general specilaties Flashcards
how to manage gestational trophoblastic disease
treated via a surgical procedure known as a suction curettage where the cervix is dilated and the trophoblastic tissue is extracted under general anaesthesia. Some of the tissue will be sampled and sent for analysis to determine the type of molar pregnancy
depending on different CIN grades how do you manage ?
CIN 1 - observation and follow up smear in 12 months
CIN 2 / CIN 3 - Large Loop Excision of Transformation Zone (LLETZ)
chest pain, sudden-onset dyspnoea, seizures and cardiac arrest in woman in labour ?
amniotic fluid embolism
The clinical features of AFE include chest pain, sudden-onset dyspnoea, seizures and cardiac arrest. Due to the disseminated intravascular coagulation that ensues, women also suffer from massive postpartum haemorrhage. It is often mistaken for a pulmonary embolism, collapse or eclampsia due to similarities in the presentation and due to how rare AFE is
difference types of prolapse in old women ?
prolapse of anterior vag wall = cystocele (bladder)/ urethrocele (urethra)/ cystourethrocele (both)
prolapse of posterior vag wall =
rectocele / enterocele
—– A digital rectal examination enables differentiation between the two on examination; a finger in the rectum will be seen to bulge into a rectocele but not into an enterocoele, which does not contain rectum
what scoring system for pharingitis/tonsilitis and how is it used ?
Fever Pain score
Fever in past 24 hoursYes +1
Absence of cough or coryzaYes +1
Symptom onset≤3 daysYes +1
Purulent tonsilsYes +1
Severe tonsil inflammationYes +1
A score of < 2 is likely not bacterial thus no antibiotics are needed.
A score of 2-3 is potentially bacterial thus a delayed antibiotic prescription should be considered.
A score of 4-5 is likely a bacterial infection and antibiotics should be considered now
Abx = o Phenoxymethylpenicillin
how to manage neonatal necrotising enterocolitis ?
if not perforation,
1. stop enteral feeding
2. drip and suck
3. parental feeding
4. Abx cefotaxime and vancomycin
types of artificial feeding what are they ?
enteral feeding (through a tube placed into the stomach or small intestine; parenteral feeding (through a tube inserted into a vein whereby nutrients enter the bloodstream directly
gastroschisis vs omphalocele
Gastroschisis is a birth defect in which the newborn’s intestines herniate through a large defect in the anterior abdominal wall that isusually lateral to the umbilicus.
Unlike an omphalocele, the herniated contents in gastroschisis are not covered by a peritoneal membrane. This means that the infants are usually at significant risk of insensible fluid and protein loss
An 8-year-old child is brought to the paediatric urgent care centre by her mother after noticing a rash on her left arm and back. The child explains that the rash is slightly itchy but is not otherwise troubling her. On examination, there is a widespread, mildly erythematous maculopapular rash with one particularly large oval shaped macule on her left arm
what and how to manage ?
Pityriasis rosea
tx = reassurance
quadraplestic/ hemiplegic / diplegic cerebral palsy??
According to the vignette, it is only the patient’s lower limbs thatare affected which is, therefore, described as diplegic cerebral palsy.
Hemiplegia is when one upper limb and one lower limb is affected. Quadriplegia is when all four limbs are affected
pregnant lady infected with parvovirus b19 - what does this mean and how do you manage ?
Erythema infectosum
Foetal anaemia is investigated using Doppler ultrasound imaging of the middle cerebral artery. This should be performed fortnightly for the remainder of the pregnancy, to detect manifestations of foetal anaemia, including hydrops foetalis.
Anaemia cannot be detected by ultrasound imaging alone. Foetal monitoring enables clinicians to determine whether in utero blood transfusions will be required to support the developing foetus. In 50% of cases, there is spontaneous resolution of foetal anaemia; therefore, in utero blood transfusionsare reserved for only a proportion of cases in which foetal anaemia is severe
abdmoinal distention (bloating), early satiety, loss of appetite - what is diagnosis ?
ovarian cancer
what is blood like in ruptured ectopic ?
It usually presents with abnormal vaginal bleeding that is dark and scanty in nature, and abdominal pain
if a type 2 diabetic is taking her meds and wants to get pregnant/ is pregnant what happens to her meds?
Diabetes medications that are not metformin or insulin should be stopped prior to conceiving`
if a lady with hypertension wants to get pregnant / is pregnant what should happen to her meds ?
Women taking statins, ACE inhibitors or angiotensin receptor blockers should be advised to stop.
In women with hypertension, suitable antihypertensives include labetalol, nifedipine or methyldopa
how to prevent pre eclampsia in high risk groups… who are these groups?
Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors:
o High-risk risk factors:
Hypertensive disease in a previous pregnancy
Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome])
o Moderate-risk risk factors:
First pregnancy (primigravid)
Age >40 years
Pregnancy interval of >10 years
BMI >35 at booking visit
FH of pre-eclampsia
Multiple pregnancy
The severity of NVP can be assessed using the ….
Pregnancy-Unique Quantification of Emesis (PUQE) score
in pregnancy Hypothyroidism is associated with an increased risk of…..
pre-eclampsia
what liquid can come out the vagina at the start of labour ?
a “show”, when the plug of mucus from your cervix (entrance to your womb, or uterus) comes away
waters breaking - rupture of membranes
how to know if pregnant woman has ruptured her membranes ? is there a more speciifc test you can use as well… ?
Pooling of amniotic fluid in the posterior vaginal fluid is diagnostic, but not always present
ROM plus test gives a positive result if it detects insulin-like growth factor binding protein-1.
Ix for small for gestational age fetus which can be picked up with small for dates symphasis fundal height…?
Umbilical artery Doppler is the most important surveillance for monitoring SGA foetuses.
It is able to predict foetal acidaemia which enables prompt delivery of the baby to avoid intrauterine death and other irreversible end-organ damage
woody uterus ?
placental abruption
how do you describe the uterus in placental abruption?
woody uterus
in paeds what is Bronchopulmonary dysplasia
refers to the lung damage that occurs following mechanical ventilation in neonates
cyanotic heart defect resulting in left axis deviation
tricuspid atresia
child finding is harder to walk and falls over. used his arms to push himself off the floor - diagnosis ?
duchenne muscular dystrophy
the arm thing is Gower’s sign
what kind of time frame do babies get GORD ?
Gastro-oesophageal reflux typically presents before 8 weeks of age with regular vomiting.
It occurs due to immaturity of the lower oesophageal sphincter and most cases will resolve spontaneously by 12 months of age
Posseting is basically the same thing as GORD
section 135 vs 136?
135 = enter a private place (patients home if required)
136 = public place
both used to take a patient to a place of safety (this can be A&E)
how does neurosyphyalis present and tx ?
present:
confusion and a change in personality. He has also complained of persistent headaches and a change in his vision
tx = benzathine penicillin
what do you need to bare in mind with past medical history and prescribing drugs in scizophrenia ?
if patients has obesity, t2dm, hypertension you want to avoid atypicals because they have lots of metabolic side effects
you can give a typical like haloperidol
how to manage kawasaki and what is interesting ab0ut this managemnt ?
Aspirin is usually contraindicated in children due to the risk of developing Reye’s syndrome (a rapidly progressive encephalopathy)
woman with signs of infection post partum (smelly discharge, painful uterus… ) - what is it ?
endometritis
Postpartum endometritis is the most common cause of postpartum infection. Most cases of postpartum endometritis are polymicrobial, involving aerobic and anaerobic bacteria, and are due to the translocation of normal vaginal flora into the uterine cavity during labor and delivery.[4] Endometritis is 5 to 20 times more common in patients undergoing cesarean delivery than vaginal delivery.[4]
consequences of maternal parvovirus b19 infection?
Effects include foetal anaemia, cardiac failure and hydrops foetalis
Risk factors for cord prolapse include:
prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie
Severe abdominal pain in a postpartum patient that is not responsive to conventional pain relief is a relatively common presentation of ….
give most common cause
puerperal sepsis originating in the urogenital tract.
Group A Strep (Strep Pyogenes) is the most commonF
first ultrasound scan for mum…
when is it and what does it aim to do ?
10 - 13+6 weeks
It aims to detect multiple pregnancies, determine gestational age and measure nuchal translucency.
It estimates the gestational age based on the crown-rump length ofthe foetus
if previous Gestational diabetes how should you appraoch testing for it in upcoming pregnancy ?
what would you screen for ?
if women have previously had GDM then offer OGTT as soon as possible after booking.
If no previous GDM, but other risk factors then offer OGTT at 24-28 weeks
Risk factors:
BMI over 30 kg/m2, previous macrosomic baby weighing over 4.5 kg, previous GDM, family history of diabetes and an ethnicity with a high prevalence of diabetes
explain induction of labour and when you would do what
Bishop’s score (how progressed the woman is)
for all women you do…
- Membrane sweep to stimulate physiological prostaglandins
Bishops < 6 means not that progressed…. therefore you would give:
- prostaglandin E1
((Tablet or Gel (Prostin®) or Pessary (Propess®) ((Risk of uterine hyperstimulation with dinoprostone and misoprostol)) - if don’t want prostaglandin can offer mechanical induction to break waters… (cervical ripening balloon(CRB)),
Bishops > 6 this means that decently advanced so you can jumpt straight to….
