain in brief(No much technical information)
Discussion all ( in brief)
During the discussion
Frequently establish That the pt understands. Is it ok? Do you have any question?
Social/psychological =Sympathy:-
Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q).
Social =Sympathy:-
5.support Including :- cancer care Nurse
- Summary all these in simple sentences..
- End Question. Do you have any question, Before we end? - Offer contact?
- Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand
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Thyroidectomy
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Explain why interview I am asked by Dr/..( or team) To come & talk to you about your
? operation that is planned tomorrow / next week
Open questions 1st establish what he Know
?- Do you know Why this operation/ surgery are planned for you
-Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure
(operation/treatment). We want you to be informed about your choices to help you to be fully involved
in making any decisions and at the end if you are satisfied you will sign an informed consent for the
surgery.
- Please ask about anything you do not fully understand or wish to have explained in more detail -
Remember, you can change your mind about having the procedure at any time
Preoperative What is a thyroidectomy?
Before Surgery A thyroidectomy is the removal of all (total) or part (partial) of the thyroid gland.
Explain; Why is a thyroidectomy?
Simply You may need to have this operation because you have a swelling which could be cancerous or because
your gland is overactive. If you do not understand any of the information please ask, since it is importan
that you make the right decision.
When will the operation be done?
Time in Preoperative= OPD Admission/ Fitness Assessments:- Attend OPD before surgery( 1- 2w
before surgery = assess fitness for sugery &1day for Admission)
1day before You will be admitted through the outpatient clinic
your operation
one or two You will be invited to attend a pre-admission assessment clinic to assess your health
weeks before needs and carry out routine tests which may be required prior to surgery such as
your operation blood tests, a heart tracing also known as electrocardiogram (ECG), or a chest X-ray
+ Ear/ose/ larynx physician will assess the normal function of the nerve that controls
your voice-box
Operative
Surgery OR Time 1-2 hours.
Name of Surgeon Consultant/or Team( name if given in scenario)
Anaesthesia GA/ -position Supine with head lower 20o & sandbags between shoulder/ skin prepared +draped
Steps (simple) Through an 8 cm transverse skin cut in lower neck then layers opened in .. .. . The
surgeon will either remove one half of the thyroid (called a thyroid lobectomy) or remove the whole thyroid
(called a total thyroidectomy), depending on the abnormality of the thyroid gland. ( ectomy =excision
=Removal of the organ out = + after control of blood supply + ensuring stop bleeding)
Post operative Time in Post operative + Treatment
After surgery
General Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in
leg veins lung vessels ( & special precaution will be taken according to patient risks), othe
cosmetic of scar problem( hypertophic / Keloid)
Specific - Damage to the nerve that controls your voice-box (0.5 -1% chance), this can
few
Day risks
of leave you hoarse.
Recovery.. Most patients
Following are ayou
the operation little husky
are after
kept in the operation,
the theatre recoverybut
areathis
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Surgery caused
aroundby 3-4having
hours andan operation
then returnedon your
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Drip for
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+pain killer
- Damage togiven
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parathyroid glands (5% chance). These are four little glands
Drain:
next Also,thyroid,
to your a little drain(
whichplastic
control tube
theconnected to a small
blood calcium. Weplastic bag to remove
will perform routineanyblood
remaining blood out) in your neck with a dressing around it.
tests after your operation to make sure that the blood calcium level is normal. If the
Drink You will be allowed to drink the same night + Walk You are encouraged to be as
blood
activecalcium level is low, then we will start you on calcium tablets. The chance of
as possible.
needing calciumtest
Daily calcium tablets at one
in blood year after
to check the operation
Hypofunction of otherisnearby
aboutgland
1%. called
- Significant
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gland ( control (3% chance)
calcium that blood)that
() in your need returnmytobeoperation
damaged room again to
or removed
1st Day evacuate
Day nextclotdrip
+control bleeding
and the drain(1- 2d or output < 100cc for 2 d) will be removed.
after Depending on the type of operation that was done on your thyroid, you may be started
Surgery on thyroxine therapy this is a natural hormone that replaces the job of the thyroid gland
And If your gland has been over-active, then the anti-thyroid medication is stopped.
2nd Day Discharge Usually on the 2nd day after you surgery you will allowed to go home
after
Surgery
5th Day There will be one stitch under the skin, which will be removed by your GPs nurse, five
Complications
after days after the operation.
