Oxford Summary 3 Flashcards
BC risks
- Developed counties
- Age, SES
- Obesity, high- fat diet, alcohol
- Early menarche, lare menopause
- Nulliparity, non breastfeeder
- OCP, HRT
- Past hx breast disease: carcinoma in situ, hyperplasia, papilloma with fibrovascular core
- Ionizing radiation
- Fhx: BRCA 1/ BRCA2
BC Management
- Urgent refer to breast surgeon
- Mammogram, USS ± FNA or core bx
- Tumour markers
- CT/MRI, liver USS, bone scan
BC Tx
RT, CT
• Surgery: lumpectomy ± axillary clearance, mastectomy
• Endocrine therapy:
o Tamoxifen: ER+. SE- endometrial ca, DVT
o Aromastase inhibitor- anastrozole, letrozole, exemastane: block estrogen synthesis. Postmenopausal»
o Trastuzumab: MAB against HER2. IV every 3 weeks for 1 year
BC PC
- Breast lump>, pain, skin changes
- Nipple change, discharge (eczema = pagets- intraepidermal, intraductal ca)
- Fhx
- Skin changes
- Distant met
- Elderly: extensive local lesions
BC Prognosis
- 73% women diagnosed will live 10years
- Recurrence usually <2yrs after treatment
- Depends on age (best if 50-59), stage, grade, and ER status
- Affluent areas have better prognosis
BC psych impact
depression, anxiety, marital and sexual problems
Menorrhagia DDx
• Dysfunctional uterine bleeding
• Fibroids, polyps
• Congenital uterine abnormality- bicornuate uterus
• Pelvic infection, endometriosis,
• Endometrial carcinoma, hormone- producing tumour
IUCD
Menorrhagia Tx
• Nonhormonal: mefenamic acid, tranexamic acid
• Hormonal
• Surgical
o Myomectomy, polypectomy
o Endometrial ablation
o Hysterectomy
• Interventional radiology: uterine artery embolization
Menorrhagia Sx suggestive of pathology
• Irregular bleeding/ sudden change in bleeding • PCB, IMB • Dyspareunia • Pelvic pain Premenstrual pain
Menopause Dx
Amnorrheoa >12 months
• Average is 51 years and brought forward 2 years if smoker
• FSH >40iU on 2 occasions >1month apart
Menopause Sx
• Flushes and sweats
• Psychological: depression and anxiety
• Ischaemic heart disease
• Osteoporosis
• Urogenital
o Vaginal dryness and atropy sexual dysfunction- tx lubricants and topical estrogen
o Loss of libido- treat with androgen with HRT
Incontinence, nocturia, urgency- tx topical E to improve outcome of surgery
Menopause premature
under 40 • Idiopathic • Infection- TB, mumps • Surgery- BSO • RT/ CT • FSH R abnormalities • Turners AI: DM, hypothyroidism, addisions
Menopause Tx
HRT
• Contraindications: estrogen sensitive cancer, hx DVT, liver disease, migraines
• Indications
o Early menopause- continue till 51years
o Hysterectomy before menopause
o Second-line tx osteoporosis
• Choice of preparation:
o W/o uterus: unopposed estrogen, unless endometriosis
o Intact uterus: combined
• SE
o Estrogenic: fluid retention, breast enlargement and tenderness, nausea and headaches
o Progesterone: headache, weight gain, bloating
• Risks: breast cancer, DVT, stroke, GB disease, ovarian ca
• Short term benefits: alleviate symptoms, decrease UTI
• Long- term benefits: decrease osteoporosis and colorectal ca
Menopause Tx
Tibolone
oestrogenic, progesteronic and weak androgen
Menopause Tx
Topical vaginal prep
pessaries, creams, rings
• For vaginal dryness/ atrophy
• 3-6 months if uterus
Menopause Tx
Tx of hot flushes
• Lifestyle changes: exercise, cool temperature, avoid alcohol, caffeine, spicy foods
• Medications
o HRT
o Megestrol acetate 40mg od- same risks as HRT
o SSRI/ SNRI- venlafaxine 3.7mg bd
o Gabapentin 300mg tds
Clonidine- can cause hypotension
Ovarian cancer
urgent referral
ascites or ovarian mass
Ovarian cancer
check Ca-125 levels if
• New IBS >50 years • Weight loss, fatigue, change in bowel habit • >12 month history of: o Bloating o Pelvic/ abdominal pain o Early satiety/ loss of appetite o Increased frequency/ urgency
Epithelial ovarian cancer
90% of all cancers
• Age: 50-70
• Family history
• Increased ovulation: infertility, nulliparity
• Lifestyle: obesity and smoking
• Breast cancer <40, cervical cancer, endometriosis, benign cysts
Ovarian cancer
Sex-cord stromal tumours:
• Thecoma, fibroma, setoli/leydig cell, granulosa cell tumour
• Early presentation with hormone production
o Precocious puberty, PMB, virlism
• Granulosa cell tumour linked w/ endometrial hyperplasia/ ca
Ovarian cancer
Germ - cell tumours:
- Immature and mature teratoma (dermoid cyst), dysgerminoma, endodermal sinus tumour (yolk sac), mixed
- Peak incidence in early 20s
