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Mikul last won the day on December 18 2016

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About Mikul

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  • Birthday 04/05/1988

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    Emma D

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    As Md Institute
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    Forensic Medicine

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  1. PLAB Blueprint GMC

  2. Fake Ultrasound Picture Maker

    Lots of these are being used for blackmailing their boyfriends, parents, families and also for extracting gifts
  3. Anatomy MCQs

    Which of the following ligaments prevent hyperextension of hip A - Illiofemoral Ligament B - Pubo Femoral Ligament C - Ischiofemoral Ligament D - Ligamentum Teres Femoralis Show Answer Answer: A Explaination
  4. Anatomy MCQs

    Angle formed by the shaft and the neck of the femur is degrees A - 115 B - 125 C - 135 D - 145 Show Answer Answer: B Explaination 125 The femoral neck and the femoral diaphysis form the femoral neck angle that normally is about 125 degrees. True about upper end of tibia is all except A - Ossification centre at the upper end fuses by 20 years B - It gives attachment to medial collateral ligament C - It gives attachment to semi-membranous D - Posterior aspect of patella articulates with upper end of tibia laterally Show Answer Answer: D Explaination Posterior aspect of patella articulates with upper end of tibia laterally Patella has no articulation with tibia; it is articulated to femur only
  5. Anatomy MCQs

    Anterior wall of the third ventricle is formed by? A - Lamina terminalis B - Pineal body C - Tuber cinereum D - Mamillary body Hide Answer Answer: A Explaination Anterior wall of third ventricle is formed by lamina terminalis, anterior commissure and anterior column of fornix.
  6. Anatomy MCQs

    This anatomy MCQ collection thread contains Anatomy multiple choice questions with single best answer. I will try to post MCQ explanations as well. You can click on any answer to see if youre correct. Click on Show answer button to see the explanation. You can also contribute to this topic by just pressing the button to add an MCQ All are true regarding axillary artery except? A - It is a continuation of subclavian artery B - It is crossed by pectoralis minor muscle C - It extends from outer border of second rib to the lower border of teres minor. D - The second part of part of axillary artery is posterior to pectoralis minor muscle Show Answer Answer: C Explaination Axillary artery extends from outer border of first rib to the lower border of teres major
  7. Mega Thread PLAB MCQs (Daily Updated)

    25-year-old man is admitted to the A&E having consumed 20 tablets of propranolol. An infusion of glucagon is prescribed. What is the main mechanism of action of glucagon in this case? A - Promotes the formation of cyclic AMP B - Stimulates lipolysis C - Increases glycogenolysis D - Promotes gluconeogenesis E - Alters protein kinase A activity Show Answer Answer: A Explaination Glucagon has become an accepted antidote to beta-blocker poisoning because it stimulates cAMP synthesis independent of the beta-adrenergic receptor. Glucagon has shown positive inotropic and chronotropic effects despite beta-receptor blockade in numerous animal models and in humans.
  8. Acute Confusional State

