February 2025 Flashcards
What is the most common cause of postpartum haemorrhage?
Uterine Atony
Fibroadenoma management
Depends on patient’s preference
- Can be safely left behind with
reassurance and periodic review.
- Surgery – excision done usually under
GA if patient wants.
Duodenal atresia features
- Neonate w/ vomiting (after first feeds)
- Down syndrome 5%
distal obstruction to the papilla of Vater 80%
-bilious vomiting - M > F
-X-ray: ‘double-bubble’ - drooling
- abdominal distension (very late symptom)
Perthes features
- Normal Caucasian boy
- 4 and 10 years, peak incidence at 5 to 7 years
- 15% bilateral
- widening of joint hip space
Hip pain result of necrosis of the involved bone
-pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. - The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture
- antalgic gait with limited hip motion, or a Trendelenburg gate (abductor lurch).
- Pain may be present with passive range of motion and
limited hip movement, especially internal rotation and abduction
Intraductal Papilloma
Clinical Features:
1. Watery/Bloody discharge
2. Just 1 duct compromised
First Investigation:
1. PE.
2. US (<35yo)
Mammography (>35yo)
Best Investigations:
1. FNAC
2. Core Biopsy
3. Breast Ductography (specific)
Management: Surgery
Development of pubic hair
Girls: 8 years
Boys: 9 years
Paget’s disease management
- lumpectomy (breast conserving surgery)
- partial mastectomy or wide local incision
- Total mastectomy only if indication of disease is severe
Management of px with breast cancer spread to several places in bones
- anticancer therapy with hormonal treatment
- chemotherapy
Ventricular septal defect (VSD)
- holosystolic murmur at left sternal border
- acyanotic
septic arthritis management
- Joint drainage & debridement
- IV antibiotics
- orthopaedic surgeon referral
Complications of thyroglossal duct cyst (TDC)
-
Infection
-Malignancy 1% - Overgrowth and pressure of the underlying
structures. - Rupture and fistula formation
Posterior triangle of the neck mass
CCP
- Cystic hygroma
- Cervical rib
- Pancoast tumour
- (Naso/oropharyngeal squamous cell carcinomas)
3-4 years of age + kidney claw sign + abdominal mass does not cross midline
nephroblastoma (Wilm’s tumour)
Rinne test
AC>BC = Normal/SNHL
BC>AC= CHL
Developmental dysplasia (DDH) of the hip features
- neonates from breech delivery
- Female 6xt more likely
- unilateral or bilateral (positive family hx)
- Diminished abduction in flexion of the
affected hip - Apparent inequality of legs: affected
leg being shortened and externally rotated - Asymmetrical skin creases of the groin and
thigh - ‘clicking’ on hip movements
Bacterial conjunctivitis in children school exclusion
- Excluded until discharge has resolved
Weight: 1 standard deviation above/below the 50th percentile
Weight: overweight/underweight
kidney scarring investigation of choice in children
DMSA (gold standard)
- Clinical suspicion of renal injury
- Reduced renal function
- Suspicion of VUR
- Suspicion of obstructive uropathy on ultrasound in older toilet-trained children
Features of Paget’s disease
- eczematous-looking
- dry scabbing nipple rash
- nipple ulceration
- nipple skin thickening
- dilated duct of the breast
Breast cancer screening age group
- 50-74 (mammograms every two years)
- Woman 40 years of age specifically asking due to family history of risk BC
Cervical masses in neonatal period
- thyroglossal duct cyst (TDC)
- teratomas
- sternocleidomastoid tumours of infancy
- vascular or lymphatic malformations.
Hypertrophic Pyloric Stenosis risk factors in children
-Formula feeding
-Male
-Caucasian background
-Firstborn
-Maternal smoking during pregnancy
-Positive family history
-Both erythromycin and azithromycin < 2weeks
slipped capital femoral epiphysis (SCFE) management
- Cease weight-bearing and refer urgently.
- lf acute slip, gentle reduction via traction is
better than manipulation for prevention of
later avascular necrosis. - Once reduced, perform pinning
Idiopathic (immune) thrombocytopenic purpura (ITP) in children management
- If not bleeding: monitoring/observation
- If bleeding: IVIG and corticosteroids (prednisone)
Mammary Duct Ectasia
Clinical Features:
- Unilateral
- Multiple ducts in the SAME breast
- Discharge: Sticky, toothpaste-like green
First Investigation: Mammography
Best Investigations: Ductal lavage (Cytology)
Management: Excisional biopsy
DMSA indications
- Clinical suspicion of renal injury
- Reduced renal function
- Suspicion of VUR
- Suspicion of obstructive uropathy on ultrasound in older toilet-trained children
murmurs that increase in
intensity when the venous return to the heart is
decreased:
- hypertrophic obstructive
cardiomyopathy (HOCM) - mitral valve prolapse
- venous hum (low-pitched continuous
murmurs produced by blood returning from
the great veins to the heart)
Perthes disease management
- refer to surgeon
Surgeon will make call on conservative or surgical
- conservative: brace
- surgical: osteotomy/femoral head fixation, hip replacement worst case
Hypertrophic Pyloric Stenosis features in children
- 2 and 6 weeks of age
- gastric outlet narrowing
- projectile vomiting a few minutes after feeding
- non bloody, non bilious vomiting (may have coffee ground appearance due to repeated vomiting)
- delayed capillary refill > 2 seconds
Renal scarring in children
- Recurrent urinary tract infections (more than
2 times during childhood) - Dimercaptosuccinic acid scintigraphy (DMSA) - Gold Standard
Breast Lumps
Clinical Features: Smooth margins
First Investigation:
1. PE.
2. US (<35yo)
3. Mammography (>35yo)
Best Investigations:
1. FNAC
2. Core Biopsy
Management:
1. Observation.
2. Excision
Paget’s disease differential dx
- Ductal carcinoma in situ
Innocent murmur
7S
-soft
- systolic
- short duration
- sounds (S1 &S2)
- symptomless
- Special tests normal (X-ray, ECG)
- Standing/Sitting changes (not fixed) (increased when supine)
Tanner stages
I:
- 0–15 years
- None
II:
- 8–15 years
- Commencement of puberty
- Breast budding first
- Pubic hair
- Scrotal/Testicular growth, penis growth after a year
III:
- Increase in hair and pigmentation
Anterior triangle of the neck mass
BCC
- Branchial cyst
- Carotid body tumour
- Carotid aneurysm
Down syndrome in children
- short stature
- microcephaly
- centrally placed hair whorl
- small ears
- redundant skin on the nape of the neck
- flat nasal bridge
- Cardiac lesions 30% to 50% (endocardial cushion defect, VSD, tetralogy of Fallot (all 30%)
- Duodenal atresia
kidney scarring features in children
- one kidney smaller than the other
Fibroadenoma features
- Most common benign breast lump
- 20-30 years
- Well defined, round with even surface,
regular margins, rubbery or soft in
consistency, freely mobile, non-tender - Does not increase the risk of cancer
Müllerian agenesis [incomplete]
Check more on clinical features of female agenesis
- Female gonads do not secrete Müllerian-inhibiting factor (MIF)
- Male testes secrete MIF
- empty scrotum
- testes are impalpable in inguinal canal
Pathological murmurs features
Family hx of sudden cardiac death or congenital heart disease
- in utero exposure to certain medications (lithium) or alcohol
- Maternal diabetes mellitus
- History of rheumatic fever
- History of Kawasaki disease
- Grade 3/6 or higher murmurs
- Harsh quality
- Abnormal S2
- The presence of a systolic click
- Increased intensity with decreased venous
return (e.g., when the patient stands) - The patient has any symptoms that could be
related to a cardiac condition (e.g. shortness
of breath, chest pain, poor feeding, etc.)
Atrial Septal Defect (ASD)
- acyanotic
- mid-systolic murmur at the pulmonary area, a split-second heart sound and a loud P2
2 main types:
- Ostium Primum: most dangerous type, can lead to pulmonary hypertension and heart failure, Prophylactic antibiotics recommended
- Ostium Secundum: most common type, e hole is higher in the septum, not serious, symptoms uncommon in infancy
Idiopathic (immune) thrombocytopenic purpura (ITP) in children features
- preceding viral infection
- s frequently < 20,000/μL
- other lab tests normal
septic arthritis in children
- S aureus
- joint aspiration
Hypertrophic Pyloric Stenosis in children management
Initial: Fluid resuscitation
Best: Ramstedts Pyloromyotomy
Developmental dysplasia (DDH) of the hip dx
Barlow test —‘telescoping’ movements in the long axis of the flexed and abducted thighs.
Ortolani test — flexed hips are abducted. thighs are the grasped between the thumbs in front and other fingers behind. The child’s knees are flexed and hip flexed to a right
angle. **positive sign makes audible and palpable ‘jerk’ or ‘clunk’ (not a click). **
- Ortolani and Barlow tests but is usually negative after two months
- Ultrasound is excellent especially up to 3-4 months
Fibroadenoma
Clinical Features: Mobile, non-tender
First Investigation: US
Best Investigations:
1. FNAC.
2. Core Biopsy
Management: Reassure/Review in 3 months
Most appropriate step in management of postpartum haemorrhage after oxytocin and manual stimulation?
