Pad notes for First Two Rotations Flashcards
How long do you have to wait after C-section before you can get pregnant again and why?
1 year because you have to wait for the womb to heal
How to manage a C-section scar
Massage it after shower to avoid fibrosis of the scar and it being pulled inwards - to get a thin and white scar
Insertion of IUD after birth
Can’t insert IUD before 3 months after birth because womb is not back to its normal size and it will be expulsed
Risk factors for late miscarriage x3
Scars on uterus
Previous late miscarriages
Fibroma or mass in uterus
Where is affected with hydra-adenitis?
Groin, armpits, between buttocks, labia, below breasts, on buttocks
What happens with hydra-adenitis?
Abscesses, swelling, pain and boils
Treatment of hydra-adenitis?
Infliximab treatment, 4-weekly infusions
What vitamin are all babies given and why?
All babies are given vitamin K because they don’t have vitamin K stores
Therefore give any child with prolonged clotting extra vitamin K, check 6 hours later and liver should have had time to synthesise vitamin K
What sort of milk do children with chronic liver disease get?
Milk with MCT’s (medium chain triglycerides) in it because they are water soluble therefore more easily absorbable
What is galactosemia?
Rare genetic disorder that affects an individuals ability to metabolise galactose leading to toxic levels of galactose-1-phosphate
Symptoms of galactosemia?
Galactosemia leads to hepatomegaly, cirrhosis, renal failure, cataracts, vomiting, seizure, hypoglycaemia, lethargy, brain damage and ovarian failure
Management of galactosemia
Stop breast milk to cure
Why is EBV bad in immunosuppressed patients and what happens pathologically?
Because T cells are low when immunosuppressed therefore get EBV B cells and these colonially expand because there are no T cells stopping them - therefore get lymphadenopathy from B cell proliferation
What is Sandifer syndrome?
Syndrome of gastro-oesophageal reflux and neurological symptoms
Symptoms of Sandifer syndrome?
Spasmodic torticolis and dystonia and gastro symptoms
Treatment of Sandifer syndrome
Treatment of associated underlying disease eg. GORD or hiatus hernia
What do you worry about with seizures in a child
Neurological problem - eg. neuro migrational disorder etc. always do MRI
Infection - eg.meningitis
Cardiac - look for cardiac SVT - floppy, sweaty and pale
Metabolic - check glucose, lactate, ammonia, amino acids, u&e’s, cardinitine
What do you query if child is not moving arm in first few months
Surgical trauma eg. clavicle fracture most common
Or NAI
When are febrile convulsions seen?
5/6 months to 5/6 years
Characteristics for febrile convulsions x5
Temperature just needs to be high
Need to normalise after seizure
Duration 1 then complex febrile seizures)
Risk of having a second febrile seizure if you have a first
30% risk of another seizure
How do you do neonatal MRI
Feed and wrap or General Anaesthesia
What do you give for status epilepticus in children
Diazepam is not given
Lorazepam if access or rectal
Another name for metopic synostosis and what is it?
Trigonocephaly - premature fusing of the metopic suture causing a triangular shape to the forehead
What does valproate to do lamotrigine?
Valproate increases lamotrigine half-life
All enzyme inducers do this to lamotrigine
What effect can topiramate have on kidney
(Treatment for tonic clonic)
It can cause renal stones
What type of pain do you get with Gall Stones?
Colicky (coming and going) RUQ pain and jaundice
What is Gilberts syndrome
GAL 1 enzyme dysfunction - high bilirubin in blood - can cause jaundice
What is given after splenectomy
Lifelong penicillin because risk of being immunocompromised and risk of pneumococcus infection
Type of wheeze in foreign body obstruction
Unilateral, sudden onset and also red in the face
What would you see in xray of foreign body
Normally in right bronchus and would see hyperinflation distal to obstruction due to air trapping
What would you hear on auscultation in bronchiolitis
More creps and crackles than a wheeze
What is burst therapy?
Back to back salbutamol nebulisers to open up the airway
What treatment differs between asthma-induced and virus-induced wheeze?
Won’t give steroids in virus induced wheeze because they are immunosuppressants
When do you get productive cough in children?
After age 5/6 - can’t really cough up sputum before this
Therefore for sputum sample will need to do gastric washout
What is NPA
Nasopharyngeal aspirate - send to lab to see if growing any viruses
Maternofetal risk factors for infection in neonate
Vaginal swab +ve for streptococcus Maternal fever during pregnancy Rupture of sac >12 hrs Meconium in amniotic fluid Neonatal fever Antibiotics to mum during birth
What is Mesenteric Adenitis?
