Make a Medic - Specialities Flashcards
ultrasound scan will reveal a solid collection of echoes with numerous small anechoic spaces
snowstorm appearance - GTD
Management of GTD
suction curettage where the cervix is dilated and the trophoblastic tissue is extracted under general anaesthesia.
Management of CIN I
Observation and follow up smear test in 12 monthsMa
Management of CIN II+III
LLETZ
NOTE: Follow up smear in 6 months
1st investigation if ?Parvovirus in pregnancy?
Check maternal IgM antibodies, if detected - do amniocentesis
Abnormal baseline rate on CTG
<100 or >180Abn
Abnormal variability on CTG
<5 for more than 50 mins or >25 for more than 25 mins or sinusoidal
Abnormal deceleartions on CTG
Variable decelerations with any concerning characteristics in > 50% of contractions for 30 mins (or less if any maternal or foetal clinical risk factors) or late decelerations for 30 mins (or less if any maternal or foetal clinical risk factors) or a single prolonged deceleration ≥3 mins
When can medical terminations be performed up untiL?
24 weeks gestation
When can medical TOP be done at home?
If patient is well and <10 weeks pregnant
Absolute contraindications to VBAC
Previous classical C-section
-Previous uterine rupture
-Normal absolute contraindications to vaginal birth (e.g. placenta praevia)
Relative contraindications to VBAC
2 or more previous C-sections
-The need for induction of labour
-Previous labour outcome suggestive of cephalopelvic disproportion
Likelihood of success in VBAC
75%
How long is LMWH given for in pregnancy if VTE?
given for the remainder of the pregnancy, once daily, and for at least 6 weeks postnatally (such that the overall treatment with LMWH is 3 months). The LMWH is temporarily stopped 24 hours before delivery to decrease the risk of intrapartum and/or post-partum haemorrhage.
Types of anterior prolapse
Prolapse of the anterior vaginal wall may involve the urethra, bladder or both. These prolapses may be referred to as urethrocele, cystoceles or cystourethrocele respectively.
Typoes of posterior prolapse? How to differentiate?
Prolapse of the posterior vaginal wall may involve the rectum if low (rectocele)or loops of small bowel if higher up (enterocoele). 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.
FeverPAIN score for ABx
Fever in past 24 hours Yes +1
Absence of cough or coryza Yes +1
Symptom onset ≤3 days Yes +1
Purulent tonsils Yes +1
Severe tonsil inflammation Yes +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.
Mx of Necrotising enterocolitis
ABx and parenteral feeding, removal of gastric contents cia a nasogastric tube
What score is used for Croup?
Westley croup score
If otacoustic emission test abnormal, what test done?
Auditory brainstem responmse
What medication given in crohn’s?
First steroids
then immunosuppressive agent like azathioprine
appearance of a large oval macule followed by the development of a more widespread rash across the
torso
Pityriasis rosea
IQ test
What section allows a patient held under section to temporarily leave? What section to force them to return?
17,18
OCPD AKA
Anakanstic
Mx of SAD
CBT
Important cause of mood disorders and psychosis
Tertiary syphillis - Trepenoma Pallidum
NB: Also get Argylles Robertson pupil - accommodate but do not react
Monitoring of foetus in parvovirus in pregnancy
Doppler US of MA fortnightly until end of pregnancy
How to calculate RMI?
RMI = Ca-125 * M * U
The serum CA-125 result is multiplied by the menopausal score, M (premenopausal = 1, postmenopausal = 3), and multiplied by the ultrasound score, U (no features = 0, 1 feature = 1, 2 or more features = 3). The scoring method is summarised below:
A urinary pregnancy test is positive, and an intrauterine pregnancy is not detected on transvaginal ultrasound. What is the most likely diagnosis?
Ectopic
What condition is hypothyroidism associated with?
Pre-eclampsia
What protein to detect in PPROM?
insulin-like growth factor binding protein-1.
What is screened for at 28 weeks?
Anaemia, anti-D and Gestational diabetes
Combined test results for downs
The combined test is offered between 11 and 13+6 weeks’ gestation and consists of estimating the nuchal translucency on ultrasound scan (> 6 mm is considered significant) and measuring hCG (high in Down syndrome) and PAPP-A levels (low in Down syndrome).
Quadruple test results for Downs
The quadruple test is offered to women between 15 and 20 weeks’ gestation and consists of 4 blood markers: hCG, inhibin A (both high in Down syndrome), AFP and uE3 (both low in Down syndrome).
Most important tool to investigate SGA foetuses
umbilical artery doppler
X ray of NRDS
diffuse ground glass opacities
Mx of NRDS
supportive (oxygen therapy and ventilation) and exogenous surfactant may be administered
Mx of Alopecia areata
Initially conservative and supportive, as hair will regrow within a year
However, if distressed can offer topical corticoosteroids for 3 months
Non invasive test for IBD
faecal calprotectin
Mx of hypospadias
referral to a specialist for consideration of surgical correction (which usually happens after the age of 12 months).
Genetic inheritance of DMD
X linked recessive
Tests for syphillis
TPPA and rapid plasma reagin
If metabolic Sx present, what medication for schizo>
TYpical antipsychotic e.g. haloperidol
Delusions related to pateitns health or bodily function
Somatic delusions
What Ix confirms the presence of foetal anaemia in parvovirus?
USS doppler, shows polyhdramnios if foetus is infected
what is PROM assocaited with?
Cord prolapse
Most commonly involved pathogen in puerperal sepsis
group A strep - strep Pyogenes
Difference in dose of anti-D through pregnancy
250iU before 20 weeks, 500iU after 20 weeks
1500iU offered to all women at 28 weeks
Aim of first USS in antenatal care? What does it detect?
The first ultrasound scan ideally takes place between 10 weeks’ and 13+6 weeks’ gestation. 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
How should a mild microcytic anaemia identified in pregnancy be treated?
Oral Iron Supplementation
Bartholin gland AKA
greater vestibular glands, are two glands located either side of the vaginal introitus, at approximately 4 and 8 o’clock. These glands secrete mucus to lubricate the vagina.
NICE guidelines for phimosis
non-retractile and/or ballooning foreskin during micturition in children under 2 years old do not routinely require referral for circumcision.
gold standard ivnestigaiton for cerebral palsy
MRI head
Gold standard investigation for Hirchsprung
anorectal pull through
When physiological jaundice expected, bets way to quantify extent of bilirubinaemia?
measuring serum bilirubin or using a transcutaneous bilirubinometer probe.
NOTE: A serum measurement is appropriate when the jaundice has developed within the first 24 hours of life, or when the baby was born before 35 weeks’ gestation. If jaundice develops after the first 24 hours, or the gestational age is more than 35 weeks, transcutaneous bilirubinometery is appropriate. If the transcutaneous bilirubinometer records a measurement of more than 250 μmol/l, serum bilirubin measurement is indicated
First treatment for opthalmia neonatorum
oral erythro for 14 days
Main causes of opthalmia neonatorum, how to distinguish?
The two major bacterial causes of infective neonatal conjunctivitis are Chlamydia trachomatisand Neisseria gonorrhoea. Chlamydia is more common and presents between 5 days and 2 weeks after birth, whereas gonococcal conjunctivitis presents within the first 24 hours and up to 5 days after birth
1st line treatment for tonic clonic or myoclonic generalised seizures
Sodium valproate
Management of absence seizuers
Ethosuximade or sodium valproate
Management of focal seizures
Carbamezapine or lamotrigine
Management of catatonia
1st line - benzo e.g. lorazepam
THEN ECT
Clomipramine drug class
TCA
best SSRI post MI
Sertraline
If Wernicke’s encephalopathy is suspected or a patient is deemed at high risk of Wernicke’s encephalopathy, mx?
Pabrinex
Types of sections
What is uterine inversion? How does it present?
Uterine inversion is a serious complication of the third stage of labour, where the uterine fundus prolapses. It can manifest with maternal shock (due to significant blood loss) and a lump (uterine fundus) may be visible at or protruding out from the vaginal introitus.
How does uterine rupture present? WHat does it usually occur after?
Uterine rupture is a major risk of a vaginal birth after caesarean section. It usually manifests with sudden-onset severe pain followed by maternal haemodynamic compromise.
Normal rate of dilatation in a multiparous woman
1cm per hour
Most appropriate step in IOL followibng ROM
Commence an oxytocin infusion
How long after birth is contraception required>
21 days
When can IUD/IUS be inserted after birth?
