Cervical Spine

I really want to be good at these techniques. General cervical spine is passable, although left handed techniques are weak; C/T is coming along, but the supine HVT is proving elusive and as for O/A, I found a way that worked for me, thanks to a patient tutor, but then we were told we weren't allowed to use it. DISASTER! I have had no success since. This is torture.

O/A - Annotated diagrams / notes

C/T - Annotated diagrams / Notes / Technique summary

Annotated diagrams; Technique and Clinical anatomy revision cards - Cervical spine

Annotated differentials textbook - Cervical spine

EMC Tutorial

Again, I find myself preparing for a tutorial, along with my colleagues in EMC this time. Public speaking even in a small group terrified the life out of me in first year. If there is one change in myself that I have really noticed, it is that this is getting easier. I still hated it at the end of third year though and just watch me at the end of this year! No doubt I will be eating my words. Something has changed though, I just can't put my finger on it. My contribution is below:


Pre-eclampsia – the most common of the dangerous pregnancy complications

AN EMERGENCY

Can affect mother & child

Typically occurs after the 20^th week, is considered early before the 32^nd week & can occur up to 6 weeks post partum

3 main characteristics:

1. Sudden hypertension

2. Proteinuria - Large amounts of protein in the urine due to glomerular endothelial cell swelling

3. Generalised oedema

Other signs & symptoms can include:

Blurred vision

Headaches

Pre-eclampsia may be related to an autoimmune or allergic reaction. Substances from the placenta can cause endothelial dysfunction in the maternal blood vessels of susceptible women. While blood pressure elevation is the most visible sign of the disease, it involves generalized damage to the maternal endothelium, kidneys and liver with the release of vasoconstrictive factors being secondary to the original damage.

Many studies have suggested the importance of a woman's immunological tolerance to her baby's father, whose genes are present in the young fetus and its placenta and which may pose a challenge to her immune system

Continued exposure to a partner's semen has a strong protective effect against pre-eclampsia, largely due to the absorption of several immune modulating factors present in seminal fluid.

Long periods of sexual cohabitation with the same partner fathering a woman's child significantly decreased her chances of suffering pre-eclampsia. As one early study described, "although preeclampsia is a disease of first pregnancies, the protective effect of multiparity is lost with change of partner.

The term Eclampsia is used when the condition is also associated with convulsions & coma

Acupuncture / Inspiration

Occasionally I see my acupuncturist - what used to be a monthly blow out, is now a very rare treat - or emergency! This is a lesson in how I would like to be as a practitioner and this time I am viewing it as a practice visit. I can't describe what this experience does for me. When I ask how I can learn, he just says it is all about intention! Oh, and lots of meditation and chi kung. I suspect there is more to it!

Interestingly, in seven years, I have never asked what he is doing or why and he never volunteers the information either! It is a very peaceful 45 minutes. Serenity. This is the effect I want to have on my patients.

Clinic reflection

13/12 Oh dear - a male returning patient who does not wear underwear "because of his eczema, " but he was asked not to return without wearing something. He "doesn't mind" - but I do. I'm taking no chances and his trousers remain on. I know it's wrong, but I hope he doesn't come back. I gave the best treatment I could and also practiced a couple of the techniques from the interconnected tissue course that I haven't used in a while. Good for him, good for me!


10/12 Today I saw a nice old lady who wouldn't remove any of her clothes! I had to soft tissue the LES and glutei through a full skirt, over a slippery underskirt and tights. I doubt that this was in any way effective and the session seemed to drag on forever. I didn't say anything to her, but now I wish I had. I need to address these issues for the comfort of patients. Then they can make a decision after I have at least made my suggestion and explained the advantages.

Formative OSPE / Formative CCA

Why is it stressful when it isn't even the real thing? I didn't do too badly. One tutor remarked on my choice of a seated Tspine HVT and asked if it was my best technique. I replied that I was better at it supine and she advised me to use my best technique in an exam situation. Common sense really! I think I automatically used the technique I had recently been practicing the most. Unfortunately it was rubbish! Other than that though, things went well. It is always good to have a dummy run, even if it is a bit stressful. Deep down I think it is the fear of utter humiliation I don't like!

CCA - D High and I can't find my feedback sheet right now. Quite disappointed, but mainly at fault for a safety issue when I had to be prompted to write a doctors' letter about pins and needles (info prompted by screening questions) occurring in alternate feet twice in the last week (when the patient had her legs crossed when it was cold) and once in the hand, on the day of  the exam when she was carrying a heavy bag. This makes me realise how cautious we have to be in CCAs not to miss anything that could cause a safety fail! Just glad to have passed really, but confidence levels are pretty low...

