everything Flashcards
serotonin syndrome presentation:
confusion, sweating, agitation, HYPEReflexia(remember as Increased Reflexes), myoclonus.
Manage: by stopping SSRI and supportive care.
TCA(tricyclic antidepressant) over dose presentation:
confusion, seizure, tachycardia, hypotension, dilated pupils(mydriadsis) and ecg: prolonged Qtc interval and QRS duration.
ALL(Acute Lymphoblastic Leukaemia) signs triad:
- Recurrent infections(Neutropenia)
- Pallor and Fatigue (Anaemia)
- Purpuric Rash (Thrombocytopaenia)
also weight loss and presenting in younger children.
ddx: HSP/ ITP= differentiating factor is that ALL has recurrent infections.
Lateral Medullary Syndrome(also called Wallenburg syndrome)- is a stroke affecting PICA
PICA lesion-cerebellar signs(ataxia/nystagmus), contralateral sensory loss and ipsilateral Horner’s(ptosis and miosis)
lateral pontine syndrome
Very similar to lateral medullary syndrome- ALSO has ipsilateral facial paralysis(as facial nerve is involved) and deafness.
Middle cerebral artery syndrome(stroke)
Hemiparesis(weakness to move one side of body)+sensory loss- UPPER is affected more than lower. (these presentations are on opposite side to site of lesion)
partial anterior circulation syndrome
Includes 2 of:
- Unilateral hemiparesis and/or Hemisensory loss
-Homonymous hemianopia
-Dysphasia(speech difficulty)
posterior cerebral artery syndrome
Presents with:
- homonymous hemianopia
-MACULAR sparing in eye opposite to lesion side
-visual agnosia(unable to recognise objects)
Parkinsons- management
patients without a diagnosis need to be referred to neurology(specialist first)- then to be started on Levo-dopa(if motor symptoms are affecting ADLs)
benign essential tremor management
Propanolol(because it is a beta blocker)
Parkinsonism Triad Symptoms
Resting tremor, Bradykinesia, Rigidity
example of MAO b inhibitors(parkinson medication)
rasagiline, selegiline, safinamide
side effects of levo dopa
dry mouth, psychosis, postural hypotension, palpitations, anorexia, one off phenomenon(large variations in motor performance), dyskinesias at peak dose
Examples of dopamine receptor agonists:
cabergoline, bromocriptine, ropinirole
GCS emergency action:
need to intubate if GCS is less than 8.
- lost airway is more immediately life threatening than blood loss.(ABC)
GCS scale:
3 sections: MVE(Motor, Verbal, Eye opening) - out of 15 points.
- Motor(out of 6):
1. none
2. Extends to pain
3. abnormal flexion to pain
4. withdraws from pain
5. localises to pain
6. obeys commands
-Verbal(out of 5):
1.none
2.sounds
3.words
4.confused
5.orientated
-Eye opening(out of 4):
1. none
2. to pain
3. to speech
4. spontaneous
PPH(post partum haemorrhage) causes:
most common cause= uterine atony
other causes= 4 Ts:
1. tone(uterine atony)
2. tissue(retained placenta eg. if there is placenta accreta)
3. thrombin: clotting/bleeding disorder
4. trauma(perineal tear)
placenta accreta
placenta is deeply implanted and grows in uterine wall.
PPH: risk factors and management:
Risk factors= previous PPH, prolonger labour, pre eclampsia, emergency c section, polyhydramnios
Management: is an emergency
- 1. ABC(cannula, lie woman flat, bloods group and save, start warm crystalloid function)
2. catherisation and rubbing up the fundus
3. medical: iv oxytocin, IV ergometrine(CI in hypertension), carboprost(IM)(CI in asthma), misoprostol(sublingual)
4. if medical mx. fails= surgical: intrauterine balloon tamponade.
epilepsy medications for different types of seizures:
- Generalised tonic clonic:
-males= sodium valproate
-females= lamotrigine - focal seizures(localised to only one side of the brain): males and females give same
1st line: lamotrigine
2nd line: carbamazepine - absence seizures: same for both genders
1st line: ethosuximide
2nd line: male= sodium valproate, female= lamotrigine - Myoclonic seizure:
males: sodium valproate
females: levetirecataM - Atonic seizure:
males: sodium valproate
females: lAmotrigine
ectopic pregnancy mx:
mEthotrexate- can be used if low amounts of pain in ectopic pregnancy(if size more than 35 mm)
- expectant management i.e monitoring for 48 hours is used if ectopic is small(less than 35 mm) with no cardiac activity.
