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P Year > Passmed Corrections > Flashcards

Passmed Corrections Flashcards

1
Q

Amiodarone SE’s

A

Amiodarone can cause thyroid dysfunction due to its high iodine content (Am-IOD-arone) and direct toxic effect on the thyroid

`EG: Patient presenting with hair loss, lethary, weight gain, constipation

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2
Q

Lochia?

A
  • = the vaginal discharge containing blood mucous and uterine tissue which may continue for 6 weeks after childbirth.
  • Keys to Dx (vs. postpartum haemorrhage):
    • Fresh bleeding, which undergoes colour change, before finally stopping
    • Not excesssive volume
    • Stable patient
  • Advise patient to seek medical help if:
    • Begins to smell badly
    • Volume increases
    • Bleeding doesn’t stop
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3
Q

Post-exposure prophylaxis for HIV (eg: needlestick from HIV +ve)

A
  • Oral antiretroviral therapy for 4 weeks
  • Serological testing at 12 weeks following completion of post-exposure prophylaxis
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4
Q

Schizoid personality disorder?

A
  • Schizoid personality disorder displays the negative symptoms of schizophrenia
  • Indifference to praise and criticism
  • Preference for solitary activities
  • Lack of interest in sexual interactions
  • Lack of desire for companionship
  • Emotional coldness
  • Few interests
  • Few friends or confidants other than family
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5
Q

Ix for secondary ammenorrhoea?

A
  • Exclude pregnancy with urinary or serum bHCG
  • Gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
  • Prolactin
  • Androgen levels: raised levels may be seen in PCOS
  • Oestradiol
  • Thyroid function tests
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6
Q

Rhinne & Weber’s tests - go through it you bellend twat

A
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7
Q

Warfarin advice for routine surgery?

A
  • In general, warfarin is usually stopped 5 days before planned surgery, and once the person’s international normalized ration (INR) is less than 1.5 surgery can go ahead.
  • Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.
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8
Q

Criteria for LTOT? (to be worn for at least 15 hours per day)

A
  • Ceased smoking
  • pO2 of < 7.3 kPa
  • pO2 of 7.3 - 8 kPa AND one of the following:
    • Secondary polycythaemia
    • Peripheral oedema
    • Pulmonary hypertension
  • Also carry out a risk assessment before offering LTOT, including:
  • Risk of falls from tripping over the equipment
  • Risk of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes)
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9
Q

Trichomonas Vaginalis

A
  • Offensive, yellow/green, frothy discharge
  • Vulvovaginitis
  • Strawberry cervix
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10
Q

Bacterial vaginosis?

A
  • Offensive, thin, white/grey, ‘fishy’ discharge
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11
Q

36 year old female up for an elective surgery - advice about COCP?

A
  • Continue taking up until 4 weeks before surgery
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12
Q

De Quervain’s thyroiditis?

A
  • aka. Subacute thyroiditis
  • Tends to occur following viral illness
  • Preceeding period of hyperthyroidism which then turns into a picture of hypothyroidism!!
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13
Q

ECG features of hypokalaemia?

A
  • U waves (lead V2 & V5 on ECG attached)
  • small or absent T waves (occasionally inversion)
  • prolong PR interval
  • ST depression
  • long QT
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14
Q

Bisphosphonates - how to take

A
  • Tablets should be swallowed whole with plenty of water while sitting or standing
  • to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication)
  • patient should stand or sit upright for at least 30 minutes after taking tablet’
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15
Q

Contraceptives - time until effective (if not first day period):

A
  • instant: IUD
  • 2 days: POP
  • 7 days: COC, injection, implant, IUS
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16
Q

Methotrexate + trimethoprim?

A
  • The concurrent use of methotrexate and trimethoprim containing antibiotics may cause bone marrow suppression and severe or fatal pancytopaenia
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17
Q

Neonate born prematurely due to maternal distress - comes out floppy & unresponsive?

A
  • Need to exclude the possibility of interventricular haemorrhage
  • Neonatal deterioration in premature babies is not infrequently due to intra ventricular haemorrhage. In extreme prematurity the prognosis can be very poor.
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18
Q

Schizotypal personality disorder?

A
  • Ideas of reference (differ from delusions in that some insight is retained)
  • Odd beliefs and magical thinking
  • Unusual perceptual disturbances
  • Paranoid ideation and suspiciousness
  • Odd, eccentric behaviour
  • Lack of close friends other than family members
  • Inappropriate affect
  • Odd speech without being incoherent
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19
Q

Candida ?

A
  • ‘Cottage cheese’ discharge
  • Vulvitis
  • Itch
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20
Q

Classical Presentations of different seizures?

Frontal lobe seizures?

Temporal lobe seizures?

Parietal lobe seizures?

Occipital lobe seizures?

Juvenile myoclonic epilepsy?

A
  • Frontal lobe seizures = Jacksonian movement (clonic movements travelling proximally), posturing, post-ictal weakness
  • Temporal lobe seizures = associated with aura, lip smacking and clothes plucking
    • HEAD
    • H - hallucinations (visual/auditory/olfactory)
    • E - epigastric rising / emotional
    • A - automisms (lip smacking /grabbing)
    • D - deja vu/dysphasia post-ictal
  • Parietal lobe seizures = associated with sensory abnormalities (eg: parasthesia)
  • Occipital lobe seizures = visual abnormalities (eg: floaters/flashes)
  • Juvenile myoclonic epilepsy is a genetic generalised epilepsy syndrome including absence, myoclonic and generalised tonic-clonic seizures.
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21
Q

Psoas Abscess?

Key points

A
  • Can be of primary origin or a result of spread from local sources such as pyelonephritis or inflammatory bowel disease
  • Left untreated it can lead to septicaemia and multi organ failure
  • Risk factors
    • Causes of immunosupression such as HIV, cancer and diabetes.
    • Being an intravenous drug user
    • Previous surgery
    • TB
  • Pain insiduous in onset - few days
  • May have fever
  • Psoas irritation evidenced when the position of comfort is the patient lying on their back with slightly flexed knees.
  • Inability to weight bear or pain when moving the hip is usually evident
  • Ix?
    • Bloods to evidence infection and a complete septic screen if systemic inflammatory response syndrome criteria are met.
    • Plain radiographs are not useful for identifying an abscess although are useful for ruling out differentials.
    • MRI = gold standard
  • Mx?
    • Abx +/- drainage.
    • Alongside managing any predisposing risk factors if appropriate.
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22
Q

Acute Confusion Screen?

A

Ix to exclude organic causes of delirium:

  • TFT’s (hypothyroid can precipitate confusion),
  • B12,
  • Folate
  • Urine dip for nitrites
  • CXR
  • CT head Consider onset of dementia
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23
Q

Criteria for blood transfusion?

A
  • Hb < 70

OR

  • Hb < 80 w/ symptoms/CVD
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24
Q

Ischaemic stroke - what antiplatelets should patient be started on initially & continued on upon discharge?

A
  • Aspirin 300mg OD for 2 weeks
  • Clopidogrel 75mg OD lifelong
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25
Q

Autonomic Dysreflexia?

What spinal level must the injury be?

A
  • 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)
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26
Q

Situations where oxygen therapy should not be used routinely if there is no evidence of hypoxia?

A
  • Myocardial infarction and acute coronary syndromes
  • Stroke
  • Obstetric emergencies
  • Anxiety-related hyperventilation
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27
Q

Glasgow Scale of Pancreatitis Severity?

(PANCREAS)

A

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
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28
Q

Recurrent unilateral epistaxis = red flag for nasopharyngeal cancer

A

Wow

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29
Q

2 key things to remember about Lewy Body Dementia?

A
  1. Auditory/visual hallucinations may accompany memory loss
  2. Use of dopamine antagonists is contraindicated (same as with Parkinson’s disease) ie. NO haloperidol
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30
Q

Bisphosphonates - SE’s?

(Eg: alondranate)

A
  • 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
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31
Q

Key gestations where routine visits & Ix/scans are performed during a pregnancy?

Booking visit?

Early scan to confirm dates/exclude multiple pregnancies?

