Misc. Flashcards
Down’s AFP
low
Down’s bHCG
high
Downs Nuchal Translucency
Thickened
Down’s Oestradiol
low
Down’s PAPPA
low
You review a 3-year-old girl who is being treated for idiopathic constipation with Movicol Paediatric Plain. Her mother has increased the dose but unfortunately there has been no response. She remains well and examination of the abdomen is normal. What is the most appropriate next step?
Add Senna (Stimulant laxtive)
DDH
Most stabilise 3-6w Pavlik harness (flexion-abduction orthosis) in children younger than 4-5 months
COCP and surgery
stop 4 weeks prior, restart 2 weeks after
Avoid whilst breasfeeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
sulphonylureas
cytotoxic drugs
amiodarone
A 2 day old baby born by a ventouse delivery- swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis?
Cephalohaematoma
A 9-day-old pre-term neonate stops tolerating his cow’s milk feeds given by the nurses in the special care baby unit. He vomited after the most recent feed and the nurse noticed bile in the vomit. Stools are normal consistency but the last stool contained fresh red blood. On examination he is well hydrated but his abdomen is grossly distended and an urgent abdominal x-ray is requested. X-ray shows distended loops of bowel with thickening of the bowel wall. What is the next best step in management?
Continue oral feeds, switching to breast milk Commence broad spectrum antibiotics Commence IV fluids Commence IV hydrocortisone Commence erythromycin
Commence broad spectrum antibiotics
This scenario describes a case of necrotising enterocolitis. Given the history and examination along with the age and prematurity of the infant, bacterial necrotising enterocolitis is the most likely diagnosis. Due to the seriousness of this, broad spectrum antibiotics must be commenced immediately. For this reason, answer 2 is the correct answer.
Although necrotising enterocolitis is seen more often in bottle fed infants, changing feeds at this stage is futile.
IV fluids are important to maintain hydration but not as urgently needed in this case as antibiotics.
Erythromycin is given antenatally to prevent necrotising enterocolitis but is not useful in treatment.
Impetigo Treatement
Topical Fusidic Acid
topical retapamulin is used second-line if fusidic acid has been ineffective or is not tolerated
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
A 31-year-old man and 30-year-old woman attend clinic after struggling to conceive for 12 months. Testing reveals mild endometriosis. What is the most appropriate management?
Continue trying to conceive naturally for another 12 months
Pre Eclampsia RF
Aged 40 years or older Nulliparity Pregnancy interval of more than 10 years Family history of pre-eclampsia Previous history of pre-eclampsia Body mass index of 30kg/m^2 or above Pre-existing vascular disease such as hypertension Pre-existing renal disease Multiple pregnancy
Placenta Praevia
5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix
Rescan at 34w
Neuroleptic Malignant Syndrome
more common in young male patients onset usually in first 10 days of treatment or after increasing dose pyrexia rigidity tachycardia
Mx
stop antipsychotic
IV fluids to prevent renal failure
dantrolene* may be useful in selected cases
bromocriptine, dopamine agonist, may also be used
A 72 year-old woman presents to the GP with an itchy, sore white plaque on her vulva. The patient has a past medical history of type 1 diabetes and no personal or family history of cancer. Which of the following is the most likely diagnosis?
Lichen sclerosus
Management
topical steroids and emollients
Contraindications to MMR
severe immunosuppression
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)
A 5-year-old girl is seen in the emergency department following her first seizure. lasted 5 minutes. falling to the floor suddenly and jerking her arms. now feels well in herself and does not remember the incident. She is otherwise well.
Neurological examination is normal. General examination reveals four de-pigmented patches of skin over her torso and areas of thickened leathery skin over her lumbar region.
What is the most likely diagnosis?
Tuberous sclerosis
Cutaneous features
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen
Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
lymphangioleiomyomatosis: multiple lung cysts
A 2-year-old child with a history of atopic eczema is brought to the local GP surgery. Her eczema is usually well controlled with emollients but her parents are concerned as the facial eczema has got significantly worse overnight. She now has painful clustered blisters on both cheeks, around her mouth on her neck. Her temperature is 37.9ºC. What is the most appropriate management?
Admit
Eczema herpeticum is a serious condition that requires IV antivirals
Bishop Score
0 1 2 3
Cervical position Posterior Intermediate Anterior -
Cervical consistency Firm Intermediate Soft -
Cervical effacement 0-30% 40-50% 60-70% 80%
Cervical dilation <1 cm 1-2 cm 3-4 cm >5 cm
Fetal station -3 -2 -1, 0 +1,+2
You are asked to see a 31-year-old woman on the labour ward who has developed a high fever (39.1ºC) 2 days post-partum. She complains of dysuria, and frequency, you suspect a urinary tract infection. She is choosing to breast feed, has severe anaphylactic reactions to penicillins. Which antibiotic would be appropriate?
