Here is a power point of the part one of spot diagnoses for final year medical students.

Explanations are put in the narrator notes, so try and view the pictures first before reading the diagnoses. 

I do not own any of the pictures nor have I taken any of them of any patient.
They have been found, freely available on the internet.

Dr. Adam Jones has compiled another amazing series of videos, this time looking at anaemia.

Try your hand at the diagnosis, using his other excellent videos to guide your learning - soon, haematology will not be a problem in your revision!

Follow LearnBlood on YouTube - and see the rest of the videos here.

​The First Video is on a Clinical Approach to anaemia, the other five are on different diagnoses. 

This list excludes paediatric and MSK topics.

This was a list compiled to cover topics in the final examinations via systems approach.

Please note - this is NOT specific to any medical school. You MUST follow your own syllabus.

Neurology

Top Mnemonic = Is That Physician Really So Cool?

• Inspection – wasting (LMN), shakes, fasciculation, ataxia, beside, sticcato speech (cerebellar)
• Tone – don’t shake everywhere. Cogwheeling = Parkinson’s
• Power – Chicken arms + driving wheel + pincer grip + abducted fingers.
• Reflexes – C5-6. C5-6. C6-7. L3-4, L5-S1 
• Sensation – Cotton wool (dorsal columns –crude touch)
     + Neurotip (spinothalamic is pain/temp/non-discrim/pressure)
• Coordination – Heel Shin, Finger Nose, Disdiadochkinesis.
  
  
•  Proprioception (dorsal columns) & Gait (cerebellar is co-ord)

UMNL –­tone, reflexs, plantars, ankle clonus, Hoffman’s +ve à THINK UP
LMNL – wasting, fasiculations, ¯tone, ¯reflexes, plantars flexor à THINK DOWN
MRC – 0-5 

Gait
Spastic – circumduction of legs +/- foot scuffling,
Extra-pyrimidal (Park) – flexed posture, shuffling, slow to start, postural instable Apraxic – glued to floor/wide-based unsteady gait à FALLS! (Multi-infarct and NPH)
Ataxic – wide-based, falls, cannot walk heel-toe à cerebellar lesions like MS, tumours, alcohol and phenytoin or sensory loss.
Myopathic – waddle, hip girdle weakness, can’t climb stairs.
Psychogenic – bizarre, not conforming to gait disturbance.
 
CN’s
I – Smell & taste, each nostril. Not alcohol hand-gel.
II – Snellen, Fundoscopy, Reading, Fields.
III, IV, VI - PERLA, eye mvts, nystagmus - LR6SO4
V – facial sens. & clench teeth whilst feeling; open jaw à say about corneal reflex.
VII – expressions – eyebrows, close eyes, smile, blow-out cheeks.
VIII – Rinne’s and Webbers (forehead)
IX, X – A,E,I,O,U and “aaaaaah”.
XI – Shrug and move head.
XII – Tongue out and side to side.
 
CN 3 Palsy - down and out eye.
 

THINK ABOUT DERMATOMES TO HELP YOU REMEMBER THE NERVE ROOTS

​Do them in order to nerve roots to make it easier for you to remember.

Reflexes
Ellicit reflexes of the:

• Biceps C5 + 6 – thumb over bicep tendon.
• Supinator C5 + 6 – palm of hand facing down on patients abdomen, hitting forearm near hand.
• Triceps C6 + 7– bony bit of elbow (near ulnar nerve)
• Knee L3 + 4 – patellar tendon
• Ankle – L5 + S1 – Achilles tendon, ankle at L shape to supine.
• Plantar – The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe. The normal reflex is toe flexion (down). If the toes extend and separate, this is an abnormal finding called a positive Babinski's sign.A positive Babinski's sign is indicative of an upper motor neuron lesion affecting the lower extremity in question.
  

 
Remember Jendrassic action.

Cranial Nerve Tests
I – OLFACTORY = SMELL
II – OPTIC = Visual acuity=light & accommodation. Fundoscopy. Visual Fields.
III – OCCULOMOTOR – Eye Movements
IV – TROCHLEAR – Eye Movements                  
V – TRIGEMINAL – Facial Sensation, Jaw Jerk, Corneal Reflex
VI – ABDUCENT – Eye Movements
VII – FACIAL – Muscles of facial expression.
VIII – VESTIBULOCOCHLEAR (AUDITORY) – Hearing and Balance
IX – GLOSSOPHARYNGEAL – Palatal Movements - Gag
X – VAGUS – Palatal Movements - Gag             
XI – ACCESSORY (SPINAL ACCESSORY) –Sternomastoid- flexion and rotation of the head.
XII – HYPOGLOSSAL – Tongue (wasting, fasiculations)

The Examinations
 
CN I
“Can You Smell....?” Freshly cut grass, coffee - noticed any problems recently?

