08. KFP: Women's Health Flashcards
Differentials for fidgety legs/leg discomfort?
- Restless leg syndrome
- Akathisia
- Nocturnal cramps
- Peripheral artery disease
- Peripheral neuropathy
- Parkinson’s disease
- Arthritis
- Iron deficiency
What is restless leg syndrome?
Urge to move the legs when lying in bed or sitting down, particularly if the symptom occurs predominantly in the evenings
Diagnostic criteria:
- An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant sensations in the legs
- Begin or worsen during periods of rest or inactivity such as lying or sitting
- Partially or totally relieved by movement
- Are worse in the evening or night than during the day
- Symptoms are not solely accounted for by another medical or behavioural condition such as leg cramps
Strong family history
Questions to ask when working up fidgety legs/leg discomfort?
- Does the leg discomfort improve with movement? (RLS)
- Do you experience a general feeling of restlessness during the day? (Akathisia)
- Do you experience any leg cramping during the night? (nocturnal cramps)
- Do you experience leg pain on exertion? (peripheral artery disease)
- Is there numbness in the legs? (peripheral neuropathy)
- Have you noticed a tremor OR slowed movement? (Parkinson’s disease)
- Do you experience any pain in your knees OR hips OR ankles? (arthritis)
- Do you consume an iron-rich diet? (iron deficiency)
What is akathisia?
- Inner sense of restlessness accompanied by an intense desire to move
- There is less relief from voluntary movement and less circadian rhythmicity compared with RLS
What are nocturnal leg cramps?
- Unlike RLS symptoms, nocturnal leg cramps are sudden in onset, short in duration, and usually associated with a palpable muscle contraction
Pneumonic for restless leg syndrome symptoms?
URGE
- Urge to move the legs (or arms) associated with an unpleasant sensation
- Rest induces symptoms
- Gets better with activity
- Evening and night time worsening
Causes of secondary restless leg syndrome?
- Systemic iron deficiency
- Uraemia/renal failure
- Peripheral neuropathy (e.g. diabetes, alcohol, amyloid, motor neuron disease)
- Spinal cord disease
- Pregnancy
- Multiple sclerosis
- Parkinson’s disease
- Medications: Antihistamines (especially centrally acting/sedating), dopamine antagonists (e.g. metoclopramide)
Initial investigations for suspected restless leg syndrome?
- FBC: anaemia
- Iron studies: low CNS intracellular iron can exacerbate RLS symptoms
- EUC: renal failure/uraemia
- Serum bHCG
Considering neuropathy:
- Diabetes
- Vitamin B12 and folate deficiency
- Hypothyroidism
- Autoimmune conditions
- Alcohol misuse
Non-pharmacological management of restless leg syndrome?
- Cognitive distraction activities e.g. crosswords or puzzles during times of rest
- Particupate in regular moderate-intensity exercise for 30 minutes a day on 5 days per week
- Gently stretch the hamstrings OR calves for 5 minutes before bed
- Keep legs cooler than the body for sleep
- Undertake a trial of abstinence from alcohol
- Warm baths when symptomatic
- Massage legs when symptomatic
- Incorporate a gradual wind-down routine at bedtime
Pharmacological management for restless leg syndrome?
- Gabapentin nocte PO OR pregabalin nocte PO
(for severe, persistent RLS)
Distinguish between irritant contact dermatitis and allergic contact dermatitis
Irritant contact dermatitis:
- Sx: burning, pruritus, pain
- Surface appearance: dry and fissured skin. Less distinct borders
- Onset: usually minutes to hours
Allergic contact dermatitis:
- Sx: Pruritus is dominant symptom
- Surface appearance: vesicles and bullae, distinct angles, lines and borders
- Onset: Usually 24 to 72 hours
Management of allergic contact dermatitis?
- Wear skin protection
- Regular use of emollient
- Loratadine 10mg PO
- Betamethasone diproprionate 0.05% cream/ointment TOP until skin is clear
- Ice pack to affected regions to soothe itch
First line therapy for acute localised otitis externa?
Flucloxacillin 500mg Q6hourly PO for 5 days
Therapy for acute localised otitis externa if allergic to penicillin?
Cephalexin 500mg QID PO for 5 days
What questions would you ask for a 3.5 year old girl presenting with language developmental concerns?
- Did she pass the statewide infant screening hearing test (SWISH) / history of recurrent ear infections or perforations or operations?
