F+C (Part 1) Flashcards
What is your first line prescription for mild acne? Write as would be written on a prescription.
Isotretinoin gel 0.05%
Apply a thin layer 1-2x daily
Supply 30g
What is your first line prescription for acne with inflammation? Write as would be written on a prescription.
Isotretinoin gel 0.05%
Apply a thin layer 1-2x daily
Supply 30g
Clindamycin gel 1%
Apply a thin layer, once daily
Supply 30g
After trying isotretinoin and clindamycin a patient’s acne is still not settled. What is your next prescription for acne with inflammation? Write as would be written on a prescription.
Benzoyl peroxide 5% gel
Apply 1-2x daily, after washing
Supply 30g
What is your first line prescription for chlamydia? Write as would be written on a prescription.
Azithromycin 500mg Tablets
Take 2 tablets immediately
Supply 2 tablets
What is your first line prescription for vulval Candida infection? Write as would be written on a prescription.
Clotrimazole pessary 500mg
Insert one into the vagina, leave overnight and remove in the morning
Supply one pessary
What is your first line emollient prescription for a patient with eczema? Write as would be written on a prescription.
Diprobase cream
Apply liberally, at least 3-4 times daily
Supply 500g
Note diprobase is 2/5 on emollient ladder, if needing stronger give Epaderm ointment
What is your first line bath emollient prescription for a patient with eczema? Write as would be written on a prescription.
Dermol 600 Bath Emollient
Add 30ml to bath, do not use undiluted
Supply 600ml
What is your first line steroid prescription for a patient with eczema on the face? Write as would be written on a prescription.
Hydrocortisone 1% cream
Apply a thin layer every 12 hours
Please supply 30g
What is your first line steroid prescription for a patient with eczema on the trunk? Write as would be written on a prescription.
Eumovate 0.05% cream
Apply to affected areas, 1-2x daily
Supply 30g
Eumovate = moderate Betnovate = potent Dermovate = very potent
What is your first line prescription for a patient with a UTI? Write as would be written on a prescription.
Nitrofurantoin 50mg tablets
Take one tablet, four times per day
Supply 28 tablets (7 days)
M: 7 days
F: 3 days
Pregnancy F: 7 days
Children: 7 days
Write a prescription for mophine (10mg) for a patient to help manage their pain.
Morphine sulphate 10(TEN)mg tablets Take 1 (one) tablet every 4 (four) hours as required Supply 56 (fifty-six) tablets
Name 3 causes of global developmental delay
Prenatal: Chromosomal disorders, alcohol or drugs in pregnancy, TORCH infection
Perinatal: Hypoxic brain injury, intraventricular haemorrhage
Postnatal: Meningitis, anoxic events, head injury
Name three causes of an isolated motor delay (usually presenting in the first year)
Cerebral palsy
Congenital myopathy
Spinal cord lesion
Visual/ balance problems
Name three causes of an isolated languagedelay (usually presenting in the second year)
Hearing loss
Anatomical deficit (cleft palate)
Environmental deprivation
Normal/ familial variant
Name three differentials for a child presenting with a social delay aged 3
Autism
Hyperactivity
ADHD
Give two differentials for jaundice in first 24 hours of life?
Haemolysis
Infection
Give three differentials for jaundice in D2-D14 of life?
Physiological
Breast milk
Infection
Haemolysis
Give three differentials for jaundice in after two weeks of age?
Breast milk
Infection
Hypothyroid
Biliary atresia (conjugated)
What is the order of puberty in girls (5 steps) and normal age?
Age 10-14
Breast enlargement > pubic hair > arm hair > growth > periods (approx 12)
What is the order of puberty in boys (4 steps) and normal age?
Age 12-16
Testicle enlargement > penis enlargement > pubic hair > growth
Give three DDx for early puberty
Normal/ familial variant
Intercranial tumour
Adrenal tumour
Ovarian/ testicular tumour
What age is classed as early puberty?
M < 9years
F <8 years
Name 5 questions which should be asked as part of a constipation history? (Presenting complaint only)
Frequency of stools interval between stools Consistency of stool Colour Straining or pain Incontinence
Name 3 additional questions (not presenting complaint) which should be asked in a constipation history?
DIET
FHx of constipation problems (50% genetic)
Stress
What are you 5 management steps for suspected non-accidental injury?
FBC/ clotting to exclude other disorders
Treat + investigate injury (analgesia, imaging etc)
Photography of injuries
Refer to safeguarding lead and social/ police as appropriate
Document fully (everything possible in patients words)
Name 5 LOC hx differentials?
Febrile convulsion (6mths-5yrs) Seizure Reflex anoxic seizure (in response to trigger/ bump) Breath holding spell Vasovagal Arrythmia/ HOCM collapse
What are the three most common causes of cyanotic heart disease?