CN II
Visual acuity – SNELLEN CHART, 6m away from patient. The pinhole test helps distinguish refractive errors from other causes of visual loss. In refractive visual disturbances, eg: myopia, vision is improved when peering through a small hole. In non-refractive disorders, improvement does not occur.
 
Visual fields Sit opposite your partner, each cover up the opposite eye (one left, one right), put your finger at the periphery of your vision equidistant between you in the centre of each quadrant and move it in until your partner can see it. Repeat for each quadrant.
 
Fundoscopy Get the room as dark as possible, put the ophthalmoscope into your eye socket and hold it firm against the bone. Make sure the light is shining away from you! Look round the room through the ophthalmoscope – if you can’t do this you won’t be able to see anything in the patient. Instruct your partner to look at a distant object. Direct the light into one eye and check for the red reflex – the same as you see with flash photography. Then come close to your partner, looking at the same eye (eg: right to right). Find an artery and follow it to the disc.

CN III, IV AND VI
Eye movements Hold your partner’s chin so there is no temptation to move the head. Hold a finger in front and ask him/her to follow it with their eyes. Move to each side and then up and down. At each position (of six) ask ‘do you see one or two?’. Check for nystagmus at the same time.

Pupil reactions Shine a light in each eye, directed from the side so that the subject does not look directly at the light (why?). Check the reaction in each eye. This is one of three instances in cranial nerve examination where a unilateral sensory stimulus produces a bilateral motor output. Ask the subject to look at a distant object and then at one close to. Watch the pupil reaction. Sorting out which nerve and which muscle is involved can be complex. However, CN lll palsies cause the eye to be turned outwards and downwards (down and out) due to unopposed action of the lV and Vl nerves. There may also be ptosis and a dilated pupil (why?). CN VI palsies cause failure of lateral gaze and isolated CN lV palsies are too rare to worry about at this stage.
 
CN V – masseter, temporalis, medial + lateral pterygoid.
Opthalmic, Mandibular and Maxillary Divisions.
Ask the subject to open the mouth against resistance and then to clench the teeth while you feel over the masseters and temporalis; test each of the sensory divisions for pain and sensation, as you did for skin sensation elsewhere; touch the cornea with a wisp of cotton wool and note the bilateral blink (the second example of a bilateral motor response to a unilateral sensory stimulus). This is unpleasant so don’t try it too often.
 
CN VII
Ask the subject to frown (raise eyebrows!), screw up the eyes, blow out the cheeks, smile or whistle. The last usually produces a smile if not a whistle. Avoid the common ‘show me your teeth’ – they may get taken out!
 
CN VIII
Occlude one ear and whisper into the other a question, such as ‘where do you live?’ The Rinne and the Weber test may seem complex for this stage but they give a clear insight into hearing mechanisms. Strike the tuning fork (517Hz) and hold it in front of the ear and then place the base of the fork on the mastoid. The first should be louder. With the fork in position now simulate conductive deafness by occluding that ear. What does the subject report? Strike the fork and place the base on the forehead. The vibrations should be appreciated equally in both ears. Now occlude one ear. What does the subject report? If you can work out the reasons for these responses you understand much of the physiology of hearing.
 
CN IX AND X
These are usually considered together and, considering the fundamental importance of X in the body, testing is limited. Ask the subject to open the mouth and touch one side of the tonsillar bed with a throat swab. The soft palate should rise up with the uvula in the middle (gag reflex). This is the third example of a bilateral sensory response. The test is uncomfortable and a compromise is to ask the subject to say ‘aah’ which tests the motor component only.
 
CN XI
Ask the subject to lift the shoulders against resistance and then to press each cheek into your hand in turn.


CN XII
Ask the subject to protrude the tongue.

Mark Dornan is a QUB and Tizard Centre Graduate in Intellectual and Developmental Disabilities. 

He has compiled an excellent PDF of resources to get you started in learning about disabilities in a meaningful way. Anecdotally, medical students say that this is a part of their course often neglected in favour of 'bigger' topics with higher yield in exams.

Intellectual and Developmental Disabilities are common, and patients who live with them can have complex health and care needs. A well rounded understanding of the conditions and problems contained in this resource sheet is vital to ensure proper and holistic care of these amazing individuals. They are, also, exam topics - and you need to know about them.

After checking out the infograms and student section on www.propofology.com , why not look at these amazing websites?