Inv: Transvaginal ultrasound
Miscarriage mx:
Use mIsoprostol.
Chicken pox presentation
Scabbed lesions, erythematous vesicles, raised temp, rash on torso and face.
Mx: topical calamine lotion
AVOID: ibuprofen= because there is a risk with using NSAIDS and getting necrotising fasciitis.
transient tachypnoea of the newborn(is the commonest cause of resp distress in neonate) presentation and mx:
CXR: Shows hyperinflation and fluid in horizontal fissure of the lungs and increased Resp rate.
- Management: observation and supportive care and maybe supplemental oxygen is required.
this usually settles within 1-2 days.
- is more common following caesarean sections.
hypoxic ischaemic encephalopathy(HIE) management in neonates:
therapeutic cooling at 33-35 degrees to reduce the chances of severe brain damage.
normal pressure hydrocephalus presentation and MRI finding:
Presentation: urinary incontinence, forgetful memory problems, cannot raise foot when walking(shuffling).
MRI imaging shows: ventriculomegaly(large ventricles) without sulcal enlargement.
Management: ventriculoperitoneal shunting.
syringomyelia presentation:
Cape like loss of pain AND temperature because of Compression of spinothalamic tract fibres that decussate.
Inv to reveal diagnosis: MRI spine.
Mx: shunt if presentation is persistent and symptomatic.
Nerve conduction studies useful for:
Differentiating axonal from demyelinating causes of neuropathy.
miller fisher syndrome
is a variant of Guillian Barre syndrome- has Anti-GQ1b antibodies.
presents with triad of:
1. Ophthalmoplegia
2. Arreflexia
3. Cerebellar dysfunction
phenytoin side effects:
Acute: dizziness, diplopia, nystagmus, slurred speech, confusion, seizures
- chronic: bleeding gums(gingival hyperplasia), lymphadenopathy
-teratogenic: associated with cleft palate and congenital heart disease.
Mnemonic to remember:
P= p450 interactions
H= hirsuitism
E= enlarged gums
N= Nystagmus
Y= yellow skin ie. jaundice
T= teratogen
O=osteomalacia
I= interference with B12 metabolism
N= neuropathies
What is contraindicated when taking contraception(like depot progestogen only injection)?
current breast cancer= is UKMEC 4
- side effects of injectable contraceptive= irregular bleeding, weight gain and may also increase risk of osteoporosis.
- is also not quickly reversible and fertility may return after a while.
Cardio Murmur: PDA(patent ductus arteriosus)
Presents with:
- Continuous machinery murmur, L subclavicular thrill, wide pulse pressure, heaving apex beat, large volume collapsing pulse.
-Indomethacin is given to neonate in postnatal period(indomethacin inhibits prostaglandin synthesis and closes the defect.)
Low pressure headache: can remember as LP headache.
- Commonly develops following a Lumbar Puncture.
Mx: with caffeine and fluids.
Stopping Epilepsy Treatment:
Can be considered if seizure free for more than 2 years, with medication stopped over 2-3 months.
status epilepticus management:
1st: try 2 doses of IV lorazepam
if seizures still hasnt stopped=
2nd: try IV phenytoin
parkinsons disease- postural hypotension
Parkinsons can lead to postural hypotension(difference of more than 20 in lying standing BP) due to autonomic failure.
drug induced parkinsonism:
- motor symptoms are more rapid onset and BILATERAL(symmetrical).
- rigidity and resting tremor is uncommon.
visual lesions- where and what it means
left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric.
Homonymous hemianopia
incongruous defects: lesion of optic tract
congruous defects: lesion of optic radiation or occipital cortex
macula sparing: lesion of occipital cortex
Homonymous quadrantanopias*
superior: lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop)
inferior: lesion of the superior optic radiations in the parietal lobe
mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Pontine haemorrhage presentation:
Presents with: Reduced GCS, Paralysis and bilateral pinpoint pupils.
guilian barre
Ascending weakness+infection, reflexes= are reduced or absent.
