Training for Exams

Ask any cyclist what their ‘routine’ is in the run up to a race and you’ll likely be there a while as they carefully recount the day-by-day, minute-to-minute strategy to ensure they’re set up for the best possible performance on the day. Nothing gets forgotten, be it training, food, sleep, clothing – you name it, a cyclist has tweaked it to beyond-neurotic perfection. While they don’t usually require figure-hugging lycra and obnoxiously fluoro sock choices, I strongly believe that a lot of the same principles seen in bike racing can be applied to examinations, as they are essentially the equivalent of a bike race for your brain. So here is my 6 part breakdown on how to prepare for that all important event, and get the most out of that spongy brain-muscle between your studious ears…

Train how you race

There’s no point doing lots of long, gentle mountain riding if the race involves a short, high intensity blast around a velodrome; you have to ensure you’re training your body for the physical requirements on the day. Likewise, if your examination is going to be a series of multiple choice questions, you should practice doing questions rather than  just reading through blocks of material in prose format. Of course you’ll need to read and learn the relevant information, but if you use MCQs as a reference, you’ll see the sort of patterns that pop up, and learn to process the information in a way that anticipates the questions that might be asked of you on the day. If your exam is an essay paper, practice writing essays under timed conditions, in the same format, with the same pen, long in advance of the exam. You’ll be surprised how tired your hands get if you’ve not written a complete essay all year and suddenly you try and do three in an hour on the day.

Don’t overdo it

My guess would be that almost every cyclist at some point has fallen into the trap of overtraining. The sport is enjoyable, addictive and it’s very easy to assume that more training means more improvement. However the gains in your performance happen when you’re resting, allowing your muscles to rebuild and strengthen. Ideally you’d be sleeping all the time you’re not riding or eating…

The same principles apply to revision. Your brain uses its down time, particularly when asleep, to subconsciously sift through the material covered during the day and consolidate the useful information into its long term memory. To make your revision worthwhile, you’ll need to ensure you’re getting enough sleep to reap what you sow, so it may be a good idea to put the pen down a little earlier and get some well earned kip. This is doubly important if you’re doing exercise as well, which you should be!

Get your food right

If you put sludge in your car, it’s not going to run very well. If you try and win a bike race on KFC and doughnuts you’ll be sorely disappointed, and probably rather ill at the end of it. Equally, if you try and work your brain overtime in the weeks before the big day, and don’t give it good fuel to use, it will burn out very quickly. Having a tub of chocolate mini-bites next to you while you work may give you a little ‘lift’ every time you have one, but it is doing your concentration, memory and general health no favours in the long run. Fill up on good quality veg, oily fats and really complex carbohydrates and your concentration, endurance and performance will all speak for themselves. You may feel that you don’t have time to cook a ‘proper’ meal, but I promise you – you do. Not only will the break from revising give you a motivation boost, but concentrating on your food will make you feel fuller and stop you snacking between meals.

Coffee – this was almost worth a post in its own right. Caffeine has proven to be a powerful performance enhancer both physically and mentally, and is thought to have numerous health benefits that I won’t delve into here. Essentially, the best thing to do is work out just how much is right for you; be it none, a little or a lot, and keep it there. Don’t go overboard in exam term. If you think you’re over-tired and the coffee is no longer enough, it means you need more sleep, not more caffeine. On the day, have the same amount as normal – it’s what your brain is used to, and the smell of the coffee will trigger memories on a subconscious level too (Google ‘state dependent learning’ for more info).

Tapering

In the weeks running up to a big event, different cyclists will do their own things, but in general the weeks immediately prior involve a lower volume of training to allow the body to be as fresh as possible on the day when it matters. That definitely doesn’t mean doing nothing at all in the week before, rather just doing enough to tick things over and stop them going stale. The same goes for revision – you don’t want to be cramming until five in the morning and then turning up to sit the paper exhausted and demoralised. I usually work fairly solidly up until two days to go, then on the day before I take it easy. I’ll do some solid exercise, and a bit of light reading, but generally let my brain rest before the event. I’m always tempted to sit and cram, especially when I see other students working, but when I’m sat in the exam room, I’m always more grateful for the rest than the extra information on the day before.

Motivation

It’s hard to stay motivated when revising, especially for medical exams with their seemingly endless quantities of information and undefined syllabus. But keeping up your motivation is key to productive work – you will process the information more effectively and it’ll stick in your memory for longer. When I feel my own motivation slipping, I like to write down as many reasons why I’m sitting that exam as I can think of. Usually it’s enough to get me back on track and keen to work, but if it doesn’t, there are always fantastic motivational videos on YouTube to get you in a productive mood!