    First of all, ascertain whether the confusion is really acute; ie does the patient have chronic confusion (dementia)?; or is this acute on chronic confusion? Not doing this (and recording it) is one of the most medicolegally dangerous things a junior doctor can do Acute Confusional State:Introduction An acute confusion state is a neuropsychiatric syndrome which is difficult to define but involves abnormalities of perception, thought and awareness levels Patients may appear confused or 'not with it' when talking to them. It may be their family or carer who notice the confusion, alternatively Typically confusion is fluctuating, and worse at night. It can occur acutely, or subactutely It is very common, especially in the elderly, and not a benign syndrome. Many of these patients subsequently do not return to their baseline function and some even require long-term institutionalisation 20% medical and surgical acute admissions have some confusion 10% of elderly admissions are primarily due to confusion (often due to drugs) Sepsis, drugs/alcohol (excess/withdrawal) and metabolic disturbance are the 'big 3', ie three commonest causes of an acute confusional state TIA/CVA rarely presents as confusion. Think about alternative diagnoses. But hyponatraemia is a common cause in the frail elderly Removal from home can cause acute confusion. The skills are not to admit the frail elderly unless its necessary (or make their stay as short as possible), and accident prevention Pain and opiates can both cause confusion (think about post-op, especially post #NOF). Think about nursing issues and it's important to sedate only if essential There is a 5% in-hospital mortality, 10% mortality (+25% functional decline) at 3 months 50% of patients are diagnosed with dementia in following 2 years Acute Confusional State Medicolegal Aspects Patients are vulnerable It is a common scenario for errors, eg missing the diagnosis and poor management. This is why this area has the potential to become serious So, do a full examination, and a full set of bloods, BC, CXR, and CT head, if necessary Do not assume confusion is due to long-term dementia or learning difficulties, even in the elderly and those with either. The diagnosis may be not true, or mild, or barely affecting their QoL. Their family may love them just like that. In other words, check previous level of function from relative/carer/home circumstance If this is not possible treat as acute confusion until proven otherwise; not doing this is medicolegally dangerous. Do not go there. You need to make great efforts to find out their baseline mental state; ring family, GP, anyone; 2am, 2pm, anytime Why is this so important? It is because as soon as a patient acquires the diagnosis 'Dementia' or 'Learning Difficulties', some doctors (followed by the nurses, and PAMs) then assume that they have a proven, chronic and worsening condition, and try less hard; even being more likely to fill out a DNA-CPR form. So, if this goes wrong, and it ends in legal action, it can look very bad; ie like you did not care. Doctors may be forgiven for making mistakes, but not caring is unacceptable Anyway. Who says that patients with such longterm conditions should have any better/worse care than patients without these diagnoses Acute Confusional State Definitions Neuropsychiatric syndrome characterised by disorientation in time and place, impaired short-term memory, and impaired consciousness; occuring over hours/days, with a tendency to fluctuate over the course of the day Delirium = in addition, there are disorders of perception (hallucination, illusion, delusion) Importantly, confusion and delerium are reversible DSM-IV Diagnostic Criteria for Delirium Due to a General Medical Condition (2000) Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention A change in cognition (such as memory deficit, disorientation, language disturbance, or all 3), or development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition Acute Confusional State : Epidemiology 20% medical and surgical acute admissions have some degree of confusion 10% of elderly admissions are primarily due to confusion often due to drugs Ie its very common. Just ask all patients some simple questionsNote: only 10% of admissions with confusion have a primary neurological problem (vs sepsis, drugs and metabolic; which are the most important groups of causes) Acute Confusional State Mnemonic Causes HIDEMAP (from GP notebook): H+H = hypoxia (CCF, respiratory failure, AKI) + head trouble (head injury; SOL (SDH? brain abscess?); meningitis; rarely .. encephalitis, cerebral malaria) I = infection (UTI, chest, wound, line, post-op, neutropenic sepsis, especially if immunosuppressed) D = DRUGS DRUGS DRUGS = recreational or prescribed, excess or withdrawal, eg: benzodiazepines, analgesics (especially opiates), anti-cholinergics, anti-convulsants, anti-parkinsonism medication, steroids E = endocrine (hyper/hypoglycaemia, hypothyroidism (especially elderly)) M = metabolic (AKI, ALF, hypercalcaemia, hyponatraemia) A + A = alcohol (excess or withdrawal) + anaemia (B12/folate deficiency) 3Ps = psychosis + postictal + postop (especially post #NOF; often multifactorial, eg septic, dry and drugs)Notes: TIA/CVA does not usually present as confusion; and steroids can cause 'steroid psychosis' presenting