Counselling Flashcards
Indications for induction of labour
Prolonged gestation which increases risk of still birth, LSCS etc
Prelabour rupture of membranes (>24 hrs before labour) which increases risk of infection
Maternal health conditions e.g. diabetes, hypertension or heart disease which can increase the risk of stillbirth and large baby
Disadvantages of induction of labour
Labour ward vs midwifery-led unit, no birth pool
May be more painful
Longer stay in hospital
Talk through the process of induction of labour
Most will get membrane sweep first (adjunct) to stimulate release of prostaglandins- increases chance of natural labour, can cause discomfort
Then depending on bishops score management is different:
<6 (unfavourable cervix) then PV prostaglandins or mechanical method e.g. balloon catheter is offered to increase favourability of cervix
> 6 (favourable cervix) then amniotomy +/- oxytocin infusion is recommended
Pros and cons of prostaglandin use in IOL
Hormones that mimic the ones in ur body that make contractions happen
Usually done when bishops <6 alongside ?balloon catheter
Reduces likelihood of needing mechanical methods
But can cause hyperstimulation
Pros and cons of amniotomy
Amnihook to artificially break the membranes to release prostaglandins
Must be done before oxytocin drip
But can be uncomfortable- pain relief can be provided
Alternative to OGD
Barium swallow
Non-invasive and doesnt require sedation
Shows motility problems in the oesophagus but can’t examine the mucosa or get a biopsy
What do you have to do before an OGD
Stop PPIs 2 weeks before
Not eat for 6 hours, clear fluids for 2 hours (same as surgery)
?stop anticoagulants also
2 options for anaesthesia during OGD
Throat spray- numbing back of throat, no gag reflex
IV sedation- relaxes patient but they stay awake, must be taken home
Side effects and risks of OGD
SE:
- gagging
- sore throat
- nausea/ abdominal pain
- minor bleeding
Risks:
- damage to teeth- mouthguard
- aspiration pneumonia
- perforation
- infection
- over-sedation
Alternative to colonoscopy
CT colonography (virtual colonoscopy)
Imaging test- air enema and then CT from different angle creates 3D model
Less invasive but not as detailed and no biopsies
How to prepare for colonoscopy
Bowel prep- low fibre diet for 2-3 days and increase fluids
Then take very strong laxative the day before -> diarrhoea
Eating 6 hrs, clear fluids 2 hrs
Pros and cons of the 2 types of dialysis
Haemodialysis and peritoneal dialysis (catheter into peritoneum- fluid changed either overnight or 4x a day )
Haemodialysis has a social aspect, performed by HCP, has dialysis-free days and can be done at home.
BUT diet and fluid intake are restricted, requires vascular access and can cause SE including infection, muscle cramps, itchy feeling
Peritoneal dialysis is more flexible and freeing, but is done every day, you have as permanent catheter in, and has risks e.g. hernia, infection, scarring
5 transfusion side effects and management
Anaphylaxis -> stop and IM adrenaline etc ABCDE
TACO -> stop and Tx as acute HF
TRALI -> stop and supportive care e.g. O2
Haemolytic reaction (ABO incompatibility) -> stop and supportive Mx
Febrile non-haemolytic transfusion reaction -> slow and paracetamol
How to differentiate between TRALI and TACO
Both present with SOB, hypoxaemia
TRALI more severe
TACO more likely in HF patients
TACO more of an overload picture, TRALi has CXR white out
How does acute haemolytic transfusion reaction present
Fever, hypotension, agitation, flushing, chest/ abdominal pain, DIC/ bleeding, AKI
Occurs in minutes of BT
If rigors consider bacterial contamination instead
What is UKMEC4 for COCP
<3wks p.p if not breastfeeding
<6wks p.p if breastfeeding
Breast cancer
> 35 and smoke >15 a day
VTE history
Recent immobilisation
Thrombogenic mutations
Antiphospholipid
AF
Migraine with aura
What percentage of women using the COCP get pregnant after a year
9%
Actually effectiveness is 99% but people dont use it right so it is 91% effective
What 2 cancers does COCP reduce chance of
Ovarian and endometrial
Increases cervical and breast cancer
Four risks of COCP
VTE
MI / stroke
Breast cancer
Cervical cancer
Common side effects of the POP
Irregular bleeding !!!!
