PACES Flashcards
Mx of Phobia
Desensitisation or CBT
Consider specific interventions e.g. community dental officer in phobia of dentists
Rx not routinely used
DDx in GAD?
What differentiates GAD from these
• Depression: Anxiety symptoms are common in depression and co-morbid
depression is often seen with GAD. The type of symptom that appears first and is
more severe is conventionally considered to be primary.
• Panic disorder: There is a discrete episode of intense fear with sudden onset and a
subjective need to escape.
• Other anxiety disorders: They have the same core symptoms as in GAD but the
symptoms occur in specific situations as in phobic anxiety disorder, OCD or PTSD.
• Substance misuse: Symptoms of alcohol or drug withdrawal may mimic those of
anxiety.
• Physical illness: A host of medical conditions can mimic GAD – endocrine disorders
such as hyperthyroidism or phaeochromocytoma; neurological disorders such as
migraine; deficiency states such as anaemia or vitamin B12 deficiency; cardiac
conditions such as arrythmias and mitral valve prolapse, and metabolic conditions
such as hypoglycaemia and porphyria.
GAD is not situation dependent
Autonomic symptoms may be present
Stepped care model in GAD
Identify, asess, educate, monitor
No improvement: low-intensity psychological support e.g. primary care counselling
GAD with inadequate response to step 2 or marked functional impairment:
CBT (first line) or drug treatment (SSRIs e.g. sertraline first line although unlicensed, then paroxetine or escitalopram)
If GAD remains refractory:
Specialist drug and or psychological treatment, crisis intervention, outpatient or inpatient care
Mx of OCD in adults
Mild functional impairment:
Referral to IAPt for low-intensity psychological therapies (CBT + Exposure response prevention, group CBT couples based course)
SSRI may be useful
Moderate functional impairment:
High intesnity CBT + ERP or SSRI (clomipramine may also be used as an SSRI alternative)
Severe functional impariemtn:
High intensity CBT +ERP AND SSRI
Mx of OCD in children
Mild dysfunnction:
Guided self-help or refer to CAMHS
Moderate to severe:
Refer to CAHMS: CBT and ERP but will involve family
If psychological treatment fails:
Investigae other factors that are affecting
In children >8 SSRi might be appropriate but should only be prescribed following paediatric psychiatrist specialist assessment of child
Stepped care approach to panic attacks
Treat in primary care: involve family, avoid anxiety-producing substances e.g. caffiene. Exclude DOA
CBT first line
Medication: SSRI unless CIed
Consider imipramine or clomipramine if this fails
Self help
If two interventions have been offered without benefit, consider referral to specialist mental health services
No Benzos
Draw the hot cross bun model in CBT
NICE guidleines when depression and anxiety co-exist
Treat depression first
Mx of depression
Mild
Moderate to severe
Severe
CBT or low-intensity psychological therapy first line
Moderate-to severe: CBT and SSRI
What are the indications for referral in depression?
Uncertain diagnosis, including possible bipolar disorder.
Failed response to two or more interventions.
Recurrence of depression <1 year from previous episode.
More persistent suicidal thoughts.
Comorbid substance, physical, or sexual abuse.
Severe psychosocial problems.
Rapid deterioration.
Cognitive impairment.
What is important in every case of anxiety disorder?
Ask questions about depression and risk
What are the key components of motivational interviewing techniques?
Shown to be more effective in dealing with substance misuse
- Use of empathy to understand patients point of view
- Allow the patient to explore the discrepancy between positive core values and his unhealthy behaviours
- Tackling the inevitable resistance with empathy rather than confrontiation
- Supporting self-efficacy and enhancing self-esteem
What is the step-wise treatment to opioid use
Based on principle of harm minimisation:
- reduce injecting
- reduce street drug use
- mainteance thrapy with heroin substutes (methdone or buprenorphine)
- reduction in substitute prescribing
- abstinence
What can be used as mood stabilising prophylaxis in women of child-bearing age?
Olanzapine
Biopsychosocial management of BPAD
Social:
Care programme appraoch
Involve friends/relatives
Advance directive
Serious mental illness register
Psychological:
Self-help
CBT: helps with trigger avoidance
Biological:
Depends on stage in cycle
Ddx for stridor in an infant
Laryngomalacia
Laryngeal cyst, haemangioma or web
Laryngeal stenosis
Vocal cord paralysis
GORD
Vascular ring
Hypocalcaemia (laryngeal tetany)
Respiratory papillomatosis
Subglottic stenosis
What differentiates between stridor and wheeze
Stridor is predominantly inspiratory
Wheeze expiratory
Mx of croup
Oral dexamethasone (nebulised budesonide may also be used)
If has improved 2-3h later and SaO2 >95-> discharge
If not, further dose of steroids can be administered 12-24h later.
