ENT OSCEs-A Guide to Passing the DO-HNS and MRCS

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 ENT OSCEs: A Guide
to Passing the DO-HNS
and MRCS (ENT) OSCE
Second Edition

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 ENT OSCEs: A Guide
to Passing the DO-HNS
and MRCS (ENT) OSCE
Second Edition

Joseph Manjaly, BSc (Hons) MBChB MRCS DOHNS

ENT Specialty Registrar, London North Thames, UK

Peter Kullar, MBChir MA MRCS DOHNS

Academic ENT Trainee, Northern Deanery, UK

Alison Carter, BMBS BMedSci (Hons) MRCS DOHNS

ENT Specialty Registrar, London North Thames, UK

Richard Fox, MBChB BSc (Hons) MRCS (ENT)

Former ENT Core Surgical Trainee, London Deanery, UK

K32124_Book.indb 3 2/15/2017 6:48:40 PM

 CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2017 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed on acid-free paper
International Standard Book Number-13: 978-1-138-63594-4 (Paperback) 978-1-138-63691-0 (Hardback)
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been
made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or
liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed
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opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or
health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their
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Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be
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Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized
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Library of Congress Cataloging-in-Publication Data

Names: Manjaly, Joseph, author. | Kullar, Peter, author. | Carter, Alison,

1985- author. | Fox, Richard, 1987- author.
Title: ENT OSCEs : a guide to passing the DO-HNS and MRCS (ENT) OSCE / Joseph
Manjaly, Peter Kullar, Alison Carter, and Richard Fox.
Other titles: Ear, nose, and throat objective structured clinical
examinations | Master pass.
Description: Second edition. | Boca Raton : CRC Press, [2016] | Series:
Masterpass
Identifiers: LCCN 2016050369| ISBN 9781138635944 (pbk.) | ISBN 9781138636910
(hardback)
Subjects: | MESH: Otolaryngology | Otorhinolaryngologic Diseases--surgery |
Otorhinolaryngologic Surgical Procedures | Test Taking Skills |
Examination Questions
Classification: LCC RF57 | NLM WV 18.2 | DDC 617.5/10076--dc23
LC record available at https://lccn.loc.gov/2016050369

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com

K32124_Book.indb 4 2/15/2017 6:48:40 PM

 Contents

Foreword to the Second Edition vii

Preface to the Second Edition ix
Acknowledgmentsxi
Authorsxiii
Abbreviationsxv
The DO-HNS and MRCS (ENT) Examination and How to Pass It xvii
General Tips for the Communication and History Stations xix
1 History Stations 1
1.1 Olfactory Dysfunction 2
1.2 Nosebleeds in Adults 5
1.3 Nosebleeds in Children 7
1.4 Dry Mouth 9
1.5 Lump in the Throat 12
1.6 Hoarse Voice 14
1.7 Catarrh and Post-Nasal Drip 17
1.8 Tinnitus19
1.9 Child with Recurrent Ear Infections 22
1.10 Facial Weakness 24
1.11 Septal Perforation 27
1.12 Hearing Loss in a Child 29
1.13 Adult with Itchy, Painful Ear 31
1.14 Adult with Non-Acute Hearing Loss 33
1.15 Adult with Sudden Hearing Loss 35
1.16 Otalgia37
1.17 Nasal Crusting 39
1.18 Dizziness41
1.19 Neck Lump 44
1.20 Snoring in a Child 46
1.21 Recurrent Tonsillitis 48
1.22 Nasal Obstruction 50
2 Examination Stations 53
2.1 Examination of the Ear 55
2.2 Examination of the Nose 62
2.3 Examination of the Neck 65
2.4 Examination of the Oral Cavity 70
2.5 Flexible Nasendoscopy 73
2.6 Vestibular Assessment 75

K32124_Book.indb 5 2/15/2017 6:48:40 PM

 Contents

3 Communication Skills Stations 81

3.1 Consent81
Grommets81
Functional Endoscopic Sinus Surgery 83
Septoplasty84
Panendoscopy and Microlaryngoscopy 85
Myringoplasty86
Parotid Surgery 87
Submandibular Surgery 89
3.2 Explanation90
Benign Paroxysmal Positional Vertigo 90
Cholesteatoma91
Thy3F Thyroid Nodule 92
Acoustic Neuroma 94
3.3 Breaking Bad News 96
3.4 Discharge Letter 98
3.5 Operation Note 99
4 Data and Picture Interpretation Stations: Cases 1–42 103

Index189

vi

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 Foreword to the
Second Edition

It is a pleasure to be able to contribute this Foreword. When I was a young trainee trying
to forge an ear, nose and throat career, life as a junior doctor was very different than today.
Perhaps the biggest hurdle was the need to complete the old ‘FRCS Primary’ prior to enter-
ing higher surgical training. This was a generic surgical exam and as soon as you said you
were an ENT trainee, the viva examiners seemed to delight in moving straight onto ques-
tions on the in-depth anatomy of the sole of the foot! Throw into the equation the fact that
I had to study for this exam whilst one of your authors was a 6-month-old baby at the time,
constantly crying and needing attention, and you can imagine what a challenge it was to
navigate the 10% pass rate.
Of course times change, babies grow up into ENT surgeons, the health service has
evolved and training has changed significantly in response to that. It’s only right that
examinations also evolve to reflect this, and I think the present-day Membership of the
Royal College of Surgeons (MRCS[ENT]), focusing much more on ENT-related anatomy,
physiology and pathology, will equip junior trainees well with the skills and knowledge
needed to do the job effectively and be ready to apply for ENT registrar national selection.
I am pleased to say this book contains the essential tools to prepare thoroughly for the
exam. It is so important as a specialty that we train and inspire the next generation of able,
motivated and knowledgeable trainees. I hope this book will be one small contributor to
making that happen around the country.

George Manjaly
MBBS MPhil FRCS(I) FRCS (ORL) (Eng)
Consultant ENT Surgeon
East Sussex Hospitals NHS Trust

vii

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Preface to the
Second Edition

We are delighted at the way this book has been received amongst ENT trainees. The idea
originally began when Peter Kullar and I met on a revision course in our junior years and
had a casual conversation on how we really ought to write a revision book since there
wasn’t one available at the time. Five years later, we are now both well into our registrar
training, mentoring the next cohort of junior trainees, and it gives us great encouragement
whenever we meet a colleague who tells us he or she has ‘the yellow/orange book’ and that
it made a difference to his or her preparation.
Of course it’s crucial to keep things up to date and relevant and we’re grateful for the
input of Ali Carter and Richard Fox for this new edition. ENT continues to be a thriving
specialty; a small world full of great colleagues. It brings great satisfaction to see talented
new trainees choose the specialty and successfully gain a national training number to join
that community. We trust this new expanded edition of our book will continue to gain the
endorsement of trainees taking the Diploma of Otolaryngology – Head and Neck Surgery
(DO-HNS)/MRCS (ENT) exam, as well as those preparing for Specialty Training Year
3 national selection, which is itself very much an exam.
Although not obvious from the book’s title, we also hope that the histories and exami-
nations sections will be useful to those in other training grades learning to do an ENT
clinic for the first time – so, once you’ve passed your exam, why not pass your copy on to
your newest Foundation/General Practice Trainee.

Joe Manjaly
April 2017

ix

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Acknowledgments

Thank you to our friends and colleagues for contributions to the images in this book:

Philip Yates
Robert Nash
Manish George
John Hardman
Nora Haloob
Fiona McClenaghan
Andrew Hall
Deepak Chandrasekharan
Samantha Holmes

xi

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Authors

Joseph Manjaly is a specialty registrar on the London North Thames ear, nose and throat
rotation. He graduated from Bristol University, gaining a first-class intercalated BSc in
physiology. He co-authored the first edition of this book whilst a core trainee in Wessex
deanery before gaining one of the four London North Thames training posts awarded at
national selection in 2012. He has held a number of Association of Otolaryngologists in
Training positions and is regularly involved in training regionally.

Peter Kullar is a Wellcome Trust Clinical Research Fellow and academic trainee in ear,
nose and throat in the Northern Deanery. He graduated from Cambridge University and
successfully obtained full Membership of the Royal College of Surgeons and Diploma of
Otolaryngology – Head and Neck Surgery prior to co-authoring the first edition of this
book. His specialist interests are otology and mitochondrial-associated hearing loss.

Alison Carter is a specialty registrar on the London North Thames ear, nose and throat
rotation, working at the Royal National Throat Nose and Ear Hospital. She graduated from
Nottingham University and was awarded her Membership of the Royal College of Surgeons
at the beginning of her core surgical training, followed by Diploma of Otolaryngology –
Head and Neck Surgery nearing the end of it, having decided mid training to pursue an
ear, nose and throat career.