On the day

It’s show time. Exam day routine is a personal affair that everyone does differently. Some rise at the crack of dawn to cram last minute information that may be of use into their short term memory, while others saunter into the exam room at the last minute having just woken up. Find what works for you, and commit to it. Personally I don’t like to do any extra work on exam day, to leave my brain as fresh as possible for the task ahead. I have a big breakfast, a couple of coffees and then try to relax as much as possible before the inevitable onslaught begins. After the exam, forget about it, if you can. It’s easier said than done, but it doesn’t help anyone to sit there dissecting what happens; partly because it serves only to stress people out, but also because you’re likely to misremember questions or answers that you gave, even if only slightly, that can lead you to thinking you got things wrong when you didn’t. So chill out, and enjoy a well-deserved rest!

 

Abdominal Examination

Being able to perform a competent examination of the abdomen is one of the most important skills to accomplish at medical school. There are a lot of things that can go wrong within the abdomen, and equally there are many ways of determining what exactly is happening. Be systematic, thorough and don’t jump to any conclusions!

As with all examinations the best way to become proficient is to practice until you find a routine that works for you. I’m strongly of the opinion that there is no one way to do an exam, rather it is a personal process that you develop over time with experience. Once you have found a way you like to do it, do it the same way every time to reinforce it effectively. This is my way of doing it, so feel free to chop and change as you wish!

Introduction

  • Wash your hands and show your name badge to the examiner
  • Introduce yourself, with name and role
  • Confirm that you have the right patient in front of you, with name and age
  • Explain why you’ve come to see them.
  • Gain consent to do the examination, and you may offer a chaperone if you feel this would make the patient more comfortable
  • Ask if they are in any pain at present, and to tell you if it becomes too uncomfortable to continue
  • Ensure your patient is sat at 45 degrees, and exposed adequately.
    • Some say ‘nipple to knee’ but in reality as long as you can see the whole abdomen down to the pubic symphysis, patient dignity should be maintained.

General Inspection

Arguably the most important part. After a while you will be able to diagnose many conditions on inspection alone.

  • Looking around the bed for things the patient has brought with them will give you a clue as to their current function, and what pathology might underly their presenting complaint
    • Medications
    • Inhalers
    • Pumps
    • Walking stick
    • Prostheses
    • Stoma bags
    • Drains
    • NG tubes
  • The patient
    • Are they comfortable at rest?
    • Are they obese/malnourished?
    • Are they short of breath?
    • What colour are they?
      • Blue – cyanotic
      • Yellow – jaundiced – liver disease
      • Grey – iron infusion, haemochromatosis
      • Pale – anaemia – liver disease, GI bleed, Malabsorption
    • Can you hear anything?
      • metallic valves
      • stridor
      • wheeze
    • Are there any obvious scars or wounds?
    • Any visible abdominal masses?
      • Transplanted organs
      • Organomegaly
      • Cysts
      • Pulsating abdominal aorta
        • normal in thin people

 

Hands

The hands will give you an idea of the chronicity of a disease as clubbing and nail changes do not occur acutely.

  • Clubbing
    • Cirrhosis
    • Inflammatory Bowel Disease
    • Malabsorption
    • Hepatopulmonary syndrome
  • Nail changes
    • Leukonychia
      • lack of protein
      • ulcerative colitis
      • trauma
      • ?zinc deficiency
    • Koilonychia
      • iron-deficiency anaemia
      • Plummer-Vinson syndrome
  • Palm colour
    • Palmar erythema
      • Portal hypertension
      • Liver disease
      • Hyperthyroidism
      • Rheumatoid arthritis
      • Pregnancy
      • Polycythaemia
  • Dupuytren’s contracture
    • Associated with:
      • manual labour
      • alcohol excess
      • familial
  • Liver flap
    • Postural failure due to encephalopathy
      • Uraemia
      • Hepatic encephalopathy

 

Arms

  • Bruising
    • suggests poor clotting
      • liver disease
  • Needle marks
    • risk of IVDU/HIV/Hepatitis
  • Excoriations
    • scratching due to pruritus
      • liver disease
  • Hair loss from axillae
    • caused by
      • malnourishment
      • iron deficiency anaemia
    • acanthosis nigricans
      • GI adenocarcinoma
      • Obesity

