Notes from MCQs Flashcards
Area of the heart supplied by leads V1-2? V3-4? V5-6? V1-6? Leads II, III and aVF?
Anterior
Septal
Lateral
Anterolateral
Inferior
Artery supplying anterior area of the heart (leads V1-2)? Septal area (leads V3-4)? Lateral area (leads V5-6)? Anterolateral area (V1-6)? Inferior area (leads II,III and aVF)?
LCA: diagonal LAD branch
LCA: septal LAD branch
LCA: left circumflex artery
LCA: left main stem disease
RCA: posterior descending branch
Signs of LVF? RVF? AF usually sign of what valvular dysfunction?
Pulmonary oedema(bibasal crepitations, pleural effusions on CXR, upper lobe blood diversion, Kerley B lines
Raised JVP, bilateral pedal oedema
Mitral stenosis- enlarged atrium disrupts the normal electrical pathways
Murmur loudest on inspiration points to what? Signs associated with aortic regurgitation? Narrow pulse pressure signifies what?
Right-sided valve lesion
Corrigan’s (visibly exaggerated pulsating carotids,) de Mussets, Traubes, Quinkes, Duroziez
Aortic stenosis
Management for CHAD2 score of 0? 1? 2 or above?
Aspirin
Warfarin or aspirin
Warfarin unless CI
Signs of myocardial ischaemia on ECG? Infarction? What is an aborted MI?
Inverted T waves and ST depression
ST elevation, Q waves and raised troponin
A patient with STEMI who goes on to have negative troponin
Signs of a PE? Scoring system for predicting the risk of a PE? Mild, moderate and high scores? RFs?
Pleural rub, coarse crackles and AF
Massive= raised JVP, RR, HR and hypotension
Geneva: <=3, 4-10 and >11
>65 y/o, previous DVT/PE, surgery/ fracture<=4 weeks, malignancy, unilateral leg pain, unilateral oedema, haemoptysis, HR 75-94, HR>95
What is heard with Barlow syndrome(mitral valve prolapse)? Austin flint murmur? Graham Steell murmur?
Mid-systolic click followed by a late systolic murmur heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole
What is a pleural rub common in?
Pleurisy, PE and pneumonia
What can PSA levels be raised by in men? What is raised in testicular cancer? What are they raised by?
Prostate cancer, BPH, older age, UTIs and prostatitis
AFP and B-hCG- yolk sac elements/ seminomas
What is raised in colorectal cancers? What can CA-125 be raised by? What is raised in bladder cancer?
CEA
Ovarian cancer, endometriosis, liver disease, PID and fibroids
Fibrin
Gold standard Ix for diagnosing bladder cancer?
Cystoscopy
Serum creatinine and urine output criteria for stage 1 AKI? Stage 2? Stage 3?
Increased level >/=0.3 mg/dl or 150-200% increase from baseline + production <0.5ml/kg/hr for >6 hours
Increased creatinine>200-300% + production <0.5ml/kg/hour for >12 hours
Increased creatinine from baseline or >/=4mg/ dl(acute increase of >/=0.5mg/dl) + urine<0.3ml/kg/hour x 24 hours or anuria in 12 hours
Persistent ARF= complete loss of RF>4 weeks
ESKD>3 months
Topical Abx used to treat otitis externa? Plus what if really inflamed/ stenosed/ obscured by debris/ fever/ lymphadenopathy?
Ciprofloxacin or gentamicin
Steroids
Tx for otitis media?
Analgesia, amoxicillin after 2-3 days if no sx improvement/ perforation/ systemically unwell
Myringotomy and drainage if no improvement after 1-2 weeks
Tx for mastoiditis?
Broad-spec IV ABx, not getting better/ intracerebral spread–> mastoidectomy and grommets, COMPS= VI/ VII palsy, abscess
Type of nystagmus seen on Dix-Hallpike test for BBPV?
Rotary nystagmus
Large volumes of 0.9% saline lead to an increased risk of what? Hartmann’s should not be used in patients with what?
Hyperchloraemic metabolic acidosis
Hyperkalaemia- contains potassium
O2 is only indicated for MI if SATs are below what %? What drugs should be indicated following an MI?
94%
ACEi/ ARB, dual antiplatelet therapy- clopidogrel and aspirin, Beta blocker, statin- CCBs only if Beta blockers are CI
What things may show ST elevation on an ECG?
Prinzmetal angina, STEMI and pericarditis
What 2 things are used during an episode of bradycardia to speed the heart up?
Atropine and adrenaline
2 most common heart murmurs? 2 less common murmurs?
Aortic stenosis–> ejection-systolic murmur and mitral regurg–> pan-systolic murmur
Aortic regurg–> early diastolic murmur, mitral stenosis–> mid-diastolic murmur
Resus council’s algorithm for anaphylaxis?
1) ABCDE 2) Check for obvious potential diagnosis 3) Call for help 4) Adrenaline (500mcg of 1:1000 IM) 5) Establish airway/ high flow O2/ IV fluid challenge/ chlorphenamine(antihistamine takes 15-20 minutes to work)/ hydrocortisone
What is terbutaline sulfate? What is formoterol fumarate?
A selective Beta2-adrenergic agonist
Long-acting β2 agonist (LABA)
What is a common cause of HAP?
Pseudomonas aeruginosa
Who are most likely to suffer from a spontaneous PE? What also increases the risk?
Young males with a low BMI, Marfan’s syndrome
Where is the most appropriate site for a needle thoracostomy for tension pneumothorax?
Over the upper edge of the rib in the 5th IC space on the MC line on the same side as the pneumothorax
Which signs would support a diagnosis of tension pneumothorax?
Tracheal deviation away from the affected lung, hypotension and hypoxia
How does large SBO present compared to LBO?
Constipation before vomiting due to being more distal in the tract
SBO= shorter hx of constipation and vomiting before the constipation
What is Mirrizi’s syndrome? Sx?
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Jaundice, fever, and right upper quadrant pain
What is UC associated with?
PSC- >75% patients with PSC have UC
Most common antibiotics causing c.diff infections?
Clindamycin, cephalosporins, quinolones, co-amoxiclav and aminopenicillins
Which drugs are known to cause drug-induced hepatitis?
NSAIDs, paracetamol, statins, methotrexate, antibiotics
Mnemonic for APL syndrome? 3 main associated antibodies? Primary thromboprophylaxis? Secondary thromboprophylaxis?
CLOT: coagulopathy, livedo reticularis, obstetric emergencies, thrombocytopenia
Anticoagulant, anti-cardiolipin, anti beta2-GP1
How do complex partial seizures compare to simple partial seizures?
Complex= awareness affected and confused after, simple= don’t affect awareness and there are no post-ictal symptoms
What is complicated malaria characterised by?
Vascular occlusion which can affect different organs therefore causing specific sx e.g. cerebral malaria= micro-infarcts and sx= drowsiness, increased intracerebral pressure causing seizures and coma
What is imatinib? What is rituximab given in? What is dexamethasone used in treating?
A tyrosine kinase inhibitor given in CML alongside chemo
CLL
Multiple myeloma
Which condition elevates bilirubin levels?
TTP- deficiency in ADAMTS13 enzyme causes the vWF to form thromboses, the body breaks down these clots down to prevent ischaemic damage to organs–> haemolytic anaemia
When should systemic treatment with oral antibacterials be used? What about topical/ oral erythromycin or clindamycin? What about systemic antibacterial (e.g. oral tetracycline)? Oral retinoid?
Moderate- severe acne or when topical preparations are not tolerated/ ineffective
If non-antibiotic antimicrobials e.g. benzoyl peroxide/ azelaic acid aren’t effective
Inflammatory acne if topical tx is ineffective/ CI
For systemic tx of severe acne(TERATOGENIC)
Flow of psoriasis tx?
Emollient–> topical steroid (e.g. hydrocortisone) and a vitamin D analogue (e.g. calcitriol)–> derm referral for phototherapy or oral drugs (e.g. methotrexate, cyclosporin)–> biological immunotherapy- NOT NSAIDs
Most common cause of cellulitis (2/3 cases)?
S.pyogenes, 2nd= s.aureus
1st and 2nd line treatment for eczema?
Topical corticosteroids, 2nd= topical calcineurin inhibitor
What can raised RBCs? What can cause neutrophilia?
Smoking, drinking alcohol or conditions such as PV
Chemo comp, viral infection e.g. Hep B/C, HIV, meds e.g. antipsychotics, carbimazole, AI disorders
When is the 6-in-1 vaccine given? What is in the 6-in-1 vaccine? MMR vaccine?
8 weeks, 12 weeks and 16 weeks in the thigh(8w= DTaP/ IPV/ Hib/ Hep B/ Men B, Rotavirus, 12w= DTaP/ IPV/ Hib/ Hep B, PCV, Rotavirus, 16w= DTaP, IPV, Hib, Hep B, Men B)
1 and 3 y/o
When is the Men B booster given? When is the 4th dose of DTap/ IPV given? When is 4th dose of Hib and Men C also given? PCV booster?
1 y/o
3 y/o
1 y/o
1 y/o
When is the HPV vaccine given? Tetanus/ diphtheria/ polio, Men ACWY? When is the influenza vaccine given?
12-13 y/o, 14 y/o
Children of primary school age and those in year 7, also from 6m to those at high risk
What is congenital adrenal hyperplasia?
An autosomal recessive disorder where there is reduced production of cortisol and aldosterone, adrenal crisis–> metabolic acidosis/ hyperkalaemia and hyponatraemia
What is the first component of the extrinsic pathway of the coagulation cascade? How can the severity of haemophilia A be assessed?
By looking at % factor VIII functionality and severity of bleeding
Who is Non-Hodgkin lymphoma more common in? What about Hodgkin lymphoma?
Childhood, adolescence
Examples of B symptoms?
Unexplained fever, unexplained weight loss, drenching sweats (particularly at night)- can be seen in HIV too
1st line tx for acute manic/ mixed episode in bipolar affective disorder? For a depressive episode? Long-term maintenance? What can be added if this doesn’t work?
Atypical antipsychotic
Atypical antipsychotic + SSRI i.e. olanzapine and fluoxetine
Lithium
Valproate
What is midazolam and what could it be prescribed in? Once alcohol detoxification is established, what should be started? When should be started to prevent relapse?
Rapid-acting benzo- status epilepticus or as an adjunct in a confused and agitated psych patient
Acamprosate and disulfiram- 6-12 months
Tx for delirium tremens?
IV Pabrinex (Vitamin B1) and high dose Benzo
1st rank sx of schizophrenia?
3rd person auditory hallucinations and/ or thought echo, passivity phenomenon(believing thoughts/ actions are being controlled by external force,) thought alienation, encompassing withdrawal, broadcast or insertion and delusional perception
Results you’d expect in neuroleptic malignant syndrome?
Raised CK due to muscle rigidity, raised WCC, deranged LFTs, acute renal failure–> abnormal U&Es, metabolic acidosis–> low pH, low HCO3
Tx for mild PID?
Start ABx immediately before swab rsults
Prescribe doxycycline, metronidazole + IM ceftriaxone
Leave in recently inserted coil
No response in 48 hours, remove the coil and prescribe any other necessary emergency contraceptives
Risk of nitrofurantoin in the 3rd trimester? Sulfonamides? Tetracyclines in general? Trimethoprim in the 1st trimester?
Haemolytic anaemia in neonate with G6PD deficiency
Kernicterus
Permanent staining of the baby’s teeth, issues with skeletal development
Neural tube defects
1st line tx for stress incontinence? If this doesn’t work?
3 months of pelvic floor training
Duloxetine/ surgery
If after 48 hours you see Beta hCG doubling what is it? If this is seen, what is done in 1-2 weeks to confirm? Rising but not doubling? Falls by half or more?
Intrauterine pregnancy- USS scan
Ectopic- needs further monitoring
Miscarriage
Clinical sx of chorioamnionitis?
Fetal tachycardia, maternal tachycardia, maternal pyrexia, rising leucocyte count, rising CRP, irritable or increased tender uterus
What does the Wolffian duct develop into? Testes develop due to the influence of what gene on the Y chromosome?
Rete testis, the ejaculatory ducts, the epididymis, the ductus deferens and the seminal vesicles
SRY gene- doesn’t require the presence of androgen nor a functional androgen receptor–> testicular development
What are the genetics and phenotype in androgen sensitivity syndrome?
Male/ female
What sx do you get with secondary syphilis? How soon after infection?
Widespread rash, neurological sx and GN
6-8 weeks
To diagnose syphilis, non-specific enzymes are looked using what? React how for a +ve result? What tests look for IgG which remains after tx to confer immunity? Features of congenital syphilis?
Cardiolipin based tests(e.g. VDRL)
With cardiolipin to be positive–> negative after tx
Specific treponemal antibody tests
Generalised lymphadenopathy, hepatosplenomegaly, rash, skeletal malformations
Comps of chlamydia in pregnancy? Neonatal meningoencephalitis can be caused by what?
Chorioamnionitis, neonatal conjunctivitis, neonatal pneumonia, prelabour rupture of membranes
Group B strep
Common sx of NEAs?
Arms flexing and extending, pelvic thrusting, eyes are usually closed, prolonged often>30 minutes, sx wax and wane
Why is there a weak left-sided pulse in aortic dissection?
Due to involvement of the subclavian artery
Signs of PE on a CXR? ECG features?
Fleischner sign= dilated pulmonary vessel, Westermark sign= collapse of vasculature distal to PE, Hampton’s hump= wedge-shaped infarct
Sinus tachycardia and/ or ST depression
When is colchicine given in pericarditis?
Recurrent/ continued sx beyond 14 days
How can post- ACS meds be remembered?
Block An ACS: Beta blocker, ACE-i, aspirin, clopidogrel, statin
Presentation of a Wilm’s tumour?
Between the age of 5-10 y/o, abdominal mass and painless haematuria
What is used to reverse the sedative effects of benzos?
Flumazenil
What heart abnormality is lithium associated with? Sx and tx of lithium toxicity?
Ebstein’s anomaly- enlarged atrium, shrunken right ventricle + pansystolic murmur caused by defective tricuspid valve
Fine tremor, dry mouth, GI dis, increased thirst and urination, drowsy, thyroid dys
12 hours or more- coarse tremor, CNS dis, arrhythmias, visual disturbance
Serious tox= >2mmol/ litre
Ix= serum lithium, electrolyte levels, TFTs, U&Es, ECG
Elec balance, U&Es, seizure control, IV fluid therapy and urine alk, benzos- agitation and seizures, haemodialysis if poor renal function/ haemodialysis, cons gastric lavage/ whole-bowel irrigation
How does placental abruption present compared to placenta praevia, uterine rupture and vasa praevia?
Abdominal pain with mild vaginal bleeding- can get concealed abruption with maternal distress and haemorrhage much greater than vaginal loss
You would only test for FSH, LH and serum karyotype if there was what? Testicular biopsy?
Azoospermia (no sperm present)
Suspect arrested spermatogenesis= less common than abnormal semen
How does a missed miscarriage present? Cervix open or closed? USS findings?
Variable presentation from no sx–> light vaginal bleeding, pregnancy sx may decrease
Closed
Non- viable fetus
How does a inevitable miscarriage present? Cervix open or closed? USS findings?
Vaginal bleeding, uterine cramps, possible intrauterine fetus w/ HB
Open
Fetus with possible HB
How does a incomplete miscarriage present? Cervix open or closed? USS findings?
Vaginal bleeding with passage of large clots/ tissue, uterine cramps, products of conception often visualised in dilated cervical os
Open
Products of conception often in cervix
How does a threatened miscarriage present? Cervix open or closed? USS findings?
Variable amount of vaginal bleeding, pregnancy can proceed to viable birth
Closed
Viable pregnancy
How does a septic miscarriage present? Cervix open or closed? USS findings?
Fever, malaise, signs of sepsis, foul-smelling vaginal discharge, cervical motion + uterine tenderness, rarely after spontaneous abortion, usually with induced abortions can be life-threatening
Usually retained products of conception
1st line tx of Alzheimer’s and Lew body dementia?
Donepezil, rivastigmine
For most paediatric cases, what bolus is given in shock? In DKA + HF due to fluid comps e.g. cerebral oedema? Estimated weight? For non-shocked patients with DKA calculation for hourly rate? If they were in DKA and shocked, then you would not do what? Assume what fluid deficit in mild DKA? Moderate? Severe?
20ml/kg, 10ml/ kg 0.9% saline over 15 minutes/ 60 minutes
(Age+4) x2
((Deficit- initial bolus)/ 48 hours) + maintenance per hour
Minus the initial bolus
5%, 7%, 10%
Fluid choice? Holliday- Segar formula for maintenance fluids? Neonates?
0.9% NaCl with 20mmol KCl in 500ml (40mmol per litre) until blood glucose levels are less than 14 mmol/l
1st 10kg= 100ml/ kg/ day, next 10kg= 50ml/kg/day, >20kg= 20ml/kg/day
Birth to day 1: 50-60 ml/kg/day
Day 2: 70-80 mL/kg/day
Day 3: 80-100 mL/kg/day
Day 4: 100-120 mL/kg/day
Days 5-28: 120-150 mL/kg/day
High prolactin prevents the release of which hormone? This decreases the release of what hormones?
GnRH
FSH + LH
Bi temporal inferior quadrantanopia is caused by what? Classically associated with what? Most common presentation?
Lesion of the optic chiasm
Craniopharyngioma
Amenorrhoea
What is homonymous hemianopia with macular sparing seen in? Why does macular sparing occur?
Posterior circulation stroke affecting the contralateral occipital lobe
Collateral flow from the MCA
What is homonymous inferior quadrantanopia caused by?
A lesion in the parietal lobe affecting the upper division of the optic radiations- parietal stroke/ tumour(same quadrant in each eye)
What causes homonymous superior quadrantanopia?
Temporal lobe lesion affecting the lower division of the optic radiations (Meyer’s loop)- stroke/ tumour
What anti-anginal medication do patients commonly develop tolerance to?
Standard release isosorbide mononitrate
What are the two shockable rhythms? Tx how? What for non-shockable rhythms? What is given to those who are in VF/ pulseless VT after 3 shocks?
VF and pulseless VT- with unsynchronised defibrillation at 120-200 J immediately, single shock followed by 2 minutes of CPR
Adrenaline 1mg ASAP- once chest compressions have restarted after the 3rd shock during a VF/VT cardiac arrest
Amiodarone 300mg, further 150mg after 5 shocks administered
Following successful resus, oxygen should be titrated to achieve sats of what? Reversible causes of cardiac arrest (the Hs and Ts)?
94-98%
Hypoxia, hypovolaemia, hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia, hypothermia
Thrombosis, tension pneumothorax, tamponade- cardiac, toxins
What is trifascicular block also known as? It means there are signal problems with what? What about a bifascicular block? What are they characterised by?
Complete heart block- with the right bundle branch and both left fascicles making up the left bundle branch
The right bundle branch and one of the two left fascicles
RBBB with left axis deviation, features of bifascicular + a 1st-degree heart block- PR interval prolongation
Causes of RBBB?
Normal variant- more common with increasing age, RVH, chronically increased right ventricular pressure e.g. cor pulmonale, PE, MI, atrial septal defect, cardiomyopathy or myocarditis
Way of remembering LBBB and RBBB?
WiLLiaM MaRRoW–> RBBB= ‘M’ in V1 + ‘W’ in V6 and vice versa for LBBB
When is ivabradine as a third-line option for HF tx? 1st + 2nd line txs?
When EF<35%
ACE-i= ramipril, Beta-blocker= bisoprolol, aldosterone antagonist= spironolactone
ACE-i and Beta-blockers have no effect on mortality in HF with what? ACE-i and beta blockers cause what?
Preserved ejection fraction
Hyperkalaemia- K+ should be monitored
When is digoxin strongly indicated in HF?
If there is co-existent AF
What is S1 heart sound caused by? S2? S3? S4?
Closure of mitral and tricuspid valves, soft if long PR/ mitral regurg, loud in mitral stenosis
Closure of aortic and pulm valves, soft in aortic stenosis, splitting during inspiration is normal
Diastolic filling of the ventricle- normal if <30 y/o, may persist in women up to 50 y/o, in LVF e.g. dilated cardiomyopathy, constrictive pericarditis + mitral regurg
Aortic stenosis, HOCM, HTN, atrial contraction against a stiff ventricle- P wave on ECG
Tx for symptomatic bradycardia?
Atropine infusion 500mcg IV - up to max 3mg, transcutaneous pacing, isoprenaline/ adrenaline infusion titrated to response
Specialist help for transvenous pacing if no response
Sx of labyrinthitis?
Hearing loss, vertigo, may experience tinnitus
Peripheral causes of vertigo? Central causes? 3 components of the HINTS test? CIs for head-impulse test?
BPPV, vestibular neuronitis, Meniere’s disease
Stroke, MS, medication toxicity, trauma, posterior fossa tumours, migraine(more in elderly)
Head impulse test, evaluation of nystagmus, test of skew
Head & neck trauma, severe cervical spine osteoarthritis
Positive head impulse test means what? Unilateral nystagmus? Changes direction or is vertical? Bidirectional nystagmus?
Issue with vestibulocochlear nerve on ipsilateral side
Peripheral origin/ central pathologies
Stroke- movement beats in direction looking, then changes direction with gaze
How to perform skew test? Associated with what and specific for what?
Look at your nose, cover one of their eyes, then move hand to cover other eye- look for movement in uncovered eye, repeat on other eye
Vertical diplopia- central cause of vertigo
Genes ass w/ Parkinson’s? Alzheimer’s? MND? Drugs to help?
SNCA, Parkin
Apolipoprotein E4 variant
TARDBP, FUS
Cholinesterase inhibitors e.g. donepezil, galantamine
NMDA receptor partial antagonists e.g. memantine
CIs for thrombolysis?
Seizure at onset of stroke, sx suggestive of SAH, LP in previous week, previous IC haemorrhage, major surgery or serious trauma within 2 weeks
Possible positive antibodies in MG? Tests?
Anti-MuSK, anti-LRP4
Tensilon test, ice test, repetitive nerve stimulation, mediastinal imaging
1st, 2nd and 3rd generation cephalosporin examples?
Cefazolin and cephalexin
Cefuroxime and cefoxitin
Ceftriaxone and ceftazidime
Abnormal gene and translocation of Philadelphia chromosome?
t(9:22)
BCR/ ABL
Medical & surgical tx for Cushing’s?
Metyrapone, others= Ketonazole, Mifepristone and Pasireotide, steroid replacement post-operatively
Pituitary surgery or radiotherapy
Glasgow score of what indicates transfer to ITU/ HDU for intensive monitoring and aggressive fluid resus? Based on degree of what potential complications? PANCREAS mnemonic?
Necrosis of surrounding tissues & saponification, reduced hormone output & ARDS
PaO2<8kPa, age> 55 y/o, neutrophils WBC>15 x 109/L, calcium<2mmol/L, urea>16 mmol, AST/ALT>200iu/L or LDH>600 IU/L, albumin<32g/L, glucose>10mmol/L
Tx for acute pancreatitis? Chronic?
Fluid resus urine output>30ml/hour, catheterisation, analgesia, anti-emetics, IV ABx for necrotising pancreatitis, calcium if hypocalcaemia, insulin in hyperglycaemia
Ethanol abstinence & good diet, analgesia, insulin, enzyme replacement, coeliac plexus block/ pancreatectomy
Ix for acute vs chronic pancreatitis? Other causes raised amylase?
Bloods FBC, U&Es, LFTs, lipase> amylase(amylase x3 upper limit suggestive,) USS, MRCP, ERCP, CT at later for comps
AXR, CT- both calcification, faecal elastase and fasting glucose/ OGTT test
Duodenal ulcer, cholecystitis, mesenteric infarction
FATSHEEP drug cases of pancreatitis?
Furosemide, azathioprine/ asparaginase, thiazides/ tetracyclines, statins/ sulfonamides/ sodium valproate/ hydrochlorothiazide, estrogens, ethanol, protease inhibitors & NRTIs
Tx of grade 1, 2, 3 and 4 haemorrhoids?
(No prolapse)- conservatively +/- topical corticosteroids
(Prolapse on straining which spontaneously reduces)- rubber band ligation, sclerotherapy or infrared photocoagulation
(Prolapse and requires manual reduction)- rubber band ligation
(Prolapse and can’t be manually reduced)- not responding to less invasive= surgical haemorrhoidectomy, diet rich in fibre and fluids
4x tx for hyperkalaemia?
Insulin 15 units + dextrose 50% 50mls, 10% calcium gluconate, calcium resonium, salbutamol nebs
SEs of alpha-1 blockers? 5 alpha reductase inhibitors?
Hypotension, retrograde ejaculation
Diminished libido, ED
Tx for non-muscle and muscle invasive bladder cancer?
TURBT, chemo, BCG immunotherapy
(T2+)- cystectomy with urinary diversion(w/o co-morbidities + no mets) + urinary diversion after removal- ileal conduit, neo-bladder, mitrofanoff
Non-surgical= radiotherapy or chemo
GnRH analogues and androgen antagonists for prostate cancer? GnRH antagonists?
Goserelin, Leuprolide
Bicalutamide and enzalutamide
Degarelix
Classification system of open fractures?
Gustilo and Anderson
Lymph nodes enlarged in tonsillitis?
Jugulodigastric lymph nodes
Branches of facial nerve?
Zygomatic, temporal, buccal, marginal mandibular, cervical branch
Stages of wound healing?
Haemostasis, inflammation, proliferation, remodelling
Grades 1, 2, 3 and 4 of hypertensive retinopathy?
Vascular attenuation, 2= above and AV nipping, 3= above and retinal haemorrhages, hard exudates and cotton wool spots
4= above and optic nerve oedema
RFs for miscarriage? Ectopic pregnancy? HG?
Foetal= genetics, placental failure
Maternal= uterine abnormality, PCOS, poorly controlled diabetes/ thyroid disease
PID, genital infection, IUD/ IUS, assisted reproduction, previous ectopic, old age, smoking
More severe in molar pregnancies and multiple pregnancies, 1st pregnancy, overweight and obese, urinary infection
RFs for molar pregnancy? VTE?
Maternal age>20 or >35 y/o, previous gestational trophoblastic disease/ miscarriage, use of COCP
Pre-existing= thrombophilia, co-morbidities, age>35, BMI> 30, parity>3, smoking/ obstetric= multiple pregnancy, pre-eclampsia, C-section, prolonged labour, stillbirth
Transient= any surgical procedure of puerperium, dehydration
RFs for GD? Pre-eclampsia? Abruption? Praevia/ accreta/ increta? Vasa praevia?
Previous GD, macrosomic>4kg, BMI>30, previous stillbirth/ perinatal death
Moderate= nulliparity, maternal age>40, maternal BMI>35, family hx, multiple pregnancy
High= chronic HTN, pre-eclampsia/ eclampsia in previous pregnancy, diabetes, SLE/ APS
Previous abruption, pre-eclampsia/HTN, bleeding early on, IUGR, increased maternal age, smoking
APH, emergency C-section, emergency hysterectomy, maternal anaemia, preterm birth, stillbirth
Accreta= previous curettage procedures, previous C-section, multigravida, increased maternal age, low-lying placenta/ praevia
Low-lying placenta, IVF, pregnancy, multiple pregnancy
RFs for APH? Shoulder dystocia? Cord prolapse?
Praevia, abruption, vasa praevia, uterine rupture, pre-eclampsia, smoking, IUGR
Large foetus, previous dystocia, high maternal BMI/ oxytocin, prolonged 1st & 2nd stage of labour
Polyhydramnios, abnormal lie, breech, ARM
5 components of the Bishop score? Apgar score?
Cervical dilatation, position, effacement and consistency of cervix, station of foetal head
Appearance, pulse, grimace, activity, respiration
4 or more RFs in pregnancy warrant what VTE tx? 3 RFs? If DVT shortly before delivery, continue for how long? Avoid what in pregnancy?
Immediate LMWH until 6 weeks post-natal
LMWH from 28 weeks until 6 weeks postnatal
At least 3 months(same as provoked DVTs)
Where do dermoid cysts typically occur?
Midline of the neck, external angle of the eye and posterior to the pinna of the ear
SEs of lithium? Avoid what when taking lithium? ECG?
LITHIUM: lethargy, insipidus- nephrogenic, fine tremor, hypothyroidism- thyroid enlargement, insides- GI N&V/ diarrhoea, urine- increased, metallic taste
NSAIDs, breastfeeding
T wave flattening/ inversion, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism and resultant hypercalcaemia
Baseline Ix for antipsychotics? Clozapine monitoring? What can increase levels?
ECG, BP & pulse, BMI, FBC, U&Es, LFTs, HbA1C, lipids, baseline trop for clozapine
Weekly FBC–> fortnightly after 18w
Smoking
If major bleeding on warfarin- tx?
Stop
Give IV vit K 5mg
Prothrombin complex concentrate- not available–> FFP(takes time to defrost)
(On warfarin,) INR>8.0 and minor bleeding?
Stop
IV Vit K 1-3mg
Repeat dose if INR still too high after 24 hours
Restart warfarin when INR<5.0
(On warfarin,) INR>8.0 and no bleeding?
Stop
Oral vit K 1-5mg by mouth, repeat dose if too high after 24 hours
restart when INR<5.0
(On warfarin,) INR 5-8 and minor bleeding?
Stop warfarin
IV Vit K 1-3mg
Restart when INR<5.0
(On warfarin,) INR 5-8 and no bleeding?
Withhold 1 or 2 doses warfarin
Reduce subsequent maintenance dose
Management of diabetic nephropathy?
Dietary protein restriction, tight glycaemic control, BP control<130/80 mmHg, ACE-i or angiotensin-II receptor antagonist- start if urinary ACR of 3mg/ mmol or more (don’t start ACE-i and angiotensin-II receptor antagonist dual therapy,) control dyslipidaemia e.g. statins
When is insertion of a chest drain contraindicated? Complications?
INR>1.3, platelet count<75, pulmonary bullae, pleural adhesions
Failure of insertion, bleeding, infection, penetration of the lung, re-expansion pulmonary oedema
Senior review for meningococcal septicaemia?
Rapidly progressive rash, poor peripheral perfusion, RR<8 or >30/ min or pulse <40 or >140/ min
pH<7.3 or WBC<4x 10^9/L or lactate > 4mmol/ L, GCS<12 or a drop of 2 points
When should LP be delayed in meningococcal septicaemia?
Signs of severe sepsis or rapidly evolving rash
Severe resp/ cardiac compromise
Significant bleeding risk, signs of raised ICP, papilloedema, continuous or uncontrolled seizures, GCS</=12
Who is adenosine contraindicated in?
Asthmatics
How does TGA present? Presentation on CXR, ECG, echo and hyperoxia (nitrogen washout) test?
Low SpO2, loud single S2, murmur only if associated septal defect or patent ductus arteriosus
‘Egg on side appearance’
Normal
Anatomical abnormalities, septal defects and patency of ductus arteriosus
Ix cyanotic heart disease in neonates
Tx TGA?
Prostaglandin infusions to maintain ductal patency
Balloon atrial septostomy
Definitive= arterial switch 1st few weeks life
Reduced or increased reticulocytes in aplastic crises? Sequestration crises? Presentations?
Reduced
Increased
Sudden fall in Hb (infection with parvovirus)
Worsening of anaemia
How many risk factors warrants treatment with LMWH in pregnancy? Until when? What if 3 RFs?
4/ more until 6 weeks post-natal
From 28w–> 6w post-natal
Tx for epistaxis?
If not stopped after 10-15 minutes?
Sit with torso forward and mouth open, pinch cart area–> topical antiseptic, self-care advice and possible admission if co-morbidities
Cautery/ packing- if visible/ not visible
Admit if HD unstable
Failed emergency department–> sphenopalatine ligation
When is HG most common?
Between 8 and 12 weeks- may persist up to 20 weeks
Causes of LBBB?
MI, HTN, aortic stenosis, cardiomyopathy
Cause, sx and tx acute haemolytic reaction? Comps?
Mismatch blood group–> intravascular haemolysis= RBC destruction by IgM-type antibodies
Fever, abdo pain, hypotension
Stop transfusion, check patient ID/ name on blood product, send blood for direct Coombs test, repeat typing and cross-matching, fluid resus
DIC & renal failure
Cause, sx and tx non-haemolytic febrile reaction?
WBC HLA antibodies
Sensitisation by previous pregnancies or transfusions
Slow or stop transfusion, paracetamol, monitor
Cause, sx and tx transfusion associated acute lung injury(TRALI)?
ARDS within 6 hours transfusion
Hypoxia, pulm infiltrates on CXR, fever, hypotension
Stop transfusion
Oxygen, supportive care
Cause, sx and tx transfusion-associated circulatory overload (TACO)?
Excessive rate of transfusion, pre-existing HF
Pulm oedema, HTN
Slow or stop transfusion
Consider IV Loop diuretic and O2
Sx and tx minor allergic reaction–> blood transfusion?
Pruritus, urticaria
Temp stop transfusion, antihistamine, monitor
When is peritoneal lavage indicated? Absolute contraindication?
Blunt abdominal trauma with haemodynamic instability
Stab wound to abdomen penetrating fascia
Multiple trauma with shock of unclear aetiology
Obvious clinical indications for laparotomy
Where to place ECG limb leads? Chest leads?
Ride Your Green Bike- clockwise from right wrist (ulnar styloid process)
V1= 4th IC space at right sternal angle
V2= 4th IC left sternal angle
V3= between V2 and V4
V4= 5th IC space in midclavicular line
V5= same as V4 left anterior axillary line
V6= left mid-axillary line same as V4 and V5
ACPVU?
Alert
Confusion- new or worsening
Voice- responds to verbal stimulus
Pain- responds to pain stimulus
Unresponsive- to verbal or pain stimulus
ACVPU- new onset/ deteriorating confusion is what?
Score on NEWS scale who are CVPU(not fully awake)? Score below 8 GCS?
Red flag- use A-E approach
3- consider calculating GCS
Urgent assessment by anaesthetics
Tx of reactive arthritis?
NSAIDs, severe= oral or intraarticular corticosteroids
Persistent= conventional synthetic DMARDs
Mnemonic for lytic bone lesion?
FEGNOMASHIC- fibrous dysplasia, enchondroma, giant cell tumour, non-ossifying fibroma, osteoblastoma, mets/ myeloma, aneurysmal bone cyst, hyperparathyroidism, infection/ infarction, chondroblastoma
Meds that may worsen osteoporosis?
SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors e.g. anastrozole
Ix for osteoporosis?
Hx & exam, FBC, U&Es, LFTs, bone profile, CRP, TFTs
Ix for osteomalacia? Tx?
Bloods- vitamin D, calcium, phosphate, U&Es, bone biopsy= GOLD standard
Imaging e.g. X-rays for pseudofractures or other bone abnormalities
Replenishing vitamin D, calcium, phosphate, addressing causes of deficiency, regular monitoring
Most common cause of primary hyperaldosteronism? 1st line Ix?
Idiopathic adrenal hyperplasia, adrenal adenoma- Conn’s syndrome
Aldosterone/ renin ratio–> high aldosterone alongside low renin levels
High res CT abdomen and adrenal vein sampling
Sx of myxoedema coma? Tx?
Hypothermia and confusion
IV thyroid replacement, fluids, IV corticosteroids, electrolyte imbalance correction, sometimes rewarming
What is Kallman syndrome caused by? Hormone levels?
Failure of GnRH- secreting neurons to migrate to the hypothalamus
Sex hormones low, LH, FSH low/ normal
General findings in Cushing’s syndrome? Ix?
Hypokalaemic metabolic alkalosis w/ IGT, ectopic ACTH= very low K+
Overnight low-dose dex test, 24hr urinary free cortisol x2
Bedtime salivary cortisol- x2
When are localisation tests for Cushing’s? Other?
9am and midnight plasma ACTH and cortisol levels
ACTH suppressed= adrenal adenoma
CRH stimulation- cortisol rises if pituitary source, ectopic/ adrenal= no change
Petrosal sinus sampling- pituitary vs ectopic ACTH
Insulin stress test true vs pseudo-Cushing’s
Ix in SLE?
Autoantibodies: ANA, anti-dsDNA= highly specific, anti-Sm
FBC- anaemia of chronic disease and reduced platelets and WCCs
Reduced C3 & C4
Urinalysis and urine protein: creatinine ratio= proteinuria in lupus nephritis
Renal biopsy for lupus nephritis
Drugs causing drug-induced lupus? Antibodies?
Sulfadiazine, hydralazine, procainamide, isoniazid, methyldopa, quinidine, minocycline, chlorpromazine
ANA, anti-histone
Comps of Sjogren’s syndrome? Histology from salivary gland biopsy?
Pneumonia
Bronchiectasis
Non-Hodgkins lymphoma
Peripheral neuropathy
Vasculitis
Renal impairment
Focal lymphocytic infiltration
Meds that may worsen osteoporosis?
SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors
Causes osteomalacia?
Vit d deficiency, lack of sunlight, diet, CKD, drug induced- anticonvulsants, inherited- hypophosphataemic rickets, liver disease e.g. cirrhosis, coeliac disease
Sx of granulomatosis with polyangiitis? Tx?
Epistaxis, hearing loss, sinusitis, saddle-shaped nose due to nasal bridge collapse, cough/ wheeze/ haemoptysis, glomerulonephritis
CXR= cavitating lesions
Renal biopsy= epithelial crescents in Bowman’s capsule
Steroids, cyclophosphamide, plasma exchange
Sx of eosinophilic granulomatosis with polyangiitis? What might precipitate disease?
Severe asthma, sinusitis, allergic rhinitis
Raised eosinophilia on FBC
LTRAs
Main feature of microscopic polyangiitis?
Renal failure with glomerulonephritis, cough/ dyspnoea/ haemoptysis
What is Goodpasture’s syndrome?
Anti-GBM antibodies against type IV collagen- more common in men
Bimodal incidence
HLA DR2
Pulm haemorrhage, rapidly progressive GN- rapidly onset AKI–> proteinuria, haematuria
Ix and tx of Goodpasture’s?