Richard Fox is a Registrar in Sydney, Australia having completed the MRCS (ENT) as a
core surgical trainee in London. After graduating from Bristol University (2012) he has
shown a commitment to medical education establishing a number of surgical courses and
has been recognised with the UCL merit teaching award amongst other trainee prizes. He
has also been faculty on the Royal of College of Surgeons post-graduate courses.

xiii

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 Abbreviations

ACE angiotensin-converting enzyme

ANCA anti-neutrophil cytoplasmic antibody

AOAEs automated otoacoustic emissions

AOM acute otitis media

AOT Association of Otolaryngologists in Training

BIPP bismuth, iodoform and paraffin paste

BPPV benign paroxysmal positional vertigo

CBT cognitive behavioural therapy

CNS central nervous system

CS Churg–Strauss syndrome

CSF cerebrospinal fluid

CSOM chronic suppurative otitis media

CT computed tomography

CXR chest X-ray

DO-HNS Diploma of Otolaryngology – Head and Neck Surgery

EAC external auditory canal

ENT ear, nose and throat

ESR erythrocyte sedimentation rate

FBC full blood count

FNA fine needle aspiration

FNE flexible nasendoscopy

FOSIT feeling of something in the throat

FY Foundation Year

GP general practitioner

GPVTS General Practice Vocational Training Scheme

GRBAS grade, roughness, breathiness, asthenia, strain scale

HIV human immunodeficiency virus

ICP intracranial pressure

xv

K32124_Book.indb 15 2/15/2017 6:48:40 PM

 Abbreviations

INR international normalised ratio

JVP jugular venous pulse

LMN lower motor neuron

LPR laryngopharyngeal reflux

MRCS Membership of the Royal College of Surgeons

MRI magnetic resonance imaging

OD olfactory dysfunction

OE otitis externa

OME otitis media with effusion

OSCE objective structured clinical examination

PNS post-nasal space

PPI proton-pump inhibitor

PTA pure-tone audiometry

SCC squamous cell carcinoma

SHO senior house officer

SNHL sensorineural hearing loss

ST3 Specialty Training Year 3

TB tuberculosis

TM tympanic membrane

TORCH toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex virus

U+Es urea and electrolytes

UMN upper motor neuron

URTI upper respiratory tract infection

USS ultrasound scan

WG Wegener granulomatosis

xvi

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 The DO-HNS and MRCS
(ENT) Examination and
How to Pass It

The Diploma of Otolaryngology – Head and Neck Surgery (DO-HNS) has existed in one
form or another since 2003, after replacing the old Diploma of Laryngology and Otology.
Your reason for sitting the examination will most likely be as a route into higher ear, nose
and throat (ENT) training or as a way of showing a special interest as part of general prac-
tice or allied specialty training. DO-HNS in combination with Membership of the Royal
College of Surgeons (MRCS), or the ‘MRCS (ENT)’, is a requirement in order to be eligible
to attend the ENT national selection interviews for registrar training, although it is not
required to be passed at the time of application.
The examination consists of two parts: Part 1, a 2-hour written paper comprising mul-
tiple-choice questions and extended matching questions, and Part 2, the objective struc-
tured clinical examination (OSCE) on which this book focuses. Historically, candidates
for ENT Specialty Training Year 3 (ST3) tended to sit the full DO-HNS examination in
addition to both parts of the regular MRCS examination.
In May 2011, ‘MRCS (ENT)’ was introduced and was awarded to candidates passing
MRCS Part A and the DO-HNS OSCE. The DO-HNS examination, in both parts, can still
be sat as a stand-alone examination for those outside of ENT higher surgical training, most
commonly, but not exclusively, general practitioners (GPs), or for prospective ENT trainees
who wish to complete it alongside the traditional MRCS sat by other surgical specialties. It
is important to note that when applying for ENT national selection, there are no additional
points awarded for either combination; therefore, the choice is a personal one for each pro-
spective candidate. Be sure to get up to speed with the latest examination announcements
and the core syllabus on the DO-HNS website (http://www.intercollegiatemrcsexams.org.
uk/dohns). We are confident that using this book will provide a firm grounding for pass-
ing the OSCE. Whilst there is no rule governing experience, time spent in an ENT job is
invaluable, as many of the questions are designed to test ‘on-the-job experience’.
The examination is held three times per year, rotating among London, Edinburgh,
Glasgow and Dublin, so be sure to register and pay fees in good time. The colleges are
very strict on application deadlines and they tend not to make exceptions for late entries. It
is a good idea to sort out travel and accommodation as early as possible, as the later these
details are arranged, the more expensive they become. You will also need to make sure you
have appropriate cover in place and have swapped on-calls as, if you happen to be taking
the exam at a distant location, you often will need 2 days in order to get there and back,
and you may not know your specific exam date within the given window until after the 6
weeks required notice period most hospitals have in place for leave requests.
Allow 2–3 months’ preparation time alongside your normal clinical commitments. In
addition to this book, you will find it useful to work through an ENT picture atlas and
to selectively read a more comprehensive ENT textbook, of which there are many on the
market.
The importance of the communication skills section of the examination must be
stressed, and many candidates tend to find this section problematic. For those who are
not native English speakers or do not have a degree from a UK medical school, it may be

xvii

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 The DO-HNS and MRCS (ENT) Examination and How to Pass It

appropriate to consider further training in communication skills. Most importantly, you

must practise the examination and communication scenarios ad nauseam. In our experi-
ence, obliging friends and relatives are a great source of practice. It may also be worthwhile
attending a dedicated DO-HNS revision course. It is surprising how effectively a substan-
tial financial outlay focuses the revision-weary mind.
You will find that the examination question style is similar to those in this book. At the
time of writing, the OSCE consists of around 25 stations plus three to four rest stations,
each lasting 7 minutes. Approximately 20 of these stations are unmanned written stations.
The examination lasts approximately 3½ hours, but with the added administration time it
allows at least 6 hours door to door.
It is also important to note that the mark scheme for the written stations tends to accept
short, succinct answers. Largely, time is in abundance for these stations. Do not feel you
have to write long paragraphs. Often, a sentence or a few words will be enough to secure
the marks. In our experience, for each question the number of lines given in the answer
booklet corresponds with the number of marks available. For example, a question with
four lines in the answer space means there are four possible marks to be picked up. We
cannot stress enough how important it is that you read and re-read the question. It sounds
obvious, but make sure you actually answer the question, too. For example, if the question
asks for four causes of something, you will be scored only for the first four that you list.
This means if you list six causes and the first two are wrong, you will only score two marks,
even if the next four are correct.
Be reassured that pass rates have tended to be between 45% and 75% in recent years.
With some considered preparation this is an eminently passable and fair examination.
On a final note, as you can imagine, a 3½ hour examination is long and most certainly
feels it. It is important to be rested before the examination. Some people find it useful to
take a small snack with them to keep up those flagging blood sugar levels.

xviii

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 General Tips for the
Communication and
History Stations

The communication stations are probably the most intimidating part of the examination.
You are faced with an actor and an examiner. To those not familiar with the OSCE set-up
this can be somewhat daunting. Staying calm and unflustered will be to your advantage.
Be reassured that there are plenty of marks available for the simple things. It is vital to
blind your mind to the contrived nature of the situation and treat the actor as a patient,
as you would in clinical practice. Do not expect too much interaction from the examiner;
it is normal for the examiner to remain entirely passive. This can be a little disconcerting
if you are looking for affirmation. Likewise, do not rely on the examiner for timekeeping.
There will be no signal that the 7 minutes allotted for the station is coming to an end. It is
well worth practising some of the scenarios in this book, to give you an idea of how best to
manage the time effectively.
For all of the history stations it is useful to adopt the ‘open to closed’ question approach.
Start general and then work on to the specifics of the presenting complaint. A useful gen-
eral opener could be: ‘Could you explain to me in your own words the symptoms that you
have been experiencing?’
It is also useful to contextualise the patient’s symptoms, so ask early on in the consulta-
tion about the effect of the symptoms on the patient’s life. This is extremely important in
the examination, as there are often marks for uncovering the patient’s ‘hidden agenda’.
Being an examination, and hence by definition an artificial situation, you will find the
actor’s healthcare-seeking motivation tends to be rather more neatly constructed than in
clinical practice. For example, the patient experiencing vertigo may have underlying con-
cerns of a brain tumour, which they will reveal with some gentle, empathetic question-
ing. Uncovering the patients’ ICE – ideas (as to aetiology), concerns (hidden agendas) and
expectations (as to treatment and prognosis) – is a useful framework for establishing this
vital narrative information.
Chapter 1 details a number of common ENT presentations and the best method for
tackling them in the examination or in clinical practice. We have detailed a number of
specific areas that will need to be explored in the consultations, but it is important in each
case that you start with general open questions. This will also help to establish a rapport
with the patient, facilitating more specific questioning. Do remember that rapport, fluency
and professionalism carry a lot of marks in the examination. Time is limited, of course, and
it is also important to focus on the core symptoms and not be too distracted by interesting
but fruitless tangential diversions.

