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Endocrinology > PACES > Flashcards

PACES Flashcards

1
Q

Mx of Phobia

A

Desensitisation or CBT

Consider specific interventions e.g. community dental officer in phobia of dentists

Rx not routinely used

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2
Q

DDx in GAD?

What differentiates GAD from these

A

• 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

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3
Q

Stepped care model in GAD

A

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

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4
Q

Mx of OCD in adults

A

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

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5
Q

Mx of OCD in children

A

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

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6
Q

Stepped care approach to panic attacks

A

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

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7
Q

Draw the hot cross bun model in CBT

A
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8
Q

NICE guidleines when depression and anxiety co-exist

A

Treat depression first

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9
Q

Mx of depression

Mild

Moderate to severe

Severe

A

CBT or low-intensity psychological therapy first line

Moderate-to severe: CBT and SSRI

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10
Q

What are the indications for referral in depression?

A

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.

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11
Q

What is important in every case of anxiety disorder?

A

Ask questions about depression and risk

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12
Q

What are the key components of motivational interviewing techniques?

A

Shown to be more effective in dealing with substance misuse

  1. Use of empathy to understand patients point of view
  2. Allow the patient to explore the discrepancy between positive core values and his unhealthy behaviours
  3. Tackling the inevitable resistance with empathy rather than confrontiation
  4. Supporting self-efficacy and enhancing self-esteem
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13
Q

What is the step-wise treatment to opioid use

A

Based on principle of harm minimisation:

  1. reduce injecting
  2. reduce street drug use
  3. mainteance thrapy with heroin substutes (methdone or buprenorphine)
  4. reduction in substitute prescribing
  5. abstinence
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14
Q

What can be used as mood stabilising prophylaxis in women of child-bearing age?

A

Olanzapine

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15
Q

Biopsychosocial management of BPAD

A

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

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16
Q

Ddx for stridor in an infant

A

Laryngomalacia

Laryngeal cyst, haemangioma or web

Laryngeal stenosis

Vocal cord paralysis

GORD

Vascular ring

Hypocalcaemia (laryngeal tetany)

Respiratory papillomatosis

Subglottic stenosis

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17
Q

What differentiates between stridor and wheeze

A

Stridor is predominantly inspiratory

Wheeze expiratory

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18
Q

Mx of croup

A

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

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19
Q

What are the indications for hospital referral in bronchiolitis

A

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

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20
Q

Secondary care mx of bronchiolitis

A

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

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21
Q

Ddx of a recurrent or persistent cough in childhood

A

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

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22
Q

Signs of impending respiratory failure

A

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

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23
Q

What is an important consideration in giving continuous nebulised salbutamol

A

Cardiac monitoring is indicated as this can lead to side effects

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24
Q

What are the components of an asthma review?

A

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.

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25
Q

Mx of pneumonia

A

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

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26
Q

DDx of chest pain in children

A

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

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27
Q

What is significant about PEFR in children

A

Have to be >5 for it to be reliably performed

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28
Q
A
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29
Q

What is the hyperoxia test?

A

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

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30
Q

DDx of a collapsed neonate

A
  • 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
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31
Q
A
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32
Q

IMB DDx

A
  • Cervical malignancy
  • Cervical ectropion
  • Endocervical polyp
  • Atrophic vaginitis
  • Pregnancy
  • Irregular bleeding related to the contraceptive pill

Endometrial polyp

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33
Q

Gold standard mx of endometrial polyp

A

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.

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34
Q

What d21 progesterone is suggestive of ovulation?

A

>30nmol/l

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35
Q

What is significant about FSH level >10?

A

Suggests poor prognosis for fertility, in absence of menopausal symptoms may be suggestive of premature ovarian failure

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36
Q

What are the options for couples with premature ovarian failurie?

A

Counselling re poor px for conception either with in vitro fertilisaiton or own ova

Donor oocyte

Adoption

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37
Q

What is advisable in the presence of large intrauterine fibroids?