Eyes

  • Corneal arcus
    • normal with increasing age
      • hypercholesterolaemia
  • Xanthelasma
    • elevated lipids
      • Hypercholesterolaemia
  • Jaundice
    • yellow sclerae
      • haemolysis
      • liver disease
      • biliary obstruction
  • Kayser-fleischer rings
    • rare
      • Wilson’s disease

Mouth

  • Anaemia
    • pallor of the underside of the tongue
  • Angular Stomatitis
    • inflammation of mouth corners
      • iron/B12 deficiency
  • Glossitis
    • beefy tongue
      • iron deficiency anaemia
  • Ulcers
    • ask about these
      • Crohn’s disease
  • Parotid hypertrophy – alcohol

Neck

  • Virchow’s node
    • left supraclavicular lymph node
      • GI malignancy
  • Lymphadenopathy
    • may suggest
      • infection
      • malignancy
  • JVP
    • may be raised in 
      • liver disease

Chest

  • Gynaecomastia
    • breast tissue develops in
      • liver disease
      • salbutamol
      • digoxin
  • Hair loss
    • seen in
      • liver disease
      • malnourishment
  • Spider Naevi
    • cherry red with wispy ‘legs’ – need more than 5 to be pathological
      • liver disease

 

Abdomen

  • Scars
  • Bruising
  • Swelling and distension
  • Prominent abdominal wall veins
    • Occlude the veins and ‘milk’ them to empty them, and see how they refill. 
      • Caput medusae refill towards the legs
      • Inferior vena cava obstruction – refill towards the head

 

NOW REPOSITION THE PATIENT SO THEY ARE LYING FLAT

People do the next bit differently depending on personal preference. I like to go organ-by-organ, palpating and percussing the liver, then the spleen etc – others like to do all of palpation, then all of percussion. Either is fine, just remember to do it all! I’ve written it here as palpation then percussion.

Palpation

  • Palpate the 9 regions of the abdomen, beginning away from painful areas
    • superficial palpation while watching patient’s face
      • guarding
      • rigidity
      • rebound tenderness
        • all signs of peritonitis
    • deep palpation for abdominal masses
      • Describe any mass by:
        • Size
        • Shape
        • Location
        • Outline
        • Consistency
        • Mobility
        • Pulsatility
        • Overlying skin (rashes/reaction)
        • Temperature
        • Auscultation – bruit?
  • Liver
    • use radial border of index finger, starting at the right iliac fossa
      • press in, and tell patient to inhale, feeling for liver edge against your hand
      • repeat, moving hand towards right costal margin each time until the costal margin is reached
  • Spleen
    • use same technique for splenic palpation, beginning in the right iliac fossa but moving towards the left costal margin
      • Features of spleen on palpation:
        • can’t get ‘above’ it (under ribs)
        • smooth edge with notch
        • moves down on inspiration
        • dull to percussion
        • if palpable, spleen is 50-100% enlarged
  • Kidneys
    • Using one hand to press into the abdomen, use the other to gently flip (ballotting) the kidney against the superior hand, and feel for an impulse. Normal kidneys aren’t ballottable except for particularly thin patients.
  • Aorta
    • gently press two thumbs above the umbilicus and feel for a pulsation
      • pulsation (moves thumbs up and down) is normal
      • expansion (moves thumbs apart) is pathological

Percussion

  • Percuss for the liver and the spleen
    • Liver
      • lower four ribs should be dull depending on level of inspiration
    • Spleen
  • Percuss for the bladder
    • ask patient if they need to urinate first!
    • begin at the umbilicus and percuss towards pubis. Dullness suggests a full or distended bladder

Test for ascites

Ascites is fluid in the peritoneal cavity that may cause distension. Remember the differential for a distended abdomen:

  • Fluid
  • Fat
  • Faeces
  • Foetus
  • Flatus
  • Fire (inflammatory mass)
  • F*** (malignancy)

 

  • Percussion
    • percuss over the umbilical region, which will be resonant in ascites as the air bubble sits at the highest point
    • percuss round towards the flank, and note the point at which the tone becomes dull – this is the fluid level
  • Shifting dullness
    • ask patient to roll onto their side (I get them to roll towards me and put their hand on my shoulder for stability)
    • The air bubble should now have moved round to the new highest point at the flank. Percussion of the flank should now be resonant and the new fluid level discovered towards the umbilicus
  • Fluid thrill
    • tapping on one side of the abdomen sends a shock wave through the abdominal fluid that is palpable on the other side. Usually only possible in massive ascites.