Down screening including nuchal scan?

Anomaly scan?

Checking presentation?

A
  • 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
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32
Q

Key bloods to point to a Dx of prerenal AKI or (UPPER) GI bleed?

A
  • 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

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33
Q

First line ix for a testicular mass?

A

Ultrasound!

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

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34
Q

ENT: CENTOR Criteria for a bacterial sore throat?

A
  • Hx of fever
  • Tonsillar exudates
  • No cough
  • Tender anterior cervical lymphadenopathy
  • Age >40

If 3 or more, then Abx: benzylpenicilling or metronidazole

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35
Q

Hormone (ER+) positive breasrt cancer:

Rx for premenopausal patient?

Rx for postmenopausal patient?

A
  • 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
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36
Q

Patient with CKD stage 3 presenting with SOBOE - Hb of 92. What Ix do you do?

A
  • 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
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37
Q

Clozapine blood levels?

What can affect them?

A
  • 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?
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38
Q

Is diarhhoea or constipation more concerning as a symtpom of cancer?

A
  • Diarrhoea can get around cancer in the bowel - concerning
  • Always ask about overflow diarrhoea / loose stools (even in a constipation history)
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39
Q

Ix for a colorectal clinic?

A
  • 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
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40
Q

Flexi sig vs colonoscopy?

A
  • 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
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41
Q

Staging haemorrhoids? & Mx?

A

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
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42
Q

Anal fissue?

A
  • 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

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43
Q

Perianal haematoma?

A
  • “Painful lump at the anus about 6 weeks ago but now it’s gone”
  • Can resolve itself
  • Short history course
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44
Q

Proctitis - DDx

A
  • 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.
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45
Q

A

B

C

D

E

of colorectal surgery/vasc patient?

A
  • A = anastomotic leak dumbass
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46
Q

Pruritis ani?

A
  • Primary condition
  • Secondary condition:
    • Neoplasia - be sure to exclude
    • Benign anorectal conditions, haemorrhoids, skin tags
    • Threadworm
    • Dermatological conditions
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47
Q

Anorectal Sepsis?

A
  • 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
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48
Q

Diverticular disease - associations? (Ask about in a Hx)

A
  • Obesity
  • NSAIDs
  • Smoking
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49
Q

Diverticular disease vs ischaemic colitis - presentation

A
  • Anyone who comes in with painful PR bleeding will NOT be diverticulitis - this will be ischaemic colitis!
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50
Q

Tenesmus?

A
  • Sign of inflammation –> sensation of incomplete evacuation
  • ?Cancer vs IBD (UC)
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51
Q

Patient comes in with constipation..

A
  • 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
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52
Q

Dysphagia - causes

Intrinsic, extrinsic, functional

A
  • 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)
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53
Q

Odonophagia - causes:

A
  • Inflammation:
    • Reflux oesophagitis
    • Peptic oesophageal ulceration
  • Infeciton:
    • Thrush
    • Herpes
    • Bacterial / viral pharyngitis
  • Spasm:
    • diffuse oesophageal spasm
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54
Q

Gastro-oesophageal reflux - specific Dx criteria?

A
  • 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)

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55
Q

Manometry & 24hr pH montioring - explaining to pt

A
  • 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
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56
Q
A
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57
Q

Diffuse oesophageal spasm

(Good DDx for achalasia)

A
  • 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
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58
Q

?Barrett’s oesophagus - Prague classification to describe it on OGD

A
  • Prague classification:
    • C = circumference (of the oesophagus)
    • M = maximumen extent (from stomach upwards)
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59
Q

Endoscopic ultrasound (EUS)?

A
  • Gold standard for staging the T stage of oesophageal cancers
  • Can also take a targetted biopsy of the lesion
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60
Q

Management of oesophageal cancer?

A
  • 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
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61
Q

Krunkenberg’s tumour?

A
  • Stomach cancer –> bilateral ovarian tumours
  • If stomach cancer causes ulcer which perforates then there can be direct seeding of the peritoneum –> ovarries
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62
Q

Classification of lower urinary tract symptoms (LUTS)?

Storgae, voiding, post-micturition

A
  • 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
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63
Q

Ix for lower urinary tract symptoms (LUTS)?

A
  • 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
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64
Q

Patient with ?BPH, what score should you do to assess them?

(Normal prostate = 20-25ml)

A
  • 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
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65
Q

Rx for BPH-LUTS?

A
  • 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
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66
Q

?Bladder overactivity syndrome

A
  • 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!
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67
Q

Anticholinergic SE’s

(EG: oxybutinin, tolterodine, fesoterodine, solifenacin, darifencin)

A
  • 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
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68
Q

Acutely painful testicle in an adolescent?

(Always stand the patient up - can’t just examine a testicle lying down - important for ?varicocele)

A
  • 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.

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69
Q

Acute Urinary Retention - 2 types:

A

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
    *
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70
Q

Mx of renal trauma?

A
  • 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
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71
Q

DDx Loin pain

A
  • Rupture AAA
  • Renal colic - ?stone
  • Constant renal pain - ?pyelonephritis
    • Pyelonephritis = 2 weeks of Abx
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72
Q

Black spot on the scrotum / perineum - feels crackly (like rice crispies under the skin) and often malodorous

A
  • Fourniere’s gangrene
  • Dont miss it
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73
Q

Painless visible haematuria

DDx

Hx

Ix

A
  • 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
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74
Q

4 causes of raised PSA

A
  • BPH
  • Cancer
  • Prostatitis
    • Or local inflammation caused by a UTI
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75
Q

Testicular cancer - tumour markers?

A
  • 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

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76
Q

Risk factors for renal stones?

A
  • 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
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77
Q

Haemophilia A - inheritence pattern

A
  • X-linked so only seen in males
  • BUT male-male transmission is not seen
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78
Q

Mx of Croup?

A

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
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79
Q

Best way to Dx pertussis?

(Whooping cough)

A

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
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80
Q

Post natal depression screening tool?

A

Edinburgh scale:

  • 10 question questionnaire
  • Score out of 30
  • score > 13 indicates a ‘depressive illness of varying severity’
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81
Q

In a female with postmenopausal bleeding (PMB), what is the diagnosis until proven otherwise?

A

Endometrial cancer !!

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82
Q

Rx for a woman of moderate or high risk of Pre-eclampsia in pregnancy?

(eg: moderate risk = FHx of pre-eclampsia in pregnancy)

A
  • Commence aspirin 75mg OD from 12 weeks until birth
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83
Q

Features of a foetus with Edward’s syndrome? (trisomy 18)

A

A baby is born with:

  • Micrognathia,
  • low-set ears,
  • rocker bottom feet
  • overlapping of fingers
  • Choroid plexus cysts
  • Small placenta
  • Polyhydramnios
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84
Q

Rx for medical Mx of ectopic pregnancy?

A

Methotrexate!

  • Only suitable if the patient is willing to attend follow up
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85
Q

3 ways of managing ectopic pregnancies & the nuances of each?

(Expectant/conservative, Medical, Surgical)

A
  • Size?
  • Ruptured?
  • Symptoms?
  • Foetal heartbeat?
  • b-hCG?
  • Another intrauterine pregnancy co-existing?
  • Follow up?
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86
Q

Features of Patau syndrome? (Trisomy 13)

A
  • Microcephaly,
  • small eyes,
  • low-set ears,
  • cleft lip
  • Polydactyly = Patau syndrome
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87
Q

Smoking cessation in pregnancy?

A
  • Motivational interviewing
  • Nicotine patch!
  • Neither bupropion or varenicline should be offered to pregnant women
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88
Q

Diagnostic criteria for Pertussis? (whoop whoop dicked)

A
  • 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.
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89
Q

Duration of Rx for a Provoked PE?

Duration of Rx for a Unprovoked PE?

A
  • Provoked PE –> warfarinise for 3 months

(NB: even COCP = provoked)

  • Unprovoked PE –> warfarinise for 6 months
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90
Q

Bleeding in pregnancy? By tremester…

A
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91
Q

Alport’s syndrome?

