last days ting Flashcards
Features making a UTI atypical, as defined by the National Institute for Health and Care Excellence (NICE) guidelines include:
seriously ill child poor urine flow abdominal or bladder mass raised creatinine septicaemia failure to respond to treatment with suitable antibiotics within 48 hours infection with non- coli organisms
According to NICE guidelines, in children younger than 6 months of age with an atypical UTI, an urgent USS is required during the acute infection, looking for any structural abnormalities in the urinary tract. Once the acute infection has resolved, 4–6 months later, a routine DMSA is performed (looking for a scar in the kidney, renal agenesis or a duplex system) and an MCUG (looking for vesico-ureteric reflux or a posterior urethral valve).
A baby is admitted to the Neonatal Intensive Care Unit with severe jaundice. On examination, there is hepatosplenomegaly. Nursing staff report that the baby does not appear to respond to audible stimuli.
What is the most likely diagnosis?
Cytomegalovirus (CMV)
This neonate has congenital CMV infection due to vertical transmission from the mother. The incidence of congenital CMV is around 0.3–0.4% in the United Kingdom. Neonates can present acutely unwell with low birthweight, jaundice, microencephaly and seizures. Treatment is with systemic antivirals.
A 2-day-old neonate is brought to the Emergency Department by concerned parents. They report that the child is refusing to feed and appears irritable. On examination, the child has hypotonia and a non-blanching petechial rash over the lower limbs.
What is the most likely diagnosis?
Group B Streptococcus (GBS)
This patient has early-onset neonatal sepsis, likely neonatal meningitis. The most common causative organism is GBS, a Gram-positive coccus that is present in up to 25% of pregnant women. A full ‘septic screen’, including a lumbar puncture, will be required. Treatment is with empirical antibiotics such as intravenous (IV) benzylpenicillin and gentamicin.
A 10-day-old neonate presents to the Paediatric Assessment Unit with a blistering rash on the scalp and face. On examination, there is jaundice and hepatomegaly. The rash appears vesicular.
What is the most likely diagnosis?
Herpes simplex
This patient has developed neonatal herpes infection, usually due to herpes simplex virus type II. If the mother has active genital herpes, there is a 50% risk of transmission to the neonate, which can be reduced by opting for a Caesarean delivery. Neonatal herpes has three main presentations: skin, eye and mouth (SEM) disease, central nervous system disease and disseminated disease. The patient likely has disseminated disease due to the combination of hepatic failure and cutaneous lesions. Treatment is with IV aciclovir.
Criteria for admission for withdrawal
Consider inpatient or residential assisted withdrawal if a service user meets one or more of the following criteria. They:
drink over 30 units of alcohol per day
have a score of more than 30 on the SADQ
have a history of epilepsy, or experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes
need concurrent withdrawal from alcohol and benzodiazepines
regularly drink between 15 and 30 units of alcohol per day and have:
significant psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease) or
a significant learning disability or cognitive impairment.
Also consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people.
Offer inpatient care to children and young people aged 10 to 17 years who need assisted withdrawal.
• Positional talipes
feet remain in their in-utero position o Aetiology = intrauterine compression o Signs & symptoms and investigations: Can be fully dorsi-flexed to touch front of lower leg Normal size foot o Management: Physiotherapy
• Talipes Equinovarus (‘club foot’) =
inverted and supinated feet
o Aetiology = idiopathic; 1 in 1,000; M > F (2: 1)
May be 2nd to oligohydramnios
Association to DDH
o Signs & symptoms and investigations:
Cannot be fully dorsi-flexed to touch front of lower leg
Inverted (not everted; i.e. calcaneovalgus) and supinated feet
Affected foot is shorter and calf muscles are thinner
o Management:
Mild-moderate Ponsetti method (plaster casting and bracing)
Severe surgery
GBS 9 weeks into preg. Tx
Intrapartum benzypenicllin only
Iv vanc if allergic severe and cephalo ifd mild
monitor newborn
Seborrhoeic dermatitis treatment
Management depends on severity
mild-moderate: baby shampoo and baby oils
severe: mild topical steroids e.g. 1% hydrocortisone
Miscarriages vs ectopics
Expectant management
- miscarriage- wait 7-14 days
- ectopic- monitor 48hr and if bhcg rises again or symptoms manifest, intervention
Medical
Miscarriage -vaginal misoprostol
Ectopic - oral MTX
Surgical management
Miscarriage- vacuum aspiration (suction curettage) or surgery in theatre under GA (evacuation)
Ectopic - salpingectomy or salpingotomy
also According to NICE guidelines published in 2018, vaginal misoprostol is most appropriate as the patients past medical history of coagulopathy (Von Willebrand disease) is a contra-indication to expectant management, but not medical management.
