3A revision Flashcards

Question

Name 5 Complications of Gastro-oesophageal Reflux Disease (GORD)?

Answer 1

Failure to thrive Sandifer’s syndrome – Distonic neck posturing Recurrent Pulmonary Aspiration – pneumonia Oesophagitis Apparent Life Threatening events (ALTE)

Answer 2

Autosomal dominant – RASopathy ``` Congenital heart defect:- pulmonary valve stenosis- atrial septal defect- hypertrophic cardiomyopathy Short stature Pectus excavatum Webbed neck Impaired blood clotting Learning difficulties ```

Answer 3

Di Georges Syndrome (CATCH-22) Williams syndrome Cru de chat syndrome

Answer 4

Microdeletion syndrome at 7q11 – autosomal dominant inheritance ``` Short stature Elf-like facies Transient hypercalcaemia in infants Supravalvular aortic stenosis Mild-moderate learning difficulties ```

Answer 5

Microdeletion syndrome – deletion at 22q11.2 – autosomal dominant CATCH-22 Cardiac – interrupted aortic arch, truncus arteriosus, tetralogy of Fallot Abnormal facies Thymic aplasia – recurrent infections due to ↓T cells Thymic aplasia – Thrombocytopenia Cleft Palate – problems with neuromuscular closure (velopharyngeal insufficiency) → feeding difficulties Hypoparathyroidism, hypocalcaemia → convulsions

Answer 6

Genetic analysis performed using Fluorescence in situ hybridisation (FISH) – detects the microdelection on chromosome 22.

Answer 7

Genes required for normal functioning only comes from one parent. Prada Willi Syndrome Angelman’s Syndrome Inherited by 2 ways: De novo deletion mutation Uniparental Disomy – both the chromosomes come from 1 parent, and none from the other.

Answer 8

Caused by failure to inherit a functioning paternal copy of the Prada Willi gene on the long arm of chromosome 15 (15q11-13) – due to de novo deletion (75%) or uniparental disomy (both copies of chromosome 15 come from mother) In infancy: Hypotonia Poor feeding (due to ↓muscle tone affecting the sucking reflex) ``` In childhood: Excessive appetite (hyperphagia) Obesity / short stature Developmental delay Hypogonadism Strabismus Low IQ Narrow forehead Thin upper lip Carp-shaped mouth Olive-shaped eyes (antimongoloid slant) / \ ```

Answer 9

Caused by failure to inherit a functioning maternal copy of the Prada Willi gene on the long arm of chromosome 15 (15q11-13) – due to de novo deletion (75%) or uniparental disomy (both copies of chromosome 15 come from father) ``` Happy disposition, laughing Little speech Severe learning disabilities Poor attention span epilepsy – variety of seizures Sleep disturbance Jerky movements – hand flapping Movement / balance disorder (ataxia)Motor developmental delay Microcephaly Strabismus Abnormal EEG – large amplitude, slow spike waves ```

Answer 10

1. Tetralogy of Fallot (ToF) 2. Transposition of the Great Arteries (TGA) 3. Truncus Arteriosus 4. Tricuspid Atresia 5. Total Anomalous Pulmonary Venous Connection (TAPVC) shunt from right to left

Answer 11

``` DiGeorges Syndrome (22q11.2) - Truncus Arteriosus - Tetralogy of Fallot ```

Answer 12

Pulmonary stenosis Right Ventricular Hypertrophy Large ventricular septal defect (VSD) Over-riding aorta

Answer 13

Boot-shaped heart (due right ventricular hypertrophy) Reduced pulmonary vasculature (as stenosis causes ↓ pulmonary blood flow) Concave pulmonary artery on the left heart border Right sided aortic arch

Answer 14

Breathless (particularly on feeding / exertion) Poor feeding Sweating Recurrent chest infections

Answer 15

``` Tachycardia Tachypnoea Hepatomegaly Pulmonary oedema Heart murmur, gallop rhythm Enlarged heart Cool peripheries Poor weight gain, faltering growth ```

Answer 16

Due to Left-ventricular out-flow obstruction ↑ Pulmonary resistance, R → L shunt via the ductus arteriosus (duct dependent circulation) Severe coarctation of the aorta Critical Aortic valve stenosis Hypoplastic left heart syndrome Interruption of the aortic arch

Answer 17

Due to high pulmonary blood flow (L → R shunts) Ventricular septal defect Atrial septal defect Patent ductus arteriosus

Answer 18

Eisenmenger syndrome (reversal of shunt causing R → L shunt) Rheumatic heart disease cardiomyopathy

Answer 19

Congenital heart disease: tetralogy of fallot transposition of great arteries ``` Respiratory diseases: Respiratory distress syndrome Persistent pulmonary hypertension of the newborn Meconium aspiration Pulmonary hypoplasia ``` Infection: Group B streptococcus Metabolic acidosis

Answer 20

Deprivation of oxygen to the neonate (<4 weeks old), that lasts long enough to cause physical harm (usually to the brain)

Answer 21

``` Reduced level of consciousness ↓ Sunken fontanelle Sunken eyes Dry mucous membranes Reduced urine output ↓ Reduced skin turgor ↓ Tachycardia ↑ Tachypnoea ↑ Low blood pressure ↓ Increased capillary refill time ↑ Cool peripheries Faint / impalpable pulse ``` Mild dehydration = <5% Moderate = 6-9% Severe = >10%

Answer 22

First 10kg = 100ml/kg/24 hour Second 10kg = 50ml/kg/24 hour Subsequent kilograms = 20ml/kg/24 hour 1620ml 0.9%NaCl +5% dextrose

Answer 23

Bronchial muscle contraction Mucosal swelling / inflammation – caused by mast cell / basophil degranulation → release in inflammatory mediat Increased mucus production

Answer 24

Inability to complete sentences / feed Pulse > 140bpm Respiratory Rate > 40/min if <5yrs, >30/min if 5-12yrs, >25/min if >12yrs Peak Flow = 33-50% predicted

Answer 25

``` Silent Chest Fatigue / exhaustion / confusion / LOC / coma Cyanosis Peak flow <33% predicted Poor respiratory effort ``` Near fatal attack – PaCO2 ↑

Answer 26

Triad: Inattention - problems paying attention Hyperactivity - excessive activity Impulsiveness - difficulty controlling behaviour ♂ (behaviour is not appropriate for age) Cause problems in 2 different settings (e.g. school, home) Symptoms present > 6 months ``` Impaired concentration Distractibility Difficulty taking turns Social disinhibition – poor relationships Fidgety Disorganised Short-tempered Poor recall of past or future planning ```

Answer 27

Mild – moderate ADHD: Behavioural psychotherapy / CBT Parenting behavioural training (e.g. rewards) Teacher classroom management Severe ADHD: (Medication) Stimulants (↑ dopamine) - Methylphenidate (Ritalin) - Dextroamphetamine Side effects: Dry mouth Loss of appetite Insomnia

Answer 28

Rash with target lesions with a surrounding red ring Causes: Drug reactions – penicillin, NSAIDs, Phenytoin Infection – atypical pneumonia, herpes simplex virus (cold sores) Idiopathic

Answer 29

JONES Criteria: Evidence of a recent Group A β-haemolytic streptococci (Strep Pyogenes) + 2 major criteria or 1 major + 2 minor criteria Major: Joints – polyarthritis, migratory, larger joints Obvious – carditis Nodules – subcutaneous nodules Erythema marginatum – rash with raised edges and a clear centre Syndenham’s Chorea ``` Minor: Inflammatory cells - leuocytosis Temperature ESR + CRP Raised PR interval Itself – Previous Rheumatic Fever Arthralgia ```

Answer 30

Cellulitis (bacterial super infection) – caused by gram positive cocci (staphylococcus aureus, streptococci). Treat with – flucloxacillin Eczema Herpeticum – caused by herpes simplex virus Treat with – Acyclovir

Answer 31

Chicken pox – varicella zoster virus - reactivation of this virus, which lies dormant in the dorsal root ganglion causes Shingles. Shingles – herpes zoster virus

Answer 32

Secondary bacterial infection (staphylococcus aureus, group A streptococcus) → toxic shock syndrome, necrotising fasciitis Encephalitis, cerebellitis, aseptic meningitis Disseminated intravascular coagulation (DIC) Purpura fulminans

Answer 33

To give contraception to young people under 16 years. The professional must be satisfied that: the young person understands the professional’s advice The young person cannot be persuaded to inform their parent The young person is likely to begin / continue having sexual intercourse with or without contraception Unless the person receives contraceptive treatment, their physical or mental health are likely to suffer Offering contraception is in the young person’s best interest

Answer 34

When making medical decisions involving consent, a child < 16 years, must be: Able to understand the advice give With sufficient maturity to understand what is involved (N.B. even though a child under the age of 18 can consent to treatment if they show the ability/maturity, they can not refuse medical treatment that is in their best interests)

Answer 35

Group B streptococcus (streptococcus agalactiae) E.Coli (Escherichia Coli) Listeria monocytogenes

Answer 36

an abnormality of movement and posture Causing activity limitation due to a non-progressive disturbance that occurred in the developing fetal or infant brain (up to age 2 years). Spastic cerebral palsy – damage to UMN pathway Dyskinetic (Athetoid) cerebral palsy – damage to basal ganglia Ataxic cerebral palsy – damage to cerebellum

Answer 37

Age 6 months – 5 years due to a rapid rise in fever Simple febrile seizures: Generalised tonic-clonic seizures Brief (usually last < 15 minutes) Single episode ``` Complex febrile seizures: Focal onset Last > 15 minutes Repeated (>1 seizure in 24 hrs) ↑risk of epilepsy ```

