Management

Question 1

Vaginal Candidiasis Mx
Oral Candidiasis Mx

Answer 1

Fluconazole- 50mg daily until symptoms subside then
150mg weekly for 6 months

Miconazole: Oral Candidiasis in Children

Question 2

Gonorrhoea Mx

Answer 2

Ceftriaxone 500mg IM stat +
Azithromycin 1g PO stat

Question 3

Chlamydia Mx, Complications

Answer 3

Inv:-
▪ Test for chlamydia and gonorrhea by PCR.
▪ First Pass Urine & swabs
▪ Screen for STIs – HIV, Syphilis, Hep A,B, Hep C,D,E.
▪ Test the partner for symptoms

Doxycycline PO 100mg BD- 7 days

Pregnancy- Azithromycin 1g PO stat

Males:-
Uncomplicated genital and pharyngeal:-
1.Doxycycline 100mg PO BD 7 days (symptomatic
2.Azithromycin 1g PO stat (asymptomatic)

Anorectal infection:-
Doxycycline 100 mg PO BD 7 days if asymptomatic
But 21 days if symptomatic
Azithromycin 1g stat and repeat in 1 week

SE:- nausea, vomiting, stomach upset.

2. Treat partner (contact tracing 6 months ) * start tx without waiting for lab results.
3. NOTIFY DHS
4. HIV repeat in 3 months
5. Syphilis repeat in 10 weeks
6. No sexual contact for 7 days after administering treatment.

CHLAMYDIA:
Asymptomatic 50%
Symptoms: (5)
1.Pain: Testicular/pelvic
2.Bleeding: Postcoital /intermenstrual
3.Discharge: Urethral/ vaginal

4.Dysuria
5.Anorectal symptoms

Complications: (5)
1.Epididymoorchitis
2.PID

3.Reactive arthritis (arthralgia, hypertrophic rash on soles, circinate balanitis, psoriatic rash)
[also k/n as Reiter’s syn: cant see, cant pee, cant climb a tree)

4.Ectopic pregnancy
5.Infertility

Question 4

Mx:
Bacterial Vaginosis (Also Cond)
Trichomoniasis
Giardiasis

Answer 4

BV:
Cause: by imbalance of the bacteria normally present in your vagina and this happens when the normal healthy bacteria is suppressed or replaced by an overgrowth of other unhealthy mixed bacteria.
-the exact Cause is unclear but could be sexually transmitted

IX:
Confirm: High vaginal swab for:
1a,b)microscopy and gram stain
& shows Clue cells
[normal vaginal epithelial cell with bacteria attached all around]
2)Amine whiff test where 10% potassium hydroxide is
added, and it will give a pungent fishy smell.
3)pH of the vaginal fluid will be greater than 4.5 if it is bacterial vaginosis.
4)some blood tests (FBC, UCE, LFT)
5)urine MCS
6)STI screen with your consent

TX:
Metronidazole- 400mg BD for 7 days (with food) or as a gel intravaginally for 5 days.
Pregnancy- Clindamycin

Avoid RFx:
1)Avoid vaginal douching because that can also alter the bacteria in your vagina.
2)Follow good genital hygiene.
-You partner does not require any treatment as of the moment, but
3)Always practice safe sex.
-
COURSE: Even after treatment, in about half of the women, it can sometimes
recur in the next 6 12 months.

TRICHOMONIASIS:
Metronidazole 400mg PO BD- 7 days
(with food)

GIARDIASIS:
1.Metronidazole 2g daily for 3 days
Paromomycin (in pregnancy)
2.Hygiene: (Fecal-oral transmission): Clean water, Disinfect toilet daily.
3.Inform Childcare.
4.Exclusion from school/childcare until No loose bowel action for 24 Hours.
5.F/up if not responsive
[C&C HUS: inform childcare, Notifiable, 2 stools negative.
Salmonella: inform childcare, Notifiable,
ALL: Don’t handle food in Diarrhea & Hand Hygiene.
Scarlet: Disinfect Toilet too]

Question 5

Intussusception (special hx/pefe) Mx

Answer 5

Hx- (5)
episodic crying (intermittent colicky pain)
Drawing up of legs
Turning pale while crying
Blood and mucus in stool
PMhx- resp or diarrhoeal illness

Pefe:-(4)
RUQ/midline/umbilicus mass
Sausage shaped mass

Intermittent signs:-(3)
Crying
Pallor
High pitched- absent bowel sounds

Late signs:-(3)
Red current jelly stool
Distended abdomen
Hypovolaemic shock

1..Admit
2. Involve specialist
3.Do not give any food/drink
4.Put IV line
5.Start fluids
6.USS/ X-ray to r/o obstruction
7.AIR ENEMA- radiologist and paediatrics surgeon
8.If fails, surgery

Question 6

Pyrolic stenosis (special hx/pefe) Mx

Answer 6

Hx:-
forceful vomiting,
non bilous,
maybe projectile,
2-6 weeks age,
hungry after feeds,
weight loss/ inadequate weight gain, dehydration

Pefe:-
1.look for peristalsis - left upper to right lower
2.feel for olive shaped mass (RUQ) , feel from left side
3. +ve feeding test

1.Admit/ transfer
2.NPO
3.IV line
4.IV fluid
5.Basic bloods- Electrolytes imbalance
6.USS +/- to confirm
7.Nasogastric tube if continues vomiting
7.Surgery: Draw
Ramstedt’s Pyloromyotomy: where the muscle of the pylorus (at the end of the stomach) is divided to allow normal stomach emptying.

Question 7

Hernias (umbilical, inguinal, femoral)
*Uncomplicated *
Undescended testes Mx

Answer 7

1.Umbilical- wait upto 4 years to disappear (smaller hernias disappear faster-by 1 yr)

2.Inguinal (6-2 rule)
Birth- 6 weeks- in 2 days
6weeks -6months- in 2 weeks
>6 months- in 2 months

3.Femoral- ASAP

4.Undescended testes
Can descend up to 6 Months
Ideal age for surgery-
6-12 Months (9 Months of age)

Complications: (7)
1.All hernias: strangulation

2.Undescended testis:

Advantages of orchidopexy: FITT PDM
1.Optimal chance of Fertility
2.Corrects coexistent Inguinal (there in 80%)

Reduces risk of:
3.Trauma
4.Torsion
5.Psychological consequence

6.Testicular Dysplasia
7.Malignancy (x5-10 more risk)

Question 8

GOR red flags &
GORD Signs

Answer 8

=7
1.pronounced Irritability with Arching

2.Refusal to feed
3.WL/ crossing percentiles

4.Hematemesis
5.chronic Cough,

6.Wheeze
7.Apnea

Question 9

Gestational Hypertension Mx

Answer 9

(4143)(4Hrs(BP),1W(Protein),4Wk(USS,CTG)3M(Resolve)
1.Repeat BP in 4 Hours
2.FBC, UEC, LFT
3.Urine Protein: Creatinine ratio
4.Urine Protein 1 Weekly
5.USS-CTG now and 4 Weekly

6.High risk pregnancy clinic- obstetrician
7.Meds- Labetalol/Methyldopa
8.LSM- Low salt diet, Left lateral position.
9.Complications: Mom, Baby
10.Red flags- PET symptoms
11.Review with blood results

*Resolved in 3 months after delivery *

Question 10

Pre-eclampsia Mx (& Inv)

Answer 10

INV:- (13)
1.FBC, UEC, LFT,
2.coagulation profile
3.Blood group /cross match

4.UDT for proteins
5.24-Hr urinary protein
6.Spot urine PCR- (substitute of 24hr urine protein)
7.Urine- Protein:Creatinine ratio

8.Uric acid
9.Urine analysis

10.CTG
11.USS

12.Chest X-ray
13. ECG

Mild:-
1.Start antihypertensive (nifedipine/labetalol/methyldopa)
2.Discharge bed rest- left lateral position
3.Low salt diet
4.High risk clinic
5. Red flags
6.Review GP- every 2nd day (do urine dipstick)

Moderate:-
1.Admit
2.O&G specialist
3.Immediate Mx:
Monitor vitals- 4 hourly BP
Urine output x2/day,
I/O chart
4.Anti-hypertensive- labetalol/hydralazine
5.IV MgSO4 to prevent fits
6.Steroid if less than 34 weeks
7.Prolong till term (consider induction)

❑ Risks of severe pre-eclampsia/hypertension
Maternal (poor control)- (6)
1.Seizures
2.Abruptio placentae
3.Coagulation failure

CVS accident:
4.HF
5.Kidney Failure
6.Stroke

BABY: (3)
1.Premature delivery
2.Hypoxia
3.IUFD (Intra-uterine fetal death)

Question 11

Eclampsia Mx (& Inv)

Answer 11

1.DR-ABCDE
2.Left lateral position
3.Call for help
4.Wait for seizure to stop
5.Secure airway, Oxygen by mask, IV line and blood for inv (fbc, uec, lft, coag profile, blood grp and cross match)
6.Start IV Diazepam
7.Transfer to tertiary hospital
8.In hospital- MgSO4
4gm bolus, then 1-2 gm infusion/hr at least 24 hrs
Recur seizure- 2gm bolus
9. IV hydralazine
10.Catheterisation
11.Fluid intake output chart
12.CTG/ USS
13. Steroid if less than 34 weeks
14.Vaginal Delivery: if >34 weeks and no fetal distress and cervix favourable
-Otherwise C-section
15.If <34 weeks fetal distress- C section
16. If stable:- monitor for 24-48hrs

Question 12

Endometritis Mx (& Inv)

Answer 12

1.Antibiotics- IV (Augmentin+ gentamicin+metronidazole)
Once IV response then
10 days of Augmentin
2. IV oxytocin (+/- ergometrine)
3. Panadol
4.IV fluids
5.Admit- specialist review
6. FBC, UEC, ESR/CRP
7.Blood grp cross match + coag profile
8.Blood culture + Urine MCS
9. USS to r/o RPOC
(If RPOC- exploration under anaesthesia) and a gentle blunt curettage (under antibiotic cover)
10. Episiotomy swab if infected and re-stitched
(dont mix with cervical suture in PROM taken out and sent for culture)

Question 13

Breast Mastitis & Breast Abscess Mx

Answer 13

MASTITIS Mx.:
1. Antibiotic
flucloxacillin 500mg 4 times a day for 5 days
2.Panadol
Start breast feeding with affected breast first
3.Hot washers- to enlarge milk ducts
4.Massage lumps towards nipple during breastfeeding
5.Cold washers after breastfeeding
6.Take plenty fluids + adequate rest
7.Red flags
8.Lactational nurse consulation

BREAST ABSCESS Mx:
-U/S
-Antibiotic and pain killers
-Temporary weaning from breastfeeding. (Make sure breast is empty by using a breast pump)

Small:-
Aspiration

Reasonably big:-
Surgical drainage under anesthesia

(Curve like incision over breast to drain, discharge will be sent for MCS,
PUT IN DRAIN FOR 2 DAYS)

Question 14

Macular degeneration (dry and wet) Mx

Answer 14

Risk factor: smoking, age, obesity, high BP, cardiovascular diseases, genetic susceptibility, UV light, Caucasian, female, unknown

Dry: early stage
1.FA (Fluorescein angiography)- refer to specialist
2.LSM
No smoking
Decrease alcohol
Healthy diet and exercise
Sunglasses
3.Supplements and anti-oxidants

Wet: late stage
(Acute bleeding in macula- sudden deterioration in vision)
Refer to Hospital
1.Anti VEGF (Vascular endothelial growth factor) injections
2.Laser photo coagulation

Macula:
is part of the Retina at the back of the eye. It is only about 5mm across, but is responsible for our central vision, most of our colour vision and the fine detail of what we see. The macula has a very high concentration of photoreceptor cells (:the cells that detect light.)

AMD(Acute Macular Degeneration):
damages your macula. Blood vessels may grow beneath your macula, causing blood and fluid to leak beneath it. This excess blood and fluid can lead to vision loss.

What does fluorescein angiography detect?
This test is done to see if there is proper blood flow in the blood vessels in the two layers in the back of your eye (the retina and choroid)

Laser photocoagulation:
Before the surgery, anesthetic eye drops are given. An intense beam of light is used to burn small areas of the macula. This seals off the leaky blood vessels preventing further vision loss.

Question 15

Open angle glaucoma Mx

Answer 15

Refer to Hospital- specialist
1.Eye drops (timolol, pilocarpine) to decrease pressure
2.Peripheral Iridotomy (surgery)
3. Do not drive until Ophthalmologist advise
4. Prevention: 2 yrly check up above 60 (if RF then from 35yr yearly check up)

RF(5):- fh+, increased age, long term Steroid, DM, high myopia

[Iris: has pigmentation which gives eye its color. Iris surrounds the small black hole in the center of the eye (the pupil) making it control how much light enters the eye.

Laser Peripheral Iridotomy: is a procedure which uses a laser device to create a hole in the iris, thereby allowing Aqueous humor to traverse directly from the Posterior to the Anterior chamber and, consequently, Relieve a pupillary Block.]

Question 16

Bi-temporal hemianopia Inv and Mx

Answer 16

1.CT/MRI
2.serum prolactin

Refer to neurosurgeon/neurologist
Micro:- meds:- Bromocriptine, Cabergoline
Macro:- Trans-sphenoidal surgery

Question 17

Haemolytic Uraemic Syndrome Dx, Sx,PEx Complic, & Mx

Answer 17

Commonality: seen in children. Most vulnerable: <5 y

Cause:
Shiga toxin producing Escherichia coli (STEC) (:has fever) leading to (EHEC:EnteroHemorrhagic Ecoli)
S. pneumoniae infection
Shigella spp.

Classic TRIAD:
1.Hemolytic anemia (nonimmune microangiopathic)
2.Thrombocytopenia
3.Acute Renal Failure (hence, “uremia” in title)

Ddx: Similar to TTP but without fever and neurologic symptoms

Hx:
prodromal GIT illness

Sx: (5)
Abdominal Pain
N/V
Bloody Diarrhea
oliguria/anuria (renal failure)

Fatigue (anemia)

PEx: (4)
Pallor (anemia)
Jaundice (hemolysis)
Petechiae/purpura uncommon
Hepatosplenomegaly (overworked spleen wt RBC removal)

COMPLICATIONS:(5)
Electrolyte abnormalities

Hypertension
Heart failure
Chronic kidney disease
Stroke

Mx:
(Paediatric registrar/ nephrologist)
1.IV fluids, Electrolyte replacement
2.ECULIZUMAB
3.Transfusion blood/platelets
4.Dialysis (renal replacement therapy)
5.Tx of Anemia, HTN, seizures.

6.prevent EHEC infection:
a)NOTIFIABLE disease
b)EXCLUSION: Food handlers, childcare workers and healthcare workers must not work until symptoms have stopped and two consecutive fecal specimens taken at least 24 hours apart are negative for VTEC (Verotoxin-producing E. coli)
c)avoid Raw meat, Unpasteurized Dairy
d)avoid Antimotility agents or Antibiotics

e) Control of contacts:
No exclusion is necessary for contacts, unless the contacts are symptomatic and work in a high-risk occupation, or are children in childcare,etc.
Asymptomatic children in childcare should be screened and excluded if positive.

Question 18

Liver metastasis Inv & Mx

Answer 18

Inv:-

1.FBC
2.UEC, LFTs
3.Coagulation profile
4.Blood group /cross match

5.Tumour markers

6.Urine tests
7.Chest x-ray

8.PET scan
9.Bone scan

10.Colonscopy
11.FNAC/Liver biopsy
12.CT already done

Mx:-

1.Specialist consult
2.MDT
3.Surgery if resectable
4.Chemo+ radiation
5.SIRT (selective internal radiation therapy)
6.RFA (Radio-frequency ablation)
7.TACE (Trans-arterial chemo-embolization)

Question 19

Hydrocele Inv & Mx

Answer 19

Inv:-
1.Basic bloods
2.Tumor markers: AFP, LDH, BetaHCG
(C&C: PSA in BPH)
3.Urine MCS
4.Urine PCR for Chlamydia/Gonorrhoea, Other STI:Syphilis, Hep
5.USS

Mx:-

Troublesome:
1.Simple surgery
2.Sclerosant injection to reduce recurrence after Aspiration of fluid

Not troublesome:
Conservative and observation
Advice-
1.comfortable underwear
2.scrotal support
3.avoidance of trauma or contact sport

Question 20

Haemochromatosis
Cond
Mx

Answer 20

Commonality:3
Ethnicity- Northern Europe
FHx: Gene mutation: HFE
Male detected earlier than female.

CFx: 9 =2+2+2+3
Fatigue
Weight loss

Tummy pain
Joint pain

Tan skin
Loss of body hair

Reduced Libido
Erectile dysfunction
Irregular/absent periods in women

1.Genetic test:- HFE gene
(Iron levels, Transferrin, Ferritin levels for relatives before gene test)
2.FBC,
3.iron studies with Transferrin

4.LFTs
5. RFTs

6.BSL
7.Liver scan
8.Liver biopsy (in complication)
9.ECHO (in complication)

Complications:-
1.Liver cancer
2.Liver cirrhosis
3.Diabetes
4.Arthritis
5.Heart failure
6.Poor memory
7.Depression

Mx:-
NO CURE
1.Phlebotomy
a) Induction- usually weekly until normal iron
b) Maintenance- 2-4 times/yr for rest of the life
2.Chelation therapy-: medicine- Deferasirox (tab once a day)- removes in urine and poo
3.Diet (avoid oysters, vit C supplement, needs to take tea coffee and milk) & avoid Alcohol
4.Liver transplant (Occasionally)

Question 21

Vestibular neuronitis Dx,Sx, Mx (positive hx and exam)

Answer 21

Hx:-
Vestibular neuritis is an inner ear disorder that affects Vestibulocochlear n or the 8th Nerve.
It causes symptoms:(4)
1.Sudden, severe vertigo
2.Dizziness
3.Balance problems
4.N/V.