Clinic reflection / Clinic reports

I was pleased to have another opportunity to use a new technique learned in the obstetric elective, although once again, the patient was not pregnant. This time a patient reported heartburn during the systemic questioning. Her primary presentation was intra scapular pain and as part of my treatment was seated anyway, it was easy to include a new seated technique to help with heartburn. I had not practiced it very often, but I think it went well and the patient was comfortable. It is not something you want to get wrong!

Clinic Reports:

Tuesday - C High
Friday - C High
Consistent at least!
Positive feedback with emphasis on strong interpersonal skills.
Need to work on following through from history and examination, directly into treatment and management plans, to ensure effective patient care.

Clinic Reports Autumn Term - Friday & Tuesday

Pharmacology tutorial at Darwin Court

Luckily for me, we have been instructed to prepare pharmacology tutorials at Darwin Court and between us, we should have the basics covered. My contribution is shown below:




ANTIDEPRESSANT DRUGS

TYPE	ACTION	COMMON DRUGS	SIDE EFFECTS
TRICYCLIC ANTIDEPRESSANTS (TCAs)	Increase neurotransmitter levels at receptors By blocking re-uptake of: Serotonin Norepinephrine (Noradrenaline) (Venlafaxine has the same action – see “other drugs” below)	Amitriptyline Amoxapine Clomipramine Dosulepin Doxepin Imipramine Lofepramine Nortriptyline Trimipramine	Anticholerginic effects: Blurred vision Dry mouth Difficulty urinating Some cause drowsiness – useful for sleep problems in depression (eg amitriptyline) Overdose can cause: Coma Fits Fatal disturbed heart rhythm Prescribed with caution for people with heart problems or epilepsy
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIs) Not generally prescribed before 18 years of age	Block re-uptake of: Serotonin	Citalopram/ Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Nausea Vomiting Possibly at beginning of treatment: Anxiety Headache Restlessness (Fewer side effects than TCAs)
MONOAMINE OXIDASE INHIBITORS (MAOIs) Issued with a card detailing prohibited drugs & foods Used less frequently than TCAs & SSRIs	Block breakdown of neurotransmitters, mainly: Serotonin Norepinephrine (Noradrenaline)	Moclobemide Phenelzine Isocarboxazid Tranylcypromine	Combined with certain drugs or foods rich in tyramine (eg cheese, meat, yeast extracts, red wine) may cause a dramatic rise in BP with headache or vomiting Overdose can cause: Muscle spasms Death Prescribed with caution for people with heart problems or epilepsy Positive side effects: Especially effective in people who are also anxious or suffer from phobias

Other drugs: Duloxetine, Flupentixol, Maprotiline, Mianserin, Mirtazepine, Riboxetine, Trazodone, Tryptophan, Venlafaxine.

Lithium is used to treat manic depression. In some cases it is used with an antidepressant for treating resistant depression.

ANTIDEPRESSANT DRUGS

Depression is thought to be caused by a reduction in the level of neurotransmitters (excitatory chemicals) released in the brain.

Neurotransmitters are constantly being reabsorbed into the brain cells, where they are broken down by the enzyme monoamine oxidase.

Antidepressants increase the level of these neurotransmitters.

Moderate to severe depression (with despair, lethargy, loss of appetite &/or sex drive) requires drug treatment, often over many months.

Treatment usually begins with a TCA or SSRI.

Antidepressant effects start after 10-14 days and may be 6-8 weeks before full effect is seen,  but side effects may happen at once.

Tolerance to side effects usually occurs.

When stopping, the dose should be gradually reduced over several weeks to avoid withdrawal symptoms.

DIAZEPAM / LORAZEPAM

An anti anxiety drug / anxiolytic / minor tranquilizer.

Also classed as a muscle relaxant & anticonvulsant.

A benzodiazepine.

Benzodiazepines:

Depress activity in the part of the brain that controls emotion

By promoting the action of the neurotransmitter GABA

Which binds to neurons & blocks the transmission of electrical impulses, thus reducing communication between cells

Preventing the excessive brain activity that causes anxiety

Side effects:

Daytime drowsiness

Dizziness / unsteadiness

Headache

Blurred vision

Forgetfulness/ confusion

Rash

Can be habit forming if taken regularly over a long period.

(Source: BMA New Guide to Medicine & Drugs, 7^th Ed, DK)

Source of information for pharmacology tutorial