The most common cause of ovarian enlargement in women of a reproductive age
Follicular cyst
known cause of infertility
immediate refferal to fertility services
If a breastfed baby loses > ?% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
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According to current NICE CKS guidance, pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain…..
Monitor expectantly and advise to repeat pregnancy test in 7 days. If negative, this confirms miscarriage. If positive, or continued or worsening symptoms, refer to the early pregnancy assessment unit
Pregnant women who are < 6 weeks gestation and present with vaginal bleeding and no pain can be managed expectantly
An infant with GORD who has troublesome symptoms despite a 1–2 week trial of alginate therapy, should be prescribed …
4-week trial of a proton pump inhibitor
Features of atypical UTI:
Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E. coli organisms.
CATFISH
- Creatinine
- Abdo/bladder mass
- Terribly ill
- Flow problems
- Infected with non-ecoli organisms
- Septicaemia
- Halted/no response to suitable abx >48 hours
Unilateral undescended testicle - review at
3 months - if persistent refer
If the testis is undescended by 3 months of age, the child should be referred to a paediatric surgeon and seen before 6 months of age. This is in line with NICE guidelines on undescended testes
IOTA criteria which help to classify cysts as being likely benign (‘B rules’) or malignant (‘M rules’). M rules include
Irregular, solid tumour. Ascites. At least 4 papillary structures. Irregular multilocular solid tumour with largest diameter ≥100 mm. Very strong blood flow.
Ondansetron during pregnancy is associated with…
a small increased risk of cleft palate/lip - the MHRA advise that these risks need to be discussed with the pregnant woman before use
Consider a diagnosis of pneumonia if the child has:
high fever (over 39°C) and/or persistently focal crackles.
A 27-year-old woman who is currently 39 weeks pregnant comes to see you complaining of itching down below. She has thick white discharge.
Given the likely diagnosis, which one of the following treatment options would you advise?
Clotrimazole pessary
This patient has thrush which is treated with antifungal medication. This patient is pregnant, therefore cannot be given oral fluconazole as this is contraindicated in pregnancy due to its association with congenital abnormalities.
Causes of neonatal hypotonia include:
neonatal sepsis
Werdnig-Hoffman disease (spinal muscular atrophy type 1)
hypothyroidism
Prader-Willi
A 39-year-old woman presents to her general practitioner with what she describes as ‘Pre-menstrual syndrome’. She describes severe pain that occurs 3-4 days before the start of her period each month which stops her from being able to go to work. She has a regular 29-day cycle which has only started being painful in the past year. She is nulliparous and uses the progesterone-only pill for contraception.
What is the most appropriate management of this patient?
All patients with secondary dysmenorrhoea need to be referred to gynaecology for investigation
This patient has secondary dysmenorrhoea as her pain precedes the first day of her menstrual cycle. Secondary dysmenorrhoea is associated with pathologies such as pelvic inflammatory disease, endometriosis, adenomyosis, and fibroids. As it is pathological, it must be investigated further with a referral to gynaecology.
The combined oral contraceptive pill may improve her symptoms, depending on the cause, however, it is important that she is investigated first.
The IQ range for categories (according to ICD 10) is as follows:
Mild: 50-69
Moderate: 35-49
Severe: 20-34
Profound: below 20
