OSCE specific Flashcards
Warfarin ATHLETICS
A: Thins blood to prevent blood clots, does this by blocking vitamin K which is usually used by the body to make proteins that cause the blood to clot
T: Take once a day in the morning
H: Oral tablet
L: Usually 3 months for a DVT, 6 months for PE, lifelong for DVT
E: Effects take 48-72hrs
T: INR on days 3, 4, 5 until INR 2-3. then regularly after that, can extend to up to 3 months
I:
C: Pregnancy, significant risk major bleeding, active bleeding
S: Bleeding - gums, easy bruising, epistaxis, blue toes
Intervention for rapid AF
Statin ATHLETICS
● Action/how it works - inhibits the production of
cholesterol and increases the uptake of cholesterol by
the liver
● Timing - once daily
● How to use it - tablet
● Length of time - long term until lipid and cholesterol
levels are under control
● Effects - muscle aches, mild transient gastrointestinal
symptoms, headache, aminotransferase elevation
● Tests required - baseline aminotransferase and
creatinine kinase
● Important side effects – rhabdomyolysis (seek
medical attention if any dark urine or any muscle
pain, tenderness or weakness, especially in the first
4-6 weeks after starting/increasing dose)
● Contraindications – treatment with systemic sodium
fusidate, pregnancy (less relevant for Bill)
ACE-I ATHLETIC
● Action/how it works: reduces narrowing of the blood
vessels, amount of salt + water retained and
sympathetic activity
● Timing: once daily
● How to use it: tablet
● Length of time: until no longer clinically indicated
● Effects: dry cough, dizziness, anaemia
● Tests required: UEC (esp potassium), eGFR
● Important SFEs: angioedema, hyperkalaemia, AKI
● Contraindications: renal artery stenosis, pregnancy,
PMHx hereditary/idiopathic angioedema, severe
renal impairment (d/w specialist), hyperkalaemia,
hypotension
Metformin ATHLETICS
Action: Increases your response to insulin so your cells take up more glucose from your blood, and increases amount of glucose produced by the liver
Timing: If you miss a dose, take it asap, unless it is too close to the next dose
How: Oral tablet that you take once daily (initially) with food, asap after your meal at a fixed date and time
500mg BD (then review after 1-2 weeks)
Length: Lifelong required, with close monitoring of complications
Effects:
Tests: Before starting long term therapy, take urea and electrolyte levels; HbA1C every 3-6 months until stable, then 6 monthly
Important Side effects: Nausea, diarrhoea abdominal pain, weight loss, lactic acidosis - can’t be taken on day of or two days after anaesthetic or after having general anaesthetic
C: Renal impairment, ketoacidosis, low BMI
Reversible causes of cardiac arrest
4H’s 4Ts:
- Hypoxia
- Hypovolemia
- Hyperkalemia/hypokalemia
- Hypothermia
- Tension pneumothorax
- Tamponade
- Toxins
- Thrombosis
SGLT2i ATHLETICS
GLP1 ATHLETICS
Anti-psychotic ATHLETICS
Clozapine ATHLETICS
Beta Blocker ATHLETICS
Dementia counselling
Parkinsons counselling
Acute asthma exacerbation - mgmt
Croup management
DOAC ATHLETICS
Risk factors for osteoporosis - SHATTERED
SHATTERED
● Steroid use, e.g. prednisolone
● Hyperthyroidism or hyperparathyroidism
● Alcohol/tobacco use (see social history)
● Thin (BMI <17)
● Testosterone – low
● oEstrogen – low
● Renal/liver disease
● Erosive (i.e. multiple myeloma) or inflammatory (i.e.
rheumatoid arthritis) bone disease
● Diabetes mellitus (type 1) or low dietary calcium
intake (see social history)
o Calcium rich foods include dairy (e.g. milk,
yoghurt), seafood (e.g. snapper, prawns,
salmon) and green vegetables (e.g. cucumber,
kale, bok choy)
Bisphosponate ATHLETICS
First line: bisphosphonates, i.e. alendronate, zoledronic acid
“ATHLETICS” mnemonic for medication counselling
● Action: Slows down the breakdown of bone
● Timing: Depends on agent – can be taken once daily,
weekly or monthly as a tablet, or yearly as an
intravenous infusion
● How to use it:
○ Tablet: Take first thing in the morning on an
empty stomach with water and stay upright
for 30 minutes to avoid GI side effects
○ Intravenous infusion: Administered over at
least 15 minutes
● Length of time: 5 years, then assess ongoing need for
treatment, consider drug holiday due to risk of
atypical fracture
● Effects: GI (e.g. oesophagitis, oesophageal ulcers,
gastric irritation)
● Tests required:
○ Serum ionised calcium
○ Vitamin D level (25-hydroxy vitamin D)
○ UEC
● Important side effects: Osteonecrosis of the jaw,
atypical fractures
● Contraindications
○ Hypocalcaemia
○ Oral: oesophagitis, achalasia, oesophageal
varices, oesophageal stricture, Barrett’s
oesophagus
○ Intravenous: reduced renal function (eGFR
≤35 mL/min
Breaking bad news mnemonic - SPIKES
Setting - appropriate setting
Perception - understanding, patient ICE
Invitation - pt wanting to hear results?
Knowledge - Chunk and check, simple language
Empathy -
Summary and strategy - make plan for next steps, arrange follow up, provide information, clarify understanding
CAGE screen
Cutting down
Annoyed
Guilt
Eye opener
5A’s for cessation
Ask
Assess
Advise
Assist
Arrange follow up
4D’s for smoking cessation
Delay
Deep breathe
Drink water
Do something else
Benefits of quitting smoking - short term and long term
Short/medium-term health benefits
○ Heart rate and blood pressure drop within 20
minutes
○ Carbon monoxide level in the blood drops to
normal within 12 hours
○ Lung function improves within 2-12 weeks
○ Coughing, shortness of breath, and wheezing
decreases within 1-9 months
Long-term benefits
○ Risk of coronary heart disease is half that of a
smoker within 1 year
○ Stroke risk is the same as that of a non-smoker
within 5 years
○ Risk of lung cancer decreases to half of that of a
smoker
○ Other – reduced risk of dementia, other cancers
(i.e. mouth, throat, oesophagus, bladder, cervix,
pancreas), fertility issues, vision loss,
osteoporosis, dental and gum disease, infections
Assessing and addressing barriers to cessation
Motivation to quit
Likes of (smoking)
Dislikes of (smoking)
Barriers of quitting
Risk factors for breast cancer?
Non-modifiable:
● Genetic mutations (BRCA1/2, RAS, PTEN, Li-Fraumeni
syndrome)
● Family history (first degree relatives)
● Age
● Early menarche, late menopause
● Nulliparity
Modifiable:
● HRT
● Physical inactivity
● Obesity
● Ionising radiation
● Alcohol
Treatment for HER-2 positive breast cancer and side effects?
Trastuzumab (Herceptin)
○ Humanised monoclonal antibody against
HER2 tyrosine kinase receptor
○ Typically every 3 weeks for 12 months
○ NOTE: would combine with chemotherapy as
doesn’t work well alone
● Main side effect
○ Cardiotoxicity (dilated cardiomyopathy) -
investigate with stress echo
ARB ATHLETIC
Angiotensin receptor blocker (ARB), e.g. candesartan
● Action/how it works: reduces narrowing of the blood
vessels, amount of salt + water retained and
sympathetic activity
● Timing: once daily
● How to use it: tablet
● Length of time: until no longer clinically indicated
● Effects: dizziness, headache
● Tests required: UEC (esp potassium), eGFR
● Important side effects: hyperkalaemia, AKI, sprue-like
enteropathy (severe chronic diarrhoea + weight loss,
months to years after initiation of drug)
● Contraindications: renal artery stenosis, pregnancy,
severe hepatic impairment, severe renal impairment
(d/w specialist), hyperkalaemia, hypotension
CC blocker ATHLETIC
Action/how it works: causes blood vessels to
expand/dilate → lowering resistance that blood has
to flow against
● Timing: once daily
● How to use it: tablet
● Length of time: until no longer clinically indicated
● Effects: peripheral oedema, facial flushing, headache,
tachycardia
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● Tests required: BP, HR
● Important side effects: gingival hyperplasia (rare)
● Contraindications: cardiogenic shock, aortic stenosis,
heart failure w/ reduced ejection fraction,
hypotension
What to do is missed dose of ACE-I/ARB?
If you forget to take one or more doses: take your next dose at the
normal time and in the normal amount, do not take any more than has
been prescribed
○ If you miss one dose, skip it and continue with your normal schedule
Treatment for alcohol use disorder
Psychosocial
○ Individual or group counselling
○ Link to social and welfare services
○ Self-help - Alcoholics Anonymous
○ Monitoring and support from health practitioner(s)
Pharmacotherapy
○ Naltrexone: opioid antagonist, reduces craving and effects reward circuitry of
alcohol
○ Acamprosate: reduces cravings, residual anxiety
○ Disulfiram: alcohol dehydrogenase inhibitor, causes adverse effects to alcohol
Symptoms of alcohol withdrawal
Mild (6-24 hours post-cessation):
○ Anxiety, tremors, N/V, insomnia
Severe (10-72 hours):
○ Hallucinations (esp visual), paranoia, diaphoresis, HTN
- Seizures (24-48 hours)
- Delirium tremens (5%, 3-10 days): global confusion + sympathetic overdrive
Psoriasis topical therapies + other options
● Topical steroids
○ Particularly helpful with flares
○ Short term (e.g. up to 6 weeks with
intermittent use)
○ Pulse treatment (e.g. steroid for 2
days/week, different drugs on other days)
■ Intermittent or pulse treatment will
help minimise adverse effects and
loss of efficacy (tachyphylaxis)
● Topical calcipotriol (vitamin D analogue)
○ May take up to 6 weeks for best results
○ Often used in combination with steroids for
greater efficacy
● Topical tars/salicylic acid
○ Safe and effective treatment however for
some patients, the colour/odour/
consistency of prepar
If topical therapy is not adequate, there are other
therapies available often coordinated with a
dermatologist (phototherapy, acitretin,
methotrexate, ciclosporin, biologics)
Non-pharmacological management of psoriasis
Keep skin moisturised
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● SNAP-W: Smoking, Nutrition, Alcohol, Physical
Activity, Weight Loss
○ Prevention for CVD and T2DM
○ Smoking cessation will also specifically
reduce risk of aggravation of psoriasis
Describe psoriasis - what, where, diagnosis. treatment considerations
Psoriasis is a chronic inflammatory skin condition, which usually presents with red, silverywhite scaly plaques which are well circumscribed and often symmetrically distributed.
Plaque psoriasis is the most common type primarily affecting the knees, elbows, and lower
back. Other types include guttate psoriasis, flexural psoriasis, nail psoriasis, palmoplantar
psoriasis, and erythrodermic psoriasis.