Within 48 hours or after 4 weeks
Most common abortion act in UK
C - That the pregnancy has not exceeded its 24th week and that continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
Degrees of perineal tear and how to repair
1st and 2nd degree tears can be repaired by midwives in the delivery room.
Usually 3rd and 4th degree tears are repaired in theatre.
cutaneous scarring, microcephaly and limb hypoplasia
congenital varicella syndrome
sensorineural deafness, congenital cataracts, blindness, encephalitis and endocrine problems
Congenital rubella infection
vesicles and pustules often involving the face and mouth
Neonatal herpes simplex infection
1st line medical agent used in PPH
Oxytocin 5iU
Uterus is massaged before, then can give ergometrine (not in HTN, then carboprost (not in asthma)
When is clompiphene most effective? What can be given before if period was a long time ago?
Between 2-5 days after period starts, can give a progestogen for 10days to preciptitate a withdrawal bleed before giving clomiphene
What does Iodine bind to in Cervical stains? How does this show which cells are abnormal?
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.
Roseola Infantum caused by
HHV6/7
Difference in rash between roseola and measles/rubella
Roseola starts on tummy and moves out, other two start behind ears and move down
What Ix for Perthes?
X ray of both hips
talipes equinovarus AKA
club foot
Px of club foot
feet are inverted and supinated
Mx of talipes quinovarus
Ponseti method
Painful vasocclusive crises in sickle cell are treated by
admission and analgesia
Also achieve adequate hydrate and oxygenation as both dehydration and hypoxia are triggers
dactylitis
hand foot syndrome - get swelling and pain of fingers and toes
What should all children with constipation have?
their abdomen examined to palpate for masses in the left iliac fossa which may suggest faecal impaction
1st line management for constipation
disimpaction regimen of polyethylene glycol (Movicol®). The number of sachets given to the child should be increased until the impaction resolves. The dose should then be maintained at 1-4 sachets daily to prevent recurrence. The GP should arrange a two-week follow-up appointment to assess for improvement.
School exclusion for measles, mumps, rubella
THINK MMR: 4,5 5, 5
Complications of mumps
meningism and epididymoorchitis
What chromosomal abnormality is associated with normal intelligence
Turners
RFs for meconium aspiration
post-dates pregnancy, prolonged rupture of membranes and chorioamnionitis
Mx of meconium aspiration
IV gentamicin and ampicillin
Triad of nephrotic syndrome
proteinuria. peripheral oedema, low serum albumin (THINK: PPL)
otalgia and a red and itchy ear which may have dry skin
otitis externa
What is otitis externa usually due to?
Staph aureus or pseudomonas
Mx of NMS
stopping the offending drug. The remainder of treatment is largely supportive with the use of external cooling devices and rehydration with IV fluids.
Mx of LBD
acetylcholinesterase inhibitors (e.g. rivastigmine)
Schizoaffective disorder classification
presence of symptoms of schizophrenia (e.g. delusions, hallucinations) for at least 1 month alongside features of a mood disorder (i.e. mania or depression)
NOTE: The mood disturbances must be present for the majority of the period of illness, however, there should be a period of at least 2 weeks where psychosis is observed in the absence of mood symptoms (to help distinguish this diagnosis from psychotic depression or mania with psychosis).
Mx of schizoaffective disorder
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.
When does postnatal depression tend to present?
6 to 8 weeks postpartum
Difference between gestational and chronic hypertension
Chronic hypertension is <20 weeks of pregnancy
Gestation is post 20, without proteinuria
What cervical length is defiend as preterm labour on TVUSS?
<15mm at gestational age of >30 weeks
1st step in managing preterm labour
administer tocolytics and corticosteroids e.g. nifedipine and betamethasone
NOTE: Atosiban can be used instead
What is a short cervix defined as?
<25mm at 16-24 weeks gestation
Management of short cervix
cervical cerclage
NOTE: Vaginal progresterone can also be an option
Presentation of Lichen planus
inflammatory skin condition that typically presents with the development of polygonal violaceous macules. It can affect the vulva and perianal region leading to discomfort, itching and dyspareunia. The disease can also affect the oral mucosa and may be described as a ‘cobweb-like’ white markings known as Wikham striae
cobweb like markings on oral mucosa
Wickham striae
Mx of antiphospholipid syndrome
combination of low dose aspirin and a LMWH - reduce risk of miscarriage
Mx of endometriosis if wanting to preserve fertility
laparoscopic excision or ablation with adhesiolysis should be offered
NOTE: If fertility was not a priority, would follow with hormonal therapy
patient has tested positive for the high-risk forms of HPV and cytological analysis reveals mild dyskaryosis, mx?
non-urgent referral to colposcopy
First-line treatment for post-menopausal women (amenorrhoeic for over 12 months)
continuous combined HRT regimen.
NOTE: Cyclical regimens are preferred for women who are peri-menopausal (i.e. still have periods)
Mx of postmenopausal women who are suffering predominantly from vaginal symptoms such as dryness and dyspareunia
vaginal oestrogen creams
Diagnostic test for asthma
Spirometry - FEV1 - In asthma, it is reduced to less than 80% of the predicted amount for the age and sex of the patient. In asthma, bronchodilator reversibility will be demonstrated -an improvement in FEV1 of 12% or more after administration of a bronchodilator is considered a positive result.
scarring alopecia
Tinea capitis (ringworm infection of scalp)
Treatment of tinea capitis
oral antifungals or topical ketoconazole shampoo.
salmon-pink rash, arthritis, uveitis and systemic features including fevers (in the absence of infection), weight loss, myalgia and reduced appetite.
Systemic-onset juvenile idiopathic arthritis (JIA) or Still’s disease
NOTE: Differs from pauciarticular JIA as this has <4 joints affected and usually ANA postiive
When is a cleft palate usually repaired?
A cleft lip is usually repaired within the first 3 months of life whilst a cleft palate is repaired when the child is 6-12 months old
type of cerebral palsy that causes dystonia? What causes it? Which part of brain is affected?
dyskinetic cerebral palsy caused by perinatal asphyxia (which causes hypoxic-ischaemic encephalopathy). If the brain damage primarily affects the basal ganglia, it causes movement abnormalities such as dystonia
What type of cerebral palsy has chorea or athetosis?
dyskinetic
What is ataxic cerebral palsy associated with?
hypotonia, particularly of the trunk and limbs, and patients often have poor balance and coordination, delayed motor development, ataxia and an intention tremor
Hemiplegic spastic cerebral palsy
Diplegic spastic cerebral palsy
Quadriplegic spastic cerebral palsy
Form of spastic cerebral palsy that affects an arm and a leg on the same side.
Form of spastic cerebral palsy that affects both lower limbs.
Form of spastic cerebral palsy affecting all four limbs.
small, round, blue cell tumour usually occurring in the pelvis or long bones
Ewings sarcoma
onion skin appearance in the X-ray
Ewings Sarcoma
Codman triangle
Osteosarcoma
bone tumour that causes pain that is worse at night
osteoid osteoma
How does presentation of eczema differ across age groups?
infants will be affected on their face and trunk whilst older children will be affected on flexor surfaces (cubital and popliteal fossae) and friction surfaces (neck, wrists and ankles)
Fregoli syndrome
delusional disorder in which an individual holds a false and fixed belief that different people are, in fact, a single person who is able to shapeshift and change their appearance
What medicaiton can cause fregoli syndrome?
Levodopa
Examples of agoraphobia? How may it manifest? How is the fear explained as by patients?
phobias that revolve around fears of leaving home and entering public places (e.g. crowded tubes). It may manifest acutely with panic attacks. Patients often explain that the fear of being unable to escape to a safe place (i.e. home) is the main driving force behind their symptoms
NOTE: Managed with CBT
Mx of Seretonin syndrome
Treatment is largely supportive and involves ceasing the causative agent. Benzodiazepines (e.g. midazolam) can help reduce agitation and muscle hyperactivity. Supportive treatment involves active cooling. Insome cases, patients will require ITU level care
painless swelling on the labia majora that tends to affect women who are sexually active between the ages of 20-30 years
Bartholin’s cyst
Mx of Bartholin’s cysts
Bartholin’s cysts that are asymptomatic can be managed conservatively with advice on warm baths/compresses and simple analgesia. For cysts that are persistent or symptomatic or have evidence of progression to an abscess, antibiotics and surgical treatment is often required
If Bartholin’s cyst/abscess requires treatment, 1st line management?