What is it? How could they ask about it?

A
  • 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
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92
Q

The 6 P’s of acute limb ischaemia?

A
  • pale,
  • pulseless,
  • pain,
  • paralysis,
  • paraesthesia,
  • perishingly cold

NB: Critical limb ischaemia = longer than 2 weeks

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93
Q

Which contraceptive type is associated with a delay in rerturn to fertility?

A
  • Injectables
  • EG: Depo Preovera (progesterone only injectable)
  • Associated with a delay in return to fertility of about 12 months
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94
Q

Steps in mangement of slipped disc? (usually presenting as sciatica for example)

A
  • ABCDE
  • Analgesia
  • Physio!
  • MRI can confirm diagnosis but even with this first option is often physiotherapy for convservative management before surgery
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95
Q

Skin types? (1-6)

1 = me

5 = sud

6 = hannah mensah

A
  • 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
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96
Q

Treatment of choice for stage I and II endometrial carcinoma?

A
  • Total abdominal hysterectomy with bilateral salpingo-oophorectomy

NOT Transcervical endometrial resection

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97
Q

Rx for acne?

A
  • 1st line = non-antibiotic topics (eg: topical Benzoyl peroxide)
  • 2nd line = add Abx (eg: topica Benzoyl peroxide + clindamycin)
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98
Q

When treating hyperkalaemia? Rx?

A
  • calcium gluconate
  • Insulin/dextrose infusion
  • Nebulised salbutamol
  • There is NO place for bicarbonate in the Mx of hyperkalaemia
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99
Q

Predisposing factors for Gout?

A
  • 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
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100
Q

Infantile spasms (West syndrome) vs Infantile colic?

A
  • 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
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101
Q

Hepatocellular carcinoma?

Most common cause in Europe vs Worldwide?

A
  • hepatitis B most common cause worldwide
  • hepatitis C most common cause in Europe
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102
Q

Ankylosing Spondylitis:

Management?

A
  • 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’
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103
Q

Which of these is an indicator of cor pulmonale?

SOBOE

Orthopnoea

Chest pain OE

Hepatomegaly

Paroxysmal nocturnal dyspnoea

A
  • Hepatomegaly - you useless fucktard
  • This is the only one which is a direct measure of right heart function
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104
Q

Melanosis Coli?

What is it and what is the underlying cause?

A
  • 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
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105
Q

Causes of an increased ferritin?

(2 categories: w/ iron overload & w/out iron overload)

A
  • 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)
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106
Q

Rabies - Rx following possible exposure in the non-vaccinated?

A
  • Give immunglobulin + vaccination
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107
Q

Surgical Management of IBD - Principles

A

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.
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108
Q

Varicocele?

A
  • 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
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109
Q

Leakage of fluid PV during late pregnancy

A
  • 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
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110
Q

Most commonly inherited hypercoagulable disorder in white population?

A
  • 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
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111
Q

Sphincter of Oddi dysfunction?

A
  • 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
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112
Q

What are normal (& therefore reduced) foetal movements?

A
  • 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
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113
Q

Poor prognostics indciators on bloods/ECG for heart failure?

A
  • Increasing pro-BNP
  • Hyponatraemia
  • Renal insufficiency
  • QRS duration >120
  • Left bundle branch block pattern
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114
Q

Spondylolisthesis?

A
  • 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
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115
Q

Congenital CMV infection?

Foetal presentation?

A
  • Growth restriction & microcephaly
  • Periventricular calcifications
  • Hepatosplenogemaly
  • Thrombocytopenia
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116
Q

Rinne’s & Weber’s - making sense of this madenss?

A

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)

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117
Q

Paediatric Septic Arthritis?

A
  • 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
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118
Q

1st line Abx in a C. diff infection?

A
  • Vancomycin

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

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119
Q

Drug-induced Lupus?

A
  • More common causes:
    • Procainamide
    • Hydralazine
  • Less common causes:
    • Isoniazid
    • Phenytoin
    • Minocycline
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120
Q

One likely cause of pancreatitis in a homeless bloke?

A
  • Alcohol
  • Hypothermia!
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121
Q

Children and young people (0-24yrs): Refer for immediate specialist assessment for leukaemia if…?

A
  • Unexplained petechiae or hepatosplenomegaly
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122
Q

Rx for smoking cessation?

A
  • Nicotinic receptor partial agonists!
    • Varenicline
    • Bupropion
  • Pregnant mothers - offer CBT first line
    • Varenicline & bupropion = contraindicated
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123
Q

Most common place along the GI tract for diverticula?

A
  • 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
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124
Q

6 Tests to confirm brain stem death?

A
  • 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
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125
Q

Important when prescribing sodium valproate?

A
  • P450 inhibitor
    • Ask about other medications?
  • Causes increased appetitie & weight gain
  • Causes alopecia
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126
Q

Focal aware seizure vs focal dystonia?

A
  • Focial dystonia - involves rigidity and writhing movements

Rather than twitching…

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127
Q

Child with Inguinal hernia vs. Umbilical hernia?

A
  • 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
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128
Q

Migraine Rx?

Acute Rx in attacks

Chronic Rx prophylaxis

A
  • Acute:
    • Triptan + NSAID
    • Triptan + paracetamol
  • Prophylaxis:
    • Topiramate
    • Propranolol
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129
Q

Most common Rx cause of gynaecomastia?

A
  • Spironalactone
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130
Q

Calcium channel blockers & SE’s?

LEARN THIS

A

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
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131
Q

Gout vs Pseudogout? Crystals?

A
  • Gout = negatively bifringent needle-shaped crystals (urate)
  • Psueodgout = weakly positive bifringent rhomboid-shaped crystals
    • Associated with acromegaly
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132
Q

Child with whooping cough - exclusion from school advice?

A
  • Exclude from school for 48hrs from commencement of antibiotics
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133
Q

Cyanotic congenital heart disease:

Presenting in first days of life?

Presenting at 1-2 months of age?

A
  • Presenting in first days of life = TGA
  • Presenting at 1-2months = ToF
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134
Q

Features of Acute Severe Asthma Attack?

A
  • Inability to complete full sentences
  • PEFR 33-50% of best or predicted
  • RR > 25/min
  • HR > 110bpm
  • Sats <92% –> indicate a life-threatening attack
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135
Q

Masood, 27, presents to the Emergency Department following a fall. He was subsequently found to have rigidity, cogwheeling and bradykinesia, along with ataxia and slurred speech. On examination he displays past pointing and a lack of co-ordination. Further examination reveals the presence of ascites and splenomegaly. He has been recently treated for haematemesis due to oesophageal varices, despite the fact that he reports he does not drink alcohol due to his religion. Otherwise, Masood is fit and well. The nursing staff have reported that Masood has shown signs of memory loss, slow thinking processes and possible psychotic symptoms since being admitted. Which of the following diagnoses fit Masood’s symptoms?

A
  • Wilson’s disease!!

Combination of liver & neurological signs –> Wilson’s disease!

DDx here = Wernicke Korsakoff syndrome, but the patient said they didn’t booze

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136
Q

Dosage of folic acid supplementation before & in first 12 weeks of pregnancy?

A
  • Normal = 400 micrograms
  • Previous pregnancy affected by neural tube defects = dosage upped to 5 miligrams
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137
Q

PC of pneumothorax?

A
  • Sudden onset SOB & pleuritic chest pain too
  • ?Hx of Marfan’s/ED
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138
Q

Breast Lump - criteria for referral under suspected cancer pathway to a specialist breast clinic?

A
  • Women >30yrs with unexplained breast lump

This patient had a breast lump which has persisted for more than one menstrual cycle.

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139
Q

TIA? Symptoms lasting less than 24hrs

A
  • 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
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140
Q

STROKE - hemianopia vs paresis

A
  • The hemianopia is ALWAYS on the same side as the hemiparesis!!
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141
Q

Cerebellar Vermis vs. Cerebellar Hemisphere lesion?