Single attack without tinnitus or deafness
Precedes a flu-like illness
Lasts days to weeks
Has N/V.

Pefe:-
Horizontal nystagmus
Caloric stimulation positive

Mx:-
1.Rest in bed, lying still
2.Gaze in direction that eases symptoms
3.IV prochlorperazine (Stemetil)12.5mg
OR
Diazepam 5-10mg
4.STEROIDS (taper over 9 days)

Question 22

Paget‘s Inv and Mx

Answer 22

Inv:-(4)
1.ALP
2.Plain x-ray (skull and pelvis)
3.PSA
4.Bone isotope scan

Mx:- (4)
1.Screen: Siblings and Children every 5 yrs after 40
(ABC)
2.Antineoplastic agent (Mithramycin)
3.Bisphosphonate
4.Calcitonins (prevent bone resorption)

[C&C colonoscopy 5yrly
Calcitriol in steroid induced osteoporosis)

Question 23

Pyelonephritis in pregnant Mx
Non-pregnant: Ix & Mx

Answer 23

Pregnant:
1. Ceftriaxone IV for 3 days
2. Oral cefalexin 10-14 days
3. IV Fluid if dehydrated
4. IV Metoclopramide
5. PCM

Non-pregnant:
1.Amoxicillin + Gentamycin
(If allergic to Gentamicin: Ceftriaxone)
2.PCM
3.GVH (Genito-Vulval Hygiene): Front to back
4.Cotton underwear

Ix:
1.FBC
2.U&E

3.UDT
4.UMCS
5.Blood Culture

6.USS(Ultra-soundScan) KUB
7.CT more sensitive: second line in young

Question 24

Genital warts Mx

Answer 24

Mx(4)

1. Medicine:-
   -Imiquimod
   -Podophylline & Podofilox
   -Tri-chloro-acetic acid (TCA)
2. Injection:-
   -Interferon
3. Minor procedures:- (don’t go away with time)
   -Cryosurgery (freezing warts)
   - Laser
   -Electrocautery (burning warts)
   -Excision (cutting off warts)
4. Minor surgery

(What is the difference between electrosurgery and cautery?
ElectroCautery refers to direct current (electrons flowing in one direction) whereas ElectroSurgery uses alternating current.
In electrosurgery, the patient is included in the circuit and current enters the patient’s body.
During electrocautery, current does not enter the patient’s body.)

Question 25

ADHD Mx

Answer 25

Ix: FBC, ESR, CRP,
Audiometry
Speech Pathologist

Dx: by specialist and if present in 2 Settings

Behavioral Modification:
a.Build social skills
b.Help stick to a routine
Learning help
Ritalin (methylphenidate) SE: N/V/Rash (Taper dose to Wt)
Fish oils (omega 3 fatty acid): CI: blood thinners, bleeding d., allergy

Question 26

Primary PPH Mx

Answer 26

Fundus massage
IV Oxytocin 10 IU
Catheterise bladder

Under Specialist guidance:-
Ergometrine
Prostaglandin
Transaminic acid

If no response:
Bimanual compression or surgery

If responds then to maintain the uterine tone:
IV Oxytocin 40IU 4hr
Misoprostol buccal or PR

Question 27

Nappy rash management

Answer 27

PIN-HZ (HIN: Candidiasis: scraping)
Paraffin
Imidazole
Nystatin
Hydrocortisone
Zinc cream

Question 28

Trigeminal neuralgia
PEFE, Dx,
Mx

Answer 28

PEFE: ENT exam 5th ,7th nerve

Condition: Often, trigeminal neuralgia is caused by a blood
vessel pressing on the trigeminal nerve. This compression
damages the nerve over time, interfering with its normal
functioning.

*carbamazepine 100 mg twice daily and increase the dose as required.
Patients should be reviewed frequently as drug toxicity may occur.
SE: Dizziness, lightheadedness, N/V,HA,etc.

1.agents (eg gabapentin, pregabaline and lamotrigine

2.(Bupivacaine + Corticosteroid)- Infiltrative Local Anesthesia or Regional Nerve block

3.Surgery:-
1) Microvascular Decompression
90-95% success rate but moderate relapse rate long term
2)other surgical procedure: a needle is placed through the skin and then either
a)Balloon Compression
b)RFL (Radio-Frequency Lesioning)
c)Glycerol Injection:.(X-Ray before injection)
3)Stereotactic Radio-Surgery (MRI used to guide radiation on nerve)
which
[Microvascular Decompression: is an open microsurgical retro-sigmoid craniotomy to access the trigeminal nerve root. The aberrant loop of the artery, most
commonly the superior cerebellar, is identified, gently moved from the nerve root and kept away by use of small pledgets of Teflon felt.
This procedure was reported to have a 90–95% success rate]

(In RFL: procedure in which special needles are used to create lesions along selected nerves. The needles heat the nerve to 80°C for about 2-3 minutes. The nerve stops carrying pain signals. The body tends to try to re-grow nerves that are blocked in this manner, but that process can take up to a year or longer.)
(Glycerol rhizotomy/injection: into the area where the trigeminal nerve comes out of the skull. It is done after identification of fibers of the nerve using X-Ray.)

Question 29

HPV 16 Mx

Answer 29

-LBC:
shows cells changes and its extent

-Colposcopy:
A process where a small tube with a camera is introduced into the cervix to look at its lining. If there is a suspicious lesion, then biopsy.

-If not visible: Acetic acid will be applied and suspicious
area will turn white for biopsy.
-Cone Biopsy: if Upper Segment is not visible

-After the biopsy, treatment according to the stage.

-Options include:(4) [CLLES]
1)Cryosurgery (extreme cold) (same as Warts)
2)Laser ablation
3)Electrotherapy
4)Loop Excision
5)Surgical removal.

Question 30

Encopresis secondary to constipation Mx

Answer 30

=13
1.Empty the bowels- enema
2. Stool softeners
3. Increase fruit and vegetable, fluids-water

4. Start toilet training again
5. Encourage to go to toilet right after meals
6. May use egg timer
7. Star chart to motivate
8. Don’t scold, needs patience on your part
9. Talk to teacher regarding teasing
   10.Give extra clothes

11.Regular r/v for constipation
12. Red flags- pain, n/v
13.Psychologist?

Question 31

PID Mx

Answer 31

In young sexually active women with no predisposing factors:-

azithromycin 1 g orally stat
+
doxycycline 100 mg twice per day for 14 days
+
metronidazole 400 mg twice per day for 14 days (Tx Trichomoniasis, BV)

+ (if gonorrhoea is suspected or proven) ceftriaxone 250 mg IM stat

(Consider adding ceftriaxone in all cases of PID but Not Chlamydia)

Postprocedural PID (including IUD insertion, operative procedures)

doxycycline 100 mg twice per day for 2–4 weeks
+
metronidazole 400 mg three times per day for 2–4 weeks

Question 32

involuntary admission

Answer 32

1)AO(Admission order) by GP/HMO: Valid for 24 Hrs

2)ECAT (Emergency Crisis Assessment Team) will follow this AO under MHA(Mental Health Act) and admit the person.

3)Psychiatry consult will see pt in 24 Hrs.
4)TTO (Temporary Tx order) by psychiatrist (can keep pt in hosp for 28 D or discharge.)

5)Done: if more time needed or parents have not agreed.
MHT ( mental health tribunal) is formed that consists of 3 people, psychiatrist, retired judge and lawyer.
5)With in 2 weeks MHT will hear the case; if agree with consultant, they will issue:
TO (treatment order) for involuntary treatment in community
or in the hospital.

6) TO order will be valid for 6 Months.
All AO, TTO, TO are for both community and hospital treatment.
7)CAT team will ensure treatment in the community.

Question 33

Cellulitis and PVD: PEx & Mx

Answer 33

GA:
 VS: BP and BMI**
 Focused leg examination:
 Inspection: skin color changes? Scars, redness, bruising, localized swelling,
any Ulcers, or Pigmentation of the skin?
 Palpation: temperature, CRT, muscle tenderness, PULSES**
 Auscultation: Aortic bruits, Renal artery, Femoral bruit
 Ankle-Brachial Index
 BUERGER’S TEST
 CNS examination: ITPRCS
 CVS
 Office test: BSL, UDT, ECG

❑ Management
1-admit to hospital to be seen by a surgeon.
2-Investigations:
FBC, ESR/CRP, LFT, UCE, TFT,
Lipid, BSL, Clotting,
Blood Culture, Swab culture
Doppler US

Cellulitis:
3-Demarcate rash + observe
4-IV Antibiotics then switch to oral
Flucloxacillin or cephazolin (IV)
flucloxacillin or cephalexin (oral)
5-Painkiller
6-Rest+ Elevate the limb
7. Treat PVD

PVD:
8.Buerger & ABI.
9.Stop BB, Switch to ACEI
10.Aspirin + Statin
11.<0.4: CT Angio then Bypass Grafting or Stenting

12.LSM:
a-Stop Smoking
b.Control HTN, Cholesterol and DM
c-Control DM + Foot care
d-Gradual exercise to level of pain with Physio

Question 34

Malaria Ix and Mx

Answer 34

PRESENTATION:(4)
HA
Fever rel
Anemia
Splenomegaly

INVESTIGATIONS: (12)
1.FBE (Hb reduced)
2.U+E’s
3.LFT’s

4.Blood cultures
5.CXR (can inv lungs)
6.Urine analysis

7.Malarial thick (to determine the presence of parasites)
8.Thin films daily (to identify species of malaria), (=positive for plasmodium falciparum, parasite count 0.1%)

Serology: (4)
9.Atypical pneumonia (Serological panel screens for Chlamydia, Legionella and Mycoplasma)
10.Dengue fever
11.HIV
12.Hep A + B,

Mx: (Supportive, Med, Prev, Chemoprophyl.)

1.Supportive and admit to hospital for:
a)fluid replacement
b)Cooling and
c)treatment of e.g. renal failure or hypoglycaemia.

2.Severe:
a)IV Quinine Dihydrochloride
b)Exchange Transfusion

3.In less severe cases: oral medications:
a)Quinine sulfate
b)Doxycycline
c)Fansidar

4.Prevention:
a)Full length/sleeves especially early in the morning and the dusk
b)Avoid dark colored clothes,
c)Use mosquito repellents
d)avoid places with mosquitos

5.Chemoprophylaxis:
a)Doxy 100mg OD:
2 Days before to 4 Wks after your travel
b)Pregnant women and children: Mefloquine

Question 35

Dengue Sx, Course, Ix, Mx

Answer 35

Symptoms:
Dengue=
1.FEVER
2.RASH
3.HEADACHE
4. MUSCLE/JOINT ACHE

Course:
Dengue fever can become hemorrhagic or even lead to “dengue shock syndrome” (more commonly seen in children under 15 years)

Investigations:
1)Serology: viral IgM and IgG Elisa test

2)FBE: leukopenia (of 2000– 4000 common by 2nd day of fever)
3)Thrombocytopenia (<100,000 in hemorrhagic form)

4)Hemoconcentration with hematocrit (increased by 20%)

MANAGEMENT: supportive, symptomatic treatment with rest, fluids and pain relief.

PREVENTION is the mainstay of therapy by: 1)avoiding mosquito Bites
2)insect Repellent and 3)mosquito Netting at night time

[C&C ELISA: HIV, Celiac, Dengue, Malaria]

Question 36

Mx: Anaphylaxis & Allergic reaction, Urticaria Dx

Answer 36

Anaphylaxis: Immediate Mx:
1)GCS
2)Remove Bee stings with Forceps

3)DR-ABCD protocol
4)O2 :6-8 L
5)IM Adrenaline 1:1000 0.01ml/kg.
Repeat every 5 M if required.
6)BP-Fluids: 20 ml/kg, 300-500ml bolus if low

7)Auscultate for wheeze: Nebulized Salbutamol,
IV Hydrocortisone 1mg/kg
8)Admit for 12-24 Hours- Chance of Rebound reaction

Allergic reaction immediate Mx:
1)Remove bee sting: forceps/finger nail
2)Wash with: soap & water
3)Rest, Ice, Elevate limb (:RICE)
4)Oral Antihistamine 1-3 Days: to relieve itching

Long-term Mx (both allergic/anaphylactic):
1)Refer to Peds registrar
2)Clinical Immunology/ Allergy specialist referral
3)Allergic testing: Skin-prick, Allergen-specific Ig-E (RAST)

4)Give Anaphylactic action plan (parent, copy: school)
5)Anaphylactic kit: Epipen, Antihistamine
6)Educator will teach kit usage.

7)Prevention:
a)Avoid colorful clothes, perfumes, gardens.
b) Wear long-sleeved clothes and close-toed shoes.
c)Cover: food containers, trash cans
d)Windows rolled up while driving
e)Hives near home: Removed by professional.

Red Flags:
1.Swollen lips/face
2.Turns pale/blue
3.SOB
4.Hoarseness of voice
5.Noisy breathing/ wheeze

Urticaria: Dx, Mx

Urticaria is a condition that affects the Skin and the Mucous Membranes
Causing:
Red
Raised
Itchy Rashes.

It occurs due to release of a chemical substances including Histamine
from Mast cells in the skin.

These Mediators activate Sensory nerves
and cause Small blood vessels to Dilate or widen causing redness, oozing of fluid.

Cause/Trigger: Unknown (majority)

Other possibilities could be:
As/w various types of infections which is also common.
insect bites,
reaction to food or medications.

Physical trigger: skin exposure to: (5)
heat, cold,
exercise,
water
sunlight.

Commonality:
common
Tends to come and go

Course:
Not serious.
Self -limited. Resolve spontaneously within 6 Weeks.
(note Mx not asked here)

Question 37

Nephrotic syndrome Inv & MX

Answer 37

Inv:-
1.FBE, UEC, ESR/CRP,
LFT (protein level), Albumin(low: Hypoalbuminemia)
2. Lipid profile (high)
3.ASO titres (normal, high in nephritic)
4.C3, C4 level (normal, low in nephritic)
5.Urine MCS (proteinuria)(nephritic- hematuria)

Mx:-
1.Steroids
2.Fluid restriction
3.Diet modification (low salt)
4.BP monitoring (high in nephritic)
5.Weigh daily
6.Antibiotics may be given (as prone for infections as proteins are lost in urine).
7.Furosemide (if edema is severe).
8.Family taught to do UDT at home followed by RFTs

PSGN -sets in after 1-2 weeks of sore throat or skin infection; (hypertension, hematuria, oliguria, azotemia, +/edema = Nephritic)
*Azotemia is an elevation of blood urea nitrogen (BUN) and serum creatinine levels
[vs Nephrotic: proteinuria, edema, hyperlipidemia, hypoalbuminemia]

Question 38

Nose bleed Mx

Answer 38

1.HD stability
2.Look for signs of shock, such as sweating and pallor.

3.Cophenylcaine forte spray:-
(Lignocaine (local anesthetic) + phenylephrine(vasopressor): adults: 5 sprays/nostril; peds: fewer

4.Simple measure- 10 minutes twice (pinch nose with head forward, breathe wt mouth, dish: don’t swallow, sneeze wt mouth open,don’t blow nose for 12 Hr /keep head elevated for hrs)

5.If blood vessel seen:
Cauterize with TCA (Trichloroacetic Acetic) Acid
6.If blood vessel is not seen:
Do nasal packing. CI: fracture of
Basal skull or septal hematoma

7.Anterior nasal packing:
Surgical sponge/ nasal tampon up to 5 days
8.Posterior nasal packing:
Rhino-catheter (done by ED or ENT doctor)

9.Flucloxacillin to cover for gram neg.
10.For persistent epistaxis: Bactrim:(Trimethoprim-Sulfamethaxazole)(10 days)

11.Vaseline/Rectinol ointment /
Nasalate nasal cream (7-10 days)
12.Humidifier

Question 39

Acute urinary retention due to BPH PEx, Mx, Complications

Answer 39

PEx: DRE:(5)
size, consistency, border, median sulcus palpable, mobility/adhesion to surrounding structure, tenderness:

non-tender
smooth
elastic
firm
enlarged prostate

Inv:- (6) (3+3U)
1.Blood- FBC, ESR/CRP, RFT
2.PSA.
3.Urine- MCS
4.Ultrasound- Post-Void Residual (PVR) volume

5.Refer to specialist:
a)Uroflowmetry (performed by urinating into a device which measures urinary flow.)
b)Urinary tract Imaging

Mx:- (6)
Combination therapy (2)
1.Tamsulosin (alpha1 blocker):
[Relaxes the muscles in your bladder and prostate, therefore improving urinary flow.]
2.Finasteride (5-alpha reductase inhibitor):
[Stops testosterone (a sex hormone) turning into another hormone called DiHydro-Testosterone (DHT), which can cause prostate enlargement.]

Surgical: severe (4)
1.TURP (Trans-Urethral Resection of Prostate): Removal of a section of the prostate.
2.TUIP (Transurethral Incision of the prostate): only 2 small cuts are made, allowing urethra to widen for easier urination. (young, fertility concern)
3.Open Prostatectomy
4.Laser Ablation

COMPLICATIONS (5)
UTI
Nephrolithiasis
Bladder stones
Chronic kidney disease
Hydronephrosis

Question 40

Buckle Fracture Mx

Answer 40

PRICE

Wrist Splint/back slab for 3-4 Weeks.
Avoid contact sports until 4 weeks of removal of splint.
No skateboarding for 6 weeks

Review in 1 week
Move the fingers and wrist to avoid any stiffness.
Red flag: severe pain, unable to move, color change

Question 41

Pulled Elbow Mx

Answer 41

1.The partial dislocation will be Reduced or Manipulated (put back into place)
Hyperpronation manoeuvre
Sit the child on the parent’s lap
a.Grasp elbow with one hand and place your Thumb over the Radial Head.
b.Grasp the Wrist with your other hand and Supinate the extended forearm in a steady and deliberate manner.
Apply slight Traction to the arm.
c.Once supinated, Flex the arm.
An audible and palpable Click signifies successful Reduction but is not always noted.