Diagnosis is primarily clinical, and biopsy is rarely required. However, tools such as the PASI
score (Psoriasis Area and Severity Index) can be used to assess the extent and severity of the
psoriasis
It is worth noting that treatment can be difficult and response to therapy can be variable.
Assessment of the psychosocial impact of the disease is important as is involvement of a
dermatologist for some patients.
Investigations for suspicion of SLE
Bloods: FBE (anaemia/ thrombocytopenia), UEC
(renal), ESR, CRP (inflammatory markers), ANA
(Anti-dsDNA, Anti-Sm if ANAs positive), Low
complement, Direct Coombs test, Antiphospholipid
antibodies
● Urinalysis/ urine dipstick (renal function)
● Imaging: depends on organ involvement
o X-ray joints
o X-ray/CT chest
o Echocardiogram
Etiology of SLE - who gets it, RF’s, type of sensitivity reaction?
Etiology
● Autoimmune disorder
● More common in women of childbearing age
● Genetic predisposition: HLA-DR2, HLA-DR3
● Risk factors: increased oestrogen, cigarette smoking, silica exposure, UV exposure,
infections, drugs (drug-induced lupus erythematosus)
● Type III hypersensitivity: immune complex formation in small vessels → complement
activation → organ damage in skin, kidneys, joints, vessels
Common SLE symptoms
○ malar rash
○ discoid rash
○ generalised photosensitivity
○ arthritis
○ Raynaud phenomenon
○ oral ulcers
○ nonscarring alopecia
○ constitutional symptoms (fever, fatigue, weight loss)
Complications of SLE
○ Cardiovascular disease: Libman-Sacks endocarditis, AMI
○ Infections
○ Renal failure
Treatment for SLE - non-pharmacological
● Avoid sun exposure
● Smoking cessation
● Immunisations
Treatment for SLE - pharmacological
● Hydroxychloroquine (all patients with lupus should use HCQ unless contraindicated)
● NSAIDS, low dose corticosteroids for mild to moderate symptom relief
● High doses of corticosteroids and immunosuppressants (azathioprine, methotrexate,
mycophenolate) for severe disease
Clinical presentation of Graves disease
Signs of hyperthyroidism
○ General: weight loss, increased appetite, heat intolerance, diarrhoea, fatigue,
pretibial myxedema
○ Cardiovascular: palpitations, hypertension
○ MSK: tremor
○ Endocrine: oligomenorrhea/ amenorrhea, gynaecomastia, decreased libido,
infertility
○ Neurological: anxiety, depression, restlessness, insomnia
Signs specific to Grave’s disease
○ Diffuse goitre
■ Smooth, uniformly enlarged
■ Bruit may be heard
○ Grave’s ophthalmopathy
■ Exophthalmos, lid lag, proptosis
Investigations to diagnose Graves disease
Diagnosis
● Most useful: Thyroid function test
○ Elevated T3/T4, decreased TSH
● Detect thyroid antibodies
○ Elevated TRAbs
○ May have elevated anti-Tg and anti-TPO antibodies (not specific to Grave’s
disease)
● Radioactive iodine scanning
○ Diffuse uptake of radioactive iodine
● Thyroid ultrasound
○ Enlarged, hyperactive thyroid gland
Management of graves disease
● Symptomatic treatment: beta blockers
● Anti-thyroid medications (e.g propylthiouracil (PTU), carbimazole, methimazole)
● Radioactive iodine ablation
● Surgical total thyroidectomy
Investigations for Chlamydia/Gonorrhea
Bedside Investigations
● Urinalysis to check for haematuria, nitrites,
leukocytes to rule out UTI/renal stones
Pathology
● First void urine sample for nucleic acid amplification
test (NAAT) for presence of Chlamydia trachomatis
and Neisseria gonorrhoeae
● Urine MCS. Rule out UTI
● Urethral swab for gram stain, culture and
susceptibility testing for Neisseria gonorrhoeae
● FBE, CRP, UEC
Imaging
● Ultrasound to rule out testicular torsion (as indicated)
Aspects of sexual history
● Sexually activity
● Sexual partners
● Type of intercourse
● Protected/unprotected sex, contraception use
● STI history
● Dyspareunia
● Discharge (urethral, vaginal, anal)
● Genital lesions/rashes/blisters
● IVDU, tattoos, piercings
Imaging for renal calculi
CTKUB
Investigations for glandular fever
FBE + Blood film (lymphocytosis + atypical
lymphocytes)
* LFTs: can be deranged (transaminitis)
* ESR/CRP- elevated
* ASOT (check for GA Strep throat DDx)
* EBV Monospot test (agglutination test for
heterophile antibodies)
* EBV/CMV serology
Symptoms for T2DM diagnosis
● Lethargy, polyuria or polydipsia
● Frequent fungal or bacterial infections
● Blurred vision
● Loss of sensation (i.e. touch, vibration, cold)
● Poor wound healing
● Weight loss
Eczema explanation
Also called atopic dermatitis.
* Common skin condition affecting children
triggered by overactive immune system that
causes chronic inflammation of the skin +
reduced barrier function of skin.
* Lesions of dry, red bumpy, very itchy skin
* Appears in areas such flexural areas (forearm
and behind knees), neck and scalp in younger
children
Eczema triggers
Heat, low humidity, allergens (pollen, dust,
fomites), wool, stress
Eczema prognosis
Can self-resolve as children get older but some
people have it lifelong.
Eczema pharmacological mgmt
Between flares
* Moisturisers–regular, daily. Apply top to toes,
after shower and swimming.
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Flare Management
* Apply moisturiser 4x a day
* Topical Steroids
* Only for flares/active eczema –withdraw if
in remission
* Use appropriate strength for age & part of
skin being treated
* Use with wet compress/ dressings e.g.
hydrocolloid: 1-4 times daily for at least 3
days. Parents education with nursing
* If crusting/ pus in wounds consider
Antimicrobials
o Impetigo→ mupirocin, bleach bath,
o Eczema herpeticum→ antiviral IV
Symptom management – itchiness
* Antihistamines eg Zyrtec
* Cold compress
Eczema non-pharmacological mgmt
Avoid triggers e.g. wool, synthetic fabrics, hot
showers
● Avoid soaps, shampoos, can irritate the skin
SSRI ATHLETIC
Action: Sertraline belongs to a group of
antidepressants called SSRIs, which increase the
serotonin levels in your brain, resulting in positive effects on mood.
○ They are relatively safe, tolerable and
effective.
○ Approximately 60% of people with major
depression respond to treatment with an
initial antidepressant.
- not associated with adverse pregnancy outcomes, which would be appropriate medication for her to commence.
● Timing: Once daily, best with food in the morning
● How to use: Start on a 50mg oral tablet (can go lower
if elderly/sensitive to SEs). Start low, go slow.
○ If missed dose: Take as soon as you remember,
but not if close to the next dose (i.e. don’t
double up).
-
● Length of time: We will monitor your symptoms and
may gradually stop the medication in 6-12 months if
they improve.
● Effects: Takes at least 2 weeks to work, and you might
not see any benefit until 4-6 weeks.
○ It is important to keep taking them even if
they don’t seem to be working at first.
■ Do not stop them suddenly as you
may experience withdrawal
symptoms, such as nausea, sweating,
electric shock-like sensations, anxiety,
tremor and even seizures. (“FINISH” -
see notes section)
- Tests: TFTs, FBE, EUC, LFTs
- Important side effects:
Discusses common side effects of SSRI’s effecting multiple systems including GIT (nausea, reduced appetite, diarrhoea), neurological (insomnia, sweating) and sexual dysfunction (lowered libido, anorgasmia). Critical
Discusses adverse effects of initiating antidepressants known as “activation syndrome” which can include symptoms of restlessness, lability, agitation and anxiety during the initial weeks. Critical
Discusses risk of serotonin syndrome associated with SSRIs and advises to avoid medications (and over-the-counter medications such as St John’s Wort’s) which may increase serotonin activity. Symptoms include shivers, increased sweating, diarrhoea, altered mental status, autonomic hyperactivity and neuromuscular symptoms (clonus, hyperreflexia, tremors, seizures). Critical
Discusses the risk of sudden withdrawal from SSRI including flu-like symptoms, insomnia, nystagmus, ataxia, sensory disturbances (i.e. hallucinations) and hyperarousal. Critical
Explains that SSRI initiation can result in increased suicidal thoughts. Critical
Discusses that antidepressants carry the risk of mania.
- Contraindications:
Discusses precautions to commencing sertraline such as patients with a history of bipolar affective disorder, patients at high risk of bleeding or undergoing surgery.
Follow up in 2 weeks and 4 weeks to review progress and side effects
SSRI discontinuation sydrome mnemonic ‘FINISH’
- Flu-like symptoms
- Insomnia
- Nausea
- Imbalance
- Sensory disturbance
- Hyperarousal
Risk factors for GDM
High Risk Factors
● Previous GDM
● Previously elevated blood glucose level
● Maternal age ≥40 years
● Family history DM (1st degree relative with diabetes
or a sister with GDM)
● BMI > 35 kg/m2
● Previous macrosomia (baby with birth weight >
4500 g or > 90th centile)
● Polycystic ovarian syndrome
● Medications: corticosteroids, antipsychotics
Moderate Risk Factors
● Ethnicity: Asian, Indian subcontinent, Aboriginal,
Torres Strait Islander, Pacific Islander, Maori,
Middle Eastern, non‐white African
● BMI 25 – 35 kg/m2
GDM diagnostic criteria
2hr OGTT 75g >8.5
When to test OGTT during pregnancy?
In early pregnancy and 24-28 weeks if normal results
Risk factors for cervical cancer
- Early onset of sexual activity - Risk X2 for those <18 yrs compared to 21 yrs
- Immunosuppression
▪ HIV infection
▪ Diabetes
▪ Corticosteroids
▪ Renal transplant - Hx of vulvar or vaginal squamous cancer
- Hx of STI
- Multiple sexual partners - X2 with 2 partners
- Long term COCP (at least 5years and more)
- Smoking —– Tobacco damages cervical cells, making cancer more likely in those who
also have HPV
Interprestation of LSIL (CIN1)
low grade - usually disappear without treatment
Interpretation of HSIL (CIN2/3)
Pre cancerous - have potential to develop into cervical cancer
in 10-15 yrs if untreated
HSIL (CIN2/3) treatment and impact on future pregnancy
Further treatment would involve cutting out the affected cells from the cervix
- Large loop excision of the transformation Zone (usually done for HSIL) – LA is used
usually
o Cut tissue with a loop that’s heated by electricity
- Cold knife cone biopsy: usually done under GA with surgical knife in day surgery
- Laser conization
Cone biopsy or LLETZ causes a slightly higher risk of preterm labour and
miscarriage as the procedure can weaken the cervix
- The cone biopsy has a greater risk compared to LLETZ
- Serious problems can be prevented with a suture and the stitch is cut before you
go into labour usually at 37 weeks
CST follow up following HSIL findings
Test of cure needed for those with treated high grade intraepithelial lesion (HSIL)
- Perform co test (HPV + cytology done in the same test) at 12 and 24 months post
treatment
- If negative for both tests twice consecutively, return to normal 5 yearly screening
interval
COCP ATHLETIC
What is it: I would like to recommend the combined oral contraceptive pill (COCP) (Levlen) that contains both oestrogen and progesterone. It is 95-98% effective if used correctly. Since you didn’t find that you liked the mini pill and prefer not to get Injections (depo provera), we might try the COCP first. The other options are a little more long acting and might be more suitable
for someone who wanted longer term contraceptives, but we can consider them if the oral contraceptive pills aren’t working the best.