Answer 38

Infantile spasms - West Syndrome Lennox-Gastaut Syndrome Absence Seizures Juvenile Myoclonic Epilepsy Benign epilepsy with centrotemporal spikes (BECTS) Early-onset Benign childhood occiplital epilepsy (Panayiotopoulos type)

Answer 39

``` InnoSent Murmurs: aSymptomatic patient Soft blowing murmur Systolic murmur Left Sternal edge Normal heart sounds, with no added sounds No parasternal thrill or heaves No radiation ```

Answer 40

Due to toxin-producing staphylococcus aureus, Group A streptococcus Fever > 39°C Hypotension Diffuse erythematous macular rash + Organ dysfunction (mucositis, GI, Renal, Liver, Clotting, CNS)

Answer 41

Third generation cephalosporin (ceftriaxone) Clindamycin (aminoglycoside – inhibits protein synthesis - ↓toxin production) Intravenous Immunoglobulin (IVIG) – neutralise the toxin

Answer 42

Otitis media with effusion Ear-wax Eustachian tube dysfunction:- Downs syndrome- Cleft Palate- Pierre Robin Sequence (congenital causes of abnormal facies)- Mid-facial hypoplasia Weber’s test – sound lateralises (louder in) affected ear Rinnie’s test – Bone conduction > air conduction Rinnie’s test (normal / positive) – air conduction > bone conduction Weber’s test (normal) – sound heard equally in both ears a child with conductive hearing loss, only receives sound from bone conduction – so it is perceived to be louder

Answer 43

``` Antenatal: - congenital infection – Rubella - pre-term - Hypoxic Ischaemic Encephalopathy - hyperbilirubinemia ``` Meningitis / encephalitis Head injury Drugs (aminoglycosides – gentamicin, furosemide) Neurodegenerative disorders Weber’s test – sound lateralises (louder in) normal ear Rinnie’s test – air conduction > bone conduction (both reduced)

Answer 44

Splenectomy Sickle cell disease Coeliac disease Howell-Jolly bodies – basophilic nuclear remnants in the cytoplasm (normally removed by the spleen)

Answer 45

Hyposplenism – impaired opsonisation of encapsulated organisms Nephrotic syndrome – leakage of immunoglobulins from the blood, and oedema Unvaccinated Pneumococcal is an encapsulated organism – macrophages in the spleen normally phagocte

Answer 46

``` Proteinuria >1g/m2/24hrs, >40mg/m2/1hr, >3.5g/24hrs Serum albumin <25g/L (hypoalbuminaemia) Oedema - periorbital oedema (on waking) - scrotal / vulval oedema ```

Answer 47

``` Age between 1 – 10 years No macroscopic haematuria Normal blood pressure Normal complement levels Normal renal function ``` ``` Indications for Renal Biopsy: Age <12 months, >12 years Macroscopic haematuria Raised blood pressure Decreased complement levels Reduced renal function Failure to respond to 1 month of daily steroid therapy ```

Answer 48

``` Cough Coryza Conjunctivitis Koplik spots Fever Maculopapular rash – starts behind ears and spreads to body, (desquamates during second week) ```

Answer 49

``` Encephalitis Subacute sclerosing panencephalitis (SSPE) – occurs ∞ 7 years after infection - virus persists in the CNS and causes ↓neurological function → dementia → death Seizures, febrile convulsions Pneumonia, tracheitis Secondary bacterial infection Corneal ulceration Myocarditis Hepatitis Appendicitis ```

Answer 50

``` Fever Malaise Parotitis - bilateral parotid gland swelling: - difficulty eating / drinking - ear ache Hearing loss (unilateral, transient) ```

Answer 51

``` Pancreatitis (serum amylase is raised) Orchiditis Encephalitis Viral meningitis Rarely oophoritis, mastitis ```

Answer 52

Maculopapular rash – starts on the face → body Post-auricular and Suboccipital lymphadenopathy Low grade fever ``` Complications: Arthritis Encephalitis Thrombocytopenia myocarditis ``` Avoid pregnant women – congenital diseases

Answer 53

The classic triad for congenital rubella syndrome is: Sensorineural deafness Eye abnormalities—especially retinopathy, cataract, and microphthalmia Congenital heart disease—especially pulmonary artery stenosis and patent ductus arteriosus Other manifestations: ``` Spleen, liver, or bone marrow problems (some of which may disappear shortly after birth) Intellectual disability Small head size (microcephaly) Eye defects Low birth weight Thrombocytopenic purpura Extramedullary hematopoiesis (presents as a characteristic blueberry muffin rash) Hepatomegaly Micrognathia ``` ``` Children who have been exposed to rubella in the womb should also be monitored for: Developmental delay Autism Schizophrenia Growth retardation Learning disabilities Diabetes mellitus Glaucoma ```

Answer 54

Explanation to child and parents Star chart – rewards each morning if the bed is dry Enuresis alarm – sensor which sounds if it gets wet Desmopressin – short term Self-help groups

Answer 55

Croup (laryngotracheobronchitis) Epiglottitis Laryingomalacia Bacterial tracheitis (pseudomembranous croup) foreign body Allergic laryngeal angioedema (anaphylaxis) Retropharyngeal abscess Infectious mononucleosis with lymph node swelling Hypocalcaemia due to poor vitamin D intake Inhalation of smoke / hot air in fires Trauma to the throat

Answer 56

Purpura – buttocks / extensor surface of legs and arms / ankles Arthritis Abdominal pain ``` Haematuria and proteinuria Periarticular oedema Haematemesis Malaena Intussusception ``` Preceded by viral upper respiratory tract infection HSP is a vasculitis, often preceded by a throat infection / URTI. HSP affects boys, aged 3-10yrs

Answer 57

Microangiopathic haemolytic anaemia Acute renal failure Thrombocytopenia Prodromal infectious bloody diarrhoea Usually follows verocytotoxin-producing Escherichia Coli strain O157:H7 (E.coli O157:H7) Contact with farm animals

Answer 58

autosomal recessive - affects the thick ascending loop of Henle - NKCC2 channel like loop diuretics (furosemide) - Less reabsorption of Na+, K+, Cl- back into the renal tubule. Hypokalaemic metabolic alkalosis Hypercalciuria Normal / low blood pressure - ↑renin Polydipsia / polyuria Growth failure

Answer 59

Autosomal dominant affects the ENaC channels in the collecting ducts Like ↑aldosterone – excess sodium reabsorption (hypertension), and excess potassium excretion (hypokalaemia) Rx – potassium-sparing diuretics

Answer 60

Autosomal recessive Affects the NCC (sodium chloride cotransporter) in the distal convoluted tubule Like thiazide diuretics, less sodium and chloride reabsorption - hypotension Hypochloremic metabolic alkalosis, hypokalemia, hypomagnesemia, hypocalcuria polyuria, polydipsia, dehydration

Answer 61

Females – breast development Thelarche → adrenarche → menarche Males – testicular enlargement

Answer 62

Ejection systolic murmur at the left upper sternal edge – due to increased blood flow through the pulmonary valve Splitting of the second heart sounds – due to right ventricular stroke volume being equal in both inspiration and expiration In partial AVSD, abnormal atrioventricular valves – pansystolic murmur (regurgitation)

Answer 63

Pansystolic murmur, heard best at lower left sternal edge ``` Small VSDs (smaller than aortic valve) = loud pansystolic murmur Larges VSDs (larger than the aortic valve) = soft pansystolic murmur ```

Answer 64

``` Ductus arteriosus (connecting the pulmonary artery to the descending aorta remains open for 1 month after the expected date of delivery. More common in pre-term infants ``` Continuous machinery murmur, head best under the left clavicle Increased pulse pressure – collapsing, bounding pulse

Answer 65

Hyperglycaemia (>11.1mmol/L) pH < 7.3 (metabolic acidosis) Urinary Ketones / ketonaemia Bicarbonate (<15mmol/L)

Answer 66

``` Excessive thirst. Frequent urination. Nausea and vomiting. Abdominal pain. Weakness or fatigue. Shortness of breath. Confusion ```

