Other Flashcards
What does the health belief model and Theory of Planned Behaviour say the most important factor in addressing behaviour change is?
Health Belief: Perceived Barriers
Theory of Planned Behaviour: Intention
What are the key determinants of health?
- Genes
- Environment
- Lifestyle
- Health care
What are some developing food behaviours?
- Maternal Diet
- Breastfeeding
- Parenting Practices
- Age of introduction to solids and types of food given
What is a health need assessment for?
Systematic method for reviewing the health issues facing a population
Therefore to determine resource allocation
What aspects of public health are involved in Health Needs Assessments and resource allocation?
- Maslow’s Heirarchy of Needs
- Types of health care need: Felt, Expressed, Normative, Comparative
- Health needs assessment (Resource allocation)
- Approach to Health Needs Assessments: Epidemiological, Comparative, Corporate
- Resource allocation Methods: Libertarian, Maximising, Egalitarian
What aspects of Public Health are involved with evaluation of health services and assessing the quality of health care?
- Evaluation: Assessment of whether a service achieves its objectives
- Donabedian Framework: Structure, Process, Outcome
- Maxwell’s Dimensions of Quality of Health Care: 3A’s and 3E’s
What is bias?
A systemic deviation from the true estimation of the association between exposure and outcome
What are some types of bias?
Selection bias: selection of participants
Information Bias: observers recall and reporting, instruments wrong
Allocation bias: Different participants in different groups
Publication Bias: Trials with negative results are les likely to be published
Lead time bias: Earlier screening does change survival outcome
Length time bias: diseases with slower progression more likely to be identified by screening
Explain what these features mean on the Bradford Hills Criteria:
- Strength
- Dose response
- Consistency
- Temporality
- Reversibility
- Biological Plausibility
- Coherence
- Analogy
- Specificity
- Strength - The strength of the association
- Dose-response – does a higher exposure produce higher incidence?
- Consistency – similar results in different studies and populations
- Temporality – does the exposure precede the outcome
- Reversibility – removing exposure reduced risk of disease
- Biological plausibility – does it make sense biologically
- Coherence – logical consistency with lab information e.g. incidence of lung cancer
with increased smoking is consistent with lab evidence that tobacco is carcinogenic - Analogy – similarity with other established cause-effect relationships in the past e.g.
thalidomide in pregnancy, not other teratogenic drugs show similar effects - Specificity – Relationship is specific to the outcome of interest e.g. introducing
helmets reduced head injuries specifically, it wasn’t that there has been an overall
lower injury rate
Should you ever inform parents about a childs actions?
No but encourage them to inform
What should you do if an Under 13 year old presents saying they have had sex?
Refer to social services
What are the Fraser Guidelines?
- Does she understand the advice?
- Has the doctor encouraged her telling the parents?
- Will she have sex anyway?
- Is the mental/physical health going to be effected if you don’t give it
- Best interests
What is Gillick’s Competency?
Does a child under 16 have capacity to make own medical decisions?
Clinical judgement made by the doctor; age, capacity, maturity
What are some different types of error and what do they mean?
- Sloth = inaccurate documenting/not checking results for accuracy
- Fixation/loss of perspective = focus on one diagnosis – confirmation bias
- Communication breakdown = unclear plan/not listening and explaining well - - - - - -
- Poor team working = some individuals out of depth and others underutilised
- Playing the odds = choosing the common and dismissing the rare
- Bravado/timidity = working beyond competence/not having confidence to object
- Ignorance = lack of knowledge (can be conscious or unconscious incompetence)
- Mistriage = over or under-estimating the severity of the situation
- Lack of skill = not having appropriate skills/training/practice
- System error = environmental/technological/equipment failure\
Define Public Health
The science and art of preventing disease, prolonging life and improving health through organised efforts of society
What should be considered in a health needs assessment?
Need: ability to benefit from an intervention
Demand: What people ask for
Supply: What is provided
What does the epidemiological perspective look at?
Size of population
Services available
Evidence base
What are the different approaches for disease prevention?
Primary Secondary and Tertiary Prevention
- Population approach: Prevention approach delivered to everyone to shift risk factor distribution curve
- High Risk Approach: Identify individuals above a cut off and treat them
- Prevention Paradox: Preventative measures which benefits the population has little impact to individual participants
How many UK Screening programs are there?
11 total:
3 in Pregnancy:
- Pregnancy infectious disease (HIV, Syphilis, Hep B)
- Thalassaemia and Sickle Cell
- Fetal Anomaly Screening (Downs, Edwards, Pataus)
3 In Newborns:
- NIPE
- Newborn Hearing screening program
- Heelprick blood spot
5 in Adults
- Cervical Cancer
- Breast Cancer
- Bowel Cancer
- AAA screening
- Diabetic Retinopathy
What are the 4 dimensions of Food insecurity?
- Availability of food
- Access - Economic and physical
- Utilisation: Opportunity to prepare food
- Stability of 3 dimensions over time
What is malnutrition in public health?