How does it work: It works by thickening the cervical mucus so sperms cannot swim through, thins the wall of the uterus so embryo cannot implant, and inhibit release of a new egg
(ovulation)
How to take: Take on the first day of menstrual period, or sometime between Day 1-5, if you decide to take it at any pointthen it would be advisable to take use other contraceptive
options for the next 7 days.
Side effects: Mood changes, bloating, breakthrough bleeding, nausea, breast tenderness, headaches
Things to take note: Can increase the risk of breast cancer and of forming blood clots in your leg (DVT)
Benefits Easy to achieve fertility by stopping the pill should you intend to fall pregnant next time
Disadvantages Requires you to remember to take your pills at a certain time every day
Reiteration of STI protection
While these methods of contraceptive do reduce the chances of incidentally falling pregnant, they unfortunately do not prevent the transmission of sexually transmitted infection, so it would be
important to use barrier contraception (condoms for males) and get regular STI checks to reduce the rate of transmission
Contraindications to COCP
■ Smoking (+ age >35)
■ Hx/FHx of
● Venous thromboembolism
● Breast/cervical cancer
● Migraine with aura
liver disease
What to do if 1 COCP missed
If you miss just one pill for > 24h,
then take the missed pill the next day, along with the pill meant
for the next day. (so 2 in a day) and resume as per normal.
What to do if 2 or more COCP missed
Take the last missed
pill and the one meant for today, don’t take any of the other missed pills. Then, tomorrow, resume the rest of the pack as normal. To prevent ovulation, use protection (condom, refrain from intercourse etc.) for the next 7 days.
What does being Rh- mean?
When you are Rh-, that means you have no antigens, so we will give you a man-made temporary Rh Ab that will prevent your body from creating its own Ab.
This is important because in the event that the child you give birth to has Rh- blood group, and there is mixing of your blood with your
baby’s blood, your body will recognize your babies’ antibodies as foreign, and will start to create its own Rh+ antibodies, to protect
you, but these will attack your babies’ red blood cells.
Usually, the first child is not affected but blood group Rh+ children in subsequent pregnancies might be.
What happens to neonate in a hemolytic reaction to Rh-?
Red blood cells are oxygen
carrying cells that are essential for their survival and as a result they can end up falling very sick with haemolytic jaundice- where their
cells are destroyed and it the process, this releases a yellow pigment which gives rise to the jaundiced appearance.
When are Anti-D injections given and why?
They are given at 28 weeks and 34 weeks to ensure enough coverage.
625IU of Rhesus D immunoglobulin, Intramuscularly, either via the
deltoid or anterolateral thigh. Avoid the buttocks.
Indications for Anti-D injections
- Miscarriage
- Antepartum haemorrhage
- Termination of pregnancy
- External cephalic version for breech babies
- Invasive prenatal testing: Chorion villus sampling, amniocentesis, cardocentesis
- IUFD
- Ectopic pregnancy
- Abdominal trauma
- Rhesus + platelet transfusion
- Manual delivery of placenta
What does the Kleihauer Test test and when is it done?
Performed for abdominal trauma/vaginal bleeding in pregnancy
To determine fetomaternal haemorrhage volume, and ensure a
significant Rhesus D immunoglobulin dose - means that there is fetal Hb in maternal
blood, indicating concealed antenatal bleeding
Indications for IOL
When we do inductions we carefully balance the risks of the baby staying inside vs delivery.
There are a lot of reasons why inductions are performed and these are when evidence has shown that the benefits outweigh the risks.
Some common ones include:
● Pre-eclampsia
● Gestational diabetes on insulin
● Abnormal CTG findings
● Post-term pregnancy - 41 weeks +
● Advanced maternal age ( > 40)
● Fetal Macrosomia
● High maternal BMI
● Premature prelabour rupture of membranes/prelabour rupture of membranes
The reason you are having an induction of labour is because you have pre-eclampsia, which puts you at a greater risk of having eclampsia and seizures the longer
you remain pregnant.
We will schedule your induction for
37 weeks to ensure that baby has grown to term.
The timing of induction varies depending on the indication
What is an IOL?
An induction of labour is when we stimulate your body to start and undergo the labour process, the process can vary a bit depending on how ready your body is but can involve
some physical/mechanical as well as medical stimulation
Contraindications to IOL
● Fetal Malpresentation
● previous classical C-section
● Placenta praevia or vasa praevia
Risks of IOL
There are risks associated with any medical procedure including spontaneous labour itself. Some risks specific to an induction are
● Uterine hyperstimulation
● Failure of induction -> conversion to emergency Csection
● Uterine rupture
Process of IOL
There are a few different ways that labour is induced, the method of induction will depend on how ready your cervix is.
If your cervix is not ready, you may need priming either with a Balloon Catheter OR Prostaglandins.
- Catheter: You will come in the day before your
actual labour and we will put in a little balloon to
put pressure on your cervix and prepare it for
labour. You can then go home and come in the
next day where we will take out the balloon and
rupture your membranes/break your water with a little hook. - Pg: gel or tablet inserted into the vagina to soften the cervix. You will need to stay at the hospital after the gel has been applied so that we can monitor you.
After your membranes have ruptured, we will start you on a medication called syntocinin which is the natural hormone your body makes to stimulate the uterus to contract.
Indications for instrumental delivery
Maternal factors: Prolonged 2nd stage of labour, maternal fatigue, maternal medical condition resulting in excessive cardiac strain, eclampsia
Fetal factors: Fetal distress reflected on CTG , Fetal malposition preventing progress in 2nd stage of labour, Breech babies, Cord prolapse
Both vacuum/ventouse and forceps methods are fairly successful, effective and safe, but they have their differences. Our choice will be influenced predominantly by the position the baby is in at time of delivery, maternal contractions, and wellbeing of baby which we
will monitor throughout
What to expect after assisted vaginal delivery
Heavier bleeding can be expected in assisted deliveries, especially in the day immediately after the delivery, this will settle down and
some light bleeding can be expected in subsequent days.
There is a chance that an episiotomy/cut has to be made so the instrument can fit nicely, there are also higher risks of vaginal tears
but these will be stitched immediately with dissolvable stitches.
More severe 3rd or 4th degree tears involving muscle and the wall of the anus or rectum respectively, can affect 4 in 100 people after
forceps birth and between 8-12 in 100 after forceps birth
Contraindications of vacuum/ventouse
Babies in OP (breech) position, Babies with IUGR, pre term
or at risk of haemophilia
Advantages and disadvantages of ventouse
Advantages: Less painful for mother, less maternal trauma, often fairly painless - can be done without pain relief. An episiotomy will
be made if it has to be
Disadvantages: Requires fair amount of maternal effort, if mother cannot push it can be very unsafe and result in a dangerous
subgaleal haematoma - a head injury that has severe repercussions
Disadvantages of forceps delivery
- Can be very painful for mother
Risk of damage to vagina and surrounding area - Usually requires an additional small cut to be made (episiotomy) to reduce the risk of damage to muscles that help to control urination
- Baby might have a forceps mark but that usually disappears in a day
- Baby has an extremely low risk of forceps laceration and very rarely, damage to nerves supplying the face and eye damage
Advantages of forceps delivery
Can be done regardless of gestational age, even for the pre term babies. Can be done on babies in breech (feet down) position. Does not require as much maternal effort in terms of pushing, compared to ventouse.
What are the requirements for assisted vaginal delivery
Fully dilated cervix (~10cm), known fetal vertex position, vertex station of at least 0, adequate analgesia, empty bladder, adequate contractions
Information giving in OSCES - BUCES with detail
B - Brief history
Take a brief history of the presenting complaint. This should be concise, especially in an
OSCE setting.
U - Understanding
Assess the patient’s baseline understanding. For example: “What’s your understanding of
what anaphylaxis is?’
C - Concerns
Ask the patient about their concerns. This can help tailor your approach to providing
information about their diagnosis.
E - Explanation
Provide an explanation of what the disease is. A good approach to this is:
● Explain normal anatomy/physiology
● Explain the disease and what causes/triggers it
● Explain common symptoms
● Explain complications
○ Don’t forget to safety net, and highlight any red flags that should prompt the
patient to seek medical attention
● Explain management options - non-pharmacological (e.g. anaphylaxis management
plan) and pharmacological
S - Summarise
Ensure the patient understands by summarising what you have told them, and
supplementing this with additional resources for reference (e.g. pamphlets). Make sure all
their questions have been answered!
4C’s of measles
○ Cough
○ Coryza
○ Conjunctivitis
○ C(K)oplik Spots (begins with a K but to make mnemonic work)
■ Pathognomonic of Measles; small white spots on inner buccal mucosa
MMR vaccine timing
12 and 18 months
Explain appendectomy
Appendicitis is inflammation or swelling of the
appendix, which is a little tube at the end of your intestines, it has a bit of bacteria in it and normally does no harm. But when the tube gets blocked, the bacteria multiply and lead to the swelling or inflammation.
● Appendectomy is the removal of the appendix when it becomes inflamed/swollen or it ruptures
○ It will most likely be done laparoscopically or
through keyhole, which means we’ll make three
small holes in your abdomen using a camera and tools to look inside your abdomen and take out the appendix.
○ If we cannot find the appendix or there are some issues, we may have to turn it into an open surgery, where we make a cut into the abdomen to see a bit better.
Benefits of appendectomy
Stop the appendix from rupturing and turning into an abscess or peritonitis.
● Laparoscopic operations have been seen to lead to shorter hospital stays and quicker recovery time.
Risks of appendectomy
● Bleeding
● Infection
● Perforation/damage to nearby organs
● May not get all the appendix, could potentially have
another episode
● Allergy to anaesthetics
● May need to convert to open surgery
Alternative treatment for appendicitis
Antibiotics - can be good in uncomplicated cases
o Leave the appendix in and put you on some
antibiotics instead. They can work in about 20-
30% of cases but only if they are uncomplicated
o Means that there is a risk that it can happen
again.
Preparation for appendectomy
On the day
o Need to fast from tonight, won’t be able to drink or eat
o Will need to stay in hospital post-op for at least 1-2 days to make sure there were no issues after the surgery, then you can go home.
● Are you happy to have this procedure?