A
  • Cerebellar hemisphere = finger-nose passpointing
  • Cerebellar vermis = ataxic gait w/out finger-nose passpointing.
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142
Q

Patient presenting with a stroke: reduced pin prick sensation over right CN5 distribution and left arm & leg. No motor weakness or other sensory deficit.

What’s the syndrome & where’s the stroke?

A
  • 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

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143
Q

Can recommend a Keto diet in the case of childhood epilepsy that is hard to control with AED’s alone

A

Fecking true plus they’ll get shredcity bitch

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144
Q

Patient presents with…

unilateral hearing loss + reduced facial sesnation & balance problems

Dx & Ix?

A
  • ?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

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145
Q

Mx of cluster headaches??

A
  • 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.
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146
Q

CASE: Diabetic w/ sensory loss of left arm & left leg with no other neurological features…

A
  • ? lacunar infarct !!! (isolated sensory loss)
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147
Q

WHERE ARE BROCA’S & WERNICKE’S AREAS???

A
  • 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)

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148
Q

Recommended antiplatelet regime following an ischaemic stroke? Assuming there are no contraindications

A
  • Aspirin 300mg OD for 2 weeks
  • Clopidogrel 75mg OD lifelong
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149
Q

What visual defect is this patient likely to have?

A 22-year-old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound is normal.

A
  • This patient has diabetes insipidus due to a craniopharyngioma.
  • This causes a lower bitemporal hemianopia.
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150
Q

Causes of cerebellar injury?? (EG: presenting with an ataxic gait)

A

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
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151
Q

Key to ask about with manifestations of MS???

A
  • Depression! (subtle and often overlooked sign)
  • but is obviously very common so dont necessarily rely on this for diagnosis
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152
Q

Migraine triggers include the mnemonic CHOCOLATE:

A
  • chocolate,
  • hangovers,
  • orgasms,
  • cheese/caffeine,
  • oral contraceptives,
  • lie-ins,
  • alcohol,
  • travel,
  • exercise
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153
Q

Humerus #’s & associated nerve injuries?

A
  • Shaft # –> radial nerve damage
  • proximal humerus # –> axillary nerve damage
  • supracondylar humerus # –> ulnar nerve damage
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154
Q

WHICH BLOOD TEST WOULD YOU ORDER TO DIFFERENTIATE BETWEEN A PSEUDOSEIZURE & GENUINE SEIZURE?

A
  • 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)
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155
Q

Iron deficiency anaemia as a cause of pruritis!

A

Always include it in the workup!

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156
Q

CASE:

A 24-year-old woman presents to the emergency department with a 2-hour history of left-sided flank pain radiating down towards her groin. The pain is constant and unrelieved by changes in position. She feels nauseous and has vomited once. Her past medical history is unremarkable and she takes no regular medications.

On examination, she is tender over the left costovertebral angle. There is evidence of guarding but no rebound tenderness. Her observations are heart rate 112/min, blood pressure 120/76mmHg, temperature 38.1ºC, respiratory rate 14/min, saturations 97%.

An ultrasound scan of the kidneys demonstrates dilation of the renal pelvis on the left. CT scan of the kidneys, ureters and bladder shows a 4mm stone in the left ureter. What is the most appropriate management?

A
  • 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
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157
Q

Most common site for an ectopic pregnanacy in the uterine tube?

A
  • AMPULLA!

Ample get stuck here.

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158
Q

CASE: A mother is experiencing lack of sleep and low mood one month after giving birth. What do you do?

A
  • 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
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159
Q

Mx of COPD?

A
  • first line = SABA (salbutamol) or SAMA (ipratropium)
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160
Q

Normal Grief Reaction?

A

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
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161
Q

Rx of Lithium in mood disorders.

Key adverse effects of chronic lithium toxicity to warn of?

A
  • 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
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162
Q

Dementia vs Depression

A
  • 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
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163
Q

LIST SE’S OF ANTIPSYCHOTICS PLEASE HUGH

A

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)
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164
Q

METABOLIC FEATURES OF ANOREXIA NERVOSA?

A
  • Most things low!
    • low FSH, LH, oestrogens and testosterone
    • Low thyroid
  • G’s and C’s raised:
    • growth hormone,
    • glucose, (impaired glucose tolerance)
    • salivary glands,
    • cortisol,
    • cholesterol,
    • carotinaemia
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165
Q

SE of lorazepam?

A
  • 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)
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166
Q

Hypomania vs. mania??

A
  • Presence of psychotic symptoms - eg: auditory hallucinations

Mania –> urgent referral to CMHT

Hypomania –> routine referral to CMHT

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167
Q

Sudden onset psychosis following course of corticosteroids – consider steroid-induced psychosis

A
  • EG: Started a course of pred for recent exacerbation of asthma!
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168
Q

Most common SE of clozapine??

A
  • Constipation!
  • Potentially a higher mortality from bowel obstruction/impaction and perforation than from agranulocytosis!
  • Can also lower seizure threshold!
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169
Q

Time course of onset of symptoms / DT’s after alcohol withdrawal?

A

Alcohol withdrawal

  • symptoms: 6-12 hours
  • seizures: 36 hours
  • delirium tremens: 72 hours
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170
Q

Can only diagnose a personality disorder in a patient >18yrs.

A

Fecking true!!

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

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171
Q

First line Mx of a teenager with Anorexia?

A
  • Anorexia focused family therapy is the first-line treatment for children and young people with anorexia nervosa
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172
Q

Which SE do atypical antipsychotics cause more than typical psychotics?

A
  • Weight gain!!
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173
Q

What is the antidepressant of choice in these cases?

Post MI in an adult?

In a child/adolescent?

A
  • Post MI in an adult = Sertraline!
  • In a child/adolescent = Fluoxetine!
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174
Q

Post concussion syndrome?

A
  • Post-concussion syndrome is seen after even minor head trauma
  • Typical features include
    • headache
    • fatigue
    • anxiety/depression
    • dizziness
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175
Q

Physical presentations on Anorexia?

A
  • 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)
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176
Q

Conversion disorder?

A
  • 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
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177
Q

CLOZAPINE CASE: A 32-year-old male patient who has a known psychiatric diagnosis of paranoid schizophrenia was admitted under the Mental Health Act following a deterioration in his mental health. Clozapine was considered as the next most appropriate anti-psychotic to start him on and this was initiated as an inpatient. Once this patient’s mental state was stabilised he was transferred back to the rehabilitation unit. Whilst at the unit, he was found to have missed his Clozapine doses for 2 consecutive days. What is the best course of action to address these missed doses of Clozapine?

A
  • 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

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178
Q

CASE: A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient and using a validated symptom measure you decide she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?

OPTIONS: Sertraline, sertraline + lanzoprazole, etc etc

A

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

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179
Q

Managament of Generalised Anxiety Disorder?

A

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

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180
Q

Metabolic abnormalities in Bulimia?

A
  • Hypochloraemia!
  • Hypokalaemia - can present with palpitations. ECG changes of tall P waves & flattened T waves!
  • Metabolic alkalosis

Just think about vomiting all the time!

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181
Q

UNEXPLAINED SYMPTOMS - SOMATISATION DISORDRE VS. HYPOCHONDRIA DISORDER

A

Somatisation = Symptoms (eg: presents repeatedly with headache & palpitations)

hypoChondria = Cancer (eg: presents worrying about fucking cancer)

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182
Q

CASE: You are called by the husband of a 45-year-old patient who is registered at your practice. Her only history of note is type 2 diabetes mellitus treated with metformin. For the past three days he states that she has been ‘talking nonsense’ and starting to hallucinate. An Approved Mental Health Professional is contacted and makes her way to the patient’s house. On arrival you find a thin, unkempt lady who is sat on the pavement outside her house, threatening to ‘kick your head in’. What is the most appropriate action?

OPTIONS: Call the police. Check her blood sugar. etc.

A
  • 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.

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183
Q

Othello syndrome ?

A
    • delusional jealously, usually believing their partner is unfaithful
  • (PSYCH)
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184
Q

Schizoid personality disorder?

A
  • Prefer to be alone, don’t like relationships, low libido
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185
Q

Exacerbating factors for plaque psoriasis?