Deficiency’s, Excess or imbalances in a persons intake of energy and/or nutrients
Includes: Undernutrition, Overweight/obesity and Triple burden
Define Undernutrition and what it includes:
Define Overweight and obesity?
Undernutrition:
- Stunting: Low height for age
- Wasting: Low weight for height
- Underweight: Low weight for age
- Micronutrient Deficiencies: Lack of important vitamins and minerals
Overweight Excess diet
What is an Asylum Seeker?
Someone who is applying for refugee status
What is a refugee?
Someone who has been granted asylum status for 5 years
What healthcare can an asylum seeker access if their claim is refused?
Emergency NHS Services
Get charged for anything after that
What are common health problems for refugees?
- Injury and illness from war and travelling
- Communicable disease
- Lack of health screening and immunisations
- Malnutrition
- Untreated chronic disease
- Untreated Mental Illness
What are some barriers against Refugees/Asylum seekers?
- Reluctance of GPs to register them
- Illiteracy
- Communication barriers
- Lack of permanent site
- Mistrust of Professionals
What support do Asylum Seekers Receive?
- Vouchers to live off (may or may not be restricted)
- NASS support package
- Access to Emergency NHS services
- Not allowed to work initially and no control over location
What is a Never Event?
Serious largely preventable patient safety incidents that should not occur
What are some levels of Alcohol Dependency?
- Withdrawal Symptoms
- Cravings - strong desire to drink
- Drinking despite negative consequences
- Tolerance - drinking larger amounts to achieve the same effect
- Primacy - Neglecting basic physical needs such as food and water
- Loss of control
- Narrowing of repertoire - Start to drink only one type of drink in one place
What is the purpose of Disulfiram?
Promotes abstinence - Alcohol intake causes severe nausea and vomiting reaction due to inhibition of acetaldehyde dehydrogenase
What is the purpose of Acomprosate?
Reduces craving by acting as a weak NMDA antagonist - improves abstinence in placebo controlled trials
What components make up drug addiction?
Craving, tolerance, compulsive drug seeking behaviour and withdrawal
What can you offer a newly presenting drug user?
- Screening for blood borne viruses
- Health check
- Sexual health and contraception advice
- Check immunisation Hx
- Signpost to drug services
What is positive and negative conditioning in relation to drug use?
Positive Conditioning: Addiction increases desire to use drug
Negative Conditioning: People don’t quit due to unpleasant symptoms
What can an association between an exposure and outcome be due to?
- Chance
- Bias
- Confounding
- Reverse Causality
- True Causal Association
What are some types of information bias?
- Measurement
- Observer
- Recall
- Reporting
What is reverse causality?
When an association between an exposure and outcome are due to the outcome causing the exposure
What is Molluscum Contagiosum?
What is it caused by?
How does it appear?
Viral condition caused by the Molluscum Contagiosum Virus (MCV) a member of the poxviridae family
Causes pink pearly white papules with a Central umbilication
When should you refer if you suspect Molluscum Contagiosum?
- Patients with HIV and extensive disease
- Patients with eye lid molluscs refer to Ophthalmology
- Anogenital lesions
What is the Management of Molluscum Contagiosum?
Clinical Diagnosis
Non-pharmacological
- reassurance its a self limiting condition
- Precautions to prevent spread (not sharing towels)
- Not to scratch
Pharmacological is rarely required
- Imiquimod cream
- Podophyllotoxin
What is vulvovaginitis?
Who does it affect?
Inflammation and irritation of the vulva and vagina
Typically affects young girls (3-10 years)
What can exacerbate Vulvovaginitis?
Wet nappies
Use of chemicals or soaps in cleaning the area
Tight clothing that traps moisture or sweat in the area
Poor toilet hygiene
Constipation
Threadworms
Pressure on the area, for example horse riding
Heavily chlorinated pools
How does Vulvovaginitis present?
Typically presents before Puberty
Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria (burning or stinging on urination)
Constipation
A urine dipstick may show leukocytes but no nitrites. This will often result in misdiagnosis as a urinary tract infection.
What is the management of Vulvovaginitis?
Patients have typically been treated for UTI/Thrush without improvement of Sx
General Advice:
Avoid washing with soap and chemicals
Avoid perfumed or antiseptic products
Good toilet hygiene, wipe from front to back
Keeping the area dry
Emollients, such as sudacrem can sooth the area
Loose cotton clothing
Treating constipation and worms where applicable
Avoiding activities that exacerbate the problem
What Helminth causes threadworms?
Enterobius vermicularis
How does threadworms present?
infestation is asymptomatic in around 90% of cases, possible features include:
- perianal itching, particularly at night
- girls may have vulval symptoms
How are threadworms diagnosed?
Apply Sellotape to the perianal area in the morning
This is sent to a lab for microscopy of eggs.
How is threadworms treated?
- combination of anthelmintic with hygiene measures for all members of the household
- mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists
What are Head lice?