- Increase in AFP and BHCG
4 common symptoms in pregnancy
Abdominal pain
Bleeding
Insomnia
Itching/ pruitis
common preg Sx
Backache:
2nd trimester + and worse in evenings
• Exercise
• Simple analgesia, physiotherapy ± massage
common preg Sx
Breast soreness
Nipples enlarge and darken around 12 weeks
common preg Sx
Carpal tunnel syndrome
Resolves after pregnancy
Use night splints and if severe steroid injections
common preg Sx
Constipation
- Increase fluid and fiber intake
- If necessary use bulk- forming laxative- ispahula husk
- Avoid bowel stimulants bc increase uterine activity
common preg Sx
Cramp
Worse at night, try raising foot of bed at night
common preg Sx
Fatigue
- Early: almost everyone and peaks at 12-15 weeks. Advice rest
- Late: due to increased physical effort and sleep deprivation
common preg Sx
Haemorrhoids: 8% in 3rd trimmers
- Px: itching, pain and bleeding
* Advice to increase fiber intake and treat prolapse with ice packs and replacement
common preg Sx
Headache: tension>
- Check BP and urine
* Treat with rest and analgesia
common preg Sx
Heartburn- 3rd trimester
- Advice low-fat, bland food, small + frequent meals, no caffeine
- Avoid eating at night and consider raising head in bed
- Antacid preperations- magnesium trisilicate
- Check BP and urine
common preg Sx
Hypotension
- Common in early pregnancy
* Check no bleeding
common preg Sx
Nausea and Vomiting
- At any time of day, worse with smells and sight of food
- If severe exclude: multiple, trophoblastic disease and UTI
- Reassure, frequent small meals, avoid spicy and greasy, fluic
- If severe: anti-emetic- cyclizine 50mg tds
common preg Sx
Peripheral paraesthesia: hands and feet
• Reassure- gone after pregnancy
common preg Sx
Skin changes
- Pigmentation- linea nigra, chloasma
- Spider naev, palmar erythema
- Abdominal straie
common preg Sx
Sweating and feeling hot
- Common, check if pyrexic
* If apyrexic- reassure
common preg Sx
Swelling
- Ankles, hands/ fingers, face
* If severe or sudden check BP/ urine dipstick
common preg Sx
Symphysis pubis dysfunction
- Separates and causes discomfort/ pain in lower abdomen/ pelvic area and radiates to lower back, upper thighs, perineum
- Constant, worse on movement and relief at rest
- Treat with analgesia, physiotherapy
common preg Sx
Urinary frequency
Do MSU- UTI common and a/w premature delivery
common preg Sx
Vaginal discharge
Investigate if smelly, itchy, sore or a/w dysuria
common preg Sx
Varicose veins
- Aching legs, fatigue, itch, swelling
- Exclude PET
- Elevate legs, support stockings, encourage walking
- Complications: thrombophlebitis and DVT
General postnatal problems
Abdominal pain Dyspareunia Hair loss Haemorrhoids Perineal bruising Baby blues Poor abdominal and pelvic muscle tone Peripheral paraesthesia Skin changes Sweating and feeling hot Swelling Symphysis pubis dysfunction Superficial thrombophlebitis Urinary frequency Vaginal discharge Varicose veins
Breast:
postnatal problems
- Engorgement
- Sore/ cracked nipples- topical remedieis and rest
- Skin infection- local around nipple- candida> tx miconazole gel
- Blocked duct- hard, tender lump. Massage during feeing
- Mastitis: tender, hot, red ± fever. Tx flucloxacillin 500mg qds + NSAID ibuprofen 400mg tds prn
- Abscess: incision and drainage
Persistent lochia
postnatal problems
bleeding >6 weeks. Causes: • Infection, RPC • Unhealed tears • Resumptiom of cycle • SE of contraception • Cervical/ uterine pathology • Abdominal exam, VE, speculum, Abx if infection
Postnatal depression
postnatal problems
10-15% peak ~12wks
Screen all moms 4-6 weeks and 3-4 months postpartum
Risks
o Depression during pregnancy, past hx, Fhx
o Bad birth experience
o Social problems, alcohol or drug use
Puerperal pyrexia
postnatal problems
> 38C within 14 days of delivery/ miscarriage
• Ask about urinary symptoms, breast, color and smell of lochia, pain, cough, sore throat
• Superficial perineal infection: flucloxacillin
• Endometritis: offensive lochia, lower abdo pain, tender uterus- amoxicillin 500mg tds + metronidazole 400mg tds or co-amoxiclac 375 tds
• Mastitis
DVT/ PE can px with fever
N+V
postnatal problems
• At any time of day, worse with smells and sight of food
• If severe exclude: multiple, trophoblastic disease and UTI
• Reassure, frequent small meals, avoid spicy and greasy, fluic
If severe: anti-emetic- cyclizine 50mg tds