Renal biopsy- linear IgG along basement membrane
Raised transfer factor secondary to pulm haemorrhages
Plasma exchange, steroids, cyclophosphamide
What can polyarteritis nodosa be secondary to? Sx?
Idiopathic or secondary to infections- particularly hepatitis B, more in middle-aged men
Renal impairment, HTN, tender erythematous skin nodules, MI, stroke, mesenteric adenitis, unilateral orchitis, livedo reticularis
Ix, tx and comps of polyarteritis nodosa?
·↑ESR and/or CRP
·HBsAg
·Biopsy: shows transmural fibrinoid necrosis
·If Hep B negative – corticosteroids + cyclophosphamide
·If Hep B positive – antiviral agent, plasma exchange and corticosteroids
●GI perforation & haemorrhages, Arthritis, Renal infarcts, Strokes, MI
Sx of Kawasaki’s disease?
High fever> 5 days, widespread red maculopapular rash, skin peeling palms and soles, bilateral conjunctivitis, strawberry tongue, cervical lymphadenopathy
High dose aspirin, IV IGs, ECHO screening for coronary artery aneurysms
Peak incidence of GCA? Features?
70s
Rapid onset<1 month, headache, jaw claudication, vision testing for AION- may–> amaurosis fugax, tender palpable temporal artery
raised ESR, CRP, temporal artery biopsy- may show skip lesions, Duplex USS= hypoechoic halo sign and stenosis of temporal artery
High dose pred before biopsy/ IV methylpred if evolving visual loss w/ PPI, aspirin, bisphosphonates, calcium, vitamin D
Urgent oph review
Bisphos, low-dose aspirin
Sx PMR?
Rapid onset<1m, aching morning stiffness in proximal limb muscles- shoulders, pelvic girdle, neck
Worse after rest
Raised ESR- before steroids= FBC, U&Es, LFTs, calcium, serum protein electrophoresis, TSH, CK, RF, urine dip
Prednisolone, 1w follow-up reducing regime
When does Takayasu’s arteritis first present? Ix? Tx?
Before age 40 in younger females and Asian people- fever, malaise, muscle aches, may be claudication sx, aortic regurg, renal artery stenosis
CT/ MRI angiography
Steroids
Gene related to Behcet’s disease? How often mouth ulcers?
HLA B51- more in men and eastern Mediterranean/ young adults
At least 3 times a year- painful sharply circumscribed with a red halo occurring on the oral mucosa and heal over 2-4 weeks, genital= similar, with anterior uveitis
Thrombophlebitis and DVT, arthritis, neurological involvement, erythema nodosum
Positive pathergy test–> erythema and induration (also Sweet’s syndrome or pyoderma gangrenosum)
Topical steroids, systemic steroids, colchicine, topical anaesthetics, immunosuppressants, biologics
Comps of Behcet’s?
Vision loss, ruptured pulm aneurysms, bowel perforation, neuro-Behcet’s disease
Most common and least severe of Ehlers- Danlos syndrome? What can result? What are classical prone to? Vascular prone to?
Hypermobile- autosomal dominant–> POTS
Also stretchy skin- hernias, prolapses, mitral regurg, aortic root dilatation, abnormal wound healing= autosomal dominant
GI perforation and spontaneous pneumothorax
Sx of kyphoscoliotic Ehlers- Danlos? Score to support Ix?
Initially hypotonia–> kyphoscoliosis as grow, joint hypermobility, joint dislocation more common, AUTOSOMAL RECESSIVE
Beighton score= one point for each side of body with max of 9
Palms flat on floor with straight legs (score 1)
Elbows hyperextend
Knees hyperextend
Thumb can bend to touch the forearm
Little finger hyperextends past 90 degrees
Ix for EDS? Tx?
Clinical for hypermobile and genetic for other types= helpful
Physio, OT, moderating activity, psychology
What is subclinical hyperthyroidism? Repeat TFTs after how often if suspected?
TSH is suppressed below the normal reference range- FT4 and FT3 are within the normal reference range
3 months
Comps of hyperthyroidism?
Graves’ orbitopathy, thyrotoxic crisis, large goitre–> compression sx, AF, HF
What does a thyroglossal cyst move with?
Swallowing and tongue protrusion
Epidemiology of Still’s disease? Sx?
Bimodal distribution 15-25 and 35-46 y/o
Arthralgia, elevated serum ferritin, salmon-pink MP rash, pyrexia in later afternoon/ early evening accomp by worsened sx and rash, lymphadenopathy
Criteria and tx for Still’s disease?
Yamaguchi disease
NSAIDs for at least 1 week–> steroids for sx not prognosis
Methotrexate, IL-1 or anti-TNF therapy
What is Prinzmetal angina caused by? Decubitus angina caused by what?
CA spasm
Lying flat
Diet and exercise changes for CVD?
Total fat= <30% calories- mono and polyunsaturated- saturated<7% calories
Reduced sugar, wholegrain options, 5/day F&V, 2/week fish, 4/week legumes, seeds and nuts
Aerobic activity 150 mins/week mod activity/ 75 mins vigorous, strength 2 days/ week
How often do people have a health check between 40-74 y/o? What is used to calc primary prev CVD meds for 25-84 year olds?
Every 5 years
Q-risk3 (lifetime risk)
Do not do a Q-risk score(10-years) in who? Also assess what?
People with CVD, high risk- T1DM/ eGFR<6, has familial hypercholesterolaemia, aged 85 or above
HbA1C and kidney function
What is Q-risk underestimated in?
Those tx for HIV, w/serious mental health issues, taking drugs cause dyslipidaemia- some APs, immunosuppressants and corticosteroids, AI conditions- SLE, taking antihypertensive/ lipid mod therapy/ recently given up smoking
Factors in Q-risk score?
Age, sex, ethnicity, postcode, smoking/ diabetes/ angina or MI 1st degree relative<60/ CKD stage 3,4 or 5/ AF/ on BP tx/ have migraines/ RA/ SLE/ severe mental illness/ on atypical APs/ regular steroids/ ix or tx for ED status
Cholesterol/ HDL ratio
Systolic BP, SD of at least 2 most recent sys BP readings, BMI
Advice for Q-risk<10%?
Advise on lifestyle factors- smoking, HTN, abnormal lipids/ weight loss if overweight or obese- assess about sleep apnoea/ alcohol
Review co-morbidities
Tx for Q-risk>10%? How do they function?
Before= assess for familial lipid disorder, exclude secondary causes- excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome
Discuss lifestyle mod- alcohol, BP, BMI, smoking, diabetes control/ optimise other RFs and co-morbidities
Offer statin e.g. atorvastatin 20mg, also CKD & T1DM for >10 years/ or are >40 y/o/ aged above 85 y/o
Inhibit HMG CoA reductase
Bloods before starting primary prev lipid therapy CVD?
When should lipids and LFTs be checked when starting statins? When should statins not be stopped with raised transaminases? When to repeat HbA1c?
Initial lipid profile(non-fasting)- total chol, HDL-C, non-HDL-C & triglycerides, TSH & renal function, LFTs, HbA1C, U&Es, CK
3m and 12m- aim for reduction in non-HDL of >40%, then review annually- consider low/ medium intensity statin vs high intensity
<3 times upper limit
at 3m
When to measure CK before starting statins?
If persistent generalised, unexplained muscle pain- if>5 times upper limit- repeat after 7 days, if remains>5- do NOT start statin, <5= start at lower dose
Action ezetimibe (w/ bempedoic acid)? Evolocumab and alirocumab? Max number statins before specialist advice?
Inhibits absorption of cholesterol/ ACL inhibitor- lowers LDL cholesterol
PCSK9 inhibitors-MABs lower cholesterol as SC injection every 2-4w
3
4 As for secondary prevention following CV event?
Antiplatelet meds, atorvastatin, atenolol/ alt Beta blocker, ACE-i titrated to max dose/ BACAS- Beta blocker, ACE-i, clop, aspirin, statin- 80mg
DAP therapy- aspirin 75mg daily continued & clop/ tic for 12m before stopping
High-risk emboli= warfarin 3-6m
Lipid profile consists of what? 3 situations when measured?
Total cholesterol, HDL- good, non-HDL including LDL- BAD, total cholesterol: HDL ratio, triglycerides
1) Recent CV event
2) Monitoring- high lipids/ CV event
3) Screening- 40-74 y/o every 5y, used as part of Q-risk 3/ has tendon xanthoma, xanthelasma or corneal arcus
When should lipid profile not be performed? Results in severe hyperlipidaemia?
Within 6w any acute illness/ injury
Total cholesterol >7.5mmol/L (hypercholesterolaemia) and/or
Non-HDL-C >5.9 mmol/L (hypercholesterolaemia) and/or
Triglycerides >4.5mmol/L (hypertriglyceridaemia)
Inheritance of familial hypercholesterolaemia? Criteria for making Ix? 3 important features?
AD- hetero or homozygous–> extremely high cholesterol above 7.5mmol/L in an adult/>9 in people aged over 30 y/o
Simon Broome criteria
Family hx of prem CVD, very high cholesterol, tendon xanthomata
Ix if familial hypercholesterolaemia is suspected? Tx?
2 x LDL measurements, assessed for signs, exclude secondary high cholesterol, SBC used to make Ix, specialist referral confirm Ix and initiate cascade testing
Lifestyle advice, high intensity lipid-mod therapy- reduce LDL>50% from baseline, consider aspirin and anti-HTN, follow-up
Homozygous/ in children= specialist tx
Target cholesterol levels?
Total cholesterol: should be 5mmol/L or less
HDL-C: should be >1 mmol/L in men and >1.2 mmol/L in women
Total cholesterol to HDL ratio: should be <6
Scoring and ix stable angina?
1= central, tight radiation to arms, jaws and neck
2= prec by exertion
3= relieved by rest
3/3= typical
2/3= atypical
1/3= non-anginal pain
ECG- ST depression, T-wave inversion, exercise ECG/ stress ECHO- monitor how long, ST dep= late-stage ischaemia, CT angio= GOLD, invasive= in cath lab
CT scan calcium scoring
SPECT/ myoview
Cardiac catheterisation, bloods- FBC, U&Es, TFTs, lipids, HbA1c, anaemia, CXR
Tx stable angina?
Modify RFs, pharm:
Aspirin, statins, GTN
BB/CCB- diltiazem or verapamil(avoid in HF w/ reduced EF,) switch, combine, 3rd= isosorbide mononitrate, ivabradine, nicorandil, ranolazine
PCI- stenting= brachial/ femoral artery, CABG= saphenous vein, internal thor/ mammary artery, radial artery
Secondary prevention- 4 As
Other things causing a raised troponin? Additional bloods & Ix?
CKD, sepsis, myocarditis, aortic dissection, PE
FBC, U&Es, LFTs, lipid profile and glucose, CXR, Echo- LV function
ECG
Trop= rise within 3-12h peak@24-48h and return to baseline by 5-14 days- above 30ng/L
CK-MB= rise within 3-12h onset pain
Myoglobin= rises within 1-4h onset pain
Pathological Q waves typically appear how many hours after onset sx? 5 types MI?
6> 25% QRS height and wider than ONE small square
1= spontaneous w/ ischaemic due to primary coronary event
2= secondary to ischaemia due to increased O2 demand/ decreased supply
3,4,5= sudden cardiac death related to PCI and CABG
Murmur in MI? ECG in STEMI & NSTEMI?
4th heart sound + pansystolic murmur
ST elevation at least two contiguous limb leads of >1mm or (1 small square)/ >2mm in 2 or more chest leads/ new LBBB
Subsequent Q waves
ST depression >0.5mm in >2 contiguous leads= ischaemia/ T wave inversion- other than V1 and III
Features of digoxin toxicity? Tx?
N&V, anorexia, diarrhoea
SVT and slow ventricular response, frequent PVCs- ventricular bigeminy and trigeminy, sinus bradycardia, slow AF, any AV block type, VT, downsloping ST depression- ‘reverse tick,’ slight PR interval prolongation, biphasic/ flattened and shortened QT interval
Stop digoxin, administer digifab
Troponin how long after MI pain? If not elevated? Also what within 3-12 hours and within 1-4h?
6 hours, another 3 hours- peak at 24 and 48 hours
CK-MB
Myoglobin
What are Q waves?
Any negative deflection that precedes an R wave
Tx for low risk GRACE score <3%? Tx for low and intermediate/ high >3%
Consider conservative without angiography
Offer aspirin + P2Y12 inhibitor- ticagrelor unless high bleeding risk–> clop or aspirin alone
Assess left ventricular function- consider assessing for unstable angina
Cardiac rehab and secondary prevention
Tx for intermediate/ higher-risk GRACE score >3%?
Offer immediate angiography if clinical condition unstable
Consider angiography with within 72 hours if no CI such as comorbidity or active bleeding
Prasugrel or ticagrelor with aspirin- pras only when PCI intended + systemic unfrac hep if having PCI
Reduced ejection fraction in heart failure? Mid-range? Preserved?
In systolic HF? Diastolic?
<40%, 40-49%, >50%
<40%
>50%
NY heart association classification?
I= no limitation on activity
II= comfortable at rest, but sx with ordinary activities
III= sx with any activity
IV= sx at rest
Tx for chronic heart failure? Other?
ABAL: ACE-i/ ARB, Beta-blocker- atenolol, aldosterone antagonist- not controlled with A and B/ REF, Loop diuretics e.g. furosemide or bumetanide
CCB and other- hydralazine with a nitrate
Digoxin
Ivabradine
SGLT2 inhibitor e.g. dapagliflozin
Sacubitril with valsartan
Procedural tx for HF?
ICD- previous vent tachy/ VF
CRT- severe with EF< 35% involves biventricular pacemakers with leads in RA, RV and LV
Severe= heart transplant
SODIUM tx for acute LVF?
Sit up
Oxygen<95%
Diuretics, GTN if systolic BP above 90mmHg
IV fluids should be stopped
Underlying causes identify and tx e.g. MI
Monitor fluid balance- daily weights reduce by 0.5kg/day
Diamorphine- consider CPAP
Tx for PEF HF? REF? Both?
Manage co-morbidities, offer cardiac rehab programme unless condition unstable
Offer ACE-i and BB- consider hydralazine and nitrate if intolerant of ACE-i and ARB,
MRA if sx continue + cardiac rehab programme
Offer annual influenza and one-off pneumococcal vaccine
Consider one of what if sx of HF continue?
Replace ACE-i with sacubitril valsartan if EF<35%
Add ivabradine for HR>75–> sinus rhythm
Add hydralazine w/nitrate if Afro-Caribbean
HF w/ sinus rhythm= digoxin
Bifascicular block commonly presents as what on ECG?
RBBB with LAD (LAFB is more susceptible to ischaemia)
What is adenosine CI in?
ASTHMA
Normal QT interval? QTc? Normal QRS complex width?
Men= 350-450ms
Women= 360-460
<430ms in males and <450ms in females
80-100ms, >120= abnormal
Indications for LTOT in COPD?
PaO2<7.3kPa on 2 readings more than 3w apart and are non-smokers
OR PaO2 of 7.3-8kPa alongside: nocturnal hypoxia, polycythaemia, peripheral oedema and pulmonary hypertension
LTOT can be also described for patients with terminal illness
2nd step of COPD management if FEV1>50% and persistent exacerbations?
LABA or LAMA
LABA AND ICS/ LAMA
Sx blue bloaters vs pink puffers?
Pink(emphysema)= near normal Pa02 and normal or low PaCO2- SOB NOT cyanosed, quiet chest, may progress to type 1 respiratory failure
Blue bloaters(chronic bronchitis)- polcythaemia, peripheral oedema, rhonchi and wheezing (low PaO2 and high PaCO2,) cyanosed but not SOB, may develop cor pulmonale
What is TCLO low in? High in?
Severe emphysema, fibrosing alveolitis, anaemia, pulmonary HTN, idiopathic pulmonary fibrosis, COPD
Pulmonary haemorrhage- more RBCs available due to bleeding
How long before spirometry should SABAs be stopped? LABAs? How is reversibility then tested?
6 hours
12 hours
400mcg salbutamol administered and spiro repeated after 15 minutes
FEV1, FVC and ratio in obstructive vs restrictive disease?
Ob= FEV1<80%, reduced FVC to lesser extent and FEV1<FVC<0.7, reduced peak flow
Restrictive= reduced FEV1 and FVC <80%, but ratio normal(>0.7,) normal PEFR
Causes of hypoxia(<PaO2)?
V/Q mismatch, hypoventilation, abnormal diffusion, R–>L cardiac shunts- V/Q= commonest
What is KCO (gas transfer coefficient) low in? High in?
Emphysema and ILD/ alveolar haemorrhage
S&S of COPD?
SOB, wheeze, exercise intolerance, chronic/ recurrent cough, regular sputum production
Tachypnoea, use of accessory muscles in respiration, hyperinflation, reduced CS distance<3cm, reduced CE, resonant percussion, quiet breath sounds, cyanosis, cor pulmonale
Ix COPD? Comps?
Info on condition & RFs, smoking cessation, pneumo and in vaccination, pulm rehab, tx comorbidities, self-management plan
FBC, CXR, ECG, ABG, lung function tests- spiro, DLCO, trial steroids- look for >15% in FEV1, 30mg pred/24h PO for 2 weeks
Acute exacerbations +/- infection, polycythaemia, resp failure, cor pulmonale, pneumothorax, lung carcinoma
Tx COPD?
General= smoking cessation, encourage exercise, tx poor nutrition/ obesity, inf and pneu vaccination, pulm rehab, NIPPV, PRN SABA or SAMA, review meds and inhaler technique/ adherence
Mild/mod= inhaled LAMA or LABA
Severe= LABA + CS e.g. Symbicort- bud + formeterol or tiotropium
Remain Sx: tiotropium and ICS + LABA, refer to specialist, home nebs, theophylline
Pulm HTN- assess need for LTOT, diuretics for oedema
Tx for advanced COPD? Indications for surgery?
Pulm rehab, LTOT if PaO2<7.3kPa
Recurrent pneumothoraces, isolated bullous disease; lung volume surgery
NIV if high CO2 on LTOT
Air travel risky if FEV1<50% or PaO2<6.7kPa
Assess home support and tx depresison
Indications for specialist referral for COPD? Pulm rehab referral?
Uncertain Ix/ suspected severe COPD/ rapid decline in FEV1, onset cor pulmonale, bullous lung disease, assessment for oral CSs, neb therapy or LTOT, <10 pack years smoking or COPD<40 y/o, sx disprop to lung function, frequent infections, suspected bronchiectasis
Functionally disabled, recent hospitalisation for acute exacerbation
Increased risk of what with ICS? Monitor for what? When is theophylline considered? Mucolytic therapy?
Pneumonia
Osteoporosis
After trial of short-acting and long-acting bronchodilators or can’t use inhaled therapy- monitor plasma levels and interactions
Stable COPD develops chronic cough productive of sputum- continue if improvement in sx
When should prophylactic macrolide ABx therapy in COPD be considered?
More than 3 exacerbations needing steroid therapy and at least one exacerbation needing hospital admission in previous
Azithromycin 500mg 3x week minimum 6-12 months
Do what before commencing proph ABx in COPD? After starting? Severe disease despited ICS and non-pharm?
ECG-QTC int, LFTs, counsel on SEs, arrange microbiological assessment sputum for NTM, consider CT scan
SEs= 250mg x3/ week
LFTs after 1 month and then every 6 months, ECG after 1m- stop if QTc prolonged
Follow up at 6m and 12m
Oral PDE4-i
4 stages of COPD?
1=>80% FEV1
2=50-79%
3= 30-49%
4=<30%
Pre flight resp assess in COPD?
Sig resp sxs, severe COPD, bullous lung disease, comorbid conditions worsened by hypoxia, discharged within 6w, recent pneumothorax, risk of/ previous VTE, pre-existing need for oxygen, CPAP or ventilator support(CI>4L needed)
Assess= walk test and or hypoxic challenge test
Sx of acute exacerbation of COPD? Severe?
Worsening SOB, cough, wheeze, fever without obvious source, URTI in past 5 days, increased RR/ pulse 20% above baseline
Marked SOB, tachypnoea, pursed-lip breathing and/or use accessory muscles at rest, new-onset cyanosis or peripheral oedema, acute confusion/ drowsiness, marked reduction in ADLs
When to arrange hospital admission for person with acute ex of COPD?
Severe SOB, inability to cope at home, poor/ det condition, rapid onset sx, acute confusion or impaired consciousness, cyanosis, worsening peripheral oedema, new arrhythmia, failure to respond to initial tx, receiving LTOT, changes on CXR, O2<90% on pulse ox- give 2-3l/min Venturi 24% or 28% 1-2l/min target sats 88-92%
Tx person with COPD not needing admission?
Increase doses/ freq SABAs, if fatigued- use nebuliser, consider ICS for increase SOB- 30mg oral pred for 5 days, consider need for AB- based on sx severity, risk comps, previous sputum culture, risk antimicrobial resistance & current ABx prophylaxis
Follow-up of exacerbation COPD?
Assess residual/ changed sx- consider need for further Ix, optimise non-pharm and pharm, use of meds, consider need for referral to specialist/ for pulm rehab
Offer short course oral steroids and AB keep at home if: ex in last year and remain at risk, understand when and how to take, know when to seek help
Review self-management plan
Factors ass w/ increased risk mortality in people with COPD? Tx?
Freq and severity exacerbations
Hosp during ex
Poor lung function on spiro
Low BMI
CMBs
Ensure has ACP, optimise sx- SOB, cough, secretions, pain, insomnia, depression, anxiety, discuss admission to hospice, family/ carer support
Sx? Signs on examination in during asthma attack?
Dyspnoea, cough- may be nocturnal, chest tightness, diurnal variation, sx may worsen following exercise, weather changes or following use of NSAIDs/ Beta blockers
Reduced chest expansion, prolonged expiratory time, bilateral expiratory polyphonic wheezes, tachypnoea, hyperinflated chest, hyperresonance on chest percussion, decreased air entry
Ix asthma?
RCP3 Qs- recent nocturnal waking/ usual asthma symptoms in day/ interference with ADLs
FeNO testing, spirometry- obstructive, BDR>12% or more of FEV1 and increase in volume of 200ml or more(children just 12%,) PEF variability>20% on >/=3d for 2w diagnostic lower in mornings, bronchial challenge testing with histamine or methacholine(PC20 value of 8mg/ml or less)
Asthma control test: 25= well controlled, 20-24= on target, <20= off target
Lung function- PEFR on waking, prior to taking BD and before bed after BD, spirometry, CO test= normal asthma
Exercise
CS trial
ENO
Blood and sputum tests- eosinophilia- sputum= more specific, raised total IgE
CXR
Ix asthma?
Presence of more than one variable sx wheeze, cough, SOB and chest tightness
Personal/ family hx of other atopic conditions- atopic eczema/ dermatitis and/ or allergic rhinitis(previous skin prick tests)
Results FeNO testing>40ppb adults/ 35 ppb in children
Tx chronic asthma?
Smoking cessation, avoidance factors, review inhaler technique, teach PEF X2/ day, emergency advice, written action plan–> relaxed breathing(Papworth)
Ask specifically about what during asthma history?
Precipitants- cold air, exercise, emotion , allergens- house dust mite, pollen fur/ infection, smoking, pollution, NSAIDs, beta-blockers
Diurnal variation
Exercise tolerance
Disturbed sleep- nights/ week
Acid reflux-tx improves spirometry
Other atopic disease- eczema, hayfever, allergy or family hx
Home- pets, carpet, feather pillows or duvet, floor cushions/ soft furnishings
Job- PEF at work (paint-sprayers, food processors, welders, and animal handlers) and home
Days per week off school or school
Monitoring asthma? Uncontrolled asthma?
At least annually
Adherence, inhaler technique, review if tx needs changing, ask about occupational asthma- refer to OT if needed, questionnaire
Spiro or PEF
3 or more days week w/ sx or 3 or more days a week with required use of SABA for relief or 1 or more nights week with awakening
When should inhaler technique be reviewed?
At every consultation relating to asthma attack, when deterioration in asthma control, when inhaler device changed, at every annual review, if person asks
People on long-term steroids or needing frequent courses offer what?
Monitoring of BP, urine or blood sugar, cholesterol, BMD, vision- cataracts or glaucoma
If meds adjusted- review response in 4-8 w
Hx for acute asthma attack?
Usual and recent tx, previous acute episodes and severity best PEFR, admitted to ICU
note agitation, consciousness, signs exhaustion- cyanosis, use accessory muscles
Examine chest- RR, pulse, BP, best of 3 PEFR, pulse oximetry
Features of moderate acute asthma attack? Acute severe? Life-threatening?
PEFR>50-75% best / predicted and normal speech, no features acute severe or life-threatening
PEFR 33-50%, RR at least 25, inability to complete sentence in one breath, accessory muscle use, O2 at least 92%, pulse>110bpm
PEFR<33%, O2<92% or altered consciousness or exhaustion or cardiac arrhythmia or hypotension/ cyanosis/ poor resp effort/ silent chest/ confusion(WARN ICU if severe or life-threatening)
Ix in acute asthma?
ABG- T2RF= life-threatening, tachypnoeic= resp alkalosis(low PaCO2 and high PaO2)
Falling RR= sign of patient fatigue, PaCO2 to normal= URGENT ESCALATION
Bloods- FBC, CRP
CXR- exclude
Tx for acute asthma?
Ensure patent airway(AE)
O2 if SATS below 94%- target 94-98%
Salb/ ipratropium nebs- O2 driven(every 20-30 minutes if intermittent or over 30-60 minutes if continuous)
(If not available- 4 puffs metered-dose inhaler with large-volume spacer–> 2 puffs every 2 minutes up to 10 puffs, repeat every 10-20 minutes if needed)
Ipra if life-threatening or severe/ poor resp to salb
Oral pred/ IV hydrocortisone
Monitor PEFR and oxygen, ECG- arrhythmias
IV MgSO4 if severe
IV aminophylline if severe and inadequate BD response from nebs–> ICU(no improvement)- invasive ventilation
Tx acute asthma not in hosp? Follow-up?
Salb large vol spacer- 4 puffs, then 2 puffs every 2 mins up to 10 puffs, repeat every 10-20 minutes
Short course oral pred
Return to SABA up to QDS once sx gone
Monitor PEFR
Within 48 hours and 2 days discharge- sx, PEFR, inhaler technique, consider increasing ICS dose, address RFs, lifestyle, recognising poor control, keep oral CSs at home
Consider referral to resp physician if person has what?
2 asthma attacks within 12 months
3 e.g. of ABGs in context?
Normal PaO2 on high-flow oxygen
Normal PaCO2 in hypoxic asthmatic patient- NEED ITU intervention
Very low PaO2 in someone who looks well, not SOB and normal O2 SATS
In someone receiving oxygen therapy, what should their PaO2 be in relation to their inspired conc?
10kPa less than % inspired conc e.g. 40%- PaO2 of 30kPa
Simple face masks can deliver a maximum FiO2 of approximately what at a flow rate of 15L/min- NEVER LESS THAN 5L/min? Reservoir masks e.g. non-rebreather? Venturi masks?
40-60%
60-90% at 10-15L/min
24, 28, 35, 40 and 60%(24 and 28% for those at risk of CO2 retention)
Normal and abnormal PaO2 and PaCO2 levels?
11-15, <10= hypoxaemic, <8= severely hypoxaemic- RF
4.6-6.4kPa, <6= normocapnic, >6kPa= hypercapnic(T2RF)
Causes of type 1 and type 2 RF?
Type 1= V/Q mismatch- PE most commonly, pulm oedema
Type 2= hypoventilation- COPD, pneumonia, rib fractures, obesity, GBS, MND, opiates
High HCO3- means what on ABG?
Low HCO3-? CO2 and HCO3- in mixed acidosis/ alkalosis? Causes?
Metabolic alkalosis/ comp respiratory acidosis
Metabolic acidosis or comp respiratory alkalosis
Move in opposite directions
Cardiac arrest, multi-organ failure= acidosis
Liver cirrhosis in addition to diuretic use, HG, excessive ventilation in COPD= alkalosis
Causes of resp acidosis? Resp alkalosis? Normal anion gap met acidosis? High anion met acidosis? Met alkalosis?
Resp depression, GBS, asthma COPD, iatrogenic
Anxiety, pain, hypoxia, PE, pneumothorax, PE, iatrogenic
GI, renal tubular disease, Addison’s disease
DKA, lactic acidosis, aspirin overdose, renal failure
GI loss, renal loss H+, iatrogenic
Anion gap formula? Normal value?
Na+- (Cl- + HCO3-)
4-12 mmol/L
How can changes in CO2 be compensated? HCO3-?
By increasing/ decreasing levels HCO3-
increasing/ decreasing levels CO2
What can a VBG be used to comment on and not?
To exclude resp acidosis and and T2RF, determining response–> treatment, resp function in comb with pulse ox
Oxygen levels- ABG needed
Tx for pneumonia?
ABC- O2 if SATS<88%, 24-28% if COPD/ hypercapnia- maintain between 94-98%
Tx hypotension/ shock- consider IV fluid
ABx- WITHIN 4 HOURS
Paracetamol/ NSAID
CPAP if still hypoxic, hypercapnic= intubation
Discuss with ICU if rising PaCO2 or remains hypoxic
ABx for CAP? Atypical?
Mild= amoxicillin/ clar/ doxy
Moderate= amox + clar/ doxy(amox + clar if IV)
Severe= co-amox or cephalosporin + clarithromycin
Add fluclo +/- rif if staph suspected; vanc if MRSA suspected
If legionella pneumophilia suspected? Chlamydophila species? Pneumocystis jiroveci? Necrotising/ other features PVL–> s.aureus? Pseudomonas- CF & bronchiectasis?
Levofloxacin and clari/ rifampicin if severe- HYPONATRAEMIA AND LYMPHOPENIA COMMON
Tetracycline- doxy/ lymecycline
High dose co-trimoxazole- DRY COUGH, EXERCISE-INDUCED DESATS & ABSENCE CHEST SIGNS
IV linezolid, IV clindamycin, IV rifampicin
IV ceftazidime w/ gent/ tobramycin- consider dual therapy minimise resistance
Tx for HAP? Aspiration? Neutropenic?
IV aminoglycoside e.g. gentamicin(Hartford protocol)-risk of oto & nephrotoxicity once-daily dosing + antipseudomonal penicillin e.g. ticarcillin/ piperacillin with tazobactam
(Ceftazidime or Tazocin)
IV ceph + metro
Aminogly + antipseudomonal/ 3rd gen caph
Consider antifungals after 48h
CXR findings in s.pneumoniae, aureus and legionella? S.aureus? Klebsiella? Tx?
Multi-lobar, multiple abscesses, upper lobe cavity- EXCLUDE TB
Cefotaxime/ imipenem
Ix pneumonia?
Bloods: FBC- WBCs for severity, ESR & CRP, U&Es- severity, LFTs, pulse ox and ABG if O2 <94%
HIV test, sputum culture and sens +/- Gram stain, blood culture, serology- viruses and atypical
Comps of pneumonia? When would someone with CAP have a CXR 6 weeks after?
Resp failure, hypotension, parapneumonic effusion and empyema, pleural effusion, septicaemia, brain abscess, myocarditis, cholestatic jaundice, pericarditisƒ
S&S persist despite tx, higher risk malignancy- >50 y/o and smokes
Indications of empyema? Ix? Tx? ABx?
Ongoing fever, failure of fever/ WBC/CRP to settle, pain deep inspiration, signs pleural collection
Pleural tap–> pH<7.2, low glucose, fluid- yellow and turbid
Chest drain
Co-amoxiclav, pip-taz, meropenem- anaerobic
CXR for lung abscess? Seen in who? Organisms? Tx?
Cavity formation
Aspiration- alcoholics, oesophageal obstruction, inadequate tx CAP, TB, foreign body, septic emboli- staph
S.milleri, Klebsiella, GRAM-VE bacteria
Prolonged ABx up to 6w- surgical drainage may be required
Idiopathic interstitial pneumonia group non-infective causes pneumonia including what? Comp of what?
Cryptogenic organising pneumonia- form bronchiolitis as comp of RA or amiodarone therapy
Discharge advice if in past 24h pneumonia patients have had 2 or more of what?
NOT DISCHARGE- temp>37.5 degrees, RR>24, HR>100, sys BP<90, O2<90% on RA, abnormal mental status, inability eat without assistance
Resolution pneumonia sx?
Fever= 1w
Chest pain & sputum= 4w
Cough & SOB= 6w
Most resolve except fatigue- 3m
6m= back to normal
S&S of TB?
FEVER- gradual onset and low-graded
Dyspnoea, initial dry cough–> productive> 3 months
Night sweats
Weight loss
Pleurisy/ chest pain/ SOB
Pleural effusion/ consolidation, pulm collapse from compression lobar bronchus
Anorexia
Can be hoarse voice
Sx of extrapulmonary TB?
swollen lymph nodes +/- discharge
Pericarditis
Pain/ swollen joints, Potts disease- spinal
Abdo- ascites, abdo LNs, ileal malabsorption
Epididymitis, LUTs, haematuria
CNS= raised ICP sx, low grade meningitis, random CN palsies
Skin- lupus vulgaris, erythema nodosum
Eyes(retinal/ ocular)- blurred vision and light sensitivity
Ix Latent TB? Active TB? Active non-resp TB?
Mantoux/ tuberculin test 48-72 hours response–> type 4 HS reaction- +ve(immunity) - consider interferon-gamma testing- use ESAT-60 and CFP10 dis between M.tub between BCG vaccine or environmental mycobacteria(indicate exposure but not active)
MILIARY/ IMMUNOSUPPRESSED WON’T TEST
If CXR suggests- take sputum samples>/= 3 samples- MC&S for AFB resist acid on Ziehl-Neelsen staining/ bronchoscopy and lavage if not possible/ pleural fluid or lung biopsy
Culture- up to 6 weeks with Lowenstein-Jensen agar, lquid media= rapid results within 1-3 weeks
Sputum, pleura and pleural fluid, early morning urine samples for dipstick, microscopy and mycobacteria culture, pus, ascites, peri, bone marrow/ CSF samples & LP for non-resp, TB culture by micro, ECHO, CT- chest/ CNS/ bones & joints
CXR- patchy/ nodular shadows in upper zones with loss volume and fibrosis w or w/o cavitation, consol, mediastinal/ hilar lymphadenopathy
PCR(NAAT,) histology= caseating granulomata
Tx active TB? Do what before and after tx? Tx latent TB?Check what? Reduce rif dose by 50% in what situation? Monitor what for ethambutol?
NOTIFY PHE & contact tracing- all household members, close contacts, most work colleagues, isolate until 2 weeks after starting tx
Rx before culture results
Fully sens TB= 6m tx, CNS= 12m(R&I, P&E during 1st 2m):
First 8 weeks= pyrazinamide- 2.5g 3 times a week
Ethambutol 30mg x3 times/ week/ streptomycin
Rifampicin 600-900mg x3 times a week for 6 months
Isoniazid= 15mg/ kg 3 times/ week max 900mg for 6m
GIVEN IN DOTS- direct observed therapy
Consider steroids for meningeal/ pericardial TB
3m isoniazid and rifampicin OR 6m isoniazid
Colour vision and visual acuity
If pre-tx creatinine clearance 10-50ml/min, U&Esp
Monitoring and SEs of TB drugs?
Sputum samples- M & C at monthly intervals
R= hepatitis, red urine, drug inter- the pill
I= hepatitis, neuropathy
P= hepatitis, arthralgia/ gout & rash
E= optic neuritis- COLOUR VISION
Common regime for resistant TB? Extensively drug-resistant TB?
Levo + bedaquiline + linezolid
At least 5 of fluoroquinolone, bedaquoline, linezolid and additional
New alternative= 26-week regimen of bedaquiline, pretomanid and linezolid
TB comps?
Haemoptysis, pneumothorax, bronchiectasis, pulm destruction, fistula, tracheobronchial stenosis, malignancy, chronic pulm aspergillosis
TB effusions and empyema
Miliary TB
Septic shock
How is TB screened for? In who? BCG vaccine?
Mantoux and IGRAs- active/ +ve–> CXR, sputum stain and culture, people starting immunosuppressant treatment e.g. anti-TNF- infliximab- should be screened
Recent exposures, healthcare workers, homeless shelters and prisons, increased risk reactivation- HIV, travellers from high-incidence countries
Live from m.bovis- children in high-risk region, healthcare
Features of mycoplasma pneumoniae? Ix? Comps? Tx?
Flu-like sx followed by cough
CXR= reticular nodular shadowing/ patchy consolidation often of 1 lower lobe and worse than signs suggest
PCR sputum or serology
Erythema multiforme, SJS, meningoencephalitis or myelitis, GBS
Clarithromycin or doxycycline or cipro
Predominant pathogens in acute sinusitis? Tx? Comps?
S.pneumoniae, h.influenzae & Moraxella catarrhalis, rhinoviruses
Facial pain, nasal discharge, nasal obstruction
Analgesics, decongestants, intranasal corticosteroids and saline irrigation, ABx- fail to improved after 7-10 days- phenoxy or co-amoxiclav if systemically unwell, sx more serious, high-risk comps
Orbital cellulitis, subperiosteal formation and intracranial extension –> meningitis or brain abscesses
Most common cause epiglottitis? Sx? Tx?
Hib
Severe sore throat and odynophagia- painful swallowing + drooling, muffled voice, stridor, resp distress, high-grade fever, tripod/ sniffing position- DON’T EXAMINE THROAT
Lateral neck radiograph= THUMB SIGN only if stable, flexible fiberoptic laryngoscopy- only if stable, blood cultures and throat swabs
Urgent endotracheal intubation, tracheostomy
IV ceftazidime, supportive, close monitoring, vaccination in children
Most PE clots from which veins? rarer causes?
Pelvic and abdominal veins- but femoral and occasionally axillary thrombosis
Right vent thrombus- post MI, septic emboli, fat embolism- long bone fracture, air embolism, amniotic fluid embolism, neoplastic cells, parasites, foreign material during IV drug misuse
Other causes of PE? Sx?