A

Arrange renal function tests and a renal tract USS
due to the potential for ureteric obstruction and hydropnephrosis

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38
Q

LLETZ procedure

A

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

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39
Q

What is significant about menorrhagia

A

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

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40
Q

Mx of prolactinomas

A

Medical suprression using dopamine agonists:

bromocriptine or carbegoline

Surgery is only indicated rarely

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41
Q

Ix of PCB in young woman

A

Speculum

STI screen:

Endocervical swab for gonorrhoea

Endocervical swab for chlamydia

High vaginal swab for trichomonas and candida

Cerbical smear

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42
Q

Dx of antiphospholipid syndrome

A

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

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43
Q

Mx of anti-phospholipid syndrome

A

Oral low-dose aspirin

and

LMWH from the time of a positive pregnancytest

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44
Q

Causes of recurrent miscarriage

A

Parental chromosomal abnormality (balanced)

Antiphospholipid syndrome

Other thrombophilia: active protein C resistance

Uterine abnormality

Uncontrolled DM or hypothyroidism

BV

Cervical incompetence

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45
Q

What is double depression

A

Depressive epsidoe superimposed on background ysthymia

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46
Q

When may psychodynamic therapy be used for depression

A

For the treatment of complex comorbidities that may present alongisde depression

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47
Q

Ddx for manic episode

A

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.

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48
Q

Drugs that may cause manic episodes

A

Antidepressants

Steroids

Stimulants

Illicit drugs e.g. cocaine, amphetamines and hallucinogens

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49
Q

Somatic syndrome

A

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.

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50
Q

What is a simple rule of thumb for somatic presentations?

A

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.

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51
Q

How to assess delusional beliefes

A

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

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52
Q

DDx for somatisation disorder

A

Organic illness

Depressive disorders

Anxiety disorders

Hypochondrial

Factitious (Munchausen’s)

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53
Q

CAGE

A

Cut down

Annoyed at people criticising you aboiut drinking

Guilty

Eye opener

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54
Q

Management of overdose and posioning

A

I would refer to thet TOXBASE

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55
Q

Paracetamol OD key questions

A

Single or staggered OD

Time of ingestion

Blood tests

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56
Q

OD of paracetamol

A

>7..5g (15 tablets)

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57
Q

Mx of paracetamol OD

A

<1h: charcoal

1-4h: blood test at 4 hours to assess levels

Refer to nomogram

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58
Q

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.

A

Complex partial seizures i.e. TLE

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59
Q

DSM Multiaxial classification

A

Clinical disorder

Personality and intellectual

Medical or physical condition

Psychosocial and environmental

Global funcitoning

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60
Q

What is an issue with hysterosalpingogram

A

Tubal blockage can sometimes be due to tubal spasm, Lap and dye needs to be used to confirm the diagnosis of tubal factor infertility

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61
Q

IVF and tubal factor infertility

A

Abnormal tubes are usually removed as success rates for pregnancy are better and ectopic pregnancy rate is reduced after BS

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62
Q

bilateral hydrosalpinges and adhesions as well as perihepatic
‘violin-string’ adhesions.

A

Indicative of previous infection with chlamydia

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63
Q

Important points in TCRF counselling

A

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

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64
Q

Hormonal management of AN

A

OCP will prevent osteoporosis and bring on periods

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65
Q

Examination of prolapse

A

Supine and standing

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66
Q

Categroisation of prolapse

A

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

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67
Q

Mx of prolapse

A

Pelvic floor muscle training for mild

Conservative: ring pessary

Surgical

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68
Q

What is a recognised complication of transcervical resection procedures

A

Fluid overload and consequent hyponatraemia

1000mL is the normal upper limit for the procedure

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69
Q

Mx of Turners

A

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

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70
Q

DDx for irregular bleeding with the COCP if examination is normal

A

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)

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71
Q

How to diagnose PMS

A

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

72
Q

Mx of PMS

A

Conservative

Interruption of ovulation with the OCP

SSRI can work not just through their antidepressant effect.

