Misc 2 Flashcards
A 35-year-old woman comes to see you in clinic with a 12 month history of heavy periods with clots and flooding. She does not experience any pelvic pain.
On examination she has a palpable bulky uterus.
You book her in for a transvaginal ultrasound scan and decide to start her on some treatment in the interim.
What is the most appropriate first line management?
Tranexamic acid
A 3-year-old boy from a Turkish family is referred to the local paediatric unit due to recurrent lethargy and pallor. His parents report no other symptoms such as fever, pain or poor feeding. He had been treated with a course of ciprofloxacin for otitis externa two weeks ago. Admission bloods show:
Hb 5.2 g/dl
WBC 10.7 *109/l
Platelets 346 *109/l
Reticulocytes 5%
What is the most likely underlying diagnosis?
Glucose-6-phoshate dehydrogenase deficiency
Ciprofloxacin is a common cause of haemolysis in patients with glucose-6-phoshate dehydrogenase deficiency
When is the peak incidence of delirium tremens following alcohol withdrawal?
72h
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Which one of the following tricyclic antidepressants is most dangerous in overdose?
Dosulepin Citalopram Clomipramine Nortriptyline Lofepramine
Dosulepin - avoid as dangerous in overdose
TCA SE
Common side-effects drowsiness dry mouth blurred vision constipation urinary retention
More sedative Amitriptyline Clomipramine Dosulepin Trazodone*
Less Sedative
Imipramine
Lofepramine
Nortriptyline
A 27 year old woman attends her GP with breast pain. She is 2 weeks postpartum and is exclusively breastfeeding. She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing. On examination, she appears well, her temperature is 38ºC. There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
Oral flucloxacillin & encourage to continue breastfeeding
A 56-year-old lady reports incontinence mainly when walking the dog. A bladder diary is inconclusive.
Urodynamic studies
Urodynamic studies are indicated when there is diagnostic uncertainty or plans for surgery.
Overflow?
A 34-year-old woman from Zimbabwe presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well.
Urinary dye studies
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
Progestogen-only pill (excluding desogestrel)
Thickens cervical mucus
desogestrel
Primary: Inhibits ovulation
Also: thickens cervical mucus
Infantile Spasms (west)
typically presents in the first 4 to 8 months of life and is more common in male infants
characteristic ‘salaam’ attacks: flexion of the head, trunk and arms followed by extension of the arms
this lasts only 1-2 seconds but may be repeated up to 50 times
progressive mental handicap
Investigation
the EEG shows hypsarrhythmia in two-thirds of infants
CT demonstrates diffuse or localised brain disease in 70% (e.g. tuberous sclerosis)
Management
poor prognosis
vigabatrin is now considered first-line therapy
ACTH is also used
A 9-year-old boy is diagnosed as having Attention Deficit Hyperactivity Disorder and started on methylphenidate. Which one of the following should be monitored during treatment?
Growth
Moro
Head extension causes abduction followed by adduction of the arms
Present from birth to around 3-4 months of age
Grasp
Flexion of fingers when object placed in palm
Present from birth to around 4-5 months of age
Rooting
Assists in breastfeeding
Present from birth to around 4 months of age
Stepping
Also known as walking reflex
Present from birth to around 2 months of age
A 5-year-old girl started to feel unwell two days ago, sore throat and headache. Overnight, temperature and vomited once. This morning rash all over her body, this has spread from her chest where it started. On examination, 38.5ºC, heart rate 130 beats per minute, she looks flushed and has an erythematous rash over her body which feels like sandpaper and blanches with pressure. There are palpable cervical lymph nodes when you examine her neck and her tongue has a white coating over it. What is the most likely diagnosis?
Scarlet fever
CF Mx
Key points
regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful
high calorie diet, including high fat intake*
vitamin supplementation
pancreatic enzyme supplements taken with meals
heart and lung transplant
You are considering prescribing a selective serotonin reuptake inhibitor for a patient with depression. Which class of drug is most likely to interact with a selective serotonin reuptake inhibitor?
Beta-blocker Thiazolidinediones Tetracycline Statin Triptan
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans: avoid SSRIs
A 32-year-old man with a longstanding moderate depression comes to see his GP after recently being started on a new medication by his psychiatrist. He complains that his appetite has increased hugely and as a result he has put on a significant amount of weight. He is also constantly tired and is struggling to concentrate at work.
Which of the following medications has most likely been started?
Sertraline Mirtazapine Lithium Carbamazepine Selegiline
Mirtazapine
Some of the most potent side effects of mirtazapine are a large increase in appetite (and subsequent weight gain) and drowsiness. These side effects are so pronounced that mirtazapine has been known to be used as an appetite stimulant and sleep aid off-formulary.
Selegiline is a monoamine oxidase inhibitor which are an older class of antidepressant which have been largely phased out due to their side effects which leaves mirtazapine as the most likely answer.
Mastitis Mx
First-line conservative management includes analgesia and encouraging effective milk removal (continue breastfeeding or expressing from affected side) in order to prevent further milk stasis. It is also important to ensure that there is correct positioning and attachment when feeding.
If symptoms do not improve after 12-24 hours of conservative management then antibiotics should be prescribed. First-line choice is oral flucloxacillin (500mg four times a day for 14 days) or erythromycin if penicillin allergic. Second-line choice is co-amoxiclav.