Ergometrine (help uterus contract)
slipped capital femoral
epiphysis (SCFE) clinical features
- Overweight adolescent of 10 to15 years
- bilateral in 20%
- Limp and irritability of hip on movement
- Knee pain — referred from the affected hip
- On flexion of the hip, it rotates externally. Hip
is often in external rotation on walking. - Most movements restricted, especially
internal rotation.
anal fissure features [incomplete]
- passage of hard stools
Hepatoblastoma clinical features
-<5 years
- mass in right upper quadrant
- abdominal distension
- right-sided abdominal pain
- familial adenomatous polyposis high risk
- lost appetite and weight
- vomiting and jaundice (very rare)
Midline of the neck mass
TTD
- Thyroid nodule
- Thyroglossal cyst
- Dermoid cyst
infant < 2 years + low-grade fever + abdominal distension + loss of appetite + limb pain + abdominal mass that crosses the midline
Neuroblastoma
- originates from adrenal glands
most common congenital heart disease in infants?
Ventricular Septal Defect (VSD) 1 in 100 Australian infants
Weight: 2 standard deviation above/below the 50th percentile
Weight: obese/severely underweight
Patent ductus arteriosus. (PDA)
-acyanotic
- pansystolic machinery murmur (harsh) at the left sternal border
- wide pulse pressure.
- Definite treatment surgical closure
Weber’s test
Normal = lateralizes equally to both ears
CHL= lateralizes to abnormal ear
SNHL= lateralizes to the normal ear
Bacterial conjunctivitis in children
- gonorrhoea: fast and aggressive (3 and 7 days after birth)
- chlamydia: slow and less aggressive (end of 1st week - 1 month after birth)
Most at risk demographic for developing iron deficiency?
toddlers (weaning off breast milk)
Tetralogy of Fallot (TOF)
4 defects
- blood going from left to right ( acyanotic)
- all have VSD (systolic murmur)
- pulmonary stenosis
- right ventricle hypertrophy
- overriding aorta
anal fissure
- most common cause of painful rectal bleeding in children
- associated with constipation
- bright blood on the
surface of stool, on the nappy or toilet paper
Management of px with breast cancer spread to one area of bone
- Radiotherapy
Colon polyp
- benign hamartomas
- ages 2 and 8 years, peak at 3 to 4 years
- mostly painless
rectal bleeding
palpable polyp
on rectal examination >60%
Transposition of the great arteries (TGA)
- central cyanotic after 10-12 hours
Aorta and pulmonary arteries are reversed - no murmur as there is no hole
- prescribe PG e1
- definite treatment: surgery to correct the transposition
adolescent + fever >38.5C + ↑WBC, ESR, CRP + Acute painful, tender and warm joint + limited movement + refusal to bear weight
Septic arthritis
Upper Limb nerve roots
Brachial Plexus Roots C5-T1:
“Randy Travis Drinks Cold Beer”
* Roots → Trunks → Divisions → Cords → Branches
- C5: Deltoid (shoulder abduction), biceps (flexion).
- C6: Biceps reflex, wrist extension.
- C7: Triceps reflex, wrist flexion, finger extension.
- C8: Finger flexion, grip strength.
- T1: Intrinsic hand muscles (fine motor).
C5 nerve root
Muscle: Biceps
Reflex: Biceps
Motor action: Shoulder abduction, elbow flexion
Sensory region: Lateral upper arm
C5 nerve root lesion
- Weak shoulder abduction
- diminished biceps reflex
- numbness over the lateral upper arm
- Weak shoulder abduction
- Diminished biceps reflex
- Numbness over the lateral upper arm
C5 nerve root lesion
C6 nerve root:
- Motor Functions: Wrist extension, elbow flexion.
- Reflex: Brachioradialis reflex.
- Sensory Area: Lateral forearm, thumb, index finger.
C6 nerve root lesion
- Weakness in wrist extension
- diminished brachioradialis reflex
- numbness over thumb and lateral forearm.
- Weakness in wrist extension
- diminished brachioradialis reflex
- numbness over thumb and lateral forearm.
C6 nerve root lesion
C7 Nerve Root
- Motor Functions: Elbow extension, wrist flexion, finger extension.
- Reflex: Triceps reflex.
- Sensory Area: Middle finger.
C7 nerve root lesion
- Weakness in elbow extension
- diminished triceps reflex
- numbness over the middle finger.
- Weakness in elbow extension
- diminished triceps reflex
- numbness over the middle finger.
C7 nerve root lesion
C8 Nerve Root
- Motor Functions: Finger flexion (grip strength).
- Reflex: None.
- Sensory Area: Medial forearm, ring and little fingers.
C8 nerve root lesion
- Weakness in finger flexion and grip
- numbness over medial forearm and little finger.
- Weakness in finger flexion and grip
- numbness over medial forearm and little finger.
C8 nerve root lesion
T1 Nerve Root
- Motor Functions: Finger abduction/adduction (intrinsic hand muscles).
- Reflex: None.
- Sensory Area: Medial upper arm.
T1 nerve root lesion
- Weakness in finger flexion and grip
- numbness over medial forearm and little finger.
