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PACES specialties Flashcards

1
Q

First rank symptoms of Schizophrenia

A 
	Thought insertion
	Thought withdrawal
	Auditory hallucinations
	Delusional Perceptions
	Passivity
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2
Q

Differentials of Psychotic episode

A

 Organic: SoL or Huntington’s
 Drug related: recreational drug-induced psychosis, corticosteroids, levodopa
 Psychotic: Schizophrenia, post-puerperal psychosis
 Affective: Psychotic depression, Schizoaffective disorder

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3
Q

Management of schizophrenia

A

Treated within the multidisciplinary mental health team…

Bio: antipsychotics
 1st: Atypical e.g. Aripiprazole 15mg OD
 2nd: Switch to another atypical agent (if poor adherence – Depot)
 3rd: CLOZAPINE after ~8 week trial.
 +modify cardiac risk factors as higher incidence

Psycho (consider EIP)
 CBT (+ve symptoms)
 Art therapy (-ve symptoms)
 Family therapy

Social
 Key worker appointed under CPA framework (Care Programme Approach)
 Addiction management as needed
 Housing support

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4
Q

Differentials of manic episode

A

 Organic: Hyperthyroidism, fronto-temporal dementia, stroke
 Iatrogenic: Corticosteroids, Levodopa, Substance misuse
 Psychiatric: bipolar disorder, depression, schizoaffective disorder, personality disorder

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5
Q

Acute management of manic episode

A

 Admit
 Cease all offending medications e.g. anti-depressants
 Anti-psychotic e.g. Olazapine (if needed add Lithium or Valproate)

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6
Q

Chronic management of bipolar disorder

A 
Bio
	Mood stabilisers: Lithium
Psycho: “Bi-polar specific therapies” 
	Psychoeducation
	CBT (for depressive episodes)
	Social Rhythm therapy
Social
	Citizen’s advice bureau (financial advice)
	Housing support
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7
Q

Grading of depression

A

 Mild = triad features only
 Moderate = triad + 3 other features
 Severe = triad + ≥4 other features (marked functional impairment)

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8
Q

Differentials of a depressive episode

A

 Organic: Hypothyroidism, Obstructive Sleep Apnoea, Parkinson’s, dementia
 Drug related: Substance misuse, methyldopa, beta blockers, opioids, racutaine
 Psychiatric: unipolar depression, Grief reaction, SAD, GAD, Bipolar.

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9
Q

Management of depression

A

Bio
 1st: SSRI e.g. Sertraline (at least 6 months)
 2nd: Trial of another SSRI

Psycho
 1st: Sleep Hygiene (i.e. low intensity interventions)
 2nd: Group CBT
 3rd: Individual CBT (IAPT): more sessions
 3rd: Interpersonal therapy
Social
 Crisis planning: Samaritans helpline 116 123
 Alcohol/smoking cessation
 Signposting to charities which can support: MIND

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10
Q

Risk factors for future completed suicide

A 
FINAL
	Finances
	Intention & planning
	Noose & violent methods
	Avoid getting caught.
	Letter to loved ones
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11
Q

Risk factors for suicide attempt

A 
S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness
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12
Q

Differentials of GAD

A

 Organic: Hyperthyroidism
 Drug-related: Salbutamol, Steroids, Caffeine
 Panic Disorder, Agoraphobia, Depression

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13
Q

Management of GAD

A 
Bio (step 3)
	1st: Sertraline
	2nd: other SSRI or SNRI (venlafaxine)
	3rd: Pregabalin
Psycho
	(step 2) Low intensity: individual guided self help e.g. sleep hygiene
	(step 3) High intensity: CBT 
Social
	(step 1) education & provision of self-help information + monitoring

Step 4 = refer to psychiatry

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14
Q

Classic features of PTSD

A

 Flashbacks
 Avoidance
 Hypervigilant state
 Emotional numbing

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15
Q

Differentials of PTSD

A

Acute stress reaction (<1m)
Abnormal grief reaction
Adjustment disorder

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16
Q

Treatment of PTSD

A

Bio
 SSRI or SNRI
 Atypical antipsychotics (if non-responsive and disabling)
Psycho
 Trauma-focussed CBT including exposure therapy
 Eye Movement Desensitisation and Reprocessing (EMDR)
Social
 Group therapy (with others who have similar experiences)

Note: In Combat-related PTSD, EMDR is contra-indicated.