2.This procedure is Painful and distressing but only lasts a Short moment.
3.An X-Ray is not necessary to Diagnose a pulled elbow.
4.Observed for a short while to check if Using arm without any problems or pain (which may be possible almost immediately.)
5.Painkiller
6.X-Ray may be ordered to check for other possible injuries such as a fracture: If Unable to be put elbow back into place or your child is still Not using the injured arm within 1 Day of procedure.
7.Rest
8.Prevention:
Make sure you don’t Pick your child up by the Lower arms or wrists to prevent the same injury from happening again.

Question 42

Tonsillitis Mx & complications,
Quinsy Special Hx, PEx, Mx

Answer 42

TONSILLITIS:
Initial Ix: Throat swab for C&S
Tx:
1.Phenoxymethylpenicillin for 10 days (or Erythromycin if allergic).
2.Paracetamol
3.Try cool drink, ice block, and ice cream.
4.Don’t worry if he stops eating for a day or two.
5.If not improving after 2-3 days will order further inv like FBE, ESR/CRP, EBV Serology

Complications of Tonsillitis(6): Spread to Sinus, Nose or Ears, quinsy (peritonsillar abscess), PSGN and rheumatic fever.

QUINSY
Hx:
Any change in your voice? (laryngitis)
Any difficulty in opening your mouth? (trismus)
Any drooling of saliva?

PEx: Throat:
Swelling or redness? Pharyngeal erythema?
Tonsillar enlargement? Exudates?
Uvular deviation?

Mx:
Investigations:
FBE, UEC, ESR/CRP, Blood Culture.
(DO NOT take a swab because you may induce respiratory distress in the child)

Admitted in the hospital
Fluid removed or drained (risk of sepsis) by ENT under anesthesia.
IV fluids
1st dose of Antibiotics

Question 43

Orbital Cellulitis PEx, Mx

Answer 43

Look(7):
swelling, redness, trauma, Discharge
Chemosis, Proptosis, dilated Conjunctival blood vessels

Feel: Tenderness, warmth
Move: Tenderness, Diplopia
Special tests: visual Acquity, field,etc

Mx:

Inv:
FBE, UEC, ESR
Blood culture, Urine m/c
CT scan with Contrast: Orbit, brain and sinuses

Admit
Refer: (3) PED, ENT, Opthalmo
Painkiller
IV Antibx: Flucloxacillin fol/by Oral when Sx resolve (total antbx duration 14 D)

Complications:
Blindness, Spread to brain

Question 44

Pertussis Hx extra points, Mx, Prophylaxis, Psychogenic Mx

Answer 44

Hx:
When was the exposure?
Any siblings at home? what are their ages? Are their immunization up to date?

Red flags:
APNOEA (excessive snoring at night)
ALTERED CONSCIOUSNESS (drowsy)
CYANOSIS (if his limbs turn blue)

Mx:
Oral Azithromycin for 5 Days.
If can’t take oral Clarithromycin syrup.
(If allergic give Bactrim).

Prophylaxis:
antibx.:
Start for the whole family.
Notify DHS and also Childcare.
Exclusion from school and childcare for 5 Days after starting.

Give 1st Contact <14 Days with coughing pt.
Adults <21D cough OR <5D of antibx:

Regardless of immunization status: give Antibx:
*Expectant parents in Last month of Pregnancy
*Health care worker in Maternity hospital or Newborn nursery.
*Childcare worker in close contact with infants <6 months
*Household member aged <6 months

*Vaccination:
Close contacts that are not up to date with their pertussis immunization should be given DTPa or dTpa as soon after exposure as possible.
Consider dTpa for adults who have not had pertussis-containing vaccine in the last 10 years.

Shaggy heart appearance: ill-definition of the Cardiac Silhouette on a CXR

[Whooping cough vaccine is recommended between 20 and 32 weeks of Every pregnancy (although it can be given up to the time of delivery.
The influenza vaccine is recommended for every pregnancy and at any stage of your pregnancy.
During pregnancy immunity to some diseases (including rubella, chickenpox and hepatitis B) is checked.]

PSYCHOGENIC COUGH:

1.Don’t worry, with proper Care and Support, your child is going to be fine.
2.Try to Spend more time with the child.

3.Family Meeting if separation and family stress
4.Liase with the school Teacher, if Hx of Bullying
5.Psychologist referral for Talk therapy

6.Diary for potential Triggers
7.Avoid Situation where the cough gets worse

Question 45

Croup: Dx & Mx

Answer 45

*Cause: It is a viral infection most likely due to parainfluenza virus

Transmission: close contact /contaminated surfaces

Pathophysiology:
inflammation & swelling of the voice box
( larynx), windpipe and the airway.

Patho/Sx: This swelling makes the airway Narrower causing: Dyspnea, Noisy breathing and Barking cough.

Course: 6 M - 5Yrs but can older

*Tx: depends on the severity:

*Mild to moderate:
Stridor at rest +Irritable child+ some Respiratory distress

Oral steroid Prednisolone AND prescribe a 2nd dose for the next Evening if needed.
Observe: for half an hour post steroid administration.
Discharge: once stridor-free at rest.

SEVERE: Stridor + Drowsy/Lethargic/ severe Distress

Nebulized Adrenaline + IM/IV Dexamethasone

If good improvement, Observe for 4 Hours post-Adrenaline.
Consider discharge once Stridor free at Rest.

If improvement, then deterioration: Give Further doses of Adrenaline and consider Admission.

Question 46

Acute Bronchiolitis Dx and Mx

Answer 46

Condition & CFx:
an infection and inflammation of the small airways of the lungs known as Bronchioles.
It results in narrowing and obstruction of the small airways causing difficulty in breathing, cough, fever and refusal to feed.

Cause:-
RSV

Commonality:
<10 months

Transmission:
Contagious droplets, secretions, laughing, sneezing.

Course:
48 hrs- Mild common cold with runny nose, fever and cough.
Then- irritating cough, wheezing and rapid breathing
7-10 days- gets better

Mx:-
1.Symptomatic management

2.Mod-Sev:
a.Hospitalization,
b.IV fluids/NG tube
c.Oxygen

3.No role of antibiotics
4.Close monitoring
5. No O2 for >2 Hrs = Discharge

Complication:
Increases risk of Asthma later in life
(In Hx ask regarding allergies in detail)

Question 47

Allergic Rhinitis Dx & Mx
Recurrent viral infection Mx

Answer 47

The inner lining of the nose gets inflamed and swollen in
response to allergic particles like dust/pollen etc

Usual symptoms:
watery nasal discharge, stuffy nose, sneezing, and itchy nose
Commonality: associated with Family or personal hx of:(HEAA) allergy/asthma/eczema or hay fever.

Mx:- Allergic Rhinitis
Ix:FBC (increased Eosinophils), ESR/CRP
Tx:
1.Prevent it by avoiding the Allergic substances that he is allergic to.
2.Avoid Smoking, Pets, Sick persons.
3.Normal Saline Drops - itchiness or affecting his sleep.
4.Steroids for short duration (4-6 weeks, intra-nasal Fluticasone, SE: Epistaxis if Little’s area (no systematic ones)
5.Antihistamine
6.Referral: allergic specialist
Otolaryngologist for turbinate reduction if req.

Mx:- Recurrent viral infection
1.Send to Smaller Childcare groups
2.Panadol for Fever
3. Ear pain/ discharge- Antibiotics
4.Avoid causative factors- Passive Smoking
5.ENT referral- if Mouth breathing, (check for enlarged Adenoids)

Implications of URTI: SOD SEL
1.Sinusitis (Acute/Chronic)
2.Otitis media
3.Dental prob Overbite) d/t mouth breathing

4.Sleep disturbance /Apnea
5.Excessive daytime fatigue/ poor school performance
6.Learning impairment.

Question 48

Respiratory Distress Syndrome Dx & Mx

Answer 48

RDS caused by lack of a substance called surfactant which helps your baby’s lungs to expand and breathe easily.

As your baby has been delivered before this surfactant can be produced by her lungs that’s why she is having this breathing difficulty.

Other reasons:
Chest infection
HypoGlycaemia
Sepsis

Mx:
Ix:?by specialist in hospital?BSL,Septic screening incl FBC,UEC,CRP,UMCS,CXR
1.Referral to tertiary hospital with NICU via air ambulance/PIPER.
2.In hospital:
a)Oxygen - breathing machine
b)Commercially manufactured intranasal surfactant (helps lungs expand more for easy breathing)
c)IV fluids- feed with tubes. No breast feeding.
d)Broad spectrum Antibiotics if needed
3.REASSURE- talk to senior and husband
4.Social worker- for other kids

(C&C NG feeding in Bronchiolitis)

Question 49

GER Dx & Mx

Answer 49

The lower part of the food pipe where it connects with the stomach is poorly developed in neonates/babies. It is the reason why the milk in the stomach flows back into his mouth
when you put him down.

Common condition:
where the baby vomits after each feed but otherwise the baby thrives well.

This condition gradually improves with time especially after the introduction of solids (4- 6 months of age). Majority of cases clear up by 1 year of age.

Mx:-
small, frequent feeding
decrease duration of feeding along with time in between (normal 20 mins on each breast).

Don’t put the baby immediately to sleep. Carry him for a while and put him in cot with head elevated 10-20 degree.
We highly recommend breastmilk because it is best for baby.

Thicken the feed -thickeners called Gaviscon.
If it doesn’t help in few Weeks , I will refer him to a gut specialist who might start on some Acid suppressant therapy.

Please don’t worry, as long as your child is growing well, feeding well there is nothing to be afraid of. I will regularly review him and give you reading materials.
Red flag: 7
Pronounced irritability with arching,
refusal to feed, weight loss,
chronic cough, hematemesis
wheeze, apnoea

Question 50

Duodenal Atresia Dx, Mx

Answer 50

Duodenal Atresia means there is an Absence of part of Small bowel called Duodenum.
Not an uncommon condition, the cause is unknown.
Association- Down’s Syndrome

Inv:
1.Double bubble sign on X-ray

Mx:-
Surgical emergency > refer to a tertiary hospital ASAP > arrange (PIPER) > assessed by a pediatric surgeon and Anesthetist >
Surgery
Do not feed the child > I/V access
> Blood for Ix
> start I/V fluid
> NG tube to decompress the tummy once in hospital.
Lactation nurse- express and store breast milk.
Reassure the outcome of surgery is very good.
After surgery risk:
Fibrous Band formation around the gut (fibrosis) and Obstruction
Don’t forget 4 ‘R’s (reading materials, review after been discharged from hospital).
Arrange a Social worker for other kids

Question 51

Asthma Special Hx & Mx

Answer 51

FHx:
heart disease, cystic fibrosis,
HEAA: Hay fever, eczema, allergy, asthma,

Mx:
Avoid Asthma triggers: 2C2PDS+EU:
carpet, cold air
pet, pollen
dust
smoke
Exercise
URTI

If Flare-up: Short term steroid + Preventer

If Severe Flare-up: 4x4x4: Have 4 puffs with each puff followed by 4 breaths, wait for 4 min and repeat.

4R:
Red Flags:
severe SOB:
Can’t Speak comfortably OR Lips look Blue
OR
No relief from your reliever inhaler: 000.

Refer: Asthma Educator
Reading: Asthma Action Plan

Question 52

DUB (Dysfunctional Uterine Bleeding):
Dx, Mx

Answer 52

Sx: Menstrual bleeding:
Prolonged
Excessive

Diagnosis of exclusion, (i.e. no organic cause is found.)

Pathology:
1.Vasoconstriction reduced.
2.Lack of platelet aggregations =Hemostatic plugs (occluding the endometrial blood vessels) are less effective in achieving Hemostasis.>
Due to increased prostaCyclin + prostaGlandin E2 secretion by Endometrium.

. E secretion may be less than normal.>
Corpus luteum does not
form.>
Normal cyclical secretion of progesterone does
not occur.>
Without progesterone, E causes the endometrium to continue to proliferate>
Eventually outgrowing
blood supply.>
Endometrium sloughs and bleeds:
Longer, incompletely, irregularly, profusely.

Find and Tx underlying cause.

DDX:
a) Non- cancerous growth:
Fibroid
Adenomyosis

OR

b) Cancerous growth:
Cervical CA
Uterine CA.

MANAGEMENT:
1)Iron if Hb low & (best: Mirena)
2)ANTIFIBRINOLYTIC AGENTS: Tranexamic acid
3)ANTIPROSTAGLANDIN: NSAIDs = Mefenamic acid
500 mg TD (4 days before menses due to end of menses) or
4)Ibuprofen.
5)COC
6)Progestogens (Norethisterone), esp. for Anovulatory patients
7)IUD (intrauterine Progesterone implant)

8)Danazol (Anti-Estrogenic, Anti-Progestogenic, Androgenic):
Reduces FSH secretion with consequent falls in E and Progesterone levels > Causes: Amenorrhea and Reduces endometrial thickness.
9)GnRH agonists

SURGICAL: (3Es)
10)Endometrial Ablation
11)ElectroDiathermy
12)Excision or hysterectomy

Hysterectomy:
is a surgical procedure under anesthesia which carries a lot of RISK:
1)Bleeding
2)infection
3)injury to surrounding structure: bowel/bladder

4)Time to recover from surgery
5)Support
6)Children: not possible

13)D+C can control heavy bleeding for a short time but there is usually a recurrence in 4 to 6 months!

ENDOMETRIOSIS:
Medical +
(C/C)
Surgical:-
Laparoscopic Excision
-Laser
-ElectroCautery

Question 53

Rheumatoid arthritis Mx
Osteoarthritits Mx

Answer 53

Condition:
Autoimmune disease and explain

Course:
-Progressive degenerative condition
-Flares of acute attack when joints are inflamed and painful followed by months or years of remission

Common:
Most common autoimmune arthritis
Family history

CF:
- affects the small joints of the hands and feet.
-later: large joints like the hip and knees might also be affected.
-The main symptoms are
joint pain,
swelling
stiffness, especially in
the morning
-It is usually symmetrical where both sides of your body are affected

Inv:-(6)

1.FBE, normocytic, normochromic anemia
2.Inflammatory markers- Elevated ESR
3.Rh factor = + in 85%
4.MOST SPECIFIC- Anti-CCP (Cyclic Citrullinated Peptide)

5.X-Ray
6.Arthro-centesis (Joint aspiration): Synovial fluid aspirate (Done sometimes): Cloudy, Sterile Synovial fluid with increased WBC.
[hallmarks of rheumatoid arthritis are:
Soft Tissue Swelling
Osteoporosis,
Narrowing of the joint spaces and marginal erosions.]

Mx:-
1.MDT& referral: (5)
GP, Rheumatologist,
Physiotherapist, Occupational worker,
Social worker
2.Conservative:
a-NSAIDs (Celecoxib)
a-Methotrexate weekly + Folic acid (6 days)
b-Infliximab (Biological DMARD)
d-Steroid for acute Flare-ups

SE:- DMARD (4)
N/V
Diarrhea
Hair fall (C&C Na valp.)
Prone to Infection

3.Non-pharma: (7)
a)Stop Working
b)Smoking cessation
c)Weight-loss

d)Splint
e)Physio(stiffness)- full ROM

e)Fish oil/glucosamine (C&C ADHD)
f)Hydrotherapy

4.Medical Certificate
5.Support group- Arthritis Association Australia
6.Second opinion regarding profession

OSTEOARTHRITIS :
PHARMACOLOGICAL: (6)
1. PCM
2. Topical NSAIDs
3. Oral NSAIDs
4. Synthetic Hyaluronic acid or Hylan products via Intra-articular injection
5. Opioid therapy
6. Intra-articular Corticosteroid injection

SE: NSAID
1.Diarrhoea
2.Indigestion
3.Stomach ulcers

4.HA
5.Drowsiness.
6.Dizziness.

7.Allergic reactions.

NON-PHARMACOLOGICAL:
1. Dietician
2. Exercise
3. WL

4.Physiotherapist
5.Occupation therapist

6.Psychologist
7.Rheumatologist referral

8.R/v in 3-6 Months
9.Education

Question 54

Mitral Stenosis Hx, Dx, Mx

Answer 54

Hx: PRAIS-P & preg
Rheumatic fever without carditis requires antibiotic treatment for 5 years
OR until the patient is aged 18-21 years (whichever is longer).

Dx: MS: explain structural defect, Back pressure on lungs,
RF, Antibx req, Hyperdynamic state (preg)

Mx:(9)

1)Inv: Echo(confirm Dx) +Pregnancy rel.

Refer:
2)High Risk Pregnancy Clinic
3)MDT:(4)
Obstetrician
Cardiologist
Pediatrician
Anesthetist.

4)BEFORE labor:
Limit activity

During labor: (3)
5)O2
6)Epidural/ Painkiller
7)2nd stage shortened: Forceps/Vacuum

Complications:(2)
8)Mom: HF
9)Baby: IUGR

Question 55

Pain Mx
#Pericarditis pt on Long-term Painkillers
(For back pain)

Answer 55

Ix: Echo (pericardial effusion)

Pain relief regimens:
1)Neurofen not started working
(Oral: 3 weeks for full effect, Topical: 1 to 2 days.)

2)Body already adapted-
a-need the adjustment of the dose, frequency
b-change the medications
c-Colchicine: add a medication
d-Morphine: may help but it is not a corner-stone

3)Pericardial effusion: Aspiration

4)TENS (Transcutaneous electrical nerve stimulation)(after hip replacement)

5)PCA (Pt controlled anesthesia)

6)Pericarditis: if bacterial infection: Antibx

Pt is on: Morphine, codeine, gabapentin, paracetamol, neurofen.