Transposition of great arteries (birth)
Tetrology of fallot (1-2 months)
Tricuspid atresia
What are the three most common causes of acyanotic heart disease?
VSD - Most common of all defects
ASD
PDA
Name 5 counselling points for a febrile convulsion
CAUSE - ACKNOWLEDGE DISTRESS + Reassure
Seizure management (stay out of way, call 999 if longer than 5mins or 111 before that if previous FebCons)
Take a video
1/3 will have further seizures
No evidence to suggest risk of serious illness in later life
1 in 50 epilepsy (normally 1 in 100)
Most grow out by age 5
Name 5 RF’s for SIDS
Prematurity Low birth weight Smoking in the home Bed sharing Hyperthemia (overwrapping) Sleeping prone
When is the 6 in 1 vaccine done? Name three counselling points?
At 2,3,4 months
Not a live vaccine
SE: Redness/ swelling/ bump @ injection site
Check allergies to vaccine and no current fever
When is the MMR vaccine given? Name three counselling points?
1yr and then 3yrs 4mths
Live vaccine
SE: Rash (6-10days), face swelling/ joint pain (2-3wks)
Can’t pass contamination to others
CI: Allergy/ pregnancy/ immunocompromised
Ask for gelatin free version
When is the HPV vaccine given, name two counselling points
Age 12-18 (two doses 12mths apart)
Protects against 16,18 (70% cancers) and 6+11
SE: Soreness, swelling, redness on arm (settle in 3 days)
Name 6 symptoms of ADHD
Inattention - forgetful, careless mistakes, struggle with tasks
Hyperactivity - excessive movement, fidgeting
Impulsiveness
Name 3 risk factors for ADHD
Smoking/ alcohol/ drugs in pregnancy
FHx
Low birthweight
Premature
Name 3 management steps when counselling for ADHD
1) Parent behaviour training and pyschotherapy for child and parents
2) Plan day, clear boundaries, intervene early
3) Speak to SENCO at school for support
4) Methylphenidate (OD or 2-3x/daily)
Name 4 complications of down’s syndrome
Hearing problems (70%) Visual problems (60%) Heart problems (50%) Bowel/ thyroid issues
When is the combined test offered, what does it consist of?
Combined = 10-13 weeks
Nuchal translucency
+ PAPP-A (low in DS)
HCG (high in DS)
When is the quadruple test offered and what does it consist of?
Quad = 15-20 weeks
BHCG (high)/ AFP (low)/ Inhibin-A (high)/ oestriol (low)
At what different times can CVS and amniocentesis be offered?
CVS = 11-13wks Amnio = >15wks
What are the misscarriage rates for CVS and amniocentesis?
CVS- 4%
Amnio- 1%
Name 5 differentials for a SOB child?
Croup (6mths- 6yrs, seal cough, preceeding illness) Bronchiolitis (<1yr - cough, wheeze, fluctuating, prodromal illness) Viral induced wheeze Asthma Whooping cough Anaphylaxis GORD (babies) Congenital heart disease (babies)
Name 5 differentials for FTT?
1) Inadequate intake GORD Cows milk protein allergy Coeliac CF Neglect Pyloric stenosis/ IBD etc.
Name 5 lines of questioning for a FTT hx?
Pregnancy - Growth, smoking/ alcohol. illness
Post birth- Meconium, previous growth, NICU
Input- Breast/ bottle, frequency, hunger, feeding trouble?
Output - Energy, anorexia, nappies/ stools/ diarrhoea
Other - General health/ happiness
What questions should be asked before performing a newborn baby check (3)
Complications in labour/ pregnancy
Feeding/ latching on ok?
Passed urine and meconium?
What are the features of bacterial vs. viral meningitis on an LP? (2)
Bac: Raised neuts, raised opening pressure
Viral: Raised lymphs, normal opening pressure
Name two features of a fungal/ TB infection on an LP?
Raised lymphocytes and very raised opening pressure
Name 4 management points to counsel a new T1DM?
1) Education about spotting hypos (dizzy/ drowsy/ hungry/ sweaty)
2) Diabetic MDT care team
3) Insulin (injections vs pump, rapid vs. long acting)
4) Monitoring of glucose levels
5) Complications (eyes, kidney, nerves)
DIRECT TO DIABETES UK
Name 3 differentials for a poorly behaving child
ADHD Conduct disorder (fights alot) Oppositional defiant disorder (loser temper, argues with adults) OCD Autism Attachment disorder
Name 3 features of autism?
Delayed speech Impaired social interaction Lack of awareness or interest in others Impaired emotional ability Repetative or compulsive behaviour
Name 5 features of psoriasis?
Well demarcated, circular to oval
Bright red/ pink plaques
White or silvery scale
Distributed symmetrically over extensor surfaces and scalp
Name 3 features of eczema for a presentation?
