ANEIL MAANAY MB MD MRCP(UK) MRCP(I) DME
Consultant in Acute Medicine and Care of Elderly Erne Hospital, Enniskillen, Northern Ireland, UK BT 74 6AY
5PREFACE
Jitendar P Vij
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Medical Emergencies for Examinations
© 2005, Aneil Maanay
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition : 2005
9788180614439
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
To
All my teachers, consultants and
senior colleagues from
whom I learnt ABC of medicine
Life is complicated!
The junior doctors and medical students are constantly struggling to get the right dose of knowledge needed to treat patients at a practical level and to pass the examinations.
There are many textbooks describing the details of diseases. There are also many books on clinical medicine. However, there is a scarcity of books on medical emergencies.
This book would provide a practical, down-to-earth assistance in handling medical emergencies. The book would also provide a comprehensive thinking on medical emergencies, even though it is not a complete textbook of medicine.
I would be happy if the book brings management of medical emergencies, to a reasonable standard.
I have to thank all my teachers and consultants who taught me. Dr Kelly deserves a special mention.
I greatly acknowledge the hard work of Ms Susan McGinnty and Ann-Marie Geoghegan for typing such a complicated text.
Thanks
Aneil Maanay
6EVERY CANDIDATE MUST READ THE FOLLOWING
Viva/voce is a part of most of the medical examinations.
The questions, which are asked in this part of examination, are usually standardized. The first question comprises of “Medical Emergency”. This question on medical emergency carries great potential to pass the examination. It carries a heavy weight in judging candidate's overall approach to medicine. If anyone fails to answer properly on medical emergency has a very meager chance of getting through the examination.
Many candidates are working successfully, in a competent manner, in their hospitals. However, answering in the viva is a different, game play, altogether.
It requires other personality skills like; organized thinking, verbal communication, proper introduction of the topic, conclusion of the topic and eye-to-eye contact, etc.
In this book, each medical emergency, which is asked in the examination, is dealt smartly. I assure you, that the medical emergency question (topics) has to be from this book!
The questions can be asked in various ways, but the core remains the same, e.g.
- A boy is admitted unconscious, with rapid breathing.His Urine showed 4+ ketones.How will you proceed?OR
- Known diabetic girl complained of vomiting, pyrexia and polyuria. She has rapid breathing. Her glucose is 28 mmol/L. Her urine revealed ketones in large amounts.What will you do?
In both these questions, the examiner wanted a core answer for diabetic ketoacidosis.
Some tips for answering in viva examination.
- Read this book carefully, at least once.
- Try to structure your answer.
- Q: How will you manage a case of shortness of breath?The wrong answer would be: “I will treat his asthma.I will give him bronchodilators, steroids, etc.”Instead, summarize the causes of shortness of breath and then deal one by one. This gives an impression that you think comprehensively.
- • Always think straight and simple.
Do not sidetrack to a main core answer, e.g. if you are asked the management of myocardial infarction, then describe the management of uncomplicated infarction first. You can discuss the management at complications later on. Do not start with complications.
- Do not teach the examiner: An example of a wrong answer:
I will give oxygen to patient of LV failure, because there is hypoxia and the hypoxia is due to pulmonary oedema. The pulmonary oedema is due to LV failure. The contractility of LV is decreased. Hence, there is a backpressure of pulmonary veins. This causes exudation of fluid into alveoli. This activates reflexes which causes shortness of breath and…
Instead, say, “I will start 40% to 100% of oxygen to a patient with LV failure”.
- Always practice many months before examination.
It will be better if you record your answers on a tape recorder and listen to yourself later. This gives you an insight to where you go wrong.
- Always give structured answers.
- Always think structurally, comprehensively according to the schemes given in this book.
- Do not enter into a controversial area. If examiner takes one view, do not contradict him/her. But, politely, you make the examiner aware that the topic is controversial. Example:I was asked about the starting of methotrexate therapy on a rheumatoid arthritis.
I said, “Some Physicians do liver biopsy before starting methotrexate. Some do not do it. I will take my consultant's opinion on this issue before starting methotrexate”.
- If you are stuck and do not remember anything: then always say that, you will ask your Seniors.