Common SE:
a.Dizziness
b.Drowsiness
c.Constipation/Diarrhea

Morphine SE: N/V

Codeine SE (like Opioids)
a.Constipation
b.Mood changes
c.Sleep disturbance

Gabapentin (also given in TN,DM neurop, Herpes) SE:
a.Weight gain
b.Tremor

PCM SE:
a.Headache (Rebound)
b.Blurry vision
c.Dry mouth
d.Hepatitis

Ibuprofen (class NSAID Not given in carpal tunnel, Aspirin: not NSAID: stop in Gout) SE:
a.Indigestion/Dyspepsia/Heart burn resulting from Ulcers in Stomach
b.HTN

Question 56

Colles’ fracture X-Ray explanation and Mx

Answer 56

X-Ray findings:
Good exposure, in AP and lateral views, showing distal radius and ulna, showing wrist joint including carpals and metacarpals, showing oblique fracture of distal part of radius with no Intra Articular Extension with minimal dorsal Displacement and dorsal Angulation.

Immediate Mx:-(9)
1)Closed reduction by
Counter Traction under Anesthesia
(1 person will Pull Hand,
2nd person will Pull Elbow to Disimpact the two Bony fragments.
3rd person will Push the Distal fragment Down for Alignment.)

2)Repeat X-Ray again to ensure Alignment.
3)Put in a Below Elbow Cast- 6-8 Weeks (PFU)
a)P=Full pronation,
b)F=Wrist Flexion,
c)U:Ulnar Deviation

4)If Intra-Articular Extension - fix it Surgically.
5)Refer -orthopedic fracture clinic
6)Review -in 24 Hrs and in 7 D.

7)Pain Management:
(PIE)
a.Pain killer- combination
Ibuprofen + acetaminophen
*Severe- specialist may give opioids- (addictive)
b.Ice
c.Elevation

8)Cast and Wound Care:
a.Replacement needed if becomes loose.
(if swelling reduces)
b.Shower time
-use plastic bag,
-dry by using hair dryer on cool setting.
c.Surgical incisions
-kept clean and dry for 5 Days or
Until the sutures (stitches) are removed, whichever occurs later.

9)Red flags for ED: Presence of below in Fingers:
1-pain
2-Discolouration
3-Swelling,
4-Inability to move

LONG TERM Mx:-
Inv:(5)
a.FBE, UEC, LFTs
b.CMP
c.vitamin D
d.TFT
e.PTH

Tx:(4)
1.Dairy products.
2.Sunlight: minimum of 25 Min/ D
3.Regular exercise.
4.Arrange another consultation to discuss about other causes of Osteoporosis.
5.Some cases-
Physical or Occupational therapist will be required to regain ROM.
6.Cast is removed about 6 Wks after surgery in a child. (coz growth plate injury?) (earlier in adults).

RECOVERY:(3)
1.Healing time: 1 year

2.Light activities -1-2 Months after your Cast is removed.
(Swimming, Lower body exercises).

3.Intense activities- 3 to 6 Months after surgery.
(Skiing, Football)
(C&C: shoulder disloc 2 wk for minimal, 16 wk for full)

COMPLICATIONS:(6)
1)Wrist will probably feel stiff
1-2 months after the cast is off.*
2)2 years- dull ache or stiffness.(OA, or >50y)
3)1 year- pain expected
4)Carpal tunnel syndrome
5)Older- might not be able to fully move their wrist.
6)Unrelenting pain: Sign of Complex Regional Pain
Syndrome (Reflex Sympathetic Dystrophy)
*Treated aggressively with medication or Nerve blocks.

PREVENTION:(5)
1.Nutrition: high Ca diet, Vit D- salmon
2.Supplements- Ca, Vit D
3.Sunlight
4.Exercise-
a.weight bearing
b.strength training
5.Wrist guard- helps prevent Injury from Fall.

DEXA fol/by Fall prevention clinic (ask minimum trauma, altho no Hx)
[Shoulder dislocation : strapping
RA: splint
clavicle Fx: sling
wrist guard: colles]

Question 57

Drug Eluting Stent(DES) Mx.

Answer 57

❑DES (Drug-eluting stent)

❑ Emergency Surgery:
*Remember: DES is 50% functional by 6 Months. 6 Months period after stent insertion is required for doing Emergency procedures.

*If inserted < 6 Months ago: < 50% stent is
functional.
-CANNOT STOP BOTH Aspirin and Clopidogrel

*If inserted > 6 Months: DES is already 50% functional
-CONTINUE ASPIRIN, may stop clopidogrel based on the procedure.

-CONTROL risk of bleeding.
1)STOP TODAY’S DOSE OF CLOPIDOGREL which reduces risk of bleeding by 15 -20%.
2)pRBC and platelets on standby
3)Perform procedure in a tertiary centre with a Cath lab available.
4) May start LMWH to prevent DVT.
5)Decision will be made by the MDT (4): anesthetist, surgeon,
cardiologist, intensivist
6)Restart clopidogrel within 24 Hrs after the surgery

❑ Elective Surgery:
Risk of thrombosis > Risk of bleeding: Time available + Stopping the drug might cause Thrombosis.

-DELAY the procedure beyond the period of risk, which is within 12 Months of insertion of the DES.
* 100% is functional within 1 Year, that’s why the patient needs additional anticoagulation for 12 Months to prevent tissue growth within the stent.

-If beyond the period of risk:-
1)CONTINUE Aspirin throughout Pre-op regardless of procedure.

BUT

2)Manage clopidogrel: Based on procedure:

❖Non-Cardiac surgery
* Stop 7 Days before

❖CABG
* Individualize use

❖PCI
* Continue throughout

Question 58

Hernia Counselling

Answer 58

What is hernia?….

Pre-op:
Don’t shave by yourself just before operation as risk of infection. It will be done in theatre.

Complications: (4)
1)Local anesthesia is preferred over general as general anesthesia has risk of cardiac or respiratory failure.
2)There is still risk of bleeding, wound infection and clots in legs, also PE. Also damage to bowel.
3)Minimal chance of recurrence.
4)Pain duration varies from person to person.

Post-op:
1)Arrange someone to pick you up because:
a)Chance of fainting in the first 24 hrs. (Needs accompanying at all times.)
b)Shouldn’t drive for 4-5 Days because braking can cause pain.
2)Panadeine Forte has Codeine, SE: Nausea, Constipation
+ Neurofen/Voltaren
3)Laxative may be req (SE of meds or pain slows digestive system)
4)Wearing shorts can help discomfort and reduce swelling.
5)Return to work
office workers: 1-2 weeks
If weight lifting job: 3-6 weeks
6)Medical Certificate
7)Ordinary exercise is encouraged immediately:
Walking and gentle bending
Swimming
8) Advise against heavy lifting and excessive straining for at least a few weeks:
Gym
Contact sports

Question 59

Gout Dx and Mx

Answer 59

cond:
Gout is a metabolic disturbance with an inherited tendency,
in which there is decreased renal clearance of uric acid, which is a waste product of the body.
This causes hyperuricemia, with
deposition of uric acid crystals in the joints, Causing:
1-Arthritis,
2-Tophi (Deposition in soft tissue)
3-Stones in Kidneys (deposition in urinary tract)

CAUSES:
Crystals accumulate due to:
-Under-excretion by kidneys
-Overproduction by body (less common)

INVESTIGATIONS:-

1.FBE - Septic arthritis
2.Uric acid level- Hyperuricemia
3.Blood Culture - if fever
4.U&E - Nephropathy (can precipitate)
5.CRP - elevated
6.BSL
7.LIPIDS
GOUT frequently occurs with other conditions like
Metabolic syndrome

8.LFT -
*HTN is associated with Fatty liver & Metabolic syndrome

9.X-RAY foot
a-Effusion: earliest sign
b-Punched out Lesions
c-Joint space: preserved

10.Synovial fluid analysis: (showing monosodium urate crystals)
not done in acute phase, unless with high suspicion of SEPTIC ARTHRITIS

Tx:
1)Stop Thiazide,Atenolol & Aspirin: Use ACEI
(C&C in PVD: Aspirin started, Thiazide not mentioned)
2)INDOMETHACIN (1ST CHOICE) 25mg capsules
3 capsules NOW
2 capsules in 2 H
1 capsules every 8 H for the next 2 D
1 capsule every 12 H for the next 1W
3)Steroids/ Prednisolone 25mg OD after Breakfast, reducing to Zero over 7 to 10 days
4)Colchicine 0.5mg PO can be used with Allopurinol (new*)
5)PCM (+/-)

NONPHARMA
1-Inc fluid intake
2-Elevate and rest foot for 24-48h
3-medical certificate
4-Once pain has subsided you can return to work (usually after 48H)

CHRONIC MGT
1-Approximately 8 Wks after the acute attack has subsided:
ALLUPURINOL 50-100mg Daily
Gradually increasing to 300mg Daily
(Now also given in acute)

2-Check Uric Acid level after 4 Wks -Aim to Reduce:

Without tophi: < 0.36mmol/L
With tophi <0.30mmol/L
1st line: NSAID or Cochicine

Question 60

Parkinsonism Mx

Answer 60

Ix:
FBE, ESR CRP UEC,
LFT’s
BSL, lipid profile, ECG
Prolactin.

Switch Risperidone to Olanzapine (cross over period: new med started while old gradually reduced till stopped completely)
Hosp because likelihood of symptoms recurrence during switch
Diphenhydramine

Question 61

Splenectomy Mx

Answer 61

1.What is spleen,
2.function of spleen 3,
3.cause to remove.

4.Immediate- post surgical
recovery time
long term- overwhleming infections

Overwhelming infections- streptococccus, meningococcemia, haemophilus
Long term antibiotics- lifelong or atleast 2 years
standby antibiotics- Amoxicillin and co-amoxiclav: Fever, tiredness, weakness

Vaccinations 4-
pneumococcus 5 yrly,
meningococcemia-
influenza yrly, Hib

medical alert bracelet
travel- malaria prophylaxis, repellants, barrier precautions
If a patient is traveling to a region where he could get an unusual infection from ticks that is called babesiosis which can be fatal because
Infectious disease consultantation and expert travel advisor

If travel to endemic receive vaccination regardless
Avoid contact sport- 3-4 weeks
Animal bites- antibiotic prophylaxis
Red flags
other complication- Hernia at incision site

Question 62

Hepatitis A Mx

Answer 62

INVESTIGATIONS
Full blood exam
UEC
CRP

LFTs (total bilirubin, AST, ALT, ALP will be high)
Hepatitis serology

Peripheral blood smear (thick and thin film)
[malaria can cause hepatosplenomegaly]

MANAGEMENT
Dx:
Condition: viral infection of the liver called
hepatitis.
As I have excluded exchange of body fluids, blood contacts, and STIs, most probably you are having hepatitis A.

-Transmission: It spreads from person to person through close contacts with use of towels, contaminated hands, contaminated food and water.
You are most infective to others 2 weeks before and 1 week after yellowish discoloration of the skin.

-Commonality: very common condition

CFx: fever and nausea.

Mx:
1.Please take adequate bed Rest at home.
2.Have a fat free diet and increase your fluid intake. Take high carbohydrate and low fat diet.
3.Please Avoid alcohol, smoking, and liver damaging drugs like PCM.
4.It is a Notifiable condition. Report this to the DHS.
5.For your girlfriend and other close contacts, we can give
Immunoglobulins, and they should be given within 2 weeks of contact.
6.2 doses of hepatitis A Vaccine, given 6 months apart. (vaccine only given to those who haven’t got the infection or never had vaccine)
7.vaccine is protective for 20 years.
8.Please avoid sharing cutlery and crockery during meals. Do not handle food.

Course: The prognosis is very good and complete recovery is expected.

(C&C nephrotic high carb low salt, fluid restriction)

Question 63

Macrocephaly Hx,PEFE, Dx(3), Mx

Answer 63

Hx:
Don’t miss:
HOPC symptoms
4 CNS
Vision & hearing,
BINDS
Social Hx
Well Baby
PM/SHx
FHx of big heads.

PEx:
General appearance: -Dysmorphic features
-Vital signs and growth chart

-Head for suture lines if rigid:
Tense, bulging anterior fontanelle
Rapid head growth

-Neck for congenital torticollis
A downward gaze of your child’s eyes.
Unusual eye movements
-Developmental assessment

Dx: Macrocephaly or Big head:
refers to a head circumference (the measurement around the widest part of the head) which is > 98th percentile on the growth chart, compared to the those of same age and sex.

Causes include:

1)Benign familial macrocephaly: This is when family members have bigger heads, so the child also has it. It is not an illness and needs no treatment.

2)BESSI:
CSF: is fluid that flows in and around brain.
When this fluid is increased between the brain and the skull, it is known as BESSI or Benign Enlarged Subarachnoid Space of Infancy. Bessi does not cause any harm and resolves on its own without Tx.

3)Hydrocephalus:
When, CSF is increased in ventricles (which are cavities or spaces deep within the brain), it is known as Hydrocephalus.
This may require surgical intervention.

4)Other causes like brain bleed, tumor or genetic.

MANAGEMENT:
Red Flags/ Signs or symptoms of increasing ICP/Complications such as: (12)

1.irritability
2.high pitched cry

3.Rapid head growth
4.Tense, bulging anterior fontanelle (soft spot of bones of your child’s skull where bone formation isn’t yet complete.)
5.Bulging veins on your child’s head

6.A downward gaze
7.Unusual eye movements

8.Projectile vomiting,
9.Poor appetite

10.epilepsy
11.autism
12.Developmental delays (not reaching learning milestones).
If no such signs, the head circumference will still be measured during each well child visit, up to the first five years of life.

If any red flags appear as mentioned, a follow up appointment in 3 months with the pediatric Neurosurgeon may be recommended who will do:
Ix: imaging of head: (3)
1.Ultrasound,
2.CT scan
3.MRI

Question 64

Tremor Ddx & BET Mx

Answer 64

1.DM
2.Thyroid

3.Parkinson
4.BET

5.Kidney
6.Liver
7.Lung d.?

8.Post-stroke
9.Brain abscess
10.MS

11.Peripheral Neuropathy
12.RA

13.GAD
14.Tea/coffee
15.Alcohol usage?, withdrawal
16.Drug usage

Other forms of tremor:
 physiologic
 Parkinson’s disease
 Poststroke
 Drugs
 Hyperthyroidism
 Cerebellar
 Toxic (liver, alcohol, uraemia)

 MANAGEMENT:
Reassurance
 Beta-blockers (propranolol, 10-40 mg bd)
 Primidone (anti-epileptic)
 Intermittent Benzodiazepines if increased with emotional stress
 Moderate Alcohol !!!!

Question 65

Acute epiglottitis Dx, Mx

Answer 65

Acute Epiglottitis:
Epiglottitis happens when there is swelling of epiglottis — Epiglottis is a small cartilage or flap of tissue that covers the windpipe and larynx/ voice box. Therefore, this swelling blocks the flow of air into the lungs. It can also encroach over the food pipe causing difficulty in swallowing.

Etiology : H. influenzae type b, relatively uncommon condition due to Hib vaccine

Commonality: any age, most commonly 1 to 4 yr (C&C 6M-5Y in Croup)

Clinical Features:
Rapid onset,
toxic looking, restlessness, cyanotic/pale
fever
sore throat
anorexia, dysphagia
inspiratory Stridor, slow breathing, lungs clear with decreased air entry,
prefers sitting up (“Tripod” posture),
Open mouth, Drooling, Tongue protruding,

Investigations and Management :

Acute epiglottitis is a medical emergency. When managing epiglottitis, it is important not to agitate the child, as this may precipitate complete obstruction
Maintain position of comfort with parents present
May lead to complete obstruction, thus preparations for Intubation or Tracheotomy Must be made prior to any Manipulation.
Admit
stat ENT/ anesthesia consult(s)

Inv:
Defer invasive examinations/ procedures (IV) or imaging (lateral neck X-Ray) in patients with severe respiratory distress due to risk of precipitating respiratory arrest:

1)WBC (elevated), blood
2)Pharyngeal cultures (after intubation)
3)Lateral neck radiograph (only done if patient stable): shows
Thumb sign: cherry shaped epiglottic swelling

Treatment:
Secure airway
IV access with hydration
IV Ceftriaxone 50 mg/kg
(max 2 g) IV 12 hourly
Early PICU/anesthetic review

Complications:
watch for Meningitis

Question 66

Alcoholic peripheral neuropathy Sx, Mx

Answer 66

[Symptoms like Stroke: B&B,sexual + Dizziness]
[Ix: Metabolic, Nerve conduction, Vit def, UGI & Small bowel series]
[Prevention, Painkiller, Vitamins, Referrals]

 Symptoms of Alcoholic Neuropathy
1.Arms and Legs Numbness, tingling and burning, prickly sensations
2.muscle spasms and cramps, muscle weakness and atrophy
:loss of muscle functioning, movement disorders

3.Urinary and Bowel
a.Incontinence
b.Constipation, diarrhea
c.problems starting urination
d.feeling that the bladder hasn’t been emptied fully
Other:
4.sexual dysfunction, impotence

5.impaired Speech, difficulty swallowing
6.heat intolerance, dizziness or lightheadedness

Inv:
1.Blood tests: FBC,
B1, B3, B6, B9, B12, A,E (vowels and multiples of 3 and 1),
(E: tocopherol or alpha-tocopherol, A: Retinol)
2.Along with U&E, LFT, RFT, TFT, BSL, serum lipid level (metabolic rel)
3.Neurological examination:
Nerve conduction & biopsy (specific nerves)
4.upper GI and small bowel series (EGD)(R/O CA as anemia),

Tx:
 Short term management -
1.Low doses of Gabapentin (to control the pain)
2.Tricyclic antidepressants
3.Anticonvulsants

4.Vitamin supplements to improve nerve health (folate,
thiamine, niacin, and vitamins B6, B12, and E)/ Vit B
complex and folate supplementation.