xix

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K32124_Book.indb 2 2/15/2017 6:48:40 PM
 History Stations

1.1 Olfactory Dysfunction 2 1.13 Adult with Itchy, Painful

1.2 Nosebleeds in Adults 5 Ear 31
1.3 Nosebleeds in Children 7 1.14 Adult with Non-Acute
1.4 Dry Mouth 9 Hearing Loss 33
1.5 Lump in the Throat 12 1.15 Adult with Sudden
Hearing Loss 35
1.6 Hoarse Voice 14
1.16 Otalgia 37
1.7 Catarrh and Post-Nasal
Drip 17 1.17 Nasal Crusting 39
1.8 Tinnitus 19 1.18 Dizziness 41
1.9 Child with Recurrent 1.19 Neck Lump 44
Ear Infections 22 1.20 Snoring in a Child 46
1.10 Facial Weakness 24 1.21 Recurrent Tonsillitis 48
1.11 Septal Perforation 27 1.22 Nasal Obstruction 50
1.12 Hearing Loss in a Child 29

There will be at least three history stations in the examination. This chapter focuses on
common presentations in the examination and ultimately reflects common scenarios in
clinical practice. Each scenario starts with a short introduction. In the examination there
will be a similar introduction to read before you start the station. There is no allotted read-
ing time, so read quickly but carefully.
For the history stations in the examination, you will only be expected to take a history –
there is no requirement to examine the patient or to plan investigations. We have included
a further discussion on investigations at the end of each section for reference.

K32124_Book.indb 1 2/15/2017 6:48:40 PM

 History Stations

1.1 OLFACTORY DYSFUNCTION

A 70-year-old woman comes to your clinic reporting a change in her sense of smell for
the last 2 months. Take a history from this patient.

Olfactory dysfunction (OD) can arise from a variety of causes and has a surprisingly large
impact on the patient’s quality of life. Often it is the compromise of taste that the patient
first notices.
OD can also lead to potentially dangerous situations, as the patient is unable to detect
environmental hazards such as spoilt food or gas leaks. It is estimated that OD will affect
1% of the population under the age of 65 years and over 50% of the population older than
65 years.

GENERAL STRUCTURE OF THE CONSULTATION

An understanding of the olfactory pathway will be your basis for structuring the consulta-
tion, as a problem at any level of the pathway can cause OD.
The olfactory pathway starts with sensory neurons in the nose. These detect odorants
and transmit via the olfactory nerve (cranial nerve I) to the olfactory bulb located on top
of the cribriform plate at the base of the frontal lobe. These subsequently transmit to the
olfactory cortex. There is also an ancillary pathway transmitting somatosensory informa-
tion such as temperature via the trigeminal nerve (cranial nerve V).
Some useful terms to begin with are as follows:
• Anosmia – absence of smell function
• Hyposmia – decreased sensitivity to odorants
• Hyperosmia – increased sensitivity to odorants
• Cacosmia – sensation of foul smells
• Phantosmia – olfactory hallucination
Structure your thinking around the possible causes of the OD. If you can work logically
through these causes, you will not miss anything.
The OD can be
• Conductive – anything that stops odorant molecules getting to the receptors
in the nose
• Sensory – loss of receptor function
• Neural – damage of peripheral and central olfactory pathways

The most common causes you will be expected to know are

• Sinonasal disease
• Postviral anosmia
• Head trauma
• Other, rarer causes (intracranial neoplasia; Addison’s disease; Turner’s, Cushing’s or
Kallmann’s syndrome)

SPECIFIC QUESTIONS
Start with an open question such as: ‘I understand you are having some problems with
your sense of smell. Perhaps you can tell me about this and how it’s affecting you?’

K32124_Book.indb 2 2/15/2017 6:48:40 PM

 1.1 Olfactory Dysfunction

This is a useful opening gambit, as it contextualises the patient’s symptoms.

• When did you last have a normal sense of smell?

• Is it getting better or getting worse, or do you have bad episodes?
• Has there been any change since it started? Does your sense of smell fluctuate?
• Can you smell anything at all? Any unusual smells? (With this question you must
be mindful that olfactory/auditory hallucinations can be a presenting feature of
epilepsy. Patients often have preserved smell for noxious chemicals [e.g. strong
perfume] through the trigeminal nerve.)
• Have you had any recent coughs or colds? (Postviral OD is the most common
aetiology.)
• Have you had any trauma to your head? (Trauma to the skull base can disrupt
olfactory neurons passing through the cribriform plate.)
• Do you have any problems with your nose normally? (Particularly, ask about nasal
obstruction, discharge and it’s quality, epistaxis, allergies and polyps. Ascertain
whether symptoms are uni- or bilateral.)
• Have you had headaches, fits, faints, loss of consciousness or vomiting? (These are
signs of raised intracranial pressure [ICP] and need to be asked about to rule out
intracranial neoplasia, a rare but important cause of OD.)
• Have you noticed anything else? (Use this opportunity to screen for associated
features of nasal disease such as swellings in the head and neck, paraesthesia,
facial pain – remember pain, epistaxis, obstruction and paraesthesia are ‘red flag’
symptoms that may suggest a malignant cause for the OD.)
• Have you had any surgery on the nose? (Patients with ongoing sinonasal disease
will often have had operative procedures. This correlates with OD as both cause and
effect.)
• Have you noticed any change in your sense of taste? Does this interfere with
eating?

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Do you have any medical problems? (Ask particularly about fevers, malaise, weight
loss and systemic disease such as thyroid problems, diabetes and neurological
conditions.)
• Have you noticed any changes in your memory? (Alzheimer’s dementia and other
neurodegenerative diseases have been associated with olfactory dysfunction [OD].)
• Do you have any children? (Explain that this may seem a strange question but
Kallmann’s syndrome [hypogonadotropic hypogonadism] can present with anosmia
and impaired fertility.)

Close this part of the history by asking if the patient has anything else to add. This can
be a useful time to screen for the patient’s ideas, concerns and expectations.

DRUG HISTORY
• Do you have any medical problems? (Ask particularly about antihypertensive and
antihyperlipidaemic drugs, as these are known to be associated with OD.)
• Do you have any allergies to medications?

K32124_Book.indb 3 2/15/2017 6:48:40 PM

 History Stations

FAMILY HISTORY
• Do any conditions run in your family? (Ask about nasal polyposis, allergic rhinitis
and cystic fibrosis, which predispose to conductive OD.)

SOCIAL HISTORY
• What do you do for work? (Try to discover if there has been any exposure to toxic
chemicals, e.g. nickel.)
• Do you smoke cigarettes?
• Do you have any pets or exposure to animals? (Allergic rhinitis can lead to OD.)

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would fully examine the patient’s head and neck, obviously paying particular
attention to the nose. Examine the nose in the standard fashion (see Chapter 2) paying
attention to the nasal mucosa for signs of inflammation, deviation of the nasal septum and
the presence of polyps. Explain you would perform nasal endoscopy with either the rigid
or the flexible nasendoscope.
Explain that routinely other tests are only ordered as appropriate from the patient’s
­h istory and examination findings and often no further investigation is helpful.
Blood tests can be used to rule out systemic disease (e.g. blood sugar, thyroid function
tests).
If nasal pathology is detected on nasendoscopy (e.g. mucopus seen at the meatal ori-
fices) then a computed tomography (CT) of the paranasal sinuses head with paranasal
sinuses can be ordered to delineate the degree of sinonasal disease, in planning for pos-
sible operative intervention.
CT imaging is also required if the patient presents with a constellation of ‘red flag’
symptoms as already detailed.
If no nasal pathology is detected then magnetic resonance imaging (MRI) of the head/
olfactory pathway can be used to rule out uncommon tumours such as meningiomas and
aesthesioblastomas (olfactory neuroblastoma).
Further evaluation of smell can be performed using the University of Pennsylvania
Smell Identification Test (rarely used in clinical practice).
Discuss treatment options depending on results of the investigations (e.g. sinonasal
disease, tumours).
If sensorineural anosmia (most often of postviral origin) is diagnosed, explain that
there are no specific treatments. Spontaneous recovery is sometimes possible, although
the loss is permanent in the majority of cases.
Patient reassurance and education are important, warning specifically about the risk of
gas leaks and contaminated food.

K32124_Book.indb 4 2/15/2017 6:48:40 PM

 1.2 Nosebleeds in Adults

1.2 NOSEBLEEDS IN ADULTS

A 45-year-old man attends your outpatient clinic reporting repeated nosebleeds over
the last few months.

