Passmed Corrections Flashcards

Question

Autonomic Dysreflexia? What spinal level must the injury be?

Answer 1

* Can only occur if the spinal injury is above the level of T6 * Autonomic dysreflexia = combination of severe hypertension, flushing and sweating without a congruent response in heart rate in the context of spinal cord injury indicates an autonomic dysreflexia * Often precipitated by noxious stimuli (eg: catheter change)

Answer 2

* Myocardial infarction and acute coronary syndromes * Stroke * Obstetric emergencies * Anxiety-related hyperventilation

Answer 3

PANCREAS: * PaO2\< 7.9kPa * Age \> 55 years * Neutrophils (WBC \> 15) * Calcium \< 2 mmol/L * Renal function: Urea \> 16 mmol/L * Enzymes LDH \> 600IU/L * Albumin \< 32g/L (serum) * Sugar (blood glucose) \> 10 mmol/L

Answer 4

1. Auditory/visual hallucinations may accompany memory loss 2. Use of dopamine antagonists is contraindicated (same as with Parkinson's disease) ie. NO haloperidol

Answer 5

* oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) * osteonecrosis of the jaw * increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate * acute phase response: fever, myalgia and arthralgia may occur following administration * hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant

Answer 6

* Booking visit: * **8-12 weeks** * General information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes * BP, urine dipstick, check BMI * FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies * Hepatitis B, syphilis, rubella * HIV test is offered to all women * Urine culture to detect asymptomatic bacteriuria * Early scan to confirm dates/exclude multiple pregnancies * **10 - 13+6 weeks** * Down screening including nuchal scan * **11 - 13+6 weeks** * Anomaly scan * **18 - 20+6 weeks** * 36 weeks * Routine care * Check presentation + offer external cephalic version if indicated * Information on breast feeding, vitamin K, baby blues

Answer 7

* Hugely raised urea in the context of a relatively normal creatinine Upper GI bleed - raised urea occurs because of breakdown of RBC's in the stomach

Answer 8

Ultrasound! (to characterise the lesion and confirm the presence of a mass - vs. normal variation in size between testes)

Answer 9

* Hx of fever * Tonsillar **e**xudates * No **c**ough * **T**ender anterior cervical lymphadenopathy * Age \>40 If 3 or more, then Abx: benzylpenicilling or metronidazole

Answer 10

* Pre/perimenopausal patient: tamoxifen * Postmenopausal patient: Anastrozole * An aromatase inhibitor that reduces peripheral oestrogen synthesis - pipheral conversion accounts for most of the oestrogen in postmenopausal women

Answer 11

* Are likely to need to commence EPO therapy * However, before this important to rule our iron deficieicny, folate & B12 deficiency! * Hb of 92 not low enough to transfuse the patient

Answer 12

* Smoking cessation can cause a rise in levels - discuss with doctor before doing so (smoking more can also cause a decrease in levels) * Binge drinking alcohol can cause a rise in levels - competes with liver for metabolism?

Answer 13

* Diarrhoea can get around cancer in the bowel - concerning * Always ask about overflow diarrhoea / loose stools (even in a constipation history)

Answer 14

* FBC (?anaemia), ferritin (?iron deficiency anaemia), ESR, U&E (before contrast CT), TFT (as cause of diarrhoea/constipation), bone profile (hypercalcaemia as cause of constipation), ceoliac screen * Stool - MC&S, faecal calprotectin (?IBD), faecal elastase ( * Proctoscopy & rigid sigmoidoscopy - will see the proctitis in clinic. Flexisig is much better for left colon visualisation as it's easier * Colonoscopy - needs oral bowel prep & usually sedation * CT cologram - needs oral bowel prep & rectal intubation (needs relatively normal U&E's). Warn them that they will have a tube in the back passage which will blow air in * Capsule endoscopy - to visualise small intestine * US/CT/MRI * SeHCAT study - bile salt malabsorption - common cause of diarrhoea in previous cholocystectomy * Colonic transit studies - how quick does the colon work * FOB - screening for colorectal cancer 65-75yrs * Barium enema - ?cancer shows as apple core stricture

Answer 15

* Same bit of kit * Just flexi sig only goes up until splenic flexure * Flexi sig: * Phosphate enema * No sedation * Twice as quick * Colonoscopy: * Oral bowel prep (can dehydrate an old person) +/- sedation (adult to drive them home afterwards) * Rectum, colon, +/- terminal ileum

Answer 16

**Staging:** * First degree - vessel cushions that do not descend below dentate line on straining * Second degree - proturde below dentate line & prolapse but reascend on their own * Third degree - prolapse out but reascend with PR exam * Fourth degree - prolapse and do not reascend (Haemorrhoids likely to only become itchy once they have prolapsed out and become irritated. Haemorrhoids become painful when they have prolapsed & thrombosed!) **Mx:** * Advice - dont strain, eat more fibre, don't stay on the toilet for too long (no newspaper or phones!) * Rubber band ligation * Surgery

Answer 17

* Painful bright red PR bleed * Usually at 6 or 12 oclock position * If lots of anal fissues everywhere then think Crohn's or HIV? (atypical skin tag) * Can have an associated skin tag Mx: * Diltiazem * GTN * Surgery NB: dont get confused with a fissue near the anus (but not at the opening) which is just from someone who scratches their fucking arse a lot

Answer 18

* "Painful lump at the anus about 6 weeks ago but now it's gone" * Can resolve itself * Short history course

Answer 19

* IBD - UC often * Chlamydia - always ask about sexual history * Infective diarrhoea - shigella etc * Radiation proctitis - usually radiation for prostate for man or cervical for a woman.

Answer 20

* A = anastomotic leak dumbass

Answer 21

* Primary condition * Secondary condition: * Neoplasia - be sure to exclude * Benign anorectal conditions, haemorrhoids, skin tags * Threadworm * Dermatological conditions

Answer 22

* Usually comes in as an emergency * Perianal abscess is most common cause Mx: * Comes in with painful anus & septic * Drain the pus * Treat the sepsis * Red buttocks may be seen / intense anal pain

Answer 23

* Obesity * NSAIDs * Smoking

Answer 24

* Anyone who comes in with painful PR bleeding will NOT be diverticulitis - this will be ischaemic colitis!

Answer 25

* Sign of inflammation --\> sensation of incomplete evacuation * ?Cancer vs IBD (UC)

Answer 26

* Ask them what they mean by this! * And what is normal for them **Ix:** * Hx - diet? * O/E - rectocele (usually as a result from childbirht in women) * Exclude serious colonic pathology if any alarm symptoms * Ca, TFT, glucose, K * Colonic transit studies * Defeacting proctography - barium, isotope, MRI

Answer 27

* Intrinsic lesions: * Malignancy * Cricoid web * INflammatory / peptic stricture * Extrinsic elsions * LAD * Bronchial carcinoma * LA enlargement in mitral stenosis * Functional causes: * Swallow initiation (MND, Post-CVA) * Oesophageal dysmotility (diffuse spasm, scleroderma)

Answer 28

* Inflammation: * Reflux oesophagitis * Peptic oesophageal ulceration * Infeciton: * Thrush * Herpes * Bacterial / viral pharyngitis * Spasm: * diffuse oesophageal spasm

Answer 29

* Needs 24hr pH monitoring * Dx = oesophageal **pH \<4** for **\>4% of a 24hr period**!! (NB: in a history also ask how many pillows they sleep on, they also prop themselves up)

Answer 30

* Manometry: * They pass a tube down the oesophagus which has little pressure sensors all over it * They will ask pt to cough, swallow, valsalva manouvers etc * Achalasia - shows as absence of peristalsis (due to lack of ganglia in Auerbach's plexus - essentially Hirschprung's for the LOS) * 24hr pH monitoring: * After the manometry they will pass a very thin NG tube down the oesophagus, into the stomach * This is attached to a battery pack and they will wear it for 24 hrs * It records pH in the stomach, vs along the oesophagus at different points

Answer 31

* Barium = nutcracker oesophagus with diffuse uncoordinated spasm (vs. birdbeak on barium swallow with achalasia or irregularity along the filling defect with oesophageal cancer) * Mx = nifedipine & reassurance

Answer 32

* Prague classification: * C = circumference (of the oesophagus) * M = maximumen extent (from stomach upwards)

Answer 33

* Gold standard for staging the T stage of oesophageal cancers * Can also take a targetted biopsy of the lesion

Answer 34

* Patient fit for surgery? * Echo * Pulmonary function tests * Anaesthetic assessment * CT scan - ?mets * Yes to mets - not fit for surgery --\> CTR / palliative (stenting for symptomatic relief) * No --\> consider surgery IF cancer is small enough and ideally placed in the oesophagus * Large tumour not eligible for surgery? * Neo-adjuvant CTR

Answer 35

* Stomach cancer --\> bilateral ovarian tumours * If stomach cancer causes ulcer which perforates then there can be direct seeding of the peritoneum --\> ovarries

Answer 36

* Storage: (FUNI) * Freqeuncy * Ugrnecy * Nocturia * Incontinence * Voiding: * Slow stream * Splitting or spraying * Intermittency * Hesistancy * Straining * Terminal dribble * Post-micturition: * Post-micrturition dribble * Feeling of incomplete emptying

Answer 37

* Hx * PR exam - ?BPH * PSA (age-specific) * Urinalysis - ?UTI * Frequency-volume charts / Voiding diary * (maybe) Urodynamics - saved for last resort * One catherter passed through the urethra into the bladder * Another catheter passed into the back passage * Both are used to measure the contractilty of the detrusor muscle

Answer 38

* **IPSS (International Prostate Symptoms Score)** * Measures how bothered/affected patients are by their BPH/LUTS and then gives an idea of how you should treat them

Answer 39

* Alpha blockers are 1st line: * Alfuzosin & tamulosin - best tolerated * SE's: * Warn them about the risk of retrograde ejaculation --\> may pass ejaculation in the urine (harmless mediaclly but may be worrisome and also may affect fertility) * May cause dizziness but most Rx are very selective alpha blockers In practice... * Patients with bothersome LUTS at _low risk of progression:_ * alpha1-AR antagonist monotherapy * Patients with bothersome LUTS at _high risk of progression:_ * Alpha1-AR antagonist + 5alpha reductase inhibitor (eg: Finasteride) * Patients with LUTS & _overactive bladder:_ * Alpha1-AR blocker + antimuscarinic agent * Patients with LUTS & _erective dysfunction_: * Alpha1-AR antagonist + PDE5 inhibitor

Answer 40

* Analogous to IBS * Do not make this diagnosis until you have excluded any other possible causes * Lifestyle changes & bladder retraining is always first line - cut down on caffeine!

Answer 41

* Brain - congitive problems * Salivary glands - dry mouth * Heart - tachycardia * GI smooth muscle - constipation * Contraindicated in UC (can cause toxic megacolon) * Eye - blurred vision * Contraindicated in glaucoma

Answer 42

* **Torsion** * High-riding testicle * Acutely painful - won't be able to examine * Antalgic gait * Absent cremasteric * N&V and abdo pain * Straight to theatre! * US might not even show it because arterial flow is preserved over venous. * **Epididymorchitis** - STD vs recurrent UTI * **Cancer** Non-urological: * **Hernia** - try to feel above it * **Renal stones** Mumps - bilateral orchitis with preceeding URTI. Worrisome for infertility. Isolate the patient.

Answer 43

_Low Pressure:_ * Low pressure retention is safe * Put catheter in and drain it _High Pressure:_ * High pressure retention is unsafe * The high pressure is passed back to the kidneys --\> hydronephrosis & give the problems of a post-renal renal failure with time * Put a catheter & LEAVE IT IN --\> refer to urologist * Another clue is that they will diurese after you catheterise and offload a huge amount of fluid - they have retained fluid with this retention AND the LoH will have been damaged in this rentention, causing them to lose Na+ & K+ and fluids _Ix when someone goes into retention:_ * Creatinine & U&E's - if these are (newly) deranged then get more worried * US of kidneys - ?hydronephrosis _Chronic Urinary Retention:_ * Often can present with nocturnal enuresis *

Answer 44

* Ix with trauma CT - arterial phase * Bleeding into the retroperitoneum from renal trauma is self-limiting due to the lack of volume in the retroperitoneum * No surgery - as soon as you open up that retroperitoneum, bleeding with increase hugely (even with things like stabbings for example) * Bed rest is best * Abx for static blood if necessary * Interventional radiology can embolise the bleeding vessel if necessary

Answer 45

* Rupture AAA * Renal colic - ?stone * Constant renal pain - ?pyelonephritis * Pyelonephritis = 2 weeks of Abx

Answer 46

* Fourniere's gangrene * Dont miss it

Answer 47

* Cancer (20%) - _bladder_, ureteric, renal * Trauma * Infection - UTI * Renal stones * BPH Ask about: * Fever * LUTS * Renal colic * Smoking, working with dyes, weight loss, lethargy, chronic inflammation (long term catheters) - bladder cancer **Ix:** * Bloods: * Creatinine, U&E's, FBC, clotting (eg: on warfarin), LFT's, Ca2+, PSA * Urine: * Urinalysis, MSU/MC&S, cytology * ?protein urea --\> nephrology input perhaps * Imaging: * USS - non-visible haematuria * CT urogram - visible haematuria (need a bit more detail as we are a bit more worried) * Cystoscopy

Answer 48

* BPH * Cancer * Prostatitis * Or local inflammation caused by a UTI

Answer 49

* AFP - only other cause is hepatocellular carcinoma * HCG - only caused of raised in a bloke Testes cancer goes to the retroperitoneal nodes - this is where the testes start

Answer 50

* Diet: animal protien, salt, oxalate * Hot climate (& _Dehydration)_ * Infection (urease) * Abnormal anatomy / strictures * Poor mobility * IBD - increased oxalate (due to poor management of bile salts) * Chemotherapy * Gout * Hyperparathyroidism

Answer 51

* X-linked so only seen in males * BUT male-male transmission is not seen

Answer 52

Can be mild, moderate, severe depending on respiratory distress etc _Admit to hospital when:_ * Moderate-severe * \<6months age * Known airway abnormalities (Laryngomalacia, Down syndrome) * Uncertainty about Dx * DDx = acute epiglottitis, bacterial tracheitis, peritonsillar abscess & foreign body inhalation _Rx:_ * Regardless of severity give oral dexamethasone * Emergency manageent: * High flow oxygen * Nebulised adrenaline

Answer 53

**Diagnostic criteria** * Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features: * Paroxysmal cough. * Inspiratory whoop. * Post-tussive vomiting. * Undiagnosed apnoeic attacks in young infants. * Nasal swab for culture for confirmatory Dx * PCR & Serology used more frequently

Answer 54

Edinburgh scale: * 10 question questionnaire * Score out of 30 * score \> 13 indicates a 'depressive illness of varying severity'

Answer 55

**Endometrial cancer !!**

Answer 56

* Commence aspirin 75mg OD from 12 weeks until birth

Answer 57

A baby is born with: * Micrognathia, * low-set ears, * **rocker bottom feet** * overlapping of fingers * **Choroid plexus cysts** * Small placenta * Polyhydramnios

Answer 58

**Methotrexate!** * Only suitable if the patient is willing to attend follow up

Answer 59

* Size? * Ruptured? * Symptoms? * Foetal heartbeat? * b-hCG? * Another intrauterine pregnancy co-existing? * Follow up?

Answer 60

* Microcephaly, * small eyes, * low-set ears, * cleft lip * **P**olydactyly = **P**atau syndrome

Answer 61

* Motivational interviewing * Nicotine patch! * Neither bupropion or varenicline should be offered to pregnant women

Answer 62

* Whooping cough should be suspected if a person has an acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features: * Paroxysmal cough. * Inspiratory whoop. * Post-tussive vomiting. * Undiagnosed apnoeic attacks in young infants.

Answer 63

* Provoked PE --\> warfarinise for 3 months (NB: even COCP = provoked) * Unprovoked PE --\> warfarinise for 6 months

Answer 64

* due to a defect in the gene which codes for type IV collagen resulting in an abnormal glomerular-basement membrane (GBM) * Disease more severe in males (females rarely progressing to CKD) * A favourite question is: * An Alport's patient with a failing renal transplant. This may be caused by the presence of anti-GBM antibodies leading to a Goodpasture's syndrome like picture * Alport's syndrome usually presents in childhood. The following features may be seen: * microscopic haematuria * progressive renal failure * bilateral sensorineural deafness * lenticonus: protrusion of the lens surface into the anterior chamber * retinitis pigmentosa * renal biopsy: splitting of lamina densa seen on electron microscopy

Answer 65

* pale, * pulseless, * pain, * paralysis, * paraesthesia, * perishingly cold NB: Critical limb ischaemia = longer than 2 weeks

Answer 66

* Injectables * EG: Depo Preovera (progesterone only injectable) * Associated with a delay in return to fertility of about 12 months

Answer 67

* ABCDE * Analgesia * Physio! * MRI can confirm diagnosis but even with this first option is often physiotherapy for convservative management before surgery

Answer 68

* I: Never tans, always burns (often red hair, freckles, and blue eyes) * II: Usually tans, always burns * III: Always tans, sometimes burns (usually dark hair and brown eyes) * IV: Always tans, rarely burns (olive skin) * V: Sunburn and tanning after extreme UV exposure (brown skin, e.g. Indian) * VI: Black skin (e.g. Afro-Caribbean), never tans, never burns

Answer 69

* Total abdominal hysterectomy with bilateral salpingo-oophorectomy NOT Transcervical endometrial resection

Answer 70

* 1st line = non-antibiotic topics (eg: topical Benzoyl peroxide) * 2nd line = add Abx (eg: topica Benzoyl peroxide + clindamycin)

Answer 71

* calcium gluconate * Insulin/dextrose infusion * Nebulised salbutamol * There is NO place for bicarbonate in the Mx of hyperkalaemia

Answer 72

* Decreased excretion of uric acid * drugs\*: diuretics * chronic kidney disease * lead toxicity * Increased production of uric acid * myeloproliferative/lymphoproliferative disorder * cytotoxic drugs * severe psoriasis * Lesch-Nyhan syndrome * hypoxanthine-guanine phosphoribosyl transferase (HGPRTase) deficiency * x-linked recessive therefore only seen in boys * features: gout, renal failure, neurological deficits, learning difficulties, self-mutilation

Answer 73

* In infantile spasms the child will become distressed (eg: crying etc) between spasms, whereas in colic the child will become distressed during the 'spasms' * Infantile spasms --\> hypsarrthymia on EEG

Answer 74

* hepatitis B most common cause worldwide * hepatitis C most common cause in Europe

Answer 75

* Encourage **regular exercise** such as swimming * Physiotherapy * **NSAIDs are the first-line treatment** * The disease-modifying drugs which are used to treat rheumatoid arthritis (such as _sulphasalazine_) are only really useful if there is _peripheral joint involvement_ * The 2010 EULAR guidelines suggest: '_Anti-TNF therapy should be given to patients with persistently high disease activity_ despite conventional treatments'

Answer 76

* Hepatomegaly - **you useless fucktard** * This is the only one which is a direct measure of right heart function

Answer 77

* Melanosis coli is the abnormal pigmentation of the large bowel due to the presence of pigment-laden macrophages. * It is most commonly due to laxative abuse. * Will often be an incidental finding on colonoscopy

Answer 78

* Without iron overload (~90% of patients): * Inflammation (due to ferritin being an acute phase reactant) * Alcohol excess!! * Liver disease * Chronic kidney disease * Malignancy * With iron overload: * Primary iron overload (hereditary haemochromatosis) * Secondary iron overload (e.g. following repeated transfusions)

Answer 79

* Give immunglobulin + vaccination

Answer 80

**Ulcerative Colitis:** * In patients with fulminant UC a sub total colectomy is the safest treatment option. * Acutely unwell patient (eg: toxic megacolon) = The rectum will be left in situ as resection of the rectum in acutely unwell patients carries an extremely high risk of complications. * Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is _only offered in the elective setting._ * Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling **_Crohn's:_** * Indications for surgery include complications such as fistulae, abscess formation and strictures. * Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. * Severe perianal and / or rectal Crohns may require proctectomy. * Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended.

Answer 81

* Presentation: * "bag of worms" soft scrotal mass * decrease in supine position * Increase with valsalva manouvers/standing * Risk of subfertility * Testicular atrophy * US findings: * Retrograde venous flow * Dilated & tortuous veins - dilatation of pampiniform plexus

Answer 82

* Most concerning loss is amniotic fluid from: * premature rupture of membranes (labour) * or intraamniotic infection * PROM: * Visualisation of amniotic fluid emerging from cervix with Valsalva (cough) * Nitrazine turns blue * Ferning on microscopy

Answer 83

* Factor V Leiden * Meaning it is unable to respond to activated protein C, causing an effective Protein C resistance * Testing should be considered in anyone with an unprovoked DVT/PE who is \<45yrs or with an unusual site of thrombus

Answer 84

* Can develop following any inflammatory process (eg: surgery, cholecystectomy, pancreatitis) * Encompasses dyskinesia & stenosis of the sphincter * Results in a functional biliary disorder, retention of bile, that mimics a stone/structural lesion * Rucurrent, episodic RUQ pain following a fatty meal, with corresponding elevated ALT & ALP rises * Visualisation of the duct on US can show a dilated duct with NO stone * Opioid analgesics (eg: morphine) can make the pain worse by causing the sphincter to contract

Answer 85

* Most women become aware of foetal movements by 18-20 weeks * Can be later if it's your first pregnancy * Multiparous women can feel them as early as 16 weeks * Evenings and at night are when most movements will be felt * Baby has 20-40 minute sleep periods during which baby's movements will not be felt * Number of movements tends to increase up to 32 weeks and then remain constant * You should feel your baby move right up until labour (and even during labour) * If you are busy, you may notice these movements less * No specific number for baby's movements which you need to be worried about but a change in the number of type of movements which makes you worried should lead you to contact your midwife * What can cause a decrease in movements: * Certain drugs (pain relief, opioids, sedatives) * Alcohol/smoking * If baby is unwell * Rarely, muscular/neurological conditions * _If you haven't felt your baby move by 24 weeks seek medical attention, where they will measure you and listen to baby's heart and maybe do a scan if they are worried_

Answer 86

* Increasing pro-BNP * Hyponatraemia * Renal insufficiency * QRS duration \>120 * Left bundle branch block pattern

Answer 87

* Anterior slippage of the vertebral body due to bilateral defects of the pars interarticularis (spondylolysis) * Classic presentation is an adolescent with pain exacerbated by lumbar extension * Adolescent - growth spurts naturally increase lumbar lordosis & also decreased bone mineralisation * Also a palpable step off in the area of the vertebra - it has shifted forward * Dx = Xray

Answer 88

* Growth restriction & microcephaly * Periventricular calcifications * Hepatosplenogemaly * Thrombocytopenia

Answer 89

Conductive hearing loss = obstruction with sound to the external ear Sensorineuronal hearing loss = involving inner ear, cochlea and auditory nerve * If you have BC \> AC on Rinne's test, then you have a conductive hearing problem * If you then have a Weber's test which localises to that affected ear, then you confirm a conductive hearing loss in that ear (because BC is louder than the ambient noise) By contrast, sensorineuronal hearing loss lateralises to the unaffected ear because they cannot sense the vibration in that ear. **NB:** Otosclerosis is the most common cause of conductive hearing loss in adults. Ototoxic drugs cause sensorineuronal hearing loss (obviously)

Answer 90

* Clinical features: * Acute-onset joint pain, swelling and limited ROM * Refusal to weight bear * Fever \> 38.5 * Dx: * Increased WBC, ESR, CRP * Blood culture * Joint aspiration (for WBC) * Joint effusion on U/S or MRI * Mx: * Joint drainage & debridement * IV Abx

Answer 91

* Vancomycin **NB:** Vancomycin also requires therapeutic monitoring in patients with renal impairment due to renal excretion!

Answer 92

* More common causes: * Procainamide * Hydralazine * Less common causes: * Isoniazid * Phenytoin * Minocycline

Answer 93

* Alcohol * Hypothermia!

Answer 94

* Unexplained petechiae or hepatosplenomegaly

Answer 95

* Nicotinic receptor partial agonists! * Varenicline * Bupropion * Pregnant mothers - offer CBT first line * Varenicline & bupropion = contraindicated

Answer 96

* Sigmoid colon - place of highest pressure causing out-pouchings of the bowel wall * Typical Hx of: * Change in bowel habit - stools being like droplets * PR bleed * Abdo pain * Refer for urgent red flag colonoscopy - malignancy vs diverticula disease

Answer 97

* Pupillary reflex * Fixed pupils * Corneal reflex * Oculo-vestibular reflex * No eye movements following injections of cold water into each ear * Cough reflex * Absent response to supra-orbital pressure * Absence of spontaneous respiratory response

Answer 98

* P450 inhibitor * Ask about other medications? * Causes increased appetitie & weight gain * Causes alopecia

Answer 99

* Focial dystonia - involves rigidity and writhing movements Rather than twitching...

Answer 100

* Inguinal hernia: * bulge lateral to pubic tubercle (usually presents on crying due to raised intra-abdominal pressure) * **Inguinal hernia in a child is pathological** with series risk of incarceration and requires surgical correction following the **six/two rule:** * \< 6 weeks old = correct within 2 days \< 6 months = correct within 2 weeks \< 6 years = correct within 2 months * Umbilical hernia in a child can resolve - monitor it closely * Usually resolve by 3yrs

Answer 101

* _Acute_: * Triptan + NSAID * Triptan + paracetamol * _Prophylaxis_: * Topiramate * Propranolol

Answer 102

* Spironalactone

Answer 103

**Verapamil:** * Indications: angina, HTN, arrhythmias * MOA: highly negatively inotropic * SE's: heart failure, constipation, hypotension, bradycardia, flushing * Contraindication: should NOT be given with B-blockers as can cause heart block **Diltiazem:** * Indications: angina, HTN * MOA: less negatively inotropic than verapamil but still use with caution in patients with heart failure or on beta-blockers * SE's: hypotension, bradycardia, heart failure, ankle swelling **Nifedipine, amlodipine, felodipine (Dihydropyridines):** * Indications: angina, HTN, Raynaud's * MOA: affect the peripheral vascular smooth muscle \> myocardium --\> therefore do NOT result in worsening heart failure * SE's: flushing, headache, ankle swelling

Answer 104

* Gout = negatively bifringent needle-shaped crystals (urate) * Psueodgout = weakly positive bifringent rhomboid-shaped crystals * Associated with acromegaly

Answer 105

* Exclude from school for 48hrs from commencement of antibiotics

Answer 106

* Presenting in _first days of life_ = _TGA_ * Presenting at _1-2months_ = **ToF**

Answer 107

* Inability to complete full sentences * PEFR 33-50% of best or predicted * RR \> 25/min * HR \> 110bpm * Sats \<92% --\> indicate a life-threatening attack

Answer 108

* Wilson's disease!! Combination of liver & neurological signs --\> Wilson's disease! DDx here = Wernicke Korsakoff syndrome, but the patient said they didn't booze

Answer 109

* Normal = 400 micrograms * Previous pregnancy affected by neural tube defects = dosage upped to 5 miligrams

Answer 110

* Sudden onset SOB & _pleuritic chest pain_ too * ?Hx of Marfan's/ED

Answer 111

* Women \>30yrs with unexplained breast lump This patient had a breast lump which has persisted for more than one menstrual cycle.

Answer 112

* In this case, can give aspirin immediately & specialist referral to be seen within 24hrs. * No need for CT scan to rule out haemorrhagic stroke unless symptoms persist

Answer 113

* The hemianopia is ALWAYS on the same side as the hemiparesis!!

Answer 114

* Cerebellar hemisphere = finger-nose passpointing * Cerebellar vermis = ataxic gait w/out finger-nose passpointing.

Answer 115

* Lateral medullary syndrome! * Stroke in the territory of posterior inferior cerebellar artery (PICA) Stroke is always ipilateral to CN lesion therefore right! NB: An anterior inferior cerebellar artery infarct would present in the same way but with the additional symptoms of a same-sided facial weakness and loss of hearing. NB: Basillar stroke --\> locked in syndrome

Answer 116

Fecking true plus they'll get shredcity bitch

Answer 117

* ?Vestibular schwannoma Ix with Audiogram + gadolinium-enhanced MRI **NB:** The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex

Answer 118

* Verapamil is used for cluster headache prophylaxis. * Sumatriptan is used as an acute rescue therapy (along with high-flow oxygen), so make sure you read the question properly.

Answer 119

* ? lacunar infarct !!! (isolated sensory loss)

Answer 120

* **Broca's =** inferior frontal gyrus * **Wernicke's =** superior temporal gyrus * Conductive aphasia = arcuate fasciculus Again the motor in front of the receptive bit. Frontal (Broca's) in front of Temporal (Wernicke's)

Answer 121

* Aspirin 300mg OD for 2 weeks * Clopidogrel 75mg OD lifelong

Answer 122

* This patient has diabetes insipidus due to a craniopharyngioma. * This causes a lower bitemporal hemianopia.

