General mix Flashcards
how to remember NMS
FALTER
- Fever
- Autonomic isntability
- Leucocytosis
- Tremor
- Elevated (CK)
- Rigor
Missing one pill (less than 72 hours since the last pill was taken): COCP
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection is required provided other pills before and after are taken correctly
Missing more than one pill (more than 72 hours since the last pill was taken):
COCP
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
Missing more than one pill (more than 72 hours since the last pill was taken):
COCP
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
May have to take emergency contraception (see below)
The best way to understand the rules is to consider that theoretically women will be protected if they perfectly take the pill in a cycle of 7 days on, 7 days off. This will prevent ovulation.
- If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
- If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
- If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
Missed pills POP
A pill is classed as “missed” if it is:
- More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
- More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
Action required, if needed:
1) take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
2) continue with rest of pack
3) extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Under which age is a child not able to consent to sexual intercourse
A child under the age of 13 is always considered to be unable to consent for sexual intercourse.
drugs for ADHD in children
First line: Methylphenidate (ritalin)
Second line: Atomoxetine
Atomoxetine is another stimulant medication. It is recommended for ADHD refractory to Methylphenidate or in those who it is not appropriate due to risk factors or development of side effects. Development of facial tics is an indication to change medications
what to always give with steroids and long term use of NSAIDs
PPI
ECOG
0- normal functioning
II- slight reduced functioning
II- >50% of time up and about
III -> 50% of time in bed
IV - bedbound
v- dead
chemo man
Cisplatin: otoxocity and nephrotoxicity
Bleomycin: pulmonary fibrosis
Cyclophosphamide- haemorrhagic cystitis
Methotrexate: bone marrow suppression
Vincristine- peripheral neuropathy
Transtuzuman and Doxorubicin- cardiotoxicity
malignant melanoma usually treated with
Mohs surgery
Immunotherapy
PD-1/PD-L1 immune checkpoint example
e.g. Nivolumab, Pembrolizumab
Used in melanoma, lung, renal cancers
Monitoring lithium
- Lithium levels in first 12 hours
- After 1 week untill stable
- every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable
Every 6 months
- Thyroid function test
- Renal function tests
Patients should be issued with an :
- information booklet
- alert card
- record book
adverse effects of lithium
- nausea/vomiting, diarrhoea
- fine tremor
- nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
- thyroid enlargement, may lead to hypothyroidism
- ECG: T wave flattening/inversion
- weight gain
- idiopathic intracranial hypertension
- leucocytosis
- hyperparathyroidism and resultant hypercalcaemia
Lithium toxicity
Lithium toxicity generally occurs following concentrations > 1.5 mmol/L.
Toxicity may be precipitated by:
- dehydration
- renal failure
- drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Features of toxicity
- coarse tremor (a fine tremor is seen in therapeutic levels)
- hyperreflexia
- acute confusion
- polyuria
- seizure
- coma
Management
- mild-moderate toxicity may respond to volume resuscitation with normal saline
- haemodialysis may be needed in severe toxicity
atypical antipsychotic monitoring
Adverse effects of clozapine
- agranulocytosis (1%), neutropaenia (3%)
- reduced seizure threshold - can induce seizures in up to 3% of patients
- constipation
- myocarditis: a baseline ECG should be taken before starting treatment
- hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
Autism definition
pervasive developmental disorder characterised by impairment in social interaction, communication and repetitive, stereotyped behaviour
ADHD definition
is characterized by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development, and are present in more than one situation. Children may present with difficulties at school and at home
4 types of melanoma
Superficial spreading
Nodular melanoma
Lentigo maligna
Acral lentiginous (black people, think feet and nails)
A 3-day-old neonate born prematurely at 34 weeks’ gestation has been slow to wean off the ventilator since birth. On examination, she has been found to have a continuous heart murmur.
An echocardiogram has detected a patent ductus arteriosus. No other structural heart abnormalities have been found. A chest x-ray shows cardiomegaly and mildly congested lung fields.
What initial treatment should be started to manage this condition?
Emergency surgery
Indomethacin
Beta-blockers
Intravenous fluids
Prostaglandins
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
A mother presents with her baby to the GP for review. She asks for advice regarding her milestones and explains that her son was born was born prematurely at 32 weeks gestation.
With the premature age in mind, when should this baby begin to show a responsive social smile?