- Weakness in finger flexion and grip
- numbness over medial forearm and little finger.
T1 nerve root lesion
Median Nerve
- Motor Functions: Wrist flexion, forearm pronation, flexion of thumb, index, and middle fingers; thumb opposition.
- Sensory Area: Palmar surface of the thumb, index and middle fingers, and half of the ring finger.
Median nerve lesion
- Proximal lesion: “Ape hand” deformity, weak forearm pronation, wrist flexion.
- Distal lesion: “Hand of benediction” (can’t flex index and middle fingers when making a fist).
- Sensory: loss of sensation over the thumb, index and middle fingers, and half of the ring finger
- Proximal lesion: “Ape hand” deformity, weak forearm pronation, wrist flexion.
- Distal lesion: “Hand of benediction” (can’t flex index and middle fingers when making a fist).
- Sensory: loss of sensation over the thumb, index and middle fingers, and half of the ring finger
Median nerve lesion
Ulnar Nerve
- Motor Functions: Finger abduction/adduction (interossei), flexion of medial fingers, wrist flexion (ulnar deviation).
- Sensory Area: Medial 1½ fingers (palmar and dorsal).
Ulnar nerve lesion
- Proximal lesion: “Claw hand” (incomplete flexion of medial fingers), weak grip.
- Distal lesion: Complete claw hand.
- Sensory loss over medial 1½ fingers.
- Proximal lesion: Incomplete flexion of medial fingers, weak grip.
- Distal lesion: Complete flexion of medial fingers, weak grip.
- Sensory loss over medial 1½ fingers.
Ulnar nerve lesion
Axillary Nerve
- Motor Functions: Shoulder abduction (deltoid).
- Sensory Area: Lateral shoulder.
Axillary nerve lesion
- Weakness in shoulder abduction (15°–90°)
- numbness over lateral shoulder.
- Weakness in shoulder abduction (15°–90°)
- numbness over lateral shoulder.
Axillary nerve lesion
Musculocutaneous Nerve
- Motor Functions: Shoulder abduction (deltoid).
- Sensory Area: Lateral shoulder.
Musculocutaneous Nerve lesion
- Weakness in elbow flexion and forearm supination
- sensory loss over lateral forearm.
- Weakness in elbow flexion and forearm supination
- sensory loss over lateral forearm.
Musculocutaneous Nerve lesion
Anterior Interosseous Nerve
- Motor Functions: Flexion of distal thumb and index finger.
- Sensory Area: None.
Anterior Interosseous Nerve lesion
Weak pinch sign (inability to form “OK” sign).
Weak pinch sign
Anterior Interosseous Nerve lesion
Anterior interosseous nerve is a branch of which nerve?
Median nerve
Posterior Interosseous Nerve
- Extends the wrist and fingers (except for the brachioradialis and extensor carpi radialis longus).
- Key muscles: Extensor digitorum, extensor indicis, extensor digiti minimi, extensor carpi ulnaris, extensor pollicis longus/brevis, abductor pollicis longus.
- Sensory Area: None (purely motor nerve).
Posterior Interosseous Nerve lesion
- Weakness in finger and thumb extension.
- Wrist extension preserved (extensor carpi radialis longus remains functional).
- No sensory loss.
- Common clinical sign: “Finger drop” (inability to extend the MCP joints of the fingers).
- Weakness in finger and thumb extension.
- Wrist extension preserved (extensor carpi radialis longus remains functional).
- No sensory loss.
- Common clinical sign: “Finger drop” (inability to extend the MCP joints of the fingers).
Posterior Interosseous Nerve lesion
Posterior Interosseous Nerve is a branch of which nerve?
Deep branch of the radial nerve
Lower Limb nerve roots
- L2-S1:
“I Get Lunch From Some People”
Iliopsoas → Gluteus medius → Lower limb flexors → Foot dorsiflexors → Sole of foot.- L2-L4: Quadriceps (knee extension), hip flexors.
- L5: Ankle dorsiflexion (tibialis anterior), great toe extension (extensor hallucis longus).
- S1: Plantar flexion (gastrocnemius), ankle reflex.
Fitness to drive Acute MI private
at least 2 weeks
Fitness to drive Acute MI commercial
at least 4 weeks
Fitness to drive CABG private
at least 4 weeks
Fitness to drive CABG commercial
at least 12 weeks (3 months)
Fitness to drive PCI private
at least 2 days
Fitness to drive PCI commercial
at least 4 weeks
Fitness to drive Paroxysmal arrhythmias (supraVT, atrial flutter, idiopathic VT) commercial
at least 4 weeks
Fitness to drive cardiac arrest private
at least 6 months
Fitness to drive cardiac arrest commercial
at least 6 months
Category 2 Colorectal cancer risk
Moderate risk
2x-4x higher than average risk
One 1st degree relative < 60 years at dx
OR
One 1st degree relative AND >One 2nd degree diagnosed at any range
OR
Two 1st degree relatives diagnosed at any age
Category 1 Colorectal cancer screening
- iFOBT every 2 years after 45 years to 74
- low-dose (100 mg) aspirin daily should be considered from age 45 to 70
Category 2 Colorectal cancer screening
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis in 1st degree relative
OR age 50, whichever is earlier, to age 74.