Pediculus humanus capitis are a parasitic infection of the scalp most commonly in school aged children.
What is the presentation of Head lice?
Infestation causes an itchy scalp. Often the nits (eggs) and even lice themselves are visible when examining the scalp.
What is the management of Head lice?
Treatment only indicated if a Live lice is identified
- Wet combing is first line
- Insecticides such as Dimeticone 4% and Malathion 0.5% can also be tried.
All Affected members of the household should be treated on the same day
What is Labyrinthitis?
Inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea.
The inflammation is usually attributed to a viral upper respiratory tract infection
How does Labyrinthitis present?
Labyrinthitis presents with acute onset vertigo, similarly to vestibular neuronitis.
Unlike vestibular neuronitis, labyrinthitis can also be associated with:
- Hearing loss
- Tinnitus
Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose.
How is Labyrinthitis Diagnosed?
Clinical diagnosis
The head impulse test can be used to identify peripheral causes of vertigo
What is the management of Labyrinthitis?
Supportive care and short-term use (up to 3 days) of medication
- Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
What is Vestibular Neuronitis?
What is the pathophysiology?
Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.
Vestibular nerve is the portion of the CN VIII responsible for balance Therefore vestibular neuronitis does not involve the cochlear nerve (responsible for hearing) meaning that vestibular neuronitis does not cause hearing problems
What are the clinical features of Vestibular Neuronitis?
History of recent viral URTI
- Acute onset vertigo
- Horizontal Nystagmus
- Associated with nausea and vomiting
Vertigo attacks are more severe at the start lasting days but then start to resolve
They may be worsened by head movements
What test can be used to identify peripheral causes of vertigo such as labyrinthitis and vestibular neuronitis?
How is it performed?
What are the results of normal
What results suggest vestibular system issue (peripheral vertigo)
What are the results if there was a central cause of vertigo?
The Head Impulse Test
- Patient stares at examiners nose
- Examiner twists head in one direct rapidly whilst patient remains fixated on the nose
Normal would be if their eyes remained fixed on examiners nose
Peripheral cause of vertigo the eyes will saccade (Rapidly move back and forth) before fixing on the examiners nose again
Central cause of vertigo would have a normal head impulse test
What is the management of Vestibular Neuronitis?
Self limiting condition and will resolve in weeks
- Prochlorperazine/Antihistamines can be used in severe attacks
- Referral If Sx do not improve after 1 week or improve after 6 weeks
- Patients may require admission if Severe nausea and vomiting/dehydration
What is the prognosis of Vestibular Neuronitis?
What may occur following the condition?
Symptoms are more severe for the first few days
They gradually resolve over 2-6 weeks
Patients may develop BBPV following vestibular neuronitis
What test is done to distinguish between peripheral and central causes of vertigo?
HINTS examination
- Head Impulse Test
- Nystagmus
- Test of Skew (Cover test)
What is the DVLA guidance for vertigo symptoms?
Patients must not drive and inform the DVLA if they get: Sudden and unprovoked episodes of disabling dizziness
What is multimorbidity?
Presence of 2 or more long term health conditions
What are the risk factors for Multimorbidity?
- Increasing age
- Female sex
- Low socioeconomic status
- Tobacco and alcohol usage
- Lack of physical activity
- Poor nutrition and obesity
How should Frailty be assessed?
Through Gait speed, Self reported health status or the PRISMA-7 Questionnaire
What is Caput Succedaneum
Collection of fluid between the periosteum and the scalp.
This fluid can accumulate following instrumental deliveries and Crosses suture lines
Typically it resolves within a few days
What is Cephalohaematoma?
Collection of blood between the skull and periosteum due to damaged blood vessels during prolonged instrumental delivery.
Blood does not cross suture lines as it is located below the periosteum.
This blood can also haemolyse leading to increased bilirubin and prolonged jaundice
What is Apnoea of Prematurity?
Apnoea is defined as periods where breathing stops spontaneously for more than 20 seconds, or shorter periods with oxygen desaturation or bradycardia.
These are very common in premature neonates
What are apnoeas caused by in neonates?
Apnoea occur due to immaturity of the autonomic nervous system that controls respiration and heart rate. This system is more immature in premature neonates.
Other conditions
- Infection
- Anaemia
- Airway obstruction (may be positional)
- CNS pathology, such as seizures or haemorrhage
- Gastro-oesophageal reflux
- Neonatal abstinence syndrome
What is the management for apnoea of prematurity?
Apnoea monitors in neonatal units
- Tactile stimulation (vigorous rubbing stimulates breathing)
- IV Caffeine can be used to prevent apnoea and bradycardia in recurrent episodes
What is retinopathy of prematurity?
Typically affects babies born before 32 weeks gestation.
Abnormal development of the blood vessels in the retina can lead to scarring, retinal detachment and blindness.
What is the pathophysiology of retinopathy of prematurity?