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17
Q

Differentials of OCD

A

 Psychotic: psychotic depression, schizophrenia
 Affective: GAD, Depression, Hypochondriasis (if mentions health)
 Personality disorder (OCPD)
 Drug related: drug-induced psychosis – cocaine, cannabis (if bizarre)

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18
Q

Treatment of OCD

A 
Bio: 2nd line
	SSRI
	Clomipramine (TCA)
Psycho: 1st line
	Low intensity: IAPT
	High intensity: CBT, ERP, Cognitive therapy. 
Social
	Encouragement of support network use.
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19
Q

Treatment of Bulimia nervosa

A 
Bio
	Consider admission if extremely low BMI
	Fluoxetine*
Psycho
	Family therapy
	Eating disorder focussed CBT
	MANTRA therapy (Maudsley hospital)
Social
	School support

*not licensed in Anorexia

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20
Q

Differentials of ADHD

A

 Organic: Thyroid disease, Hearing problem (glue ear),
 Neurodevelopmental: ADHD, Autism, Learning Disability,
 Affective: GAD, Depression.
 Drug-related: Substance misuse, Caffeine intake.

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21
Q

What scale can be used to screen for ADHD

A

Connor’s rating scale

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22
Q

Treatment of ADHD

A 
Bio
	Methylphenidate (need to check weight every 6 months for both)
	Dexamfetamine
Psycho
	Behavioural management therapy
	Family counselling
	Cognitive behaviour therapy
Social
	Educational support (specialists, contact school)
	Family & patient Education
	Sleep hygiene
	Limit caffeine/stimulant intake
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23
Q

Causes of hyperemesis gravidarum

A

 Hyperthyroid
 Multip
 Trophoblastic disease

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24
Q

Grounds for admission in hyperemesis gravidarum

A

 Inability to keep down PO anti-emetics
 Ketonuria
 Weight loss >5%

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25
Q

Treatment of hyperemesis gravidarum

A

Conservative
 IV fluids
 Thiamine

Medicals: anti-emetics
 1st: Cyclizine or Promethiazine (a TCA)
 2nd: Metoclopramide or Ondansetron
 3rd: Corticosteroids

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26
Q

Diagnostic threshold of GDM on testing

A

 Fasting ≥ 5.6 mmol/l

 2 hour OGTT ≥ 7.8 mmol/l

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27
Q

Treatment of GDM

A 
Conservative
	Consultant-led care
	Education on regular BM measurement
	Diet: low glycaemic index foods
	Exercise
Medical:
	1st: consider trial of lifestyle 
	2nd: consider trial of metformin
	3rd: short acting insulin therapy
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28
Q

Complications of GDM

A

Maternal
 Recurrent GDM / T2DM development
 Pre-eclampsia

Fetal
	Macrosomia (increases risk of shoulder dystocia)
	Polyhydramnios
	Pre-term delivery
	Caesarean section
	Neonatal hypoglycaemia
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29
Q

Definition of Pre-eclampsia

A

Pre-eclampsia: Gestational HTN + significant proteinuria* OR organ dysfunction**

*Significant Proteinuria: After a +ve Urine dip: 1+ proteinuria.
 Protein:Creatinine (PCR) ratio >30mg
 Albumin:Creatinine (ACR) ratio >8mg

** Other organ dysfunction:
	Renal: Creatinine elevated
	Neuro (Eclampsia, headaches, AMS)
	Placental: (IUGR, Stillbirth)
	Liver (HELLP)
	Haematological (HELLP, DIC)
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30
Q

Risk factors for pre-eclampsia

A

1 = treat
Past medical factors: DM, CKD, Chronic Hypertension/PMHx, Auto-immune disease

2 = treat
Pregnancy factors: >40, Primip, Multiple pregnancy, >35 BMI.

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31
Q

Pre-eclampsia management

A

Conservative
 Monitoring: every week BP, protein ratio measurements
 Blood tests: HELLP check at time of presentation.
 Safety netting: features of eclampsia = headache, visual changes, swelling
Medical
 1st: Labetalol PO
 2nd: Nifedipine PO (if asthmatic)

32
Q

Eclampsia treatment

A

Conservative:
 Admit, Resusitate as needed
 Call for Help
 Monitoring: mother (neuro-obs) and fetus (CTG)
 Consider delivery: Steroids
Medical:
 1st: Magnesium Sulphate 4g IV bolus -> infusion
 If resp depression occurs due to Mg: Calcium Gluconate

Note: HELLP treatment = Urgent delivery

33
Q

Differentials of obstretric cholestasis

A

Obstetric: Intrahepatic cholestasis, Acute fatty liver, HELLP, PUPPPs.
Non-Obstetric: Gilbert’s, Acute hepatitis, Cholecystitis, drug related