Puerperal psychosis
postnatal problems
1:500 births
Severe depression, suicidal, mania, psychotic symptoms
Anaphylaxis CAUSES
- Food: nuts, milk, fruit, fish, shellfish, eggs, beans, peas
- Drugs: Abx, aspirin and other NSAIDs, opiods
- Insect stings: wasp, bee
- Latex
Anaphylaxis Sx
o Airway problems: difficulty breathing/ swallowing, throat closing, hoarseness, stridor
o Breathing problems: tachypnea, wheeze, SOB, O2 sat <92%, cyanosis, confusion due to anoxia, respiratory arrest
o Circulation problems: shock (pallor, clammy, tachy, brady is late), hypotension, dizziness, collapse, confusion, LOC
• Skin/ mucosal changes: flushing, erythema, utricaria ± angioedema, rhinitis, conjunctivitis
• Other: abdominal pain, vomiting or incontinence, anxiety
Anaphylaxis DDx
- Life- threatening: severe asthma, septic shock
* Non- life threatening: simple faint, panic attack, lone urticarial/ angioedema
Anaphylaxis follow up
- Warn about reoccurrence
- Advice to wear medic-alert bracelet
- Supply with Epipen- IM adrenaline
Shock PC
hypotension, tachycardia, peripheral cyanosis, low urine output
Shock TYPES
• Anaphylactic shock • Septic shock • Cardiogenic shock o Hypotension- systolic BP <80-90 o Pulse can be normal, high or low o SOB ± cyanosis • Neurogenic: cerebral trauma or haemorrhage • Poisoning, liver failure
Shock IMMEDIATE MANAGEMENT
• Sit up, call for ambulance, IV access
• Atropine for bradycardia
• Diamorphine, fureosemide, GTN spray if LVF
100% O2 unless COPD then 24%
Hypovolemic shock
• Initially: tachycardia, pallor, sweating ± restlessness
• Later: decompensation- sudden fall in HR and BP
Causes: HI bleed, menorrhagia, laceration, ruptured AAA, dissecting thoracic aneurysm, epistaxis
Ruptured AA PC
- ~80% die before reaching hospital and 10% during surgery
* Px: hypotension + abdominal pain
Dissecting Thoracic Aneurysm Px
sudden tearing chest pain radiating to back
With dissection, branches of aorta are occluded hemiplegia, unequal pulses and BP in arms, paraplegia, acute renal failure, aortic incompetence, MI
Action for ruptured AAA or dissecting thoracic aneurysm
- Lie flat and raise legs, call ambulance
- IV access: FBS, cross- match, IV fluids
- 100% O2
Epistaxis
ruptured BV on nasal septum
Young causes
nose picking
coryza
allergic rhinitis
blood dyscrasias
Epistaxis elderly causes
degenerative arterial disease = arteriosclerosis HT nose picking coryza allergic rhinitis medications (warfarin, aspirin) blood dyscrasias telangiectasia tumour
Chest Pain and Palpitations
Hx + Exam
ACS, PE, dissecting aneurysm, pericarditis
• General appearance, BP in both arms, JV and carotid
• HS, apex beat
• Lung fields
• Tenderness, pain on moving chest, rash, legs
Chest Pain and Palpitations
Investigations
ECG and chest XRAY
Increased ICP symptoms
Septicaemia symptoms
Chest Pain and Palpitations
DDx
ACS Pericarditis Dissecting thoracic aneurysm PE Pleurisy Pneumothorax Esophageal spasm, esophagitis MSK pain Costochondritis Shingles Bornholm's disease Idiopathic chest pain
ACS PC
Central dull aching pain, ratiates to jaw and L arm
Nausea, sweating, SOB
Pericarditis PC
- Sharp constant sternal pain relieved by sitting forward, radiates to L shoulder ± arm or into abdomen
- Worse on left side, on inspiration, swallowing, coughing
PE PC
- Acute SOB, sharp chest pain worse on inspiration, haemoptysis ± syncope
- Tachycardia and mild pyrexia
Pleurisy PC
Sharp, localized chest pain worse on inspiration
Pneumothorax PC
Sudden pleuretic chest pain or SOB ± pallor, tachy
Esophageal spasm, esophagitis PC
Central burning chest pain ± acid reflux
MSK pain PC
Localized pain, worse on movement with hx injury
Costochondritis PC
Tenderness over costochondral junction
Shingles PC
- Intense, sharp, unilateral pain
- Poor response to analgesia
- Px days before rash
Bornholm’s disease PC
- Unilateral chest and/ or abdominal pain, rhinitis
- Coxsakie virus infection
- Treat with analgesia
Idiopathic chest pain PC
- Young and elderly
* Males>
ACS Action
Ambulance
Morphine 5-110mg, O2, GTN spray, aspirin 300mg, clopidogrel
Antiemetic- metoclopramide 10mg
Atropine 500mcg (max 3mg) if bradycardia
ECG
ACS includes
STEMI
• ECG: ST elevation or new LBBB
• Raised troponin levels
NSTEMI
• ECG: normal or MI signs- ST depression, T-wave inversion
• Raised troponin levles
Unstable angina
• ECG: normal or signs of MI
Normal troponin levels