What are the long term complications of abdominal surgery?
● Bowel obstruction
● Hernia
● Regional pain syndrome
Consent station mnemonic (NBARCO)
Nature - discussing what the patient has and what the surgery is and what it involves.
● Benefits - why using this method to manage them (e.g. surgery vs conservative management)
● Alternatives - what other options do they have (e.g. Antibiotics)
● Risks - what are the risks of the treatment
● Consequences - what will happen if the condition is not managed.
● On the day/opt out/other:
○ discuss what the patient may need to do on the day if coming into hospital or
discussing what will happen to the patient prior to the surgery if the patient is inpatient.
○ Letting them know they have the option to opt out if they wish to do so.
○ Anything that may be specific to the treatment.
What is a UGIB?
● Defined as bleeding from above the Ligament of Treitz (duodeno-jejunal flexure)
● Up to 50-150 pts per 100,000 population per year
● Mortality of 11-33%
S&S of UGIB to look for in Hx and exam
Hints on Hx/Ex
● Hx: Melena, haematemesis, iron deficiency anaemia, Hx liver disease/cirrhosis,
certain Mx (NSAIDs, anticoagulants), EtOH, H. Pylori/PUD
● Ex: Pallor, hypovolaemia and haemodynamic compromise, signs of chronic liver
disease (e.g. variceal bleeding)
Important DDx of UGIB
Important DDx
● Peptic ulcer disease
● Oesophagitis/gastritis/duodenitis
(severe)
● Oesophagogastric varices
● Portal hypertensive gastropathy
● Angiodysplasia
● Mallory-Weiss and Boerhaave
Risk stratification tool for UGIB
the Blatchford-Glasgow score
● If low risk (no risk factors) then can manage very conservatively
● If high risk, requires admission and prompt management
What to do with haemodynamically unstable UGIB
● This dictates the priority of management. Unstable bleeds MUST be stabilised
with resuscitative measures +/- massive transfusion protocols before any
formal investigation/management (oesophagogastroduodenoscopy/variceal
banding etc.)
Risks of blood tranfusions
Risks which you must inform patients of for consent
o Common/expected: Fever, mild rash/itching, feeling unwell
o SOB (due to over-transfusion)
o Haemolysis
o Transfusion reactions (mild to life threatening)
o Viral infection/other blood-borne disease from donor (very rare)
o Severe harm and death
Management of haemodynamically stable UGIB
Regular obs + reassessment; keep NBM + ?catheterise
● Recognise need for transfusion
o Bonus if able to quote criteria (Hb <70g/L
(90 if high risk), serious clinical
deterioration, 2L crystalloids w/ no
response)
● Consider IV PPI
o No octreotide, IV ABx, or terlipressin given
no sign of variceal bleed as the cause
● Erect AXR/CXR to determine if pneumoperitoneum
● Refer to gastro/gen surg for likely
diagnostic/therapeutic
oesophagogastroduodenoscopy
Contraindications to colonoscopy
A perforation is known or suspected
● Patient unable to tolerate sedationrespiratory/cardiac reasons
● pregnant
● Acute diverticulitis
● Fulminant colitis
Alternatives to colonoscopy
Barium enema, sigmoidoscopy, CT, pill cam
Risks of colonoscopy
Common risks: bleeding, infection, anaesthesia,
risks to damaging surrounding structures
● Specific risks:
- Abdominal discomfort
- Discomfort during bowel motion for a while
after procedure
- Perforation (rare)
- Allergic reaction to bowel preparation
● Risks of NOT undergoing procedure:
- Disease can be undetected and untreated -
disease progression
Details of colonoscopy procedure (before, during, after)
Before:
- Cease certain medications e.g. anticoagulants and oral iron 5-7 days prior to procedure
- Clear fluids and low fibre diet at least 1 day prior
- Bowel prep 1 day prior- will need to go toilet often (ensure have access)
- Need to be fasted 4-8 hours before the procedure
During:
- Day procedure- the colonoscopy itself takes 20-30 minutes
- Will be under sedation (asleep) throughout the
procedure
- What are we looking for:
● Signs of inflammation, ulcers, polyps,
lumps, any active bleeding
- Tissue samples can be taken for further laboratory investigations or ‘ abnormal lumps’ can be removed
After:
- Able to go home few hours after as sedative effects wear off
- Driving is not recommended (for 24 hrs)- have
someone to pick up
Differential diagnoses of oesophageal dysphagia
Oesophageal dysphagia is associated with a sensation of food arresting after swallowing. It
is important to distinguish if this is associated with solids only, or both liquids and solids.
● If affecting both, this can indicate a motility disorder, e.g. achalasia, connective tissue
disorder
● If only affecting solids, this suggests an anatomical obstruction, e.g. strictures,
malignancy
What is oropharyngeal dysphagia and what causes it?
Oropharyngeal dysphagia occurs at the oral and pharyngeal phase. It is associated with
difficulty initiating a swallow, affects both liquids and solids and is accompanied by choking,
coughing and regurgitation. Causes include:
● Neuromuscular disorders (e.g. stroke, CNS tumours, Parkinson’s, Alzheimer’s,
Myasthenia Gravis)
● Anatomical causes (e.g. compression from tumour or thyroid mass, Zenker
diverticulum)
Hepatic/cholestatic/RUQ investigations and reasonings
Bedside Investigations
* Urine dipstick – expect elevated urinary bilirubin due to jaundice. Will be able to decrease likelihood of UTI/renal causes of the abdominal pain if the dipstick results are negative for presence of protein, nitrites and blood.
* ECG – to rule out cardiac causes due to CV RFs and sudden onset. May have tachycardia given febrile and unwell
Bloods:
* FBE – may have elevated WBC count due to
infection, low platelets.
* LFT – if patient has a gallbladder-related pathologycausing their RUQ, ALP and GGT may be elevated. For hepatitis, expect AST and ALT to be significantly elevated (in the 1000s) with ALP being mildly elevated and GGT being normal. Bilirubin levels are also expected to be elevated in a patient with jaundice. The patient may have low albumin due to impaired synthetic function of the liver, however this would be associated with fulminant hepatitis (acute liver failure) or chronic liver disease, which is not consistent with this presentation.
* Coagulation profile – may see prolonged INR due to impaired clotting factor production, however this would be associated with fulminant hepatitis (acute liver failure) or chronic liver disease, which is
not consistent with this presentation.
* CRP – may be elevated if there is an infection
causing the abdominal pain.
* Hepatitis serology (see question below for details)
* Lipase – lipase less than 3x upper limit of normal help rule out acute pancreatitis as a cause of the abdominal pain.
* Ca, Phosphate, Magnesium – if have elevated
calcium and phosphate levels this may suggest
presence of kidney stones or renal pathologies.
Imaging for ?liver/gallbladder/RUQ presentation
Abdominal ultrasound – observe for hepatomegaly and dilation of hepatic vessels. In hepatitis, it is expected to see coarsened hepatic echogenicity and hepatomegaly.
* Hepatic doppler ultrasound – used to assess
patency of the hepatic vasculature and blood flow through the portal system.
* Biliary tract ultrasound – observe for any stones, masses, thickening of the gallbladder wall or dilation of the bile ducts which may indicate the presence of gallstones as the cause of the RUQ pain.
* Chest x ray – may show consolidation due to
pneumonia which may be causing RUQ pain if the pneumonia is affecting the lower lobe of the right lung. Will demonstrate if there is air under diaphragm which may suggest a perforated viscus, but this is unlikely to cause localised RUQ pain. In hepatitis, the chest x ray findings are expected to be normal.
* CT abdomen – expect to see fatty strands and
oedema around the liver, hepatomegaly,
lymphadenopathy.
4 stages of acute viral hepatitis
- Incubation period: The virus multiplies and spreads without causing symptoms (see
table).
● Prodromal (pre-icteric) phase: Nonspecific symptoms occur; they include profound
anorexia, malaise, nausea and vomiting, a newly developed distaste for cigarettes (in
smokers), and often fever or right upper quadrant abdominal pain. Urticaria and
arthralgias occasionally occur, especially in HBV infection.
● Icteric phase: After 3 to 10 days, the urine darkens, followed by jaundice. Systemic
symptoms often regress, and patients feel better despite worsening jaundice. The
liver is usually enlarged and tender, but the edge of the liver remains soft and
smooth. Mild splenomegaly occurs in 15 to 20% of patients. Jaundice usually peaks
within 1 to 2 weeks.
● Recovery phase: During this 2- to 4-week period, jaundice fades.
‘SPIDER’ acronym for DKA mgmt
‘SPIDER’ acronym:
1. Saline IV (rehydrate!)
a. initial bolus (N/Saline 10mL/kg) →
maintenance (N/Saline + potassium)
b. do this before insulin, as insulin causes
glucose to re-enter cells → brings water (i.e.
will dehydrate further)
2. Potassium infusion once <5 until normal lab values
are reached and glucose <10
a. insulin stimulates Na/K ATPase (K+ into
cells) → risk hypokalaemia, even if patient
is ‘hyperkalemic’
3. Insulin (SA) → when BSL <15, add 5% dextrose
a. slow insulin infusion until acidosis resolved,
if too quick you risk cerebral oedema from
high CSF/low plasma glucose
4. Eat nothing (NBM)
5. Reason (find the underlying cause)
a. in this case most likely due to
noncompliance; in the long-term, discussion
with Sasha should be arranged re: risks of
insulin non-compliance, current concerns
with body image/friend groups, EtOH as
precipitate for DKA etc.
HEEADSSS screenting tool - best completed with adolescent pt alone
Home
Education and employment
Eating and exercise
Activities
Drugs and alcohol
Sexuality and gender
Suicide, depression and self harm
Safety
Approach to vomiting in a child
It’s a UTI until proven otherwise - always do a dipstick!