Inv: nerve conduction studies- will be abnormal in patients with guilian barre.
- could also do Lumbar puncture= would show raised protein, normal WCC
caused by Campylobacter jejuni
suspected cases of encephalitis mx:
start acyclovir immediately.
- most common cause- herpes simplex virus 1.
Lochia ?
is vaginal discharge containing blood which can continue after 6 weeks after childbirth- colour changes from bright red to brown.
most effective method of contraception (emergency)?
copper IUD- is the most effective and is also not affected by BMI.
- it would also provide long term contraception.
NB: a DOUBLE dose of levonelle is advised for patients with BMI more than 26.
neuropathic pain treatment:
is normally: gabapentin and pregabalin
if these fail and need to give an opoid= give tramadol.
first line investigation for suspected stroke:
NON CONTRAST CT scan- to rule out if it is a ischaemic stroke or haemorrhagic stroke
hoover’s sign:
differentiates between organic and non-organic lower leg weakness
features of atypical UTI:
- poor urine flow
-seriously ill
-abdo mass
-raised creatinine
-septicaemia
-failure to respond to abx with 48 hours.
Contraindications to Lumbar puncture:
- Papilloedema
- DIC
-focal neurological signs
-significant bulging of the fontanelle
-signs of cerebral herniation
Meningitis Management:
Abx:
- less than 3 months: IV amoxicillin+IV cefotaxime
-more than 3 months: IV cefotaxime(or ceftriaxone)
intussusception investigation:
abdominal ultrasound- normally is always abdo ultrasound.
intussusception presentation:
- abdo colic pain
-infant will draw knees up and be turn pale
-vomiting
-blood stained red currant jelly stool(as a late sign)
-sausage shaped mass(target mass)
Mx: now reduction by air insufflation. if this fails= then surgery is performed.
Steven Johnson Syndrome:
- is a skin rash- can be caused by many medications for eg. lamotrigine, carbamazepine, phenytoin, sertraline etc.
cerebral palsy presentation and lesion:
- child who is unable to pull themselves up, abnormal tone, abnormal gait, is not reaching their developmental milestones, feeding difficulties= suspect cerebral palsy.
- NB: Spastic cerebral palsy results from damage to upper motor neuron.
cerebral palsy types:
- Spastic= hemiplegia, increased tone from damage to upper motor neurons- treatment= oral diazepam and baclofen
- Dyskinetic= caused by damage to basal ganglia and substantia niagra
- Ataxic= caused by damage to cerebellum with signs
- Mixed
cocaine abuse signs during pregnancy:
dilated pupils+hyper reflexia
absolute contraindication to copper IUD:
= is pelvic inflammatory disease
Amaurosis Fugax(affects retinal artery) symptoms:
Affects internal carotid artery= and is IPSILATERAL. therefore if curtain closing presentation is on right side= RIGHT internal carotid artery is affected.
APGAR score
Apgar score
The Apgar score is used to assess the health of a newborn baby. NICE recommend that it is assessed at 1, and 5 minutes of age. If the score is low then it is again repeated at 10 minutes.
Score Pulse Respiratory effort Colour Muscle tone Reflex irritability
2 > 100 Strong, crying Pink Active movement Cries on stimulation/sneezes, coughs
1 < 100 Weak, irregular Body pink, extremities blue Limb flexion Grimace
0 Absent Nil Blue all over Flaccid Nil
A score of 0-3 is very low score, between 4-6 is moderate low and between 7 - 10 means the baby is in a good state
if plasma glucose is more than 7(gestational diabetes) then management:
start: insulin.
if not= then do diet changes and commence metformin first.
diagnostic thresholds for gestational diabetes:
- fasting glucose- more than 5.6 mmol/L
- 2 hour glucose- more than 7.8 mmol/l
CONSENT guidelines:
in england- child CAN consent to treatment but NOT refuse treatment even if child has demonstrated capacity.
Croup= reason for admission
AUDIBLE stridor at rest- is an indication for admission.