Answer 67

``` signs of dehydration - e.g. reduced skin turgor tachycardia tachyopnoea - kussmaul breathing hypotension ketotic breath confusion ```

Answer 68

The development of secondary sexual characteristics: in girls <8 years old In boys <9 years old

Answer 69

Girls causes – most likely idiopathic Boy causes – most likely organic – intracranial tumours Gonadotrophin dependent (↑↑LH > ↑FSH): ``` Idiopathic / familial CNS abnormalities: - congenital - hydrocephalus - acquired – irradiation, infection, surgery Intracranial tumours Hypothyroidism ``` Gonadotrophin independent (↓LH, ↓FSH) : ``` Adrenal disorders: - congenital adrenal hyperplasia Ovarian tumour – granulosa cell Testicular tumour – leydig cell Exogenous sex steroids ```

Answer 70

First Line: Levonorgestrel-releasing Intrauterine System (Mirena coil) Second Line: Tranexamic acid (anti-fibrinolytic) Mefanamic acid (NSAIDs) Combined Oral Contraceptive pill (COCP) Third Line: Oral progestogens Gonadotrophin-releasing hormone agonist (GnRH analogues)

Answer 71

Endometrium outside the uterus ``` Pelvic Pain Dysmenorrhea Dyschezia Dysuria Dysparunia ``` Subfertility

Answer 72

Nulliparity Obesity – peripheral conversion of androgens to oestrogen Polycystic Ovarian Syndrome (PCOS) – prolonged amenorrhea / infertility Early menarche / Late menopause Oestrogen-secreting tumours (Ovarian granulosa cell tumours) Excess Exogenous Oestrogen: Tamoxifen (SERM) – oestrogen agonist in endometrium Other: Diabetes Hypertension Lynch II syndrome (↑ risk of colon, ovarian, endometrial cancer) Cowden Syndrome (↑ risk of breast, thyroid, endometrial, kidney cancer) Lynch II syndrome (hereditary non-polyposis colorectal cancer HNPCC – type 1) – autosomal dominant - a mutation in a mismatch repair gene – cell cannot correct mistakes in the DNA. Cowden syndrome – autosomal dominant – causes cancerous growths called harmatomas – mutation in a tumour suppressor protein

Answer 73

Combined Oral Contraceptive Pill (COCP) – progestogen and oestrogen Smoking Grand-parity (>5 children) Breast feeding

Answer 74

A form of hypogonadotropic hypogonadism – caused by a failure of GnRH releasing hormones to migrate to the hypothalamus. No GnRH is released → no FSH or LH is released from the Anterior pituitary → hypogonadism Hypogonadism → failure to start puberty Infertility Anosomnia (failure to smell)

Answer 75

Stimulates endometrial growth (proliferation of glandular and stromal parts of the endometrium) Increases the progesterone receptors in the endometrium Stimulates production of thin cervical mucus - easily penetrated by sperm bone resorption Increases fat deposition

Answer 76

Creates secretory changes of the endometrium Decreases the contractility of the uterus Inhibits lactation Suppresses maternal immune response – prevents rejection of fetus ↑ increases respiratory rate ↑ increases sodium excretion ↓ bowel motility ↑ increase in body temperature

Answer 77

Causes a negative feedback of GnRH release - ↓FSH /↓LH – inhibits ovulation Thins the endometrium Thickens the cervical mucus

Answer 78

Fibroids are oestrogen-dependent (regress after menopause) Nulliparity Older Women – more common near menopause Afro-Caribbean Fibroids – leiomyomata – benign smooth muscle tumours of the myometrium Combined Oral Contraceptive Pills are protective

Answer 79

Torsion of pedunculated fibroids Red degeneration – (fibroid outgrows its blood supply) – common in pregnancy Hyaline / cystic degeneration (fibroid is soft, liquidified) Calcification Leiomyosarcoma (malignancy) Pressure effects

Answer 80

Premature Menopause Polycystic Ovarian Syndrome (PCOS) Hyperprolactinaemia

Answer 81

Surgical Termination: - (7-13 weeks) – Suction Curettage - (>13 weeks) – Dilatation and Evacuation Medical Termination (usually <7weeks, 7-9 weeks): - Mifepristone (antiprogesterone) - Misoprostol (prostaglandin E1 analogue) (>22 weeks) – inject KCl into umbilical vein or fetal heart - usually due to fetal abnormality

Answer 82

``` Infection Bleeding Uterine perforation Cervical trauma Failure of abortions Psychological sequelae Unsafe abortions – maternal deaths Multiple abortions → increased risk of subsequent pre-term ```

Answer 83

Abortion Act 1967 states 2 doctors must agree that a women fits the criteria: - Continuing the pregnancy would involve more risk to the life of the pregnant women more than if the pregnancy was terminated. - Termination is necessary to prevent grave permanent injury to the physical / mental health of the pregnant woman - Pregnancy <24 weeks, and continuing pregnancy would have increased risk to the physical / mental health of the pregnant woman. - Pregnancy <24 weeks, and continuing pregnancy would have increased risk to the physical / mental health of any existing children of the family of the pregnant women - There is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be serious handicapped. Every abortion must be notified to department of health

Answer 84

Increased number of sexual partners Having Sexual contact at an earlier age Oral contraceptive Pill use Smoking Immunocompromised - HIV, long-term steroid usage, transplant patients Not vaccinated Not attending regular cervical cancer screening (Pap smear tests)

Answer 85

Squamous cell carcinomas (90%) Occurs in the transformation zone – where the endocervix (columnar epithelium and the ectocervix meet (squamous epithelium) – squamocolumnar junction. other adenocarcinoma (from the columnar epithelium) – worse prognosis

Answer 86

Large loop excision of the transformation zone (LLETZ), also called diathermy loop excision. Complications: (same as Cone biopsy) Post-operative haemorrhage Subsequent pre-term birth

Answer 87

``` Postcoital bleeding (PCB) Offensive vaginal discharge Intermentstrual bleeding (IMB) Post-menopausal bleeding (PMB) Incidental finding from biopsy screening – occult carcinoma ``` Signs: Ulcer Visible mass on cervix ``` Involvement of: Ureters – uraemia Bladder – haematuria Rectum – rectal bleeding Nerves – pain ```

Answer 88

International federation of Gynaecology and Obstetrics (FIGO) classification Stage 1 – lesions confined to the cervix 1a – diagnosed with microscope - (1ai - Rx with cone biopsy) 1b – clinically visible lesions Stage 2 – Invasion in to the vagina, but not the pelvic side 2a – involvement of upper 2/3 of vagina 2b – involvement of the parametrium Stage 3 – Invasion into the lower vagina or pelvic wall, or causing ureteric ……………..obstruction Stage 4 – invasion of the bladder or rectal mucosa, or beyond the true pelvis

Answer 89

Pelvic node clearance Hysterectomy Removal of the parametrium Upper third of the vagina ``` Complications: Haemorrhage Ureteric / bladder damage Fistulae Voiding problems Accumulation of lymph ``` Used for treatment of cervical cancer

Answer 90

Parametrium – fibrous tissue which separates the supravaginal part of the cervix from the bladder. ``` The parametrium contains the: Ovarian ligament Uterine artery Ureters Connective tissue ``` Involvement of the parametrium in cervical cancer, upgrades the stage – 2b

Answer 91

Removal of the cervix and upper vagina Used in women who wish to conserve fertility Used in stage Iaii and Ibi (tumour is <20 mm)

Answer 92

``` Maternal: Ectopic pregnancy Pre-eclampsia Pregnancy-induced hypertension Complications whilst collecting the eggs – intraperitoneal haemorrhage, pelvic infections ``` ``` Fetal: Twins or multiple Low birth weight (LBW) Small for gestational age (SGA) Congenital abnormalities Perinatal morbidity / mortality ```

Answer 93

No audible / visible fetal heart beat (no cardiac activity) β-hCG level < 3000 IU/ml <35mm mass unruptured ectopic – no acute signs / symptoms

Answer 94

Two or more of the following: ovarian cysts on ultrasound - >12 small follicles (2-8mm) - enlarge ovary volume (>10ml) Irregular periods (>35 days or 5 weeks apart) Evidence of raised androgens: - clinical – acne, hirsutism - biochemical – raised serum testosterone

Answer 95

Due to continuous ovulation: ``` Nulliparity Early menarche / late menopause Family History BRCA 1/2 genes Lynch II syndrome (↑ risk of colon, ovarian, endometrial cancer) ```

Answer 96

Factors which interrupt ovulation: Pregnancy Breast feeding / lactation Combined Oral Contraceptive Pill (COCP)

Answer 97

``` Rapid growth, >5cm Ascites Advanced age (>55 years) Bilateral masses Solid / septate nature on ultrasound Increased vascularity ```

Answer 98

Human Papilloma virus (HPV) strains 6 and 11 Strains 16, 18, 31, 33 cause Cervical intraepithelial neoplasia (CIN) and cervical cancer

Answer 99

Hydatidiform mole: - Complete mole – paternal origin, sperm fertilise empty oocyte + …mitosis (46 XX, 46 XY) - Partial mole – 2 sperm fertilise one oocyte (69 XXY) Invasive mole – locally invades uterus Choriocarcinoma – metastatic Gestational trophoblastic neoplasia (GTN) – persistent elevated hCG Risk Factors: Extremes of maternal age Asian Previous Gestational trophoblastic disease

Answer 100

``` Infection Peritonitis Chronic pain adhesions Sepsis Infertility ```

Answer 101

Fetal causes: (any break in fetal skin) Open neural tube defect – spina bifida, anencephaly Abdominal wall defects Multiple gestation Maternal causes: Placental abruption Tumour markers – hepatocellular carcinoma, endodermal sinus tumour (yolk sac carcinoma), germ cell tumour, neuroblastoma

Answer 102

``` Infection in neonate leads to: Hearing and vision problems Mental retardation and learning disabilities Fetal hydrops Intra-uterine growth restriction Microcephaly Thrombocytopenia pneumonia ```

Answer 103

For Pregnant Woman: Non-specific flu Macular rash (face → body) ``` For Fetus (effects are worse if infection is in earlier gestation) Sensineural deafness Cataracts Congenital heart disease Learning difficulties Hepatosplenomegaly Microencephaly ``` Spread via droplet route MMR vaccine is live – therefore contraindicated during pregnancy

Answer 104

``` For Fetus (effects are worse if infection is in earlier gestation) Miscarriage / Still-birth Mental impairment convulsions Deafness Blindness Hydrocephalus ``` Treatment - Spiramycin

Answer 105

Dermatomal skin scarring Limb hypoplasia Neurological defects Eye defects Exposed mothers are treated with varicella zoster immune globulin (VZIG) and aciclovir

Answer 106

Pre-eclampsia Gestational Diabetes Still-birth Intra-uterine Growth restriction (IUGR) Prematurity Vertical transmission in-utero, during delivery, or breastfeeding

Answer 107

Maternal highly active anti-retroviral therapy (HAART) – zidovudine Neonatal anti-retroviral therapy Avoid Breastfeeding Elective Caesarean Section