If the child deteriorates further then nebulised adrenaline can be administered. Senior help and anaesthetics should be summoned
Intubation and ventilation are necessary if there is still no control
What are the indications for hospital referral in bronchiolitis
Poor feeding (<50% usual intake over the previous 24 hours) which is inadequate to maintain hydration
Lethargy
History of apnoea
Respiratory rate >70 breaths/minute
Nasal flaring or grunting
Severe chest wall recession
Cyanosis
Saturations ≤94%
Uncertainty regarding diagnosis
Where home care or rapid review cannot be assured
Secondary care mx of bronchiolitis
Supportive
CXR only indicated if unusual clinical course
Blood tests only if there is diagnositc uncertainty e.g. >39 temperature
Keep SaO2 >92
NG fed if they cannot maintain >50% of normal intake
CBG if there is deterioriation
CPAP may be used as an alternative to intubation
Ddx of a recurrent or persistent cough in childhood
Recurrent viral URTIs – very common in all age groups but more so in infants
and toddlers
• Asthma – unlikely without wheeze or dyspnoea
• Allergic rhinitis – often nocturnal due to ‘post-nasal drip’
• Chronic non-specific cough – probably post-viral with increased cough receptor
sensitivity
• Post-infectious – a ‘pertussis (whooping cough)-like’ illness can continue for
months following pertussis, adenovirus, mycoplasma and chlamydia
• Recurrent aspiration – gastro-oesophageal reflux
• Environmental – especially smoking, active or passive
• Suppurative lung disease – cystic fibrosis or primary ciliary dyskinesia
• Tuberculosis
• Habit
Signs of impending respiratory failure
Exhaustion (this is a clinical impression)
• Unable to speak or complete sentences
• Colour – cyanosis pallor
• Hypoxia despite high-flow humidified oxygen
• Restlessness and agitation are signs of hypoxia, especially in small children
• Silent chest – so little air entry that no wheeze is audible
• Tachycardia
• Drowsiness
• Peak expiratory flow rate (PEFR) persistently 30 per cent of predicted for height
(tables are available) or personal best. Children 7 years cannot perform PEFR
reliably and technique in sick children is often poor
What is an important consideration in giving continuous nebulised salbutamol
Cardiac monitoring is indicated as this can lead to side effects
What are the components of an asthma review?
How often does he miss his regular drugs?
• Is there parental supervision?
• What device does he use? Children rarely use MDIs effectively and need a spacer.
However, he is unlikely to use one because they are cumbersome and not ‘cool’.
Agree an alternative ‘breath-activated’ device with the proviso that, if acutely
wheezy, he must use a spacer.
• Consider changing to a combined steroid/long-acting β-agonist inhaler. This should
improve adherence.
• Ask about smoking – him and his family. Adults should be encouraged to stop
smoking or to smoke outside.
• Educate about allergen avoidance, e.g. daily vacuuming to reduce house dust mites.
Consider measuring total IgE and specific allergen IgE (RAST) if the history suggests
allergies.
• All asthmatics should have a written home management plan.
Provide an asthma symptom diary and arrange hospital follow-up until control
improves. Most children can and should be managed in primary care. Primary care
and hospital-based asthma specialist nurses are very helpful.
Mx of pneumonia
Assess for need to admit
O2 to maintain SaO2 >92
Analgesia for pleuritic pain
IV antibiotics according to loca guidlines
Fluid restriction if SIADH
Fluid balance
PT: bubble blowing
Monitor for development of pleural effusion (longer course of antibiotics is indicated to prevent empyema) Chest drain may be required
NG tube feeding if indicated
Immunisation before discharge if they have vaccination equivalent
FU CXR in 6-8w if there is lobar collapse +/- effusion, if still abnormal consider ?IFB
DDx of chest pain in children
Trauma, e.g. fractured rib
• Exercise, e.g. overuse injury
• Idiopathic
• Psychological, e.g. anxiety
• Costochondritis
• Pneumonia with pleural involvement
• Asthma
• Severe cough
• Pneumothorax
• Reflux oesophagitis
• Sickle cell disease with chest crisis and/or pneumonia
• Rare: pericarditis, angina, e.g. from severe aortic stenosis, osteomyelitis, tumour
What is significant about PEFR in children
Have to be >5 for it to be reliably performed
What is the hyperoxia test?
The hyperoxia test provides a means of diagnosing whether cyanosis is due to cardiac
or respiratory disease. Normally arterial PaO2 is greater than 9 kPa and rises to more than
20 kPa after exposure to 90–100 per cent oxygen. If the PaO2 fails to rise, this is strongly
suggestive of cyanotic heart disease
DDx of a collapsed neonate
- Infection – e.g. group B Streptococcus, herpes simplex
- Cardiogenic – e.g. hypoplastic left heart syndrome, supraventricular tachycardia
- Hypovolaemic – e.g. dehydration, bleeding
- Neurogenic – e.g. meningitis, subdural haematoma (‘shaken baby’)
- Lung disorder – e.g. congenital diaphragmatic hernia (late presentation)
- Metabolic – e.g. propionic acidaemia, methylmalonic acidaemia
- Endocrine – e.g. panhypopituitarism
IMB DDx
- Cervical malignancy
- Cervical ectropion
- Endocervical polyp
- Atrophic vaginitis
- Pregnancy
- Irregular bleeding related to the contraceptive pill
Endometrial polyp
Gold standard mx of endometrial polyp
Management involves outpatient or day case hysteroscopy, and resection of the polyp
under direct vision using a diathermy loop or other resection technique (Fig. 1.2). This
allows certainty that the polyp had been completely excised and also allows full inspection
of the rest of the cavity to check for any other lesions or suspicious areas. In some
settings, where hysteroscopic facilities are not available, a dilatation and curettage may
be carried out with blind avulsion of the polyp with polyp forceps. This was the standard
management in the past but is not the gold standard now, for the reasons explained.