Nitrofurantoin Trimethoprim Cefaclor (a cephalosporin) Ciprofloxacin Fosfomycin
Trimethoprim is present in milk but is not known to be harmful for short term use. This would be an appropriate choice.
Nitrofurantoin should be avoided when breastfeeding - small amounts in milk but can cause haemolysis in G6PD infants.
Cefaclor is safe to use when breastfeeding but should be avoided in this instance due to history of anaphylaxis with penicillins as cephalosporins have cross-sensitivity with beta-lactams (penicillin).
Ciprofloxacin should be avoided when breast feeding.
Fosfomycin may be used for uncomplicated lower urinary tract infections caused by multiple resistant bacteria when other antibacterials cannot be used, but this is an unlicensed use.
A 7-year-old boy is admitted to your ward after being struck by car.
patient also has type-1 Von Willebrand disease
Which of the following agents can be administered to reduce bleeding while awaiting theatre?
Desmopressin
is a synthetic analogue of vasopressin a.k.a antidiuretic hormone (ADH). It stimulates the release of Von Willebrand factor from Weibel-Palade bodies in endothelial cells.
SSRI Discontinuation symptoms
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
Which one of the following contraceptives do the Faculty of Sexual and Reproductive Healthcare (FSRH) recommend should be discontinued after the age of 50 years?
Injectable contraceptives (e.g. Depo-Provera)
A 69-year-old man is diagnosed as having Parkinson’s disease. Which one of the following psychiatric problems is most likely to occur in this patient?
Depression
Whilst dementia is common in patients with Parkinson’s disease depression is known to exist in around 40%
Diagnose Hirschsprung’s disease
Rectal Biopsy
A 6-year-old boy weighing 28kg is admitted to the paediatric intensive care unit with severe meningococcal meningitis. Due to his level of consciousness he is intubated and receives ventilation via an endotrachael tube. As he is nil by mouth, the consultant asks you to prescribe his maintenance fluids for the following 24 hours. How much maintenance fluid should he be given over the next 24 hours?
1000 + 500 + 160 = 1660ml
At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP). Which procedure carries the greatest risk of haemorrhage in the newborn?
Prolonged ventouse delivery
A 14-year-old male being investigated for iron-deficiency anaemia is found to have numerous polyps in his jejunum. On examination he is also noted to have pigmented lesions on his palms and soles. What is the likely diagnosis?
Peutz-Jeghers syndrome
Genetics
autosomal dominant
responsible gene encodes serine threonine kinase LKB1 or STK11
Features
hamartomatous polyps in GI tract (mainly small bowel)
pigmented lesions on lips, oral mucosa, face, palms and soles
intestinal obstruction e.g. intussusception
gastrointestinal bleeding
Management
conservative unless complications develop
A hepatitis B serology positive woman gives birth to a healthy baby girl. She is surface antigen positive. What treatment should be given to the baby?
Hep B vaccine
0.5 millilitres of HBIG within 12 hours of birth with a
further hepatitis vaccine at 1-2 months and a further vaccine at 6 months
A 24-year-old female has an abdominal ultrasound performed as she has had repeat urinary tract infections in the past 12 months. It is reported as follows:
4cm simple ovarian cyst noted on left ovary
Repeat ultrasound in 12 weeks
Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.
Postmenopausal women
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment
A 64-year-old woman presents as she is feeling down and sleeping poorly. she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?
Start sertraline + lansoprazole
SSRI + NSAID = GI bleeding risk - give a PPI
Barlow and Ortolani tests
Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head
Which condition may be significantly worsened if haloperidol is prescribed for sedation?
All antipsychotics may worsen the symptoms of Parkinson’s disease and should be avoided if possible.
A small dose of oral lorazepam may be an alternative in such a situation.
A 31-year-old female with a history of epilepsy consults you following an uneventful pregnancy. Which one of the following drugs would it be safe to continue during breast feeding?
Phenytoin Carbamazepine Lamotrigine Sodium valproate All of the above
All
A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus.
What is the most appropriate treatment?
Examination under anaesthesia
A 3-year-old girl presented to the general practitioners 1 week ago for recurrent epistaxis and bruising on her flanks. Clotting has also been assessed and revealed a prolonged prothrombin time.
Results (with normal ranges for a 3-year-old)
Hb 80g/l (115-135)
Platelets 100 * 109/l (150-450)
WBC 10.0 * 109/l (5.0-17.0)
Neutrophils 1.0 * 109/l (1.5-8.5)
What is the most likely diagnosis?