Poorly demarkated Erythematous Dry Lesions Look eczematous \+/- lichenification (thickening of epidermis)
Name three causes of a microcytic anemia?
IDA
Thalassemia
Sideroblastic anaemia
Name thee causes of a normocytic anemia?
Anaemia of chronic disease
CKD
Haemolytic
Aplastic anaemia
Name 3 causes of a macrocytic anaemia?
B12/ folate deficiency (megaloblastic)
Pregnancy
Alcohol/ liver disease
Hypothyroidism
What treatment is given for IDA?
3 months of ferrous sulphate
200mg BD/TDS with review
What treatment is given for B12/ folate deficiency?
B12 injections (first) followed by folate supplementation
Name 5 symptoms of leukaemia?
Fatigue Dizziness Palpations Bone pain Brusing Fever Dysponea
What do each of the following indicate:
1) HepA IgM
2) HepA IgG
1- Current infection (IgM)
2- Past infection/ vaccination (igG)
G=Gone (infection)
What do each of the following indicate:
1) HBsAg
2) HBeAg
3) Anti-HBs
4) Anti-HBc
1) HBsAg = Acute disease
2) HBeAg = Marker of current infectivity
3) Anti-HBs = Immunity (vaccine or infection)
4) Anti-HBc = Previous/ current infection (IgM <6mths, IgG >6mths)
What do each of the following indicate?
1) Anti-HCV
2) HCV RNA
1) Anti-HCV = Current/ recovered infection
2) HCV RNA = Active infection
Only treat those with +ve HCV RNA
How do you manage HepA?
Rest, fluids, antiemetics
Stop alcohol and ?paracetamol
Recovery in 3-6mths
How do you manage HepB?
No intercourse til non-infective
Treat as HepA
If HBeAg +ve then add: Peginterferon-alfa-2a (48wks)
Symptoms should resolve in 4-8 weeks
What % of HepB and HepC become chronic?
B = 10% C= 85% (treat same as HepB)
Name 5 counselling points for a patient with eczema?
Keep skin dry, nails short Avoid temperature extremes Avoid wearing wool or synthetics Recognise flare ups and infection 90% grow out by adulthood REFER TO NHS WEBSITE FOR SUPPORT
Name 5 RFs/ triggers for Psoriasis?
Genetic Stress Drugs Low sunlight Smoking and alcohol
Name two tools which can be used to assess severity of Psoriasis infection?
PASI - Psoriasis area severity index
DLQI - Derm life quality index
Name 3 management options for psoriasis
1) Emollients
2) Vit D analogues (Dovobet also contains steroid)
3) Phototherapy/ cyclophosphamide/ methotrexate
You have a patient newly diagnosed with psoriasis, in addition to an emollient what should you prescribe? Write as if on an FP10 form.
Dovobet 0.05% ointment
Apply a thin layer once daily
Supply 30g
Name 5 things which should be asked about in an incontinence hx?
Primary or secondary Triggers (cough, laugh) Urgency Frequency Dysuria Flow/ stream strength
PMHx (Pregnancy, childbirth)
Effects on lifestyle
What is first line management for stress incontinence?
Pelvic floor exercises
8 contractions TDS
Minimum of 3 months
What is first line management for urge incontinence?
Bladder retraining
Gradually increases intervals for minimum of 6 weeks
2) Oxybutanin
Name 4 differentials for incontinence
OAB/ urge
Stress
Mixed
Overflow from obstruction
Name 5 differentials for a breast lump
Breast cancer (ductal most common) Fibroadenoma Breast cyst Ductal papilloma Inflammatory breast cancer/ pagets disease (if other syx)
How does scarlet fever usually present?
Age 2-6 (4yrs most common)
Fever: typically lasts 24 to 48 hours
Malaise
Tonsillitis
‘Strawberry’ tongue - may just have white coat
Rash - fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the face. Sandpaper like appearance
Scarlet fever - S’s (Sore throat, Strawberry tongue, Sandpaper rash, up to Six years + fever)
What identifiers should be checked on all 2ww referrals?
Name
DOB
Address
Phone number
What is the general Hx station structure? (7)
1- Open Q's 2- PC/ HPC 3- ICE 4- Differentials out and in/ screen for red flags 5- PMHx/DHx/FHx 6- Shx and support @ home 7- Summarise
What is the most common cause of spotting?
Anything with progesterone
What four questions should be asked in all paeds histories?
PIDS P- Pregnancy/ birth I- Immunisations D- Development S- Social services
What phase should you use to start any explanation station?
Intro
“It’s the first time I’ve met you so can you bring me up to date with whats been happening so far?”
(Into brief Hx)
What age does coeliac disease tend to present? Name one common association?