Answer 123

PASTRIES * P - Posterior fossa tumour A - Alcohol S - Multiple sclerosis T - Trauma R - Rare causes I - Inherited (e.g. Friedreich's ataxia) E - Epilepsy treatments S - Stroke

Answer 124

* Depression! (subtle and often overlooked sign) * but is obviously very common so dont necessarily rely on this for diagnosis

Answer 125

* chocolate, * hangovers, * orgasms, * cheese/caffeine, * oral contraceptives, * lie-ins, * alcohol, * travel, * exercise

Answer 126

* Shaft # --\> radial nerve damage * proximal humerus # --\> axillary nerve damage * supracondylar humerus # --\> ulnar nerve damage

Answer 127

* Elevated serum **prolactin** 10 to 20 minutes after an episode can be used to differentiate a general tonic-clonic/partial seizure (RAISED) from a non-epileptic pseudo seizure (NORMAL)

Answer 128

Always include it in the workup!

Answer 129

* Mx = surgical decompression! (Over using shock waves etc) * Patients with obstructive urinary calculi and signs of infection require urgent renal decompression and IV antibiotics due to the risk of sepsis

Answer 130

* **AMPULLA!** **Ample get stuck here.**

Answer 131

* NOT baby blues as this should pass by 3 days post giving birth * Likely to be postpartum depression * So, ask the mother to complete the **Edinburgh Depression Scale**

Answer 132

* first line = SABA (salbutamol) or SAMA (ipratropium)

Answer 133

CASE EXAMPLE: A 62-year-old man is brought to the doctors by his daughter. Four weeks ago his wife died from metastatic breast cancer. He reports being tearful every day but his daughter is concerned because he is constantly 'picking fights' with her over minor matters and issues relating to their family past. The daughter also reports that he has on occasion described hearing his wife talking to him and on one occasion he prepared a meal for her. Despite this he has started going walking again with friends and says that he is determined to get 'back on track'. * Normal grief reactions can last up to a year or beyond. * Normal grief reaction can have psuedohallucinations (insight is maintained) - eg: hearing wife but ackowledging she's not actually there * DABDA

Answer 134

* nausea/vomiting, diarrhoea * fine tremor * nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus * thyroid enlargement, may lead to **_hypothyroidism_** * ECG: T wave flattening/inversion * weight gain * idiopathic intracranial hypertension

Answer 135

* Can be differentiated by the short course of onset! * Biological symptoms of lack of sleep & appetite will also point towards depression (psuedodementia) * Global memory loss (rather than specific memory loss) is more likely in depression (pseudodementia) **CASE:** * A 71-year-old male presents to the GP because he is worried about memory loss. Over the last three weeks, he has been very forgetful and absent minded. He does not remember conversations that have happened earlier that day, and has been forgetting to lock the front door. He has also been very tired and has not been wanting to go out for bingo as he usually does. He is concerned about the memory loss as he lives alone, and is worried that he may put himself at risk. Initially he appears to be cheerful, but starts crying during the consultation when talking about his symptoms. * (PRESENTATION OF DEPRESSION!). SHORT COURSE OF HISTORY PLUS PATIENTS WITH DEMENTIA ARE NOT USUALLY THE FIRST TO NOTICE THEIR SYMPTOMS - FAMILY/FRIENDS ARE - AND THEREFORE THEY ARE NOT AS CONCERNED

Answer 136

Conventional antipsychotics are associated with problematic extrapyramidal side-effects which has led to the development of atypical antipsychotics such as clozapine **Extrapyramidal side-effects:** * Parkinsonism * Acute dystonia (e.g. torticollis, oculogyric crisis) * Akathisia (severe restlessness) * Tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw) The Medicines and Healthcare products Regulatory Agency has issued specific warnings when _antipsychotics are used in elderly patients_: * Increased risk of stroke * Increased risk of venous thromboembolism **Other side-effects:** * Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation * Sedation, weight gain * Raised prolactin: galactorrhoea, impaired glucose tolerance * Neuroleptic malignant syndrome: pyrexia, muscle stiffness * Reduced seizure threshold (greater with atypicals) * Prolonged QT interval (particularly haloperidol)

Answer 137

* Most things low! * low FSH, LH, oestrogens and testosterone * Low thyroid * G's and C's raised: * **_g_**rowth hormone, * **_g_**lucose, (impaired glucose tolerance) * salivary **g**lands, * **c**ortisol, * **c**holesterol, * **c**arotinaemia

Answer 138

* Lorazepam belongs to the benzodiazepine class of drugs. * One of the side effects of this drug is that this can cause anterograde amnesia. * So can present with memory problems which mimic dementia (patient who loses their keys and often forgets what they have been doing during the day)

Answer 139

* Presence of psychotic symptoms - eg: auditory hallucinations Mania --\> urgent referral to CMHT Hypomania --\> routine referral to CMHT

Answer 140

* EG: Started a course of pred for recent exacerbation of asthma!

Answer 141

* Constipation! * Potentially a higher mortality from bowel obstruction/impaction and perforation than from agranulocytosis! * Can also lower seizure threshold!

Answer 142

Alcohol withdrawal * symptoms: 6-12 hours * seizures: 36 hours * delirium tremens: 72 hours

Answer 143

Fecking true!! The diagnosis can therefore only be made once a person's personality has fully developed and their adaptive behaviours have become fixed

Answer 144

* Anorexia focused family therapy is the first-line treatment for children and young people with anorexia nervosa

Answer 145

* Weight gain!!

Answer 146

* Post MI in an adult = Sertraline! * In a child/adolescent = Fluoxetine!

Answer 147

* Post-concussion syndrome is seen after even minor head trauma * Typical features include * headache * fatigue * anxiety/depression * dizziness

Answer 148

* Lanugo hair (fine downy hair growth in response to the loss of body fat) * Failure of secondary sexual characteristics, * bradycardia, * cold-intolerance * yellow tinge on the skin (hypercarotenaemia)

Answer 149

* Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress * EG: non organic cause of loss of sensation below the knee in a non-dermatomal distribution

Answer 150

* Re-titrate the clozapine again slowly! If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly

Answer 151

SSRI + NSAID = GI bleeding risk - therefore give a PPI NB: Sertraline = SSRI of choice in patients with CVD, therefore all the other options were wrong

Answer 152

**NICE suggest a step-wise approach:** step 1: education about GAD + active monitoring step 2: low intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups) step 3: high intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information step 4: highly specialist input e.g. Multi agency teams **Drug treatment** NICE suggest sertraline should be considered the first-line SSRI interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Answer 153

* Hypochloraemia! * Hypokalaemia - can present with palpitations. ECG changes of tall P waves & flattened T waves! * Metabolic alkalosis Just think about vomiting all the time!

Answer 154

## Footnote **S**omatisation = **S**ymptoms (eg: presents repeatedly with headache & palpitations) hypo**C**hondria = **C**ancer (eg: presents worrying about fucking cancer)

Answer 155

* Call the police! * The patient is in a public place and threatening violent behaviour. The police should be contacted to transport her to a place of safety where she may be formally assessed. Metformin would not cause hypoglycaemia.

Answer 156

* - delusional jealously, usually believing their partner is unfaithful * (PSYCH)

Answer 157

* Prefer to be alone, don't like relationships, low libido

Answer 158

The following factors may exacerbate psoriasis: * trauma * alcohol * drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab * withdrawal of systemic steroids

Answer 159

ANSWER: the death must be discussed with the coronor, but wil most likely not be investigated Deaths occurring within 24 hours of admission to hospital should be discussed with the coroner before a death certificate is issued

Answer 160

* The classic triad of vasa praevia is rupture of membranes followed by painless vaginal bleeding and fetal bradycardia. * Unlike placenta praevia, vasa praevia carries no major maternal risk but fetal mortality rates are significant. The two conditions may be difficult to distinguish in acute clinical situations, but for examination purposes a preceding rupture of membranes will usually be emphasised. * Although ultrasound scans can detect vasa praevia, many cases are undetectable antenatally.

Answer 161

* "pruritic, erythematous, oozing rash with vesicles & oedema"

Answer 162

* Benzoyl peroxide (antimicrobial) * Vitamin A derivatives (eg: isoretinoin)

Answer 163

* "well-circumscribed, salmon-coloured plaques with silvery scale - often on scalp & extensor surfaces" * Vs. eczema which is less well circumscribed & is on flexors * Pathophys = Extensive keratinocyte proliferation * Rx: * Corticosteroids * IV light with psoralen * Immune-modulating therapies * Associations: * Nail pitting * Metabolic syndrome - always ask about DM, HTN, CVD

Answer 164

* Lichen planus - pruritic, polygonal , purple papules

Answer 165

* Autoimmune destruction of desmosomes between keratinocytes - due to IgG antibody against desmoglein (Type II HSR!) * Presents as skin & oral mucosa bullae * Thin-walled bullae rupture easily (Nikolsky sign) * Leading to shallow erosions with dried crust

Answer 166

* Autoimmune destruction of components of the basement membrane. * Due to IgG antibody against hemidesmosome components of the basement membrane * Presents as: * Blisters of skin * Usually in elderly * Oral mucosa is spared!!! * Tense bullae that do NOT rupture easily - therefore **clinically milder than pemphigus vulgaris**

Answer 167

* Autoimmune deposition of IgA at tips of dermal papillae * Presents as: * Pruritic vesicles & bullae that are grouped - herpetiform! * Strong association = coeliac disease!

Answer 168

* HSR characterised by targetoid rash & bullae! * Targetoid appearance = due to central epidermal necrosis surrounded by erythema * Associated with: * HSV infection * Mycoplasma infection * Drugs - penicillin & sulfonamides * Autoimmune disease - SLE * Malignancy

Answer 169

* **Erythema multiforme + oral mucosa/lip involvement + fever** _Toxic Epidermal Necorsis?_ * Severe form of SJS characterised by diffuse sloughing of the skin - resembling a large burn * Preceded by general malaise * Drugs are most common cause - lamotrigine!!

Answer 170

* Benign squamous proliferation * One of most common tumours in elderly * Presents as: * Raised, discoloured plaques on extremities or face * Often have "stuck on" appearance * Leser-Trélat sign? (SEE IMAGE ATTACHED) * Sudden onset of multiple seborrhoeic keratoses * Suggests underlying GI tract carcnoma

Answer 171

* Epidermal hyperplasia with darkening of the skin ("velvet-like skin") often involving the axilla or groin * Associated with: * Insulin resistance (T2DM) * Malignancy (especially gastric carcinoma)

Answer 172

* Elevated nodule with central, ulcerated crater surrounded by dilated (telangiectatic) vessels * "pink, pearl-like papule" * Classic location = upper lip!

Answer 173

* Ulcerated, nodular mass * Usually on the face - classically involving the lower lip

Answer 174

* Precursor lesion to SCC * Presents as: hyperkeratotic, scaly plaque - often on face, back or neck

Answer 175

Localised loss of skin pigmentation Due to autoimmune destruction of melanocytes

Answer 176

* Congenital lack of pigmentation * Due to an enzymatic defect (usually tyrosinase) that impairs melanin production * 2 different forms: * Ocular form - involves the eyes * Oculocutaneous form - both the eyes & the skin * Increased risk of SCC, basal cel carcinoma & melanoma (dueto reduced protection against UVB)

Answer 177

* Small tan/brown macule * Darkens when exposed to sunlight!! * Due to increased number of melanosomes (melanocytes NOT increased!!)

Answer 178

* mask-like hyperpigmentation of the cheeks * Assocaited with: * Pregnancy * Oral contraceptives

Answer 179

* Flat macule or raised papule * With symmetry, sharp borders, evenly distributed colour & small diameter (\<6mm)

Answer 180

* Risk factors based on UVB damage * Additional risk factor = dysplastic nevus syndrome (Autosomal dominant) * ABCDE! * Characterised by 2 growth phases: * Radial growth horizontally along epidermis & superficial dermis - low risk of metastasis * Vertical growht into deep dermis - increased risk of metastasis (HENCE, Breslow thickness score = key prognostic factor) * Variants: * Superficial spreading - best prognosis (refer to earlier comments) * Lentigo maligna melanoma - good prognosis * Nodular - early vertical growth = poor prognosis * Acral lentiginous - arises on palms/soles & not related to UV exposure

Answer 181

* Superficial bacterial skin infection * Most commonly due to * Staph aureus * Strep pyogenes * Commonly affects kids * Presents as: * Erythematous mcules that progress to pustules * Usually on the face * Rupture of pustules resutls in erosions & dry, crusted, honey-coloured serum

Answer 182

* Depper infection (dermal & subcut) * Usually due to: (same as for impetigo) * Staph aureus * Strep pyogenes * Presents as: * Red, tender, swollen rash * WITH FEVER!! * Risk factors: * Recent surgery * Trauma * Insect bite * Necrotizing fasciitis: * Can progress to nec fasc with necrosis of subcut tissue due to infection with anaerobic 'flesh-eating bacteria' * Produciton of CO2 --\> crepitus * Surgical emergency!!

Answer 183

* Sloughing of skin with erythematous rash & FEVER * Leads to significant skin loss * Due to staph aureus infection!! * Distinguished histologically from TEN by level of skin separation! (TEN separation occurs at dermal-epidermal junction) * Here separation occurs within the epidermis!

Answer 184

* Flesh-coloured papules with rough surface * Due to HPV infection of kertinocytes * Hands & feet commonly

Answer 185

* Typical history for acne rosacea!

Answer 186

* Painful skin = result of skin necrosis so probably not a good fucking sign - often admit to hospital!

Answer 187

* True innit bruv!

Answer 188

* Seborrhoeic dermatitis CASE: A 67-year-old man with a history of Parkinson's disease presents due to the development of an itchy, red rash on his neck, behind his ears and around the nasolabial folds. He had a similar flare up last winter but did not seek medical attention. What is the most likely diagnosis?

Answer 189

_Wallace's Rule of Nine:_ Each of the following is 9% of the body when calculating surface area % if a burn: * Head + neck, * each arm, * each anterior part of leg, * each posterior part of leg, * anterior chest, * posterior chest, * anterior abdomen, * posterior abdomen

Answer 190

* Used to assess patients at risk of pressure sores

Answer 191

* AVASCULAR NECROSIS OF FEMORAL HEAD Long-term steroid use (such as in this patient taking prednisolone for polymyalgia rheumatica) is a key risk factor for the development of avascular necrosis of the femoral head.

Answer 192

* lactose intolerance!! **Transient lactose intolerance is a common complication of viral gastroenteritis.** Removal of lactose from the diet for a few months followed by a gradual reintroduction usually resolves the problem.

Answer 193

The most common bacterial organisms that cause infective exacerbations of COPD are: * Haemophilus influenzae (most common cause) * Streptococcus pneumoniae * Moraxella catarrhalis

Answer 194

Visual changes secondary to drugs * blue vision: Viagra ('the blue pill') * yellow-green vision: digoxin

Answer 195

* Serious risk of cerebral oedema due to acidosis + fluid & electrolyte depletion * Therefore rehydrate at slower rate & also maintenance fluids is less per Kg * REMEMBER TO SAY THIS IN AN OSCE STATION! Can assume 5% dehydrated if pH \>7.1 Can assume 10% dehydrated if pH \<7.1

Answer 196

* A - NG tube inserted & placed on open drainage if vomiting/reduced GCS * B - give 100% oxygen if needed * C - tachycardia may be an indicator of shock (due to volume depletion from vomiting + osmotic diuresis due to hyperglycaemia). ECG to monitor for signs of hyperkalaemia * D - assess GCS regularly. Cerebral oedema is a key complication of DKA not to miss & hence the slow rehydration protocol & hence why monitoring of corrected sodium levels in the blood are key with rehydration. Insulin therapy should be started AT LEAST ONE HOUR AFTER initiating fluid therapy

Answer 197

Contraindication to lumbar puncture (any signs of raised ICP): * focal neurological signs * papilloedema * significant bulging of the fontanelle * disseminated intravascular coagulation * signs of cerebral herniation **NB:** For patients with **meningococcal septicaemia a lumbar puncture is contraindicated** - blood cultures and PCR for meningococcus should be obtained!!

Answer 198

* Coxsackie A16 and enterovirus 17 * Low grade fever, oral ulcers, erythematous hands/feet

Answer 199

* Fragile X! (a trinucleotide repeat disorder on chromosome X)

Answer 200

* Retinal haemorrhages, * **subdural** haematoma - tearing of the fragile bridging veins * encephalopathy

Answer 201

Parainfluenza virus : Croup RSV : Bronchiolitis Pseudomonas aeruginosa : pseudomonas Streptococcus pneumoniae : Pneumonia Bordetella pertussis : Whooping cough

Answer 202

* Internal fixation across the growth plate! In the meantime, bed rest without weight bearing & analgesia

Answer 203

* Observe & encourage regular feeding!! * TRANSIENT HYPOGLYCAEMIA IS COMMON IN 1ST HOUR AFTER BIRTH

Answer 204

* High dose aspirin * Single dose of IV immunoglobulin

Answer 205

* A young boy with: * learning difficulties, * macrocephaly, * large ears and * macro-orchidism

Answer 206

* Hip U/S * Up to 20% of those born breech will have DDH

Answer 207

**Neonatal Respiratory Distress Syndrome (NRDS)?** * Prematurity!! * CXR: In NRDS the characteristic features are a diffuse ground glass lungs with low volumes and a bell-shaped thorax. **Aspiration pneumonia?** * Meconium staning of the liquor at birth!! **Transient tachypnoea of the newborn?** * C-section!! * (Tachypnoea which resolves after 1 day ish) * CXR: heart failure type pattern (e.g. interstitial oedema and pleural effusions) but key distinguishing features from congenital heart disease are a normal heart size and rapid resolution of the failure type pattern within days.

Answer 208

* Multiple myeloma * Hyperparathyroidism

Answer 209

* "Mid-cycle" pain * Therefore will occur in the middle of a womans cycle so ask when her LMP and can include/exclude this as a DDx

Answer 210

**Hypercalcaemia!!**

Answer 211

* Infleunza * Pertussis * There is no individual pertussis vaccine therefore it is given in a vaccine alongside polio, diphtheria and tetanus.

Answer 212

**ANSWER:** Arrange radiotherapy!! * Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds * **NB:** Radiotherapy is routine following breast-conserving surgery. Without irradiation, the local recurrence rates are approximately 40%.

Answer 213

* REFER TO ENT This patient has a unilateral nasal polyp. Polyps due to rhinosinusitis are usually bilateral so it is important to refer this gentleman to be seen by an ENT doctor to exclude malignancy.

Answer 214

* Respiratory distress * Cerebral signs * Petechial rash Usually develops 12-72 hours post-op.

Answer 215

* Aspiration of stomach contents! * NB: He has absence of a raised temperature which indicates something other than an infective cause * This man has a number of risks for aspiration including a neurological injury, supported feeding and a tracheostomy.

Answer 216

* Hydralazine * isoniazid, * penicillamine, * procainamide, * phenytoin

Answer 217

* Meckel's diverticulum Meckels diverticulum is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.

Answer 218

* Occurs after membrane rupture when the umbilical cord descends below the presenting part of the fetus. It can lead to fetal hypoxia and death due to the cord being compressed or going into spasm. * 1: Tocolytics should be used to reduce cord compression and allow Caesarean delivery * 2: Correct, to avoid compression * 3: The patient is advised to go onto all fours * 4: The cord should not be pushed back into the uterus * 5: Immediate Caesarean section is the delivery method of choice

Answer 219

* fluorescein angiography is utilised if neovascular ARMD is suspected, as this can guide intervention with anti-VEGF therapy. This may be complemented with indocyanine green angiography to visualise any changes in the choroidal circulation. * ocular coherence tomography is used to visualise the retina in three dimensions, because it can reveal areas of disease which aren't visible using microscopy alone.

Answer 220

* **Nimodipine!** * to prevent vasospasm in aneurysmal subarachnoid haemorrhages * Patients presenting following sub arachnoid haemorrhage may suffer from cerebral vasospasm. Vasospasm occurs in approximately 30% of patients. In the sub population that this occurs in, it may result in further ischemia due to a reduction in distal blood flow. All patients are prescribed a calcium channel blocker to prophylactically prevent this from occurring.

Answer 221

* NSAIDs (eg: naproxen) = 1st line (Over physiotherapy - there is a delay whereas NSAIDs can be started now)

Answer 222

* **Urgent delivery & IV magnesium sulphate** This woman has severe pre-eclampsia as she has presented with moderate hypertension and also has symptoms of headache and vomiting. NICE guidelines recommend delivery within 24-48 hours in those women who has pre-eclampsia with mild or moderate hypertension after 37 weeks. Magnesium sulphate is used to treat women with severe hypertension or severe pre-eclampsia that have already had a seizure. IV magnesium sulphate should also be considered if birth is planned within 24 hours or if there is concern that a woman may develop eclampsia.

Answer 223

* The combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest autoimmune hepatitis

Answer 224

* Electrical cardioversion if have been in AF \>48 hours (apparently)

Answer 225

* **Caput Succedanem:** * Caput succedaneum is a subcutaneous, extraperiosteal, collection of fluid that collects as the result of pressure on the baby's head during delivery * **C**aput **S**uccedanem = **C**rosses **S**utures!! * **Cephalohaematoma:** * ****A cephalhaematoma is a haemorrhage between the skull and periosteum. Because the swelling is subperiosteal, it's limited by the boundaries of the baby's cranial bones. * **Chignon:** * Occurs in babys who have had a ventouse delivery

Answer 226

* Dry macular degeneration * Look like yellow spots/deposits (see picture)

Answer 227

* US with doppler flow (of hepatic vein)

Answer 228

**Primary Hyperparathyroidism:** * PTH elevated --\> Ca2+ elevated & phosphate low * Most cases due to solitary hyperparathyroid adenoma (80%), **Secondary Hyperparathyroidism:** * Ca2+ low --\> PTH elevated & phosphate low * NB: Ca2+ may be low or normal in this case due to the secondary increase in PTH * Parathyroid gland hyperplasia occurs as a result of low calcium, almost always in a setting of chronic renal failure **Tertiary Hyperparathyroidism:** * Correction of underlying renal disorder however ongoing hyperplasia of hyperthyroid glands --\> PTH elevated --\> Ca2+ normal/high & phosphate low * Alk phos elevated!!

Answer 229

* Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. * **Spider naevi fill from the centre** * Causes: liver disease, pregnancy, COCP use * **Telangiectasia from the edge**

Answer 230

**Psoriatic arthritis!!** Nail changes are clearly shown!

Answer 231

Migraine * **acute**: triptan + NSAID or triptan + paracetamol * **prophylaxis**: topiramate or propranolol

Answer 232

* **Lower zones** predominantly affected in **idiopathic pulmonary fibrosis** * **Upper zones** predominantly affected in: * Sarcoidosis * Coal Workers Pneumoconiosis * TB

Answer 233

* Dx = primary sclerosing cholangitis * (associated with UC) * Ix of PSC = ERCP

Answer 234

The following drugs should be avoided: * antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides * psychiatric drugs: lithium, benzodiazepines, clozapine! * aspirin * carbimazole * methotrexate * sulfonylureas * cytotoxic drugs * amiodarone

Answer 235

Blisters/bullae: * no mucosal involvement (in exams at least\*): **bullous pemphigoid** * mucosal involvement: **pemphigus vulgaris**

Answer 236

Recommend Adult Life Support (ALS) adrenaline doses * anaphylaxis: **0.5ml 1:1,000 _IM_** * cardiac arrest: **10ml 1:10,000 IV** or **1ml of 1:1000 IV**

Answer 237

Since the blood supply is threatened in intracapsular fractures, as a general rule: * Intracapsular femoral fracture - hemiarthroplasty * Extracapsular femoral fracture - dynamic hip screw _NB:_ A subcapital fracture is the commonest type of intracapsular fracture of the proximal femur.

Answer 238

* Wolff-Parkinson White (WPW) syndrome is caused by a congenital accessory conducting pathway between the atria and ventricles leading to a atrioventricular re-entry tachycardia (AVRT). _ECG Changes:_ * short PR interval * wide QRS complexes with a slurred upstroke - 'delta wave' * left axis deviation if right-sided accessory pathway\* * right axis deviation if left-sided accessory pathway\* See example ECG attached, showing short PR interval, delta waves with broad QRS, nonspecific ST-T changes which could be mistaken for myocardial ischaemia & the left axis deviation meaning this is type B WPW, ie. a right-sided accessory pathway!

Answer 239

* Previously non-sensitised 16 week pregnant mother undergoing amniocentesis * *Potentially sensitising events in pregnancy:** - Ectopic pregnancy - Evacuation of retained products of conception and molar pregnancy - Vaginal bleeding \< 12 weeks, only if painful, heavy or persistent - Vaginal bleeding \> 12 weeks - Chorionic villus sampling and amniocentesis - Antepartum haemorrhage - Abdominal trauma - External cephalic version - Intra-uterine death - Post-delivery (if baby is RhD-positive

Answer 240

* Intrapartum IV benzylpenicillin ONLY GBS is a vaginal commensal isolated in many women. It is known to be the most frequent cause of severe early-onset infection in the newborn and can cause significant morbidity and mortality. Only needs treating inpartum to reduce reduce of transmission to foetus.

Answer 241

**Psuedogout!** Chondrocalcinosis helps to distinguish pseudogout from gout

Answer 242

48 hours!!

Answer 243

* **Psoriatic Arthritis!**

Answer 244

**The following results would be expected in a trisomy 21 (Down's syndrome) pregnancy:** * Low alpha fetoprotein (AFP) * Low oestriol * High human chorionic gonadotrophin beta-subunit (-HCG) * Low pregnancy-associated plasma protein A (PAPP-A) * Thickened nuchal translucency

Answer 245

* Obese women BMI \>30

Answer 246

* Painless, transient monocular blindness together with the description of a 'black curtain coming down' is characteristic of amaurosis fugax Amaurosis fugax simply refers to painless transient loss of vision in one or both eye. Common causes include retinal ischaemia due to an embolic or thrombotic event - which in this case is supported by the patient's past medical history.

Answer 247

Acute viral labrynthitis: * sudden onset horizontal nystagmus, * hearing disturbances, * nausea, vomiting * vertigo

Answer 248

* Disseminated haemorrhagic chickenpox * Secondary bacterial infection * Encephalitis * Pneumonia

Answer 249

* Vesiculovaginal fistula! * Continuous driblling * Prolonged labour * Area with poor O&G services

Answer 250

* ACE inhibitors * spironolactone * beta-blockers * hydralazine with nitrates Drugs that do not impact mortality and only improve symptoms = loop diuretics (furosemide)

Answer 251

* Consolidation = fluid (blood, pus, transudate, water) or solid material (cells, fat, protein) * Atelectasis = most common finding in PE * Upper love **D**iversion = finding on heart failure CXR

Answer 252

* first metatarsophalangeal joint. * ie. the big toe 'knuckle' joint NOT the joint within the big toe

Answer 253

* Gallstones * Ethanol * Trauma * Steroids * Mumps (other viruses include Coxsackie B) * Autoimmune (e.g. polyarteritis nodosa), Ascaris infection * Scorpion venom * Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia * ERCP * Drugs (azathioprine, mesalazine\*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Answer 254

* Weight loss * Hyponatraemia * Hyperkalaemia Otherwise can be very nonspecific

Answer 255

LOOK THIS UP DUMBASS

Answer 256

* 0.1 ml of PPD injected intradermally * result read 48-72 hours later * erythema & induration \> 10mm = positive result - this implies previous exposure including BCG * if strongly positive TB likely (response to previous BCG decreases with time), needs further investigation including e.g. CXR

Answer 257

Metabolic acidosis is commonly classified according to the anion gap. This can be calculated by: **(Na+ + K+) - (Cl- + HCO-3)**. If a question supplies the chloride level then this is often a clue that the anion gap should be calculated. The **normal range = 10-18 mmol/L** Normal anion gap ( = hyperchloraemic metabolic acidosis) * gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula * renal tubular acidosis * drugs: e.g. acetazolamide * ammonium chloride injection * Addison's disease Raised anion gap * lactate: shock, sepsis, hypoxia * ketones: diabetic ketoacidosis, alcohol * urate: renal failure * acid poisoning: salicylates, methanol Metabolic acidosis secondary to high lactate levels may be subdivided into two types: * lactic acidosis type A: sepsis, shock, hypoxia, burns * lactic acidosis type B: metformin

Answer 258

Umbilical hernias: Usually self-resolve, but * if large or symptomatic perform elective repair at 2-3 years of age. * If small and asymptomatic peform elective repair at 4-5 years of age.

Answer 259

Shortened, internally rotated femur? **posterior hip dislocation!** Shortened, externally rotated femur? **NOF#**

Answer 260

Following weight loss, CPAP is offered first line

Answer 261

* Steroids - course of pred * Abx - if concurrent infection * Liver transplant last line Thrombocytopenia (low platelets) = sensitive & specific sign of cirrhosis!

Answer 262

* PCP pneumonia! * CXR will show very subtle signs which are hard to pick up

Answer 263

* Taking last thing at night improves efficacy

Answer 264

* intravenous antibiotics * early laparoscopic cholecystectomy within 1 week of diagnosis

Answer 265

Specific antibodies

Answer 266

Tamoxifen is used for oestrogen receptor-positive breast cancer, in the breast, it has anti-oestrogenic effects. However, on the endometrium, it has pro-oestrogenic effects. This effect, if unopposed by progesterone, can result in endometrial hyperplasia.