Artificial rupture of membranes (ARM) Amniotomy (* Only possible if the cervix is beginning to dilate and efface) use an amnihook
do this followed by IV Syntocinon (synthetic oxytocin) which promotes contractions
if combined test results in high suspicuous of Downs what Ix do you do
amniocentesis (15-20 weeks) or chorionic villus sampling (11- 14 weeks)
check gestational of mother to see which one is best to offer
most common cause + 2nd most common of secondary post partum haemorrhage
endometritis
retained products of conception
26 y/o female non painful lump, 2 weeks, unconfortbale to sit down, soft lump less than 1 cm in size, just left of the vaginal introitus. There is slight tenderness on palpation
bartholin’s cyst
gold standard for cerebral palsy
An MRI head is the gold standard investigation for suspected cerebral palsy
duchenne vs becker musclar dystrophy ?
duchenne is much more severe and present < 5 y/o
- calf pseudohypertrophy
- Gower’s sign: child uses arms to stand up from a squatted position
Becker’s less severe, develops after the age of 10 years
name of the surgery for hirschprung’s
The treatment procedure is called an anorectal pull-through, and involves an initial colostomy followed by anastomosis of normally innervated bowel to the anus.
neonatal jaundice how do you investigate ?
depends on when it develops
< 24 hours of life - serum measurement is appropriate (or when the baby was born before 35 weeks’ gestation)
> 24 hours of life - transcutaneous bilirubinometery (or the gestational age is more than 35 weeks)
- Transcutaneous bilirubin is a Non-invasive method of measuring bilirubin which is more pleasant for the neonate
opthalmia neonatorum - which pathogen is most likely and how does this effect management ?
Chlamydia is more common and presents between 5 days and 2 weeks after birth
= The first-line treatment is oral erythromycin for 14 days
Gonococcal conjunctivitis presents within the first 24 hours and up to 5 days after birth.
= IV cefotaxime
Before receiving the culture results, topical chloramphenicol eye ointment may be applied to the eyes if there is evidence of inflammation or purulent discharge.
tonic-clonic or myoclonic generalised seizures what is first line ?
sodium valproate
focal seizure management ?
Focal seizures are treated with carbamazepine or lamotrigine.
how does bronchiolitis present ? signs sx ix
The clinical features include a dry cough and increasing breathlessness. This episode is often preceded by a coryzal illness, and parents may report a recent history of rhinitis, nasal obstruction, sneezing and/or sore throat. As the infant becomes dyspnoeic, feeds become increasingly difficult.
On examination, the infant is likely to be tachypnoeic and tachycardic. Subcostal and intercostal recession may be observed, as well as hyperinflation of the chest.
Fine end-inspiratory crackles may be auscultated, and a high-pitched expiratory wheeze may be present
how to manage catatonia ?
The first-line treatment option for catatonia is a benzodiazepine such as lorazepam. If the benzodiazepines are ineffective, electroconvulsive therapy should be considered.
post delivery, woman bleeds + maternal shock + lump protruding at vaginal introitus - what is it ?
uterine inversion
a serious complication of the third stage of labour, where the uterine fundus prolapses
uterus should be manually reduced and if this is ineffective then surgery
this must not be confused with uterine involution where uertus shrinks during the first month after delivery. The trend of involution in primiparous and multiparous women is similar; however, in multiparous women, it lasts longer than 6–8 weeks
rate of cervix dilation for multiparous woman?
cervix of a multiparous woman to dilate at around 1 cm per hour
time periods where IUS can be inserted post delivery
The levonorgestrel intrauterine system (LNG-IUS) can be inserted within 48 hours of birth or after 4 weeks. It is effective immediately and is not contraindicated whilst breastfeeding
next step once mother has perineal tear ?
Once identified, the next most appropriate step in assessing a perineal tear is to perform a digitalrectal examination (DRE) to assess the extent of involvement of the anal canal
neonatal vesicles and pustules often involving the face and mouth (+ milia) - what disease ?
herpes simplex virus
Neonatal herpes simplex infection can manifest in three main forms: localised to the skin, eyes and mouth (SEM), localised to the central nervous system (i.e. encephalitis) and disseminated infection
perineal tear degree classifications
First
Perineal skin and/or vaginal mucosa
Second
Perineal muscles, no involvement of anal sphincter
Third
Involvement of anal sphincter
●3A<50% of external anal sphincter
●3B>50% external anal sphincter
●3CExternal and internal anal sphincter
Fourth
Involvement of anal sphincter and anorectal mucosa
cutaneous scarring, microcephaly and limb hypoplasia of neonate
congenital varicella zoster infection
what is A boggy uterus
A boggy uterus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis.
explain the basis of the staining during colpsoscopy when looking for CIN
During colposcopy insert speculum
add acetic acid - presence of ‘egg-white’ (aceto-white) lesions indicates the presence of an abnormal nuclear: protein ratio within cells.
