Introduction To Clinical Application Flashcards
Define abuse and neglect
Abuse and neglect are forms of maltreatment
Somebody may abuse or neglect by inflicting harm or by failing to act to prevent harm
What piece of legislation and guidance was released around safeguarding in 2018?
Working together to safeguard children 2018
What 3 areas are included in the assessment framework triangle for a child’s needs?
Childs development needs
Parenting/ carer capacity
Family and environmental factors
What age does a child need to be and have unexplained bruising to have an automatic referral to social care?
Children under 2
What are the 4 categories of abuse?
Physical
Sexual
Emotional
Neglect
What is syncope and how does it happen?
Transient loss of consciousness characterised by fast onset and spontaneous recovery
Caused by a reduced perfusion pressure in the brain
Syncope is usually self limiting being horizontal will fix low blood pressure due to the baroreceptor reflex
What is pre-syncope?
Symptoms preceding a syncopal episode includes:
Light headed ness
Sweating
Pallor
Blurred vision
What are a few broad categories for syncope?
Reflex syncope - baroreceptor reflex not working as quickly
Orthostatic hypotension - some as above but commonly in elderly
Cardiac/ cardiopulmonary disease - serious cause
What is the mechanism causing reflex syncope?
Disorder of the autonomic regulation of postural tone
Activation of part of the medulla leads to decrease in sympathetic output and increase in parasympathetic
Fall in cardiac output and BP leads to reduced cerebral perfusion
What are 3 examples of reflex syncope?
Vasovagal - simple faint - from prolonged standing, stress, sight of blood, pain
Situational syncope - e.g. coughing, straining, lifting heavy weight
Carotid sinus massage
How much of a blood pressure drop is defined as orthostatic hypotension?
20 mmHg on SBP
What is the pathophysiology with standing causing syncope?
Standing causes 500-800ml of blood to pool in legs
Reduction in end diastolic volume
Reduced cardiac stretch therefore reduced stroke volume and cardiac output
Normally managed by the baroreceptor reflex
If this fails then cerebral perfusion will drop and syncope occurs
Why would the baroreceptor reflex fail?
Baroreceptor become less sensitive with age and hypertension
Medications such as antihypertensives can impair this response or venous return
Dehydration - hypovolaemia is common in elderly
What is cardiac syncope?
Syncope caused by cardiac disease
Any patient who presents with a fall should have an ECG done
What are the 3 broad categories of cardiac syncope?
Electrical problem - bradycardia or tachycardia
Structural - aortic stenosis or hypertrophic obstructive cardiomyopathy
Coronary - MI/ IHD
Why does aortic stenosis cause syncope?
Narrowing of aortic valve - harder to push blood through the valve - heart has to work harder then in exercise it can fail to adequately perfuse the brain
Syncope with AS have a mean survival of 2-5 years untreated
Also ejection systolic murmur
What are risk factors of cardiac syncope?
FHx of cardiac disease or sudden cardiac death
Preceding chest pain or palpaitations
PMHx of IHD or ASD repairs
Abnormal ECG
What is important to note about the elderly cardiovascular and respiratory systems?
CVS - cardiac output falls by 3% per decade - arm-brain circulation time for drugs therefore reduces.
Decreased cardiac conducting cells therefore more arrhythmias and AF present.
Large and medium sized blood vessels become less elastic and compliant - therefore raised TPR and HTN therefore LV strain and hypertrophy
Respiratory system -
Lung and chest wall have decreased compliance.
TLC, FVC, FEV1 and VC all reduced. Reduction in elastic support of airways.
Atelectasis, PE and pneumonia are common post-op complications in elderly. Increase with smokers and chronic lung disease.
Upper airways tissues lose elasticity too and result in partial or complete obstruction of the airways in sleep or sedative states.
Increase incidence of arterial desaturation during sleep with rising age
With respect to pharmacology what are the changes seen in elderly people?
Reduced CO therefore delayed onset of IV anaesthesia
Reduced total body water and increased adipose tissue therefore leads to altered VD of some drugs
Plasma proteins also reduced therefore reduced drug binding and increased free drug
What is the malnutrition screen tool used in leicester?