8-24mnths (can be later if mild)
Associated with T1DM
How should coeliac disease be diagnosed?
Trial gluten free diet
No longer do jejunal biopsy
Name 3 red flags in a paediatric breathlessness Hx?
Apnoeic spells
Cyanosis
Exhaustion
Worsening symptoms
Name 3 signs of increased work of breathing to be commented on in a paeds respiratory exam?
Increased RR or tachycardia
Nasal flaring
Grunting
Retractions (under neck/ breastbone)
Name 4 things which should be asked for every paeds social history?
Who else is at home?
How is everyone else at home?
Does anyone smoke at home?
Nursery/ school?
A child presents with croup like symptoms, what is your main differential to rule out and what should you not do?
What is the causative pathogen?
Acute epiglottitis
- More sudden onset than croup and more severe, higher fever, will be very unwell, caused by HiB (normally vaccinated against)
DO NOT - examine throat
DO - admit urgently to hospital
How will an autosomal dominant condition show on a family tree?
Someone in every generation affected
How will an autosomal recessive condition show on a family tree?
Unaffected parents > affected child
How does an x-linked condition show on a family tree?
M to M transmission (almost exclusively)
What is the most common cause of bacterial meningitis if 0-3mths?
Group B Strep
What is the most common cause of bacterial meningitis if >3mths?
Streptococcus pneumoniae
(2nd) Neisseria meningitides
What is Duchenne’s muscular dystrophy? Name 3 counselling points for an explanation station?
X-linked recessive disorder (so almost only males affected)
Problem with dystrophin genes = muscle necrosis
Normally clumsy as kids, wheelchair by teens, dead by 20’s
Associated with Gowers sign (too weak to get up from sitting), Pseudohypertrophy of calves
1/3 have learning difficulties
What diagnosis/ management is offered for Duchenne’s muscular dystrophy?
Dx: Raised CK > muscle biopsy > DNA test
Physio
Supportive
Genetic counselling
NIV overnight (poor function of resp muscles)
What structure should be used for a diabetic pre-pregnancy counselling station?
Intro/ how can I help?
I’m not familiar with your case… brief HX
Why now/ other pregnancies/ are you already trying
Explain risks (worsen mums diabetes, baby = macrosomia, miscarriage, heart defects)
ICE
Make plan, offer short term contraception, start on folic acid
When doing diabetic counselling for pre-pregnancy what drug advice should be given?
Metformin (plus insulin if needs better control)
NO- Gliclazide, ACEI, statins
Start folic acid!
What is the bishops score, what sort of cut offs are used?
To predict whether labour will begin spontaneously
<5 = very unlikely to start
>7 = labour should commence easily
Name two CI to the POP?
Breast ca, undiagnosed PV bleed
How should patients be advised regarding taking the POP?
Take at same time every day
If miss dose, take as soon as remembered, if you miss just one day thats ok, miss 2 or more then you need to use additional protection
When are the POP and COCP effective from?
D1-D5 in cycle = immediate
Any other time
- POP = within 48hrs
- COCP = within one week
How should patients be followed up for the COCP and the POP?
Review in 3 months, then every 12 months
BP, heigh and weight, smoking check
Name the structure of every contraception station? (6)
Intro- how can I help?
What contraception do they know? Considered any others? Why that one?
Short or long term/ good with tablets?
Is there anything specific you’d like to know about X?
CATHLETICS
ICE
Note doesn’t protect against STI’s!!!
Name 3 CI to having a coil inserted?
Current pelvic infection
PID < 3mths
Undiagnosed PV bleed
High STI risk (multiple partners)
What are the risks associated with coil insertion?
Expulsion (1 in 20 so coil check at 6 weeks)
Perforation (1 in 10000)
Bleeding
Infection
What history should be taken in an emergency contraception station?
Exact timing
Using any contraception at the time?
Was it consensual?
ICE
What 5 things should be counselled on in any emergency contraception station?
Choice of medicine and how to take (timeline)
Side effects - nausea, tiredness, headache
Was the sexual
STD risks
Signs of ectopic (abdo pain, vag bleed)
Offer long term contraception
What options are available for emergency contraception?
1) Copper coil (within 5 days)
2 - Levonelle (within 72hrs, start other contraception within 2 days)
3- EllaOne (within 120hrs, best options, start other contraception within 5 days)
Name 5 contraindications which must be checked before starting the COCP?
How are your periods?
I’ll need to check a few things like your BMI (>35) and blood pressure
Smoker > 35
Migraine with aura
Hx of clots in legs or lungs (or strong FHx)
Post-natal <6weeks
Hx Breast or liver cancer
Check they are not pregnant!
What advice should women be given regarding taking the COCP?