Immobility
Recent surgery
Long-haul travel
Pregnancy
Hormone therapy with oestrogen (e.g., combined oral contraceptive pill or hormone replacement therapy)
Malignancy
Polycythaemia (raised haemoglobin)
Systemic lupus erythematosus
Thrombophilia
SOB, tachypnoea, pleuritic chest pain, haemoptysis, dizziness, syncope, pyrexia, cyanosis, past hx or family hx
Gallop rhythm, raised JVP, loud P2, right vent heave, pleural rub, AF, DVT
Ix PE?
FBC, U&E baseline clotting, D-dimers, ABG–> reduced PaO2 and PaCO2
CXR- often normal, decreased vascular markings, small pleural effusion, wedge-shaped area infarction, atelectasis, pulm oligaemia
ECG- sinus tachy, RAD, RBBB, AF, “SIQIIITIII,” RV strain
ABG- T1RF
Two-level Wells score unless HD unstable, pregnant or has given birth within 6 weeks
Serum D-dimer- rules out
CTPA- interim anticoagulation–> V/Q scan- also if RENAL IMPAIRMENT/ CONTRAST ALLERGY/ AT RISK FROM RADIATION
Tx of PE?
Immediate admission if pregnant/ HD unstable- cardiac arrest, obstructive shock, sys BP<90, eng-organ hypoperfusion, persistent hypotension/given birth within the past 6 weeks
Wells score>4 immediate CTPA/ interim anticoagulation–>V/Q scan
<4= D-dimer with results within 4 hours- if not–> anticoagulation, -ve= stop anticoag + consider alt
+ve–> CTPA/ interim anticoag
Features in Wells score for PE?
Clinical S& S of DVT
PE is number 1 diagnosis/ equally likely
HR>100
Immobilisation at least 3 days OR surgery in previous 4 weeks
Previous Ix PE/ DVT
Haemoptysis
Malignancy w/ tx within 6m or palliative
Follow-up after PE confirmed and AC started?
Adequate monitoring, info booklet, alert card, verbal and written info on AC treatment, Ix for unprovoked, hereditary thrombophilia testing where appropriate
Ix for unprovoked= FBC, U&Es, LFTs, APTT, PT, physical exam
If planned to stop AC- consider AP antibodies, hereditary thrombophilia for 1st degree relative with DVT/PE
If clinical suspicion is low for PE, consider using what to determine further Ix? Use of score?
PERC:
Age>50, HR>/=100, O2 sat on room air<95%, unilateral leg swelling, haemoptysis, recent surgery/ trauma, prior PE/ DVT, hormone use
All absent to rule out PE
Options for interim anticoagulation in PE? blood tests?
Apixaban or rivaroxaban/ LMWH for at least 5 days followed by dabigatran or edoxaban
LMWH with vit K ant(warfarin) at least 5 days
FBC, U&Es, LFTs, PT and APTT- don’t wait for results to tx
Tx for PE?
Oxygen if hypoxic 10-15L/min
Morphine 5-10mg IV w/ anti-emetic if pain/ distressed
LMWH unless CI e.g. active bleeding/ existing AC w/ DOAC/ warfarin
Anti-embolic stocking unless CI e.g. PAD
HD= immediate thrombolysis + cont infusion fibrinolytic unfrac heparin/ LMWH e.g. alteplase, streptokinase- IV/ catheter-directed OR embolectomy- less common
IVC filters- repeat despite adequate AC
Score for considering OP tx in PE?
PESI: age, sex, hx cancer/ HF/ chronic lung disease, HR>/=110, sys BP<100, RR>30, temp<36, altered mental status, O2<90%
AC following PE Ix?
Apixaban or rivaroxaban
Unsuitable= LMWH–> dabigatran or edoxaban/ LMWH–> VKA e.g. warfarin at least 5 days until INR 2
Renal impair<15ml/min= LMWH, unfrac heparin/ LMWH–> VKA
APS= LMWH–> VKA, target INR= 2-3
Pregnancy= LMWH
Length AC in PE? Score for assessing risk of bleeding on AC?
3 months- provoked
Unprovoked/ recurrent/ irreversible cause e.g. thrombophilia= 6m
3-6m in active cancer, then review
HASBLED (mainly AF)- HTN>160mmHg, renal disease, liver disease, stroke hx, prior major bleeding/ predis–> bleeding, labile INR, age>65, med predis–> bleeding, alcohol use>/=8 drinks/ week
Give what in PE if BP<90mmHg? Still reduced after 500ml? Still low? Still<90 after 30-60 min standard tx? If BP>90 mmHg?
Colloid infusion+ ICU input
Dobutamine- aim for BP>90 mmHg
IV noradrenaline infusion
Consider thrombolysis- unless already given
Warfarin loading regimen e.g. 5-10mg PO- confirm Ix
Comps of PE?
Acute RVF, cardiogenic shock, arrhythmias-SVT/VT, resp failure, infarction & lung necrosis, pleural effusion, pneumothoax
CTEPH= pulm HTN + right HF eventually
Legionella pneumophilia features? Ix? Tx?
Flu-like, dyspnoea and dry cough, anorexia, D&V, hepatitis, renal failure, confusion and coma
CXR= bi-basal consolidation
Bloods= lymphopenia, hyponatraemia, deranged LFTs, urinalysis may show haematuria
Legionella urine antigen/ culture
Fluoroquin(cipro) for 2-3 weeks/ clari
Chlamydophila pneumoniae features? Ix? Tx?
Biphasic- pharyngitis, hoarsenss, otitis, followed by pneumonia
Chlam complement fixation test, PCR invasive samples
Tx= doxy/ clari
Chlamydophila psittaci features? Ix? Tx?
Causes psittacosis- from infected birds
Headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V
Meningo-encephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly
Chlam serology
Doxy/ clari
Pneumocystis pneumonia features? Ix? Tx?
Pneumonia in immunosuppressed- dry cough, ex dyspnoea, reduced PaO2, fever, bilateral creps
CXR- may be normal or show bil perihilar interstitial shadowing
Visual organism in induced sputum, bronch lavage/ lung biopsy
High dose co-trimoxazole/ pentamidine for 2-3w
Steroids in severe hypoxaemia
Prophylaxis if CD4<200x10^6/ after first attack
Mnemonic for causes upper lobe fibrosis?
CHARTS= coal workers’ pneumoconiosis, histiocytosis, ankylosing spondylitis/ allergic bronchopulmonary aspergillosis, radiation, tuberculosis, silicosis/ sarcoidosis
Drugs causing secondary pulmonary fibrosis? Conditions?
Nitrofurantoin, bleomycin, amiodarone- also causes grey/ blue skin, sulfasalazine, busulfan, cyclophosphamide, methotrexate
ALAT deficiency, RA, SLE, systemic sclerosis, sarcoidosis
2 medications licensed for idiopathic pulm fibrosis?
Pirfenidone
Nintedanib- inhibits tyrosine kinase
Drugs that cause secondary pulmonary fibrosis? Conditions?
Amiodarone, cyclophosphamide, methotrexate, nitrofurantoin
A1AT deficiency, RA, SLE, systemic sclerosis, sarcoidosis
EXPLAIN mnemonic for causes of pulmonary fibrosis?
Exogenous drugs- sulfonylureas or insulin
Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours- insulinomas
Non-pancreatic neoplasms
What can you not get above with hernias?
A hernia or an infantile hydrocele due to a patent processus vaginalis- is irreducible, testis is impalpable and has no cough impulse
RILE mnemonic for murmurs?
Right-sided= best on inspiration
Left-sided= best on expiration
Causes of bronchiectasis?
Idiopathic, pneumonia, whooping cough, TB, A1AT deficiency, connective- rheumatoid arthritis, CF, yellow nail syndrome, primary ciliary dyskinesia, allergic BP aspergillosis (CAPT Kangaroo has Mounier-Kuhn)
Most common organisms in bronchiectasis?
H.influenzae, pseudomonas, Klebsiella, s.pneumoniae
A1AT deficiency is caused by what?
Lack of protease inhibitor normally produced by the liver
Ch 14- autosomal recessive fashion(SERPINA1 gene)
Alleles classified by their electrophoretic mobility- M for normal, S for slow and Z for very slow(most common)
Normal= PiMM, heterozygous= PiMZ
Normal A1AT levels in homozygous PiSS and PiZZ? Ass w/ A1AT?
50% and 10%- manifest disease= usually PiZZ genotype, PIMZ= asymptomatic, S only symptomatic with Z(PISZ)
Asthma, pancreatitis, aneurysms, including intracranial aneurysms
Apical vs basal fibrosis mnemonic?
TEARS IN THE SKY- TB, extrinsic allergic alveolitis, AS/ allergic bronchopulmonary aspergillosis, radiation, silicosis/ sarcoidosis/ berylliosis/ pneumoconiosis- coal worker’s
CRABS ON THE FLOOR- cryptogenic fibrosing alveolitis (IPF,) rheumatoid arthritis/ systemic sclerosis, asbestosis/ aspiration/ A1AT deficiency, busulfan/bleomycin/ bronchiectasis, scleroderma
Staging of ABPA? Major and minor criteria?
1= acute, II= remission, III= recurrent exacerbation, IV= steroid-dependent asthma, V= pulmonary fibrosis
Major= asthma, pulmonary opacities, central bronchiectasis, blood eosinophilia, elevated IgG or IgE against A. fumigatus, IgE>1000IU/ ml
Minor= fungal elements in sputum, expectoration of brown plugs/ flecks, delayed skin reactivity to fungal antigens
What may be seen in the sputum of people with bronchial asthma and ABPA?
Charcot-Leyden crystals
Light’s criteria for pleural fluid interpretation? If though transudative, but Light’s suggest exudate what done?
Pleural fluid: serum protein>0.5
Fluid: serum LDH>0.6
Fluid LDH> 2/3 upper limit normal serum value
Serum- pleural fluid protein gradient
Pleural fluid LDH>1000 IU/L? Low pleural glucose <3.4mmol/L? <1.6?
Empyema, malignancy or rheumatoid effusion
Empyema, rheumatoid pleuritis ass w/ TB, malignancy and oesophageal rupture
Empyema and rheumatoid disease
Low pleural pH <7.3? High amylase above 110 IU/L?
Same pathologies causing low pleural fluid glucose levels
Pancreatitis, malignancy or ruptured oesophagus
WBCs in transudative or exudates? Lymphocytosis? Neutrophils?
Exudates>50,000 cells/ microL
Trans<1000 cells/ microL
TB, sarcoidosis or malignancy
Empyema or PE
Triglyceride and cholesterol levels in chylothorax and pseudochylothoax diagnoses?
Tri>1.24mmol/L, chol<5.18 mmol/L
Tri<0.56mmol/L, chol>5.18
Causes of resp acidosis and alkalosis?
COPD, life-threatening asthma, opiates overdose, benzos, NM disease, obesity hypoventilation syndrome
PE, anxiety–> hyperventilation, CNS disorders- stroke, SAH, encephalitis, altitude, pregnancy, salicylate poisoning
Diagnostic criteria for OHS? Tx? Ass w what?
BMI>/= 30kg/ m^2, daytime PaCO2>45mmHg, ass sleep-breathing disorder, absence of other known causes of hypoventilation
Return to normal body weight, severe= bariatric, assisted ventilation supp by O2
CHF, pulm HTN, cor pulmonale, angina
Ix for OHS?
ABGs- daytime hypercapnia and hypoxaemia, serum HCO3- exclude in low-risk, nocturnal oximetry for sleep apnoea, CXR, ECHO- RVH, ECG- RBBB, pulm function- flow volume loop (exp volume by spirometry against flow rate–> sawtooth pattern,) FVC + exp reserve volume reduced and airways resistance increased
Overnight polysomnography- hypovent, hypoxia and hypercapnia during sleep, especially in children and adolescents, FBC & TFTs- anaemia and mxyoedema
Features indicating urgent CXR within 2 weeks aged 40 and over for suspected lung cancer/ mesothelioma?
Persistent or recurrent chest infection, finger clubbing, SC lymphadenopathy or persistent cervical lymphadenopathy, chest signs cons, thrombocytosis
CXR recommended to patients over 40 y/o who have never smoked with two or more of what sx (one or more if they have ever smoked/ had asbestos exposure)
Cough, SOB, chest pain, fatigue, weight loss, appetite loss
Ix for lung cancer?
Staging CT, PET-CT, bronchoscopy with endobronchial ultrasound(EBUS,) histological diagnosis needs biopsy by bronchoscopy or percutaneous biopsy through skin
Cytology from sputum and pleural fluid
FBC
MRI= spread to brain or bones
Sites of met spread from lung cancer?
Liver, bone, adrenal glands, brain(more common to spread TO lung)
Breast, bowel, kidney- MOST COMMONLY, bladder
TNM class of lung cancer?
T1<3cm, T2>3cm, T3= chest wall, diaphragm and pericardium, T4= mediastinum, heart, great vessels, trachea, oesophagus, vertebra, carina, malignant effusion, mets in same lobe
N1= hilar nodes, N2= same side mediastinal nodes or subcarinal, N3= contralateral mediastinum/ supraclavicular
M1a= tumour same side, M1b= tumour elsewhere
What is pulm HTN defined as?
mPAP above 25mmHg as measured at right heart catheterisation and secondary right ventricular failure
5 groups of causes of pulmonary hypertension?
Idiopathic/ CTD e.g. SLE
Left heart failure- MI/ systemic HTN
Chronic lung disease- COPD/ pulm fibrosis
Pulmonary vascular disease- PE
Miscellaneous- sarcoidosis, glycogen storage disease and haematological disorders
Gene involved in Goodpasture’s syndrome? Antibodies?
HLA-DRB1
Anti-GBM vs alpha-3 chain of type IV collagen
Auto-antibodies in Wegener’s granulomatosis (granulomatosis with polyangiitis)? Drugs? Nasal carriage of what?
PR3-ANCA(cANCA,) A1AT, HLA-DP, raised ESR & CRP
Propylthiouracil, hydralazine, sulfasalazine, phenytoin and allopurinol
Silica dust, mercury
S.aureus
Presentation of GPA?
Fever, malaise, arthralgias and weight loss–> rhinosinusitis, cough, dyspnoea, hearing loss, purpura, urinary sediment or neurological dysfunction
Upper(90%)= sinusitis, nasal crusting, subglottic stenosis, otitis media, hearing loss, ear pain
Dyspnoea, cough, pleuritis, haemoptysis, pulm infiltrates
Micro haematuria, urinary sediment, pauci-immune RPGN–> CKD
60%= scleritis/ episcleritis, orbital mass, 50%= cutaneous skin lesions, 15%= mononeuritis multiplex, peripheral sensorimotor polyneuropathy, cranial neuropathy
Sx of Churg- Strauss syndrome/ eosinophilic granulomatosis with polyangiitis?
Asthma, pneumonitis, haemoptysis
Allergic rhinitis, paransal sinusitis, nasal polyposis
HF, myocarditis and MI
Leukocytoclastic angiitis, livedo reticularis, urticardia
GN, HTN, advanced CKD
Peripheral neuropathy
ANCA autoantibodies in CSS?
p-ANCA, elevated CRP & ESR, eosinophilia and anaemia on FBC, elevated serum creatinineSus
Suspect atelectasis in dyspnoea and hypoxaemia how long after surgery? Also?
72 hours
Pyrexia in first 48 hours–> chest physio and breathing exercises
5 groups of pulmonary hypertension?
Idiopathic/ CTD e.g. SLE
Left heart failure
Chronic lung disease- COPD/ pulm fibrosis
Pulmonary vasc- PE
Misc- sarcoidosis, haem disorders, glycogen storage
Levine scale for murmurs?
Grade I= very fine- may only be heard by an expert, not heard in all positions, no thrill
II= soft, heart in all positions- no thrill
III= moderately loud, no thrill
IV= loud and associated with palpable thrill
V= very loud with thrill, heard with stethoscope partly off chest
VI= loudest with thrill, heard with stetho entirely off chest (just above precordium)
SE of cyclophosphamide?
Haemorrhagic cystitis
Mnemonic for causes erythema nodosum?
NO/DOSOUM- no cause, drugs- antibiotics, oral contraceptives, sarcoidosis/ Lofgren’s syndrome, UC/ Crohn’s/ Behcet’s, micro- TB/ viral/ bacterial/ psittacosis/ parasitic
Naegele’s rule?
Add 1 year and 7 days to first day of LMP and then subtract 3 months
Tx for mild-moderate acne?
12-weeks of topical adapalene with topical benzoyl peroxide(0.1 or 0.3% with 2.5%)
Topical retinoin with topical clindamycin (0.025% with 1% clindamycin)
Topical BP + clindamycin (3 or 5% with 1% clindamycin)
Mono= topical benzoyl peroxide
Once or twice a week–> daily if tolerated
Moderate- severe acne?
12w of topical ada w/ topical BP ON
Topical retinoin with topical clindamycin ON
Ada with topical benzoyl peroxide ON w/ oral lymecycline 408mg/ oral doxy
Topical azelaic acid BD with oral lym 408mg/ oral doxy 100mg OD
Topical benzoyl peroxide
(Trimeth or oral macro instead of lymecycline or oral doxy)
Last-line option acne? Most effective contraception for acne?
Oral retinoids- isotretinoin (pregnant only 1 month after)
Co-cyprindiol (Dianette)- discontinue 3 months after controlled, also spiro- CI IN PREGNANCY TOO
Refer who to on-call derm team within 24 hours? To consultant led team?
Acne fulminans
Ix uncertainty, acne conglobata, nodulo-cystic acne
Consider if mild-moderate not responded to x2 completed courses tx/ not responses to previous tx including oral AB, acne w/ scarring/ w/ pigmentary changes, causing psych distress
Follow-up acne patients when? Taking oral isotretinoin?
12 weeks- review ABx at 3-monthly intervals- stop ASAP
Review after 1 week- monitor for suicidal ideation, sexual function, dry skin & lips, photosensitivity–> sunlight, rarely= SJS & TEN
STOP FOR 1 MONTH AT LEAST BEFORE BECOMING PREGNANT
Surgical sieve?
VITAMIN DEF
Ix for acne rosacea?
At least one of phymatous changes, persistent erythema/ two of:
Major= flushing/ transient erythema, papules and pustules, telangiectasia, ocular
(Minor= skin and/ or stinging sensation, skin dryness, oedema)
Tx for rosacea? Refer to dermatologist? Oph?
Persistent erythema= topical brimonidine
Topical ivermectin for mild-moderate papules/ pustules
Oral doxy for moderate- to-severe papules/ pustules depending on CIs
Persistent erythema or papules/ pustules not responded to optimal management in primary care, severe telangiectasia
Keratitis/ anterior uveitis
4x things for examining skin?
1) Inspect- general, site & number lesions- pattern distribution and configuration
2) Describe: SCAM- size/ shape, colour, ass secondary change, morphology/ margin
If pigmented: ABCDE- asymmetry, irregular border, two or more colours within lesion/ pink/ grey/ white, diameter>6mm, E- quick growing or rapid appearance changes
3) Palpate- surface, consistency, mobility, tenderness, temperature, tenderness, edge- induration?, bleeding?
4) Systematic- nails, scalp, hair and mucous membranes, general examination
OR LOOK, FEEL, MOVE, REGIONAL LYMPHATIC DRAINAGE, SPECIAL TESTS- peripheral pulses, light touch & pressure sensation, evidence bony involvement, additional examination from PC
Tx for eczema?
Emollients, consider topical steroids for red, inflamed skin- lowest potency and amount of topical corticosteroid
Persistent severe itch or urticaria= 1 month trial non-sedating antihistamine
Affecting sleep= short course sedating antihistamine
Severe extensive eczema= short course oral CSs
Weeping, crusting/ pustules w/ fever or malaise= consider 2 bacterial infection
Thin vs thick greasy emollients for eczema?
E45, Diprobase, Oilatum, Aveeno, Cetraben, Epaderm
50:50, hydromol, diprobase, cetraben, epaderm ointments
Steroid ladder for eczema(ONLY INFLAMED AREAS)? Severe eczema? 2nd line tx?
Hydrocortisone 0.5, 1 and 2.5%
Eumovate- clobetasone butyrate 0.05%
Betnovate- betamethasone 0.1%
Very potent- Dermovate- clobetasol proprionate 0.05%
Ciclosporin, azathioprine, phototherapy UVA, antihistamines e.g. chlorphenamine
Oral corticosteroids e.g. 30mg pred for 1 week
Topical calcineurin inhibitors- less SE, more useful for sensitive areas e.g. tacrolimus or pimecrolimus–> burning/ stinging
When should corticosteroids be continued for? Delicate areas skin? Review emollients? Topical CSs? Non-sedating antihistamines?
48 hours after flare controlled
5 days max
Annually
3-6 monthly, 3 months
Refer within 2w to derm for eczema? Routine?
If severe and not responded to optimum topical tx after 1 week
Ix uncertain, adverse reaction–> emollients, facial eczema not responding, contact allergic dermatitis suspected, social/ psych issues
Tx for infected eczema?
Flucloxacillin/ clarithromycin/ localised= fusidic acid
Not respond–> refer within 2 weeks
Amount and freq emollient eczema?
250-500g/ week child
500-750g/ week for adult
LAMBSKIN for exacerbating factors for psoriasis? Drugs causing mnemonic?
Lithium/ UVA exposure, alcohol, meds- chloroquine & derivatives, steroid withdrawal, M, stress/ smoking, infection with Group A strep, N
Relieving= sunlight
BALI: beta blockers, anti-malarials, lithium, indomethacin- NSAIDs
Tx for psoriasis?
Emollients
Topical CSs- potent no longer than 8 weeks at time
Vit D analogues e.g. calcipotriol/ Dovobet
Coal tar
Short-contact dithranol
CV review every 5y, advice reducing VTE risk- if severe
Derm referral for psoriasis?
Uncertainty, extensive>10%, mod-severe, resistant in primary care, not tolerated, severe nail disease, psych effects
Specialist treatments
Referral to rheumatologist for psoriasis? Severity tool? QOL tool? Rules of 9 for body surface area?
3/more out of 5 on PEST tool
PGA- 6 points
DLQI/ CDLQI
Arm-9%, head-9%, neck- 1%, leg- 18%, anterior trunk- 18%, posterior trunk- 18%
Lund and Browder chart
Types of psoriasis?
Pustular, erythrodermic, chronic plaque, scalp, facial, flexural, guttate, nail
Review psoriasis after how many weeks?
4 weeks, at least annually if using multiple courses potent topical corticosteroids
CV risk every 5 years, advice reduce risk VTE
Specialist tx for psoriasis? Advice?
Skin biopsy
Calcineurin inhibitors- tacrolimus and pimecrolimus- flexural/ facial psoriasis
UVB phototherapy- mild-moderate/ guttate
Severe= methotrexate, ciclosporin, acitretin, apremilast- severe plaque/ nail disease/ high-impact sites (phototherapy ineffective/CI/rapid relapse within 3 months)
Contraception, effects during conception and pregnancy, vaccines= CI, regular influenza and pneumococcal jabs
Anti-TNF for mod-severe plaque- target IL-17 and IL-23 (after phototherapy when conventional failed/ not tolerated/ CI)
Tx for flexural psoriasis? Guttate? Palmoplantar?
Topical mild-mod corticosteroids- short course
Top vit D analogue
Topical mild-mod CSs, UVB, coal tar
Emollients, salicylic acid, potent topical CSs, UVA, oral retinoid alongside phototherapy, anti-TNF only once systemic FAILED- IV inflix/ etan/ adalimumab
What is the Parkland formula for calculating fluid requirements in burns?
Total body surface area % x body weight (kg) x 4 ml
Mnemonic for multiple myeloma?
CRABBI: calcium- high/ renal- light chain deposition, amyloidosis, nephrocalcinosis, nephrolithiasis/ anaemia/ bleeding/ bones- pathological fractures/ infection
Also: carpal tunnel, neuropathy, hyperviscosity
Major and minor criteria for diagnosing multiple myeloma?(one minor and major/ three minor)
Plasmacytoma, 30% plasma cells in bone marrow sample, elevated levels of M protein in blood or urine
10-30% plasma in bone marrow sample, minor elevations in level M protein in blood or urine, low levels antibodies in blood
What is group and save and crossmatching for?
Blood loss is not anticipated but blood may be required if greater blood loss is expected- DONE BEFORE XMATCH
Mix patient with donor blood to see if any immune reaction takes place- if none, donor blood can be issued
Done if blood loss anticipated
BOTH TAKE 40 MINUTES
What is Wallace’s Rule of Nine?
Head & neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen
What are the thresholds and targets for Hb g/L in patients without and with ACS? Rate in non-urgent?
Without= 70g/L- target= 70-90
With ACS= 80g/L- target= 80-100g/L
STORED AT 4 DEGREES PRIOR TO TRANSFUSION
90-120 minutes- 3 hours with HF, urgent= STAT
Common causes of an itch with a rash? With no rash?
urticari, atopic eczema, psoriasis, scabies
Renal failure, jaundice, iron deficiency, lymphoma- Hodgkin’s, polycythaemia, pregnancy, drugs, diabetes, cholestasis, ageing
Fitzpatrick scale for skin?
1= never tans, always burns
2= usually tans, always burns
3= always tans, sometimes burns
4= always tans, rarely burns- olive skin
5= sunburn and tanning after extreme UV exposure
6= black skin, never tans/ burns
Causes of DIC? Blood picture?
Sepsis, trauma, obstetric, malignancy
Low platelets, fibrinogen, high PT & APTT, high fibrinogen deg products, schistocytes
Possible cause of pityriasis rosea? Versicolor?
HHV-6 or HHV-7
Gold, ACE-i, penicillamine, biologics
BCG, hep B & pneumococcal vaccine
Malassezia fungi
Ix and tx of pityriasis versicolor?
Wood lamp exam–> yellow-green fluorescence
Dermoscopy microscopy of skin scrapings- hyphae and yeast cells that resemble spag and meatballs
Dermoscopy= pallor- background faint pigment network
Fungal culture
Skin biopsy- fungal elements within outer cells of stratum corneum
Topical antifungal shampoo- selenium sulfide(not in pregnancy or breastfeeding,) ketoconazole/ econazole, oral if extensive/ topical ineffective
Small areas= imidazole cream
Terbinafine gel
(Refer pregnant/ breastfeeding–> derm)
Resolve within 2-3 months
Is relapse of pityriasis versicolor common?
Yes- usually when warm weather, regular use topical tx minimises risk- ket shampoo OD for max 3 days prior to exposure
Sx of pityriasis alba?
1-20 patches/ thin plaques on face on cheeks/ chin, may appear on neck, shoulders, upper arms
0.5-5cm diameter, slightly scaly pink patch/ plaque–> hypopigment patch/ plaque with fine surface scale–> post-inflam hypopigment macule without scale–> resolution
May have well-demarcated or/ poorly defined edges
Minimal/ absent itch
Hypopigment noticeable in summer
Dryness more in winter
Ix and tx of pityriasis alba?
Wood lamp- hypopig doesn’t enhance, no fluorescence, mycology scrapings= negative
Skin biopsy= rarely needed
No tx- maybe moisturiser, mild topical steroid, calcineurin inhibitors
USE SUNSCREEN, usually clears after one year
Cause and presentation of lichen planus(6 Ps)?
T-cell mediated AI disorder- attack unknown protein within skin and mucosal keratinocytes
Genetics, physical & emotional stress, injury–> skin, herpes zoster, hep C, contact, drugs- gold, quinine, quinidine, others–> lichenoid rash, vit D deficiency
10%= nails, 50%= oral- W>M
Pruritic- not painful, purple- except palms and soles= yellowish- brown, polygonal, planar, papules and plaques- interspersed with Wickham striae
Often wrists, lower back and ankles, also genitals
Ix and tx lichen planus?
Clinically- skin biopsy often recommended(lichenoid tissue reaction affecting epidermis), patch testing for oral those affecting gums & amalgam fillings
Avoid soaps and shower gels, use emollients regularly, sedating antihistamines
MOST RESOLVE WITHIN COUPLE YEARS
Drugs causing lichenoid eruption? Fixed drug eruption?
Absent Wickham’s striae, usually 2m before, affects trunk, ACE-i, BBx, nifedipine, diuretics- thiazide, NSAIDs, anticonvulsants, TB meds, antifungals, hydroxychloroquine, gold, allopurinol, tetracyclines
Quinine
MOST RESOLVE BY 12M SPONT
Paracetamol, tetracyclines, sulfonamides, aspirin
Types lichen planus?
Planopilaris, nail, oral, cutaneous, pigmentosus, actinicus- sunlight, lichenoid drug eruption, bullous & pemphigoides
Ix and tx or vitiligo?
Wood’s lamp= enhances white patches
Dermoscopy= white glow
Skin biopsy sometimes
Blood tests- other autoimmune e.g. TFTs, ANA and B12 levels
Loose fitting clothing, cosmetic camouflage, sun protection, topical CSs, calcineurin inhibitors
Topical vitamin D derivatives
Ruxolitinib cream- JK1 and JK2 inhibitor, topical tacrolimus, phototherapy- UVB twice weekly for 3-4 months
ABPI values indicating arterial disease? Features and tx venous ulcers?
Below 0.9, >1.3
Diabetes, RA, vasculitis, SCD, malignancy, drugs- nicorandil, corticosteroids, NSAIDs, radiotherapy, hydroxycarbamide, varicose veins, DVT
Gaiter area- ankle–> mid calf, chronic venous changes, after minor injury larger than arterial, more superficial than arterial, irregular gently sloping border, more likely to bleed, less painful than arterial, pain relieved by elevation and worse on lowering, pulses present
Normal ABPI, Doppler exclude arterial disease- every 6-12 months
Clean and dress wound, high compression 4 layered bandage, leg elevation, ABx for infection, analgesia, support stockings for life
Pentoxifylline improves healing- NOT LICENSED
Regular walking, avoiding leg trauma, emollient frequently
No healing after 2 weeks comp therapy= specialist referral
Recurrent ulcer= refer for superficial venous surgery
Comps venous ulcers?
Allergic contact dermatitis, infection- osteomyelitis, sepsis, nec fas, chronic pain, malignant transformation= Marjolin’s ulcer, sinus formation and fistula
In hx- ASK ABOUT LATEX ALLERGY
Sx and Ix of arterial ulcers?
Feet, heels or toes, from diabetes, smoking, high blood fat and cholesterol, renal failure, obesity, RA, clotting and circulation disorders, other arterial disease
Typically punched out out appearance, painful- particularly at night or when the legs are at rest and elevated, may be areas of gangrene, cold with no palpable pulses, smaller than venous ulcers, well defined borders, less likely to bleed, NO OEDEMA
Low ABPI measurements<0.9, severe=<0.5
Bloods- FBC, CRP, HbA1C, CRP, charcoal swab- infection, skin biopsy in suspected skin cancer- 2 week wait referral
CRT, Buerger test, Doppler- transcutaneous oximetry<20mmHg= severe insufficiency
Tx arterial ulcers?
Lifestyle- stop smoking, change diet to reduce blood lipids and cholesterol and blood sugar, wound care, tx wound infection
Skin grafting/ skin flap
Sx, Ix and tx of neuropathic ulcers?
Often painless, abnormal sensation, hx diabetes/ neuro disease
Pressure sites
Variable size and depth, granulating base, may be surrounded/ underneath hyperkeratotic lesions
Warm skin, normal peripheral pulses, peripheral neuropathy
ABPI<0.8 neuroischaemic ulcer, XR exclude osteomyelitis
Wound debridement
Regular repositioning, footwear, good nutrition
Vasculitis causing ulcers? Causes? Tx?
LCV/ angiitis–> symmetrical palpable purpura- don’t blanch with pressure from glass slide
Idiopathic, drugs, infection, inflammatory disease, malignant disease, often settles spont
Analgesia, support stockings, Dapsone/ prednisolone
Which layers does TEN affect? Drugs causing? Sx and tx?
Between epidermis and dermis>30% body surface area(10-30%= mixed TEN/ SJS,) +ve Nikolsky’s sign, pyrexia, tachycardia
Phenytoin, sulfonamides, allopurinol, penicillins, carbamazepine, NSAIDs
Herpes simplex, mycoplasma pneumonia, CMV, HIV
Stop prec factor, supportive in burns unit/ICU-IVIG recommended, immunosuppressants, plasmapheresis
Can lead to infection, permanent skin damage, visual comps
Sx and tx of SJS? Comps?
Vague upper respiratory tract sx occur 2–3w after starting a drug and 2 days before a rash that affects <10% body surface
Signs: Painful erythematous macules evolving to form target lesions
Severe mucosal ulceration of ≥2 surfaces eg conjunctivae, oral cavity, labia, urethra
Tx= same as TEN- supportive
Secondary infection- cellulitis & sepsis, perm skin damage, visual complications
Epi, cause, sx, Ix and tx erythema multiforme?
20-40y/o
Herpes simplex, mycoplasma pneumoniae, sulfonamides, antiepileptics
Cytotoxic T cells inhibit apoptosis of keratinocytes
HLA-DQB1 0301 allele
Target lesions peripheries–> centrally usually symmetrical extensor surfaces, may be painful, pruritic or swollen, x3 concentric rings
Favours oral membranes
Comp blood exam, LFTs, ESR, serology, CXR, skin biopsy- histopath and direct immunofluoro
Self-resolve within 4 weeks
Eyes can–> keratitis, conjunct scarring, uveitis, perm visual impairment- OPH REFERRAL
Recurrent= 6m aciclovir
What is erythroderma? Causes? Erythrodermic psoriasis?
When more than 95% of the skin is involved in a rash of any kind, M>F, any age
Eczema, psoriasis, drugs e.g. gold, lymphomas, leukaemias, idiopathic
May result from progression of chronic disease to an exfoliative phase with plaques covering most of the body- ass w/ systemic upset, scaling 2-6 days after onset of erythema as fine flakes or large sheets
May be triggered by withdrawal of systemic steroids
Blood count- anaemia, white cell count abnormalities, eosinophilia, hypoalbuminaemia, >20% Sezary cells–> Sezary syndrome
Need admitting- emollients, wet-wraps, topical steroids
Secondary infection, fluid loss, electrolyte imbalance, hypothermia, high-output cardiac failure and capillary leak syndrome
Ass w/ necrotising fasciitis? PP?
DIABETES, CKD, cirrhosis, chronic HF, obesity, alcohol abuse, SLE, immunodeficiency e.g. due to HIV, chemo regimes
Trauma/ wound: type 1- polymicrobial multiple anaerobic on trunk/ perineum- diabetics post-op
II= monomicrobial s.pyogenes- younger patients affecting limbs> trunk
III= clostridium species also vibrios species in IV drug users
IV= fungal candida in immunocompromised aggressive and extensive
Layers, features, Ix and tx nec fasc?
Initially spares skin- SC tissue and fascia–> swelling, pain, erythema, induration, pain severe and exaggerated compared to normally suspected from soft tissue infection, blistering & bullae, failure to respond–> broad-spec ABx
Grey dusky skin–> crackling feeling to touch, D&V, tachy, fever, hypotension, tachypnoea, signs sepsis
Crepitus- SC emphysema
Perineal, genitalia, perianal= Fournier gangrene
Ix and tx nec fasc?
Soft tissue gas on XR, raised CRP, very raised WCC, tx aggressively and promptly- surgical debridement
Broad spec ABx- IV fluclox, IV benz, IV metronidazole, IV clindamycin, IV gentamicin
Factors involved in LRINEC scoring system for nec fasc?
Hb>13.5-0, <11-2
WCC-<15= 0, 15-25-1, >25-2
Na+<135- 2
Creatinine>141-2
Glucose>10- 1
CRP>150- 4
Wound culture, plain X-rays, CT & MRI imaging, incisional biopsy w/ frozen section evaluation
Positive finger test
What does cellulitis affect? Cause?
The dermis and deeper SC tissues
S.pyogenes or less commonly s.aureus
Venous insufficiency and PVD
Obesity
Skin breaks
Lymphoedema
Previous cellulitis
Surgery–> lower limb including saphenectomy
Tinea pedis
Skin conditions disrupting dermis- eczema, psoriasis, chronic venous ulcers, T2DM, IVDU, alcoholism, immunosuppression, pregnancy
Features of cellulitis? Classification for managing?
Commonly on shins- usually unilateral, erythema, blisters & bullae with more severe disease, systemic- fever, malaise, nausea
Eron classification:
1= no signs systemic toxicity or uncontrolled comorbidities
2= systemically unwell/ well with a comorbidity
3= systemic upset/ limb-threatening infection due to vascular compromise
4= sepsis/ life-threatening infection e.g. nec fasc
Ix cellulitis? Tx for cellulitis?
FBC- leucocytosis/ neutrophilia, U&Es, CRP or ESR, blood cultures
Admit class III or class IV cellulitis, severe/ rapidly deteriorating cellulitis, very young<1 y/o or frail, immunocompromised, significant lymphoedema, facial cellulitis/ periorbital cellulitis–> IV co-amox- for near eyes or nose/ clindamycin/ cefuroxime/ ceftriaxone
MRSA= vancomycin/ teicoplanin/ linezolid
Other= oral antibiotics- flucloxacillin/ clari/ erythromycin/ doxy if PenA/ pregnancy
Mark area erythema, elevate the leg, paracetamol/ ibuprofen for pain/ fever
Might–> systemic infection, SC abscess formation, myositis, fasciitis, possible recurrence, death
What does erysipelas affect? Causes? Presentation?
Dermis and upper SC tissue
S.pyogenes and s.aureus
Immunosuppression, wounds, leg ulcers, toeweb intertrigo, minor skin injury
Most lower limbs, swelling, erythema, warmth, lymphangitis, syst unwell, abrupt in onset
Infants= umbilicus/ diaper/ napkin region
WELL-DEFINED RED BORDER
Ix, tx and comps of erysipelas?