Answer 267

* Reduced serum copper & reduced ceruloplasmin - it has all deposited in tissues! Management is with penicillamine.

Answer 268

Hydrocele vs. large epididymal cyst

Answer 269

Often students find it difficult to differentiate biliary colic, cholecystitis and cholangitis. This is acute cholecystitis because this woman is systemically unwell and in pain, whereas in biliary colic she won't be systemically unwell. In acute cholangitis, the woman will most likely be jaundiced, which there is no mention of. Murphy's positive sign is also a sign typical in acute cholecystitis, and is pain on inspiration during palpation of the right upper quadrant. IV antibiotics and laparoscopic cholecystectomy are the management.

Answer 270

If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV * if HPV negative the patient goes back to routine recall * if HPV positive the patient is referred for colposcopy

Answer 271

* Neurogenic --\> desmopressin (vasopressin analogue) * Nephrogenic --\> thiazide diuretic! * In simple terms DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes more sodium to be released into the urine. This lowers the serum osmolarity which helps to break the polyuria-polydipsia cycle.

Answer 272

* ie. patient starts nasal decongestants which help initially but they then develop it again * Mx = cease nasal decongestants! (cold turkey!!)

Answer 273

* GBS - IV Benzyllpenicillin (or erythromycin if penicillin allergic) * Preterm prelabour rupture of membranes - erythromycin

Answer 274

* **Pityriasis rosea**

Answer 275

* Postpartum haemorrhage is defined as blood loss of **500 ml or more** within **24 hours** of the **birth of a baby** **(NOT WITHIN 24HRS OF DELIVERY OF THE PLACENTA DICKED)**

Answer 276

* **ATA1 deficiency** * Suspect this in cases of COPD-like disease in a young kid * Bronchiectasis would also present with a cough, recurrent chest infections and mucus production

Answer 277

Expectant management of an ectopic pregnancy can only be performed for 1) An unruptured embryo 2) \<30mm in size 3) Have no heartbeat 4) Be asymptomatic 5) Have a B-hCG level of \<200IU/L and declining

Answer 278

* 3 YOU FUCKING MINGMONG * ANTIGEN-ANTIBODY COMPLEXES!!

Answer 279

**VASOVAGAL!!** * A generalised tonic-clonic would have a wayy longer post-ictal state! * PLus she had job interview etc so may have been stressed * Slight limb shaking can be common in vaso-vagal!

Answer 280

Low-dose aspirin!!

Answer 281

_**Lifestyle**:_ * encourage high fibre, low glycaemic index sources of carbohydrates * discourage use of foods marketed specifically at people with diabetes * initial target weight loss in an overweight person is 5-10% **_HbA1c:_** * HbA1c should be checked every 3 months until stable, then every 6 months * _Essentially, good = 48 (6.5%) and consider adding something/changing something at 58 (7.5%)_ * It's worthwhile thinking of the average patient who is taking metformin for T2DM, you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%) Unfortunately, HbA1c guidelines vary depending on treatment... 1. Lifestyle --\> target 48 (6.5%) 2. Lifestyle + metformin --\> target 48 (6.5%) 3. Any drug which has a hypoglycaemic risk (eg: sulphonylurea) --\> target 53mmol/mol (7%) **_Risk Factor Modification:_** _Blood pressure:_ * target is **\< 140/80 mmHg** (or \< 130/80 mmHg if end-organ damage is present) * ACE inhibitors are first-line _Antiplatelets:_ * Should NOT be offered unless patient has coexisting CVD _Lipids:_ * Only patients with a 10-year cardiovascular risk \>10% (QRISK2) should be offered a statin * If primary prevention (ie. QRISK2 10%, most T1 diabetics, etc) = atorvastatin 20mg OD * If secondary prevention (ie. known CVD, cerebrovascular disease, or peripheral arterial disease) = atorvastatin 80mg OD **_Drug Treatment Pathway:_** (See the diagram attached!) * Dx of T2DM = 48mmol (and this is also the level where metformin should be offered) SO essentially offer metformin to all people at diagnosis but lots will choose to try lifestyle measures first! * If the HbA1c rises to 58mmol/mol (7.5%) then a second drug should be offered - 4 choices! * sulfonylurea (MOA = stimulate insulin release from ATP-dependent K+ channels in beta cells in panreas) * gliptin (MOA = blocks enzyme DPP4, which in turn breaks down incretin - a hormone which helps increase insulin) * pioglitazone (MOA = increases insulin sensitivity at the periphery, therefore need insulin in the blood for this to work) * SGLT-2 inhibitor (MOA = inhibit reabsorption of glucose in the kidney and therefore lower BG) * Again, 58mmol/mol (7.5%) is your cut off for considering triple therapy OR using a glucagon-like peptide1 (GLP1) mimetic IF THEY ARE OBESE (BMI \>35) or intolerant of insulin! * Ultimately, starting insulin... * Metformin should be continued. In terms of other drugs NICE advice: 'Review the continued need for other blood glucose lowering therapies' * NICE recommend starting with human NPH insulin (isophane, intermediate acting) taken at bed-time or twice daily according to need

Answer 282

* Calamine lotion - to reduce itch * Paracetamol - to reduce temp AVOID ibuprofen!! Risk with chickenpox & NSAIDs for necrotizing fasciitis

Answer 283

Internal malignancy!! Dermatomyositis can also present as part of a paraneoplastic syndrome

Answer 284

* British Thoracic Society guidelines state that in patients with an acute exacerbation of COPD in whom there is a **persistent respiratory acidosis** despite maximal medical therapy, non-invasive ventilation (NIV) should be considered. This patient has already had maximal standard medical therapy in the form of nebulisers, steroids and theophylline. While the other options are all concerning features of this patient's condition, it is the findings of a PaCO2 \>6 kPa and pH \<7.35 that are an indication for commencement of NIV.

Answer 285

* Acute Mx: * NSAIDs or colchicine!! * NB: watch for contraindications to NSAIDs (eg: GI bleed) * Chronic Mx: = urate lowering therapy * Allopurinol Lifestyle modifications * reduce alcohol intake and avoid during an acute attack * lose weight if obese * avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

Answer 286

* epistaxis : spontaneous, recurrent nosebleeds * telangiectases: multiple at characteristic sites (lips, oral cavity, fingers, nose) * visceral lesions: for example gastrointestinal telangiectasia (with or without bleeding), pulmonary arteriovenous malformations (AVM), hepatic AVM, cerebral AVM, spinal AVM * family history: a first-degree relative with HHT

Answer 287

**BASAL CELL CARCINOMA** Classic description!

Answer 288

**CT head immediately:** * _GCS \< 13 on initial assessment_ * _GCS \< 15 at 2 hours_ post-injury * suspected _open or depressed skull fracture_. * any sign of _basal skull fracture_ (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). * post-traumatic _seizure_. * _focal neurological defici_t. * _more than 1 episode of vomiting_

Answer 289

* Raised transferrin * Raised ferritin * Low TIBC Transferrin is the main protein that iron binds to for transport in the blood. Haemochromatosis causes increased iron, so more will be available to bind to transferrin so the saturation (percentage of transferrin bound to iron) is increased.

Answer 290

* Pneumocystis jiroveci pneumonia causes **desaturation on exercise**

Answer 291

* Every year from 40yrs of age

Answer 292

Paediatric BLS: In an infant, the appropriate places to check for a pulse are the brachial and femoral arteries NOT carotid! fat necks

Answer 293

**Coffee bean appearance!!** Three dense lines converging towards the site of obstruction (Frimann Dahl's sign) in keeping with sigmoid volvulus.

Answer 294

* Hold medications which are nephrotoxic! (**EG: ACE inhibitors)** * Give IV fluids * Treat underlying case

Answer 295

* *NO** – idiopathic * *D** – drugs (penicillin sulphonamides) * *O** – _oral contraceptive_/_pregnancy_ * *S** – _sarcoidosis_/TB * *U** – _ulcerative colitis_/Crohn's disease/Behçet's disease * *M** – microbiology (streptococcus, mycoplasma, EBV and more)

Answer 296

Serotonergic drugs that are associated with serotonin syndrome include: * tramadol, * selective serotonin reuptake inhibitors (SSRI), * monoamine oxidase inhibitors (MAOI), * triptans * St Johns wort. * Ecstasy & amphetamines!!

Answer 297

_What do they measure?_ * A cardiotocogram (CTG) measures fetal heart rate and uterine contractions. _When are they used?_ * It is used when there are risk factors for fetal hypoxia, such as pre-eclampsia, post-dates gestation, induction of labour, epidural use and prolonged labour. * CTGs are not specific and do increase medical intervention, but changes should be taken seriously as changes in fetal heart rate are an indicator of fetal distress. _How to interpret them? (DR C BRA VADO)_ * **DR-** **define risk**: why is this patient on a CTG monitor? e.g. pre-eclampsia, antepartum haemorrhage, maternal obesity, maternal ill health * **C- contractions**. Look at the bottom of the trace, each contraction is shown by a peak. In established labour you would expect 5 contractions in 10 minutes. Each large square = 1 minute duration, so count the number of contractions in 10 squares. * **BRA- baseline rate**. The fetal baseline rate should be approximately 110-160 beats per minute. Each large square = 10 beats and each small square = 5 beats. A fetal bradycardia is below 110 beats per minute and a fetal tachycardia is above 160 beats per minute. * **V- baseline variability**. The fetal heart rate should vary between 5 to 25 beats per minute. _Below 5 beats per minute, the variability is said to be reduced._ * **A- accelerations**. Are there accelerations in fetal heart rate? Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. _There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions._ * **D- decelerations.** Are there decelerations in fetal heart rate? These are a reduction in fetal heart rate by 15 beats or more for at least 15 seconds. _Decelerations are generally abnormal_ and should prompt senior review. In particular, _late decelerations, which are slow to recover are indicative of fetal hypoxia._ O- overall impression/diagnosis. As a medical student it is important to be aware of two features- terminal bradycardia and terminal decelerations. A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a 'pre-terminal' CTG and are indicators for Emergency Caesarean section.

Answer 298

* PT = extrinsic pathway (shorter) * APTT = intrinsic pathway (longer) Warfarin causes **both to be prolonged** as factors in both are vitamin K dependent! **NB:** Patients on DOAC's have NORMAL PT & NORMAL APTT

Answer 299

_Thyroglossal cyst?_ * Located in the anterior triangle, usually in the midline and below the hyoid (65% cases) _Branchial cyst?_ * Usually located anterior to the sternocleidomastoid near the angle of the mandible _Dermoids/dermoid cyst?_ * Derived from pleuripotent stem cells and are located in the midline Most commonly in a suprahyoid location They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat

Answer 300

**Magnesium should continue for 24 hours after delivery or last seizure!**

Answer 301

* Admit for 48 hours at least * Rx: * Steroids - for foetal lung maturity * Abx - due ot risk of sepsis & postnatal lung infection This woman is only 32 weeks gestation and it could be that she is going into labour with the rupture of the membranes. **NB:** If the woman does not progress to labour, she may be able to be managed at home and advised to take her temperature every 4-8 hours and to return to the hospital if she spikes a temperature. You should consider delivery at 34 weeks where the risks of infection may outweigh the risk of prematurity now you have allowed the lungs to mature.

Answer 302

**Adrenal hyperplasia!!** Small testes in the case of precocious puberty indicate an adrenal cause!

Answer 303

* **Hydrocephalus!** Common complication of interventricular haemorrhage Expansion of the haematoma can be worrying if it causes midline shift, but is not as likely as hydrocephalus. Hyponatraemia can occur with many types of cerebral insult but does not present with reduced responsiveness. **Vasospasm occurs only in patients with subarachnoid haemorrhages**. Hypoglycaemia should always be a worry when a patient has reduced consciousness but is not linked to cerebral bleeds.

Answer 304

* The NHS Breast Screening Programme is being expanded to include women **aged 47-73 years** * Women are offered a **mammogram every 3 years**

Answer 305

* beta blockers, * propylthiouracil * hydrocortisone Beta blockers are used to treat the tachycardia, however, these as always would be contraindicated in patients suffering from asthma. Propylthiouracil is used as an anti-thyroid treatment to help reduce the effect of raised serum thyroid hormones that are causing her symptoms. Hydrocortisone is used to treat any underlying adrenal insufficiency which is more common in patients suffering from hyperthyroidism and can also help to reduce serum thyroid hormone levels.

Answer 306

12 months after the last period in women \> 50 years 24 months after the last period in women \< 50 years

Answer 307

**Activated protein C resistance** (Factor V Leiden) is the most common inherited thrombophilia

Answer 308

**Bile duct stones!** Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result.

Answer 309

Neurogenic!! Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries

Answer 310

* Intrapartum Abx! * Maternal intravenous antibiotic prophylaxis should be offered to women with a previous baby with early- or late-onset GBS disease Ie. wrong answer = swaps to culture GBS - just give them intrapartum Abx!

Answer 311

* This patient is presenting with **Pancoast's syndrome.** Symptoms are caused by an apical malignant neoplasm of the lung. These include ipsilateral _invasion of the sympathetic cervical plexus_ leading to Horner's syndrome with shoulder and arm pain due to _Brachial Plexus invasion_. * **A smoking history** is the most important of the above questions to ask, as 90% of cancers are caused by smoking.

Answer 312

* A further abnormal HbA1c result!! Asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading before a diagnosis of type 2 diabetes is confirmed

Answer 313

Salpingotomy = 1st line & most successful if patient is not infertile (risk factors) Salpingectomy = 2nd line - 20% risk of failure Based on the NICE guidelines, salpingectomy is offered to women who has a tubal ectopic unless they have other risk factors for infertility eg. Contra lateral tube damage. Otherwise, salpingotomy is offered as an alternative. Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy.

Answer 314

Lung cancer --\> SVC obstruction!

Answer 315

Management of mastitis focuses on relieving pain with simple analgesia and warm compresses, and encouraging complete emptying of the breast after feeding (this may require the woman to express the remaining milk by hand or by using a breast pump). The woman should be encouraged to continue breast feeding as this improves milk removal and prevent nipple damage. If pain prevents the woman from breast feeding she should be encouraged to express breast milk by hand or pump until breastfeeding can be resumed. Antibiotics are only recommended if the lady has an infected nipple fissure, symptoms do not improve or are worsening after 12-24 hours despite effective milk removal, or bacterial culture is positive. The first line antibiotic is flucloxacillin

Answer 316

Hashimoto's thyroiditis = **hypothyroidism** + **goitre** + **anti-TPO**

Answer 317

The most common cause of this is H.Pylori infection, however, drugs such as NSAIDs, steroids and selective serotonin reuptake inhibitors (SSRI) can also cause the condition. Sertraline is an SSRI and thus should be stopped.

Answer 318

* Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve. * Features * auricular pain is often the first feature * facial nerve palsy * vesicular rash around the ear * other features include vertigo and tinnitus * Management * oral aciclovir and corticosteroids are usually given

Answer 319

TERLIPRESSIN! the patient has developed hepatorenal syndrome!!

Answer 320

* String of pearls - US appearance of cysts * Hyperandrogenism * Oligmenorrheoa * Prolactin normal - common cause of oligomenorrhoea to imporatnt to rule this out

Answer 321

* Shoulder dystocia * Macrosomia * Amniotic fluid excess * Stillbirth * Hypertension / Neonatal Hypoglycaemia _PLUS in pre-existing diabetes:_ * Congenital abnormaliteis * Miscarriage _NB:_ This is already a 'high risk' pregnancy and will be closely managed throughout, especially trying to optimise sugar control!

Answer 322

**G4P1⁺²** Pregnancies delivery at \<24/40 are denoted by a suffix Gravidity = number of times a woman has been pregnant (includes miscarriage, ectopic, termination, live birth, stillbirth, molar pregnancies!) Parity = how many times a woman has delievered at 24+ weeks gestation (dead OR alive!)

Answer 323

**DATING SCAN US at 12/40 weeks!** * Crown-rump length is used! Using LMP is NOT as reliable becasuse not every woman has a predictably regular cycle. It is a good method if the woman typically had a very regular cycle Use of the dating scan is less accurate beyong this gestation, particularly \>20/40

Answer 324

**Nagele's rule (for a regular 28 day cycle):** * LMP, subtract 3 months, add 1 year and 7 days

Answer 325

* Booking appointment = 8-10 weeks * Dating scan = 11-13 weeks * Anomaly scan = 20 weeks * OGTT (if needed) = 24-28 weeks * Anti-D prophylaxis if resus negative = 28 or 34 weeks NB: A trimester = 14 weeks!

Answer 326

* Cord prolapse - breech is a less effective "plug" in the cervix, the head is a great plug * Difficulty delivering head ("head entrapment") * Foetal hypoxia due to head entrapment * Increased foetal mortality & morbidity * The "Term Breech Trial" * Developmental dysplasia of the hip (DDH) * All breech babies go for hip US as 20% will have it

Answer 327

* Offered at 36 weeks in nulliparous women & 37-38 weeks in multiparous women * Uterine relaxants given prior or during procedure (eg: terbutaline or salbutamol) * Foetal heart monitoring with CTG pre & post procedure * In case by turning you cause a knot in the umbilical cord or tug on the placenta causing an abruption * Benefits: * May prevent breech delivery & associated risks or C-section * Risks: * Foetal distress, sometimes transient * Contraindicated with: * PV bleeding in previous week (abruption risk) * Twin pregnancy * Intrauterine growth restricted pregnancy * Success rate = ~50% * Emergency C-section in 1/200 * How its done: * Using US to see where baby's head is * We will move the head and let the baby move around with it * We will move it and hold it in position and then move the baby a little bit more * VERY UNCOMFORTABLE * Can have gas & air * Usually takes 10-15 mins

Answer 328

* Wrong dates! * Big baby: genetic, diabetes * Polyhydramnios * Big baby + poyhydramnios: diabetes

Answer 329

* Idiopathic * Maternal problem: * Diabetes * Infection - CMV & Parvovirus (parvovirus - goes for foetal bone marrow --\> anaemia --\> heart failure --\> increase BNP --\> increase foetal urine) * Foetal abnormality * Twin-twin transfusion etc (Heart failure of recipient)

Answer 330

**Causes of Polyhydramnios??** (DITCH) * Single DITCH of amniotic fluid of 8cm or more on US * D - diabetes * I - idiopathic * T - twins * C - congenital abnormalities (eg: anencephaly, GI atresia, VSD --\> HF) * H - heart failure **Risks associated with Polyhydramnios??** (6 P's) * P - placental abruption * P - pretty unusual lie * P - premature labour * P - prolapse of cord * P - post partum haemorrhage * P - perinatal mortality

Answer 331

* First: * From onset of regular painful contractions to full dilatation * Latent phase = up to 4cm dilatation * Active phase = from 4cm to 10cm (full dilated) * Average 8hrs in primiparous women. * Average 5hrs in multiparous women. * Second: * From ful dilatation to delivery of infant * 1-2hrs in primiparous women * 1hr in multiparous women * Third: * From delivery of infant to delivery of placenta * Up to 30mins in both

Answer 332

* Post dates * Pre-labour rupture of membranes * Pre-eclampsia * Plus diabetes! _Post dates:_ * Common reason for induction * Increased risk of stillbirth beyond 42 weeks: recommend induction at 41-42 weeks * NB: women undergoing induction immediately become 'higher risk' pregnancies and therefore require additional monitoring _Pre-labour rupture of membranes at term:_ * After rupture of membranes, women are likely to labour within 24hrs * After this 24hrs, the likelihood of spontaneous labour significantly decreases & risk of ascending infections needs to be considered * Therefore all women are offered an induction 24hrs after spontaneous rupture of membranes * Guidance is less clear if this is a PROM \<37weeks _VBAC_ * Risk of wound dehiscence is considerable if inducing a vaginal birth after C-section previously. Involve seniors

Answer 333

_Membrane sweeping:_ * May increase the chances of spontaneous labour & avoid induction in some cases * Finger passed between cervix & membranes at time of PV examination * Thought to cause release of hormones _Three stages of induction:_ * Cervical ripening - softening, shortening & opening of the cervix, eventually to allow artificial rupture of membranes (equivalent to latent phase of first stage of labour) * Artificial rupture of membranes * Cevical dilatation to full dilated (equivalent to active phase of first stage of labour) Stage 1: ripening of the cervix.. * Vaginal prostaglandin E2 pessaries for nullips or gel for multips * Soften & shorten cervix and cause uterine tightening * Risk of hyperstimulation & foetal distress: CTG monitoring used **Modified Bishop score** at this point: * BS \< 5 - further prostin needed * BS 5-8 - consider further prostin, artificial rupture of membranes may be possible * BS \>8 - amniotomy, further prostin not required Stage 2: amniotomy... * Artificial rupture of membranes * Possible once cervix is sufficiently effaced * Performed using 'amnihook' at time of vaginal examination * Risk of cord prolapse if high presenting part Stage 3: cervical dilatation... * IV oxytocin (syntocinon) used to generate uterine contractions * Doses titrated to achieve 3-4 strong contractions ever 10 mins * Risk of uterine hyperstimulation although more easily reversed as infusion can be turned off * CTG monitoring is used _NB:_ Uterine hyperstimulation: * Oxytocin vs. terbutaline * Terbutaline = b-adrenergic receptor agonist, relaxes myometrial smooth muscle

Answer 334

Can include symphysis pubis pain + low back pain + sacro-iliac pain _Symphysis pubis pain?_ * May radiate to groin & medial thighs * Worse standing on one leg (eg: getting dressed) or climbing stairs * Worse abducting hips (eg: getting out of bath or car) * Tender over pubic symphysis * Hip abduction reproduces pain _Mx:_ * Keep active within limits of pain * Pillow between legs at night * Physio * Hip abductor exercises * Paracetamol = safe (AVOID NSAIDs)

Answer 335

_Pre-conception advice:_ * Impact on pregnancy starts from pre-conception * High dose folic acid (5mg OD) * Don't stop contraception until good gylcaemic control is achieved (HbA1c \<48) * Avoid pregnancy if poor control (HbA1c \>86) due to high risk of congenital malformations * Monitor eyes & renal function carefully before & during pregnancy _Diagnosis of pre-existing diabetes in pregnancy?_ * **First trimester presentation** of persistent glycosuria, high random sugars, confirmed with OGTT, **suggests pre-existing diabetes** _Principles of Mx for pre-existing diabetes:_ * Pre-conceptual counselling * Stop ACE inhibitors & statins!!! * Increased insulin requirement in pregnancy! * Early viability scan at 8 weeks plus detailed anomaly scan & regular growth scans

Answer 336

* Unlikely to impact on pregnancy until 2nd trimester * Therefore no risk of miscarriage or congenital malformations * No macro- or microvascular complications * "_Pregnancy is a diabetogenic state"_ - increased glucose load combined with increased insulin resistance pushes body into a temporary diabetic state * Increased risk of: * Subsequent gestational diabetes (OGTT around 16 weeks) * T2DM * OGTT: * Used to screen selected women for GDM at 28 weeks! (eg: 1st degree family relative) * Fasting venous plasma glucose measured * Drink sugary 75g glucose drink * Venous plasma glucose measured 2hrs later * No HbA1c used for diagnosis of diabetes in pregnancy!! * Increased plasma volume --\> diluted HbA1c _Diagnosing GDM:_ * Anything above normal = GDM * The concepts of "impaired fasting glycaemia" & "impaired glucose tolerance" do not apply in pregnancy * GDM Dx: * Fasting glucose \> /= 5.6 * OGTT 2hrs post \>/= 7.8 * "**5, 6, 7, 8!"** _Mx algorythm:_ 1. Diet & exercsie - refer to dietician, walk for 30mins after meals 2. Metformin - start with 500mg daily with food 3. Single injection intermediate acting insulin 4. Add short acting insulin before meals (eg: novorapid) _Obstetric management of GDM pregnancy:_ * If large for dates, consider elective C-section * If not, plan indution at 38-40 weeks * Be alert for possible shoulder dystocia * Close neonatal monitoring of blood sugars!!

Answer 337

* McRobert's * Flex & externally rotate hips to stretch symphysis & open pelvic outlet * 95% solved * Suprapubic pressure * Rotates foetal shoulder into wider pelvic oblique diameter * Episiotomy * Only if needed to give access for the following advanced procedures - doesn't fix shoulder dystocia! This is a bony problem * Woodscrew manouvre: * Rotate shoulder + deliver posterior arm! * Break clavicle * Emergency C-section (Zavanelli manouevre): * Push baby back inside. * Very poor outcomes by this time

Answer 338

_Inpsection:_ * Abdominal distension consistent with pregnancy * Striae, linea nigra, foetal movements * Umbilical eversion may suggest polyhydramnios _Uterine Fundal Palpation:_ * Using ulnar border of hand * Measurement of symphyseal fundal height (SFH) * Umbilicus = ~20 weeks * First reaches xiphisternum at 36 weeks * From 24 weeks: SFH(cm) = gestation (weeks) +/2 cm _Lateral palpation:_ * Conventional position? * Look at woman's face for discomfort * Amniotic fluid assessment: easily felt parts ?oligohydramnios. No felt parts ?polyhydramnios. * Lie of foetus: is long axis of fetus parrallel to long axis of uterus? Longitudinal lie. _Palpation of presenting part:_ * Facing woman's feet, palpate gently the lower abdomen * Cephalic: head = presenting part * Breech: bottom/legs = presenting part * Engagement? for cephalic this is quoted as proportion of head palpable per abdomen (eg: 4/5 if head is only just descended into pelvis) * Optional extra: Pawlick's manouvre facing patient's head with one had ballotting the foetal head _Auscultation:_ * Using Pinard's or doppler * Over anterior shoulder _Extras:_ * Check urine sample * Check for tenderness over pubic symphysis CHECK LIST: S - size & SFH A - amniotic fluid L - lie P - presenting part I - inlet of pelvis - engagement N - number of foetuses X - X marks the spot (over anterior shoulder) for doppler or Pinard

Answer 339

* Hypertension = BP \>140/90 on more than one occassion * **NB:** With all types of HTN in pregnancy, overtreatment can cause _intrauterine growth restriction_ * TARGET BP \<150/80-100 _Chronic HTN:_ * Uncommon * Pre-existing * High BP at booking visit * 30% --\> pre-eclampsia _Gestational HTN:_ * Common * Onset **after 20/40** * **No proteinuria!!** * 20% --\> pre-eclampsia * Resolves after delivery _Pre-eclampsia:_ * Common * Onset **after 20/40** * **With proteinuria!!** * Multi-system disease due to endothelial dysfunction * Significant morbidity * Resolves after delivery **Hypertension Treatment:** * Reduces risk of stroke * Probably does NOT reduce risk of progression from gestational HTN --\> pre-eclampsia --\> eclampsia * Because this is a problem with endothelial dysfunction rather than systolic BP! * First line Rx = labetalol * Second line Rx = nifedipine or methyldopa * NOT: * ACEi (risk of congenital malformations) * Diuretics (reduce maternal plasma volume)

Answer 340

* Disease of the placenta * Resolves 1-2 weeks post delivery * Onset after 20 weeks - affects ~5% of pregnancies * Dx = **HTN** and **proteinuria** * NB: every fucking pregnant woman has oedematous ankles! * Variable oedema - hands and face as well as ankles ("non-dependent oedema") _Buzz words:_ * Gestational proteinuric hypertension * Non-dependent oedema * Pre-eclamptic toxaemia _Diagnosis:_ * HTN \>140/90 on one occassion * AND * Proteinuria \>0.3g / 24hrs (approx equivalent to 2+ on dipstick) * IN THE ABSENCE OF UTI (need to confirm the absence of nitrites/leukocytes on urine dip as this can cause proteinuria) _Complications:_ * Foetal: * Foetal growth restriction * Intra-uterine death * Premature delivery (iatrogenic) * Maternal (SHAME): * S - stroke * H - HELLP syndrome * A - abruption of placenta * M - multi-organ failure (+/- DIC +/- death) * E - eclampsia

Answer 341

* E - existing (chronic) HTN * C - chronic kidney disease * L - lupus (SLE) * A - antiphospholipid syndrome * M - maternal diabetes (pre-existing, NOT GDM) * P - previous pregnancy with HTN * O - obesity

Answer 342

* Haemolysis * Elevated liver enzymes * Low platelets Endothelial dysfunction in small vessels - increasing severity: * Low platelets - early finding as platelets adhere to endothelium in small vessels * Low platelets + haemolysis --\> HELLP syndrome. Occurs as mesh shreds RBCs (microangiopathic haemolysis) * Low platelets + haemolysis + bleeding! --\> DIC. Clotting factors have been consumed.

Answer 343

* Admit for hospital monitoring * Treat moderate & severe HTN to prevent stroke * Does not alter underlying disease * Delivery of placenta is key * Mild = systolic of 140-149. Don't treat * Moderate = systolic of 150-159. Rx = labetalol * Severe = systolic \>160. Rx = labetolol.