● Severity is often best assessed by asking for symptoms of dehydration (e.g. number
of wet nappies)
● Progressive non-bilious projectile vomits in an infant (especially 4-6 weeks old) are a
sign of hypertrophic pyloric stenosis (HPS), which requires surgery
● DKA is the first presentation of T1DM in only 10-20% of cases
● Diarrhoea is practically part of the definition of gastroenteritis – it’s highly unlikely to
be this if the child is only vomiting (unless it’s early on in the disease course)
Metabolic acidosis causes - high (more common - LTKR) and normal anion gap
i. high gap (HAGMA) is more common: ‘Left Total Knee Replacement’
(Lactate, Toxins, Ketones, Renal)
ii. normal gap (NAGMA) e.g. diarrhoea, renal tubular acidosis, N/Saline
Risk factors for haemorrhoids
● Age
● Diet
● History of chronic constipation
● Obesity
● Pregnancy
● Portal hypertension – for internal haemorrhoids
Investigations for elderly pt with acute confusion
Bedside tests:
● ECG (arrhythmia, MI)
● Capillary BGL (hypoglycaemia)
● Urine dipstick & MCS
Biochemistry:
● Complete blood examination
○ WCC (infection)
○ Hb (IDA)
● Electrolyte, urea, creatinine
○ Electrolyte disturbances → hyponatraemia as a
particularly common cause of delirium
○ Urea elevated in isolation → bleed
● Liver function tests
● Thyroid Function Tests, Thiamine, Vitamin B12, Folate
● Urine MC&S and urinalysis (UTI)
● Bladder scan if urinary retention present
● Others: Blood cultures and urine toxicology & drug
screen and blood alcohol level (BAL)
Imaging
● CXR (pneumonia)
● CT Brain
○ Rule out intracranial pathology
○ Have to include for dementia screening for
diagnosis, delirium +/- consult consultant
Other non routine investigations for consideration
● Lumbar puncture (only if suspecting meningitis)
● EEG (only if seizure suspected)
Acute management of delirium - non-pharmacological
- Behavioral charts - to record antecedents, behavioural aspects, consequences
- All about me tool - to understand tools that bring patients a sense of comfort + assist with behavioural deescalation
- Alcohol withdrawal scale - for people with a strong history of binge drinking
- Charts - fluid balance, bowel, bladder
- Pain scores
- Environmental sensitization - give patient visual and hearing aids, re-orientation with calendars and clocks, provide 1 to 1 nursing, ensure patient is in a well lit and
well ventilated quiet environment - Frequent communication + reassurance of patients; provide electronics for patients to video call family
Manage precipitating factors
Ensure good hydration, adequate pain relief, bowels open and patient not in a state of faecal retention or urinary retention (bladder scan if necessary)
Pharmacological management of acute delirium
Haloperidol or lorazepam (patients with no sedation)
Risperidone (patients already on sedative)
Psychosis in the context of delirium (antipsychotics +/- benzodiazepines)
Important medications to think of in acute delirium
○ Anti-hypertensives
○ Anti-psychotics
○ Antidepressants
○ Medications with high anticholinergic burden- even if not directly anticholinergics
Aspects of falls history taking
Mechanism of injury
- Positioning
- Timing of injury, duration
- Witnesses of fall
- Presence of headstrike, loss of consciousness
- Loss of function and motion, ability to weight bear
- Previous functional level
- Past history of fractures
- Stiffness, swelling, pain level, tenderness
Risk factors for hip fracture
Osteoporosis/osteopenia
o Low hip BMD weakens proximal femur and increases hip fracture risk
- Older age
- Malignancy
o Pathological fractures caused by metastatic cancer to the bone, primary
bone tumour
- Female sex
- Falls
o Balance issues, muscle weakness, visual impairment, cognitive impairment,
depression, functional decline
- High energy trauma in younger patients
- Medications
o Drugs increasing fracture risk
§ Levothyroxine: Decrease bone density
§ Loop diuretics: Impairs renal calcium absorption
§ PPI: Reduce calcium absorption
§ Corticosteroids: Long term use can cause osteoporosis
§ Long term bisphosphonates: Can cause atypical hip fractures
o Drugs increasing falls risk
§ Antidepressants, sedatives: Increase falls risk due to sedation
§ Antihypertensives: Increase falls risk due to postural hypotension
and dizziness
§ Opioid analgesics: increase falls risk due to sedation
- Alcohol consumption
Blood supply to femoral head
External iliac artery → common femoral artery → profunda femoris artery →
medial + lateral circumflex femoral artery → retinacular arteries
o Medial circumflex femoral artery provides major blood supply for the
femoral neck
- Retrograde blood supply similar to the scaphoid
- Intracapsular NOF fracture disrupts blood supply of retinacular arteries and can
lead to AVN
Explanation, benefits and risk of CT + contrast
Explains that it is a form of imaging that uses ionising radiation, just like simple X-rays, but in greater doses, the risk of which is minimal as described
Explains the indication of a CT scan for the patient’s case, that it would help in confirming their diagnosis, ruling out other possible differentials, identifying the aetiology, and assessing the complications
Describes both benefits and risks of CT scan, and that the benefits outweigh the risks. Benefits include added confirmation, a clue to aetiology, and ruling out of complications or further masked conditions. Risk is minimal in the form of radiation exposure that is not a concern outside pregnancy or prior radiation-induced problems.
Explains that contrast-enhanced CT scan uses a dye similar to any other medication and will be injected both intravenously and consumed orally prior to the scan
Touches on some contraindications for dye administration such as prior allergic reactions or current medication use
Describes the need for necessary laboratory investigations prior to the scan, especially for evaluation of renal function
Investigations for neonatal jaundice <24hrs
FBE, reticulocyte count, blood film, neonatal blood group, bilirubin, coombs test and G6PD screening
‘A thorough examination is essential to assess the baby’s general wellbeing and detect birth trauma or ongoing haemorrhage. Investigations include FBE, film and reticulocytes, neonatal blood group, direct antiglobulin test (Coombs), and possibly G6PD screening. Septic workup is appropriate if neonatal sepsis is suspected.’
Causes of pathological neonatal jaundice
Early onset jaundice (<24 hours) is pathological, with causes such as sepsis or haemolysis, including isoimmunisation (ABO or Rhesus D alloantibodies), RBC enzyme defects (G6PD, hereditary spherocytosis, alpha thalassemia), haemorrhage (cerebral, intra-abdominal), and blood extravasation (bruising/birth trauma).
Causes of physiological neonatal jaundice
Physiological jaundice results from excessive bilirubin formation, with the neonatal liver unable to clear bilirubin rapidly. In normal term babies, unconjugated hyperbilirubinaemia usually appears between 24-72 hours, peaks on the 4th-5th day, and disappears after 14 days. No further investigations are needed unless red flags suggest other causes.
What does a rise in conjugated bilirubin indicate?
Conjugated bilirubin at any age point raises suspicion of neonatal hepatitis, extrahepatic obstruction (e.g., biliary atresia, choledochal cyst), and metabolic diseases.
Management of neonatal jaundice
Phototherapy is initiated when total serum bilirubin (TSB) reaches the phototherapy threshold, with lower thresholds for preterm and low birth weight babies.
Regular monitoring for vital signs, including temperature, hydration status, and urine output, is crucial.
Phototherapy is ceased when serum bilirubin is below the conventional phototherapy level.
Exchange transfusion is considered when TSB reaches the exchange transfusion threshold.
Menoupause/perimenopause symptoms
Vasomotor/General physical symptoms - recognises hot flushes, headaches, muscles/joints pain, formication, sleep disturbances as common symptoms in menopause Critical
Urogenital symptoms - assesses dyspareunia and vaginal dryness, postcoital bleed and urinary frequency as part of the genitourinary syndrome of menopause (GSM) Critical
Psychological symptoms - asks about depressive/anxiety symptoms, sleep disturbances, decreased concentration and memory
Differential diagnoses of menopause
Hyperthyroidism - recognises that irregular menses, heat intolerance, and mood changes are potential clinical manifestations of hyperthyroidism. Differentiating features can include increased bowel movements, tremors, appetite and weight changes. Critical
Hypothyroidism - recognises that irregular menses and mood changes are potential clinical manifestations of hypothyroidism. Differentiating features can include decreased bowel movements, heat intolerance, appetite and weight changes. Critical
Hyperprolactinemia - differentiating features can include increased lactation.
Endometrial carcinoma - recognises irregular/heavy/ prolonged bleeding is a common finding in endometrial carcinoma, although most endometrial cancers occur in patients >55 years of age. May be accompanied by constitutional symptoms of malignancy. Critical
Sexually-transmitted infections/Pelvic inflammatory disease - recognises abnormal uterine bleeding and dyspareunia as possible manifestations in STI/PID. Differentiating features can include pelvic pain and abnormal vaginal discharge. Critical
Pregnancy - Amenorrhoea with breast tenderness, fatigue, nausea, and an enlarging abdomen may indicate pregnancy.
Contraindications to HRT
Cardiovascular, liver or thromboembolic disease may represent a relative or absolute contraindications to MHT
Patients with hysterectomy can be put on menopausal hormonal therapy (MHT) with oestrogen therapy alone whereas patients with an intact uterus require oestrogen/progesterone therapy.
Explanation of menopause and perimenopause
Menopause usually happens between age 45 and 55 years, when the ovaries stop producing eggs (ovulating) and menstrual periods end. A woman is said to have completed menopause once she has gone a full year without having a period.
Perimenopause is the time when your periods start to change (usually becoming less frequent). This phase lasts an average of four years and ends when you have your final period.
The average age for a woman to stop having periods is 51 years. After menopause, a woman can no longer get pregnant.
Menopause occurs because the ovaries run out of eggs. During this time, many women also start to have menopausal symptoms. These result from declining levels of oestrogen in the body and can include hot flashes, night sweats, mood changes, sleep problems, and vaginal dryness.
Common screening tests for menopause
Consider the following test to exclude common causes of fatigue, mood change, hotness: TSH (thyroid disease), FBC and iron stores (iron deficiency)
Pharmacological treatment options for menopause
Consider menopausal hormonal therapy (MHT) for the relief of troublesome vasomotor symptoms (VMS). In this case, she requires a combination of oestrogen and progesterone replacement since she still has an intact uterus. Cyclical MHT should be used. Critical
In addition to relieving hot flashes, MHT may help with other symptoms of menopause as well, including vaginal dryness, depression, and other mood problems.
If patient does not prefer hormonal options, alternatives include SSRI and SNRI
To manage localised urogenital symptoms, the patient can consider vaginal oestrogen therapy (ring/cream) or moisturisers/lubricants
Investigations for RA
Bloods:
A Full Blood Examination (FBE): is a standard investigation for most conditions. In rheumatoid arthritis, it may show anemia of chronic disease.
ESR and CRP: non-specific markers of inflammation that are commonly elevated in RA patients. Therefore, they are useful in monitoring disease activity and response to treatment.
Rheumatoid Factor: is an antibody that is present in the serum of approximately 70-80% of RA patients. It is not specific to RA and may also be elevated in other autoimmune diseases and infections, but it is used in the criteria for diagnosing rheumatoid arthritis.
Anti-CCP antibodies: are more specific to RA than RF and can be detected in up to 60-80% of RA patients. Therefore, they are a more reliable marker for the diagnosis of RA.
What is HLA-B27 and what is it associated with
HLA-B27 is a genetic marker that is associated with the seronegative spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis, reactive arthritis and enteropathic arthritis. It is not associated with RA.
Characteristic findings of RA on Xray
Joint space narrowing
periarticular erosions
bony deformities
First line agent for RA mgmt and how does it work
Methotrexate is considered the gold standard Disease-Modifying Anti-Rheumatic Drug (DMARD) for RA and is typically the first-line agent used in most patients.
It has been shown to effectively reduce inflammation and joint damage in RA and is usually well-tolerated.
Folic acid is routinely co-prescribed with methotrexate to reduce the risk of side effects.
What tests should be ordered before starting methotrexate?