This list is updated regularly - don't see something you think should be on here? Let me know!

Best Medical Student Resources

ALL FREE

Spot Diagnoses for Final Year Medical Students
ABG Exam Questions for Finals & PACES - amazing resource
Intellectual and Developmental Disability Resource List - by Mark Dornan
ATACC - The 'new ATLS' (Advanced Trauma and Life Support), free online manual, #FOAMed driven
Meducation - entirely free, online, medical education - a vast repository of excellent material
AlmostADoctor - free revision notes for medical students
OneMinuteMedicalSchool - Videos/Tutorials on everything
Medical Mnemonics - A library of the best mnemonics in medicine
​Anatomy Atlas - A library of the entire human body, in pro-section
Anatomy Zone - pretty self evident
eLearning for Health - Free for NHS workers & students in the NHS - lots of projects/specialties
MedNotes - Full Lecture Notes from a Medical Student on all of the basic sciences
IV Fluids Tutorial - A full module in assessment and prescription of IV fluids (MORE here)
Handwritten Tutorials A great resource for those wishing to revise physiology and anatomy. 
Anaesthesia UK - A phenomenal website dedicated to those revising for the anaesthetics exams
CEACCP - Continuing Education in Anaesthesia, Critical Care & Pain (BJA) - Free Articles on Everything!
Critical Care Reviews - full and unbiased account of the facts on papers affecting ICU medicine
PHARM - Dr. Minh Le Cong's Brilliant website on Prehospital And Retrival Medicine (PHARM)
Life In the Fast Lane - FOAMed at its finest - Cutting Edge Emergency Medicine Tutorials 
The Bottom Line - A UK project dealing you 'the bottom line' on current topics in ICU/Critical Care
NYSORA - Regional Anaesthesia (Nerve Blocks) - Lots of amazing educational material on how to block.
​LSORA - Regional Anaesthesia (UK)
NeuroSim - The best neurocritical care tutorials from @TheNeuroSim
​Nervous System Online Textbook - Best for cranial nerves
100 ECG Self-Assessment Quiz
Emergency Neurocritical Life Support - Free Resources - also offer a fully online accredited course ~£70

Ultrasound
Ultrasound of the Week - learn US, one week at a time
5 Min Sono - If you want to learn ultrasound - learn it here - this is an amazing site.

Communities
Medi Wikis - great student community for exploring the entirety of medicine​

Haematology
LearnBlood - a great playlist created by Dr. Adam Jones on haematology, blood cancers & coagulation

Paediatrics
MRCPCH - Extensive Paediatric Revision Notes
Don't Forget The Bubbles! - Paediatric FOAMed blog - super-fun from the beginning!

Clinical Examinations & Procedures
LITFL - Clinical Examination Video Database - A searchable database of clinical examinations
Clinical Procedure Database - A full list of procedures large to small - and videos of how to do them
Neuro Exam Video Library - A full list of neurological examinations with pathologies on video
OSCE Stop - Great website for all of your OSCE-focused needs!

Dermatology
DermNet - Searchable image library of skin diseases
DermNetNZ 
Interactive Dermatology Atlas

GP
GPNotebook - an enormous repository of conditions, with a GP-view in mind
PatientInfoPlus - patient information, for professionals, on almost all conditions.

Surgery
Surgical Videos - 100's of free videos of surgeries from Ortho to Cardiac

Radiology Interpretation
MyPacs - enormous resource allowing radiologists throughout the world to upload their images
Radiology Courses - University of Virginia - Every modality, every body-part!
CT Brain Interpretation
​Gastro-Images - From endoscopies - compiled on this website

Statistics
Medical Stats BMJ - (no subscription needed) - start at stats from square one.

Pharmacology
PharmacologyCorner - Tutorials on Pharmacology
Pharmacology2000 - All of the medical school pharmacology with full tutorials and MCQ's

Caring4OurKids Resource Links (Autism, CFS and Fibromyalgia)  (www.caring4ourkids.com)

Here is a link to the entire list of weekly tutorials from the Association of Anaesthetists of GB and Ireland.

Many of these topics emerge in post-graduate exams.

All of these topics are useful for a variety of different specialties. 

A wealth of wonderful videos, compiling the best videos on the most popular techniques.