A

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
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186
Q

CASE: You are an FY2 working in Acute Medicine. You clerk and admit a 90-year-old man with an infectious exacerbation of COPD.

The patient is admitted to your ward, and dies overnight, 12 hours after presenting to hospital. There was no suspicion of negligence.

Which legal imperative regarding the death is correct?

A

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

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187
Q

VASA PREVIA vs. PLACENTA PREVIA?

A
  • 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.
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188
Q

Describe the eczema rash?

A
  • “pruritic, erythematous, oozing rash with vesicles & oedema”
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189
Q

Rx for Acne Vulgaris? (2 things)

A
  • Benzoyl peroxide (antimicrobial)
  • Vitamin A derivatives (eg: isoretinoin)
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190
Q

Psoriasis!

  • Describe the rash
  • Pathophysiology
  • Rx (3 things)
  • Associations?
A
  • “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
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191
Q

Dermatological condition associated with Chronic Hep C infection?

A
  • Lichen planus - pruritic, polygonal , purple papules
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192
Q

Pemphigus Valgaris?

Pathophys?

Presentation?

A
  • 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
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193
Q

Bullous Pemphigoid?

Pathophys?

Presentation?

A
  • 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
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194
Q

Dermatitis Herpetiformis?

Pathophys?

Presents as?

Association?

A
  • Autoimmune deposition of IgA at tips of dermal papillae
  • Presents as:
    • Pruritic vesicles & bullae that are grouped - herpetiform!
  • Strong association = coeliac disease!
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195
Q

Erythema Multiforme?

Pathophys?

Presents as?

Associations? (5 of them)

A
  • 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
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196
Q

Stevens-Johnson Syndrome??

(TRIAD OF 3 THINGS)

A
  • 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!!
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197
Q

Seborrhoeic Keratosis?

Pathophys?

Presents as?

Leser-Trélat sign??

A
  • 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
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198
Q

Acanthosis Nigricans?

WHat is it?
Presents as?

Associated with?

A
  • 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)
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199
Q

Basal Cell Caricnoma?

Presents as?

Classical location?

A
  • Elevated nodule with central, ulcerated crater surrounded by dilated (telangiectatic) vessels
  • “pink, pearl-like papule”
  • Classic location = upper lip!
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200
Q

Squamous cell carcinoma?

Presents as?

A
  • Ulcerated, nodular mass
  • Usually on the face - classically involving the lower lip
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201
Q

Actinic Keratosis?

What is it?

How does it present?

A
  • Precursor lesion to SCC
  • Presents as: hyperkeratotic, scaly plaque - often on face, back or neck
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202
Q

Vitiligo?

A

Localised loss of skin pigmentation

Due to autoimmune destruction of melanocytes

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203
Q

Albinism?

What is it due to?

Different forms?

Increased risk of?

A
  • 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)
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204
Q

Freckles (ephelis)

A
  • Small tan/brown macule
  • Darkens when exposed to sunlight!!
  • Due to increased number of melanosomes (melanocytes NOT increased!!)
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205
Q

Melasma

A
  • mask-like hyperpigmentation of the cheeks
  • Assocaited with:
    • Pregnancy
    • Oral contraceptives
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206
Q

Benign Nevus

A
  • Flat macule or raised papule
  • With symmetry, sharp borders, evenly distributed colour & small diameter (<6mm)
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207
Q

Malignant Melanoma?

A
  • 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
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208
Q

Impetigo?

Causes?

Presents as?

A
  • 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
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209
Q

Cellulitis?

Pathophys? COmmon causes?

Presents as?

Risk factors?

Nec fasc?

A
  • 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!!
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210
Q

Staphylococcal Scalded Skin Syndrome?

A
  • 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!
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211
Q

Verruca?

A
  • Flesh-coloured papules with rough surface
  • Due to HPV infection of kertinocytes
  • Hands & feet commonly
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212
Q

DERM CASE: A 43-year-old woman comes for review. A few months ago she developed redness around her nose and cheeks. This is worse after drinking alcohol. She is concerned as one of her work colleagues asked her if she had a drink problem despite her drinking 10 units per week.

A
  • Typical history for acne rosacea!
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213
Q

KEY DERM PRINCIPLE ABOUT PAINFUL SKIN?

A
  • Painful skin = result of skin necrosis so probably not a good fucking sign - often admit to hospital!
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214
Q

Children with new-onset purpura should be referred immediately for investigations to exclude ALL and meningococcal disease

A
  • True innit bruv!
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215
Q

which dermatological condition is Parkinson’s associated with?

A
  • 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?

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216
Q

RULE OF 9%’s FOR SURFACE AREA OF BURNS?

A

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
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217
Q

Waterlow score?

A
  • Used to assess patients at risk of pressure sores
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218
Q

CASE: A 67-year-old woman who is taking long-term prednisolone for polymyalgia rheumatica presents with progressive pain in her right hip joint. On examination movement is painful in all directions but there is no evidence of limb shortening or external rotation.

An x-ray of the hip shows osteopenia and microfractures.

What is the most likely diagnosis?

A
  • 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.

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219
Q

CASE: A 4-year-old boy was discharged from the hospital six weeks ago after an episode of viral gastroenteritis. He now has 4-5 loose stools each day which has been present for the past four weeks.

What is the most likely diagnosis?

A
  • 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.

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220
Q

Most common causes of acute infective exacerbations of COPD?

A

The most common bacterial organisms that cause infective exacerbations of COPD are:

  • Haemophilus influenzae (most common cause)
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
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221
Q

Visual changes secondary to drugs?

Blue vision // Green vision

A

Visual changes secondary to drugs

  • blue vision: Viagra (‘the blue pill’)
  • yellow-green vision: digoxin
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222
Q

If a kid has DKA and is seriously dehydrated, why don’t you just bang them full of fluids as quickly as possible??

A
  • 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

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223
Q

Management & resuscitation of DKA?

A
  • 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

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224
Q

Contraindications to an LP?

A

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!!

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225
Q

What causes Hand, Foot & Mouth disease??

A
  • Coxsackie A16 and enterovirus 17
  • Low grade fever, oral ulcers, erythematous hands/feet
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226
Q

Autism associated with which chromosomal abnormality?

A
  • Fragile X! (a trinucleotide repeat disorder on chromosome X)
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227
Q

THE TRIAD OF SHAKEN BABY SYNDROME??

A
  • Retinal haemorrhages,
  • subdural haematoma - tearing of the fragile bridging veins
  • encephalopathy
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228
Q

Paeds - What causes each of the following?

Croup?

Bronchiolitis?

Pseudomonas?

Pneumonia?

Whooping cough?

A

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

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229
Q

PAEDS CASE - A 13-year-old boy comes into the Emergency Department with his parents, as he has had left-sided hip pain for the last few days. X-rays show a slipped upper femoral epiphysis (SUFE). What is the definitive management of this condition?

A
  • Internal fixation across the growth plate!

In the meantime, bed rest without weight bearing & analgesia

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230
Q

PAEDS CASE - You are asked to review a 1-hour-old neonate on the delivery suite. They were born via elective Caesarean section. Maternal antenatal history is significant for gestational diabetes. A heel prick test shows the baby’s blood glucose is 2.2 mmol/L. What is the next step in management?

A
  • Observe & encourage regular feeding!!
  • TRANSIENT HYPOGLYCAEMIA IS COMMON IN 1ST HOUR AFTER BIRTH
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231
Q

Rx for Kawasaki Disease?

A
  • High dose aspirin
  • Single dose of IV immunoglobulin
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232
Q

Clues in the vignette pointing towards Fragile X??

A
  • A young boy with:
  • learning difficulties,
  • macrocephaly,
  • large ears and
  • macro-orchidism
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233
Q

PAEDS CASE - Child born in the breech position who then has a normal (ie. negative) Barlow’s & Ortolani’s test. What, if any, follow up is needed?

A
  • Hip U/S
  • Up to 20% of those born breech will have DDH
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234
Q

PAEDS: Be aware of the major risk factors for each of the following…

Neonatal Respiratory Distress Syndrome (NRDS)?