MUST - malnutrition universal screening tool
What is phimosis?
Inability to retract the foreskin (prepuce)
Incidence 1% adult non-circumcised population
When is the prevalence of physiological phimosis in the age ranges?
50% at 1 year
10% at 3 years
1% at 17 years
What is balanitis xerotica obliterans?
Scarring and oedema of the prepuce causing phimosis
What is paraphimosis?
When the foreskin is too taught that it cant be pulled over the head of the penis.
It can lead to the head of the penis not getting blood
What is the most common penile cancer?
Squamous cell carcinoma
What are risk factors for penile cancer?
Phimosis - hygiene - smegma
HPV 16 and 18
What are indications for circumcision?
Paediatric - religious or recurrent balanitis/ UTIs
Adult - recurrent balanitis Phimosis Penile cancer BXO Recurrent paraphimosis
What is a common testicular torsion presentation?
Young patient
Sudden onset - woke from sleep and short duration
Unilateral pain; may be nauseated/ vomit, often no LUTS
OE= Testis is very tender
Lying high in scrotum with horizontal lie - may even lie vertical or have undone the torsion by the time of presentation
Surgery indicated ideally within 6 hours - no point >18hours
How does epididymo-orchitis present usually?
STI/ UTI
Gradual onset
Unilateral usually
Recent Hx of UTI/ unprotected sex/ Catheter/ check for mumps history
OE= pyrexial can be septic Scrotum erythematous Testis/ epididymis enlarged, tender Fluctuate areas may represent abcess May have reactive hydrocoele
What is fournier’s gangrene?
Necrotic area of scrotal skin
High mortality rate - approx 50%
What are 4 presentations of painless scrotal lumps that are not tender?
Testis tumour - >90% painless
Epididymal cyst
Hydrocoele
Reducible inguino-scrotal hernia
What is one potential presentation of a painless/ aching at end of the day - not tender scrotal lump?
Varicocoele
- Bag of worms - chronic aching
What are 3 acute presentations with scrotal lumps that are painful and tender?
- Epididymitis
- Epididymo-orchitis
- Strangulated inguino-scrotal hernia - emergency
What is the reason for hydrocoele formation?
Imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
Why can varicocoeles cause infertility?
Bilateral varicocoeles have the greatest risk of infertility
Due to reduced blood drainage and therefore perfusion the testis may die and become non-functional
Define urinary retention
Inability to pass urine rather than inability to make urine
Common in males, rare in females
What are 5 causes of urinary retention
Prostatic enlargement - BPH/ cancer
Phimosis/ urethral stricture/ meatal stenosis
Constipation
UTI
Drugs - anticholinergic
Over distension - too much fluids
Following surgery - anaesthetics, colorectal surgery could destroy nerves in the process
Neurological - cauda equina - painless retention
What are the 3 types of urinary retention?
Acute
Chronic
Acute on chronic
What is a treatment for acute urinary retention?
Catheterisation
Trial without catheter after addressing exacerbating factors
How much fluid is held in the urinary retention types?
Acute - residual volume <1L
Chronic - Residual volume >300ml
Acute on chronic - Residual volume >1L
How would you treat chronic urinary retention?
Patient would have to learn to self catheterise and this would have to be done regularly
How would you treat acute on chronic urinary retention?
TWOC (not usually successful and no place if kidney insult)
Long term catheter or surgical intervention
Which types of urinary retention are painful?
Acute - painful
Chronic - painless/ less painful
Acute on chronic - painful
Which of the urinary retention types have kidney insult?
Acute - no kidney insult
Chronic - may have kidney insult
Acute on chronic - usually have kidney insult
What is the medical term for bed wetting?
Nocturnal enuresis
What two areas can LUTS be predominant?
Voiding phase
Storage phase
What are voiding phase LUTS?
Suggestive of bladder outflow obstruction
Hesitancy
Poor flow
Post micturition dribbling
What are storage phase LUTS?
Frequency
Urgency
Nocturia
How much urine has to be produced to be classed as nocturnal polyuria?