Airway/Pulm
    •    ET extubation (NEJM)
    •    LMA in medical emergencies (NEJM | Marhaba2000 | TamingTheSRU)
    •    Fiberoptic intubation (NEJM | TamingTheSRU | TamingTheSRU2)
    •    Cricothyroidotomy (NEJM | UMEM | Ped EM Morsels | EMCrit | HQMedEd | Dr.AMBHeardAirway | TamingTheSRU | TamingTheSRU2)
    •    Exam of larynx and pharynx (NEJM)
    •    Pulm art catheterization (NEJM)
    •    Needle aspiration of primary spontaneous ptx (NEJM)
    •    Monitoring ventilation w/ capnography (NEJM)
    •    Pulse oximetry (NEJM)
    •    Arterial puncture for blood gas analysis (NEJM | UCSF)
    •    Chest tube insertion (NEJM)
    •    Bag Valve Mask (EMT & Fire Training | Ruben Strayer)
    •    Orotracheal intubation (NEJM | EMCrit | TamingTheSRU)
    •    NG intubation (NEJM)
    •    Retrograde intubation (UMEM)
    •    Thoracentesis (NEJM)
    •    Tube thoracostomy (UMEM | LITFL)
    •    Pigtail thoracostomy (Sacchetti)
    •    Needle thoracostomy (Mellick | TamingTheSRU)
    •    Finger thoracostomy (TamingTheSRU)
    •    Meconium Aspirator for GI Bleed (Mt. Sinai)
    •    OPA insertion (EMT & Fire Training)
    •    NPA insertion (EMT & Fire Training)
    •    Suction (EMT & Fire Training)
    •    Ventilator for Reoxygenation (EMCrit)
    •    Using a Bougie (HQMedEd)

Access
    •    US guided radial arterial catheter (NEJM)
    •    Insertion of IOs (NEJM | Mt. Sinai | EM:RAP)
    •    US guided PIV placement (NEJM)
    •    US guided IJ cannulation (NEJM)
    •    PIV cannulation (NEJM | UCSF | Mt. Sinai)
    •    Central venous catheterization: subclavian (NEJM | UMEM | EMCrit)
    •    Central venous catheterization: landmark method (Clinisnips | EMCrit | Dr. Gallagher)
    •    Placement of a femoral venous catheter (NEJM)
    •    Central venous catheterization (NEJM)
    •    Placement of arterial line (NEJM | Sacchetti)
    •    Phlebotomy (UCSF)


CV
    •    EKG monitoring (NEJM)
    •    Emergency pericardiocentesis (NEJM | TamingTheSRU | TamingTheSRU2)
    •    Thoracotomy (UMEM | Mellick)
    •    Finding Echo windows (EchoVTutorials)
    •    External pacing (Duke)
    •    Transvenous pacing (UArizona | Sacchetti | TamingTheSRU | TamingTheSRU2)
    •    Pacemaker knobology (Dr. Gallagher)

GI
    •    G-tube exchange (NEJM | Sacchetti)
    •    Paracentesis (NEJM)
    •    NG tube hook (Procedurettes)
    •    NG tube insertion (Sacchetti)

GU/GYN
    •    Suprapubic bladder aspiration (NEJM | UMEM)
    •    Urethral catheterization in girls (NEJM)
    •    Endometrial biopsy (NEJM)
    •    Female urethral catheterization (NEJM | Common Currency)
    •    Pelvic Exam (NEJM)
    •    Male urethral cauterization (NEJM | Common Currency)
    •    Priapism - Intracavernous aspiration (Mt. Sinai | Mellick)
    •    Testicular Detorsion (Mt. Sinai)
    •    Continuous bladder irrigation (Sacchetti)
    •    IUD removal (MedicalVideos)

Paediatrics
    •    PICC placement in neonate (NEJM)
    •    Procedural sedation and analgesia in children (NEJM)
    •    Reduction of paraphimosis in boys (NEJM)
    •    Neonatal circumcision (NEJM)
    •    IO catheter placement in children (NEJM)
    •    Tympanocentesis in children with AOM (NEJM)
    •    Catheterization of urethra in male children (NEJM)
    •    Umbilical vascular catheterization (NEJM | EM:RAP | CCHMC)