73
Q

Staging of endoemtrail carcinoma

A

Surgical

74
Q

Staging of cervical carcinoma

A

Clinical under sedation

75
Q

Struma ovarri

A

Ovarian teratoma developing thyroid tissue-> hyperthyroidism

76
Q

Why is surgery recommended in mx of cysts?

A

Due to risk of torsion or malignant change

77
Q

What are Schneider’s 3 features of normal thought content?

A

Constancy

Organisation

Consistency

78
Q

What are five featurs of Schneider’s formal thought disorder?

A

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

79
Q

What is the difference between primary, secondary and bizarre delusion?

A

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.

80
Q

What are the minor symptoms of depression necessary for a DSM dx of depression

A

† Decreased concentration
† Reduced self-esteem
† Guilt
† Pessimism about the future
† Self-harm ideation
† Disturbed sleep
† Reduced appetite

81
Q

What is the significance of opiods coRxed with SSRIs?

A

May precipitate serotonin syndrome

82
Q

Perseveration is highly suggestive of

A

Organic brain disease

83
Q

Dysprosody

A

Loss of the normal melody of speech

84
Q

Expressive aphasia

A

Difficulty verbalising thought with intact comprehension

85
Q

Receptive aphasia

A

Difficulty understanding althought the patient feels they are speaking fluently it is not always possible to make out any words in their voice.

86
Q

After an act of self harm, what is the risk of completed suicide within the next year?

A

1% (100x the risk in the general population)

87
Q

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.

A

It is
thought that piblokto may be related to vitamin A toxicity, as the native
Eskimo provides large quantities of it.

88
Q

Raised LH to FSH ratio

A

?PCOS

89
Q

co-cyprindiol

A

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.

90
Q

Mx of septic miscarriage

A

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

91
Q

Cx of septic miscarraige

A

Massive haemorrhage

Hysterectomy

DIC

Multisystem failure: secondary to haemorrahge or sepsis

Death

92
Q

Ovarian cyst rupture and USS findings

A

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

93
Q

Significance of POP in ovarian cysts

A

POP increases incidence of ovarian cysts whereas OCP reduces occurance through inhibition of ovulation

94
Q

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

A

Bartholin cyst; requires drainage and marsupialisation

95
Q

What is significant re aetiology of Bartholin cysts?

A

Pus should always be sent for culture as gonorrhoea is isolated from <20% of Bartholin’s abscesses

96
Q

Initial management for suspected ruptured ectopic pregnancy

A

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

97
Q

What is the leading cause of maternal death in early pregnancy?

A

Rupture ectopic pregnancy

98
Q

Preoperative USS if ?ectopic rupture

A

Not indicated due to risks of delaying Sx

99
Q

Primary infection:

General malaise

Fever

Anorexia

Lymphadenoapthy

Genital blisters

Urinary retention

Secondary infection:

genital blisters

Often occuring at times of stress or tiredness

A

HSV infection

100
Q

Immediate mx of HSV infection with urinary retention

A

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

101
Q

Ddx for acute RIF

A

Gynaecological:

Torsion

Ovarian cyst rupture

Ovarian cyst haemorrhage

Ectopic pregnancy

Appendicitis

UTI

Renal colic

102
Q

Mx of PID with pelvic abscess

A

May be given a trial of conservative broad spectrum Abx for 24-48h prior to surgical drainage

103
Q

Fetal heart beat present in ectopic pregnancy

A

Renders conservative options both dangerous and unlikely to be sucessful

Surgical mx is the only option

104
Q

Postoperative counselling points after ectopic pregnancy

A

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

105
Q

DDx for pain in early pregnancy

A

Corpus luteum

Ectopic

Miscarriage

Ovarian cyst

UTI

Renal calculus

Constipation

Appendicits

Unexplained pain

106
Q

Ring of fire appearnce on Doppler USS

A

Corpus luteal cyst

107
Q

Spider web or reticulated echo pattern within the cyst suggestive of

A

Haemorrahge

108
Q

PUL

A

Pregnancy of unknown location

No signs of either intra or extra-uterine pregnancy or retianed products of conception ina woman with a positive pregnancy