What d21 progesterone is suggestive of ovulation?
>30nmol/l
What is significant about FSH level >10?
Suggests poor prognosis for fertility, in absence of menopausal symptoms may be suggestive of premature ovarian failure
What are the options for couples with premature ovarian failurie?
Counselling re poor px for conception either with in vitro fertilisaiton or own ova
Donor oocyte
Adoption
What is advisable in the presence of large intrauterine fibroids?
Arrange renal function tests and a renal tract USS
due to the potential for ureteric obstruction and hydropnephrosis
LLETZ procedure
CIN- not cancer, but there is a risk of it developing into cancer over the next few years, hence we need to remove it during a procedure known as LLETZ
Can be done under local anaesthetic
Loop excision of area that is affected to remove abnormal cervical tissue
We will examine the tissue to see that we have removed all of the abnormal tissue
After the LLETZ
Continue bleeding for several days
If heavy bleeding occurs, recur as you may get infected
Avoid sexual intercrouse and tampon use for 4 weeks to allow healing
Fertility is generally unaffected although cervical stenosis has been reported and you may experience mid-trimester loss from cervical weakness
What is significant about menorrhagia
A woman’s perception of bleeding is not always proportionate to the actual volume lost, so Hb should be checked in any women suspected of menorrhagia to assess the severity
Mx of prolactinomas
Medical suprression using dopamine agonists:
bromocriptine or carbegoline
Surgery is only indicated rarely
Ix of PCB in young woman
Speculum
STI screen:
Endocervical swab for gonorrhoea
Endocervical swab for chlamydia
High vaginal swab for trichomonas and candida
Cerbical smear
Dx of antiphospholipid syndrome
Presence of one from:
3 or more consecutive miscarriages
Mid-trimester fetal loss
Severe early-onset pre-eclampsia, IUGR or abruption
Arterial or venous thrombosis
And haematological features:
anticardiolipin antibody or lupus anticoagulant detected on two occasions at least 6w apart
Mx of anti-phospholipid syndrome
Oral low-dose aspirin
and
LMWH from the time of a positive pregnancytest
Causes of recurrent miscarriage
Parental chromosomal abnormality (balanced)
Antiphospholipid syndrome
Other thrombophilia: active protein C resistance
Uterine abnormality
Uncontrolled DM or hypothyroidism
BV
Cervical incompetence
What is double depression
Depressive epsidoe superimposed on background ysthymia
When may psychodynamic therapy be used for depression
For the treatment of complex comorbidities that may present alongisde depression
Ddx for manic episode
Hypomania.
• Drug-induced manic episode. Apart from antidepressants, other medications such
as steroids and stimulants may cause manic episodes. Illicit drugs such as cocaine,
amphetamines and hallucinogen intoxication can cause manic episodes and
alcohol withdrawal may also mimic a manic episode.
• Organic mood disorder. Manic episodes can occur secondary to neurological
conditions such as strokes, space occupying lesions or medical conditions such as
hyperthyroidism, or Cushing’s disorder.
• Schizophrenia is characterized by mood-incongruent delusions, hallucinations and
prominent psychotic symptoms as opposed to mood symptoms.
• Schizoaffective disorder. Mood symptoms and schizophrenia symptoms are equally
prominent.
• Acute confusional state. The agitation and affective lability seen in acute
confusional states may mimic a manic episode.
Drugs that may cause manic episodes
Antidepressants
Steroids
Stimulants
Illicit drugs e.g. cocaine, amphetamines and hallucinogens
Somatic syndrome
Somatic syndrome is a specific subtype of depression characterized by at least four of the
following: (1) loss of interest or pleasure; (2) lack of emotional reactivity to normally
pleasurable surroundings and events; (3) waking in the morning 2 hours or more before
the usual time; (4) depression worse in the morning (diurnal variation in mood); (5)
psychomotor retardation or agitation; (6) loss of appetite and/or weight (often defined as
5% or more of body weight in the past month); (7) marked loss of libido.
What is a simple rule of thumb for somatic presentations?
A simple rule of thumb is to ask screening questions for depression when there
are three or more somatic symptoms irrespective of their cause. Somatic presentations
have been reported to be more common in certain ethnic minorities; however, in primary
care somatic presentations are very common.