MSK
    •    Reduction of pulled elbow (NEJM | Mellick)
    •    Repositioning dislocated TMJ (NEJM)
    •    Pelvic stabilization s/p trauma (NEJM)
    •    Clinical eval of knee (NEJM)
    •    Basic splinting (NEJM)
    •    Arthrocentesis of knee (NEJM | UMEM | EM:RAP)
    •    Arthrocentesis of wrist (UMEM)
    •    Arthrocentesis of elbow (Mellick)
    •    Arthrocentesis of MTP (Mellick)
    •    Thumb guard (Procedurettes)
    •    Thompson test to evaluate Achilles tendon injury (Mellick)
    •    Humeral head fracture reduction (Mellick)
    •    Shoulder dislocation reduction (Mellick | ShoulderDislocation.net | EM:RAP)
    •    Open ankle dislocation reduction (Mellick)
    •    Boxer Fracture Reduction and splinting (Mellick)
    •    Forearm fracture reduction and splinting (Mellick)
    •    Open lower leg fracture reduction (Mellick)
    •    Thumb dislocation reduction (Mellick)
    •    Nursemaid’s elbow reduction (Mellick)
    •    Wrist Fracture (Mellick)
    •    Hip dislocation reduction (Mellick | Sacchetti)
    •    Trigger point injection (Mellick)
    •    Distal radius fracture reduction & hematoma block (Mellick)
    •    Dislocated toe reduction (Mellick)
    •    Subacromial bursa injection (Mellick)


Derm
    •    Punch biopsy of skin (NEJM | Univ of Queensland)


Blocks
    •    Infraorbital nerve block (UMEM)
    •    Supraorbital nerve block (UMEM)
    •    Greater auricular and lesser occipital nerve blocks (UMEM)
    •    Alveolar nerve blocks (Mellick)
    •    Facial and dental nerve blocks (Mt. Sinai)
    •    Mental nerve block (Mellick)
    •    Digital block (Sacchetti | MedicalVideos)
    •    Paraspinous block (Sacchetti)
    •    Fascia iliaca block (Sacchetti)
    •    Brachial Plexus block (MedicalVideos)


Ophtho
    •    EM Eye exam (ALiEM)
    •    Visual acuity exam (ALiEM)
    •    Slit Lamp (ALiEM | Mt. Sinai)
    •    Tonometry (ALiEM | Procedurettes)
    •    Lateral canthotomy (UMEM)
    •    Removing corneal foreign body (Root Atlas)
    •    Retrobulbar injection (Eye Rounds)
    •    Panoptic (Sobolewski)

Misc
    •    Treatment of septal hematoma (NEJM)
    •    PPE donning and doffing (NEJM)
    •    Conscious sedation for minor procedures in adults (NEJM)
    •    Hand hygiene (NEJM)
    •    Diagnosis OM - otoscopy and cerumen removal (NEJM | Procedurettes)
    •    ABIs (NEJM)
    •    Bone marrow aspiration and biopsy (NEJM)
    •    BP measurement (NEJM)
    •    Abscess I&D (NEJM | Procedurettes)
    •    Basic lac repair (NEJM)
    •    LP (NEJM | Mellick)
    •    LP pediatric (Sacchetti)
    •    PTA (Core EM)
    •    Nail trephination (Mellick)
    •    Tooth avulsion (LITFL)
    •    Dry Socket /Alveolar Osteitis Packing (Mellick)
    •    Nasal packing (Mellick)
    •    Dix Hallpike/Epley (Henry’s Claymations)
    •    Burr Holes (RJK2103)

When you begin your anaesthetics placement - it's likely you won't have a notion what is going on.

Don't worry - everyone felt like this the first time they walked toward a ventilator. 

Take your time and orientate yourself to the anaesthetics machine - it's essentially a big machine/bellow that moves vapour-laden gas into the patient's lungs in a closed-circuit. There's a tube from the machine going IN to the patient and one for the gasses when they are exhaled from the patient. The vaporisers (sevoflurane is yellow coded) are situated on the machine and they change the liquid you put into them into a vapour which are then added to the inhaled gases. The machine interprets all the volumes (ml),  flows (L/min) and pressures (cmH2O) and fires out lots of numbers that tell you various things. The machine will tell you about the volume of breathes the patient is either taking (or being put into the patient by the machine), it will also calculate CO2 output of the patient and track it as a waveform called capnography. The machine furthermore calculates the pressure of the closed system and calls them airway pressures - you essentially don't want these do be above 30cmH2O - or damage can occur to the lungs. PEEP is the peak end expiratory pressure generated by the machine - it stops the alveoli collapsing and is often set around 4-5cmH2O - but this goes up and down as appropriate.  Just ask your supervisor if you can sit and play around with the machine settings.

You should also know what MAC is - MAC is a measure of potency and is defined as the minimum alveolar concentration at steady-state that prevents reaction to a standard surgical stimulus (skin incision) in 50% of patients at 1 atmosphere (i.e. sea level). This measurement is done at steady state (assuming a constant alveolar concentration for 15 minutes), under the assumption that this allows for an equilibration between the gasses in the alveoli, the blood and the brain. End-tidal agent monitoring is used by modern anaesthetic monitors to calculate MAC.

If you're feeling like you could watch a short course in introducing the anaesthetic machine - HERE is a good idea to start - watching all the videos.