Management of I.I.H(Idiopathic Intracranial Hypertension)
Acetazolamide- it reduces the production of CSF and hence reduces the pressure.
- topiramate can also be used
- Classical presentation: young, obese females presenting with: headache, blurred vision, papilloedema, enlarged blind spot, sixth cranial nerve palsy.
mx: with weight loss.
pituitary apoplexy triad:
- sudden onset headache, visual field defect, pituitary insufficiency eg.(hypotension)
- pathophys: is a sudden enlarging of a non-functioning benign pituitary tumour.
vestibular neuritis presentation:
commonly occurs after upper resp viral infection+short bursts of dizziness.
ddx= Labyrinthitis but this would also present with hearing loss.
Meniere’s disease= will present with aural fullness.
-Ototoxicity: is caused by aminoglycoside abx and loop diuretics.
Normal developmental milestones:
Normal gross motor milestones:
- 6 weeks: Good head control - raises head to 45 degrees when on tummy
- 6 months: Sit without support - rounded back; rolls tummy (prone) to back (supine) - vice versa slightly later.
9 months: Stands holding on
12 months: Walks alone (12-18m). 18 months is threshold for concern.
18 months: Runs
2 years: Runs on tiptoes; walks up stairs - 2 feet per step
2.5 years: Kicks ball
3 years: Hops on one foot for 3 steps; walks up stairs 1 foot per step but still 2 feet per step on the way down.
4 years: Walks up and down stairs in an adult fashion
ALL child presentation:
with blast cells- classical cancer presentation causing anaemia and thrombocytopaenia and lymphadenopathy is the most common sign.
- Is definitively diagnosed through bone marrow biopsy.
NB: condition has bimodal distribution at 5 yrs of age and at 60 years of age.
most likely pathogens of sepsis:
neonate= group B strep, 72 hours after birth: staph aureus.
Lumbar puncture= essential if neonatal meningitis is suspected.
empirical treatment: is gentamycin and benzylpenicillin
obstetric analgesia: what is safe to take?
NSAIDs are NOT safe to take.
-can take paracetamol but this crosses the placenta barrier.
opiate analgesia to use= is codeine phosphate.
jugular foramen syndrome:
The Jugular foramen syndrome is the classic syndrome of unilateral X and XI palsies, with soft palate and uvula deviation, weakness of head twisting and shoulder shrugging. Causes include tumours (neurofibroma, meningioma, glomus jugulare), infiltration (e.g. CNS lymphoma, carcinomatosis), sarcoidosis and spreading of a middle ear infection
Bishop Score:
Interpretation of Bishop score:
The Bishop Score-
The Bishop score is used to assess whether a patient is likely be a good candidate for an induction of labour.
Usually a score of 9 or more means that the patient is likely to achieve a successful vaginal delivery and would be a favourable candidate for induction. The lower the score, the less favourable the cervix is.
Calculating the Bishop score
The following components are assessed:
Cervical Score 0 1 2 3
Position Posterior Middle Anterior N/A
Consistency Firm Medium Soft N/A
Effacement 0-30% 40-50% 60-70% ≥80%
Dilation Closed 1-2cm 3-4cm ≥5cm
Foetal station -3 -2 -1, 0 +1, +2
The components can be remembered with the following mnemonic: Pregnancy Can Enlarge Dainty Stomachs! (Position, Consistency, Effacement, Dilation, Station).
Certain circumstances call for addition or subtraction of points (Bishops score modifiers):
1 point is added to the score for each of the following:
Presence of pre-eclampsia
Each previous vaginal delivery
1 point is subtracted for each of the following:
Post-dates pregnancy
No previous vaginal deliveries
Premature pre-term rupture of membranes
surfactant lung deficient disease:
- Risk factor: maternal diabetes, c- section, male sex,
primary sclerosing cholangitis:
inflammation and fibrosis of the bile ducts.
Px: with deranged LFTs, jaundice, WEIGHT LOSS, pruritus,right upper quadrant pain
Ascending Cholangitis:
Infection of the biliary tract. It typically presents with Charcot’s triad(3) of jaundice, fever and right upper quadrant pain.