> 1/3 of total 24hour urine
Where does tamsulosin work in terms of receptors and anatomically in the urinary system?
Alpha 1 receptors
Sympathetic smooth muscle of the prostate and bladder neck
What are the treatments for male LUTS - BPH?
Reduce caffeine intake, fizzy drinks and don’t drink more than 2.5L a day
Alpha blockers
5alpha- reductase inhibitors
Surgical intervention - Transurethral resection of prostate
How does finasteride work?
5alpha - reductase inhibitor
Acts by shrinking the prostate by means of androgen deprivation
Symptoms relief slower than alpha blockade
Slows progression
Reduces the risk of retention
What tool is used for evaluation of CVS risk?
QRISK3
What things are taken into account when stratifying someone’s CVS risk?
Migraines Corticosteroid use SLE Atypical antipsychotics Severe mental illness Erectile dysfunction CKD stage 3 and beyond Postcode BMI Rheumatoid arthritis Total and HDL cholesterol
What is a normal voiding frequency?
4-8 times per day and once at night
What is erythroderma?
Intense and widespread reddening of the skin usually attributed to inflammation
> 90% of body surface area is affected - erythematous and exfoliatitive
- caused by psoriasis, eczema, drugs, cutaneous T cell lymphoma
Symptoms - pruritus, fatigue, anorexia, feeling cold
Signs - erythematous, thickened, inflamed, scaly, no sparing
What are complications of erythroderma?
It is total skin failure
- hypothermia - loss of thermoregulation
- infection - loss protective barrier
- renal failure - insensible losses
- high output cardiac failure - dilated skin vessels
- protein malnutrition - high turnover of skin
What are 4 major cell types of the epidermis?
Keratinocytes - protective barrier
Langerhan cells - antigen presenting cells
Melanocytes - produce melanin which provides pigment to the skin and protects cell nuclei from UV DNA damage
Merkel cells - contain specialised nerve endings for sensation
What are the 4 layers of the epidermis?
Stratum corneum
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale
Dermis
What is the normal epidermal turnover time?
30 days
Pathology of the epidermis causes what 3 things?
Change in epidermal turnover
Change in surface of the skin
Change in pigmentation of the skin
What is the dermis composed of?
Collagen, elastin and GAG
What is dermographia?
Scratching of the skin causes release of histamine in the dermis and therefore local oedema
What is granuloma annulare?
Raised ring-shaped patch of skin
Local inflammation in dermis
Causes are unknown but goes away on its own
What is the condition called when glands on the skin become colonised by bacteria?
Acne vulgaris
Stimulated by conversion of androgen to dihydrotestosterone
What are the 3 main types of hair?
Lanugo hair
Vellum hair - short hair all over the body
Terminal hair - coarse long hair
What are the 3 main phases of hair follicle growth?
Anagen - growth phase of hair growth of 1cm/month and lasts for 3-5 years
Catagen - transitional stage where hair follicle renews and lasts for 2 weeks
Telogen - shedding phase lasting for 4 weeks of no growth
What is the difference between alopecia areata and genetic alopecia?
Alopecia areata is an autoimmune condition that causes hair to fall out by prematurely moving hair follicles from anagen to telogen
Genetic alopecia is where there is increased levels of androgens around the hair follicles causing decreased hair growth cycle length and shorter and thinner hair
What is the anatomy of the nail?
Nail plate which arises from the nail matrix at the posterior nail fold and rests on the nail bed
Nail bed contains blood capillaries
Nail root is where the nail grows from
Lunula is white area at the base of the finger nail
Eponychium - cuticle protects the proximal nail and epidermis from bacteria
What is Lichen planus?
Inflammatory disorder that can appears as purplish flat-topped bumps. Bumps may appear in clusters or lines on the skin but in the nails appears as white areas
Swelling and irritation of the skin
What is melanonychia?
Familial
Mole in the nail bed that extends into the nail
Potentially a sign of melanoma
What is the Fitzpatrick skin types chart?
Type 1 to 6 getting darker skin at each stage
Burn level and tan level
Type 1 is the whitest skin that always burns and never tans
Type 6 is the darkest skin (black) which does not burn but tans very easily
What mnemonic would be used to describe abnormal skin?