Otherwise, below is a good video showing an anaesthetic machine check. 

You should be able to interpret a basic U&E and accompanying electrolytes. 
​
An understanding of how sodium, potassium, magnesium and phosphate work in the body is needed - Na and K most importantly.

Why can you not replace sodium too quickly? How quickly can you replace sodium? What does a high sodium mean? 
You can replace potassium (in a non-ICU environment) at around 10mmol per hour - how does this affect you on the ward? How can you replace potassium?

You should also understand calcium and its role in the body with bones, metabolism and PTH etc.

You must understand how creatinine and urea are used to interpret kidney function and the definition of an AKI (addressed in another topic) - what is eGFR?

You should know the simple 'AEIOU' indications for dialysis.

What is SIADH? What does ADH do in the body? What is the RAAS system? What does hypercalcaemia mean for the patient and how is it treated?

EXPECTED BASIC KNOWLEDGE: This is a good finals document from OSCE STOP with associated diagrams - Here

Lactate is a conundrum that comes up frequently in actual medical practice. Found at the bottom of an ABG You'll be asked to find out someone's lactate in a variety of conditions like drug overdoses, trauma, hypoxia and SEPSIS.But why?
The team at St Emlyns virtual hospital have been trying to explain some very new thoughts on the physiology of lactate and why it's important. 
http://stemlynsblog.org/lactate-lacthate/
http://www.stemlyns.org.uk
Sign up for their free online course in emergency medicine http://stemlynsblog.org/new-foamed-foundation-course-in-em-st-emlyns/
If you don't know much about #FOAMed - take some time to look into it now. The world of interactive and online medical education in a wide number of specialties (that is free) is rapidly taking off and there's lots of us involved in it. Join the movement.

Atrial Fibrillation
​
Brief: Most common in 65+, QRS is normal. No p-waves. Fibrillation waves. Decrease in atrial function. Commonly caused by HTN, MI, LVF, CAD, Valvular disease, alcohol, thyroid. Warfarin and rate control <100 in many patients. INR 2-3. Ablation of pulmonary veins etc can yield good results in COPD patients. 

Issues: 

• Sustained vs Paroxysmal, 
• Symptomatic vs Asymptomatic - 30% are asymptomatic - screening? 
• Anticoagulants - why are they needed? What agents can be used? What is a NOAC?
• Rate control vs Rhythm control - what age groups need which? What are the clinical issues that can arise with each?
• NICE Guidelines on AF Management
• Post-operative AF - causes?
• AF in sepsis - causes? treatments?
• What investigations would you want to do? GP vs in-hospital tests?
• What pharmacological treatment is there for RATE control and RHYTHM control?
• What other treatments are available for refractory AF?
• What electrolyte imbalances cause AF?
• What serious co-morbidities can be caused by AF?
• What is CHADS2VASC? - ***KNOW THIS

Please be ready to discuss the case below/feel free to post below:
You are called to see a lady on an acute medical ward as the out of hours FY1. She is 67, in hospital with a community-acquired chest infection and has just been commenced on co-amoxiclav. The nurse has done her routine obs and found her heart rate at 150bpm. Her blood pressure is lower than earlier in the day, now sitting at 80/30 compared to 160/80. She can feel palpitations in her chest. She is pyrexic and feels tired, lethargic and is getting 'pangs' of chest pain radiating down her left arm. She tells you she has never known herself to be in AF and is on no usual medication other than her ramipril 2.5mg OD that she has been 'taking for years'. She looks unwell - she has only really arrived onto the medical assessment unit.


1. What investigations would you like to see?
2. What arrhythmia differentials come to mind with a heart rate at 150bpm, without seeing an ECG?
3. What could be causing the pain down this lady's left arm?
4. If you thought this lady was in AF - what would be your first actions? (Start as if she has not been treated by anyone else other than you)
5. What is a likely cause of this lady's tachycardia?
6. What significant co-morbidities are associated with untreated atrial fibrillation?
7. What pharmacological treatment would you consider instigating in this lady?
8. What is the effect on the heart with tachycardias with respect to cardiac output? What is the significance of diastole with respect to this? 

Three Favourite Exam Topics on ACS/Heart Failure...
 