How to assess delusional beliefes
Establishing that this
idea is delusional involves proving that the belief is false or even if true held on false
grounds (for example, believing that colleagues are talking about him based on the
arrangement of price labels). The belief is fixed and firmly held despite provision of
evidence to the contrary and this is out of cultural norms. Gently challenging these ideas
by providing evidence that is contradictory is vital in establishing the delusional nature of
the belief. Providing alternative explanations, such as ‘could the marks on the phone be
accidental damage?’, is an important part of history taking. So is further elucidation – ‘I
find it difficult to understand how a dental filling could act as a transmitter?’ He has firm
conviction in the delusional idea. Assessment of other dimensions such as preoccupation,
interference with work and acting out
NB do not colllude with delusional beliefs as this will damage the therapeutic relationship
DDx for somatisation disorder
Organic illness
Depressive disorders
Anxiety disorders
Hypochondrial
Factitious (Munchausen’s)
CAGE
Cut down
Annoyed at people criticising you aboiut drinking
Guilty
Eye opener
Management of overdose and posioning
I would refer to thet TOXBASE
Paracetamol OD key questions
Single or staggered OD
Time of ingestion
Blood tests
OD of paracetamol
>7..5g (15 tablets)
Mx of paracetamol OD
<1h: charcoal
1-4h: blood test at 4 hours to assess levels
Refer to nomogram
They occur while
consciousness is maintained. There may be a mixture of different feelings, emotions,
thoughts, and experiences, which may be familiar (sense of déjà vu) or completely foreign
(jamais vu). Hallucinations of voices, music, people, smells, or tastes may occur. A simple
seizure or aura can evolve to more complex or generalized seizures, where consciousness
is impaired. Auras may last for just a few seconds, or may continue as long as a minute
or two. If they spread to local areas in the temporal lobes they become complex partial
seizures. About 40% to 80% of people with … perform repetitive, automatic movements
(called automatisms), such as lip smacking and rubbing the hands together. Some people
have only simple partial seizures and never have a change in consciousness. In about
60% of people with …. the seizures spread leading to a grand mal seizure.
Complex partial seizures i.e. TLE
DSM Multiaxial classification
Clinical disorder
Personality and intellectual
Medical or physical condition
Psychosocial and environmental
Global funcitoning
What is an issue with hysterosalpingogram
Tubal blockage can sometimes be due to tubal spasm, Lap and dye needs to be used to confirm the diagnosis of tubal factor infertility
IVF and tubal factor infertility
Abnormal tubes are usually removed as success rates for pregnancy are better and ectopic pregnancy rate is reduced after BS
bilateral hydrosalpinges and adhesions as well as perihepatic
‘violin-string’ adhesions.
Indicative of previous infection with chlamydia
Important points in TCRF counselling
Stretching of the cervix and endoscopic into uterus to view the fibroid, fibroid is shaved away and fluid is circulated to enhance the view
Risks:
bleeding, may require transfusion or even hysterectomy if severe
Infection
Fluid overload
Uterine perforation
Afterwards: bleeding, discharge and passing of debris for up to 2w post procedure
Hormonal management of AN
OCP will prevent osteoporosis and bring on periods
Examination of prolapse
Supine and standing
Categroisation of prolapse
Categorised of level of descent of the cervix in relation to the introitus
first degree: descent within the vagina
second degree: descent to the introitus
third degree: descent of the cervix outside the vagina
Procidentia: complete eversion of the vagina outside the introitus
Mx of prolapse
Pelvic floor muscle training for mild
Conservative: ring pessary
Surgical
What is a recognised complication of transcervical resection procedures
Fluid overload and consequent hyponatraemia
1000mL is the normal upper limit for the procedure
Mx of Turners
Psychological
Medical:
height- growth hormone
Oestrogen therapy: to promote secondary sexual charactersitics. Cyclical progestogens are added later to induce withdrawal bleed and to protect vs malignacy.
Oestrogen therapy should be continued until 50y/o to prevent early onset osteoporosis
Fertility: ovum donation and hormonal support
DDx for irregular bleeding with the COCP if examination is normal
Poor compliance
• Concurrent antibiotics (impair COCP absorption)
• Diarrhoea or vomiting (impair absorption)
• Infection (chlamydia, gonorrhoea or candida)
• Cervical ectropion
• Bleeding diathesis
• Drug interactions (e.g. antiepileptics)
How to diagnose PMS
Symptom diary with annotation of when mensturation occurs
PMS should start after midcycle and should resolve with the period and there should be a number of symptom free days during each month
Mx of PMS
Conservative
Interruption of ovulation with the OCP
SSRI can work not just through their antidepressant effect.
Staging of endoemtrail carcinoma
Surgical
Staging of cervical carcinoma
Clinical under sedation
Struma ovarri
Ovarian teratoma developing thyroid tissue-> hyperthyroidism
Why is surgery recommended in mx of cysts?
Due to risk of torsion or malignant change
What are Schneider’s 3 features of normal thought content?
Constancy
Organisation
Consistency
What are five featurs of Schneider’s formal thought disorder?
Derailment
Drvielling: disordered intermixture of consitutent parts of a thought
Fusion: heterogenous thoughts interwoven with one another
Omission
Substitution: a major thought is substitutde with a subsidiary thought
What is the difference between primary, secondary and bizarre delusion?
A delusion is a belief held with absolute conviction, such that it is not changeable,
even by compelling counterargument or proof to the contrary. A
primary delusion has no obvious cause considering the patient’s circumstances.
Secondary delusions are more closely linked with the rest of the clinical picture,
for example grandiose delusions (which is the belief of inflated self worth) are
common in mania, and a persecutory delusion may be seen in paranoid schizophrenia.
A bizarre delusion is one which would be seen as totally implausible
within the patient’s culture.
What are the minor symptoms of depression necessary for a DSM dx of depression
† Decreased concentration
† Reduced self-esteem
† Guilt
† Pessimism about the future
† Self-harm ideation
† Disturbed sleep
† Reduced appetite
What is the significance of opiods coRxed with SSRIs?