109
Q

Possible causes of PUL

A

Early intrauterine pregnancy

Failed pregnancy

Ectopic pregnancy

110
Q

Mx of persistent PUL

A

Methotrexate

111
Q

When can naegle’s rule not be applied

A

Where the cycle is not regular or there has been a pregnancy or hormonal contraception in the last 3 months

112
Q

Transvaginal markers in early pregnancy

A

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

113
Q

What should women with uncertain LMP be offered?

A

Early first-trimester USS examination to estimate gestational age

114
Q

Conditions for fetal heart rate

A

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

115
Q

Empty sac/blighted ovum

A

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

116
Q

When can a diagnosis of empty gestational sac be made?

A

When the mean sac diameter exceeds 20mm with no visible fetal pole

117
Q

Mx of miscarriage

A

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.

118
Q

Mx of misccariage missed vs incomplete

A

Medical and surgical for missed

Expectant for incomplete

119
Q

Counselling after miscarriage

A

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

120
Q

What is the commonest pathological arrythmia in childhood?

A

SVT

121
Q

What differentiates between SVT and sinus tachycardia

A

Sinus tachycardia is <220 beats/min, greater HR variability and there is often a history consistent with shock

122
Q

SVT presentation in younger infants

A

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

123
Q

Mx of SVT

A

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.

124
Q

Mx of pS

A

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

125
Q

Insulin maintenance therapy

A

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.

126
Q

Diagnosis of Marfans

A

Ghent criteria

Skeletal e.g. pectus excavatum, wrist and thumb signs

Ocular: ectopia lentis

Cardiovascular: dilatation of the ascending aorta etc.

127
Q

Height, what should always be done

A

Plot parents centiles to see whether the child falls within the expected height range for the family

128
Q

What are the clinical signs suggesting a pathological cause for short stature

A

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

129
Q

BMI=

A

Weight in kg/ height in m2

130
Q

BMI cut offs

A

>91st centile= overweight

>98th centile= obese

131
Q

How can gonadotrophin dependant precocious puberty be diagnosed

A

LHRH test

LH >8 with predominantly LH response is diagnostic

132
Q

Why is 17-OH progesterone sent after 48h in ?CAH

A

Raised in all newborns

133
Q

Ddx for gynaecomastia in a pubertal boy

A

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

134
Q

What adjunctive Rx should be given during air insufflation of intussuception

A

Antibiotics to reduce risk of sepsis and to

135
Q

Approach to rectifying dehydration

A

Oral where possible

If not, trial with NG

If shocked/ unsuccessful, IV

136
Q

Maintenance fluid requirements in children

A

100ml/kg for first 10kg

50ml/kg for next 10 kg

20ml/kg thereafter

137
Q

Child of bodyweight 11kg

5% dehydration

Calculate fluid deficit and maintenance rquirements

Rate per hour

A

Maintenance= 100x10 + 50 x 1= 1050

5/100x100= 0.55

Rate per hour= 1600ml/24 + losses

67mL/h + losses

138
Q

Triad of abdo pain, vomiting and low-grade fever

A

Suggestive of appendicitis

139
Q

Organic cause of pain and location in relation to umbilicus

A

Further away from umbilicus, the more likely to be organic in nature

140
Q

DDx of chronic abdo pain

A

Psychosomatic

UTI

Constipation

GORd

Coeliac

CMPI

Abnormal renal anatomy

Abdominal migraine

Peptic ulcer

Sexual or other abuse

141
Q

Name of the procedure performed in biliary atresia

A

Kasai procedure (portoenterostomy)

142
Q

What should you always ask about in jaundice

A

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

143
Q

Phenotypically female infants with inguinal hernias, especially bilateral should be?

