SMEC: YEAR 4 REVISION 1st July 2009

1. SMEC: YEAR 4 REVISION1st July 2009 A Student Insight…

2. Tonight’s timetable

3. Reproductive and Sexual Health To be discussed… Gynaecology (5) Obstetrics Genito-Urinary Medicine (GUM) (1) Breast (1) Family planning (1)

5. Gynaecology-Speculum examination Wash hands, Introduce, Confirm patient, Consent, Exposure, Position (WICCEP) Same principles as bimanual, with consent, chaperone, door locking and exposure Explain purpose: TO LOOK FOR CHANGING CELLS (DO NOT MENTION CANCER) Abdominal exam Quick palpation for MASSES and PAIN Speculum examination Lubricate speculum: SIDES NOT TIP (as will interfere with interpretation of results) Part labia with left hand (now dirty hand), and insert speculum vertically, then turn horizontally NB: Arms of speculum can point upwards or downwards Open speculum slowly, and visualise cervix IF NOT VISIBLE THEN ASK PATIENT TO COUGH Take smear Rotate around 360 degrees x 3, in clockwise direction Shake specimen into pot vigorously Label pot and specimen type Remove speculum slowly, and allow to close naturally IF PLASTIC DISPOSE OF, IF METAL SEND FOR STERILISATION Inform patient they may get dressed, and offer them a tissue Thank the patient and summarise If you find a mass describe the lump (Size, Site, Consistency, Mobility, Pain) YOU MAY BE ASKED TO DO BIMANUAL and SMEAR AS ONE STATION

6. Gynaecology-Bimanual Examination Wash hands, Introduce, Confirm patient, Consent, Exposure, Position (WICCEP) Extra for Bimanual: Ask if the patient would like door locked for privacy, and state chaperone will be present Explain procedure: “An examination to feel the womb and ovaries” Inform the patient that the examination should not be painful but may be uncomfortable Expose: Ask patient to undress from the waste down, bring heels to their bottom and let their knees drop to either side, then cover themselves with a sheet for privacy Abdominal exam Quick palpation for MASSES and PAIN Bimanual exam Inspect: Labia, Vulva (Skin changes, discharge, masses) Lubricate two gloved fingers, and insert them into the vagina (turning 90 degrees), while palpating the abdomen with the other hand Palpating for 1) Uterus size (use fruit size i.e Orange, Grapefruit! It is acceptable) 2) Position of uterus anteverted, retroverted Palpate the two adnexae, by turning fingers to either side, while palpating in the iliac fossae for PAIN and MASSES On withdrawing fingers inspect Glove for blood and discharge Inform patient they may get dressed, and offer them a tissue Explanation of results: when and what to expect.  Thank the patient and summarise If you find a mass describe the lump (Size, Site, Consistency, Mobility, Pain)

8. Obstetric- History

9. Intro- Gain consent, Chaperone, Expose abdomen Inspection- “The patients abdomen is distended, suggestive of pregnancy” KNOW THE OTHER CAUSES OF A DISTENDED ABDOMEN Note any scars (pfanenstiel), skin changes (linea nigra, striae), distended veins Look for obvious foetal movements General examination- Hands (palmar erythema), Heart (flow murmur), Breasts (fullness), Legs (oedema, varicose veins) Palpation- Sympyseal Fundal Height Lie- foetal spine in relation to the long axis (the models only allow longitudinal lies!) Presentation- cephalic or breach Engagement- won’t be expected to estimate fifths, just is the presenting part ballotable Estimate liquor volume (oligo/poly) they can change the volume of the liquor volume on the models Auscultation- with pinard over anterior shoulder of foetus Finish/Thank EXTRAS: “I would do a BP measurement and a Urine dip”

10. Breast History/Examination

11. 2. Examination Intro (expose chest for shortest amount of time, explain need for chaperone, and that you can lock door for privacy) Inspection- Look for asymmetry of breasts, look for scars (lift breasts), skin changes (erythema, peau d’orange) Inspect with arms ON HIPS, BEHIND THE HEAD (for tethering) Palpalpation- Palpate with hands behind head, in all four quadrants, start away from lump (the model has loads of lumps) Describe lump: size, shape, border, tethering, pain Ask patient to elicit discharge from the nipple (don’t do it yourself) Axillary nodes: abduct, and lift arm feeling in all the regions Finish- ask to carry out respiratory exam (lung mets), and spinal exam (bony mets), feel supra / infraclavicular nodes

13. Introduction: - Confidentiality - Embarrassing nature of interview PC, HPC – Open Questions Specific Symptoms: - Vaginal Discharge, Colour, Itch, Smell - Vaginal Irritation - Dysuria - Lower Abdo Pain - Genital Ulcer - Last Passed Urine Sexual Hx in the past 3 months PMHx – General, STI, Hep A/B/C Offer HIV test (if appropriate, 3 month window), Ob/Gyn Hx – LMP, duration, regular; Forms of contraception; Cervical Smear DHx - NKDA SHx – Smoke, EtOH, IVDU  ICE – Any concerns.