Aspiration pneumonia?

Transient tachypnoea of the newborn?

A

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.
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235
Q

Pepperpot skull? Two causes?

A
  • Multiple myeloma
  • Hyperparathyroidism
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236
Q

primary hyperaldosteronism - hypokalaemia with HTN

Conn’s = hyperaldosternism due to adrenal adenoma

A

NB DICKED

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237
Q

Mittelschmerz?

A
  • “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
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238
Q

Which metabolic abnormality do thiazide diuretics cause??

A

Hypercalcaemia!!

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239
Q

Which two vaccinations are routinely offered to pregnant women in the UK?

A
  • Infleunza
  • Pertussis
  • There is no individual pertussis vaccine therefore it is given in a vaccine alongside polio, diphtheria and tetanus.
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240
Q

BREAST CASE: A 55-year-old lady has undergone a wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The tumour is oestrogen receptor negative. What is the next course of action?

A

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%.
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241
Q

Mx: Unilateral nasal polyp??

A
  • 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.

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242
Q

Classical triad of Fat Embolism Syndrome (FES)??

A
  • Respiratory distress
  • Cerebral signs
  • Petechial rash

Usually develops 12-72 hours post-op.

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243
Q

CASE: A 17-year-old is admitted to a rehabilitation unit following a road traffic accident in which he sustained spinal cord injury at C2. He is stable and making good progress the first two days but then becomes acutely unwell on the third day and is found to be coughing profusely.

On examination his temperature is 36.7ºC, he is tachycardic at 127 bpm, his blood pressure is 117/76 mmHg and he is hypoxic with his oxygen saturations reading at 91% on air. Examination is unremarkable except he has a tracheostomy and nasogastric tube in situ and some reduced air entry at the right base. A chest x-ray is performed which demonstrates patchy consolidation of the right base.

What is the most likely cause of his pneumonia??

A
  • 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.
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244
Q

5 Drugs which can cause drug-induced lupus?

A
  • Hydralazine
  • isoniazid,
  • penicillamine,
  • procainamide,
  • phenytoin
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245
Q

CASE: An 18 month old boy is brought to the emergency room by his parents. He was found in bed with a nappy filled with dark red blood. He is haemodynamically unstable and requires a blood transfusion. Prior to this episode he was well with no prior medical history. What is the most likely cause?

A
  • 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.

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246
Q

O&G: CORD PROLAPSE

A
  • 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
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247
Q

Opthalmology Investigations?

A
  • 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.
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248
Q

CASE: A 27 year old male with polycystic kidney disease presents with sudden onset headache and collapse. On admission to emergency department his blood pressure 190/105 mmHg, tachycardic with a Glasgow Coma Score of 7/15. He is intubated and transferred for a CT scan. The scan reveals a subarachnoid haemorrhage. He is transferred to the critical care unit for monitoring. Which medication should be prescribed to reduce the chance of any acute complications?

A
  • 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.
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249
Q

First line Mx for lower back pain in a GP setting?

A
  • NSAIDs (eg: naproxen) = 1st line

(Over physiotherapy - there is a delay whereas NSAIDs can be started now)

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250
Q

Mx of Severe Pre-eclampsia or Eclampsia??

A
  • 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.

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251
Q

Autoimmune hepatitis?

A
  • The combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest autoimmune hepatitis
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252
Q

AF lasting >48 hours: anticoagulate for 3 weeks AND then electrical OR pharmacological cardioversion??

A
  • Electrical cardioversion if have been in AF >48 hours (apparently)
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253
Q

Swelling on the head of a baby/newborn: Caput Succedanem vs. Cephalohaematoma vs. Chignon??

A
  • 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
    • Caput Succedanem = Crosses Sutures!!
  • 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
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254
Q

FUNDOSCOPY:Drusen around the macula - what do they look like & which condition do they occur in?

A
  • Dry macular degeneration
  • Look like yellow spots/deposits (see picture)
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255
Q

Budd-Chiara - 1st line Ix?

A
  • US with doppler flow (of hepatic vein)
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256
Q

HYPERPARATHYROIDISM

Primary vs. Secondary vs. Tertiary

A

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!!
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257
Q

SPIDER NAEVI vs. TELANGIECTASIA

A
  • 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
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258
Q

CASE: What arthritis is shown in this image?? (Rheumatoid, psoriatic, osteo, gout)

A

Psoriatic arthritis!!

Nail changes are clearly shown!

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259
Q

Migraine Mx:

Acute:

Prophylaxis:

A

Migraine

  • acute: triptan + NSAID or triptan + paracetamol
  • prophylaxis: topiramate or propranolol
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260
Q

Conditons causing lung fibrosis - which affect the upper vs. lower lobes?

A
  • Lower zones predominantly affected in idiopathic pulmonary fibrosis
  • Upper zones predominantly affected in:
    • Sarcoidosis
    • Coal Workers Pneumoconiosis
    • TB
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261
Q

CASE: A 35-year-old lady presents to the emergency department with right upper quadrant pain. She has also noticed that her skin seems slightly yellower over the last week or so and you notice a yellow tinge to her sclera. On further questioning, she complains of itching of her arms. Her only past medical history of note includes ulcerative colitis for which she takes mesalazine.

Given her presentation, what is the best investigation to diagnose the most likely underlying condition?

A
  • Dx = primary sclerosing cholangitis
    • (associated with UC)
  • Ix of PSC = ERCP
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262
Q

DRUGS TO BE AVOIDED IN MOTHERS WHO ARE BREASTFEEDING?

A

The following drugs should be avoided:

  • antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
  • psychiatric drugs: lithium, benzodiazepines, clozapine!
  • aspirin
  • carbimazole
  • methotrexate
  • sulfonylureas
  • cytotoxic drugs
  • amiodarone
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263
Q

DERMATOLOGY BLISTERS/BULLAE:

BULLOUS PEMPHIGOID vs. PEMPHIGUS VULGARIS

A

Blisters/bullae:

  • no mucosal involvement (in exams at least*): bullous pemphigoid
  • mucosal involvement: pemphigus vulgaris
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264
Q

ADRENALINE DOSES:

ANAPHYLAXIS?

CARDIAC ARREST?

A

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
265
Q

Dynamic Hip Screw vs. Hemiarthroplasty?

A

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.

266
Q

WOLFF-PARKINSON WHITE?

A
  • 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!

267
Q

CASE:: Which of the following is a potentially sensitising event in pregnancy and requires administration of anti-D in a RhD-negative woman?

A
  • 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
268
Q

CASE: A 19-year-old woman who is 9 weeks into her first pregnancy is seen in the early pregnancy assessment unit with vaginal bleeding. Her ultrasound scan confirms a viable intrauterine pregnancy. However, the high vaginal swab has isolated group B streptococcus (GBS). How should she be managed?

A
  • 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.

269
Q

Xray shows of a joint shows Chondrocalcinosis - Dx??

A

Psuedogout!

Chondrocalcinosis helps to distinguish pseudogout from gout

270
Q

PSA testing can only be undertaken after refraining from ejaculation or vigorous exercise for ___ hours?

A

48 hours!!

271
Q

“Pencil in cup” appearance of a joint on Xray - Dx??

A
  • Psoriatic Arthritis!
272
Q

Expected results for a Trisomy 21 pregnancy?

Nuchal translucency, AFP, ostriol, b-HCG, PAPP-A?

A

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
273
Q

Indication for high dose folic acid (5mg) while trying to get pregnant?

A
  • Obese women BMI >30
274
Q

Amaurosis Fugax?

A
  • 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.

275
Q

Features typical of acute viral labrynthitis?

A

Acute viral labrynthitis:

  • sudden onset horizontal nystagmus,
  • hearing disturbances,
  • nausea, vomiting
  • vertigo
276
Q

4 complications of chickenpox?

A
  • Disseminated haemorrhagic chickenpox
  • Secondary bacterial infection
  • Encephalitis
  • Pneumonia
277
Q

CASE: A 34-year-old woman from Chad presents with continuous dribbling incontinence after having her 2nd child. Apart from prolonged labour the woman denies any complications related to her pregnancies. She is normally fit and well. What is the most likely diagnosis?