as confusion, as well as a psychiatric state Risk Factors Dementia (ie worsening confusion) Alcohol + recreational drugs Recent surgery (especially neurosurgery) Acute Confusional State Symptoms History has limited value But in mild confusion, patients may be able to recognise it, and may have an idea of cause (ask them) Key Questions Vital to get history from witnesses (relative, carer, ambulanceman) Do you have depression (ever taken an overdose?) or other mental health problems, or epilepsy? How much alcohol do you drink? Ever taken a recreational drug? (you may have to explain) What tablets are you on? Any changes recently? Any recent operations (eg head and neck infection (brain abscess); cerebral shunt)?Note: pick up the phone if necessary. Remember, the 'poor historian' is you Acute Confusional State Signs Record mental test score (partly as baseline)Note: if you are in a hurry, do at least the first three, ie is the patient orientated in time, place and person?. If they know the date, they are not confused Look for needle tracks, and signs of head injury and alcohol Check for bladder (retention can cause confusion in elderly)Note: patient may be a danger to you (aggression or HIV/Hep B/C positive, ie wear gloves) Investigation for Acute Confusional State First of all, check the blood glucose. Don't forget the '3 Treatable Ts' = Thyroid(hypo), TPHA + BTwelve deficiency Blood FBC, CRP U+E, LFTs, GGT, Bone (?calcium), Glucose B12/folate,TFTs, TPHA/VDRLNote: don't forget the '3 Ts' (Thyroid(hypo), TPHA + BTwelve deficiency. Even though these are rare causes of acute confusion, they (and subdural haemorrhage) are 4 of the important reversible causes of chronic confusion ie dementia. In fact, many dementia clinics will not take a referral from a GP, unless those 4 things have been excluded O2 saturation (± ABG, if low), BC ± CK, if has been on floor for long ± Thick/thin films (malaria) ± SLE serology Other Urinalysis: leucocytes? nitrites? (catheterise slowly if cannot get sample) Urinary toxin screen (overdose?)? MSU CXR (pneumonia, ?carcinoma if patient hyponatraemic) AXR: ?constipation (can cause confusion in elderly) CT head ± LP , if no obvious diagnosis, or not improving at 48 hrsNote: look on back of drug card. The diagnosis may be there Key Investigations Glucose CT head ± LP Specialist Investigation EEG Differential Diagnoses Learning difficulties, dementia (chronic confusion) - all easy to confuse Drunk Deafness Dysphasia Dysarthria DepressionHysterical confusion Bipolar disorder Other psychoses eg schizophrenia Treatment of Acute Confusional State Patients with ACS may be a danger to themselves, and others; ie the most important 'treatment' may be making them safe - so think about nursing issues. If necessary, you may have to make decisions, against their will, under the Mental Capacity Act (2005) Treatment (first line) Drugs: IV GLUCOSE 20 mls 50%, if BG < 4 mmol/LNote: GLUCOSE increases risk of Wernicke's encephalopathy, so give IV PABRINEX first, if suspect patient is alcohol dependent and hypoglycaemic IV PABRINEX 2 vials tds, if ?Wernicke's or alcohol withdrawal possible PO CHLORDIAZEPOXIDE 20-40 mg qds, reducing over 5d; if alcohol withdrawal; but benzodiazepines can make confusion worse; so, only Rx with benzodiazepine if sureNote: larger doses are used in severe withdrawal, eg 40 mg qds, reducing over 10 days IV NALOXONE 400 mcg, if small pupils (?opiate OD) IV FLUMAZENIL 200 mcg, over 15 secs, if ?benzodiazepine OD; then 100 mcg every 60 secs; max 1mg (2mg ITU)Note: flumazenil is contraindicated in patients with epilepsy on longterm benzodiazepines; you may need to give further doses of naloxone and flumazenil (see BNF) Procedures: (see supportive measures below) IV (+IV fluids, if dry) OXYGEN, in hypoxic patient (this can quickly calm patient, and reduce confusion); if pulling mask off, try nasal cannulae Warm up/cool down, as necessary Supportive Measures Room: don't move about unecessarily; moderately lit side room preferable. Avoid excess noise, avoid over- or under-stimulation Communication: clear. Avoid speciality jargon. Staff consistency (both doctors and nurses). Use health advocates (eg interpreters) where needed Orientatation: reminders of the day, time, location and identification of surrounding persons; have a clock visible Relaxation: eg watch television. Involve family and carers. Familiarity: have familiar objects from home around patients especially glasses, walking aids and hearing aids. Maintain competence eg maintain walking in ambulant patient Accident prevention: nurse on floor if necessary (to prevent falls and fractures). Only use restraints if essential (patient may pull out central line and exsanguinate) Stop Drug cause (especially hyponatraemia secondary to diuretics and/or SSRIs) Alcohol Any sedative drug (if in doubt, stop almost everything) Treatment (second line) Drugs Have low threshold for broad spectrum IV antibiotics (± antivirals ± antimalarials): IV BENZYLPENICILLIN 1.2 g qds + GENTAMICIN 5 mg/kg od; before CT ± LP, if meningitis possible ± IV ACICLOVIR 10 mg/kg tds (infused over 60 mins) for 10-14 days, if encephalitis possibility (reduced dose in renal insufficiency) ± IV QUININE DIHYDROCHLORIDE: loading dose 20 mg/kg (maximum 1.4 g) over 4 hrs; then 8 hrs after loading