- Family history of hearing impairment or family history of developmental delay
- Ability to run or jump - gross motor development
- Ability to feed herself with utensils - fine motor development and vision
- Interest in playing with others - social development
- Difficulty sitting still hyperactivity can be a feature of ADHD although this could be normal for her age
- Snoring at night - obstructive sleep apnea may be associated with difficulty daytime behaviour
- Identify as Aboriginal or Torres Strait islander? - higher rates of otitis media
- Smoking exposure?
What are some differentials for expressive language delay in a child?
- Hearing impairment e.g. from chronic otitis media
- Isolated language delay
- Anxiety
- Visual impairment
- Child abuse or family violence
- Autism spectrum disorder
- OSA
- Global developmental delay
- ADHD
What examination findings would you seek for a 3.5 year old girl presenting with language developmental concerns?
- Otoscopy
- Plot current height/weight on age appropriate centile chart
- Observe ability to climb onto a chair or jump - gross motor
- Assess ability to pick up a pen or pencil - fine motor and vision
- Assess ability to articulate words clearly - speech and hearing
- Assess ability to engage in pretend or imaginative play - social
- Assess visual acuity using a Lea chart
What visual acuity do you refer a 3-5 year old to an optometrist?
6/9 or less in either eye
Non-pharmacological management for bilateral conductive hearing loss in a 3.5 year old paediatric patient?
- Refer to a speech therapist for speech therapy
- Refer to ear nose and throat specialist for consideration of tympanostomy tube insertion
- Recommend that visual instructions are given face to face / give instructions in a quiet environment
- Encourage shared book reading or storytelling - activities that stimulate speech and language
- Discuss the adverse effects of smoking on a child with otitis media with effusion
What are some clinical signs of middle ear effusion?
- Loss of lucency of the tympanic membrane
- Visible grey-white or blue fluid
- An immobile tympanic membrane with dilated blood vessels on pneumatic otoscopy or tympanometry
When does otitis media with effusion need a referral?
Effusion present for three months or longer
What questions would you ask on history for an elderly male patient presenting with weight loss in the context of the death of his wife 6 months ago?
- Is the weight loss intentional?
- Depressed mood or anhedonia or memory loss - both major depression and dementia may affect energy intake
- Suicidal ideation - major depression
- Difficulty getting to the shops or cooking or finances - Intake/access issue
- Early satiety or epigastric pain - gastric cancer
- Difficulty swallowing or sensation of food getting stuck in the throat - oesophageal cancer, achalasia, esophageal stricture
- Heat intolerance or tremor - hyperthyroidism
- Polyuria or polydipsia - Poorly controlled diabetes mellitus
- Fevers or night sweats - occult malignancy or infection
- Difficulty chewing - neurological conditions such as stroke or motor neuron disease, or poor dentition
- Constipation or bowel habit change - Colorectal cancer
- Breathlessness on exertion or new leg swelling - heart failure
- Presence of reduced urinary flow or other stated lower urinary tract symptoms - prostate cancer
Differentials for unintentional weight loss?
- Malignancy (e.g. gastrointestinal, lung, lymphoma, renal, prostate cancers)
- Non-malignant gastrointestinal diseases e.g. peptic ulcer disease, coeliac disease, inflammatory bowel disease
- Psychiatric disorders e.g. depression, eating disorders
- Endocinropathies e.g. hyperthyroidism, diabetes, adrenal insufficiency
- Infectious diseases e.g. HIV, viral hepatitis, tuberculosis
- Advanced chronic disease e.g. cardiac cachexia from heart failure, pulmonary cachexia, renal failure
- Neurological diseases e.g. stroke, dementia, Parkinson’s disease
- Medications/substances: alcohol, cocaine, amphetamines
- Side effects from medications: antiseizure medications, diabetes medications, thyroid medications
What investigations are required for the evaluation of unintentional weight loss?
- FBC with peripheral film
- EUC
- Glucose
- HBA1c
- CMP
- LFT
- TSH
- ESR / CRP
- Urinalysis
- FOBT
- Serology for HIV, Hep C
- Chest XR
- Age appropriate cancer screening
What investigations are required for the evaluation of malnutrition?
- Full blood count and peripheral blood film
- Ferritin, folate and INR
- Blood biochem: Na, K, protein, albumin, glucose, urea, calcium, phosphate, magnesium, zinc, selenium
- Creatine kinase - check for statin myopathy
- Lipid profile
- Vitamin D and Vitamin A
Non pharmacological management for unintentional weight loss from psychological cause in an elderly patient?