Answer 344

* Headache * Visual disturbance - ?flashing lights * Epigastric or RUQ pain (hepatic capsule distension or infarcts - ?HELLP) * Breathlessness (pulmonary oedema due to ARDS) PLUS... * Per-orbital oedema * Hyper-reflexia * Clonus * FITS!!

Answer 345

_Montitor:_ * Admit to hospital * Symptoms & BP * US for foetal growth * Umbilical artery blood flow * Pre-eclampsia bloods * FBC - ?low platelets & ?low Hb (HELLP) * U&E's - raised urea & creatinine * LFT - raised AST & ALT (**"transaminitis"**). Raised bilirubin if haemolysis _Timing of delivery in pre-eclampsia:_ * Aim for best chance of foetal survivial (ie. 34 weeks or later) * Use maternal steroids up to 36 weeks * Delaying delivery by 24hrs for maternal steroid injection reduces foetal mortality by 50%!! * Decreased risk of intraventricular haemorrhage, respiratory distress & NEC * High BP, impaired renal or hepatic function & foetal distress may prompt early delivery!!

Answer 346

* ABC - need oxygen, & ?intubation * Manual uterine displacement (MUD) or turn patient onto her side (to reduce risk of aspiration and prevent aorto-caval compression) * Control fits: IV magnessium sulphate * Control HTN: IV labetalol or hydralazine

Answer 347

* Zygosity = number of eggs * Determines identical vs non-identical * Chorionicity = number of placentas * Determines risk for pregnancy _Dizygous twins:_ * Dizygous twins are always dichorionic * Each has it's own placenta _Monozygotic twins:_ * From one splitting of one fertilised ovum * 28% of monozygotic twins are dichorionic * Other 72% are monochorionic: * Monochorionic Diamniotic (MCDA) (70%) - each foetus with it's own amniotic sac * Monochorionic Monoamniotic (MCMA) (2%) - both foetuses in same amniotic sac * With Monochorionic twins - 20% have twin-twin transfusion syndrome (TTTS) _Principles of antenatal care for twin pregnancies?_ * Early diagnosis (especially if IVF) * Frequent consultant-led antenatal appointments * Adequate diet: * High dose folic acid (5mg) * Iron - they're prone to anaemia * 75mg aspirin daily for high risk women - increased risk of pre-eclampsia * Extra growth scans to detect discordant growth * Planned delivery earlier! depending on type of twins _Explaining to a patient about management from 28 weeks_ * You will need more frequent antenatal appointments - probably every 2 weeks * We will take special care to check your blood pressure doesn't go up * You will also need blood tests at around 28 weeks to make sure you don't have diabetes * Additional growth scans will be needed to check that both babies are thriving * We will plan to deliver your babies well before you get to 40 weeks * The exact timing will depend on the scans!

Answer 348

* Occurs with monochorionic twins when there are intraplacental anastomoses * Develops in 20% of monochorionic twins * Umbilical arteries of the donor twin feed the vein of the recipient * High pressure --\> low pressure * Varies in severity * May need laser to connecting vessels _Twin 1 - recipient:_ * Polycythaemic * Hypertensive * Cardiac hypertrophy --\> high output cardiac failure * Oedema (hydrops) * Polyhydramnios _Twin 2 - donor:_ * Anaemic * Growth restricted * Hypotension * Oligohydramnios

Answer 349

* In older women, some of whom may have subclinical arterial disease, it may be that HRT can destabilise an atheromatous plaque --\> stroke etc * But in younger women it appears to be protective against arterial disease and certainly seems safe up to the age of 60! * Current guidelines recommend using HRT for as short a length of time as possible, in practice HRT is often needed for 2-5yrs or longer * Overall, NICE recommend that there is "no evidence" that HRT is effective for prevention of vascular disease, and should not be used for this * Similarly, HRT is very effective at preventing osteoporosis, but it is recommended that other treatments should be tried first (eg: bisphosphonates) _HRT & Premature Ovarian Insufficiency?_ * HRT should be used up to the normal age of menopause * No additional risk of breast cancer or CVD in these circumstances! _Main Indications for HRT in Menopausal Women:_ = symptoms!! * Vasomotor (hot flushes, night sweats) * Urogenital (vaginal dryness, dypareunia, recurrent UTI) * Neuropsychiatric (poor concentration, low mood, mood swings) - these symptoms respond to HRT variably! _NB:_ Women with urogenital symptoms such as vaginal dryness may opt to use topical oestrogens which appear to have little effect on endometrium so no need for progesterone protection in women with a uterus. Need for topical treatment should be reviewed annually. _Systemic combined HRT - increased risk of breast cancer?_ * Background risk of breast ca = 1% * After 5yrs of systemic combined HRT, this risk is slightly elevated to 2% * And quickly returns to baseline after HRT is stopped * No additionally elevated risk if using oestrogen-only HRT _HRT in peri-menopausal women with intact uterus:_ * In the first year after the menopause, cyclical HRT, with monthly bleeds are recommended * Because intermittent bleeding is common with continuous treatment during this time * And this then gives rise to fruitless investigations of postmenopausal bleeding _HRT in post-menopausal women with intract uterus:_ * Several options for women who are at least one year post menopausal with an intact uterus... * Coontinuous combined oral HRT * Continuous combined patches - applied twice per week * Oestrogen gel or oestrogen-only patch WITH mirena coil providing progesterone to protect endometrium * Topical vaginal oestrogen (if urogynae symptoms only) with NO need for progesterone cover _Post hysterectomy:_ * Oestrogen-only HRT as tablets, gels or patch is suitable * No increased risk of breast cancer interestingly

Answer 350

* SGA definition: * For newborn baby = birth weight \<10th percental for gestational age * For foetus = estimated foetal weight \<10th percental for gestational age _Aetiologies:_ * S - starved small (IUGR) * W - wrong small * A - abnormal small * N - normal small Wrong small: * Wrong dates * Growth velocity ok Normal small: * Genetic * Constitutional * Growth velocity ok Starved small (IUGR; decreased growth velocity): * Placental dysfunction * Maternal diseases * Pre-eclampsia * Drug/alcohol use * IUGR --\> common cause of stillbirth & prematurity (with associated complications of intraventricular haemorrhage, respiratory distress & NEC) Abnormal small (decreased growth velocity): * Chromosomes * Structural anomaly * Infection * Genetic syndromes _"Brain sparing effect of placental insufficiency!!"_ * On scans: abdominal circumference (AC) is more affected than head circumference (HC) * Assymetrical growth restriction ccurs only with starved small!

Answer 351

_Common:_ * S - smoking * H - hypertension & pre-eclampsia * I - IUGR previously * T - twins * S - stillbirth previously _Rarer:_ * C - cocaine * R - renal disease * A - antiphospholipid syndrome * P - PAPP-A levels LOW! _Mx of high risk pregnancies:_ * Screen for pre-eclampsia * Risk reduction & optimising medical conditions * Serial scans: foetal growth, liquor volume, umbilical artery flow * Umbilical artery flow - assesses placental arterial resistance. Buzz word = "pulsatility index"

Answer 352

_Three indications:_ * Planned pre-term birth * P-PROM * Spontaneous pre-term labour _Helps how?_ * Reduces risk of: * Interventricular haemorrhage * Patent ductus arteriosus * Respiratory distress syndrome * Necrotising enterocolitis * ("**HEADS & HEARTS & LUNGS & GUTS")** * Foetal death _How is it given:_ * Single course of two IM injections of betamethasone OR dexamethasone 12hours apart * Used when delivery expected in next 48hrs * Diabetic mothers need careful monitoring: may need additional insulin!

Answer 353

* Used for neuroprotection * Improves blood flow & reduces hypoxic damage at time of delivery * Reduces risk of cerebral palsy * Beneficial from 24-30 weeks * Given when delivery is planned in the next 12 hours!

Answer 354

* Antepartum haemorrhage = bleeding in pregnancy _after 24 weeks gestation_ * Bleeding at \<24 weeks known as **threatened miscarriage** _Causes of antepartum haemorrhage:_ * Uterine: * Placental abruption (premature separation) * Placenta praevia * Vasa praevia * Marginal bleed (bleeding from placental edge) * Cervical: * "Show" - loss of mucus plug from cervix (often at term) * Cervical cancer * Cervical polyp / ectropion * Vaginal: * Trauma * Infection

Answer 355

**Placental Abruption** * Premature separation of placenta from uterus * Risk factors: * Smoking * Previous abruption * Hypertensive disorders * Thrombophilias * Cocaine * Trauma * Symptoms: * Vaginal bleeding (often present but not always - "conceiled" = bleeding behind placenta!) * Blood usually _dark red_ * Abdominal pain * Uterine contractions - blood irritates uterus * O/E: * Shock (in severe cases) * Uterine tenderness * 'Woody' hard uterus * Foetal distress - foetal death in extreme cases **Placenta Praevia** * A placenta that is wholly or partially implanted in the lower segment of the uterus * Minor vs. Major * Major covers internal os! * Symptoms: * Painless bright red vaginal bleeding! * Blood on toes (usually indicates significant blood loss) * May cause hypovolaemic shock * Foetus relatively unaffected (unless massive haemorrhage) * Women with placenta praevias who bleed are often advised to remain inpatient until delivery! * Admit for 48hrs at least!! * Major placenta praevias: * Delivery by C-section at 39 weeks (or before significant bleed) * **Avoid internal examination** until placental site has been determined - may precipiate heavier bleed * _NB:_ Rule of thumb = always know if there is a low lying placenta before any internal examination! **TAKE HOME MESSAGE:** Painless bright red vaginal bleeding = placenta praevia! Painful bleeding with dark red blood = abruption!

Answer 356

* Given **routinely at 28weeks** to prevent rhesus D alloimmunisation **in D-negative women** who may be carrying a D-positive foetus * _First pregnancy:_ (if no anti-D given) sensatisation can occur * ie. maternal antibodies to foetal rhesus D antigen are produced * _Second pregnancy:_ antibodies produced in the first pregnancy attack this foetus if it is Rhesus D antigen are produced * Causing haemolytic disease of the newborn _Giving anti-D routinely OR at a sensitising event:_ * Rx of anti-D is too small to cause foetal anemia * Prevents exposure of maternal immune system to rhesus D antigen on foetal blood cells * Anti-D "mops up" rhesus D antigen * IgG antibody --\> so crosses placenta * Low concentrations in the foetus, not enough to cause haemolysis _Examples of sensitising events:_ * Amniocentesis / CVS * Termination of pregnancy * Threatened or complete miscarriage after 12weeks * Antepartum haemorrhage * External cephalic version! * Closed abdominal injury

Answer 357

* PPH = loss of \> 500ml of blood after delivery * _Primary PPH_ = loss \> 500ml of blood within 24hrs of delivery * Minor = 500ml - 1000ml * Major = \>1,000ml * Massive obstetric haemorrhage = 1,500ml or more * _Secondary PPH_ = loss of excessive blood between 24hrs and 6 weeks following delivery _Primary PPH Causes: the 4 T's:_ * Tone - atonic uterus (most common) * Tissue - retained placenta with prolonged third stage * Also leads to poor uterine contraction * Trauma - vaginal or cervical tear * Thrombin - associated with pre-eclampsia or DIC Tone - risk factors: * Uterine muscle - previous episode of PPH, prolonged third stage * Uterine contents - multiple pregnancy, foetal macrosomia, polyhydramnios _Prophylaxis:_ * Oxytocin ("syntocinon") given IM to mother routinely with delivery of the anterior shoulder * IF significant risk factors & NO hypertension, consider using oxytocin with ergometrine ("syntometrine") * Ergometrine can cause increased BP _Management of Haemorrhage:_ "This is an obstetric emergency, I'm going to..." * Call for help from seniors * ABC & IV access x2 wide bore canula * Left lateral position - to avoid aortocaval compression * FBC, clotting, group & save/cross match! * Replacement fluid / blood / clotting factors if necessary * Consider urinary catheter - empty bladder can help contract uterus as there's nothing in it's way * Pharmacological: * Oxytocin IV * May be repeated +/- ergometrine IM * Then consider using oxytocin infusion over 4hrs * Surgical options: * Evacuation of retained products * Intrauterine balloon tamponade * Haemostatic suture * Internal iliac ligation * Consider hysterectomy

Answer 358

**Trichomonas Vaginalis** * Flagellated protozoon * Incubation = 1-3 weeks * Sx: frothy, green or grey discharge * Frothy because of flagella! * O/E: strawberry cervix!! * Rx: metronidazole 400mg PO BD for 7 days * Or single dose 2g **Bacterial Vaginosis** * Imbalance of vaginal flora rather than STI * No symptoms in male partner of affected female! * May be triggered by: vaginal douching or by sexual intercourse * Sx: fishy smelling discharge with minimal/no itch * O/E: increased vaginal pH to \>4.5 * "Clue cells" on microscopy: vaginal epithelial cell coated with numerous bacteria * Typical swab report: "heavy growth of anaerobes" (eg: Gardnerella vaginalis typically) * Mx = PO metronidazole OR topical clindamycin cream **Chlamydia Trichomatis** * Commenest STI * Obligate intracellular bacteria so tricky to culture! * Incubation period 1-3 weeks * 50% men & 75% women are asymptomatic * Sx: * Dysuria or discharge * Intermenstrual or post-coital bleeding * Ascending infection: acute salpingitis or PID * Chlamydia is indicated in about 75% of ectopics and 75% of cases of tubal infertility! * Life cycle: * 1) elementary bodies (EB) - attach to sperm & endocervix once infected cells lyse. Elementary bodies ascending up your repro tract --\> PID * 2) reticulate bodies (RB) - intracytoplasmic form of chylamydia involved in replication. Looks like a "cloak" around nucleus (Chlamydia = cloak in latin). These produce the discharge! * Mx = single oral dose azithromycin 1g * OR oral doxycycline 100mg for 7 days * Erythromycin in pregnancy! **Gonorrhoea** * Intracellular gram-negative diplococci * Sx: green/yellow discharge (within 2 weeks of infection), dysuria, IMB * Ix: endocervical swab or urine for NAAT * Rx: ceftriaxone 500mg IM & azithromycin 1g **Thrush (candida albicans)** * Fungus * Sx: Ithcing, with white discharge * Ix: swab & culture * Rx: clotrimazole pessary OR fluconazole PO **Human Papilloma Virus** * Primary: multiple, painful blisters. Lymphadenopathy. Urinary retention **Syphillis** * *Treponema Pallidum* is hard to isolate * Hence, serology is the mainstay of diagnosis in secondary & tertiary stages * However, serology alone cannot differentiate between syphillis & other similar diseases caused by treponemes - serology used in combination with clinical findings _Stages of syphillis:_ * Exposure * Asymptomatic incubation period ~3 weeks * Primary syphillis - non-painful ulcer * Swab the ulcer * Secondary syphillis - rash/nodes (immune reaction) * Develops 6 weeks after primary syphillis * Tertiary syphillis - cardiac / CNS / nodules / Gumma * Develops after a latent phase of 3-15yrs of being asymptomatic _Diagnosing Syphillis:_ * Primary syphillis - swab ulcer/lesion and under dark-field microscopy you will see a motile, spiral-shaped organism * Secondary/tertiary syphillis - immune response has been activated so can now use serological testing * VDRL and RPR together are used _Mx:_ * Syphillis remains sensitive to penicillin no matter which stage so treatment is often quite simple **DDx for bacterial discharge with "fishy smell"?** * Bacterial vaginosis * Retained tampon * Trichomonas vaginalis

Answer 359

* S - screen for other STI's (they "hunt in packs") * E - education (eg: use of condoms) * X - xplain about partner notification!! _Triple Testing:_ * High vaginal swab: * Candida, Gardnerella (B.V.) & Trichomonas * Endocervical dry swab: * Neisseria gonorrhoeae (nucleic amplification test: NAAT) * Endocervical dry swab or urine sample: * Chlamydia trachomatis test (NAAT) NB: Actually only two swaps now mostly because many sexual health clinics use urine or "self swab" for NAAT in place of 2 and 3.

Answer 360

Intermenstrual bleeding? * Carcinoma of endometrium! Post-menopausal bleeding? * Carcinoma of endometrium! Post-coital bleeding? * Carcinoma of cervix! Missed period? * Pregnancy, including ectopic etc

Answer 361

* Type 1 = excision of clitoris * Type 2 = excision of clitoris & labia minora * Type 3 = infundibulation (stitching up)

Answer 362

* Ectropion is normal * Normal squamous epithelium of ectocervix is overtaken by everted columnar endocervix! * Can cause post-coital bleeding * Driven by oestrogen * Occurs during COCP or pregnancy * Good DDx for antepartum haemorrhage

Answer 363

* Ectopic endometrial tissue outside of the uterus _Pathology:_ * Deposits thicken cyclically causing an inflammatory reaction * Sx: pain worse pre-mestrually & at onset of period! * Chronic inflammation causes scarring & adhesions * Pelvis may then have "fixed pelvis organs!" * Deposits may occur on the ovaries --\> causing endometriotic ('chocolate') cysts _Sx's:_ * Lesions often asymptomatic & symptoms correlte poorly with findings on laparoscopy * Pain: * Premestrual pain * Dysmenorrhoea * Deep dyspareunia * Chronic pelvic pain * Subfertility: * Endometriosis found at 25% of laparoscopies for subfertility * Rarer presentations: * Bowel & bladder involvement ("deep infiltrating endometriosis") * Haemoptysis * Bleeding from umbilicus * Nodules in scars _Pelvic Examination:_ * Tenderness * Mass (endometrioma) * Fixed pelvic organs * Endometriosis of the utero-sacral ligament will cause the uterus to become "fixed in retroversion" * Endometriotic nodules in Pouch of Douglas * PR examination: noule in rectovaginal septum _BUZZ WORDS FOR Dx OF ENDOMETRIOSIS:_ * Pre-menstrual pain * Deposits on the ovaries causing endometriotic "chocolate cysts" * The uterus is fixed in retroversion _Ix:_ * Diagnostic laparoscopy * Diagnosis confirmed by biopsy * Ca125 levels may be raised due to peritoneal involvement (NOT a useful diagnostic tool) _Mx:_ * **key question = do you want to get pregnant?** * Expectant: treatment not indicated in asymptomatic women with mild disease * Medical 1: symptomatic relief (eg: analgesia) * Medical 2: prevent hormonal stimulation of ectopic endometrium (inhibit ovarian hormonal production) * EG: COCP - "ride the tricycle" = 3 packs back to back to supress hormonal stimulation * Progestogens (eg: depo provera) * Mirena coil (acts directly on ovary) * GnRH analogues - causing temporary menopause! (INDICATED in deep infiltrating endometriosis) * Surgical: remove endometriosis: * Diathermy or laser - subfertility/wants to get pregnant! * Excision of endometrioma - has had their family!

Answer 364

_First 21 days:_ * Contraception NOT required in first 21 days * But can be started if woman wishes * Earliest ovulation in non breast-feeding women is 28 days! * AVOID: * IUCD - increased risk of perforation with early use * COCP - increased risk of DVT in first 21 days _Lactational Amenorrheoa Method:_ * Said to be over 98% effective if \<6 months postpartum, amenorrhoeic & fully breastfeeding * Risk of pregnancy increased if: * Frequency of breastfeeding decreases * When menstruation returns * Emphasise the other benefits of breast feeding too! _Concerns about starting COCP?_ * Risk of DVT in first 21 days * Concern oestrogen may inhibit lactation if used early * Some oestrogen secreted into breast milk: unkown effects! * Avoid if possible if fully breast feeding _Post partum options:_ * Condoms * POP - can be started at any time * COCP - from day 21 if not breast feeding * Long acting reversible contraception * Copper coil (from day 28; lasts 10 years) * Mirena coil (from day 28; lasts 5 years) * Progesterone implant (at any time) * Injectible ( at any time if not breast feeding)

Answer 365

1. Pituitary FSH levels rise, stimulating follicular growth & oestradiol production 2. Oestradiol initially causes negative feedback reducing FSH levels 3. Oestradiol reaches a critical level - pituitary cells switch to positive feedback, increasing the output of gonadotrophins, particularly LH 4. LH surge, causing ovulation

Answer 366

* Spectrum of symptoms & signs * Insulin resistance is commonly associated * Hypothalamic disturbance leads to: * Basal increase in LH * With relative reduction in FSH _Spectrum of clinical presentations:_ * **Increased androgens** --\> acne, hirsuitism * **Reduced oestrogens** relative to oestrogens: * **Loss of positive feedback** to hypothalamus --\> contsantly high LH with **no LH surge** --\> no ovulation * **Anovulation** --\> **subfertility** * Lack of corpus luteum ("inadequate luteal phase") leads to proliferative endometrium --\> **heavy irregular bleeding!** **Rotterdam criteria again! (2/3 needed for Dx)** * S - string of pearls on US * Hyperandrogenism * Oligomenorrhoea * (Prolactin normal) * Also key to check T4, cortisol are normal and exclude congenital adrenal hyperplasia! _NB:_ Oligmenorrhoea = periods occuring at intervals of greater than 35 days! _Ix - Blood tests:_ * Serum total & free testosterone * Fasting glucose & lipids * To assess effect of insulin resistance - a key part of the condition which it's though may cause loss of hypothalamic/pituitary function * Prolactin * T4 & TSH - hypothyroidism can cause oligmenorrhoea * 17-hydroxyprogesterone - to exclude CAH **Management of PCOS:** _All women:_ * Advise on weight loss if overweight * Screen for CVS risk factors * Annual OGTT * "What are your fertility plans?" _Acne:_ * Benzoyl peroxide +/- topical Abx _Oligomenorrhoea:_ * Check endometrial thickness * Induce regular withdrawal bleed: eg: COCP or progestogen _Infertility:_ * Weight loss - ?**metformin!!** (off label) * Ovulation induction with **clomifene!!** * IVF with gonadotrophins _Hirsuitism:_ * Shaving, waxing, electrolysis, laser * Eflornithin cream for facial hirsuitism * Rx = cyproterone acetate (androgen receptor antagonist)

Answer 367

* Pregnancy * Prolactinoma * Polycystic ovarian syndrome * Premature ovarian insufficiency * Will have raised gonadotrophins (from pituitary!) * + stress - women in 20's with exams / who exercise loads

Answer 368

**Definitions - Primary vs Secondary** * Primary amenorrhoea - failure of menstruation by 16yrs in presence of otherwise normal secondary sexual characteristics * Secondary amenorrhoea - absent periods for at least 6 months in a woman who had previously regular periods (or 12 months in a woman who had irregular periods) **Causes** * Hypothalamic: eg: GnRH deficiency * Stress * Weight change * Idiotpathic * Kallman's * Pituitary: * Tumour (causing gonadotrophin deficiency and/or hyperprolactinaemia - prolactin inhibits ovulation) * Pituitary necrosis - Sheehan's syndrome * Ovarian: * PCOS * Premature ovarian insufficiency * Outflow tract: * Imperforate hymen * Vaginal septum * Cervical stenosis * Absent uterus * Don't forget the commonest cause: **pregnancy!** **Ix** * Pregnancy test * Thyroid function - both hyper- & hypo- can inhibit ovarian function * LH / FSH: * If raised --\> ?ovarian insufficiency * If reduced --\> ?hypothalamic/pituitary problem * If increased LH/FSH ratio --\> ?PCOS * Testosterone - exclude androgen secreting tumour * US scan - if abnormal genital tract anatomy is suspected **Treating** Depends on underlying cause & desire for fertility! * Gonadotrophin deficiency: * Replacement of gonadotrophins - if fertility desired * COCP - if fertility not desired! * PCOS: * Weight loss / metformin / ovulation induction - if fertility desired * Weight loss / COCP - if fertility not desired * Ovarian insufficiency: * No treatment but COCP or HRT may improve symptoms * Egg donation - if fertility desired * Genital tract abnormality: * Surgical

Answer 369

_PID_ * Sx: * Low abdominal pain, typically bilateral * Deep dyspareunia * Vaginal discharge * Abnormal vaginal bleeding * Chronic PID --\> ectopic pregnancy / subfertility due to adhesions _Acute Salpingitis:_ * Sx: * Fever, tachycardia * Low abdo tenderness * Cervicitis * Cervical motion tenderness * Adnexal tenderness _PID/Salpingitis - The work up?_ * Differentials: * Acute appendicitis * UTI * Ectopic * Ovarian cyst torsion/rupture * Endometriosis * IBS * Ix: FBC, CRP, triple swabs * Pelvic US or laparoscopy if Dx uncertain - ?abscess * Rx = broad spectrum Abx * If uncomplicated - single dose IM ceftriaxone (to cover gonorrhoea) & then oral doxy and metronidazole for 14 days! * If fever/unwell/peritonism, admit for IV therapy

Answer 370

* A failure to conceive after **12 months** regular, unprotected intercourse * Primary subfertility - the female partner has never conceived previously * Secondary subfertility - the female partner has conceived previously **Causes of subfertility - 4 categories:** * Anovulation * Tubal patency * Male factor / unhealthy sperm * Unexplained _Anovulation:_ * Commonest cause of subfertility * Can result from a problem anywhere along the HPO axis * Hypothalamus: * Stress * Anorexia * Anterior pituitary: * EG: prolactinoma * Ovaries: * PCOS * Premature ovarian insufficiency _Tubal disease:_ * PID - commonly caused by Chlamydia * Endometriosis * Thought to adversey affect fertility even without tubal involvement * Surgical adhesions * Ix: with hysterosalpingogram "fill & spill" OR lap & dye test (if you suspect you might need to treat at same time) _Male factor subfertility:_ * Absent spermatozoa - azospermia * Few spermatozoa - oligospermia * Excess numbers of abnormal sperm - teratozoospermia * A significant proportion of immotile sperm - asthenozoospermia **Ix the subfertile couple?** _Assessment of axis:_ * Prolactin * FSH / LH * Low in hypothalamo-pituitary failure * High in ovarian insufficiency * Oestrogen * Testosterone * Progesterone - Day 21 to confirm ovulation _Assess tubal patency:_ * Lap & dye * Hysterosalpingogram _Semen analysis to assess:_ * Count (\>15million/ml) * Motility (\>40%) * Normal forms (\>4%) **Mx** _Lifestyle:_ * Weight loss if overweight * Smoking cessation / reducing caffeine intake / reducing alcohol intake * Intercourse: 2-3 times per week * Timing during cycle NOT recommended - too stressful for the couple, just shag! _Other causes:_ * Anovulation: stimulate ovulation using * Clomifene * Gonadotrophins * GnRH * With/without assissted reprocution * Premature ovarian insufficiency: egg donation & IVF! * Tubal damage: tubal surgery or IVF * Male factor: assissted reproduction

Answer 371

**Intrauterine insemination (IUI)?** * Insert seminal fluid into uterus around time of ovulation * Good for asthenozoospermia as can pick out the fast sperm * Live birth rate: 10% per cycle **In-vitro fertilisation (IVF)?** * Egg + sperm are fertilised in laboratory * The fertilised egg (embryo) is then placed into the uterus * Live birth rate: 25% per cycle * Multiple pregnancy rates as high as 24% **Intracytoplasmic sperm injection (ICSI)?** * A single sperm is injected directly into a single egg * Good fo cases where there is oligospermia * Live birth rate: 25% per cycle * Multiple pregnancy rates as high as 24%

Answer 372

* Bleeding in early pregnancy (first 12 weeks): * Normal * Miscarriage * Ectopic _Spontaneous miscarriage:_ * Loss of an intrauterine pregnancy before 24 weeks * 80% occur in first 12 weeks: early pregnancy loss! * Affects 1 in 5 pregnancies _Aetiology of miscarriage:_ * Unknown!! * Foetal chromosomal abnormalities - 50% * Maternal medical conditions: * DM - poorly controlled * SLE * APS * Environmental: * Increased maternal age * Obesity * Smoking * Alcohol * Cannabis * Anatomical: * Uterine abnormalities --\> later miscarriages (problem as uterus grows) * Infection: * Listeria * Toxoplasmosis * Varicella zoster * Malaria **Types of Miscarriage** * Threatened miscarriage: * PV bleed * Cervical os closed * Can be reversed * Inevitable miscarriage: * PV bleed * Cervical os open * WILL end in miscarriage * Incomplete miscarriage: * PV bleed * Cervical os open * Some products of conception remains in the uterus but some has passed * Delayed miscarriage: * No PV bleed - symptomless * Cervical os closed * Foetus is dead - no foetal heart beat found in scan * Complete miscarriage: * PV bleed * Cervical os closed * Empty uterus * Can only be diagnosed on US - looking at this cervical os and this could be a threatened miscarriage! **Management options** * ABCDE - stabilise patient if bleeding * Ix: FBC, blood group/antibody, rhesus status _Three main options:_ * Expectant management: wait and see * Will often need further medical or surgical intervention as won't expell all the contents * Medical management: vaginal prostaglandin (misoprostol) * Causes uterus to contract & expell pregnancy * Surgical management of miscarriage _NB:_ Give anti-D if rhesus negative!! * Expectant management is suitable for 7-14 days as 1st line management but NOT suitable IF: * Increased risk of bleeding * Coagulopathies * Previous adverse experiences of pregnancy * Infection present * Mother doesn't wish to use this method **Information post miscarriage?** * Conselling: pregnancy loss/bereavement * Miscarriage Association! * Advised to wait for one period before trying again * AND when they are psychologically ready! * Emphasise probably success of subsequent pregnancies * 50% due to foetal chromosomal abnormalities! * 1st miscarriage does NOT increase risk of a miscarriage with subsequent pregnancy! * If trying again: folic acid, healthy diet, smoking cessation, good DM control, etc!