FBE, EUC, LFT, Hep B and C serology, HIV serology, CXR
Methotrexate can be hepatotoxic and is an immunosuppressive agent. It is therefore important to ascertain any baseline liver derangements and chronic infections.
An FBE assesses for any cytopaenias before initiation to ensure that the patient has no underlying hematological disorders that may be exacerbated by methotrexate.
Methotrexate is renally cleared and may be contraindicated, require dose adjustment or additional monitoring in patients with renal impairment.
Metrotrexate can cause hepatotoxicity, thus it is necessary to measure liver function before starting the treatment, as well as after treatment is initiated.
Methotrexate is an immunosuppressive agent; consequently, it is important to be aware of any chronic underlying infections. If escalation of immunosuppression is considered in future, treatment of latent infection or prophylaxis may be required. It is thus necessary to perform serology for both hepatitis B and C, and HIV prior to commencement, as well as chest X-ray to assess for latent tuberculosis.
Common side effect of methotrexate and what to do if it occurs
The most common side effect of methotrexate is nausea. One option to address this is to switch to injectable methotrexate which is typically associated with fewer gastrointestinal side effects
Time before methotrexate reaches its full efficacy?
Methotrexate does not work immediately and it can be 3 months before it reaches full efficacy
What to do if methotrexate not providing adequate response for RA?
Can increase dose
Try another DMARD
Commence another DMAR (leflunomide) with methotrexate
Typical presentation pneumonia
Pneumonia is associated with dyspnoea that progresses over days rather than years. It may also be associated with a productive cough, fever and focal lung findings on examination. The dyspnoea returns to baseline with resolution of the infection.
Typical presentation pulmonary fibrosis
Pulmonary fibrosis can present in a very similar way to COPD but may not be associated with a significant smoking history and may include exposure to environmental toxins such as asbestos or beryllium (historically used in fluorescent light manufacture and aerospace production).
Typical presentation COPD
Clinically, it is characterised by progressive dyspnoea and loss of exercise tolerance. It is often associated with a cough, which may be productive, and intermittent respiratory tract infections that can trigger acute exacerbations. A significant smoking history is vitally important in making the diagnosis.
Typical presentation Bronchiectasis and chronic bronchitis
Bronchiectasis and chronic bronchitis are both associated with chronic infections and may be difficult to differentiate from COPD initially. Again, the key point is a significant smoking history. However, be aware there is significant overlap, with 50% of people with chronic bronchitis having COPD.
Reversibility definition for asthma vs COPD
Administering a short acting bronchodilator, such as salbutamol, waiting 15 minutes and then repeating the test.
Asthmatic patients should demonstrate an increase above pre-bronchodilator baseline in FEV1 and/or FVC of at least 12% and 200mL.
If reversibility is less than this, COPD is suggested.
Non-pharmacological Rx of COPD - improving prognosis
Smoking cessation
Pulmonary rehabilitation programs - usually 6-8 week programs - manage breathlessness and improve wellbeing
Influenza, pneumococcal, COVID and RSV vaccinations
Physical activity - aerobic and resistance
Pharmacological treatment of stable COPD
COPD patients can be classed into GOLD A,B,C and D according to number of exacerbations/hospitalisations in the past year as well as severity of symptoms according to the modified Medical Research Council (mMRC) scale.
GOLD A - short acting bronchodilators - The two main types are short-acting beta-2 agonists (salbutamol) and short acting anti-cholinergics (ipratropium bromide). These can be inhaled and are ‘reliever’ therapies.
GOLD B - long-acting bronchodilators can be used. These include long acting beta-2 agonists (LABA) such as eformeterol and salmeterol. They also include long acting anti-cholinergics such as tiotropium bromide. Again, these therapies are inhaled and have been shown to improve quality of life in comparison to short-acting bronchodilators. This is the key area of difference with asthma, where long acting bronchodilators are introduced AFTER inhaled corticosteroids and LABA therapy is NEVER indicated without the use of inhaled corticosteroids.
GOLD C - LAMA monotherapy is initiated.
GOLD D - dual therapy with LAMA/LABA is the mainstay of treatment. Inhaled corticosteroids can be added. They are indicated in patients with an eosinophil count of >300cells/μL and those suffering 2 or more exacerbations requiring systemic corticosteroids and antibiotics in a 12 month period. They aim to reduce the number of exacerbations and improve quality of life by controlling dyspnoeic symptoms. Combinations of long acting bronchodilators and inhaled corticosteroids are available to help improve compliance.
Other pharmacological treatment for COPD
Systemic corticosteroids and antibiotics are indicated in the treatment of acute exacerbations of COPD.
Theophylline is an end-stage therapy in patients who can’t tolerate inhaled therapies or have otherwise uncontrollable symptoms. It’s rarely used today.
Mucolytic therapy may be used to improve symptoms and reduce the frequency of exacerbations in patients with a chronic productive cough.
Home oxygen is used as a last-line treatment for symptom control.
Explanation of COPD
COPD causes non-reversible airway destruction and is predominantly caused by long term tobacco use.
Hallmark symptoms include progressive dyspnoea and reduced exercise tolerance.
COPD can be diagnosed based on a clinical history of progressive dyspnoea in the context of long term tobacco smoking and demonstrated on chest X-ray and with the use of pulmonary function tests.
The primary intervention is smoking cessation, no pharmacological treatment can alter the disease course as much as this can.
Explanation of post-streptococcal glomerulonephritis
Acute Post-streptococcal Glomerulonephritis (APSGN) is a classic example of acute nephritic syndrome marked by sudden onset of gross haematuria, oedema, hypertension, and renal insufficiency.
It ranks among the most common causes of gross haematuria in children due to Group A Streptococcal infections, typically resolving completely in over 95% of cases with rare recurrences.
Mortality in the acute phase can be prevented by effectively managing acute renal failure, cardiac failure, and hypertension.
Investigations for suspected nepritic syndrome
Urinalysis
Complement levels (C3 and 4)
Anti streptolysin O Titre (ASOT)
EUC
Urinalysis: In APSGN, there will be the presence of RBCs, RBC casts, proteinuria, and some polymorphonuclear leukocytes.
C3 & C4 levels: Serum C3 level is significantly reduced in over 90% of patients during the acute phase and returns to normal within 6-8 weeks. The C4 level will be normal. If both levels are low, an alternate diagnosis needs to be considered.
Anti Streptolysin O Titre (ASOT): A raised titre establishes recent exposure to streptococcus, which helps to confirm the diagnosis. It is important to note that ASOT is rarely raised after streptococcal skin infections. A positive throat culture report might support the diagnosis or might simply represent the carrier state.
Renal function tests: In acute glomerulonephritis, acute renal failure is a recognised complication. Hence, it is necessary to perform a renal function test to assess a child with decreased urine output.
Not indicated: renal US (may show slight kidney enlargement)
Differential between nephotic and nephritic syndrome in child
Nephrotic syndrome (NS): In uncomplicated idiopathic NS, it is rare for a child to present with haematuria or hypertension.
Common cause of respiratory distress/ increased RR in PSGN
Acute Pulmonary Oedema:
This is a common cause of respiratory distress in APSGN patients. Due to hypertension and hypervolaemia, cardiac failure can develop, leading to pulmonary oedema. The patient may also show signs like orthopnoea and cough. Pulmonary oedema results in tachypnoea as the body attempts to compensate for reduced oxygenation and increased fluid in the lungs.
Metabolic Acidosis:
APSGN can cause acute renal failure, which may lead to metabolic acidosis due to impaired excretion of hydrogen ions. The respiratory system compensates by increasing the respiratory rate to expel CO2 and maintain acid-base homeostasis. This mechanism results in tachypnoea as a compensatory response.
Presentation of influenza
Influenza is suggested by myalgia, lethargy and tiredness, with a bad cough, fever and nasal congestion. It has a faster onset and more severe course. The common cold has nasal stuffiness and a cough commonly, and in children may also have fevers. It has a slightly slower onset and is less severe in nature.
Complications of URTI
acute rhinosinusitis, bronchitis, pneumonia, asthma exacerbation, and acute otitis media.
Management of common cold
Analgesics (paracetamol/NSAIDs), nasal decongestant + anti-histamine and zinc lozenges all at least have some partial evidence for effectiveness. Cough suppressants, antibiotics, anti-virals and vitamin C all have little to no evidence for the standard cold/flu that is non-severe and non-complicated.
Spread of common cold
Mostly hand contact
Presentation of intussusception
The classic triad of symptoms includes colicky abdominal pain, vomiting, and “currant jelly” stool, which is indicative of gastrointestinal bleeding.
However, not all patients present with this triad, and symptoms may be nonspecific, such as irritability, lethargy, or inconsolable crying.
In some cases, intussusception may lead to bowel obstruction, causing abdominal distension, palpable mass, and signs of peritonitis if perforation occurs.
Age ranges for intussusception
Intussusception primarily affects infants and young children, typically between the ages of 3 months and 3 years.
Risk factors for intussusception
While often idiopathic, several predisposing factors have been identified.
These include viral infections, such as adenovirus or rotavirus, which can lead to lymphoid hyperplasia in the intestine, serving as a lead point for intussusception.
Additionally, structural abnormalities in the intestine, such as Meckel’s diverticulum or polyps, may predispose individuals to intussusception.
Certain medical conditions, such as cystic fibrosis or Henoch-Schönlein purpura, have also been associated with an increased risk of intussusception.
Imaging for suspected intussusception
Abdominal ultrasound is the preferred initial diagnostic modality due to its high sensitivity and specificity in detecting intussusception. Ultrasonographic findings may include the classic “target sign” or “doughnut sign,” indicating the presence of the telescoped bowel segments.
Treatment for intussusception
In cases where ultrasound findings are inconclusive or unavailable, contrast enema can be performed both diagnostically and therapeutically.
Contrast enema not only confirms the diagnosis but also allows for non-operative reduction of the intussuscepted bowel under fluoroscopic guidance. Currently either air enema or saline enema is commonly used for nonoperative reduction.
In enema reduction, air or liquid contrast material is injected into the rectum under controlled pressure and reduction of the telescoped bowel segment is observed by imaging. Success rates for non-operative reduction range from 70% to 90%.
Minimally invasive surgical techniques, such as laparoscopic or laparoscopic-assisted procedures, have become increasingly utilized, offering advantages such as shorter hospital stay and faster recovery time.
Iron tablets ATHLETIC
A: Replace your body’s store of iron, a mineral required to make RBCs
T: 1-3 times daily tablet or syrup or infusion once
H: Infusion, oral tablet
L: Takes 3-4 weeks for Hb to normalise, then further 3 months to normalise iron stores (oral)
E:
T: Hb in 1 month to assess response
I: GI irritation, abdominal pain, black/green stools, metallic tast
C: None
Investigation for suspected aortic dissection
A CT angiogram (CTA) is the gold standard diagnostic investigation for aortic dissection. It provides high yield information, is reliable, widely available and is relatively efficient.