 

Auscultation

  • Auscultate for
    • bowel sounds
    • renal bruits
    • aortic bruits
    • venous hum (portal hypertension)

Finishing up

  • Check for leg swelling
    • pitting oedema in liver failure
  • Thank the patient
  • Sit them back up and help them get dressed
  • Wash your hands

 

Practise, Practise, Practise!

Preparation 

Fail to prepare, prepare to fail. Preparation is key in a lot of situations, and Medicine as a whole is one of those situations. Having a solid plan, thinking it through and making sure you have everything ready beforehand will save you a lot of trouble. A good way to do this is through visualisation […]

Instructions

Like it or not, as a medical practitioner people are going to take what you say seriously. They will look to you for advice and reassurance during their most vulnerable moments, and will often follow exactly what you say to the letter. This means you have to be careful about what you say, and how. […]

Gunners

 

Urban Dictionary – A person who is competitive,overly-ambitious and substantially exceeds minimum requirements. A gunner will compromise his/her peer relationships and/or reputation among peers in order to obtain recognition and praise from his/her superiors.

It’s good to be good…

It’s always good to want to improve your own ability, build upon your existing knowledge and broaden your knowledge base. Medicine is a continuously evolving subject that requires by law that you do the same. I’d be worried if I knew my doctor wasn’t at least trying a little bit to learn more about the subject they’d chosen for their career…

However, comparing yourself to others can be dangerous. When we go out in the world we put on our public face, our public clothes, and our public attitudes. We don’t reveal our inner fears, our problems, our weaknesses. And since everyone else is doing the exact same thing we don’t ever see theirs. This combination of caging away our own issues and not witnessing those of others gives us the false impression that they’re finding everything so much easier, or that they’re so much better off than we are. This is further perpetuated online, as Facebook and Instagram give the opportunity to sell yourself to the world as that perfectly happy, exciting and fulfilled individual that couldn’t possibly exist in real life. It’s not exactly a recipe for sound psychological well-being.

But there is a limit…

Medical schools rank their students. Presumably it’s intended as an incentive to work harder, as a higher rank apparently brings the tantalising promise of a better job, more research opportunities and greater respect. Maybe it produces better doctors, maybe it doesn’t. What it definitely does do is discourage students from helping each other out. The stakes are raised, forcing us to show that we’re not struggling, that we know the required information, that we can hack it in this apparently brutal world of medicine. People become so preoccupied with that centile rating that they will give up relationships with their peers in an attempt to make excruciatingly small gains over them, be that by hiding information or learning opportunities, or even misleading them deliberately in the hope of sabotaging this ‘competitor’ and boosting their own ranking.

WTF?

I once asked someone what topics were covered in a teaching session that I had missed through illness, and they said to me, “It’s your fault you weren’t there”Turns out it was the Krebs’ cycle…

I’ve also heard rumours of students sabotaging the computers/iPad available during OSCEs to disadvantage those yet to complete that station.

It’s crazy!

The qualities we want in our doctors are compassion, teamwork, communication and integrity. Healthcare is never done on an individual basis, it’s always a team of teams of teams, each with their own area of expertise and interest, cooperating and communicating to ensure the best outcome for the person that really matters most – the patient. You can only gain by communicating well with others. Either you find out something you didn’t know before, you deepen your own understanding of a subject, or you have that satisfying feeling of helping someone else understand something just a little bit better, and knowing that you’re helping their patients as a result.

So I ignore the rankings. Always have, always will. I don’t care if the person I’m talking to is going to score higher than me. In fact, I’m happy if they do. Why? Because I’m determined to be a good doctor – it’s what I’ve always wanted to be – so anyone scoring higher than me in the rankings has to be pretty good as well, and they might be looking after my Mum one day.

 

Don’t be that guy – help each other!

How I work

Deciding how to work

After more than fourteen years of school and six years of Medicine at University, you’d think I’d have figured out how I work best when it came to studying for exams. Surely after that many years of studying, cramming seemingly endless reams of information into my head for retrieval on the big day, I would know whether I was benefiting most from writing out notes, listening to lectures and podcasts, making flashcards, or reading the textbooks…

 

I didn’t.

 

This was a constant source of stress for me as each year I would begin the process of walking out into the lapping waters of bottomless information, and not have a clue as to how best to study. Should I try and write everything down? Type it out? Make flashcards? Just listen? Whichever tactic I tried soon became either unmanageable, tedious, or I simply didn’t think I was learning anything from the process. So what did I do?