- Referral to a psychologist
- Referral to a dietitian for further in-depth nutritional assessment
- Refer to My Aged Care for assessment for home support or Meals on Wheels
- Encourage small frequent meals / recommend increased dietary protein / recommend supplemental nutritional shake e.g. Resource/Sustagen
- Review in one month to track weight
List some nutritional support and advice for the elderly at risk of undernutrition
- Liberalise the patients diet (review dietary restrictions)
- Encourage use or flavour enhancers
- Recommend frequent small meals and snacks eg cheese and crackers, scrambled poached or boiled eggs, baked beans, Fortified soups, milk based puddings and drinks, sandwiches with high protein fillings
- Ensure ready availability of nourishing snacks eg nuts, yoghurt, cheese and crackers
- Ensure food texture suits chewing and swallowing ability
- Suggest ways to increase protein and energy intake by fortifying foods eg incorporate milk, butter or cheese in foods such as soups, sandwiches or mashed potato or add powdered nutritional supplements
- Consider high energyAnd protein nutritional supplements
- Ensure sufficient fluid intake
- Use a micronutrient supplement eg iron, folate, vitamin d
What questions do you ask on history for a patient presenting teary and overwhelmed?
- Depressed mood or anhedonia / fatigue or low energy / poor concentration or motivation - Major depression or organic disorder
- Presence of panic attacks / feeling anxious in social situations or in general or in open spaces - anxiety disorders
- Decreased need for sleep or excessive productivity - mania
- Hallucinations or delusions or ideas of reference - psychosis
- Intense fear of gaining weight - anorexia nervosa
- Unstable or absent sense of self identity / history of impulsive behaviour / history of breakdown of intense interpersonal relationships - borderline personality disorder
- History of trauma or exposure to a stressful event or situation - PTSD
- Palpitations or heat intolerance - hyperthyroidism
What is the diagnostic criteria for borderline personality disorder?
A pervasive pattern of instability of interpersonal relationships, self image, and affects and market impulsive iti, beginning by early adulthood.
Five or more of the following:
* Efforts to avoid real or imagined abandonment
* Unstable and intense interpersonal relationships
* Unstable self image
* Impulsivity
* Recurrent suicidal behaviour
* Marked reactivity of mood
* Chronic feelings of emptiness
* Difficulty controlling anger
* Stress related paranoid ideation or severe dissociative symptoms
What is different between complex post traumatic stress disorder and borderline personality disorder?
Complex PTSD:
* Severe but stable negative self concept
* Relational difficulties are characterised by a tendency to avoid
Borderline personality disorder:
* Shifts in self image between highly positive and highly negative
* Associated with rapid engagement followed by ups and downs or idealisation and devaluation of relationships
Non pharmacological management of borderline personality disorder?
- Refer to a psychologist for dialectical behaviour therapy
- Provide with the number for Lifeline or Mental Health Line
- Suggest replacing self harm with exercise or distraction
- Suggest a period of relaxing wine down time before bed or any other suitable sleep hygiene strategy
- Review in 48 hours to assess for safety
What psychological therapies are useful in the treatment of borderline personality disorder?
- Dialectical behaviour therapy: encourages patients to accept the way they are and change in order to move forward to reach personal goals
- Cognitive behavioural therapy
- Dynamic deconstructive psychotherapy
- Emotional regulation training
- Interpersonal psychotherapy
- General psychiatric management
- Mentalization based therapy
- Motive-oriented therapeutic relationship
- Psychoanalysis
- Psychoeducation
- Schema focused therapy
- Systems training for emotional predictability and problem solving
- Psychodynamic psychotherapy
List alternative strategies to replace self harm
- Holding ice cubes on your hand
- Use a red pen to draw on the areas you might normally cut
- Work it off with exercise
- Deep breathing and relaxation exercises
What would you include on a safety plan for a patient at mental health risk?
- Identification of warning signs or triggering events
- Suggestions to keep her environment safe or limiting access to harmful items
- Identifying reasons to live
- Developing coping strategies she can do by herself
- Learning socialisation strategies for distraction and support
- Identification of a trusted support person she can call when feeling overwhelmed
- Professional contact she can access for support
When should a patient stop non steroidal anti inflammatories before a high bleeding risk surgery?
3 Days before
When should a patient stop direct oral anticoagulant therapy before a high bleeding risk surgery?
Two days before