Take at same time every day
Take for 21 days then 7 day break (can get dummy pill packs)
If miss dose, take as soon as remembered, if you miss just one day thats ok, miss 2 or more then you need to use additional protection for one week
Name 4 hormonal side effects of the pills, which pill tends to have worst SE’s?
Weight gain, acne, mood changes, headache < long term
Breast tenderness and intermittent bleeding < tends to resolve in 3 months
COCP tends to be worse
COCP increases your risk of (A) and decreases risk of (B)
A- Breast and VTE/ HTN
B - Endometrial and ovarian
How should an ectopic pregnancy be explained to a patient?
Intro- How can I help?
SPIKES
(What, why, consequences, management)
- Don’t forget to say risk of death!
What are the three management options for ectopic?
Low risk - Expectant (HcG <200, mass <3cm)
Med risk- Single dose IM methotrexate
- Do HCG on D4 and D7 (15% decrease)
High risk- Salpingectomy
What 4 factors should a patient about to undergo a salpingectomy be counselled on?
GA and laproscopic ICE - find out specific concerns No decreased risk of fertility Can try again straight away 10% risk of future ectopic so needs USS @7wks
If no other tube/ other fertility reasons can consider salpingectomy
Name 5 symptoms of menopause?
Hot flushes Night sweats Vaginal dryness Poor sleep Low mood/ anxiety Low sex drive No periods (for 12 months)
What are the different types of HRT and when should each be prescribed?
Cyclical - If LMP <1yr ago
Continuous - If LMP >1yr ago, or 2yrs if premature failure
Oestrogen only - Given only to those who don’t have a uterus!
What modes can HRT be delivered by? (3)
Patch, tablet, cream, pessaries etc.
Name 6 contraceptive options?
Mirena coil Copper coil COCP POP Implant - lasts 3 years Weekly patch Depot injection - 3 monthly Condoms
What are the three most common post-partum mental health conditions, when do they each occur?
Baby blues (60%) : D3-D7 - Support + reassure Post-natal depression (10%) : 1-3mths - S+R, CBT, sertraline if severe (safe for breastfeed) Puerperal pyschosis (0.1%) : 2-3wks : Admit to hospital, 20% chance of reoccurance
What are your top 5 differentials for menorrhagia?
Dysfunctional uterine bleed (60%) Fibroids - look for urine/ constipation symptoms Cervical or endometrial polyps Bleeding disorders i.e. Von Willibrands Thyroid disease
What 5 questions should be asked about all bleeding from the vagina in PC/HPC?
Timing - Onset (acute of gradual + when) - Duration (intermittent or continuous) - Progression Bleed - Amount - Clots - Pain - Urinary or bowel symptoms
What are the first three lines of treatment for fibroids?
1) COCP/ transexamic/ mefanamic
> If no success then TVUS
2) GnRH agonist (leuprolein)
3) Myomectomy
Which 7 areas should be covered in an infertility hx?
How long trying? Reassure 80% in one year, 90% in 2 years
Takes two to make a baby so need to ask about you and your partner - do either have children already?
Intercourse (How often/ methods/ contraception)
Gynae Hx (MOSC)
Medical Hx (Bleeding, pain, dysparenunia - PCOS and endometriosis symptoms)
Weight/ smoking/ alcohol
What does the acronym PISS WARD F stand for?
P- pre existing medical conditions I- Intercourse (frequency, method) S- Smoking S- Smears W - Weight A - Alcohol R - Rubella D - Drugs F - Folic Acid (400mcg)
Name 5 differentials for infertility?
Unknown cause (25%) Ovarian - an-ovulation i.e. PCOS, prem ovarian failure Tubal/ uterine disoders - PID/ endometriosis Male factor
Name 5 risk factors for miscarriage?
20% of all pregnancies! Previous miscarriage Alcohol Drugs Smoking Diabetes Increase age
What investigations should be done for all miscarriages?
TVUS + hcG (confirm if complete or incomplete)
- Rule out ectopic
What are the management options of an incomplete miscarriage? (4)
Bereavement counselling!!!
1) Expectant - preg test in 3 weeks
2) Medical - mifepristone + mifeprostol 48hrs later as pessary
3) Surgical - under LA, tube hoover into cervix
What acronym is used to remember gynae histories?
MOSC M- Menstrual (LMP plus details) O- Obstetric S - Sexual C - Contraception + cervical smear
What acronym is used to remember obs histories?
WIMPP W- Weeks, first baby? I - Issues (Apppointments, scans, health) M - Movements (refer at 24 wks) P - Previous pregnancies (+outcomes) P - PMHx/DHx/SHx
What acronym is used to remember sexual histories?
SEX CASP S- Sexually active? Ex- Partners (number and M/F) C - Condoms and contraception A - Activites (Vag, oral, anal) S - STI's P - Paid for/ same sex/ abroad (high risks)
Name 5 risk factors for prematurity?