A chest X-ray is a reasonable investigation to consider. It is commonly done during initial work up to assist with differentiating causes of chest pain. The most common finding suggestive of aortic dissection is widening of the aortic silhouette (Image). However a chest X-ray is insufficient in providing definitive diagnosis of aortic dissection and provides little to no information regarding further management planning.
An echocardiogram is a reasonable investigation to consider. A transoesophageal echocardiogram (TOE) can be used for confirming the diagnosis of aortic dissection. However, a CTA is considered the superior investigation and is more readily accessible. A transthoracic echocardiogram (TTE) can be considered but is less reliable.
Type of shock following aortic dissection - tachycardic, hypotensive and SpO2 94%RA, distended neck veins, muffled heart sounds, bibasal crepitations
This is the picture of obstructive shock (cardiac tamponade). Although Mr Lim is likely bleeding (given the clinical picture and haemoglobin drop) and there may be some hypovolaemic element to his presentation, this clinical picture could not be explained by hypovolaemic shock alone, and the examination findings do not support it.
The presentation of Beck’s triad: hypotension, muffled heart sounds and distended neck veins is highly suggestive of acute cardiac tamponade. In addition, Mr Lim’s telemetry via arterial line shows pulsus paradoxus, which is commonly associated with cardiac tamponade, especially in the post-operative setting.
What is pulsus paradoxus?
Pulsus paradoxus is a phenomenon where a patient’s blood pressure falls by at least 10mmHg during normal inspiration.
What is the management of cardiac tamponade?
Surgical intervention (surgical drainage) is preferred in severe haemodynamic compromise, the history of recent aortic dissection and surgical repair and the need for direct visualisation of the pericardium and aorta to stop further bleeding and to insert new drains
Although pericardiocentesis is an effective option for managing tamponade, it is not preferred in this scenario due to reasons outlined above.
Management of pleural effusion
Chest drain
Breast cancer typical presentation
Breast cancer typically presents as a painless lump in the breast of a post-menopausal woman.
Most commonly lump in Upper outer quadrant
May also see dimpling of skin, nipple retraction
Initial investigation of suspected breast cancer
U/S of axilla: The axilla is clinically negative (no palpable lymphadenopathy), however radiological assessment of the lymph nodes is also required. If any appear suspicious, this should be FNA’d (only confirmation of malignant cells in abnormal lymph node is required)
U/S affected breast: Ultrasound imaging of the affected breast can give more information regarding the offending lump, as well as assess the rest of the breast for other, non-symptomatic lesion
Bilateral Mammography – Imaging of both breasts is paramount; mammogram to assess the breast with the lesion but also to assess the non-affected side in case of any suspicious, asmptomatic findings there.
Core biopsy: Core biopsy is the main pathological investigation for a suspected breast cancer. It can confirm the presence of non-invasive or invasive malignancy, as well as give additional information regarding type/subtype, grade, hormone and HER2 receptor status and proliferative index.
If not suspiscous for malignancy:
Fine needle aspiration – Fine needle aspiration can be used to investigate breast lumps, however is not the best for a solid lump. It is often used for cystic lesions. If a breast cancer is FNA’d, it will still need core biopsy for further diagnostic imaging and therefore core would be the preferred initial biopsy methody.
Prognosis for small-moderate sized localised breast cancer, hormone positive
Greater than 80%
Septic screen
“Septic screen” often consists of chest x-ray, cultures of blood, urine, and other specimens as directed by history and physical examination.
Which pathogens for pneumonia should be considered in immunocompromised patients?
In addition to common pathogens, opportunistic infections, such as Cryptococcus spp, Pneumocystis jirovecii should be considered in immunocompromised patients with pneumonia.
Treatment for cryptococcal infections
Amphotericin B, in combination with flucytosine, is the recommended induction treatment for cryptococcal pneumonia in immunocompromised patients
Amphotericin B is associated with adverse effects including electrolyte disturbances, infusion reactions, and nephrotoxicity.
When are fine inspiratory crackles heard typically?
Fine inspiratory crackles is typically heard in pulmonary fibrosis. In contrast, coarse inspiratory crackles are heard in congestive cardiac failure or pneumonia.
Typical bacteria causing CAP? SHEPS KM
Streptococcus pneumoniae
Haemophilus influenzae
Escherichia coli
Pseudomonas aeruginosa
Staphylococcus aureus
Klebsiella pneumoniae
Moraxella catarrhalis
Atypical bacteria causing CAP? MLC
Mycoplasma pneumoniae
Legionella pneumophila
Chlamydia pneumoniae
Viral causes of CAP? IRP
Influenza
Respiratory syncytial virus
Parainfluenza
Does Interferon-gamma release assay test for latent or active TB?
Interferon-gamma release assays (e.g., Quantiferon-tuberculosis) are used to diagnosed latent rather than active tuberculosis (TB) infection.
Timelines for PCI and thrombolysis for MI
In cases where a PCI facility is not available or if the hospital with a PCI facility is more than 120 minutes, thrombolytic therapy should be started immediately. If PCI is available, it should be the immediate management option (performed within 90 minutes). If the patient’s symptoms do not resolve after thrombolytic therapy, the patient should be referred to a hospital with PCI capability.
Long term therapy after MI
Long-term management of a myocardial infarction includes dual anti-platelet therapy, cardiac rehabilitation, statin, and consideration of prescribing a beta-blocker and/or ACE inhibitor, and MRA (spironolactone)
As per existing guidelines, dual-antiplatelet therapy in the form of aspirin and clopidogrel should be prescribed as part of long-term management post-MI unless it cannot be tolerated.
All patients are recommended to undergo cardiac rehabilitation after a MI to help to prevent secondary complications.
Statins (that is HMG-CoA reductase inhibitors) are indicated for patients as well, unless contraindicated.
Patients with evidence of heart failure, diabetes, existing hypertension, anterior infarct, or left ventricular systolic dysfunction are recommended ACE inhibitors such as perindorpil, or ARBs.
Beta-blockers such as metroprolol are also recommended for all patients who have signs of reduced left ventricular systolic function, measured by a LVEF of less than 40%.
Spironolactone should be added as the patient has severely reduced LV function. This is mineralocorcpid receptor antagonist and will help with cardiac remodelling and provide. survival benefit
When to refer for PCI after thrombolysis for MI
Referring the patient for percutaneous intervention (rescue PCI) is the next step when a patient fails thrombolysis. This occurs when the patient’s symptoms are persisting or there is evidence of < 50% ST-segment resolution (ST segments remain elevated).
Non-pharmacological management for GORD
Losing weight (if overweight)
Avoiding chocolate, citrus drinks, tomato-based foodstuffs, coffee
Having small frequent meals
Avoiding food within three hours of bedtime
Elevating the head of the bed
Use of an acid-suppressing medication.
Pharmacologic management of GORD
A proton pump inhibitor (eg, pantoprazole, esomeprazole) could be considered, only following life style advice.
An H2-receptor antagonist (such as ranitidine) would also be considered, along with PRN usage of an antacid.
Red flag symptoms indicating need for upper GI endoscopy (e.g. in a presentation of suspected GORD)
Unintentional weight loss
Vomiting blood
Dysphagia
Symptoms of anaemia
Age over 45 with long-standing reflux symptoms
Recent onset of reflux symptoms in an elderly patient
Obesity with weekly reflux symptoms
Wheezing or a cough.
CHA2DS2 Vas score - details, indication and interpretation
Calculates stroke risk for patients with atrial fibrillation
CHF history (+1)
HTN (+1)
Age (65-74 +1, 75+ +2)
Diabetes (+1)
Sex (female +1)
Stroke/TIA/Thromboembolism history (+2)
Vascular disease Hx (prior MI, PAD, aortic plaque) (+1)
Interpretation:
0 for men or 1 for women = low risk, may not require anticoagulation
1 for men, 2 for women = low-moderate risk, consider anticoagulation
2 or more for men, 3 or more for women = moderate-high risk, anticoagulation candidate
HAS-BLED score - details, indication and interpretation
Estimates risk of major bleeding for patients on anticoagulation to assess risk-benefit in atrial fibrillation care.
HTN (+1)
Age (>65 +1)
Stroke hx (+1)
Bleeding - major or predisposed (+1)
Labile INR (+1)
Ethanol use (>8 drinks/wk +1)
Disease: Liver (+1), renal (+1)
Medications (aspirin, clopidogrel, NSAIDs +1)
0: anticoagulation should be considered
1: Anticoagulation should be considered: Patient has a relatively low risk for major bleeding (~1/100 patient-years).
2: Anticoagulation can be considered, however patient does have moderate risk for major bleeding (~2/100 patient-years).
3+: Alternatives to anticoagulation should be considered: Patient is at high risk for major bleeding.
Typical causes of exudative effusion
Amyloidosis
Chylothorax
Constrictive pericarditis
Malignancy
Pulmonary embolism
Sarcoidosis
Trapped lung
Sensitivity and specificity defn
Sensitivity refers to a test’s ability to designate an individual with disease as positive. A highly sensitive test means that there are few false negative results, and thus fewer cases of disease are missed.
The specificity of a test is its ability to designate an individual who does not have a disease as negative.
Explain atrial fibrillation and its complications
For example: Your heart is made up of four chambers, the top two chambers are called the atrium and the lower two chambers are the ventricles. Electrical impulses help your atrium to contract so that blood is pushed into the ventricles before it circulates the body. With atrial fibrillation, the abnormal electrical rhythm causes your atrium to contract at different times, meaning there is poor blood flow out of your heart. This abnormal electrical can cause palpitations and other symptoms such as chest pain and shortness of breath.
Explains the complications of atrial fibrillation (i.e. risk of clotting leading to stroke, ischaemic bowel, ischaemic limb) and poor cardiac output (i.e. risk of acute myocardial infarction).
Pharmacological mgmt of AF
DOAC
Beta blocker - Discuss that rate control with a beta-blocker i.e. metropolol, is important to prevent haemodynamic deterioration by controlling ventricular rate. (Critical)
Discuss that this is indicated in patients who are symptomatic, or have a high ventricular rate.
ACD counselling points
Clear explanation of what is involved in an ACD including: Critical
- Appointing substitute decision makers
- Main goals for care
- Any treatment that the patient decline.
Explain that an ACD will only take effect if the patient cannot make their own decisions, either temporarily or permanently. Critical
Explain that the patient can change their ACD at any time, provided they have capacity to make decisions at that time.
Explain that an ACD does not replace a will, and cannot be used to make any financial decisions.
Ask the patient if they have considered their wishes for end-of-life care.
Explore the patient’s values and goals regarding care.
Arrange follow-up in an appropriate timeframe to further discuss any questions that they may have or help them complete the ACD.