Aortic Stenosis triad of signs:
SAD:
- S: Syncope
- A: Angina
-D: Dyspnoea (shortness of breath)
Aortic Stenosis triad of signs:
SAD:
- S: Syncope
- A: Angina
-D: Dyspnoea (shortness of breath)
Shaken Baby Syndrome triad: (SER)
- Subdural Haematoma
- Encephalopathy
- Retinal haemorrhages
progressive supranuclear palsy(PSP):
Presentation: Supranuclear ophthalmoplegia, Pseudobulbar palsy, prominent neck dystonia, parkinsonism, behavioural and cognitive disturbances, and gait imbalance
COCP(combined pill) contraindications:
- less than 6 weeks post partum
-aged above 35 and smoking more than 15 cigarettes in a day
COCP(combined pill) contraindications:
- less than 6 weeks post partum
-aged above 35 and smoking more than 15 cigarettes in a day
UKMEC 3 examples:
- more than 35 years old and smoking less than 15 cigarettes/day
- BMI > 35 kg/m^2*
- family history of thromboembolic disease in first degree relatives < 45 years
- controlled hypertension
- immobility e.g. wheel chair use
- carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
- current gallbladder disease
UKMEC 4 examples:
Examples of UKMEC 4 conditions include:
- more than 35 years old and smoking more than 15 cigarettes/day
- migraine with aura
- history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
CURRENT breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
ecological study:
Ecological studies assesses the overall frequency of disease in a series of populations and looks for a correlation with the average exposure in the populations. These studies are unique in that the analysis is not based on data on individuals- is a population based study.
ebstein’s anomaly:
-is a heart defect associated with lithium that can get during pregnancy
-characterised by large right atrium, small right ventricle, and tricuspid incompetence
when should you give steroids(like dexamethasone) for meningitis?
- cannot give in children less than 3 years
- criteria to give:
-purulent CSF
-CSF WBC more than 1000
-CSF protein raised
-is a bacteria on a gram stain
Meningitis: need to inform Public Health England and for prophylaxis of household contacts= give Ciprofloxacin(used to be rifampicin)
Study Designs:
-Case-control study: finds individuals with a given outcome along with a suitable control group and looks back retrospectively at how many individuals from both groups had the exposure(s) of interest.
-Cross-Sectional study: measures prevalence in a population at a given point in time.
- Randomised clinical trial tests the effects of a specific intervention or interventions against a control group
next step for child less than 3 years presenting with an acute limp:
Refer for urgent paediatric assessment.
NB; even if you know ddx as transient synovitis is rare in younger age group.
ovarian cancer staging:
Staging:
- Stage I (limited to the ovaries):
- Stage IA: limited to one ovary, the capsule is intact
Stage IB: limited to both ovaries, capsules intact.
Stage IC: tumour limited to one or both ovaries with any of the following: capsule ruptured, tumour on ovarian surface, malignant cells in ascites or peritoneal washings.
Stage II involving one or both ovaries with pelvic extension and/or implants:
Stage IIA: extension and/or implants on the uterus and/or Fallopian tubes. No malignant cells in ascites or peritoneal washings
Stage IIB: extension to and/or implants on other pelvic tissues. No malignant cells in ascites or peritoneal washings
Stage IIC: pelvic extension and/or implants (Stage IIA or Stage IIB) with malignant cells in ascites or peritoneal washings.
Stage III involving one or both ovaries with microscopically confirmed peritoneal implants outside the pelvis:
Stage IIIA: microscopic peritoneal metastasis beyond pelvis (no macroscopic tumour)
Stage IIIB: macroscopic peritoneal metastasis beyond pelvis <2 cm
Stage IIIC: peritoneal metastasis beyond pelvis >2 cm and/or regional lymph node metastasis.
Stage IV ovarian cancer is tumour involving one or both ovaries with distant metastasis.
oxford stroke classification:
Oxford stroke classification:
TACS - the patient must have all 3 of the following:
Unilateral weakness (and/or sensory deficit) of face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)
PACS - the patient must have 2 of the following:
Unilateral weakness (and/or sensory deficit) of face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)
POCS - the patient must have 1 of the following:
Cerebellar or brainstem syndromes
Loss of consciousness
Isolated homonymous hemianopia
LACS - the patient must have 1 of the following:
Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three
Pure sensory stroke
Ataxic hemiparesis
Steven-Johnson syndrome:
Can be caused by medications like Lamotrigine, immediate management= is by stopping the drug that has caused it.