With the symptoms of epistaxis and bruising leukaemia is the most likely choice out of the options given. This is compounded by the anaemia associated with low platelets. Disseminated intravascular coagulation is also hinted at by the low platelets and prolonged prothrombin time. This would also fit with acute lymphoblastic leukaemia. Acute myeloid leukaemia is unlikely due to the age group. White blood cells are normal which would point away from a long standing infection. Although aplastic anaemia and myelodysplasia would give lowered erythrocytes and platelets, they would not produce the symptoms of epistaxis and bruising.
anaemia: lethargy and pallor
neutropaenia: frequent or severe infections
thrombocytopenia: easy bruising, petechiae
Turner’s Likely Heart Murmur
Systolic, loudest over the aortic valve
Turner’s syndrome are prone to have bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation
You review the blood results taken from a pregnant woman at her booking visit. She is now 11 weeks pregnant, currently well and has no past medical history of note.
Rubella IgG NOT detected
What is the most appropriate course of action?
Advise her of the risks and the need to keep away from anyone who has rubella
women normally have their immunity checked before becoming pregnant
rubella immunity is routinely checked at the booking visit. If the no immunity is demonstrated pregnant women need to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
Next question
An 18-month-old boy is brought to the GP by his mother as she is concerned about his breathing. Three days ago he started with fever, cough and rhinorrhoea. For the past 24 hours his mother reports that he has been ‘wheezy’. On examination his temperature is 37.9ºC, heart rate 126/min, respiratory rate 42/min and a bilateral expiratory wheeze is noted. You prescribe a salbutamol inhaler along with a spacer. Two days later the mother represents noting the inhaler has made little difference to the wheeze. Clinical findings are similar, although his temperature today is 37.4ºC. What is the most appropriate next step in management?
Oral montelukast or inhaled corticosteroid
This child is likely to have a viral-induced wheeze, also known as episodic viral wheeze. First-line treatment is short-acting bronchodilator therapy. If this is not successful then either oral montelukast or inhaled corticosteroids should be tried.
Viral Induced Wheeze Mx
Episodic viral wheeze
treatment is symptomatic only
first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer
next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both
there is now thought to be little role for oral prednisolone in children who do not require hospital treatment
Multiple trigger wheeze
trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks
Squint (strabismus) is characterised by misalignment of the visual axes. Squints may be divided into
concomitant (common)
Due to imbalance in extraocular muscles
Convergent is more common than divergent
and paralytic (rare) Due to paralysis of extraocular muscles
Detection of a squint
Detection of a squint may be made by the corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils
Testing nature of a squint
The cover test is used to identify the nature of the squint ask the child to focus on a object cover one eye observe movement of uncovered eye cover other eye and repeat test
Mx of Squint
Management
eye patches may help prevent amblyopia
referral to secondary care is appropriate
Endometriosis Mx
The COCP is the first line option, and can be used back-to-back with no pill-free interval.
Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation.
The copper intra-uterine device can make menstrual cycles longer and more painful and would not be a suitable option.
If the above methods fail to improve a patient’s symptoms, then GnRH analogues may be used.
Partial Mole
69XXY 69XXX
What is the investigation of choice to look for renal scarring in a child with vesicoureteric reflux?
DMSA
RF for SIDS
Risk factors prematurity parental smoking hyperthermia (e.g. over-wrapping) putting the baby to sleep prone male sex multiple births bottle feeding social classes IV and V maternal drug use incidence increases in winter
Cerebral Palsy Mx
Management
multidisciplinary
treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery selective dorsal rhizotomy anticonvulsants, analgesia as required
fetal macrosomia. An infant weighing 4.4kg is born who has a noticeably large tongue which obstructs his airway. Shortly after intervention, he becomes hypoglycemic
Beckwith-Wiedemann syndrome
An 80 year-old woman presents to her GP with a 1.5cm ulcerated lesion on her left labium majus. Her history includes a two year history of vulval itching and soreness, which has failed to respond to topical steroid treatment. What is the most likely diagnosis?
Vulval carcinoma
Vulval carcinomas are commonly ulcerated and can present on the labium majora. Melanomas are usually pigmented. Vulval intraepithelial neoplasia tend to be white or plaque like and don’t tend to ulcerate. Herpes simplex tend to be smaller vesicles and chancre tends to be painless and is seen in the first phase of syphilis.
Inactivated preparations
vaccines
rabies influenza (intramuscular) - Intranasal is live attenuated
Pertussis Mx
an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
antibiotic therapy has not been shown to alter the course of the illness
A 29-year-old primiparous woman is in a prolonged labour following an induction at 41 weeks gestation. She is 6 cm dilated and the fetal head is 1 cm above the ischial spines. The midwife calls you to look at her CTG. The fetal heart rate is progressively dropping, it is now below 100 beats per minute, and it has not recovered for more than 3 minutes.