Lugol’s iodine is then used to stain the cervix. The Iodine binds to glycogen (which is present in normal cells), resulting in a chemical reaction that turns cells brown.
However, abnormal cells lack glycogen, so these cells remain yellow.
A cervical biopsy will be taken simultaneously for histological analysis, to determine the grade of CIN
how does roseola infantum present ?
recent febrile illness
macular rash which appears as the child starts to recover. The rash begins on the chest and abdomen, and spreads to the limbs over days.
caused by human herpes viruses 6 and 7 (HHV6 and HHV7)
roseola infantum vs measles/rubella
Roseola infantum is often misdiagnosed as measles or rubella. These are unlikely diagnoses, given that in both diseases, the rash typically begins on the face and appears simultaneously with the fever, not afterwards.
Furthermore, the child is vaccinated, making these differentials less likely
mx sickle cell crisis ?
- ANALGESIA (Opioids)
- fluids
- oxygen
ix for perthes with findings
If Perthes disease is suspected, an X-ray of both hips should be requested (including anteroposterior and frog leg lateral views). This characteristically shows increased density of the femoral head, which may be fragmented as a result of necrosis
safety netting with mumps diagnosis ?
It is recommended that patients stay away from school or work for 5 days following the onset of parotitis.
Key red flags that parents should be warned about include signs of meningism and epididymo-orchitis in males
outline section 5(2) and 5(4)
Section 5(2) can be used by a doctor for patients under their care. It lasts for 72 hours, allowing time for assessment.
Section 5(4) is used by nurses to detain patients for up to 6 hours to allow time for further assessment, and further sections to be implemented by the relevant staff
mx = neuroleptic malignant syndrome
Neuroleptic malignant syndrome (NMS) is characterised by hyperthermia, confusion, muscle rigidity and autonomic instability. It usually occurs after treatment with dopamine antagonists (e.g. haloperidol). NMS can lead to a number of life-threatening consequences -for example, the muscle rigidity can lead to rhabdomyolysis, acute kidney injury and hyperkalaemia.
The first-step in the management of NMS involves stopping the offending drug.
The remainder of treatment is largely supportive with the use of external cooling devices and rehydration with IV fluids
drug for dementia with lewy bodies
rivastigmine
scizoaffective disorder vs scizophrenia
schizoaffective - they have mood sx (e.g. depression, mania, etc… as well as psychosis)
In schizophrenia, there may be negative mood symptoms such as flat affect, social withdrawal, lack of motivation or catatonic behaviour. However, these features are usually less prominent than the psychotic features
mx schizoaffective disorder
Schizoaffective disorder is usually initially treated with an antipsychotic (e.g. risperidone) with a mood stabiliser (e.g. lithium). Other examples of mood stabilisers that may be considered include sodium valproate, lamotrigine and carbamazepine
important complication of eczema and how to treat?
eczema herpeticum
tx = aciclovir
how to investigate underlying cause of someone presenting with bronchiectasis
Investigating the underlying cause
* Sweat chloride test or genetic testing for CF
o Should be offered to all children
* Screen for antibody deficiency
o IgG/ IgA/ IgM
o Done for all patients with confirmed diagnosis
* Test for primary ciliary dyskinesia in children
o Only if no other cause for bronchiectasis is found and if there is a history of continuous rhinitis, neonatal respiratory distress, and/or dextrocardia
what congenital heart defect in turners
bicuspid aorta
what is Henoch Schonlein Purpura**
and how does it present ?
IgA mediated vasculitis
In children 3-15 yrs
Preceding URTI → glomerulonephritis
Triad of:
* Purpuric rash on lower limb extensors + buttocks
* Abdo pain
* Arthralgia
nasal polyps ?
cystic fibrosis
when does puberty start ?