SCAM
S - site, distribution (rash) or size and shape (lesion)
C - colour (and configuration)
A - associated changes e.g. surface features
M - morphology
What mnemonic is used for pigmented lesions?
ABCD
A - asymmetry
B - border (irregular or blurred)
C - colour
D - diameter
What 4 things are used to describe site and distribution?
Generalised
Flexural
Extensor
Photosensitive region
What 4 terms are used to describe configuration of skin lesions?
Discrete - small and few of them
Confluent
Linear - psoriasis
Target - concentric rings with a little blister in the middle. Causes = erythema multiforme, reactive rash post cold sore
4 terms used to describe the colour of a lesion?
Erythematous - red and blanching
Purpuric - red or purple and non-blanching = Lower limbs with papules- vasculitis - meningitis can be a cause
Non-blanching because red cells are outside of the vessels
Brown or black - pigmented or hyperpigmented - post rash skin colour different
Hypopigmented - depigmented if total loss of colour - in vitiligo the immune system attacks melanocytes
4 words used to describe surface features of skin lesions?
Scale - built up keratin
Crust - dried exudate
Impetigo
Erosion/ ulceration - partial or full thickness loss of skin. Deep = ulceration. Topical = erosion.
Excoriation = erosion from scratching = pruritis
12 words to describe the morphology of skin lesions?
Macula - flat and different colour, e.g. freckles
Paulette - raised small erythematous. E.g. acne/ psoriasis
Patch - flat to skin e.g. vitiligo
Plaque - Raised, under plaque is active and thick under layers. Plaque is patch that is erythematous
Nodule - from under the skin. E.g. telangiectasia, skin cancer - BCC
Vesicle - fluid comes out and blisters fill with fluid but are small in size
Pustule - Pus filled blisters that can be small in size - signs of infection
Bulla - large vesicles that are fluid filled
Annular - ring shaped e.g. eczema discoid
Wheal - urticaria - transient raised areas e.g. stinging nettles
Discoid/ nummulite - discoid eczema
Come done - open (black head) or close (white head)
4 words for hair findings in dermatology?
Alopecia - patchy loss of hair areata/ genetic. Not itchy but is autoimmune
Alopecia diffuse - commonly in women later in life
Hypertrichosis - excess hair over a mole
Hirsuitism - male pattern hair in females
4 words for nail findings
Koilonychia- iron deficiency severe - nail spooning
Pitting - indicative of psoriasis
Only holy sis - separation post sun exposure where the white nail has separated from the nail bed
Clubbing - lung cancer, bronchiectasis, heart failure, lung fibrosis, CF, ILD, sarcoidosis, tetralogy of fallot, subacute bacterial endocarditis
What does frailty mean?
Accumulation of deficits.
People who are off their baseline in terms of ADL’s.
Needing help to do things they previously didn’t need help with.
Manifestations - delirium, falls and fractures, immobility and pressure sores, incontinence, iatrogenesis
What is the clinical frailty scale?
A scoring system used to identify frail people
Scored from 1 to 9
1 being very fit and 9 being severely frail
Score 8/9 - 50% mortality at one year
Score 1/2 - 2-3% mortality at one year
What is the progression from treatment to feeling fully normal after pneumonia?
1 week - fever resolved
4 weeks - chest pain and sputum reduced substantially
6 weeks - cough and breathlessness reduced
3 months - most symptoms resolved by fatigue may still be present
6 months - most people feel back to normal
What is the goal of CURB scoring?
Prognostic of risk of death
0 low risk <1% mortality risk
1 or 2 intermediate risk 1-10% mortality risk
3 or 4 high risk >10% mortality risk
How does frailty link with response to stressors?
The more frail the patient the worse their response to stress is.
Severely frail people never come back to their baseline they always end up worse and more in need of care than they previously did
What are the component parts of the comprehensive geriatric assessment?
- Social networks
- Environment
- Medical
- Psychological/cognitive
- Functional
Coordinated , communicated, patient centred care
What is the adult definition of sepsis?