- Presents as: rash, usually has pro-dromal viral upper resp tract infection.
ectopic pregnancy management:
Expectant management of an ectopic pregnancy can only be performed for
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
- check Beta HcG levels in 48 hours to get an accurate check.
Orbital Cellulitis Presentation:
child with erythema and oedema around one eye, fever, reduced visual acuity, double vision, limited eye movements. most commonly first presents with bacterial sinusitis symptoms(headache, fever, copious yellow snot)
- is generally caused by strep or staph
Noonan’s syndrome presenting features:
- hypertrophic cardiomyopathy
- pulmonary stenosis(ejection systolic murmur)
- spinal and chest wall deformities
- widely spaced nipples.
rectal bleeding in a child: common cause?
Meckel’s Diverticulum
investigation of choice= Technetium Scan- will highlight ectopic gastric mucosa
osteosarcoma- presents with a sunburnt sign
xray findings show: new bony growth and periosteal reaction and pain and swelling
- most common primary bone cancer.
what would CXR show of a person with asthma/wheeze?
hyperinflation of the lungs
modes of inheritance of common disorders:
-Autosomal dominant: huntingtons, marfans, neurofibromatosis
- x linked recessive- duchenne muscular dystrophy
-autosomal recessive- cystic fibrosis, sickle cell disease thalassemia
acute asthma management:
- oxygen saturations should be maintained between 94-98% with high flow oxygen if necessary.
- inhaled salbutamol
- nebulised salbutamol
4.nebulised ipratropium bromide - if o2 sats is less than 92%, add magnesium sulphate
- IV salbutamol
- if still not responding= add aminophylline.
AND ALL patients need to receive steroids.
inguinal hernia presentation in 1 yr old boy:
cannot get above the mass, no transillumination, positive cough impulse- most likely to be a hernia.
delirium tremens presentation:
acute alcohol withdrawal+hallucinations+seizures
hirschsprung’s disease management:
gold standard: is anorectal pull through surgery/Swenson procedure
1st line: is rectal washouts(as patient is constipated)- conservative management wont work.
loop diuretic side effect:
Eg. Furosemide= side effect is ototoxicity (vertigo and difficulty hearing).
antibiotics like gentamycin and vancomycin could also cause ototoxicity.
causes of sensory peripheral neuropathy:
ABCDE
- A: alcohol toxicity
b- B12/folate
C- Chronic kidney disease
D- Diabetes mellitus
E- everything else(vasculitic and paraneoplastic)
question will normally say: glove and stocking distribution
motor neuron disease ALS:
Amyotrophic lateral Sclerosis (has both MIXED upper and lower signs): management= riluzole
- Progressive muscular Atrophy: only LMN features
- Primary lateral sclerosis: only UMN features
Examples of UMN and LMN signs include:
- Upper motor neuron signs include spasticity, hyperreflexia and upgoing plantars (though they are often down going in MND).
- Lower motor neuron signs include fasciculations, and later atrophy.
glasgow coma scale score:
Children’s Glasgow Coma Scale
The Children’s Glasgow Coma Scale is used to assess the level of consciousness of paediatric patients. It is commonly used in the emergency setting.
The Children’s Glasgow Coma Scale
5 years old and above Less than 5 years old
Eye opening
E4 Spontaneous Spontaneous
E3 To voice To voice
E2 To pain To pain
E1 None None
Closed due to swelling or bandage
Verbal
V5 Orientated to place or person Alert, babbles, coos, words or sentences to normal ability
V4 Confused Less than normal ability
V3 Inappropriate words Cries to pain
V2 Incomprehensible sounds Moans to pain
V1 No response No response
Intubated
Motor
M6 Obeys commands Normal spontaneous movements
M5 Localises to supraorbital pain or withdraws to touch Localises to supraorbital pain or withdraws to touch
M4 Withdraws from nail bed pain Withdraws from nail bed pain
M3 Flexion to supraorbital pain Flexion to supraorbital pain
M2 Extension to supraorbital Extension to supraorbital pain
M1 No response No response
opioid (eg. heroin) withdrawal symptoms:
sweating, watery eyes, rhinorrhoea, anxiety and agitation- symptoms come 12 hours after stopping the drug.