Before:
Multiple pregnancy/ Overweight/ Diabetes/ Fertility Tx
During:
Infection/ Pre-eclampsia / Polyhydramnious /Placenta praevia
What is the structure of all obstetric stations which require an explanation? (4)
Intro + how can I help?
I’m not familiar with your case… how’s pregnancy been so far… Brief Obs Hx (WIMPP) including PMHx etc.
SPIKES for topic explanation
Summary, their choice, give leaflet
What risks regarding prematurity should parents be counselled on?
May need to go to NICU
Need help with breathing/ feeding/ staying warm
Born after 28weeks (80% survive)
Increased risk future birth of prem
How should you counsel a woman regarding breast screening (structure)?
How can I help?
Any specific concerns?
Explain pro’s and con’s
Explain process
Name 4 risk factors for developing candidasis?
Diabetes
Pregnancy
DHx - Antibiotics/ steroids
Immunosuppresion
What are your top 5 differentials for a post-coital bleed?
Infection Cervical ectropion (Increased risk with COCP) Atrophic Cervical/ endometrial polyp Cervical cancer Trauma
What are your top 5 differentials for intermenstrual bleeds?
Idiopathic (50%) Hormonal (increased risk if on pill) Polyps PID (pain/ dysparenunia) Fibroids
What management steps do you undertake for a vaginal bleed - including referal? (5)
Refer (over 45, mass, abnormal cervix, high cancer risk)
Examination
Pregnancy test, swabs for STI’s
FBC and TFTs, clotting
TVUS
What acronym is used to interpret a CTG?
DR C BRAVADO
Dr- Define risk (Diabetes, HTN, multip, previous etc.)
C- Contractions (in 10 mins)
Bra- Baseline rate (110-160)
V - Variability (Normal 5-25)
A- Accelerations (normal)
D- Decelerations (variable are normal if <90mins)
O - Overall (reassuring, non-reassuring or abnormal)
Name three causes of a fetal tachycardia on a CTG?
Fetal hypoxia
Chorioamnionitis
Fetal or maternal anaemia
Name three causes of a fetal bradycardia on a CTG?
Cord compression
Cord prolapse
Epidural
Name the most common cause of late deceleration’s on a CTG?
Fetal hypoxia and acidosis
Can be from Pre-eclampsia or maternal hypotension
How do you investigate late deceleration s on an CTG?
Do FBS
If acidosis then do c-section
What are the key steps in a vasectomy explanation station? (7)
Intro - how can I help?
History- Why now, previous children, brief PMHx
Options- how much do you know? Others considered?
Concerns
Explain procedure
Empathy, give time to make decision
S: Leaflet
A patient asks you to explain a vasectomy to him, name 5 points you’d counsel on?
Done under LA as a day case
Will still ejaculate as normal
Test 12 wees post-procedure to check effectiveness
1 in 2000 failure rate (very small)
Very small risks of bleeding and infection with procedure
Make sure they’ve thought it through and won’t regret it! Reversal is not always available on the NHS and success rates aren’t great
Name 5 parts of a primary ammenorrhoea Hx?
(No menses by 14) Other secondary sexual characteristics Family menses timing HPC: Pain (cyclical), discharge PMHx, DHx (contraception) SHx (Eating, stress, exercise)
A 16 year old girl presents with primary ammenorrhoea, what’s the most likely cause and how should she be counselled?
Likely constitutional delay
- Periods are last thing to develop
If all other secondary sexual characteristics are normal then reassure.
What are your top three differentials for primary ammenorrhoea?
Consitutional delay
Imperforate hymen
Hyperprolactinemia (hypothyroid/ pituitary tumour)
What investigations (4) would you do for primary ammenorrhoea?
HcG (rule out pregnancy)
FSH/ LH < pituitary tumour causing hyperprolactinaemia
TFT < hypothyroid
Prolactin
What are your top 5 differentials for a secondary ammenorrhoea?
Pregnancy, lactation < Always rule this out!
Menopause or premature ovarian failure
PCOS (acne, alopecia, obesity) < very high LH
Post-contraception
Thyroid disease < weight gain, lethargic, constipation
Weight loss/ cushings < Low BMI
What investigations (4) would you do for secondary ammenorrhoea?
1) HcG < rule out pregnancy
2) FSH+LH < Raised if POM, low if hypothalamic cause
3) Prolactin < raised if pituitary tumour
4) TFT < hypothyroid
Name 4 lines of management options for endometriosis?
1) Do nothing (30% get better, 40% get worse)
2) Paracetamol, NSAIDS, codiene
3) COCP or mirena coil
4) INVESTIGATE < DIAGNOSTIC LAPROSCOPY (see and treat approach)
5) Hysterectomy
What are the complications of a see and treat laproscopy for endometriosis? (4)
General anaesthetic
Adhesions in pelvis (stuck together can cause problems)
Infection
50% reoccurance in 5 years
Name 5 symptoms of endometriosis?