May precipitate serotonin syndrome
Perseveration is highly suggestive of
Organic brain disease
Dysprosody
Loss of the normal melody of speech
Expressive aphasia
Difficulty verbalising thought with intact comprehension
Receptive aphasia
Difficulty understanding althought the patient feels they are speaking fluently it is not always possible to make out any words in their voice.
After an act of self harm, what is the risk of completed suicide within the next year?
1% (100x the risk in the general population)
Piblokto is described in Inuit women living within the Arctic Circle. There is
sudden-onset hysteria (screaming, crying, etc.) and bizarre behaviour. This
may include removal of clothes, coprophagia (ingestion of faeces) and violence.
Attacks last a couple of hours and there is often amnesia after the event.
It is
thought that piblokto may be related to vitamin A toxicity, as the native
Eskimo provides large quantities of it.
Raised LH to FSH ratio
?PCOS
co-cyprindiol
Various treatments are used for hirsutism once serious causes of hyperandrogenism have
been excluded. One of the commonest is to commence the cyproterone acetate-containing
combined oral contraceptive pill (co-cyprindiol). Cyproterone acetate is an anti-androgen
with progestogenic activity. It takes several months for an improvement to be seen in the
hair growth and she will continue to need to use the cosmetic treatments in the meantime.
If this is ineffective then cyproterone acetate at a higher dose can be used either alone, or
in addition to co-cyprindiol.
General advice should include weight loss, as this counteracts the metabolic imbalance
associated with PCOS and is favourable in the long term in terms of the known cardiovascular
risks associated with hyperandrogenism.
Mx of septic miscarriage
ABC
Admit
Aggressive IV fluids if volume depleted
Catheterise and monitor UO
?ICU transfer
Broad spectrum IV antibiotics pending MC+S
ERCP arranged urgently after first dose of Abx
Senior gynaecologist should be involved due to significant risks
Cx of septic miscarraige
Massive haemorrhage
Hysterectomy
DIC
Multisystem failure: secondary to haemorrahge or sepsis
Death
Ovarian cyst rupture and USS findings
If a cyst ruptures it is common for the ovary to appear ultrasonographically normal but the finding of free fluid in the pouch of Douglas suggests there may have been a ruptured cyst
Significance of POP in ovarian cysts
POP increases incidence of ovarian cysts whereas OCP reduces occurance through inhibition of ovulation
A 17-year-old girl presents with a vulval swelling. She noticed a lump a few weeks earlier
and in the last 2 days it has enlarged and become painful. She cannot walk normally and
has not been able to wear her normal jeans because of the discomfort. She feels well in herself
however.
She has been sexually active since the age of 14 years and uses the depot progesterone
injection for contraception and therefore does not have periods. She has been with her
boyfriend for 8 months and on direct questioning reports unprotected intercourse with
two other boys in that time. She had a sexual health screen in a genitourinary clinic 1 year
ago and the result was normal. There is no other medical history of note and she takes no
medication.
Examination
The temperature is 37.7°C, heart rate 68/min and blood pressure normal. Abdominal
examination is normal. There is a left-sided posterior labial swelling extending anteriorly
from the level of the introitus, measuring 6 4 4 cm. It appears red, fluctuant, tense
and is exquisitely tender to touch. Bilateral tender inguinal lymph nodes are noted
Bartholin cyst; requires drainage and marsupialisation
What is significant re aetiology of Bartholin cysts?
Pus should always be sent for culture as gonorrhoea is isolated from <20% of Bartholin’s abscesses
Initial management for suspected ruptured ectopic pregnancy
Help
ABC
Facial O2
Lie flat with head down
Two alrge bore cannula and 2l of IV fluids
Crossmatch and alert haematologist
Consent for laparotomy and salpingectomy
Transfer to theatre
What is the leading cause of maternal death in early pregnancy?
Rupture ectopic pregnancy
Preoperative USS if ?ectopic rupture
Not indicated due to risks of delaying Sx
Primary infection:
General malaise
Fever
Anorexia
Lymphadenoapthy
Genital blisters
Urinary retention
Secondary infection:
genital blisters
Often occuring at times of stress or tiredness
HSV infection
Immediate mx of HSV infection with urinary retention
Vulval viral swab
Immediate management:
Indwelling suprapubic catheter, analgesia and paracetamol
local anaesthetic gel
Oral aciclovir started within 24h of attack reduces severity and duration of the episode
Further management:
Referral to health counsellor
Some women have recurrent attacks
Ddx for acute RIF
Gynaecological:
Torsion
Ovarian cyst rupture
Ovarian cyst haemorrhage
Ectopic pregnancy
Appendicitis
UTI
Renal colic
Mx of PID with pelvic abscess
May be given a trial of conservative broad spectrum Abx for 24-48h prior to surgical drainage
Fetal heart beat present in ectopic pregnancy
Renders conservative options both dangerous and unlikely to be sucessful
Surgical mx is the only option
Postoperative counselling points after ectopic pregnancy
Explanation of dx and operation
Appropriate counselling that the woman may grieve with adivce about further support
Avoid the POP and IUCD as both are associated with slightly higher risk of ectopic
Approximately 65-70% go on to have a live birth following this but there is a 10-15% chance of further ectopic pregnancy
Early transvaginal scan is indicated at 5w gestation to confirm the location of any future pregnancy
Contraception if she doesn’t want to get pregnant again at this time
DDx for pain in early pregnancy
Corpus luteum
Ectopic
Miscarriage
Ovarian cyst
UTI
Renal calculus
Constipation
Appendicits
Unexplained pain
Ring of fire appearnce on Doppler USS
Corpus luteal cyst
Spider web or reticulated echo pattern within the cyst suggestive of
Haemorrahge
PUL
Pregnancy of unknown location
No signs of either intra or extra-uterine pregnancy or retianed products of conception ina woman with a positive pregnancy
Possible causes of PUL
Early intrauterine pregnancy
Failed pregnancy
Ectopic pregnancy
Mx of persistent PUL
Methotrexate
When can naegle’s rule not be applied
Where the cycle is not regular or there has been a pregnancy or hormonal contraception in the last 3 months
Transvaginal markers in early pregnancy
4-5w: appearance of gestational sac
5w: appearance of yolk sac
6w: appearance of fetal pole
7-8w: appearnace of the amniotic sac
8w: appearance of fetal limb buds
What should women with uncertain LMP be offered?