- CT colonography if clinically indicated
- Low dose aspirin (100mg)
- Update history
Category 3 Colorectal cancer risk
High risk
Two 1st degree relatives AND One 2nd degree relative diagnosed < 50
OR
Two 1st degree relatives + > Two 2nd degree relative diagnosed at ANY age
OR
> Three 1st degree relatives diagnosed at ANY age
Category 3 Colorectal cancer screening
- Colonoscopy every 5 years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first-degree relative
OR
age 40, whichever is earlier, to age 74. - CT colonography if clinically indicated
- Low dose aspirin (100mg)
- Update history
Category 1 Colorectal cancer risk
- Near average risk if they have no family history of colorectal cancer
- Above-average risk 1 1st degree relative > 60 years at dx
Horner’s syndrome triad
Ptosis + Myosis + anhidrosis
Ptosis + Myosis + anhidrosis
Horner’s syndrome
ptosis + mydriasis
3rd CN palsy
Most common cause 3rd CN palsy
Diabetic neuropathy
diabetic neuropathy treatment
TCA
clock drawing test assesses
severity of dementia
clock drawing test
Frontal and Temporo-parietal functioning
Permanent commercial driving restriction
- stable angina
- ICD (defibrillator)
occupational therapist / ophthalmologist referral to drive
persistent hemianopia after stroke
medications avoided in patients with rest less leg syndrome
– Metoclopramide (dopamine antagonists)
– Droperidol (dopamine antagonists)
– Lithium
– Naloxone (opioid antagonist)
– Antidepressants that increase serotonin levels
ataxia + falls + past pointing + positive Romberg’s sign
+ nystagmus
Cerebellar stroke
restless leg syndrome dx
clincal + Iron studies
restless leg syndrome treatment
Dopamine agonist:
- ropinirole
- levodopa
Alzheimer’s vs Fronto-temporal dementia
- behavioural change early in fronto-temporal
6th nerve palsy diseases
- diabetes
- Meningitis
- multiple sclerosis
- Wernicke’s encephalopathy
- nasopharyngeal tumour
“raccoon eyes” + blood behind the ears + mastoid ecchymosis (battle)
Basilar skull fracture
vascular dementia treatment
- prevent strokes
- control hypertension
abrupt onset of right face and hand weakness +
disturbed speech production, + a right homonymous hemianopsia
Left middle cerebral artery occlusion
fluctuating level of consciousness + trivial force
Subdural hematoma
head trauma + no loss of consciousness + deteriorating a few hours/days later
epidural hematoma
Visual hallucinations + Parkinsonism +
+Fluctuation in the mental state
Lewy body dementia
A headache exacerbated by coughing, sneezing or straining
brain tumours and raised intracranial pressure
red flag
TIA 1st line treatment
Aspirin + dipyridamole
Epileptic px planning to conceive + seizure free 2 years
Gradually cease anti-epileptic over 6 months
vascular dementia memory treatment
acetylcholinesterase inhibitor (donepezil)
Horner’s syndrome + nystagmus + facial sensory deficit + side of the body sensory deficit
- posterior inferior cerebellar artery infarct (PICA)
- lateral medullary syndrome (Wallenberg syndrome)
contralateral hemiparesis + contralateral homonyms hemianopia + aphasia + sensory neglect
middle cerebral artery lesion (MCA)
vascular dementia features
-Sudden onset of memory decline after a stroke with step-wise deterioration
-Variable cognitive impairment and emotional lability.
-Gait abnormalities.
-Urinary dysfunction.
-Parkinsonian motor features.
-Vascular lesions on MRI/CT.