Headaches
Nausea
Mood changes
Breast tenderness
Missed pill times for types of POP
Desorgestrel= half Day= 12 hours ok
Levonorgestrel/ norethisterone= 3 hours
Indications for double dose of levonorgestrel
BMI>26
Weight >70kg
Enzyme-inducing meds
No double dosing for Ella-One
6 enzyme inducers
Carbemazepine (mood stabilizer, anticonvulsant)
Rifampicin (Abx)
Alcohol
Phenytoin (seizure prevention)
Griseofulvin (antifungal)
Phenobarbitone (seizure prevention)
Sulphonylureas (T2DM e.g. gliclazide)
They induce P450 which increases the amount of NAPQI which is hepatoxic which is relevant in paracetamol overdose
Inhibitors of P450 enzyme (9)
SSRIs
Omeprazole
Valproate
Acute Achilles
Antibiotics e.g. ciproflox, eryth
Amiodarone
Allopurinol
Isoniazid
Zoles e.g. ketoconazole
Can you restart hormonal contraception after emergency
Yes if levonorgestrel
No if EllaOne- wait for 5 days
UKMEC4 for contraceptive implant
Current breast cancer
Cons of contraceptive implant
Unpredictable bleeding that doesn’t necessarily get better
Procedure to fit and remove
Small increased risk of breast cancers
UKMEC 4 for copper coil
P.p sepsis
PID active
STI active
Cervical/ endometrial cancer
Pelvic TB a
Cons of copper coil
Heavier and more painful periods
1/20 risk of expulsion
Ectopic pregnancy
No protection vs PMS
When do you take methotrexate
Once a week
Folic acid on the other days/ also once a week? But on different days
FA helps to reduce side effects
Analgesia in copper coil insertion?
Yes!
Take ibuprofen/ paracetamol 1/2 hours before
Can have LA in the cervix, spray into cervix, gel into uterus or just simple analgesia
How does IUS work
3 ways:
- thins endometrium to prevent implantation of egg
- thickens cervical mucous to prevent sperm from entering uterus
- can prevent ovulation sometimes
How does depot injection work contraception
3 ways:
- thins lining of uterus
- thickens cervical mucous
- inhibits ovulation
(Same as IUS as is progesterone, POP doesn’t seem to thin uterus lining like the other two do)
How often is depot injection given
Every 13 weeks (3 months)
What is chance of anaphylaxis in vaccinations
1 in 1 million in UK
Which vaccines are live
Measles
Mumps
Rotavirus
Rubella
5 cautions for corticosteroid prescribing
Liver impairment
Stomach ulcers
Diabetes
MH problems
Pregnancy!! (Lower dose as affects growth)
What should be avoided in those taking immunosuppressive doses of steroid
Live vaccines!
Polio, MMR, BCG
Missed pill rule for steroids
Take as soon as remember
BUT
Don’t take 2 doses at once to compensate
How do we monitor people on steroids
BP, body weight and BMI to check for weight gain i guess
Eye exam for glaucoma/ catacts
HBA1C 1 month after stating then every 3 months
Common short and long term side effects fo steroids
Short-term:
Sleep disturbance/ insomnia
Weight gain
Mood changes
long term:
Cushings
Osteroporosis
HTN
Muscle weakness
Diatebetes
Peptic ulcers
Cataracts
What not to forget in steroid counselling
Steroid withdrawl-> adrenal insufficiency! Do not stop a suddenly
Steroid emergency card
Double dose (hydrocortisone) during illness
Do you stop metformin in low eGFR
Yes
EGFR <30
As risk of lactic acidosis
Missed pill rule for metformin
Take next dose as normal, don’t take two together !