Although epistaxis is a common occurrence in all age groups, typically it has a bimodal
distribution presenting in children and the elderly. The nose has a rich blood supply from
both the internal (anterior and posterior ethmoid arteries) and external carotid arteries
(facial and internal maxillary arteries). Bleeding is classically described as originating from
the anterior or posterior septum, although the distinction between these is somewhat
arbitrary. Anterior bleeds are most often from Little’s, whereas posterior bleeds are more
often from the sphenopalatine artery or are of venous origin.

GENERAL STRUCTURE OF THE CONSULTATION

Most cases will not have a singular cause but will be the result of a number of concomitant
factors such as nasal trauma, rhinitis, hypertension and anticoagulation. These risk factors
tend to increase with age, and hence the increasing prevalence in the elderly population.
It is important to differentiate these cases from those that may have a more sinister cause,
such as intranasal malignancy.

SPECIFIC QUESTIONS
• How long have you been having nosebleeds?
• How often do they occur?
• When you have a nosebleed, how long does it last?
• How much blood do you lose? (Measures such as an egg cup, teaspoon, etc. can be
useful to quantify amounts.)
• Does it come from one side or both sides?
• Does blood come into the mouth? (This may be indicative of posterior bleeds.)
• What do you do to stop the bleeding? (This question can also ascertain whether the
patient has an understanding of first aid.)
• Have you required hospital treatment to stop the bleeding in the past?
• Do you have any associated nasal symptoms? (Ask particularly about nasal
obstruction, pain, discharge, crusting, paraesthesia, and lymphadenopathy in the
neck. These are ‘red flag’ symptoms for intranasal malignancy.)
• Have you had any trauma to the nose? (Particularly ask about nasal picking.)
• Are you exposed to animals/pollen? (Allergens are a common cause of epistaxis, by
causing inflammation and hyperaemia of the nasal mucosa.)
• Ask about how the condition is affecting the patient, e.g. interfering with social
function and so forth. This is a useful place to screen for any ‘hidden agendas’.

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Ask about hypertension, heart disease, bleeding diatheses and liver disease.

These are all known bleeding risk factors.

K32124_Book.indb 5 2/15/2017 6:48:41 PM

 History Stations

DRUG HISTORY
• Do you take any blood-thinning tablets? (Particularly, warfarin, aspirin and
clopidogrel.)
• Do you use intranasal oxygen? (This predisposes to epistaxis by drying the nasal
mucosa.)
• Ask sensitively about intranasal drug use, e.g. cocaine.
• Do you have any allergies to medications?

FAMILY HISTORY
• Do any blood clotting disorders run in your family? (Hereditary coagulopathies
predispose to epistaxis.)

SOCIAL HISTORY
• Do you smoke or drink alcohol?

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would examine the patient’s head and neck, paying particular attention to the
nose and nasal septum.
Often with anterior bleeding points you can visualise a septal vessel that can
be ­cauterised. A week of intranasal antibiotic such as Naseptin cream can then be
prescribed.
If there is no obvious bleeding point to visualise on anterior rhinoscopy, you would
perform rigid endoscopy.
Blood tests are rarely necessary. However, in cases of severe blood loss with suspected
anaemia, or in cases where there is the suspicion of an underlying coagulopathy, a full
blood count (FBC) and clotting profile should be ordered.
With patients on warfarin the international normalised ratio (INR) should be checked
(their ‘yellow book’ should document the normal range for their INR).
Patients with ‘red flag’ symptoms for neoplasia should undergo computed tomography
(CT) examination of the head and paranasal sinuses.
If the patient does not have a working knowledge of first aid measures then these
should be explained. For example, place the head forwards and pinch the soft part of the
nose, and ice on the back of the neck can also be tried.
Explain to the patient that any bleeds that do not stop with first aid require them to
come in to hospital. Initially it is very likely that nasal cautery will be attempted; severe
bleeding may require recourse to nasal packing and a stay as an inpatient.
In recurrent nosebleeds, refractor y to more conservative management, surgical ligation
of the bleeding vessel, e.g. sphenopalatine artery ligation or radiological embolisation, is
possible.

K32124_Book.indb 6 2/15/2017 6:48:41 PM

 1.3 Nosebleeds in Children

1.3 NOSEBLEEDS IN CHILDREN

A 10-year-old girl comes to clinic with her mother who tells you the child has been
having two or three nosebleeds a week for the last year.

Nosebleeds are a common complaint in children. The vast majority are not serious; how-
ever, they are often a source of serious parental concern and a source of social embar-
rassment for the child. As with adult epistaxis, bleeds can be classified on their site of
origin: either anterior or posterior. Anterior bleeds from the Kiesselbach plexus/Little’s
(where multiple arteries anastomose) are the most common. In older children most epi-
staxes result from nasal trauma or nasal picking; however, nasal foreign bodies are also
common.

GENERAL STRUCTURE OF THE CONSULTATION

This is a similar structure to the history for nosebleeds in adults (see Section 1.2), with
some specific additions. You will be faced with an actor playing the parent; there will never
be children in the examination. Think about the possible causes of a nosebleed in a child
to help structure your approach to this station.
Causes include

• Nasal picking
• Allergies
• Infection
• Trauma
• Very rarely, neoplasia

SPECIFIC QUESTIONS
• How long has she been having nosebleeds?
• How often do they occur?
• How long do they last?
• How much blood does she lose? (Refer to familiar quantities such as an egg cup to
help the mother here.)
• Does it come from one side or from both sides?
• Does it come into the mouth?
• What do you do to stop the bleeding?
• Has she had any treatment in the past?
• Are there any associated nasal symptoms? (Ask particularly about nasal obstruction,
pain, discharge, crusting, paraesthesias, and swellings in the head and neck. These
are ‘red flag’ symptoms for intranasal malignancy.)
• Has she had any trauma to the nose? (Particularly ask about nasal picking.)
• What is the impact on her life? (Ask about problems at school – recurrent nosebleeds
can be socially isolating.)
• Does she have any exposure to animals/pollen? (Allergens are a common cause of
epistaxis, by causing inflammation and hyperaemia of the nasal mucosa.)
• Try to illicit the mother’s ideas, concerns and expectations, as it is very likely she will
be anxious about serious underlying pathology.

K32124_Book.indb 7 2/15/2017 6:48:41 PM

 History Stations

PAST MEDICAL HISTORY AND GENERAL SYSTEMS REVIEW

• Is she otherwise well? (Ask about weight and development, fevers and malaise.
These are useful questions for ruling out systemic disease.)
• Has she had any unexpected bruising or bleeding from other sites? (Many
haematological disorders can present with epistaxis, e.g. childhood leukaemias.)

DRUG HISTORY
• Is she on any medications?
• Does she have any allergies to medications?

FAMILY HISTORY
• Do any conditions run in the family?

SOCIAL HISTORY
• Does she have any siblings? If so, does the sibling have similar problems?
• Is there any smoking in the household? (This predisposes to epistaxis by irritating
the nasal mucosa.)

FURTHER DISCUSSION: EXPLANATION AND PLANNING

Explain you would examine the child’s head and neck, paying particular attention to the
nose and nasal septum. The first-line treatment would be a 10-day course of Naseptin.
Cautery is a second-line therapy, as it is often difficult in children. If you are unable to per-
form a satisfactory examination and the child is having severe symptoms, then an exami-
nation under anaesthetic may be appropriate.
Rigid endoscopy is surprisingly well tolerated by children and should be performed if
there is no initially obvious cause for the bleeding.
Explain blood tests are not usually required but may be appropriate in heavy recurrent
bleeds or when there is suspicion of an underlying haematological condition.
In exceptional cases, MRI of the head may be appropriate to rule out neoplasia.
Reassure appropriately, as most children will grow out of nosebleeds. Often a short
course of intranasal antibiotic such as Naseptin is all that is needed.
Educate the parent about first aid techniques if he or she is not familiar with them.