Clinically, bloods, cultures- raised WCC, CRP, MRI & CT for deep infection
Cold packs and analgesics, elevation, compression stockings, wound care w/ saline dressings frequently changed
Oral/ IV flucloxacillin/ ery in allergy, facial by MRSA- vancomycin for 10-14 days
Long term penicillin tx for recurrence, abscess, gangrene, thrombophlebitis, chronic leg swelling, IE, septic arthritis, bursitis, tendonitis, post-strep GN, cavernous sinus thrombosis, strep toxic shock syndrome
Who gets erythema annulare centrifugum/ marginatum?
Most often in 40 years old- cutaneous fungal infection, internal malignancy, adverse reaction–> medications, pregnancy, haem disorders, endocrine disorders, rheumatic disease
Blue cheese, tomatoes, stress
Sx, Ix and tx of erythema annulare centrifugum/ marginatum?
Thighs, buttocks and upper arms- small pink papule gradually enlarges over several weeks–> annular plaques with central clearing, can vary in size
Outer erythematous edge with inner scaly edge, may be itchy
Clinically, skin biopsy
Toenail clippings and skin scrapings for mycology if onychomycosis, tinea pedis or tinea corporis
What is erythema marginatum?
Annular erythema in about 10% first attacks of ARF in children- rare in adults
Trunk and upper arms and legs
Pink/ red macules or papules spread outwards in circular shape–> raised and red, centre clears, not itchy or painful
May persist for weeks to months- even after successful tx
What is Lyme disease caused by? Rash? Comps?
Borrelia burgdorferi bacteria from woodland and fields, increased duration tick attachment (Ixodes tickets- scapularis in USA and ricinus in Europe)
Erythema migrans- bull’s eye rash within 30 days usually painless >5cm + flu-like- fever, malaise, joint aches–> neuro, cardiac and MSK involvement
Also facial nerve palsy, meningitis, carditis w/ heart block and migratory joint pain
Late= chronic arthritis, encephalopathy, or peripheral neuropathy
Ix for Lyme disease?
Clinically if erythema migrans present- indication to START ABx
ELISA antibodies to Borrelia burgdorferi 1st-line test
If negative and still suspected- repeat in 4-6 weeks, >12w–> immunoblot test- negative–> refer to specialist
Tx for Lyme disease?
Remove tick using fine-tipped tweezers grasping tick as close to skin as possible and pulling upwards firmly, washed following
NOT FOR TICK BITE BUT LYME- doxy if early disease, amoxicillin if doxy CI(pregnancy)
Disseminated disease= ceftriaxone
Jarisch- Herxheimer reaction sometimes seen after initiating- fever, rash, tachycardia after 1st dose- more commonly seen in syphilis
Comps of Lyme disease? Prevention?
Severe neuro sx, acrodermatitis chronica atrophans, Lyme arthritis, post-tx Lyme disease syndrome
Avoid areas, wear white clothes in high grass/ woodland with long sleeves, trousers tucked in, repellents/ pesticides, change clothes after, check body for ticks, remove tick, watch site for several weeks
What is scabies caused by?
Sarcoptes scabiei- infestation with low number of mites
Crusted(Norweigan)= hyperinfestation with 1000s/ millions mites in exfol scales skin
Close contact, high levels poverty and social deprivation, crowded living conditions, winter months
Crusted= immunosuppression, reduced ability to scratch, learning difficulties/ neuro disorders, elderly
Sx, Ix and tx of scabies?
Intense pruritus due to delayed- type IV HS reaction–> mites/ eggs about 30 days after initial infection
Linear burrows on side of fingers, interdigital webs and flexor aspects of wrist
Infants= face and scalp
Excoriation, infection
Hx & exam Ix–> skin scraping biopsy
Tx of scabies?
Permethrin 5% = 1st-line
Malathion 0.5%= second line
Pruritus= up to 4-6 weeks
Avoid close contact until tx is complete, household and close contacts= tx at same time
Launder, iron or tumble dry clothing, bedding, towels etc on 1st day of tx
Cool, dry skin- fingers & toes, under nails, armpit area, creases of skin- wrist and elbow, dry and leave on skin for 8-12 hours permethrin/ 24 hours malathion before washing off
Reapply if removed during tx period, repeat tx 7 days later
Crusted= cons dermatologist, Ix for immunodeficiency
What is erythema nodosum?
Inflammatory affecting SC fats–>
tender red nodules on anterior shins
<thighs and forearms
Most= 25-40 ass w/ infection, drug, inflam condition/ malignancy- strep/ viral infection, primary TB, Yersinia, chlamydia, fungal- mycoplasma pneumonia, parasitic, sarcoidosis, IBD
Sx, Ix, comps and tx of erythema nodosum?
Fever & joint pain
Resolve within 6w
Encapsulated fat necrosis
Inflammation of septa between SC fat lobules without vasculitis–> bruise-like discolouration as resolve
FBC, CRP, CXR, throat swab, viral serology, stool culture and evaluation for ova and parasites, Mantoux test, deep incisional/ excisional skin biopsy
Colchicine, NSAIDs, venous comp therapy, sys CSs, oral KI-
What is pyoderma gangrenosum?
Rapidly growing, very painful recurring nodulo- pustular ulcers, with tender red/ blue overhanging necrotic edge Often preceded by a tender pustule
Site: leg; abdomen; face. 50%= idiopathic, myeloproliferative disorders/ lymphoma/ myeloid leukaemias/ IgA monoclonal gammopathy, granulmatosis with polyangiitis, IBD- UC/ Crohn’s, RA/ SLE, PBC
Isotretinoin, propylthiouracil and sunitib
PP, sx pyoderma gangrenosum?
Neutrophilic dermatosis- dense infiltration of neutrophils in affected tissue often seen on biopsy
Typically lower limb soften site of minor injury- pathergy where skin prick test causes papule/ pustule/ ulcer, often starts suddenly small pustule, red bump or blood-blister, later= ulcer often painful, edge often purple, fever & myalgia
Tx pyoderma granulosum?
Oral steroids, immunosuppressives for larger ulcers- ciclosporin and infliximab, prednisolone, baricitinib, postpone surgery until controlled
Skin grafting once active disease settled
Expert wound care, pain management, taper systemic therapy over several months
Avoid trauma to trigger new ulcer
What is bullous pemphigoid?
Type II HS reaction to hemidesmosomal proteins BP180- type XVII collagen and BP230- dystonin
Elderly
Pruritus, erythematous plaques, urticarial lesions, large tense blisters w/ serous/ haemorrhagic fluid around flexures trunk and limbs, severe= mucosal, Nik sign -ve
Ix and tx of bullous pemphigoid?
Skin biopsy- immunfluorescence shows IgG and C3 at dermoepidermal junction
Derm referral for biopsy and confirmation
Oral corticosteroids
Topical corticosteroids, immunosuppressants and ABx
What is pemphigus vulgaris?
Blistering affects middle-aged
Auto-ABs against antigens within epidermis targeting desmoglein proteins
Painful, usually mucosal flaccid bullae
Nik often +VE
Often trunk, face, scalp and intertriginous areas
Can–> cellulitis, impetigo/ sepsis, hyperpigmentation/ scarring, nutritional deficiencies, dysphagia
Presentation basal cell carcinoma?
Most common malignant skin cancer- ulcer with raised rolled edge, prominent fine blood vessels around lesion or nodule on skin
Non-pigmented in 95%- can resemble melanoma when pigmented
Most in elderly on head and neck
Ulcerate= rodent ulcer
Tumour basal keratinocytes
Later in life, less metastatic and aggressive than SCC
Slow growing
Locally invasive
Tx BCC?
Routine referral
Surgically excised with wide borders and histology
Superficial= cryotherapy, photodynamic therapy, radiotherapy unable tolerate surgery
RFs for leukaemia?
Down’s syndrome, Klinefelter syndrome, Noonan syndrome, Fanconi’s anaemia
Li Fraumeni syndrome
Ataxia telangiectasia
Nijmegen breakage syndrome
Exposure to ionising radiation
Pesticides
Viruses such as Epstein-Barr virus (EBV), human immunodeficiency virus (HIV)
Comps of chemo for leukaemia?
Failure to treat the leukaemia, stunted growth and development, immunodeficiency and infections, neurotoxicity, infertility, secondary malignancy, cardiotoxicity
Sx leukaemia?
Fatigue, malaise, bone and joint pain- legs, dyspnoea, dizziness & palpitations, recurrent and/ or severe infections, fevers, thrombocytopenia- bleeding tendency
Wt loss, pallor, petechial rash, bruising, tachycardia, flow murmur, distension, hepatomegaly and/ or splenomegaly, lymphadenopathyU
Urgent specialist assessment/ FBC within 48 hours when?
Unexplained petechiae, hepatosplenomegaly
Pallor, persistent fatigue, unexplained fever, persistent infection, generalised lymphadenopathy, unexplained bruising/ bleeding, persistent/ unexplained bone pain
Ix for leukaemia?
FBC, blood film, bone marrow biopsy- diagnosis and monitoring/ minimal residual disease- blast cell count<5% for “remission,”- presence= more intensive chemo lymph node biopsy
CXR, CT, LP, genetic analysis and immunophenotyping- disease classification
Tx and comps leukaemia?
ECHO- prior to chemo, radiotherapy BM transplant, surgery
Failure to treat, stunted growth and development, immunodeficiency and infections, infertility, secondary malignancy, cardiotoxicity
Classification of ALL & AML?
FAB- morphology and cytochemical staining of leukaemic cells
WHO- cytogenetics and immunogenotyping
Chemo regimen in ALL?
Induction- 4-6w hydration and allopurinol/ rasburicase to prevent tumour lysis syndrome
LP w/ intrathecal methotrexate prevent spread–> CNS
Delayed intensification
Tx 2y in girls and 3y in boys- oral or IV chemo, steroids and intrathecal tx
Tx regimen for AML?
Induction destroy leukaemic cells- post-remission tx= x2 further courses chemo destroy residual cells, bone marrow tests following
Also BM transplant, testicular radiotherapy, CNS treatments
Supportive: education, broad-spec ABx, proph antimicrobials, blood transfusions, allopurinol, insertion of central venous catheter for chemo and blood sampling, G-CSF support cell counts, psychosocial support
Comps leukaemia?
Neutropenic sepsis, thrombocytopenia, blast cell lysis, leucostasis, CNS infiltration
CS SEs, tumour lysis syndrome, mucositis, GI inflammation, renal and hepatic toxicity, neurotoxicity, VTE, alopecia
Secondary, avascular necrosis, cardiotoxicity, reduced GH, fertility issues
Electrolytes in tumour lysis syndrome? Tx?
High PO43-, high potassium, hypocalcaemia, hyperuricaemia
AKI, cardiac arrhythmias, N&V, seizures
Proph hydration and allopurinol prior to chemo
Rasburicase if WCC>50- breaks down uric acid
What causes most cases anaemia in infancy?
Physiological anaemia of infancy
Anaemia of prematurity, blood loss, haemolysis, twin-twin transfusion
Haemolysis= haemolytic disease of newborn ABO/ resus incomp
HS, G6PD deficiency
Causes anaemia in older children?
Iron deficiency secondary to dietary insufficiency, blood loss- menstruation in older girls, sickle cell, thalassaemia, leukaemia, HS, hereditary eliptocytosis, sideroblastic anaemia
Helminth infection- roundworms, hookworms or whipworms in developing countries–> albendazole or mebendazole single dose
TAILS microcytic anaemia? 3 As and 2 Hs for normocytic anaemia?
Thalassaemia, anaemia of chronic disease, iron deficiency anaemia, lead poisoning, sideroblastic anaemia
Acute blood loss, aplastic anaemia, haemolytic anaemia, hypothyroidism
2 types macrocytic anaemia? Causes?
Megaloblastic- B12, folate def
Normo= alcohol, reticulocytosis, hypothyroidism, liver disease, drugs- azathioprine
Sx anaemia?
Tiredness, SOB, headaches, dizziness, palpitations, worsening of other conditions
Pica- dietary cravings for abnormal things, hair loss
Pale skin, conjun pallor, tachy, raised RR
Signs of anaemia?
Koilonychia, angular chelitis, atrophic glossitis, brittle hair and nails, jaundice in haemolytic, bone deformities
Ix anaemia?
FBC, blood film, ret count, ferritin, B12 and folate, bilirubin, direct Coombs test- AI haemolytic, Hb electrophoresis
How does TIBC and transferrin change with iron def/ overload? Relationship between ferritin and TIBC?
Both increase in def
Decrease in overload
Inverse
Inheritance and cause of hereditary spherocytosis? Sx?
Autosomal dominant
Jaundice, anaemia, gallstones, splenomegaly
Haemolytic crises often triggered by infection, aplastic crisis–> anaemia, haemolysis & jaundice–> high reticulocytes
Aplastic= no ret response- PARVOVIRUS TRIGGER
Ix HS, tx?
Family hx and clinical features, spherocytes on blood film, MCHC raised on FBC, high reticulocytes & uric acid
Folate, splenectomy, cholecystectomy, transfusions may be needed during acute crises
Ix in iron def anaemia? Tx in children?
Low MCV, serum iron, transferrin, ferritin, high TIBC
Input from a dietician- ferrous sulfate/ fumarate unsuitable if malabsorption
Defective synthesis what in sideroblastic anaemia?
Protoporphyrin synthesis–> lack of haem
Congenital= ALAS, also Wolfram’s syndrome
Acquired= alcoholism, lead poisoning, vitamin B6 def- co-factor for ALAS, myeloma, polycythaemia rubra vera, myelosclerosis, leukaemias
Hepatosplenomegaly in 1/3-1/2 people, anaemia, infection, bruising, haemorrhage
Ix in sideroblastic anaemia? Tx?
FBC, serum ferritin and iron levels, blood film, BM biopsy–> iron deposition and ringed sideroblasts
High iron, high %, high ferritin, low TIBC
Avoid alcohol or other toxins, chelation therapy after 20-25 units of red cells, reduce vitamin C intake
EPO, G-CSF, hereditary- pyridoxine(vitamin B6)–> peripheral stem cell transplantation
What does thalassaemia affect?
Ix findings? S&S?
Globin gene- alpha or beta + severity- major, minor or trait(both autosomal recessive)
Microcytic anaemia-LOW MCV, fatigue, pallor, jaundice, gallstones, splenomegaly, poor growth and development, pronounced forehead and malar eminences
Ix for thalassaemia?
FBC, Hb electrophoresis globin abnorm, DNA for genetics, pregnant= screening at booking
Monitor ferritin levels
Iron overload in thalassaemia?
Fatigue, liver cirrhosis, infertility, impotence, HF, arthritis, diabetes, osteoporosis & joint pain
Ch for alpha and beta thalassaemia? Tx alpha?
Ch 16, Ch 11
Monitor FBC, comps, blood transfusions, splenectomy, BM transplant
3x types Beta thalassaemia?
Minor, intermedia, major
Mild microcytic anaemia, only need monitoring- isolate microcytosis & mild anaemia, ferritin= usually normal or high
More significant microcytic anaemia- monitoring and occasional blood transfusions- may need iron chelation
Severe anaemia@3-9m age and failure to thrive, reduced MCHC, increased reticulocytes, splenomegaly, bone deformities
Regular transfusions, iron chelation- desferrioxamine via SC pump over 2-5 days each week/ deferiprone orally in x3 divided doses/ desferasirox–> 3m ferritin, annual cardiac/ liver T2 MRI, endocrine tests, audiology and ophthalmology, hydroxycarbamide to boost HbF levels, splenectomy, BM transplant from sibling or matched unrelated donor
Anisopoikilocytosis, target cells and nucleated RBCs, teardrop cells
x2 defective copies alpha-thalassaemia trait? x3? x4?
Trait- mild asymp anaemia
HbH disease- microcytic anaemia, haemolysis, splenomegaly, normal survival, hydrops fetalis
Comps B-thalassaemia?
Cardiomyopathy, cardiac arrhythmia/ cardiac failure, AF= older
Acute sepsis- CV catheter infection- broad-spec ABx
Liver cirrhosis, portal HTN and acute deocmp
Endocrine- hypocalc w/ tetany, diabetes, iron overload
Death= usually HF
Screening for thalassaemia?
Gen counselling and prenatal testing for homo and heterozygous
Test partner if patient has
FOQ and FBC and if required of father too
If maternal<27pg, iron studies and HPLC are performed- if negative–> DNA studies/ analyses for alpha-thalassaemia
Major= CVS sampling
Most common cause iron def in adults? Causes raised ferritin? Ix? Tx?
Blood loss- menorrhagia, GI tract
Cancer, oesophagitis, gastritis, peptic ulcers, IBD, angiodysplasia
Inflammation, liver disease, iron supplements, haemochromatosis
Colonoscopy and OGD
Oral–> const and black stools, infusion–> allergic reactions, transfusion
Causes of anaemia of chronic disease?
Autoimmune, IBD, chronic- TB, HIV, osteomyelitis, malignancies, CKD, CLD- hepcidin release altered due to IL-1 and IL-6
Ix and tx in anaemia of chronic disease? Tx?
FBC- low Hb and MCV
Blood film- thrombocytosis in chronic haemorrhage
Serum iron- low iron, normal/ high ferritin
CRP & ESR
BM aspiration and biopsy
EPO stimulating agents
Hb in sickle cell disease?
HbS- autosomal recessive, affecting beta-globin on Ch11, one abnormal= sickle-cell trait
More likely to survive malaria
Ix in sickle cell anaemia?
High reticulocytes, high serum uric acid, blood film- sickling erythrocytes and features of hyposplenism including target cells and Howell-Jolly bodies
Comps sickle cell disease?
Anaemia, increased infection risk, CKD, sickle cell crises, acute chest syndrome, stroke, avascular necrosis in large joints, pulmonary HTN, gallstones, priapism
Most common sickle cell crisis? Also? Tx?
Vaso-occlusive–> distal ischaemia
Pain in swelling in hands and feet also chest, back and other areas, fever, priapism
Sickle cell crises- low threshold admission–> hospital, keep warm, good hydration, analgesia- avoid NSAIDs in renal impairment
Splenic crises in sickle cell can lead to what? Tx?
Severe anaemia and hypovolaemic shock
Supportive, transfusions and fluid resus, hypsplenism, infection susc due to encapsulated bacteria- s. pneumoniae and h.influenzae
Splenectomy prevents crises
Significant anaemia? Management?
Aplastic- supportive- resolve within around week
Acute chest syndrome caused by what? Tx?
Vessels supplying lungs become clogged w/ RBCs- can be triggered by VO crisis, fat embolism or infection
Fever, SOB, CP, cough and hypoxia–> pulm infiltrates on CXR
Analgesia, good hydration, ABx, antivitals, blood transfusions for anaemia, incentive spirometry, resp support w/ O2, NIV or mechanical ventilation
General tx for sickle cell disease?
Avoid triggers for crisis, up to date vaccines, ABx prophylaxis, hydroxycarbamide, crizanlizumab= MAB tagrets P-selecti, blood transfusions, BM transplant
Cause, sx, Ix and tx of paroxysmal nocturnal haemoglobinuria?
Reticulocyte normal, serum uric acid increased
Activation clotting cascade on RBCs
Red urine morning- Hb and haemosiderin, anaemia, thrombosis & smooth muscle dystonia
Eculizumab/ BM transplantation= MAB vs C5
Inheritance of G6PD? Ix?
X-linked recessive–> crises triggered by infections, meds or broad beans
Increased reticulocytes
Increased serum uric acid
Sx, Ix and tx G6PD?
Neonatal jaundice, anaemia, intermittent jaundice, gallstones, splenomegaly
Blood film–> Heinz bodies, bite and blister cells may be seen
G6PD enzyme assay
Avoid triggers- primaquine, ciprofloxacin, nitro, trimeth, sulfonylureas, sulfasalazine and other sulfonamides
Aplastic anaemia characterised by what? Causes?
Pancytopaenia and hypoplastic bone marrow
Idiopathic, Fanconi anaemia, dyskeratosis congenita
Drugs- cytotoxics, chloramphenicol, sulf, phenytoin, gold
Toxins- benzene
Parvo, hepaitis, radiation
Sx and tx aplastic anaemia?
Normochromic normocytic anaemia, leucopenia, thrombocytopaenia, minority–> paroxys noc haemoglobinuria or myelodysplasia
Blood products, prevention and tx of infection
ATG and ALG- steroid cover given, immunosuppression, stem cell transplant
Causes haemolytic anaemia?
HS, hereditary elliptocytosis, thalassaemia, sickle cell anaemia, G6PD
AI
Alloimmune- transfusion & haemolytic disease newborn, paroxysmal nocturnal haemoglobinuria, microangiopathic, prosthetic valve-related
Sx and Ix haemolytic anaemia?
Anaemia, splenomegaly, jaundice, FBC- normocytic, blood film= schistocytes, direct Coombs= AI haemolytic anaemia
Drugs- methyldopa, penicillin
Types of immune haemolytic anaemia? Ix findings?
IgG-mediated- extravascular
IgM-mediated- intravascular
Increased reticulocytes, increased serum uric acid
Types autoimmune haemolytic anaemia? Tx?
Warm- more common, at normal or above-normal temps, usually idiopathic
Cold-reactive/ cold agglutinin disease<10 degrees,–> agglutination
(due to lymphoma, leukaemia, SLE & infections)
FBC, reticulocytosis, blood film, LFTs= raised bilirubin, raised LDH, raised urinary urobilinogen, DAT, electrophoresis, blood film examination
Blood transfusions, pred, rituximab, splenectomy
2x scenarios alloimmune haemolytic anaemia?
Transfusion reactions and haemolytic disease of newborn- prev by anti-D prophylaxis
Causes of non-autoimmune haemolytic anaemia?
Microangiopathic
PNH
Physical lysis
HUS
DIC
Cause of microangiopathic HA? Blood film?
Destruction of RBCs through circulation- HUS, DIC, TTP, SLE, cancer
Schistocytes
Meds reducing B12 absorption? Ix? Neurological symptoms? Ix?
PPIs and metformin
Antibodies vs parietal cells/ intrinsic factor, FBC- high LDH, low reticulocytes, blood film- circulating megaloblasts, megaloblastic changes in bone marrow, megaloblastic changes in bone marrow, serum cobalamin & MMA and Hcy- elevated
HoloTC
Peripheral neuropathy, loss virbation sense, proprioception, visual changes, mood and cognitive changes
IF antibodies, gastric parietal cell antibodies
Tx B12 def? Maintenance?
4 micrograms/d
More animal products, urgent referral- haem, GI, dietetic issues
No neuro sx= IM hydroxocobalamin x3 weekly for 2 weeks, maintenance= 1mg x2 a year diet-related, non-diet related= once every 2-3 months
Neuro sx= alternate days until no further improvement
2-3 monthly injections for life
Oral cyanocobalamin/ twice-yearly injections
Check FBC within 7-10 days, no response= check serum folate, iron and folate 8 weeks after- MCV should be within normal range
Giving folic acid when B12 def can lead to what? Signs of late B12 def?
Subacute combined degeneration of the cord–> extensor plantar, brisk knee reflex, absent ankle jerk, tone & power reserved, UMN signs lower limbs
MRI- inverted V, pairs of binocular and dot signs
Pallor, petechial rash, glossitis, angular cheilitis
Severe= HF, hepatomegaly, splenomegaly
Issues with pernicious anaemia?
Increased risk gastric cancer, spont abortion, IUGR, LBW, neural tube defects, temporary infertility
Drugs causing folate deficiency? Ix? Causing non-megaloblastic macrocytic anaemia?
Hydroxycarbamide, azathioprine, cytosine arabinoside, azidothymidine
Increased serum homocysteine, normal serum MMA
Liver disease, alcohol, hypothyroidism, myelodysplastic syndrome, hypothyroidism, pregnancy- mild macrocytosis
Blood film and FBC show what in macrocytic anaemia? Also what?
Hypersegmented neutrophils
TFTs, LFTs, antibodies, bilirubin, DAT testing, LDH
Fraser guidelines and Gilick competency apply to what? Fraser guidelines?
Fraser= contraceptive advice, Gillick= general issues
the young person understands the professional’s advice
the young person cannot be persuaded to inform their parents
the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment
unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer
the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent
Causes of biliary atresia? Sx?
Genetics and environmental factors
Prolonged jaundice >14 days in term babies and 21 in premature babies
Differentials of jaundice in newborn? Neonatal hepatitis?
Alagille syndrome- peripheral pulmonary artery stenosis and facial features
Choledochal cyst- abdo pain, jaundice and abdominal mass
Jaundice, hepatosplenomegaly and elevated liver enyzmes
Inborn errors of metabolism- galactosemia and tyrosinemia–> jaundice, poor feeding and developmental delay
Ix for biliary atresia?
Bloods- raised conjugated bilirubin and deranged LFTs- raised GGT
USS- triangular cord sign, hepatic artery changes, gallbladder ghost triad
Hepatic scintigraphy- poor excretion–> the bowel & good hepatic uptake
Abdominal USS- echogenic fibrosis
Cholangiography- fail to show architecture of biliary tree
Tx biliary atresia? Comps?
Surgical- hepatoportoenterostomy Kasai procedure by 45 days of life- new pathway from liver–> gut bypasses fibrosed bile ducts, ABx and bile acid enhancers following surgery
Liver transplant may be required in end-stage liver failure w/ pruritus & coagulopathy, portal HTN & comps, growth retardation non-responsive to intensive nutritional support
Ascending cholangitis and portal HTN
Comps and types biliary atresia?
Unsuccessful anastomosis formation, progressive liver disease, cirrhosis with eventual HCC
1= patent proximal ducts, atresia of common bile duct
2= atresia of CBD and hepatic duct
3= atresia of almost all extrahepatic ducts including porta hepatis>90% cases
Treatments for CF who are homozygous for delta F508 mutation?
Lumacaftor/ Ivacaftor
When should meconium be passed? Other presentations ileus? Ddx? Ix?
Within 24 hours- bilious vomiting, abdominal distension
Not= sign of cystic fibrosis
Hirschsprung’s disease, intestinal atresia, malrotation of the bowel
AXR, blood tests, sweat/ genetic testing for CF
Tx meconium ileus?
Suctioning of airways at birth in case MAS, bowel rest and decompression for meconium ileus, ABx prevent infection, surgical in severe cases/ perforation/ peritonitis
What is meconium aspiration syndrome?
Passage of meconium from amniotic fluid–> fetal lungs- meconium in amniotic fluid
More common in post-term deliveries, hx maternal HTN, pre-eclampsia, chorioamnionitis, smoking/ substance abuse
Ddx for meconium aspiration? Ix and tx?
Hirschsprung, neonatal sepsis, intestinal atresia
Assess amniotic fluid for meconium, CXR, clinical exam for bowel obstruction signs, AXR/ USS confirm, sweat test
Immediate suctioning after birth, O2 therapy, potentially ABx
Neonatal hypoglycaemia level? Causes? Sx? Tx?
<2.6mmol/L
Preterm birth<37 weeks, maternal DM, IUGR, hypothermia, neonatal sepsis, inborn errors of metabolism, nesidioblastosis, Beckwith-Wiedemann syndrome
May be asymptomatic, jittery, tachypnoea, pallor, poor feeding/ sucking, weak cry, drowsy, hypotonia, seizures
Apnoea, hypothermia
Encourage normal feeding, monitor BG
Sx/ very low= admit–> neonatal unit, IV 10% dextrose infusion
Sx CF in neonates, infants, toddlers and older children?
Ch 7- CFTR gene F508 del mutation–> meconium ileus
Salty sweat when kissing, faltering growth, recurrent chest infections
Faltering growth, recurrent chest infections, malabsorption syndromes
Faltering growth, recurrent chest infections, malabsorption, delayed puberty onset
Other= nasal polyps, short stature, DM, rectal prolapse, male infertility- bilateral absence of vas deferens & female subfertility, biliary cirrhosis, distal intestinal obstruction syndrome
Ddx for CF?
Bronchiectasis, asthma, COPD, GORD, coeliac disease
Ix and tx CF?
Sweat test, neonatal blood spot test-raised blood immunoreactive trypsinogen–> genetics, lung functioning= obstructive, urine dip- diabetes, FBC, CRP, U&Es, fasting glucose, LFTs, vit A, C and E levels, sputum culture and sensitivity, faecal elastase, CXR, high res-CT chest, CT angiography
Daily chest physio, proph ABx, bronchodilators, dornase alfa
Regular influenza and pneumococcal vaccines
Consideration for bilateral lung transplant with end-stage pulm disease
Cause of PCD/ Kartagener’s syndrome? Sx? Ix and tx?
AR trait–> dynein arm defect
Sinusitis, situs inversus and bronchiectasis
Recurrent RT infections–> CXR, semen analysis
Sample of ciliated epithelium of upper airway through nasal brushing or bronchoscopy
Daily physio, high calorie diet and ABx
Sx infantile colic?
<5m age- recurrent and prolonged periods infant crying/ irritability, no faltering growth/ fever/ illness
Late afternoon/ evening crying, drawing up knees, clenching fists
Tx infantile colic?
Reassurance, holding baby, gentle motion, white noise, winding techniques, rest, support, continue BF wherever possible, follow-up
Cause and sx of scarlet fever? What is an outbreak classed as?
S.pyogenes- group A strep
Inc period 2-3 days- can be infectious for 2-3 weeks after onset sx- BETWEEN 2-8 Y/O
Two or more probable / confirmed scarlet fever cases attending same school/ nursery notified within 10 days of each other
Comps of scarlet fever?
Otitis media, peritonsillar abscess, acute sinusitis
Acute rheumatic fever, acute post-strep GN
Pneumonia, meningitis, streptococcal toxic shock syndrome or nec fasc
Sx scarlet fever? Tx?
Initial sore throat, fever, headache, fatigue, nausea and vomiting
Pinpoint sandpaper-like blanching rash on trunk 12-48 hours after initial sx before–> body and flexures
Possibly strawberry tongue, cerv lymphadenopathy, circumoral pallor
Urgent hospital admission if severe sx/ serious comp–> 10 days phenoxymethylpenicillin/ clarithromycin/ azithromycin, notify local health protection team within 3 days, self-care measures, follow-up not improved after 7 days
Exclusion at least 24 hours after starting ABx, avoid sharing utensils and towels
Sx of Kawasaki disease? Ix? Tx?
<5 years old
High-grade fever>5 days + 4/5 of CREAM: conjunctivitis, rash- widespread erythematous maculopapular rash and desquamation on palms and soles, oedema/ erythema of hands and feet, adenopathy- unilateral and non-tender, mucosal involvement- strawberry tongue/ oral fissures
Acute, subacute and convalescent stages
(fever, rash lymphadenopathy–> arthralgia–> coronary aneurysms regress)
FBC, LFTs, ESR, urinalysis raised WCCs
ECHO- coronary aneurysms- regular ECHOs, close monitoring, CRP & ESR
IVIg- high dose aspirin
Age affecting for transient synovitis?
3-10 w/ recent URTI
Limp, refusal to weight bear, groin/ hip pain- presents in flexion, abduction and external rotation, limited range motion- most commonly hip abduction & internal rotation, mild low grade temperature –> normal obs, afebrile
USS & joint aspirate if septic arthritis
Tx transient synovitis?
Aged 3-9 y/o= manage in primary care if limp present for <48 hours and otherwise well- need safety netting if worsen/ fever- follow up at 48 hours and 1 week
Bed rest, activity restriction, paracetamol & NSAIDs, physio
Improve after 24-48 hours and resolve within 1-2 weeks
What is Perthe’s disease? What age and gender do they get it? Sx?
Avascular necrosis of the femoral head in children
M>F- 3-10 years old
Gradual onset of limp, hip pain which may be referred to the knee
Loss of internal rotation and abduction, antalgic gait, muscle spasms, leg length discrepancy
Pain> 4 weeks
Multifactorial
Ix and tx of Perthe’s disease?
Bilateral AP pelvic X-ray and ‘frog-leg’ lateral X-ray–> sclerosis and fragmentation of the epiphysis
Arthrography under GA w/ conventional fluoroscopy for femoral head vs acetabulum, Deformity of femoral head, congruence, containment
Bone scans
<50%= conservative measures- non-weight bearing and traction
>50%/ age>8 y/o, non-surgical unsuccessful- plaster cast to keep hip abducted or even an osteotomy- risk of degenerative arthritis
Radiographic findings of Perthes’ disease?
Those of osteonecrosis- reduction in epiphysis size, lucency–> fragmentation, destruction, width femoral neck increases (coxa magna)
Stage 4= coxa plana- femoral head widening and flattening, coxa magna- proximal femoral neck deformity, “sagging rope sign”- sclerotic line running across across the femoral neck
Asymmetrical femoral epiphyseal size, increased density of femoral head epiphysis
“Crescent’s sign”- late stages= subchondral fracture
What is SUFE? Sx?
Slipped capital femoral epiphysis- head of femur displaced along growth plate
Average age 12 in boys- slightly earlier in females, M>F, >obese children, hypothyroidism, hypogonadism, AC & Hispanic
Hx minor trauma/ chemo/ radiotherapy
Vague- hip pain & limp, referred pain–> knee
Reduced ROM- particular upon hip flexion (preferred external rotation, restricted internal rotation)
+ Trendelenburg gait
Ix SUFE? Tx? Comps?
AL frog-leg X-rays- shortened, displaced epiphysis & widened growth plate, Trethowan sign- line of Klein cannot intersect epiphysis
Bloods- TFTs and GH for endocrine disorders, normal, technetium bone scan, CT & MRI
Surgery- in situ fixation with a screw, bone graft epiphysiodesis, spica cast, in situ fixation with multiple pins
Degen osteoarthritis, osteonecrosis femoral head, chondrolysis- acute cartilage necrosis, deformity, femoroacetabular impingement, limb length discrepancy
Who gets OSD? Sx?
M>F
Rep traction on tibial tubercle from patellar tendon during rapid growth periods in adolescence- also tight quadriceps muscle group and poor flexibility
Unilateral anterior knee pain localised to tibial tubercle- exacerbated by activities- severe= visible/ palpable lump over tibial tuberosity
Ddx for OSD?
Patellofemoral pain syndrome- ex by prolonged activities
Sinding-Larsen Johansson syndrome- lower pole patella rather than tibial tuberosity
Tibial tubercle fractures- acute severe pain unable to weight bear
Prepatellar bursitis- front patella pain
Ix and tx OSD? Rare comp?
ROUTINE XR NOT NEEDED- RULE OUT OTHER CAUSES
Analgesia- NSAIDs, knee pads and ice packs, exercise modification and muscle stretching exercises
Doesn’t improve/ worsen–> paediatrician or orthopaedic surgeon, consider physio referral, temporary immobilisation with a knee brace or cast
Avulsion fracture
Cause, sx and Ix septic arthritis? Tx?
Cause= s.aureus/ n.gonorrhoea/ s.pyogenes, h.influenzae, E.coli, mainly < 4 y/o, common and important comp of joint replacement- higher in REVISION SURGERY
Hot, swollen, red painful joint- hip/ knee
Refusing to weight bear
Stiffness and reduced ROM
Synovial fluid analysis- analysis, gram stain, culture, cell count, crystal analysis, may be purulent
FBC, CRP, ESR, blood cultures
XR- joint space widening/ effusion, MRI/ USS- more detailed images
Surgical drainage by arthroscopy or open surgery
Empirical antibiotics- IV typically needed initially followed by oral ABx, usually 3-6 weeks
May be drainage and washout
Cause and where does osteomyelitis affect? RFs?
S.aureus/ coag -ve staph, metaphysis of lone
Seeding from haematogenous infection/ adjacent tissues or joints, direct inoculation of infection into bone due to wound contamination
Open bone fractures, orthopaedic surgery, immunocompromised, sickle cell anaemia, HIV, TB, diabetes, PVD
Sx osteomyelitis? Ix and tx?
Refusing to use limb/ weight bear, pain, swelling, tenderness, may have low grade fever/ high if septic
MRI, bloods= raised CRP & ESR, WCCs, blood cultures, BM aspiration or bone biopsy with histology and culture
ABx minimum 4-6 weeks chronic= at least 12 weeks to 3-6 months- fusidic/ rifampicin/ vancomycin if MRSA suspected, pen allergic= clindamycin
Chronic= deferred until culture and sens results
Drainage and debridement of infected bone for chronic
What is JIA?
AI inflammation in the joints without any other cause >6 weeks in patient under age 16- systemic, polyarticular, oligoarticular, enthesitis related, juvenile psoriatic
F>M
Sx JIA?
Systemic signs followed by joint sx- fever, malaise, salmon pink rash
Joints= can be single/ multiple–> pain, swelling, stiffness, limited ROM
Systemic/ Still’s disease: salmon-pink rash, high-swinging fevers, lymphadenopathy, wt loss, joint inflammation and pain, splenomegaly, muscle pain, pleuritis and pericarditis–> raised inflam markers, platelets and serum ferritin
MAS= DIC, anaemia, low platelets, bleeding and non-blanching rash- LOW ESR
Polyarticular=>4 joints: small and large joints, minimal systemic sx= seronegative, older= often sero+ve
Oligoarticular/ pauciarticular up to and including 4 joints: single larger joint often knee or ankles more <6 y/o, anterior uveitis- refer–> ophthalmologist, no systemic sx, inflam normal or mildly elevated, ANA often +ve, RF usually negative
Enthesitis related: >6 y/o, enthesitis from repetitive strain or AI process–> MRI, HLA B27 +ve, psoriasis sx, IBD, anterior uveitis
(IP joints in the hand
Wrist
Over the greater trochanter on the lateral aspect of the hip
Quadriceps insertion at the anterior superior iliac spine
Quadriceps and patella tendon insertion around the patella
Base of achilles, at the calcaneus
Metatarsal heads on the base of the foot)
Juvenile psoriatic: sero-ve, can symmetrical affecting small joints/ asymmetrical affecting large joints–> plaques, nail pitting, onycholysis, dactylitis, enthesitis
Tx of JIA? Comps?
NSAIDs, steroids- oral, IM, intra-articular in oligo
DMARDs, biologic- TNF inhibitors
Flexion contractures- physical therapy and splinting, joint destruction–> prostheses at young age, growth failure, anterior uveitis
What is osteochondritis dissecans? Sx, ix?