 Refer to Neurologist for confirmation of diagnosis and
further management.

Long term management
1.Stop drinking: inpatient Rehab/ outpatient therapy /social support.
2.Avoid Smoking as it’s an important trigger
3.Improve nutrition. Refer to Dietician.

4.Refer to Physiotherapist helps with muscle atrophy.
5.Refer to Occupational therapist for:
a.Orthotic devices/Splints/orthopedic appliances to stabilize extremities
b.Walking Aids which might improve lifestyle
c.Safety gear, such as stabilizing footwear, to prevent injuries,
d.special Stockings to prevent Dizziness
6.Refer to Podiatrist for proper foot and nail care to prevent foot Ulcers.
7.Refer to Fall Prevention Clinic.

Question 67

PVD Dx & Mx

Answer 67

peripheral vascular disease:
Narrowing of blood vessels supplying legs Due to build up of fat.
Causing reduced blood or oxygen supply. So at time of walking there is increase body demand to blood and O2 so this lead to pain while at rest the demand is less so that there is no pain.

❑Investigations
-take blood for FBC, ESR/CRP, UCE, LFT, BSL, lipid
-arrange Doppler ultrasound to look at the vessels of the legs

❑SNAP
1.advise to maintain healthy Lifestyle
2.stop Smoking + arrange another consultation
3.healthy balanced Diet (low fat, no junk food) + refer to dietician
4.limit Alcohol intake to safe level
5.gradual Exercising to the level of the pain to increase collateral circulation + refer to Physio

❑ Chronic diseases
-control HTN, Cholesterol and DM
-start Aspirin and Statin
-stop B-blocker and replace with ACEI
-control DM + Foot care

❑ Referral
-to Vascular surgeon to decide upon any need for
1)Surgical intervention + CT Angio
Intervention options
2)Endovascular stent: stent inside the vessel to dilate
and improve blood flow
3)Bypass Graft

Question 68

Vit B12 Ddx, PEx, Mx

Answer 68

Ddx:
Bilateral weakness + numbness= PAD2S BVM
Peripheral Neuropathy
Alcohol
DM
Stroke
Spinal Cord Compression
Brain tumor
Vit B12 Deficiency
MS

PEx:
GA: Pallor
Vitals: Tachycardia
ENT: Beefy, red, smooth, and sore tongue with loss of papillae that is more pronounced along edges;

CNS: ITPR(hypo)CS(1st: Vibration& Proprioception, light touch/pinprick)+ Rhomberg test (positive: late)
+SLR (R/O Spinal cord compression)

Mx: 6
Ix: (HIMSS M)
1.Hematological-(Mean corpuscular volume): MCV>100fL
2.Serum B12 levels
3.Storage levels

4.IFA: Intrinsic factor antibodies
5.MMA: Methyl Malonic Acid: Dx test: increased
6. HomoCysteine - more for Folate

Tx: 4
Treatment of patient with B12 levels less than 12 with 1 mg weekly for
3 weeks and then monthly for 3 months

1.Induction: Hydroxocobalamine 1mg IM alternate days for 2 Weeks (Start with high dose to replenish storage)
2.Maintenance: Hydroxocobalamine 1mg IM, once every 2 Months
3.Folic Acid
4.▪ Review at 4 months and then regularly thereafter

COMPLICATION: 2
[First few weeks of the symptoms, complete recovery usually occurs]
1.If it is Delayed (>1-2months) it might not recover completely
2.If left untreated, it can result in progressive and irreversible damage to the Nervous system

[Methylmalonic acid (MMA) is a substance that is created when your body digests protein. The amount of vitamin B12 in your body controls how much MMA your body makes. A high amount of MMA typically means you have a vitamin B12 deficiency. There are two types of low risk methylmalonic acid tests: blood & urine]

Question 69

Alopecia Areata Tx

Answer 69

1.Topical steroid: Betamethasone or Hydrocortisone cream- 3-6 months
2.Intralesion Corticosteroid inj - Triamcinolone acetonide for small patches- multiple inj
3.Oral Steroid- with tapering dose over 2 months
Dermatologist:
1.Topical immunotherapy
2.UV phototherapy
Wig- while meds take to effect
3-hair transplant

Question 70

Asthma Hosp Mx

Answer 70

MILD:
6 puff rule
every 20 min
+/- steroid

MOD:
6 puff rule
add Oxygen + Steroid

SEV:(7)
1.Oxygen+ steroid
3.Continuous Nebul Salbutamol
4.Ipratropium Bromide (Atrovent)
5.Hydrocortisone
6.Aminophylline (bronchodilator Theophylline with ethylenediamine),
7.Magnesium Sulphate

Question 71

Hemorrhoids Dx, Mx

Answer 71

Dx:
Hemorrhoids happen when the veins or blood vessels in and around your anus and lower rectum become swollen and irritated.
This happens when there is extra pressure on these veins. Hemorrhoids can be either inside your anus (internal) or under the skin around your anus (external).

❑Diagnosis and Management
Most likely you have haemorrhoids. Haemorrhoids are
cushion-like structures which helps to buffer the increased
pressure in the abdomen. Since you are constipated, and you are straining too much, these structures, they are subjected to increased amount of stress thereby becoming enlarged and they start to bleed.
(always ask for family history of malignancy, if positive,
follow protocol for that)

❑ Refer: general Surgeon: colonoscopy to rule out nasty lesions.
Tx: non-operative and operative.

NON-OPERATIVE measures are appropriate for grade 1 and grade 2. (=7)
▪ Lifestyle modifications to address constipation: 4
▪ Diet - green, leafy vegetable, fruits, increase fluid intake
▪ Stool softner
▪ Avoid straining
▪ Avoid prolonged sitting

MINOR PROCEDURES: 3
▪ Band ligation
▪ Heat coagulation
▪ Sclerotherapy (C&C Hydrocele)

OPERATIVE measures are appropriate for grade 3 and grade 4.
1.Hemorrhoidectomy (surgical removal of the hemorrhoid)

[Rubber band ligation (a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the hemorrhoid.)
Infrared coagulation (IRC) is a non-surgical treatment for hemorrhoids that uses heat to
coagulate (clot) the veins to cut off the blood supply to the hemorrhoid.
It’s painless and relatively quick with virtually no recovery time.
a liquid containing drugs such as quinine, polidocanol or zinc chloride is
injected into the area around the enlarged hemorrhoids]

Question 72

Rotator Cuff Tear
Hx
Dx

Answer 72

Explain USS
Shoulder: ball and socket joint: the ball, or head, of
your upper arm bone fits into a shallow socket in your shoulder blade.
Rotator Cuff and its Function:
Your arm is kept in your shoulder socket by your rotator cuff.
The rotator cuff is a group of four muscles (Supraspinatus,
Infraspinatus, Teres minor and Subscapularis muscles) that come together and attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

Bursa: There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). That allows to glide freely when you move your arm.

 When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful

 When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.

 In many cases, torn tendons begin by fraying. As the damage
progresses, the tendon can completely tear, sometimes with lifting a heavy object.

Complications: (4)
1.Weakness
2.Joint Stiffness
3.Muscle atrophy
4.Frozen Shoulder: connective tissue enclosing joint becomes thickened and tight

Types of tears:
Partial/Incomplete
Full thickness/Complete: hole

Hx:
HOPC:
Aggravating: Night? Sleeping on shoulder? Over-head activities like combing?
Hows it affecting ur life?
Cause: Injury? Occupation?(degeneration)
Numbness, tingling?
Arthritis: weakness in arm? Decreased grip strength?
Crackling sensation when moving shoulder?

Ask Complications
Ask Cause

Ddx: NIP2T 2FO3R B2C2D

Ix: MRI, USS

Tx:
Non-surgical:
Rest
Sling
Activity Modification: Avoid painful activities.
NSAIDS
Strengthening exercises
Physical therapy: Stretches to improve flexibility & ROM

Steroid injection

Surgical Tx: Indications:
1.No improvement with non surgical Tx
2.Sx >6-12 M
3.Large>3cm with good surrounding tissue
4.Significant weakness and loss of function

Question 73

Ulcerative Colitis
explain
Mx

Answer 73

condition & clinical features,
commonality,
cause,
course

IP 3A 4S
1.immunosuppressants
2.pain killer
3.aminosalicylate, antidiarrhoeal,antibiotics
4.supplements
5.steroids
6.surgery
7.specific diet

DRES-ACCI
Diet Diary
Relaxation Techniques
Exercise

Smoking cessation
Alcohol

Colonoscopies for CA
Crohns & Colitis Austr
IBD Helpline

F(5)OP-BTCON:
Fulminant colitis (inflammation & swelling)
Osteoporosis
Perforation (hole in gut)
Bleeding- heavy
Toxic megacolon (Non-obstructive dilation of the colon)
CA
Organs: liver, bile duct (thin tubes that go from the liver to the small intestine), skin, eye (red eye), joint
Nutritional deficiency & weight loss

Question 74

Down’s syndrome :
CFx
Complications,
Inv and Mx

Answer 74

condition
cause

clinical features-
PHYSICAL
upward slanting eyes,
small fold of skin on the inside of eyes, rounded face with flat profile,
flat nose,
low set ears,
short neck,
reduced muscle tone,
smaller and weigh less at birth

MENTAL:
They usually tend to grow slowly but eventually meet many milestone.
*They can develop communication skills but might take a little longer.

Complications-
Hearing and vision,
Hypothyroidism,
Heart problems,
Gut problems,

learning difficulties,
Bone problems

Ix: TFT, Echo, USS

MDT:
1.Speech and language therapists
2.Physiotherapist
3.Emotional and Behavioural Therapists
4.Psychologists
5.Social worker
6.Centrelink
7.Down Syndrome Association Australia
8.Routine visits: 3, 6, 12 M then Annually
9.Reglularly check his vision and hearing

[C&C Speech & Language: ADHD: Behavioral modification
, Macrocephaly]

Question 75

C/S request

Answer 75

FORMAT:
What is C/S?:
Indications C/S- Planned and Emergency
CI
Complication (possible)- surgical
Disadvantages

Vaginal delivery:
Advantages
Disadvantages/Risk

Concerns:
Pain
Incontinence

INDICATIONS:
C-section.

• CPD
  CPD-due to big baby or narrow

baby (2)
* 1 Planned
Placenta praevia
* Malpresentations

Mom (4)
* birth canal.
* Previous 2 C C-sections.
DM,HTN,
Infection in mom

• 2 Emergency
  Obstructed labour

Baby/cord(5):
* Cord prolapse.
* Foetal distress.
Meconium staining
Abnormal HR in baby
Twins

Mom(2)
* Abruptio placentae.
* Eclampsia.

Contraindications.
* Not recommended >3 C-sections VS any number in Vaginal

Complication of C/S
MOM:(5)
*Anesthetic risks.
* Bleeding.
* Injury to surrounding structures.
* Infections.
* DVT

BABY:
*Respiratory distress.

Disadvantages of C/S (3)
* Longer stay in hospital.
* Pain duration more.
* Scar rupture with VBAC.

VAGINAL BIRTH:

Advantages of vaginal birth (4)
* Shorter stay.
* Recovery quick.
Immediate complications rare.
* Pain but nowadays very good option for pain relief
* Can have any number of future vaginal deliveries

’Risks’ of vaginal delivery (2)
* Failure.
* Damage to pelvic floor.(incontinence without K exercise)

PAIN RELIEF OPTIONS/Mx: (4+4=8)

Pharmacological (4)
*Epidural
* injection Morphine
* injection Pethidine.
* N2O + 02.

Non Pharmacological (4)
* Deep breathing technique
* Positioning.
* TENS. (C&C Pericarditis,OA)
* Hydrotherapy.(C&C RA)

KEGEL EXERCISES (for incontinence concern)

Question 76

Endometriosis Mx

Answer 76

Investigations (IMP):
1.FBC, UEC, LFT, BSL,
blood group.
2.Pelvic Ultrasound and transvaginal
ultrasound.
3.Laparoscopy

Mx:
1.Painkiller
2.COC pill continuously for 6
months, Skipping sugar pills

3.Depo provera or minipill
4.Mirena.
(3 and 4- Can cause endometrial regression)

5.GnRH analogues
(-medical menopause ,
not for more than 6 months- severe menopausal symptoms like hot flushes, bone pain and osteoporosis.

6.Danazol
(medical menopause,
not for more than 6 months- develop male characteristics like voice changes, hair growth because it is an androgen.

7.Surgical:-
Laparoscopic Excision
-Laser
-Electrocautery

(cutting away or burning away of
endometrial deposits)

(Red Flags: If medical management fails
-you present with infertility
-severe symptoms)

Question 77

Cervical ectropion Dx & Mx

Answer 77

Condition:-
The cervix or the neck of your womb has an outer surface called the Ectocervix, covered by flat cells (squamous cells), and the inner part called Endocervix, covered by tall cells (columnar cells), and these two meet at the Squamocolumnar junction or at the opening of the cervix. A cervical ectropion happens when the rim of the cervix, Rolls Outwards Exposing the Endocervix into the vagina, and this is what you see as a Red ring.
And this endocervix has the appearance of a Granulation tissue or a Reddish appearance.
There is nothing to worry about cervical ectropion.

Causes:
-during pregnancy,
-teenagers
-women who use oral contraceptives.

Inv :
Blood,
UDT,
UPT,
Hormone profile,
USG

Stop OCP, use condom meanwhile
*We can just leave it behind if it does not cause symptoms, but make sure that:
Good genital hygiene
Cervical screening up to date

Refer to specialist:
Ablation procedure-
(burn away by
-Laser
-Cryotherapy
-ElectroCautery)

Red flags:
excessive mucosal discharge
post coital bleed, then we need to refer you to the specialist
to do ablation techniques using or electrocautery

Question 78

Pneumonia risk assessment +
Ix

Answer 78

Management:
CURB65
Pneumonia severity:
Confusion
Urea > 7 mmol
RR >= 30
BP <= 90/60
>65 years old

0 = outpatient
1 2 = medical ward with IV antibiotics
>=3 = ICU because he might need vasopressor support

A patient can only be in the low-risk group if they satisfy the following criteria:
1)Age <50, AND
2)No malignancy, CCF, cerebrovascular, renal or liver disease, AND
3)Normal mental state, AND
4)Satisfactory vital signs: HR90 mmHg, temp 35-40C

Ix:
ABG’s: pH,pO2, pCO2, bicarb,
▪ UEC: NAD
▪ FBE: WCC 14.4 (neutrophilic leucocytosis)
▪ LFT: NAD
▪ Urinanalysis: + protein, 1+ blood

CXR: right middle lobe pneumonia
[UMCS, Serology, Nasopharngeal aspirate, Sputum culture)
▪ Sputum for micro and culture: not available yet but most
common:
▪ Strept. pneumoniae
▪ H. influenzae
▪ Mycoplasma pnuemoniae (serology!)
▪ Legionella (serology + urine antigen)
▪ Viral (serology, naso-pharyngeal aspirate!)
▪ Tuberculosis
▪ Chlamydophila (chlamydia) pneumoniae (serology!)

PSI scoring:
Age: years

Female-10
Male0
Nursing home resident
Yes+10

Neoplastic disease
Yes+30

Liver disease history
Yes+20

CHF history
Yes+10

Cerebrovascular disease history
Yes+10

Renal disease history
Yes+10

Altered mental status
Yes+20

Respiratory rate ≥30 breaths/min
Yes+20

Systolic blood pressure <90 mmHg
Yes+20

Temperature <35°C (95°F) or >39.9°C (103.8°F)
Yes+15
Pulse ≥125 beats/min
Yes+10

pH <7.35
Yes+30

BUN ≥30 mg/dL or ≥11 mmol/L
Yes+20

Sodium <130 mmol/L
Yes+20

Glucose ≥250 mg/dL or ≥14 mmol/L
Yes+10

Hematocrit <30%
Yes+10

Partial pressure of oxygen <60 mmHg or <8 kPa
Yes+10

Pleural effusion on x-ray
Yes+10

Age <50
PMHX:1(HF)
2(COPD, asthma)
3(Dementia, seizure,stroke)
Smoke, Alcohol

Tx: [AD BD CE]
A+R/D (outpt): Amoxycillin + Roxithromycin/Doxycycline
(1-70: Class 2)

B+R/D (inpt) IV BenzylPenicillin + Roxithromycin/Doxycycline
(70-130: Class 3-4)

ICU: IV Ceftriaxone + IV Erythromycin
(>130: Class 5)

Question 79

MVA in pregnancy Mx

Answer 79

(>60km would be major)
????monitored for 24 hrs
CTG every 4 hr
USS

Question 80

Pilonidal cyst/sinus

Answer 80

• CONSERVATIVE: providing there is no sepsis, some patient may be
  treated by:
  -careful hair control with depilatory creams,
  -regularly shaving the natal cleft and proper hygiene.
  -Antibiotics are prescribed
  for the acute exacerbation.

Abscess:
* SURGERY:
-patients with an abscess should, in the first instance, have
it drained.
-Some surgeons advocate injection of the track with Phenol
with the aim of obliterating (destroying) it.

Surgical treatment ranges from:
-un Roofing the sinus,
to Excision with the wound

left Open to heal by secondary intention
OR is primarily Sutured.
-The wound also can be Closed with Flaps.

-Another method is
Marsupiliasation (creation of a pouch). These procedures are usually done by colon and rectal surgeons.
-In general the incision should be
laterally, away from the midline due to poor wound healing in the midline.

Question 81

Postpartum Hemorrhage with broken cord: explain to pt

Answer 81

Massage,
Catheterization,
Control cord traction,
Manual removal,
Synto shot 40IU
Ergo(Obs),

Bleeding continues after removal of placenta:
Bimanual/ Balloon tamponade,
Blocking arteries(internal iliac, uterine),

Last resort: Hysterectomy (accreta)

Question 82

Difficulty swallowing
DDx
Hx, PEFE

Dx & Mx:
Esophageal CA
Esophageal Stricture

Answer 82

HISTORY:
HOPC: Dysphagia: (SOCRATES)
What do you mean by difficulty in swallowing? (sticky or painful?)
S: Are you aware of the Level of Obstruction that you feel sticky/pain? Can you show me with one finger?
O: Since when?1st time? Is it getting worse?
A/R: Anything makes it better or worse?
Severity: How is your diet these days? (liquid diet?),
Any vomiting?