Infection
Dysregulation host response
Life threatening organ dysfunction
What is a q-SOFA score and what does it include?
Risk scoring system for prognosis outside of ITU
Takes into account
Altered GCS
RR >22
SBP <100
What is the paediatric definition of Sepsis?
SIRS- systemic inflammatory response
+
Suspected/ proven infection
What features make sepsis into severe sepsis?
SIRS + suspected/ proven infection
+ organ dysfunction - CV/ Resp/ 2 or more other organs
What is SIRS?
Inflammation throughout the whole body
Broad categories - infectious or not-infectious
Trauma, pancreatitis, haemorrhage, anaphylaxis, burns, infection
Marked by - tachycardia, hypotension, hyper/hypothermia, leukopenia/ leukocytosis
What are the basic principles of sepsis management in paediatrics?
A-E assessment
Hypotension - give fluids IO/IV
Tachypnea - high flow oxygen to improve sats
Hypoglycaemia/ hypocalcaemia- correct accordingly
Adrenaline (ionotropic) continuous infusion peripherally
How do we calculate mean arterial pressure?
[SBP + (2x DBP)] / 3
For peripheral inotropes which is best for cold shock and for warm shock?
Cold shock - adrenaline
Warm shock - noradrenaline
What is more likely to cause mortality - giving IV fluid boluses or giving the same amount of fluid in a continuous IV drip?
Fluid boluses
In a neonate age <1 month what antibiotics would be used to treat sepsis?
Gentamicin
Amoxicillin
Cefotaxime
In a child aged 1 -3 months what antibiotics would be given to treat sepsis?
Amoxicillin
Ceftriaxone
In a child aged 3 months and over what antibiotics would be given to treat sepsis?
Ceftriaxone
What factors are included in the assessment of breast disease?
Physiological swelling and tenderness
Modularity
Breast pain (not usually associated with malignancy)
Palpable breast lumps
Nipple discharged including galactorrhoea
Breast infection and inflammation - usually associated with lactation
What is the medical term for breast bud development?
Thelarche
30 year old women with pain leading up to and during periods in the breast could have a benign cause - what is the differential?
Fibrotic changes is benign - fibroadenoma
Usually ages between 20-50 (menstruation) - therefore hormonal aetiology
Pain and nodularity
Asymmetrical nodularity, symptoms one week before menstruation and decreases when it starts, OE - area of nodularity or thickening in the upper outer quadrant of the breast.
What would you do?
Refer on as asymmetrical after a review after 1-2 menstrual cycles and seeing her mid-cycle
Bilateral would be commonly normal but unilateral is abnormal
What is cyclical mastalgia?
Tenderness and nodularity in premenstrual phase is common - affecting up to 2 thirds of all menstruating women
A palpable benign breast lump can usually be 2 things which are and what are the features of them?
Cysts
Fibroadenomas
3 dimensional, mobile and smooth regular borders
solid or cystic in consistency
What is intraductal papilloma and what is it caused by?
Benign growth in single milk duct - makes breast sore as prevents breast milk from passing through the duct
Multiple milk ducts not just one - duct ectasia (blockage)
What is mastitis and how does it present?
Infection of the breast
Point tenderness, erythema and fever
Generalised cellulitis of the breast
Treated with antibiotics or I&D
What bacteria cause mastitis?
Staph or strep
What age of the patient and features of the breast would require referral on a suspected cancer pathway?
Aged >30 and unexplained breast lump with or without pain
Aged >50 with any of the following symptoms in one nipple only:
Discharge, retraction, other changes of concern (lymph nodes), skin changes
What is the journey of grief?
Immobilisation
Denial
Anger
Bargaining
Depression
Testing
Acceptance
What happens to the breast lobules and interlobular stroma as age increases?
Prepubertal breast - few lobules - before puberty male and female breasts are identical)
Menarche - increase in the number of lobules, increase volume of interlobular stroma
Menstrual cycle - follicular phase lobules quiescent, after ovulation cell proliferation and stromal oedema, with menstruation see decrease in size of lobules
Pregnancy - increase in size and number of lobules, decrease in stroma, secretory changes
What physiological changes are seen in breast tissue on the cessation of lactation in terms of lobules?