Small piece subchondral bone begins to separate from its surrounding area due to disturbance to blood supply- MOSTLY IN KNEE
M>F
Swelling particularly after exercise, joint locking, decreased ROM
XR- lucencies in articular epiphysis, MRI- bone and cartilage
CT
Scintigraphy
Tx osteochondritis dissecans?
Conservative- avoid activities that ex sx
Arthroscopy- more severe- cons not yielded
Surgical intervention- screws/ drilling techniques
Sx chondromalacia patellae?
Anterior knee pain when walking up or down stairs
3:1 for F:M
5 Fs for RFs for developmental dysplasia of the hip? Method for classification of DDH severity?
Females, firstborn, family hx, frank breech, low amniotic fluid levels- more in LEFT HIP
Also torticollis
Graf method
Sx and Ix for DDH?
Different leg lengths in 3-6m, restricted abduction on one side, significant bilateral abduction, difference in knee level when hips flexed, clunking of hips on special tests- Ortolani(relocation in hip abduction) & Barlow (tests for posterior dislocation,) +Trendelenburg and toe walking may be seen>1 y/o
USS of hips esp<6 months age, X-rays can also be helpful particular in older infants
Tx DDH?
Pavlik harness if presents<6 months age- holds femoral head- keeps baby’s hips flexed and abducted
Removed usually after 6-8 weeks
Surgery when harness fails or Ix made after 6 months age- after= closed reduction and hip spica cast used
Open reduction= for children older than 2 y/o/ closed reduction is unsuccessful- femoral/ pelvic osteotomies may be needed, regular monitoring and clinical exams
What is calcaneal apophysitis (Sever’s disease) caused by?
Micro-fractures of the calcaneal apophysis at the site of attachment of the achilles tendon
Typically 8-14 y/o- commoner in more active children especially in weight-bearing sports
Sx Sever disease?
Gradual onset heel pain worse on standing and with activity typically relieved by rest- can be unilateral but often bilateral
Medial and lateral compression of the heel causes pain
May have pain on ankle dorsiflexion especially on active toe raise, mild heel swelling, calcaneal enlargement- only if chronic which is rare
Ix Sever disease? Tx?
Clinical- X ray to exclude fractures/ tumour- may be normal/ non-specific sclerosis
CT/MRI exclude osteomyelitis
Red flags= rest pain, night pain or large swelling
Conservative, avoid sports for 2 months- continue non- weight bearing exercises
Physio, footwear advice, heel pads, consider NSAIDs in severe, rarely needs orthopaedic referral
What is torticollis? Most common cause in 1st few weeks life?
A twisted/ wry neck
Sternomastoid tumour- later= muscular spasm, secondary to ENT infection, spinal tumour, CS arthritis
Sx torticollis?
Mobile non-tender nodule can be felt within the body of the sternocleidomastoid muscle
May be restriction of head turning and tilting of the head- usually resolves in 2-6 months
Muscles supporting neck on one side become painful- come on quickly often overnight- wake up with pain and stiffness down one side of your neck
Difficult to straighten neck
May spread to back of head/ shoulder
Muscles may be tender
Pressure may trigger ‘spasm’ of these muscles
Movement restricted
Ix and tx torticollis?
Clinical diagnosis
If persistent- physio helps by lengthening the muscle; surgical division is more drastic
Cause of osteogenesis imperfecta?
Mutations in COLA1 and COL1A2 genes- ALPHA CHAINS TYPE 1 COLLAGEN–> decrease amount collagen produced/ abnormal collagen molecules
AUTOSOMAL DOMINANT
Sx osteogenesis imperfecta?
x8 types
Type 1= blue sclerae- 50%= hearing loss- fractures typically before puberty
2= many fractures, blue sclera, dwarfism, recessive
3= severe, recessive, fractures at birth & progressive spinal and limb deformity–> short stature, blue/ white sclerae, transparent/ discoloured teeth
4= moderate, AD, fragile bones, white sclerae after infancy
Ix osteogenesis imperfecta? Tx?
Many fractures, osteoporotic bones with thin cortex and deformity of long bones
Immature unorganised bone with abnormal cortex on histology
Genetics, audiologic- hearing loss
Prevent injury, physio, rehab, OT, osteotomies may correct, IM rods sometimes, bisphosphonates
What is achondroplasia?
Most common form disproportionate short stature due to reduced growth cartilaginous bone
AD from sporadic mutation of FGFR3 on Ch4–> abnormal function of epiphyseal plates, 80%= spontaneous
Short digits, bow legs- genu varum, disproportiante skull, foramen magnum stenosis, flattened mid-face and nasal bridge, frontal bossing
XR= short proximal long bones and wide epiphyses
Tx= leg lengthening surgery- osteotomy- distraction (creating gap between bones)–> chronic pain and reduced function, monitoring potential comps- obesity and psychosocial comps, GH been tried
Ass w/ achondroplasia?
Recurrent otitis media, kyphoscoliosis, spinal stenosis, OSA, obesity, foramen magnum stenosis–> cervical cord compression and hydrocephalus
What is osteopetrosis?
Lack of diff between cortex and medulla of bone- failure osteoclastic bone resorption–> dense hard marble bones
Anaemia, thrombocytopaenia, deafness, optic atrophy
What is scoliosis?
Curvature of the spine in the coronal plane- lateral curvature w/ secondary vertebral rotation- Cobb angle>10^4(risk progression= higher with greater Cobb angles)–> structural and non-structural
Commonest adolescent females
Postural= disappears on manoeuvres such as bending forwards
Cause, sx and tx scoliosis?
Structural=>1 vertebral body–> idiopathic, congenital and NM in origin- not correct by posture
Idiopathic= most common
Girls more likely to progress
Severe= bil rod stabilisation of spine
Refer to measure Cobb angle
Surgery<7 y/o- attempts optimise further growth spine and lungs- older if deformity causing issues- deformity correction with spinal fusion and stabilisation
IO spinal cord monitoring prevents paralysis
EXCLUDE OSTEOID OSTEOMA, OSTEOBLASTOMA, SPONDYLOLISTHESIS AND SPINAL TUMOURS IN YOUTH PAIN AT NIGHT
Causes of kyphosis?
TC spine>40 degrees, sometimes with lordosis lumbar spine- congenital, osteoporosis, spina bifida, calve’s vertebrae, cancer; wedge fractures, TB, polio, Paget’s disease, AS
What is talipes? Equinovarus? Cause? Associations? Calcaneovalgus?
Fixed abnormal ankle position
Plantar flexion and supination- M>F, 50%= bilateral
Idiopathic- spina bifida, cerebral palsy, Edward’s syndrome, oligohydramnios, arthrogryposis
Dorsiflexion and pronation
Ix and tx of talipes? Positional/ equinovarus?
Clinical
Cons- Ponseti method- manipulation and progressive casting from birth- corrected after 6-10 weeks
Achilles tenotomy in 85% cases under local anaesthetic
Night braces until aged 4 y/o- “boots and bars”
Physio referral- resolves with time
What is discoid meniscus? Ix? Tx?
Hypertrophic and crescent shaped meniscus
Squaring lateral condyle with cupping of lateral tibial plateau on XR
MRI= Wrisberg
Obs for asymptomatic- continued pain and sx e.g. inability to extend knee= arthroscopic meniscectomy and saucerization
When is neonatal sepsis? Causes/ RFs?
Within 28 days of life- early onset within 72 hours, late-onset 7-28 days
Listeria, toxoplasma, rubella, CMV(TP,) cervical= group B strep, e.coli
Late= s.aureus, s.epidermidis, e.coli, pseudomonas, Klebsiella from genital tract/ transplacental infections or hospital/ infant’s intestinal flora in late onset
Prem birth, multiple pregnancies, prolonged rupture of membranes, maternal IP fever, GBS previous, mat temp>38 degrees, chorioamnionitis
Black= RF for group B strep-related sepsis
Sx and red flags for GBS?
Fever- more in terms/ hypothermic in pre-term, reduced tone and activity, resp distress/ apnoea, vomiting, tachy/ bradycardia, hypoxia, jaundice within 24 hours, seizures, hypoglycaemia
Confirmed/ suspected sepsis mother, shock signs, seizures, term baby needing mechanical ventilation, resp distress>4 hours after birth, presumed sepsis in another baby in multiple
Ix and tx neonatal sepsis?
2x blood cultures, FBC- abnormal neutrophils, CRP for tx progress
Blood gas- met acidosis= concerning
Urine microscopy, culture and sensitivity- more in late-onset
LP
IV benzylpenicillin w/ gentamicin/ cefotaxime- START IF SINGLE RED FLAG/ 2 OR MORE RFs WITHIN 1 HOUR DECISION MADE
BASELINE FBC & CRP
CRP 24 hours after given ABx & cultures at 36 hours- cease at 48 hours with CRP< 10mg/ L and -ve blood culture, clinically well, LP if CRP>10
Usually 10 days treatment- maintain O2, fluids, electrolytes, hypoglycaemia, met acidosis
Components to APGAR score?
Appearance, pulse, grimace, activity, respiration
Cause and ass of group B infection in pregnancy?
S.agalactiae- bowel commensal
Preterm prelabour rupture of membranes and preterm delivery
Tx of women with previous group B infection? Swabs timing? When else is IAP offered? What AB?
Told risk is 50%- offer intrapartum ABx prophylaxis (IAP) or testing in late pregnancy and then ABx if still positive
35-37 weeks / 3-5 weeks prior to anticipated delivery date
In preterm labour regardless of their GBS status, women with temp >38 degrees
Benzylpenicillin onset labour and at least 2h before delivery
Sx, CT shows and tx in cerebral toxoplasmosis in HIV?
Headache, confusion, drowsiness, CT- single/ multiple ring-enhancing lesions, mass effect may be seen
Pyrimethamine plus sulphadiazine at least 6 weeks, spiramycin
How does Erb’s palsy present?
Dermatomal sensory loss in C5-6 dis, “waiter’s tip”- shoulder adduction, elbow extension, forearm pronation, wrist flexion
Subscapular, musculocutaneous and axillary nerves–> paralysis of supraspinatus, infraspinatus, biceps, brachialis, deltoid, teres minor
Winged scapula
Can result from shoulder dystocia/ breech presentation- exclude fractured clavicle & arrange physio- not resolved by 6 months unlikely to improve
How does Klumpke’s palsy present?
Dermatomal sensory loss in C8-T1 distribution- median and ulnar nerves, weakness intrinsic hand muscles, potential ipsilateral Horner’s syndrome if T1 involved
Claw hand, arm held in adduction, extension at MCP joints, flexion at DIP/PIP joints due to loss of lumbrical
Tx Erb’s palsy?
Daily physical therapy from 3 weeks- prevent joint contracture, surgery after -6 months- nerve graft/ transfer, release contractures, tendon transfer, reduction joints, osteotomy
Do what once a baby is born?
IM vitamin K in thigh- helps prevent bleeding- intracranial, umbilical stump and GI bleeding/ orally- needs doses at birth, 7 days and 6 weeks, label baby, measure weight and length, skin–> skin contact
Dry baby- stimulates breathing, keep warm with warm delivery rooms and management under a heat lamp
<28 weeks= placed in a plastic bag while still wet and managed under a heat lamp
Initial check- tone, pulse, RR
Place baby’s head in a neutral position to keep airway open- towel under shoulder can help keep it neutral
If not breathing/ gasping- check for obstruction i.e. meconium and consider aspiration under direct visualisation
Give 5 rescue breaths x2 cycles, low HR and no response= 30 seconds ventilation breaths- still no= chest compressions coordinated w/ ventilation breaths 3:1- still below <60bpm- consider venous or osseous access and administering drugs
What is given for inflation breaths in term/ near term babies and pre-term babies? Prolonged hypoxia increases risk of what?
Air
Air and oxygen- aim for gradual rise- not exceeding 95%
Hypoxic-ischaemic encephalopathy- consider IV drugs and intubation in severe, near/ at term- might benefit from therapeutic hypothermia with active cooling
Delaying cord clamping does what?
Leads to improved Hb, iron stores, BP and reduction in IV haemorrhage and NEC
Increase in neonatal jaundice potentially needing more phototherapy- AT LEAST 1 MINUTE
Needing resus- should have sooner to prevent delays in getting baby to resus team
What happens as soon as the baby is outside of the delivery room?
Initiate breast feeding/ bottle feeding as soon as baby is alert enough
First bath when baby is warm and stable, newborn exam within 72 hours, blood spot test, newborn hearing test
9 conditions tested for on day 5 in bloodspot test?
SCD, cystic fibrosis, congenital hypothyroidism, phenylketonuria, MCADD, MSUD, IVA, GA1, homocystin- takes 6-8 weeks to come back
What is HIE (hypoxic ischaemic encephalopathy higher in)? Causes?
Premature & LBW infants
Placental abruption, cord compression, prolonged resp arrest- can cause cerebral palsy
Suspected HIE when events could lead to hypoxia?
pH<7 on umbilical artery blood gas, poor APGAR scores, features of mild/ moderate/ severe HIE or evidence of multi organ failure
Maternal shock, intrapartum haemorrhage, prolapsed cord, nuchal cord(anything–> asphyxia)
Ix HIE? Tx?
EEG monitoring, multiple MRI scans
Resp support, anticonvulsants, fluid balance and electrolyte monitoring, use inotropes- BP and cardiac function, cooling therapy- induce mild hypothermia prevent further damage from secondary reperfusion injury, some= therapeutic hypothermia- blankets and hat target 33-34 degrees using rectal probe continued for 72 hours after–> warmed to normal temp over 6 hours
Who are at risk of vitamin K deficiency? Sx? Ddx?
Exclusively breastfed & no prophylaxis at birth
Easy bruising/ petechiae, bleeding from nose/ gums, blood in stool/ urine, prolonged clotting times, severe= internal bleeding
Haemophilia, DIC, Von Willebrand disease
Ix vitamin K deficiency? Risks?
Coagulation studies- PT and aPTT which will be prolonged, assess vit K levels
Haemorrhagic disease of the newborn
Can rapidly progress into haemorrhagic shock
What is cephalohaematoma? Sx?
Bleeding between periosteum and skull- most common site= parietal region within 24-48 hours following delivery
(Traumatic subperiosteal haematoma)
Fluctuant non-pulsatile swelling overlying one or more cranial bones, well-defined margins, firm yet resilient without signs tenderness/ warmth–> indurated resolves- DOES NOT CROSS SUTURE
Jaundice may result
Takes up to 3 months to resolve- USS= vs subgaleal haemorrhage & extent
Tx acute asthma child <3 y/o?
Inhaled/ nebulised salbutamol via a spacer using a close-fitting mask in a child <3 y/o–> inhaled/ nebulised ipratropium–> IV magnesium sulfate–> IV aminophylline
1 puff every 30-60 seconds up to max 10 puffs
Mild= outpatient with regular salbutamol inhalers via spacer 4-6 puffs every 4 hours
Not controlled by repeat beta-2 agonist= refer to hospital
Steroid therapy= all with exacerbation for 3-5 days (pred oral or IV hydrocortisone)
Supplementary O2 if needed<94% or working hard
ABx only if bacterial cause suspected e.g. amoxicillin or erythromycin
Moderate- severe acute asthma approach?
Salb inhalers via space device 10 puffs every 2 hours
Salb/ iptratropium bromide nebs
Oral pred
IV hydrocortisone
IV MgSO4
IV salbutamol
IV aminophylline–> anaesthetist and ICU- intubation and ventilation
Review before next dose of bronchodilator, look for cyanosis, tracheal tug, subcostal recessions, hypoxia, tachypnoea/ wheeze on auscultation - step down if well–> 10 puffs 4 hourly–> 6 puffs 4 hourly–> 4 puffs 6 hourly- MONITOR POTASSIUM FOR HYPOKALAEMIA, BLOOD GLUCOSE IN DIABETICS FOR HYPERGLYCAEMIA AND KETOACIDOSIS WHEN GIVEN IV
When can a child be discharged with asthma?
6 puffs 4 hourly for 48 hours
Then 4 puffs 6 hourly for 48 hours
Then 2-4 puffs as required
Finish course steroids if these were started- typically 3 days
Safety netting
Individualised asthma action plan
Ix chronic asthma (in child>5 y/o)?
Spirometry w/ reversibility testing
Direct bronchial challenge test w/ histamine or methacholine
FeNO
Peak flow variability- peak flow several times a day for 2-4 weeks
Tx chronic asthma in Paeds <5 y/o?
SABA + ICS/ LTRA- add other option from step 2
Refer–> specialist
Tx chronic asthma in Paeds 5-12 y/o?
SABA
Regular low dose CS
LABA e.g. salmeterol- continue salmeterol only if good response
Titrate up CS inhaler–> medium dose-
Consider adding LTRA , oral theophylline
Increase corticosteroid–> high dose
Referral–> specialist- may need daily oral steroids
Tx chronic asthma in Paeds >12 y/o?(same as adults)
SABA
Low dose CS inhaler
LABA- continue if good response
Titrate CS–> medium dose, consider trial LTRA, oral theophylline or inhaled LAMA
Titrate up CS–> high dose
Combine CS, LTRA, LAMA
Oral steroids@ lowest dose
RFs and sx viral induced wheeze? Tx?
RSV/ rhinovirus
Maternal smoking during and/ or after pregnancy
Prematurity, NO ATOPIC HISTORY, multiple trigger wheeze- also cold air, dust, animal dander, exercise
Only during viral infections 1-2 days prior= SOB, signs resp distress, expiratory wheeze throughout chest
Same as acute asthma in children
Age group for croup?
6 months- 2 y/o during autumn and winter months
URTI–> oedema in larynx
Parainfluenza, influenza, adenovirus, RSV
Used to be cause by diphtheria- leads to epiglottitis
Sx croup? Ddx? Ix croup?
Barking/ seal-like cough, stridor, fever, increased work of breathing e.g. retractions or nasal flaring, agitation/ lethargy in severe
Bacterial tracheitis, epiglottitis, inhaled foreign body or laryngomalacia, asthma
Viral throat swabs for viral PCR
XR neck–> steeple sign/ wine bottle sign, PA view CXR- subglottic narrowing in severe or atypical
Tx mild/ moderate and severe croup?
May be sent home if settles e.g. with dex PO/ pred if not available- regardless of severity
High flow oxygen, nebulised budesonide, nebulised adrenalin, intubation & ventilation
Admit who with croup?
Moderate/ severe croup, <3m age, known upper airway abnormalities e.g. laryngomalacia, Down’s, uncertainty about diagnosis
Cause of epiglottitis? Sx?
Haemophilus influenzae type B
High fever, sore throat, stridor, drooling, rapid increase resp difficulty over hours, tendency to sit upright with open mouth to optimise airway patency, minimal or absent cough, tripod position
Ix for epiglottitis? Tx? Common complication?
Lateral XR- thumb sign/ thumbprint sign, neck XR for excluding a foreign body, cultures may be taken
DO NOT EXAMINE WITHOUT SENIOR- possible endotracheal intubation, once secure= culture and examination, IV ABx- typically cefuroxime
Epiglottic abscess
Common age for bacterial tracheitis? Most common cause? Sx?
1-6 y/o, both genders= equally affected
S.aureus
High fever, stridor, barking cough, tachypnoea, difficulty breathing, dyspnoea, cyanosis
Ix for bacterial tracheitis? Tx?
Blood tests- signs of infection, throat swabs for causative, CXR- airway obstruction/ pneumonia, CT scan- more detailed
IV ABx- often broad- spectrum
Intubation in severe
Airway humidification and chest physio may assist in clearance
Causes and sx of pneumonia in children?
S.pneumoniae, group A strep pyogenes, group B in pre-vacc infants, s.uareus–> pneumatoceles and consolidations in multiple lobes, h.influenzae, mycoplasma pnuemonia atypical w/ extra-pulm e.g erythema multiforme
RSV, parainfluenza, influenza
Sx and Ix in pneumonia?
Cough, high fever, tachypnoea, tachycardia, increased WOB, lethargy, delirium, hypoxia, hypotension, confusion
Bronchial breath sounds, focal coarse crackles, dullness to percussion
CXR in doubt, sputum cultures, throat swabs and viral PCR, sepsis= BLOOD CULTURES, capillary blood gas analysis
Tx pneumonia?
Amoxicillin- macrolide for atypical e.g. erythromycin, clari, azithromycin, monotherapy in penicillin allergy
O2>92%
Ix for recurrent LRTIs?
Hx, examination, assess for reflux, neurological disease, heart disease, asthma, CF, PCD, immune deficiency
FBC, CXR, serum Igs, IgGs= Ig class-switch recombination deficiency, sweat test, HIV test if Mum’s status unknown or positive
Gender that laryngomalacia is more common in? Types?
Males>females
Type 1= tightening of the aryepiglottic folds
Type 2= redundant tissue in supraglottic region
3= ass w/ other disorders e.g. NM disease/ GORD
Sx, Ix and tx of laryngomalacia?
Inspiratory stridor- usually intermittent occurring in supine position - increase in severity during first 8 months, resolve by 18-24 months- PEAK@6 months
Resp distress, failure to thrive, cyanosis= rare
O2 saturations monitored and blood gases taken, laryngoscopy and bronchoscopy if severe features or if there is diagnostic difficulty
Sx relief by hyperextending neck during stridor episodes
Severe resp distress= tracheostomy, laryngoplasty, excision redundant mucosa, laser epiglottoplexy/ laser division of aryepiglottic folds
Ix for anaphylaxis? Tx?
Serum mast cell tryptase- rises within an hour
Adrenaline, removing trigger, early call for help, placing patient–> supine position and raising legs, managing airway and high flow oxygen, IV fluids in shock, hydrocortisone when not urgent, attach patient –> monitoring equipment
Monitor for 6-12 hours after initial presentation, upon discharge= counselling on adrenaline auto-injectors, supply x2 auto-injectors, written advice, referral–> local allergy service follow-up
Between what layers is a subgaleal haemorrhage?
Galea aponeurotica and periosteum- can croos suture lines unlike cephalohaematoma- may present with pallor, tachycardia, hypotension and shock due to significant blood loss
Comps from a cephalohaemtoma?
Infection, calcification, rare= intraosseous haematoma
Anaemia- monitor Hb levels
Jaundice
Cosmetic deformity
Where does caput succedaneum present?
Outside periosteum- CROSSES SUTURE LINES, usually from pressure on cervix/ ventouse delivery
May have USS- usually resolves spontaneously
Usually no/ mild discolouration of the skin
Presents within days birth and resolves within few days
Tx facial paralysis?
Usually resolves spontaneously within few months- may need neurosurgical input
What is a fractured clavicle associated?
Shoulder dystocia, traumatic/ instrumental delivery and LBW
Lack movement/ asymmetry movement in affected arm
Asymmetry shoulders - affected lower than normal shoulder
Pain and distress on movement of arm
USS/ XR
Conservative management occasionally with immobilisation of affected arm- comp= brachial nerve palsy
Ix for jaundice in the newborn?
FBC & blood film, blood type testing for ABO/ rhesus incompatibility, direct Coombs test for haemolysis, TFTs for hypothyroid, blood & urine cultures for infection, G6PD deficiency
Transcutaneous bilirubinometer in >35/40 gestation + >24 hours old for first measurement first 72 hours life- low threshold in pre-term babies and dark-skin tone/ serum bilirubin if <35/40 gestation, <24 hours old or TCB>250micromol/L
Sx haemolytic disease of the newborn?
RFs for neonatal jaundice?
Breastfed babies, significant bruising/ cephalohaematoma, preterm babies
CSF in SAH? MS? GBS?
Blood-stained initially w/ xanthochromia>12 hours later, elevated protein, RBC and RBC, WBC, normal glucose
PERFORM CT WITHIN 6 HOURS
Oligoclonal bands, primarily lymphocytes, normal appearance, pressure, glucose, protein mildly elevated
Normal appearance, WBC, glucose level, pressure= normal/ elevated, protein markedly elevated>5.5g/L- may not be seen in first week illness
Sx of whooping cough?
Catarrhal phase similar to viral URTI around 1-2 weeks long
Paroxysmal phase where cough increases in severity- bouts worse@night and after feeding, may be ended by vomiting and associated central cyanosis, inspiratory whoop not always present, may have spells of apnoea, persistent coughing may cause subconjunctival haemorrhages/ anoxia–> syncope/ seizures, between 2-8 weeks
Cough subsides over weeks to months
Ix of whooping cough? Tx?
Per nasal swab within 2-3 weeks onset sx/ anti-pertussis toxin IgG>2 weeks cough in oral fluid 5-16 y/o/ blood >17 y/o- PCR and serology now increasingly used
<6m old= admit, notifiable disease
Oral clari/ azithromycin/ erythromycin/ co-trimoxazole if onset cough within previous 21 days, household contacts= AB prophylaxis, 48hour exclusion after commencing antibiotics
Comps whooping cough?
Subconjunctival haemorrhage, pneumonia, bronchiectasis, seizures, pneumothorax
Women 16-32 weeks pregnant= offered vaccine
Definition of enuresis, primary and seconday?
Involuntary discharge of urine by day or night or both in child aged 5 years or older in absence congenital or acquired defects of nervous system or urinary tract
Never achieved continence- family history, overactive bladder, increase intake before bed/ has been dry for at least 6 months before- diabetes, psych distress, chronic constipation, UTI, learning disability, cerebral palsy
Tx enuresis?
Look for constipation, diabetes mellitus, UTI if recent onset
Gen advice= fluid intake, encourage empty bladder during day and before sleep, lifting and waking
Star charts
>5 y/o== enuresis alarm= generally first-line, sensor pads sense wetness, high success rate
>7y/o- desmopressin- short-term/ alarm ineffective/ not effective to family
Not responded to alarm/ need rapid control= trial DDAVP can be considered
Ix for enuresis?
Hx & exam, urine dip
Secondary= urine dip, urine osmolarity & renal USS, 2w toileting diary, possibly urinalysis
Who does cow’s milk protein allergy affect?
First 3 months life in formula fed infants and/ or family hx atopic conditions- IgE and non-IgE mediated
Immediate reaction= CMPA/ mild-moderate delayed= CMPI
Sx CMPA? TX?
Abdo pain, diarrhoea, vomiting, bloating and wind
Allergic= urticarial rash, angio-oedema, cough/ wheeze, sneezing, watery eyes, eczema
Skin prick testing can help, total IgE and specific IgE (RAST)
Hydrolysed formulas, severe= elemental formulas made of basic amino acids- most outgrow by 3 y/o often earlier
Every 6m= try on first step milk ladder
Sx CMPI?
Same sx without allergic features- can tolerate with GI sx
Grow out by 2-3 y/o- fed with breast milk, hydrolysed formulas weaned to foods not containing cow’s milk
After one year age–> started on milk ladder
Tx CMPI in breastfed?
Continue breastfeeding, eliminate cow’s milk protein from maternal diet, consider Ca2+ supplements for those have/ suspected to have CMPI, eHF when breastfeeding stops until 12m age and at least for 6 months
Cause mesenteric appendicitis?
Inflammation of mesenteric lymph nodes- EBV, adenovirus, enterovirus, Yersinia, campylobacter, mycobacterium, salmonella, strep
Sx mesenteric adenitis, Ix and tx?
Diffused abdo pain mistaken for appendicitis, low-grade fever, generalised abdo pain, pharyngitis/ sore throat, unaltered appetite
FBC- typically normal
US abdomen- enlarged mesenteric lymph nodes, normal appendix
Observation and reassurance, consider surgical with caution
What is Meckel’s diverticulum? Epidemiology?
Remnant of vitellointestinal duct in distal ileum within 100cm ileocaecal valve
2% population, 2% symptomatic, usually less than 2 y/o, M>F
Sx Meckel’s diverticulum?
Painless rectal bleeding, abdo pain, symptomless, intussusception, volvulus/ diverticulitis, obstruction if trapped in a hernia- Littre’s hernia, reduction in Hb
Ix and tx Meckel’s diverticulum?
CT scan 99mTC scan ectopic gastric mucosa, small bowel enema in some cases
NG tube if obstruction, surgical resection of diverticulum by wedge excision/ small bowel resection and anastomosis
Sx, RFs and Ix TOF?
Unrepaired–> hypercyanotic tet spells= tachypnoea and severe cyanosis often when upset/ in pain/ has fever
Ejection systolic murmur= due to pulm stenosis(AT 1-2m- TGA= more common at birth)
Rubella, increased age of mother, alcohol consumption in pregnancy, diabetic mother, Down’s, DiGeorge syndrome
CXR= boot-shaped heart, ECG= RVH, ECHO using Doppler flow studies, cardiac catheter might be needed
Tx for tet spell in tetralogy of Fallot?
Supplementary oxygen, Beta blockers, IV fluids, morphine- decreases resp drive, sodium bicarbonate- buffers metabolic acidosis, phenylephrine infusion
Definitive tx of TOF?
Prostaglandin to maintain PDA, total surgical repair by open heart surgery
Definition precocious puberty?
Sexual char<8y/o females, 9 y/o in males- F>M
GT dependent- prem act H-P-G axis
FSH & LH raised
GT independent- FSH & LH low
Females= idiopathic/ familial
Organic= rare- rapid onset, neuro sx and signs and dissonance e.g. McCune Albright syndrome
Who does intussusception affect? Ass w/ what conditions?
6m-2 y/o
Usually boys
Invagination one portion bowel–> lumen adjacent bowel commonly around ileo-caecal region
Meckel diverticulum, viral illness, HSP, CF, intestinal polyps
Sx & tx intussusception?
Intermittent, severe, crampy, progressive abdominal pain, inconsolable crying , during paroxysm- draws knees up and turns pale, red-currant jelly stool= late sign, sausage- shaped mass RUQ
USS- target-like mass
Rectal air insufflation/ contrast enema if stable, operative reduction if non-op failed, peritonitis/ perforation, HD stable
Hearing test done if otoacoustic emission test abnormal? @6-9 months? 18m-2.5 years? >2.5 years? >3 years?
Auditory brainstem response test
Distraction test- x2 trained staff
Recognition familiar objects
Performance testing
Speech dis tests- Kendall toy/ McCormick Toy
Pure tone audiometry- school entry
Cause and sx of H, F & M disease?
Coxsackie A16 and enterovirus 71
Tired, sore throat, dry cough, raised temp- after 1-2 days= small mouth ulcers followed by blistering red spots across body, painful ulcers on tongue- rash may be itchy
Ix and tx of hand, foot and mouth disease? Comps?
Hydration, analgesia, NO NEED TO EXCLUDE, resolve after a week- 10 days
Avoid sharing towels, bedding, washing hands, careful handling dirty nappies
Dehydration, bacterial superinfection, encephalitis
Test for cardiac vs non-cardiac causes cyanosis in neonates?
Nitrogen washout test- 100% oxygen given for 10 minutes before ABGs taken, PaO2< 15kPa= cyanotic congenital heart disease
Sx Edward’s syndrome (trisomy 18)? Vs Patau (trisomy 13)?
Rocker bottom feet
Micrognathia- small jaw, low-set ears, overlapping fingers
Rocker bottom feet,
microcephalic, small eyes, cleft lip/ palate, polydactyly, scalp lesions
When does nausea and vomiting occur in pregnancy?
Between 4th and 7th week gestation- peaks at 9th-16th, resolves by 20th weeks
When do women usually feel fetal movements? When do you get an USS? Qs to ask about vaginal bleeding?
16-24 weeks
18-20+6 weeks
Pain, trauma, fever/ malaise, recent USS results, cervical screening history, sexual history, past medical history, fatigue, sx hypovolaemic shock e.g. pre-syncope/ syncope
Qs to ask about current pregnancy in obs history?
Growth fetus, placental position, fetal anomalies
Down’s screening, Rhesus status and presence of antibodies, Hep B, HIV and syphilis
Singleton/ multiple
Folic acid prior to conception and during first trimester
Planned mode delivery, illness during pregnancy
Flu, whooping cough, hep B vaccinations
Screen for depression, bipolar, schizophrenia, previous diagnoses, self-harm/ suicide
Qs regarding term pregnancies >24 weeks? <24 weeks? Gynae hx?
Gestation, birth weight, mode delivery, comps, assisted reproduction, stillbirths
Trimester, medical/ surgical tx miscarriage, gestation & medical/ surgical tx for terminations
Site & tx of ectopic pregnancy
Cervical screening any treatments, previous gynae conditions and treatments
Conditions for family hx in obs history?
Inherited- CF/ SCD, T2DM, pre-eclampsia
Mnemonic for exploring psychiatric symptoms?
Nature, onset, triggers, exacerbating/ relieving factors, progression, associated symptoms, disability
Family hx in gynaecological history?
Ovarian, endometrial, breast cancer
Bleeding disorders e.g. Von Willebrand’s disease, VTE in first- degree relative
Things included in a mental state examination?
Appearance
Behaviour
Speech- rate, quantity, tone, volume, fluency and rhythm
Mood & affect- range and mobility, intensity, congruency of affect
Thought- form- speed, flow & coherence of thoughts/ content- delusions, obsessions, compulsions, overvalued ideas, suicidal thoughts, homicidal/ violent thoughts/ possession- insertion, withdrawal, broadcasting
Perception- hallucinations, pseudo-hallucinations, illusions, depersonalisation, derealisation
Cognition
Insight and judgment
Risk to self and others
Mutation in Fragile X syndrome?
FMR1 gene on X chromosome- fragile X mental retardation protein–> CGG repeat expansion
MALES ALWAYS AFFECTED- FEMALES CAN VARY
Mother phenotypically normal= affected child may have inherited X chromosome from mother or may result from de novo mutation
Sx Fragile X syndrome?
Intellectual disability, long, narrow face, large ears, large testicles after puberty, hypermobile joints, ADHD, autism, seizures
Sx Down’s syndrome?
Hypotonia, brachycephaly, short neck, short stature, flattened face & nose, prominent epicanthic folds, upward sloping palpebral fissures, single palmar crease, Brushfield spots in iris, duodenal atresia, Hirschsprung’s disease
Comps Down’s syndrome?
Learning dis, recurrent otitis media, deafness, Eustachian tube anomalies, visual issues- myopia, strabismus and cataracts, hypothyroidism, ASD/ VSD/ patent ductus arteriosus/ tetralogy of Fallot/ endocardial cushion defect, atlantoaxial instability, leukaemia, dementia
Subfertility, ALL, Alzheimer’s
Tx Down’s syndrome?
OT, SLT, physio, dietician, paediatrician, GP, health visitor, cardiologist, ENT, audiologist, optician, social services, charities
Regular TFTs, echo, regular audiometry, regular eye checks
What does cleft lip and palate result from?
Issues and tx?
Fronto-nasal and maxillary processes to fuse
Palate= palatine processes and nasal septum to fuse
Speech therapy, increased otitis media for cleft palate babies
Cleft lip= repaired earlier than palate 1 week-3m
Palate= 6-12m
ORBIT score risk groups?
0-2 = low, 3= medium, 4-7= high
Sx meningitis? When is LP indicated? 2x tests?
Non-blanching rash- DIC, hypotonia, poor feeding, lethargy, hypothermia and bulging fontanelle
Lethargy, headache, fever, rigors and vomiting, hypovolaemic shock, adrenal haemorrhage= Waterhouse- Friderichsen syndrome
Under 1m w/ fever, 1-3 m w/ fever and are unwell
Under 1 unexplained fever and other features serious illness
Kernig’s and Brudzinski’s test
Ix meningitis? Tx?
Blood cultures, PCR testing for n.meningitidis, LP prior to starting antibiotics- WITHIN HOUR ARRIVING AT HOSPITAL, FBC, clotting, blood culture, glucose, blood gases
Pre-hospital= IM benzylpenicillin
<3m= cefotaxime + amoxicillin- for listeria during pregnancy
>3m= ceftriaxone
Recent foreign travel or prolonged antibiotics= vancomycin
Dex QDS 4 days >3 months if LP suggestive bacterial
Notify PHE
Close prolonged contacts within 7 days= prophylactic ciprofloxacin within 24hours initial diagnosis
Encephalitis= IV aciclovir for HSV encephalitis
CI to LP?
Raised ICP- reduced or fluctuating consciousness, bradycardia and HTN, focal neuro signs, abnormal posturing, abnormal pupil reflexes, papilloedema, bulging fontanelle
GCS<9, HD unstable, active seizures or post-ictal
Comps of meningitis? Meningitis follow-up?
Hearing loss, seizures, epilepsy, cognitive impairment and learning disability, memory loss, cerebral palsy w/ focal neuro deficits such as limb weakness or spasticity
Review w/ Paediatrician within 4-6 weeks- viral= usually complete resolution within 10 days
Most common causes encephalitis in children?
HSV-1 from cold sores- neonates= HSV-2 from genital herpes during birth
VZV, cmv ass w/ immunodeficiency, EBV, enterovirus, adenovirus and influenza
Vaccinations- polio, mumps, rubella, measles
Sx and Ix encephalitis?
Altered cognition, consciousness, behaviour, acute onset focal neuro sx, acute onset focal seizures, fever
LP–> viral PCR, CT if LP= CI, MRI after LP, EEG in mild/ ambiguous sx, throat and vesicle swabs, HIV testing recommended
Tx encephalitis? Follow-up?
Aciclovir in HSV & VZV
Ganciclovir in CMV
Repeat LP prior to stopping antivirals
Lasting fatigue and prolonged recovery, change in personality/ mood, changes to memory and cognition, learning disability, headaches, chronic pain, sensory disturbance, seizures, hormonal imbalance
What can’t you get above with scrotal swellings? Test for epididymitis vs testicular torsion?
Infantile hydrocele- irreducible, has no cough impulse and testes is impalpable and hernia
Prehn’s test- reduction in pain on lifting= epididymitis
Sx and ix for VUR?
Antenatal= hydronephrosis on USS, recent childhood UTIs
Reflux nephropathy- chronic pyelonephritis secondary to VUR
Recurrent UTIs, persistent bacteriuria, unexplained fevers, abdominal/ flank pain, severe= HTN and CKD
MCUG, DMSA= for renal scarring
When is an MCUG indicated?