Very common
Surgery
= 10 %
1- 2w after You can return to work
common= Surgery
1% 6-8w after You will attend OPD to assess thyroid function by doing hormone tests (TFTs)
Surgery
Uncommon
(1 /1000 ) Complications General Specific
In OR - Death/ bleeding - injury of the nearby structures
Rare= Post operative - Pain - Effects of the nearby structures injury)
(1/ 10,000) Immediate ( 1st - Bleeding / haematoma - wound blood clot may need push to
day ) - Those of Anaesthesia lung collapse operation room again to evacuate clot
very rare= due air passage block +control bleeding
(1/100,000)
Early ( 2nd d - Bleeding , bruises, infections( wound, - Wound Abscess) wound open
1st 2 w) UTI Respiratory) wound open effects of the nearby structures injury)
DVT/ PE ( clots in leg/ lung vs) - Effects of the nearby structures injury)
Other Treatment options if pt Afraid of Complications give him what other option if available for his case
indications+ benefit &risks for each e.g. medical /radiotherapy radioactive iodine,/ radiation/ chemotherap
As
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Same in all OR Consent
Steps (simple) Through Acm skin cut in then other layers opened in .. .. . The surgeon will
remove. . ( ectomy =excision =Removal of the organ out = +
after control of blood supply + ensuring stop bleeding) to be sent for analysis
Post operative Time in Post operative + Treatment Same as before Unless A day case surgery (discharge in same da
After surgery and some few specific Postoperative follow up (Drain removal stitch removal
Complications General Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in
Very common leg veins lung vessels ( & special precaution will be taken according to patient risks),
= 10 % other cosmetic of scar problem( hypertophic / Keloid)
Specific
common= few risks
1%
Uncommon
(1 /1000 )
Rare=
(1/ 10,000) Complications General Specific
In OR - Death/ bleeding - injury of the nearby structures
very rare= Post operative - Pain - Effects of the nearby structures injury)
(1/100,000) Immediate ( 1st - Bleeding / haematoma - wound blood clot may need push to
day ) - Those of Anaesthesia lung collapse operation room again to evacuate clot
due air passage block +control bleeding
Early ( 2nd d - Bleeding , bruises, infections( wound, - Wound Abscess) wound open
1st 2 w) UTI Respiratory) wound open effects of the nearby structures injury)
DVT/ PE ( clots in leg/ lung vs) - Effects of the nearby structures injury)
Information gathering
The history of the present illness (HPI) includes all of the patient's history, both recent and
remote, that is pertinent to understanding the current illness
Complete present history (= you will have collected a great deal of data)
the remaining medical history = past medical history+ family history+ social history/patient
profile ( sympathy ), and + review of systems.
Of course, new information may appear at any time. During the remainder of the interview, the
physician directs the patient to fill in the blanks, completing the rest of the history.
Each new piece of information is assessed for reliability, completeness, and relevance to the
patient's problem. The physician should repeatedly scan the information already gathered
looking for symptom complexes or diagnostic patterns. For example, the physician
interviewing a 30-year-old woman with fever, back pain, and urinary frequency would
immediately consider the possibility of a urinary tract infection. With increasing knowledge of
clinical syndromes, the clinician's ability to form more complex diagnostic hypotheses
improves. Each hypothesis is tested for validity with further specific questions such as, "Have
you ever had a bladder or kidney infection? Any kidney stones? Are you sexually active?"
Through this process, speculations are tested against objective reality and accurate
hypotheses are generated.
Communication problems Example; Patients cry peace= best to let the storm pass.
Then gently resume "You seem angry about that . Can you tell me more about what has been
going on?"
patient does not want to talk about issues that seem important. "You seem reluctant to talk
with me about your problems. I wonder if you may be uncertain about whether or not you can
trust me . .. For me to be able to help you I need to know as much as possible about your
problems . . . . How do you think we should proceed?" These statements identify the problem
with a confrontation, suggest a possible cause for the problem (distrust), establish the
physician's need to know more, and invite patient participation in deciding what course the
interview will take .
Type of Questions Begin each line of inquiry with an open-ended question and proceed to
more specific questions to fill in the gaps.
Effective questions are usually simple. Avoid double-barreled questions, such as "Are you
having any stomach pains or bladder problems?"
To do a complete ROS, however, would take forever. Look in any good history and physical
examination book and see the list that they dedicate to ROS. Impossible.
LIST of RoS questions from the Schwarz physical exam book onto a cheat sheet.
who on earth asks about exposure to diethylstilbestrol?!
I don't ask about this on all of my patients especially if I think I know what is going on or the
patient has a specific organ system complaint. I also occasionally ask more if I have no idea
what is going on. What the other poster said about a focused ROS is acutally called
associated symptoms which should be part of your HPI. Usually when I see a patient I will
tailor my ROS to areas that are appropriate to the pts age. I usually always ask about the
lungs, heart and abdomen.