Answer 373

* Positive pregnancy test AND no visible pregnancy on US! * Several possibilities: * Early intrauterine pregnancy * Failing intrauterine or extrauterine pregnancy * Ectopic pregnancy * An empty uterus does NOT necessarily mean a miscarriage **Role of beta-hCG in haemodynamically stable women with PUL on transvaginal US:** * Serum hCG at 0 and 48 hours! * _hCG increases **\> 63%** = likely intrauterine pregnancy!_ * Repeat TVUS in 7-14 days * _hCG suboptimal rise/fall = likely ectopic pregnancy_ * Clinical review within 48hrs * _hCG decreases **\> 50%** = likely failing pregnancy_ * Urine pregnancy test in two weeks

Answer 374

* The conceptus implants outside the uterine cavity (or in an abnormal position within the uterus) * 95% are tubal (isthmus, ampulla, infundibular) * Interstitial * Ovarian * Cervical * Abdominal **Risk Factors for Ectopic Pregnancy?** * P - Previous ectopic * I - intrauterine contraceptive device * P - pelvic inflammatory device * P - pelvic or tubal surgery * A - assisted reproduction NB: A third of women with an ectopic have no risk factors **Presentation & Ix's?** Sx: classic triad not always present * Pain * Amenorrhoea * Bleeding * Can have: collapse, shoulder pain, peritonism etc * Clinical features: * ABC * Fit, young women can lose up to 40% of their circulating volume before obs change - look for tachycardia! (precedes hypotension) * Pelvic examination: * Was the examination well tolerated? * Note any cervical motion tenderness ("cervical excitation") - from blood * Is uterine size equivalent to gestation? * Labs: * FBC * Group & save / cross match 4 units * hCG - repeat after 48hrs; ~doubles every 2 days in early pregnancy * \<63% rise over 48hrs associated with ectopic pregnancies & miscarriages "**suboptimal rise in hCG"** * _hCG of 1500 is the level at which an intrauterine pregnancy should normally be seen on TVUS!_ * US: findings dependent on the stage of development of the ectopic. ?empty uterus + adnexal mass **Management Options?** * Expectant * Obviously worry about rupture if you leave the ectopic to pass naturally * Medical: methotrexate * Surgical: * Laparoscopy is preferred approach wherever possible * Salpingectomy is preferred to salpingostomy if no other risk factors for subfertility - ectopic usually causes scarring in tube! _NB:_ These guys should be followed up in next pregnancy! All should be seen in Early Pregnancy Unit at 6 weeks for assessment & US!

Answer 375

* Technically \>80ml blood loss per period * IRL: excessive menstrual blood loss which interferes with the woman's physical, emotional, social & material quality of life * So... if they say they have heavy periods... they HAVE heavy periods! **Causes: 4 categories** _Idiopathic:_ * "Dysfunctional uterine bleeding" _Local:_ * Polyp / fibroid * Adenomyosis * PID * Cancer _Systemic:_ * Hypothyroidism * Coagulopathy _Iatrogenic:_ * Copper coil * Warfarin * NOAC's **Dysfunctional Uterine Bleeding:** * "Abnormal uterine bleeding in the absence of recognisable pelvic pathology, general medical disease or pregnancy" * Common at extremities of reproductive life - teens & peri-menopausal women * Typically, irregular heavy periods (metromenorrhagia) * Problems with luteal phase of cycle - often due to anovulation * Often due to inadequate oestrogen to cause LH surge and subsequent ovulation: * Young teenagers with immature follicles! * Peri-menopausal women with falling oestrogen levels * PCOS **Fibroids:** * Always think about fibroids with heavy periods! * Benign tumours of uterine smooth muscle * Protrude into uterine cavity making cavity irregular & increasing SA of endometrium * May also cause pressure effects on surrounding structures: bladder, bowel * May also cause: dysmenorrhoea **Adenomyosis:** * Clusters of endometrial cells within myometrium * Sx: heavy, often painful periods - typically in a woman in her 40's * O/E: tender, enlarged uterus * TVUS: "varied density myometrium," sometimes with small cysts * MRI: thickened junctional zone between endo & myometrium **Menorrhagia: The Work Up?** _Hx:_ * Exclude red flag symptoms (IMB, PCB!) * Future fertility plans or contraceptive needs! _O/E:_ * Abdominal - ?fibroid uterus * Speculum - polyp / ectropion / mass / swabs/ smear if due! * Bimanual - ?enlarged uterus ?tender uterus _Ix:_ * **FBC on all women presenting with heavy menstrual bleeding** * ?anaemia * ?iron-deficient * Thyroid function tests * Von-Willderbrand's factor * US scan - if structural abnormality is suspected * ?Endometrial problem --\> hysteroscopy & endometrial biopsy * ?myometrial problem --\> TVUS **Management** _Medical treatments:_ * Non-hormonal (fertility sparing): * Anti-fibrinolytics (**tranexamic acid)** * NSAIDs (help dysmenorrhoea) * Hormonal: * Mirena coil (very effective) * COCP (also effective - go on the tricycle!) * Oral progestogens in luteal phase (eg: norethisterone from day 19 to 26) * Tranexamic acid: * Inhibits production of plasmin * Reduces blood loss by 50% * Taken by mouth - 500mg tablets, two taken 3x day for three days * Contraindicated: in those with previous VTE or FHx _Surgical options:_ * Fertility sparing: * Myomectomy (hysteroscopic, laparoscopic or open) * Non-fertility sparing: * Endometrial ablation * Uterine artery embolization * Hysterectomy

Answer 376

* Contraception * Primary menorrhagia * Endometrial protection during HRT

Answer 377

* Intermenstrual bleeding --\> ?endometrial ca * Post coital bleeding --\> ?cervical ca * Post menopausal bleeding --\> ?endometrial ca _NB;_ IMB under 40 --\> chlamydia & endometrial polyps are most common cause IMB over 40 --\> need to exclude carcinoma of endometrium

Answer 378

**Risk Factors** _Unopposed oestrogen:_ * Age * Early menarche * Late menopause * Nulliparity * Obesity * Oestrogen only HRT * Tamoxifen _Chronic anovulation:_ (--\> no corpus luteum --\> no progesterone) * PCOS * Infertility * Associated progesterone deficiency **Investigation** * US - endometrial thickness * Hysteroscopy & endometrial biopsy * MRI - help stage cancer **Management** * Total abdominal hysterectomy and bilateral salpingo-oophrectomy = standard * +/- radiotherapy * Chemotherapy in advanced cases

Answer 379

**Example Case:** * 78yr old female * PC: bloating of her abdomen & bowel motions are "a bit loose" * GP organises colonoscopy which is negative * HER SYMPTOMS COULD EASILY BE DUE TO OVARIAN CARCINOMA **Presentation** * Poor prognosis - 25% 5 year survival * Pelvis is deisgned for pregnancy and can accomodate a large tumour - presents late * If identified early (stage 1) 5 year survival = 90% * Presents with (typically): * Abdominal pain * Abdominal swelling - due to ascites * Sx: * Low abdominal pain & bloating * Very occasionally with bleeding if tumour is hormone-secreting * Ix: * Consider US for new symptoms in any woman over 40yrs! * ?Adnexal masses + ascites * MRI/CT to stage * Ca125 * No effective screening method - even in high risk groups etc **Risk Factors** * Anything that increases number of ovulations * Nulliparity * FHx * BRCA gene (1 \> 2) * Increased age * Smoking * HRT * NB: COCP & pregnancy = protective (stop ovulation) **Staging** * Stage 1 = confined to organ * Stage 2 = local spread but confined to pelvis * Stage 3 = spread to abdomen, but confined to peritoneal cavity * Stage 4 = distant spread **Mx** * Surgery: * Debulking for advanced disease * Pelvic clearance for early disease * Neo-adjuvant chemotherapy with platinum-based drugs: taxane & cisplatin!

Answer 380

**HPV** _Associations with common types of HPV:_ * Veruccas: 1 & 2 * Warts: 2 & 7 * Genital warts: 6 & 11 _Treatment of CIN:_ * Excision/destruction of affected area at colposcopy * Large loop excision of transformation zone (LLETZ) * Cold coagulation / cryotherapy / laser vaporisation * Under GA: cone biopsy **Carinoma of the Cervix** _FIGO staging of cervical cancer:_ * Stage 1 = confined to cervix * Stage 2 = local spread (parametrium & upper vagina) * Stage 3 = extending to wall of pelvis (& causing hydronephrosis) * Stage 4 = distant spread (bladder, rectum, liver & lungs) _Management_ * Combination of surgery / radiotherapy / chemotherapy - depending on pt and stage of cancer * Surgery: * LLETZ / cone biopsy excision - for early stage * Radical hysterectomy * Trachelectomy = removal of cervix & pelvic lymph nodes with preservation of body of uterus for those to preserve fertility **Cervical Screening** * Dysplasia = cytology (on smear) * CIN = histology (on biopsy) _Cervical Cytology & HPV triage!!_**KNOW THIS** * Normal --\> routine smear recall 3 years * Borderline & mild dysplasia --\> HPV test * HPV negative (35%) --\> back to routine recall 3yrs * HPV positive (65%) --\> refer to colposcopy * Moderate & severe dysplasia --\> colposcopy!

Answer 381

**Levonorgestrel:** * _Failure rate_ = 22/1,000 * _Mechanism_: delays ovulation * _When_: up to 72hrs after UPSI. Earlier the better * _Twice in a cycle?_ Yes. * _Contraindications_: No medical C/I's. If BMI \> 26/weight \>70kg, double dose. * _Interactions_: efficacy not affected by having taken hormonal contraception or EllaOne. Double dose if on enzyme inducers\*\*. * _Starting hormonal contraception_: Immediately. Condoms/abstain for 7/7. * _Ethics/law:_ does NOT disrupt existing pregnancy or cause foetal abnormalities **Ulipristal (EllaOne):** * _Failure rate_ = 14/1,000 * _Mechanism_: delays ovulation * _When_: Up to 120hrs after UPSI. Earlier the better. * _Twice in a cycle?_ Yes. * _Contraindications_: severe asthma on ORAL STEROIDS (makes steroids less effective) * _Interactions_: * Do not use within 7 days of using hormonal contraception * Avoid if taking enzyme inducers * Ranitidine & PPI's make it less effective: avoid * Discard breast milk for 7/7 * _Starting hormonal contraception:_ * After 5 days for COCP * After 7/7 for POP * Condoms/abstain for 12days for COCP * _Ethics/law:_ does NOT disrupt existing pregnancies or cause foetal abnormalities **Copper coil:** * _Failure rate_ = 1/1,000 * _Mechanism_: prevents impantation * _When_? Up to 5 days after UPSI or up to 5 days after earliest ovulation * _Twice in a cycle?_ N/A * _Contraindications_: * Current STI * Menorrhagia may be exacerbated but not a C/I * _Interactions_: N/A * _Starting hormonal contraception_: not needed! * _Ethics/law:_ must not use if risk of implanted pregnancy _\*\* Enzyme inducers:_ * Some anti-epileptic drugs * Some anti-retroviral drugs * Rifampicin * St. John's wort UPA is out. LNG can be used but double dose **History Taking** * When was the UPSI? Date & time * Have you had unprotected sex on any other occasion since your last period * Are you using contraception * When was your last period? Did it start at the usual tiem? Was your last period normal for you? * How long is there between your periods? Do you ever come on a few days early or late? * Medications: * Enzyme inducers * Ranitidine and PPI's * Recent hormoneal contraception including emergency contraception **Counselling about oral EC** * 10% will get headache or nausea * 2% will vomit - repeat dose if within 3hrs or use copper coil * Period may be delayed by up to a week after the expected time * _Oral EC does NOT provide ongoing contraception_ * Chec pregnancy test 21 days after last UPSI if starting on hormonal contraception or period delayed by more than 7 days

Answer 382

**COCP: missed pill rules** * One missed pill: take next one as planned & no need EC * Two or more missed pills: used condoms for 7 days PLUS need for EC depends on where you are in pack: * Week 1 - EC may be needed * Week 2 - EC not needed * Week 3 - EC not needed, but carry straight on into next pack! **POP: missed pill rules** * If UPSI before missed POP, no problem as mechanism is to thicken & make hostile the cervical mucus and it was thick PRIOR to missed POP * Take POP as soon as remembered and keep taking as usual * Need condoms for 2 days after missed POP as mucus will be less hostile * If UPSI during this time, EC is indicated * If ammenorrhoea or irregular bleeding, you can't predict ovulation --\> so copper coil use is restricted to within 5 days of UPSI!!

Answer 383

* Pregnancy test * Cervical smear & triple swabs! * US & endometrial biopsy * Imaging if pelvis mass found

Answer 384

Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml EG: 25% burn in 60kg woman... 25% x 60 x 4 = 6,000mls over next 24hrs

Answer 385

Pityriasis versicolour is a fungal infection that characteristically causes light patches on the trunk which can be mildly pruritic. It affects many groups including the healthy, the immunocompromised and physically active individuals. DDx = vitiligo - usually presents with a more symmetrical pattern

Answer 386

Acute pancreatitis is known to precipitate **ARDS**. ARDS is characterised by bilateral pulmonary infiltrates and hypoxaemia. **Acute Respiratory Distress Syndrome** * Defined as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia (PaO2/FiO2 ratio \< 200) in the absence of evidence for cardiogenic pulmonary oedema * Causes: * Sepsis * Direct lung injury * Trauma * Acute pancreatitis * Long bone fracture or multiple fractures (through fat embolism) * Head injury (causes sympathetic nervous stimulation which leads to acute pulmonary hypertension) * Management: * Treat the underlying cause * Antibiotics (if signs of sepsis) * Negative fluid balance i.e. Diuretics * Mechanical ventilation

Answer 387

* Hypokalaemic metabolic alkalosis

Answer 388

* In descending order... * prostate * breast * lung

Answer 389

**Foetal Alcohol Syndrome** * Microcephaly (small head) * Short palpebral fissures (small eye opening) * Hypoplastic upper lip (thin) * Absent philtrum * We had had a beer when Lucy ripped my frenulum (think of frenulum = philtrum) * Reduced IQ * Variable cardiac abnormalities. **Smoking?** * Increased risk of: * Miscarriage, * stillbirth, * pre-term labour * intrauterine growth retardation **Congenital Rubella?** * Most at risk in first 16w of pregnancy * Classic features: * _cataract,_ * _deafness,_ * cardiac abnormalities * Other possible features: * jaundice, * hepatosplenomegaly, * microcephaly, * reduced IQ **Congenital Varicella?** * Features: * skin scarring, * eye defects (small eyes, cataracts or chorioretinitis), * neurological defects (reduced IQ, abnormal sphincter function, microcephaly) **Congenital Syphillis?** * Rhinitis, * saddle shaped nose, * deafness (sensorineural hearing loss) and * Hutchinson’s incisors Also: Hepatosplenomegaly, lymphadenopathy, anaemia, jaundice

Answer 390

von Willerbrand disease! (type 1)

Answer 391

* **Metformin** increases the risk of lactic acidosis - suspend during intercurrent illness eg. diarrhoea and vomiting

Answer 392

* Cardiac ECHO * Coronary artery aneurysms are acknowledged complication of Kawasaki - screened for with an echo

Answer 393

* Erratic blood glucose control, bloating and vomiting think gastroparesis * This question is asking about a young man with type 1 diabetes, presenting with bloating, vomiting and impaired glucose control. This is a typical pattern of gastroparesis. Gastroparesis can occur in diabetics due to neuropathy of the vagus nerve, causing abnormal gut movement.

Answer 394

_The RCP guidelines essentially divide patients into two groups._ 1. Patients **over the age of 65 years** or those who've **previously had a fragility fracture** should be offered bone protection. 2. Patients **under the age of 65 years** should be offered a bone density scan, with further management dependent: * T scoreManagement * Greater than 0 - Reassure * Between 0 and -1.5 - Repeat bone density scan in 1-3 years * **Less than -1.5 - Offer bone protection** The first-line treatment is **alendronate**. Patients should also be **calcium and vitamin D replete.**

Answer 395

* Correct answer: discuss the complications of this with the mother and ask her to make a joint appointment with her daughter, to see you next week, to discuss further **She's over 18..!** You'll break confidentiality or some shit. The GMC guidance about Female genital mutilation (FGM) and child protection states; 'The mandatory duty (to tell an appropriate agency) will not apply in relation to at risk or suspected cases or over 18s, although doctors must follow our guidance on child protection if they think that a child is at risk. It also will not apply if a professional can identify that another individual working in the same profession has already made a report to the police in connection with the same act of FGM.'

Answer 396

* **Subscapularis** - positioned anteriorly on your chest, helps with internal rotation of shoulder * **Supraspinatus** - positioned on top of your shoulder and runs parallel to your deltoid. Needed for _the first 20° of shoulder abduction_, then the rest of abduction is done by the deltoid * * **Infraspinatus** - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder * * **Teres mino**r - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder NOTE: Infraspinatus & teres minor are positioned near each other and basically do the same thing

Answer 397

* Oral monteleukast OR inhaled corticosteroid This child is likely to have a **viral-induced wheeze**, also known as episodic viral wheeze. First-line treatment is short-acting bronchodilator therapy. If this is not successful then either oral montelukast or inhaled corticosteroids should be tried.

Answer 398

* Leave the child on the parent' knee if that is where they are most comfortable * Always explain what you are going to do * Use one of the parents as a "dummy" - eg: listen to parent's heart first * Be systematic, yet _opportunistic_, ie. auscultate before they start cyring, look into the throat when they're screaming * Examiners WILL UNDERSTAND if a child has been difficult to examine! * Baby's don't have a neck so chekc for enlargement of liver instead of assessing the JVP!

Answer 399

In kids under one, there's a common disease With cough, snotty nose, crackles & wheeze Always record the respiratory rate, If it's severe, they'll desaturate! Age \<1; RR = 30-40 (bronchiolitis) Age 5-12: RR = 20-25 (acute asthma)

Answer 400

**Normal splitting of the second heart sound?** * During inspiration, increase in negative intra-thoracic pressure * Causes increased venous return to the right atrium * More blood in right side of heart (more ejected from right ventricle) * Causing slight delay in closure of the pulmonary valve **ASD?** * Wide, fixed splitting of the second heart sound * _Wide_: due to shunting, with increased flow to the right side of the heart, delaying closure of the pulmonary valve * _Fixed_: no variation with respiration because of "common atrium" (due to defect, changes with respiration affect both sides of the heart equally) * NB: this is a subtle sign that you are NOT expected to pick up **Pansystolic murmur?** * DDx: * Ventricular septal defect (at lower sternal edge, often with thrill!) * Mitral regurgitation (loudest at apex & radiates to axilla) * Tricuspid regurgitation (with pulsatile hepatomegaly and V waves in JVP) _NB:_ Easy to differentiate a murmur depending on whether it is heard above or below the nipple line. * Above nipple line* = ejection systolic murmur & PDA murmur * Below nipple line* = pansystolci murmur (VSD & MR) **Ejection systolic murmur?** * Audible gap between murmur & HS2 * Ejection systolic murmur above nipple line: * Aortic stenosis - radiates to neck * Pulmonary stenosis - radiates to back **Machinary murmur?** * Continuous murmur throughout systole & diastole * Patent ductus arteriosis

Answer 401

* Short * Soft * Systolic * S1 & S2 normal * Standing & sitting variation * Symptomless * Special tests normal (ECG, CXR, Echo) Innocent murmurs often heard with fever (tachycardia with increased cardiac output) Will have no associated radiations or thrills.

Answer 402

* Loudness of murmur inversely related to size of shunt * Buzz words: large VSD may cause **"a left to right shunt at ventricular level"** _Small VSD:_ * High velocity "blowing" jet * May have thrill (palpable murmur) * but NO significant left to right shunt * Increased risk of endocarditis! * DDx = other pansystolic murmurs * Mitral regurg * Tricuspid regurg * Therefore key question = V waves in JVP & liver! _Large VSD:_ * Can cause heart failure! * With a big VSD there is volume overload of the ventricles because of shunting * Similar to how sheer volume of traffic can slow down traffic flor on a motorway even without an obstruction such as road works * Sx: * Breathless & sweaty on feeding or crying (sympathetic overdrive) * Faltering growht * Recurrent chest infections * Typically presents as: * Left parasternal heave (due to RV hypertrophy) * Quiet or absent pansystolic murmur * Pulomary ejection murmur * (ie. signs of pulmonary HTN) **Ix a VSD** * ECG - right ventricular hypertrophy (dominant R wave in V1) * CXR - cardiomegaly, prominent pulmonary artery & plethoric lung fields (increased blood flow = more whiteness) * Echo - shows size of lesion & doppler flow may indicate size of shunt **Mx a VSD** * None if small * Abx prophylaxis to prevent enchocarditis - controversial * NICE do NOT recommend it * Diuretics & ACEi for heart failure * Large defect with risk of pulmonary HTN - repair

Answer 403

* Wide fixed splitting of second heart sound! * "A left to right shunt at atrial level" * May be asymptomatic * Recurrent chest infections or HF * Arrythmias common in 30s & 40s - SVT & AF * Isolated ASD: low risk of endocarditis & Abx prophylaxis not needed _Mx:_ * Trans-catheter closure using a double-umbrella occluder device "Amplatzer septal occluder" (via femoral vein & IVC to right atrium) * Open heart surgery with patch repair before 5th birthday

Answer 404

* Commoner in premature babies (kept open by hypoxia) * Expanded lungs are also main site of prostaglandin breakdown! * Normally closes within a day or two of birth * If persists, left to right shunt occurs as right sided pressures fall with lung expansion * "a left to right shunt at ductal level" _O/E:_ * Collapsing or bounding pulses * *IF you can feel a radial pulse, then this is abnormal and could be a PDA!!!* * The shunting leads to extra blood flow through the lungs & hence extra blood returning to the left of the heart (volume overload) * Wide pulse pressure: * Extra blood ejected from LV causes high systolic pulse pressure * Rapid "run off" through the ductus leads to low diastolic pressure * Auscultation: continous "machinery" murmur * Loudest below left clavicle * Radiates to back * Small shunt: well neonate with machinery murmur * Large shunt: heart failure or recurrent chest infections * Mx: * Prostaglandin inhibtors to close duct (eg: ibuprofen) * Transcatheter occlusion * Surgical ligation

Answer 405

* Pulmonary outflow tract stenosis * Right ventricular hypertrophy * VSD * Over-riding aorta * With R --\> L shunt Ejection systolic murmur - through the stenotic pulmonary outflow _O/E:_ * Clubbing and cyanosis * Right ventricular hypertrophy - with L. parasternal heave * Ejection systolic murmur * Squatting posture: * Partially occludes femoral arteries * Increases systemic vascular resistance * More blood flows across PDA into pulmonary artery * Improves oxygenation _Surgery_ * Usually two-stage procedure * Shunt operation to increase pulmonary flow in order to develop the pulmonary arteries - which have been "Starved" of blood flow by the stenosis --\> improves oxygenation * Followed by definitive correction * LATEST EVIDENCE: * Beta blockers prevent infundibular spasm (RV outflow tract spasm) and reduce cyanotic spells

Answer 406

* R - round face * O - occipital (& nasal) flattening * S - speckled iris (Brushfield spots) * E - epicanthic folds * O - open mouth with protruding tongue * L - low set ears * A - almost (oval) upslanting eyes _Hands_ - single, transverse palmar crease, short fingers, curved little finger _Feet_ - sandle gap between big toe & other digits _Increased risk of_: duodenal atresia, coeliac disease, Hirschprung's, leukaemia, hypothyroidism All should have an echo at time of Dx. Down syndrome associated with: * ASD * VSD * Atrioventricular canal defect * **"Endocardial cushion defect" leads to "failure of septation" of the heart**

Answer 407

_Diagnosis:_ * Fever for 5 days plus 4/5 of the following: * Conjunctivitis * LAD * Rash * Lips - redness, cracking or strawberry tongue * Extremity changes (eg: peeling of skin on the fingers) * Pneumonic = CLEAR * Conjunctivitis * LAD & lips * Extremity changes * Aneurysms * Rash!

Answer 408

**Rheumatic Fever** * Occurs after the usual immunological 2-6 week gap following infection with Strep. pyogenes (Group A beta-haemolytic strep) * \>50% assocaited with an acute carditis * Molecular mimicry - Ab's cross-react with bacterial cell wall & heart antigens * Chronic rheumatic heart disease: * Recurrent episodes --\> damage heart valves * Typically leads to mitral stenosis or aortic regurg years later **Diagnosis** * Based on evidence of Strep (_Throat swab or ASO titre)_ plus major and minor criteria _Duckett Jones' major criteria:_ * Mitral diastolic murmur * Erythema marginatum * Nodules (painless, subcutaneous, rare) * Arthritis * Chorea _Minor criteria:_ * Arthralgia * Fever * Raised ESR * Heart block

Answer 409

SEE PICTURE _Airway Opening Manouvres:_ * Head tilt, chin lift or jaw thrust * Neutral of sniffing positions _Look, Listen, Feel:_ * For 10 seconds * Irregular, gasping agonal breaths don't count as "signs of life" _Rescue breaths:_ * 1 second per breath _Check for pulse & signs of circulation:_ * Carotid or brachial pulse \>60 _Chest compressions:_ * 100-120 bpm * Lower third of sternum * Compress by a third of AP diameter of chest * Infant under 1, use 2 fingers or encircling technique **Favourite questions?** * How long would you continue before going for help? * 5 cycles or 1 minute * Carry an infant with you if possible when going for help * How long would you continue CPR? * Until further help arrives * Until signs of life are noted * Until you are exhausted * When would you perform CPR in the presence of a pulse? * Brady \<60 * Thready pulse in a collapsed child * No signs of life * What are signs of life? * SPontaneous movement * Spontaneous breathing * Response to stimulation **The ABCDE approach to a child?** * Airway: * Treat choking * Maintain airway * High flow O2 * Call anaesthetist * Breathing: * High flow oxygen if needed * Nebulised salbutamol if bronchospasm * Emgernecy needle decompression for tension pneumothorax * Circulation: * IV access & fluid bolus for shock (I SHOCKS) * Disability - AVPU, moving all 4 limbs? * Check capillary glucose * Treat hypoglycaemia * Treat seizures * Exposure - check mucous membranes & entire skin: * Check for urticaria & for non-blanching or evolving rash * Preserve patient dignity * Repeat checks if initially normal **DKA: Fluid Resuscitation** * If pH \> 7.1, assume 5% dehydration * If pH \< 7.1, assume 10% dehydration * Replace over 48hrs (NOT 24hrs) Consider NG tube if decreased GCS & vomiting loads to reduce risk of aspiration. **Anaphylaxis:** * ABCDE * Dx: * Sudden onset * Life-threatening airway / breathing / circulation problems * Skin changes often * Call for help & remove allergen * STOP ANY DRUG INFUSION * Lie patient flat & raise legs - if volume deplete * Adrenaline IM: * Establish airway & high flow oxygen (are they misting their mask?) * IV fluid bolus if hypotensive * Nebulised salbutamol if wheezing * Repeat adrenaline after 5 mins if needed * Following initial resuscitation: * IV hydrocortisone * Antihistamine (eg: chlorphenamine) * Observe for rebound symptoms ("biphasic anaphylaxis") * Education re basic life support & use of an adrenaline autoinjector * Blood (IgE panel) and/or skin prick testing **Inasvive Meningococcal Disease** * Meningitis: * Neck stiffness * Photophobia * Kernig's sign * Bulging fontanelle in infants * Systemic sepsis: (ie. not just confined to meninges) * Non-blancing rash * Reduced GCS * Shock * Multi-organ failure MOST HAVE BOTH MENINGITIS COMBINED WITH SYSTEMIC SEPSIS. _Management:_ * ABCDE * Check bloods - FBC, U&E, glucose, lactate, clotting, cultures, PCR * Check blood gases Both asking how bad the organ failure is... * Shock: * No lumbar puncture! getting baby into LP position will cause them to decompensate * IV ceftriaxone * Bolus IV saline * Reassess and repeat PRN * Secure airway * Consider inotropes * Raised ICP suspected: * Focal neurology / papilloedema / seizures / GCS \<12 * No lumbar puncture! * IV ceftriaxone * Call anaesthetist * Secure airway * PICU * Meningitis: * With no contraindications to LP * Perform LP * Then IV ceftriaxone * Plus dexamethasone!! * Do not allow LP to delay Abx!! Check CSF to confirm bacterial cause. Notifiable disease. Offer prophylactic Abx to household contacts. **Traffic Light System for Children with Fever or Unwell** _Red:_ * Obviously unwell child * Ill child / high risk _Amber (AMBER):_ * A - appears pale (to parent or carer) * M - mucous membranes dry (or poor intake) * B - behaviour reduced (or reduced GCS) * E - elevated resp or heart rate or CPT * R - rigors _Green:_ * Well child / low risk * Usually obvious **Status Epilepticus** Oh My Lord, Phone the Anaesthetist * O - Oxygen (after checking ABC) * M - Midazolam (buccal; or rectal diazepaml; or IV lorazepam) * L - Lorazepam (IV) * P - Phenytoin (infusion IV) * A - rapid induction anesthesia (with thiopentone)

Answer 410

As part of our safeguarding obligation when treating all children, we will need to ask you some specific questions relating to the care of your child and their overall "safety" No I'm absolutely making any accusations. Anyone coming in with any similar injuries and we would admit the child and properly investigate to ensure that the child is safe when they go home. We may contact social services but that is only because that is routine. No one is taking your child from you at the moment. We will just want to ask you some more questions. **This is about putting [name]'s safety first.** **I understand you must be very worried about [name]. I assure you we are doing everything we can to help her. Her well-being is our absolute priority.**

Answer 411

* ALL is commonest in children * Peak incidence 2-5yrs * Malignant disease of the bone marrow * Lymphoid precursors (blasts) proliferate & replace normal haematopoetic cells * Dx: confirmed on bone marrow aspirate * Under GA * "Testes and CNS are sanctuary sites" * Sx: * Bone pain - eg: presents with knee pain due to bone infiltration * LAD & hepatosplenomegaly * Bone marrow failure (anaemia, neutropaenia, thrombocytopaenia) _Management:_ * Induction chemotherapy at a tertiary centre * Shared care with local hospital for consolidation & maintenance * 2 years in girls * 3 years in boys (longer because of sanctuary sites) * EG of drugs used: vincristine, methotrexate, steroids * Radiotherapy can be required for sanctuary sites BUZZ WORDS: **"minimal residual disease burden"** * Induction chemotherapy for 4 weeks * Then repeat bone marrow aspirate * Good prognosis IF no circulating blasts on blood film and less than 5% blasts in marrow _Key Complications of ALL:_ * Bone Marrow Failure: * Malignant infiltration of bone marrow + burden of chemotherapy drugs * Mx: transfusion of blood products. Granulocyte colony stimulating factor (G-CSF) * Sepsis (Febrile neutropaenia): * Low WBC count * Rx: broad spectrum Abx * Tumour lysis syndrome: * Renal failure secondary to increased levels of urate, phosphate & potassium following initiation of chemotherapy * Rx: hyperhydration!! Allopurinol. Dialysis (due to AKI) _Outcomes of ALL:_ * Best prognosis: * Age 1-10yrs * Lower WBC at diagnosis (under 50 x10^9/L) * Good response to induction chemotherapy with MINIMAL RESIDUAL DISEASE BURDEN * Overall cure rate around 90%

Answer 412

* Accidental injury * Osteogenesis imperfecta * Coagulation disorders eg: ITP * Mongolian blue spot!! * Scalded skin syndrome

Answer 413

* S - safety of child is absolute priority * M - manage presenting medical problem appropriately * A - always discuss concerns with a senior paediatrician * C - contact Social Care * K - keep clear & contemporaneous notes!!

