This slideshow covers history taking and examination, management, complications, pathophysiology of upper GI bleeding and classes of shock.
over 4 years ago
This video - produced by students at Oxford University Medical School in conjunction with the faculty - demonstrates how to perform the initial assessment of a patient with suspected traumatic injury.<br>This video is part 2 of a muti-system injury scenario (airway compromise, tension pneumothorax, bleeding and head injury).
over 7 years ago
This video - produced by students at Oxford University Medical School in conjunction with the faculty - demonstrates how to perform the initial assessment of a patient with suspected traumatic injury.<br>This scenario is of a patient with a suspected pelvic fracture and internal haemorrhage.
over 7 years ago
This video - produced by students at Oxford University Medical School in conjunction with the faculty - demonstrates how to perform the initial assessment of a patient with suspected traumatic injury.<br>This video is part 1 of a muti-system injury scenario (airway compromise, tension pneumothorax, bleeding and head injury).
over 7 years ago
Cranial Nerve 1- Olfaction This patient has difficulty identifying the smells presented. Loss of smell is anosmia. The most common cause is a cold (as in this patient) or nasal allergies. Other causes include trauma or a meningioma affecting the olfactory tracts. Anosmia is also seen in Kallman syndrome because of agenesis of the olfactory bulbs. Cranial Nerve 2- Visual acuity This patientâs visual acuity is being tested with a Rosenbaum chart. First the left eye is tested, then the right eye. He is tested with his glasses on so this represents corrected visual acuity. He has 20/70 vision in the left eye and 20/40 in the right. His decreased visual acuity is from optic nerve damage. Cranial Nerve II- Visual field The patient's visual fields are being tested with gross confrontation. A right sided visual field deficit for both eyes is shown. This is a right hemianopia from a lesion behind the optic chiasm involving the left optic tract, radiation or striate cortex. Cranial Nerve II- Fundoscopy The first photograph is of a fundus showing papilledema. The findings of papilledema include 1. Loss of venous pulsation 2. Swelling of the optic nerve head so there is loss of the disc margin 3. Venous engorgement 4. Disc hyperemi 5. Loss of the physiologic cup an 6. Flame shaped hemorrhages. This photograph shows all the signs except the hemorrhages and loss of venous pulsations. The second photograph shows optic atrophy, which is pallor of the optic disc resulting form damage to the optic nerve from pressure, ischemia, or demyelination. Images Courtesy Dr. Kathleen Digre, University of Uta Cranial Nerves 2 & 3- Pupillary Light Refle The swinging flashlight test is used to show a relative afferent pupillary defect or a Marcus Gunn pupil of the left eye. The left eye has perceived less light stimulus (a defect in the sensory or afferent pathway) then the opposite eye so the pupil dilates with the same light stimulus that caused constriction when the normal eye was stimulated. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Inspection & Ocular Alignmen This patient with ocular myasthenia gravis has bilateral ptosis, left greater than right. There is also ocular misalignment because of weakness of the eye muscles especially of the left eye. Note the reflection of the light source doesn't fall on the same location of each eyeball. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Versions • The first patient shown has incomplete abduction of her left eye from a 6th nerve palsy. • The second patient has a left 3rd nerve palsy resulting in ptosis, dilated pupil, limited adduction, elevation, and depression of the left eye. Second Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Duction Each eye is examined with the other covered (this is called ductions). The patient is unable to adduct either the left or the right eye. If you watch closely you can see nystagmus upon abduction of each eye. When both eyes are tested together (testing versions) you can see the bilateral adduction defect with nystagmus of the abducting eye. This is bilateral internuclear ophthalmoplegia often caused by a demyelinating lesion effecting the MLF bilaterally. The adduction defect occurs because there is disruption of the MLF (internuclear) connections between the abducens nucleus and the lower motor neurons in the oculomotor nucleus that innervate the medial rectus muscle. Saccades Smooth Pursui The patient shown has progressive supranuclear palsy. As part of this disease there is disruption of fixation by square wave jerks and impairment of smooth pursuit movements. Saccadic eye movements are also impaired. Although not shown in this video, vertical saccadic eye movements are usually the initial deficit in this disorder. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Utah Optokinetic Nystagmu This patient has poor optokinetic nystagmus when the tape is moved to the right or left. The patient lacks the input from the parietal-occipital gaze centers to initiate smooth pursuit movements therefore her visual tracking of the objects on the tape is inconsistent and erratic. Patients who have a lesion of the parietal-occipital gaze center will have absent optokinetic nystagmus when the tape is moved toward the side of the lesion. Vestibulo-ocular refle The vestibulo-ocular reflex should be present in a comatose patient with intact brainstem function. This is called intact "Doll’s eyes" because in the old fashion dolls the eyes were weighted with lead so when the head was turned one way the eyes turned in the opposite direction. Absent "Doll’s eyes" or vestibulo-ocular reflex indicates brainstem dysfunction at the midbrain-pontine level. Vergenc Light-near dissociation occurs when the pupils don't react to light but constrict with convergence as part of the near reflex. This is what happens in the Argyll-Robertson pupil (usually seen with neurosyphilis) where there is a pretectal lesion affecting the retinomesencephalic afferents controlling the light reflex but sparing the occipitomesencephalic pathways for the near reflex. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerve 5- Sensor There is a sensory deficit for both light touch and pain on the left side of the face for all divisions of the 5th nerve. Note that the deficit is first recognized just to the left of the midline and not exactly at the midline. Patients with psychogenic sensory loss often identify the sensory change as beginning right at the midline. Cranial Nerves 5 & 7 - Corneal refle A patient with an absent corneal reflex either has a CN 5 sensory deficit or a CN 7 motor deficit. The corneal reflex is particularly helpful in assessing brainstem function in the unconscious patient. An absent corneal reflex in this setting would indicate brainstem dysfunction. Cranial Nerve 5- Motor • The first patient shown has weakness of the pterygoids and the jaw deviates towards the side of the weakness. • The second patient shown has a positive jaw jerk which indicates an upper motor lesion affecting the 5th cranial nerve. First Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 7- Motor • The first patient has weakness of all the muscles of facial expression on the right side of the face indicating a lesion of the facial nucleus or the peripheral 7th nerve. • The second patient has weakness of the lower half of his left face including the orbicularis oculi muscle but sparing the forehead. This is consistent with a central 7th or upper motor neuron lesion. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 7- Sensory, Tast The patient has difficulty correctly identifying taste on the right side of the tongue indicating a lesion of the sensory limb of the 7th nerve. Cranial Nerve 8- Auditory Acuity, Weber & Rinne Test This patient has decreased hearing acuity of the right ear. The Weber test lateralizes to the right ear and bone conduction is greater than air conduction on the right. He has a conductive hearing loss. Cranial Nerve 8- Vestibula Patients with vestibular disease typically complain of vertigo – the illusion of a spinning movement. Nystagmus is the principle finding in vestibular disease. It is horizontal and torsional with the slow phase of the nystagmus toward the abnormal side in peripheral vestibular nerve disease. Visual fixation can suppress the nystagmus. In central causes of vertigo (located in the brainstem) the nystagmus can be horizontal, upbeat, downbeat, or torsional and is not suppressed by visual fixation. Cranial Nerve 9 & 10- Moto When the patient says "ah" there is excessive nasal air escape. The palate elevates more on the left side and the uvula deviates toward the left side because the right side is weak. This patient has a deficit of the right 9th & 10th cranial nerves. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 9 & 10- Sensory and Motor: Gag Refle Using a tongue blade, the left side of the patient's palate is touched which results in a gag reflex with the left side of the palate elevating more then the right and the uvula deviating to the left consistent with a right CN 9 & 10 deficit. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 11- Moto When the patient contracts the muscles of the neck the left sternocleidomastoid muscle is easily seen but the right is absent. Looking at the back of the patient, the left trapezius muscle is outlined and present but the right is atrophic and hard to identify. These findings indicate a lesion of the right 11th cranial nerve. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 12- Moto Notice the atrophy and fasciculation of the right side of this patient's tongue. The tongue deviates to the right as well because of weakness of the right intrinsic tongue muscles. These findings are present because of a lesion of the right 12th cranial nerve.