Puberty starts age 8 – 14 in girls and 9 – 15 in boys
physiological abnormalities in anorexia
Physiological abnormalities:
* hypokalaemia
* low FSH, LH, oestrogens and testosterone
* raised cortisol and growth hormone
* impaired glucose tolerance
* hypercholesterolaemia
* hypercarotinaemia
* low T3
week old baby is seen for his routine baby check in General Practice with his mother. She has no concerns. A soft systolic murmur is heard on examination. It varies with posture and does not radiate
innocent murmur
what is important to bear in mind when switching some antidepressants
- Be especially cautious when switching the following antidepressants:
o From fluoxetine to other antidepressants (as fluoxetine has a long half-life). NICE recommends a washout period of 4-7 days with NO antidepressant before starting a low dose of another SSRI
o From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed to reduce risk of serotonin syndrome)
o To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)
o From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)
can you just stop an antidepressant drug immediately ?
Discontinuation syndrome is a collection of unpleasant symptoms that occur from suddenly discontinuing an antidepressant. Such symptoms include flu-like symptoms, insomnia, tremors, vertigo, and irritability. This can be prevented by reducing the dose over a 4-
week period. Discontinuation syndrome is more common with paroxetine and venlafaxine.
what is this thought disorder
‘Doctor, that’s a difficult question. When I woke up at 7am, I thought about how much I’d like to make myself a boiled egg. I watched the news for a bit, and then found my favourite leather shoes. Later on I popped over to Tesco to get some fruit, and after that I came here to discuss a change in my medication’
circumstantiality
long winded but eventually you answer the question
I’m really hungry I want fish, you know fish swim in the sea, the sea is blue, blue sky
flight of ideas
common in mania
pressure of speech
Pressured speech is when you talk faster than usual. You may feel like you can’t stop. It’s different than talking fast because you’re excited or you naturally speak that way. You might jump from one idea to the next. People could have trouble following the conversation
common in mania
Derailment (loosening of associations)
the phrases don’t have connection - it doesn’t make sence
schizophrenia
forceps vs ventouse delivery
this is about position. you want to delvier occiput anterior (OA)
ventouse delivery allows rotation - this involves attaching a suction cup to the head and applying traction to rotate the foetus.
Neville Barnes forceps do not allow rotation and can only be used for occipito-anterior positions.
The requirements for delivery with Neville Barnes forceps can be remembered with the mnemonic
FORCEPS: Fully dilated, Occipito-anterior position, Ruptured membranes, Cephalic presentation, Engaged presenting part, adequate Pain relief, and Sphincter (empty bladder).
NB: Kielland forceps are rotational forceps that can turn the baby to an occipito-anterior position but are rarely used due to the risk of perineal tears and need for episiotomy
what is the most sensitive screening test for genetic abnormalities like downs syndrome in a fetus ?
non invasive pre natal testing
outline post dural tap headache
Postdural puncture headache is a potential complication of a lumbar puncture, with symptoms caused by traction on pain-sensitive structures from low cerebrospinal fluid pressure (intracranial hypotension) following a leak of cerebrospinal fluid at the puncture site.
Symptoms of this condition include a bilateral frontal or occipital headache that is worse in the upright position, along with nausea, neck pain, dizziness, visual changes, tinnitius, hearing loss, or radicular symptoms in the arms
stress incontinuence mx
- 1st line: Pelvic floor muscle training
- Supervised training involving least 8 contractions performed 3 times per day for a minimum of 3 months (continue for longer if beneficial)
- 2nd line: Surgical procedures (only initiated by 2° services)
Colposuspension - sutures are used to lift the neck of the bladder and fix in place to Cooper’s ligaments
Autologous rectus fascial sling - elevate the urethra
Retropubic mid-urethral mesh sling - elevate the urethra
Intramural urethral bulking agents - injection of a bulking agent around the urethra
F/U for all surgeries should happen within 6 months - 3rd line: Duloxetine (enhances sphincter contraction) then r/v in 2-4 weeks if unsuitable for surgery/prefer pharmacological to surgical Rx
when should oxytocin be admiintereed in active third stage of labour ?
after delivery of the baby’s anterior shoudler
A 34 year old woman has an evacuation of retained products of conception, which are sent for cytogenetics. She is told she had a molar pregnancy. Which is the most appropriate follow up?
serial quantitative hBCG measurements
A 5 month old baby who is unvaccinated is in the Paediatric Emergency Department following apnoeic episodes with coughing at home. What is the most likely causative organism?
Bordetella pertussis
threadworm mx
mebendazole to household
mx for milia
nothing
asymptoatmic nappy rash if conservative measures have been tried ?
Zinc and Castor oil ointment BP
A 28 year old woman with a twin IVF pregnancy has a scan at 18 weeks gestation. This shows a marked difference in foetal size with oligohydramnios in one twin and polyhydramnios in the other twin. What is the most likely diagnosis?