Answer 414

**Summary?** * Incidence: 1 in 2500 live born GIRLS * Aetiology: Complete or partial absence of an X chromosome * Diagnosis: Karyotype analysis * Clinical features: * Short stature * Non functioning ovaries * Abnormal appearance _NB:_ Can present with variety of clinical features but *short stature* and *infertility* are nearly always present. Therefore ALL girls presenting with short stature or delayed puberty should have their karyotype checked. **Phenotypic features?** * Short stature (often normal growth until 3/4yrs then slows) * Low hairline * Neck webbing * Broad chest (widely spaced nipples) * Increased carrying angle (cubitus valgus) **Associated features?** * Cardiac defects (eg: coarctation of the aorta) * Renal anomalies * Autoimmune thyroiditis * Diabetes * Middle ear disease * Learning difficulties * Hypertension **Management?** * MDT, including paediatric endocrinologist * Growth hormone to optimise final height * Sex hormone replacement * Oestrogen to induce secondary sexual characteristics * Progesterone to induce menstruation * Monitor BP * Monitor for thyroid disease & diabetes * Monitor for hearing loss * IVF for ferility - using donor eggs * Family support!

Answer 415

* CORRECT ANSWER: Explore his concerns and offer him counseeling to deal with his situation (Wrong answer: remove the DNACPR as he has full capacity to refuse this decision) **DNACPR is not a decision made by the patient and so removing this is not an option.**

Answer 416

* Patient within 12 months of giving birth * Clinical manifestations suggestive of hypothyroidism * Thyroid function tests support diagnosis

Answer 417

* Renal ADENOCARCINOMA Renal adenocarcinoma = most common renal malignancy (75% cases) Way more common than RCC.

Answer 418

* _Vesicovaginal fistulae_ should be suspected in patients with **continuous dribbling incontinence after prolonged labour** and from a country with poor obstetric services. * **Ix = urinary dye studies** - A dye stains the urine and hence identifies the presence of a fistula. * _Stress Incontinence:_ incontinence with straining - coughing or sneezing * **Mx = pelvic floor exercises for 3 months**

Answer 419

**Mesenteric Adenitis** Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment

Answer 420

* Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour. * Tongue can be itchy with it. Pretty gross. * Predisposing factors * poor oral hygiene * antibiotics * head and neck radiation * HIV * intravenous drug use * The tongue should be swabbed to exclude Candida * Management * tongue scraping * topical antifungals if Candida

Answer 421

* Bilaterally enlarged kidneys (in early disease) * Or normal sized kidneys (in late disease) * Whereas most other causes of CKD, will have bilaterally shrunken kidneys SAME WITH HIV NEPHROPATHY!!!

Answer 422

**Spironalactone** **Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ \< 4.5mmol/l - add spironolactone.** K+ \> 4.5mmol/L - add higher dose thiazide-like treatment

Answer 423

If everyone else in the house is fine, they're a smoker, you've excluded all red flag causes of a headache (eg: meningitis) Then consider other causes of headache (eg: primary headache - migraine)

Answer 424

**IV Abx & surgical drainage** Quinsy should be treated with IV antibiotics and surgical drainage, and a tonsillectomy should be considered in 6 weeks

Answer 425

* A **body mass index of less than 18.5kg/m²** * A **body mass index of less than 20kg/m²** _AND_ unintentional **weight loss greater than 5%** within the last 3-6 months * Unintentional **weight loss greater than 10%** within the last **3-6 months**

Answer 426

* Uncontrollable splenic bleeding * Hilar vascular injuries * Devascularised spleen

Answer 427

**Osteopaenia in vertebrae** **Osteoporosis in femoral neck** _T score_ * \> -1.0 = normal* * -1.0 to -2.5 = osteopaenia* \< -*2.5 = osteoporosis*

Answer 428

Dx: **Psoas abscess** * Characterised by: * Lumbar tenderness ( the point of insertion of the psoas muscle is T12-L5) * her preferring to lie with her knees slightly flexed * IVDU = high risk (+ diabetes / HIV / other immunosuppressed) **Likely organism = Staph aureus or strep**

Answer 429

* The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100% * An ankle x-ray is required only if there is any _pain in the malleolar zone_ AND any one of the following findings: * _bony tenderness at the lateral malleolar zone_ (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular) * _bony tenderness at the medial malleolar zone_ (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia) * _inability to **walk four weight bearing steps** immediately after the injury and in the emergency department_

Answer 430

1) **Marjolin's ulcer** Marjolin's ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury. 2) **Pyoderma Gangrenosum** Pyoderma gangrenosum is associated with inflammatory bowel disease. It is commonly found on lower limbs and described as being painful, the size of an insect bite and growing. It looks like a margherita pizza (with a red base and yellow topping) Treatment involves steroids.

Answer 431

**'Baby blues'** * Typically seen 3-7 days following birth and is more common in primips * Mothers are characteristically anxious, tearful and irritable * Mx: reassurance and support ONLY, health visitors have key role **Postnatal depression** * Affects around 10% of women * Most cases start within a month and typically peaks at 3 months * Features are similar to depression seen in other circumstances * Mx: * As with the baby blues reassurance and support are important * Cognitive behavioural therapy may be beneficial. * Certain SSRIs such as sertraline and paroxetine\* may be used if symptoms are severe\*\* - whilst they are secreted in breast milk it is not thought to be harmful to the infant **Postnatal psychosis** * Onset usually within the first 2-3 weeks following birth * Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations) * Mx: * Admission to hospital is usually required * There is around a 20% risk of recurrence following future pregnancies

Answer 432

**King's College Hospital criteria for liver transplantation (paracetamol liver failure)** * Arterial pH \< 7.3, 24 hours after ingestion OR all of the following: * prothrombin time \> 100 seconds * creatinine \> 300 µmol/l * grade III or IV encephalopathy

Answer 433

**Gram-positive cocci = staphylococci + streptococci** (including enterococci - E. coli) **Gram-negative cocci = Neisseria** meningitidis **+ Neisseria** gonorrhoeae**,** also Moraxella catarrhalis (**N**eisseria = **N**egative)

Answer 434

**No.** Not all patients on insulin have to inform the DVLA. The exceptions are those on temporary treatment for 3 months or less, or gestational diabetes that are taking insulin for less than 3 months post delivery

Answer 435

**Periductal Mastitis** Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav. _Duct Ectasia vs Periductal Mastitis:_ Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with nipple retraction and occasionally creamy nipple discharge. I*t may be confused with periductal mastitis, which presents in younger women, the vast majority of whom are smokers. Periductal mastitis typically presents with periareolar or subareolar infections and may be recurrent.*

Answer 436

* Cannot interpret IgA tissue transglutaminase (TTG) levels without looking at overall IgA levels May NOT be elevated if the patient is IgA deficient EG: if they have another autoimmune condition (eg: Graves) as they often do. Duodenal biopsy = definitive diagnosis

Answer 437

Asymptomatic gallstones which are **located in the gallbladder** are common and do **not require treatmen**t. However, **if stones are present in the common bile duct** there is an increased risk of complications such as cholangitis or pancreatitis and **surgical management should be considered**.

Answer 438

**Polymyalgia Rheumatica** _Pathophysiology_ * Overlaps with temporal arteritis * Histology shows vasculitis with giant cells, characteristically 'skips' certain sections of affected artery whilst damaging others * Muscle bed arteries affected most in polymyalgia rheumatica _Features:_ * Typically patient \> 60 years old * Usually rapid onset (e.g. \< 1 month) * Aching, morning stiffness in proximal limb muscles (not weakness) * Also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats _Investigations_ * ESR \> 40 mm/hr * Note CK and EMG normal * Reduced CD8+ T cells _Treatment_ * Prednisolone e.g. 15mg/od - dramatic response **Fibromyalgia** Fibromyalgia is a syndrome characterised by _widespread pain throughout the body_ with t_ender points at specific anatomical sites._ The cause of fibromyalgia is unknown. * Women are around 5 times more likely to be affected * Typically presents between 30-50 years old _Features_ * Chronic pain: at multiple site, sometimes 'pain all over' * Lethargy * Cognitive impairment: 'fibro fog' * Sleep disturbance, headaches, dizziness are common _Dx:_ clinical _Mx:_ Difficult... * Aerobic exercise has best response * CBT * Analgesia: pregabalin etc

Answer 439

* Old man, * bone pain, * raised ALP

Answer 440

**LMWH!!** Low Molecular Weight Heparin - induced thrombocytopenia!! (prothrombotic state) Though rare, heparin-induced thrombocytopenia is an immune-mediated response to heparin exposure which entails an increased risk of developing venous and arterial thromboembolism. It occurs when molecules of the cytokine Platelet factor 4 (PF4) bind to heparin to form an antigen. This antigen is then recognised by antibodies which in turn activate platelets through their Fc receptors, and thereby initiate a pro-thrombotic cascade.

Answer 441

NICE recommend considering a diagnosis of COPD in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production. The following investigations are recommended in patients with suspected COPD: * _post-bronchodilator spirometry_ to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% * _chest x-ray:_ hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer * f_ull blood count:_ exclude secondary polycythaemia * body mass index (BMI) calculation The severity of COPD is categorised using the FEV (see picture attached!)

Answer 442

Acute respiratory distress syndrome (ARDS) is caused by the increased permeability of alveolar capillaries leading to fluid accumulation in the alveoli, i.e. non-cardiogenic pulmonary oedema. _Causes_ * infection: sepsis, pneumonia * massive blood transfusion * trauma * smoke inhalation * pancreatitis * cardio-pulmonary bypass _Clinical features_ are typically of an acute onset and severe: * dyspnoea * elevated respiratory rate * bilateral lung crackles * low oxygen saturations

Answer 443

**Ciprofloxacin PO**

Answer 444

**Guillain-Barre**

Answer 445

_Recurrent chest infections_ + _subfertility_ - think **primary ciliary dyskinesia syndrome** (Kartagener's syndrome)

Answer 446

**Iron AND B12 AND folate** Coeliac can cause you to be deficient in any/_ALL_ of these

Answer 447

**Pulmonary embolism and renal impairment** **→ _V/Q scan_** is the investigation of choice

Answer 448

**Bleeding time** is a marker of _primary haemostasis_ and so is **raised in vWD**, but normal in haemophilia

Answer 449

**\>6.5%**!! (on one occassion) In 2011 WHO released supplementary guidance on the use of HbA1c on the diagnosis of diabetes. A HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus in a symptomatic patient.

Answer 450

You should think chorioamnionitis in women with preterm-PROM with a triad of maternal pyrexia, maternal tachycardia, and fetal tachycardia

Answer 451

_OVERVIEW:_ * Acute reactions occur **within 24 hours of transfusion**: * Acute haemolytic, * Febrile non-haemolytic, * Allergic, * Transfusion-related acute lung injury (TRALI). * Delayed reactions occur days to weeks after the transfusion: * Delayed haemolytic transfusion reactions, * Transfusion-associated graft- versus-host disease, * Post-transfusion purpura. **Transfusion-Related Associated Lung Injury (TRALI)** * Characterized by bilateral lung infiltrates and hypoxemia during transfusion or within 6 hours after * Usually occurs in the absence signs of fluid overload and within the first two hours of transfusion * Sx: * dyspnea, * hypoxemia, * hypotension, * fever * Cases typically resolve within 24-72 hours with supportive care * Steroids & diuretics are NOT directly helpful * Mx: * Many patients with TRALI will require supplemental oxygen and ventilator support. * Patients with TRALI should be managed with lung protective ventilation similar to ARDS. **Transfusion Associated Circulatory Overload (TACO)** * Sx: * Dyspnea, * Orthopnea, * Hypoxemia, * Tachycardia, * Hypertension. * O/E: Clinical exam and imaging will demonstrate volume overload. * The use of loop diuretics prior to transfusion should be individualized depending on patient risk of volume overload. * The pre-test probability of TACO may be estimated based on the presence of risk factors for TACO including: * Age \>70 (or age \<3) * History of CHF, Left Ventricular dysfunction, or MI * Renal Dysfunction * Positive fluid balance in the preceding 24h * Mx: * TACO can be managed similarly to acute decompensated heart failure with supplemental oxygen and intravenous furosemide. * Consider non-invasive positive pressure ventilation or intubation in severe cases. **Graft vs Host Disease** * Rare, and primarily observed in immunodeficient patients in whom transfused white cells react with recipient antigens. * Sx: * maculopapular rash, * fever, * diarrhoea, * usually begin 8 to 10 days following transfusion. * Tends to lead to marrow aplasia, with rapid progress towards death. **Acute or Delayed Haemolysis** * Usually the result of ABO red-cell incompatibility. * Most often the result of clerical error resulting in mistransfusion. * Sx: * Chills and fever, * headache, * nausea and vomiting, * anxiety * Pain along the infused extremity, or abdominal, chest, or back pain may accompany generalised symptoms. * Haemoglobinuria * Severe acute haemolytic transfusion reaction may progress toward hypotension, renal failure, and disseminated intravascular coagulation (DIC). **Allergic** * Hypersensitivity reactions to allergens in the transfused component. * Sx: * Pruritus, * flushing, * dyspnoea * Urticaria +/- angioedema * Anaphylaxis with hypotension can follow **Febrile non-haemolytic** * Present with fever, defined as a rise in temperature of at least 1°C (1.8°F ) above 37°C (98. 6°F) for which no other cause is identifiable.

Answer 452

Carcinoid syndrome can affect the **right side of the heart**. The valvular effects are tricuspid insufficiency and pulmonary stenosis (Think of the carcinoid tumour (in the bowel commonly, also in the lungs but whatever) secreting serotonin into the systemic circulation --\> hitting the valves of the R. heart.

Answer 453

* AL type amyloidosis, * Bence Jones nephropathy, * nephrocalcinosis, * nephrolithiasis _NB CASE:_ This man has an AKI with hypercalcaemia and proteinuria, along with anaemia and thrombocytopenia. This should raise alarm bells for myeloma.

Answer 454

**Posseting** * 40% of otherwise healthy babies have effortless regurgitation due to normal reflux after feeds * Usually starts \<8 weeks and self-limiting by 12 months in 90% * "Colic" - many babies pull their legs up, arch their backs & scream after feeds * ONLY IF the child is constantly miserable, coughing or wheezing after feeds or failing to put on weight = GORD!! **GORD** * Vomiting after feeds + constantly miserable, coughing, wheezing, failing to put on weight! * Explain reflux to mother: * The muscle ring at the lower end of the gullet isnt well developed yet * "Immaturity of the lower oesophageal sphincter" _Complications:_ * Problems related to vomiting milk: * Faltering growth * Problems related to acidity in oesophagus: * Oesophageal stricture * Respiratory complications: * Apnoeic episodes * Recurrent micro-aspiration with wheeze/pneumonitis _Mx - simple measures:_ * Smaller, more frequent feeds * Wind baby during feeds * Keep baby upright for ~20mins after feeds * Add thickeners to feeds * If this fails, trial alginate (eg: Gaviscon) for 2 weeks * Add this to feed but remove thickener!

Answer 455

* Commonly viral - Rotavirus, Adenovirus * Less commonly bacterial (Salmonella, Campylobacter, E.coli 0157) * Most cases self-limiting BUT some fuckers require admission for rehydration _NB:_ Differentiate signs of dehydration (dry mucus membranes, reduced skin turgot, sunken eyes, reduced urine output, tachy, irritable/lethargic) FROM signs of shock (dehydration plus "I SHOCKS"). * Dehydrated --\> oral rehydration solution. * if persistently dehydrated/vomiting --\> IV rehydration * Shocked --\> IV fluid resus _KEY PRINCIPLES FOR A KID WITH GASTRO:_ * Oral fluid replacement --\> NG route --\> IV resus * IF giving IV fluids, use an isotonic crystalloid (0.9% saline) * Amount of fluid to give = maintenance + estimated deficit + ongoing losses * Always discuss route, volume & rates of rehydration with a senior!! * ISOLATE CHILDREN WITH D&V

Answer 456

* Commonest cause of AKI in children * Typically 1-2 days after onset of diarrhoea due to E. Coli 0157 - 1/20 of E. Coli 0157 get HUS * Occassionally follows campylobacter or shigella * Sx - TRIAD of: * Acute kidney injury (causing raised urea) * Low platelets * Haemolytic anaemia * Key investigations = FBC & blood film!! * Anaemia * Low platelets * Film shows schistiocytes (fragmented RBC's) * Treatment: * Supportive +/- blood transfusion if needed * Dialysis for AKI _NB:_ Abx make it worse!! (Despite being a bacterial infection. Abx --\> breakdown of bacteria --\> more toxins released)

Answer 457

* Hypertrophy of muscle of gastric pylorus * Progressive projectile vomiting secondary to gastric outflow obstruction * Presents: 3-12 weeks of age * Commoner in first born males * Assess ABC * Do a test feed if stable: * Observe a feed * Witness a projectile vomit! * Vomit is yellow (not green) as it is non-bilious * Ix: * Capillary blood gas: **hypokalaemic, hypochloraemic, metabolic alkalosis** * US: thickened & lengthened pyloric muscle * U&E's: raised sodium, urea, creatinine // low potassium, chloride - _NB:_ need to correct these before surgery * Management: * ABC * Nil by mouth!! * NG tube on free drainage * IV access for fluid & electrolyte resus and maintenance * Surgery = Ramstedt's pyloromyotomy _NB:_ 2 reasons for hypokalaemia: * K+ lost as KCL in vomit * Dehydration activates RAAS, resulting in renal sodium retention with K+ loss in urine

Answer 458

* Paediatric surgical emergency * Age 6months - 2yrs * Episodic pain with screaming, drawing up legs & pallor * Preceding viral illness - lymph node "lead point" * Bowel obstruction * Causes fluid shifts - air-fluid levels on CT * "Redcurrant jelly stool" (stool mixed with blood & pus) = late sign (ischaemic bowel) _Management:_ * Airway & breathing * Circulation: IV access; fluid resuscitation * Diagnosis: US - target sign/doughnut sign * Treatment: Air enema reduction or surgery

Answer 459

_Hx:_ * Child smallest in their class * 5-6 loose stalls per day - stools that float * Difficulty weaning _O/E:_ * Distended abdomen * Thin skin with loss of subcutaneous fat * Wasted buttocks with reduced muscle bulk * Pallor - due to anaemia * Short stature **Pathophys:** * Autoimmune disease triggered by gluten in cereals (WHEAT, BARLEY & RYE) * Progressive flattening of the small bowel mucosa --\> malabsorption with steatorrhoea * Undiagnosed, it can result in: * Faltering growth * Iron deficiency anaemia * Osteopaenia **Serology** * Check total IgA - 2% have deficiency which can cause false negatives * Check that child is on normal diet!! * Gluten avoidance leads to disappearance of IgA antibodies * 1st line: IgA anti-tissue transglutaminase antibodies (tTG) * If borderline, check IgA anti-endomysial antibodies (EMA) _HLA testing:_ * 95% of patients have DQ2 genotype & most of the rest express DQ8 * However, most caucasians have DQ2 genotype even without coeliac disease * Therefore NICE do not recommend routine HLA testing **Definitive Diagnosis** * Gold standard = Jejunal biopsy while on a normal diet containing gluten * Crypt hypertrophy! * Lymphocytic infiltrate! * Subtotal villus atrophy! **Associations:** * Dermatitis herpetiformis * Autoimmune disorders: * Vitiligo * Pernicious anaemia * Hashimoto's disease * Type 1 diabetes (annual blood tests for antibodies!!) * Late development of small bowel lymphoma! **Management:** * Lifelong gluten free diet * Involve paediatric dieticians * Gluten re-challenge if diagnosed before 2yrs old or diagnostic uncertainty * EG: cow's milk intolerance can occassionally cause sub-total villus atrophy **Explaining Coeliac Disease to a patient/parent:** * Autoimmune diseas where the body attacks part of the gut * Triggered by a protein called "gluten" which is found in cereals and flour * The lining of part of the gut becomes sore/inflamed and the normal finger-like projections get flattened: this leads to difficulty absorbing food * This can lead to tummy pain, diarrhoea, weight loss and tiredness * Lifelong condition which gets better if you stop eating foods that contain gluten _completely_ and _forever_ * There's lots of help available from dieticians and also from self-help groups * I'll get an information leaflet for you

Answer 460

**Crohn's & Ulcerative Colitis** * Chronic inflammatory bowel diseases of unknown aetiology * Inappropriate activation of the mucosal immune system * May present with abdominal pain & diarrhoea * May cause total colitis, which may present acutely with a toxic megacolon (toxic dilatation) **Symptom Severity Grading** * Mild - less than 4 stools per day & systemically well * Moderate - more than 4 stools per day & systemically well * Severe - more than 6 stools per day OR systemically unwel Systemically unwell: tachycardia, fever, anaemia, hypoalbuminaemia **Crohn's Disease** * A quarter of cases present in childhood & adolescence * Commoner than UC in this age group * Chronic, relapsing remitting inflammatory bowel disorder * Can affect anywhere from mouth to anus * _NB:_ Look for mouth ulcers & ask to check for anal skin tags, fistulae & fissures!! **Pathology** * Typically affects terminal ileum - may extend into colon - skip lesions! * Terminal ileum involvement --\> malabsorption due to loss of bile salts * Transmural inflammation with non-caseating granulomas * May cause: * Strictures * Adhesions * Abscesses **Presentation** * Weight loss with diarrhoea & abdominal pain * Bloody dirahhoea with UC * Growth failure with delayed puberty * Systemic features: anaemia, fever, poor appetite * Extra-intestinal: * Uveitis * Arthritis * Erythema nodosum * Pyoderma gangrenosum * Toxic megacolon **Investigations** * FBC - aneamia of chronic disease (due to blood loss from colitis) * Raised CRP & ESR * Stool cultures negative; Foecal calprotectin raised!! * Barium follow-through: thickening of bowel wall, strictures, cobblestone mucosa, rose thorn ulcers * Colonoscopy & biopsy! **Management** * Elemental diet for 6 weeks to induce remission * Anti-inflammatory aminosalicylates * Sulfasalazine & mesalazine * Relapses: steroids! * Maintaining remission: azathioprine (is also "steroid sparing") * Infiximab & other anti-TNF drugs may be indicated * Surgery

Answer 461

**Neonates** * _Respiratory distress syndrome_ * _Pneumonia_ * Chronic lung disease * Congenital lung malformations **Infants** * _Bronchiolitis_ * _Pneumonia_ * _Croup_ * Cystic fibrosis * Chronic lung disease * Epiglottitis **Under 5's** * _Viral-induced wheeze_ * _Croup_ * _Pneumonia_ * Cystic fibrosis * Epiglottitis **Over 5's** * _Asthma_ * _Pneumonia_ * Cystic fibrosis

Answer 462

**Stridor** * Uniphasic - heard on inspiration! * A low to medium pitched sound that signifies _upper airway obstruction_ * DDx: * Croup * Epiglottitis * Bacterial tracheitis * Severe tonsillitis * Foreign body aspiration * Anaphylaxis **Stertor** * Nosing, snoring-type breathing * Results from airflow obstruction higher up - nose, nasopharynx, oropharynx * DDx: * Viral URTI (snotty nose) * Obstructive sleep apnoea - Down syndrome! * Craniofacial abnormalities **Grunting** * End-expiratoy sound due to closure of glottis * `Self-induced positive end-expiratory pressure to keep airways open * Equivalent to pursed lips in adults with emphysema * Severe respiraoty distress! * Commonly bronchiolitis **Wheeze** * A whistling sound on expiration! * Flow of high-velocity air through narrowed airways * DDx: * Asthma * Viral-induced wheeze * Anaphylaxis * Foreign body aspiration

Answer 463

* Usually occurs in kids under 1yrs * 1 in 3 infants will get it: only 2% of those need admission * Seasonal! * Viral infection --\> small airways obstruction * 80% caused by RSV (respiratory syncytial virus) * Other causes: adenovirus, influenza & parainfluenza viruses * Ie. any virus that would normally cause a cold BUT in a baby because of their small airways you get this overall lung inflammation _Course of the illness:_ * Typically a 9 day illness * 3 day prodrome - with "cold" and harsh cough * 3 day ill with fever, high-pitched wheeze and breathlessness * 3 days recovering _O/E:_ * Low grade fever (\<39 degrees) and tachycardia * Increased resp rate * Nasal flaring, harsh cough, wheeze * Subcostal & intercostal recession * Assess for cyanosis * Auscultation: * Fine inspiratory _crackles_ * Expiratory _wheeze_ _Ix:_ * None in mild cases - clinical diagnosis based on symptoms & signs More severe cases: * Capillary blood gas (looking for resp acidosis) - before ventillation! * *NEVER ABG IN A YOUNG KID* * CXR: not routine. Only performed in Dx uncertainty * Nasal swab or nasopharyngeal aspirate for respiratory viruses _RED FLAG SYMPTOMS FOR PARENTS!_ * Disrupted breathing (apnoeic episodes) * Skin inside the child's lips turning blue (central cyanosis) * No wet nappy for 12hrs _Admission indicated if "**DRAMAS"**_ * D - dehydration * R - resp rate \> 70 (or marked recession / grunting) * A - apnoeic episodes * M - milk / fluid intake \<50% of normal * A - appearance: ill or exhausted in view of docs * S - sats \< 92% on air or cyanosis **Management** * Do NOT: * Give Abx, salbutamol or iptratropoim * Give inhaled or oral steroids * DO give: * Fluids * Oxygen * Respiratory support **Management algorithym** _Mild illness:_ * Sx: * Minimal resp distress * Feed ok * No oxygen * No risk factors * Sensible parents * Home with advice on reasons to return _Moderate Illness:_ * Sx: * Increased work of breathing * Poor feeding * Low sats * Risk factors * Admit for feeding support +/- oxygen _Severe Illness:_ * Sx: * Worsening resp distress * Respiratory acidosis * Apnoea * Dehydration * Risk factors * HDU / PICU --\> CPAP, ventillation, IV fluids **Advice to parents following discharge?** * D - don't smoke at home * I - immediate advice sought if poor fluid intake, worse breathing or no wet nappy for 12hrs * B - bring back for review in OPD **Which children are at risk of severe bronchiolitis?** * Infants born \<35 weeks gestation up to 6months old * Chronic lung disease in first 2yrs * Significant congenital heart disease in first 2yrs ADMIT THESE KIDS EVEN IF NOT THAT SEVERE!! Therefore always ask in the Hx!!