34
Q

Differentials of antepartum haemorrhage

A

 Obstetric: Bloody show, Placental Abruption, Placenta Praevia, Vasa Previa, Uterine rupture
 Gynaecological: Cervical ectropion, Cervical polyp, idiopathic

35
Q

Treatment of placental abruption/praevia at >34 weeks

A

Conservative
 Call for help: alarm + Major Obstretric Haemorrhage
 Resuscitation: wide bore cannulae
 Admit
Medical
 Dexamethasone: Abruption - if <37 weeks. Praevia if <35 weeks.
 Blood products
 Consider Anti-D prophylaxis
Surgical
 For expedited delivery (could need hysterectomy)

36
Q

Risk factors for PPH

A 
	Previous
	Prolonged labour
	Pre-eclampsia
	Polyhydramnios
	Placenta Praevia
37
Q

Causes of PPH

A

 Tone
 Trauma
 Tissue
 Thrombin (coagulopathy)

38
Q

Acute management of PPH

A 
Conservative
	Call for help: alarm + major obstetric haemorrhage
	Lie flat + uterine massage/bimanual compression
	Resuscitation: two wide bore cannulae + blood tests
	Catheterise
Medical
	Oxytocin 10 units IV
	Ergometrin 500mcg IM (NOT IN HTN)
	Tranexamic Acide 1g
	Blood products
Surgical
	1st: Intrauterine balloon
	2nd: B-lynch suture
	3rd: Ligation of uterine arteries
	Last: Hysterectomy
39
Q

Differentials of post menopausal bleeding

A

 Age related: Climacteric period, Atrophic vaginitis
 Malignant: Endometrial, Cervical, Ovarian, Vulval
 Inflammatory: endometrial hyperplasia, endometrial or cervical polyps
 STI: chlamydia

40
Q

Risk factors for endometrial cancer

A

All increased levels of oestrogen exposure:
 Oestrogen/anovulation: Early Menarche, Late Menopause, Nulliparous,
 Metabolic: Obesity, PCOS, DM
 Genetic: FHx, Lynch syndrome
 Medications: tamoxifen, unopposed HRT

41
Q

Treatment for endometrial cancer

A

Non-invasive
 Psychologist referral
 Follow up with specialist cancer nurse
Invasive treatment FIGO staging:

1 Confined to uterus (on microscope) Total hysterectomy + BSO

2 Extends to cervix Radical hysterectomy

3 Extends into pelvis Maximal debulking surgery
+ chemotherapy

4	Metastases (bladder, rectal involvement)	Maximal debulking surgery
\+ rad/chemotherapy
42
Q

Treatment for endometrial hyperplasia

A

 Treatment with atypia: Hysterectomy + BSO

 Treatment without atypia: Progesterone therapy – IUS + resample in 3 months.

43
Q

Differentials of Menorrhagia

A 
Structural
	Polyps
	Adenomyosis
	Leiomyoma
	Malignancy
Systemic
	Coagulopathy
	Ovulatory disorders
	Endometrial disorders: endometriosis, abnormal uterine bleeding
	Iatrogenic (contraceptives)
	Not otherwise classified (hypothyroidism, PID)
44
Q

What is the most common cause of menorrhagia

A

Abnormal Uterine Bleeding

45
Q

Treatment for menorrhagia

A 
Conservative
	Reassurance and education
Medical
If she wants contraception…
	1st: LNG-IUS insertion
	2nd: COCP
	3rd: Depo-Provera (long acting progesterone)
If she does not want contraception
	Mefenamic acid  or  Tranexamic acid
46
Q

Differentials of post-coital bleeding

A

 Infectious: Chlamydia, PID
 Inflammatory: Cervical polyps, ectropion, trauma, Atrophic vaginitis
 Malignancy: Cervical cancer

47
Q

Risk factors for cervical cancer

A 
	HPV infection
	Precancerous smears: CIN & CGIN
	Smoking
	COCP
	Multiparity
48
Q

Treatment of cervical cancer

A

Non-invasive
 Psychologist referral
 Fertility counselling
 Follow up with specialist cancer nurse

Invasive
Dependant on FIGO cancer stage…
1a Confined to cervix (on microscope) Cone biopsy (fertility sparing),
Wertheim’s Hysterectomy
1b(ig) Confined to cervix (macroscopic lesions) Wertheim’s Hysterectomy (radical)
2 Beyond cervix, spares lower 1/3 vagina Wertheim’s Hysterectomy,
Radio-chemotherapy
3 Beyond cervix, involves lower 1/3 vagina Radio-chemotherapy
4 Metastases (bladder, rectal involvement) Radial Pelvic exenteration

49
Q

Differentials of an ovarian mass

A

 Physiological cysts: follicular, corpus luteal
 Epithelial (surface): Serous, mucinous, Brenner
 Germ cell (interesting bit): Teratoma, dysgerminoma
 Stromal (middle): thecoma, granulosa
 Metastatic: Krukenberg

50
Q

How can the risk of ovarian malignancy be quantified

A 
Risk of Malignancy Index
	Ultrasound findings
	Menopausal status
	CA125 score 
>250 = refer to secondary care.
51
Q

What tumour markers should be ordered for a patient <40 suspected of ovarian cancer?