Answer 108

HIV Syphillis Hepatitis B Rubella screening has been taken out since April 2016

Answer 109

Parvovirus B19 suppresses fetal erythropoiesis → fetal anaemia → fetal hydrops Fetal death in 10% when infection is before 20 weeks gestation

Answer 110

``` Maternal Causes: Gestational Diabetes TORCH infections Rhesus Immunisation Renal Failure Chorioangioma of the placenta Twin-twin transfusion syndrome ``` Fetal Causes: Upper GI obstruction (oesophageal atresia, diaphragmatic hernia) Swallowing difficulties (facial cleft, anencephaly) Fetal renal disorders (Bartter’s syndrome)

Answer 111

GBS – Group B streptococcus Early onset Infection (<7 days) Maternal colonisation with GBS (Streptococcus Agalactiae) Premature Birth (<37 weeks) Prolonged Rupture of Membranes (>18 hours) Intrapartum Maternal Fever (>38°C) Young maternal age Amniotic Infections (chorioamnionitis)

Answer 112

Blood Pressure >140/90 mmHg - two separate readings - taken 4-6 hours apart - after 20 weeks gestation- individual with previously normal Blood Pressure Proteinuria >0.3 grams of protein in 24-hour urine

Answer 113

Abnormal trophoblastic invasion of the decidua and spiral arterioles Spiral arterioles have atheromatous lesions and fail to vasodilate ↓ utero-placental blood flow Ischaemic placenta releases inflammatory factors → endothelial cell damage: Vasoconstriction – hypertension, eclampsia, liver damage Increased vascular permeability – proteinuria, oedema Clotting Abnormalities

Answer 114

Immune causes: Anaemia Haemolysis (due to Rhesus Disease) Non-immune Causes: Chromosomal abnormalities (Trisomy 21) Structural abnormalities (e.g. pleural effusions, fetal tumors – congenital cystic adenomatoid malformation) Cardiac abnormalities, arrhythmias Anaemia (due to parvovirus B19, fetomatermal haemorrhage, thalassemia) Twin-twin transfusion syndrome Fetal Hydrops: when fluid accumulates in 2 or more fetal compartments (subcutaneous tissue, pleura, pericardium, ascites) Normally due to fetal anaemia – heart needs to pump a much greater volume of blood to deliver the same amount of oxygen – leads to increased cardiac output and oedema. Parvovirus B19 suppresses fetal erythropoiesis – leading to anaemia Anaemia is detected by increased blood flow velocity in the fetal middle cerebral artery

Answer 115

Hypertensive Disorders of Pregnancy (Pre-eclampsia, eclampsia, gestational hypertension and chronic hypertension) Post-partum bleeding Puerperal Infections

Answer 116

Hypertension (>140/90mmHg) – due to ↑ peripheral resistance Proteinuria (>0.3g/24h) – due to ↑ vascular permeability Intra-uterine Growth Restriction (IUGR) – due to ↓ placental blood flow Eclampsia (seizures) – due to ↓ cerebral perfusion Headaches Visual problems Oedema Epigastric pain ↑ liver enzymes Clotting → DIC BP = CO x TPR

Answer 117

``` Hyper-reflexia Clonus Epigastric tenderness Papilloedema Peripheral oedema Fetal size not compatible with stage of pregnancy Confusion / pre-coma ```

Answer 118

``` Nulliparity Previous history of pre-eclampsia Family History of pre-eclampsia Older maternal age Chronic hypertension Diabetes Mellitus Twin Pregnancies Autoimmune Disease Renal Disease Obesity Antiphospholipid Antibody Syndrome ```

Answer 119

Oral low-dose aspirin (75g) | Regular blood pressure and urinalysis checks for high-risk patients

Answer 120

``` Eclampsia – grand-mal seizures Cerebrovascular accident (CVA) HELLP Syndrome Disseminated Intravascular Coagulation (DIC) Liver Failure Renal Failure Pulmonary Oedema ```

Answer 121

Haemolysis → dark urine, ↑lactic dehydrogenase (LDH), anaemia Elevated Liver enzymes → epigastric pain, liver failure, abnormal clotting Low Platelets Nausea & vomiting Epigastric / RUQ pain – due to stretching of the liver capsule Complications → DIC, renal failure, placental abruptions Caused by activation of the coagulation system, LDH is released in haemolysis (tissue break down) Treatment = delivery of the fetus

Answer 122

``` Still-birth Pre-term birth Intra-uterine growth restriction (IUGR) before 34 weeks Hypoxia Placental abruption ```

Answer 123

↑ uric acid Haemoglobin ↑ ↓ Platelets → platelets aggregate on damaged endothelium LFT ↑ – ALT (alanine aminotransferase) – (liver damage or HELLP) Renal Function: Creatinine ↑ (renal failure) Lactase dehydrogenase (LDH) ↑(haemolysis or liver damage) Urine protein:creatinine ratio for PCR – (faster than 24-hour urine)

Answer 124

Delivery is the cure – as placenta is the origin of disease Antihypertensive Drugs: - labetalol (α and β adrenergic blocker) - Nifedipine (calcium channel blocker) Antenatal steroids – promote fetal lung maturity if gestation is < 34 weeks Prevention of eclampsia – seizures Methyldopa, hydralazine (vasodilator) can also be used ACE inhibitors are not used in 2nd / 3rd trimester – abnormalities

Answer 125

Lie patient flat on a left lateral tilt – to prevent aorto-caval compression, and choking due to vomiting Protect the airway Magnesium sulphate – cerebral membrane stabiliser - ↑ cerebral perfusion - (also used as a prophylaxis to prevent eclampsia) After mother is stable: Repeat maternal BP Monitor fetal heart rate Magnesium toxicity can lead to hypotension and respiratory depression – but this is preceded by loss of patella reflexes, so reflexes are tested regularly

Answer 126

Maternal: 2 previous Lower Segment C-section (LSCS), previous vertical uterine scar Placenta Praevia Maternal disease / Maternal request Primary maternal herpes simplex (Type 2) virus (HSV) infection (within 6 weeks of delivery), or primary genital lesions at delivery. HIV positive pregnant women ``` Fetal: Breech and Abnormal lie Twins – malpresentation of first twin Fetal distress Cord prolapse ```

Answer 127

Macrosomia (large for gestational age – ↑ induction of labour, operative delivery and caesarean section) Shoulder dystocia – and other birth injuries Neonatal hypoglycaemia – (due to pancreatic hyperplasia of the β cells → hyperglycaemia and fat deposition) ↑ urine output → Polyhydramnios → malpresentation ↓ fetal lung maturity Neural Tube / Cardiac / Skeletal defects

Answer 128

``` Pre-eclampsia Pre-term labour Still-birth Miscarriage ↑risk of developing Type II diabetes ↑insulin requirement – overmedication → hypoglycaemia Urinary / wound / endometrial infections post-delivery Diabetic ketoacidosis Diabetic retinopathy / nephropathy ↑ischaemic heart disease ```

Answer 129

First Trimester – Conception to 12 weeks Second Trimester – 12 weeks to 28 weeks Third Trimester – 28 weeks to 40 weeks / Delivery

Answer 130

``` Thromboembolism Pre-eclampsia – increases fetal mortality Gestational diabetes Caesarean section Wound infections Post-partum haemorrhage Difficult surgery Congenital abnormalities – (neural tube defects) ```

Answer 131

1 clinical event + 2 antibody blood test (spaced 3 months apart) Clinical Criteria: - vascular thrombosis - 1 fetal death > 10 weeks - 3 fetal losses < 10 weeks - pre-eclampsia - IUGR Laboratory Criteria: - Lupus anticoagulant - anticardiolipin antibody - anti-β2 glycoprotein antibody Antiphospholipid syndrome – characterised by CLOTS – Coagulation defect, Livedo reticularis, Obstetric (recurrent miscarriages), Thromboctyopenia Treatment = aspirin and LMWH

Answer 132

Encourage mobilisation Maintain hydration Compression stocking Thromboprophylaxis – low molecular weight heparin (LMWH) - given for 6 weeks to high risk (antenatal use or previous VTE) - given for 1 week to intermediate risk, and those with 2 moderate risk

Answer 133

Propythiouracil (PTU) Carbimazole is not used in pregnancy because: - it affects oestrogen production - crosses the placenta – causes congenital defects and neonatal aaahypothyroidism PTU also crosses the placenta – can cause neonatal hypothyroidism

Answer 134

< 2.5kg Normal Birth Weight = 2.5kg – 4.2kg Low Birth Weight (LBW) = <2.5kg Very Low Birth Weight (VLBW) = <1.5kg Extremely Low Birth Weight (ELBW) = <1kg

Answer 135

fetus which is less than the 10th centile for weight at any gestational age Also known as small for gestational age (SGA) and can lead to a Low birth weight (LBW) IUGR (Intrauterine Growth Restriction) Constitutionally Small – genetic trait Large for gestational age – babies above the 90th centile for weight at any gestational age

Answer 136

Small compared to its genetic determination Fetus is not able to achieve its genetically determined potential size Compromised

Answer 137

Asymmetrical – more common - Restriction in weight, followed by length - Head continues to grow (head sparing), abdomen stops growing first - Poor growth during Third Trimester - Caused by malnutrition, ↑BP - leads to hypoxia, hypoglycaemia Symmetrical (global growth restriction) - fetus developing slowly throughout entire pregnancy - head circumference is in proportion to body - permanent neurological sequelae - Causes: intrauterine infections (CMV, rubella, toxoplasmosis) llllllchromosomal abnormalities, maternal substance abuse, anaemia Asymmetrical IUGR – thin, dry peeling skin, thin umbilical cord If cause of IUGR is extrinsic (maternal or uteroplacental), fetus has less oxygen and nutrients – fetus have reduced glycogen and lipid supply – causes hypoglycaemia at birth. Low oxygen causes the fetus to make more erythropoietin – leads to polycythaemia

Answer 138