Marsupialisation and broad-spectrum ABx
An endometrial thickness greater than what is abnormal in a post menopausal female?
a thickness greater than 4 mm is abnormal in a post-menopausal female and requires further investigations with an endometrial biopsy
1st line management of endometrial hyperplasia without atypia
First-line treatment involves commencing continuous progestogens using the levonorgestrel intrauterine system as it causes the endometrial lining to thin. They should be continued for at least 6 months and the patient should be reviewed with a TVUSS and endometrial biopsy every 6 months
1st line management of endometrial cancer or endometrial hyperplasia with atypia
A total hysterectomy and bilateral salpingo-oophorectomy
NOTE: If a premenopausal patient had endometrial hyperplasia with atypia and wanted to preserve fertility, continuous progestogens and 3-monthly reviews would be required
Medical management of urge incontinence if old and frail
Mirabegron
Physiological change in tidal volume in pregnancy
Increases tidal volume
1st line management of UTI in pregnancy
7-day course of nitrofurantoin (unless the pregnancy is at term) - then cefalexin
Mx of pregnant patients presenting with a primary infection in the 1st or 2nd trimester
oral aciclovir is recommended from 36 weeks’ gestation until delivery with a vaginal delivery anticipated.
Mx of pregnant patients presenting with a primary infection in the 3rd trimester
oral aciclovir should be commenced immediately until delivery
NOTE: 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
painless, fresh vaginal bleeding during spontaneous or artificial rupture of membranes
vasa praevia
What to do whilst waiting for an emergency C section in cord prolapse?
presenting part should be elevated manually or by filling the bladder to elevate the cord and, hence, reduce cord compression. The knee-to-chest position can further help reduce cord compression
transilluminates and painless lump in testes
Hydrocele
NOTE: Usually resolve spontaneously
bag of worms
Varicocele
What supplements are given in CF?
Creon
Achrondoplasia mutation and inheritance
autosomal dominant mutation of FGFR-3
Rare complication of mumps
Pancreatitis
What investigations are needed to confirm Parkinson’s?
Largely clinical diagnosis
What is progressive supranuclear Palsy?
Parkinson’s plus syndrome that presents similarly to Parkinson’s disease but is also classically associated with an upgaze palsy.
NOTE: It is commonly misdiagnosed as Parkinson’s disease and does not tend to respond as well toconventional Parkinson’s disease treatments.
Which women with chickenpox should be given medication? How soon after they present should it be given? If not, what happens?
Pregnant women who are more than 20 weeks’ pregnant and develop chickenpox should be started on a course of aciclovir provided that they present within 24 hours of the onset of symptoms. Pregnant women are at increased risk of the complication of varicellazoster virus (pneumonia, hepatitis, encephalitis) and, if they develop chickenpox before 20 weeks’ gestation, there is a small chance that the baby will be born with congenital varicella syndrome.
What is cervical ectropion? Who is it more common in?
Cervical ectropion refers to a natural cervical response to oestrogen when cells of the endocervix appear on the ectocervix. These cells are more fragile and prone to bleed following contact. Cervical ectropion is more common in young women and women taking the combined oral contraceptive pill.
empty uterus on ultrasound and a closed os on speculum examination
Complete miscarriage - patient has evacuated her uterus of products of conception
presence of a foetus with no foetal heartbeat within the uterus that is not associated with significant abdominal pain or vaginal bleeding
Missed miscarriage
Recurrent miscarriage is defined as?
3 or more successive misvarriages
atient has developed abdominal pain and vaginal bleeding and the cervical os remains open
Incomplete miscarraige
Mx of HIV in pregnancy and manner of delivery
Women with a viral load of less than 50 copies/mL at 36 weeks’ gestation can consider vaginal delivery. If the viral load is greater than 50 copies/mL, elective C-section should be recommended to reduce the risk of transmission to the baby
ECV and whent o do
singleton breech pregnancy - 36 weeks in nulliparous, 37 weeks in multiparous
How is proteinuria measure din preeclampsia?
urine protein: creatinine ratio (PCR). A urine PCR > 30 mg/mmol in the context of high bloodpressure is suggestive of pre-eclampsia.
NOTE: NOT 24 HOUR URINE QUANTIFICATION
lack of red reflex and, instead, a white pupil (leukocoria). Children may also have a squint.
Retinoblastoma
Mx of retinoblastoma
enucleation, radiotherapy and chemotherapy
how to differentiate between periorbital and orbital cellulitis?
orbital signs including reduced and/or painful eye movements, visual symptoms and relative afferent pupillary defect
Causative organ isms of periorbital/orbital cellulitsi
Staph aureus/epidermidis, strep
inheritance of BMD
X linked recessive
What is talipes equinovarus assocaited with?
Spinda bifida, cerebral palsy, oligohydramnios and Edward syndrome
two main signs in testicular torsion
Loss of the cremasteric reflex and negative Prehn’s sign. pregn’s sign refers to relief of scrotal pain upon elevation of the testicles (it is negative in testicular torsion and positive in epididymitis).
What is omphalitis> what causes it? What can it lead to?
Omphalitis is a rare condition in which the umbilicus and surrounding tissues become infected and inflamed (usually caused by Staphylococcus sp.and Streptococcus sp.). The umbilicus and stump may appear red and warm and be discharging pus. This can quickly progress to a more widespread infection (e.g. necrotising fasciitis) as it makes its way across the abdominal wall.
Mx of omphalitis
Depends on severity, if fever and ? sespsis - admit and IV ABx
What occurs in Ebstein’s anomaly?
Ebstein’s anomaly is a congenital defect which involves the downward displacement of an abnormal tricuspid valve which causes the atrium to increase in size and the right ventricle to become smaller or ‘atrialise’.
rosenthal fibres
Pilocytic astrocytoma
Features of Hemangioblastomas
benign slow growing, cerebellar tumours that may be associated with VOn hippel Lindau. Often slow growing
Features of Meningiomas
2nd most common primary brain tumour, typically benign. Psammaoma bodies
omiting, hypotonia and circulatory collapse on a background of congenital adrenal hyperplasia (CAH)
Salt losing crisis
CAH inheritance
AR
Pathophys of CAH (just to understand)
deficiency of a certain enzyme within the adrenal steroid synthesis pathway leads to a low output of cortisol. This, in turn, leads to increased ACTH secretion from the anterior pituitary gland in an attempt to compensate. The ACTH stimulates the adrenalglands and, as cortisol cannot be produced, it leads to the shunting of the precursors towards sex steroid production. The elevated circulating levels of sex steroids leads to virilisation in female infants(e.g. hypertrophy of the clitoris) and enlarged penises in male infants. They may also have a pigmented scrotum. If aldosterone secretion is also affected, it would result in serious electrolyte derangements.
Types of CAH and how they present (just to understand)
Most cases of CAH are caused by 21-hydroxylase deficiency. If the deficiency is complete, they will present soon after birth with abnormal genitalia or a salt-losing crisis. Around 1/20 cases are caused by 11-beta hydroxylase deficiency. The condition is generally milder andmay present with virilisation of female genitalia, precocious puberty, hypertension and hypokalaemia. 17-hydroxylase deficiency is a very rare form of CAH. It often causes hypertension and may have hypokalaemia.
Illness anxiety disorder AKA
hypochondriasis
What is Munchausaen’s syndrome?
Factitious disorder, also known as Munchausen’s syndrome, is a disorder in which the patient assumes the sick role by feigning symptoms for internal gain; the patient does not have an ulterior motive, and their behaviours are usually a manifestation of psychological distress.
What is malingering?
Malingering is the feigning of symptoms for the external gain of being diagnosed with an illness; for example, to avoid criminal prosecution or to be eligible for benefits. Here, the person is conscious of what they are doing; this is not the result of psychological suffering.
What enzyme is elevated in NMS?
CK
Ekbom syndrome AKA
delusional parsitosis
NOTE: Treated with antipsychotics and antidepressants
stepwise decline in memory
Vascular dementia
How often should monochorionic diamniotic twins have appointments? What should these be combined with?
Monochorionic diamniotic twins should have appointments combined with growth scans every 2 weeks from 16 to 24 weeks, followed by scans at 28, 32 and 34 weeks’ gestation.
!st line management for stress incontinence
pelvic floor muscle training. NICE recommends performing at least 8 contractions, 3 times per day for a minimum of 3 months
Mx of vulvovaginal candidiasis in pregnancy
clotrimazole pessary (intravaginal)
Defintion of menopause
essation of periods for 12 months in the absence of any other causes of amenorrhoea (e.g. being underweight, using contraceptives).
What insulin is required during labour in GDM?
variable-rate insulin infusion (sliding scale) during labour with the aim of maintaining blood glucose concentration within 4-7 mmol/L.