almost 9 years ago
This image displays a large left sided haemothorax with mediastinal displacement to the opposite side. Clinically the patient would be in respiratory distress - percussion of the left side of the chest would be dull and breath sounds and vocal resonance would be reduced. A Haemothorax such as this falls into the category of life threatening chest injuries (ATOMFC) and requires emergent treatment using a chest drain in the 5th intercostal space, mid-axillary line and treatment according to ALS or ATLS protocols. ATOMFC = A = airway obstruction, T = tension pneumothorax, O = open pneumothorax, M = massive haemothorax, F = flail chest, C = cardiac tamponade.
about 10 years ago
"Stroke Series" video 1 of 7: Hypertensive haemorrhage and lobar haemorrhage are two distinct forms of haemorrhagic stroke. This video discusses the imaging characteristics of hypertensive haemorrhage, the underlying pathology (Charcot-Bouchard aneurysms) and the relevant differential diagnosis.
almost 7 years ago
"Stroke Series" video 2 of 7: Lobar haemorrhage and hypertensive haemorrhage are two distinct forms of haemorrhagic stroke. This video discusses the imaging characteristics of primary lobar haemorrhage, the underlying pathology (cerebral amyloid angiopathy) and the relevant differential diagnosis.
almost 7 years ago
Complimentary medicine (CAM) is controversial, especially when it is offered by the NHS! You only have to read the recent health section of the Telegraph to see Max Pemberton and James LeFanu exchanging strong opinions. Most of the ‘therapies’ available on the market have little to no evidence base to support their use and yet, I believe that it has an important role to play in modern medicine. I believe that CAM is useful not because of any voodoo magic water or because the soul of a tiger lives on in the dust of one of its claws but because modern medicine hasn’t tested EVERYTHING yet and because EVERY DOCTOR should be allowed to use a sugar pill or magic water to ease the anguish of the worried well every now and again. The placebo effect is powerful and could be used to help a lot of patients as well as save the NHS a lot of money. I visited my grandfather for a cup of coffee today. As old people tend to do we discussed his life, his life lessons and his health . My grandfather is 80-something years old and worked as a collier underground for about 25 years before rising up through the ranks of management. In his entire life he has been to hospital twice: Once to have his tonsils removed and once to have a TKR – total knee replacement. My granddad maintains that the secret of his good health is good food, plenty of exercise, keeping his mind active and 1 dried Ivy berry every month! He takes the dried ivy berries because a gypsie once told his father that doing so would prevent infection of open wounds; common injuries in those working under ground. It is my granddad’s firm belief that the ivy berries have kept him healthy over the past 60 years, despite significant drinking and a 40 year pack history! My grandfather is the only person I know who takes this quite bizarre and potentially dangerous CAM, but he has done so for over half a century now and has suffered no adverse effects (that we can tell anyway)! This has led me to think about the origin of medicine and the evolution of modern medicine from ancient treatments: Long ago medicine meant ‘take this berry and see what happens’. Today, medicine means ‘take this drug (or several drugs) and see what happens, except we’ll write it down if it all goes wrong’. Just as evidence for modern therapies have been established, is there any known evidence for the ivy berry and what else is it used for? My grandfather gave me a second piece of practical advice this afternoon, in relation to the treatment of open wounds: To stop bleeding cover the wound in a bundle of spiders web. You can collect webs by wrapping them up with a stick, then slide the bundle of webs off the stick onto the wound and hold it in place. If the wound is quite deep then cover the wound in ground white pepper. I have no idea whether these two tips actually work but they reminded me of ‘QuickClot’ (http://www.z-medica.com/healthcare/About-Us/QuikClot-Product-History.aspx) a powder that the British Army currently issues to all its frontline troops for the treatment of wounds. The powder is poured into the wound and it forms a synthetic clot reducing blood loss. This technology has been a life-saver in Afghanistan but is relatively expensive. Supposing that crushed white pepper has similar properties, wouldn’t that be cheaper? While I appreciate that the two are unlikely to have the same level of efficacy, I am merely suggesting that we do not necessarily dismiss old layman’s practices without a little investigation. I intend to go and do a few searches on pubmed and google but just thought I’d put this in the public domain and see if anyone has any corroborating stories. If your grandparents have any rather strange but potentially useful health tips I’d be interested in hearing them. You never know they may just be the treatments of the future!