``` Maternal: Poor weight gain / poor nutrition Anaemia Substance abuse / maternal smoking Gestational diabetes Celiac disease Hypertension Recent pregnancy Pulmonary / CVS / renal disease ``` ``` Utero-placental: Pre-eclamspia Multiple gestation Uterine malformations Placental insufficiency ``` Fetal: Chromosomal abnormalities Vertically transmitted infections

Answer 139

``` Pre-term delivery IUGR (Intrauterine growth restriction) Congenital abnormalities Intrapartum (hypoxia) Placental abruption Unexplained ```

Answer 140

Maternal age Nuchal Translucency measurement PAPPA-A (Pregnancy-associated Pasma Protein A) - Low ↓ β-hCG (β-Human chorionic gonadotrophin) – High ↑

Answer 141

Combined Test (11 – 14 weeks) Quadruple Test (14 – 20 weeks)

Answer 142

AFP (alpha-fetoprotein) – Low ↓ β-hCG (β-Human chorionic gonadotrophin) – High ↑ Unconjugated Oestroldiol – Low ↓ Inhibin A – High ↑

Answer 143

Downs syndrome Placental Abruption IUGR Still-birth

Answer 144

Maternal History – past obstetric History: assisted conception, Past small for dates baby - Extremes of reproductive age - Smoking / Drug abuse PAPP-A Blood tests – first trimester Maternal Uterine Artery Doppler at 23 weeks

Answer 145

Ultrasound assessment of fetal growth: measuring head circumference, abdominal circumference and femur / humerus length Umbilical artery Doppler Doppler of Fetal Circulation – (Middle cerebral artery / Ductus venosus* Doppler) Ultrasound assessment of Bio-physical Profile (limb movements, tone, breathing movements and liquor volume) Daily CTG analysis Kick Chart – record fetal movements *Ductus venosus – shunts oxygenated blood from the left umbilical vein directly into the Inferior vena cava – allows circulation to bypass the liver.

Answer 146

Prolonged Pregnancy = > 42 weeks Nulliparity Previous prolonged Pregnancy Rarer / greater risks in South Asian Women Rarer in African women

Answer 147

``` Still birth Neonatal illness Encephalopathy Fetal meconium aspiration Fetal distress ```

Answer 148

Tocolytic is a drug which inhibits uterine contractions – used to delay premature labour ``` Nifedipine (Ca2+ channel blocker) Ritodrine (β agonist) Atisoban (oxytocin inhibitor) Salbutamol Indometacin (NSAID) Magnesium Sulphate ```

Answer 149

Intrauterine infections Rupture of Membranes Fetal distress

Answer 150

Extended – most common Flexed Footling – least common - most likely to have cord prolapse

Answer 151

Premature Labour Circumstances that allow more room to turn: - Polyhydramnios - high-parity – due to more lax uterus Circumstances that prevent turning: - uterine abnormalities - twin pregnancies Conditions that prevent engagement: - Placenta praevia - pelvic tumours - uterine abnormalities

Answer 152

``` Fetal Compromise - IUGR - Pre-eclampsia Ruptured membranes Placenta praevia Antepartum haemorrhage Twins Isoimmunisation Previous C-section ``` ``` Relative contraindications include: Obesity Oligohydramnios Nulliparous, Caucasians – lower success rate High uterine tone ```

Answer 153

``` Increasing maternal age Grand-parity Assisted conception – IVF, clomiphene assisted pregnancy Genetic factors Family History of Twins Races - Black and Non-hispanic ```

Answer 154

``` Maternal: Pre-eclampsia Gestational diabetes Anaemia Miscarriage Antepartum / Post partum haemorrhages ``` Fetal: Pre-term delivery Twin-twin transfusion syndrome (only in monochorionic twins) - polyhydramnios Congenital abnormalities (more common in monochorionic twins) Long-term handicap Intra-uterine growth restriction Malpresentation

Answer 155

16 – 22 weeks In Monochorionic Diamniotic twins (MCDA) Vascular anastomosis between parts of the shared placenta, leading to: ``` Donor twin: Receives less blood anaemia Poor urine output Oligohydramnios IUGR ``` ``` Recipient twin: Receives more blood Polycythaemia Fluid overload / Heart failure Increased urine output Polyhydramnios ```

Answer 156

``` Previous Preterm delivery Maternal age <20yrs Low socioeconomic class Multiparity Smoking Uterine abnormalities Fibroids Twins – assisted conception Polyhydramnios Pre-eclampsia IUGR ``` Cervical incompetence: previous cervical surgery Cervical cancer ``` Infection: Chorioamnionitis neonatal sepsis endometritis Bacterial vaginosis Group B strep (GBS) Trichomonas Chlamydia ```

Answer 157

``` Fetal fibronectin assay Transvaginal Ultrasound Scan to assess cervical length (short cervix is more likely) CTG Vaginal swab White cell count (WCC) CRP ```

Answer 158

If <34 weeks, administer IM steroids (betamethasone) – given to stimulate surfactant production, to prevent Respiratory distress syndrome - needs 24 hrs to work Delay delivery using tocolytics (inhibit uterine smooth muscle contractions):- Atisoban – oxytocin inhibitor - Ritodrine – β2-agonist - Nifedipine – CCB - Indometacin (NSAID) Magnesium sulfate – has a fetal neuroprotective affect

Answer 159

Cardiac affect – maternal tachycardia, increased BP Hyperglycaemia – causes gluconeogenesis (avoid in diabetic patients) Headache

Answer 160

Intrauterine infections Rupture of membranes Fetal distress

Answer 161

Erythromycin – macrolide antibiotic

Answer 162

NEC (necrotising enterocolitis)

Answer 163

``` Maternal pyrexia Offensive vaginal discharge Fetal tachycardia (>160bpm) Maternal leucocytosis Uterine tenderness Abdominal pain ```

Answer 164

Maternal pyrexia = >37.5°C Chorioamnionitis Epidural analgesia prolonged labour

Answer 165

``` Multiple vaginal examinations Carriage of Group B Streptococcus Prolonged Rupture of Membranes Prolonged labour Preterm delivery Low socioeconomic status Pre-existing infection of the lower genital tract Nulliparity Young age ```

Answer 166

Bleeding from the genital tract after 24 weeks

Answer 167

``` Placenta praevia Placental Abruption Uterine rupture Vasa Praevia Genital tract Pathology – e.g. cervical cancer Undetermined origin ```

Answer 168

``` Previous placenta praevia Extremes of age (<20yrs or >35yrs) Multi-parity Previous caesarean section Previous myomectomy Damaged endometrium by Dilation & Curettage Large placenta (twins) ```

Answer 169

``` Previous placental abruption Intrauterine growth restriction (IUGR) Pre-eclampsia or pre-existing hypertension Autoimmune disease Maternal smoking Cocaine use Multiparity Multiple pregnancy Rapid reduction in uterine volume (rupture of membranes in a women with polyhydramnios) ```

Answer 170

Doppler Ultrasound of the peak velocity of the fetal Middle Cerebral artery (MCA) Fetal Blood sampling from umbilical vein under ultrasound

Answer 171

Given to Rh-Negative mothers at 28 weeks and within 72 hrs of any sensitization event: ``` Miscarriage or threatened miscarriage Termination of pregnancy or Evacuation of retained products of conception (ERCP) after miscarriage Invasive tests - amniocentesis, chorionic villus sampling (CVS) External cephalic version Vaginal bleeding < 12 weeks or heavy Intrauterine death Antepartum haemorrhage After Delivery ``` IM (intra-muscular) Anti-D (Rho (D) immune globulin) - used to prevent Rh disease (haemolytic disease of the newborn) – - Works by mopping up any fetal RhD-positive erythrocytes in the maternal blood stream, before the maternal immune system reacts – prevents maternal sensitisation.