What is offered to assist the third stage of labour? When is it offered>
10 IU of oxytocin is injected IM either following delivery of the anterior shoulder or immediately after delivery of the baby and prior to the clamping of the cord. This augments the contracting down of the uterus after delivery of the baby, and facilitates the delivery of the placenta and membranes. Controlled cord traction is then used to remove the placenta.
When is IOL offered to women post term?
Induction is offered between 41-42 weeks’ gestation in women for whom labour has failed to start spontaneously.
What is balanitis? What causes it? How to manage?
Balanitis is inflammation of the glans penis, usually due to an infection that may be bacterial or fungal.
In all cases, hygiene (including under the foreskin) with saline washes and a short-course of topical 1% hydrocortisone cream is recommended
NOTE: If fungal, topical clotrimazole may be useful
How long should conservative methods be trialled for in ADHD?
10 weeks
2nd line management for ADHD
dexamphetamine (used if methylphenidate doesn’t work)
inheritance of sickle cell
AR
Mx of appendicitis
Group and save
Abx
Mouth (Nil by)
Enter (IV fluids + analgesia)
Grow out of laryngomalacia by?
2 years
vesicular rash that is classically associated with coeliac disease
Dermatitis herpetiformis
How to differ between IgA nephropathy and post-streptococcal glomerulonephrits
IgA typically occurs days after the onset of an upper respiratory tract infection, whereas post-streptococcal glomerulonephritis tends to occurs weeks after an illness
what murmur in Marfan’s?
Aortic regurg
ASx of marfan’s
Pneumothoracees
Mx of primary pneumothorax >2cm and breathless
Initially be treated by needle aspiration. If this is unsuccessful, a chest drain should be inserted
Mx of secondary pneumothorax >2cm and breathlessness
Chest drain
Types of FGM
type 1: part or total removal of the clitoris or clitoral hood (Clitoridectomy)
type 2: part or total removal of the clitoris and the labia minor. (Excision)
type 3: narrowing of the vaginal opening. (Infibulation)
type 4: all other harmful procedures to the female genitalia for non-medical purposes. (Other)
Incubation period for rubella? How long is child infectious from?
incubation period for rubella is 14-21 days and the child is infectious from 7 days before symptoms until 4 days after the rashhas appeared.
ASx of neurofibromatosis T1 and T2
NF1 is associated with axillary freckling, Lisch nodules (hamartomas of the iris), cafe-au-lait, phaeochromocytomas, neurofibromas and bone deformities (e.g. scoliosis)
NF2 is commonly associated with acoustic neuromas, meningiomas and ependymomas
Acetycholinesterase inhibitors that are used in Alzheimer’s
Donepezil, galantamine and rivastigmine
THINK: Dementia got real
If patient experiencing SEs of medication in Alzheimer’s, what to do?
Stop the drug, and trial a diffrent drug that doesn’t have that side effect
microcephaly, smooth philtrum, thin upper lip and small palpebral fissures.
Foetal alcohol syndrome
progressing changes of character and social deterioration, followed by impairment of intellect, memory, and language functions
Frontotemporal dementia
1st thing to do if patient presents with delayed speech and language milestones
Refer to audiology clinic
Mx of bartholin’s abscess
Marsupialisation and broad spectrum ABx
sudden-onset lower abdominal pain with an ultrasound scan showing an enlarged ovary and a thickened fallopian tube
Ovarian torsion
name of HPV vaccine
Gardasil
1st line management of cervical cancer of stage IIB-IVA
chemoradiation
Management of stage IA1 cervical cancer
conservative
Mx of Stage IA2-IIA or early stage disease when tumours are 4cm or less
Radical hysterectomy with lymphadenectomy
When can COCP be started if breastfeeding? If not?
6 weeks after, 3 weeks after
What surgery means that no cervical smears are needed?
Total hysterectomy
Mx of AShermans
hysteroscopy with adhesiolysis
Alternative to mirabegron if frail old with urge incontinence
Tolterodine
Blood test resultks in osteogenesis
All normal - same as Pagets
Abdominal migraine
paroxysmal episodes of intense acute umbilical pain which interferes with daily activities. These occur more than two times in 12 months and are associated with more than two of anorexia, vomiting, photophobia, nausea, headache and pallor.
When should patients with tonsilitis be referred?
NICE guidelines state that patients who have recurrent tonsillitis (defined as more than 7 episodes per year for 1 year, 5 episodes per year for 2 years or 3 episodes per year for 3 years) should be referred to an ENT specialist for consideration of tonsillectomy
history of recurrent ear infections with the development of a conductive hearing impairment, dx? If in toddlers?
Chronic otitis media
In toddlers, otitis media with effusion (glue ear) should be considered -it results from eustachian t
Whenever a patient with asthma is being reviewed in a clinic, most important thing to review before deciding to escalate treatment?
Review their inhaler technique and compliance
Difference between presentation of pneumonia and bronchiolitis in children
Pneumonia is more likely to cause significant tachypnoea and the signs suggestive of focal consolidation is more suggestive of bacterial pneumonia than bronchiolitis or viral pneumonia. Furthermore, bronchiolitis typically manifests with a wheeze upon auscultation
Likely causative organism of pneumonia in children by age
Neonate: Group B Streptococcus, Gram-negative Enterococcus
Infants and Young Children: Streptococcus pneumoniaeor Haemophilus influenzae
Children > 5 years: Mycoplasma pneumoniae, Streptococcus pneumoniaeand Chlamydia pneumoniae
Mx of mild eczema
Emollients and topical 1% hydrocortisone acetate cream
Mx of moderate eczema
Clobetasone butyrate 0.05% and emollients
honey-coloured, weeping, crusted lesions
Impetigo
Cause of impeitgo
Staph aureus
painless blisters that are fluid-filled with surrounding erythema and they are often noted in skin folds
Impetigo
Mx of impetigo
It is usually treated with topical antibiotics (e.g. fusidic acid) but in more severe cases (like bullous impetigo) oral agents like flucloxacillin are more likely to be required.
Pathophys of PDA and how it closes spontaneously (just to understand)
The foetus circulation is specially designed to bypass the lungs (which are non-functional in utero). After birth, this circulation must rapidly reconfigure as the lungs become responsible for oxygenating the blood. The ductus arteriosus is a connection between the pulmonary trunk and the aorta which allows blood from the pulmonary artery to pass into the aorta thereby bypassing the lungs. At birth, the rise in pulmonary vascular resistance leads to an increase in concentration of oxygen in the blood and subsequent decrease in prostaglandins, causing closure of the ductus arteriosus. If the ductus arteriosus remains patent, there is abnormal transmission of blood from the aorta in tothe pulmonary artery due to the increased pressure in the left side of the heart at birth.
Questionnaire for OCD
Yale brown
2nd line mood stabiliser for BPAD if lithium not tolerated
sodium valproate
32 mm right adnexal mass; no visible foetal heartbeat; no intrauterine pregnancy. IF ADNEXAL MASS - ALWAYS ECTOPIC PREGNANCY
IF ADNEXAL MASS - ALWAYS ECTOPIC PREGNANCY
first-line treatment for women with heavy menstrual bleeding due to leiomyomas?
Mirena coil
Conservative management of ectopics when
Conservative management:
●hCG < 200 IU/L
●No foetal heartbeat
●Adnexal mass <30mm
Patients managed conservatively should have repeat hCG levels until they are undetectable.
Medical management of ectopics when
Medical management with IM methotrexate:
●No significant pain,
●hCG < 1500 IU/L
●No foetal heartbeat or intrauterine pregnancy
●Adnexal mass <35mm.
WHat is asherman’s? How does it present?
Asherman syndrome which is characterised by uterine adhesions that tend to arise after intrauterine procedures (e.g. previous dilation and curettage) or after endometrial infection (e.g. pelvic inflammatory disease). The formation of scar tissue within theuterus can affect periods and fertility
What type of lesion is seen on laparoscopy of endometriosis?
Common sites include the ovary (usually bilateral) with a “chocolate-cyst appearance” aka endometrioma and the peritoneum with a classic “gun-powder lesion appearance”.
Mild UC is treated with
topical (i.e. per rectal) 5-ASAs such as mesalazine.
itchy, papular rash associated with head lice
Pediculus humanus capitus
papular, red rash, finely spread across the base of the neck and into the hairline.