Children<6m old for atypical/ recurrent UTIs, family hx VUR, dilatation of the ureter on USS/ poor urinary flow
Proph ABx given 3 days
Tx of VUR? Comps?
Avoid constipation, avoid excessively full bladder, proph antibiotics, surgical input from Paed urology- ureteral reimplantation in severe/ cons management fails
Recurrent UTIs, pyelonephritis, renal scarring and CKD, HTN
Grading 1-5 of VUR?
1= reflux–> ureter only no dilatation
2= reflux into renal pelvis on micturition, no dilatation
3= mild/ mod dilatation of ureter, renal pelvis and calyces
4= dilation of renal pelvis and calyces with moderate ureteral tortuosity
5= gross dilatation of ureter, pelvis and calyces with ureteral tortuosity
Causes of UTIs in children?
E.coli, Klebsiella, proteus- more common in boys, pseudomonas- may indicate structural abnormality, strep faecalis, staph saprophyticus
Incomplete bladder emptying/ constipation/ VUR
Isolated dysuria= cystitis OR girls= vulvitis, uncircumcised boys= balanitis
Sx UTI<3m old? Aged 3-12m? >1 y/o?
Fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, jaundice, haematuria, offensive urine
Fever, poor feeding, abdo pain, vomiting
Frequency, dysuria, abdo pain
Fever= less common in children over 1 y/o
Ix UTI in children?
Clean catch- urine sample–> nitrites, leucocytes, leucocyte esterase- NOT AS SENSITIVE
Send MSU sample to microbiology lab to be cultured and have sensitivity testing
Features of atypical UTI? Pyelonephritis?
Non E-coli, failure respond–> ABx within 48 hours, septicaemia, poor urine flow, abdominal/ bladder mass, raised creatinine
Fever + systemic involvement/ loin pain/ tenderness
Tx UTI in <3m old w/ fever?
Immediate IV ABx and septic screen, blood cultures, bloods, lactate, consider LP
Consider oral ABx>3m if otherwise well
Ix recurrent UTIs<6m? Atypical UTIs? What 4-6 months after the illness?
Abdominal USS within 6 weeks/ during illness if there are recurrent UTIs or atypical bacteria
DMSA
Tx for UTI in children?
<3m= refer–> Paediatrician
>3m w/ upper UTI= consider admission to hospital
Not admitted= oral ABx 7-10 days
>3m with pyelo= cefalexin/ co-amoxiclav
>3m w/ cystitis/ lower UTI= oral trimethoprim/ nitro if eGFR>45ml/ minute/ amoxicillin if culture results available and susceptible/ cefalexin
Bring back in if unwell after 24-48 hours
When is GORD in children usually? RFs?
<8 weeks, resolve by 1 years of age- vomiting/ regurgitation, milky vomit after feeds may occur after being laid flat, excessive crying whilst feeding especially
Premature birth, parental hx heartburn or acid regurg, obesity, hiatus hernia, hx congenital diaphragmatic hernia/ oesophageal atresia
Neurodisability
Tx simple GORD in children? More bothersome?
Sleep on backs, not overfeed, smaller and more frequent feeds, burping regularly to help milk settle, keep upright after feeding
Gaviscon mixed with feeds, thickened milk/ formula- NOT AT SAME TIME, PPIs- unexplained feeding difficulties, distressed behaviour, faltering growth
Red flags for GORD in children? Further Ix?
Not keeping down feeds, projectile/ forceful vomiting, bile stained vomit, haematemesis/ melena, abdominal distension, reduced consciousness, bulging fontanelle/ neuro signs, resp sx, blood in stools, signs infection, rash/ angioedema/ allergy, apnoeas
Barium meal and endoscopy, surgical fundoplication
Sx febrile convulsions? Simple vs complex?
Early in viral infection, less than 5 minutes, tonic-clonic, 6m-5y/o
Generalised<15 minutes, only once during febrile illness
Partial/ focal seizures >15 minutes/ multiple times during same febrile illness
Features of Sandifer’s syndrome?
Torticollis and dystonia- tends to resolve as reflux is treated/ improves- refer for assessment to rule out West syndrome and seizures
When would would someone with febrile convulsion be admitted?
First febrile seizure, child<18m age, complex febrile seizures, diagnostic uncertainty/ recent antibiotic use/ parental anxiety
Refer–> Paeds if developmental delay
Ensure vaccinations completed
Most common delayed milestones in children with CP? RFs?
Not sitting by 8m, not walking by 18m, asymmetry hand function before 1 year
Antenatal= H-I encephalopathy, infection
Birth asphyxia/ trauma
Postnatal= meningitis, trauma, haemorrhage, medication toxicity, kernicterus
Sx spastic cerebral palsy?
Pyramidal weakness- clasp-knife spasticity, scissor gait, HYPERTONIA, hemi/ di- mainly legs affected= UMN LESION- leg extended with plantar flexion of feet and toes/ quadriplegia- often seizures, speech disturbance and other impairments
Dyskinetic- damage to basal ganglia, choreiform movements, oro-motor problems, HYPER & HYPOTONIA
Ataxia- cerebellar signs
Mixed
High stepping gait= foot drop/ LMN lesion, waddling gait= pelvic muscle weakness due to myopathy
Comps and tx cerebral palsy?
IX= MRI
Learning disability, epilepsy, kyphoscoliosis, muscle contractures, hearing and visual impairment, GORD
Physio, OT, SLT, dieticians, ortho surgeons- tenotomy, paeds- muscle relaxant e.g. baclofen, anti-epileptics, glycopyrronium bromide for drooling, social workers, charities and support groups
Who is affected in roseola infantum?
HHV6–> 6m-2 y/o
High fever–> MP rash, nagayama spots, febrile convulsions, diarrhoea and cough commonly seen
Aseptic meningitis, hepatitis
SCHOOL EXCLUSION NOT NEEDED
Cause measles? Sx?
Morbillivirus RNA paramyxovirus- resp droplets/ direct contact with nasal/ throat secretions
Infective from prodrome until 4d after rash starts
Irritable, conjunctivitis, fever, Koplik spots- white spots buccal mucosa, before rash- behind ears–> whole body- desquamation sparing palms and soles may occur after a week
Ix and tx measles? Comps?
IgM antibodies within few days rash onset- measles PCR swabs taken 1-3 days after rash onset
Supportive- admission in immunosuppressed/ pregnant, notifiable–> PHE
Vitamin A<2 y/o
Otitis media, pneumonia- most common cause death, encephalitis, subacute sclerosing panencephalitis, febrile convulsions, keratoconjunctivitis, corneal ulceration, diarrhoea, increased appendicitis incidence, myocarditis
Offer MMR WITHIN 72 HOURS
Who gets pyloric stenosis? Sx?
6-8w, M>F, first-borns
Projectile vomiting, thin, pale, failure to thrive, firm, round mass in upper abdomen
Blood gas= hypochloric metabolic alkalosis
USS= thickened pylorus
Lap pyloromyotomy- Ramstedt’s operation
Tx pyloric stenosis?
Supportive- NBM, IV fluids, fluid resus may be needed
Inheritance of Down’s syndrome?
Gamete non-dysjunction, Robertsonian translocation, mosaic Down syndrome
Cause retinoblastoma? Sx & tx?
AD RB1 on Ch12
Absence red reflex replaced by white pupil- leukocoria, strabismus, visual problems
Enucleation, external beam radiation therapy, chemo and photocoagulation
Cause and sx Turner’s?
Short stature, wide space nipples, webbed neck, bicuspid aortic valve, coarctation of the aorta- increased risk aortic dilatation and dissection, primary amenorrhoea, cystic hygroma, high-arched palate, short 4th metacarpal, multiple pig naevi, lymphoedema in neonates, elevated GT levels, hypthyroidism, horseshoe kidney, AI thyroiditis and Crohn’s disease, cubitus valgus, recurrent otitis media, osteoporosis
Tx for Turner syndrome?
GH therapy, oestrogen and progesterone replacement, fertility treatment- manage HTN & hypothyroidism
Cyanotic causes of congenital HD?
VSD, ASD, PDA, coarctation of the aorta, aortic valve stenosis
VSD>ASD, ASD more in adults
Sx of nephrotic syndrome in children?
Low serum albumin<25g/L, high urine protein content >3+ protein on urine dip, oedema
BETWEEN 2 & 5 Y/O
Deranged lipids- high cholesterol, triglyceries and LDLs, high BP, hypercoagulability, predisposition to infection
MOST MINIMAL CHANGE DISEASE
secondary causes nephrotic syndrome in children?
Intrinsic- focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis
HSP, diabetes, infection- HIV, hepatitis and malaria
Ix for nephrotic syndrome?
Urine dip= proteinuria, urine analysis= raised A:creatinine ratio, small molecular weight proteins and hyaline casts in MCD
Renal biopsy- all adults and children w/ atypical presentation- steroid unresponsive, haematuria, under 1 y/o or over 12 y/o
Tx minimal change disease? Tx in steroid resistant?
High dose steroids 4w and weaned over 8 weeks- pred(steroid dependant or resistant,) low salt diet, diuretics for oedema, albumin infusions in severe, ABx proph in severe
ACE-i, immunosuppressants e.g. cyclosporin, tacrolimus or rituximab
Comps nephrotic syndrome?
Infection- urinary loss Iggs, VTE- loss antithrombin III, hyperlipidaemia- increased hepatic production, hypovolaemia, acute/ chronic renal failure, relapse
Cause of malrotation? Sx? Ix and tx?
Abnormal rotation and fixation of midgut during embryonic development during 4th-12th week gestation
Bilious vomiting- often occurring within first day of life
Upper GI contrast study- proximal bowel= corkscrew appearance/ coffee bean sign
Urgent surgery
Most common type of congenital DH? Sx? Ix & tx?
Failure of pleuroperitoneal canal to close completely
Left-sided posterolateral Bochdalek hernia= 85% cases
Respiratory distress, bowel sounds in chest, absent breath sounds on one side, failure to respond to resuscitation, displaced apex beat, scaphoid abdomen
Prenatal USS screening
NG tube passed & suction applied to prevent distension of intrathoracic bowel then repaired surgically after stabilisation
Cause of ITP? Sx and Ix? Tx?
Immune-mediated reduction in platelet count antibodies against glycoprotein IIb/ IIIa
Type II hypersensitivity <10 y/o over 24-48 hours, chronic= HIV, hepatitis C and SLE
Urgent FBC for platelet count
Blood film, BM examination- atypical = LN enlargement/ splenomegaly, high/ low white cells, failure to resolve/ respond to tx
No tx- 80% resolve within 6 months with/ without treatment, avoid trauma, low platelet count/ significant bleeding= oral/ IV corticosteroid, IV immunoglobulins, platelet transfusion in emergency
Comps of ITP?
Chronic ITP, anaemia, intracranial and SAH, GI bleeding
Inheritance, sx and Ix haemophilia?
X-linked recessive
Bleeding early on in life–> joints etc, bleeding–> muscles= compartment syndrome
Factor VIII/IX assay
High APTT, vWF antigen= normal in A type, defective platelet function
Minor bleeds in haemophilia A tx with what? Mild and moderate haemophilia?
Desmopressin- stimulate Von Willebrand factor, gene therapy
Antifibrinolytics e.g. TXA- avoid in muscle haematomas, haemarthrosis and urinary bleeding–> fibrosis
Hep B vaccination, hydrotherapy, ortho and dental advice
IV clotting VIII or IX either regularly/ in response to bleeding- comp= antibodies against tx
RFs for NEC?
Prematurity, formula feeds, resp distress and assisted ventilation, PDA and other congenital heart disease, LBW, non-breast-milk feeds, sepsis, acute hypoxia, poor intestinal perfusion–> bowel necrotic–> perforation, peritonitis and shock
Sx NEC?
Intolerance–> feeds, vomiting- green bile, unwell, distended tender abdomen, absent bowel sounds, blood in stools
FBC- low platelets and neutropenia
CRP, cap blood gas- met acidosis, blood culture for sepsis
AXR- supine position and lateral decubitus- dilated loops bowel, bowel wall oedema, pneumatosis intestinalis- gas in bowel wall, pneumoperitoneum, gas in portal veins
Bell’s classification, Riglers sign and Football sign
Tx for NEC? Comps?
NBM, TPN & ABx, refer–> neonatal surgical team- may be left with temporary stoma if significant bowel removed
Perforation and peritonitis, sepsis, death, stricture, abscess formation, recurrence, long term stoma, short bowel syndrome after surgery
Encourage breastfeeding in premature babies and delayed cord clamping
Number features ADHD up to 16 y/o? Over 17?
x6/ x5- inattention, hyperactivity/ impulsivity, sx inattention at least 6 months, hyper/ impuls= 6m extent= disruptive and inappropriate
Several before age 12 y/o, in two more settings
Presentation= x10 weeks watch and wait period- persist= secondary care referral
Drugs>5 y/o
Methylphenidate for 6 weeks- dopamine/ norepinephrine reuptake inhibitor–> abdo pain, nausea and dyspepsia, monitor weight and height every 6 months
Ind–> lisdexamfetamine- can’t tolerate but benefit–> dexamfetamine
BASELINE ECG
Causes constipation in children?
Idiopathic/ functional
Hirschsprung’s disease, CF, hypothyroidism
<3 stools/ week, retentive posturing, overflow soiling
When is encopresis pathological?
4 y/o- rarer causes= spina bifida, cerebral palsy, learning disability, psychosocial stress, abuse
Red flags with constipation?
Not passing meconium within 48 hours birth- CF/ Hirsch
Neuro signs- lower limbs, vomiting, ribbon stool- anal stenosis, abnormal anus, abnormal lower back/ buttocks, failure to thrive, acute severe abdo pain/ bloating- obstruction, intussusception
Tx constipation children?
Correct factors, laxatives- Movicol first line- macrogol, disimpaction regime- high doses at first, scheduling vists, bowel diary and star charts, slowly weaned off- not yet weaned<6m- bottle-fed= extra water between feeds, abdo massage and bicycling infant’s legs, breast-fed= consider organic causes
High fibre diet
Review after Movicol plan?
2 weeks- add stimulant laxative(Senna)- singly or in combination with osmotic e.g. lactulose/ docusate if not tolerated
When does coeliac present in children? Genes? Features, Ix and tx?
<3 y/o, HLA-DQ2 & HLA-DQ8
Failure to thrive, diarrhoea, abdominal distension, bruising- vit k deficiency, steatorrhoea, wasted buttocks, short stature, older= anaemia, rare= peripheral neuropathy, cerebellar ataxia, epilepsy
Jejunal biopsy–> subtotal villous atrophy, anti-endomysial and anti-gliadin antibodies(anti TTG & anti-EMA,) anti-DGPs screening tests, total IgA, FBC, U&Es, LFTs, vit D, B12, folate, iron levels, STOOL CULTURE FIRST FOR INFECTION- ass w/ T1DM, thyroid disease, AI hepatitis, PBC, PSC, Down’s
Comps of coeliac disease?
Anaemia, def in iron, B12 & folate, hyposplenism, osteoporosis, EATL, ulcerative jejunitis, small bowel adenocarcinoma
Who does benign affect? type of seizures? EEG shows what?
4-12 y/o, seizures= typically@night, partial, secondary may occur, child= otherwise normal
Centrotemporal spikes
What is Hirschsprung’s disease?
Where nerve cells of the myenteric plexus are absent in the distal bowel and rectum- absence PS ganglion cells
Entire colon= total colonic aganglionosis–> constricted and proximal= distended and full
Cause and ass of Hirschsprung’s disease?
Family hx, Down’s syndrome, neurofibromatosis, Waadernburg syndrome–> pale blue eyes, hearing loss and patches white skin and hair, MEN 2
Sx of Hirschsprung’s?
Delay passing meconium > 24 hours, chronic constipation since birth, abdominal pain and distension, vomiting, poor weight gain and failure to thrive
What is Hirschsprung- associated enterocolitis?
Within 2-4 weeks birth w/ fever, abdominal distension, diarrhoea and sepsis features(3 Ds- dysmotility, dysbiosis of the gut microbiome, defective intestinal barrier function and mucosal immune response)- can lead to toxic megacolon and perforation of the bowel- needs urgent ABx, fluid resus and decompression of obstructed bowel
Tx Hirschsprung’s disease?
FBC, sepsis Ix, ABG, serum electrolytes, TFTs- hypothyroidism, AXR, rectal biopsy, enterocolitis= fluid resus and int obstruction, IV ABx in HAEC, barium studies after AXR–> saw-tooth of aganglionic segment, anorectal manometry
Def tx= surgical removal aganglionic section of bowel
When is a rectal biopsy indicated?
Failure to pass meconium within 48 hours following birth in term infants, constipation since neonatal period, chronic abdominal distension ass w/ vomiting, family hx of Hirschprung’s disease, failure to thrive/ growth faltering along with any of above
Causes of impetigo?
S.aureus, s.pyogenes- non-bullous or bullous- bullae>5mm in diameter fluid-filled lesions, MRSA= more common
Sx non-bullous impetigo? Bullous impetigo?
Usually asymptomatic- may be mildly itchy, thin walled vesicles/ pustules around mouth and nose–> golden crust
Flaccid fluid filled vesicles and blisters can persist for 2-3 days- rupture–> thin flat yellow/ brown curst, on flexures, face, trunk and limbs, can be widespread in infants, can have systemic sx, be painful & itchy(more in neonates and children<2y/o,) severe–> staphylococcus scalded skin syndrome
Ix impetigo? Tx non-bullous impetigo?
Skin swab for microscopy, culture and sensitivity
Hydrogen peroxide 1% cream–> fusidic acid or mupirocin
Widespread= topical fusidic acid/ topical ABx for 5 days e.g. flucloxacillin, clari/ erythromycin= alternatives
Tx for bullous impetigo?
Oral ABx up to 7 days- flucloxacillin/ clarithromycin
Stay away from school/ work until all lesions are crusted over/ until 48 hours after treatment, not touching/ scratching lesions, hand hygiene, avoiding face towels & cutlery
Comps of impetigo?
Cellulitis if infection gets deeper in the skin, sepsis, scarring, post- strep GN, staph scalded skin syndrome, scarlet fever
Sx chickenpox? Tx?
Fever initially, itchy, rash starting on head/ trunk before spreading, initially macular–> papular–> vesicular
Cool, trim nails, calamine lotion, school exclusion- 1-2 days before, until all lesions crusted over
Immunocompromised and peripartum exposure= VZIG, develops/ immunocompromised/ adults over 14 y/o presenting within 24 hours, neonates/ at risk of comps= IV aciclovir
Comps of chickenpox?
Bacterial superinfection, dehydration, conjunctival lesions, pneumonia, encephalitis–> ataxia, hepatitis and haemorrhagic comps
Shingles/ Ramsay Hunt syndrome, Reye’s syndrome
Causes of Kallman syndrome?
Hypogonadotrophic hypogondadism
X-linked= from KAL gene
Autosomal dominant and recessive forms–> delayed puberty- less common in females
Synkinesia, renal agenesis, visual problems, craniofacial anomalies, expression= highly variable
Onset of typical absence seizures (petit mal)? Sx, Ix, tx?
4-8 y/o, 30 seconds long, no warning, quick recovery, often many per day, EEG= 3Hz generalised, symmetrical, sodium valproate, ethosuximide
90%= seizure free in adolescence
How does infantile spasms present? Tx?
Aroun 6m age, poor prognosis, clusters full body spasms- Salaam attack
EEG= hypsarrhythmia, usually secondary to serious neurological abnormality e.g. tuberous sclerosis, encephalitis, birth asphyxia/ idiopathic
Prednisolone, vigabatrin
Atonic seizures/ drop attacks may be indicative of what? Tx?
Lennox-Gastaut syndrome- not usually more than 5 minutes, typically begin in childhood
Sodium valproate/ ethosuximide, ketogenic diet might help
Management of juvenile myoclonic epilepsy?
Often in morning/ following sleep deprivation, daytime absences
Sodium valproate, lamotrigine, levetiracetam or topiramate
Do an EEG when and MRI brain in epilepsy?
After 2nd simple tonic-clonic seizure
First seizure under 2 y/o, focal seizures, no response–> first line anti-epileptics
Consider ECG, electrolytes- Na+, K+, Ca+, Mg2+, blood glucose, blood cultures, urine cultures, LP
General advice with childhood epilepsy?
Take showers rather than baths, cautious w/ swimming, heights, traffic and heavy, hot or electrical equipment
Older= avoid driving unless specific criteria
Tests in neonatal jaundice?
Conjugated and unconjugated bilirubin, direct Coombs- direct antiglobulin test, TFTs, FBC, blood film, urine for MC&S & reducing sugars, U&Es, LFTs
When should anti-D injections be given?
Test for D antibodies at booking
28w and birth routinely
Sensitisation events- APH, amniocentesis, abdominal trauma, miscarriage>12w, termination, ectopic pregnancy, ECV, delivery Rhesus +ve individual
GIVEN WITHIN 72 HOURS- after 20 weeks= Kleinhauer test to see how much foetal RBCs–> mother’s bloodstream
All Rhesus negative have cord blood taken at birth for what? Features affected foetus?
FBC, crossmatch, direct Coombs test
Hydrops foetalis, hepatosplenomegaly, foetal anaemia–> pallor, Kernicterus, severe oedema if hydrops fetalis in utero, yellow amniotic fluid
LFTs, US for oedema
Tx of HDOTN?
Transfusions, UVA phototherapy, Ig to newborn, delivery if severe
Sx maternal hyperthyroidism? Sx?
Fetal tachycardia on CT, fetal goitre on USS, neonate= irritable, weight loss, tachycardia, HF, diarrhoea, exophthalmos in first 2 weeks life- eye signs less common
Carbimazole/ propylthiouracil, Beta-blockers for sx relief for about 2 years
Check what in women planning a pregnancy?
TSH, FT4 and TPOAb, TRAbs if history/ current Graves’ disease(CHECK AFTER BIRTH AND AT 6 WEEKS)- delay conception and use contraception until thyroid function normalised
Avoid pregnancy for 6 months after radioactive thyroid tx, give leaflet
Annual monitoring TFTs hx postpartum thyroiditis
RFs for RDS? Sx? DDx?
Maternal diabetes, males, 2nd twin, C-sections
Increased WOB shortly after birth>60/min, grunting, nasal flaring, intercostal recession, cyanosis, CXR: diffuse granular patterns- ground glass +/- air bronchograms
TTOTN- 1st 4 hours>60, more common after C-sections- CXR= hyperinflation of the lungs and fluid in horizontal fissure–> observation, supportive care, supplementary oxygen, usually within 1-2 days, mec asp, TO fistula
Prev RDS?
dex/ betamethasone from 23-35 weeks- high risk–> perinatal centres
Delay cord clamping, O2-air blender 21%-85% normal within 5-10 minutes if active baby, increase by 10% every minute until improving
CPAP
May need endotracheal surfactant, intubation and ventilation, supp O2 91-95% in preterm neonates, gradually step down
Comps of RDS?
Pneumothorax, infection, apnoea, IV haemorrhage, pulm haemorrhage, NEC
Chronic lung disease of prematurity, retinopathy of prematurity, neuro, hearing and visual impairment
Most common type of GI malformation? Sx?
OA + distal TOF
Prenatal= polyhydramnios, postnatal= blowing bubbles, salivation + drooling, cyanotic episodes, resp distress + aspiration, distended abdomen, difficulty passing NG tube
Ix, tx oesophageal atresia +/- TOF? DDx? Tx?
NG tube= coiled in oesophagus, AXR= no bubbles- isolated OA, renal USS + ECHO
Congenital diaphragmatic hernia, duodenal atresia, GORD- VACTERL associations
Surgical tx soon after birth to connect- monitor for anastomotic leaks, strictures, or recurrent fistula
Sx of bronchopulmonary dysplasia?
Persistent hypoxia +/- difficult ventilator weaning- still needing ventilation at 36w postmens age SaO2<88% in air- from barotrauma and oxygen toxicity, surfactant- related= multifactorial
IN PREMATURE BABIES
CXR= hyperinflation, rounded radiolucent areas alt w/ thin denser lines
Prev= steroids antenatal and postnatal, once born= CPAP, caffeine= stimulates resp effort, not over-oxygenating
Formal sleep study- oxygen during sleep- discharge from unit on low dose oxygen, follow- up to wean
What do babies with CLDP need monthly injections of?
MAB- palivizumab
Sx pulmonary hypoplasia?
Persisting neonatal tachypnoea +/- feeding difficulties- esp if prenatal oligohydramnios e.g. Potter’s syndrome, prem rupture of membranes/ congenital diaphragmatic hernia
Fetal anomaly US, CXR may be normal
Sx persistent pulmonary hypertension of the newborn?
From birth asphyxia, meconium aspiration, septicaemia/ RDS
Cyanosis soon after birth, murmurs/ signs of HF= often ABSENT
Pulmonary oligaemia on CXR
ECHO- exclude congenital heart disease
Mech ventilation & circulatory support, inhaled NO, sildenafil for some, high freq/ oscill ventilation= sometimes helpful
ECMO= where placed on heart and lung bypass for several days for severe but reversible cases
What can cause congenital diaphragmatic hernias cause? Sx?
Pulmonary hypertension, pulmonary hypoplasia
Prenatal US, postnatal CXR
Difficult resus at birth, resp distress, bowel sounds in one hemithorax- usually LEFT, displaced apex beat, scaphoid abdomen
Most common= posterolateral Bochdalek hernia- only around 50% survive
Ass w/ trisomy 18, chromosome deletions, Pierre Robin syndrome
Tx of congenital diaphragmatic hernia?
Refer to tertiary fetal medicine centre for fetal surgery- may cause premature birth
Large-bore NG tube when Ix suspected- birth= if prenatal Ix- immediately intubate, ventilate and paralyse with minimal pressures, surgery in an appropriate centre
Sx inguinal hernia?
Patent processus vaginalis lateral to pubic tubercle- commoner in males e.g. during crying
Most= lap repair prevent incarceration
6/2 rule- <6w- operate within 2 days, <6m== within 2 weeks, <6 years= within 2 months
Premature infants and neonates= kept overnight as risk of post-operative apnoea, most= day cases
Tx umbilical hernia? Ass?
Resolve by 3 y/o
Afro-Caribbean infants, Down’s, mucopolysaccharide storage diseases
Cause of duodenal atresia? Sx?
Other intestinal atresias, VACTERL association
Polyhydramnios, post-natally= distended abdomen and vomiting- billious/ non-billious depending on size of atresia
Ix= AXR- double bubble sign
Tx= duodenoduodenostomy
Incubation period for s.aureus, bacillus cereus? Salmonella & E.coli? Shigella, campylobacter? Giardiasis, amoebiasis?
1-6hours
12-48 hours
48-72 hours
>7 days
Viral causes gastroenteritis? Parasitic?
Rotavirus- infantile, norovirus- all ages, adeno= resp infections- resp infections in children
Cryptosporidium, entamoeba histolytica, giardia intestinalis, schistosoma
Location of s.aureus, clostridium perfringens? Tx salmonella and shigella? Campylobacter? Cholera? Giardiasis?
Cooked meats and cream products
Reheated meat dishes/ cooked meats
Ciprofloxacin/ azithromycin- guided by stool sample & sensitivities
Macrolide- erythromycin
Tetracycline- reduce transmission e.g. doxy/ lymecycline
Metronidazole
Sx yersinia?
Raw/ undercooked pork- urine/ faeces of mammal
Watery/ bloody diarrhoea–> diarrhoea, abdominal pain, fever and lymphadenopathy
Can last>3 weeks
Older children/ adults= right-sided abdominal pain due to mesenteric lymphadenitis- imp appendicitis
Guided by stool culture and sensitivities
Tx gastroenteritis? Post gastroenteritis comps?
Barrier nursing, rigorous infection control, stay off school for 48 hour after sx completely resolved
Stool sample= microscopy, culture and sensitivities
Fluid challenge- record small volume given orally every 5-10 minutes- can tolerate= manage at home
Rehydation= dioralyte/ IV fluids
Light diet re-introduce
Lactose intolerance, IBS, reactive arthritis, GBS
Crows NESTS for Crohn’s? CLOSEUP for UC?
No blood/ mucus, entire GI tract, skip lesions on endoscopy, terminal ileum most affected & transmural inflammation- full thickness, smoking= RF- wt loss, strictures and fistulas
Cont inflammation, limited to colon & rectum, only superficial mucosa, smoking= protective, excrete blood & mucus, use aminosalicylates, PSC
Extra-int and ix of IBD?
Finger clubbing, erythema nodosum, pyoderma gangrenosum, episcleritis & iritis, inflammatory iritis, PSC- UC
CRP, FBC, TFTs, U&ES, LFTs, faecal calprotectin, coeliac serology, serum ferritin, vitamin B12, folate, vitamin D levels, OGD & colonoscopy w/ biopsy= GOLD, USS, CT & MRI= imaging- comps, AXR/ CT in acute flare for toxic megacolon and/ or perforation
Colonoscopy & barium enema= CI due to risk perforation, acute severe UC flare= flexi sig for biopsy
MRI- fistulating perianal disease, if needed EUA may be needed, may need CT imaging in acute setting for obstruction/ perforation
Score for classifying Crohn’s disease? Tx acute flare Crohn’s?
Montreal score- age, location, behaviour, “p” if concurrent perianal disease
CS therapy- pred/ hydrocortisone–> azathioprine, mercaptopurine, methotrexate, infliximab/ adalimumab >2 exacerbations in 12 months + anti-embolic stockings, low residue diets, fluid resus, proph heparin
First presentation/ single ex in 12 months/ CS not tolerate/ CI–> aminosalicylates- sulfasalazine
Possible enteral nutrition
Impact on daily life, sources information, encourage stop smoking, assess risk osteoporosis, arrange specialist referrals
Tx for maintaining remission in Crohn’s disease? When surgery?
Azathioprine/ methotrexate/ infliximab/ adalimumab
IBD nurses
Colonoscopic surveillance >10 years with >1 segment bowel affected
Failed medical tx/ severe complications- strictures/ perforation- bowel-sparing approach prevent short gut syndrome
Ileocaecal resection, small bowel resection, surgery for peri-anal disease, stricturoplasty- stricture causing obstruction
Active severe flare= primary bowel anastomosis should not be performed
Tx for inducing remission in UC? Maintaining remission? Surgery?
Aminosalicylate- mesalazine oral/ rectal/ pred
Severe= IV hydrocortisone/ ciclosporin
Mesalazine, azathioprine, mercaptopurine
Panproctocolectomy–> ileostomy or ileo-anal anastomosis J= pouch
Emergency= segmental colectomy or subtotal colectomy w/ stoma formation
Comps UC?
Toxic megacolon- decompression needed ASAP, colorectal adenocarcinoma, pouchitis- inflam ileal pouch undergone IPAA- metronidazole and ciprofloxacin
Severity of UC what score?
Truelove and Witt criteria- bowel movements, blood in stool, pyrexia, pulse>90bpm, anaemia, ESR
Montreal score= disease extent, Mayo score= disease severity
RFs for premature delivery?
Previous preterm delivery, multiple pregnancy, smoking and illicit drug use, being under or overweight, early pregnancy, issues with cervix, uterus/ placenta, diabetes, HTN, trauma
What is apnoea of prematurity? Causes?
Breathing stops spontaneously for>20 seconds/ shorter periods with oxygen desaturation/ bradycardia
Often w/ bradycardia- very common in premature
Immaturity of autonomic nervous system controlling respiration and HR
Infection, anaemia, airway obstruction, CNS pathology- seizures/ haemorrhage, GI reflux, neonatal abstinence syndrome
Tx apnoea of prematurity?
Apnoea monitors, tactile stimulation, IV caffeine, settle as baby develops
Who should be screened for ROP by ophthalmologist?
Babies born before 32 weeks/ under 1.5kg
Starts at 30-31w GESTATIONAL AGE born before 27 weeks
4-5w babies born after 27 weeks
Screening= at least every 2 weeks- cease once retinal vessels–> zone 3 at around 36 weeks
Examination and screening for ROP?
Monitoring retinal vessels and looking for plus disease
Transpupillary laser photocoagulation halt and reverse neovascularisation
Cryotherapy & intravitreal VEGF inhibitors
Surgery for retinal detachment
Sx foetal alcohol syndrome?
1st 3 months–> miscarriage, small for dates, preterm delivery
Microcephaly, thin upper lip, smooth flat philtrum, short palpebral fissure, LD, behavioural, hearing and vision, cerebral palsy
Zika spread by what?
Aedes mosquito–> congenital Zika syndrome
Microcephaly, FGR, ventriculomegaly and cerebellar atrophy
Test w/ viral PCR and antibodies to Zika virus- +ve= refer to fetal medicine monitor
Withdrawal from most opiates, diazepam, SSRIs and alcohol occurs when? Methadone and benzos? CNS, vasomotor and resp effects, meta and GI effects?
3-72 hours
24 hours- 21 days
Irritability, increased tone, not settling, high pitched cry, not settling, tremors, seizures
Yawning, sweating, unstable temp and pyrexia, tachypnoea
Poor feeding, regurg & vomiting, hypoglycaemia, loose stools with sore nappy area
Neonatal abstinence syndrome chart kept for how long? What collected from neonate? Tx opiate and non-opiate withdrawal? Other considerations?
3 days
Morphine sulfate
Phenobarbitone- slowly weaned off
Testing for hep B, C & HIV
Safeguarding & social care, safety netting, follow up, support mother, check suitability for breastfeeding
RFs for cot death? Measures reduce risk?
Premature, LBW, smoking during pregnancy, male baby
Put on back, keep head uncovered, place feet at foot of bed to prevent sliding down and under blanket, keep cot clear of lots of toys and blankets, maintain comfortable room temp, avoid smoking, co-sleeping- part sofa/ chair
What are choledochal cysts?
Cystic dilatations of the extrahepatic biliary system
May be detected on antenatal scan, present with neonatal jaundice or in older children w/ abdominal pain, palp mass, jaundice or cholangitis
USS/ MRCP
Surgical excision of cyst with formation of a Roux-en-Y anastomosis to the biliary duct
Comps= cholangitis and 2% risk malignancy
Sx neonatal hepatitis syndrome?
Prolonged neonatal jaundice and hepatic inflammation- may have LBW and faltering growth
Jaundice may be severe and diff from biliary atresia= essential
Liver biopsy= often non-specific- shows giant cell hepatitis
Sx Alagille syndrome?
Rare autosomal dominant condition with widely varying penetrance within families
Triangular facies, skeletal abnormalities- butterfly vertebrae, congenital heart disease- peripheral pulm stenosis, renal tubular disorders, defects in the eye
Severe pruritus and faltering growth
Nutrition and fat-soluble vitamins
Small number= liver transplant, mortality= due to cardiac disease
What does progressive familial intrahepatic cholestasis affect? Sx?
Bile salt transport–> jaundice, intense pruritus, faltering growth, rickets and some diarrhoea and hearing loss, older= gallstones
Identify mutations in bile salt transport genes
Nutritional support & fat soluble vitamins, pruritus can be severe
Most= need liver transplant
What is acute liver failure?
Development of massive hepatic necrosis with loss liver function with or without hepatic encephalopathy
Infection & metabolic conditions
Within hours/ weeks with jaundice, encephalopathy, coagulopathy, hypoglycaemia and electrolyte abnormalities
Early signs encephalopathy= alternate periods irritability & confusion w/ drowsiness
Older may be aggressive
Comps= cerebral oedema, haemorrhage from gastritis/ coagulopathy, sepsis and pancreatitis
Causes of acute liver failure in children <2 y/o? >2 y/o?
Infection, metabolic disease, seronegative hepatitis, drug induced, neonatal haemochromatosis
Seronegative hepatitis, paracetamol overdose, mitochondrial disease, Wilson disease, AI hepatitis
Ix and tx acute liver failure in children? EEG & CT findings?
Bilirubin may be normal in early stages- part with metabolic disease
Transaminases are greatly increased, ALP is increased, coagulation is very abnormal and plasma ammonia= elevated- monitor acid-base balance, blood glucose and coagulation times
Hepatic encephalopathy & cerebral oedema
Early referral to national paediatric liver centre
Steps to stabilise child before transfer for liver transplant?
Maintain blood glucose>4mmol/L with IV dextrose
Broad-spec ABx & antifungal agents prevent sepsis
IV vitamin K and H2-blocking drugs or PPIs- prevents haemorrhage from GI tract
Fluid restriction and mannitol diuresis if oedema develops
Features poor prognosis in liver failure?
Shrinking liver, rising bilirubin w/ falling transaminases a worsening coagulopathy/ progression–> coma
Without- 70%–> coma will die
What is chignon? When does erythema toxicum neonaturum appear?
Temporary swelling on head seen in newborn infants delivered with Ventouse
Day 2-3= white pinpoint papules filled with eosinophils- last 24 hours- MORE COMMON IN FULL TERM BABIES, settles spontaneously
When do strawberry naevi grow until?
6-9 months, then regress spontaneously especially in premature babies
Can be ass with LBW, prematurity, multiple gestation and CVS sampling
Topical propanolol can speed regression
MORE THAN 5= USS of the liver
Where are Mongolian blue spots seen? Capillary haemangioma/ stork bite/ salmon patch?
Base of the back and on the buttocks- common in dark-skinned parents, can occur in white infants
Normally disappear over first year
Around eyes, nape of neck- eyes normally disappear in first year and commonly persist if on nape of neck
Day of Guthrie heel-prick test?
5
PKU
Congenital hypothyroidism-<32w need repeat test at 28 postnatal age
SCD
CF- immunoreactive trypsinogen
MCADD- prevents normal breakdown of fat
Homocystinuria
MSUD- AR disease mutation in at least 4 genes–> encephalopathy
GA1–> movement disorder- dystonia
IVA- massive metabolic acidosis rapid death, chronic= ketoacidosis and asymptomatic periods
Sx psoriasis in children? Tx?
Guttate= more common often triggered by a throat infection- plaques= likely to be smaller, softer and less prominent
Topical steroids, topical vitamin D analogues, topical dithranol
Topical calcineurin inhibitors- tacrolimus only in ADULT
Phototherapy w/ UVB in extensive
Fails–> methotrexate, ciclosporin, retinoids/ biologics
Steroid + vit D= Dovobet, Enstilar
Cause of molluscum contagiosum?