You'd be surprised how much of this is positive. Most of it is just passing annoyances, but you
never want to miss a red flag or a collection of positives that may indicate an underlying
syndrome (such as cold intolerance, recent weight gain, and thinning hair possibly indicating
a thyroid abnormality).
REVIEW OF SYSTEMS (ROS):- If positive analysis as usual ( OCD + what you think it
cause this Site Quantity/ Quality what & what.
History (H/O) Taking Never to use medical term use simple language if you cannot know just
simplify the term by defining it. as we call it.OR Ask patient to describe what he feels.
How you feel during he pass urine Is there any trouble ?
Explain why interview:- I am asked by Dr/.( or team) to come to talk to you about you concern
Social /psychological =Sympathy:- I will ask you some questions about your concern that are
very important in assessment of your diseases and so its management
Take a permission to write these notes: 1st please I would like to ask you a permission to write these
notes bec I will present these information to my consultants at the end of the interview Is it ok?
I am going to star now is it ok?
During H/ O Taking frequently establish that the pt any question. Do you have any question?
Is it ok? Or something to added or explain Anything else or any thing to explain
Social /psychological =Sympathy:-
Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q).
3. DD symptoms
Systems
CVS
Respiratory
GIT
Genitourinary
Female
III- H/o of present invest/ ttt
PAST H/O
(SURGICAL):-
1- Surgery Past history
admitted to any hospital at / /
2 - Previous evaluation of or (treatment for) a disease (e.g., medications , surgery, compression).
3 - Other diseases:-
Related disease.
Associated.
(MEDICAL)
1- Medical Systemic disease (affect outcome) (e.g. DM, HTN, CHD, CVA)
2- Medications Do you take any medication or contraceptive pills (Female)?
4- Allergy ( food, Drugs) Do you have any allergy?
FAMILY H/O
Systemic symptoms( cause/ complication/ DD/ surgery Do you have trouble with ..
fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) )
other body system quick direct Questions & if any +ve
analysis
3- DD ( could be local causes/ referred) Do you receive any recent treat
or have any test for your problem
H/ O of Present Investigation & treatment
.
Chest Respiratory o Pain o Shortness of breath o Cough o Sputum (quantity, appearance) o Coughing up blood o
Wheezing
o Last x-ray
Vascular o Pain in hips, legs, calves, thigh while walking o Coolness of extremity o Loss of hair on legs o
Discoloration of extremity o Swelling of legs o Varicose veins o Ulcers
Male genitalia o Pain o Discharge o Lump o Sexual Activities o Frequency of intercourse o Infections o Fertility
Female genitalia o Pain o itching o Discharge o Lump o lump/ passing gush of small amount of urine (on straining)
o Sexual Activities oCarotid
Frequency Artery disease o pain on intercourse o Infections
of intercourse o Fertility
problems Contraception H/o o birth control methods o OCP exposure
Extracranial arterial periods
diseaseH/ois aocommon
age at menarche(
disorder 1st period) + ( interval
characterized between periods
by atherosclerosis of theo carotid
durationoro amount o date of
vertebral arteries last period o bleeding between periods o menstrual pain
cerebral-ocular (stroke, TIA, amaurosis fugax) or
Obstetric H/o o number of pregnancies o abortions
Vertebrobasilar symptoms: Cerebellar
o term deliveries (vertigo,ofataxia,
o number dizziness,osyncope,
living children bilateral
complications paraesthesia,
of pregnancies visual
o description of labor
hallucinations). o age at menopause o menopausal symptoms o post menopausal bleeding
A cerebrovascular accident (CVA) or stroke is a sudden onset of irreversible neurological deficit.
A transient ischaemic attack (TIA) is a sudden onset of neurological deficit that resolves within 24h
musculoskeletal
INCEDENCE:- CVA is the 3 rdo most
weakness o paralysis o muscle stiffness o limitation of movement o joint pain o joint stiffness o
common cause of death in the UK after coronary heart disease and cancer.
arthritis
CVA has an incidence of 2 /1000. 15% of these
o gout o back are due
problems to atherosclerotic
o muscle disease of the carotid arteries.
cramps o deformities
-:Risk factors Same as Atherosclerosis
-:Causes
neurologic
Complications o fainting
cerebral-ocular o dizziness
(stroke, o blackouts
TIA, amaurosis o paralysis o strokes
fugax)
o numbness o tingling o burning o tremors o unsteadiness of gait o loss of memory o loss
PATHOPHYSIOLOGY of consciousness o psychiatric disorders o
Mechanisms:- Atherosclerosis and thrombosis. Thromboemboli. Fibromuscular dysplasia.
general behavioral change o mood changes o nervousness o depression o speech disorders o
Atheromatous plaques form athallucinations
the bifurcationoofdisorientation
the common carotid artery and progress into the external and internal carotid
vessels.