Twin-twin transfusion syndrome
Twin-twin transfusion syndrome (also called TTTS or twin to twin transfusion syndrome) is a condition in which the blood flows unequally between twins that share a placenta (monochorionic twins). TTTS occurs in about 10 to 15 percent of monochorionic, diamniotic (two amniotic sacs) twins.
A 30 year old woman in the third trimester of her first pregnancy develops an itchy, bumpy rash on her abdomen, with sparing of the periumbilical area. She is usually fit and well and has had an uneventful pregnancy so far. What is the most likely diagnosis?
Pruritic urticarial papules and plaques of pregnancy occur most often during the last month of pregnancy and only rarely appear in the postpartum period. The rash consists of itchy small erythematous and edematous papules and plaques usually first start in the stretch marks, typically with periumbilical sparing.
child presents with lump behind ear - what is it ?
mastoiditis
complication of acute otitis media –> treat with abx
lymph nodes in infection vs lymphoma ?
lymphoma is painless lymph nodes (Hodkins can be painful when drinkning alcohol)
Kid with 2cm mass (inframandibular) on left side, painful – blood film shows: toxic left shift with reactive neutrophilia.
lymphoma or lymphadenitis
lymphadenitis
child has 5 min seizure, stopped when ambulance arrived so they didn’t do anything - he comes to hospital - now what can you do for him ?
Children with prolonged epileptic seizures (convulsive seizures with loss of consciousness > 5 mins) are given rescue therapy to keep with them
This is usually buccal midazolam
then you can just discharge them after this…
status epilepticus pathway
- Step 1: (0 min)
o Secure airway
o Check ABC, high flow Oxygen2 if available
o Check blood glucose
o Confirm clinically that it is an epileptic seizure - Step 2: (5 min)
o If IV access, IV lorazepam
o If NO immediate IV access:
Buccal midazolam
Rectal diazepam - Step 3: (15 min)
o if no response, give a second dose of IV lorazepam
o Call for senior help
o Start to prepare phenytoin for step 4
o Re-confirm it is an epileptic seizure - Step 4: (25 min)
o Seek senior anaesthetist / inform ICU
o Phenytoin 20 mg/kg by intravenous infusion over 20 mins
or (if on regular phenytoin): Phenobarbital 20 mg/kg intravenously over 5 mins
o Consider rectal paraldehyde 0.8 ml/kg - Step 4: (45 min)
o Rapid sequence induction of anaesthesia using thiopental sodium - Consider dexamethasone if vasculitis/cerebral oedema is possible
- NOTE: treat reversible causes if identified (e.g. thiamine if malnourished or glucose if hypoglycaemic)
precocious puberty differential
Central Precocious Puberty (CPP):
Idiopathic (most common, especially in girls)
Brain tumors or lesions (e.g., hypothalamic hamartoma)
Central nervous system abnormalities (e.g., hydrocephalus, radiation therapy)
Genetic mutations
Peripheral Precocious
Puberty (PPP):
Hormone-secreting tumors (e.g., adrenal or gonadal tumors)
Congenital adrenal hyperplasia
McCune-Albright syndrome
Exogenous hormone exposure (e.g., estrogen or testosterone creams)
Other Causes:
Hypothyroidism
Genetic factors
Obesity
factors associated with poor prognosis in schizophrenia
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
how long to take antidepressant for ? when do you start feeling effects ?
It usually takes around 7 days before you begin to notice the effects of antidepressants.
Contact your doctor if you have not noticed any improvement after 4 weeks, as they may recommend increasing your dose or trying a different antidepressant.
It’s usually recommended that a course of antidepressants continues for at least 6 months after you feel better, to prevent your condition recurring when you stop.
Some people with recurrent illness are advised to carry on taking medicine indefinitely.
Pregnant lady with bullous rash on R forearm, started at umbilicus and spread from there
Pemphigoid gestationis
aftercare following vaginal hysterectomy
Recovery after vaginal hysterectomy is shorter and less painful than it is after an abdominal hysterectomy. A full recovery might take three to four weeks. Even if you feel recovered, don’t lift anything heavy — more than 20 pounds (9.1 kilograms) — or have vaginal intercourse until six weeks after surgery
Woman with controlled hypothyroidism presents to GP as just fell pregnant, what should be done about her levothyroxine during pregnancy?
continue dose and check TFTs to see how much to change to …
Continue thyroid replacement therapy
Adjust dose throughout pregnancy according to TFTs
* It is typical to increase the dose of thyroxine by 25 micrograms.
what is follow up for is you have CIN and get LLETZ ?
Requires a test of cure 6mo later (smear)
pregnant woman falls over but she’s completely fine - what should you also be thinking about ?
what is her rhesus status - do I need to give anti-D
best test for predicting pre term labour ?