Anaphylaxis Adrenaline
< 6 months 150 micrograms (0.15ml 1 in 1,000)
6m - 6y 150
6-12y 300
12+ 500mg
Anaphylaxis Hydrocortisone
0-6m 25mg
6m-6y 50mg
6-12 100mg
12+ 200mg
Anaphylaxis Chlorphenamine
0-6m 20ug/kg
6m-6y 2.5mg
6-12y 5mg
12+ 10mg
Gestational DM diagnostic criteria (OGTT 24-28w)
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/l
2-hour glucose is >= 7.8 mmol/l
COCP Missed pill 1 day
If 1 pill is missed (at any time in the cycle)
take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
no additional contraceptive protection needed
COCP missed pill 2 days
If 2 or more pills missed
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
serious blistering form of impetigo
Bullous impetigo (S aureus mainly)
Blistering of skin + mucous membranes
Blisters occur spontaneously/following minor trauma
Epidermolysis bullosa
They need to be dydx from scalds
Erythematous, includes skin flexures + may be satellite lesions
Candida infection
Rash sparing flexures
affects convex surfaces of buttocks, perineal region, lower abdomen + top of thighs
Rash erythematous + may have scalded appearance
may even ulcerate
Irritant dermatitis
Mild cases respond to use of protective emollient
More severe cases may need topical corticosteroids
Leaving child without napkin accelerates resolution - rarely practical
lesions small, skin coloured, pearly papules w central umbilication
Molluscum contagiosum
tend to disappear within a year
Scaling, patchy alopecia with broken hairs
Examination under filtered UV (wood’s) light - may show bright greenish yellow fluorescence of infected hairs - w some fungal species
Tinea capitis (scalp ringworm)
burrows, papules + vesicles - skin between fingers + toes, axillae, flexor aspect of wrists, belt line + around the nipples, penis + buttocks
Scabies - caused by infestation w mite - Sarcoptes scabiei
Confirmation can be made by microscopic examination of skin scrapings from lesions - ID mite, eggs, mite faeces
Spread close bodily contact - treat child + whole family (even w/o evidence)
Permethrin cream (5%)
Benzyl benzoate emulsions (25%)
Malathion lotion (0.5% aqueous)
itching of scalp + nape or ID live lice on scalp Or nits (empty egg cases) on hairs
Pediculosis capitis (head lice)
single round oval scaly macule - herald patch - 2-5cm in diameter on trunk, upper arm, neck or thigh
After few days - numerous smaller dull pink macules develop
On trunk, upper arms, thighs
Rash tends to follow line of ribs posteriorly - fir tree pattern
Pityriasis Rosea
No Tx rash resolves 4-6 weekes
Lesions typically ringed (annular) w raised flesh coloured non-scaling edge (unlike ring worm) - may be anywhere - usually over bony prominences (esp hands + feet)
Granuloma annulare
look a bit like ringworm tbh
bruising and oedema of presenting part
Extending beyond margins of skull bones - resolves in few days
Caput succedaneum
resolves few days
haematoma from bleeding below periosteum
Confined within margins of skull structures
Usually involves parietal born
Cephalhaematoma
Centre of haematoma soft - resolves - several weeks
oedema + bruising from ventouse delivery
Chignon
common rash appearing 2-3 days of age
Consisting white pinpoint papules at centre of erythematous base
Fluid contains eosinophils
Lesions concentrated on trunk - come and go at different sites
Neonatal urticaria (erythema toxicum)
raised Pink macules on upper eyelids, mid-forehead + nape of neck common
Arise from distension of dermal capillaries
Those on eyelids gradually fade over 1st year
On neck become covered w hair
Capillary haemangioma (stork bites)
white pimples on nose + cheek
Retention of keratin + sebaceous material in pilaceous follicles
Milla
blue/black macular discolouration at base of spine + buttocks
Occasionally occur on legs + other parts of body
Usually but not always in afrocaribbean or asian infants
Fade slowly over first few years - no sign unless misdiagnosed as bruises
Mongolian blue spots
feet often remain in utero position
Unlike true talipes equinovarus - foot can be fully dorsiflexed to touch front of lower leg
Positional talipes
Present from birth usually grows w infant
Due to vascular malformation in capillaries in dermis
Port wine stain (naevus flammeus)
Rarely if along distribution of trigeminal nerve - may be assw vascular anomalies - Sturge-Weber syndrome
Or severe lesions on limbs + bone hypertrophy (Klippel-Treynaunay syndrome) - disfiguring lesions now improved w laser therapy
Benign red tumour
Often present at birth - appear first months life + may be multiple
More common in preterm infants | increases in size until 3-15m
Then gradually regresses
Strawberry naevus (cavernous haemangioma)
No treatment indicated unless lesions interferes w airway or vision
Ulceration or haemorrhage may occur
Thrombocytopenia may occur w large lesions
May need systemic steroids or IFN-alpha
Antipsychotic SE
Other side-effects
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
prolonged QT interval (particularly haloperidol)
in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Selective serotonin reuptake inhibitors SE
Adverse effects
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
SSRI Interactions
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans: avoid SSRIs
Akathisia Treatment
Benzodiazipines
Propanolol
Anticholinergics
Acute Dystonia
torticollois, oculogyric crisis
Tardive Dyskinesia
late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw
tardive diskinesia treatemtn
Venlabenzine
Tetrabenzing - dopamine depleting drug
Alzheimer’s Tx
Acetyl Cholinesterase Inhibitors (Donepezil, rivastigmine, galantamine)
Atypical Depression Tx
MAOI Phenylzine
Hypertensive crisis - cheese reaction - assw consumption of products containing tyramine (cheese, fava beans, red wine, liver)
Moclobemide - reversible MAOI - less likely HPT reactions
Other SE - anticholingergic, postural HPT, insomnia, ankle oedema + paraesthesia
Aids abstinence from opiates
Naltrexone - inhibits kappa and mu opioid receptors
in alcohol dependency - reduces high of alcohol
Acamprosate
enhance GABA by blocking glutamate
Reduce alcohol cravings
Dilsulfram MOA
acetaldehyde dehydrogenase inhibitor