Advanced care planning is an important process in which patients can document what medical and personal care they would want if they are not able to communicate their wishes or make decisions about their care. The process of discussion and advanced care plan allows patients to take time to consider their values and what type of care they want, before they are unwell or unable to make these decisions. Advanced care discussions should be had with any patients that are elderly, have terminal illnesses or conditions that may affect their cognitive function.
An Advanced Care Directive is a legal document that allows patients to appoint one or more substitute decision-maker(s) as well as state their wishes and goals for care. It may also include refusal of any specific care (for example CPR or blood transfusions). For an ACD to be valid it must be voluntarily made and made whilst the patient has decision-making capacity. If there is doubt about a patient’s capacity, a formal capacity assessment should be performed.
It is important to discuss the patient’s own expectations, values and goals for care rather than that of family, and encourage them to be as specific as possible when preparing an ACD. ACDs should include a patient’s wishes for both medical care as well as their preferences for accommodation, personal care and religious or spiritual care.
Once an ACD has been prepared, it can be updated and changed at any time providing the patient continues to have capacity. If there is an active ACD and the patient expresses wishes that differ to those documented in the ACD, these should still be taken into account providing the patient has capacity to make these decisions. A substitute decision maker should make decisions that are in line with the patient’s values, their wishes and what is in their best interest.
An ACD does not replace a will as it documents medical and personal care wishes whilst the patient is alive, and does not dictate the management of their estate following their death.
Osteoporosis screening tests and reasoning
Laboratory investigations: FBE, CMP, EUC, LFTs, TFTs.
Laboratory investigation justifications: FBE to determine if there is an elevated white cell count which can indicate infection or anaemia which may occur in multiple myeloma. CMP and EUC to determine if there is evidence of electrolyte abnormalities (hypocalcaemia etc.) or renal failure which is associated with osteoporosis. LFTs as these can be elevated in bone disease. TFTs as hyperthyroidism can contribute to osteoporosis risk.
Imaging for suspected crush fracture
Imaging/other: Spine X-ray, Spinal CT, bone density test (DEXA scan - if not already completed).
Imaging/other investigation justifications: The X-ray can be used to assess for a potential vertebral crush fracture, with a CT to assess for other possible causes such as a disc compression. A DEXA scan can further provide insights regarding the extent of the osteoporosis.
Different diagnoses for crush #/osteoporosis
malignancy, metabolic bone disease, ankylosing spondylitis, hyperparathyroidism, hyperthyroidism, osteomalacia, and infection.
Side effects of lithium? LITHIUM-R
Leucocytosis
Insipidus
Tremor / teratogenic
Hypothyroidism, hyperparathyroidism, hypercalcaemia
Increased weight
Upset stomach (nausea, vomiting, diarrhoea)
Misc: muscle weakness, memory impairment, metallic taste, ECG
Renal failure
Lithium ATHLETIC
A: Lithium is the drug of choice for preventing manic or depressive episodes, as well as treatment of acute mania, and has been associated with reduced risk of suicide. The mode of action of lithium remains unknown, however, it is hypothesised to inhibit dopamine while enhancing serotonin release.
T: Daily, maximum benefits of lithium can be delayed, occurring within one to three weeks of commencing lithium.
H: Oral, initially 750-1000mg and can be up-titrated by 250-500mg daily if necessary
L: Life long
E:
T: Initial investigations such as an ECG and FBE, UEC, TFT, calcium, magnesium and phosphate levels are required before starting lithium.
Explains measurement of lithium concentration will be monitored within a week after starting treatment and after each dose change until stabilised.
Further ongoing tests with FBE, UEC, TFT, calcium, magnesium and phosphate levels, as well as serum lithium levels, are required every three months.
Hydration status is an important factor that can influence the concentration of lithium.
The therapeutic range for an adult patient with mania is 0.5–1.2 mmol/L. Lithium concentration >1.5 mmol/L (or >1.2 mmol/L in the elderly) may result in lithium toxicity which may present with neurological and gastrointestinal symptoms as well as seizure, coma and death.
Increased monitoring may be required in unwell patients (i.e. gastroenteritis), in individuals who are actively having manic or depressive phases, with changes in weight or diet, pregnancy and commencement of new medications such as diuretics.
I: LITHIUM-R
Leucocytosis
Insipidus
Tremor / teratogenic
Hypothyroidism, hyperparathyroidism, hypercalcaemia
Increased weight
Upset stomach (nausea, vomiting, diarrhoea)
Misc: muscle weakness, memory impairment, metallic taste, ECG
Renal failure
C: Discusses that lithium needs to be used cautiously in patients with renal insufficiency, thyroid disease and adrenocortical deficiency, none of which apply to this patient..
Outlines that lithium is teratogenic and that strict adherence to the oral contraception pill is advised.
Discusses with the patient to be aware of signs and symptoms of lithium toxicity (i.e. extreme thirst and frequent urination, nausea and vomiting), especially during illness, excessive sweating or low fluid intake. Critical
Explains that if these occur, stop taking the tablets and seek medical attention or present to the emergency department immediately due to the risk of coma and death.
Follow up: 1 week in clinic and sooner in community setting if acute episode of mania.
Explain bipolar disorder
Bipolar one disorder is defined as having persistently elevated mood lasting over a week (or if hospitalisation is required) with periods of mood disturbances (≥3 of inflated self-esteem, decreased need for sleep, talkatively, flight of ideas, distractibility, increased goal activity or psychomotor agitation, excessive high-risk behaviour). These symptoms must result in social and occupational functioning and are not attributable to substance use or another medication condition.
Pharmacological management of bipolar
Mood stabilisers such as lithium, sodium valproate and lamotrigine are the preferred pharmacological agents for Bipolar Disorder. They can be used as monotherapy or in combination with second-generation antipsychotics such as quetiapine and aripiprazole. In patients with severe bipolar disorder, electroconvulsive therapy and transcranial magnetic stimulation can be considered.
Definition of CKD
Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73m2, persisting for three months or more. The most common causes of CKD are poorly controlled diabetes mellitus and hypertension.
Clinical presentation of CKD
Patients with CKD may show symptoms like oedema or hypertension due to reduced kidney function. Often, CKD is detected incidentally during routine tests when elevated serum creatinine, reduced eGFR, or abnormal urinalysis are found. Imaging tests may reveal kidney damage or abnormalities, such as small and echogenic kidneys on ultrasound.
Symptoms of prolonged kidney failure, such as weakness, fatigue, anorexia, vomiting, and itching, may also occur, especially in advanced stages of CKD. Decreased urine output (oliguria or anuria) is rare with CKD alone but may suggest AKI when present.
Labratory findings of CKD
Laboratory tests often show:
- increased serum creatinine, BUN, and proteinuria, with possible abnormalities in red or white blood cells in urine.
Anaemia
hyperphosphataemia, hyperkalaemia, acidosis, hypocalcaemia, and elevated parathyroid hormone levels are common laboratory findings in CKD, varying in severity depending on the stage of the disease.
General management principles of CKD
- Treatment of reversible causes of kidney failure
- Preventing or slowing the progression of kidney disease
- Treatment of complications of kidney failure
- Adjusting drug doses based on eGFR
- Identification and adequate preparation for renal replacement therapy
Treatment of reversible causes of kidney failure: May include managing conditions such as hypertension, diabetes, or urinary tract obstruction, as well as addressing lifestyle factors like smoking and obesity.
Preventing or slowing the progression of kidney disease: Involves controlling blood pressure and blood glucose levels within target ranges, reducing proteinuria through medications such as ACE inhibitors or ARBs, and implementing lifestyle modifications such as adopting a healthy diet low in salt and saturated fats, maintaining a healthy weight, and regular exercise. SGLT2 inhibitors should also be considered for slowing the progression of kidney disease. Fluid status should be monitored routinely.
Treatment of complications of kidney failure: Management of these complications may involve medications such as statins for dyslipidaemia, erythropoiesis-stimulating agents for anaemia, phosphate binders for hyperphosphatemia, and vitamin D supplements for bone health.
Adjusting drug doses based on eGFR: May involve dose reductions, extended dosing intervals, or switching to alternative medications with lower renal clearance. Nephrotoxic medications should be avoided.
Identification and adequate preparation for renal replacement therapy: Timely identification and preparation for kidney replacement therapy (such as dialysis or kidney transplantation) are essential. Involves educating patients about their treatment options, addressing psychosocial concerns, and facilitating access to specialised care from nephrology and transplant teams.
Immediate management of acute asthma exacerbation
Immediate management entails the following:
- Involvement of specialists and senior staff.
- Performing an ABCDE assessment and ensure that patient is stable.
- Provide humidified oxygen if SpO2 is below 90%.
- 12 puffs salbutamol Metered dose inhaler (MDI) via a spacer and mask. 3 doses to be given every 20 minutes.
- 8 puffs of ipratropium bromide MDI via spacer and mask; 3 doses to be given every 20 minutes.
- Establishing IV access.
- Oral or IV steroids (Methylprednisolone / Hydrocortisone / Dexamethasone).
- Ongoing monitoring of work of breathing, mental state, oxygen saturations and activity levels.
- Continue to provide salbutamol and ipratropium bromide if there are not signs of improvement.
- Second line IV treatment options include Magnesium sulphate and/or aminophylline.
Signs of severe asthma
Involves the occurrence of agitation, notable increased work of breathing with accessory muscle usage, tachycardia, major difficulty in being able to talk, and may also include signs of anaphylaxis.
What is immune thrombocytopenia (ITP)
Immune Thrombocytopenia (ITP) is an autoimmune disorder characterised by the production of antibodies against platelets, leading to their premature destruction.
This condition is classified into primary ITP, which occurs without an identifiable cause, and secondary ITP, which is associated with other conditions such as autoimmune diseases, infections, or medications.
Who does ITP affect?
It predominantly affects children under five years, where it usually presents as a self-limiting condition, and adults over 55 years, in whom it often progresses chronically. It is more commonly diagnosed in females.
The aetiology of primary ITP is typically idiopathic, while secondary ITP may be triggered by autoimmune diseases (such as SLE), infections (such as HIV or hepatitis C), malignancies (including lymphoma and leukaemia), or adverse reactions to medications like quinine and heparin.
Diagnosis of ITP
ITP is primarily a diagnosis of exclusion, confirmed by a low platelet count with normal morphology and the absence of other systemic causes as assessed by coagulation parameters.
Investigations for ITP
Key investigations include CBC, peripheral blood smear, and specific screenings for underlying causes such as HIV or hepatitis C. A bone marrow biopsy may be necessary in atypical or unresponsive cases to exclude other haematological abnormalities.
Management of ITP
Management strategies in ITP aim to address the underlying autoimmune activity and prevent bleeding complications. This includes:
In children, the majority of cases are self-limiting, and many paediatric patients can be managed conservatively with minimal complications.
Emergency treatment for severe cases includes haemostatic control measures, corticosteroids, IVIG, and platelet transfusions.
What age and gender does slipped upper femoral epiphysis occur in?
It is most common in secondary-school aged male students, particularly those who are overweight.
