1. Medical Protection: The Medical Protection Society

The MPS has a range of online resources and clinical information to help guide medical students and healthcare professionals through their medical training. One thing we like is their magazine for newly qualified junior doctors which are handy for a quick read through relevant junior doctor experiences of life at work. New Doctor magazine can be found here, and Medical Student pages (UK) here.

2. Mnemonics: Medical Mnemonics

We love Mnemonics. Take this one for joint pain.

SOFTER TISSUE:
Sepsis
Osteoarthritis
Fractures
Tendon/muscle
Epiphyseal
Referred
Tumor
Ischaemia
Seropositive arthritides
Seronegative arthritides
Urate
Extra-articular rheumatism (such as polymylagia)

They missed trauma out but hey, nobody’s perfect.

3. Anatomy Guides: Cross sectional Anatomy from anatomy atlases .

We think this picture is of a brain. It’s definitely not the glenohumeral joint.

4. Radiology Help: IMIAIOS

We like this sitter from IMAIOS, who provide detailed pictures like the one you can see here of the famous Scottie dog. We thought it looked like a lumbar spine. How wrong we were.

By the way, you won’t see many more lumbar spine radiographs because your local radiologist will probably have a heart attack if you try to request one! This is because they are notoriously useless at picking anything important up, other than fractures.

5. Stats Advice: BMJ Stats Pages

The BMJ weigh in with a great free resource which requires no subscription. The BMJ really are helping doctors make better decisions (we’re aiming to help you as a medical student make the best decision).

6. iPhone App: IResus

We love this app from the developers at Imobilemedic.com.  You might get a few funny looks from doctors over45 at the next cardiac arrest if you whip this out, and remember not to spill your coffee on your iPhone.

7. Apps for all Smartphones: Med Calc

Thought the Anion Gap was a tourist attraction north of Watford? We’ve got new for you….

If you need to work out a BMI, GCS or Disease Activity score quick? Check out Med Calc… It works on most smart phones. As one contributor said: “I use this most days at work”*

We are fairly certain this is just to show off, but we love this app.

8. General Information: GP Notebook

Most of the GPs that we deal with from medical educator would be doing well to be dealing with most of the complex stuff listed on here. Need to know the classification system for bone tumours? Look no further.

9. Quick information: Wikipedia

Wikipedia is still top of our list for those obscure things you need to know about. As students you always need to be sure to check your sources, however there comes a time when you need fast reliable information, or when you need to read round a topic.  The Journal Nature found that Wikipedia was as good as the Encyclopaedia Britannica across a range of scientific areas. That’s good enough for us, this represents web2.0 in action!

10. Free MCQs & video: Medical Educator

You didnt think we would leave ourselves out did you? If you don’t know already, signing up is completely free and gives you access to loads of our sample multi-questions, videos and podcasts.

Got any other top free resources that you know, use and love? Leave a comment and share the joy!

Life is hard for a first-time buyer, now more than ever. There are fewer high loan-to-value mortgages than back in the glory days pre-2007 and after prompting from the Financial Services Agency, banks are reeling in on interest-only mortgages, which were a lifeline to first-time buyers.

It is going to be a while before you save for a deposit, what with paying back your student loan and saying goodbye to student discounts and benefits. However, once you have a few thousand in the bank you then need to find a mortgage you can actually afford.

Many potential borrowers get excited when they calculate how much they could actually borrow. The rate is usually four times your salary, so with an average doctor’s starting salary being around £33,000 or so, you could borrow £132,000. But, and there are some buts, what you can actually afford to pay back and what you can borrow quite often differ.

Say you want to borrow £120,000, if you can muster up a 10% deposit and opt for a three-year fixed rate deal over a 25-year term, you are looking at paying back £772.43 per month. And, seeing as the average UK house price is £205,598, this £120,000 figure is miles below this price.

Getting an affordable mortgage is therefore rather tricky. So what do you do? Well the best advice is to save as big a deposit as possible. Bigger deposits mean less risk for the bank and this results in a better rate for you, and opens you up to better mortgage deals.

You can also look at paying over a longer term as this will work to reduce your rate. But some banks are rather restrictive over this, so you need to fully investigate what each mortgage offers and thoroughly read the small print.

Before going to your bank, make use of online calculators such as the mortgage calculator from Santander. There are also repayments calculators so you can see how much you can borrow and how much you will have to pay back each month. Once you have found the right balance, only then can you approach your bank.

And if you do decide to get a mortgage, right now could be time to lock in a fixed-rate deal. OK – so for the past few months and for probably the next couple of months a tracker mortgage will come out as more cost effective, but the interest rate isn’t likely to get any lower, and with fixed-rate deals at their lowest levels right now, it makes sense to secure these rates for the next two to five years.

This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.

Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.

Let’s consider the following features and clinical examination…

A 36 year old male gives the following history:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.

Your Examination Findings are:

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 1. Look professional

Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.

Tip 2. Organise your presenting posture to minimise nerves

This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.

Tip 3. Structure your presentation of medical terminology

This needs to be structured in the same was that you elicited the history. PC, HPC PMHx, for example:

Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…

Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!

Tip 4. Interpret as you go

Don’t be afraid to explain your interpretations as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”

Tip 5. Learn to summarise in one sentence

Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”

We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

But what about when you are asked to expose your weaknesses?

When posed the question “Please can you tell me your weaknesses or flaws” think about this in a positive manner.

Explain your weaknesses as strengths to maximise the return on the interview you are having.