for opiod withdrawal maintenance= naloxone
for opoid dependence patients= can use methadone
Rheumatic Fever:
is caused by group A strep infection as a complication
- Rheumatic fever
Definition
Rheumatic fever is a systemic complication of Lancefield group A beta-haemolytic streptococcal infection (typically a pharyngitis) that occurs two to four weeks post infection. Antibodies formed as a result of the infection cross-react with the myocardial tissue, causing the effects of rheumatic fever.
Epidemiology
The incidence of RF in developed countries is low.
It is more common in developing countries, particularly where there is overcrowding and poor access to healthcare.
Clinical findings
Rheumatic fever typically presents with various clinical findings. To aid diagnosis, findings are classified by the Jones criteria into major and minor manifestations.
Jones Criteria
A diagnosis is considered likely if there is:
Evidence of recent streptococcal infection (eg, history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/mL or DNase B titre).
Plus two major criteria; or
One major and two minor criteria.
Major Jones criteria
Arthritis
Usually the earliest manifestation, typically a “flitting” or migratory polyarthritis affecting one joint then others in quick succession. Most commonly affected joints are the knees, ankles, elbows and wrists.
Pancarditis
Affects all layers of the myocardium, however endocardial inflammation may predominate causing valvulitis. This may manifest clinically as a tachycardia, new murmur or new conduction defect.
Sydenham’s chorea
Neurologic disorder consisting of abrupt, non-rhythmic, involuntary movements along with muscular weakness and emotional disturbance. They are most frequently marked on one side and cease during sleep.
Erythema marginatum
Geographical pink/red, nonpruritic rash involving mainly the trunk, thighs and arms. Characteristically, the rash has raised, sharp outer edges with a diffuse clear centre, making a ring (and contributing to its alternate name, erythema annulare).
Subcutaneous nodules
Firm, mobile painless lesions
- Minor Jones criteria
Fever
Arthralgia (unless if arthritis meets major criterion)
Raised acute phase proteins (ESR and CRP)
Prolonged PR interval on ECG (except if carditis meets major criterion)
Management
Management of rheumatic fever involves multiple goals:
Eradication of group-A beta-haemolytic streptococcal infection
STAT dose of IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow
Analgesia for arthritic symptoms
Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen.
Aspirin should be used with caution in young children due to the small risk of Reye syndrome.
There is no evidence to suggest that NSAIDs help with outcomes related to carditis.
If carditis is complicated by heart failure
Glucocorticoids (e.g. Prednisolone) can provide benefit (NSAIDs should be stopped concurrently).
Diuretic treatment may also be necessary, and valve surgery if severe.
Sydenham’s chorea is self-limiting and does not require treatment, however Haloperidol or Diazepam may be used for distressing symptoms or risk of harm.
Erythema marginatum is associated with rheumatic fever is temporary and doesn’t require treatment, although antihistamines can help with pruritus.
Mechanism of valve complications
Rheumatic heart disease is a major cause of valvulopathy in children and young adults in the developing world. The most recent study in 2015 suggests that year there were over 30 million cases worldwide. Streptococcal antigens secondary to bacterial infection cross-reacts with the valve tissue, causing damage. Progressive damage commonly occurs in the years following acute rheumatic fever.
Mitral disease occurs in 70% of cases and is the most common affected valve; aortic valves are involved in 40% (most commonly regurgitation), tricuspid valves in 10% and pulmonary valves in 2%.
Common presentations of valve defects secondary to rheumatic heart disease
Mitral stenosis - isolated mitral stenosis it is the most commonly encountered single valve lesion secondary to rheumatic heart disease
Mitral regurgitation
Mixed mitral stenosis and regurgitation
Aortic regurgitation
Aortic stenosis (rare in isolation)
Tricuspid regurgitation or stenosis
Pelvic Inflammatory disease presentation:
Bilateral abdominal pain, raised ca125, inter-menstrual bleeding.