Poxvirus- small flesh coloured papules w/ central dimple in crops in local area spread through direct contact/ sharing towels/ bedsheets- COMMON IN PRESCHOOL CHILDREN
Resolve without tx- up to 18 months
Avoid scratching/ picking lesions
Topical fusidic acid/ oral flucloxacillin if bacterial superinfection
Immunocompromised/ extensive/ problematic areas= specialist- topical K+ hydroxide, benzoyl peroxide, podophyllotoxin, imiquimod or isotretinoin
Surgical removal & cryotherapy- leads to scarring
Causes of erythema multiforme?
Hypersensitivity- viral infections and medications- HSV, mycoplasma, drugs- penicillins, sulphonamides, carbamazepine, allopurinol, NSAIDs, COCP, nevirapine, SLE, sarcoidosis, malignancy
Widespread, itchy, erythematous, target lesions initially back hands/ feet–> torso, upper> lower limbs- can cause stomatitis, fever, muscle & joint aches, headaches, flu-like symptoms
Identify cause e.g. CXR- mild usually resolves within one-4 weeks without treatment- may be recurrent
May need admission affecting oral mucosa- IV fluids, analgesia, steroids, ABx/ antivirals where infection present
Most common type of tinea corporis? Sx?
Trichophyton/ microsporum/ epidermophyton species- spread through infected individuals, animals or soil
Erythematous scaly plaques with active, advancing often pruritic border
Centre may clear up as it expands–> ring-like
Ix and tx tinea corporis?
Clinical, uncertain= KOH preparation of skin scrapings confirm fungal elements under microscopy
Cultures for cause
Some= Wood’s lamp examination- microsporum= fluoresce
Topical clotrimazole/ terbinafine to lesion and margin around for at least 2 weeks/ until week after resolution
Extensive= systemic= oral terbinafine, itraconazole, fluconazole
Fungal nail infections tx? Simple advice for tinea corporis?
Amorolfine nail lacquer for 6-12 months- resistant= oral terbinafine- need LFTs monitored before and while
Loose breathable clothing, keep clean & dry, avoid sharing, use separate towel for feet with tinea pedis, avoid scratching and spreading to other areas, wear clean dry socks every day
What is tinea incognito?
More extensive and less well recognised fungal skin infection from steroid use to treat initial fungal infection
Initial= dermatitis and topical steroid prescribed
Less well demarcated border and fewer scales
Who does tinea capitis affect in children? Ix? Tx?
6m- 10-12 years- trichophyton, microsporum
Scaling & hair loss, inflammation in erythema and pustule formation can occur, ‘black dot’ might occur
Scalp scrapings–> direct microscopy and culture/ sterile brushes
Moistened dressings, do not share towels, inspect other children & household contacts
Oral antifungal agent- attend school as normal- griseofulvin / oral terbinafine empirically until culture results available
Tx tinea capitis in urban area?
Terbinafine for 4 weeks, rural= griseofulvin for 4-8 weeks
Tricho= continue–> switch to terbinafine
Microsporum= continue/ switch to griseofulvin
Griseo not tolerated= consider itraconazole
Consider additional topical agent- selenium sulfide/ ketoconazole shampoo twice weekly 2-4 weeks/ imidazole cream daily for one week
Persistent tinea capitis tx?
Tx for another month
Carriers= topical preparation
Cause of scabies?
Sarcoptes scabiei- up to 8 weeks for sx to appear
Severe itching 2-6 weeks after infestation= worse in warm conditions and at night
Older= burrows, papules and vesicles skin between fingers & toes, axillae, flexors of wrists, belt line and around nipples, penis, and buttocks
Young= palms, soles and trunk
Clinical Ix/ microscopic examination of skin scrapings from lesions= mite, eggs and faeces
Tx and comps of scabies?
Permethrin cream to whole body when skin is cool- left on for 8-12 hours & wash off- repeat week later- difficult to treat/ crusted= oral ivermectin
Tx household contacts in same way, wash everything on hot wash
Itching can be up to 4 weeks- crotamiton cream and chlorphenamine at night
Crusted scabies also known as what?
Norweigan scabies- serious in immuncompromised- patches red skin–> scaly plaques- extremely contagious
Misdiagnosed as psoriasis
Immuncompromised may not have itch as they don’t mount immune response- need admission for tx as inpatient with oral ivermectin and isolation
Causes of erythema nodosum? Ix?
HS reaction–> SC layer, No cause- idiopathic, drugs- sulfonamides & dapsone, OCP, sarcoidosis, UC & Crohn’s, microorganisms- TB, strep, toxoplasmosis
Sx, Ix and tx for erythema nodosum?
Flu-like symptoms, painful nodules on legs last for about 2 weeks, new nodules can last up to 6 weeks- hot & firm–> squashy
Clinical Ix/ biopsy- bloods, CXR, strep test, TB Ix, for sarcoidosis, stool sample, bowel Ix
NSAIDs, bed rest and legs raised, stockings, cool wet compresses, K iodide, steroids might help inflammation- most resolve within 6 weeks
Sx pityriasis rosea? Tx?
Headache, loss of appetite, flu-like sx- herald patch faint red or pink, scaly, oval 2cm or more 2/ more days prior to rest of rash- usually on TORSO
Can be arranged in Xmas tree fashion
Resolves without tx within 3 months- can leave discolouration- resolve within another few months- continue normal activities, patient education
Emollients, topical steroids, sedating antihistamines at night for symptoms
Cause of granuloma annulare?
Delayed HS reaction to component of dermis/ numerous triggers, also systemic conditions
Any site of body, occasionally widespread, tender when knocked
Localised= most common in children- one/ more skin coloured/ red bumps form rings in skin over joints particularly the knuckles, surface smooth and centre= often little depressed, also top foot/ ankle and over one or both elbows
SC= rare- mistaken for rheumatoid nodules
Ix and tx of granuloma annulare?
Clinically, sometimes= biopsy- necrobiotic degeneration of dermal collagen surrounded by inflam reaction
Resolve in few months- sometimes years
Consider topical CS ointment under occlusion, steroid injections, cryotherapy/ laser ablation, imiquimod cream topical calcineurin inhibitors
Widespread= systemic therapy
Can recur even at same sitea
Ass w/ alopecia areata? Sx? Ix & tx?
Down’s, AI conditions e.g. vitiligo, thyroid disease, family hx- x16 genetic risk loci
Exclamation point hairs in 10-40%- pitting & ridging most common
Trichoscopy, hair pull test>10% hairs pulled out easily, skin biopsy- bee-swarm pattern
Topical/ intralesional corticosteroids- triamcinolone 4-6 weekly, topical minoxidil, phototherapy, dithranol, contact immunotherapy- extensive, systemic corticosteroids for refractory/ severe cases, baricitinib, , support groups, wigs
Parasite for headlice? Sx & tx?
Pediculus humanus capitis- spread by close contact
Itchy scalp
Dimeticone 4% lotion/ wet combing, isopropyl myristate/ cyclomethicone if living lice found - left on for 8 hours then washed off repeated 7 days later
Fine combs of wet/ dry hair, detection combing, Bug Buster kit
NO EXCLUSION/ TX contacts only if affected
What is allergic rhinitis?
A type 1 HS IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed and sensitised to allergens–> sneezing, nasal itching, rhinorrhoea and congestion
Classification of allergic rhinitis?
Seasonal- same time each year from grass and tree pollen allergens
Perennial= throughout the year due to allergens from house dust mites and animal dander
Intermittent= <4 days/ week/ <4 consecutive weeks
Persistent=> 4 days a week AND >4 consecutive weeks
Occupational
Ix and tx of allergic rhinitis?
Type, frequency, timing, persistence and location symptoms, severity and impact of sx
Housing conditions, pets, occupation
Drugs- that may cause aggravate or alleviate sx, family history of atopy, examine for rhinitis and/ or associated conditions
Skin prick testing might be useful for pollen, animals and house dust mite allergy
Information & support, saline nasal irrigation, avoidance techniques
Mild, intermittent or both sx- intranasal antihistamine/ non-sedating oral antihistamine- cetirizine/ loratadine, fexofenadine
Moderate- severe persistent sx/ initial ineffective= regular intranasal corticosteroids e.g. fluticasone and mometasone
Review after 2-4 weeks if symptoms persist
Possible IN decongestant- not prolonged due to hypertrophy nasal mucosa= rhinitis medicamentosa, anticholinergic/ LTRA
Oral CS short course, affecting QOL
Referral to allergy/ ENT specialist for who w/ allergic rhinitis?
Red flags for alternative, persistent despite optimal tx, avoidance techniques being considered- allergy testing may be needed
Would like to consider immunotherapy treatment instead of long-term tx
Once anaphylaxis diagnosed, 3x medications?
IM adrenaline repeated after 5 minutes if required
Antihistamines e.g. oral chlorphenamine(sedating,)/ cetirizine(non-sedating)
Steroids- IV hydrocortisone
After anaphylaxis event tx?
Period of assessment and observation due to biphasic reactions
Serum mast cell tryptase within 6 hours event
Education and follow-up, trained in BLS- training in adrenalin auto-injector
Indications for adrenalin auto-injector?
Epipen, Jext and Emerade- all with an reactions, considered in children with generalised allergic reactions w/: asthma needing inhaled steroids, poor access to medical tx, adolescents at higher risk, nut/ insect sting allergies, co-morbidities e.g. CVD
Epipen in mid-thigh for 3 seconds, Jext= 10 seconds before removing device- gently massage for 10 seconds
Phone emergency ambulance- 2nd dose may be given after 5 minutes if needed
What is urticaria and angio-oedema?
Superficial swelling of epidermis and mucous membranes–> red, raised, itchy rash
Deeper form swelling in dermis and submucosal/ SC tissues
Classification of urticaria? Tx?
Acute<6 weeks
Chronic>6weeks on nearly daily basis
Chronic spontaneous- no identifiable cause
Autoimmune- presence IgG autoantibodies to IgE e.g. SLE
Chronic inducible- result to physical stimulus–> aquagenic, cholinergic, solar, cold heat, dermatographism, delayed pressure, vibratory and contact urticaria
Non-sedating antihistamine daily for up to 6 weeks- fexofenadine, severe= 7d course oral corticosteroid
Sx improve= AH tx daily for 3-6 months/ as required
Inadequate response= increasing dose to x4 times licensed dose, alt non-sedating AH, +calamine lotion, sedating antihistamine@night, refer–> dermatologist or immunologist for LTRA, omalizumab, ciclosporin
Refer to dermatologist/ immunologist for who w/ urticaria?
Vasculitic urticaria, food/ latex allergy, form of CINDU difficult to manage e.g. solar/ cold
Poss referral to clinical psychologist
Clinical signs of dehydration in children?
appears unwell/deteriorating, altered responsiveness, sunken eyes, tachycardia, tachypnoea, reduced skin turgor, dry mucous membranes, decreased urine output
Signs of clinical shock?
Decreased LOC, pale/ mottled skin, cold extremities, pronounced tachycardia, pronounced tachypnoea, weak peripheral pulses, prolonged CRT, hypotension
HYPOTENSION= SIGN OF DECOMPENSATED SHOCK
Fluid of choice in Paeds for maintenance fluids? In shock?
NaCl 0.9% + Dextrose 5% + KCl 10mmol
(Neonates= 10% +/- dextrose)
NaCl 0.9% at 20ml/kg- 10ml/kg <10 minutes in DKA, trauma, primary cardiac pathology e.g. HF
Above 3 boluses–> call Paeds ICU support in case child–> pulmonary oedema
Fluid in replacement Paeds? U&Es and plasma glucose monitored at least every what?
0.9% NaCl + 5% glucose
Losses e.g. diarrhoea, vomiting= w/ potassium e.g. 10mmol/L
Every 24 hours
Calculating % dehdyration by weight equation? Clinical assessment?
Well weight- current weight/ well weight x 100
No red flags= 5% dehydrated
Shocked/ red flags= 10% dehydrated- tx with fluid bolus before replacement fluids
How is fluid deficit calculated?
Fluid deficit= % dehydration x weight (kg) x 10
Total= maintenance fluids + fluid deficit
What is given for fluid given in shock?
0.9% NaCl no additives IV of 10ml/ kg over<10 minutes, smaller- neoantes, DKA, septic shock, trauma, cardiac pathology
After admin= volume status re-assessed- HR, RR, CRT- still shocked= urgent senior advice should be sought- contact Paeds ICU
Fluid used in hyponatramia? Signs of dehydration in hypernatraemia, switch to what?
2.7% sodium NaCl- hypertonic boluses
0.45% NaCl- CORRECT SLOWLY OVER 48 HOURS FOR HYPOVOLAEMIC HYPERNATRAEMIA
NO MORE THAN 12MMOL/L RISE/ FALL IN SERUM SODIUM OVER 24 HOUR PERIOD–> central pontine myelinolysis and cerebral oedema
Primitive reflexes persist until when usually?
4-6m- past= sign of CNS dysfunction
Moro
Grasp/ palmar reflex
Sucking
Rooting
Stepping
Asymmetrical tonic neck reflex
–> POSTURAL:
Labyrinthine righting
Postural support
Lateral propping
Parachute
What is common following an inferior MI? What is common in the 48 hours following an transmural MI? When does left ventricular free wall rupture occur? What occurs in 1st week? What is acute mitral regurgitation more common?
AV block
Pericarditis
1-2 weeks after- acute HF secondary to cardiac tamponade
Ventricular septal defect- acute HF w/ pansystolic murmur- ECHO exclude mitral regurgitation- urgent surgical correction
Infero-posterior infarction due to ischaemia/ rupture of papillary muscle- acute hypotension and pulm oedema may occur- early to mid systolic murmur- vasodilator, often require emergency surgical repair
Red flags for developmental milestones?
Lost developmental milestones, not able to hold an object at 5m
Not sitting unsupported at 12m
Not standing independently by 18m
Not walking independently at 2y
Not running at 2.5y
No words/ interest in others at 18m
Who gets parvovirus B19 and months? Incubation and sx?
3-15 y/o- April & May= peak
7-10 days
Infectious 4-20 days before rash- once rash= not infectious
Mild fever, coryza and non-specific viral sx e.g. myalgia & lethargy- after 2-5 days= rash rapidly as diffuse bright red rash on both cheeks
Few days later= reticular mildly reticular erythematous rash affecting trunk and limbs appears can be raised and itchy
Rash fades over 1-2 weeks
Ix and tx slapped cheek syndrome? At risk require what? Comps?
Sx relief, avoid increased risk comps- immunocompromised/ haem disorders/ pregnant women
Serology testing- high titre viral DNA for parvovirus to confirm Ix and checking of FBC and reticulocyte count for aplastic anaemia
Aplastic anaemia, encephalitis/ meningitis, pregnancy comps including hydrops foetalis, mirror syndrome- ass w/ severe pre-eclampsia, fetal death, rarely= hepatitis, myocarditis or nephritis
How is mumps spread? Incubation period? Sx?
Respiratory droplets of Paramyxovirus
14-25 days- 7 days before and 9 days after parotid swelling starts
prodromal flu sx few days before parotid swelling- uni/ bilateral, trismus
fever- 3-4 days, muscle aches, reduced appetite, headache, dry mouth, abdominal pain, testicular pain & swelling-within week, confusion, neck stiffness & headache, pancreatitis, sensorineural hearing loss
Tx mumps?
Rest, paracetamol for high fever/ discomfort, notifiable disease, stay off school/ work for 5 days for initial development
Admit for meningitis, encephalitis, epididymo-orchitis
Cause of SSSS? Sx, Ix and tx?
S.aureus–> TSST-1 superantigen toxin- splits stratum granulosum
<5 y/o affected
Generalised patches erythema–> bullae–> burst–> scalding, hypotension systolic<90mmHg, desquam of rash especially palms and soles
Involve 3/more organ systems= D&V, mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, confusion
Nikolsky positive, ORAL MUCOSA UNAFFECTED
Skin biopsy can diff from TEN, blood cultures
Systemic sx- can lead to sepsis
Admission- IV flucloxacillin
Cause of toxic shock syndrome? Sx?
Sever systemic reaction–> staph exotoxin–> T cell activation- IL-1 and TNF-alpha, group A strep, MRSA- tampons, breaks in skin, nasal packing
Non-specific flu-like sx–> high fever and eruption widespread macular rash becomes erythrodermic with >90% body surface involved including mucosal membranes
Multi-organ= hypotension, confusion- encephalopathy
Ix and tx of toxic shock syndrome?
Sepsis 6, throat swabs, wound swabs
DRABCDE, central venous pressure monitoring for shock
Clindamycin + cephalosporin/ meropenem/ vancomycin for broad spectrum + IV IG
Debridement, drainage/ amputation, corticosteroids
Cause and sx diphtheria infection? Ix & tx?
Corynbacterium diphtheriae
Necrosis of myocardial, neural and renal tissue
Sore throat- grey pseudomembrane on posterior pharyngeal wall
Bulky cervical lymphadenopathy–> bull neck membrane
Neuritis
Heart block
Throat swab uses tellurite agar or Loeffler’s media
IM penicillin, diphtheria antitoxin
How is polio spread and in who? Incubation? Sx? Ix? Tx?
Stools/ droplets
3-21 days, infectious 1 day before and up to 2 weeks after paralytic polio
Most no sx, 2-5 days of fever, tiredness, headache, sore throat, stomach pain, N/vomiting, neck stiffness, pain in arms and legs
Sx relief, physio, ventilators, meds for muscle spasms, mobility
Can lead to meningitis and paralysis
2x types vaccine
Types of immunodeficiency?
Primary- genetically determined- X-linked/ autosomal recessive, may be family hx of parental consanguinity & unexplained death especially in boys
Secondary- another disease/ tx
Suspect in Severe Prolonged Unusual / Recurrent Infections
E.g. of T cell defects in immunodeficiency?
SCID
HIV infection
Wiskott-Aldrich syndrome
Di George syndrome
Duncan disease
Ataxia telangiectasia
PNP deficiency
E.g. of B-cell disorders? Neutrophil disorders? Leucocyte function defects? Complement defects?
Common variable immunodeficiency
Hyper IgM syndrome
Selective IgA deficiency
Chronic granulomatous disease
Leucocyte adhesion deficiency- LAD
Early complement component deficiency
Terminal complement component deficiency
Mannose-binding lectin MBL deficiency
Cause of SCID? Sx?
> 50% = common gamma chain mutation on X chromosome for interleukin receptors on T & B cells= X-linked recessive
JAC3 gene mutations, adenosine deaminase deficiency
Persistent severe diarrhoea, FTT, opportunistic infections more frequent & severe, pneumocystis jiroveci pneumonia and CMV, unwell after live vaccinations, Omenn syndrome
Mutation for Omenn syndrome (rare cause SCID)?
RAG 1/ 2 proteins in T & B cells= autosomal recessive
Erythroderma, alopecia, diarrhoea, FTT, lymphadenopathy, hepatosplenomegaly
IG therapy, sterile environment, avoiding live vaccines, haematopoietic stem cell transplantation
Cause and sx of Wiskott-Aldrich syndrome?
WASP gene= X-linked recessive
Eczema, thrombocytopenia, neutropenia, recurrent infections, chronic bloody diarrhoea
Low IGM levels
Increased risk AI disorders and malignancy
Cause of Di George syndrome? Sx?
Abnormal dev 3 & 4th branchial cleft- deletion section chromosome 22; 22q11–>incomplete thymus gland–> CATCH-22:
Congenital HD, abnormal facies, thymus gland, cleft palate, hypoparathyroidism & resulting hypocalcaemia, 22nd chromosome affected
What is Duncan disease/ X-linked lymphoproliferative disorder? Sx, tx?
Xq25- EBV infection
Fatal infectious mononucleosis–> acquired hypogammaglobulinaemia, red cell aplasia/ lymphomatoid granulomatosis
Pharyngitis, hepatosplenomegaly, liver failure, lymphocytosis, thrombocytopenia/ BM failure, hepatic encephalopathy
BM transplant, genetic testinf
EBV– hepatic necrosis/ BM failure
Cause of ataxia telangiectasia? Sx?
AR condition affecting ATM serine/ threonine kinase protein on Ch 11 for DNA coding
Low T-cell and Igs, ataxia, telangiectasia, predisp to cancers, slow growth and delayed puberty, accelerate ageing, liver failure
Type of condition PNP deficiency?
AR PNPase breaks down purines–> dGTP builds up
Cause of Bruton’s agammaglobulinaemia? Sx? Tx?
X-linked tyrosine kinase–> lack B cell development
Recurrent bacterial infections, absence B cells with reduced Iggs
IV immunoglobulin, high dosage ABx therapy, inhaled bronchodilators and steroids usually needed
Nasal steroids for sinusitis in older
Tx eczema
Can cause bronchiectasis
What is common variable immunodeficiency caused by? Sx?
Many causes- low IgG, IgM and IgA
Recurrent chest infections & chronic lung disease over time
Prone to RA, Hodgkin’s lymphoma
Ig infusions
Later onset than Bruton’s
What is hyper IgM syndrome?
B cells produce IgM but prevented switching to IgG and IgA
Pneumocystis pneumonia, hepatitis, diarrhoea
Most common primary immune defect? Sx?
Selective IgA deficiency
Recurrent sinus and resp infections
Ass w/ coeliac disease
Severe reactions to blood transfusions
OFTEN ASYMPTOMATIC
Cause of Leucocyte adhesion deficiency? sx?
Def of neutrophil surface adhesion molecules CD18, CD11B- inability neutrophils migrate to sites of infection/ inflammation
Delay in umbilical cord sloughing, absence of neutrophils/ pus at sites of infection
Complement used for dealing with what? Examples?
HIB, S.pneumoniae, n.meningitidis
Early complement component deficiency
Terminal complement component deficiency
Mannose-binding lectin MBL deficiency
Sx of complement deficiency? Tx hereditary angiodema?
Recurrent bacterial infections, SLE-like illness, recurrent meningococcal, pneumococcal and HIB infections
C1 esterase inhibitor before dental/ surgical procedures
Ix for T cell def? B cells? Combined? Neutrophil? Complement?
FBC, lymphocytes,
Immunoglobulins, IgG subclasses in children>2 years, antibody responses, lymph subsets
Ix above, genetics for SCID
FBC, NBT test, CD11b/ CD18 for LAD, neutrophil mobility - chemotaxis
CH50, AP50, complement proteins, MBL levels
Causes of global developmental delay? Gross motor delay(isolated= CK test)? Fine motor delay? Language? Social & personal?
Down’s- hypotonia, Fragile X, fetal alcohol, Rett syndrome, metabolic disorders- first 2 years of life
CP- hypertonia, ataxia, myopathy, spina bifida, visual impairment- 3m- 2 y/o
Dyspraxia- handwriting, dressing, cutting up food, poorly est laterality, copying and drawing, messy eating, saliva dribbling, CP, muscular dystrophy- 4-6 y/o, visual impairment, congenital ataxia- rare
Specific social circumstances, hearing impairment, global delay, learning disability, neglect, autism, cerebral palsy- refer to S&L, audiology and health visitor, neglect concern= safeguarding- Symbolic Toy and Reynell test
Autism, emotional and social neglect, parenting issues- 2-4 y/o
1st-line Ix for global developmental delay?
FBC & haematinics- iron def & folate/ B12 deficiency
U&e- renal failure and hyponatraemia
CK- duchenne muscular dystrophy
TFTs- Congenital hypothyroidism
LFTs- Metabolic disorders
Vitamin D- motor delay
Hearing test- isolated speech and language delay
2nd line= karyotyping/ DNA analysis, more detailed metabolic screens, MRI and EEG
Tx dev delay?
Comm Paediatrician= detailed dev assessment & holistic assessment e.g. Griffiths scales of child development/ schedule growing skills
MDT- S&L, OT, portage practitioners and orthoptists
Sx ADHD? Ix & tx?
Hyperactivity, inattention and or/ impulsivity since childhood
Short attention span, quickly moving from one activity to another, quickly losing interest, constantly moving/ fidgeting, impulsive behaviour, disruptive/ rule breaking
Healthy diet and exercise- food dirary
Conser tx failed/ severe= medications- methylphenidate- 6w trial basis–> GI upset, dexamfetamine, atomoxetine
PERFORM BASELINE ECG
Necessary for ADHD ix?
3-7y/o- may not be recognised until after 7 y/o- esp if hyperactivity not present
Sx for at least 6 months
At least 2 settings
Other causes excluded
Before 12 y/o
Parent education/ support programmes & watchful waiting for up to 10 weeks, group CBT, individual psych tx, drug tx only above 5 y/o
Monitor what every 3m in children older than 10 y/o in ADHD? Specialist advice when?
Weight- 3 & 6 months after tx has started
Height every 6 months
BP & HR before and after each dose change & every 6 months
>120bpm, arrhythmia, sys BP>95th percentile on x2 occasions/ other adverse effects
When are autistic features usually observable? Sx?
Before 3 y/o
Social: lack eye contact, avoids physical contact, delay in smiling, unable to read non-verbal cues, difficulty establishing friendships, not displaying desire to share attention
Communication: delay/ absence/ regression in language development, lack app non-verbal comm, diff w/ imaginative/ imitative behaviour, repetitive use of words/ phrases
Behaviour= greater interest in objects/ numbers/ patterns than people, repetitive movements- may be self-stimulating like hand-flapping/ rocking, intensive and deep interests persistent and rigid, fixed routines, anxiety outside this, restricted food preferences
Tx autism?
CAMHS, S&L, dietician, Paediatrician, social workers, special school environments, charitis
What forms largest group of eating disorders? Also?
Atypical eating disorders- sx for eating disorder, not specific diagnostic criteria- over-concern with body weight and shape- many have had anorexia or bulimia previously
Anorexia nervosa, bulimia nervosa, binge eating disorder
Sx anorexia nervosa?
BMI<18.5/ <5th percentile on growth chart, intense fear gaining weight, behaviour interfering with weight gain, psych disturbance, denial seriousness of malnutrition- may be secrecy, hormonal disturbance, physical signs
Hypokalaemia, raised cortisol & GH, hypotension, hypothermia, bradycardia, arrhythmias, cardiac atrophy, sudden cardiac death
Sx bulimia nervosa?
Recurrent episodes binge eating at least once a week for 3 months
Recurrent inappropriate comp behaviour to prevent weight gain at 1/week for 3m- vomiting, purging, fasting, excessive exercise, laxative, diuretic/ diet pill use, weight often within normal limits/ above weight range for age, psych sx, physical- Russell’s sign(knuckles,) alkalosis, hypokalaemia, swollen salivary glands, mouth ulcers, erosion teeth
Sx binge eating disorder?
Planned binge involving binge foods- excessive amount food in discreet time followed by feeling loss control cannot stop eating/ control amount food eat, may eat more rapidly/ until uncomfortably full
BW may be normal, overweight/ obese
Ix and tx eating disorders?
SCOFF questionnaire- two or more positive answers
‘Do you ever make yourself sick because you feel uncomfortably full?’
‘Do you worry that you have lost control over how much you eat?’
‘Have you recently lost more than one stone in a 3-month period?’
‘Do you believe yourself to be fat when others say you are too thin?’
‘Would you say that food dominates your life?’
Score of 2/ less on Sit up- Squat-Stand test(SUSS)
Consider FBC, ESR, U&Es, LFTs, blood glucose, creatinine, urinalysis, ECG
Ca2+, Mg2+, phosphate, B12, folate, ferritin, TFTs, FSH, LH, oestradiol, prolactin, urinalysis, pregnancy test, coeliac screening
Tx eating disorders? Admit who?
Refer to CMHT/ CAMHS, Paeds referral, arrange regular review, poss comps, vomiting- dental and medical review regular, gradually reduce and stop laxatives, contraception advice, bone scanning possibly
Wt loss>1kg/ week, bradycardia 40 bpm/ less, CV instability, hypothermia, reduced muscle power on SUSS, concurrent infection, overall ill health/ rapid deterioration, abnormal blood tests- electrolytes/ hypoglycaemia, risk refeeding syndrome, acute mental health risk, lack home support
Risk of refeeding syndrome increased by what? Sx & tx?
Rapid weight loss, fasting for over 5 days, BMI<16, comp behaviours, dehydrations, use diet pills/ diuretics, water loading or excessive exercise
Hypomagnesaemia, hypokalaemia, hypophosphataemia, hyperglycaemia, risk of arrhythmias, HF & fluid overload
Slowly reintroduce food w/ restricted calories
Mg2+, K+, phosphate and glucose monitoring, fluid balance monitoring, ECG monitoring in severe, vit B and thiamine supplementation
Specialist tx for anorexia?
CBT-ED 40 sessions over 40 weeks twice-weekly in first 2/ 3 weeks
MANTRA
SSCM- specialist supportive clinical management–> psychodynamic therapy if effective
FT-AN in children–> CBT-ED/ adolescent focussed psychotherapy(AFP-AN)
Specialist tx for bulimia? Binge-eating?
Self-help programmes–> after 4 weeks= CBT-ED
Children= FT-BN–> CBT-ED
Self-help–> group CBT-ED after 4 weeks/ individual CBT-ED
Sx of Tourette’s syndrome? Sx and complex tics? Tx?
Tics for over a year- involuntary movements or sounds- overwhelming urge= premonitory sensations
Often around/ after 5 y/o- ass w/ OCD & ADHD
Clearing throat, blinking, head jerking, sniffing, grunting, eye rolling
Twirling on spot/ touching objects, copropraxia= obscene gestures, coprolalia= obscene words, echolalia= repeating other people’s words
Mild= reassurance and monitoring, reduce stresses, severe= habit reversal training, exposure with response prevention, medications= antipsychotics
Types atrial septal defect from most–> least common? Comps?
Ostium secundum- septum secundum fails to close- Treacher-Collins syndrome, TAR syndrome
Patient foramen ovale
Ostium primum–> complete/ partial AVSD, present earlier than secundum
Stroke, AF/ atrial flutter, pulm HTN & right-sided HF, Eisenmenger syndrome(R–>L shunt)
Sx ASD? DDx and tx?
Often asymptomatic- incidental finding of ejection systolic murmur on auscultation 2nd ICS, split S2
May–> HF- SOB, fatigue, oedema, rapid HR in adulthood
Migraine w/ aura ass w/ PFO
VSD/ PDA/ pulmonary stenosis
Transthoracic echocardiogram, ECG= RBBB with RAD/ primum= RBBB w/ LAD & prolonged PR interval
Most cons tx- most close within 12m birth, surgical may be needed for larger defects/ sx- transvenous catheter closure via femoral vein/ open heart surgery, anticoagulants, routine echocardiograms every 2-3y
Comps= HF, paradoxical embolisms- clot from right side–> left, arrhythmias, cyanosis, peripheral oedema, TIA/ stroke
Most common and RF for VSDs? Sx and examination?
Maternal DM, rubella, foetal alcohol syndrome, uncontrolled maternal PKU, family hx VSD, Down’s, trisomy 18, trisomy 13, Holt-Oram syndrome
Asymptomatic until later- poor feeding, dyspnoea, tachypnoea, FTT, sx HF
Pansystolic murmur lower sternal border in 3rd and 4th IC spaces- systolic thrill, tachypnoea- 1st sign left-sided HF, can lead to cyanosis & haemoptysis, Eisenmenger’s syndrome
Ix, DDx and tx VSD?
ECG- LVG, P pulmonale/ BVH, septic screen, U&E before starting meds, microarray for genetics
Transthoracic echo, CXR= cardiomegaly, cardiac CT angiography, cardiac catheterisation
Mitral regurg, tricuspid regurg- Carvalho’s sign increase in intensity with inspiration
ASD, PDA, pulmonary stenosis, TOF
Medical and surgical tx VSD? Comps?
Adequate weight gain, diuretics, ACE-i, digoxin, dentral hygiene for IE
Surgical repair- open heart via median sternotomy, catheter procedure less common, hybrid approach
Pulm artery banding palliative surgery
CHF, growth failure, aortic valve regurg, pulm HTN- CI in pregnancy, frequent chest infections, IE, arrhythmias, most spont close by 10 y/o
Strong ass w/ AVSD?
Down’s syndrome, complete= in Heterotaxy syndromes
Failure closure superior and inferior endocardial cushions–> single common AV valve
L–> R shunt, HF sx, increased distance between aorta and apex of heart, aortic valve= displaced anterosuperior
Sx of AVSD?
Tachycardia, tachypnoea, poor feeding, sweating, FTT
All w/ complete AVSD= sx by year one, systolic heave & ejection systolic murmur along left sternal border, accentuated S1 in complete/ wide split S2 in partial AVSD, partial= wide and fixed splitting of S2, apical thrill, ES murmur left upper sternal border/ mid-diastolic murmur along left lower sternal border, pansystolic left lower sternal border
Complete= not usually associated with separate murmur
Ix, ddx and tx of AVSD?
ECG= superior QRS axis between -40- 150 degrees, prolonged PR interval, RVH
CXR= cardiomegaly
Karyotyping
ECHO
Gooseneck sign on lateral left ventricular angiogram
MRI
ASD, VSD, PDA, HF, sepsis
Diuretics, ACE-i, digoxin, caloric intake
Complete= need corrective surgery usually around 3-6 months age, Down’s may need earlier
Pulm artery banding palliative surgery
Median sternotomy under CP bypass- single/ double/ modified single patch repair
COMPS= FTT, recurrent LRTIs, CHF, pulm vascular disease, Eisenmenger’s syndrome
What increases the risk of PDA? Sx?
Females, preterm, LBW
Post-partum if beyond 3 months in preterm infants/ 1 year in term infants
Small= asymptomatic, large= FTT, feeding difficulties, LRTI, pulm oedema and resp failure can occur
HF
Pulm HTN
Tachypnoea, resp distress, episodes apnoea, tachycardia, wide pulse pressure>30mmHg
Hyperactive precordium, forceful apex beat, bounding pulse
Continuous machinery murmur
DDx, Ix and tx of PDA?
VSD & AVSD, truncus arteriosus, venous hum, aortopulmonary window, TOF, ruptured aneurysm of Valsalva in Marfans
Increases creatinine- reduced renal hypoperfusion, unexplained metabolic acidosis, decreased urine output
ECHO short axis view, + Doppler flow studies,- monitored until 1 y/o left heart volume overload with dilated LA and LV in HD significant PDA
CXR= plethoric lung fields- pulm oedema
Tx PDA?
Cons- high calorie formula, fluid restriction, monitor urine output, PEEP for pulmonary oedema, monitor for NEC- usually 7d closure
Pharm= indomethacin, ibuprofen, diuretics
Surgical ligation- cannot ween from ventilation–> injury to descending aorta and recurrent laryngeal nerve
Trans-catheter PDA device closure via key-hole- device embolisation, haemolysis
COMPS= NEC, RDS, RHF, pulm HTN, Eisenmenger syndrome
What is coarctation of the aorta? Ass? Sx?
Congenital narrowing of descending aorta
Turner’s, NF, bicuspid aortic valve, berry aneurysms
Mild= asymptomatic, HF in infancy, HTN in adults, RF delay, systolic murmur below left clavicle and scapula
Tachypnoea, poor feeding, grey and floppy baby, LV heave due to LVH, underdeveloped left arm & legs
Ddx, Ix and tx of coarctation of the aorta?
Aortic stenosis- sx of decreased CO, PDA, HTN
ECHO + Doppler studies
Mild= monitored w/ echo & anti-hypertensives if needed
Severe= angioplasty & stent insertion
Prostaglandin presenting w/ shock to keep patent until defect correct
RFs for TOF? Ix? Sx? Tx for tet spells?
Rubella, increased age of mother, alcohol consumption in pregnancy, diabetic mother, 1-2m
CXR= boot shaped heart
ECHO, cardiac catheterisation
ES murmur from pulmonary stenosis on newborn check, HF before age of 1
Cyanosis- determined by degree of RV OUTFLOW OBSTRUCTION, poor feeding, clubbing, poor weight, gain, tet spells
Older= squat, younger= knees to chest
Tx TOF?
Cyanotic episodes= beta-blockers reduce infundibular spasm, surgical repair in 2 parts- correction RV outflow tract obstruction, closure of VSD
Supp O2, IV fluids, morphine- more effective breathing, NaCO3- buffers met acidosis, phenyl-epinephrine infusion- increased systemic vascular resistance
Neonates= prostaglandin maintain ductus arteriosus
Sx tricuspid atresia?
Poor feeding, general= progressive cyanosis, hepatomegaly, single S2 with pan-systolic murmur due to VSD at left lower sternal edge, continuous mechanical murmur, signs of HF
Ix, tx and comps of tricuspid atresia?
Superior QRS axis, LVH, RAH and bi-atrial hypertrophy all common
CXR- reduced/ increased pulm vascular markings depending on relation of great vessels
ECHO- small RV, enlarged RA, LA and LV
IV PGE1, Rashkind balloon atrial septostomy
Stage 1 at birth= BT shunt, DKS, PDA stenting
Stage 2@3-6m= BGS, hemi-Fontan procedure
Stage 3@3-4y= Fontan procedure
Palliative= Fontan circulation–> anticoagulation
Post - Fontan comps= low CO and HF, pleural effusion and chylothorax, thrombus formation
Late= SV arrhythmias, protein losing enteropathy, progressive drop in arterial saturations
TGA associated with what?
VSD, coarctation of the aorta, pulmonary stenosis
Most= aorta anterior and to right of pulmonary artery, M>F
Aetiology and RFs for tricuspid atresia?
Dextroposition of the aorta/ no rotation of the aorto-pulmonary septum at the infundibular level. This causes the fourth aortic arch, which will later become the aorta, to interact with the anterior conus on the right ventricle
Age>40 y/o, maternal diabetes, rubella, poor nutrition, alcohol consumption
Cyanosis first 24h, signs CHF, may become evident over 3-6 weeks if large VSD
RVH, single second heart sound, systolic murmur if VSD present, no signs resp distress
Tricuspid- ECG= LAD
Ix and tx of TGA?