Fetal fibronectin (FFN) acts as a ‘glue’ between the pregnancy and the uterus. Normally very low levels of FFN can be found in secretions of the vagina and cervix. Raised levels at or after 22 weeks have been associated with an increased risk of spontaneous preterm birth.
molluscum contagiosum mx
- Does not require treatment if immunocompetent (it is self-limiting), with spontaneous resolution usually occurs within 18 months
Small child with UTI, name test where dye is injected into urinary tracts to visualise them
Micturating cystourethrogram
scoting system for croup ?
Westley Croup Score
persistent delusions that are not related to any other psychiatric condition. Psychotic symptoms such as hallucinations are not typically present in this diagnosis.
Delusional Disorder: Delusional disorder is a rare mental illness characterized by persistent delusions that are not related to any other psychiatric condition. Psychotic symptoms such as hallucinations are not typically present in this diagnosis.
Best opiate replacement (OST) for 6 week pregnant lady on a menagerie of other drugs?
methadone or buprenorphine
on baby’s head what are suture lines like on the front and back ?
anterior = 4 suture lines
posterior = 3 suture lines
ovarian multi loculated cyst seen on USS - what do you do ?
Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.
Androgen insensitivity syndrome
Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome
Features
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol
what to give in severe croup?
nebulised adrenaline
+ oxygen
define personality disorder
Personality disorders may be defined as a series of maladaptive personality traits that interfere with normal function in life
how long is normal grief reaction ?
can be many months - year
prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
PHQ-9 = 6, what does this mean ?
less severe depression - probs just CBT but can consider SSRIs as welll
how to manage fibroid in preganncy ?
Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.
This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.
how long until you can conceive again after having tx for ectopic - and what is this medical treatment ?
methotrexate
can’t conceieve for 3 months !!!
if suspecting endometrial cancer and Outpatient endometrial sampling fails because of cervical stenosis - what do you do?
bring them into hospital
hysteroscopy with dilatation and curettage
options for hyperemessi gradivdarum ?
- antihistamines: oral cyclizine or promethazine
- phenothiazines: oral prochlorperazine or chlorpromazine
- ondansetron
- 29 y/o woman with past history of cocaine and cannabis use denies using for the past 3 years. Which additional test should be done for this patient at booking?
Hep C
- A 3 y/o boy in GP has left-sided neck lump on a background of 6 days of coryza, cough, and mild fever, but no systemic symptoms. Temperature 37.0, HR 105, capillary refill <1s, RR 26, O2 sats 99% on room air. ENT exam is normal and chest is clear. He has a single enlarged lymph node in the left posterior chain. What is the most appropriate next step in management?
lymphadenitis
wathcful waiting
- 25 y/o woman who is 38 weeks pregnant is seen in triage for irregular painful contractions lasting 6 hours. She took paracetamol 6 hours ago. She is examined and found to be 2cm dilated. Which analgesia is most appropriate?
a. Co-dydramol
b. Epidural analgesia
c. Nitrous oxide
d. NSAID
e. Warm bath
a. Co-dydramol
what congenital heart defect in turners ?
bicuspid aortic valve
- 5 y/o boy has a systolic murmur which is soft and audible at the left sternal edge. The boy is asymptomatic. What is the most likely diagnosis?
Innocent murmur
Child has symptoms of perennial rhinitis (blocked nose, nasal voice, running eyes). What is the most likely causative allergen in this scenario?
perennial = dust mites
also seasonal and occupational
seasonal = hay fever (pollen)
- 2 y/o girl has a fever of 39.7 and a painful, swollen right eye with preserved eye movements (see picture below). What is the most appropriate first-line treatment?
oral co amoxiclav
- A ‘clunk’ is felt when examining the hips of a 48 hour old baby at the routine check. Which investigation should now be requested?
USS of the hip
- Mother with SLE has a baby who is born with a slow heartbeat. What is the most likely diagnosis?
Congenital heart block
- 97 y/o woman has dementia and frequently tries to leave her nursing home an 03:00 in her nightgown to feed the swans. What legal framework may be considered in order to prevent her from leaving?
Deprivation of Liberty Safeguards
what is it called when you think you aren’t real ?
Depersonalization-derealization disorder
- 78 y/o woman has 2 weeks of progressive lethargy, nausea, and dizziness. She has depression and has recently increased her dose of Citalopram. What is the most likely biochemical abnormality?
Hyponatraemia
- 16 y/o attends GP with difficulties at college: she fears sitting on public transport and feels scared to leave her house. She avoids the supermarket and now does her grocery shopping online. What is the most likely diagnosis?