Answer 172

Kleihauer-Betke Test: A blood test – measures the amount of fetal haemoglobin in the mother’s blood stream Performed on Rh-Negative mothers

Answer 173

Acute fatty liver of pregnancy has: - hypoglycaemia - ↑ uric acid

Answer 174

Onset of painful uterine contractions Leading to full dilation (10 cm) and effacement of the cervix Usually 37 – 42 weeks gestation

Answer 175

First stage – onset of contractions to full cervical dilation (10 cm) - latent phase – cervix dilates slowly for the first 3 cm - active phase – follows, cervical dilation 1cm/hr in nulliparous and …2cm/hr in multiparous women Second stage – Full cervical dilation to delivery of the fetus Third stage – delivery of the fetus to delivery of the placenta

Answer 176

Slow labour – progress slower than 1cm/hr dilation after the latent phase Prolonged labour – >12 hours duration after the latent phase

Answer 177

Power – degree of force expelling the fetus Passage – dimensions of the pelvis and resistance of the soft tissues Passenger – diameter of fetal head

Answer 178

In labour contractions last 45-60 seconds every 2-3 minutes Poor contractions can be due to: Nulliparity Induction of labour

Answer 179

Occipito-anterior (OA) Anteriorly – posterior fontanelle is Y or Δ shaped Straight (sagittal) suture Posteriorly – anterior fontanelle (bregma) is diamond-shaped ◊

Answer 180

‘false labour’ – prodromal contractions Involuntary Uterine contractions - intermittent and irregular in early pregnancy As labour approaches the frequency and amplitude of contractions increase

Answer 181

Descent of fetal head it compared with the ischial spines – known as stations Station -2 = 2cm above the ischial spines Station 0 = in line with the ischial spines Station +2 = 2cm below the ischial spines

Answer 182

``` Engagement in Occipito-transverse (OT) Descent Flexion Internal Rotation 90° to Occipito-anterior (OA) Descent Extension to deliver Restitution - External rotation ```

Answer 183

Tear involving the perineal muscles or an episiotomy First degree tears only involve the fourchette Second degree tears involve the perineal muscles / episiotomy Third degree tears involve the anal sphincter Fourth degree tears involve the anal mucosa

Answer 184

Third degree tear involves the anal sphincter Nulliparity Forcep delivery Large fetus Midline Episiotomy

Answer 185

``` Cervical dilation Cervical effacement Cervical position Cervical consistency Fetal Station ``` Used to assess the favourability of the cervix, to predict whether induction of labour is required. Score 0 – 5 = unfavourable cervix – give vaginal prostaglandin Score 6 – 13 = favourable cervix – spontaneous pregnancy likely

Answer 186

Partogram Cervical dilation – alert and action lines indicate slow progress Fetal descent of head Maternal vital signs: pulse, temperature, BP, Fetal heart rate liquor colour Oxytocin drops Drugs and IV fluids given

Answer 187

Power: Inefficient uterine contractions – common in: - nulliparous - induction of labour ``` Passage: Fetal size Disorder of rotation: - occipitotransverse (OT) - occipitoposterior (OP) Disorder of Flexion - brow presentation ``` Passenger: Cephalo-pelvic disproportion Role of cervix Pelvic variants / deformities

Answer 188

Fetal distress – hypoxia that might result in fetal damage or death if not reversed or the fetus or delivered urgently pH < 7.2 in the fetal scalp capillaries – indicates hypoxia ``` Placental abruption Hypertonic uterine states Use of oxytocin Prolapse of the umbilical cord Maternal hypotension ```

Answer 189

``` Fetal hypoxia Fetal distress Prematurity Maternal pyrexia Exogenous β-agonist use (e.g. salbutamol) ```

Answer 190

Normal Baseline Fetal heart rate (110 – 160bpm) Normal fetal variability (>5bpm) Accelerations present Absence of Decelerations

Answer 191

Cord Compression

Answer 192

``` Maternal: Previous C-section Pre-eclampsia Diabetes Antepartum haemorrhage Maternal fever ``` ``` Fetal: IUGR Prematurity Oligohydramnios Breech Multiple pregnancy Meconium stained liquor ``` Intrapartum: Oxytocin use Epidural analgesia Induction of Labour

Answer 193

Non-medical: - back-rubbing - transcutaneous electrical nerve stimulation (TENS) - acupuncture Entonox (Gas & air) – nitric oxide and oxygen Opiates: (+ antiemetic) - Pethidine - Diamorphine - Remifentanil Spinal analgesia – into the CSF Epidural analgesia – (L3 – L4) into the epidural space Pudendal nerve block

Answer 194

``` Sepsis Hypovolaemia Active neurological disease Anticoagulant therapy or coagulopathy Local infection on back at L3-L4 Raised intracranial pressure Spinal abnormalities – spina bifida occulta ```

Answer 195

Spinal tap – puncture of the dura mater → leakage of CSF → severe headache worse on sitting up Inadvertent Intravenous injection – convulsions or cardiac arrest Total spinal analgesia – inadvertent analgesia in to the CSF + progression up the spinal cord → respiratory paralysis Urinary retention Poor mobility – bed sores Hypotension Higher instrumental delivery rate Local anaesthetic toxicity Maternal fever

Answer 196

``` Pre-eclampsia Multiple gestation Prolonged pregnancy Obesity Anticipated instrumental delivery ```

Answer 197

``` Augmentation = artificial strengthening the contractions in established labour (amniotomy, oxytocin) Induction = artificial initiation of labour ```

Answer 198

Prostaglandin E2 pessary inserted into the posterior vaginal fornix Amniotomy – (artificial rupture of membranes with an amnihook) Oxytocin infusion

Answer 199

``` Prolonged pregnancy Preterm rupture of membranes IUGR Maternal disease (pre-eclampsia, diabetes) In-utero death ```

Answer 200

Shoulder dystocia – seen in obstructed deliveries, where the anterior shoulder of the infant, fails to pass below the pubic symphysis, after the head. Turtle sign, head bobbing ``` Maternal diabetes (gestational / type 1) Obesity Previous large for gestational age baby Fetal macrosomia (weight > 4500g) Large for gestational age Prolonged labour Post-dates (prolonged pregnancy) Male fetus ```

Answer 201

Erb’s Palsy (Upper brachial plexus C5-C6) – waiter’s tip position – arm lies straight, limp, hand pronated and fingers flexed. Klumpke’s paralysis (Lower brachial plexus C8-T1) – claw hand, loss of sensation in ulnar part of forearm. Hypoxia Fetal distress / death Maternal post-partum haemorrhage Cerebral palsy Maternal 3rd / 4th degree tears, extended episiotomies Uterine rupture

Answer 202

ALARMER: Ask for Help – obstetrician, paediatrician, anaesthetist Leg hyperflexion – (MacRobert’s position) Anterior Shoulder disimpaction (suprapubic pressue) Rubin Manoeuvre – pressure on posterior shoulder (wood’s screw manoeuvre) Manual delivery of posterior arm Episiotomy Roll over onto all fours Zavenelli manoeuvre – pushing delivered head back into the birth canal → caesarean section Intentional clavicular fracture

Answer 203

Cord prolapse – descent of the umbilical cord through the cervix, past the presenting part, when the membranes have ruptured: → cord compression or spasm of the umbilical cord → fetal hypoxia ``` Artificial rupture of membranes Preterm delivery Low-birth weight Breech presentation / abnormal lie / unengaged presenting part Multiple pregnancy Polyhydramnios ``` Management – put patient in trendelenberg position (knees to chest) / or sitting on all fours, and pushing the presenting part upwards, catheter with fluid. If the cord is outside, it should be kept warm and moist – urgent c-section

Answer 204

4T’s & 4H’s Thromboembolism - amniotic fluid embolism Toxicity - Magnesium toxicity – give calcium gluconate antidote - Anaesthesia toxicity – give intralipid Tension pneumothorax Tamponade (cardiac) Hypovolaemia Hypoxia Hypo/hyperkalaemia – other electrolyte abnormalities Hypothermia Pre-eclampsia / Eclampsia Intracranial haemorrhage sepsis

Answer 205

Amniotic fluid embolism Antepartum / postpartum haemorrhages HELLP syndrome Placental abruption

Answer 206

``` Scar dehiscence from a Previous caesarean section (more common if classic scar) Increased use of oxytocin Previous myomectomy Obstructed labour Multiparity Perforation during operative procedures ```

Answer 207

``` Endometritis – due to retained products of conception UTI Wound infection Perineal infection Breast infection (mastitis) Chest infection Thromboembolism ```

Answer 208

loss of >500ml blood in the first 24 hours after delivery (>1000ml if caesarean section) Secondary post partum haemorrhage is bleeding after 24 hours – 6 weeks after delivery

Answer 209

4 T’s: Tone – atonic uterus Tissue – retained placenta, infection Trauma – high vaginal tear, cervical tear, perineal tear, episiotomy Thrombin – coagulopathy, anticoagulant therapy, DIC Uterine inversion Uterine rupture

Answer 210

``` Antepartum haemorrhage Previous history of PPH Previous caesarean delivery Grand-multiparity Over-distention of the uterus: (cause atonic uterus)- Polyhydramnios- Multiple pregnancy - macrosomic fetus Fibroids and uterine malformations Coagulation defect or anticoagulant therapy Instrumental or caesarean delivery Retained placenta Prolonged pregnancy Induction of labour ```

Answer 211

Third Person Auditory Hallucinations (running commentary, thought sonarization) Thought alienation (thought insertion, thought withdrawal, thought broadcasting) Delusional Perception Passivity Phenomena -Made feelings / impulses / actions Thought sonarization – hearing own thoughts out loud (either at the same time as thought – gedankenlautwerden, or after a thought – echo de le pensee) Diagnostic Criteria – >1 very clear firth rank symptom, or >2 other symptoms for longer than >1 month,

Answer 212

``` Apathy Poverty of speech Blunting / incongruent affect Slowness Lack of drive Social withdrawal ```

Answer 213

Paranoid Schizophrenia – most common – persecutory delusions, Hebephrenic Schizophrenia – affect change, fleeting hallucinations - starts at young age (15-25 years), poor prognosis Catatonic Schizophrenia – stupor, excitement, posturing, negativism, rigidity, waxy flexibility. Simple Schizophrenia – gradual onset, negative symptoms develop before positive symptoms Residual / chronic schizophrenia – follows other types of schizophrenia – negative symptoms

Answer 214

A fixed belief, held with conviction Usually false Cannot be altered with evidence / proof Is inappropriate according to the social / cultural norm

Answer 215

Hypothyroidism – check TFT’s Lithium-induced Nephrogenic Diabetes Insipidus (Excreted by kidneys – check renal function) Arrhythmias – check ECG Lithium Toxicity – narrow therapeutic range Teratogenic – cardiac defects (Ebstein’s anomaly) ``` Dry mouth, metallic taste Nausea, vomiting Fatigue Weight gain Diarrhoea ```