I thought about what I do when I come to retrieving the information. That is, in exams, whenever I’m trying to remember answers from my brain and wondering why I couldn’t remember medical facts like I could with cat videos or insulting jokes, how was the information presented in my head. Was it remembering the page of notes? Remembering the lecturer’s voice? The diagram on the flashcard?

It turns out that there were three main ways that I was retrieving these facts:

  • Remembering answers to previous questions that were similar to the one in front of me
  • Recalling specific experiences I’d had on the wards
  • Diagrams that I’d drawn and re-drawn until I could do it by heart
  • Flashcards that I’d done so many times that I didn’t even have to try and remember them.

It was a very rare occasion that I would remember a piece of information from notes I’d written or textbooks I’d read. So I figured I’d stick to these four categories, and hope that my analysis wasn’t way off..

How I work now

  1. I spend as much time on the wards as possible. This is largely because final year is meant to be as much of an apprenticeship as possible; you’re learning how to do the job of those a year ahead of you, so you’ll benefit most from observing, trying (and failing) to do the same things. Your brain is very good at remembering experiences that it has because it has so many ways of programming the information; sights, sounds, smells, temperatures, emotions – think of a time you screwed something important up – bet you never had to revise that again!
  2. I make flashcards. This is largely a convenience thing as you can make one or two in a spare moment, and review them during quiet parts of the day. I use Anki, purely because it’s free on android and you have your cards with you wherever you go.
  3. Nearer the time, when exams are looming, I talk myself through a topic, while drawing out diagrams. I then use the books to check what I’ve missed, and add the information to the diagram. Then I store the diagram away until next time, and attempt to copy it perfectly. Repeat until smart.
  4. teach! You never know information properly until you can teach it to someone who knows nothing about it. If you can explain something simply to a friend or patient, then you truly understand a topic.

Find your own groove

Learning is incredibly personal, and everyone does it differently. Try different methods, see which you like, and more importantly, which ones seem to work, and focus on those, rather than spending time doing ineffective studying that bores you and doesn’t help your exam performance.

 

Good Luck!

 

 

 

Right iliac fossa mass

What on earth is that lump?

You have a young patient screaming in pain “my appendix!“, but her mother is much more worried that it might be cancer. You ask her why she thinks he has cancer, and she says

  • appendix mass
  • caecal carcinoma

“He’s had diarrhoea that floats!” to which you reply “Sounds more like Crohn’s…”

  • Crohn’s

You’re interrupted by the patient, who is now convinced her ovaries are exploding and her intestine is eating itself.

  • Ovarian mass
  • Intussusception

Do you think it could be her transplant?” asks the mother quietly – this surprises you so you look at the patient’s abdomen for scars, but instead you see a huge pulsating lump that looks like an aneurysm of some sort.

  • Pelvic kidney
  • Common iliac aneurysm

Have you had a fever?”  you ask? You’re thinking it could be an infection, either TB or an abscess.

  • Iliocaecal TB
  • Iliac lymphadenitis
  • Actinomycosis
  • Psoas abscess

The patient shakes her head, you then ask “can you push it back in?

  • Spigelian hernia

Both mother and daughter look at you like you’re an idiot, before daughter wets herself all over the bed. “What’s wrong with my bladder?” Which makes you think of her other bladder.

  • Gall bladder enlargement

The differential diagnosis for a right iliac fossa mass includes the following:

  • Appendix mass
  • Caecal carcinoma
  • Crohn’s disease
  • Ovarian mass
  • Intussusception
  • Pelvic kidney
  • Enlarged gall bladder
  • Iliocaecal TB
  • Iliac lymphadenitis
  • Psoas abscess
  • Retroperitoneal tumour
  • Actinomycosis
  • Common iliac artery aneurysm
  • Spigelian hernia

Clearly the likelihood of each is going to depend on the patient, the history, and the presentation. Caecal carcinoma is much more common in an elderly person than a teenager, while appendicitis is less likely if the patient has already had an appendicectomy…

Yellow Babies

Sometimes you have to talk to people about their problems. The incidence of this occurring rises dramatically if you become a doctor.

One of these problems is the finding that after giving birth to a child, it starts to turn yellow. This is rather unsettling for parents, and sometimes cats, and so they may ask you about (the parents) about why it’s happening. Given more than half of babies go yellow, this conversation tends to come up a lot.

Here I’ve written my two cents on how to explain it to Mum, and then some of the sciencey stuff underneath.