Rash associated with head lice, treat with wet combing
Features of innocent mumurs
The key features of an innocent features can be remembered as the S’s:
-Sensitive tochanges in position and breathing
-Short duration(i.e. not pansystolic)
-Single (i.e.no associated clicks or gallops)
-Small(present in a limited area and does not radiate)
-Soft (low amplitude)
-Systolic
Skin-coloured rash with central umbilication
Molluscum contagiosum
pink/pearly white papules
Molluscum contagiosum
What is EDPS? How long is it taken over? Criteria?
The Edinburgh Postnatal Depression Scale (EDPS) is a ten-item questionnaire that is self-administered. Women are asked to describe their feelings over the last 7 days, typically a score of 12 or above indicates that the patient is likely to be suffering from PND. In order for PND to be diagnosed, the patient must be at least 2 weeks postpartum.
How to differentiate between conduct disorder and oppositional deficant disorder
Oppositional defiant disorder (ODD) can be differentiated from conduct disorder based on the nature of the child’s behaviour. Children with conduct disorder may be more aggressive and violent towards other individuals or animals. If these behaviours persist beyond the age of 18 years, it will be referred to as antisocial personality disorder. Children with ODD on the other hand tend to only behave badly in the presence of authoritative figures such as teachers and parents.
Triad for meigs syndrome
benign ovarian tumour (usually a fibroma), ascites, and pleural effusions
NOTE: Fibromas do not secrete sex steroid hormones
How to investigate post menopausal bleeding?
Endometrial cancer till proven otherwise
Arrange an urgent USS to assess thickness of endometrium with subsequent hysteroscopy and biopsy if indicated
HELLP
Haemolysis, elevated liver enzymes, low platelets
Way to calculate gravida and parity
A simple way to remember gravidity and parity is ‘Got pregnant, Pushed a baby’. To calculate gravidity, all pregnancies are counted, regardless of the outcome. This woman has had 8 pregnancies, including the current pregnancy. To calculate parity, all babies birthed after 24 weeks’ gestation are counted, even if the baby is stillborn. Therefore, this woman is para 3 due to her two children and 1 previous stillbirth at38 weeks’ gestation. One area of contention is the notation for multiple pregnancies. Many doctors and midwives will not follow this, but the correct way is to count multiple birth as a single event(e.g. a woman who has given birth to twins is G1P1).
first step in assessing a patient who has presented with reduced foetal movements
auscultate the foetal heartbeat using a handheld Doppler. I
If no heartbeat is heard, the next step would involve an ultrasound scan to confirm intrauterine death. If a heartbeat is present, a CTG should be performed next to assess foetal wellbeing.
sudden-onset, constant and severe abdominal pain during labour
Uterine rupture
Most significant risk factor for uterine rupture
previous C-section (which leaves a weak point in the uterine wall)
How to know what type of twin pregnancy it is? LEARN THIS
The time at which the developing zygote divides corresponds with the chorionicity of the developing pregnancy. If the zygote divides before day 4 after fertilisation, it will become a dichorionic diamniotic pregnancy. If it divides between day 4 and 8, it will become a monochorionic diamniotic twin pregnancy. Between days 8 and 12 it will become monochorionic monoamniotic, and after day 13 it will result in conjoined twins. There is no such thing as dichorionic monoamniotic twins.
hypogonatrophic hypogonadism
Kallman’s
Elevated LH/FSH and low oestradiol
Turners
Mot common childhood arrhythmia? Mx?
SVT - WPW
Tru vagal manouevures then IV adenosine
Initial management of cyanotic heart disease
Prostaglandin infusion
most common cause of viral encephalitis
HSV1
What type of UTI is it if no response to ABx within 48 hours of treatment?
Atypical
Who should receive an urgent USS during acute UTI?
All children with atypical UTIs should receive an urgent ultrasound scan during the acute infection. Atypical UTIs can beindicated by poor urine flow, an abdominal or bladder mass, raised creatinine, sepsis, a failure to respond to antibiotics within 48 hours of commencing treatment and an infection with non-E. coliorganisms. All children under the age of 6 months with recurrent UTIs should also undergo an ultrasound during the acute infection.
Who should receive non-urgent USS in children?
Non-urgent ultrasound scans (within 6 weeks) should be organised for children over the age of 6 months with recurrent UTIs and those under the age of 6 months who develop their firstUTI.
When should a DMSA be performed?
4-6 months after an acute infection in children under the age of 3 years with an atypical UTI or recurrent UTIs and in children over the age of 3 years with recurrent UTIs.
Who are MCUGs indicated in?
children under the age of 6 months with atypical or recurrent UTIs.
What syndromes can lead to third trimester miscarriages?
TORCH - Toxoplasma gondii, Others (Treponema pallidum, listeria, varicella zoster virus, parvovirus B19, syphilis), Rubella, Cytomegalovirus (CMV), Herpes simplex virus
Lesions tend to be found onexposed areas such as the face, neck and hands and begin as erythematous macules which become vesicular/pustular. These vesicles then rupture and cause fluid to leak out, leading to honey-coloured crusted lesions on the child’s face
Impetigo
Exclusion from school until lesionsa re dry and scabbed over
sual blood test abnormalities that are seen in patient with anorexia nervosa
hypokalaemia, hypercholesterolaemia and hypercarotenaemia
first-line management option for moderate-severe depression
antidepressant plus referral for psychological therapy.
How to consider treatment in a single overdose of paracetemol?
the paracetamol level should be measured 4 hours after ingestion and plotted on a nomogram to determine whether N-acetylcysteine should be given
How to consider treatment in a staggered overdose of paracetemol?
In the case of a staggered overdose (taken over more than 1 hour), treatment should be commenced immediately and bloods should be taken to measure the serum paracetamol concentration, LFTs and coagulation.
What is the antidote for paracetemol overdose?
N-acetylcysteine
What can be given in patients who have presented within 1 hour of paracetemol OD ingestion?
Activated charcoal
How to differ between prolonged grief reaction and persistent complex bereavement disorer
PGD is when these symptoms persist for over 6 months, distinguishing it from a normal grief reaction, and patients often exhibit preoccupation with the deceased and feelings of guilt or self-blame. Meanwhile, PCBD has a similar criteria but must be present for over 12 months and is indicated when a patient expresses a desire to die, in order “to be with” the loved one.
First-line management for GAD
psychological therapy, such as CBT, combined with either an SSRI (such as sertraline), an SNRI (such as venlafaxine) or an atypical antidepressant (such as mirtazapine).
Which intervention in PCOS would increase chances of conceiving and be useful in managing troublesome symptoms?
Metformin and weight losss
What can be used to manage just the Sx of hyperandrogenism in PCOS?
Cyproterone acetate
active stage of labour
4-10cm
Pain relief commonly used during the 1ststage of labour before admission
paracetamol, co-dydramol, and pethidine
Indications for assisted vaginal delivery
poor progress in the 2ndstage of labour, foetal compromise, maternal exhaustion or distress, or the need to reduce time spent pushing (e.g. maternal cardiac disease).
When is ventouse superior to forceps?
In reducing trauma to the vagina and post-operative pain. The use of ventouse also reduces the risk of facial trauma to the baby, such as lacerations and facial nerve palsy.
Indications for ventouse delivery
cephalic vertex presentation and should not be used in deliveries that are less than 34 weeks’ gestation due to the risk of intracranial haemorrhage
Why to use forceps over ventouse?
Forceps are more likely to be successful than ventouse in delivering the baby. The use of forceps is also associated with lower risk of intracranial and retinal haemorrhage.
A mnemonic to remember the criteria for forceps delivery is:
FORCEPS
F: fetus alive
O: os dilated
R: ruptured membrane / rotation complete
C: cervix take-up
E: engagement of head
P: presentation suitable
S: sagittal suture in AP diameter of inlet
Causes of oligohydramnios
placental insufficiency, foetal renal tract abnormalities, NSAID use, and post-dates gestation
Causes of polyhydramnios
GI atresia, cleft palate, foetal anaemia, maternal diabetes mellitus and multiple pregnancy
When to review patients with GDM after giving insulin?
after 1 week
Mx of asymptomatic bacteriura in pregnancy
TREAT AS IF IT IS A UTI
High dose (5 mg) folic acid is recommended in the presence of the following risk factors
Use of antiepileptic drugs
Previous pregnancy with spina bifida
Maternal/partner with spina bifida
Coeliac disease
Diabetes
Sickle cell disease, thalassaemia
BMI > 30 kg/m2
What type of pincer group is expected by 12 months?
it is expected that the child will have developed a mature pincer grip (limit age = 12 months) and so should no longer have an inferior pincer grip, indicating this child’s fine motor skills are delayed
Sx of Kawasaki disease
CRASH and Burn(Conjunctivitis, Rash, Adenopathy, Strawberry tongue, Hand and feet swelling and Burnindicating a high fever lasting more than 5 days).