Answer 216

``` Tinnitus Blurred vision Dysarthria Poor concentration Sleepiness Diarrhoea & vomiting Coarse Tremor Muscle weakness / twitching seizures ``` Do not use diuretics with lithium – reduces excretion of lithium – lithium toxicity Treatment – fluid therapy, haemodialysis, treat seizures with benzodiazipines

Answer 217

Diuretics ACE inhibitors Some NSAIDS Other drugs which prolong the QT interval, e.g. amiodarone, amisulpride (antipsychotic), citalopram Amitriptyline Drugs which cause hypokalaemia, e.g. betamethasone – increase the risk of torsade de pointes

Answer 218

``` Vitamin B1 (thiamine) deficiency Common in alcoholics ``` Confusion Ophthalmoplegia Ataxia Nystagmus Peripheral neuropathy Periaqueductal punctuate haemorrhages. Causes of Wernicke’s encephalopathy – chronic alcoholism, eating disorders, malnutrition, prolonged vomiting (with chemotherapy, hyperemesis gravidum), GI malignancy

Answer 219

Thiamine (vitamin B1) replacement (Pabrinex) | Replace thiamine before correcting glucose

Answer 220

``` Irreversible Korsakoff’s Syndrome: Confusion Antegrade / retrograde amnesia Confabulation Lack of insight / apathy ↓ability to acquire new memories ``` Hypothalamic damage and cerebral atrophy due to thiamine deficiency in alcoholics

Answer 221

≥ 3 of the following features must be present together in the previous year: Strong desire / compulsion to drink Difficulties controlling drinking (onset, termination) Physiological withdrawal state – drinking alcohol to avoid withdrawal symptoms Tolerance – the CNS effects of drugs diminish with repeated use ∴ increasing doses of alcohol is required to achieved the same effect Neglect – priority of drinking over other activities Persisting with drinking despite evidence of harm Narrowing of drinking repertoire – drinking in the same way / same time Reinstatement after abstinence

Answer 222

Occurs when the desired CNS effects of a psychoactive substance, diminish with repeated use Therefore increasing doses are administered to achieve the same effect

Answer 223

Within 12 hours – tremor, insomnia, nausea, increased sweating, anorexia, anxiety, tachycardia, restlessness 10 – 60 hours – withdrawal fits Alcoholic hallucinosis 48 - 72 hours – Delirium Tremens (lasts 5 days): - clouding of consciousness / confusion - vivid hallucinations and illusions (Lilliputian hallucinations, tactile …hallucinations - formication) - marked tremor

Answer 224

Blood Alcohol concentration (can be tested in expired air using Alcometer) LFT’s: - GGT (Gamma-glutamyl-transpeptidase) ↑ - AST (Aspartate transferase) ↑↑ (AST:ALT ratio = 2:1) FBC – macrocytic anaemia - ↑ MCV – B12 and Folate deficiency Glucose ↓ U&E’s:- uric acid ↑ Carbohydrate-deficient transferrin (CDT) – detects heavy alcohol consumption Phosphatidylethanol – detects regular alcohol consumption

Answer 225

``` Reducing regime of Benzodiazepines (e.g. chlordiazepoxide, chlormethiazole) – gradually reducing dose in 5-6 days Withdrawal fits are treated with rectal diazepam Give thiamine (Pabrinex) BEFORE treating hypoglycaemia to prevent wernickes encephalopathy ```

Answer 226

Disulfiram (Antabuse) – blocks acetaldehyde dehydrogenase Acamprosate – reduces conditioned aspects of drinking and prevents craving-related relapses – enhances GABA transmission Naltrexone – opioid antagonist – reduces reinforcing actions of alcohol (reduces the pleasure from alcohol Motivational interviewing Supportive psychotherapy / group behaviour therapy Self-help – Alcoholics anonymous

Answer 227

Inhibits the enzyme acetaldehyde dehydrogenase Normally alcohol is converted to acetaldehyde by alcohol dehydrogenase (produces the hangover effects) Acetaldehyde is then broken down by acetaldehyde dehydrogenase into an acetic acid derivative Disulfiram increases the concentration of acetaldehyde in the blood – if alcohol is consumed, causes a reaction: - hypotension - facial flushing - throbbing headache - tachycardia and palpitations - nausea & vomiting - arrhythmias Disulfiram (antabuse) can be used on a regular basis as a prophylactic treatment of alcohol dependence syndrome. The ingestion of even small amounts of alcohol whilst on this drug leads to unpleasant systemic reactions, including facial flushing, headache, palpitations, tachycardia, nausea and vomiting. Disulfiram acts by blocking the oxidation of alcohol at the acetaldehyde stage. The subsequent accumulation of acetaldehyde in the blood gives rise to the unpleasant symptoms referred to as the disulfiram-alcohol interaction.

Answer 228

A neurological condition due to loss of inhibition of REM sleep: Cataplexy – sudden loss of muscle tone, when intense emotion occurs, leading to collapse Hypnogogic (going asleep) / hypnopompic (waking-up) Hallucinations Irresistible Attacks of sleep at inappropriate times Sleep Paralysis Catalepsy – rigidity and fixity of posture – related to Parkinson’s disease, epilepsy, schizophrenia, antipsychotic medication ``` Narcolepsy: symptoms, epidemiology CHAP: Cataplexy Hallucinations Attacks of sleep Paralysis on waking· ``` Usual presentation is a young male, hence "chap".

Answer 229

``` SAD PERSONS Sex – male Age (<19 or >45 years) Depression Previous Attempt Excess Alcohol or Substance Misuse Rational thinking loss Separated / Divorced / Widowed Organised plan No Social Support Sickness / Stated future intent ```

Answer 230

Having children Being religious Access to clinical care for mental, physical and substance misuse disorders Family / community support

Answer 231

``` Microcephaly Ocular hypertelorism Low IQ, mild-moderate mental retardation Strabismus Small nose Long, thin upper lip Indistinct philtrum Pectus excavatum Cardiac murmurs (ASD) Poor Growth ```

Answer 232

``` Stimulants: Amphetamines (speed) Cocaine MDMA – Ecstasy Coffee ``` Sedatives: Alcohol Barbiturates Benzodiazepines ``` Opiates: Morphine Diamorphine (heroin) Methadone Tramadol Codeine ``` Other: Cannabis Hallucinogens (LSD)

Answer 233

Opioids – heroin (diamorphine), morphine, methadone, codeine, tramadol ``` Pin-point pupils (miosis) Constipation Euphoria Tremor Nausea & vomiting Respiratory depression Hypotension Anorexia Erectile dysfunction Venepunture marks (IVDU) ```

Answer 234

``` Diarrhoea Dilated pupils (mydriasis) Lacrimation Sweating Insomnia Tachycardia Abdominal cramp-like pains Nausea & vomiting ``` Managed using methadone and buprenorphine (partial agonist)

Answer 235

``` Opiate overdose: Reduced level of consciousness Pin-point pupils Respiratory depression Seizures Muscle spasms ``` Treatment: Oxygen, IV or IM Naloxone – (has a short half-life – requires continuous infusion / multiple doses)

Answer 236

Δ9-tetrahydrocannabinol

Answer 237

Conjunctival injection Dry cough Increased appetite Fatigue ``` Euphoria Relaxation Altered perception of time Paranoia Persecutory delusions Social withdrawal Depersonalisation / derealisation ```

Answer 238

``` tachycardia Dilated pupils (mydriasis) hypertension Sweating Nausea & vomiting ↑risk of cardiovascular disease ``` ``` Euphoria Visual or tactile hallucinations (insects crawling under skin – formication) Increased Sexual interest Grandiose delusions Ideas of reference Agitation Impaired judgement ```

Answer 239

``` Dysphoric mood – rebound crash Cravings Irritability Fatigue Insomnia / hypersomnia Paranoia Suicidal thoughts delirium ```

Answer 240

Benzodiazepines barbiturates ``` Slurred speech Incoordination Unsteady gait Impaired attention / memory Disinhibition Aggression Respiratory depression hypotension ```

Answer 241

``` Nausea & vomiting Autonomic hyperactivity - tachycardia - sweating Anxiety Irritability Hypotension Insomnia Delirium seizures Coarse Tremor Loss of appetite / weight loss pyrexia ```

Answer 242

CNS depression Respiratory depression→ coma Flumazenil

Answer 243

Treatment of ADHD and Narcolepsy

Answer 244

``` Euphoria Hypervigilance dilated pupils Insomnia Agitation Hallucinations / illusions Hypertension Tachycardia cardiac arrhythmia impaired judgment Perspiration Confusion ``` The use of high doses of amphetamines may cause a paranoid psychosis with persecutory delusions, auditory and visual hallucinations, and sometimes hostile and dangerously aggressive behaviour. (indistinguishable from paranoid schizophrenia) The condition usually subsides in about a week, but occasionally it persists for months.

Answer 245

``` dysphoric mood irritability depression fatigue insomnia agitation ```

Answer 246

Hyperthermia → death Ecstasy (MDMA) produces a positive mood state with feelings of euphoria, sociability and intimacy. Rarely, it can cause severe adversereactions and deaths due to hyperthermia. The hyperthermia probably results from the effect of ecstasy in increasing brain 5-HT release, together with the social setting in which the drug is customarily taken (crowded parties with prolonged and strenuous dancing).