Answer 464

* Chronic inflammatory disorder characterised by *reversible airflow obstruction* * Hard to Dx under 3yrs old * Dx = viral-induced wheeze * Typically assocciated with atopy (eczema, allergy, hay fever) * ASk about previous prolonged / PICU admissions **Clinical Assessment of Acute Asthma** _Five **"props"** for asthma assessment_ * p - peak flow * r - resp rate * o - oxygen sats * p - pulse rate * s - sentences _"33, 92 CHEST"_ - life threatning asthma! * 33 - PFR \<33% predicted/best * 92 - oxygen sats \<92% * C - cyanosis * H - hypotension * E - exhaustion with poor resp effort * S - silent chest * T - tired or confused (dec GCS) **Management** _Mild/Moderate:_ * Often managed in the community * Inhaled beta2 agonist via spacer * Up to 10 puffs 30 seconds apart; repeated every 4hrs * Any more than this then admit * Oral prednisolone * Admit if not responding or out of hours presentation _Severe:_ * Transfer to hospital urgently * If SpO2 is less than 94%, give high flow oxygen * Nebulised beta2 agonists * Under 5yrs: salbutamol 2.5mg * Over 5yrs: salbutamol 5mg * "*Burst therapy":* repeated every 20-30 mins if needed, checking PFR * Add nebulised ipratropium if not improving after initial nebuliser * IV hydrocortisone every 4hrs _Acute severe/life-threatening asthma: **"O SHIT ME"**_ O - oxygen if sats \<94% S - salbutamol (via oxygen driven nebuliser) H - hydrocortisone (if can't take oral pred) I - ipratropium bromide nebulised T - theophylline IV Me - magnesium sulphate (nebulised or IV) **Use of Peak Flow in kids** * Children aged over 7 can use a meter * Encourage to keep peak flow diary * Twice daily to help make a diagnosis * Looking for **"morning dips"** * Indicates viral illness coming on --\> increase oral steroid!! * Obtain early warning of an exacerbation * A "fast blast" is better than a "slow blow" **Chronic Asthma** _3 Screening Questions to assesss control of asthma:_ * Have you had symptoms during the day? * Have you had difficulty sleeping because of your symptoms? (cough or wheeze) * Does it interfere with normal activities? (Time missed from school, sports, etc) _When to step someone up/down:_ * Consider stepping up if: * Using a reliever at least once per day 3x per week * If using onereliever inhaler per month, asthma is poorly controlled and needs review * Consider stepping down if: * Good control for 3/12 * Obviously worried about overtreatment with steroids * Stepping down = slow 25-50% reduction in ICS over 3months * Exhaled nitric oxide = measure of airway inflammation and can help guide decision to step down _Chronic Asthma UNDER 5yrs:_ * Step 1 - inhaled SABA * Step 2 - inhaled SABA + very low dose ICS / monteleukast * Step 3 - inhaled SABA + very low dose ICS + monteleukast * Step 4 - inhaled SABA + *increased dose of ICS* + monteleukast + referral to resp paediatrician Rules for under 5's": * Avoid LABA - increased toxicity in under 5's * Monteleukast = single daily dose tablet (cherry flavoured); main benefit seen in under 5's _Chronic Asthma OVER 5yrs:_ * Step 1 - inhaled SABA * Step 2 - inhaled SABA + very low dose ICS * Step 3 - inhaled SABA + very low dose ICS + add in LABA * Step 4 - inhaled SABA + low/medium dose inhaled steroid + add in LABA + refer * Step 5 - inhaled SABA + medium dose inhaled steroid + add in LABA + daily oral steroid tablet Notes for over 5's: * Low dose ICS = beclometasone 50micrograms two puffs BD * Step 4 - additional options may include trial of monteleukast & addition of slow-release theophylline by mouth * If child is on medium dose ICS - child should be under specialist care AND given advice about steroid replacement in severe illness or surgery **Peak Flow & Spacers** * Peak flow: * Stand up * Zero the meter * Hold it at the side so your fingers don't get in the way of the pointer * Take a big breath, clamp your lips around the mouthpiece and breathe out hard and fast * "Like you're trying to blow out the candles on your birthday cake" * Note position of pointer and repeat this 3 times * Record the best of your 3 attempts * Spacers: * Ideal for use with metered dose inhalers * Bigger ones are more effective but bulky * Aerochamber = medium sized & fits any inhaler * To clean, rinse in warm water & drip dry * Do NOT use a cloth: static leads to aerosol deposition on wall * Used with face mask in pre-school children as they suck at making the fucking seal with their lips

Answer 465

* Wheezing episode associated with viral URTI * Typically children \<5yrs * Absence of strong Hx of atopy, no cough at night, no wheeze with exercise/cold weather etc * Previous episodes of wheeze BUT PICU/prolonged admissions unlikely * BUZZ WORDS: "no interval symptoms" **Management** * Assess & manage acute cases as you would for child with asthma * Steroids NOT effective * Only give steroids if suspecting asthma * Can use monteleukast

Answer 466

* Acute viral laryngotracheobronchitis * Commonest cause of stridor in kids * Coryzal illness for a few days * Followed by: * Mild fever * Hoarse voice * Barking seal-like cough * +/- respiratory distress * Age: 6months - 6yrs * Parainfluenza virus ("*Paras* in the military go around in *groups*" * Can be: RSV / influenza **Management** * Do NOT distress child! * No cannulas etc initially * Assesss clinical severity _Mild:_ * Sx: * Happy child * Occassional cough * **No stridor at rest!** * No respiratoy distress * Reassure parents * Home with advice * Consider Rx oral steroids _Moderate:_ * Sx: * Barking cough * **Easily audible stridor at rest** * Mild respiratory distress * O2 sats 94% or above * Admit * Oral dexamethasone!! * Nebulised budesonide _Severe:_ * Sx: * Constant stridor * Marked respiratory distress * Tiredness, agitation * **O2 sats below 94%** * Call for senior help * Oxygen * Steroids * Nebulised adrenaline * Anaesthetist / ENT **Dexamethasone** * Long half-life: single oral dose usually enough * Usually given prior to admission * May be repeated on arrival to hospital and again after 12hrs if needed

Answer 467

**Croup** * Very common * Mild to severely unwell * Drooling not usually seen * Mx: * steroids * +/- adrenaline nebs **Epiglottitis** * Rare due to Hib vacine * Very unwell & toxic * Drooling - blockage --\> can't even swallow own saliva * Mx: * Leave well alone! * Get ENT and anaesthetist * Abx after securing airway

Answer 468

* All have increased work of breathing with increased resp rate **Bronchiolitis** * Usually under 1yr * Difference: * Inspiratory crackles AND expiratory wheeze * Main management = supportive **Croup** * 6months - 6yrs * Difference: * Barking cough * Inspiratory stridor * No crackles/wheeze * Main management = dexamethasone **Viral-induced Wheeze** * Under 5's * Difference: * Expiratory wheeze! * No crackles * No stridor * Main management = bronchodilators

Answer 469

* Autosomal recessive inheritance * 1/25 people in UK are CF carriers * Mutation on chromosome 7 in CTFR gene * Mutated CTFR gene, which is responsible for cellular chloride transport, causing thick secretions - leads to: * Pancreatic insufficiency --\> diabetes & malabsoprtion * Recurrent chest infections & bronchiectasis * Malabsorption + recurrent chest infections --\> faltering growth & chronic poor health **Investigations** * Newborn screening: * Raised immunoreactive trypsin (IRT) on newborn bloodspot card * Sweat test: * Gold standard * High chloride levels - 2 abnormal tests necessary for Dx * Genetics: * \>1600 mutations identified * \>98% detectable on genetic testing * CXR: * Hyperinflation * Peribronchial thickening * Bronchiectasis * Lung Function: * Obstructive ventilatory defect * Sputum: * Haemophilus influenzae * Staph aureus * _Pseudomonas aeruginosa_ * Burkholderiacepacia * E. coli * Klebsiella

Answer 470

* Crown-rump length \>7mm * Presence of a foetal heart

Answer 471

**SPECULUM - look at the cervix!** * DDx * Cervical carcinoma * Ectropion * Cervical polyp * STI * Contraception * You can differentiate most of these simply by looking at the cervix!

Answer 472

THIS IS CANCER OF THE LOWER GENITAL TRACT UNTIL PROVEN OTHERWISE * Actually ends up being cancer in about 10% * Speculum! - Visualise vulva, vagina & cervix * TVUS - visualise endometrium * If find an enlagred endometrium (\>4mm) then biopsy or do a hysteroscopy

Answer 473

* Endometrial * FHx of bowel cancer?? Lynch & HNPCC * Ovarian * Increased risk with increased ovulations (nulliparous, no COCP use etc) * FHx - BRCA 1 & 2?? * Cervical * HPV

Answer 474

* Triad of: * Proteinuria * Hypoalbuminaemia * Oedema * Massive protein leak leads to... * _Frothy urine with protein +++_ - frothy urine --\> ?albumin in the urine! * Hypoalbuminaemia * Compensatory increase in liver protein synthesis * Leads to lipoproteins & _hyperlipidaemia_ * Loss of immunoglobulins --\> _risk of infection_ * Loss of antithrombin III --\> small _risk of clotting_ **Ix:** * FBC: * Haematocrit (haemoconcentration in the vascular space due to intravascular volume depletion) * ?Infection * U&E's and creatinine - check renal function * LFT - check albumin (typically \<25g/L) **Diagnosis & Mx** * Dx = clinical features + proteinuria * 95% of cases are due to minimal change disease * Renal biopsy not typically indicated * ABC - may be fluid deplete * Careful fluid balance with IV albumin (rather than saline) * Rx = six week course of prednisolone! * Consider penicillin prophylaxis against streptococcal infection! **Classification:** * Steroid resistant - 10% need biopsy * Steroid sensitive - 90% * 30% resolves * 30% one relapse * 30% multiple relapses (steroid dependent) **Prognosis** ****Excellent prognosis if... * Aged 1-12yrs * No HTN * No macroscopic haematuria * No impaired renal function * Normal complement levels * Good response to steroids within 4 weeks Essentially... excellent prognosis if not nephritic.

Answer 475

* H - hypertension * O - oliguria * S - smoky brown _haematuria_ "coca cola urine" * T - trace oedema Urine dip shows haematuria NOT proteinuria * Immune compelx dissease; usually 2 weeks post strep * Low c3 & c4 and high anti-streptolysin Ab

Answer 476

* Infection: * Meningococcal septicaemia * Other viral/bacterial infections * Bleeding disorder: * Idiopathic thrombocytopaenic purpura * Acute leukaemia * Haemolytic uraemic syndrome * Vasculitis: * Henoch-schonlein purpura * Mechanical/trauma: * Recurrent coughing/vomiting * NAI

Answer 477

**ALL** * Sx: * Fever & lymph nodes * FBC & blood film: * Low Hb * Blasts on film * High lymphocytes * Low neutrophils * Low platelets **ITP** * Sx: * Well child with purpura * FBC & blood film: * Low platelets **HSP** * Sx: * Well child with palpable purpura on buttocks and lower limbs * FBC & blood film: * Normal * Normal platelets!! **Meningococcal Sepsis** * Sx: * Critically ill child with shock * Widespread non-blanching rash * FBC & blood film: * Variable * Low platelets **HUS** * Sx: * Unwell * AKI * Jaundice * FBC & blood film: * Low Hb * _Schistocytes_ * Low platelets

Answer 478

* 3-10yrs old * Often history of recent URTI * Type of IgA vasculitis * Multi-system involvement * Skin: palpable purpura on extensor surfacess * Arthropathy * Gut: abdo pain, GI bleed, risk of intussusception * Renal: IgA nephropathy; proteinuria common * Testes: orchitis * Mx: * Symptomatic treatment * 75% resolve spontaneously * Minority develop long term renal complications * Check for HTN, renal complications, intussusception!

Answer 479

* Petechiae (\<3mm) and purpura (3-10mm) in a _well_ child * Immunologically mediated destruction of platelets * Often 1-2 weeks after viral URTI * Ix: * Normal HB & WCC * PLatelet count typically below 40x10⁹/L * Mx: * Usually mild and resolves spontaneously in ~3weeks * Avoid NSAIDs * Avoid contact sports as 1/300 develop intracranial haemorrhage * If severe with mucosal bleeding, may need IV immunoglobulin & steroids * A few get chronic relapsing form - splenectomy may be indicated

Answer 480

**Age 1 - 3 yrs** * _Painful limp:_ * Septic arthritis * Transient synovitis * _Painless limp:_ * __Developmental dysplasia of hip * Congenital cause (eg: cerebral palsy) **Age 3 - 10 yrs** * _Painful limp:_ * Transient synovitis * Septic arthritis * Juvenile idiopathic arthritis * Perthes' disease (acute) * Malignancy * _Painless limp:_ * __Perthes' disease (chronic) * Juvenile idiopathic arthritis **Age 10-16 yrs** * _Painful limp:_ * __Slipped upper femoral epiphysis (acute) * Juvenile idiopathic arthritis * Septic arthritis * Malignancy * _Painless limp:_ * __Slipped upper femoral epiphysis (chronic) * Juvenile idiopathic arthritis

Answer 481

**Transient Synovitis** * Commonest cause of acute limp in childhood * Transiently inflamed synovium of hip * Underlying cause unclear though often preceded by viral infection * Age 2-12yrs. M:F = 2:1 * Sx: * Unilateral sudden onset painful limp * Not unwell child. Normal CRP on Ix * Pain may be referred to medial thigh or knee (medial knee pain can be referred from hip but NOT lateral knee pain) * NO pain at rest! * O/E: * Mildly decreased range of movement * 1/3rd have no restriction of movement * Child well with no fever * FBC, CRP, Blood culture, X-ray - all normal! * US - shows joint effusion * Rx = analgesia * Spontaneously resolves within a few days **Septic arthritis** * Acute painful hip WITH pain at rest! * Unwell child with fever * O/E: * Reluctance to move hip with decreased range of movement * Ix: = neutrophil count & CRP raised * Dx = US-guided joint aspirate cuture * Rx = Abx & surgical drainage * Without prompt treatment, joint destruction can occur --\> hip replacement needed **Perthes' disease** * Idiopathic ischaemia of femoral epiphysis * Leads to avascular necrosis * Re-vascularisation and re-ossification follows (over 1.5 - 3yrs) * Age 5 - 10 yrs. M:F = 5:1 * Sx = _insiduous_ onset of limp, *initially* painful * O/E: decreased range of movement (*especially* abduction and internal rotation) * Ix: * X-ray (initially) - increased density of femoral head * X-ray (later) - irregular edge to femoral head * Mx: * Good prognosis if less than half of epiphysis involved & under 6yrs * Mx = generally conservative * If severe, may need surgery **Slipped upper femoral epiphysis** * Displacement of femoral head * Usually posteriorly & medially * Age 10 - 15yrs (coingiciding with growth spurt) * M\>F (slight predominance) * Commoner with obesity * PC: Acute painful limp often after minor trauma * Pain may be referred to medial knee * O/E: restricted range of movement (esp abduction & internal rotation) **Juvenile idiopathic arthritis** * Arthritis for mroe than 6 weeks before age 16yrs * Rheumatoid factor usually negative * Antinuclear Ab's usually present in commonest form: pauci-articular * Some older girls with polyarticular disease similar to rheumatoid arthritis may be RF positive - good DDx _Classified by onset:_ * Pauci-articular or oligoarthritis - 4 or fewer joints in first 6 months * Poyarticular - 5 or more joints * Systemic: Still's disease * Other: Enthesitis related, psoriatic _Systemic JIA:_ * Usually before age 5 * Acute illness with high swinign fever and salmon coloured macular rash * Systemic onset with myalgia may precede arthritis * LAD & hepatosplenomegaly often present * Pleurisy & pericarditis may occur * NO eye involvement * Ix: * Anaemia, raised ESR & CRP - typical of acute phase response * Majority recover; 1/3rd progress to severe arthritis * DDx from other causes of fever & myalgia/arthralgia: * Rheumatic fever * Kawasaki's * Leukaemia * SLE * Reactive arthritis _Pauci-articular JIA:_ * Young children - typicall 2-6yrs * Medium-sized joints - NOT hips, commonly knees, ankles, elbow, wrists * Asymmetrical oligoarthritis * 1/3rd get chronic eye problems - anterior uveitis * Usually ANA positive _Mx:_ * MDT - physio etc * Simple analgesia - paracetamol/ibuprofen * Steroid injection into join often used in pauci-articular disease * Disease modifying: methotrexate, systemic steroids, * Biologicals: anti-TNF (eg: infliximab)

Answer 482

**Measles** * **Mumps** **Rubella** **Chickenpox** **Slapped Cheek Disease / Erythema Infectiosum** **Scarlet Fever**

Answer 483

**"Port wine stain"** * Vascular malformation * Present at birth! * Flat & does NOT increase in size * Opthalmic and maxillary distribution - always! * Superficial sign of deeper AVM's * "Associated with leptomeningeal angiomas" * Associations: * Seizures * Glaucoma * Hemiparesis **Cavernous Haemangioma** * "Strawbery naevus" * Normal! * Not present at birth * Does increase in size ! * Due to endothelial proliferation * Not associated with intracranial abnormalities * Fades spontaneously by 5th birthday * Only treat if: * Will block vision * Catches on things & bleeds **Absent red reflex** * Unilateral - retinoblastoma * Bilateral - congenital cataracts **Talipes equinovarus** * Positional vs. fixed * Can be associated with chromosomal syndromes * Treatment involves physiotherapy (serial casting) +/- surgery

Answer 484

* Heads - intraventricular haemorrhage * Hearts - patent ductus arteriosus * Lungs - respiratory distress syndrome * Guts - NEC * Eyes - retinitis of prematurity

Answer 485

* Gait: * Watch child walking * Tip-toes * Heel-walking * Running * Sit to stand * Cerebellar: * Gait * Finger-nose test * Eye movements * "Pat-a-cake" * Cranial: * Cranial nerves * Eye movements * Facial movements * Fundoscopy * Peripheral: * Inspection * Tone * Power * Reflexes * Sensation

Answer 486

* Seizure = transient clinical event that is the result of abnormal electrical activity in the brain * Epilepsy = a chronic brain disorder with recurrent (two or more) non-febrile seizures in teh absence of acute cerebral insult **Ix** * EEG: * Can't exclude epilepsy - 50% of kids with epilepsy have normal EEG * Consider sleep deprived EEG is standard EEG is normal! * Should NOT be ordered if non-epileptic attack disorder is suspected * MRI - 3 main indications: * Onset before 2yrs * Focal features (from Hx, O/E or EEG) - ?SOL, AVM * Poor control despite first line AED **Mx** * Status - seizure longer than 5mins: * Oh My Lord, Phone the Anaesthetist

Answer 487

* Infantile spasms ("flexor spasms") * Development delay * Hypsarrhythmia on EEG ("choatic" pattern) Poor prognosis.

Answer 488

**Generalised tonic-clonic (GTC)** * Lamotrigine * Valproate - avoid in girls of reproductive age **Focal** * Carbamazepine * Lamotrigine **Absence** * Ethosuximide * Valproate **Infantile spasms** * Prednisolone * Vigabatrin

Answer 489

* CP is not a single diagnosis * It is an "umbrella" term describing * A non-progressive brain lesion that manifests as motor or postural abnormalities * The lesion can occur at any point between conception & 3yrs of age * Typically presents as - in a neonate: * Hypotonia * Poor feeding * Fits * Spasitisty develops later * Clinical diagnosis supported by MRI brain findings: * EG: periventricular leucomalacia **Causes** * In utero: * Congenital infections - TORCH * Perinatal: * Birth asphyxia * Prematurity * Kernicterus * After delivery: * Brain injury * Meningitis * Encephalitis * Unknown - common **Four Common Presentations** _NB:_ Spastic cerebral palsy (UMN signs) = hemiplegia, diplegia & quadriplegia! * Hemiplegia * Diplegia * Quadriplegia * Dyskinetic Spastic diplegia - all due to UMN signs: * Adduction of hips with "scissoring" gait * Flexion of knees * Plantar flexion at ankles with "equinovarus" deformity **Complications & Associations** * Epilepsy & learning disability * Needs special needs assessment for education * Needs AED's * Speech & swallowing problems: * SALT assessment * Surgeons - ?PEG tube * Spastisity & contractures: * Physio & OT input * Orthopaedics * Paeds: muscle relaxantts (eg: baclofen)

Answer 490

**Breath Holding Attacks** * Common in 6 month to 2yrs * Pain or anger followed by brief cyring * Child takes deep breath & stops breathing * Turns blue & limbs extend * Then limp with LOC * Someties a few convulsive jerks * No post-ictal phase **Reflex Anoxic Seizures** * Also affect infants & toddlers * Equivalent to faint in an older child * Triggers: * Minor injury * Cold food * Fright * Fever * Vagal activation --\> bradycardia * Child turns pale & collapses to floor * May induce tonic-clonic convulsion

Answer 491

**Triad of Impairment** Children typicaly present with impairment \<3yrs in each of the following categories: 1. Reciprocal social interaction (poor eye contact, difficulty with peer relationships, lack of shared enjoyment) 2. Social communication (delayed or disordered speech, lack of gestures, absent imaginative play) 3. Restricted, repetitive, stereotyped interests or behaviours (including preoccupations, adherence to routines, stereotyped motor mannierisms) **Dx & Mx** * Dx based on a number of standardised neuropsyclogical tests * Intervention is supportive & MDT (Paeds, SLT, OT, psych) & multi-agency (social care & education)

Answer 492

**Characterised by:** * Inattentiveness * Hyperactivity * Impulsiveness

Answer 493

* A pattern of disruptive behaviour in which basic rights of others & major age-appropriate social norms are violated * Features: * Chronic conflict with parents, teachers,etc * aggressive behaviour towards people / animals * Destructive behaviour towards property * Lying * Participation in anti-social behaviour - stealing, truancy, substance misuse, running away * Mx = CBT * Comorbidities = anxiety, depression, learning difficulties etc

Answer 494

**DDx:** * Functional dyspepsia * IBS * Abdominal migraine * Functional abdominal pain syndrome **Clinical Features:** * Child well betweeeeen attacks * No weight loss / faltering growth * No blood in stool or perianal disease * Examination normal **Ix:** * Urine dipstick & MSU ( exclude UTI & renal disease) * FBC, ESR, CRP (exclude inflammatory bowel disease) * Stool culture * Stool microscopy for giardia * Stool for calprotectin (raised in IBD) * Coeliac screen **Explanation to parent** * Never say "it isn't serious" as this can sound dismissive * Say "serious but not dangerous" - serious as it can interfere with normal activities * Disturbance of the movement of the bowel which becomes sensitive * Encourage: * Healthy diet * Exercise * School attendance **Reattribution - 3 components** * Ackowledge ("the pain is real") * Explain * Eg: "it is due to spasm of the bowerl" / "sensitive intestines which can feel the food going round the bends" * Make the link * "even minor stress can release adrenaline which can make the bowel go into spasm more easily. I wonder if the trouble at school / family problems you told me about might be contributing..?"

Answer 495

**Community Acquired Pneumonia (CAP)** * 1st line: * Low severity = doxycycline PO * Moderate-severe = Ben. pen IV + Doxycycline PO * CURB 65 & send sputum/blood cultures **Hospital Acquired Pneumonia (HAP)** * 1st line: doxycycline PO * OR IV benzyl pen if severe or unable to swallow * CURB 65 & send sputum cultures/blood cultures **Infective Exacerbation of COPD and LRTI** * 1st line: doxycycline PO * No CXR changes. Send sputum. **Aspiration Pneumonia** * 1st line: doxycycline PO + metronidazole * CXR evidence of consolidation 48-72hrs following aspiration. Send sputum/blood cultures **Urinary Tract Infection** * Uncomplicated UTI - 1st line: Nitrofurantoin PO 50mg 6hrly * Complicated UTI/pyelonephritis - 1st line: Co-amoxiclav IV 1.2g 8hrly (+ Amikacin IV STAT if shocked) * Complicated UTI = structural abnormality or after urological surgery (+ pyelonephritis) **Intra-abdominal Sepsis** * 1st line: Co-amoxiclav IV 1.2g 8hrly + Gentamicin IV STAT dose * Senc blood cultures & sample of pus, where possible **Cellulitis** * Non-severe - 1st line: Flucloxacillin PO 500mg 6hrly * Severe - 1st line: Flucloxacillin IV 2g 6hrly * Wound swab if skin is broken, mark out affected area, contact micro if patient is shocked or necrotic skin infection **Osteomyelitis / Septic arthritis** * Unknown organism/known Gram +ve organism - 1st line: Flucloxacillin IV 2g 6hrly * If prosthesis, do not start Abx - contact microbio/senior orthopaedics **Infection - unknown source (w/out sepsis)** * 1st line: Amoxicillin IV/PO 1g 8hrly + Gentamicin IV 5mg/kg STAT * Order CXR, Urine dipstick/MC&S, blood cultures **Suspected sepsis - site & organism unknown** * 1st line: Co-amoxiclav IV 1.2g 8hrly + Amikacin IV STAT dose * Abx should be administered within an hour. * Sepsis = clinical signs of infection (sweats, chills, malaise, rigors, etc) + 2 of the following: * Temp \>38 or \<36 * HR \> 90bpm * RR \> 20 (most sensitive!) * WCC \<4 or \>12 * CXR, blood & urine cultures **Meningitis** * 1st line: Ceftriaxone IV + Aciclovir IV (if viral suspected) + Amoxicillin IV (if immunocompromised or \>55yrs to cover for listeria) * Start Abx immediately. Take blood cultures and throt swab. Seek advice on need for CT scan, timing of LP and need for dexamethasone. **C. Diff** * 1st line: Vancomycin PO/NG for 10-14days * 2nd line: if oral/NG Rx not possible, then Metronidazole IV with oral switch as soon as possible * Suspected c. diff (?all cases of infectious diarrhoea on broad spectrum Abx) then start empirical Abx immediately. Do not wait for toxin testing to come back.

Answer 496

**Beta blockers & SSRI's**

Answer 497

**PID or Ectopic Pregnancy!**

Answer 498

**Squamous cell carcinoma** (NOT adenocarcinoma - this is GORD/Barrett's!)

Answer 499

**Hepatocellular picture of liver injury** High ALT. Normal ALP. High ALT:ALP ratio. _NB:_ ALP is produced by the cells lining the bile ducts. Hence the levels in the blood will rise in obstructive disease.

Answer 500

* Lithium in pregnancy * congenital condition where the tricuspid valve leaflets are attached to the walls and septum of the right ventricle. This may lead to tricuspid regurgitation and in 50% of patients Wolff-Parkinson-White syndrome * Dilated right atrium as a result of regurg *

Answer 501

* Life-long blood transfusions! PLUS iron-chelation therapy to reduce risk of iron-overload

Answer 502

* Get the registrar to obtain **intraosseous access** If intravenous access is difficult or impossible, consider the intraosseous (IO) route during a cardiac arrest!!

Answer 503

* Use simple analgesia * Continue breast feeding * If unable/this is too painful, then women are advised to express milk by hand or using a pump. * The following are indications for oral antibiotics: * an infected nipple fissure, * symptoms not improving after 12-24 hours despite effective milk removal * breast milk culture positive.

Answer 504

As an **antioestrogen**, it works by blocking oestrogen receptors in the hypothalamus and pituitary and **increasing the release of LH and follicle stimulating hormone** (FSH), which are inhibited by oestrogen. It is only **given on days 2 to 6 of each cycle to initiate follicular maturation**. If no follicles develop then the dose can be increased from 50mg/day to 100mg/day and finally 150mg/day in subsequent cycles. It is limited to 6 months use

Answer 505

**Initial respiratory alkalosis** due to stimulation of the central respiratory centre causing increased respiratory effort. Following this, a **metabolic acidosis develops** along side the respiratory alkalosis. This is due to the direct effect of the metabolite salicylic acid

Answer 506

**Give according to *_chronological age_*** REMEMBER THIS YOU FUCKING SPAZOID

Answer 507

**Serum IGF-1**

Answer 508

* Normally, _supportive only!_ * NICE guidelines only recommend treatment with intra-nasal corticosteroids if the symptoms of sinusitis are severe or have lasted for a period of 10 days or more. * Antibiotics are only advised if individuals are systemically unwell or have significant co-morbidities that pre-dispose them complications (for example chronic severe COPD)

Answer 509

* Hypothermia, * hyporeflexia, * bradycardia * seizures

Answer 510

I guess you need to consider.. * Where it is, this is clearly on the tonsills * Quinsy would be anterior and unilateral

Answer 511

**The ECG in Eisenmenger's syndrome shows right ventricular hypertrophy** This is a VSD (pansystolic, blowing murmur!) which now demonstrates Eisenmenger's syndrome!

