22/11/21 - 23/11/21 Flashcards
Conditions associated with vitiligo?
Thyroid Dysfunction
Diabetes
Pernicious Anaemia
Management points for vitiligo?
- Cosmetic Camouflage
- Betamethasone Dipropionate 0.05% or Mometasone Furoate 0.1%
- Pimecrolimus 1% cream
- Calcipotriol + Betamethasone Dipropionate 50/500microg/g ointment or gel
- Phototherapy
Cause of stress urinary incontinence and clinical features.
Weakness in the urinary sphincter and/or pelvic floor
Loss or urine with activities that raise intra-abdominal pressure such as coughing, sneezing, high impact exercise and heavy lifting.
Urge Urinary Incontinence - causes and clinical features
Detrusor overactivity → bladder muscle that contracts involuntarily, usually at lower bladder volumes and with little warning.
Loss of urine preceded by a sudden and severe desire to pass urine with loss of urine en route to toilet. Triggers: running water, cold weather, inserting the key in the door upon returning home
Mixed Urinary Incontinence - definition (duh). approach to management?
A combination of stress and urge incontinence. Define which symptom is predominant and most bothersome and treat this symptom first.
Overflow Urinary Incontinence - cause/mechanism.
Occurs when patient is chronic urinary retention due to leakage from an overdistended bladder → bladder outlet obstruction and/or poor bladder muscle function
Urinary Fistula - cause/mechanism.
Fistulous connections can occur between bladder, vagina, ureter or urethra. Obstetric trauma is a cause of this.
Functional Incontinence - cause/mechanism
Involuntary loss of urine caused by either physical limitations such as poor mobility or cognitive disability resulting in an inability to toilet normally
Risk Factors for Female Urinary Incontinence (6)
- Age
- Obesity
- Increasing Parity
- Vaginal Delivery
- Family History
- Smoking
- Other: Caffeine Intake, Diabetes, Stroke, Depression, Faecal Incontinence, Menopause/Vaginal Atrophy, Hormone Replacement Therapy, Genitourinary Surgery, Radiation
- High Impact Activities → jumping and running → stress incontinence
Investigations for Female Urinary Incontinence (3)
- Urinalysis - Urine MCS
- Bladder Ultrasound with Post-Void Residual OR Renal Tract Ultrasound
- Bladder Diary
Non-Pharmacological Female Urinary Incontinence (6 points)
- Water → 6-8 cups of fluid a day, reduce fluids after the evening meals
- Caffiene and Alcohol → eliminate caffeiene, fizzy drinks + alcohol can worsen symptoms
- Fibre → avoid constipation
- Physical Activity → 30mins of exercise most day of the week. Avoid fitness activities that cause bladder leakage
- Pelvic Floor Exercises
- Avoid lifting - can weaken pelvic floor
- Toilet Habits → empty bladder with urge, do not strain to empty bladder
Bladder Training → referral to continence nurse or pelvic floor physiotherapist - Continence pads or accessories - increase QoL
Explain how bladder training works.
-
Bladder Training
- FIRST LINE THERAPY** → reduce void frequenct, increase bladder capacity, eliminate detrusor overactivity → scheduled voiding rather than voiding in response to urgency
- Bladder diary reviewed → longest comfortable interval between voiding is chosen
- Empty bladder on waking and then each time during the day when the interval is reached and again at bed-time
- If patient feels the urge to void in between → encouraged to used urge suppression techniques (distractions, relaxation etc)
- After 1-2 weeks → decrease interval by 15mins → reduce interval between the voids
- A minimum of 6 weeks is required to see benefit.
Pharmacological options for management of female urinary incontinence
- oxybutynin
- duloxetine
- little evidence for estrogen - can consider in patients with vaginal atrophy.
2 first degree family members >55yo with CRC -> what level of risk? screening + management?
Moderately increased risk.
iFOBT every 2 years from 40-49 years of age
Colonoscopy every 5 years from 50-74 years of age
Aspirin for at least 2.5 years commencing at 50 until 70 years of age
1 first degree relative >55yo with CRC -> what level of risk? screening + management.
Average Risk
Every 2 years from 50-74yo
Aspirin for at least 2.5 years commencing at 50 until 70 years of age
1 first degree relative <55y0 with CRC -> what level of risk? screening + management.
Moderately increased risk.
iFOBT every 2 years from 40-49 years of age
Colonoscopy every 5 years from 50-74 years of age
Aspirin for at least 2.5 years commencing at 50 until 70 years of age
1 first degree relative + 1 second degree relative >55yo -> what level of risk? screening + management.
Average Risk
Every 2 years from 50-74yo
Aspirin for at least 2.5 years commencing at 50 until 70 years of age
Clinical Features that warrant further investigation of GIT symptoms (9)
- FHx of bowel cancer or coeliac disease
- older than 50 yo for onset of symptoms
- significant weight loss
- dysphagia (difficulty swallowing)
- severe large-volume diarrhoea
- steatorrhoea
- persistent vomiting
- severe abdominal pain
- fever
- symptoms that interfere with sleep
- anaemia
- evidence of gastrointestinal bleeding (rectal bleeding, haematemesis, positive FOBT)
- abnormality on abdo examination
- evidence of inflammation on blood tests or stool samples
Criteria for the diagnosis of IBS? (4 points)
3 days of the month for the last 3 months.