- Retinal blood vessels begin developing at 16 weeks and complete by 37-40 weeks
- This process is Driven by hypoxia
- Premature babies often require supplemental oxygen
- When the retina is exposed to high oxygen concentrations the Stimulation for new blood vessel development is lost
- When the hypoxic environment re-occurs there is excessive neovascularisation which leads to scarring and retinal detachment
How is Retinopathy of prematurity screened for?
Babies born before 32 weeks or under 1.5kg are screened by an ophthalmologist at
- 30 – 31 weeks gestational age in babies born before 27 weeks
- 4 – 5 weeks of age in babies born after 27 weeks
Screening occurs every 2 weeks until the retinal develops normally
What is the treatment for retinopathy of prematurity?
First line is transpupillary laser photocoagulation to halt and reverse neovascularisation.
Other options are cryotherapy and injections of intravitreal VEGF inhibitors. Surgery may be required if retinal detachment occurs.
What is the most accurate way to measure the gestation of a fetus?
Crown rump length
what are the main causes of preterm birth?
Uterine Infection
- ascending from vagina
- Transplacental (haematogenous)
- Retrograde seeding from peritoneal cavity
- iatrogenic
Uterine Ischaemia
- same process as pre-eclampsia
Overstretching of the uterus
- Polyhydramnios
- Multiple Pregnancy
Weakness of the Cervix/incompetence
- Following LLETZ
what is a screening method that can be done to screen for preterm birth?
TVUSS looking at cervical length
<25 mm suggests increased risk of preterm birth if between 16-24 weeks gestation.
What can be done to prevent preterm birth?
Vaginal progesterone
Cervical Cerclage
How can preterm birth be managed?
- Tocolytics - as long as its not contraindicated such as in infection
- Antenatal steroids - betamethasone ex IM injections
- Magnesium Sulphate before 34 weeks
- delayed cord clamping
- keep baby warm with thermoregulation
How is gestational age measured?
Crown Rump length
What are the routine antenatal appointments where imaging is used?
12 scan for nuchal thickness
20 week anomaly scan
all other appointments where scans are used are based on clinical need
how can you test ovarian reserve?
FSH
antral follicle count
Anti Mullerian hormone
What are the initial investigations for fertility analysis?
Female hormone profile (day 2 FSH, day 21 Progesterone)
Tft, prolactin
Rubella testing
Smear test
Swabs
Seaman analysis
What is the Starvation Hypothesis for Eating Disorders?
Physiological and Psychological Effects of Starvation:
- Starvation leads to significant physical and psychological changes, such as heightened food preoccupation, mood disturbances, and anxiety.
Starvation as a Catalyst
Self perpetuating Cycle
Vulnerable pre-disposing factors (genetics)
What are the Dopaminergic Pathways in the brain?
- Mesocortical Pathway
- Mesolimbic Pathway
- Nigrostriatal Pathway
- Tuberoinfundibular Pathway
What is the Triad of Symptoms in EUPD?
- Unstable affect and impulsivity
- Lack of sense of self
- Intense unstable relationships and fear of abandonment
What is the aetiological biosocial model of EUPD?
Emotional Sensitivity
Invalidating environment
leads to pervasive emotion dysregulation
What is attachment theory?
Attachment functions to protect infants from danger
provides emotional connection
Essential for development
Affects individuals lifestyle
What are the different types of attachment?
Secure
Anxious
Ambivalent
Avoidant
What is secure attachment
Can internally self regulate the emotional neural systems
What is anxious attachment?
Maintaining attachment with a caregiver who is unpredictable
What is ambivalent attachment?
Alternate clinging with excessive submissiveness to no trust at all.
Role reversal as parent is cared for by child.
Dysregulation of fear and anger
What is avoidant attachment?
Minimise need for attachment
Remains in distant contact with caregiver
When severe can freeze.
How do attachment styles predispose you to personality disorders?
Avoidant goes to cluster A (suspicious and paranoid)
Ambivalent goes to cluster B (emotional)
Anxious goes to cluster C (Avoidant)
What is the treatment of attachment disorders in children?
Dialectical behavioural therapy
Tret Co-morbidities
What are the different uses of MOAIs?
Selective (MAOI-B) for Parkinson’s Disease
- Selegiline
- Rasagiline
Non-selective MOAI for Atypical Depression
- Phenelzine
- Isocarboxide
- Tranylcypromine
When would you use MOAI for depression?
Atypical Depression where there is evidence of Hyperphagia or anxiety
What are the side effects of MOAI?
- Hypertensive reactions with tyramine containing foods e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad beans
- Anticholinergic effects
What are the features of Drug dependence (criteria)?
> 3 features means dependence in a 12 month period
- Withdrawal Sx - use drugs to avoid withdrawal Sx onset
- Tolerance - require higher doses to achieve same effect
- Narrow Repetoir
- Cravings
- Loss of Control
- Rapid Reinforcement - Quick return to old levels after stopping briefly
- Primacy - Takes precedence over physiological need (eg. spend money on drugs not food)
- Continued use despite harm
What are the features of Opioid misuse?
vs
Features of Opioid Withdrawal
Misuse:
- Low BP
- Pinpoint pupils
- Needle Trackmarks
- Rhinorrhoea
Withdrawal
- Dilated Pupils
- High BP
- Muscle Aches/Cramps
- Sweating
What is the criteria for alcohol dependence syndrome?