What is labial fusion? When does it resolve by?
Labial fusion is a common, benign condition where, in female children below the age of 7 years, it may present with partial fusion of the labia minora. It usually develops at 1-2 years of age and often resolves by puberty.
Mx of labial fusion
If the patient is asymptomatic, it is advised to reassure the parents and arrange follow-up to ensure resolution. If the patient is symptomatic, a 4-6-week course of topical oestrogen may be prescribed.
Triad of reactive arthritis
arthritis (usually asymmetrical oligoarthritis), urethritis and uveitis which can be remembered using the saying ‘Can’t see, can’t pee, can’t climb a tree
Mx of reactive arthritis
It is self-resolving and does not require any active treatment. The patient may benefit from some pain relief in the interim.
Initial investigation for suspected appendicitis
The initial investigation used in most cases of suspected appendicitis is an abdominal ultrasound scan
small head, widely-spaced eyes and a rounded sole of the foot (rocker bottom feet)
Edwards’ syndrome is caused by trisomy 18
What cardiac defect is seen in Edward’s syndrome?
VSD
What cardiac defect in Noonan’s syndrome?
ASD
What cardiac defect is seen in Marfan’s syndrome?
Aortic regurg
Scaly rash, what should you think of?
Psoriasis
What type of psoriasis occurs after infection?
guttate psoriasis often occurs following Streptococcal infections and tends to develop on the upper trunk and proximal upper limbs.
dry, thickened hyperkeratotic plaques involving the palmar surfaces
Hyperkeratotic eczema
large herald patch with smaller lesions in a “Christmas Tree” distribution, mainly on the trunk and limbs
Pityriasis rosea
flat, purple, polygonal papules and a white reticular surface known as Wickam’s striae.
Lichen planus
Variant CJD AKA
Bovine Spongiform Encephalopathy (mad cow disease)
Where is the fluid collected in the hydrocele?
Tunica vaginalis
How to differ between variant and sporadic CJD?
Variant occurs in younger patients, and has psychiatric Sx before neutro
Sporadic is the opposite
5 A’s of Alzheimer’s
amnesia, anomia, apraxia, agnosia and aphasia.
Which lobe is affected firstg in Alzheimer’s?
Temporal lobe atrophy
Mx of vascular dementia
he mainstay of management for vascular dementia is to modify cardiovascular risk factors. This may include starting the patient on an antiplatelet agent (e.g. aspirin) as well as managing their blood pressure, cholesterol and glycaemic control
Tetrad of NMS
altered mental state, muscle rigidity, autonomic instability and hyperthermia
first-line treatment option for women with vulvovaginal candidiasis
Clotrimazole pessary
When are pregnant women tested for ID? Which ID?
All pregnant women are tested for HIV, hepatitis B and syphilis at booking. Booking is recommended as soon as possible, ideally before 10 weeks’ gestation.
What swabs should be sent when a patient presents with an STI?
Endocervical and high vaginal swab
criteria for pregnant women to be offered an OGTT at 26-28 weeks gestation
Pregnant women are offered an OGTT at 26-28 weeks gestation if they fit any 1 of the following criteria, which can be remembered using the mnemonic BIG PE:
●BMI > 30 kg/m2
●1st degree relative who has had gestational diabetes (GDM)
●Gestational diabetes in the past
●Previous pregnancy with birthweight >4.5kg
●Ethnicity with high prevalence of diabetes e.g. South-Asian, Black or Middle-Eastern
When does vasa praevia present? What with? Who’s observations are affected?
Vasa praevia classically presents with an antepartum haemorrhage, often after spontaneous rupture of membranes with significant foetal compromise. As the blood is lost from the foetal circulation, the mother’s observations may remain largely stable.
scoring system for hyperemesis gravidarum
Pregnancy-Unique Quantification of Emesis (PUQE)
rapid deterioration with hypoxia and a low blood pressure
Amniotic fluid embolism
NEEDS ITU LEVEL SUPPROT
arched back and crying
Infantile colic
Mx of Meckel’s
If the Meckel’s diverticulum is asymptomatic (as in this case), it can be managed by providing safetynetting advice about complications. If the Meckel’s is causing symptoms (e.g. bleeding, obstruction), it will require surgical excision.
double bubble sign’ on both ultrasound and X-rays
Duodenal atresia
Blalock-Taussig shunt
Surgery used in ToF
Types of spina bifida (just be aware)
Spina bifida occulta belongs to a spectrum of neural tube defects that occur due to failure of fusion of the neural tube during intrauterine life. Spina bifida is often an incidental X-ray finding, however, there may be an overlying lesion such as a tuft of hair, a birthmark, a lipoma or a dermal sinus. Tethered spinal cord syndrome may be a complication of spina bifida where the inelastic tissue of the caudal spine is fixed and may cause an insidious onset of symptoms such as lower back pain, gait disturbance, scoliosis, high-arched feet and neurological dysfunction (bladder and bowel).
A meningocele is the herniation of the meninges between the vertebrae forming a sac containing cerebrospinal fluid. The sac does not contain any neural tissue so neurology is normal however, the sac is at risk of rupture which could lead to meningitis and hydrocephalus.
Myelomeningocele is the most severe form of spina bifida which occurs when the spinal cord protrudes through an opening in an unfused portion of the spinal column. This can be associated with severe neurological complications such as paresis, talipes, neuropathic bowel and bladder andhydrocephalus.
Undescended testicles (be aware)
It is relatively common for a male child to be born with a single undescended testicle. In cases of unilateral undescended testicles, given there are no other abnormalities suggestive of disorders of sexual development, no urgent intervention is required as the testicle often migrates into the scrotum over time. If, at 6 weeks, the testicle is still undescended, the infant should be reviewed at 4-5 months. At this point, if the testicle has still not descended into the scrotum, they should be referred to a paediatric urologist and should be seen before 6 months of age. This may also be done to differentiate between an undescended and retractile testicle. Finally, an orchidopexy may be performed in order to fix the testicle within the scrotum. If bilateral undescended testes are suspected, this would warrant an urgent referral to a paediatrician within 24 hours, to allow for genetic and endocrine testing. Undescended testes are a cause of concern due to the implications on fertility and the future risk of testicular cancer.
greasy rash with yellow scales
Infantile seborrhoeic dermatitis (cradle cap)
Mx of cradle cap
self-limiting and resolves within several months with emollients and shampoos. Hydrocortisone 1% may be used in severe disease
itchy, painful, monomorphic blisters filled with clear yellow fluid which eventually become crusted over in someone with eczema
Eczema herpeticum
progressive bowing in a child with normal vit D
Blount’s disease
triad of cataracts, sensorineural deafness and congenital heart disease (often patent ductus arteriosus)
Congenital rubella syndrome
capgras syndrome
patients have a false, fixed belief that someone they know or recognisehas been replaced by an imposte
THINK: Imposters wear caps
What is acute dystonia? How to mx?
involuntary, sustained muscular contractions which can affect the neck and cause torticollis
Procyclidine
Mx of tardive dyskinesia
Tetrabenazine
Active mx of third stage of labour includes
involuntary, sustained muscular contractions which can affect the neck and cause torticollis
Synctocin is first choice medication (oxytocin)
Define 1st stage of labour, latent and active
active phase of the first stage of labour, defined as a cervix that is effaced and between 3 and 10 cm dilated. The preceding latent phase of the first stage is defined by cervical dilation of 0-3 cm
failure to progress in a multiparous patient
Less than 2 cm dilation in 2 hours
Most apppropriate intervention in a multiparous patient who is failing to progress with no evidence of foetal compromise
Artifical ROM
When to avoid prostaglandin pessary?
patients with a previous C-section as there is a small but significant risk of uterine rupture
What is used in nulliparous patients who fail to progress due to ineffective uterine contractions.
Oxytocin infusion
What scan to use if ?PE in pregnancy?
RCOG guidelines state that patientswith no sign of DVT and normal CXR should have a V/Q scan. to diagnose pulmonary embolism. V/Q scans are associated with an increased risk of childhood cancer, but CTPAs are associated with an increased risk of maternal breast cancer.
Choice of fluid in DKA
0.9% NaCl with 40 mmol/L KCl is used for dehydration until the plasma glucose is below 14 mmol/L, at which point, 5% dextrose is added.
What tissue is Meckel’s made from?