OP vs [Esophageal: obstructive &/ Dysmotility)]:
Is it rel to solid or liquid or both?
Do you feel difficulty initiating the swallowing or food gets stuck after swallowing?

If PAIN +:
Odynophagia: Any pain associated with swallowing difficulty?
Candida: Any pain in oral cavity or throat?

CA: Any LOW/A, Lump or bump?
Red flag for Esophageal CA: Any changes in voice?

REFLUX Qs:
GORD and Barrett’s esophagus: Any history of heart burn? Any burning sensation in your throat?
Any worsening of reflux symptoms?

OTHER DDx:
Esophageal spasm: any intermittent chest pain?
Scleroderma: Any joint pain? Any skin changes? Any discoloration of your fingers or toes?
Zenker’s diverticulum: any regurgitation of undigested/old food? Any bad breath?
Globus: Any feeling of something stuck in your throat?
Stroke: any weakness in any part? Any hx of stroke?
MG: Do u feel tired at the end of the day?
MS: Any BOV?
Thyroid: Any Swelling in front of the neck?

Any tummy pain, N/V?
B&B

Any chronic medical illness (HIV, candidiasis)?
PMHX: any past medical condition?
PSHX: Radiation treatment or surgical illness?
Occupation Hx: Any radiation exposure to neck?
FHX: of cancer
SADMA ( smoking, stress, alcohol, medication)

ESOPHAGEAL CA
: Positive points in the history indigestive symptoms (burning pain in chest, indigestion)
Started on omeprazole
No consistent relationship to food, Bending forward and lying down makes it bad
Lost 7- 8 kg in the last 3 months, difficulty swallowing solids, Smokes 1 pack/day since 17 years old

Dx and Mx
 There could have been many reasons of your swallowing difficulty, but based on your history
of weight loss and diff in swallowing of solid foods I am suspecting it could be a nasty growth in your food pipe called Esophageal cancer.
 Please don’t get scared, its just a possibility, I am no sure yet.
It could be due to Motility disorder of your food pipe called Achalasia cardia,
It could be due to Narrowing or Stricture of food pipe,
could be esophageal Spasm/ scleroderma/
esophageal ring or web
Further inv barium swallow and endoscopy

PEFE (not a task in this case)
GA– skin changes, vitals
Dehydration (if vomiting)
Nutritional deficiency (anaemia, leukonychia, koilonychias, hair changes)
Oral cavity – tonsil, oesophageal web, dental problems, Peritonsillar abscess
Neck – thyroid
CVS, Respiratory
Neuro – 9,10 cranial nerves, Upper limb and lower limb neurological
Bedside test
– oesophageal obstruction test (normal – hear sound of
gurgling at 7-10s, obstruction ->10s) check by swallowing water

ESOPHAGEAL STRICTURE Dx & Mx:
Based on your Hx, you have difficulty in swallowing which is progressive over time. We can see that there is delay in passage of food
which means that there is Obstruction in your gullet/food pipe.
(Draw a diagram, mouth, gullet and stomach)

Most likely the problem is esophageal stricture (narrowing of gullet) caused by long standing Reflux.
When there is long standing reflux, Sphincter in lower end of the gullet become incompetent and causes the regurgitation of food and stomach content into gullet.
That results in chronic inflammation of lower end of gullet leading to:
Fibrosis (new tissue formation) and Stricture.

Other possibilities are cell changes in lower gullet also due to repeated Regurgitation. we call it Barret’s Esophagus.
It could be Achalasia cardia which is the lesions of nerves supplying the gullet.
Another complication of chronic reflux is nasty condition of the gullet causing growth and obstruction.
So, I will refer you to the specialist who will assess you and do the investigations:
Baseline blood tests (FBE– anemia?)
Barium swallow (a special dye needs to be swallowed and do a serial X ray for any growth – filling defect)
OGD – small flexible tube with light source and camera
will have to be swallowed and check the gullet for any lesion. and take Biopsy.
You will be treated accordingly after the diagnosis.

Ix:

Upper Endoscopy (all): shows:
Esophagitis
Dysmotility
Strictures
Masses
Diverticulum
Rings or webs

Barium swallow: (solids alone)
Achalasia (bird beak apperance)
Diffuse esophageal spasm (corkscrew esophagus)
Strictures
Rings or webs
Masses

Esophageal Manometry: (solids & liquids)
a.Achalasia (abnormal Relaxation of lower esophageal sphincter (LES) and absent Distal peristalsis)
b.Diffuse esophageal spasms(incomplete LES sphincter relaxation and Progressive peristalsis)
c.Scleroderma (Absence of all peristalsis)

Question 83

Community acquired pneumonia
1.risk factors
2.major risk factors to consider for admission
3.Mx

Answer 83

1.Factors that increase risk of community-acquired pneumonia:
1.Age>50
2.Smoking
3.Alcohol

4.Medical:
a.Heart failure
b.COPD,Asthma
c.Dementia, Seizure, Stroke

5.Immunosuppression-neoplastic disease
6.Indigenous background
7.Instituitionalisation

Major risk factors to consider for admission:-

Patient classification using Pneumonia Severity Index (PSI)
▪ PSI risk class I (lowest risk).

Patient has none of the following:
1.Age > 50 years;
2.History of :
a.neoplastic disease
b.congestive cardiac failure
c.cerebrovascular
d.renal or liver disease

3.Clinical signs —
altered mental state,
pulse rate ≥ 125 per minute,
respiratory rate ≥ 30 per minute, systolic blood pressure < 90 mmHg,
temperature < 35°C or ≥ 40°C.

PSI risk classes II–V. Patients with any of the above characteristics are
classified according to their PSI score, calculated according to the
table below.

MANAGEMENT:-
Inv:

1.ABG’s
2.UEC
3.FBE
4.LFT
5.Urinanalysis
6.Sputum for micro and culture
7.Chest X-ray

Tx:-
low risk score 1-70
Outpatient:-
Amoxycilline + doxycycline

score 71-130
In patient:-
IV Benzylpenicillin+
IV Doxycycline

score >130
In patient:
Severe:-
IV Ceftriaxone + IV Erthryomycin

Question 84

Fibroadenoma Mx and
DDs for amc cases for breast lump

Answer 84

things we forget Hx and PEFE:
headache?
chest pain?SOB?
tummy pain?
back pain?

Any redness, dilated veins,
tethering?
Any nipple retraction, distortion or ulceration?
▪ Lungs
▪ Liver: hepatomegaly
▪ Spine: specific tenderness

Triple therapy:
PE + USS/Mammo (age 35) + FNAC
1.Conservative: Monitor 6m then yearly + Continue OCP
2.Lumpectomy
3.Cryocoagulation

Breast lump AMC Cases:
1. Cyclical mastalgia
2. Fibroadenoma
3. Breast abscess
4. Breast Mastitis
5. Fibrocystic disease- PE
6. Breast Cancer councelling- metastasis, ductal carcinoma
7. Gynecomastia

Question 85

Immune Thrombocytopenic Purpura

Answer 85

Cond:
Dx,
Cell types,
Thrombocytopenia, (cause)Idiopathic thrombocytopenic purpura
Course: Most recover in 4-6wk,
10% recover in 6M
1,Observe
2. Avoid IV/IM
3.If active bleeding: Steroids/ Immunoglobulins
4. Refer to specialist , no resolution in 6 Months, r/o other disorders
5.Recurring/ Unresponsive- Splenectomy

Question 86

Neonatal Hepatitis Mx:

a.Conjugated Hyperbilirubinemia
b.ABO incompatibility
c.Hereditary Spherocytosis
d.Galactosemia
e.Breastmilk Jaundice

Answer 86

Mx: Conjugated Hyperbilirubinemia:
Ix:
1.FBE, UEC, CRP/ESR, LFT,
2.TFT,
3.BSL
4.Direct (Conjugated)
5.Indirect biilirubin (Unconjugated),
6.blood group of mother and baby
7.Direct Coomb’s test (measures the level of antibodies of the mother present in the baby’s blood. The direct test looks for antibodies that are stuck to red blood cells. The indirect test looks for antibodies floating in the liquid part of your blood, called serum),
8.Peripheral blood film (Hereditary S.),
9.TORCH Serology (R/O Neonatal Sepsis)
10.Septic workup
10.Hepatitis Serology

• If you think it is Unconjugated Bilirubin, check for Hemolysis: (9)
  1.Reticulocytes,
  2.LDH,
  3.haptoglobin
  4.unconjugated bilirubin,
  5.peripheral blood film (spherocytes for HS)
  o Urine:
  6.urine MCS,
  7.bilirubin and urobilinogen
  8.urine for reducing substances (galactosemia)
  o Imaging:
  9.US Abdomen

▪ Diagnosis and Management
Most likely having Obstructive jaundice as presented with
pale stool, dark urine along with increase in conjugated bilirubin.
Conjugated Hyperbilirubinemia is where a “certain type of pigment” has gone up in the baby’s blood. There are multiple causes of it.

Draw: This is the liver, these are the ducts or tubes that drain bile from the liver.
Bile is the substance that is required to digest the fats.

Ddx with definition:
1.Neonatal hepatitis which is infection of the liver
2.Biliary atresia is a malformation of the tubes carrying the bile from the liver,
3.Choledochal cyst is an obstruction of the biliary tubes thereby leading of retention of the bile
4.Galactosemia is a genetic problem where you have a deposition of galactose in the liver.

Admit him
Pediatric registrar for further evaluation.
**Phototherapy does not work for Conjugated Hyperbilirubinemia

ABO INCOMPATIBILITY:
The RBC have a special protein on their surface called Antigens.
There are certain proteins in the blood called Antibodies which help fight against infections.
Your blood group is O positive.
In people with O blood group, they have no antigens on the surface of their RBCs, but they have anti-A and anti-B antibodies which are the proteins that fight against infection or foreign RBCs.
The baby has A positive blood. So he has the A antigen and anti-B antibodies.
Sometimes during the 3rd stage of labor, or during delivery, there is silent exchange of blood between the mother and the baby.
Since you’ve got anti-A antibodies which reacted to the baby’s A antigen, that lead to the breakdown of the RBCs in the baby’s blood, leading to formation of a pigment, making the baby jaundiced.
It is a serious condition because if it is left untreated, this pigment can damage the baby’s Brain, leading to long-term Neurological deficits, Hearing impairment, Learning disabilities, and Mental retardation, or what we call Kernicterus.
Admit > Phototherapy (placed under special type of lights which will help in excreting this pigment from the body through her urine and feces.)
SE: of this Tx: Retinal and Genital damage, Dehydration, Green-colored stools
So Cover eyes & genitals
Only under the lights when she is sleeping and not feeding. (Dehyd&eye)
Green-colored stools is expected, because the excessive pigment will be excreted in the feces.

We will continuously monitor her pigment levels or bilirubin levels. If the bilirubin level keeps going up despite the treatment, we will consider another treatment modality called Exchange transfusion, (where we will try to exchange the baby’s blood with a fresh blood.)

HEREDITARY SPHEROCYTOSIS:
Ix:
OSMOTIC FRAGILITY TEST - first line
FLOW CYTOMETRY - staining with 5-eosin Malleomide. Confirmatory test.
Abdominal Ultrasound - check for gallstones - high risk to have pigmented gallstones

Dx:
The surface protein called Beta-ankyrin is absent which maintains the normal biconcave or disc shape of RBCs. Since that Skeletal protein is absent because of a genetic condition, the RBCs become Spherical. The blood vessels in the spleen are very narrow. Normally the biconcave shaped RBCs can easily pass through these. However, the spherical RBCs cannot, and result to hemolysis or breaking down.

I will refer you to a Hematologist who will monitor his condition. He might start the child on FOLIC ACID 5mg once a day (The bone marrow is under stressed to produce more RBCs (fear of becoming pancytopenic). We will monitor his Hemoglobin levels regularly. He might be given a blood Transfusion if his hemoglobin levels fall below 70.
After 6 years of age, the hematologist might suggest Removal of the spleen, but you have to be aware of the possible complications of not having a spleen (post-splenectomy overwhelming sepsis) that’s why we are going to give him the Antibiotics he needs to take and the vaccinations needed to protect him from these bugs. I can arrange another consultation with you to discuss about this further.
Avoid contact Sports as they are at high risk for splenic rupture.
Review materials
***
Viral URTI makes the transition of biconcave to spherical faster.

GALACTOSEMIA:
Positive points in the PE/Investigations: cataracts, reducing substances in UDT, Total 178 mmol, conjugated 110 mmol, unconjugated 68 mmol
Dx:
Your milk has got a substance called Lactose, which is broken down to Glucose and Galactose by your baby’s body. He has a condition called Galactosemia, in which the enzyme required to breakdown Galactose is absent, leading to deposition of Galactose throughout the body, including Brain, Eyes causing cataract, Liver causing jaundice, Pancreas causing diabetes, ovaries or testes causing Gonadal failure. That is why I am going to refer him to the pediatric registrar who will manage him from now on. He will most likely need Lactose-free formula milk and he will managed by an Pediatric Ophthalmologist for his cataracts.

BREASTMILK JAUNDICE:
Most likely your baby is having breastmilk jaundice. There are some factors within the breastmilk that prevents conjugation of the bilirubin. There is nothing wrong with your breastmilk, and it is a benign condition, and doesn’t require treatment, and you can continue breastfeeding. Breastmilk jaundice can persist for as long as 3 months of age, but baby will remain active and gain weight. The diagnosis can be confirmed by suspending breastfeeding for 24 to 48 hours, which results in fall of bilirubin levels, after which the breastfeeding can be continued. During the time of temporary suspension, please express your breastmilk in order to maintain lactation. If the feeding has gone down, or the baby is overly sleepy, not gaining weight, jaundice becomes worse, wet nappies has gone down, please report back immediately.

Question 87

Mx.:
Ectropion
Warts
HPV
Endometriosis
DUB
Endometritis
Fibroids

Answer 87

ECTROPION:
1)Cryotherapy
2)Laser Ablation
3)Electrocautery

WARTS:
1)non-invasive…med & injection
2)Cryosurgery
3)Laser
4)Electrocautery
5)Excision
5)Minor Surgery

HPV: (same as Warts except Cone Bopsy)
Ix:LBC
Colposcopy (+-Acetic acid) +Biopsy
Cone Biopsy: Cone shaped segment
Mx:
1)Cryosurgery
2)Laser
3)Electrotherapy
4)Loop excision
5)Excision/Surgery

Endometriosis:
1)Medical: Contraceptive methods
2)Laser
3)Electrocautery
4)Laparoscopic Excision

DUB:
1)Medical: Mefenamic/ Contraceptive methods
2)Endometrial laser ablation
3)ElectroDiathermy (Ds: DUB & Diathermy)
4)Excision
5)Hysterectomy

Endometritis:
1)PCM
2)IV Antibx AUGMENTIN + Gentamicin + Metronidazole) and when you start responding then Oral Augmentin
3)IV Oxytocin
+/- IV/IM Ergometrine
4)If RPOC: EUA, Gental Blunt Curettage
5)If Episiotomy: Swab & Restitch

(look out: Electrocautery in Endometriosis, Ectropion, Warts, Electrotherapy in HPV, Electrodiathermy in DUB, Curretage in Endometritis)

Fibroids with urinary retention:
1)Myomectomy either by laparoscopy, hysteroscopy or open surgery,
(wherein only the fibroids are removed leaving the uterus.)
2)Uterine Artery Embolization.
▪ It is done by an interventional radiologist wherein a small catheter or tube will be passed to one of your leg arteries under US guidance.
It will be proceeded to the artery that supplies the fibroid. An inert material like Colloid or jelly will be injected
which will block the artery making the fibroid shrink.

Complications: (3)
Severe bleeding that might necessitate a Hysterectomy, Recurrence of the fibroids or
Scar rupture (if you go for a pregnancy)

Question 88

Recurrent OM:
Hx, Mx

Answer 88

Hx: HOPC, PMHx of infec Qs, RARE FNC+HL+Speech delay
Ix: Swab for C&S if discharge, Audiometry
1.PCM
2.Ear toilet
3.Longer coarse abs-amoxycillin

Long-term:
4.avoid Swimming
5.Tympanostomy tube: (A grommet is a small ventilation tube inserted into the Eardrum to allow air into the middle ear and prevent a build-up of fluid.)
6.Refer- peds and ENT- tonsillectomy and adenoidectomy maybe
7.R/v 2 days- 2 weeks
8.Glue ear

Question 89

Clavicle Fx:
Mx

Answer 89

Dx:
Inv & Tx.:
X Ray explanation: This is your collar bone. As you can see there is a it is broken or has Fracture. Fx in middle third of clavicle with minimal displacement.
Good thing is your vessels and nerves look intact.
Painkiller
Sling for 7-10 D
Physiotherapy
Early mobilization of wrist and fingers to prevent stiffness.
Course 2-4 W
Red Flags: SOB,
Arms/hands: color change, numbness,
severe pain
Refer to Fracture Clinic
Review in 24 Hr

Question 90

Detergent intake
Hx, PEx, Mx

Answer 90

▪ Stability
▪A] Explore more about detergent: (3)
1.which one?
2.Liquid or powder?
3.Did you bring it?(concentration, pH),

B] More about intake:(4)
4.amount,
5.time?
what was done?:
6.What did you do after you saw it? (any irrigation with water?),
7.Did you give him anything like water after that?