5 to 7 weeks
8 to 10 weeks
11 to 13 weeks
14 to 16 weeks
17 to 19 weeks
14-16 weeks
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
The corrected age is taken into consideration when looking at milestones until the age of 2.
management of bed wetting
desmopressin last line
An 8-year-old boy is brought to the attention of a psychiatrist by his mother with complaints of difficulty concentrating at home and at school. He is reported by the teachers to be easily distracted which is adversely affecting his learning. He also shows repeated outbursts of anger and his mother thinks he has ‘too much energy’. The psychiatrist diagnoses him with attention-deficit hyperactivity disorder (ADHD) and starts him on methylphenidate (Ritalin).
Which of the following parameters must be monitored every 6 months in this patient?
Full blood count (FBC)
Urea and electrolytes (U+E)
Thyroid function test
Weight and height
Visual acuity
Methylphenidate - monitor weight and height every 6 months
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
A 30-year-old lady presents to the gynaecological outpatient department after she presented to her GP complaining of inability to conceive despite attempting for 2 years.
A trans-vaginal ultrasound scan is performed, and the report is given below:
TV USS A single 5 cm by 7 cm septated cyst is seen on the superior aspect of the right ovary. The left ovary is normal in size and morphology.
What further management would you suggest for this patient?
Book for a bilateral salpingo-oophorectomy
Commence metformin
Perform a serum CA-125, αFP and βHCG, and book for elective cystectomy
Perform an ultrasound-guided fine needle aspiration of the cyst for cytology
Reassurance and review with repeat ultrasound in 8 weeks / 3 menstrual cycles’ time
Perform a serum CA-125, αFP and βHCG, and book for elective cystectomy
Complex (i.e. multi-loculated) ovarian cysts should be biopsied with high suspicion of ovarian malignancy
An obstetrician is preparing themselves to perform an emergency lower segmental caesarian section for a 24-year-old woman who is suffering from complications of pre-eclampsia. After making an incision through the skin and superficial and deep fascia, what layers will the obstetrician have to cut through/traverse to reach the fetus?
Linea alba - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
External oblique - internal oblique - transversalis fascia - extraperitoneal fat - parietal peritoneum - uterus
Rectus abdominis muscle - posterior rectus sheath - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Rectus abdominis muscle - linea alba - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
A 34-year-old pregnant woman presents at 30 weeks gestation for a routine check. On examination she has a symphysis-fundal height of 25 cm. What is the next most important investigation to confirm the examination findings?
Ultrasound
Cardiotocography
Biophysical profile
Umbilical artery Doppler
Urinalysis
US
The measurement of the symphysis-fundal height in centimetres should closely match the foetal gestational age in weeks within 1 or 2 cm from 20 weeks gestation. Therefore it can be inferred that the woman in this case is small for dates. It is therefore important to perform an ultrasound to confirm whether or not the foetus is small for gestational age.
Discuss (3)
Improve
Management of umbilical cord prolapse
- keep cord warm
- push any presenting part of fetus back in
- tocolytics e.g. terbutaline
- all 4s until CS ready
A 26-year-old primigravida woman attends the maternity centre at the start of labour at 38 weeks. Her pregnancy was marked high-risk because she was diagnosed with HIV last year and started on regular antiretroviral therapy. Her viral load at 36 weeks is shown below:
HIV Viral Load 35 RNA copies/mL (0-50)
What is the most appropriate delivery plan for this woman?
Continue with normal vaginal delivery
Prepare for an emergency caesarean section
Prepare for non-emergency caesarean section
Re-test her HIV viral load
Start an antiretroviral infusion during vaginal delivery
HIV in pregnancy: vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks
medical management of PPH not controlled by catheterisation and rubbing up the uterus
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
CAT 1 and CAT 2 caesareans should be done in
CAT 1- 30 mins
CAT 2- 75 mins
Caesarean sections may be categorised by the urgency
Category 1
- an immediate threat to the life of the mother or baby
- examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
- delivery of the baby should occur within 30 minutes of making the decision
Category 2
- maternal or fetal compromise which is not immediately life-threatening
- delivery of the baby should occur within 75 minutes of making the decision
Category 3
- delivery is required, but mother and baby are stable
Category 4
- elective caesarean
ascreening for DM in pregnancy
- women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
- NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
- women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds
- fasting glucose is >= 5.6 mmol/L
- 2-hour glucose is >= 7.8 mmol/L
antenatal screening
A 26-year-old woman is seen in the maternity unit at 12 weeks gestation regarding antenatal testing for Down’s syndrome and undergoes a screening test.