Ectopic gastric and pancreatic tissue
presence of hyperpigmentedspots on thelips, hands and genitalia and hamartomas throughout the GI tract
Peutz-Jegher - Autosomal Dominant
Turcot syndrome
familial adenomatous polyposis (FAP) with malignant central nervous system tumours
Gardner syndrome
FAP associated withosseous and soft tissue tumours
What is FAP? What mutation?
FAP is an autosomal dominant disorder due to a mutation of the APC tumoursuppressor and is characterisedby the presence of thousands of colonic polyps that almost always progress to cancer.
cyst that moves upon swallowing
Thyroglossal cyst
When is strabismus common up until? Most common cause? When to refer?
Strabismus is common up to 3 months of age, with the most common cause being refractive error. A baby over 3 months old with a persistent strabismus (as in this case) should be referred forspecialist ophthalmological opinion
In children aged 1-5, RR> then what is asx with severe asthma?
40
Features of severe asthma
●Can’t complete sentences in one breath or too breathless to talk/feed
●SpO2 < 92%
●Peak flow 33–50% best or predicted
●Heart rate > 140/minutein children aged 1–5 years
●Respiratory rate > 40/minute in children aged 1–5 years
Features of moderate asthma
Able to talk in sentences
●Arterial oxygen saturation (SpO2) ≥ 92%
●Peak flow ≥ 50% best or predicted
●Heart rate ≤ 110/minute in children aged 12-18 years.
●Respiratory rate ≤ 25/minute in children aged 12-18
red and bulging tympanic membrane with loss of the cone of light.
Otitis media
visible burrows usually in the hands and feet
Scabies - v itchy, and highly contagiopus
Most common cause of stabismus
Refractive error
presence of a haemangiomatous facial lesion (port wine stain) in the distribution of the trigeminal nerve, abnormal intracranial blood vessels and eye abnormalities (e.g. glaucoma)
Sturge-Weber syndrome
Features of tuberous sclerosis (just understand)
Tuberous sclerosis again is an autosomal dominant neurocutaneous syndrome. Cutaneous features include ash leaf patches, shagreen patches and adenoma sebaceum. Neurological features include infantile spasms and developmental delay, epilepsy and intellectual disability
Mx of ADHD
First-line management involves a 10 week ‘watch and wait’ period combined with ADHD-focused, group-based parental training. Failure of this or severe symptoms warrant referral to child and adolescent mental health services (CAMHS). Methylphenidate used after this.
How to check Lithium dosing once they are changed?
Levels should be checked weekly (12 hours post-dose) until lithium levels are stable. Once established, lithium levels should then be routinely checked every 3 months. Lithium therapy can cause thyroid and renal dysfunction, so patients should have their thyroid and renal function checked every 6 months
How to switch fluox to another antidepressant?
When switching from fluoxetine toanother SSRI (e.g. citalopram), fluoxetine must be withdrawn completely with a wash-out period of 4-7 days until low-dose citalopram can be started
How to switch between SSRIs? What does this exclude?
When switching between SSRIs (excluding fluoxetine), the SSRI should be withdrawn completely and a low-dose of the replacement SSRI started immediately.
How is magnesium sulphate given in terms of dosage?
t is given as a 4 mg loading dose followed by a continuous infusion until 24 hours after the last seizure
How does magnesium sulphate work on preterm infants?
Has neuroprotective infants
flagellated unicellular organism
Trichomonas vaginalis
Contraindications for the COCP
These can be remembered using the mnemonic SAILBOAT.
*Smoking >15 cigarettes a day and >35 years old
*Aura:migraine with aura
*Immobility or recent surgery
*Liver disease
*Blood pressure >140/90mmHg
*Obesity: BMI ≥30
*Any oestrogen dependent tumour or unexplained PV bleed
*Thromboembolism or stroke history, cardiovascular disease, or family history of VTE under 45-years-old.
Triad of Sx for endometriosis
dysmenorrhea, dyspareunia and subfertility
dyspareunia, itching, skin spitting, bleeding and thinned skin.
Lichen sclerosis
Mx of lichen sclerosis
managed with a short course of topical steroids which may be accompanied by an antimicrobial agent (e.g. betnovate and fusidicacid). It is associated with an increased risk of developing vulval cancer.
What features are suspicious of vulval cancer and require urgent (2 week wait) referral?
unexplained vulval bleeding or unexplained vulval lump or ulceration are suspicious for vulval cancer and require urgent (2-week wait) referral
Vesicles present on the vulva could be indicative
Herpex simplex infection
Pale areas which bleed on palpation
lichen sclerosis
Vulval lump which is fluctuant and transilluminating
Vulval cyst
Bowel Sx and prolapse
Rectocele
Mx of rectocele
lifestyle changes, then shelf pessary, then surgical repair should be considered.
Types of miscarriages with an open cervical os
Inevitable miscarriage
heavy bleeding with clots and pain
cervical os is open
Incomplete miscarriage
not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
Types of miscarriage with a closed cervical os
Threatened miscarriage
painless vaginal bleeding occurring before 24 weeks, but typically occurs at 6 - 9 weeks
the bleeding is often less than menstruation
cervical os is closed
complicates up to 25% of all pregnancies
Missed (delayed) miscarriage
a gestational sac which contains a dead fetus before 20 weeks without the symptoms of expulsion
mother may have light vaginal bleeding / discharge and the symptoms of pregnancy which disappear. Pain is not usually a feature
cervical os is closed
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
When to have colposcopy if low grade/high grade dyskaryosis?
2 weeks/6 weeks
what ABx regime in necrotising enterocolitis
Ampicillin and gentamycin combined with metronidazole
non-caseating epitheloid cell granuloma
Crohn’s disease
widespread nature of the rash with skin fold involvementand a well-demarcated scaly border with satellite lesions is highly suggestive of? How to mx?
candida infection. As such, parents should be advised to avoidbarrier protection and a topical antifungal cream, such as clotrimazole, should be prescribed
mx of nappy rash with a bacterial infection
bacterial infection was suspected or confirmed via a swab, a course of flucloxacillin would be appropriate
1st thing to do in mx of whooping cough
isolate patient in hospital
irritability and diarrhoea in young children who may not be able to express any discomfort whilst passing urine.
UTIs can present atypically
Tender retro-auricular, posterior cervical and suboccipital lymph nodes in the context of mild coryza, palatal petechiae and a maculopapular rash on the face and trunk
Rubella
Painful bilateral submandibular and salivary gland swelling preceded by a mild prodrome of fever, anorexia and headache
Mumps
Splenomegaly in a child, what to suspect?
EBV
cyanotic heart disease where heart sounds are normal with no added sounds.
TGA
Most common ASD? Asc with? Mx?
Secundum ASD(80%) –defect involving the fossa ovalis in the centre of the atrial septum.
○Associated with an ejection systolic murmur at the upper left sternal edge and a widely split second heart sound due to the ventricular stroke volume being equal in both inspiration and expiration. It is usually managed with device closure in a catheter laboratory at 3-5 years.
abdominal distension or a mass alongside constitutional upset (e.g. reduced appetite and fatigue)
Neuroblastoma, Ix with urinary catecholamines (VMA and HVA), then abdo USS
fever, generalised muscle and joint pains, abdominal pains and ‘everything runs’ (diarrhoea, vomiting, lacrimation and rhinorrhoea. Also get piloerection (goosebumps) and dilated pupils.
Opioid withdrawal
How does cocaine withdrawal present?
Cocaine withdrawal occurs in two distinct phases. The crash phase is characterised by depression, exhaustion, agitation and irritability several hours after the last use. The continual withdrawal phase is then characterised by increased cravings, irritability, lackof energy, poor concentration, insomnia and reduced energy
When does a normal grief reaction become abnormal?
The grief is unusually intense and fulfils the criteria for depression
●The grief is prolonged (over 6 months)
●The onset of grief is delayed, or the grieving process becomes ‘stuck
Mx of EUPD
Dialectical behavioural therapy
What cancer is an absolute contraindication to COCP?