What do you monitor in metformin
Renal function
As metformin is excreted by the kidneys so in bad renal function it could build up and cause lactic acidosis
2 serious risks of metformin
Lactic acidosis
B12 deficiency-> neuro symptoms
Serious side effects of methotrexate
Liver toxicity -> jaundice
Thrombocytopenia -> bleeding gums, bruising etc
Serious infection -> fever, chills etc
Stevens-Johnson syndrome -> severe skin rash/ blisters
Which drug do you not take with methotrexate
Trimethoprim (or co-trimoxazole)
Increases risk of bone marrow suppression
4 serious side effects of clozapine
Agranulocytosis-> neutropenic sepsis
Lowers seizure threshold
Ileus/ bowel obstruction due to constipation
Cardiac complications e.g. myocarditis/ cardiomyopathy due to potential persistent tachycardia
Statins side effects
Generally well tolerated
Myalgia (muscle pain) is common but not concerning, but muscle toxicity can be severe
Also common is nausea, constipation, headache
Can cause ILD
When to take Levothyroxine
At least 30 mins before breakfast as food etc can reduce absorption
Also don’t suddenly stop taking it
Also dont take two doses together if u miss one
How to describe levothyroxine side effects
Based on levels of drug
So hypothyroid symptoms if too much dose
Hyperthyroidism if too little
Monitor levels at least yearly once stable
Who should not be taking PrEP
HIV positive people
It wouldn’t work on them and increase drug resistance
2 options for taking PrEP
Daily dosing
Event-based dosing- two tablets <24 hours before sex, 2 pills each day after
Common lithium side effects vs lithium toxicity
Common:
- thirst
- tiredness
- weight gain
- fine tremor
Toxicity:
- confusion
- drowsy
- difficulty speaking
- seizures
- vision problems
Common and serious side effects of bisphosphonates
Common:
- Oesophageal irritation - advise not to take ibuprofen as can worsen
- abdo pain, nausea
Serious:
- osteonecrosis of the jaw
5 A’s of smoking cessation
Ask about smoking history
Assess their understanding of risks of smoking
Advise on risk of smoking
Assist:
- Set a quit date
- Tell family and friends
- Anticipate challenges
- Remove tobacco
Arrange follow up appt
Pros of HRT
Reduction of vasomotor symptoms e.g. hot flushes
Improved mood
Improved dryness etc
Reduces osteoporosis risk
CV protection
Disadvantages of HRT
Depends on type, common includes breast tenderness, bloating, headaches
RISKS:
- VTE (combined and oestrogen only)
- Stroke
- Breast cancer (with combined- small risk only)
- endometrial (oestrogen only is not prescribed in people with a womb)
How to counsel bleeding on warfarin
If small amount then ok e.g. long periods, cutting self, nosebleeds <10 mins, bleeding gums
SERIOUS if nosebleed >10 mins, any blood in bodily fluid, cut that doesnt stop
How to do a pre-op assessment
History/ why getting surgery
On the day- ?explain op and fasting period
Previous anaesthetics- screen for MH (muscle contractions, high body temp) and sux apnoea (unable to move/ breathe) and anaphylaxis
Meds- ask about anticoagulants, antiplatelet, antiHTN, painkillers
PMH- resp, cardio, diabetes, kidneys, GI, neuro e.g. stroke, MSK e.g. arthritis
FH
social Hx- smoking, alcohol, diet, exercise, who will pick them up after, job
How does DOACs affect INR
Can prolong it due to prolonging PT (i.e takes longer to clot), however these effects are predictable and so we dont need to monitor clotting in DOACs too closely
Baseline FBC, U+E, LFT, clotting and should recheck every 6 months
Reference ranges for ABG
pH: 7.35 – 7.45
pCO2: 4.6 – 6.4 kPa
pO2: 11.0 – 14.4 kPa,
Bicarbonate 22-29
How to interpret CURB65
0 / 1 -> treat as outpatient
2 -> treat as inpatient (potentially with IV abx)
3 or more -> treat as inpatient, consider ITU admission
How to interpret chadsvasc score
0 in males, 1 in females= no tx required, low risk of stroke
1 in males= moderate risk, consider oral anticoagulants treatment
2 or more in either gender= high risk, give oral anticoagulants
Driving rules after TIA
Can’t drive for 1 month after TIA
Only tell the DVLA if you still have symptoms after a month, if not can go back to driving
Common OSCE station presentations that you need to notify urgently to UK Health Security Agency (7)
Hepatitis
Encephalitis
Meningitis
Typhoid
Haemolytic Uraemic Syndrome
Legionella
Measles
Whooping cough
Is c diff notifiable
No
What are the spirometry findings in obstructive and restrictive lung disease
Obstructive:
- reduced FEV1/FVC ration (<0.7)
- FEV1 <80% of predicted
- slightly reduced FVC
Restrictive:
- normal FEV1/FVC ration (>0.7)