Category 1 Caesarean section
An antenatal ultrasound scan demonstrates a hyperechogenic bowel. Which conditions are this finding most associated with?
cystic fibrosis
Down’s syndrome
cytomegalovirus infection
A nuchal scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include:
Down’s syndrome
congenital heart defects
abdominal wall defects
Bronchiolitis Peak incidence
Peak incidence is 3-6 months of age
Management is largely supportive
humidified oxygen is given via a head box
Next question
A 20 year old woman who is 16 weeks pregnant presents with pain passing urine and an irritating rash. On examination she has a tender, red, vesicular rash on her vulva. A urine dipstick shows both blood and white cells. What is the best treatment?
Oral aciclovir
The primary purpose of treatment is to reduce the risk of transmission to the neonate at birth. The risk is much more considerable with primary genital herpes simplex within the final six weeks of pregnancy. Caesarian section should be the recommended mode of delivery for all women developing the first episode of genital HSV in the third trimester.
benzodiazepine withdrawal syndrome
insomnia irritability anxiety tremor loss of appetite tinnitus perspiration perceptual disturbances seizures
An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates a voiding detrusor pressure of 90 cm H20 (normal value < 70 cm H2O) and peak flow rate of 5 mL/second (normal value > 15 mL/second). What is the most likely diagnosis?
overflow incontinence
Normal bladder function should have a voiding detrusor pressure rise of < 70 cm H20 with a peak flow rate of > 15 ml/second A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction. Therefore the most likely answer is overflow incontinence. Voiding symptoms (e.g. straining, poor flow, and incomplete emptying of the bladder) are also suggestive of bladder outlet obstruction.
PPH Mx
Management
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Section 5(4)
Section 17a
Section 5(4) similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
Section 17a
Supervised Community Treatment (Community Treatment Order)
Pre-eclampsia and gestational hypertension would only occur after
20 weeks gestation. Pre-eclampsia with significant proteinuria, gestational hypertension without.
GBS
Intrapartum benzylpenicillin
A 4-year-old boy is brought to the clinic by his mother who has noticed a small lesion at the external angle of his eye. On examination there is a small cystic structure which has obviously been recently infected. On removal of the scab, there is hair visible within the lesion. What is the most likely diagnosis?
Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types. They occur most often in children.
Menorrhagia: management
Investigations
a full blood count should be performed in all women
further investigations are based upon the history and examination findings
Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral
Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens
A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries.
Choanal atresia
ECT Side Effects
Short-term side-effects headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
Long-term side-effects
some patients report impaired memory
Next question
4: Vaginal investigations should always be avoided in a pregnant woman with unexplained vaginal bleeding
good
A 3-year-old male cold becoming worse’.cough he has had for 4 days has become louder and more frequent and he hasn’t eaten 24 hours. On examination he is febrile (38.4ºC) and mildly agitated with overt coryzal symptoms. There is mild retraction of the skin around the sternal wall and a gentle, soft inspiratory high pitched noise heard between fits of coughing. What is the most appropriate management in this case?
Croup
Soft inspiratory high pitched noise heard is stridor
Oral dexamethasone
Features of growing pains
never present at the start of the day after the child has woken
no limp
no limitation of physical activity
systemically well
normal physical examination
motor milestones normal
symptoms are often intermittent and worse after a day of vigorous activity
A 34-year old pregnant female at 12 weeks gestation presents with a two week history of severe nausea and vomiting. On examination the pulse is 110 beats/min and blood pressure 110/80 mmHg. It is also noted that the patient is experiencing diplopia and ataxia. Urinalysis demonstrates an increased specific gravity and 3+ ketones. A diagnosis of hyperemesis gravidarum is made. The patient responds suitably to fluid resuscitation with 0.9% saline. What other treatment should this patient receive?
Nasogastric tube feeding Vitamin B12 Insulin Intravenous vitamins B and C (Pabrinex) Low molecular weight heparin
In this case the patient has presented with diplopia and ataxia suggestive of Wernicke’s encephalopathy. Therefore, supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.
PPH medical failed What is the most appropriate initial surgical intervention?
Intrauterine balloon tamponade
Missed ‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)
If less than 3 hours late
no action required, continue as normal
If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed - see below
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Missed Cerazette (desogestrel)
If less than 12 hours late
no action required, continue as normal
If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below
Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
You are asked to see a baby on the post-natal ward 10 hours post vaginal delivery. The midwife informs you that the mother was positive for group B streptococcus. On examination you note a yellow discolouration to the skin. What is the next most appropriate action to take?
Measure serum bilirubin within 2 hours Measure serum bilirubin within 6 hours Measure bilirubin via transcutaneous bilirubinometer Start empirical phototherapy Reassess after 24 hours of age
As this baby is less than 24 hours old they are high risk for developing severe hyperbilirubinaemia and must have their serum bilirubin urgently (within 2 hours). As this baby is less than 24 hours old the use of a transcutaneous bilirubinometer is inappropriate. Phototherapy is a treatment option for jaundice, but a serum bilirubin should be measured in case it is beyond the threshold for exchange transfusion.