Alzheimer EEG
Generalized background slowing
Alzheimer’s lobe atrophy
frontotemporal lobe atrophy
Nerve injury - Clavicular
Brachial Plexus - Subclavian artery
Nerve injury - anterior GH dislocation
N.axillaris
Nerve injury - Surgical neck of humerus
N.axillaris
Nerve injury - Midshaft humerus
N.radialis
Nerve injury - medial epicondyle
N.ulnaris
Nerve injury - greater tuberosity of the humerus
N.axillaris
Nerve injury - Supracondylar humerus
Median nerve - brachial artery
Nerve injury - Colles
N.median
Nerve injury - ERB
Brachial plexus – high: C5 – C6
Nerve injury - Klumpke
Brachial plexus – low: C8 – T1
Biceps reflex
C5/6
Supinator -Brachioradialis reflex
C5/6
Triceps reflex
C7
Injury Ulnar nerve - at wrist
Sensory
* numbness in the little and ring fingers
Motor
* weakness of abduction of his little finger
* weakness of flexion of the terminal
phalanx of his little and ring fingers
Myotomes - upper limb
C4 = shoulder shrugs
C5 = Shoulder abduction and elbow flexion
C6 = Wrist extension
C7 = Elbow extension and wrist flexion
C8 = Thumb extension and fingers flexion
T1 = Finger abduction
Clavicle Fracture
- Fall onto affected shoulder
- Pat is supporting arm which is in full adduction
Clavicle Fracture - Things to look for
- Careful NEUROVASCULAR examination
- skin integrity to r/o open fracture
- lung fields to r/o apical lung injury
Clavicle Fracture - Classification
- middle third
- lateral third
- medial third
Clavicle Fracture - Middle third
- 80%
- Defined by shortening/comminution/angulation
MX
* Broad arm sling to support limb for 2 weeks or untilcomfortable.Regular analgesia as required
Clavicle Fracture -Lateral third
- 15%
- Around and lateral to
coracoclavicular Ligaments
Mx
* If undisplaced,no reduction required
* If displaced,refer
* Broad arm sling to support limb for 2 weeks or until
comfortable
Regular analgesia as required
SIADH in children
- hyponatremia
- excessive amount of ADH from hypothalamus-pituitary
Hyponatremia in children types
Dehydration: hypernatremia
Cardiac: Pseudohyponatremia
Addisons:
- Low aldosterone
- Hyperkalaemia
- hypotension
SIADH in children symptoms
- mental changes (confusion, memory problems)
- seizures or worst case, coma
- nausea and vomiting
- headache
- problems with balance
SIADH in children causes
- type 2 DM medication:
- antiepileptic
- antidepressant
- surgery under general anaesthesia
- brain disorders, injury, infections, stroke
- lung disease (pneumonia, tuberculosis, cancer, chronic infections)
- cancer of lung, small intestine, brain, leukaemia
Hyponatraemic seizures in children
- increasing irritability
- increasing lethargy, - increasing tonic-clonic generalised
seizures - respond poorly to conventional anticonvulsants (phenytoin, phenobarbitone)
- address hyponatraemia by 3% NaCl solution
Hypernatremia in children appearance and initial management
- “doughy” skin
- Isotonic (normal) saline for an initial bolus
Addison’s disease in children
- 21-hydroxylase deficiency
- Dehydration, hypotension, and shock
- hyponatraemia with hyperkalaemia
List of autosomal dominant diseases
D -dystrophy myotonia
O - osteogenisis imperfecta
M - Marfan’s
I - intermittent porphyria
N - Noonan’s
A - achondroplasia, familial adenomatous polyposis (FAP)
N - neurofibromatosis
T - Tuberous sclerosis
V- Von Willebrand
H - Huntington’s HNPCC
H - hereditary spherocytosis
H- familial hypocholesteraemia
R - retinoblastoma
List of autosomal recessive diseases
A - albinism
B - thalassaemia
C - cystic fibrosis
D - deafness
E - emphysema
F - Friederich’s ataxia (trinucleotide test, repeat GAA)
G - Gaucher’s disease
H Hemochromatosis, homocystinuria
S - sickle cell
P - phenylketonuria
N - Wilson’s
X - xeroderma pigmentosa
List of X-linked recessive diseases
D- diabetes insipidus
D - Duchenne’s
C - colour blindness
C - chronic granulomatous disease (membranous type)
F - Fabry’s disease (alpha- glucosidase deficiency)
F - fragile X syndrome (Martin Bell Syndrome)
2 blood - haemophilia. G6PD
2 syndrome Lesch Nylon syndrome, Wiskots Aldrich yndrome
Ostoporosis RISK FACTORS
Diet- low in calcium
Low BMI < 19
Lack of exercise
Inadequate exposure to sunlight
SAD and excessive coffee intake
Medications: glucocorticoids, anticonvulsants (phenothiazines), GnRh, aromatase inhibitors (Letrozole, Anastrozole, Exemestane), heparin, Depo, thiazolidinedions (glitazones), PPI’s
Medical conditions: hyperthyroidism, hyperparathyroidism, chronic liver or renal disorders, rheumatoid arthritis, coeliac disease
Menopause
Family history
Ostoporosis First Investigation
25 hydroxy Vitamin D
Ostoporosis Best Investigation
DEXA Scan (Don’t take Ca 24 hours before)
- T-score:
> -1: Normal, - 0.9 to -2.4: Osteopenia
< -2.5: Osteoporosis - Z score: ≤ -2: Investigation for underlying causes
Osteoporosis CRITERIA FOR TREATMENT
Any man or woman with spine or hip fractures after minimal trauma even if the T score is more than -2.5. Treatment may be initiated without confirmation of low bone mineral density.