K32124_Book.indb 8 2/15/2017 6:48:41 PM

Another Random Scribd Document
with Unrelated Content
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4Si OROAXIC DIH\:S f/Tll.U THE VEGETABLE KlXlilKtM

Vlxstt-. — Wwxlj- ciiml>crs, stom. ^'vcnil inolios tliioV, omits milky
jiikx>; loavo:' rouirli: tlnwors (.Vt. Nov., tT('am-ti>K>r, yoHow at
liase, puritlo-sixittitl !tlx>\o. I'vjiio:;: wmlla irainoix-talous, loU-s
estendeil in iiamiw. tail-like nuls. :JJ.'> SO t"m. i;t 12"' loni:: fruit
June, jiair of follii-li.'s. J(*-;i7,ri Cm. i.S-l,"i'^ Kiiij:. -.'» fui. ^^■'
tliiok, acuminate, oacli ivntaiuinj: alxnit :ll*0 lunc-awnrtl snideiis*
txwtiiiir of clost-ly iiii[irvss(.>ii hairs 1,.'^. Kf'iht"- . or liyht liark-
hn.wn, iH-arly ^mth. ^nariniilj liairj' (.i^. A(>;.-..v-..«\ riiij;,- oil oHf
sitlo fnim ivutTx- to summit: fnu-tuix' short. si>ft. whitish. oiI>:
ixiorlu-avy when (.TiishiH) ami moistonrtl: taste verj" bitter, rownKK.
):™,''''''>-l"^"*»> *>Jor iHstini't: mien^s^vpiiijlly — ehiolly
]vm'nfhj-ma ivlls am) frag^ menis of hairs .few in S, hi^j'itli-,*^:
monniiNl in hvilratoii ohIt»r«l T, ,'^. shows numerous oil jrlobuW;
many frainnents of eutKvii|ionn irrtvuish with sulpluiric aeid vstnv
phiimliiuV Should K- kept in iij;htl>-\'!os«>l ouitainers. adding; (XY-
asionally a few di\>iw of ehlot\>fomi or i-arlx>n tetraeldotide. to
prevent iiisivt attaek. Si^iv.in: aUvhol jiv p. e-\ Kuling water jwrtially.
IVse, pr, J 1 v.lU'S ,i';l Om.V Ami.TV.tt^TiONs.- \Vhite. wix'lly
stix'phamhus. S. .YiVW«»h"(i liw';*''^- '>''>''^ white, loiii;,
pixxhieiui: shai:i;>'. stoiit apixiiraiu-e; S. ffTii'iuit. ^H«,ls hn>wn.
without hairs: S. (\^:,'-i\'n'tii. seeils siiuiU, bnwuisli. ventral ridj:^'
ol>M'ur»'. with eali-iinu o\aIate er\st;ils; KicL'x'ia itfrUii'iKi. se^^ls
with Ixnh emls aeuminaie. ier»-to. hairless, l\'"t"iirt':aehini: the
liii:he>t tr»vs. and luiiiinng in festixins and tiuls nix'Ti the ground,
Tniit is o^llrt-tixi by the luitives who ixtI iiIT hnsks ,epi('aq», niestx-
arj''', preser\o, and dry the snux^th, \ellowish-br<>wTi, mon-
leathery inner ivveriuj; endix-arp^ enoKtsing the >ee»ls, and as
sneh t-onsists of s»hiIs :;7 p, e.. endiH-itrp ^^xxl^ o7 p. c. hairs
'2.'t p. e.: the tii;liler in ivlor the pjippus, the hiclier in t:Ridotbe
tvntaint>l s»ls; txvnrs on the market in i>o.ls and as eleaii set>ls.
("oNsTiTi K\Ts. — Strophanihin I :i p. e.. elioiiue. t^i^^lllellino, fixed
oil -.'>;!|i p. e., starch, pnneids. )>S(>udi>-stn*phainhin .^\ ash 4-
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Ix'iizin vrvnuwiiic fat\ then extntetinj: with 70 p, e. aUvhol.
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STROPUASTHfS—STSOPHAXTHlS 483 AFOCntACKX latter.

dU^oNing residue in water, filtering; add tannin, wash [wecipitate.
mix nith litharge, dr>'. exhaust with al«>hol, precipitate with ether:
heated with (Hluted hydrochloric acid becomes hydrolv'zed, yielding
strophanthidin, C,;!!,^; + 2IIiO, which precipitates, and
stmphanthobiose-meth^l-ether. CuHnOi^Hj. remaining in solution. It
is a white. >'elluwish powder, containing var>'ing amounts of water,
which it does nut lose entirdy without decomposition, pennanent
(must use great caution in tasting and then only in ver>' dilute
solutions), ruiluhle in water, diluted alcohol, less so in deh}-drated
alcohol, nearly in^uble in chloroform, ether, benzene; solutions
i>eutral, deTtrorotatorj-. Testa: 1. With sulphuric acid — «nerald-
preen color, changing to brown; incinerate .1 Gm. — ash non-
weighable. 2. Aqueous Fioluti'>n with trace of ferric chloride T. S.
and a few Ml, (Cc) of sulphuric add — rc"l-brown precipitate, turning
dark green in 1-2 hours. Should l)e kept dark, in well-closed
containers. Dose, gr. gig ^\f OKur^-.dilii.-, Om.i. Filed Oil. — IJmn
ni>h-preen. non-ing. heavy odor, sp. pr. 0.925, {-iintni!- voUiilt- oil.
ph\tostcrin. formic acid, oleates, stearates, anu-liiiiiHc-: may Im- tin-
irritatine ingreilient. I*KF.J'4K\TM\"S. — 1. Tinrlurn ^Iroiihanlhi.
Tincture of Strophanthn.-. Syn,. Tr. >tr(i|ih:tnth.: Fr. Teinture 'de
Semencesl de Strophanthiis: (It-r, ."-trophanthus sanien tinktur.l
Mmi'ifiiiurr: ]i> p. c. IVrcnIate slowly 10 Gm. with purified petroleum
bcnzin until no greasy stain left; unpack and expose contents to
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4S4 ORGAXIC DRUGS FKO.V THE VBGBTABLB Kl.\aDO.V Hir

until <1r\' and Viencin odor disappeared, then proceed fdmilar to
Tinotura Veiatri Viridis, page 101; menstruum: alcohol— moistening
and macerating for 4S hours (instead of 24 hours) before starting
pcra^tion. Dose, mj-lO (.(»0-.6 MI. iCc-)). I Fto, 31S. —
Siinphanthus s«*d wiih mnHwr «irn. I'noff. PrriK*.: Otmrtion. 1 p. c.
dose. lTlx-«i(l l..(>-4 Ml. (Cc.)). Exirarttim Simiihanlhi (.Br.>. 50 p. c,
d«>se. gr. J-l (.OllKWi Gm,). Test: I. The tinctuiv or extract + ferric
chloride T. S, + sulphuric acid, gives brown precipitate changing to
green after 1 hour, and so remains 3—1 hours. Properties. — Similar
to digitalis: heart stimnUnt. diuretic. Acts directly on muscular tissue
of the hean, increasing the contractile {xmcr: small d^viM-.'^
stimulate contractions, strengthen the force and lower tlie rate of
heart-beats, thus prolonging diastole without altering
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STROPHASTHCSSTia)PHA\-THLS 485 ArocTN*rK.e the

iliiratioii tif tlio systole, makinf; ivgular an invfrular bcart: larjK i!it:
iwralyze tlie ht-art. Wvinp cardiac niusde ripd. It L; a better (liiiretii-
and a more powerful mrdiac stimulant than di^talis. the etTett
(xmiinp on much more quicUy, yet heinj; less permanent : reduces
pii1-inte^tiiial deran^ment: the increased cardiac action stimulates
renal circulation, thereby cauang the diuretic action. Frc. 319—
.4porv»«i I'sFs. — Canliac dy*pn;il}'ii^itii-ii. wciik hcjirt. pulmonar>'
oedema from pneumonia, cardiac ■ir>i;'\\ . iTiil'!r-. rtniiiiiiic pui^' lii-
oii lieats. at the same lime incrwi.-ing force ;i:.i •.••liiiiif. The naiivf^
make of it an arrow poison liomhfi, which i- an i\lP-i.t. til U- applitil
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4Sti OBGASIC FtRri7S FffO.W THE VEGETABLE KIXGDOM