1.   Angina vs Myocardial Infarction - pain is less severe in angina and lasts <20mins

•    STEMI Treatment Options --> MONARCHS (Morphine, Oxygen if hypoxic, Nitrates, Aspirin/Atenolol (or betablocker), Reperfusion and Ramipril, Clopidogrel, Heparin/Enoxaparin, Simvastatin

2.   Complications of an MI - SPARED (Sudden Death, Pump Failure, Aneurysm/Arrythmia, Rupture of papillary muscle or septum, Embolism, Dressler's Syndrome 1 in 300-400, immune response/ESR+CRP raised/pericardial pain) + Early Pericarditis (19/20 will have no 'rub' though)
 
3.   Principles of treatment of an acute left ventricular failure & it's signs - "This patient would look ill"
 
·      Sinus tachy/AF, Systolic HTN, Cardiomegaly on CXR, 3rd and 4th Heart Sounds, RHS or bilat pleural effusions
·      What are the SIGNS on a CXR? ABCD - Alveolar Oedema (Bat Wing Oedema), B-Lines (Kerley), Cardiomegaly, Dilated Upper Lobe Vessels, Effusion (Pleural)
·      TREATMENT = High dose oxygen if hypoxia present, Treat significant arrhythmias, IV diuretics ?furosemide, IV opiates like diamorph are pulmonary venodilators and reduce preload on the heart)
·      Consider repeat diuretics, and vasodilators like isosorbide infusions.
·      What is the New York Heart Association Classification? (Buzz Word - "Functional  Capacity)
 
Others
·      What are the features of pericardial pain?
·      What are the features of acute LVF on inspection of the patient? 
·      (Bronchial veins --> Pulmonary veins --> Venous congestion = Bronchial Congestion - 'Cardiac Asthma?')
·      What is a gallop rhythm? (It is hard to hear with a HR >100)

These videos were created by a friend and colleague Dr. Adam Jones who works in Bristol. The videos detail anaemias, coagulation disorders and the blood cancers.
 
They were made within the last year: "LEARN BLOOD"
 
There is an EXCELLENT 10 minute video tutorial with animations on Blood Cancers - this is really the height of what you will need to understand for any questions about haematology in your clinical exams. They really are excellent videos and a very new resource on understanding blood disorders - particular for those of us (like me) who are not natural haematologists!
 
I would advise you all to spend one hour total watching the six videos - it will leave you in great stead for common haematology questions.
 
Being able to see the animations and have someone explain it quite concisely is very useful. 
 
If you have any feedback for Dr. Jones, can you PLEASE post here if you found the videos useful or have any suggestions.

Neutropenic Sepsis - discuss after watching these. They were made within the last year: "LEARN BLOOD".

​1. What is neutropenia?2. What patient demographic is it most common in?
3. What is your initial management plan/investigations?
4. Where do they need to be placed if admitted to hospital and why is it important?
5. What pharmacological treatments for neutropenia are there?
6. Describe the timeframe for treatment in cases of neutropenic sepsis 
7. What is Filgrastim? How does it work? 
8. What cell lineage does a neutrophil come from?

If you can do these following tutorials and answer the questions, you should have no problem in interpreting common ABG problems presented in the final exams (click below)

ABG Parameter/Physiology Interactive Tutorial (Bristol University)

A thorough ABG interpretation tutorial (AlmostADoctor)

BMJ ABG Interpretation Tutorial

Any conundrums can be posted below. 

It's good to know how to calculate the ion gap and know what it means.
​
It's ALSO good to know about Base Excess (BE) value...

• The base excess is a calculated figure which provides an estimate of the metabolic component of the acid-base balance. 
• The base excess is defined as the amount of H+ ions that would be required to return the pH of the blood to 7.35 if the pCO2 were adjusted to normal.

Alcohol comes up in many different ways in the final exams.
​
Posted above, is one of my teaching Powerpoints. Alcohol is a big problem in GI wards, hepatobiliary medicine and mostly the EMERGENCY department!

Some of the things you should likely be aware of:

1. Social issues
2. PABRINEX - what it is and what it is used for? How is it made up for administration? What colour is it? What is the dose regime?
3. Follow-on medications from pabrinex in alcoholics - vitamin B co-strong, thiamine etc.
4. Health effects of alcohol - GI, liver, CVS, neurological, cerebrovascular disease - so many! GI bleeds are common questions. What is octreotide? 
5. Alcohol induced psychosis
6. Alcohol levels in biochemistry - glucose levels/diabetic alcoholics
7. Decreased GCS due to alcohol
8. Detox regimes using chlordiazepoxide - signs of alcohol withdrawal etc.
9. Withdrawal seizures and management
10. Wernicke's encephalopathy and Korsakoff's Psychosis - what medication helps with these conditions?
11. Alcohol liaison nurses
12. Capacity and consent of intoxicated persons
13. Support networks for alcoholics including hostels, helplines, specialist nurses, addiction psychiatrist
14. What do liver function tests include? What emzymes are raised (or what is low?) in alcohol related disease? Could you interpret the synthetic function of the liver? What other biochemical products are useful to know in hepatic disease?
15. Nutritional compromise - are alcoholics deplete of certain electrolytes?
16. Are there any cardiac side effects of long-term alcohol abuse?