Symptoms he presented with: (10)
▪ Severity –
8.breathlessness,
9.noisy breathing,
10.increased breathing rate,
11.cough,

12.blue lips., Blue skin,
13.cried a lot? (pain),
14.Collapse?
15.nausea, vomiting,

16.drowsiness?
17.Drooling of saliva?

18▪ BINDS history
▪ Social history – who is taking care? Why was the baby unattended?

▪ PEFE –
General appearance, vitals, Growth chart
▪ Oral cavity (4)
– any Erosion, Lesions, Ulcers
▪ Drooling of saliva

▪ Signs of respiratory distress – (3)
nasal flaring, accessory muscle, chest
indrawing
▪ Respiratory, CVS, Abdomen

▪ Invx –(5)
FBE, UEC,LFT,
Urine RE,
pH testing of product (>11.5 likely to cause ulcerations in GI)
▪ ABG (for systemic toxicity),
CXR

▪ Management –(4)
▪ NEVER activated charcoal
▪ Asymptomatic – fluid dilution 10ml/kg of water (max 250 ml)
▪ Discharge: If Asymptomatic after 4 Hrs and can eat and drink –
▪ If Any Symptoms – contact the senior and admit – OGD

▪ Follow-up visit (Stricture complication)

Question 91

Seborrhoic Dermatitis
Dx,
Ddx
Mx

Answer 91

Dx:
-Cond:
inflammation of Oil secreting gland in the skin.
-Cause
is Unknown but can be related to Familial or environmental factors
-Sx:
itchy skin rash,
Typical Distribution around:
mouth (cheeks), behind ears and Groin.

-Commonality:
quite common
not infectious

-Course:
Resolve usually by 18 months of age.

Ddx: (5)
1-Atopic dermatitis .
2-contact dermatitis
3-allergic dermatitis
4-insect bite.
5-seborrheic dermatitis
6.(psoariasis)

Ulcer around mouth Ddx:
6▪ HFMD (fever, throat, ulcers in mouth, palm and soles of the foot and nappy areas)
7▪ Herpes stomatitis: most common
8▪ Herpangina
9▪ Agranulocytosis
10▪ Traumatic ulceration (burn)
11▪ Drug-induced

Mx: (3)
-steroid cream
-steroid shampoo
(its rarely get infected but if it becomes then topical
Mupirocin ointment can be prescribed)

(C&C Miconazole in Candidiasis in mouth, if nappy rash becomes infected: candidiasis: HIN)

-reading materials
-red flags

Question 92

PMR:
PEx, Ddx, Mx

Answer 92

PEFE:
Vitals+ PRICKLED +BMI
Resp, Abd, Breast/Prostate, (for CA)

Neck, trunk, Shoulder, Hip (for PMR)
Other Joints(hands, knees,sacroiliac for OA/RA):

Musculoskeletal exam: Look, Feel, Move (Active&Passive), +against Resistance

Neuro exam: Gait + ITPRCS
(Coordination:(4)
finger nose, heel shin, Romberg, dysdiadochokinesia.)

Ddx: As/w Temporal Arteritis
Metastatic Prostate CA, Colon CA, & other CA
(Also Ddx are:
POLYMYOSITIS is as/w Lung CA, Bladder CA, non-Hodgkins Lymphoma ),
breast CA,
R/O DM, Thyroid,
Fibromyalgia, Chronic Fatigue syndrome
other tiredness Dx incl Depression

Dx: In polymyalgia rheumatica, the immune system targets the Soft tissue and Lining of the joints, causing the pain and stiffness of proximal muscles.
Sx incl:
stiffness and pain in morning or after inactivity
Mild fever,
fatigue,
loss of appetite, unintended weight loss
Depression

CFx: proximal muscle wasting, may have minimal limitation in movement. PE normal compared to symptoms felt by pt.

Mx:
ESR/CRP, CK (Creatinine Kinase)
TFT, BSL, relevant tumor markers eg PSA
Prednisolone

Red Flags: (15%) Temporal Arteritis with
BOV with permanent vision loss,
diff chewing (jaw claudication)

Question 93

Ureteric Colic Mx and DDs

Answer 93

Inv:-
1.Ct without contrast (ureteric stone at vesico ureteral junction
2.FBC,UEC,LFT
3.Uric acid
4.Serum calcium
5.UDT
6.UMCS
7.X-ray

Mx:-
1.Strong painkiller- NSAIDs
*tamsulosin- expedited passing of stone
If small-passes spontaneously- discharge
2.Pass urine in a container and collect stone for analysis purpose.
3.Repeat Ct scan in 6 weeks

4.Big stone- >6mm refer to urologist
a.instruments
b.USS destruction
c.open surgery
Ureteroscopic laser Lithiotripsy- flexible tube inserted from urinary opening and stone will be destroyed with laser.

5.Prevention:
a.avoid added salt
b.avoid oxalate rich food (tea, coffee,chocolate)
c.avoid Uric acid containing food (red meat, red wine)
d.increase fluid intake
e.fibrous diet- well balanced

Ddx:
1.Pyelonephritis
2.Appendicitis
3.Cholecystitis
4.IBD
5.Trauma
6.Kidney stones
7.Hernia
8.Epididimo-orchitis

Question 94

ECT

Answer 94

POINTS NOT TO FORGET:
20 -50 Seconds: Duration of therapeutic jerks
TWICE WKLY for
6 to 8 weeks

4 to 6 weeks: Recovery time for Memory loss

FORMAT:
Consent + Concern
Indication + CI
Adv + Disadv: Adv>Disadv
ECT: Before, During, After
Qs: no of times, if not given
Rs

INDICATIONS for ECT:
1.Acute Schizophrenia
2.Acute Mania
3.Depression with severe suicidal tendencies
4.Postpartum psychosis
5.Neuroleptic Malignant syndrome.

CONTRAINDICATIONS for ECT: 2HIRO
1.HTN
2.HF
3.Intracranial HTN increased: possibly CT/ MRI
4.Retinal detachment: Fundoscopic or eye examination
5.Osteoporosis

MANAGEMENT:
Ix:
1.UEC blood tests
2.urine test
3.ECG
4.Fundoscopic or eye examination
5.possibly CT or MRI

Tx.
1.Muscle Relaxants,
2.ECT under Anesthesia: 2 electrodes on scalp

Side Effects of ECT: (5)
1.Headache
2.Nausea/Vomiting
3.Muscle pains
4.Disorientation and confusion: MIN-HRS
5.Memory loss: usually recovers in 4 to 6 weeks times but in some patients: Permanent

Disadvantages of not doing ECT:
Suicide risk
No eating/ drinking

Question 95

Gardasil vaccine counselling

Answer 95

Gardasil counselling:
1) Vaccine Pathophysio: inactivated virus & memory cells,
2)Strains,9 types incl. HPV6/11:warts,HPV16/18 out of 100strains

3)WHO: (6)
b4 27 yrs,
even if sexual activity started some protection
Boys,
MSM,
breast feeding,
use condom
4)WHEN:12-13 yrs old in immunization program, catch up vaccine
5)HOW:IM
Dosage:
9-25 YOUNG adults single dose
26 and above/immunocompromised 3 doses (2 months and 4 months apart)

6)INDICATION:(6)
protection against CA of: Vulva, vagina, cervix, penis, anus, throat
7)CI:(5)
after 27, pregnant, sev allergy to previous dose or any component of vaccine, yeast allergy
8)SE:(5)
fever, rash, Injection site pain, swelling, body ache BUT for 1-2D

9)PREVENTION:(2)
Safe sex regardless of vaccine
Cervical Screening: in lesbians/transgender too

Question 96

Pubertal Menorrhagia Mx

Answer 96

Cause: Imbalance of hormones
Admission to prevent: Shock
IV Premarin(1-4doses)(=High dose conjugated Estrogen)fol/by
Oral Progestogen( for next 14 D)

Tranexamic acid/mefenamic/COC for 2-3 cycles
Iron supplements+Iron rich diet

Question 97

Asherman Syn

Answer 97

Cond: Band of scar tissue that joins walls of uterus
Cause: Complication of Curretage
Curable

Ix:TFT, Prolactin,FSH, LH, E, Progesterone, USS

Tx: Hysteroscopy under anesthesia
Cut adhesions by using micro-scissors fol/by E for 3W for:
Healing
New vessel formation
Prevent scar formation.

Question 98

Diabetic Ketoacidosis

Answer 98

diabetic ketoacidosis. It usually occurs in people with type 1 DM.
This means that there is a high sugar level in your blood, but there is insufficient insulin hormone.
Insulin usually lets sugar get into the body’s cells so if there is insufficient insulin, the body cannot use glucose for
energy and starts to use fat instead. And the glucose level becomes high.

this usually happens when the body’s demand for insulin suddenly increase may be due to Stress or recent infection or illnesses.
so when the body uses Fat for energy, chemicals called Ketones are released into the blood causing DKA.
Here other dd like hypothyroidism

Question 99

PCOS

Answer 99

Ix: pregnancy test.Then LH :FSH ratio(> 2:1), testosterone, USG, TFT,BSL, Prolactin.

Question 100

Thyroid CA: Papillary

Answer 100

Dx:
in our neck there is butterfly shaped gland , we called thyroid gland that produces thyroid
hormones which is very important for the metabolism of each and every cell in our body .
Now the cancer is in the thyroid gland , ( explain with pic ) the type of cancer is Papillary
thyroid cancer which is Most Common type of cancer in thyroid . good thing is , it is a
slow growing tumor . and it spreads usually through the lymphatic channel , but i cannot
see any gland or lymph node enlargement in your neck , thats the good point , most likely
your cancer is in the early stage .

Tx:
MDT: ENT, endocrinologist, oncologist
CT
Thyroidectomy: partial or complete fol/by TSH testing + Radioiodine therapy to kill remaining cells.
Thyroid hormone lifelong

Complications:
1.injury to nerve that supply the voice box leading to HOV (Hoarseness of voice)
2.injury to Parathyroid gland that maintains the normal calcium level in body can lead to low calcium level
3.low thyroid hormone level

4.infection ,
5.injury to surrounding structure ,
6.bleeding ,
7.anesthesia side effect ,

Question 101

DCIS Mx

Answer 101

Breast is made up of lobules and milk ducts that travel to nipple and fat tissue
DCIS means it is still within ducts (ie localized)
tx options: Mastectomy or Lumpectomy

Adv&Disadv of mastectomy: low recurrence, easy fol/up, Cosmetic appearance but Reconstructive surgery possible

Adv & Disadv of Lumpectomy: cosmetic appearance, relapse high, 6 weeks Radio req. with Daily hosp visits

Hormone replacement (possibly Tamoxifen) only given to E/P receptor +: these hormones are rel to being woman: menses, reproduction
if no + then fewer chance of relapse

Screen relatives with Mammogram

Question 102

Melanoma Mx

Answer 102

CLARK scale: it determines the depth of the cancer. In your case it has grown upto the upper…
Breslow: it measures the thickness of the growth by a special scale.
found some break in the skin over the growth called ulcer which is not a sign of
good prognosis, (level 1: 95%)
Melanoma in situ: 5-10mm
Level 1-2: 1cm
level 3 & 5: Excision 2cm CA free margin
Spread through direct, LN, blood

Follow ups –
<1mm: 6monthly for 2 years
2 mm: 4monthly for 2 years and 6 monthly for 2 years
and yearly for 2 years
> 2mm: Regularly by both specialist and GP for 10 years

LSM Sun exposure

Question 103

Aortic Stenosis Mx

Answer 103

PEFE : 2M dyspnea, SOB with exercise, chest tightness, pain
Left Apical impulse displaced and forceful, ejection Systolic murmur in
the aortic area radiating to the neck/Carotid
Mx:
Refer to hosp to be seen by Cardiologist
Tx depends on grade of narrowing: Valve replacement/repair
Supportive: Diuretics if pulmonary edema
Ix:Basic + ECG+CXR+Echo
Avoid strenous exercise
Complication: Endocarditis, HF

Question 104

Prolonged QT Syndrome

Answer 104

This is the electrocardiogram of your heart which is the recording of electrical activity of heart
Draw
This is your heart and heart has electrical activity to pump the blood And this ecg has different parts which represents different components of this activity

In your case, the part called QT interval is markedly prolonged called Prolonged QT interval.
This condition is commonly associated with Abnormal heart rhythm resulting in impaired pumping of blood causing frequent collapse like in your case
Sometimes this condition runs in the family and sometimes it can be also due to Medication/ Dehydration/ salt and water Imbalance Give DDx
Unfortunately, this condition sometimes can cause serious consequences

Management
Ix: FBE, U& E, BSL and Echocardiogram
Admit you in the hospital
heart specialist

Beta blocker
if it fails Cardiac pacing as well
Also if all the investigations come normal and we cant find any cause, then we call it Congenital prolonged qt syndrome which usually runs in families At that time we might need to arrange Family screening by doing ECG

Question 105

Vasovagal syncope

Answer 105

Syncope: The temporary loss of consciousness

There are many reasons which can cause it but in your child case there are two possibilities:
One is called vasovagal syncope
In this condition in response to certain triggers such as Overexerting in Hot sunny weather can stimulate a nerve in the body that causes Pooling of blood in legs
decreased return of blood towards heart
n thus blood supply towards the brain can be temporarily compromised which can lead to
sudden faintness and collapse

very common cause of fainting
other Dx: hypoglycemia

Question 106

Pericarditis

Answer 106

POSITIVE POINTS IN HISTORY:
Chest pain since 2 hours
Aggravated by lying down and deep breathing
Relieved by leaning forward
Stabbing type of pain
Can radiate to back and in between shoulder blades
Flu like illness a week before

Pericarditis is inflammation of the outer layer of your heart called pericardium. Most likely its due to the
reaction of the viral infection you had a week before.
It can result in complications such as Pericardial effusion, and cardiac tamponade
my senior and the heart specialist who might do further investigation like FBE, ESR/CRP,
RFT,ECG, CXR (to R/O Pneumonia before Dx)
Troponin,
Echocardiogram.
bed rest, Pain relief, keep under Observation

Question 107

Infective Endocarditis

Answer 107

PEFE:
CVS : PSM that radiates to axilla ,
no raise JVP , ankle swelling
 HAND: splinter hemorrhage + ve , osler node and janeway lesion negative
 Abdominal Ex: splenomegaly 2 cm below left costal margin
 urine dipstick , BSL and ECG not available

Admit, Cardiologist will further do
investigations to confirm the diagnosis.
Ix: FBE, ESR/CRP, and ECG, and Echocardiogram to identify the lining and valvular damage.
3 sets of blood culture samples from 3 different sites for microscopy culture and sensitivity.

Once the blood samples are taken, you will be given IV Antibiotics
[Benzyl penicillin (1.2g q4h for strep), flucloxacillin (2g q4h for staph), gentamicin (46kg/day for enterococcal).
Change Antibx according to Culture
We will continue these antibiotics for 1- 2 weeks and then you can have outpatient IV medications for further 4- 6 weeks.
MDT: cardiologist, microbiologist/infectious disease specialist.
 How long should I stay in the hospital? 2 weeks, then you can go home but take IV antibiotics on an outpatient basis.

Question 108

Sleep apnea Dx & MX

Answer 108

Dx:
Obstructive sleep apnea syndrome is a condition where your breathing stops for a short duration due to obstruction to the flow of air down your airway when you are asleep.
 What happens is that when we sleep, the throat muscles relax and become floppy. In most people, this does not affect breathing.
But in your case, your throat muscles become so relaxed and floppy during sleep that they cause a narrowing or even a complete blockage of your airway which causes snoring and sometimes stop of breathing for few seconds.
That’s why your sleep at night is disturbed and you feel sleepy and tired in the morning.

Mx: 5
ENT referral for Nasal Polp removal(Hx mentions it)
Sleep study: polysomnography
Sleep hygeine,
Smoking and Alcohol Counselling
LSM incl Weight Loss
4R

Question 109

PE
DVT with warfarin counselling
Upper arm DVT

Answer 109

Draw:
These are your lungs. Your lungs are supplied by blood pipes .
In your case most likely there is a clot obstructing these blood pipes and as a result of that your lungs are not getting enough blood and oxygen and that’s why you are having SOB.

 Most likely it is due to your long travel history and not moving your legs during the flight==there is stasis of blood in the legs leading to clot formation that can travel up and
block the blood supply to your lungs.
 It is an emergency condition. I need to admit u to the hospital right now and call my senior.

 Once admitted you will be seen by the chest specialist. He might order few
investigations like 8
FBC, ESR/CRP,
D-Dimer,
ECG, CXR,
Coagulation profile, Thrombophilia screening, (C&C SLE,recurrent miscarriage)
ABG
CTPA to obtain imaging of your lung blood pipes.

 Mx: blood thinner medication called heparin and
warfarin for 3-6 months depending on the cause.

DVT:
DVT means there is clot within the deep veins of
your legs. It could be because of a number of causes. Most likely, because you were
immobile for a long period of time during the flight, there is pooling of blood in the veins
that leads to the formation of clots. Sometimes the use of the pill can be a risk factor but I am wondering if the family history may be relevant in this case.

 Complication:
DVT carries certain risks including swelling and pain that gets worse with time or
PE compromising its blood supply that can sometimes be life-threatening.

 Admit you to the hospital and I will call in the medical registrar.
Ix include FBE, coagulation profile including D-dimer, thrombophilia screening, tumor markers (if suspecting malignancy), LFTs
Later on, the specialist might decide to do CTPA to check whether the clot has reached the lungs.

What is important at this time is to start you on blood thinning medications known as heparin and warfarin which prevent further clots from forming.
Usually, we get injections of heparin once or twice a day and at the same time, we will start you on warfarin. It is a tablet
that you need to take 2 or 3x a day. The aim of the treatment is to prevent further clotting.

 We will check daily INR levels. Usually, a target is reached within 5-10 days and we will then
stop heparin and continue with warfarin. Depending upon the results of thrombophilia screening, the warfarin might be continued lifelong. If no cause is detected, you can stop taking the medication after 6 months after specialist consultation.