Swollen lymph glands in the abdomen - causes abdominal pain similar to appendicitis therefore diagnosis of exclusion when appendicitis can be excluded
Usually clears up without treatment
Lung infection in child with CRP 160 will pretty much always be …
…pneumococcus
DDX for difficulty breathing and fever in
Ear infection
Green vomit
Obstruction
Presentation of volvulus
Acute and grave presentation with vomiting and occlusive signs
Choking patient develops unilateral wheeze - what should you do
Not do Haemlick because obstruction has passed into the bronchus and can make it worse
What should not be given nutritionally before age 1
Salt
What do Barlow and Ortalami look for
Hip dislocation due to developmental dysplasia of the hip
What is the significance of PCT
Rises early when bacterial infection - doesn’t rise in viral
What can be confused with cardiomegaly on infant chest x-ray
Thymus gland
What does herpes eye infection give
Keratitis - very sore granuley/gritty infection of cornea
Very painful to move eyelid - infant will keep eye shut to avoid pain
What do you suspect if recurrent prolonged fever in infants - at least a week every 1/2 months
Ask if it is an inflammatory syndrome
Signs of respiratory distress
Intercostal and subcostal pulling
Balancement thoracoabdominal
presternal pulling
Nostrils
How will a child with spondylitis present?
Inflammation of joints of backbone - won’t be able to stay sitting up because will be too painful
What do you suspect if limping and fever
Joint infection
Which way should babies sleep?
Not on their front because they do not have the instinct to turn their head if they can’t breathe and this can lead to suffocation
What is Marshall syndrome?
Genetic disorder of connective tissue that can cause hearing loss.
Areas commonly affected are eyes (uncommonly large), joints and mouth and facial structures
When does neck stiffness become significant? (what age)
Before 18months-2 years - therefore before then not very useful
How does neonatal colic present?
Crying, abdominal pain, bloated and gas - not really blood in stoold
Normal neonatal stool
Semi-liquid with bits in it (yellow/gold) becomes more consistent as mothers milk changes
What is Sanfillipo syndrome?
Inability to break down mucopolysaccardies (type of sugar)
Presents later in life, post-2, may have abnormal facies and then neurological problems and marked behavioural problems
Do not usually live past early 20s
What is neonatal mastitis
Inflammation of neonatal breast tissue due to hormones from mothers milk - not a problem but can get infected -
What happens to proteins with inflammation
All go up except albumin which goes down and transferrin which doesn’t change
Presentation of bowel invagination
PR bleed, sudden pain, malaise, can lose consciousness
Treatment of bowel invagination
Wash out up anus with sodium solution - should undo vagination. If it doesnt then surgery to undo and check for necrotic bowel
Minimum 3 things that need assessing in mobility assessment of elderly
Proprioception
Hip flexion and extension
Gait
What sort of fracture are osteoporotic fractures?
Low trauma fractures in bones which are normally strong eg.hip, femur, spine and humerus
When do Bisphosphonates need to be taken and how? 2 details
Take first thing in the morning on empty stomach because poor bioavailability and food therefore decreases availability of medication
Also upright with large glass of water to reduce risk of oesophagitis
Eg of Bisphosphonate
Alendronic acid
What dosage can be used for Bisphosphonates?
Once a week large dose
Which medication is relevant in dhx for oestoporosis?
Steroids
What 3 conditions are risk factors for osteoporosis?
T1DM
Rheumatoid arthritis
Any malabsorption syndrome
Social risk factor for osteoporosis x2
Smoking
Drinking >21 units of alcohol a week in women
1st step of Who Pain ladder
1) paracetamol regular
+/- NSAIDs if no contraindication
4 red flags for bowel Cancer
Change in bowel habits
Blood in stool
Tenesmus
Palpable mass
Who is needed to intervene if patient gets pressure ulcer in hospital
Tissue viability nurse
4 ways to prevent pressure ulcer in hospital
Rotation every 2/4 hours
Pressure relieving mattress
Prevlon boots
Check elbows, sacrum and heels at least once a week
Blood clot prevention in hospital, and change if poor renal function
Enoxaparin LMWH normal
If eGFR is
Two molecular indicators of rheumatoid arthritis
Anti-CCP antibody has highest specificity
Rheumatoid factor has high sensitivity but low specificity
What does paracetamol regularly need to be based on
Weight - only 1g QDS if >50kg
Also check LFTs
Contraindications for NSAIDs x3
Stomach problems, asthma/COPD, kidney problems
What sort of pain are NSAIDs good for?
Good for bone pain
Can be given PR to reduce GIT side effects
What is step 2 of WHO pain ladder?