A
  • Vesiculovaginal fistula!
    • Continuous driblling
    • Prolonged labour
    • Area with poor O&G services
278
Q

Drugs that reduce mortality in Heart Failure? (as opposed to just treating symptoms)

A
  • ACE inhibitors
  • spironolactone
  • beta-blockers
  • hydralazine with nitrates

Drugs that do not impact mortality and only improve symptoms = loop diuretics (furosemide)

279
Q

CXR Features:In which pathologies would you see each of these features?

Consolidation, atelectasis, metastasis

A
  • Consolidation = fluid (blood, pus, transudate, water) or solid material (cells, fat, protein)
  • Atelectasis = most common finding in PE
  • Upper love Diversion = finding on heart failure CXR
280
Q

Which joint does gout most commonly affect?

A
  • first metatarsophalangeal joint.
    • ie. the big toe ‘knuckle’ joint NOT the joint within the big toe
281
Q

Causes of acute pancreatitis?

GET SMASHED

A
  • 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)
282
Q

How would a patient with Addison’s disease/adrenal insufficiency present?

A
  • Weight loss
  • Hyponatraemia
  • Hyperkalaemia

Otherwise can be very nonspecific

283
Q

MOA of Rx for T2DM??

A

LOOK THIS UP DUMBASS

284
Q

MANTOUX TEST (TB)

A
  • 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
285
Q

METABOLIC ACIDOSIS CONSIDERING THE ANION GAP

How to calculate? Normal range?

Causes of raised or normal anion gap in the context of metabolic acidosis?

A

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
286
Q

Umbilical Hernias in kids - ages of repair?

A

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.
287
Q

What is the likely cause of each of these?

Shortened, internally rotated femur?

Shortened, externally rotated femur?

A

Shortened, internally rotated femur? posterior hip dislocation!

Shortened, externally rotated femur? NOF#

288
Q

1st line Mx for moderate sleep apnoea?

A

Following weight loss, CPAP is offered first line

289
Q

Mx of alcoholic liver disease??

A
  • Steroids - course of pred
  • Abx - if concurrent infection
  • Liver transplant last line

Thrombocytopenia (low platelets) = sensitive & specific sign of cirrhosis!

290
Q

HIV patient + chest symptoms + no findings to auscultation of the chest –> Dx = ?

A
  • PCP pneumonia!
  • CXR will show very subtle signs which are hard to pick up
291
Q

When to take a statin in the day?

A
  • Taking last thing at night improves efficacy
292
Q

Acute cholecystitis treatment:

A
  • intravenous antibiotics
  • early laparoscopic cholecystectomy within 1 week of diagnosis
293
Q

Rx for overdose of digoxin?

A

Specific antibodies

294
Q

Tamoxifen increases risk of endometrial hyperplasia! WTF??

A

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.

295
Q

Wilson’s disease - bloods?

A
  • Reduced serum copper & reduced ceruloplasmin - it has all deposited in tissues!

Management is with penicillamine.

296
Q

A testicular lump that transilluminates - DDx?

A

Hydrocele vs. large epididymal cyst

297
Q

This is for YOU dumbass:

Acute cholangitis vs. Acute cholestetitis vs. Biliary colic?

A

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.

298
Q

Smear test showing mild dyskariosis - what do you do next??

A

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
299
Q

Rx of Nephrogenic vs Neurogenic Diabetes Insipidus??

A
  • 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.
300
Q

Rhinitis medicamentosa is a condition of rebound nasal congestion brought on by extended use of topical decongestants

A
  • ie. patient starts nasal decongestants which help initially but they then develop it again
  • Mx = cease nasal decongestants! (cold turkey!!)
301
Q

Abx in pregnancy: which do you use in each of these scenarios?

GBS?

PPROM?

A
  • GBS - IV Benzyllpenicillin (or erythromycin if penicillin allergic)
  • Preterm prelabour rupture of membranes - erythromycin
302
Q

Derm: herald patch - Dx?

A
  • Pityriasis rosea
303
Q

DEFINE POST-PARTUM HAEMORRHAGE

A
  • 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)

304
Q

CASE: A 21-year-old is seen in respiratory clinic for refractory asthma.

He has been suffering from shortness of breath after exercise and wheezing for about 3 years. He has been using a salbutamol and steroid inhaler with minimal benefit. He has also tried a salmeterol inhaler but again seen no benefit. His GP has also prescribed montelukast which has not helped. He is a non-smoker.

This is beginning to affect his life now as it is stopping him from being able to go the gym and practice his gymnastics.

The respiratory doctor considers the possibility of misdiagnosis.

Which alternative diagnosis is most likely to be causing these symptoms?

ANSWER CHOICES: COPD, Pneumonia, A1AT deficiency, Bronciectasis, Idiopathic pulmonary fibrosis

A
  • 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
305
Q

What are the criteria to allow expectant management of an ectopic pregnancy? (5 things)

A

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

306
Q

WHAT TYPE HYPERSENSITIVITY REACTION IS SLE??

A
  • 3 YOU FUCKING MINGMONG
  • ANTIGEN-ANTIBODY COMPLEXES!!
307
Q

CASE: A 26-year-old female, with no past medical history, has been admitted to the emergency department. She temporarily lost consciousness on the bus, whilst heading for a job interview. She has no recollection of the event, although she states feeling lightheaded this morning. Witnesses on the bus informed paramedics that they had seen her shake her limbs for a few seconds. They also state that she lost consciousness for around 20 seconds. The patient did not bite her tongue or experience incontinence during the event. When she came around, she was pale, and it took her a few minutes before she felt orientated again. This was the first time this has happened.

Based on this brief history, which of the following is the patient most likely to have experienced?

A

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!
308
Q

CASE: You review a 34-year-old woman who is 13 weeks pregnant. During her previous pregnancy she developed pre-eclampsia and had to have a caesarean section at 36 weeks gestation. Her blood pressure both following the last pregnancy and today is normal. Which one of the following interventions should be offered to reduce the risk of developing pre-eclampsia again?

A

Low-dose aspirin!!

309
Q

Right fuck this… KEY POINTS FOR MANAGEMENT OF T2DM

A

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
310
Q

Mx of chickenpox??

A
  • Calamine lotion - to reduce itch
  • Paracetamol - to reduce temp

AVOID ibuprofen!! Risk with chickenpox & NSAIDs for necrotizing fasciitis

311
Q

CASE: A 75 year-old male patient presents with a feeling of weakness of the legs. On examination there are also some skin changes present, with purple plaques on the dorsum of the hands. You suspect a diagnosis of dermatomyositis. Which of the following underlying conditions is associated with dermatomyositis and should be considered?

A

Internal malignancy!!

Dermatomyositis can also present as part of a paraneoplastic syndrome

312
Q

When to consider non-invasive ventilation in an infective exacerbation of COPD??

A
  • 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.

313
Q

Mx of GOUT??

Acute Mx of flare ups?

Chronic Mx?

A
  • 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
314
Q

Diagnostic criteria for Dx of Hereditary Haemorrhagic Telangiectasia??

2 = possible diagnosis

3 or more = definitive diagnosis

A
  • 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
315
Q

CASE: A 78-year-old man asks you to look at a lesion on the right side of nose which has been getting slowly bigger over the past 2-3 months. On examination you observe a round, raised, flesh coloured lesion which is 3mm in diameter and has a central depression. The edges of the lesion appear rolled and contain some telangiectasia.

What is the single most likely diagnosis?

A

BASAL CELL CARCINOMA

Classic description!

316
Q

Indications for CT head following head trauma??

CT head immediately

A

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
317
Q

Results of iron studdies in haemochromatosis??

A
  • 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.

318
Q

Key thing to distinguish pneumocystis jiroveci pneumonia??

A
  • Pneumocystis jiroveci pneumonia causes desaturation on exercise
319
Q

+ve FH for glaucoma, when should they receive screening??

A
  • Every year from 40yrs of age
320
Q

Where is a good place to check for pulses in a kid in a BLS situation?