Cyclical pain and other pain Dysparenuina Heavy periods Pain after going to the the toilet Sickness, constipation, diarrhoea Problems getting pregnant
Name two protective/ relieving factors for endometriosis?
Multiparity
COCP
What are the Rotterdam criteria?
Diagnosis of PCOS needs 2/3
1- Oligomenorrhoea (<9/yr)
2- Polycystic ovaries (>12 follicles or >10cm3)
3- Clinical/ biochemical hyperandrogenism (alopecia, acne, hirsutism)
What are your firstline investigations if suspecting PCOS?
Pelvic US (for cysts)
Gonadotrophins (FSH/ LH) < normal in PCOS, however very very high can indicate PremOvarianFailure
TFT (exclude thyroid cause)
Glucose tolerance test (assess insulin resistance)
How should PCOS be managed? (6)
Advise on complications (weight, CHD, infertility, cancer, T2DM) - can’t be cured but tx symptoms
1) COCP or IUS (reduce risk endometrial cancer)
2) Orlistat (help weight loss)
3) Metformin (if insulin resistance problems)
4) Co-cyprindol (for hirsuitism or acne)
5) Clomifene (for fertility)
Name 5 complications of PCOS?
Weight gain (dyslipidaemia) T2DM (insulin resistance) Endometrial cancer (lack of bleeds) CVD (due to weight, sugars etc.) Infertility
What are the four most common causes of PPH (in order)?
Tone - uterine atony
Tissue - retained placenta
Trauma - eg. from operative delivery
Thrombin - Coagulopathies
Namw 5 risk factors for PPH?
Previous PPH Placenta praevia (12x) Retained placenta (4x) Episiotomy/ operative delivery Multiple pregnancy Induction of Labour Big baby/ obese mother Fibroids
Name 4 complications of PPH
Hypovolemic shock AKI DIC Sepsis Death
What are your 7 management steps of a PPH
1) ABCDE + emergency button to get team in
2) Uterine rub
3) Bimanual compression
4) Oxytocin/ ergometrine
5) Misoprostol or carboprost
6) Ballon tamponade/ suturing in theatre
7) Bilateral uterine artery ligation/ hysterectomy
What questions should be asked about in a PMB hx?
O- When did it start?
C - Heavy/ light
R
A - Pain, dryness, dysparenunia, Postcoital bleed,
T- Has it happened before? Getting better or worse?
MOSC - RF’s (early menarche, nulliparious, late menopause)
- RF’s not in MOSC (PCOS etc.)
What are your top 5 differentials for a PMB?
Atrophic vaginitis HRT use Endometrial hyperplasia Endometrical ca Cervical cancer Cervical/ endometrial polyp
50% are idiopathic!
What percentage of women will experience a PMB, what percentage of these are cancer?
Up-to 10% all women experience PMB
Of these 1 in 10 will be endometrial cancer
(This should be explained when doing the 2ww)
What is the first line treatment for endometrial cancer?
Hysterectomy with bilateral salpingoophrectomy
+/- radio/chemo is stage II/III/IV
(if fertility needed then do surgical excision and progesterone tx)
Name 5 risk factors for endometrial cancer
Increasing age Early menarche Late menopause Nulliparity Late age of first child Bottle feeding Diabetes PCOS Tamoxifen use
How should a woman be counselled for Hysterectomy with bilateral salpingoophrectomy?
Removal of womb, ovaries, fallopian tubes and cervix
Need GA
5 days in hospital, 6-8 weeks recovery time
Risk: Bleeding, infection, damage to bladder or bowel
WILL go through menopause if hasn’t already
What symptoms are common with fibroids?
Heavy periods
Abdo pain
Increased wind and constipation
Pain during sex
What are you first three management steps for fibroids?
1) Nothing - will improve during menopause so can leave
2) COCP, transexamic or mefanamic acid
3) Leuprorelin or mifepristone
4) Myomectomy or hysterectomy
Name 3 complications of fibroids in pregnancy?
IUGR
PPH
Prematurity
What are fibroids, what age do the affect and what do they normally grow in response to?
Non-cancerous growths of muscle/ fiberous tissue
Affect 15-50 (Rf’s all oestrogen exposure)
Grow in response to oestrogen
What are polyps and what symptoms do they cause?
Overgrowth of the womb, most not cancerous but can become precancerous then cancerous
Syx: Heavy bleeding, irregular bleeding, IMB, PMB
How are polyps investigated and treated?
I: Hysteroscopy
Tx: Hysteroscopy under LA or GA
What are the 5 steps to conducting a home birth counselling station?