A

 CA125
 LDH
 AFP
 hCG

52
Q

Risk factors for ovarian cancer

A

 FHx: BRCA1/2
 Ovulations: early menarche, late menopause, nulliparous, PCOS
 Smoking

53
Q

Management of ovarian cancer

A

Conservative
 Monitoring CA125 for 5 years.
 Fertility counselling
 Follow up with specialist cancer nurse

Medical
 Adjuvant Chemotherapy

Surgical
 RMI >25 = bilateral oophorectomy, if cancer found then see below
 RMI >250 = staging laparotomy & debulking

54
Q

Risk factors for ovarian torsion

A

 Young (reproductive age)
 Pregnant
 OHSS
 Ovarian mass/cyst

55
Q

Treatment of ovarian torsion

A 
Conservative
	Admit
	Refer to Gynae
	NBM
Medical
	IV fluids
	Analgesia
	Anti-emetics
Surgical
	1st: Surgical reversal +/- cystectomy +/- oophropexy
	2nd: salpingo-oophorectomy
56
Q

Risk factors for ectopic pregnancy

A

 Tubal: defect (e.g. salpingotomy), PID/previous STI, Smoking
 Uterine: copper IUD in situ, IVF

57
Q

Management of ectopic pregnancy

A

Expectant
 Stable + pain free + tubal ectopic <35mm + no FHB + Serum hCG <1000 + will follow up.
 Consider if <1500 hCG
Treatment…
 Repeat serum hCGs on Day, 2, 4, 7 (think: 24/7) after first test
 Education
Medical
 No significant pain + tubal ectopic unruptured >35mm + no FHB + <1500 + will return to follow up
 Consider if 5000 > x < 1500
 Note: must have no confirmed intrauterine pregnancy
Treatment…
 IM Methotrexate
 Repeat serum hCGs (4, 7 + weekly until negative) + FBC & LFTs on day 7.
 Education (no pregnancies for next 3 months)
Surgical (any)
 Significant pain
 >35 mm
 FHB visible
 >5000 serum hCG
Treatment…
 Laparoscopic > open
 1st: Salpingectomy
 2nd: Salpingotomy IF infertility risk factors
 IF RHESUS NEGATIVE: 250IU (no kleihauer)
 Education
 Advise to take urine pregnancy test after 3 weeks.

58
Q

Complications of ectopic

A

Disease related
 Rupture -> internal bleeding -> hypovolaemic shock -> death

Treatment related
 Treatment failure (95% success in methotrexate)
 Future infertility

59
Q

Management of miscarriage

A

Expectant
 Discharge with safety netting
 To return if lasts >14 days
 Urine pregnancy test after 3 weeks
Note: 1st line but consider other if any of…
 Increased risk of haemorrhage or its effects (inc. late first trimester, sickle cell)
 Previous traumatic pregnancy experience
 Infection

Medical
 PV Misoprostol 800 micrograms if missed, 600 if incomplete
 Education about what to expect
 Urine pregnancy test after 3 weeks

Surgical
	Manual vacuum aspiration under local
	Surgical removal under general
	Misoprostol often given neo-adjuvantly to aid cervix ripening
	No follow up usually needed
60
Q

Differentials of incontinance (in woman)

A 
	Urge incontinence
	Stress incontinence
	Mixed incontinence
	Functional incontenence
	Dietary: related (caffeine intake)
	Neurological: stroke-related
	Malignancy: bladder, prostate
61
Q

Urge incontenance management

A

Conservative
 Pads & packs
 BLADDER RETRAINING for 6 weeks at minimum (hold it for as long as you can)
Medical:
 Oxybutynin (leads to cant see, cant pee, cant spit, cant shit.)
 mirabegron (a beta-3 agonist) can be used in elderly afraid of these side effects.
Surgical:
 Colposuspension (Birch’s procedure: where suture support the vaginal wall by attaching them to Cooper’s ligament)