.illinl /V.iHfa; I. .sVni/.A.iHMrw JU-hnl'omu.1. Fati»- Stn^i>hmlhu.t
Smf.«. —llicse are chi'stnut-bniwu «iul It-ss ileiist'ly wventt with
Imirs, otlit'nvi-* ivsemble tht' otKml. i. .l/Kn-'j/WMM ttJtitMh'iiiiiai.
.l/MH-j/MMHi, (\iN. 1 J M. tli-ti'l Iiijrii. glnhnnis, bram-hoii; loavfs
opixisitf. I'litirt*. nnuTonate: ttowers, i'\iiios. gnt'iiisli-white; fniit anite
folliolo. Jll rni, ^S'1 loiij:. 4 Mm. i.i'1 thii-k. lUiizome. vnriaWe knijrtli.
:! S Mm. (J J'l thick, eylimluiil. loiiptiuliiially wniikltHl, tniiisvers«-]y
tissun>1, ytllowisli, limwiiisli, Urittle; w(> (i5 p. c. t>f the t\K>t;
«ilveiits: ttoiliiif; water ali'ohol if>o i>, i'.>; iinitaiiis eyiiotoxiii inu>st
aetive\ aiHK'^iiin, tnniiiii. n'siii. stan'h. ash ."> p. v. Piimtio.
ilinphorftic, fxntttorant. anti|>eri«»iie. alterati\e. caniiae ;^iiiml«i)t
isiinilnr to atijiitalis^ : tniietic; camliae
aiMlh'iiaIiIn>iisy,intonuitteiits,ilysiioiwia. l>ost\)rr. --5 v.i;{-.;i(im.);
emetie, fx. IS -10 (1 - (im.l: Ituidextrnet ^^:ly^vriH 10. ale. (iO,
water W\. mij o — ;HH.i;>-.3 — 2M1. tCe.'tV
alstMnaquetmsextraft.diitK-tion, tiiirtun'. Pio. »LV.— .(pi*vt«" S. .1.
amtnifirmifo'liuin. Sprimlinff /'i^f/fiiwc— Tlie Hiixonw inx>t\ ofheial
lS2t> ISSlt; N, .\meriea. (.miws assix-iattni with the preewiiiip.
ha\'iiii; stem mor^> sprt-aiiitiir, leaves hrtxnler, rhi/onie thinner,
toiij^er, with eentral pith; Imrk thiiuier with layer of stone (vUs;
flowers pinkish; ixmtains (.siipixv^sllyl aln^ut tlie same as .1.
iiiniMbinum, eansinj; it to Ix' useii for similar piirix>ses. bnt, as a
faet. it produces qnite ditTerent etTtxts. ASnOOSrER-MA. A:?
riPosrEnMA. I The dritx) Ivirk. with not morp I than 1' p. e. of wixxl.
forei(ni matter, ete. Ui^:,ii. S. Anwrii-a: Aiywn bnfhi>; tVr. (iuATsu-
lxi.
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ASPIDOSPERMA—ASPIDOSPERUA 487 ArOCTNACBf As-pi-

do-sper'ma. L. fr. Gr urwiit.tai, a round thidd, + ««iM^ a s«d — t. („
rrseiiilifarire trf !*

ellonish, 5's, panides; fruit

July, capsule, dehiscent,
pericarp thick, woody. Babk,
in irregular chips, longitudinal
pieces. 5-14 Cm. (2-ti'i long,
10-35 Mm. (i-l|') thidt; outer
corky layer 3-iJ Mm. Ij-l'}
thick, reddish-hrown, deeply
fturowed, frequently'
reticulate with longitudinal
and shallow transverse
fissures, crevices occasionally
lined with myodia f^ gra>ish
moiit equal thickness marked
with dots, stone cells and
striie: nearly ino^iorous:
taste hitter, slightly aromatic.
Powder, reildish-brown —
Iiast-fibres single, long,
surrounded by crjstal fibres,
thick proup-i (if lahiilar >tone
cells, pol\'gDnal thick cork
cells, spherical starch
CT-.iin..^-. _T. \r,-.-^i 1-
JGmJ. /",,",.,,, r, ,".,/.- Trtf ri-
cn»l'ic> the weeping willow,
being not only omaiiuntal i>iii
valiiaMt for its wood in
building, carving, etc: bark
shoul.l !■(• tak(-ii fn.ni (■M
trees to insure well-
developed corky layer; }\i'uv
I'f tin- LTn,-ii fniii ofiiii iiM^iI
like rennet. -|icnnine,
('i!nii.N^Oi.
aspidospennatine, r-H:.N.-
<.>amine, ("sII-AiOi
lamorphous), quebradiine.
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•iss oRiiAMc nuras from rin: vKaKTMU.b: Kixaix)M (\jlI«6N*

(>s.qiu*l>rarlunuiiu\hyiHH|iiohnu*hiiu\(\inwN-(\i,«morphous),
q\iol)nu*hit i,siipir\ tannin 15 I p. o. Alkuloiiis ^li'i.- OhtaintMl l\v
trt'atin^ extract 0^4 aKn>hoh with SiHlimn hy(ln)\ido and
rhlon)forin, ova)H)ratin^. taking up n'siiluc with iHhittHl sulphurir
aciil, pnvipitatinjr liltroto withsiHliumhydmxiile: tlissi^lvo pnvipitatc
i^niixtHl alkaloiils^ in iHtilint; alin^hol ami ujHm iHH)Hn>;
aspiilos|HTnnno. nuohnirhino, anil tiuchniohaniiuo iTystallizo ont
i^sqnmittHl by iTystalli/ation frtnn ilihittHl hyiliwhK>rio aoid\
aspiilos|HTinino ixMnaininv: in tho (.ariil^ niothtT-Iiqnor: to the
aUn^holic niothor-Hqnor a*Kl airtic ariil, fmni which aspiiK)S4uninc
is piwipitateii by annnonia water. aspidosiHTniatino anil
liyiKH]nohnu*hino by schIiuiu hydrt^xiilo i^st^panittnl by InnHn^
bcn/.in in which hy|HHinebnu*hine is insuhibh*^; all nion* i>r loss
soluble in aK'ohi>l. ctluT, chlonrfonn, Umiziii i^ipicbraohaniino tho
loast so^. Aspiilos|H*nnino is tho loading alkaloiil visually a niixtnn*
in i*i>nnuonv>. U^inj: pri^siTiUnl as sulphate or ehlori«le. l>osi\
>;r. I *J (.lH> .i;^ (tui,^: quebniehine, tho next most im|H)rtant
alkaloid. alsi> fonns s^Uts. l>oso. jrr. J I J i,.iV> .1 (ini."^.
I^iF.rAKVTU^Ns. I . Fluuhwfractutu . I,f/»/«w;)fTw. Kluiilextnu*t of
Aspiilos|HTnia, iS\ n.. FKlext. Aspiilosp., Fhiiil Kxtniet of
Aspitli>sjHTnia. Fluidextniet of (^lebnioho; Fr. F.xtrait fluide do
(^lebraeho; (uT. Quobnioholluiilext nikt ."^ Matnifavturr: Similar Xo
Fluidoxtniotmu F.r>*i>ta\ j>age IW; 1st menstnnnu: ah'ohol (u ML
^(\\\ water 22, glytvrin 11; 2nd me«stnnuu: 07 \\ e. aWhol. Posi*.
Illxv lU) \,\ I Mh i^(V.>\ I'noff, /Vf7vf.: f>^nir/. dos4\ j:r. 2 v^ i^.Uv
.">ltnu\ Tifuiurt\"M \\c. i^dilutinl ahvhob. dost\ oj 1 ll 1*^ Mh
i.^V.^^. nVwi', 1> p, e., dose, oj jisnuHlio, anti|HTiiHlio: solutions
pnntvthe to wounds. I'sKs. (\mliae and asthmatie ilyspna^a.
[phthisis, asthma frtmi briHU'hitis or olmHiie pneumonia, shortiu^s
of brtNith: facilitates absi>rption of oxygt*n by the bliHHl: if ust*
i^tntimuHi have headache, vertij^v s{di\ation. intoloniniv. and death
fri>m asphyxia; enables the endunuuv of fatijjue. climbing
elevations, etc.; luirk natively for tumiin^. Alliiil rhifih: - S. America.
Hark cluvkert\l, wihhI rtnl. lisrht bnuvn i,C\Jonidoh iHMUains taimin
2i) p. c. loxopterypne; n^sinous exudation of l>ark n^siMublcs kino;
rt^st^nblos otlicial but div|HT inJor. lanrely use^l in taiuiinc*
Qiif'hrijrho Jto'ja yl^sii'na rkof^thifo'ho'^, S. Amerii'a. anil Co^Hihhi
tujrh yi'ri^toft tii'iYu^^^ Mexii*i^. All thrtv ivlWteil and siJd as
aspidosjHTma. 2. .I,*c/f';»;ii.f ttJurt^'siU Ast^lrpiiU^, Phurhy
titH^,- Asi*lepiadaeeR\ The drit\l nn^t. otlicial IS,V^ UHH>; Inittnl
States, (^mada. IVrvnnuU plant >\ith nmuertnis stems. .t> 1 M. v2
o '"^ hijrh. hairy, green or itnldish. dilTcrini: frtnn other as\*lepias in
not eniitting milky juitv; flow^ers U'autiful onuigi^rixl. lun^t. Iari:t\
fusifonn. in pieit.^ 2.5-15 Cm.
 ASPIDOSPERMA—ASPIDOSPERMA 489 CON VOL VULACE^
{\-i\') lon^, 2.5 Cm. (V) thick, head knotty, annulate,
yellowishbrown, fracture tou^h. uneven, bark thin, wood with large
medullar^' ray>; inoot (rhizome), official 18-20-lSt 2.5 Cm. (T) long,
knotty, oblong, brownish, bark thin, central pith, sweet, then acrid
bitter, emits milky juice when wounde^l; contains volatile oil, 2 acrid
resins, asdepiadin. Used as alterative, emetic, cathartic, diuretic, like
Asclepias tuherosa; in decoction, infusion, tincture. Dose, gr. 15-40
(1-2.G Gm.). 4. .1. suri'nra iCornn'ti), Common Milkweed, SUkweed,
— ^The root frhizonu-r, official ls2i)-lS', browni>h: bark tough, thick,
with laticifemus vessels, wood-wedges yellow, bitter, nauseous;
contains asclepion (tasteless), bitter, crystalline principle, caoutchouc
(0 p. c. of milk-juice), resin, tannin, starch. Vm^I like preccnling,
also to coat over wounds, ulcers, etc., to promote cicairiziition. Dose,
gr. 15-40 (1-2.0 Gm.). .1. curassat^ica. Bastard IjMmrnanho, C. and
S. .\merica; flowers bright red; the glossy seedhair<. calle=""
vejretable="" silk="" firmer="" than="" the="" preceding=""
contains="" asdepiadin="" u="">ctanli. mirn. a
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W ORi^AMC nRl'OS FRiWl THE VKOETAliLK K I Mi DOM