The conversation


“Hi, my baby’s yellow, did I do something wrong?”

Hello, my name is medical student and I’m a medical student. I’ve been asked to come and sp….”


“..yeah but why’s my baby yellow?”

“Well, could you tell me what you know so far?”


“………the baby………..it’s yellow….”

1 – It’s probably fine

Drop in a statistic like 60% of babies go yellow after birth, and it’s absolutely normal, especially if they came along a little early. Even more so if you’re breast feeding them.

2 – Why do they go yellow

The yellow is called Jaundice and it’s caused by ‘bilirubin’. It’s a normal breakdown product of the blood that the baby uses while in the womb, which is broken down after it switches to what’s called ‘adult’ blood. Since baby’s liver isn’t quite warmed up yet, this bilirubin builds up in the body, giving the yellow tinge. If it gets really really high, it can cause damage to the brain, so it’s good to check the level and make sure it’s just normal baby jaundice.

3 – What if it’s really high

If the level is a bit high, we can use a special light that helps the liver to convert this bilirubin into the molecules that baby can then get rid of. Only 1 in 20 babies needs any treatment at all.

4 – When did it start?

If it started after a day or so, it’s much more likely to be this normal baby jaundice, however if it started much sooner, it may be that we need to give the liver a bit more help, and we’d like to check that there isn’t something else going on.

5 – What else could it be?

It could be that the baby’s making too much of this bilirubin, or that there’s something stopping it being broken down. Infection can do this, or if the baby is dehydrated. There are other rare things that it could be, which it is always good to rule out.


6 – How’s their poop?

If their poop is pale and the urine very dark, then it gives us an idea as to where the problem might be, and how to fix it. Also ask about any other symptoms (irritability, incessant crying, poor feeding)

7- Anything run in the family?

Family history may suggest a pattern that we can start treating early.

8 – Any other concerns?

“Is it cancer?/Did I do something wrong?/Is it going to go back to normal colour?” All of these you can knock out the park with all that rapport and clinical acumen that you have.

Key points:

When did it start?

– Are they breast feeding?

– Any other symptoms?

– How’s their poo?

– Urine?

– Any change in behaviour?

– Full term or premature?

– Was mum on any antibiotics?

– How was delivery?

– Any problems after birth?

– Mum’s blood group?

– Family history of jaundice, or metabolic conditions?

– Patient concerns?

– Summarise

– Offer a plan and a follow up? (Usually – We’ll test the blood and see if we need to help the liver out, which most likely we won’t need to, and then if it doesn’t go away after a few days come back and we can have another look…)

The science

Jaundice – or icterus – describes a yellowing of the skin caused by the build up of bilirubin.

Usually – <25 micromol/L

Bad – >50 micromol/L

Neonatal jaundice is normal after around 24 hours until around 2 weeks. This occurs for three reasons:

You can’t ignore neonatal jaundice, though, as it could be due to:

  • haemolytic anaemia
  • infection
  • liver disease
  • metabolic disease

and severe build up of unconjugated bilirubin in the brain can cause kernicterus, especially in the basal ganglia

Bilirubin is fat-soluble, so it can cross the BBB and lead to kernicterus (encephalopathy)

If the amount of bilirubin exceeds the ability of albumin to bind it, then it can build up in the basal ganglia and brainstem nuclei

Symptoms:

  • lethargy
  • poor feeding
  • irritability
  • increased muscle tone – baby lies with arched back (opisthotonos)(67 points in scrabble)
  • seizures
  • coma

Kid’s that survive kernicterus can have

  • choreoathetoid cerebral palsy
  • sensorineural deafness
  • learning difficulties

An interesting aside: Kernicterus used to cause a lot of brain damage in kids with really bad rhesus haemolytic disease, but since the introduction of anti-D immunoglobulin for rhesus-negative mothers, there’s not a whole lot of it around…

So that’s why we care about it – but how do you go about investigating a yellow baby?

1 – when did it start?