 Red flags:
Certain side effects to this medication. If you develop symptoms like excessive heavy periods, black stools, nose bleeds, and unexpected bleeding after minor trauma, please contact the hospital ASAP.

If you need to take other medications, please inform your doctor beforehand because there are certain drug interactions that might affect the metabolism of warfarin (antibiotics, antihistamines, NSAIDs, antacids, ASA, antifungals).

If you require any Dental procedures or dental surgeries, you need to inform the surgeon beforehand.
Stop the pill as it is CI in patients with clotting problems. You can use another form of contraception like
condoms.
*
Before you travel again, please come and see the doctor as there are certain precautions that you need to take like increasing fluid intake to maintain hydration,
avoid prolonged sitting and try to walk every hour or so. I can teach you some leg exercises that you can do while sitting.
Your doctor might decide to put you on heparin
injections 2 days before traveling.
Also you can wear elastic stockings during your travel.

I will give you some written material to read about these precautions.
*warfarin can produce defects in the baby.
*Can I be treated at home? Not really.

UPPER ARM DVT
HOPC: Pain questions
 Swelling question
 DIFFERENTIALS:
 Upper Limb DVT: associated redness?
 C5 -C6 Radiculopathy: neck pain? Numbness/ tingling sensation over the arms?
 Cellulitis: fever and warmth overlying skin?
 Trauma: Did you hurt yourself in that area?
 Insect bite
 Any recent excessive movement throughout the arm (sports or related to your
occupation)?
 Any recent surgeries or procedures within the upper arm or the shoulder? Any
catheterization within the veins?
COMPLICATION:
* Pulmonary Embolism: SOB, cough with blood, chest pain?
RISK FACTORS OF THROMBOEMBOLISM: COSTVMPF

Physical Exam:
* GA:
* VS: temp, tachycardia
* Focused upper limb:
* 1. Inspection: swelling/ redness/ discoloration/ insect bite marks
* 2. Palpation: (+)Tenderness, normal pulses, CRT normal
* 3. Movement: Normal
* Upper Limb Neuro: TPRS: Normal
* Neck Exam: Look, Feel, Move
* Calf tenderness
* Lung Exam

Acute effort thrombosis:
There is blockage of the veins draining the right arm because of formation of Clots resulting in Swelling, Discoloration and Pain in that arm.
not Uncommon.
mostly seen in young active people
who do a lot of weightlifting, basketball, swimming, tennis, and skiing.
It also affects people who work with a lot of pulling, pushing, and lifting of the arms.
Might turn serious as the clot can extend and travel towards the heart.
Admit you to the hospital and do continuous monitoring of your PR, BP, and ECG.
Will seen by the specialist who will do further investigation
If confirmed, specialist will start you on certain blood thinning medications in the form
of injections and oral tablets.
I will refer you to a thoracic surgeon and hematologist. They will decide regarding the best method to Remove the clot. Sometimes, an Invasive procedure is
carried out OR
they Inject a clot dissolving agent.

Reading material regarding risk factors for clotting problems

Lifestyle modification including quitting smoking, maintaining ideal body weight,
healthy diet, regular exercise. You will need to stay here until you have reached a
stable INR and invasive procedure is done

Question 110

Pneumonia Mx

Answer 110

Management:
 Pneumonia severity: CURB65
 Confusion
 Urea > 7 mmol
 RR >= 30
 BP <= 90/60
 >65 years old

 0 = outpatient
 1 -2 = medical ward with IV antibiotics
 >=3 = ICU because he might need vasopressor support

Patient’s score is 0. Can be managed as outpatient.
Amoxicillin 1g TDS (still provide atypical cover with Doxycycline 100mg OD
x 14 days)
2.Repeat chest x ray after 1 week
No referral req.

Question 111

How to Reduce risk of pneumonia recurrence

Answer 111

Risk assessment: these put you in risk of further pneumonia:

Age
Smoking
COPD increases the risk as your lungs are not able to expel the air out properly and also you are taking
steroid
GERD increases the risk of Aspiration Pneumonia which is the Reflux fluids can enter into the airway and cause infection.
Sleep apnea causes obstruction of airway during sleep resulting in low o2 supply which can lead to further risk of pneumonia.
Also CPAP you have been using it can lead to infection if not used properly.

Advice
You should use your cpap properly and make sure u follow all the instructions
Try to keep ur GERD under control by:
taking the medication properly,
avoiding certain foods and drinks and
raising ur head higher during sleeping
Make sure u take deep breath regularly
Try to avoid densely populated places and places with poor air circulation.

Question 112

Atelectasis

Answer 112

pulmonary atelectasis is Collapse or Shrinkage of part/ whole of the lungs.
As a result of that there is Reduction of gas
Exchange in the lungs causing the SOB u r having.

 Don’t worry it’s a very Common complication after sx and most pt suffer from this complication in the first few Days after sx .
Certain risk factors which increases the chance of having it after sx are: 4
 If the pain is Not well controlled
 Previous hx of Lung disease
 Smoking
 Sx for longer period of time

 Ddx:
pneumonia or chest infection,
infection of Drainage sites/ Cannula sites called septic Thrombophlebitis,
wound infection, DVT,
Allergic reaction to drug or blood .

Inv like FBC, ESR/CRP. UA, CXR and blood culture

 Also we will involve the chest Physiotherapist who will teach you the Breathing exercises to help u expel the Sputum
 Also I would like to attach pulse Oximeter to monitor ur o2 saturation and if needed Oxygen by mask.
 For fever Paracetamol
 May able to go home in 1-2 days.

 Smoking cessation appointment
 Please move your legs and try to walk around, also try to take deep breathing.

Question 113

Persistent asthma

Answer 113

Now, based on your recent flare up of asthma, using the Salbutamol puffer 5 -6 times a week and having night time symptoms put you in a poor control of asthma.

To assess the severity, I need to do your Lung Function Test But based on the symptoms, most likely you are having persistent asthma Please don’t get scared, with proper management and regular follow up, asthma can be controlled very effectively.

Mx:
refer you to a Chest specialist for review of the
medication
– lung function test to assess the severity
–start you with a new puffer known as Symbicort which is a combination of Budesonide Puffer you are taking with a longer acting Relaxant of the airway
–Please discard the Budesonide puffer (white color) that you are taking currently You can take 1 puff twice daily now and if that does not help, we will increase the dose to 2
puff twice daily

Regarding Risk Factors:
Stop smoking
If you agree, appointment for smoking cessation
 Annual flu shot and Covid vaccination

Avoid contacting Pets who are more allergic and vacuum Carpets regularly
Try to maintain ideal BMI

I will also request my Nurse to show you how to use this new puffer appropriately
I will refer you to a Chest educator and a Physiotherapist who will show you breathing exercises to improve the lung function
Also, I will refer you to an Allergic specialist for specific allergen test to identify any specific triggers

Explain Asthma Action Plan

Question 114

Diverticulitis Mx

Answer 114

Mx of Diverticulitis:
Investigations:
FBE, ESR/CRP,
pus and blood in Stools,
Abdominal USD/CT scan (detect, fistula, abscess or perforation),
erect CXR,
erect and supine abdominal x-ray

Mx:

Admit
NPO
Painkiller
Antibiotics
Screening Colonoscopy after acute episode

Question 115

IgA nephropathy Dx, Mx

Answer 115

Because of your URTI, the body produced certain factors called antibodies toward those bugs and unfortunately those antibodies have dislodged in your kidney causing
inflammation and damage resulting in blood in the urine.

At this stage, Admission
 nephrologist and they will monitor you closely and do investigation (4)
: FBE, U&E,
urine MCS,
24-hour urine protein test,
ASO titer and complement levels.

 Explain treatment and prognosis:
 Most likely it is a self-limiting condition
Prognosis: good esp if normal BP and Renal function.
Course: Usually it clears up in about 1 Week.

but the specialist: may give you a trial of Immunosuppressive drug or/& blood pressure meds (if increase in BP)
Steroids: If protein in your urine is high

Red flags: please report if:
any problems with Urination,
persistent Hematuria,
WL or
HTN

Question 116

Kawasaki Dx

Answer 116

 Kawasaki disease is a systemic vasculitis that predominantly affects children < 5 years of age.
 Cause: unknown , it is believed to be a response to
some form of infection (though it is not transmitted from person to person).
 It is caused by inflammation of blood vessels throughout the body, including those of the heart (the
coronary vessels). This inflammation is known as Vasculitis.
 Not an uncommon condition

 Diagnostic criteria: MHEART
Fever for 5 days or more, plus 4 out of 5 of:
1. Polymorphous rash
2. Bilateral (non purulent) Conjunctival Injection
3.Mucous membrane changes
-reddened or dry cracked Lips,
strawberry Tongue,
diffuse redness of oral or pharyngeal Mucosa
4.Cervical lymphadenopathy (usually unilateral, single, non purulent and painful)
5. Peripheral changes
-Erythema of the palms or soles,
Edema of the hands or feet, and desquamation
6. and Exclusion of diseases with a similar presentation such as staphylococcal infection , streptococcal infection

 Course: most children with Kawasaki disease recover completely
 Admit >Ambulance and transfer as child is severely ill
 At the Hospital he will be seen by a pediatrician, and they will do some blood investigations
{ Invx: FBE (platelet count count-as thrombocytosis can occur), ESR/CRP, KFT, ASOT / Anti DNAase , LFT, Blood Culture
 There is no simple test for confirmation>Clinical Dx

 Treatment is a drug called Immunoglobulin given into a vein through a drip
 IV Gamma globulin are usually effective in stopping the fever and other
symptoms of Kawasaki disease, and seem to help prevent coronary artery problems as well.

 Most children will also be given Aspirin for a few Weeks too
 One main complication is affecting blood vessels supplying the heart:
Echocardiogram (scanning of heart which is a painless procedure) and it should be Repeated after 6-8 Weeks
 Hospital stay: for a few days until the illness begins to settle.
 Follow-up: Long-term by your GP and a Pediatrician.

Question 117

Recurrent /Non-specific Abdominal pain

Answer 117

Common in this age
Psy stress may be present
Labs normal

Ix: Basic + Urine & Stool Analysis
Tx: PCM, warm packs
Diary for triggers
Family meeting with Insight therapy if req.

Red flags:3
Pain lasts Hrs
OR wakes her up
N/V

Question 118

Toddler’s Diarrhea Dx, Tx

Answer 118

Positive points in history:
diarrhea and vomiting, brought to GP, stopped after 3-4 days, then diarrhea came back but
different from the last time
4/5 times stools in a day, normal color, no blood, with Undigested food particles, not smelly,
not floating in the bowl, not hard to flush
Feeding is good, appetite is good
No tummy pain, no fever, gaining weight properly
Have not introduced new food to her
Loves fruit juices.

Chronic diarrhea= more than 3 times per day for >2 weeks
Due to high fibre diet + fruit juice intake: runny, watery with undigested food particles
Ix: suchas FBE, ESR/CRP,UEC,
Stool microscopy and culture and for Reducing sugars (Lactose intolerance) & Undigested food particles (Toddlers), Celiac serology

Tx:
Dietician
Reduce intake
Review after 24 hrs

[NOTE: Reducing SUGARS: lactose intolerance
Reducing SUBSTANCES: Galactossemia
Undigested food particles: Toddler’s diarrhea]

Question 119

SLE pt wants pregnancy.

Answer 119

Hx:
are u having any symptoms like joint pain? Skin rash? Any kidney problem?

How long have you been symptom-free?
Criteria for pregnancy:
Symptom-free for 6 months
(If epilepsy 2 years to 6 months)

 What medications were you put on?
 Are u still taking the medication? Any side effects from the medication?
 Do you go for regular appointments with your specialist? When was the last consult?
 Have you ever been hospitalized?

 When are you planning for your pregnancy?
 Period history: when was your LMP? Is it regular? Any problems with your periods?
 Have you ever had miscarriages or pregnancies in the past? (key point)

 Blood group? Rubella status?
 Do you smoke, drink alcohol or take recreational drugs?
 Any other medications you are taking? Any other medical illness esp clot formation?
 Fhx of SLE/ recurrent miscarriage?

SLE is an autoimmune disorder in which certain factors
called Antibodies develop against your own cells leading to inflammation of the body tissues especially the skin, the joints, and the kidneys.
It is unfortunately common in women of childbearing age (20-45 years)
 there is No known cure
With modern advances in medicine this illness can however be very well controlled with medications to avoid flare ups
This also means that majority of women with SLE can get pregnant and have fewer
complications relating to the disease and deliver healthy babies(reassurance)
Its important you are symptom free for at least 6 months prior to getting pregnancy

We will start you on Folic acid( 0 5 mg) the vitamin that’s good for you baby You can
take it regularly and continue at least 3 months into your pregnancy
You will be relieved to know that pregnancy per say doesn’t cause exacerbations of the disease.
However the disease may adversely affect pregnancy outcome depending on its severity.
That’s why it is important to be symptom free when you are planning a pregnancy, (like the way you are.)

Risks with SLE:
TO the mother
early pregnancy loss,
recurrent abortions,
(PET),
risk of have premature birth,
(IUGR), and
increased problems in baby after birth(perinatal morbidity and mortality)

To the baby
Of being low birth weight,
premature,
having a lupus like Syndrome after birth(due to maternal antibodies that it gets from the placenta (This settles in a few days),
Congenital heart block (rare but needs attention at birth)

The specialist will decide on the best medications for you in your pregnancy.
Steroids are usually safe and the specialist will endeavor to give the lowest dose required.
You need to follow up with me early (as soon as you miss your periods) We will confirm your pregnancy, do a Dating scan confirm viability and arrange a specialist referral

The specialist may start you on Aspirin or LMWH from 14 weeks that you continue thru pregnancy and well after delivery to prevent clotting problems which are known to occur in women with SLE

Extra visits to the doctors will be more than those that are routinely advised for other
pregnant women and you and your baby will be closely monitored(such as growth scans,
heart rate monitoring CTG) to facilitate early pick up of any complications
Timing of delivery and Mode of delivery:
Specialist
Tertiary Hospital with facility for a baby doctor and neonatal care
[Please be assured that you will be kept informed at every
stage and your wishes will be taken into consideration.
I will give you some reading material and slips for the blood tests]
I understand living with a chronic illness can be very stressful I will refer you to a
>social worker if you wish and you can discuss what
>support is available for you
Please go thru the
>pamphlet and feel free to ask me any questions when I >review you after your blood tests are here
SLE Australia is a support group which provides valuable information for you I will give you their contact.
Do you have any questions? (Always check understanding throughout)

Question 120

Lichen Sclerosis:
hx
pefe

Answer 120

Hx:
ITCHING Qs (SOCRATES same as rash Qs: site, severity, onset, duration, affect on life, bleeding):
Itchiness associated Qs: bleeding, discharge, pain, fever? (BDPF)
Itchiness RFx Qs: tight clothes, obesity, DM, CA? (TO DC)

5P incl: (perimenopause & Postcoital)
-do you feel your vagina is dry or thin?
-any symptoms like Hot flashes, excessive sweating or mood changes? (menopause symptoms)

Partner: -any Pain or Bleeding during intercourse?

PEFE:
1-General appearance
-BMI
-pallor, lymph node enlargements, generalized rash, Eczematic or Psoriatic patch?
2-Vital signs
3-CVS/Resp
4-Abdomen

PELVIC:
Inspection of the VULVA & VAGINA:
-visible discharge, any bleed?
-Any other skin lesions?

White, Shiny, Wrinkled plaques in the vulva and perivaginal areas in a Laced-like pattern (ask specifically if not given by examiner.)

Inspection of the ANAL AREA:
is there any lesions, excoriation marks, plaques?

SPECULUM exam:
-is the cervix healthy or not? Any discharge or bleed?
-Does the vagina appear thin or atrophic?

PER VAGINAL EXAM: normal
Office tests: UDT, BSL (rule out diabetes)

DDX:(-itis,-isis)
1-Atrophic vaginitis / menopause
2-Infections/ candidiasis/ UTI
3-Lichen sclerosis
4-Skin conditions (Dermatitis, Eczema, Psoriasis) / Skin allergies due to cosmetics or undergarments
5-Diabetes/ Steroids

AIDSS
Atrophic Vaginitis
Infec (4) Candidiasis, Lichen Sclerosis
DM
Steroids
Skin cond (PEAD): Psoriasis, Eczema, Allergic reaction, Dermatitis)

Explanation:4C
lichen sclerosis is a chronic inflammatory skin condition. It is not an infection nor is contagious.

Clinical feature
this usually presents with severe Itching and causes white, wrinkled plaques in your genital area.

Cause:
Autoimmune
Can happen at any age, not only in menopause.

Complication
It can result to Scar formation and it can join up with the surrounding genital skin leading to Adhesions.

Outcome
because this is an autoimmune condition, there is no permanent cure for lichen sclerosis. But we can keep the condition under control.

Occasionally or 4% of the lichen sclerosis can turn nasty or be pre-cancerous.
multiple punch biopsy needs to be done.

Mx:
Investigations:

FBE, UEC
TFT (autoimmune thyroiditis)
refer to specialist for multiple punch biopsy (critical error)

TX:
Local steroid creams which you need to apply twice daily for the first 1 month
Then OD for the 2nd month
Then depending upon your response the strength and number of applications can be reduced.
Lifelong Maintenance therapy of 1-2 applications per week.

-If not responding to steroids, we can use Retinoids or Ultraviolet therapy.

SURGERY:
1.scar formation
2.adhesions
3.CA

PREVENTION:
maintain a good genital hygiene.
-keep your HPV and mammogram up to date
-lifelong surveillance because of the malignant change to begin with 6 monthly intervals, and then annually.

-RED FLAGS:
bleeding, abnormal discharge, or if the itching is becoming worse
REVIEW:
1 month time