dose, 10 mg/kg tds (also infused over 4 hrs); doses diluted in 250 mls N Saline, if cerebral malaria possible; watch for toxicity (QT prolongation) Avoid sedation, unless absolutely necessary. But if extremely agitated/aggressive (ie danger to themselves or others) consider O/IM HALOPERIDOL 2-10 mg (start as low as possible, even 0.5 mg); maximum 18 mg/d; or PO QUETIAPINE 12.5-200 mg od. Start with 12.5mg od especially in elderly; and if more needed than 25 mg bd, please consult psychiatrist-on-call Procedures If unwell, urinary catheter, CVP, arterial lineNote: but may pull out any of these; so can make situation worse Mental Capacity Act (2005) The Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. You need a working knowledge of this act and the Mental Health Act (1983, amended in 2007). The MHA is more used to treat patients who lack capacity because of mental illness (eg depression, schizophrenia) So, for a patient with an 'organic' cause of the mental disorder (like ACS), the MCA will normally be used, rather than the MHA For a mentally ill patient, carrying out a '5/2' section on the MHA is usually more appropriate For either, the basic issue, is whether you think the patient's mental state makes them them a danger to themselves or other people. If it is, you may need to act Specifically, if a patient has an ACS (or dementia, or acute-on-chronic confusion) (or other reasons for lacking capacity, eg learning difficulties), you may need to use the act (ie fill out a form and sign it) to give patients short-term treatment against their will; eg calling security or using haloperidol or midazolam to control an aggressive, agitated and confused patient If you are thinking of doing this, you should involve a senior The MCA says: - Everyone has the right to make his or her own decisions. Health and care professionals should always assume an individual has the capacity to make a decision themselves, unless it is proved otherwise through a capacity assessment - Individuals must be given help to make a decision themselves. This might include, for example, providing the person with information in a format that is easier for them to understand - Just because someone makes what those caring for them consider to be an 'unwise' decision, they should not be treated as lacking the capacity to make that decision. Everyone has the right to make their own life choices, where they have the capacity to do so - Where someone is judged not to have the capacity to make a specific decision, that decision can be taken for them, but it must be in their best interests - Treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms possible, while still providing the required treatment and care Prescribing Issues If drugs might be the cause (and no other diagnosis made), consider stopping all but essential ones - and inform GP when they go home. Polypharmacy is a problem in the elderly Admit? UsuallyNote: but if frail elderly, consider alternative management plan, in community; ring GP, if you are doing this plan Bed Plan Medical admission ward ± ITU Referrals Medical Depends on cause ± ITU Other SALT team etc, if CVA (pneumonia, 2o to aspiration?); does patient need NG feed? PEG? Maxim "Sedating a confused patient may make them worse" Complications Hospital acquired infections, eg Clostridium difficile and MRSA Pressure sores Accidents: eg fractures (femoral or hip fractures from falls) Residual psychiatric and cognitive impairment Some progress to stupor, coma and eventual deathNote: patient may be a danger to you (aggression or HIV/Hep B/C positive, ie wear gloves) Follow-up Depends on cause. Nil if cause is benign and confusion better But consider HCE follow-up, if thought to be first presentation of dementia Confusion may last longer than the underlying condition, sometimes for up to a year. This means that some patients will be discharged with persisting abnormalities. It is good idea to warn the family (and GP) about this issue Prognosis Good, if confusion is mild 5% in-hospital mortaliy, 10% mortality (25% functional decline) at 3 months 50% diagnosed dementia in 2 years Quicker inpatient recovery is associated with a better outcome 2° Prevention + Health Promotion If alcohol or recreational drugs all/part of problem, refer to appropriate community services Don't Forget Encephalitis; DO NOT MISS THIS DIAGNOSIS; it's treatable SDH; so is this DRUGS DRUGS DRUGS (and look on back of card). If in doubt, stop almost everything. Ring GP, if necessary Find out whether this is acute, chronic (dementia), or acute-on-chronic confusion Look at vital signs (including oximetry) and glucose Record mental test score (important baseline; like GCS in coma; note if fluctuating) CT head/LP if no obvious diagnosis, or no better at 48h Check for retention and constipation, in the elderly '3 treatable Ts' = Thyroid(hypo), TPHA + BTwelve deficiency Know the bascis of the Mental Capacity and Mental Health Acts Red Flags Pulling at lines, catheter etc Falling out of bed .. ie, may be danger to him/herself (protect them)
  9. We frequently encounter patients with very high BP and associated numbness, headache, nausea, blurring of vision. Whats the best drug to lower BP quickly?
  10. what is the approx cost involved in the procedure?

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