Atrophy of lobules but not to former levels
What physiological changes are seen in breast tissue on increasing age in terms of lobules?
Terminal duct lobular units decrease in number and size, interlobular stroma replaced by adipose tissue - mammograms easier to interpret
Non-cyclical and focal pain in the breast could be an indicator of what?
Ruptured cysts, injury, inflammation
What type of features of a palpable mass would be worrying?
Hard, craggy and fixed
What age range would fibroadenomas occur most often at?
<30years
Can occur at any age during reproductive period though
What age does a phyllodes tumour usually present?
6th Decade
Stromal tumour
What is the most common breast lesion?
Fibrotic changes
May present as a mass or mammographic abnormality
Mass often disappears after fine needle aspiration - cysts refill once aspirated and then patient represents
Why does transient gynaecomastia affect boys in puberty?
Oestrogen production peaks earlier than that of testosterone
What type of cancers are >95% of all breast cancers?
Adenocarcinoma
What area of the breast are most commonly associated with breast cancer?
Upper outer quadrant - approx 50%
Apart from age and gender what are risk factors related to breast cancer?
Uninterrupted menses
Early menarche (<11 years)
Late menopause
Parity and age at first full term pregnancy
Breast -feeding
Obesity and high fat diet
Exogenous oestrogen (HRT increases risk by 1.2-1.7times)
Breast density
Geographic influence - diet, physical activity, breast feeding
What is the hereditary risk factors to breast cancer?
10% breast cancers are hereditary
3% of all breast cancers and 25% of familial cancers attributed to mutations in BRCA1 or BRCA2 - both are tumour suppressor genes - proteins repair damaged DNA
How do we classify breast carcinoma?
Carcinomas are divided into insult and invasive
Carcinomas can be ductal or lobular
What is in situ breast carcinoma?
Neoplastic population of cells limited to ducts and lobules by basement membrane, myoepithelial cells are preserved
Does not invade into vessels and therefore cannot metastasise or kill the patient
Why are ductal carcinoma in situ (DCIS) a problem?
Non-obligate precursor of invasive carcinoma
Most often presents as mammographic calcification (clusters or linear and branching) but can present as a mass
Can spread through ducts and lobules and be very extensive
Histologically often shows central (comedo) necrosis with calcification
What is Paget’s disease of the breast?
Adenocarcinoma of the beast that extend to nipple skin without crossing the basement membrane
Unilateral red and crusting nipple
Eczematous or inflammatory conditions of the nipple should be regarded as suspicious and biopsy performed
How does invasive carcinoma differ from DCIS?
Neoplastic cells invaded beyond basement membrane into the stroma
Can invade vessels and therefore metastasise to lymph nodes and other sites
By the time a cancer is palpable more than half of the patients will have a ill arm lymph node metastases
Peau d’orange - involvement f lymphatic drainage of skin - yellowing of the skin
How is invasive breast carcinoma classified?
Invasive ductal carcinoma - 70-80% prognosis
Invasive lobular carcinoma - 5-15% prognosis
What are the most frequent locations of breast cancer metastases?
Bone
Lung
Liver
Brain
Invasive lobular carcinoma can spread to odd sites - peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries, uterus
How do we stage breast cancer?
TNM
What is the 10 year survival of grade 1/2/3 breast cancer?
Grade 1 - 80%
Grade 2 - 50%
Grade 3 - 40%
What would be the molecular classifications of breast cancer?
Oestrogen receptor positive or negative
HER2 positive or negative
What is the worst molecular classification for breast cancer?
Oestrogen receptor negative
HER2 negative
Basal-like phenotype
Most BRCA1 tumours have this phenotype
What is tamoxifen used for?
Oestrogen receptor positive breast carcinoma
What is Herceptin used for?
HER2 receptor positive breast carcinoma
What is HER2?
Member of the human epidermal growth factor receptor family
Encodes a transmembrane tyrosine kinase receptor
Humanised monoclonal antibody against the HER2 protein