ICD 10 Criteria for diagnosis requires 3 of the following:
- Craving (desire or compulsion to take the substance)
- Difficulties in controlling intake
- Physiological withdrawal
- Tolerance (more needed to achieve the same effect)
- Priority is given to substance, with neglect to other aspects of life
- Persistence despite being aware of the harm the substance causes
Patients can be dependent but have no physiological dependence on alcohol (no withdrawal or tolerance)
What are some features of lithium Toxicity?
What are some precipitants to Lithium Toxicity?
What is the management of Lithium Toxicity?
Features of Toxicity (TOXIC):
- Tremor (coarse)
- Oliguric renal failure
- ataXia (affects coordination, balance and speech)
- Increased reflexes
- Convulsions / Coma / loss of Consciousness
Precipitants: (4 D’s):
- Dehydration
- Drugs (NSAIDS,ACEis)
- Diuretics
- Depletion of Sodium
Management:
- Stop and withdraw Lithium
- Rehydrate with normal IV Saline Fluids
What are the autoantibodies found in Type I Diabetes Mellitus?
anti-GAD, ICA, IAA
What are some screening questionnaires for eating disorders?
- Eating disorder assessment tool
- SCOFF Questionnaire
What examination may be used to assess muscle strength in an Eating Disorders Physical Exam?
Sit up- Squat and Stand test (SUSS)
What are the main Childhood Epilepsy Syndromes?
- West Syndrome/Infantile Spasms
- Dravet Syndrome
- Lennox-Gastaut Syndrome
- Juvenile Myoclonic Epilepsy
- Childhood Absence Epilepsy
- Benign Rolandic Epilepsy
West Syndrome:
Onset?
Key features
Treatment?
Infantile “Jack-knife” Spasms
- Onset 3-12 months
- Triad of infantile spasms, Developmental regression and Hypsarrhythmia on EEG
- Treated with Vigabatrin, ACTH and Corticosteroids
Associated with Tuberous Sclerosis
Dravet Syndrome:
Onset
Key features
Treatment
Onset before 1 year often triggered by a fever
Key features of:
- Prolonged febrile seizures
- Later develops into afebrile seizures (Myoclonic, Tonic clonic)
- Mutation in SCN1A
Treatment with Valproate or Clobazam. Has a poor prognosis
Lennox-Gastaut Syndrome
Onset
Key features
Treatment
Onset 1-7 years
Key features of:
- Multiple Seizure types (mainly Tonic, Atonic, Atypical Absence)
- Significant Cognitive Impairment
- Slow spike and wave EEG
Treatment with Valproate, Lamotrigine and Ketogenic Diet
Benign Rolandic Epilepsy
Onset
Key Features
Also known as Benign Epilepsy with Centrotemporal Spikes (BECTS)
Onset 3-13 years
Key features of:
- Focal seizures affecting face or speech
- Often occur during sleep
- EEG shows Centrotemporal Spikes
Good prognosis and resolves by adolescence without treatment
Juvenile Myoclonic Epilepsy
Onset
Key features
Treatment
Onset 12-18 years
Key features of:
- Myoclonic jerks typically in the morning/after sleep deprivation
- Daytime absence seizures (occasionally tonic-clonic)
- Normal cognition
Treatment with Valproate, or Levetiracetam
What is Tuberous Sclerosis?
Genetics?
Autosomal Dominant condition affecting multiple systems due to the development of hamartomas
TSC1 Gene on Chromosome 9 encoding Hamartin
TSC2 Gene on Chromosome 16 Encoding Tuberin
What are the common skin features in tuberous Sclerosis?
- Ash leaf spots (depigmented areas of skin shaped like an ash leaf)
- Shagreen patches (thickened, dimpled, pigmented patches of skin)
- Angiofibromas (small skin-coloured or pigmented papules that occur over the nose and cheeks)
- Ungual fibromas (circular painless lumps that slowly grow from the nail bed and displace the nail)
- Cafe-au-lait spots (light brown “coffee and milk” coloured flat pigmented lesions on the skin)
Poliosis (an isolated patch of white hair on the head, eyebrows, eyelashes or beard)
What are the neurological Features of Tuberous Sclerosis?
- Epilepsy
- Learning disability
- Brain tumours
What is the management of Tuberous Sclerosis?
No Treatment for the condition only for supportive and symptom control
- mTOR inhibitors (Sirolimus, Everolimus) may suppress the growth of brain, lung or kidney tumours
What is Neuromyelitis Optica?
What are the associated antibodies?