The results of her screening are as follows:
b-hCG increased
PAPP-A decreased
Ultrasound thickened nuchal translucency
Chance 1/80
She states that if she requires testing, she would like whichever option carries the least risk of harm to her and her baby. She has no past medical history.
What is the most appropriate next step in her management?
Arrange quadruple test
Discuss decisions regarding continuing pregnancy
Down’s syndrome unlikely - no further tests necessary
Offer amniocentesis
Offer non-invasive prenatal screening test (NIPT)
Offer non-invasive prenatal screening test (NIPT)
66%
Results of combined or quadruple tests for chromosomal conditions are reported as ‘lower chance’ or ‘higher chance’, using a cut-off of 1 in 150 to differentiate
A 32-year-old female patient attends clinic. She is 33 weeks pregnant and so far has had no complications with the pregnancy. However, she is now worried as she feels that her baby’s usual kicking and moving has reduced over the past few days. She has not noticed any other symptoms of concern and otherwise feels well. She has no significant past medical history, nor family history. She has had two previous uncomplicated pregnancies.
Physical examination is unremarkable, and observations are stable and within normal parameters. A handheld Doppler scan is performed; no fetal heartbeat is detected.
What is the next step in management?
Fetal blood sampling
Ultrasound scan
Repeat Doppler in 1 hour
Cardiotocography for 10 minutes
Cardiotocography for 20 minutes
Ultrasound scan
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
2 forms of emergencvy contraception
- 72h (3 days)- Levonogestrel (levonelle)
- 120 h (5 days) Ulipristal acetate (EllaOne)
PID
Pus cells
Management of PID
- A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
- Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
VTE in pregnancy
DR C BRaVADO
DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order:
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
normal contractions in labour
4-5 in 10
> 5 = hyperstimulation
normal baseline
110-160
normal variability in HR
5-25
summary of normal baseline and variability
Decelerations
Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs. There are four types of decelerations to be aware of:
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. The lowest point of the declaration corresponds to the peak of the contraction. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.
Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction. Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.
Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.
CTG is reassuring when
there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.
scarlet fever vs strep A pharyingitis
Bacteria called group A Streptococcus (group A strep) cause scarlet fever.
These bacteria are also the cause of strep throat.
The bacteria sometimes make a toxin (poison), which causes a rash — the “scarlet” of scarlet fever.
Presentation temporal arteritis
- Unilateral headache typically around temple and forehead
- Scalp tenderness when brushing hair
- Jaw claudication
- Blurred or double vision
- Associated: fever, muscle aches, fatigue, weight loss, lossof appetite, peripheral oedema
Can cause papilloedema
Pathophysiology congenital hydrocephalus
Most common cause is aqueductal stenosis ->Insuff drainage of CSF
Cerebral aqueduct which connect third and fourth ventricle is stenosed
describing mass on head imaging
- Patient and imaging technique used
- Intra or extra-axial
- Shape
- Location
o Supra or infratentorial
o Lobes/ part of brain involved - Density OR intensity
o Hypo/hyperdense used with CT
o Hypo/hyperintense used with MRI - Border
o How defined
o Oedema - Contrast enhancement
o Homogenous/heterogenous
o Rim enhancement - Mass effect
o Effacement of sulci : ipsilateral / contralateral
o Midline shift
o Ventricle compression
o Basal cisterns: obliterated/patent - Hydrocephalus
DVLA and epilepsy
Car/motorbike licence
- one off seizure (not diagnosed with epilepsy/ no EEG changes)= reapply in 6 months
- epileptic who has had seizure = reapply in 12 months
seizure following change in antiepileptic medications = reapply to drive if seizure was more than 6 months ago or you’ve been back on previous medication for 6 months
Bus/coach/lorry licence
- one off seizure - reapply in 5 years or if you haven’t taken anti epileptic medications for 5 years
- more than one seizure = reapply once you haven’t had a seizure for 10 years or you haven’t taken any anti-epileptic medication for 10 years
management of tumour lysis syndrome
- Vigrourous rehydration (fluid resus: 500ml normal saline over 15 mins)
- Rasburicase to lower uric acid levels
- Calcium gluconate for hyperkalaemia
- Allopurinal to prevent i.e. give to patients at risk
Margins for BCC or SCC
- Surgical excision with 4mm margins if lesion <20mm in diameter.