Early first-trimester USS examination to estimate gestational age
Conditions for fetal heart rate
Seen previously on USS
When the crown-rump length exceeds 6mm a fetal heart beat should be visible on TVUS in all cases of viable pregnancy
Empty sac/blighted ovum
Anembryonic pregnancy: where the pregnancy has failed at a much earlier stage, such that the embryo did not become large enough to be visualised but the sac is still seen
When can a diagnosis of empty gestational sac be made?
When the mean sac diameter exceeds 20mm with no visible fetal pole
Mx of miscarriage
Expectant:
Wait and see.
Can be completed at home
May involve significant pain and bleeding
unpredictable time frame
More successful for incomplete miscarriage than missed miscarraige.
Medical;
Oral mifepristone followed 48h layer by misoprostol intravaginal tablets
Avoids surgical intervention and GA
Woman may retain some feeling of being in control
Equivalent infection and bleeding rate as for surgical management
Surgical evacuation may be indicated if medical management fails
Surgical: ERPC
Avoids prolonged follow up
Low failure rate
Very small risk of tuerine perforation or anaesthetic complications.
Mx of misccariage missed vs incomplete
Medical and surgical for missed
Expectant for incomplete
Counselling after miscarriage
Express sympathy
Offer further counselling
Reassure that the miscararige would not have been as a result of anything she has done
Explain that over 60% are due to sporadic chormosomal abnormalities
After 2 miscarraiges there is still a high (>70%0 cahnce of a normal pregnancy
What is the commonest pathological arrythmia in childhood?
SVT
What differentiates between SVT and sinus tachycardia
Sinus tachycardia is <220 beats/min, greater HR variability and there is often a history consistent with shock
SVT presentation in younger infants
Can present as shock
Tachycardia, tachypnoea, hepatomegaly, poor feeding, sweating, excessive weight gain acutely, poor weight gain chronically, gallop rhythmn, cyanosis, heart murmur
Echo should be performed as associated with congenital heart disease in 1/3rd
Mx of SVT
Vagal stimulation
Rubber glove filled with ice water over the baby’s face
If this fails, baby’s face can be immersed in iced water for 5s
IV adenosine is second line treatment
Synchornised DC cardioversion can be used
Maintenance treatment with amiodarone can be started.
Mx of pS
Ix: echocardiogram
Confirm clinical diagnosis
Assess severity and to guide further Ix and treatment
Exclude associated cardiac lesions e.g. VSD
Doppler echocardiography measures velocity across the valve, the higher the velocity the greater the need for intervention
Insulin maintenance therapy
Basal bolus:
background ‘basal’ insulin given
once daily with rapid-acting ‘bolus’ insulin at mealtimes. Alternatives are twice-daily
injections of pre-mixed long and rapidly acting insulins or insulin via a pump.
Diagnosis of Marfans
Ghent criteria
Skeletal e.g. pectus excavatum, wrist and thumb signs
Ocular: ectopia lentis
Cardiovascular: dilatation of the ascending aorta etc.