Devic’s Disease/NMO is a spectrum of autoimmune demyelinating CNS conditions that presents similarly to Multiple Sclerosis
Autoantibodies in NMO are:
- Aquaporin-4 Antibodies
- Anti-MOG (Myelin Oligodendrocyte Glycoprotein)
How does Neuromyelitis Optica Present?
Presents with Optic Neuritis and features of Transverse Myelitis (limb weakness, bladder dysfunction and sensory loss below the spinal cord lesion)
What is Syringomyelia?
Causes of Syringomyelia?
What is Syringobulbia?
Collection of CSF within the spinal cord.
Caused by:
- Idiopathic
- Chiari Malformation
- Trauma
- Tumors
Syringobulbia is a similar phenomenon where there is a fluid filled cavity within the medulla of the brainstem
What are the features of Syringomyelia?
‘cape-like’ (neck, shoulders and arms)
- loss of sensation to temperature but the preservation of light touch, proprioception and vibration
- classic examples are of patients who accidentally burn their hands without realising
- this is due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected
Other Features
- spastic weakness (predominantly of the lower limbs)
- neuropathic pain
- upgoing plantars
Autonomic Features:
- Horner’s syndrome due to compression of the sympathetic chain, but this is rare
- bowel and bladder dysfunction
- scoliosis will occur over a matter of years if the syrinx is not treated
What are the investigations for Syringomyelia?
- Full Spine MRI with contrast to exclude a tumour or tethered cord
- Brain MRI to exclude Chiari Malformation
What is the Treatment of Syringomyelia?
Treat the underlying cause
May require a shunt to be placed
What are the 4 main types of Delusions?
- Grandiose - belief one has special powers, is important or chosen by god
- Persecutory - belief that people are conspiring against them to inflict harm or damage reputation
- Reference - belief that events, objects or behaviour of others have special significance to oneself
- Guilt - belief they have done something sinful or harmful
What is a Folie a Deux delusion?
Shared delusion between 2 people in close association
What is Ekbom’s Syndrome?
Patient feels that they are infested with parasites
What is Othello Syndrome?
Delusional belief in which an individual believes their partner is unfaithful
What is Fregoli Syndrome?
Belief that strangers are familiar to the individual or that a group of different people are the same person in disguise
What are some ICD-10 subtypes of Schizophrenia?
- Paranoid - commonest subtype, paranoid delusions, auditory hallucinations and perceptual disturbances
- Hebephrenic - fluctuating affect prominent with fleeting fragmented delusions and hallucinations
- Catatonic (extreme changes in movement)
- Simple
- Residual
What are the major risk factors for Schizophrenia?
- Family History
- Early Cannabis use
- Urbanisation (Being brought up in cities)
- Migration
- Migrant groups (Asians, African, Afro-caribbean’s)
What are some factors associated with a worse prognosis of Schizophrenia?
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious precipitant
What is the theory of Positive and Negative symptoms in Schizophrenia?
Positive Symptoms: An excess or distortion of normal functioning
- Caused by overactivity of the receptors in the mesolimbic pathway
Negative Symptoms: Decrease or loss of functioning
- Caused by underactivity of receptors in the mesocortical pathway
What is Knights Move Thinking?
Unexpected and illogical leaps from one idea to another
No clear link between each sentence
What are the different types of Thought Disorder?
Abnormal Thought Content:
- Delusions/Preoccupations and Overvalued ideas
- Thought insertion and withdrawal
- Obsessions, Compulsions and Ruminations
Abnormal Thought Form
- Loosening of Association - Tangential, Word salad, Derailment of thought
- Circumstantiality
- Perseveration
- Neologisms
Abnormal Thought Stream
- Acceleration - Pressure of Speech, Flight of ideas
- Retardation - Poverty of Speech/thought
- Thought Blocking
What is the Presentation of Coarctation of the Aorta?
Weak Femoral Pulses
A four limb BP reveals high BP in the upper limbs (From before the narrowing) and a low BP in the lower limbs (After the narrowing)
What is the management of Coarctation of the Aorta?
Many patients can live symptom frere without the need for surgery.
If critical Coarctation/high risk of HF, then Prostaglandin E infusion is used to keep the ductus arteriosus open to enable some blood flow into the systemic circulation.
What is seen on contrast enema in cystic fibrosis with delayed passage of meconium?
impacted meconium pellets
Microcolon which differentiates it between Hirschsprungs which would show a transitional zone but not a microcolon
Presentation of Primary Syphilis?
Painless ulcer (Chancre) and local painless lymphadenopathy
First line laxatives in faecal impaction?
Macrogol
What are the vital signs of a severe asthma exacerbation?
Respiratory rate:
> 40 in 1-5 years
> 30 in >5 years
Heart rate:
> 140 in 1-5 years
> 125 in >5 years
How to calculate paediatric Fluid Deficits?
How do you treat fluid deficits?
How do you calculate % dehydration?
How do you calculate fluid resuscitation?