CVA or TIA arise from disease and may be due to:
Pathophysiology
Ocular or cerebral symptoms: an atherosclerotic plaque (commonest extracranial lesion) at the carotid bifurcation (origin of the
internal carotid artery). Platelet aggregation from the surface of the plaque (usually after an acute rupture or opening of the
plaque surface); embolization of atheromatous material from the plaque& platelet embolization. CVA or TIA or Ocular
symptoms.
Symptoms due to flow reduction are rare in the carotid territory, but vertebrobasilar symptoms are usually flow related.
Reversed flow in the vertebral artery in the presence of ipsilateral subclavian occlusion leads to cerebral symptoms as the arm
steals blood from the cerebellum subclavian steal syndrome.
H/O Usually male >65y smoking , HTN, DM, with other risk factors of atherosclerosis & associated atherosclerosis
Ask diseases IHD, AAA, PVD (( should ask about)
Symptoms ( should ask about & analysis onset/ duration)
Neurological features:- These depend on:- the territory supplied by the vessel affected by the embolism. -
the degree of collateral circulation to that territory. - and the size/resolution of the embolism.
Cerebral (or ocular) Transient or permanent
Cerebral symptoms motor (weakness, clumsiness or paralysis of a limb);
(contralateral) sensory (numbness, paraesthesia); speech related (receptive or expressive
dysphasia).
Ocular symptoms amaurosis fugax (transient loss of vision described as a veil coming down
(ipsilateral): over the visual field).
Amaurosis fugax. Transient monocular visual loss (described as a curtain coming down across the eye)
lasting for a few seconds or minutes central retinal artery.
Hemianopia. loss of vision in one half of the visual field.
Internal capsular stroke. Dense hemiplegia usually including the face striate branches of the middle cerebral
artery.
Environment - Introduce - Expose neck Proceed as for neck examination. - Wash your hand
Inspect Look for Pulsatile swelling noted in line of carotid artery at base of neck or scar.
Look Look for neurological associations
Palpate For Artery itself may be firm due to calcified plaque - Expansile Mass
Feel pulse ( one by one from behind)
Auscultation - Bruit over carotid arteries, best heard over course of common carotid artery (anterior triangle)
Both side & in expiration. Tell the examiner you will hear /Listen over praecordium to ensure not transmitted aortic
stenosis( ejection systolic murmur at Right 2nd intercostal space, parasternal)
- Carotid bruits are detectable in over 10% of patients > 60 years of age and do not correlate well with the
degree of stenosis or risk of CVA. So it is an unreliable indicator of pathology.
Patients with a significant stenosis may have no audible bruit.
Completing Neurological Examination ; Previous CVA ; focal neurological signs, ipsilateral Horner's syn.,)
Examine for cardiovascular associations (BP, peripheral pulses, heart) Check for signs of atherosclerosis
elsewhere
Investigations All patients with transient neurological symptoms should undergo screening for carotid disease clinical
examination is not accurate. In addition to those in general with atheroscelrosis; CBC, FBS, Urine, RFTs.
Carotid colour duplex scan: B-mode scan and Doppler ultrasonic velocitometry: method of choice for assessing degree of
carotid stenosis. all patients who have had a TIA or stroke within the last 6 months. 95% accuracy for assessment of degree
of stenosis.
CT or MRI brain scan: demonstrate the presence of a cerebral infarct.
Carotid angiography: no longer essential prior to surgery( itself risk of stroke = 2%).
MRA is reserved for those patients in whom duplex are inconclusive or difficult due to calcified vessels.
Treatment:-
Conservative Medical management; Same as Atherosclerosis
Best medical therapy is an antiplatelet agent (e.g. aspirin, dipyridamole), smoking cessation, optimization of BP
and diabetes control, and a statin for cholesterol lowering.
Anticoagulation is indicated in patients with cardiac embolic disease.
Surgery Carotid endarterectomy (CEA):- Targeted carotid endarterectomy offers optimal risk benefit in stroke
prevention. 6-fold reduction in stroke / 3 years
Offered to patients with symptomatic > 70% stenosis of the internal carotid artery.