Pulse ox= cyanosis, meta acidosis w/ decreased PaO2, echo, CXR- egg on string
PGE1 infusion, correct met acidosis, emergency atrial balloon septostomy- mixing, def surg= arterial switch operation (ASO) before 4w, follow-up for HF & arrhythmias
COMPS= neopulmonary stenosis, neoaortic regurgitation, neoaortic root dilatation
What is pulm stenosis ass w/? Sx?
TOF, Noonan syndrome & Williams, rubella, due to carcinoid syndrome
Often asymptomatic
Signs of right HF- dyspnoea, fatigue, peripheral oedema, ascites
ES murmur at pulm area, thrill, RVH due to RVH, raised JVP with giant a waves
Ix and tx of pulmonary stenosis?
ECHO
ECG= P pulmonale, RAD, RVH
CXR= prominent pulm arteries
Mild= watch and wait, surg= valvotomy and balloon angioplasty for supravalvular lesions- consider with transvalvular pressure gradients>50mmHg
COMPS= right HF & IE
What is Ebstein’s anomaly?
Tricuspid set lower in right side heart- ass w/ ASD, patent foramen ovale & WPW syndrome
May be caused by lithium in-utero
Cyanosis, prominent A wave in distended jugular venous pulse, hepatomegaly, tricuspid regurgitation- pansystolic murmur worse on inspiration, RBBB- widely split S1 & S2, ass/ASD often present few days after birth when DA closes–> cyanotic and symptomatic
ECHO
Tx arrhythmias & HF, proph ABx for IE
What is Eisenmenger’s syndrome? 3x conditions causing?
R–> L heart bypassing lungs
ASD, VSD & PDA
Can develop after 1-2 years with large shunts/ adulthood with small shunts
Sx Eisenmenger’s syndrome? Ix and tx?
Late teens= cyanosis- might develop RVF, haemoptysis, embolism, RV heave, loud P2, raised JVP, peripheral oedema, plethoric complexion- ECHO, pulm function tests, cardiac catheterisation= GOLD- identify and degree of pulm HTN
Identify and prompt tx- heart-lung transplant- not possible= palliative care
Medical = O2, tx pulm HTN- sildenafil, arrhythmias, polycythaemia w/ venesection, thrombosis= anticoagulation, IE= proph ABx
Sx aortic valve stenosis? Ix and tx?
SOB, fatigue, dizziness, fainting, worse on EXERTION, severe= HF within months birth
ES murmur cre-decr- radiates to carotids
Ejection click, thrill during systole, slow rising pulse and narrow pulse pressure
ECHO, ECGs & exercise testing, more sig= restrict exercise
Perc balloon aortic valvoplasty, surgical aortic valvotomy, valve replacement
COMPS= LV outflow tract obstruction, HF, vent arrhythmia, bacterial endocarditis, sudden death often on exertion
Sx HF in infants?
Poor feeding/faltering growth
Sweating
Tachypnoea
Tachycardia
Gallop rhythm
Cardiomegaly
Hepatomegaly
Common underlying causes of IE in Paeds?
VSD, PDA, aortic valve abnormalities- bicuspid and TOF- can be pre/ post-repair
Causes of IE in Paeds?
S.aureus , viridans- after dental procedures, s.pneumoniae, HACEK organisms, enterococci after GU/ GI surgery
Sx IE? Ix?
Low-grade fever, change in heart murmur= concerning
Splenomegaly, petechiae, Osler’s nodes- painful fingers/ toes, Janeway lesions- palms/ soles, splinter haemorrhages- haemorrhagic streaks in nail bed, splinter haemorrhages, haematuria, PE, seizures/ hemiparesis/ Roth spots
Non-specific symptoms- myalgia
Blood cultures from different sites + anaemia, leucocytosis and raised ESR, microscopic haematuria + Modified Duke’s criteria
Major= + BC, evidence endocardial involvement
Minor= pre-disposing heart condition/ IV drug user, temp>38 degrees, vascular phenomenoa, immunologic phenomena, micro/ ECHO +ve doesn’t meet major criteria
2 major/ one major and 3 minor/ x5 minor
Tx IE? Methicillin-susceptible, resistant? Enterococcus? HACEK?
Proph abx IV penicillin or ceftriaxone for 4w/ 2w above w/ gentamicin
B-lac res penicillin for 6 weeks with/ without gentamicin for 3-5 days
Vancomycin for 6w w or without gentamicin for first 3-5 days
4-6w IV penicillin w/gentamicin, allergic penicillin= 6w vancomycin and gentamicin
Ceftriaxone w/ gentamicin for 4w, fungal= amphotericin B
PPx of rheumatic fever?
2-4w after Beta-haemolytic strep–> auto-antibodies cross react with the endocardium= molecular mimicry- mitral valve disease= commonly in years after
Major and minor Jones’ criteria for rheumatic fever?
Evidence recent strep infection plus 2 major or one major and two minor criteria:
Major= arthritis- knees, ankles, elbows, wrists, pancarditis–> new tachycardia/ murmur/ conduction defect, Sydenham’s chorea- abrupt non rhythmic involuntary movements + muscular weakness + emotional disturbance more on one side and cease during sleep, often late feature
Erythema marginatum- trunk, thighs and arms raised sharp outer edges w/ diffuse clear centre
SC nodules over extensor surfaces and bony prominences
Minor: fever, arthralgia, raised ESR & CRP, prolonged PR on ECG
Ix and tx rheumatic fever?
ESR, CRP, FBC, cultures, RAD test, throat culture, anti-strep serology, ECG, CXR, ECHO
Benzylpenicillin, aspirin/ NSAIDs, assess for emergency valve replacement, severe= glucocorticoids and diuretics may be needed
Proph w/ IM benzylpenicillin every 3-4 weeks, oral phenoxy BD 10d following BP, oral sulfadiazine daily/ oral azithromycin- allergy
Haloperidol/ diazepam for chorea
40% require surgery
Most common arrhythmia Paeds? Tx?
SVT- HR 250-300 bpm, pulm oedema, hydrops foetalis & IU death
Complete heart block- presyncope/ syncope, often those undergone surgery- endocardial pacemaker
Long QT syndrome- sudden LOC during exercise, stress/ emotion
ECHO, correct acidosis, PEEP, vagal manoeuvres, IV adenosine, electrical cardioversion w/ synchronised direct current shock if adenosine fails
Maintenance w/ flecainide/ sotalol, no delta wave= digoxin, is= propanolol
Relapse= RF ablation/ cryoablation of accessory pathway
What is asthenopenia?
Eye strain/ fatigue/ pain- particularly in afternoon or at end of day
Examples of innocent murmurs?
Still’s murmur, venous hum, turbulent flow in pulm artery bifurcation
10 Ss- soft, systolic, short, S1 & S2 normal, symptomless, special test- XR & ECG normal, standing/ sitting vary with position, sternal depression
What is aniso vs isometropia?
Difference in refractive error vs same reduction in RE in both eyes
RFs for cryptochordism? Tx?
Family hx, LBW, SGA, prematurity, maternal smoking during pregnancy
W&W- most descended in first 3-6 months- not desc by 6m= seen by Paediatric urologist
Orchidopexy between 6 and 12m age
Peak age for test torsion? Tx?
12 y/o
Bell-clapper deformity- absent fixation between testicle and tunica vaginalis–> horizontal position
Firm swollen testicle, unilateral pain, elevated testicle- elevated, absent cremasteric reflex, abnormal test lie, rotation- epididymis not in normal posterior position
NBM, analgesia, Immediate scrotal exploration- orchidopexy- orchidectomy if surgery delayed or necrosis
USS can show whirlpool sign
Sx androgen insensitivity syndrome?
Genetically male, female phenotype- normal female external genitalia
Testes in abdomen/ inguinal canal- anti-Mullerian hormone, no uterus/ upper vagina/ cervix/ Fallopian tubes/ ovaries
Primary amenorrhoea@puberty, little/ no axillary and pubic hair, undescended testes–> groin swellings, taller than female average, infertile, increased risk testicular cancer unless removed
Partial= ambiguous features
Infancy= inguinal hernias containing testes
Raised LH, normal/ riased FSH, normal/ raised testosterone levels, raised oestrogen levels for male
Ix and tx AIS?
Buccal semar/ chromosomal analysis
Counselling- raise child as female, bilateral orchidectomy, oestrogen therapy, vaginal dilators/ surgery
Causes congenital hypothyroidism? Sx? Ix, tx and comps?
Thyroid dysgenesis- usually sporadic–> aplasia/ hypoplasia, ectopic- lingual/ sublingual, cong TSH deficiency, Pendred’s syndrome, iodine deficiency, congenital TSH deficiency
Umbilical hernia, prolonged jaundice, constipation, hypotonia, hoarse cry, poor feeding, excessive sleepiness, dry skin, coarse facies, delayed ND
Guthrie card- TSH high and/ or FT4 low- levothyroxine
Comps= ND delay & mental retardation, poor motor coordination, hypotonia, ataxia, poor growth and short stature
Time for 1st, 2nd and 3rd trimesters? Feel movements?
0-12 weeks, 12-26w, 27+ weeks
10 midwife appointments in nulliparous and 7 in second pregnancy
From 20 weeks
Things covered in antenatal appointments?
Discuss plans for the remainder of the pregnancy and delivery
Symphysis–fundal height measurement from 24 weeks onwards
Fetal presentation assessment from 36 weeks onwards
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture for asymptomatic bacteriuria
When is pertussis vaccine offered in pregnant women?
From 16 weeks, influenza when available in Autumn/ Winter
Systems for estimating degree liver fibrosis in nAFLD?
NAFLD Fibrosis Score(NFS,) fibrosis 4 (FIB-4) score
What is Knight’s move thinking also known as? Flight of ideas is what? Tangentiality?
Loosening of association- ideas may appear loosely connected
Rapid speech often without pauses- pressured speech, meaningful connections often maintained
Jump from one topic to another without clear connection- immediate response to question
Qs in an abbreviated mental test?
Recall an address, age and DOB, time, year, dates of WW2, name present monarch, count backwards from 20
How should citalopram, escitalopram, sertraline or paroxetine be switched to another SSRI? To venlafaxine? Fluoxetine to another SSRI? Venlafaxine? SSRI–> TCA?
First withdrawn before alternative started
Cross-taper cautiously- start 37.5mg daily and increase very slowly
Leave of 4-7 days before starting low-dose alternative SSRI
Withdraw and start at 37.5mg each day and increase very slowly
Cross-tapering- current dose reduced slowly, whilst dose new drug increased slowly- fluoxetine withdrawn prior to TCAs starting
Ix for schizophrenia? Poor prognosis factors?
Tx?
FBC & LFT, U&Es- baseline before medication, serological testing for syphilis
Strong family hx, gradual onset, low IQ, prodromal phase of social withdrawal, lack of obvious precipitant
Oral atypical antipsychotics= first line- resistant= clozapine- good for positive and negative sx
Depot if suits patient
Psychotherapy- CBT
Acute= lorazepam, promethazine/ haloperidol
CBT to all
CV RF modification due to high rates CVD in patients
Drugs causing psychosis?
Anticonvulsants, high-dose corticosteroids, levodopa and dopamine agonists or opioids
E.g. typical and atypical antipsychotics? SEs?
Haloperidol, chlorpromazine= D2 receptor antagonists
Olanzapine, quetiapine, risperidone, aripiprazole- D2/ D3 and 5-HT2A antagonists
EP SEs, hyperprolactinaemia, drowsiness, orthostatic hypotension, anticholinergic SEs
As effective as typical- reduced EP SEs & sedation & seizures & anticholinergic SEs, some = orthostatic hypotension
Increased metabolic SEs, weight gain, dyslipidaemia and glucose met, INCREASED STROKE AND VTE IN ELDERLY
Monitoring for antipsychotics?
Weight at start, then weekly for first 6 weeks, then at at 12 weeks , at 1 year and then yearly
Fasting blood glucose, HbA1C, blood lipid concs@baseline, 12 weeks, at 1 year and then yearly
Prolactin@baseline
ECG may be needed- part if CV RFs/ personal hx/ admitted as inpatient, BP before@12 weeks, 1 year and then yearly during treatment & dose titration
Action, CI and SEs of SNRIs?
Increases serotonin and norepinephrine levels- venlafaxine and duloxetine,
Hx heart disease and high BP
Nausea, insomnia, increased HR, agitation
Action of noradrenergic and specific serotonergic antidepressants(NASSAS?) SEs?
Mirtazapine- modulating norepinephrine and serotonin levels, blocks alpha receptors to increase monoamines
Sedation, increased appetite and weight gain, constipation and diarrhoea
Action, cautions and SEs of tricyclic antidepressants?
Blocks re-uptake of serotonin and NAD e.g. amitriptyline, clomipramine and imipramine
Also antimuscarinic
Previous HD, can ex schizophrenia, ex long QT syndrome, preg & BF, blood sugar in T1 & T2DM, may prec urinary ret- avoid in men with enlarged prostates, those on other CP450 meds
Anti-cholinergic SEs- drowsy, confusion, arrhythmias, seizures, vomiting, flushing, dilated pupils- FBC, U&Es, CRP, LFTs, VBG, ECG
Action, e.g., cautions and SEs of MAO-is?
Inhibits monoamine oxidase–> elevation in brain levels of catecholamines and serotonin
Moclobemide- B inhibitor, phenelzine- A inhibitor
Cerebrovascular disease, manic phase of bipolar, phaeochromocytoma, severe CVD
Hypertensive reactions with tyramine- containing foods, avoid broad bean pods- contain dopa, anticholinergic effects
Action of benzos?
Increase GABA- increases frequency of chloride channels & barbiturates increase duration of Cl- channel opening- used for sedation, hypnotic, anxiolytic, anticonvulsant, muscle relaxant
E.g. of anxiolytics? Issue? Withdrawal sx?
Antidepressants, buspirone, benzos, pregabalin, hydroxyzine
Long-term dependence- short time 2-4 weeks- withdraw in steps about 1/8 of daily dose every fortnight, SEs= drowsy, confusion, hypoventilation, lack coordination- part elderly
Up to 3 weeks after stopping= seizures, tinnitus, tremor, loss of appetite, anxiety and irritability, risk falls in elderly
Antidote to benzos? Cautions/ CIs? Sx overdose?
Flumazenil- comp at GABAA receptor- can induce seizure- overdose prolonged sleep usually without serious dep respiration
Acute pulm insuff, NM resp weakness, obsessional states, phobia states, sleep apnoea, unstable MG
Drowsy, dysarthria, ataxia, nystagmus, resp depression and coma
E.g. of hypnotics(Z-drugs)?
Benzos and barbiturates- risk of resp depression
CI lithium? Monitoring for lithium?
Addison’s disease, cardiac ass w/ rhythm disorder, personal/ family hx Brugada syndrome, low Na+ diets and untreated hypothyroidism
Severe renal impairment- narrow index 0.4-1
Before= U&Es, ECG, TFTs, BMI and FBC, monitor BMI, serum electrolytes, eGFR and TFT every 6 months during tx
Check lithium 12 hours post-dose- weekly and after each dose change until concs stable, then 3 monthly
Info booklet, alert card and record book
E.g. stimulants? Action?
Methylphenidate, dexamfetamine sulfate, lisdexamfetamine mesilate
Taken up into presynaptic nerves w/ two Na+ ions and one chloride ion via monoamine reuptake transporters
Displace other monoamines to be stored by VMAT2 which releases neurotransmitters into the synapse via retro-transport. They also weakly inhibit dopamine and serotonin reuptake and moderately inhibit noradrenaline reuptake. Furthermore, they inhibit the mitochondrial-bound enzyme mono-amine oxidase (MAO) which is the catalytic enzyme in charge of degrading all the excess of neurotransmitter
SEs, cautions/ CIs and monitoring for stimulants?
Upper abdo pain, decreased appetite, tachy, tremor, hyperhidrosis, insomnia, movement disorders, nausea–> wakefulness, excessive activity, paranoia, hallucinations and HTN–> exhaustion, convulsions, hyperthermia and coma
Advanced arteriosclerosis, agitated states, hyperthyroidism, moderate and severe HTN, sx CVD
Pulse, BP and psych sx before start, following dose adjustment & every 6 months, weight in adults and weight/ height in children every 6m
Indications, mechanism and SEs of ECT?
Severe dep refractory to medication e.g. catatonia those with psych sx
ABSOLUTE CI= RAISED ICP
Electric current through brain causing surge of electrical activity, usually 6-12 sessions (2/wk)
Headache, nausea, short memory impairment, memory loss of events prior to ECT, cardiac arrhythmia
Impaired mem= long-term memory
Types and aim of psych therapies?
Psychotherapy: talking
CBT: hot cross bun model (thoughts, emotions, behaviour, bodily sensations.) Depression, GAD, phobias, OCD, PTSD, bulimia
Behavioural therapy: relaxation, densensitisation
Dynamic psychotherapy: patient narrates and Dr makes links
Family therapy
Counselling: recent events
Group psychotherapy: forming, storming, norming, performing. Personality disorders, addiction
Cognitive analytical therapy: Dr writes letter at beginning and end. Depression, personality disorders
Interpersonal therapy
DBT: manage emotions by experiencing, recognising and accepting them- EUPD
Causes of a raised ferritin?
Haemochromatosis- raised transferrin and low TIBC, infection, chronic alcohol consumption, NAFLD, hepatitis C, cancer
Causes of a painful and painless red eye?
Acute angle-closure glaucoma, anterior uveitis, scleritis, corneal abrasions/ ulceration, keratitis, foreign body, traumatic/ chemical injury
Conjunctivitis, episcleritis, subconjunctival haemorrhage
Causes of sudden loss of vision?
Ischaemic/ vascular- ischaemic optic neuropathy/ central vein/ artery occlusion, vitreous haemorrhage, retinal detachment, retinal migraine
Causes of ptosis?
3rd nerve palsy, Horner’s syndrome, myaesthenia gravis, carotid artery dissection, cluster headache, myotonic dystrophy, LES syndrome, paroxysmal hemicrania
Causes of relative afferent pupillary defect?
Lesion anterior to optic chiasm
Optic neuritis, glaucoma, retinal detachment, severe retinal ischaemia/ optic nerve compression due to tumours or inflammation
Treatment for a brain abscess?
CT, MRI for abscess vs cerebral metastases
Craniotomy and cavity debrided, may reform
IV 3rd generation cephalosporin + metronidazole 6-8 weeks
ICP tx e.g. dexamethasone
Cause of folliculitis? Tx?
S.aureus- eosinophilic= immunosuppression like in HIV- not infectious cause- needs skin biopsy–> eosinophils in skin surface
Papules and pustules except palms and soles of feet
Topical antibiotics, antibacterial soaps, oral in severe cases, gram negative/ hot tub= different approach
Cause gangrene? Sx? Ix and tx?
C. perfringens
Acute severe localised pain, minimal local inflammation, skin darkening and spreading erythema, fever, gas production in affected area, potent smell
Radiographic, WCC and inflammatory markers, tissue cultures
Surgical debridement, ABx administration, amputation, hyperbaric oxygen therapy
Causes of wet and dry gangrene?
Wet= s.pyogenes, gas= c.perfringens, dry= chronically reduced blood flow- atherosclerosis and PAD, thrombosis- vasculitis, vasospasm
Wet= poorly demarcated from surrounding tissue, fever & septic symptoms
Dry= well demarcated necrotic area without signs of infection, auto-amputation
Ix and tx of wet and dry gangrene?
FBC, CRP/ ESR, blood cultures, lactic acid levels, imaging, tissue biopsy
‘’, Dopper USS/ angiography, tissue biopsy
Surgical debridement or amputation and broad-spec IV ABx
Surgical debridement/ amputation
Eligible GBMSM under 25 y/o receive what HPV vaccination? 25-45 y/o? Who gets a 3 dose- schedule?
1-dose through SH clinics
2-dose schedule through SH clinics
Immunocompromised/ HIV positive
Investigations in returning traveller?
FBC, U&Es, LFTs, 2x blood cultures, malaria blood film and rapid diagnostic test, CXR, urine MC&S- also PCR
Ricksettsia serology, viral haemorrhagic fever testing, leptospirosis serology, cross-sectional imaging, LP
Mnemonic for upper vs lower lobe predominance?
CASSET HPP= CF, AS, silicosis, sarcoidosis, eosinophilic granuloma, TB, hypersensitivity pneumonitis, pleuroparenchymal fibroelastosis, pneumocystis pneumonia
SET CAP- silicosis/ sarcoidosis, EG/ extrinsic allergic alveolitis, TB/ fungal, cystic fibrosis, ankylosing spondylitis, PCP
BAD RASH: bronchiectasis, aspiration, DIP, RA, asbestosis, scleroderma, Hamman- Rich syndrome/ acute interstitial pneumonitis
Ottawa rules for ankle injury? Knee? Foot?
Pain in malleolar zone and any one of: bony tender at lateral malleolar zone/ medial malleolus, inability to walk x4 weight-bearing steps
Age>55, isolated patellar tenderness without other bone tenderness, tenderness of fibular head, inability to flex 90 degrees, inability to weight bear after injury and in A&E 4 steps regardless of limping
Bone tenderness at navicular bone, at base 5th metatarsal, inability to weight bear both immediately and in A&E department
2WW referral for laryngeal cancer? Oral cancer?
Aged 45 and over= persistent unexplained hoarseness or unexplained lump in neck
Unexplained ulceration in oral cavity for more than 3 weeks/ persistent and unexplained lump in neck
Assessment by dentist= lump on lip or in oral cavity or red or red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia
Tx for inguinal hernias?
Medically fit even if they are asymptomatic, truss for fit for surgery, mesh repair= lowest recurrence rate- unilateral= open approach/ bilateral or recurrent repaired laparoscopically
Open repair–> non-manual work after 2-3 weeks and laparoscopic repair after 1-2 weeks
Comps= early- bruising, wound infection, late= chronic, recurrence
Inheritance and ass of VHL syndrome?
VHL autosomal dominant inheritance, haemangioblastomas in brain/ spinal cord–> ataxia, retinal angiomas–> vision loss
Cysts in kidneys, increased clear cell RCC risk, pancreatic neuroendocrine tumour, phaeochromocytomas, inner ear tumours, liver/ lungs
Presentation of Stauffer syndrome?
Paraneoplastic disorder ass/w RCC–> cholestasis/ hepatosplenomegaly, secondary to increased levels of IL-6
Cause of malignant hyperthermia? S&S, Ix and tx?
AD mutation in ryanodine receptor 1 gene–> abnormality in Ca2+ regulation within muscle cells–> increased Ca2+ levels in sarcoplasmic reticulum and cons increased in met rate
Rapid increase in body temp, muscle rigidity, met acidosis, tachycardia, increased exhaled CO2
Bloods for met acidosis and CK raised, ABG for resp and met acidosis, core temp
Immediate discontinue agent, IV Dantrolene, cooling techniques- ice packs/ IV fluids and cooling blankets, correct acidosis and cooling blankets, supportive- oxygen, ventilation and HD support
Tx for central vs peripheral vertigo?
HINTs: head impulse, nystagmus, test of skew
Head impulse normal= eyes fixed on examiner nose–> no sx/ central cause
VN/ labyrinthitis= eyes will saccade
Nystagmus: few beats normal, unilateral horizontal peripheral, bilateral/ vertical nystagmus= central
Test of skew(alternate cover test): covers one eye at a time- should remain fixed on examiner’s nose with no deviation, if vertical correction= central cause
How is vestibular migraine treated?
Avoiding triggers, lifestyle, medical= triptans, propanolol, topiramate, amitriptyline prevent
DON’T DRIVE AND INFORM DVLA IF LIABLE TO SUDDEN/ UNPROVOKED/ UNPREC EPISODES DISABLING DIZZINESS
Red flags for neck lumps?
Hard, painful & fixed lump
Associated otalgia, dysphagia, stridor, or hoarse voice, unilateral nasal sx, unexplained wt loss, night sweats/ fever/ rigors, CN palsies
>40 y/o generally
Child= + Supraclavicular mass, lumps>2cm & previous hx malignancy
4x classes of anti-arrhythmic drugs?
Class I= sodium-channel blockers e.g. quinidine, procainamide, lidocaine, flecainide- suppression of atrial/ ventricular premature beats
II= beta-blockers e.g. bisoprolol, carvedilol, timolol, atropine
III= potassium channel blockers e.g. amiodarone
IV= CCBs e.g. amlodipine, nifedipine, verapamil, diltiazem, adenosine, digoxin
What do you get with flail chest? Ass with what?
Chest wall disconnects from thoracic cage, multiple rib fractures, ass w/ pulm contusion- ABGs and pulse oximetry important, significant hypoxia= early intubation, abnormal chest motion, avoid over hydration and fluid overload
Trimodal death distribution following trauma? Presence of mediastinal haematoma indicates what?
Immediately- brain/ high spinal injuries, cardiac/ great vessel damage, salvage rate= low
Early hours= splenic rupture, SDH, haemopneumothoraces, days following= sepsis of multi organ failure
Great vessel injury–> CT angio and oesophageal contrast swallow
Haemothorax caused by what? Tx and indications for thoracotomy?
Laceration of lung vessel or internal mammary artery by rib fracture
Wide bore 36F chest drain
Loss of more than 1.5L blood initially / ongoing losses of >200ml/ per hour for > 2 hours
Ix for cardiac contusions? Commonest cause death after RTA/ falls? Tx pulmonary contusion?
ECHO for pericardial effusions and tamponade, risk arrhythmias after 24 hours, diaphragmatic injury= usually left sided
Traumatic aortic disruption- incomplete laceration near ligamentum arteriosum- all will have contained haematoma
Early intubation and ventilation
In blunt trauma needing laparotomy, what is most commonly injured? Ix for abdominal trauma?
Spleen
Stab wounds= liver
Gunshot= small bowel
Ix peritoneal lavage- bleeding if hypotensive- 98% effective- may miss RP and diaphragmatic injury
Abdominal CT= organ injury if normotensive- time for reporting, need for contrast
USS= document fluid if hypotensive- non invasive and repeatable, operator dependent, may miss RP injury
Urethrography if suspected urethral injury
Sx post-op ileus?
Green bilious vomiting, abdominal distension, diffuse abdominal pain, constipation and lack of flatulence, absent bowel sounds
CHECK POTASSIUM, MAGNESIUM AND PHOSPHATE- NBM, NG tube, IV fluids mobilisation, TPN
Causes of post-op N&V? Tx?
Infection, hypovolaemia, pain, paralytic ileus, drugs
Minimise patient movement, analgesia, IV fluids
Ondansetron- risk QT prolong and constipation
Cyclizine- avoid in severe HF
Prochlorperazine- risk EP SEs
Drugs given before GA? 7 Ps of RSI?
Benzos for muscle relaxation, fentanyl/ alfentanyl for pain and HTN response to laryngoscope, alpha-2-adrenergic agonists
Prep, preoxygenation 5 minutes prior, pretreatment- opiate analgesia or fluid bolus, pretreatment, paralysis- propofol or sodium thiopental and sux/ rocoronium, protection and positioning- intubation with laryngoscopy- direct vision, end-tidal CO2 and bilateral auscultation, placement and proof, post-intubation management- taping/ tying ETT, mechanical ventilation and sedation agents
Cricoid pressure= reduces risk of gastric aspiration
What can reduce NM blocking agents? Non-depolarising e.g. rocoronium? Where is nerve stimulator used to test muscle relaxant has worn off?
Neostigmine
Sugammadex
Ulnar nerve- watch thumb to twitch/ facial nerve- watch orbiculares oculi at eye- train of four stimulation TOF needed- stimulated x4 times, once worn off= inhaled anaesthetic stopped
Where is spinal anaesthetic injected? What is normally used as epidural anaesthetic?
Subarachnoid space- into L3/L4 or L4/L5, cold spray used to see if it’s worked, takes 1-3 hours to wear off
Levobupivacaine with or without fentanyl–> headache, hypotension, motor weakness in legs, nerve damage, meningitis, haematoma
Increased risk instrumental delivery and prolonged second stage
Cause of sux apnoea? S&Sx, Ix and tx?
Rare genetic defect in plasma cholinesterase
Prolonged period paralysis following administration, little effort to breathe or cough spont at end
Check levels
Intubate and ventilate until spont breathe- avoid in future procedures
Cuff pressure for ETT can be checked using what? Extra hole in case opening at tip of ETT–> occluded? Laryngoscope with camera? What helps with intubation? ETT when patient awake? Check what?
Manometer
Murphy’s eye
McGrath
Bougie/ stylet
Awake fibre-optic intubation- restricted mouth opening/ difficult anatomy e.g. trismus
End-tidal CO2- capnography
Supraglottic airways with an inflatable? When are tracheostomies used?
Laryngeal mask airways e.g. LMA, non-inflatable= I-gel
After a laryngectomy procedure- resp failure with long-term ventilation required, prolonged weaning from mechanical ventilation, upper airway obstruction, tx resp secretions, reducing risk aspiration
Plan A-D for difficult airways? What is a type of central venous catheter used for haemodialysis? When are PICC lines used? Where does a Hickman line go? Pulm artery catheter?
Laryngoscopy with tracheal intubation, supraglottic airway device, face mask ventilation, cricothyroidotomy
Vas cath- has 2/3 lumens
Low risk infection- medium term IV access
Through SC tissue–> SC/ jugular vein with tip sits in SVC- cuff surrounds for chemo/ haemodialysis
Swan- Ganz= into internal jugular vein into RA, RV and into pulmonary artery, pressure distal to wedged balloon can be measured= pressures in LA- specialist cardiac centres
Portacath?
Port under skin top chest through SC tissue and into SC vein- tip sits in SVC or RA- bump on skin- for chemo
Tx heat burns? Chemical burns? Wallace’s rule of 9s? Chart most accurate?
Within 20 minutes= irrigate burn with cool water for between 10-30 minutes- cover w/ cling film, layered
Irrigate with water for about hour
Each arm, head & neck, each anterior leg, each posterior leg, anterior, posterior chest, anterior, posterior abdomen= 9%, palm= 1%- not accurate for burns>15% TBSA
Lund and Browder
Degree of burn for superficial epidermal, superficial derma, deep dermal and full thickness burns? Initial tx for superficial epidermal? Dermal burns? When should early intubation be considered? Parkland formula?
1st degree
2nd degree for dermal
3rd degree
First aid, analgesia/ emollients
Clean wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours
Deep burns to face or neck, blisters or oedema of oropharynx, stridor
IV fluids for children burns>10% TBSA/ adults>15%
Weight kg x 4 x % burn- half in first 8 hours
Refer who to secondary for burns? Tx more severe burns?
All deep dermal and full thickness
Superficial>3% in adults/ 2% in children
Superficial dermal involving face, hands, perineum, genitalia/ flexure/ circumferential burns of limbs, torso/ neck, any inhalation injury, any electrical/ chemical burn injury/ suspicion NAI
Tx more severe burns?
Cons early intubation, IV fluids, urinary catheter, analgesia, burns>10% adults/ 5% children–> burns unit
Circumferential burns affecting limb/ severe torso burns impeding respiration may need escharotomy
Complex may need excision and skin grafting
Dressing for burns?
Paraffin gauze, silicone- coated nylon dressing, polyurethane film/ hydrocolloid dressing.
Secondary non-fibrous absorbent dressing such as dressing pad and secured with conforming bandage/ tubular gauze bandage
Consider tetanus vaccination
Empirical ABx for infection, consider different after 7 days
Tx local anaesthetic toxicity?
20% intralipid emulsion- A-E approach and ECG monitoring
Modes of ventilation for mechnical ventilation?
Volume controlled ventilation- specific tidal volume, pressure controlled ventilation- specific pressure per breath, assist control- breaths are triggered by the patient, CPAP
What is the most extreme or respiratory support?
ECMO- where respiratory failure is not adequately managed by intubation and ventilation- similar to haemodialysis
Short-term, potentially reversible cause of resp failure- in specialist ECMO centres- not available in most ICUs- need to be transferred
What is peritoneal dialysis usually used in? Haemodialysis?
Acute renal failure- limited to CKD, not usually AKI
Vas cath in acute setting- anticoagulation with citrate or heparin is needed to prevent clotting in machine and during process- for continuous RRT- CRRT- 24 hours a day, intermittent haemodialysis 3-12 hours before taking a break
Tx anaemia before surgery?
<6 weeks= IV iron
>6 weeks= oral iron
B12/ folate replacement, ESA therapy, transfusion if profound anaemia and can’t be delayed
Peri-op tx on steroids?
Oral–> 50-100mg IV hydrocortisone, hypotension= add fludrocortisone
Minor= oral pred can be restarted immediately post-operatively, major= IV hydrocortisone up to 72 hours post-op
Post-op fluid management?
Hartman’s to prevent hyperchloraemic acidosis, restart asap if HD stable and euvolaemic, review if urinary sodium <20, if oedematous- tx hypovolaemic first, monitor urinary Na
Early causes pyrexia post-op?
Blood transfusion, cellulitis, UTI, physiological systemic inflam reaction, pulm atelectasis
Late= VTE= pneumonia, wound infection, anastomotic leak- 4Ws and iatrogenic
Special tests for surgical comps?
CT scanning for intra-abdominal abscesses, air and if luminal contrast used an leak
Gastrograffin enema for rectal an leaks
Doppler USS leg veins
Peritoneal fluid for U&Es, ECHO
What does thermoregulation refer to in periop period?
1 hour prior to until 24 hours after surgery completed
Prevent hypothermia mainly
Risks= ASA grade 2 or above, major surgery, low body weight, large volumes unwarmed IV infusions, unwarmed blood transfusions
If <36 before- start warming 30 mins prior to anaesthetic
Bair hugger from onset anaesthesia any >30 minutes/ for patients at high risk periop hypothermia regardless duration
Fluid volumes>500ml warmed prior to admin as all blood products- won’t correct existing hypothermia
Post-op temp monitoring?
Initially then every 15 minutes until transfer to ward
Not to ward if temp is below 36 degrees
Comps= coagulopathy, prolonged recovery from anaesthesia, reduced wound healing, infection, shivering–> myocardial ischaemia
Stages wound healing?
Haemostasis- minutes to hours following injury- minutes to hours, vasospasm in adjacent vessels- platelet plug formation and generation fibrin rich clot
Inflammation= days 1-5, neutrophils to wound
Growth factors released- FGF & VEGF, fibroblasts, macrophages
Regeneration- days 7-56, platelet derived growth factor and transformation growth factors- stim fibroblasts and epithelial cells, fibroblasts= collagen network, angiogenesis
Remodelling- 6w to 1 years, fibroblasts differentiate, collagen fibres remodelled, microvessels regress–> pale scar
Hypertrophic, keloid scars
x4 types of fistulae?
Enterocutaneous- intestine to skin- high/ low output depending on source, enteroenteric or enterocolic- large/ small intestine may malabsorption syndromes in IBD serious, enterovaginal- as above, enterovesicular- to bladder may result in frequent UTIs/ passage gas from urethra during urination
Tx fistulae?
Well-fitted stoma bag, high output= use of ocreotide reduce volume pancreatic secretions
High fistulae–> nutritional comps
Secondary to Crohn’s= drain acute sepsis
Barium and CT show track for abscesses and fistulae
Perianal= Goodsall’s rule
How to measure leg swelling in DVT? THROMBOSIS causes? Refer who?
Measure circumference of calf 10cm below tibial tuberosity- more than 3cm difference= significant
Trauma/ thrombophilia, hormonal- COCP, pregnancy, HRT/ relatives- family history, recent surgery/ old age>60 y/o/ obesity, malignancy, bone fractures, obesity, smoking, immobilisation, sicknessPregnant/ has given birth within the past 6 weeks
>2 Wells score= Doppler USS proximal leg veins within 4 hours
<1= D-dimer- positive–> proximal leg vein USS within 4 hours
-ve= stop interim AC, consider alternatives
Non-modifiable RFs= lifelong anticoagulation
Signs of hypothermia on an ECG?
Osborne waves/ J waves- small hump at end of QRS complex, long QT interval, 1st degree heart block, atrial and ventricular arrhythmias, bradycardia
Causes of sick sinus syndrome? ECG abnormalities? Tx?
Idiopathic degenerative fibrosis, ischaemia, cardiomyopathies, drugs- digoxin, Beta-blockers, calcium channel blockers
Sinus bradycardia, sinus arrhythmia, sinoatrial exit block, sinus arrest>3 seconds, bradycardia- tachycardia syndrome
Correction extrinsic causes, pacemaker insertion
High-risk characteristics for pneumothorax?
HD compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, >/=50 y/o age significant smoking history, haemothorax
Triangle of safety for chest drain insertion?
Base of axilla, lateral edge pec major, 5th IC space and anterior border of lat dorsi
Causes of ARDS? Criteria?
Infection- sepsis, pneumonia, massive blood transfusion, trauma, smoke inhalation, acute pancreatitis, COVID-19, CP bypass
Acute onset within 1 week RF
Pulm oedema- bil infil on CXR, non-cardiogenic- pulm artery wedge pressure not raised, pO2/FiO2<40kPa
Tx= ITU, oxygenation/ ventilation to treat hypoxaemia, vasopressors, ABx for sepsis, prone positioning and muscle relaxation
5 As of ankylosing spondylitis?
Apical fibrosis, anterior uveitis, aortic regurgitation, achilles tendonitis, AV node block, amyloidosis
Sx of amyloidosis?
Feeling very tired or weak, losing weight without trying to, SOB, swollen feet/ legs, bruising around the eyes
Fast/ slow HB/ chest pain if heart affected
Loss of appetite, feeling or being sick, diarrhoea/ constipation if digestive system affected
Frothy urine if kidneys affected
Pain, numbness/ tingling in hands and feet if nerves affected
Causes of main types of amyloidosis?
AL= issue with bone marrow- sometimes linked with multiple myeloma
AA= long-term RA, Crohn’s/ UC/ TB
Hereditary ATTR= inherited genetic condition
Wild-type- develops as you get older usually in men> 75 y/o
Beta-2 microglobulin= having long-term dialysis