Height, what should always be done
Plot parents centiles to see whether the child falls within the expected height range for the family
What are the clinical signs suggesting a pathological cause for short stature
Extreme short stature: on or below the 0.4th centile
Short for family size
Short and relatively overweight
Short and very underweight
Growth failure
Dysmorphic features
Skeletal disproprotion
Signs of systemic disease
BMI=
Weight in kg/ height in m2
BMI cut offs
>91st centile= overweight
>98th centile= obese
How can gonadotrophin dependant precocious puberty be diagnosed
LHRH test
LH >8 with predominantly LH response is diagnostic
Why is 17-OH progesterone sent after 48h in ?CAH
Raised in all newborns
Ddx for gynaecomastia in a pubertal boy
Pubertal gynaecomastia
Klinefelter’s: LD and small testes
Familial
Oestrogen secreting tumours e.g. a feminising adrenal tumor or a leydig cell tumour. absence of abdominal signs or unilateral testicular enlargement makes this unlikely
Drugs such as oestrogen, spironolactone and DOA can also cause gynaecomastia
What adjunctive Rx should be given during air insufflation of intussuception
Antibiotics to reduce risk of sepsis and to
Approach to rectifying dehydration
Oral where possible
If not, trial with NG
If shocked/ unsuccessful, IV
Maintenance fluid requirements in children
100ml/kg for first 10kg
50ml/kg for next 10 kg
20ml/kg thereafter
Child of bodyweight 11kg
5% dehydration
Calculate fluid deficit and maintenance rquirements
Rate per hour
Maintenance= 100x10 + 50 x 1= 1050
5/100x100= 0.55
Rate per hour= 1600ml/24 + losses
67mL/h + losses
Triad of abdo pain, vomiting and low-grade fever
Suggestive of appendicitis
Organic cause of pain and location in relation to umbilicus
Further away from umbilicus, the more likely to be organic in nature
DDx of chronic abdo pain
Psychosomatic
UTI
Constipation
GORd
Coeliac
CMPI
Abnormal renal anatomy
Abdominal migraine
Peptic ulcer
Sexual or other abuse
Name of the procedure performed in biliary atresia
Kasai procedure (portoenterostomy)
What should you always ask about in jaundice
Stool and urine
If there is increased
unconjugated bilirubin production from increased red cell destruction (e.g. haemolysis) then
there will be jaundice with normally pigmented stool and urine. If there is obstruction to
bile excretion (e.g. common bile duct stone), conjugated bilirubin accumulates (which causes
itching), overflows into urine (causing it to appear dark), and does not reach the gut (resulting
in pale stools). Hepatic causes may produce a combination of these patterns
Phenotypically female infants with inguinal hernias, especially bilateral should be?
Examined carefully to exclude complete androgen insensitivity syndrome
The VACTERL association
sporadic, non-random, concurrence of at least
three of: vertebral, anal, cardiac, tracheo-oesophageal, renal and limb abnormalities.
red urine which will be dipstick-positive for blood but there
will be no red blood cells on microscopy.
Haemoglobinuria due to
haemolysis
Ix in child presenting with nephrotic syndrome
Bloods:
Cholesterol and TG
ASOT
ANA
HBV if from an at risk population
Measles and varicella zoster as children who are put on immunosuppresive therapy are more vulnerable to these conditiosn
Mx of nephrotic syndrome
Fluid balance
Prednisolone
Prophlactic antibiotics
4 hourly observations
Low salt diet
Mechanisms of primary nocturnal enuresis
Lack of arousal from sleep
Bladder instability or low funcitonal bladder capacity
Low vasopressin levels
Ex in nocturnal enuresis
Weight and height
Genitalia and spine should be inspected for abnormality
Lower limb neurology
Causes of paediatric hypertension CREED
Cardilogical: coarctation of the aorta
Renal: GN, RAS
Essential
Endorcine: thyrotoxicosis, Cuishing’s, phaeo
Drugs: steroids, OCP, amphetamines
Ix in child with HTN
Ambulatory BP to confirm
Renal USS with Doppler
ECG to exclude cardiobascular
Exclude DM
Lipid profile
Mx of paediatric essential HTN/obesity
Lifestyle changes- refer to dietician
Adive about low salt diet
1 hour exercise every day
Beta blocker or CCB should be used
What should be done with a child’s BP?
What is the cut off?
Consult a published centile chart
>95th centile= HTN
History
Euan, a 2-year-old boy, is referred to the paediatric day unit by his GP with a history of
fever, cough, blocked runny nose and sticky eyes for 6 days. His GP prescribed amoxicillin
2 days ago for otitis media, and that evening he started to develop a rash around his
ears and hairline. His parents stopped giving the antibiotics, but the rash continued to
spread over most of his body.
The parents report that he has been very miserable and lethargic for the last 5 days.
They thought the rash may be an allergic reaction to amoxicillin. He attends nursery but
his parents are not aware of any other children there who have been unwell. His parents
are well, and he has an older brother who has autism.
Examination
Euan has a temperature of 38.5C, his heart rate is 115 beats/min, respiratory rate 20/min,
and oxygen saturation is 97 per cent in air. He weighs 14 kg (75th centile) and he is
miserable and lethargic. He has a widespread maculopapular erythematous rash, which
is coalescing over his face, neck and torso. Heart sounds are normal, capillary refill time
is 2 s. There is no respiratory distress but he is coughing and there are lots of transmitted
upper airway noises heard throughout his chest. His abdomen is normal. His nose is
streaming with catarrh and he has a purulent discharge from his right ear. His pharynx
is red and he has exudative conjunctivitis.
Measles
DDx of measles
Kawasaki disease Not catarrhal
Rubella Much milder prodrome, occipital
lymphadenopathy
Epstein–Barr virus Tonsillitis, lymphadenopathy, not catarrhal
Roseola infantum (human herpes Fever ends as rash appears
virus 6, HHV6)
Scarlet fever Pharyngitis or tonsillitis, not catarrhal
Fluids in DKA
Only give fluid bolus if shocked
Assume a 5% fluid deficit in children with mild or moderate DKA (pH >7.1)
Assume 10% fluid deficit if severe DKA <7.1
Calculate maintenance using the reduced volume rules
Ensure you subtract any bolus from the calculation
Hourly rate= deficit/48h + maintenance per hour
Maintenance fluid requirement in DKA
if they weigh less than 10 kg, give 2 ml/kg/hour
if they weigh between 10 and 40 kg, give 1 ml/kg/hour
if they weigh more than 40 kg, give a fixed volume of 40 ml/hour.