• Something that became apparent during my time in A&E is the lack of awareness of Hep B prophylaxis amongst front-line NHS workers and how virulent yet preventable. 
  
  
• We are all immunised as healthcare workers, but most of the population are not. It can have devastating outcomes for patients, their family and carers - it is MUCH more virulent than HIV.
  
  
• For example - did you know there is Hepatitis B immunoglobulin available as well as the vaccine? Why do we use this?
  
  
• Although unlikely to be direct exam-topics, you ought to know about modern HIV and Hep B issues. HIV, however, in itself seems to be a common exam topic.
  
  
• You should obviously know about HIV HAART regimes and AIDS defining illnesses - but these documents are aimed at addressing PROPHYLACTIC measures aimed at stopping the patient acquiring HIV and/or HEP B.

• Given within 72h of potential exposure, HIV PEP is effective at stopping an individual from becoming HIV positive - it is a month-long course of HAART tablets with close GUM clinic follow-up
  
  
• This has potential impact on GP practices, A&E departments and GUM clinics.
  
  
• The documents focus on assessing the risk of the encounter and stratifies it to a 'PEP Advised/Not advised or 'Consider PEP' category.

​
Some prompter-questions:

1. What is an AIDS defining illness? Can you name 5-10?
2. What would a patient's CD4 count be if they had AIDS?
3. What is the difference between HIV and AIDS?
4. Can you name a HAART regime and what the medications individually do?
5. What are the main side effects of PEP or HAART?
6. What is 'PCP' with respect to the respiratory system in the immunocompromised patient? What antibiotic should be considered? What might you see on a chest xray?
7. Are there common micro-organisms in the immunocompromised patient?
8. Where can candidiasis be seen in the immunocompromised patient? What causes this?
9. How would you consent someone for an HIV/Hep B test?
10. When would you offer a patient Hep B immunoglobulin?
11. What medications cause immunocompromise outside the HIV positive population
12. Can you name two skin lesions seen in patients with HIV/AIDS?
13. What is the most common cause of death in the UK for patients with AIDS?

In our career as anaesthetists, we are expected to deal with a very wide mix of emergency cases from difficult airways, cardiac arrests to the lifeless child in its parents arms - and pretty much everything in between. The gravity of emergency situations is enormous and can be the difference between life and death (obviously) but also the difference between quality of life and profound morbidity. Timely and methodical approaches save lives.

All cases in emergency management should be approached with an ABCD style. This is the same for 1st year students as it is for consultants. We may roll our eyes when we announce 'checking for danger' but checklists do much to enable us to focus on a thorough assessment and should be thought of (in exam scenarios) as an opportunity to explain your knowledge of emergency assessment. 

Topics in Emergencies that frequently come up in exams test, at a fundamental level, your safety to practice as an FY1. You could honestly be starting your first working day in the NHS on a night shift. Whilst support is plentiful - a good knowledge of emergency algorithms is essential and I would thoroughly advise you to be aware of the ALS algorithms as a basis of your practice. 

By no means an exhaustive list of revision - here are the topics that are taught on common Acute Illness Recognition Training courses throughout UK medical schools:

1. ACS/Acute Heart Failure
2. Sepsis/Infection
3. Diabetic  Emergencies
4. STEMI/NSTEMI, Acute Heart Failure
5. Assessment/investigation/management.
6. Vasodilatory shock: including pneumonia,meningococcal disease
7. DKA ,hypoglycaemia
8. Assessment/ management of acidosis
9. ABG Interpretation
10. Electrolytes/renal
11. ECG Rhythms
12. Respiratory and metabolic acidosis/alkalosis. Acute and chronic changes.
13. Hypo/Hyper Natraemia/Kalaemia. Oliguria.

 
In context of acute care:

1. Rapid AF, Atrial flutter, Heart blocks.
2. Liver Disease
3. Common Poisons
4. Asthma/COPD 
5. Recognition and initial management of liver failure in the acute setting.
6. Paracetamol, salicylates , tricyclics, benzos,  (opiates, ecstasy)
7. Compare/contrast asthma/COPD, differences in management, controlled oxygen therapy.

​
HERE (Click) is a great collection of Emergency Medicine Resources for general perusal for those interested- covering abdominal emergencies to Battlefield Trauma.