No fracture but score < or equal to -2.5 if risk factors are present
Osteoporosis due to secondary causes
Treatment with medications has to be started along with Calcium and Vitamin D supplementation
1200- 1500 mg/day of calcium
800- 2000 IU/day of Vitamin D
Notes: Medications increase bone density in the hip approximately by 1-3% and in the spine by 4-8% over 3-4 years
Osteoporosis FIRST-LINE Treatment
- Bisphosphonates
- Alendronate
- Risedronate
- Zoledronic Acid - Denosumab
- Strontium ranelate
- Raloxifene
- MHT
Osteoporosis SECOND-LINE Treatment
Teriparatide:
- Is a recombinant parathyroid hormone.
- Stimulates bone-forming cells.
- Only if other treatments fail.
- Given as daily injections subcutaneously for 18 months.
INDICATIONS: > 1 symptomatic new fracture after 12 months of biphosphonate or if T score is ≤-3
Osteoporosis FIRST-LINE Treatment: BISPHOSPHONATES Zoledronic Acid
Annual infusion for a maximum of 3 years.
Used if patients have Oesophagitis.
Vitamin D levels should be corrected to 50nmol/L before starting the treatment.
Osteoporosis FIRST-LINE Treatment: Denosumab
- Monoclonal antibody against osteoclast.
- Given as 6 monthly injections subcutaneously for 36 months.
- No gastrointestinal side effects.
- But increases hypocalcemia.
Osteoporosis FIRST-LINE Treatment: Strontium ranelate
Given orally 2 grams/day.
Should not be given with calcium supplements.
Reserved for severe osteoporosis because can cause MI
- Contraindications:
- DVT
- Prolonged immobilisation
Osteoporosis FIRST-LINE Treatment: Raloxifene
- Selective estrogen receptor modulator
- Oestrogen-like effect on bone but antagonistic for uterus and breast.
- Can be considered as second-line treatment for postmenopausal women with osteoporosis at risk of breast cancer.
- Reduces risk of vertebral fractures.
Osteoporosis FIRST-LINE Treatment: MHT
In peri or postmenopausal women with osteoporosis associated with other menopausal symptoms
OSTEOPENIA CRITERIA FOR TREATMENT
T score between -1 and -2.5 without minimal trauma fracture
Treat with calcium and Vitamin D supplementation and lifestyle modifications:
1200- 1500 mg/day of calcium
800- 2000 IU/day of Vitamin D
Osteoporosis Treatment Follow-up
Repeat DEXA in 2 years.
Every year if medication is changed, termination of the treatment or high-risk patient.
Osteopenia Follow-up
Repeat DEXA every 2 - 5 years
Osteoporosis Treatment: BISPHOSPHONATES General Features
- Decrease bone loss and increase mineral density.
- Measure Vit D and RFT before starting the treatment.
- Useful for vertebral & non-vertebral fractures.
- Contraindicated in pregnancy because it’s teratogenic.
- Side Effects: GI discomfort, oesophagitis, and jaw necrosis
Osteoporosis FIRST-LINE Treatment: BISPHOSPHONATES Alendronate & Risedronate
- Alendronate - weekly dose
- Risedronate - daily/weekly/monthly
For 5 to 10 years in postmenopausal women.
OSTEOPOROSIS
Treatment for people with special circumstances: Corticosteroid therapy
All people above 50 years on corticosteroid therapy of 7.5 mg/day for at least 3 months with a T score of -1.5 or less have to be given bisphosphonates for the duration of therapy.
- First-line: Alendronate and risedronate with adjuvant Calcium and Vit D.
- Second-line: Zoledronic acid.
OSTEOPOROSIS
Treatment for people with special circumstances: Renal impairment
Raloxifene or Denosumab.