A

Examined carefully to exclude complete androgen insensitivity syndrome

144
Q

The VACTERL association

A

sporadic, non-random, concurrence of at least
three of: vertebral, anal, cardiac, tracheo-oesophageal, renal and limb abnormalities.

145
Q

red urine which will be dipstick-positive for blood but there
will be no red blood cells on microscopy.

A

Haemoglobinuria due to
haemolysis

146
Q

Ix in child presenting with nephrotic syndrome

A

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

147
Q

Mx of nephrotic syndrome

A

Fluid balance

Prednisolone

Prophlactic antibiotics

4 hourly observations

Low salt diet

148
Q

Mechanisms of primary nocturnal enuresis

A

Lack of arousal from sleep

Bladder instability or low funcitonal bladder capacity

Low vasopressin levels

149
Q

Ex in nocturnal enuresis

A

Weight and height

Genitalia and spine should be inspected for abnormality

Lower limb neurology

150
Q

Causes of paediatric hypertension CREED

A

Cardilogical: coarctation of the aorta

Renal: GN, RAS

Essential

Endorcine: thyrotoxicosis, Cuishing’s, phaeo

Drugs: steroids, OCP, amphetamines

151
Q

Ix in child with HTN

A

Ambulatory BP to confirm

Renal USS with Doppler

ECG to exclude cardiobascular

Exclude DM

Lipid profile

152
Q

Mx of paediatric essential HTN/obesity

A

Lifestyle changes- refer to dietician

Adive about low salt diet

1 hour exercise every day

Beta blocker or CCB should be used

153
Q

What should be done with a child’s BP?

What is the cut off?

A

Consult a published centile chart

>95th centile= HTN

154
Q

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.

A

Measles

155
Q

DDx of measles

A

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

156
Q

Fluids in DKA

A

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

157
Q

Maintenance fluid requirement in DKA

A

 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.

158
Q

A 20 kg 6 year old boy who has a pH of 7.15, who did not have a sodium chloride bolus, will require

A

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

159
Q

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

A

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

160
Q

When do you add dextrose to fluid in DKA

A

Once the BG has fallen to 15mmol/l

161
Q

Potassium in DKA

A

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

162
Q

Causes of Wernicke’s encephalopathy

A

ETOH

Prolonged D+V

Hyperemsis gravidarum

Severe malnutrition

Prolonged TPN

Carcinoma of the stomach

163
Q

Complications of Wernicke’s

A

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

164
Q

Thiamine administration in Wernicke’s

A

50mg IV over 10mins due to risk of anaphylaxis

Should be accompanied by 50mg thiamine IM which should be continued for 5d

165
Q

Pabrinex

A

Containes nicotinamide

Rbiloflavin

Pyridioxine

Ascorbic acid

Thiamine

166
Q
  • 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
A

Somatisation

167
Q

How to explain somatisaation

A

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.

168
Q

What is an issue with antipsychotics and negative symptoms of schizophrenia?

A

Poor evidence for atypicals in negative symptoms except for clozapine

169
Q

Anticholinergic syndrome

A

Blind as a bat

Red as a beet

Hot as a hare

Dry as a bone

Mad as a hatter

170
Q

Toxic effects of TCA OD

A

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

171
Q

ABG and TCA OD

A

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

172
Q

limb lead QRS >160 milliseconds and
R wave >3 mm in lead aVR are associated with

A

increased risk of seizures and ventricular
arrhythmias and are better predictors than plasma TCA levels.

173
Q

Monitoring of TCA OD

A

ECG monitoring (NB prolonged resuscitation is known to be successful)

She should be monitored for 24h after ECG returns to normal

174
Q

CT and MRI brain scans reveal dilated
ventricles with atrophy of the caudate nuclei

A

Huntingtons

175
Q

Mx of Huntingtons

A

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

176
Q

Mx of schizophrenia following episode of NMS

A

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

177
Q
A

Endocrinology (27 decks)

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