- The dosages of drugs: It is hard to remember the dosages of many medicines, especially those that are used rarely. The examiner may not expect the doses of such drugs. However he/she may expect the doses of drugs used in the emergencies. If asked about the doses of non-emergency medicines, and if you do not remember, always say that, you will consult the British National Formulary (BNF).
- Do not speak lies: If you do not know anything, say, “I will ask my consultant”.
- Some questions would be of rare types:e.g. How will you manage a case of poisoning due to aniline dyes?
The natural reaction on your side is, “I don't know”. But, a smart candidate would answer in a very good manner, such as:
- ⇒ I will check ABC,
- ⇒ I will make patient hemodynamically stable,
- ⇒ I will contact poison information center about antidotes, gastric lavage and complications etc.
- Think of common and uncommon presentations of common diseases first, than uncommon diseases.
- For ethical questions:
- It is better to say that the topic is controversial and is a matter of debate.
- Then, describe ‘pro’ and ‘cons’ of each view.
- Then, always say that you will like to take opinion of your seniors.
- Again say, that you will liase with colleagues, judiciary, and religious leaders, etc.
For topics on ethical issues: Always look out in the mass media 6 months before the examination.
- Practise presenting emergencies to your friend, colleague or registrar. One emergency every day would make a good deal.
- Try to be practical in the examination. Answer in a way as if the patient is in front of you, e.g.I will check ABCs,I will take blood pressure,I will cannulate and take bloods sample for tests, etc.
- Do not number the conditions while answering, example, If you say:
“I will categorize shock into 7 types”. Then, you are expected to enumerate all the 7 types. Otherwise it may not create a good impression. Rather, simply say, “I will divide shock into many categories like anaphylactic, septic, cardiogenic, hypovolemic etc”.
- Try to learn to classify and categorize the answers.Try to take a bird's eye view.
- Show that, you are a competent junior doctor rather than professor of medicine.
- Do not speak very fast or very slow.
- Speak fluently by making simple sentences.
- Never mind if your prior performance in the long case or short cases was so called, poor, (you never know)! Many candidates have passed when they felt they had poor performance. (The example is me)!.
- They are not looking for a professor of medicine. They are looking for a practical doctor. Try to avoid rare conditions initially in your discussion. Try to be practical than perfectionist.
THE EXAMINATION SCHEME
- Have a good night sleep.
- Arrive on time.
- Give double time (than expected) for transits and delays in transport on the day of examination.
- Dress decently.
- Walk decently.
- Sit in a chair elegantly.
- Always greet your examiners and introduce yourself.
- After viva, thank the examiner and leave the hall in an elegant manner.
- Do not smell of cigarettes, alcohol or curries
You will be definitely successful, at some stage; if you follow these simple rules and the scheme in this book.
Best of luck!
Aneil Maanay
10Abbreviations
AAVRT:
Antidromic atrioventricular re-entry tachycardia
ABC:
Airway, breathing and circulation
ABG:
Arterial blood gas
A fib:
Atrial fibrillation
AICD:
Automatic implantible cardioverter and defibrillator
AMI:
Acute myocardial infarction
APTT:
Activated partial thromboplastin time
ARDS:
Adult respiratory distress syndrome
ARF:
Acute renal failure
AVNRT:
Atrioventricular nodal re-entry tachycardia
BiPAP:
Bilevel positive airway pressure
BP:
Blood pressure
CABG:
Coronary artery bypass graft
CCF:
Congestive cardiac failure
CCU:
Coronary care unit
CHF:
Congestive heart failure
CMV:
Cytomegalovirus
CNS:
Central nervous system
CO:
Carbon monoxide
COPD/COAD:
Chronic obstructive pulmonary/ airways disease
CPAP:
Continuous positive airway pressure
CPK:
Creatinine phosphokinase
CPR:
Cardiopulmonary resuscitation
CT:
Computerized tomography
CVA:
Cerebrovascular accident
CVP:
Central venous pressure
DC:
Direct current
DIC:
Disseminated intravascular coagulation
DKA:
Diabetic ketoacidosis
ECG:
Electrocardiograph
EMD:
Electromechanical dissociation
ESR:
Erythrocyte sedimentation rate
EST:
Exercise stress test
FBC:
Full blood count
FiO2:
Fraction of inspired oxygen
GCS:
Glasgow coma scale
GIT:
Gastrointestinal tract
GP:
General practitioner
GUT:
Genitourinary tract
HD:
Hemodialysis
HDU:
High dependency unit
Hib:
HIV:
Human immunodeficiency virus
HT:
Hypertension
ICD:
Intercostal drainage
ICU:
Intensive care unit
IHD:
Ischaemic heart disease
IM:
Intramuscularly
INH:
Isoniazid
INR:
International normalized ratio
ITU:
Intensive therapy/thoracic unit
IV:
Intravenous
JVP:
Jugular venous pressure
KCL:
Potassium chloride
LA:
Left atrium
LBBB:
Left bundle branch block
LDH:
Lactose dehydrogenase
LFT:
Liver function tests
LP:
Lumbar puncture
LV:
Left ventricle
LVEF:
Left ventricular ejection fraction
LVF:
Left ventricular failure
MAO:
Mono amino oxidase
MAT:
Multifocal atrial ectopic tachycardia
MCGN:
Mesangiocapillary glomerulonephritis
MELAS:
Mitochondrial encephalopathy lactic acidosis and strokes
MRI:
Magnetic resonance imaging
MRSA:
Methicillin resistant Staphylococcus aureus
Ms:
Milliseconds, mitral stenosis, multiple sclerosis
MSU:
Midstream urine
NAC:
N-acetyl cysteine
NaHCO3:
Sodium bicarbonate
NB:
Nota bene
NG:
Nasogastric tube
NIPPV:
Non-invasive positive pressure ventilation
NSAIDs:
Non-steroidal anti-inflammatory drugs
OAVRT:
Orthodromic atrioventricular re-entry tachycardia
OP:
Organophosphates
PAT:
Paroxysmal atrial tachycardia
PCP:
Pneumocystis carinii pneumonia
PCR:
Polymerase chain reaction
PCWP:
Pulmonary capillary wedge pressure
PE:
Pulmonary embolism
PEA:
Pulseless electrical activity
PEFR:
Peak expiratory flow rate
PFA:
Plain film of abdomen
PO:
Per oral
PR:
PRN:
Pro rata
PSVT:
Paroxysmal supraventricular tachycardia
PT:
Prothrombin time
PTH:
Parathormone
qid/qds:
Four times a day
RBBB:
Right bundle branch blocks
RFT:
Renal function tests
RIG:
Rabies immunoglobulin
RTA:
Renal tubular acidosis
rt-pa:
Recombinant tissue plasminogen activator
SAH:
Sub arachnoid haemorrhage
SC:
Subcutaneous
SIADH:
Syndrome of inappropriate secretion of antidiuretic hormone
SOL:
Space occupying lesion
SPO2:
Saturation of haemoglobin with O2
SSRIS
Selective serotonin reuptake inhibitors
SVT:
Supraventricular tachycardia
T3:
Triiodo thyronine
T4:
Thyroxine hormone
TB:
Tuberculosis
TDD:
Total daily dose
tDS/tID:
Three times a day
TFT:
Thyroid function tests
TIA:
Transient ischaemic attack
TOE:
Transoesophageal echocardiography.
TPA:
Tissue plasminogen activator
TSH:
Thyroid stimulating hormone
TT:
Tetanus toxoid, tuberculin test
U&E:
Urea and electrolytes
USG:
Ultrasonography
UTI:
Urinary tract infection
V. fib:
Ventricular fibrillation
V/Q:
Ventilation/perfusion scan
VP:
Ventriculoperitoneal
VT:
Ventricular tachycardia
WHO:
World health organisation
Wt:
Weight
XRC:
Chest radiograph
ZN:
14Conversion Factors for mmol/L and mg%
Blood Urea | (mg%) × 0.055 = mmol/L |
Serum Creatinine | (mg%) × 88.4 = micromol/L |
Blood Glucose Level | (mg%) × 0.0555 = mmol/L |
Blood PCO2 | (mm of Hg) × 0.13 = kPa |
Blood PO2 | (mm of Hg) × 0.13 = kPa |
Serum Bilirubin | (mg%) × 17 = micromol/L |
Serum Calcium (Total) | (mg%) × 0.25 = mmol/L |