15. Child Health, Development and Ageing Things to be discussed… Paediatrics Geriatrics Dermatology

16. Paediatrics Hx taking (e.g. epilepsy & jaundice) Examinations (Cardiovascular, Respiratory, Abdominal and Neurological)

17. Geriatrics Discharge assessment Palliative care assessment Depression & Suicide Risk

18. Dermatology Hx taking Examination Sun protection & topical medication application

19. Logbook Skills (3) Paediatrics 1. Take a history from a parent and child 2. Examine a child 3. Examine a baby 4. Perform and interpret a basic developmental assessment of an infant or young child 5. Explain a common complaint to a child

20. Paediatric Hx FOCUSSED! Expanded PMHx (pregnancy & birth), development, immunisations, nutrition, breast/formula, introduction of solids (infant), childhood illnesses & education Careful with asking FAM Hx Cough/wheeze, Headaches, Vomiting, Diarrhoea, Convulsions, Fever & Rash, Persistent Neonatal Jaundice

21. Paediatric Examination Cardiovascular, Respiratory, Abdominal & Neurological Use simple language and instructions! Gait examination is slightly more tricky! Neonatal examination - UNLIKELY

22. Logbook Skills (2) Medicine and Psychiatry of Old Age 1. Take a history and examine an older patient including an assessment of function 2. Take a history from a third party on behalf of an older patient 3. Formulate a problem list and management plan from admission to discharge 4. Take and present a psychiatric history within a defined period of time 5. Examine and present the mental state including the cognitive state within a defined period of time

23. Discharge assessment Guaranteed last year Need to be quick because the patients are very slow Long vignette! Bulk of marks available for assessment of ADLs Have a routine Assess what they can already do Suggest solutions as you go along Follow up

24. Palliative Care Another long vignette, but specific instructions available Establish what they are suffering from ASAP, I understand you are…. Focus on the specific complaint and suggest solutions for e.g. pain & analgesia Pain, Breathlessness, Constipation, Anorexia, Nausea & Vomiting and Agitation

25. Logbook Skills Dermatology 1. Take a dermatological history 2. Take a drug history in relation to a skin disorder 3. Examine the skin for a common condition 4. Give health advice on risks of excess sun exposure 5. Explain to patient how to apply a skin preparation

26. Stations I got… Practical Skills: Resuscitation Clinical Skills Paediatric: Abdomen Elderly Psychiatry Video Community Study: Breast Feeding Clinical Skills: Obstetric Palpation & Urine Testing Clinical Skills: Breast History and Examination Communication Skills: Ectopic Pregnancy Clinical Skills: Dermatology - Skin Tumour Practical Skills: EMTL – Suturing Family Planning: COC Pill and headaches Palliative Care: Nausea and Vomiting Clinical Skills: Orthopaedics - Pain in the Hip Paediatric Communication Skills: Explaining Diabetes to a Child Elderly Communication Skills: Pneumonia Practical Skills: IV Cannulation Gynaecological History Taking: Menopause Genito-Urinary Medicine History Taking Communication Skills: EMTL – HIP Practical Skills: Taking a Cervical Smear Clinical Skills: EMTL - Rheumatology – GALS Dealing With Crisis: Anxiety Practical Skills: EMTL - Moulage - Neck Examination

29. Orthopaedics & Rheumatology History taking-Brief Examination: ‘look, feel, and move’ (back, hip, knee, GALS, hands). Ask for pain! Know your special tests Complete examination: Joints above and below; Neurovascular examination; Plain X-ray in AP and lateral view of the affected joint and joints above and below; MRI; Referral to orthopaedics

30. Orthopaedics and Rheumatology Common cases Back: Ankylosing spondylosis, Muscular back pain, OA, Scoliosis, Prolapsed lumbar disc Hip: OA, hip replacement, arthrodesis, AVN Knee: OA, Collateral ligament tear, Cruciate ligament tear, Menisceal tear, Recurrent patellar subluxation, Patellar bursitis Hands: RA, OA, Carpal Tunnel, Gout, Psoriatic arthritis, Sclerodactyly, Dupuytren’s, Trigger, Median n. palsy, Ulnar n. palsy

31. Orthopaedics and Rheumatology GALS Wash hands, introduction, consent, expose, position Screening questions: Pain/stiffness, Climb, Dress Gait: Base, rhythm, speed, limp, arm-swing, turn Spine: Look, Feel-tenderness, Move Arms: Look (Hands and elbows), Feel, Move Legs: Look, Feel (knee & MTP), Move (Hip, Knee) Summarise: Positive findings only

32. Orthopaedics and Rheumatology Hands Don’t shake hands. Pillow underneath hands. Questions on function Examination of the elbows! Do not forget to examine/mention examination of the pinna Description on inspection, palpation Always ask pain before palpation Active movements Functional tests and special tests

33. Orthopaedics and Rheumatology Special tests Back- Schober’s test*, Straight leg raise, Bragard’s, Femoral stretch Hip- Trendelenburg’s*, Thomas’ Knee- Sag sign + Drawer/Lachman’s, Collateral ligament, McMurray’s test Hands- Tinel’s, Phalen’s, Froment’s

34. Orthopaedics and Rheumatology Smile! ? Do not forget to introduce self and get patients’ name Expose patients adequately (especially hands) Position (pillow for hands) PAIN, LOOK, FEEL, MOVE! Special tests How you would complete the assessment and management (if you have spare time)

35. CONTINUED… EMTL (A&E / Anaesthetics) Dr. Mohammed Faraaz

36. A big thanks too… Tonight’s SPEAKERS George Pavey Li Tay Leila Nemazee Wenzhuang Chin Hemanshoo Thakkar Matee Ullah Aaron Ng Mohammed Faraz