Answer 247

Hallucinogen Synaesthesia – translation from one sensory modality to another, e.g. sees a sound Merging of objects Slowing of the passage of time Lysergic acid diethylamide (LSD) is a synthetic hallucinogen. Its psychological effects develop during a period of two hours after consumption and generally last from 8 to 14 hours. The most remarkable experiences are distortions or intensifications of sensory perception. ‘Synaesthesia’ refers to the experience of translation from one sensory modality to another so that one may, for example see a sound or smell a colour. Other effects may include the merging of objects with one another and slowing of the passage of time

Answer 248

Severe depression, particularly life-threatening behaviour (e.g. refusing to eat) Puerperal depressive illness Catatonic schizophrenia Mania

Answer 249

``` Early onset of illness Poor compliance Severe mania Persistent depressive symptoms Co-morbid personality disorder Substance misuse Family history of non-response Rapid cycling (4 or more episodes a year) ```

Answer 250

Graded Exposure Techniques - Systematic desensitisation involves gradual exposure to a phobic stimulus over a number of sessions. Flooding – requires patient to confront the sources of their anxiety and remain there until the anxiety dissipates.

Answer 251

Relaxation therapy – involves progressive muscular relaxation and breathing exercises.

Answer 252

Prolonged severe abnormal response to stress Beginning within 1 month of a stressful life event Lasting no longer than 6 months Interferes with social functioning

Answer 253

An intense delayed, prolonged reaction to a traumatic / stressful event Symptoms (begin within 6 months of traumatic event): Intrusions – flashbacks, nightmares, vivid memories, frequent thoughts of the incident Avoidance – avoids reminders, inability to recall some of the events, poor interest in everyday life, emotional detachment, avoids discussing the incident Hyperarousal – persistent anxiety, hypervigilance, exaggerated startle response, insomnia, irritability, poor concentration

Answer 254

``` Creatinine phosphokinase (CPK) Increased white cell count (WCC) ```

Answer 255

Syncope Epilepsy Non-epileptic attacks

Answer 256

an abrupt and transient loss of consciousness associated with loss of postural muscle which follows a sudden fall in cerebral perfusion

Answer 257

Neurogenic Syncope: Vasovagal syncope Situational (reflex) syncope - coughing, micturition Carotid sinus hypersensitivity Cardiac syncope: Arrhythmias Valvular hear disease Aortic stenosis Orthostatic syncope

Answer 258

Tendency to have recurrent seizures Seizure – clinical manifestation of disordered electrical activity in the brain (paroxysmal discharge of cerebral neurones) spontaneous, intermittent abnormal electrical discharge in the brain

Answer 259

A series of Seizures lasting > 30mins | Without regaining consciousness between attacks

Answer 260

``` SLIDE: Sleep Deprivation Lights (flashing) Infection Drugs/alcohol and Withdrawal Exhaustion Menstruation ```

Answer 261

Simple partial seizures (awareness is unimpaired) Complex partial seizures (awareness is impaired) Partial seizures with secondary generalisation

Answer 262

``` Absence Seizures (petit-mal) Tonic-Clonic seizure (grand-mal) Myoclonic seizures Atonic (akinetic) seizures – No LOC Infantile Spasms (West Syndrome) ```

Answer 263

Tuberous Sclerosis

Answer 264

hypsarrhythmia

Answer 265

3 Hz Spike and Wave Discharges

Answer 266

Childhood onset epilepsy characterised by: Frequent seizures of different types Abnormal EEG pattern of <2.5 Hz slow spike wave activity Moderate to severe intellectual impairment

Answer 267

Seizures lasting longer than 2 minutes (tonic-clonic seizures usually last up to 90 secs) Eyes tightly closed – tend to resist having their eyes forced open Mouth tightly closed Hip thrusting Side-to-side head movements Uncommon to have automatisms

Answer 268

Partial seizure (with or without secondary generalisation) ``` Leucopenia Diplopia Blurred vision Drowsiness Impaired balance Mild generalised erythematous rash SIADH (rare) ```

Answer 269

``` Steven-Johnsons syndrome (epidermis separates from the dermis) → Toxic Epidermal necrolysis (>30% body surface area is involved) Maculopapular rash Hypersensitivity (fever, ↑LFT’s, DIC) Diplopia, blurred vision photosensitivity Tremor Aplastic Anaemia ```

Answer 270

Keppra – used in >16yrs ``` Psychiatric side effects, depression, agitation Blood dyscrasias Diplopia D&V drowsiness ```

Answer 271

``` Toxicity (nystagmus, ataxia, tremor, dysarthria, diplopia) Gum hypertrophy Blood dyscrasias Polyneuropathy Acne ```

Answer 272

``` Vomiting & Nausea (advise to take with food) Appetite (weight gain) Liver failure Pancreatitis Reversible hair loss (grows back curly) Oedema Ataxia Teratogenic, thrombocytopenia, tremor Encephalopathy (due to hyperammonaemia) ```

Answer 273

Vigabatrin used to treat infantile spasms Visual field defects

Answer 274

Take folic acid supplements (5mg/day) | Avoid Valproate – use Lamotrigine

Answer 275

``` Meningitis Encephalitis Subarachnoid Haemorrhage Head injury Venous sinus thrombosis Low pressure headache Acute Glaucoma Sinusitis ```

Answer 276

Headache, worse on lying down, bending forward, coughing Headache causing night-time wakening Morning vomiting Associated confusion, ↓GCS, personality change Seizures Visual field defects Cranial nerve palsies (6th nerve – abducens) – diplopia, new-onset squint Abnormal gait Torticollis Growth failure Papilledema (late feature)

Answer 277

Rule out raised ICP - Reduce the risk of coning (cerebellar tonsils herniate through the foramen magnum)

Answer 278

Spasticity - ↑tone – velocity dependent, non-uniform – faster you move the muscle, the more resistance – until if gives way in a clasp-knife manner. Rigidity - ↑tone – not velocity dependent, constant through passive movement

Answer 279

Amyotrophic Lateral Sclerosis (ALS) - UMN + LMN Progressive Bulbar palsy - LMN Progressive muscular atrophy - LMN Primary lateral Sclerosis - UMN Progressive muscular atrophy – weakness of distal limb muscles first (anterior horn cell lesions Pseudobulbar palsy – UMN lesion affecting tongue, muscles of swallowing / talking

Answer 280

Riluzole (antiglutamatergic drug) – increases life expectancy by ≈ 3 months Drooling – propantheline

Answer 281

Sudden-onset focal neurological deficit Usually vascular in origin Lasting > 24 hours TIA – focal deficit that resolves within 24 hours

Answer 282

Ischaemic stroke Haemorrhagic stroke Causes: Small vessel occlusion, cerebral microangiopathy Cardiac emboli - due to Atrial fibrillation, Endocarditis, MI Atherothromboembolism (from carotids) CNS bleeds (trauma, aneurysm rupture, anticoagulation)

Answer 283

``` Sudden BP drop by >40mmHg, due to ‘Watershed’ area Carotid artery dissection Subarachnoid haemorrhage antiphospholipid syndrome thrombophilia Fabry’s disease CADASIL, CARASIL ```

Answer 284

ABCDE If within <4.5 hours after onset of symptoms: Alteplase (tissue plasminogen activator - tPA) High-dose Aspirin (300mg)

Answer 285

``` >4.5 hours after onset of symptoms Major infarct or haemorrhage on CT Recent birth - pregnancy Recent surgery Recent trauma Past CNS bleed Arteriovenous malformation (AVM) Aneurysms Seizure on onset Mild non-disabling deficit Liver disease, varices or portal hypertension ```

Answer 286

Junction between the posterior communicating artery and the internal carotid artery Junction between the anterior communicating artery and the anterior cerebral artery Bifurcation of the middle cerebral artery

Answer 287

MRI at day 1 with diffusion weighted imaging

Answer 288

Gait apraxia Urinary incontinence Dementia

Answer 289

Hippocampal atrophy Generalised cerebral atrophy Enlarged ventricles

Answer 290

Visual hallucinations Fluctuating cognitive impairment (lucid periods) Parkinsonian features Also get: sleep disturbance, transient loss of consciousness, recurrent falls Parkinsonian features – tremor, rigidity, bradykinesia, postural instability.

Answer 291

Antipsychotics – precipitates severe parkinsonism

Answer 292

Step-wise deterioration – due to accumulation of infarcts

Answer 293

McDonald’s criteria Diagnosis of MS requires the presence of multiple CNS lesions which cause symptoms that: Last >24 hours Are disseminated in space (clinically or on MRI) Are disseminated in time (>1month apart)

Answer 294

Medical Assessment – Problem list (diagnosis and treatment), co-morbid conditions & disease severity, Medication review- doctor / consultant Functional Assessment – ADL, gait, balance- occupational therapist, physiotherapist Psychological Assessment – cognition, mood- nurse, psychiatrist Social assessment – care resources, finances- social worker Environmental assessment – home saftey

Answer 295

``` Meningococcal sepsis Bacterial meningitis Herpes Simplex encephalitis Pneumonia Urinary tract infection Septic arthritis Kawasaki disease ```

Answer 296

Used in patients who are a low-risk, and do not need to be admitted to hospital, but no diagnosis has been reached. Provide parent or carer with verbal or written information on warning signs Arrange follow-up at specific time / place Liaise with healthcare professionals, (out-of-hours providers) to ensure direct access for the child if further assessment is required

Answer 297

``` HIV malnutrition contact with TB Homelessness Overcrowding damp housing IVDU Diabetes Immunosuppression - extremes of age - malignancy - steroids Renal disease Smoking Alcohol silicosis ```

Answer 298

Consolidation Cavitation Calcification Fibrosis – upper zone

Answer 299

Excessive alcohol Beta blockers, thiazide diuretics anxiety