Fluid Deficit = Weight (Kg) x % Dehydration x 10
50% fluid deficit over first 8 hrs and then 50% over the next 16 hrs
% dehydration = (Pre-illness weight - Current weight) / Pre-illness weight
Fluid Resuscitation = 10mls/kg 0.9% NaCl in < 10 mins
Most fluids are 0.9% Saline (NaCl) + 5% dextrose
What are some newborn weight loss facts?
What are some red-flag features of weightloss in the neonatal period?
Lose 5-10% of birth weight in first week (usually 3-5 days)
Regain back to birth weight by 14 days
Red Flag Features:
- Loss of more than 10%
- Failure to reach birth weight by 2 weeks
What happens to an innocent murmur on standing?
Usually innocent murmurs get quieter on standing
Birth dates for different types of twins?
MCMA (one sac, one placenta) → 32–34 weeks.
MCDA (two sacs, one placenta) → 36–37 weeks.
DCDA (two sacs, two placentas) → 37–38 weeks.
Delivery dates for Placenta Accreta, Vasa Praevia and Placenta Praevia
Placenta Accreta (high risk for maternal hemorrhage) → 34–35 weeks.
Vasa Praevia (high risk for fetal death) → 34–36 weeks.
Placenta Praevia (moderate risk with bleeding) → 36–37 weeks.
Name some non-pharmacological psychiatric interventions
Cognitive Behavioural Therapy
Dialectical Behavioural Therapy
Psychoeducation
Family Therapy
Interpersonal Therapy
Self-guided Therapy
What is the Gross Motor Function Classification System used for?
GMFCS is a tool to classify the severity of Motor impairment in Cerebral palsy.
- Has 5 levels based on Functional Mobility and self-initiated movement
What are the Main components of combined screening for trisomy conditions?
Ultrasound Measurement of Nuchal tranleucency
Serum Free b-hCG levels
Serum PAPP-A Levels
What is a contraindication to taking Phosphodiesterase 5 inhibitors?
With other BP meds (Eg. GTN) it can cause severe hypotension
What are the key features and benefits of Randomisation in RCTs?
Assigning patients is totally by chance
Balance arms during comparison.
What are some sources of Bias in RCTs and how are they minimised?
Selection bias - by randomisation
Performance bias - by blinding participants
Observation bias - by double blinding
Attrition bias - Ensuring follow up of all participants to minimise effects of dropouts
What is the pathophysiology of the Jarisch Herxheimer Reaction?
Acute worsening of Sx as Abx cause release of toxin from bacteria
When do you perform the APGAR score?
1 & 5 minutes
Repeated at 10 minutes if either score is < 7
What electrolyte abnormalities would be seen in CAH?
Hyponatraemia, Hyperkalaemia, Hypoglycaemia, Metabolic Acidosis
What is the pathophysiology of DMD?
X-linked recessive mutation (Xp21)
Causing absence of dystrophin
Important for muscle architecture
leading to loss of muscle and replacement of adipose tissue
What is the inheritence of Noonans and the heart defects associated?
Autosomal dominant chromosome 12 - PTPN11 mutation
- Pulmonary Valve Stenosis
- Hypertrophic Obstructive Cardiomyopathy
- Atrial Septal Defect
Give some risk factors for UTIs in children?
- Female
- Anatomical Abnormalities
- Poor Hygiene
- Wiping back to front (Girls)
- Posterior urethral valve
- Immunosuppression
What are the guidelines if a child has a limp and is less than 3 years old?
Urgent referral to paeds for specialist review as transient synovitis is rare < 3yrs old
What biochemical abnormalities occur in tumour lysis syndrome?
Hypocalcaemia
Hyperkalaemia
High phosphate
High uric acid
What medications are used in Alcohol Withdrawal?
Chlordiazepoxide
Lorazepam (if liver dysfunction)
+ Pabrinex/High dose B vitamins
What is the scoring system for sepsis?
Rochester Criteria
What is the scoring system of Appendicitis?
Alvarado Criteria
Clinical features of Pre-eclampsia
Hypertension
Significant Proteinuria
Oedema (Leg)
Features seen on examination in Endometriosis?
Fixed retroverted uterus
Pelvic mass
Endometriotic lesions in posterior vaginal fornix
Non-gynaecological symptoms of endometriosis?
Dyschezia (pain on bowel opening)
Dysuria
Haematuria
What is the management of DDH after 6 months old?
Requires surgery to correct (spica Casting)
What is the name of haemangiomas?
Strawberry Nevus.
Usually resolve with time.
Can be treated with Beta blockers (Propranolol)
if affecting the eyes, mouth or airway can cause blindness, airway obstruction
What are port wine stains?
Birth mark of pink patch of skin on the face due to abnormalities of the capiliaries.
Don’t fade over time and turn darker/purple in colour.
Can give laser therapy or camouflage of lesions
May be associated with Sturge Weber Syndrome
MOA of Acamprosate?
Weak NMDA (Glutamate) Antagonist
GABA Agonist
Major side effect of non-ergo dopamine agonists?