Intro
1) Why do they want this and ICE
2) Take brief medical Hx (determine risk)
3) Explain it’s their choice, however you are there to advise
4) Discuss pro’s and con’s
5) Offer options (middle ground = midwife led unit)
What are the pros (1) and cons (3) of a home birth?
Pro- More relaxing for mother
Con-
1) Can’t access drugs/ equipment if something goes wrong
2) Can’t have epidural if wants one
3) Can’t always get a doctor to you in time if needing help
(Birth centre compromise)
What are the 5 steps to conducting a breech counselling station?
Intro
1) What do they know so far (P)
2) ICE - what do they want to know
3) Explain breech and draw picture
4) Explain risks
5) Explain options (ECV-50% work so C-section is backup)
6) Ask mum what she’d like to do
What is the management of a breech presentation for which ECV is failed at 38 weeks?
Deliver by c-section at 39 weeks
Name three counselling points for an ECV
Takes 15mins, some drugs to soften uterus
Very safe, rare complication PROM, abruption or badycardia - baby monitored all the way through
Stay for an hour or so to be monitored, return in one week to double check
50% success rate
Name 2 risks of a breech delivery?
Cord prolapse
= Oxygen not delivered
= cerebral palsy, death
Risks of damaging mum (trauma)
What order should a breast vs. bottle counselling station be done in?
1) Intro
2) Thoughts on preference? Heard from other mums? Why?
3) It’s always your choice but I can talk you through pro’s and cons
4) Any specific questions?
5) Pros vs. cons
6) Their decision
Name 3 pro’s for bottle feeding over breast?
More convenient - anyone can feed
Need feeding less often
Medically might not be able to produce enough
Name 5 pro’s for breast feeding over bottle
WHO and NHS advised (exclusive to 6mths, ween at 1yr)
All nutrients needed - less likely to have diarrhoea
Cheaper
Better for babies immune system
Can prevent asthma, allergies and obesity
Helps mum and baby bond
Helps mum lose weight
Reduces mums chance of some cancers
How should pre-eclampsia be managed?
Admit all women with pre-eclampsia
1) Start labetalol
2) If severe risk start magnesium sulfate
3) Three times weekly bloods (looking for HELLP) and 4x daily BP’s
Only definitive Tx is delivery, do any time after 37 weeks (give steroids if doing early or to mums likely to delivery early)
Name 5 risk factors for pre-eclampsia. What action should be taken if risk factors are present?
Previous pre-eclampsia Family hx Diabetes Kidney disease Obesity Over 40 Lupus
If >2 RF’s then give Aspirin from 12weeks
How many pregnancies are affected by pre-eclampsia?
1 in 20
1 in 100 severely
Name 4 complications of pre-eclampsia?
Eclampsia (seizures > give magnesium sulphate)
HELLP (haemolysis, elevated liver, low platelets)
Increased risk of stroke, liver and renal disease
Inreased risk of pre-term labour and stillbirth
What is hyperemesis gravidarum?
70% of women experience morning sickeness. For 1% this is very severe and called HG
Name 3 symptoms of hyperemesis gravidarum?
N+V (some upto 50x/day) Low BP (postural hypotension especially) Dehydration Ketosis Weight loss
How do you manage HELLP syndrome?
1) IV labetolol
2) Magnesium sulphate
3) IV dexamethosone
When do morning sickness and HG typically resolve by?
Morning sickness resolves by 14weeks
HG by 20 weeks although can continue to term
Name some complications for mum and baby of hyperemesis gravidarum
Doesn't harm baby! Maternal weight loss may lead to small baby Maternal depression Maternal exhaustion Likely to reoccur in future pregnancies
How is hyperemesis gravidarum treated? (6)
R- Refer if severe dehydration or ketosis
C - Advice on diet
M- Cyclizine or promethasine for sickness
+ Thiamine, LMWH and fluid/ nutrition support
2nd line - add steroids
What is TV and what is your first line treatment for?
Trichomonas vaginalis (parasite) Causes smelly, yellow/green, frothy discharge Tx: Metronidazole
What is BV and what is the first line treatment?
Bacterial vaginosis (not STI) Fishy, thin white discharge Tx: 7 days of oral metronidazole
What sort of bacteria is gonorrhoea? What is the incubation period and the first line tx?
Gram negative diplococci
2-5 days incubation period
Ceftriazone 500mg IM and azithromycin stat (also helps cover co-existing chlamydia)
How is herpes treated?
Oral acyclovir
What structure should be used for a vaginal discharge hx?
COCP-DBT
(Colour, odour, consistency, pain, duration, blood, timing)
Plus MOSC (menstrual, obs, sexual, contraception)
What are the steps to reporting a chest x-ray?
Patient details (Name, date)
Quality (Projection, exposure, inspiration, rotation)
Obvious abnormality
ABCDE
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