A 20 kg 6 year old boy who has a pH of 7.15, who did not have a sodium chloride bolus, will require
6 year old boy who has a pH of 7.15, who did not have a sodium chloride bolus, will require
deficit 5 % x 20 kg = 1000 mls
divide over 48 hours = 21 ml/hr
plus maintenance 1ml/kg/hr = 20 ml/hr
Total = 41 ml/hour
A 60 kg 16 year old girl with a pH of 6.9, and who was given 30 ml/kg 0.9% sodium chloride for circulatory collapse will require
deficit 10 % x 60 kg = 6000 mls
minus 10ml/kg resuscitation fluid = - 600 ml
divide over 48 hours = 113 ml/hr
plus maintenance fixed rate = 40 ml/hr
Total = 153 ml/hour
When do you add dextrose to fluid in DKA
Once the BG has fallen to 15mmol/l
Potassium in DKA
Ensure that all fluids contain 40mmol/l KCl unless there is evidence of renal failure.
If a child or young person with DKA develops hypokalaemia (<3)
Think about suspending insulin infusion
Discuss with critical care as central venous catheter is needed for IV administration of K solutions
Causes of Wernicke’s encephalopathy
ETOH
Prolonged D+V
Hyperemsis gravidarum
Severe malnutrition
Prolonged TPN
Carcinoma of the stomach
Complications of Wernicke’s
Strict bed rest is required due to a risk fo CV collapse, sudden death can occur due to cardiac decompensation in patients with signs of cardiac failure, digitilization may be needed
Thiamine should awlays be administered before carbohydrate or glucose as thiamine is required for glucose metabolism and glucose infusion can rapidly deplete thiamine stores and further aggravate the condition
Thiamine administration in Wernicke’s
50mg IV over 10mins due to risk of anaphylaxis
Should be accompanied by 50mg thiamine IM which should be continued for 5d
Pabrinex
Containes nicotinamide
Rbiloflavin
Pyridioxine
Ascorbic acid
Thiamine
- Chronic single or multiple symptoms
- Symptoms occurring across different body systems
- Symptoms with no explanatory objective signs or investigations
- Psychiatric disorder such as depression is often present
- Numerous past investigations
- Rejection of previous physicians
Somatisation
How to explain somatisaation
Clinicians may explain that the body’s nervous system is very
complicated and that sometimes pain or other symptoms can occur when there is no
physical treatable pathology. Some people experience pains or symptoms spontaneously
for no known reason and some experience them where stress or factors such as poor sleep
or poor diet affect nervous system function. Opening up this discourse allows the
clinician to make appropriate referrals to professionals such as a clinical psychologist or
liaison psychiatrist who can give support to these aspects of functioning. The focus may
not be on cure, but on coping. If the woman is not receptive to such a referral an
alternative pragmatic approach would be to discuss lifestyle changes, coping strategies or
holistic activities such as yoga or aromatherapy that focus on general wellbeing, not the
main symptom.
Finally screen for depression which is commonly present. If it is present appropriate
treatment may help.
What is an issue with antipsychotics and negative symptoms of schizophrenia?
Poor evidence for atypicals in negative symptoms except for clozapine
Anticholinergic syndrome
Blind as a bat
Red as a beet
Hot as a hare
Dry as a bone
Mad as a hatter
Toxic effects of TCA OD
Alpha adgrenergic blockade: vasodilation, hypotension, cardiogenic shock
Reuptake inhibition of noradrenaline and serotonin (tachycardia and seizures)
Na channel blockade
Impaired cardiac conduction may lead to heart block, unstable ventricular arrythmias or asystole.
Direct depression of myocardial contractility may also be seen
ABG and TCA OD
TCA toxicity leads to a mixed acidosis due to respiratory depression
Hypotension secondary to myocardial depression and peripheral vasodilation
Acidosis decreases protei binding thus increasing plasma levels of free drug
limb lead QRS >160 milliseconds and
R wave >3 mm in lead aVR are associated with
increased risk of seizures and ventricular
arrhythmias and are better predictors than plasma TCA levels.
Monitoring of TCA OD
ECG monitoring (NB prolonged resuscitation is known to be successful)
She should be monitored for 24h after ECG returns to normal
CT and MRI brain scans reveal dilated
ventricles with atrophy of the caudate nuclei
Huntingtons
Mx of Huntingtons
MDT
Psychotic symptoms: atypical
Depressive symptoms: SSRI
Manic: mood tabiliser
Obsessive rituals: fluoxetine
Speech therapy for dysarthria
PT for muscle rigidity
OT to maintain and enhance ADLs
Support for Carers
Signpots to Huntington’s disease association
Refer to social services
Mx of schizophrenia following episode of NMS
Treatment should be commenced in an in=patient setting only 2w after successful resolution of NMS
Long acting or depot preparation should be avoided
Atypical
Low and slow