Impulse control disorder
What is the MOA of Tetrabenazine?
Dopamine-depleting agent
What should be done for all cases of secondary Dysmenorrhoea?
Refer to gynae
How long should you continue to use SSRIs following remission of OCD?
at least 12 months to prevent relapse.
Which of the following tests can be used to differentiate between a true seizure and a pseudoseizure?
Prolactin levels
What is the Duty of Candour?
Every healthcare professional must be open and honest with patients when
something that goes wrong with their treatment causes, or has the potential to
cause, harm or distress.
What follow-up is required after a first seizure in children?
Urgent referral to paediatrics neurology to be seen within 2 weeks
What monitoring would you do in an asthma exacerbation?
Oxygen saturations
Serum Potassium
PEF
What medications are often co-prescribed with SSRIs?
Proton Pump Inhibitors due to the risk of bleeding
After notifiable disease diagnosis who should be notified?
Local Public Health Team
Long term management of Cows milk protein allergy?
Follow up in allergy clinic
Oral challenges with milk ladder
Oral antihistamines
Personalised allergy action plan
Non-pharmacological management options of less severe depression?
Guided self help
Group - CBT
Group exercise
Interpersonal therapy
Management of schizophrenia according to NICE CKS?
Referral to psychiatric team (eg. CMHT)
Atypical Antipsychotics
Signpost to support for self and family
CBT
Social determinants of health influencing a persons substance abuse
Access to substances
Opinions towards substance misuse
Family history of substance abuse
Social stigma
Access to healthcare services
2 strategies to reduce risks associated with IVDU?
Avoid mixing drugs
avoid sharing needles
Use fresh needles
Good hand hygiene
Practice safe sex
rotate injections sites
What are the features of a neuropathic ulcer?
Absent/reduced monofilament reflex
Clawed neuropathic foot
Charcot foot
what is the screening tool for OSA?
Epworth sleepiness scale
What is the DVLA guidance for OSA?
inform DVLA and not drive until satisfactory symptom control for at least 3 months
In Neonatal Abstinence Syndrome what is the treatment of choice for:
Cocaine
Opiates
SSRIs?
Cocaine - IV Phenobarbital
Opiates IV Morphine
SSRIs - Typically supportive
What is the level of bilirubin when neonatal jaundice is typically seen?
85.5 micromol/l
How is premature menopause diagnosed and when are the tests take?
Raised FSH (> 30IU/L) level taken 4-6 weeks apart
How long does NICE recommend pelvic floor training for before referral for surgical or medical Mx?
minimum of 3 months
what are the nerve routes for Erbs palsy and klumpke’s palsy?
Erbs Palsy - C5-6
Klumpke’s Palsy - C8-T1
What are the nerve routes for:
Biceps
Triceps
Dorsiflexion
Plantar Flexion
Biceps - C6
Triceps - C7
Dorsiflexion - L5
Plantar Flexion S1
What is Ovarian Hyperthecosis?
A non-neoplastic disorder causing the ovaries to produce excessive amounts of androgens such as testosterone.
What is a contraindication to triptans?
Coronary artery disease
What are the features of GCS
Eye Opening (E) – Score 1 to 4
- 4: Spontaneous (eyes open without stimulation).
- 3: To voice (eyes open in response to verbal command).
- 2: To pain (eyes open in response to painful stimuli).
- 1: None (no eye opening).
Verbal Response (V) – Score 1 to 5
- 5: Oriented (speaks coherently, knows who and where they are and the time/date).
- 4: Confused (able to speak but disoriented or confused).
- 3: Inappropriate words (random or disorganized speech, not conversational).
- 2: Incomprehensible sounds (moaning, groaning, or sounds without words).
- 1: None (no verbal response).
Motor Response (M) – Score 1 to 6
6: Obeys commands (follows verbal instructions, e.g., “Move your arm”).
5: Localizes pain (purposeful movement toward the source of painful stimulus).
4: Withdraws from pain (pulls away from painful stimulus).
3: Abnormal flexion (decorticate posturing in response to pain).
2: Abnormal extension (decerebrate posturing in response to pain).
1: None (no motor response).
What is Mittelschmerz Syndrome?
Benign preovulatory lower abdominal pain occurring midcycle between days 7 and 24
What can be prescribed if a lady is suffering with menorrhagia after having the contraceptive implant inserted?
A 3 month course of the COCP or POP
Why do you not give women Saline with added dextrose but potassium instead during hyperemesis gravidarum?
Dextrose increases the bodies need for thiamine and therefore may precipitate Wernicke’s Encephalopathy
What is Autonomic Dysreflexia and what is the spinal cord level where it occurs?
Combination of hypertension, flushing and sweating without a congruent response to HR.
Occurs in Spinal cord injuries above the level of T6
How long after emergency contraception with Ulipristal or levonorgestrel can a patient restart their normal COCP?
Must wait 5 days following Ulipristal use
Can be immediately after Levonorgestrel