- If tumour >20mm then margins should be 6mm.
margins for melanoma
Full assessment in Eye Casualty
- Visual acuity testing
- Near vision and colour vision
- Pupillary defects
- Visual fields and blind spot
- Oculomotor testing (H)
- Slit lamp (fluoresceine stain and Mydriatics (tropicamide, atropine)
- Fundoscopy
- Optical coherence topography or US
management of acne roseacia
first line: topical ivermectin
second line: topical metronidazole
third line: topical + lymecycline
management of norweigon crusted scabies
ivermectin
(normal permethrin or malathion)
length of follicular phase vs luteal
follicular is variable - usually around 14
luteal- always 14 days
14+14 = 28 (average cycle lenght)
if cycle length 24 days, then follicular phase wuld be 24-14 therefor day 10
summarise GBS
flaccid paralysis with some sensory defects caused by peripheral nerve destruction by antibdoies produced by B cells against recent infection (mimicry)
e.g. Epstein-Barr virus, CMV, campylobacter
- symetrical
- ascending weakness
Management of GBS
- IV immunoglobulins- KEY
- Plasma exchange (alternative to IV IG)- *plasmapheresis *
- Supportive care e.g. nutrition and hydration
- VTE prophylaxis (pulmonary embolism is a leading cause of death)
- In severe cases with respiratory failure patients may need intubation, ventilation and admission to the intensive care unit.
management of MND
No effective treatments for halting or reversing progression of the disease
Drug
Riluzole
o Can slow progression and extend survival by a few months in ALS
Edaravone
o Used in US and not UK
o Potential to slow progression of disease
Supportive
Non-invasive ventilation at night
Palliative
Prognosis
Patient will die between 2-3 years after diagnosis
A 68-year-old man is in hospital after suffering a stroke ten days ago. Focused history and neurological exam is taken in the rehabilitation ward.
You report to your senior doctor that the patient has ataxia, nystagmus, right-sided ptosis and miosis, and diminished sensation in his left arm and leg. The patient can raise his eyebrows and has a symmetrical smile.
Where is the lesion most likely located?
Basilar artery
Left anterior cerebral artery
Left anterior inferior cerebellar artery
Right posterior cerebral artery
Right posterior inferior cerebellar artery
Right posterior inferior cerebellar artery
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
A lesion in this artery caused lateral medullary syndrome, caused by ischemia to the lateral part of the medulla, which is responsible for various tracts, cranial nerve nuclei and physiological centres. Damage to this part of the medulla results in the clinical manifestations seen in the question stem. These include ataxia, nystagmus, ipsilateral Horner’s syndrome (ptosis and miosis) and contralateral upper and lower limb sensory loss.
brainstem anatomy
A 38-year-old man is brought to the emergency department after falling down the stairs. His past medical history is unknown.
On examination, he has scalp bruises and lacerations, but no obvious external bleeding. He is not opening his eyes and when supraorbital pressure is applied, he makes groaning noises without distinct words and his right arm reaches to his eye and tries to pull the examiner’s hand away.
What is his Glasgow coma score?
8
GCS: Motor (6 points) Verbal (5 points) Eye opening (4 points). Can remember as ‘654…MoVE’
when to head CT
A 45-year-old man with schizophrenia taking chlorpromazine develops a bilateral resting tremor. What side-effect of antipsychotic medication is this an example of?
Tardive dyskinesia
Parkinsonism
Acute dystonia
Akathisia
Neuroleptic malignant syndrome
Parkinsonism
bishops score
options for induction
- membrane sweep
- vaginal prostaglandins
- cervical balloon ripening
- artifical rupture of membranes with oxytocin infusion (beware with previous c-section)
The Bishop Score should be assessed prior to induction of labour
Important for meLess important
- Cervical position (posterior/intermediate/anterior)
- Cervical consistency (firm/intermediate/soft)
- Cervical effacement (0-30%/40-50%/60-70%/80%)
- Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
- Foetal station (-3/-2/-1, 0/+1,+2)