You shouldnt mislead or lie to interviewers but if you strategically prepare your responses as explained in this video it will assist in getting the maximum from an interview situation.

www.youtube.com/watch?v=fr_ZThSU2fo

• No Jaundice , anaemia, cyanosis, jaundice or lymphadenopathy
• noted rash under both eyelids.
• BP 134/66
• Pulse 78 regular
• Sats 98% air
• BM 4.5 mmol/l  RR 16
• Normal Cardiovascular Respiratory Gastrointestinal examination.

Neurology as follows:

• Grade 4 power upper and lower limbs symmetrically.
• Normal sensory examination.
• Normal reflexes.
• No clonus
• No fatigability

Where is the likely pathology?

Central Brain Lesion
Brainstem Lesion
Cord Lesion
Peripheral Nerve
Neuromuscular Junction
Acetylcholimesterase enzyme problem
Muscle lesion
None of the above

Let us know what you think, answer to follow soon. Remember: more questions like these can be found in the free trial area.

The answer is….. b. Warfarin

Based on NICE Guidance 36 (AF) and the CHADS 2 scoring system.

The CHADS2 score is an excellent aide memoir to anticoagulation in AF. It is based on:

SCORE

• 2 or over=Warfarin
• 1= Warfarin or aspirin
• 0=aspirin

This means our chap here will score:

• 1 for being >75
• 1 for being hypertensive

This means he should be treated with warfarin (assuming he has no contraindications)

A link to the original publication citation in circulation is available here. (link will open in a new window)

Get more questions like this in our free trial. ]]> http://medicaleducator.co.uk/answer-to-question-of-the-day-atrial-fibrillation.html/feed 1 http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html http://medicaleducator.co.uk/question-of-the-day-atrial-fibrillation.html#comments Fri, 26 Jun 2009 08:05:10 +0000 admin http://medicaleducator.co.uk/?p=427 A 76 year old man presents with atrial fibrillation which is permanent. He is lucid and has specifically made an appointment with you to discuss the best way of stopping him “dying ” as a result of the AF.

PMHx:
Hypertension (treated), Mild COPD. Nil else of note.

DHx
Verapamil (as treatment for AF)
Amlodipine
Simvastatin
PRN inhalers

SHx
Lives alone. Independent. Can carry out all ADL’s (activities of daily living)

What is the anticoagulation schedule you would recommend to prevent stroke?

a. Clopidrogel
b. Warfarin
c. Aspirin
d. No anticoagulation
e. Warfarin and Aspirin

Symmetrical disease?
Erosions?
This is classical of RA X-ray changes that include

1. Erosions
2. Reduced joint space
3. Peri-articular osteoporosis
4. Nodules

So from the initial history of disease [small joints, both hands], the likely diagnoses would be

• RA
• PsA
• (less likely) gout.

Erosive changes are not specific to RA however but the findings were symmetrical

• both gout and PsA tend to be asymmetrical

Don’t be put off by the fact he’s male, although RA is roughly 3x commoner in women. You dont get a mention of which joints are affected here: RA has a penchant for the wrists and MCP joints. Erosions of the ulnar styloid are very common.

Common x-ray changes of the different arthritides are shown below:

Non Inflammatory

Primary OA: Asymmetrical

There are classically 4 signs of OA on an X-ray: Occurs in classic joints eight bearing e.g. Hips& Knees. May not be symmetrical.

1. Subchondral bone sclerosis
2. Cystic Change
3. Osteophytes
4. Reduced Joint Space

Charcot Joints:

1. Destruction of the joint
2. Disorganisation (bones not arranged in the correct /usual arrangement through gross destruction e.g. cuniforms of the foot.
3. Increased density (sclerosis)
4. Debris (boney debris from a destroyed joint: often with well defined margins
5. Dislocation

Secondary OA

As per primary OA but occurring in a joint that has been previously damaged from any other disease process (inflammatory disease etc)

Inflammatory

Gout: Asymmetrical

The classical signs of gout on an Xray are: Erosions with sclerotic margins. Asymmetrical.

1. A relatively preserved joint space
2. Minimal periarticular osteoporosis
3. Nodules (these are in fact tophi)

Psoriatic Arthritis: Asymmetrical

The X-ray Changes are similar to rheumatoid but they differ in their distribution, and the formation of pencil in cup deformities along with osteolysis.

1. Asymmetrical distribution of disease
2. Often affects PIP and DIP joints
3. relative absence of peri-articular osteoporosis
4. Erosions seen at the distal interphalangeal joints joints
5. Reduced joint space
6. Pencil in cup deformity (arthritis mutilans with telescoping of the fingers)- this is a result of osteolysis
7. Loss of the terminal tufts of the phalanges (acro-osteolysis)
8. Sacroiliac and spondylitic changes (similar to those of Ank. Spond.)

Rheumatoid Arthritis: Symmetrical

1. Erosions
2. Reduced joint space
3. Periarticular osteoporosis
4. Nodules

Septic Arthritis: Asymmetrical

1. Periarticular osteoporosis
2. Loss of joint space
3. Deformity/subluxation
4. Erosions
5. Effusion
6. Usually just 1 joint

Periarticular osteoporosis of the MCP joints
Erosion on the ulnar styloid
Symmetrical distribution of disease
Reduced joint space at the carpal bones

What is the most likely diagnosis?

a. Ankylosing Spondylitis
b. Rheumatoid arthritis
c. Gout
d. Secondary Osteoarthritis
e. Psoriatic Arthritis