Answer 512

**Roseola infantum - fever followed later by rash**

Answer 513

In the acute management of DKA, insulin should be **fixed rate** whilst **continuing regular injected long-acting insulin** but **stopping short actin injected insuli**n THINK ABOUT IT. You need to replace the SHORT-ACTING insulin with a FIXED RATE INFUSION, hence you STOP short-acintg but CONTINUE long-acting

Answer 514

* Well's score! * 1st line with Well's score \<4 = D-Dimer * Positive D-dimer --\> CTPA to look for the PE!!

Answer 515

* no mucosal involvement: bullous pemphigoid * mucosal involvement: pemphigus vulgaris think of the VULVA as a mucosal surface (or entrance to one)

Answer 516

* IV atropine - 6 doses * External heart pacing - if not improved w/ 6 doses of atropine

Answer 517

* Previous vertical (classical) caesarean scars, * As oppossed to the now conventional lower segment caesarean section * previous episodes of uterine rupture * patients with other contraindications to vaginal birth (e.g. placenta praevia) Things like 2x previous vaginal birth, post-term dates do NOT consititute _absolute_ contraindications

Answer 518

**REITER's SYNDROME (Reactive arthritis)** _NB:_ The absence of white cells and crystals immediately rules out septic arthritis and gout or pseudo-gout.

Answer 519

* Normal = 90-120mins * Pt. w/ HF = 3hrs (to reduce chance of circulatory overload) * Trauma/major haemorrhage scenarious - blood may be transfused STAT

Answer 520

**Purulent sputum + clinical signs of pneumonia**

Answer 521

* Laxatives + topical vasodialtor (eg: GTN)

Answer 522

* C - hypercalcaemia * R - renal insufficiency * A - anaemia (& thrombocytopaenia) * B - Bence-Jones proteins / bone lesions!

Answer 523

* B-symptoms * Older patient * Male sex * Stage IV disease - extranodal sites involves * Lymphocyte-deplete subtype

Answer 524

**Thrombotic / Painful crisis** * Vaso-occlusion --\> infarction * EG: Dactylitis in kids **Sequestriation crisis:** * Sickling --\> pooling within organs (lungs or spleen) * "Acute chest syndrome" * Sx = SOB, chest pain, low PO2, pulmonary infiltrates on CXR **Aplastic crisis:** * Sudden decrease in Hb * EG: due to Parvovirus B19 **Haemolytic crisis:** * Sudden decrease in Hb due to increase in haemolysis

Answer 525

**Direct FXa inhibitor!**

Answer 526

**Heparin** * Heparin inactivates ATIII * Rule of 3's: * HEP = increases PTT * PTT = intrinsic pathway (has more letters and also intrinsic pathway has more coag factors) * PTT activated by SEC (subendothelial collagen) **Warfarin** * Warfarin inhibits factors: 2, 7, 9 & 10 - vitamin K antagonist * Rule of 2's: * warfarin - increases PT (extrinsic pathway) * PT activated by TT (tissue thromboplastin)

Answer 527

**Parvovirus B19 infection!** _NB:_ Acute sequestriation & acute haemolysis --\> increased corrected reticulocyte count (\>3%)

Answer 528

**Atherosclerosis!** Atherosclerosis --\> thickened intima (endothelium) --\> increased diffusion barrier --\> vessel wall weakens

Answer 529

**1st line:** GTN, aspirin, statin **2nd line:** add CCB (eg: verapamil) or beta-blocker **3rd line:** add ivabradine or nicoradil (K+ channel agonist)

Answer 530

**ST depression** in **2 or more leads V1 - V4** should be considered a _posterior MI_ and therefore treated as a **STEMI**

Answer 531

**LBBB on ECG = MI** until proven otherwise! William = Left bundle branch block Correlate with clinical history obviously

Answer 532

**Initially, then at 6hrs, then at 12hrs** You want to see the rise! Tropnin levels rise 2-4hrs post MI, peak at 24hrs and return to normal 7-10 days post MI **Ck-MB** = detecting for reinfarction! (levels return to normal by 72hrs!)

Answer 533

* Hydration * Eyesight ?glasses * Screen time * Sleep * Sinus things - hayfever, recurrent URTI's * Nutrition * Reduce stress * ?analgesia overuse headaches

Answer 534

"I would be reluctant to discharge a tachycardic child of unkown cause in the absence of a fever"

Answer 535

* pH \< 7.1 - assume 10% dehydrated * pH \> 7.1 - assume 5% dehydrated Always ask if they are in shock with the DKA!! Makes life more complicated: * Fluid resus for shock vs. careful fluids with DKA ?cerebral oedema * Only ever bolus 10ml/kg in paeds DKA

Answer 536

* Urine dip * Urine MC&S - ?UTI * Bloods - U&E's ?renal function _Microscopic haematuria:_ * US +/- Xray _Frank haematuria:_ * CT scan _BOTH types_ * Flexi cystoscopy!

Answer 537

* Genetic * Myocarditis - eg: coxsackie A or B --\> lymphocytic infiltrate in myocardium * Alcohol abuse!! * Drugs - doxorubicin, cocaine * Pregnancy * Haemochromatosis!

Answer 538

**HAP** * Pseudomonas * MRSA **CAP** * Strep pneumoniae = commonest * H influenzae = smokers/COPD * Klebsiella = aspiration * Staph aureus = secondary pneumonia (after viral infection) * Legionella = immunocompromised

Answer 539

* Hypoxaemia - eg: COPD, interstitial lung disease * Increased volume in pulmonary circuit - eg: HF, congenital heart disease * Recurrent PE's

Answer 540

**PPI (omeprazole) + Amoxicillin + Clarithromycin** Twice daily for 7 days. If penicillin allergic, Rx = metronidazole Negaive urea breath test + lack of stool antigen - confirms eradication of H. pylori

Answer 541

**Infective & ischaemic causes of bloody diarrhoea!**

Answer 542

**Crohn's disease** * Ankylosing spondylitis * Sacroiliitis * Migratory polyarthritis * Erythema nodosum * Uveitis **Ulcerative colitis** * Primary sclerosing cholangitis! * p-ANCA positivity: * UC * Primary sclerosing cholangitis * Microscopic polyangiitis * Churg-Strauss

Answer 543

**Mesenteric ischaemia** = post-prandial pain, ischaemia at watershed areas, due to hypotension/decrease perfusion etc **Ischaemic colitis** = due to AF --\> thromboemolism to GI tract --\> PR bleed due to bowel infarction

Answer 544

**Ix** ## Footnote acute pancreatitis = serum amylase! acute cholecystitis = alkaine phosphatase!

Answer 545

**Key Principles for Hep B serology** _Hep B surface antigen:_ * Key marker of infection * First marker to rise with infection * When infection resolves, HbsAg disappears * If present for \>6 months, it defines chronic hep B infection _Hepatitis B core antibody:_ * IgM against core = antibody produced during acute phase * IgG against core = antibody produced during chronic infection OR resolved infection * Chronic infecion = IgG + hep B surface antigens * Resolved infection = IgG in the absence of HepB surface antigens _Hepatitis B surface antibody:_ * IgG against the surface is the indicator of victory! * Only get IgG against the surface if the infection resolves OR you are immunissed * If the infection becomes chronic, you will NOT get IgG against the surface * Anytime you have HBsAg you are protected against infection!! * Immunisation: * You simply give the Hep B surface antigen and nothing else --\> you then develop the IgG HBsAg and nothing else (you are protected) _Hep B envelope antigen (HbeAg)_ * Indicates infectivity! * WHenever it is present, indicaes that the virus can be transmitted to another person * "If you mail a letter you need an envelope - if you are to give the virus to someone else you will need the envelope antigen) * It is present during the acute phase & can also be present during the chronic phase

Answer 546

**Decreased detoxification...** * Increased serum ammonia --\> mental status changes, astereixis, eventually coma * Hyperoestrogenism --\> gynaecomastia, spider angiomata, palmar erythema * Jaundice **Decreased protein synthesis...** * Hypoalbuminaemia --\> oedema * Coagulopathy - measured with PT **Portal HTN..** * Ascites * Congestive splenomegaly * Portosystemic shunts - oeseophageal varices, haemorrhoids, caput medusae * Hepatorenal syndrome!

Answer 547

**FLUIDS + allopurinol**

Answer 548

* Hypoalbuminaemia --\> pitting oedema * Hypogammaglobulinaemia --\> increased risk of infection * Hypercoagulable state --\> preferential loss of ATIII * Hyperlipidaemia & hypercholesterolaemia * May result in fatty casts in urine * THink of it as the blood has lost so much protein, the blood becomes thin and the liver throws fat into the blood to thicken it up

Answer 549

**Minimal change disease** * Hodgkin lymphoma **Focal segmental glomerulosclerosis (FSGS)** * HIV * Heroin use * Sickle cell disease **Membranous Nephopathy** * Hep B or C * SLE * Drugs (eg: NSAIDs & penicillamine) **Membranoproliferative Glomerulonephritis** * Hep B or C

Answer 550

**Poststreptococcal Glomerulonephritis** * Arises following group A beta-haemolytic strep infeection of skin (impetigo) or pharynx * Presents: _2-3 weeks post infection_!! * Haematuria (coca-cola coloured urine) * Mx = supportive **IgA Nephropathy** * Presents: usually _immedately_ after mucosal infection (eg: gastroenteritis) - IgA production increased during infection

Answer 551

* Isolated haematuria * Sensoryneural hearing loss * Ocular disturbances Due to inherited defect in type IV collagen - problems with basement membranes

Answer 552

Do NOT biopsy - risk of seeding the scrotum Definitive Mx = radical orchidectomy

Answer 553

PC: Poor lactation, loss of pubic hair, fatigue In a woman who is post-partum and had a PPH after labour!!

Answer 554

* Nephrolithiasis - calcium oxalate stones * Nephrocalcinosis - metastatic calcification of renal tubules, leading to renal insufficiency * CNS disturbances - depression & seizures * GI - constipation, peptic ulcer disease, acute pancreatitis * Osteitis fibrosa cystica - massive resorption of bone, leading to fibrosis & cystic spaces

Answer 555

* Renal failure --\> decreased phosphate excretion --\> phosphate binds free calcium --\> decreased free calcium stimulates all 4 parathyroid glands --\> raised PTH leads to bone resorption (contributing to renal osteodystrophy)

Answer 556

* Suspected with increased 24-hr urine cortisol level _Dexmethasone suppression test:_ * Low-dose dexamethasone: * Suppresses cortisol in normal individuals * Fails to suppress cortisol in ALL causes of cushing syndrome _Plasma ACTH levels:_ * Distinguishes ACTH-dependent causes of Cushing syndrome * ACTH-independent, next step = CT to look for adrenal lesion * ACTH-dependent, next step = high dose dexamethasone test _High Dose dexamethasone test:_ * Suppresses ACTH production by a pituitary adenoma --\> decreased serum cortisol * Does NOT suppress ectopic ACTH production - cortisol remains high * Then you are thinking ectopic cortisol production --\> CT chest ?lung tumour

Answer 557

**17-0H deficiency!** 21-OH and 11b-OH deficiency cause increase androgens and therefore virilisation and clitoral enlargement in a female 21-OH = classic with life-threatening hypotension, hyponatraemia and hyperkalaemia (decrease aldosterone) 11b-OH = non-classical with HTN and milk hypokalaemia

Answer 558

Haemorrhagic necrosis of adrenal glands - classically due to sepsis & DIC in young childrne with Neisseria meningitidis infection --\> acute adrenal insufficiency --\> weakness and shock

Answer 559

ie. Chronic adrenal insufficiency * PC: * Vague, progressive symptoms * Hypotension * Weakness * Fatigue * N&V * WEight loss * Hyperpigmentation (with primary disease) * Causes - most commonly arises with progressive adrenal damage: * Autoimmune * TB * Metastatic carcinoma (eg: from lung) _NB:_ Autoimmune adrenalitis is a component of autoimmune polyendocrine syndromes therefore say you would screen for this further in an OSCE!! * May arise with pituitary (secondary) or hypothalamic (tertiary) disease: * Primary adrenal insufficiency = hyperpigmentatio (high ACTH) & hyperkalaemia (low aldosterone) * Secondary & tertiary = no hyperpigmentation and normal potassium * Rx = glucocorticoids & mineralocorticoids!!

Answer 560

* Accidental injury * NAI - pattern and location of fracture * Osteogenesis imperfecta: * Autosomal dominant defect in collagen type 1 synthesis most commonly * Multiple #'s - without bruising!! * Blue sclera! * Hearing loss - bones of the middle ear fracture easily

Answer 561

**Osteomalacia** * Defective **M**ineralisation of osteoid * Due to low levels of vitamin D --\> results in low levels of Ca2+ & phosphate * Vit D deficiency seen in: * Decreased sun exposure * Poor diet * Malabsorption - vit D = fat-soluble vitamin * Liver & renal failure _Rickets:_ * Low vitamin D in children, most commonly \<1yrs * Presents as: * Pigeon chest deformity * Frontal bossing of forehead * Bowing of the legs _Osteomalacia:_ * Low vit D in adults * Increased risk of #'s! * Bloods will show: * Decreased serum Ca2+ & phosphate * Increased PTH! * Increased alk phos! - any activation of osteoblasts leads to incr. alk phos **Osteoporosis** * Reduction in trabecular bone mass --\> results in porous bone - hence "POROSIS" * Increased risk of #'s! * Peak bone mass achieved by 30yrs and decreases by 1% every year after that * Bone mass lost more quickly with: * Lack of weight-bearing exercise * Poor diet * Decreased oestrogen (eg: menopause) - oestrogen is protective to bones * Osteoporosis commonly happens either in the senile form or in the postmenopausal form * PC: * Bone pain with fractures * Bloods: * Serum calcium, phosphate, PTH & alk phos are all **normal!!** * Alk phos goes up at the time of a fracture! * Bone density is measured using DEXA scan! * Mx: * Exercise, vit D & calcium * Bisphosphonates - induce apoptosis of osteoclasts * _NB:_ Commonest cause of bisphosphonates NOT working = untreated vitamin D deficiency!! * Glucocorticoids are cONTRAINDICATED.

Answer 562

* Imbalance between osteoclast & osteoblast function * Normally: osteoclast is activated by osteoblast * Here: * Osteoclasts go mental & don't need osteoblast activation * Then, so much bone resorption has occured that eventually osteoblasts become activates * Lastly, osteoclasts burn out and you are left with only osteoblasts working but these are laying down bone in a rush so do a shit job * Hence, three stages: * Osteoclastic * Mixed osteoblastic-osteoclastic * Osteoblastic * End result - thick, sclerotic bone that fractures easily * Localised process involving one or more bones - NOT the entire skeleton * PC: * Bone pain - due to microfractures * Increasing hat size - skull commonly affected * Hearing loss * Lion-like facies * **Isolated elevated alk phos**!! * Mx: * Calcitonin - inhibits osteoclast function (halts first phase) * Bisphosphonates - induce apoptosis of osteoclasts * Complications: * High output cardiac failure - AV shunts form in bone * Osteosarcoma

Answer 563

**Osteoarthritis!** These are osteophytes formed (reactive bony outgrowths) Outer Hebredes! (DIP)

Answer 564

Uncontrolled inflammation (eg: persistent CRP of 10-12 - not even that high) in a rheumatoid patient, accelerates the atherogenic process (via interleukins etc) - will cause patients to die of a stroke or MI in 10/15yrs time!! **Complications** * Anaemia of chronic diseaase * Secondary AA amoyloidosis * Stroke, vasculitis etc **Treatment** * Fast acting = corticosteroids * Slow acting = DMARDs * Methotrexate * Sulphasalazine * Hydrochloroquine * Biologic therapies: * Anti TNF-alpha * etc.

Answer 565

* NSAIDs - Naproxen 500mg BD! * Intra-articular corticosteroid injection (hydrocortisone) * Sufasalazine - for peripheral joint involvement

Answer 566

**TRIAD of symptoms** * Arthritis * Urethritis * Conjunctivitis CAN'T SEE, CAN'T PEE, CAN'T CLIMB A TREE! **Joint aspirate culture ?** * There will be NO culture on joint aspirate with this!! **Common causative organisms?** * This will occur weeks after GI infection or Chylamydia infection!!

Answer 567

**Presents as? - Acute vs. Chronic** * Acute gout: * Equisitely painful joints - particularly big toe (podagra) * Painful joints precipitated by _alcohol_ (competes with uric acid for excretion in kidney) and consumption of _red meat (_lots of RNA) * Chronic gout: * Development of tophi - aggregates of uric acid crystals * Renal failure - urate nephropathy **Primary vs. Secondary Gout?** * Primary - aetiology of hyperuricaemia unknown * Secondary: * Leukaemia & myeloproliferative disorders - increased cell turnover * Renal insufficiency - decreased excretion of uric acid * Others.. **Synovial fluid aspirate?** * _NEGATIVE NEEDLES_

Answer 568

1. SLE 2. Dermatomyositis Differentiate them... * SLE - positive double-stranded DNA test * Dermatomyositis - positive anti-Jo-1 antibody (plus proximal muscle weakness and red papules on elbows, knuckles & knees)

Answer 569

Myasthenia gravis = **Ab against post-synaptic Ach receptor of NMJ** Lambert-Eaton syndrome = **Ab against presynaptic Ca2+ channels of NMJ**

Answer 570

**Erythema Mutiforme?** * HSR characterised by targetoid rash (cerntral necrosis with surronding erythema) & bullae * Associated with: * HSV infection * Mycoplasma infection * Drugs - penicillin & sulfonamides * Autoimmune diseases - SLE * Malignancy **Stevens-Johnson syndrome (SJS)?** * SJS = erythema multiforme + oral mucosa/lip involvement + fever!! **Toxic Epidermal Necrolysis?** * TEN = sevre form of SJS, characterised by DIFFUSE sloughing of skin * Most often due to adverse drug reaaction (eg: lamotrigine)

Answer 571

**Impetigo** * Usually due to Staph aureus & strep pyogenes (same for both) * PC: erythematous macules / pustules on the skin * Systemically well! **Cellulitis** * Usually due to Staph aureus & strep pyogenes (same for both) * PC: skin is red, tender, swollen AND patient has a _fever_ * Can progress to necrotizing fasciitis - surgical emergency!

Answer 572

1. **P**ain relief - morphine & metoclopromide 2. **P**latelets - aspirin loading dose 300mg & clopidogrel/ticagrelor & LMWH (realistically after coronary angio) 3. **P**erfusion of myocardium - Coronary angiography (PCI) ideally within 2hrs of symptoms but ultimately within 12hrs if ongoing chest pain 4. **P**laque stabilisation - high dose statin STAT to reduce the inflammation of the plaque Down the line post angio - to help reduce myocardial remodelling: * ACEi * Beta blockers

Answer 573

* ACEi / ARB's * Beta-blocker * Spironalactone Anything that reduces sympathetic load & reduces RAAS. NB: CCB's, digoxin, diuretics - do NOT reduce prognosis! (A's & B's do save lives, the C's & D's do NOT save lives)

Answer 574

* AKI * Angioedema! (closed throat) * Documented bilateral renal artery stenosis * Hyperkalaemia \>6 * Hypotension * Severe aortic stenosis * Dry cough --\> swap to ARB

Answer 575

1. Loop diuretic - furosemide / bumetinide 2. NYHA class 1 or 2: * beta blocker * ACEi 3. NYHA class 3 or 4 (still in pulmonary oedema / peripheral oedema): * Spironolactone! 4. After this, has the spironalactone helped..? * NYHA class I or 2 --\> add beta blocker! * NYHA class 3 or 4 (ie. still NOT improving) --\> Swap ACEi with entresto (not tachycardic and narrow QRS), add ivabradine (if still tachycardic/HR\>70), biventricular pacing (wide QRS on ECG, hoping to resynchronise), increase diuretic dose! In summary, everyone gets ACEi & Beta-blocker but if they do NOT get better then give them spironalactone! Which beta blockers are used in heart failure: * Bisoprolol * Nebivolol * Carvedilol **Essentially, everyone should be on ACEi, beta-blocker & spironolactone -** prognostic benefit!!

Answer 576

**Beta blockers**

Answer 577

**ACEi !!**

Answer 578

**Phaeo, Conn's, Cushing's, Renal artery stenosis**

Answer 579

* RBBB * Right ventricular hypertrophy (RVH) * Left sided Wolf-Parkinson white * Dextrocardia * Right ventricular cardiomyopathy Look for "strain pattern" * RVH strain pattern: * ST depressoin and T wave inversion in leads V2 & V3

Answer 580

flattened P waves Tall tented T waves Sagging of the ST segments Widening of the QRS Flatline...

Answer 581

Digoxin & verapamil These drugs block the AV node and then increase conduction through the accessory pathway & make the problem worse

Answer 582

Hardly ever happens **Right ventricular infarction !** (ST elevation in V1 --\> the right ventricle has been battered) * Inferior MI * Which then later develops hypotension & rasied JVP!

Answer 583

10-30% --\> Offer CT calcium scoring 30-60% --\> dobutamine stress echo \>60% --\> coronary angio

Answer 584

Young person who dies at rest - often during their sleep? ECG: Small R, big S, downsloping ST segment!

Answer 585

**ECG!** Looking for cardiac arrythmia or silent infarction You will get this in A&E before you let little old Doris go home...

Answer 586

Marcolides (Erythromycin, Clarithromycin) Quinolones Trimethprim

Answer 587

**Me and my friend _John_,** **_drinking_ & _smoking_,** **having _carbs_ on the _barbie_,** **and a _rifin_ good time!** * St John's wart * Drinking & smoking * Carbamazapine (AED) * Barbituates * Rifampicin

Answer 588

* PC: * Sudden, unilateral pelvic pain * After exercise often * N&V * O/E: PV exam shows adnexal mass & tenderness * Ix: * USS * beta-hCG * Mx: * Laparotomy - detorsion and ovarian preservation in pre-menopausal women

Answer 589

Hepatorenal syndrome is split into type 1 and 2. Type 1 is a rapid onset hepatorenal syndrome (less than two weeks). This typically occurs following an acute event such as an upper GI bleed. Type 2 is a more gradual decline in renal function and is generally associated with refractory ascites.

Answer 590

**Bite and blister cells!**

Answer 591

Typhoid fever normally presents within 21 days of a return from travel, especially to countries around the Indian subcontinent. **It has four stages:** the first stage lasts for approximately the first week and often precedes the classical 'pea green diarrhoea' of typhoid. It can present with abdominal pain, malaise, headache, fever, a dry cough and epistaxis. Blood cultures are most appropriate to diagnose the disease here (bone marrow aspiration yields the most sensitive result). A relative bradycardia, also known as **Faget's sign,** is a recognised sign of typhoid fever. It is defined as a heart rate that is slower than expected for the degree of fever. This patient's fever is reaching 40.4ºC, so one would expect a heart rate faster than 59 beats per minute.

Answer 592

**Left mixed hearing loss!** (NOT left conductive hearing loss - there is also sensorineural hearing loss as BOTH masked and unmasked are below the normal range!)

Answer 593

**is a direct complication of respiratory distress syndrome & incidence is decrease with oxygen therapy**

Answer 594

**Immediate return to theatre** * Primary (reactive) haemorrhage occurs within 24 hours after tonsillectomy, and requires immediate return to theatre due to the risk of further, more extensive bleeding which may need surgical intervention. * Secondary haemorrhage \>24 hours after tonsillectomy is more likely to be due to infection.

Answer 595

**Prickle/spur cells** are typical of pyruvate kinase deficiency on blood film

Answer 596

Escalate to the ITU team !

Answer 597

**Four main features:** * rigidity, * hyperthermia, * autonomic instability (hypotension, tachycardia) * altered mental status (confusion) Can also cause an AKI --\> derranged U&E's!

Answer 598

**Supraspinatus Tendonitis!** The x-ray shows calcification of the supraspinatus tendon consistent with prolonged inflammation. On examination the patient exhibits the classical 'painful arc' associated with this condition.

Answer 599

**Small cell lung cancer:** * ADH --\> siAHD * ACTH --\> Cushingoid * Lambert-Eaton syndrome **Squamous Cell Carcinoma:** * PTHrP --\> hypercalcaemia!

Answer 600

**Mitral regurgitation -** Rupture of the papillary muscle due to a myocardial infarction can lead to acute mitral regurgitation

Answer 601

ULTRASOUND 3monthly

Answer 602

* haemochromatosis * hyperparathyroidism * acromegaly * low magnesium, low phosphate * Wilson's disease

Answer 603

**Sx:** * Renal failure * Liver failure * Optic atrophy * Metabolic acidosis * LV dysfunction **Rx?** * Lavage the stomach if presenting in first few hours * IV fomepizole! * INhibits alcohol dehydrogenase - better to have methanol in the blood than its metabolite methanoic acid * Also give folic acid - to prevent blindness * Used to give IV ethanol * Can dialyse if severe

Answer 604

**Alfacalcidol** This is activated vit D

Answer 605

* Volume overload: * HTN * Pulmonary oedema * Peripheral oedema * Acidosis: * Breathlessness * Hyperkalaemia: * Cardiac arrest * Reduced EPO: * Anaemia * Reduced ability to hydroxylate 25 HCC: * Osteodystrophy * Chronic uraemia: * Pericarditis & pleurisy * Pericardial & pleural effusions

Answer 606

This buys you one hour to give IV insulin & salbutamol Definitive treatment may be dialysis

Answer 607

NITROFURANTOIN NOT Trimethoprim (folate antagonist)

Answer 608

**Cerebellum !** Sx: * N&V * Tremor * Cerbellar signs * Coma * Seizures * Fever * Can cause: * Diabetes insipidus * Hypothyroidism Lithium toxicity can be precipitated by any which will reduce renal function (decreased creatinine clearance) - eg: diuretics, ACEi, NSAID's AND anything which drops serum sodium - eg: excessive vomiting, diuretics, diarrhoea,

Answer 609

* Metformin - chronic renal failure (creatinine \>150) * Pioglitazone - heart failure or liver failure

Answer 610

Brain - TBI, SOL (infective, malignant), haemorrhage Lung - TBI, SOL (infective, malignant), haemorrhage Pills: * SSRI's * TCA's * chemotherapeutic agents * Cyclophosphamide * Carbamazepine

Answer 611

Ishcaemic heart disease! Remember rasied CRP --\> inflammation --\> MI etc

Answer 612

Memory loss Hallucinations Parkinsonism

Answer 613

**Cryoprecipitate (or FFP)**

Answer 614

* Aspiration pneumonias * Pleural empyema * Ascneding cholangitis

Answer 615

**ACE inhibitors eg. ramipril should be used first-line for treating hypertension in diabetics,** exceptions to this are people of Afro-Caribbean origin and women for whom there is a possibility of becoming pregnant. If the patient develops a cough with ACE inhibitors then they should be given an angiotensin-II receptor antagonist eg. losartan. Without DM, the patient would have been started on a CCB as they were \>55yrs

Answer 616

Safe strong opioid to use in patients with renal failure!

Answer 617

* Rheumatoid factor +ve * Anti-CCP +ve * poor functional status at presentation * HLA DR4 * X-ray: early erosions (e.g. after \< 2 years) * extra articular features e.g. nodules * insidious onset

Answer 618

**Charcot's triad?** * right upper quadrant pain, * fever/rigors * vomiting **Reynold's pentad?** * Charcot's triad + * hypotension * confusion **Beck's triad?** * hypotension, * raised jugular venous pressure (JVP) * muffled heart sounds Seen in cardiac tamponade patients. **Cushing's triad?** * irregular and decreased respiratory rate, * bradycardia * hypertension Seen in patients with raised intracranial pressure.

Answer 619

**Indirect** - hernia passess through both deep & superficial inguinal rings - most likely due to a patent processus vaginalis **Direct** - where the hernia passes straight through the superficial inguinal ring is likely in older people due to increased abdo pressure

Answer 620

* Reducing aqueous secretion * Inducing pupillary constriction Overall to reducing intraoccular pressure

Answer 621

**IM Vit b12 followed by oral folate replacement - when the B12 has reached normal**

Answer 622

**Calcium gluconate** is first-line treatment for magnesium sulphate induced respiratory depression

Answer 623

**A**bdominal pain, **B**loating and **C**hange in bowel habit

Answer 624

* Post-TURP for BPH * Massive cardiovascular collapse with hyponatraemia and metabolic acidosis * Caused by entry into the circulatory system of the irrigation fluid * Treat with: * Furosemide * Fluid restriction

Answer 625

**Peyronies Disease** * Hard fibrous plaques in the tnic of the corpus cavernosa cause angulation toward the affected side, resulting in painful erections * Increasing incidence with more and more blokes trying to stretch their cocks out **Balanitis Xerotica Obliterans** * Autoimmune condition * Characterised by ivory-white patches on the glans, typically around the meatus * Rx = steroid creams or circumcision **Balanitis** * Inflammation of the glans * Usually associated with a tight foreskin (phimosis) **Paraphimosis** * Inability to replace the foreskin when it has been retracted * Caused by a narrowed or inflamed foreskkin * EG: after urinary catheterisation when you don't replace the foreskin * Can lead to gangrene **Phimosis** * A tight foreskin cannot be drawn back over the underlying glans, predisposing to inflammation (balanitis) * Either congenital or due to infection * Mx = circumcision ("PHImosis = penis can't say HI")