Agoraphobia
- 35 y/o woman has frothy and thin offensive yellow vaginal discharge. She is afebrile and last has sexual intercourse 3 weeks ago. She describes dysuria for the last few days and soreness and itchiness of her vulva. What is the most likely diagnosis?
Trichomonas vaginalis infection
- 8 y/o girl brought to gynaecology clinic with offensive vaginal discharge, but is otherwise well. What is the most likely cause?
Vaginal foreign body
how to calc due date for pregancy from last menstrual period
add 9 months + 7 days from the last menstrual period if 28 day cycle
+ 14 days if its a 35 day cycle
- 32 y/o with mild asthma has unexplained intra-uterine death at 37 weeks gestation. She is induced and has epidural analgesia and a spontaneous vaginal delivery. She is very distressed and would like to go home. What should be given to prevent her from expressing breast milk in this scenario?
Cabergoline
- 19 y/o woman with intra uterine device in situ presents to GP with new onset low abdominal pain and spotting. Temperature 36.3, HR 83, BP 110/90, RR 18, O2 sats 98% on room air. What is the most appropriate initial investigation?
Urinary beta-hCG
what can be offered for short cervix / mid trimester pregnancy loss?
This patient has a background of mid-trimester pregnancy loss and the ultrasound scan reveals a short cervix (< 25 mm at 16-24 weeks’ gestation).
The most appropriate option in this case would be cervical cerclage -this involves placing a band around the cervix to maintain its integrity.
A plan should be in place to remove the suture. The patient should be advised to present to labour ward immediately if she begins to experience contractions, as they are at risk of developing a cervical tear.
Vaginal progesterone is another option that can be offered to patients with a short cervix and a history of mid-trimester pregnancy loss
cyclical vs continuous HRT ?
Cyclical combined HRT is recommended in peri-menopausal women. Since this patient has not had periodsfor the past 18 months, she is now post-menopausal and should receive continuous combined HRT
A transvaginal ultrasound scan indicates an endometrial thickness of 9 mm and, following a biopsy, she is diagnosed with endometrial hyperplasia with no atypia.
mx?
IUS
how to manage urge incontinence in frail elderly women ?
Often, the first bladder-stabilising drugs to be offered at antimuscarinics such as tolterodine, darifenacin and oxybutynin, however, these are generally avoided in frail and elderly women as it can increase their risk of falls. Mirabegron, a beta-3 agonist, is a suitable alternative. If symptoms fail to resolve with medical treatment, interventions such as botox injections and percutaneous tibial nerve stimulation should be considered
pregnant women with UTI - what do you give and how long ?
nitrofurantoin 7 days
what hapens if mum gets herpes during pregnancy ?
For patients presenting with a primary infection in the 1stor 2ndtrimester, oral aciclovir is recommended from 36 weeks’ gestation until delivery with a vaginal delivery anticipated. For patients presenting in the 3rdtrimester, oral aciclovir should be commenced
Distributing this file can amount to a criminal offence©Make a Medic. Reg: 1192343immediately until delivery. For all patients developing a first episode of genital herpes in the 3rdtrimester (especially if within 6 weeks of delivery), C-section is the recommended mode of delivery to reduce the risk of transmission to the foetus. Invasive procedures such as instrumental delivery should be avoided if there are genital lesions. Recurrent episodes of genital herpes do not require a C-section delivery however oral acyclovir should be considered from 36 weeks onwards
if pregnant woman gets PE/DVT what ix do you do ?
This patient has developed features of both a DVT and a PE. There are considerable risks associated with both CTPAs and VQ scans in pregnancy. CTPAs are associated with an increased risk of breast cancer in the mother and VQ scans are associated with an increased risk of childhood cancer. If the patient has features of DVT, they should undergo a duplex ultrasound scan to confirm the presence of a DVT as this does not involve exposing the patient to radiation
new name for hypochondriasis disorder ?
Illness anxiety disorder (previously known as hypochondriacal disorder
vaginal candidiasis in pregnant lady tx ?
intravaginal clotrimazole
This patient has features suggestive of vulvovaginal candidiasis (thick white vaginal discharge and vulvar itching). As the patient is also pregnant, intravaginal antifungal treatments are preferred over oral options.
mastitis mx ?
This patient has likely developed mastitis due to milk stasis. The most effective treatment is to continue breastfeeding to encourage the passage of milk and relieve milk duct obstruction. This will not harm the baby.
As the symptoms have persisted for over hours despite adequate milk expression, oral antibiotics are indicated. Flucloxacillin is usually used in the first instance.
tx for balanitis ?
hydrocortisone
topical clotrimazole