General rule – after 24 hours = fine, before = bad

Bad is the technical term

90% of the time it’s totes fine

yeah your liver should probably pick up its game a little

If jaundice has kicked in within 24 hours, it’s likely there’s a haemolytic process afoot. This is important to spot as it can get a lot worse very quickly:

  • Rhesus haemolytic disease – usually picked up antenatally
    • may have anaemia, hydrops and hepatosplenomegaly
  • ABO incompatibility – more common that RHD, most ABO antibodies are IgM and don’t cross the placenta, but some women that are group O have IgG anti-A antibodies, than can react with the babies cells.
    • do Coombs’ test to check
  • G6PD deficiency – mainly in people from the Middle-east and Mediterranean (also Africans and Far East)
    • important to give parents information on drugs to avoid
  • Spherocytosis – much less common, usually a family history
    • Check the blood film
  • Congenital infection – usually have other signs such as
    • hepatosplenomegaly
    • thrombocytopenic purpura
    • growth restriction
    • remember it’s a conjugated hyperbilirubinaemia

If the jaundice is after 24 hours and up to 2 weeks, then this is most likely the physiological jaundice described above. The way I remember these ones is the noise the minion makes when it’s got that stupid light on it’s head in Despicable Me 2 “BIIDOOO BIIDOO”

  • Breast milk jaundice – thought to be protective as an antioxidant
  • Infection – unconjugated due to haemolysis and poor fluid intake – think UTI
  • Dehydration – may need IV fluids
  • Other – Bruising, polycythaemia and rare stuff like Crigler-Najjar 

2 – how bad is it?

Testing the jaundice is a logical next step – you can do it:

  • clinically
    • how much yellow are we talking?
  • blood test

3 – how fast is it building?

Like a sinking yellow ship it’s nice to know how bad the situation is, and how quickly it’s getting worse. Usually the level rises in a linear fashion, so keep these plotted on a chart somewhere so you’re not caught by surprise.

4 – what drugs are they on?

If you’ve given a newborn a sulphonamide or diazepam then these can displace bilirubin from albumin and make the jaundice worse. Don’t give these to a newborn. It’s silly.

So what to do?

There are 3 key things to do with a yellow child, after you’ve checked it isn’t an unfortunate highlighter incident:

  • Keep the kid hydrated and fed
  • Phototherapy
  • Exchange transfusion

The mainly used one is phototherapy, where 450nm light is used to convert bilirubin into different isomeric configurations that are water soluble. In exchange transfusion the baby’s blood is swapped bit-by-bit with donor blood. We don’t know at what level kernicterus becomes inevitable, so basically keep it as low as possible.

It won’t stop! – jaundice beyond 2 weeks

Persistent/prolonged jaundice might be due to biliary atresia, which is the main concern, but it is usually an unconjugated hyperbilirubinaemia due to:

  • Breast milk jaundice (may last up to 5 weeks)
  • Infection
  • Congenital hypothyroidism – should be picked up on the Guthrie test.

How do I know it’s conjugated?

Dark pee, pale poo.

Also hepatomegaly and poor weight gain.

Pelvic exam

This is my script for a pelvic examination. Everyone has their own, so feel free to chop and change it how you like.

Introduction:

  • “Hello, Mrs Jones, I’m Will Sloper, one of the doctors here, how are you doing today?”
  • “Can I check your date of birth quickly?”
  • “May I double check that you know what it is you’ve come here for today? Have you had one before?”
  • “Excellent, and do you understand why we do this test?”

o   Not a clue

  • “This exam is a routine test that we offer to all women over the age of 25, and it allows us to see whether there is a risk of cervical cancer further down the road. It’s not a test for cancer now, it just lets us intervene nice and early should we need to, alright?”
  • “Would you like me to explain what I’ll be doing?”

o   Yes

  • “There are two parts of today’s exam, the first is the smear test, and the other is a manual examination”
  • “For the smear test, I’ll use a soft little brush to take some cells from the cervix, so that we can send these cells off to the lab. To do this, I’ll gently insert a speculum, which will just hold the vaginal walls open so that I can see the cervix. It’ll be lubricated to make it more comfortable. Would you like to see the speculum beforehand?”

o   Yes

  • “Here’s an example, of course I’ll be using a sterile one in the examination itself”
  • “The second part of the exam is the manual exam. For this I’ll gently insert two fingers, with gloves on, into the vagina, and with the other hand I’ll press gently on your tummy. This will allow me to check that all of the reproductive organs are healthy. Is that alright?”
  • “Neither of the two parts should hurt, but they can be a little uncomfortable. It’s important that you know that you can say stop anytime, and I’ll stop straight away.”
  • “Having explained the procedures, do I have your consent to go ahead?”

Preparation:

  • “First of all do you need to go to the toilet? I will be pressing on your tummy”
  • “There will be a chaperone present, is that alright?”
  • “Would you like me to lock the door? The curtain will be drawn, but sometimes people walk in without knocking”
  • “Lastly, have you had any children?”

o   “Was that through normal delivery or Caesarean section?”