ECST (Europe) and NASCET (North America) have both demonstrated a reduction in stroke in the first year
following CEA, from 18% with best medical treatment to 3-5% with surgery and best medical therapy. There is
no significant benefit to symptomatic patients with < 70% stenoses.
ACST (UK) and ACAS (North American) trials have shown some benefit of CEA to asymptomatic patients with
> 70% stenosis but the number needed to prevent one stroke is 22 patients treated.
Indication Carotid distribution TIA or stroke with good recovery after 1-month delay:
70% ipsilateral stenosis;
50% ipsilateral stenosis with ulceration.
Asymptomatic carotid stenosis >80% (controversial).
Carotid endarterectomy has about 5% morbidity and mortality.
stenting Carotid angioplasty - controversial
Technical Increasingly undertaken under regional (LA) block.
details Oblique incision anterior to sternomastoid.
Carotid vessels controlled after dissection.
IV heparin prior to trial clamp (if patient awake).
Cerebral circulation protected in 10% of awake patients without an intact circle of Willis
with a shunt (Pruitt/Javed).
Shunt in GA patients depending on surgeon preference and cerebral monitoring (stump
pressure of 50mmHg or transcranial Doppler monitoring of middle cerebral artery blood
flow).
Patch closure with Dacron if small vessel.
Dysphagia
INCEDENCE:-
Risk factors:-
Causes:- Mechanical Within the lumen
Obstruction - FB - Oesophageal web (scleroderma) - Plummer-Vinson syndrome
In the wall
Congenital:- web, OA &TOF, Dysphagia Lusoria
Traumatic ( FB, Corrosive, Iatrogenic instrumentation, Violent vomiting,/ rupture)
Oesophagitis (Candida, corrosive, or chronic reflux)
Strictures:- Benign (Post-radiation/ corrosive /or chronic reflux) - Malignant Cancer
Tumours benign malignant
Outside the wall = compression:- Neck ( Goitre/ Pharyngeal pouch)
in chest (mediastinal syndrome, Retrosternal goitre, LN, Lung carcinoma)
Co-ordination Motility disorders :- Oesophageal spasm - Achalasia
abnormalities Neurological disease :- Myasthenia gravis, Bulbar palsy (including MND), CVA
Complications Weight loss & Cachexia ( Cancer)
Regurgitation & Aspiration pneumonia
Stasis infection ulceration, He
Metastasis ( cancer)
PATHOPHYSIOLOGY
H/O Vital = The main task + Risk ( Age/ smoking, family + precancerous diseases)
Ask Medical:-
PERSONAL / patient or Mr. / Mrs.,(Family Name) ., Age.y, work as .
H/O: - + Social h/o married/kids/ special habits
C/O= concern / Dysphagia = difficulty in swallowing
problem
PRESENT Present History Analysis
H/O:- - Should mention onset, course and duration. What & What .
You Should Ask About..
1 - Duration& Onset:- The condition start since of sudden/ acute/ insidious( onset)
2 - Following H/O of (cause):-
"At what level does the food appear to stick?"
"What is causing difficulty: solids, liquids, or both?" solids often first in strictures whereas
liquids first in neurological
3- With (H/O of symptoms) ...........................................
What ..& What ..
4 - Course :- ( progressive/ regressive/ intermittent/ stationary)
Treatment:- Conservative
Surgery
Prognosis
Thyroid History
Approach
I- Analysis of Main Symptoms Neck Lump
Site
OCD Onset
Course; change in size - suddenly increased (haemorrhage into necrotic nodule,
subacute thyroiditis, rapidly growing carcinoma)
Duration
Cosmetic symptoms
Ass symptoms ( Painful/ painless) ( cause / complication/ DD)
pain other associated ( Causes/ complications Symptoms from the swelling)
General Constitutional symptoms ( fever wt loss) + General weakness any yellowish colour change of
eye+ preference to hot cold & dry or sweaty skin
Systemic symptoms (cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT,
GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis
3- DD ( could be local causes/ referred/ same system or other system)
Trauma history
Vital points = AMPLE (Allergies; Medications; Past illness ( quick Not detailed); Last Meal; Events or
Environment related to injury= History of mechanism of trauma + Symptoms of trauma;)
Tumour / cancer history = Main Bulk
I- Analysis of Main Symptoms pain/ Lump/ Ulcer + associated
II- A Review of Systems (ROS) Ask for
Causes Risk factors DD
Complications ( local regional & general constuitional fever anorexia wt loss) + systemic metastasis
III- H/ O of Present Investigation & treatment
Definitive treatment