An Eye to Cyanide - Part 2

Hello awesome people :)

So, talking about differentials for the cyanide case.. (see previous post Here)

What all u can guess could be the case in such patient if not cyanide..?? Anyone? Think before you read it further..

Here it is...

It could be Carbon Monoxide poisoning. Reason? OK so you remember the patient had shown Cherry Red color of skin when she was brought to the emergency. Carbon monoxide also causes such discoloration of skin as well as blood. This is due to formation of carboxyhemoglobin, which causes decrease in oxygen carrying capacity of blood. So less supply of oxygen and essential nutrients to brain as well as other vitals of the patient, leading to neurological, cardiac as well as other systemic problems!!

An Eye to Cyanide

Hello awesomites!

Hope your weekend is going well :D

I just read about a case of cyanide poisoning and learnt some important points related to it. So here it is -

"A 27 year old comatose woman was brought to emergency by paramedics, and a strong odor of bitter almonds is present. Her past medical history is significant for malignant hypertension. For the past few months, she was given injections of sodium nitroprusside for the treatment, according to her accompanying relatives. She is a housewife and has been under stress regarding family problems. Also she had consumed few almonds a day ago."

Do it for the better, to achieve your Best!!!

Thinking of starting something new? That's great! Don't wait, just start it. Open the first page. C'mon you can do it. Haha.. don't worry. I know it's difficult, but trust me once you start it, you will enjoy it. Yes you will.

Remember one thing always.. Consume your time in doing something productive. Keep yourself busy in some task, create new ideas, think about something and do it. Dream a lot. Yes you really should.

Do it for the betterment of society. Do it for yourself. To achieve the best of yourself. Trust me, the day when u do that, you will feel really happy. Because you did what you wanted to. That you loved. You lived!!!

Thanks! :)
-Jaskunwar Singh.

Step 2 CS: Challenging questions

Here are some of my sample closures for challenging questions.

All my closures are generic with little word play. Whatever the SP says, I would say it back to them saying I understand it. So your sympathy - empathy is done.

See how all three closures are almost the same - 

"Will I need surgery?"
I understand that you are concerned about the possibility of having a surgery. Yes, you might require a surgery. But I assure you that we will be there to support you, throughout the treatment, regardless of the diagnosis. Does that sound okay to you?

Step 2 CS: Introduction

Here's how I introduced myself -

"Mr. Smith? Hi. I am doctor D. I'm the attending physician and I'll be taking care of you."

"Are you comfortable in the room?" (Yes.)

"May I take a seat and write a few notes as we talk?" (Yes.)
"So can you tell me what brought you to the clinic?" (Blah blah blah...)
"Can you tell me more about it?"

Step 2 CS: Counselling for PTSD

I can see that you are distressed about an event that occurred in your life. We have some medical therapy available that can help you with this. Medicines take time to work, in the mean while I can get you in touch with some support groups and social help organizations that have patients who have witnessed similar traumatic events in their life.

Step 2 CS: Physical exam findings in a patient with calf pain

We were practicing a case of calf pain (DVT / cellulitis) today and my friends told me that I documented the physical examination findings well, which is why I posted the note on the blog :)

Things in brackets are for reference only and I didn't type those in my 10 minutes encounter.

Step 2 CS: Headache LOC tip

In a case of headache or loss of consciousness, any weakness or numbness is the first question you ask - because if there is anything suggestive of stroke or transient ischemic attack, you can time yourself to do a neuro exam which includes cranial nerves and strength, reflexes and sensations.

Step 2 CS: Musculoskeletal patient note

IPROM MRSP is a brilliant mnemonic
You can use it for patient notes as well!

For shoulder pain:
Inspection - R arm is closely held to the chest wall. R shoulder appears red compared to the L.
Palpation - Non localized tenderness on palpation of R shoulder, arm and clavicle.
ROM - Pain and restricted flexion, extension, abduction, adduction, internal rotation and external rotation.
Motor - Unable to assess strength due to pain.
DTR's - 2+ intact, symmetric (If time, mention - Biceps, triceps and supinator)
Sensations - Intact to pin prick and light touch
Pulses - 2+ in brachial and radial arteries

For wrist pain:
Palpation - Non tender to palpation
ROM - Flexion, extension, abduction, adduction are WNL
Motor - 5/5 strength in shoulder, elbow and wrist
DTR's - 2+ intact, symmetric
Sensations - Intact to pin prick and light touch except decreased sensation in the palmar aspect of right arm
Pulse - 2+ in brachial and radial arteries
Tinels, Phalens test +ve. Finkelsteins test -ve.

Step 2 CS: Memory loss / confusion

Soo.. I wanted to remember "medical terms" to report my findings in my patient note. I made a mnemonic for remembering "findings in Alzheimer's disease:

AC MI EF

- Decline in Activities of daily living
- Cognitive decline
- Memory Impairment
- Executive Functioning

For activities of daily living, DEATH SHAFT is a tedious mnemonic. Keep it simple -ABCD
Ask for ABCD - accounts, bathing, cooking, dressing and transport - Can you walk in the house / drive a car?

Other diagnoses:

Normal Pressure Hydrocephalus - Ask for urinary incontinence, gait disturbance

Syphilis / AIDS - Have you ever been diagnosed with a STD in the past?

Major depressive disorder (Psuedodementia) - SIGECAPS

Hypothyroidism - Cold intolerance, constipation, slowing of movement, etc

Step 2 CS: Writing a psychiatry note and mini mental status

Mnemonic: ABC MATTS

Appearance - Well groomed / Dishevealed
Behaviour - Appropritate / Inappropriate
Co-operation - Cooperative / Non-cooperative

Mood - Euphoric / Depressed
Affect - Normal / Blunt affect with poor eye contact
Thought Process- Direct / Disorganized
Thought Content - Normal / Delusional
Speech - Fluent speech / Slow speech

"Now I am going to ask you a few questions that may seem odd, but these are just to assess your mental status."

"What is your name?"
"Do you know where we are?"
"Do you know what time is it?"
AAOx 3

"I will name three objects for you, can you repeat them after me? I will ask you to repeat the same objects after a while."
3/3 registration, 3/3 recall at 3 minutes

Step 2 CS: Headache / photophobia

When dealing with a patient with severe photophobia, you might want to dim the light out for the patient just to make the patient comfortable. Say, "I see that the light is making you uncomfortable, let me dim the lights out for you to make you feel more comfortable."

Then you start taking history.

Think of differentials, then ask  about -

Migraine - Ask about aura, catamenial migraine

Cluster headache - Ask about tearing of eyes, rhinorrhea

Tension headache - Ask about stresses in life

Meningitis - Ask for neck stiffness, fever

Excess use of antibiotics can cause Diabetes

New research has pointed out that excess of antibiotics in children can increase there risk of getting diabetes in future.

Why?