over 6 years ago
Shattered. Third consecutive day of on-calls at the birth centre. I’m afraid I have little to show for it. The logbook hangs limply at my side, the pages where my name is printed await signatures; surrogate markers of new found skills. Half asleep I slump against the wall and cast my mind back to the peripheral attachment from which I have not long returned. The old-school consultant’s mutterings are still fresh: “Medical education was different back then you see....you are dealt a tough hand nowadays.” I quite agree, it is Saturday. Might it be said the clinical apprenticeship we know today is a shadow of its former self? Medical school was more a way of life, students lived in the hospital, they even had their laundry done for them. Incredulous, I could scarcely restrain a chuckle at the consultant’s stories of delivering babies while merely a student and how the dishing out of “character building” grillings by their seniors was de rigeur. Seldom am I plied with any such questions. Teaching is a rare commodity at times. Hours on a busy ward can bear little return. Frequently do I hear students barely a rotation into their clinical years, bemoan a woeful lack of attention. All recollection of the starry-eyed second year, romanced by anything remotely clinical, has evaporated like the morning dew. “Make way, make way!...” cries a thin voice from the far reaches of the centre. A squeal of bed wheels. The newly crowned obs & gynae reg drives past the midwife station executing an impressive Tokyo drift into the corridor where I stand. Through the theatre doors opposite me he vanishes. I follow. Major postpartum haemorrhage. A bevy of scrubs flit across the room in a live performance of the RCOG guidelines for obstetric haemorrhage. They resuscitate the women on the table, her clammy body flat across the carmine blotched sheets. ABC, intravenous access and a rapid two litres of Hartmann’s later, the bleeding can not be arrested by rubbing up contraction. Pharmacological measures: syntocinon and ergometrine preparations do not staunch the flow. Blood pressure still falling, I watch the consciousness slowly ebb from the woman’s eyes. Then in a tone of voice, seemingly beyond his years, the reversely gowned anaesthetist clocks my badge and says, “Fetch me the carboprost.” I could feel an exercise in futility sprout as I gave an empty but ingratiating nod. “It’s hemabate....in the fridge” he continues. In the anaesthetic room I find the fridge and rummage blindly through. Thirty seconds later having discovered nothing but my general inadequacy, I crawl back into theatre. I was as good as useless though to my surprise the anaesthetist disappeared and returned with a vial. Handing me both it and a prepped syringe, he instructs me to inject intramuscularly into the woman’s thigh. The most common cause of postpartum haemorrhage is uterine atony. Prostaglandin analogues like carboprost promote coordinated contractions of the body of the pregnant uterus. Constriction of the vessels by myometrial fibres within the uterine walls achieves postpartum haemostasis. This textbook definition does not quite echo my thoughts as I gingerly approach the operating table. Alarmingly I am unaware that aside from the usual side effects of the drug in my syringe; the nausea and vomiting, should the needle stray into a nearby vessel and its contents escape into the circulation, cardiovascular collapse might be the unfortunate result. Suddenly the anaesthetist’s dour expression as I inject now assumes some meaning. What a relief to see the woman’s vitals begin to stabilise. As we wheel her into the recovery bay, the anaesthetist unleashes an onslaught of questions. Keen to redeem some lost pride, I can to varying degrees, resurrect long buried preclinical knowledge: basic pharmacology, transfusion-related complications, the importance of fresh frozen plasma. Although, the final threat of drawing the clotting cascade from memory is a challenge too far. Before long I am already being demonstrated the techniques of regional analgesia, why you should always aspirate before injecting lidocaine and thrust headlong into managing the most common adverse effects of epidurals. To have thought I had been ready to retire home early on this Saturday morning had serendipity not played its part. A little persistence would have been just as effective. It’s the quality so easily overlooked in these apparently austere times of medical education. And not a single logbook signature gained. Oh the shame! This blog post is a reproduction of an article published in the Medical Student Newspaper, February 2014 issue.
almost 6 years ago
Sorry, I kinda feel like I turned two pages at once, and at the risk of asking a blindingly dumb question...Is there anywhere in the world where it is actually standard practice to do NGT lavage as a diagnostic tool in patients presenting with upper GI haemorrhage?
about 4 years ago