  • “Ok great, if you could head behind the curtain, and undress from the waist down, you can leave shoes and socks on if you’d prefer. If you lie on the bed, there’s a towel to cover yourself, and I’ll be in in a minute”

Wash hands

Get trolley ready:

  • Wipe with tissue and alcohol gel
  • Cover with tissue
  • Prepare the vial

o   Full name and DOB

o   Remove lid, discard seal

  • Place cytology brush on trolley
  • Squirt some lubricating jelly onto the trolley, and put the jelly down somewhere else
  • Select speculum and empty onto the trolley

o   Small if no children/caesarean

o   Medium if vaginal delivery

“Alright Mrs Jones, are you ready?”
Alcohol gel

1.       Abdominal examination

  • “Please could I ask you to slide your top up so I can have a look at your tummy first”
  • Visual inspection

o   Abdominal masses

o   Scars

o   Bruising

  • “Have you had any pain in this area?”
  • Abdominal examination

o   Press abdomen from umbilicus to pubic bone, across the width of the abdomen

o   Masses and tenderness

2.       Smear test

  • Put on gloves (NOW BE THINKING ABOUT WHAT YOU ARE TOUCHING)
  • Open the packet and assemble the speculum

o   Check it works

o   Apply a drop of lubricant to both sides but not the tip and spread with finger

  • Ask the chaperone to turn on the light
  • “Alright Mrs Jones, please could you bring your heels towards your bottom and let your knees flop out to either side”

o   “I’m just going to have a look before I do anything”

o   Inspect for signs of infection, genital warts etc

o   “Ok, I’m going to do the smear test now”

  • Part the labia with left thumb and index finger
  • With speculum horizontal, slowly insert towards the small of the back
  • When the lever reaches the inner thigh, turn so the mechanism is pointing upwards
  • When all the way in, turn left hand so that the thumb is in position to open the lever
  • With right thumb holding the base firmly in place, slowly open the speculum

o   Look inside as you do

o   When you can see the os, fix the speculum with the nut

  • If you cannot see the os, ask the patient:
  • “Mrs Jones may I ask you to put your hands under your bottom for me?”
  • Gently rotate speculum if necessary
  • Take cells

o   Insert the central bristles of the brush into the os and rotate clockwise five times

o   Push the brush to the bottom of the vial 10 times and swirl vigorously

  • Inspect brush to ensure no material is left
  • Throw the brush away
  • Ask chaperone to put lid on the vial, otherwise wait until the end to do so with non-gloved hands
  • Make sure the black lines are aligned
  • Remove speculum

o   Release nut while holding speculum open with left hand

o   Retract slowly until the blades are clear of the cervix

o   Let go of the speculum completely with the left hand and slowly remove the speculum with right hand

o   Dispose of speculum

  • “Alright Mrs Jones, I’ve finished the smear test, is it alright for me to do the manual examination now?”

3.       Bimanual exam

  • Apply a little gel to the index and middle fingers of the right hand
  • Part labia with left hand and insert the two fingers into the vagina, towards the small of the back, turning as they go in
  • Feel for the cervix

o   Try to get your fingertips underneath it into the posterior fornix

o   Push the cervix up with a steady pressure

  • “May I ask you to uncover your tummy please?”
  • Start at the umbilicus and press firmly down towards the pubic bone

o   Move down in increments until you feel the cervix moving onto your inside fingers

  • Assess the uterus for:
  • Size
  • Mobility
  • Pain
  • Position
  • Palpate the right adnexa
  • Place fingers in right lateral fornix
  • With outside hand press down the inside of the hip bone and work down in increments
  • Do the same for the left
  • Withdraw fingers and examine for blood
  • Remove gloves away from the patient
  • “Alright Mrs Jones that’s all finished”

o   Deal with vial if necessary

  • “Here’s some tissue to wipe away the gel, just pop them in the yellow bin when you’re done”
  • “I’ll let you get dressed in privacy, I’ll just wash my hands, and you let me know when you’re ready”

Clear trolley

Explanation of results:

  • “Alright, was that okay?”
  • “The smear test results will come in the post in about 2 weeks, and I’ll get a copy, as well as your GP”
  • “The vast majority of these tests are completely normal so there’s no need to worry in the mean time”
  • “In the examination everything felt healthy and normal, and sometimes there’s a little blood after a smear test. It shouldn’t be prolonged or painful, but if you have any worries then you can see your GP”
  • “Do you have any other questions for me?”
  • “Thank you for coming”