Non- cardiac surgery clopidorel
Cease 5 days prior
Non- cardiac surgery ticagrelor
Cease 5 days prior
Coronary artery bypass graft aspirin
continue through surgery
Coronary artery bypass graft clopidogrel
Cease 5 days prior
Coronary artery bypass graft Prasugrel
Cease 5-10 days prior
Coronary artery bypass graft ticagrelor
Cease 5 days prior
Spinal, intercranial, TURP, extraocular, plastic surgery asipirin
Cease 7-10 days prior
Spinal, intercranial, TURP, extraocular, plastic surgery clopidogrel
Cease 5 days prior
Spinal, intercranial, TURP, extraocular, plastic surgery prasugrel
Cease 5-10 days prior
Non- cardiac surgery aspirin
Continue through surgery
Spinal, intercranial, TURP, extraocular, plastic surgery ticagrelor
Cease 5 days prior
Px < 3 doses or uncertain clean wound
DTPa/ ADT or combo: YES
Tetanus immunoglobulin: No
Px < 3 doses or uncertain dirty wound
DTPa/ ADT or combo: YES
Tetanus immunoglobulin: YES
Px > 3 doses > 10 years dirty wound
DTPa/ ADT or combo: YES
Tetanus immunoglobulin: No
Px > 3 doses >10 years clean wound
DTPa/ADT: YES
Tetanus immunoglobulin: No
Px > 3 doses 5-10 years dirty wound
DTPa/ADT or combo: YES
Tetanus immunoglobulin: No
Px > 3 doses 5-10 years clean wound
DTPa/ADT or combo: No
Tetanus immunoglobulin: No
px immunised > 3 doses < 5 years dirty wound
DTPa/ADT or combo: No
Tetanus immunoglobulin: No
px immunised > 3 doses < 5 years clean wound
DTPa, ADT or combo: No
Tetanus immunoglobulin: No
septic arthritis management
- IV antibiotics (flucloxacillin) for 2 weeks
- Oral antibiotics after 6 weeks
hip joint degeneration affected movement
Internal rotation
injuries warranting knee X-ray in children
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency
‘twinge’ or sudden pain + Medial Joint line tenderness + able to continue activity with some discomfort
Medial meniscus tear
Medial meniscus tear investigation
- barefooted with the knee flexed to 20 degrees and rotates the body
and knee three times internally and externally (Thessaly test) most useful
Flexion/rotation test (McMurray test) for screening
volleyball and baseball injury + flexion deformity + inability to actively extend finger
Mallet finger
posterolateral buttock + posterior thigh + lateral leg +
L5 radiculopathy
posterolateral buttock + posterior thigh + lateral leg posterior calf + lateral foot + diminished Ankle jerk
L5-S1 radiculopathy
shooting radiating pain through the posterior thigh and posterior leg to little toe + anterior + posterior motor symptoms
Sciatica
pain radiates through posterior buttock + posterior calf +
lateral foot + diminished Ankle jerk
S1 radiculopathy
pain radiating to the hip + anterior thigh + medial aspect of knee + calf + diminished knee jerk
L4 radiculopathy
Overweight adolescent + limping + hip stiffness + hip pain radiating to antero-medial thigh and knee
Slipped capital femoral epiphysis
sudden onset of severe calf pain + limping + absent plantar reflex
Achilles tendon rupture
Achilles tendon rupture investigation
Thompson Test
- absent plantar reflex
prominent acromion + loss of deltoid contour + slightly abducted and externally rotated
anterior shoulder dislocation
severe burning pain between the third and fourth toe + gets better walking barefoot + gets worse on weight bearing + localised tenderness
Morton Neuroma
anterior shoulder dislocation nerve injury
Axillary nerve
Mallet finger management
Maintain hyper-extension of the distal interphalangeal joint for 6-8 weeks
Paget’s most common location
Pelvis 70%
Slipped capital femoral epiphysis management
Percutaneous pin fixation
bilateral leg pain + worse on erect posture + responds to exercise
Spinal stenosis
Paget’s disease features
-Elevated alkaline phosphatase (early finding)
- bone pain (most common symptom)
bone pain + tibia bowing + enlarged skull with frontal bossing
Paget’s disease
genital pruritus + soreness + white wrinkled plaques
lichen sclerosus
Lichen sclerosus
inflammatory condition of the skin.
Bimodal peak: prepubertal
girls, perimenopause.
Pruritus is the main symptom.
Main differential diagnosis is atrophic vaginitis.
First-line treatment includes steroids.
Lifelong surveillance with 6-monthly check-up is required due to the risk of squamous cell carcinoma of the skin
Diagnosis of Lichen Planus
commonly occurs as pruritic, purple/pink, polygonal
papules and plaques on the skin of the extremities and trunk (cutaneous LP), but
lesions may also appear on the genitalia (genital LP) (genital LP) or oral mucosa (oral LP). The
lesions often have white, lacy markings known as Wickham striae and can form along the lines of minor trauma
Treatment includes topical high-potency glucocorticoids topical high-potency glucocorticoids (eg, betamethasone). The disorder is self-limited and typically resolves within 2 years.
Atrophic vaginitis ddx
- Candidiasis (topical antifungal)
- Lichen Sclerosis (very potent topical corticosteroids)
Testosterone cream uses
- Lichen sclerosis
- vaginal dryness
- vulvar atrophy
- post menopause
Treatment of Lichen- sclerosis
- 4% risk of SCC
- Clobetasol ( steroid)
- Retinoids/UV Therapy
- Calcineurin
- Cyyclosporin, Methothrexate
- Lifelong follow up with 6 monyh than yearly
Lichen- Sclerosis dx
- pre-pubertal and peri-menopausal women
TRIAD: genital itching, soreness and white wrinkled plaques in the genital area
-Dx: biopsy