Breast
surgical management of TOP upto 14 weeks
VAcuum aspiration
surgical management of TOP post 14 weeks
Dilatation and evacuation
Big RF for cervical cancer alongside HPV
Smoking
Mx of endometrial hypeplasia with atypica
Fertility sparing - IUS
Fertility non-sparing - hysterectomy alone if pre menopausal, if post - hysterectomy and total BSO
Summary table of missed pill rules in COCP
1st line investigation if suspecting ovarian cancer?
carry out an abdominal and pelvic examination. If this reveals ascites, such as in our case, or an abdominal/pelvic mass which is not known to be caused by uterine fibroids, the patient should be referred urgently to gynaecology for further investigation
NOTE: If examination normal, CA125 is then done. If rasied, urgent USS is then done
cyanosis or heart failure as a newborn (difficulty feeding due to breathlessness). Often a murmur will not be audible
AVSD - most common heart defect seen in Down’s syndrome
loud pan-systolic murmur may be heard at the left sternal edge with a quiet pulmonary second heart sound
Most common type of congenital heart defect
ejection systolic murmur at the upper left sternal edge with a fixed, widely split second heart sound
ASD
neonate may be asymptomatic at birth but will rapidly become cyanosed and breathless with a pansystolic murmur
Tricuspid atresia
What is scabies? How does it present? Mx?
Scabies is a parasitic infestation by Sarcoptes scabiei(a parasitic mite). On close inspection, burrows can be visualised around the webbing of the fingers - get itchy rash on hands. It is highly infectious, so household contacts should be treated even if they have not developed symptoms. It tends to be treated with permethrin (topical insecticide), which should be applied to the whole body and allowed to dry before being washed off 8-12 hours later. A second application must be done one week after the first. Bedding and clothing should be washed at high temperatures
Mutation for retinoblastoma
Rb mutation on chromosome 13
intrinsic renal mass on MRI with macroscopic haematuria and palpable abdominal mass
WIlm’s tumour
In babies who develop jaundice within the first 24 hours of life and those that are born at a gestational age of 35 weeks or less, Ix of choice?
Serum bilirubin
NOTE: Otherwise use non-invasice transcutaneous bilirubinometer
What is complete situs ineversus seen in? AKA?
Some patients with primary ciliary dyskinesia, therefore, can be born with complete situs inversus, in which case it is referred to as Kartagener’s syndrome.
When should a baby be investigated for investigation?
Babies under the age of 3 months who develop a fever should be investigation to identify the source of the infection
How to differ between PD and LBD
PD has motor Sx first, then cognitive decline. LBD also has hallucinations, and has a classic triad of a pill-rolling tremor, bradykinesia and rigidity. The tremor is worst at rest, which helps to differentiate from a benign essential tremor which is worse during action.
4 main criteria of anorexia nervosa
Low BMI
Deliberate weight loss
morbid fear of fatness
endocrine dysfunction
What sections can non-section 12 approved doctors use?
Section 4 and 5(2). Section 4 is an emergency power that may be used to admit people to hospital for 72 hours for assessment but it cannot be used to treat patients against their will
Most appropriate contraceptive method for postpartum who is breastfeeding
POP
if bimanual not tolerated, do what instead of TVUSS?
Transabdominal USS
Only time to do an OGTT at booking
if previous GDM, otherwise use BIG PE acronym
Treatment option of trichomoniasis
metronidazole 2 g PO STAT or metronidazole 400-500 mg PO BD for 5-7 days
Difference between PPROM, PROM and PTL
Preterm prelabour rupture of membranes (PPROM) –rupture of membranes prior to the onset of painful contractions before 37 weeks’ gestation·
Prelabour rupture of membranes (PROM) -rupture of membranes prior to the onset of painful contractions at or after 37 weeks’ gestation·
Preterm labour (PTL) –onset of labour prior to 37 weeks’ gestation
Management of PPROM
Regular monitoring or hospital admission (depending on clinical presentation and gestational age)·
Dexamethasone –expedites foetal lung maturation (as PTL is likely to follow)·
Magnesium sulphate –for foetal neuroprotection·10 days of erythromycin –due to risk of ascending infection (chorioamnionitis)·
No tocolytics –these are used to reduce the contractions in preterm labour
Only time to give tocolytics in pregnancy
Preterm labour
Presentation of placenta accreta/increta/percreta
Asymptomatic until birth, then PPH due to difficulty to deliver placenta
Ix for cerebral venous sinus thrombosis
MRI is gold standard, can do CT head
Mx of cerebral venous sinus thrombosis
IV heparin infusion is the first-line management option after which catheter-guided local thrombolysis can be performed. Patients usually require 3-6 months of anticoagulation following initial treatment.
Two types of growth restriction? Give examples of each
Symmetrical (congenital issues)
Congenital/chromosomal abnormalities
Intrauterine infections
Environmental factors (maternal malnourishment)
Assymetrical (placental issuess)
Pre-eclampsia, HTN, maternal smoking, diabetes etc
Hyperemesis gravidarum score interpretation
A score ≤6 indicates mild HG, between 7 and 12 moderate HG, ≥13 severe HG
median age for walking unsteadily
21 months
AML genetic association
Down’s
How can duodenal atresia present? What does this depend on?
Duodenal atresia can present with either bilious or non-bilious vomiting, depending on the site of the obstruction relative to the position of the ampulla of Vater. If the atresia is proximal to the ampulla of Vater, the vomitus will be clear, as seen in this case. If the atresia is distal, the vomitus is more likely to be bilious (green).
Diagnostic intervention for biliary atresia
Liver biopsy
presence of crypt abscesses and depletion of goblet cells
UC
nflammation of all layers of the bowel wall, with an increase in the number of goblet cells
Crohn’s
crypt hyperplasia, intraepithelial lymphocytes, and villous atrophy.
Coeliac
Chest X-ray shows widespread areas of opacification, premature baby with grunting and sternal recession
Bronchopulmonary dysplasi
Mx of hydrocele
usually resolve within the first few months of life but can be considered for surgical repair if still present at 1-2 years of age.
diffuse testicular swelling which you can get above and transilluminates
Hydrocele
Cardiac complication of haloperidol
QT prolongation, if occurs, speak to cardiology reg
Couvade syndrome
also known as sympathetic pregnancy, is a condition in which a pregnant woman’s partner begins to experience symptoms that mimic pregnancy.
What test can be used to rule out a diagnosis of preterm labour?
Fetal fibronectin
Contraindications to taking a cervical smear
Menstruation
-< 12 weeks postnatal
-< 12 weeks post TOP/miscarriage
-Vaginal discharge or pelvic infection
oval-shaped, scaly patches often distributed in a ‘fir-tree’ pattern. It is often preceded by a larger herald patch (seen toward the bottom of the image)
Pityriasis rosea
When to use an escalataing and maintenance dose of Movicol?
Escalating if faecal impaction, maintenance if not
1st line investigation of secondary enuresis
Bladder diary
Posseting
common condition in which infants painlessly regurgitate some of their feed.
Benzo OD is treated with
IM flumanezeil
creamy, white vaginal discharge associated with vulvar itching and soreness
Vulvovaginal candidiasis
1st Ix if SGA
US to estimate foetal size
Criteria for PCOS on USS
either ≥20 follicles per ovary or ovarian volume ≥10ml
Ix for SUFE
requesting X-rays of the hips and pelvis in the AP and frog-leg lateral views
progressive proximal weakness primarily affecting the lower limbs before age of 6 months
Spinal muscular atrophy
1stline treatment in Parkinson’s disease to treat motor symptoms
Levodopa
Medication that is used in the treatment of severe Alzheimer’s dementia and severe Lewy-Body dementia, or ifacetylcholinesterase inhibitors are ineffective
Memantine
How many months of Sx before GAD Dx?
6 months
Requirements for Dx of ADHD
Symptoms must be present for over 6 months, cause at least moderate impairment to day-to-day life and occur in 2 or more settings to meet diagnosis.
Duration of Sx to reach Dx of conduct?
> 6 months
What mental health condition occurs alongside OCD often?
Tic disorder
Which SSRI in breastfeeding?
Fluox and parox
Best Ix for mixed incontinence
Bladder diary
If the placenta is low-lying or covering the os at 20 weeks’ gestation the scan is repeated at
32 weeks
If not moved up, think about C-section
persistent pain that in the leg that is worse at night time and is described as dull and unremitting
Osteosarcoma
presents soon after birth with irritability, vomiting and, in severe cases, seizures
Hydrocephalus
NOTE: Do an MRI
A 20-year-old man has presented to the respiratory clinic with reduced exercise tolerance and chest pain on exertion. Upon assessment, his oxygen saturations are 91% at rest and he has a bluish tinge to his lips. He adds that, when he was much younger, he used to go to a paediatric cardiology clinic for follow-up but has not had an appointment in the last 10 years. Given the likely diagnosis, which of the following underlying heart defects is most likely to be responsible?
VSD - this is Eisenmenger Syndrome
What congenital heart defect is Eisenmenger most associated with?
VSD
Mx of tic
Clonidine and stress management
What abx for GBS infection in pregnancy?
benpen in partum
