Chest pain

DDx

• Cardiac – Angina, AMI, aortic dissection, aortis, aneursymal rupture pericarditis, myocarditis, pericardial tamponade
• Respiratory - PE, pneumonia, pneumothorax, COPD(with bullae rupture), mediastinitis
• Gastro - GORD, Ulcer, Oesophageal spasm, FB, oesophageal rupture
• Musculoskeletal - Muscle strain, Cosotochondritis, rib fracture

History:

HOPC

• When did it happen?
• What were you doing at that time?
• Describe the chest pain? Site, radiation Severity, quality, duration, Agg/relief.
• Associated symptoms.
• Chest pain/Palpitations/SOB
• Chest infections? Fever/chills/rigors. Cough/wheeze/sputum production
• Burning sensation after a heavy meal? History of heart burn?
• Recent chest trauma, muscle strains, heavy lifting
• Recent surgery, calf tenderness, immobility

Med hx

• CVD rf – smoke, drink, HT, DM, hypercholesterolemia, FH

FH

• Heart problems
• Clotting problems

O/E

Descrip

V/S- HR + regular, PR, RR, oxygen sats, temp

Cardioresp

• No peripheral signs of anemia, no clubbing, (no hepatic flap, HPOA, -ve pemberton’s sign, dupetryon’s contracture. No stigmata of infective endocarditis)
• Apex beat not displaced. No thrills or heaves. Heart sounds dual, no murmers. JVP not elevated. Carotid pulses clear. Lung bases clear. No peripheral odema. No local calf tenderness.
• Chest expansion equal&normal. No stridor. Trachea midline, not deviated. Normal to percussion. No wheeze, crackles

GIT, musculoskeletal.

“I wasn’t driven into medicine by a social conscience but by rampant curiosity” - Dr Jonathan Miller

Subdural haematoma

Patient: Fall, No LOC
CT-findings: Small dense left subdural haematoma, mass effect with sulcal obliteration with subfalcine herniation.

Findings in subdural hematoma:

1. 90% supratentorial
2. cresentic shape
3. cross suture lines.
4. does not cross dural reflections
5. acute - hyperdense, chronic - hypodense.

Definition of dynamisation

Dynamisation: The mechanical load transferred across a fracture locus can be increased, at a certain healing stage, in order to enhance bone formation, or to promote "maturation" of the healing tissues. An example would be the reduction in stiffness of an external fixation, either by loosening some clamps, reducing the number of pins, or moving the tubular construct further from the bone. Early dynamisation, i.e. before solid bridging of the bone, can result in stimulation of callus formation. The value of later dynamisation is debatable.

Pin fixators

Advantage: routine work, stabilises diaphyseal fractures, good wound access.

Disadvantages: requires reduction, limited angulatory and rotatory deformities, no axial loading permitted, high incidence of union or non-union, angulatory deformities in bone lengthing, no progressive correction allowed.

• Pin: Schanz screw/half-pin,Steinmann pin
• Clamp
• Central body
• Compression and distraction system
  

Dropping TAGs

To drop TAG below 1.7 use

1. very low fat diet
2. diet of 6-12 capsules of fish oil
3. diabetic control (esp if bad)
4. meds: fibrates/fenofibrates/nicotinic acid

Guilty conscience

Hmm I know I'll pass med school. I know I'll make a good doctor given time. But I dont feel confident enough to excel in my current exams. And if I dont, the one overwhelming feeling I would have is guilt towards my parents...then I'll hear my mummy say "Its alright you tried your best". Strange how this guilt far weighs any guilt I have towards my own inadequecies. Gotta get in my head that God controls everything that I'm merely riding a roller coaster. Arh.....Funny how though people all think I know my stuff....work!