aoriil, milky. piirjrsUive jukv; leaves exstipulate, sometimes }>arasiuc
aiul leafless: «ilyx ,">. imbrii^ate. inferior: cim^lla rt^giilar, 5-plaiteil
or -IoIhxI: ovary 2-4-iv1Uh1: oviik^ 2 in each wll: fniit t^i^sule, 2-
4iX^lUnl. Allieil to Si>lanai\w and Si»it^phiilariai\w, but differinjj in
habit, alternate leaves, and large siJitary seetls, with enimpleil
embno; tn>pii»s, tem|H^rate elhnates; purgative (^ghicosides in
juices); some nxus tnlible i^stari'h, sugar). Genera: 1. Exofonimii. 2.
ConvolTiiIiis. JALAPA- JALAP. Kxof^onium pur]|a« The drieil
tulx^FiHis Foot, containing 7 p. c* of HKihiUi!. K. Moxiiv. in damp,
rich, shady wixnis: cultivaiV»i. Tnio Jal:ip. \'on4 Cnii Jalap. Radix
Jala^xi^: Kr. Jala|) — luUwux — officinal: Gor. l\iN*ra Jala|vi\
Jala|XMiwiiriol. JalaiK'nknoUon. .lalaiH". Ex-o-go*nl-um. L, tr. l«r.
I^w, iHit^ado. + ^iSnn. offspring — i. e^., |)ail« i^ genoral ion
vstanuMis. pistil ^ oxA^rtc^l — i^xtcndcil alxwc ivn^lla. Pur ga. I.,
tr, pu/y^K f»t.fy*i/r. to purge, cleans, purify — i. f ,, it«i cathartic act
ion on the wtHl, snuKUh, puri>lish. S.lV-(> M. O-"*-^^^) hmg,
twining around neighUmng objei*ts: leaves exstipulate, U>-12.o
l^m. i,4-o') long, cordate, entin\ snux^tlu jx^intetl, untler side
i>aler, pnmiinently veineii, on long jvtioles: Howers Sept.-Nov.,
purj^le, siUver-shaixni, tul^ 5 Cm. (2') long, limb 5-7.0 Tm. ^2-3'^
wiile, in I^-Howeitxl eymes, stamens exst^rttnl ycxi^otnum^,
Rix^T, fusifonn, irrvgularly ovoid, pyrifortn, up|XT end moTt^ or less
roundtxi, lower slightly taix^ring, 4-15 Cm. Oi nn>aet. non-fibrous:
intenially dark brown, mealy or waxy: Ivirk I 2 Mm. i^^V" i*5*^
thick, outer bundles soiHirated from outer ix^rtii^jd layer by distinct,
brown i^ambium zi^ne: oilor slight, distinctive, smoky: tas^^te
somewhat swtvt, acrid. Powdkr, light bnnvn: microsivpii.*idly -
munerous stan*h grains. .lKK>-.lUtt ^Im. Uv^^ t't'^ Imxid. i'idcunn
oxalate n^sette aggrvgatt^. traches^, laticiferous vessels with
brownish ivsinous mass. Sti/nt*M/.*: diluted aliH^hol extracts vinui^
ixnnpletely: water or alcohol alone only jvir* tially, each taking out a
|x>rtion of purgative pro^x^rty. the alcoholie st^lution Ixnng mort*
griping than the aqueinis. Hose, gr. 5-2l) (.3-U3 (im.\
.\nri.TF.KVTio\s. - Falst* Jalap rtxns {Iinmiati .^imulafh*^ /. orisa-^
»,\NV>'^, and nx>ts of allitxl s^xxnes: inumitun:^ jalap rvxits,
a>llected at impn^IxT times and ivntaining very little rosin: jalap
nx>ts depri\Td of n\^in by Siviking in aU\>hol, lx\*i>ming sticky to
the touch, darker internally and thereby easily rev*i\snn7.eil: nxus of
other species of
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JALAPA—JALAP 491 CONTOLVLXACKA EjmgoHium an' few

resin cells. fVimHjcm'rt/,— I'lant resembles our Morning-glory,
demands rich forest-I(tam and a climate suitable to Cinchona; grows
on the eastern slope of the Mexican Andes, 1 ,5(IIV2,4 year-; nlci
arid imly tliereaftiT every thirtl year. Roots are dug in :ill >ca->iiis lu-
ntv varyini; aii]>earance and strength), but chiefly in tile s])riiii:.
wlifii youni: shoot* appear, and in the autumn (best), after aerinl y
lii'liliii:: invr tire ithere l>eing no sunshine during the rainy seii*<>n\
wlii,h imparts a sliijht smoky odor and hydrates much of the stari'h;
jtrior to dcsitx-ation the very large pieces are divided into
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■m OIKSAXIC liKl'liS FHOM TlIK VEGETMilE KISGDOM