62
Q

Stress incontinance management

A 
Conservative: 
	Kegels – pelvic floor exercises
Medical: 
	Duloxetine (noradrenaline and serotonin reuptake inhibitor) if surgery is not appropriate. Enhances contraction of the pelvic muscle by stimulating the pudendal nerve. 
Surgical: 
	Mid-urethral tape surgery.
63
Q

Key features of Endometriosis

A

 Cyclical pelvic pain
 Dysmenorrhoea
 Deep Dyspareunia
 Subfertility

64
Q

Treatment of endometriosis

A 
Conservative
	Analgesia: NSAIDs, Paracetamol
	Counselling on subfertility
Medical
	COCP 
	GnRH analogues (pseudomenopause)
Surgery
	Laparoscopic excision
	Laser treatment
65
Q

Differentials of dyspareunia

A

 Infectious: STI, PID, Candida, BV, TV, Bartholin’s Cyst
 Non-infectious: Endometriosis, Vulvodynia
 Age related: atrophic vaginitis

Note:
Superficial is suggestive of acquired STI, Bartholin’s & vulvodynia
Deep is suggestive of PID, Endometriosis.

66
Q

Causes of amenorrhoea

A

Primary
 Endocrine: Turner’s syndrome, Kallmann syndrome, CAH
 Obstetric: Imperforate hymen & other genital tract abnormalities

Secondary
 PREGNANCY
 Hypothalamic: stress, exercise, anorexia
 Pituitary: Hyperprolactinaemia, thyroid disease
 Gonadal: PCOS, premature ovarian insufficiency, Fibroids

67
Q

Infertility causes

A

 Idiopathic
 Lifestyle: obesity, smoking

In women…
 Ovary: PCOS, premature ovarian insufficiency
 Tubal: PID, STI, post-ectopic pregnancy
 Uterine: Fibroids, Endometriosis/Adenomyosis
 Endocrine: hyperprolactinaemia, thyroid disease

In men…
 Endocrine: Kleinefelter’s, Kallmans, Hyperprolactinaemia
 Gonadal: CBAVD, Cystic fibrosis
 Acquired: torsion, chemotherapy

68
Q

Investigations for infertility

A 
In women…
Bloods
	Day ~21 serum progesterone
	LH & FSH
	Prolactin
	TFTs
Imaging
	Hysterosalpingogram (tubal pathology)
	TVUSS (fibroids)

In men…
 Semen analysis
 Prolactin

69
Q

Treatment for infertility

A 
Conservative
	Family planning: increased sex frequency during ovulation
	Weight loss
	Smoking/alcohol cessation
	Disease optimisation (e.g. DM)
Medical
	Clomiphene
	IVF
	ICSI
70
Q

Criteria for diagnosing PCOS

A

Rotterdam Criteria needs 2 out of 3:
 USS showing ovarian cysts (12+ in one ovary)
 Evidence of oligo/anovulation (>2 years)
 Hyperandrogenism

71
Q

Management of PCOS

A 
Not hoping to conceive…
Conservative
	Patient education: cardiovascular & metabolic risk
	Diet & Exercise
	Family planning counselling: infertility, miscarriage
	Hair removal 
Medical
	Metformin
	COCP*
	Co-cypyrindiol (dianette)
*note: prolonged anovulation leads to endometrial hyperplasia – withdrawal bleed can be induced using a progestogen for 14 days. 
Hoping to conceive…
Medical
	Clomiphene (Multip pregnancy risk↑ : SERM – increases GnRH pulsatility)
	Metformin
Surgical
	Laparoscopic ovarian drilling
72
Q

Risk factors of PCOS

A

 Early menarche
 Obese
 Age
 Afro-Caribbean

73
Q

Treatment of fibroids

A

Conservative: symptom control
 LNG-IUS
 Analgesia: NSAIDs – mefanmenic acid
 COCP

Medical:
 GnRH agonists (short term)

Surgical
 Fertility preserving: Myomectomy.
 Endometrial ablation
 Hysterectomy

74
Q

Complications of fibroids

A

 Sub/infertility
 Iron deficiency anaemia
 Red degeneration (during pregnancy)

75
Q

UKMEC4 contraindications to the COCP

A

 B: Breastfeeding < 6 weeks, Breast cancer
 A: Migraine with aura
 S: Smoker >15 a day, >35 y/o, Stroke/IHD/VTE history, Surgery (during), Severe DM.
 H: uncontrolled hypertension.

76
Q

Treatment for menopause

A 
Conservative
	Weight loss: D&E
	Sleep hygiene
	Cognitive behaviour therapy
Medical
	SSRIs
	HRT

PACES Vivas (4 decks)

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