Weak opiates (codeine, tramadol, dihydrocodeine)
+ PRN laxatives and antiemetics
Keep baseline paracetamol
Step 3 of WHO pain ladder
Strong opioids (morphine sulphate, buprophine, oxycodone, fentanyl, alfentinil, diamorphine)
Which is first choice in WHO Step 3 and when is this changed?
Morphine is first choice but if liver/kidney function goes then fentanyl or alfentinil
What do you do with step 2 medication when escalating to step 3 of WHO pain ladder?
If just need a bit more pain relief to top up when moving - the keep step 1 and 2 and use anticipatory PRN oromorph
If pain all the time with step 2, then get rid of weak opiate and use strong opiate
How do you decide dose for strong opiate in WHO step 3?
Do PRN oromorph, see how much they need. Then add it up and the next day give half in the am and half in the pm and PRN if they need extra
What can be added to who pain ladder if neuropathic pain
All away along can give neuropathic pain adjuvants - gabapentin, pregabalin, amitriptyline, carbamazepine
Non-pharmacological management of pain x4
TENS machine, hot water bottle, hydrotherapy, CBT
Non pharmacological management of nausea and vomiting x2
Ginger
Peppermint water
Non pharmacological management of breathlessness x5
Chest physio, handheld fan, relaxation, singing, CBT
Pharmacological management of breathlessness
Weak opiates
Which is the best laxative for Opiate constipation?
Senna
Which antiemetic is not good to give with bowel obstruction?
Domperidone because it is a prokinetic
Most common cause of fine crackles on auscultation
Pulmonary fibrosis (IPF, drugs, rheumatoid, chemo) Sarcoid
Which drugs can cause pulmonary fibrosis? X4
Methotrexate, amiodarone, chemotherapy, nitrofurantoin
What is nitrofurantoin
Antibiotic used for urinary tract infections
Cause of coarse crackles
Chest infection
What is indapamide?
Thiazide diuretic (causes k+ loss)
What is ondansetron?
Antiemetic used to treat nausea caused by chemotherapy and surgery
What is DOLS?
Deprivation of liberty safeguard - keeping against wishes but in best interest
Should be used for basically any patient with dementia who can’t leave a hospital
What is HNA?
Health needs assessment
How can fluids be given in palliative care and what sort?
Can be given SC rather than IV but only saline (not dextrose or Hartmann) and very slowly - 10-12hr bag
What do you hear on cardiac auscultation with pulmonary hypertension?
Loud p2 over pulmonary valve area
How are left sided murmurs best heard?
In expiration
What can occur after the release of renal obstruction?
Post obstruction diuresis - get large electrolyte imbalance
Indications for using NG tube x4
Unsafe swallow (smaller feeding tube)
Neuromuscular
Aspiration for obstruction and vomiting (Rialls tube - larger)
Giving medications which can’t be given IV eg.betablockers
Investigations of causes of a fall x2
Sitting and standing BP
infection screen
Investigations of consequences of a fall x2
Ct scan
X-ray for fractures
What is needed for capacity according to the mental capacity act x4 stages
Need to understand a clear question
Need to understand risk and benefits
Need to be able to remember long enough to make an informed decision
They need to be able to communicate this decision to you
What should be starting point for assessing capacity
Assume they have capacity unless proven otherwise
What act comes into play if they lack capacity
Best interest act
What is an Advanced Care Plan?
Supposed to influence best interest decisions - not legally binding and can’t get sued if you don’t use it but you should try to
What is an advanced directive which is legally binding?
Advanced decision to refuse treatment - unlike the advanced care plan is is legally binding
Sections for discharging patient as part of continuing healthcare checklist
Section 2 needs to be done minimum of 48hours before discharge to prepare package of care
Section 5 done minimum 24hours after section 2 and 24hrs before discharge - means patient is now fit for discharge
Effects of long term steroids x5
Bone problems - osteoporosis Gastritis therefore give PPI Can cause and derange diabetes Weight gain Immunosuppression
Side effects of quetiapine
Drowsiness
Effect of dementia treatment on MMSE scores
Study showed that MMSE score increased when dementia patients are treated with paracetamol instead of anticholinesterase inhibitors - implying pain may have a role in dementia
What is risk associated with c.diff infection
Can cause toxic mega colon which is very dangerous - therefore monitor inflammatory markets and check for bloated abdomen
What can occur post prostate treatment
Stress incontinence
What is functional incontinence
Because unable to reach the toilet eg. Due to immobility
Lifestyle risk factor for gynaecomastia
Increased alcohol intake
Causes of mastalgia
Usually no pathological cause - breast cancer is typically painless
Scale for risk of breast cancer from examination/investigation
B1 - normal B2 - something but benign B3 - something probably benign B4 - something probably malignant B5 - something and malignant