- both FEV1 and FVC reduced to <80% of normal
5 examples of restrictive lung disease
Pulmonary fibrosis
Pulmonary oedema
Lung tumour
Neuromuscular disease e.g. MND, Guillan-Barre
Obesity / pregnancy
How does digoxin work
Slows heart rate and increases myocardial contractility
It has a narrow therapeutic index
Can cause gynaecomastia, hypokalaemia, and interacts with lots of drugs
When is safe to discharge asthma patients
FEV1 >75% of best
Salbutamol less than 4 hourly
Symptoms no longer significant
Discharge with asthma discharge plan- inhaler technique, GP follow up, written instructions on when to attend ED, ensure asthma meds
Which meds to stop in AKI
NSAIDS (apart from low dose aspirin 75mg)
ACE inhibitors
Angiotensin II receptor blockers
Diuretics (unless overloaded in which case can give furosemide etc)
Aminoglycosides e.g. gentamicin
Consider stopping the following as they can increase the risk of toxicity:
- metformin
- lithium
- digoxin
Which 3 medications can put you at risk of renal toxicity but dont worsen AKI
Metformin
Lithium
Digoxin
So consider stopping
Venturi masks, required flow rate and FiO2 given
Blue= 2-4L/min, 24%
White= 4-6L/min, 28%
Yellow= 8-10L/min, 35%
Red= 10-12L/min, 40%
Green= 12-15L/min, 60%
UC management
Mild- moderate= mesalazine (an aminosalicylate) to maintain and induce remission, severe give IV hydrocortisone
Chrons management
Steroids to induce remission (oral pred or IV hydrocortisone)
Maintain remission with azathioprine or mercaptopurine
How to interpret ABCD2 score in TIA management
If above 4 then do not discharge to TIA clinic, keep them in hospital as 1 in 9 chance of major stroke in 6 days
Management of GORD
LIFESTYLE:
- lose weight
- avoid trigger foods e.g. choc, spicy food, coffee
- smaller meals
- stop smoking
- reduce alcohol
- sleep with bed raised slightly (not more pillows)
PRESCRIBE:
- PPI
Which anti-epileptic should pregnant women be taking
Lamotrigine or levetiracetam
What causes a bitemporal hemianopia
Lesion to the optic chaism (where the nerves cross)
Next to pituitary
So caused by pituitary adenoma
What causes homonymous hemianopia
Contralateral optic tract lesion (before they cross)
Caused by stroke/ neoplasm
What causes mono-ocular blindness
3 categories
Ocular medial
- corneal ulcer
- ocular trauma
Retinal
- retinal detachment
- CRAO, CRVO
Neurological
- ipsilateral optic nerve lesions e.g. optic neuritis
STEMI on V1-V2 what type and artery
Septal MI
Proximal LAD
STEMI on V3-V4 which type and artery
True anterior
LAD
STEMI on V5-V6 which type and artery
(Antero)Lateral
Could be distal LAD, Left Circumflex or RCA
STEMI V5, V6, I, AvL which type and artery
Lateral
Left circumflex is most likely
STEMI II, III, AvF which type and artery
Inferior STEMI
80% chance of RCA, LCx in 18%
What are the reciprocal leads for each type of stemi
Anterior (V1-V4)= inferior leads (II, III, AvF)
Lateral (V5-6, I, AvL)= inferior leads (II, III, AvF)
Inferior (II, III, AvF)= lateral leads (I, AvL)
Posterior (V7,8,9)= anterior (V1-V4)
What is section 136
Police can detain person to a place of safety for up to 24 hours for assessment by medical practitioner
From public place
135 is from house to place of safety
What is section 135
Allows police officers to enter a private property to take them to a place of safety if they:
- have been neglected
- unable to care for themselves
Up to 24 hours
What section do you use if inpatient in hospital and thinks should be sectioned
5(2) if doctor- holds for 72 hours against their will for assessment
5(4) if nurse- holds for 6 hours against their will for assessment
How long do section 2 and 3 last for
2= 28 days
3= 6 months
Who needs to be involved in a section 2/3
AMHP
AND
Two doctors (one must be section 12 approved) q
AAA screening management
<3cm-> normal
3-4.5-> rescan yearly
4.5-5.5-> rescan 3 monthly
> 5,5-> refer 2nd to vascular surgery
4 ways to diagnose H Pylori
Urea breath test
Stool test
Blood test for antibodies vs H.pylori
OGD biopsy (most accurate)
Stop taking PPIs for 4 weeks before this
Antibodies for SLE
ANA is most sensitive
Anti-dsDNA is most specific
Antibodies for systemic sclerosis
Limited (CREST)= Anti-centromere
Diffuse= anti-Scl70
SJogren’s syndrome antibodies §
Anti-Ro and anti-La
Polymyositis/ dermatomyositis antibodies
Anti-Jo1
Glaucoma on fundoscopy
Increased cup:disk ratio !!!
Cataracts would cause absent red light reflex
What causes AV nipping
Most commonly is HYPERTENSVIE RETINOPATHY
Most common cause of drusen
DIABETES
What commonly causes dot and blot haemorrhage
Retinal haemorrhage due to diabetic retinopathy
Also get drusen