liiiK(>s. ()iiHrtiTs. or Jr«iis\i'rscly tlmt tfiuls to ninki- it U-ss ilvsirwlile;
ufttT dryiii}; it is {tilt into hnpi (.UX> '-''M) ihiuiuIs; -)*> HO Kg.)
uiul shiptMil fr»iii Vrni Cm/.. CoxsTiTiKXTs. Itcsiii 7 I ">:;:) p, ('..
stim'li, pim lii p. c, supiar :i J), v., IxisMiriit. wIoriiiR matter, nsli 5 -
(Lo p. c. Rostn,— Consists of; 1. ,Uthf»ii (j>ml>ahl,v iiK'iitin)) with
smmmoiiiii), I- U> p, f., s*>ft. waxy, solulilr in i-tluT, nlkHlifs.
reprwi|iit«t«l by «ciy alkalies intt> jalapiirjiic (convdlvuUinWe aeiil.
which is soluble in waterl, CtsIlsaOi,. Iiy wannin); with itilutnl aeids
or emulsion into );'""*=**'• v(»latile meth,^■^-etIl^■^ atvtii- acitl.
lMli,A\. mul eonvolvulJe aoiit. and this latter In- ct^iitimml aetion
into gliux>s4.> and crjslalline «>nvolvulinolie aeiil. ('i«IIw(^: the
name jalapin has tnifortnnatelv' l>een assj^nied to Imtli rt-siiis.
I'kki'auatioxs,— I . I'lihi.* Jalui>(r Comixi*"'imiw\.T«"«viiiin. ' !'''•*■
t'omiKiniul I'tiwiter of Jalap, ^^'^■n., l\ilv. Jalap. Co.. l^llvis IViyan*
— (^athattii'iis or Jalajw tartanitns: Fr. I'ondr*.- ile .lalap ivmiKisee;
Ger, Jala* IH-npnber nnt Weinstein.) .Uitn;i/nj:hIy. pass llmni};h No.
(Ut sieve. It Js lij:hl brrnvii; mienistvpically-nutnewus ani^ilar,
ttt'tangiilar fraj^ inents slowl.v solnble in water or hyilrat<>nfd>'
ixilariitin}: li);ht with display of eotors (,)^>tnssi)ini bitnrtrateV
ntiniefous
 JALAP A— JALAP 493 CONVOLVrLACEyB Starch grains, .
(KIS-AIj Mm. {rirr^z) broad, few fragments of jalap with laticiferous
vessels and parench.Mna liaving trachese and rosi'tte aggregates of
calcium oxalate. Dose, gr. 15-(K) (1-4 Gm.). 2. Hvsina Jalapcr. Hesin
of Jalap. (Syn., Hes. Jalap.; Br. Jalapce Hesiiia; Fr. Hesiiie de Jalap;
(ier. Jalapenharz.) Manufariurc: Mawrate, jx^reolate KM) (Jm. with
alcohol until the IK»rct>late when droppenstantly stirring, to water
3()() Ml. (Cc.), let precipitate subside, decant supernatant liquid,
wash precipitate t^ice by dei-antation. eacli tune with water 1()0 Ml.
(Cc), drain, dr>' on waterbath. It is in yellowish-brown masses,
fragments, breaking with resinous, glossy fracture, translucent at
edges, or yelloninsh-lirown powder, slight, i)eculiar odor, somewhat
acrid taste, permanent, soluble in alcohol, insoluble in cart)on
disulphide, benzene, fixed or volatile oils; alcoholic solution faintly
acid. Tests: 1. Shake occasionally for an hour in a stopi)ereorate
filtrate, dry residue — should weigh .3 Gm. 2. Dissolve in aninionia
water ( 5) — solution not gelatinous on standing; acidify with
hydnxhloric acid — only slight turbidity (abs. of rosin, guaiac,
resins). Imifuritits: Hosin, guaiac, aloin, acid resins, orizaba, other
resins, water, soluble substances. Dose. gr. 1-5 (.06-.3 Gm.)L Prep.:
1. Pilxda Caihartica ComposittF, resin of jalap \ gr. (.02 (im.). Vnoff,
Prejts.: Abstract (alcohol), dose, gr. 2-5 (.13-.3 Gm.). Extrarf
(alcohol;, dose, gr. 2-10 (.13-.(> Gm.). Fluidextract (alcohol), (lose*.
mij-lO (.13-.(> Ml. (Cc.)). Tinciura Jalapa 20 p. c. (67 p. c. alcohol',
dose. 5"^'>-l (--4 Ml. (Cc.)). Tinciura JalajXB Composiia, 12.0 p. c.
4- resin of scammony 3 p. c, (>7 p. c. alcohol q. s., dose, ON-l (2 4
Ml. (Cc.)). pKuPKimns. — Ilydragogue cathartic, diuretic. Has no
effect until the diHHJcnum is reached, where with the bile it forms a
purgative comIkmiikI that stinuilates vascularity, peristalsis, and
profuse secretion fn)ni intotinal glands,,with no action on biliarj*
flow; usually acts in 4 hours. It is lcoge, pocs is likewise* an active
irritant or poison. \ >¥<. i="" cc="" in="" febrile="" and=""
inflammatory="" affections="" head="" troubles:="" wa-=""
intnxluethi="" into="" eurojie="" early="" the="" centur="">', ami
i» r\tn now (jiiite jHipular, l>eing combined usually with calomel,
cn^aiii of tartar, ete. 1. //^»"'//'// jHindiim'ta (Contfthulus
]Hindura'tus), Wild Potato or ./'//'//'. M'lu lu'^^t, M'ln f'f the pMrth.
— The nnit. official ls*2()-lMil); InittNl Statr<. plant="" rtn-
ognizetl="" by="" its="" field="" le-sha="">eli-h, < linii»inL'
.*J.'>-4.") M. (12-15°) high; flowers campanulate,
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494 ORiiAMC DRl'OS FRi^M THE VEGETABLE KISGIXKM

white, puq^Hsh: i\x>t ci^nical. .iWl M. ^^2-:V> lone. r>-7.5 Cm.
i,2-;>') thick, in sliivs, wrinkleii, hrownisb-vellow, milky inside. Ixirk
thin with a zone of resin-cells, oilor slight, taste sx^eetish, hitter,
acrkl; cinitains ivsin 1-2 p. c. ^irlucosideK TmhI as diuretic, i^thartic
in stranciin', calculi. Dose. ^. 1iV-4'h» ^1—4 Gm.K 1 . IjK» ruTii sim
' uhms, Ta mj *ico Jahij ». — Koin irre^ilari y iHoInilar or elongateil
deeply wrinkletl, no transverse ridpes — as in the official; yields resin
yfavipirifi'^ UV-lo p. c, neariy all Ivinsr st>luhle in ether, and
Wlieve^l identical with nesin of scammonv. «. /. oriziihe7i >?>,
Fusifonn {Falsf^ Malf)JaUip. — luxn spindle-sha]vd. .(> M. 1 2^^
lone. stiv>nc radiate stnicttire with pix^jectin*: fihies on transverse
fracture, larpe, wooily, often cut uito sliivs 5-7.5 Cm. i,2-;V> hroad,
dark brown, hroad concentric rincs. ixvirse projeininj: fibnes, and
e\ix>neil liWrally for its resin, julapin, vriuibin — false scammony —
of which it contains 17 p. c, resemblinir dor^ely genuine scammony,
but entirely st^luble in ether, and Ivlieve^l identical with tampicin. It
is unfortunate that the resin of this plant Tviviveil the name,7(i/iT;)in
primarily, as it thus prvcludes in a sense its applii^tion to the n^in of
the official dniir. The synon\iii oriziihifi, as pro^x^seil ami nametl by
Fliickiirer, may sometime Iv acceptcil hen\ and thus allow the term
jiihpiu to be usetl where it would seem more proj^riy to belonir. ^v
Conf\^'ruIus MechiMictw'na^ MtThiMicavua Rixif, — i^onsidened by
st>me identii'al with Ijiomarxi yHjiuiurxiUi: occurs in sei^tions, lights
whitish, mealy, contains little resin. SC.\>DIONLE RADIX.
SCAMMONY RtXTT. CoiiTolTulus SrammonLi. \ ^^ j^^^ ^^^^
aMitainini: S p. c. of lesins. Hiihi^ai. W. Asia .Syria. Asia Minor,
An.^Toli.*i \ Onxvo ■ Arohi|x*l.^^\ cultivatoil. S'i/^. Sirani. Rati.: Fr.
Kaoino do Si'iimmoniV: Cior. ScanmKMii.i«-urtol. Scammoniawimio,
I^l^frio^win^i^^ SxuiiiiKMiy-hinilwixxi. Con-vol vu-lus. L. bind^wii.
six^ oTyi«oK>:jk\ jv^s* 4M^, of Convolviila^vap, Scam-mo "ni-a. L.
fr. l^r. c^eu^kx, cT\\ksule. ovate, 12 Mm. [V^ long, 4-see^le^l.
lu>OT, vertii'al, cylindrii'al, st>mewhat ta)iering, lt>-i"> C^n. i4-
10'^ long, 1-4.5 t"m. ij-lj'^ thick, grayish-l^fownu rv»ldish-bn>wn,
usually distinctly twiste^l. deeply longitudinally furnnveil. distinct
nxn-s^*ars, otherwise nearly snuxnh exivpt for lenticels and
abrade^! ivrk, up}x*r |x^nion temiinatcil gtMierally by a number of
short stem branches: hanl, heavy: fracture tough, irregular with
pix^jccting wixxl-fibrvs; internally mottKnl. sliowing yellowish,
pofOUS« wixxl-weilges sei>arated by whitish parenchyma,
containing starch and
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SCAMMOXIS RADIX— SCAMMOXY ROOT 495

CONTOLTi:i^CE£ resin, bark thin; odor slight, jalap-like; taste ven*
slightly sweet and acrid. Powder, light grayish-brown, microscopica]
[>'— starch grains, .OflS-.lUS Mm. (g^'i,; laW) broad, monodinic
prisms of calcium oxalate, fragments of leptomes or sieve with resin
cells, tracheie, short wood-fibres, stone cells, few ligmfied cork cells.
Solrrnis: alcohol; ether. Dose, gr. 5-211 (..^1..3 Gm.). Commercial.—
V\ant twines around near objects, and b richest in resin just I>efore
flowering, when the root should be dug. properiy prepared and dried
for market. The once official (I8'2I)-19I0) gumresin, scatiimoriium:
srammony. was subject to much adulteration and irref^larit\' in
consequence of which it has been discarded. It is still an article of
commerce under its two varieties: I. Genuine, best; 2, Virgin
iSnijTna, .\leppo), being collected vei^" similar to asafetida by laying
bare and slicing upper portion of root, catching in mussel shelb the
ereamj- exudate, which contains resin 70-90 p. c gum 3-8 p. c; in
ilrjing often undci^oes fernientation rendering it porous, dark, miiliiy.
;ind of thcesy o«ior. r..N.TiTi-KNT<. ke="">in :>-lii p. c, gum. tannin
3 p. c., sugar l.'>p. c, ^liirch, oxirm-tive. Resin. ('.,11 />:-. —
Mentical with orizabin Cjalapin of Ifiomaa ••ri:uil--n.-"'.-' —
F•^l.■•^^ or Mixi'rnn Sr^inmon^ Rod), being an ether-soluble
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