- having a STI in the past= is at an increased risk of developing P.I.D
idiopathic intracranial hypertension:
presents with: headache and visual changes(loss of visual acuity when changing posture is typical)
Mx: 1st line= weight loss
2nd line= acetazolamide
Bell’s Palsy:
presentation: isolated facial weakness INVOLVING the forehead.
- if question says forehead sparing= think Stroke.
umbilical cord prolapse presentation:
presents as: foetal bradycardia and decelerations.
risk factors for umbilical cord prolapse= multiparity, polyhydramnios, artificial rupture of membranes
Ectopic Pregnancy classical presentation:
Unilateral Abdo pain with cramping for 6 weeks. scant vaginal bleeding of dark brown colour+previous history of pelvic inflammatory disease.
measles complication:
otitis media(think ear)
Herpex virus in pregnancy medication:
need a higher dose so 400mg 3 times a day(normal dose is 200), as in pregnancy there is a higher blood volume going around.
vasa praevia presentation triad:
painless vaginal bleeding, rupture of membranes, fetal bradycardia
Mx: is c section prior to rupture of membranes- if happens- need to do a emergency c section.,
- has an increased risk of fetal death.
if migraine/headache and in the history, patient is taking medication= think MOH(medication overuse headache)
treat by: stopping medication like paracetamol and codeine
red flags for headaches:
weight loss, neuro deficits, positional features, thunderclap nature of headache, altered GCS score
most likely cause of Non traumatic vertebral collapse in an elderly person:
metastatic malignancy
mx: give oral steroids and do Decompression.
sub dural haematoma risk factors:
recent trauma(falls), advanced age(more than 65yr), anticoagulant use, coagulopathy
commonest cause of intracerebral haemorrhage:
hypertension
body signs for HIV infection:
Maculopapular Rash on upper areas and mucosal ulcers.
classically= patients present with fever and cervical lympohadenopathy
women more than 50+bloating inv?
do ca125 bloods to rule out ovarian cancer!
obs pregnancy nerve you block for anesthetic:
puedendal nerve
viral induced wheeze vs. asthma:
viral wheeze= would not present over so long- would present over a few days with symptoms of breathlessness and wheeze
- asthma will have triggers like cat and dog etc.
metoclopramide: uses and side effect:
is an anti-emetic but has parkinsonian side effects
nsaids for periods:
transexamic: for mainly blood loss(menorrhagia)
mefenamic- for pain
blurred vision in one eye and loss of colour vision= what is affected?
optic nerve
other lesions:
-occipital lobe lesion= homonymous hemianopia+macular sparing
-optic chiasm= bitemporal hemianopia
lumbar spinal stenosis presentation:
neurogenic claudication with pain on exercise made WORSE by hip extension and BETTER by hip flexion.
diagnosis for left sided pelvic pain and peritonis and urine preg is negative?
ddx= could be ruptured ovarian cyst.
inital investigation- transvaginal uss
polyhydramnios risk factor:
maternal diabetes
guilian barre syndrome resp depression lung function test?
ONLY FvC not ratio.
miller fisher syndrome:
- is a variant of GBS
= presents with: ataxia, opthalmoplegia, areflexia
child should be able to run and jump by?
2.5 years
roseola pathogen?
HHV6
- can also feature nagayama spots.
nimodipine
is a CCB that prevents vasospasm-induced cerebral ischaemia
long term mx for stroke?
clopidogrel(anti-platelet) and could give atorvastatin(lipid-lowering) therapy
asherman syndrome:
is adhesions and scarring caused by DILATION and curettage procedure.
sheehan syndrome?
is hypopituitarism caused by ischaemic necrosis of the pituitary gland following excessive peri-partum blood loss.
- rare condition in developed countries.
ddx for croup with barking cough that would not normally consider?
bacterial tracheitis
measles investigation?
if rash onset 48 hour ago= do PCR for measles RNA as diagnostic
-if patient has presented 3 days after rash=measles specific IgM and igG do
role of oxytocin postpartum?
to prevent PPH(as it is a uterotonic agent and prevents bleeding)