2 of the following:
- pain improves after defecation
- change in bowel frequency
- change in stool appearance
Investigations for IBS (4 points)
- FBE
- Coeliac Serology
- CRP (only if faecal calprotectin cannot be performed)
- For patients with diarrhoea predominant IBS - faecal calprotectin
Non-Pharmacological Management of IBS. (4 points)
In regards to eating patters → regular meal times and portion control
Fibre: adequate fibre intake → can be useful esp in constipation predominant IBS but there are some types of fibre that can worsen IBS symptoms
Low FODMAP Diet: FODMAPs are fermentable carbohydrates that are poorly absorbed. This results in bloating, diarrhoea and discomfort
Psychological Therapies: even if patients do not meet the diagnostic criteria for anxiety or depression → behavioural and psychological therapies can be effective.
Pharmacological Management of IBS (3)
- Loperamide (Diarrhoea)
- Hyoscine Butylbromide (Buscopan) 20mg PO, up to 4 times daily PRN
- Mebeverine 135mg orally, up to 3 times daily PRN
- amitriptyline 5-10mg PO nocte → increase slowly as tolerated up to 30-50mg nocte
Risk Factors of Suicide (5)
- Psychiatric Disorder → especially major depression, bipolar disorder, schizophrenia, schizoaffective disorder, substance use disorder, personality disorder
- Current Psychosis
- Family History of Suicide
- Access to Means of Suicide with high potential lethality → guns, firearms, ropes, hosepipes
- Definite plan of suicide attempt
- History of dangerous behaviour on impulse
- Low likelihood of suicide attempt being detected
- Ambivalence toward survival of suicide attempt
- Social isolation or absence of social supports
- Chronic Medical Illness → especially if painful
- Recent Major Loss → includes loss of face in some cultures
- Feeling of Hopelessness
When evaluating patients risk of suicide, what questions need to be asked of the patient? (6)
- Suicidal Thinking → frequency and persistence of suicidal thoughts
- Plan → how detailed and realistic?
- Lethality → method and how lethal?
- Means → access to means of suicide
- Past History → previous attempts of suicide?
- Suicide of family member of peer
- *Consider**
- Risk and Protective Factors
- Mental State
- Substance Use
- Strengths and Supports
- Prepatory Actions → weapon, putting affairs in order, making a plan, suicide note, giving away prized possessions
Investigations in context of lithium prescribing. (4 points)
- Serum Lithium Concentration - 3-6 months
- Serum Creatinine and Urea Concentrations - 3-6 months
- Serum Sodium Concentration - assess hydration, assess hypernatraemia in patients with altered conscious state, review every 6-12 hours
- TFTs - 6-12 months
- Serum Calcium - 12 months
- Screen for hyperparathyroidism
ECG
- Screen for hyperparathyroidism
Clinical Features of Hypomanic/Manic Episode + how many need to be positive in diagnosis of manic/hypomanic episode (5 points)
B: 3 (or more) of following symptoms (4 if the mood is only irritable)
- Inflated self-esteem or grandiosity
- Decreased need for sleep → feels rested after less sleep
- More talkative than usual or pressure to keep talking
- Flight of Ideas or Subjective experience that thoughts are racing
- Distractibility → attention is drawn to unimportant stimuli
- Increased in goal-directed behaviour or psychomotor agitation
- Excessive involvement in activities that have a high potential for painful consequences → spending, sexual, speeding
Difference between manic and hypomanic episode
- marked impairment or hospitalisation
2. psychotic features
Difference between bipolar 1 and bipolar 2?
Manic Episodes in Bipolar 1, Hypomanic episode Bipolar 2
Depressive episodes -> yes in bipolar 2, not required for bipolar 1
Malaria Prevention (4)
Dusk and Dawn - avoid activities from dusk to dawn
DEET -> apply insect repellant
DAKS -> wear light long trousers
Doxycycline -> malaria chemoprophylaxis -> doxycycline, malarone, mefloquine
- sleeping in screened accomodation
- avoid perfume and aftershave
- spray thin clothing with insect repellant and pre-impregnate with permethrin
General Travel Advice (6 points)
- Purchase Travel Insurance
- Food Safety → Avoid unwashed/uncooked food, Cook it, peel it, boil it or forget it.
- Water Safety → bottle water, no ice please, brush teeth with bottled water.
- Diarrhoea Management → azithromycin stat
- Carry first aid kit
- Sun protection - for severe sunburn
- Avoid risk-taking behaviour → drug trafficking/road safety (wear a helmet while on a motorbike or scooter)/sex (use a condom)/tattoos (fresh needles)
- Safe Sex practices
- Insect bite precautions → insect repellant/chemoprophylaxis for malaria
- Avoid swimming in contaminated fresh water
- Beware of animal exposure for rabies
- Beware of risk of dengue fever, lymphatic filariasis and chikungynya
- DVT Prophylaxis → compression stockings, calf exercises, walking around plane
Clinical Features of Urethritis (3)
- Urethral Discharge → Gonorrhoea - usually copious and purulent. More common in MSM and indigenous population. Non-Gonococcal urethritis - usually less discharge
- Dysuria → in young men → dysuria indicates an STI until proven otherwise
- Urinary Frequency → suggestive of bladder infection
Management of Urethritis (pharm 2 and non-pharm 3)
Non-Gonococcal Urethritis → Doxycycline 100mg PO BD for 7/7
Gonorrhoea → Ceftriaxone 500mg in 2ml of 1% lignocaine IM stat + Azithromycin 1g PO stat
- *Other**
- if considering non-gonococcal urethritis → can add doxycycline to ceftriaxone instead of azithromycin
- Advise no sexual contact for 7/7 after treatment is administered
- No sex with partners from last 6 months until parters have been tested and treated as necessary
- Contact Tracing - if gonorrhoea → 2 months
- Notify Health Department