A

Paediatric BLS: In an infant, the appropriate places to check for a pulse are the brachial and femoral arteries

NOT carotid! fat necks

321
Q

?Sigmoid Volvulus - What are you looking for on AXR??

A

Coffee bean appearance!!

Three dense lines converging towards the site of obstruction (Frimann Dahl’s sign) in keeping with sigmoid volvulus.

322
Q

Mx of AKI??

A
  • Hold medications which are nephrotoxic! (EG: ACE inhibitors)
  • Give IV fluids
  • Treat underlying case
323
Q

School Exclusion criteria?? Have an idea of these!

A
324
Q

Causes of Erythema Nodosum??

(Pneumonic = NODOSUM)

A
  • *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)
325
Q

Drugs associated with Serotonin Syndrome??

A

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!!
326
Q

Foetal CTG’s??

What do they measure?

When are they used?

How to interpret them? (DR C BRA VADO)

A

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.

327
Q

Patient on warfarin: will the PT or APTT be prolonged? And which pathway does each one represent?

A
  • 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

328
Q

Neck Masses in Kids?

Thyroglossal cyst?

Branchial cyst?

Dermoids/dermoid cyst?

A

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

329
Q

ECLAMPSIA CASE: A 28-year-old pregnant woman with pre-eclampsia suffered an eclamptic seizure at 11 am yesterday. She was started on magnesium, the baby was delivered an hour later at midday, but she had another eclamptic seizure at 2 pm. She has been well since then, as is the baby. When should the magnesium infusion be stopped?

A

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

330
Q

PROM CASE: A 33-year-old primigravida woman of 32 weeks gestation presents to the Emergency Department with premature rupture of membranes. There have been no complications of the pregnancy so far and the woman is normally fit and well. How is she best managed?

A
  • 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.

331
Q

CASE: A 7-year-old boy presents to the GP as he does not seem to be developing in the same way as his classmates. He is now a lot taller than most of his friends and he has started to develop hair around his genitalia and armpits. On examination, his penis is also large for his age however his testes remain prepubertal, with a size of 2.4cm.

Which of the following is the most likely cause of this boy’s precocious puberty?

A

Adrenal hyperplasia!!

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

332
Q

CASE: You are covering the neurosurgical unit over night. One of your patients is a man in his seventies, who presented with an intracerebral bleed. CT scan showed there was some extension of the bleed into the ventricles. The patient has remained stable during the day, but one of the nurses bleeps you to inform you that the patient’s Glasgow Coma Scale score has dropped. It was previously 15, but now he only localising to pain. What is the most likely cause of his symptoms?

A
  • 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.

333
Q

UK Breast Screening?

High risk cohorts are those with first degree family relatives with a history of breast cancer etc

A
  • The NHS Breast Screening Programme is being expanded to include women aged 47-73 years
  • Women are offered a mammogram every 3 years
334
Q

Mx of Thyroid Storm???

A
  • 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.

335
Q

How long do you Need to continue contraception after the suspected menopause??

A

12 months after the last period in women > 50 years

24 months after the last period in women < 50 years

336
Q

What is the mechanism of pathology behind Factor 5 leiden?

A

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

337
Q

CASE:

A 32-year-old man who has suffered from Crohns disease for many years presents with intermittent jaundice. When it occurs it is obstructive in nature. It then usually resolves spontaneously.

A

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.

338
Q

SHOCK CASE: A middle age woman is found unconscious on the street and brought to the emergency department. She is found to have a blood pressure of 64/42 mmHg, heart rate of 120 bpm and respiratory rate of 22/min. Despite her blood pressure and heart rate, her hands are warm and well perfused, with a capillary refill time of 2 seconds. A blood culture, chest x-ray, and urine culture are all performed and none show an infectious process. What type of shock is this woman suffering from?

A

Neurogenic!!

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

339
Q

CASE PREGNANT GBS: A woman who is 20 weeks pregnant presents for review She informs you that she has had a previous baby who has developed a Group B streptococcus infection shortly following delivery. What additional treatment will this mother require?

A
  • 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!

340
Q

CASE WTF: A 73-year-old female presents to her GP with left shoulder and arm pain which came on quite suddenly a week ago and has been worsening. The pain is now unmanageable with regular co-codamol. The GP also notes that the patient’s left pupil is smaller than the other side and the eyelid is lagging slightly. Which question would most likely aid in diagnosing this lady?

A
  • 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.
341
Q

CASE FUCKING DIABETES Dx: You are working in general practice reviewing a 54-year-old male who has come for a ‘check-up.’ He advises you that he feels perfectly well and is not suffering from any symptoms but would just like to be reviewed. During the consultation the patient mentions that he has a strong family history of type 2 diabetes mellitus and you advise him that, due to his large body habitus (his latest body mass index is recorded as 39 kg/m²), he is at further risk of developing the disease. He agrees to a check of his HbA1c levels to investigate his blood glucose control. This subsequently comes back as 54 mmol/mol.

What is required to diagnose type 2 diabetes in this patient?

A
  • 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

342
Q

Surgical Mx of an ectopic where medical Mx (methotrexate) has failed: salpingectomy vs. salpingotomy?

A

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.

343
Q

CASE: A 70-year-old gentleman a past medical history of ischemic heart disease and hypertension, presents with progressive facial and upper limb swelling. Visibly distended veins can be observed on his chest and neck. This has been ongoing for the past three weeks and he also complains of increased breathlessness, particularly on exertion. He is an ex-smoker and drinks 13 units of alcohol per week.

What is the most likely cause of this presentation?

A

Lung cancer –> SVC obstruction!

344
Q

Breast Mastitis Mx:

A

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

345
Q

3 things to remember for Hashimoto’s thyroiditis?

A

Hashimoto’s thyroiditis = hypothyroidism + goitre + anti-TPO

346
Q

Risk factors for duodenal ulcers?

A

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.

347
Q

Ramsay Hunt Syndrome?

A
  • 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
348
Q

CASE: A 34-year-old woman with a history of alcohol excess is admitted with abdominal swelling to the Acute Medical Unit. A diagnosis of ascites secondary to liver cirrhosis is made and paracentesis is performed. The serum creatinine on admission is 95 µmol/l. Ten days after admission urine output decreases significantly and blood tests reveal:

Na+129 mmol/l

K+3.7 mmol/l

Urea14.2 mmol/l

Creatinine221 µmol/l

Albumin is given to correct suspected hypovolaemia. What is the most appropriate further management?

A

TERLIPRESSIN!

the patient has developed hepatorenal syndrome!!

349
Q

PCOS: Rotterdam criteria?

SHOP

A
  • String of pearls - US appearance of cysts
  • Hyperandrogenism
  • Oligmenorrheoa
  • Prolactin normal - common cause of oligomenorrhoea to imporatnt to rule this out
350
Q

Risks from gestational diabetes??

SMASH!

(Big babies SMASH their way out!)

A
  • 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!

351
Q

Gravidity & Parity: Mrs X, currently 12/40, two miscarriages at 8/40 & at 20/40, one son born at 38/40…

A

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!)

352
Q

BEST way to estimate gestational age of a pregnancy?

A

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

353
Q

What is Nagele’s rule & how do you use it to calculate gestation of a pregnancy?

A

Nagele’s rule (for a regular 28 day cycle):

  • LMP, subtract 3 months, add 1 year and 7 days
354
Q

Pregnancy timeline

A
  • 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!

355
Q

Risks of breech presentation?

A
  • 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
356
Q

External Cephalic Version?

(Student report - transverse lie at term: I was asked to explain possible causes, management options (ECV) and the risk of cord prolapse.(

A
  • 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
357
Q

Causes for a pregnant abdomen which is LARGE for gestational dates?

A
  • Wrong dates!
  • Big baby: genetic, diabetes
  • Polyhydramnios
  • Big baby + poyhydramnios: diabetes
358
Q

Causes of Polyhydramnios?

A
  • 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)
359
Q

Causes of Polyhydramnios??

(DITCH)

Risks associated with Polyhydramnios??

(6 P’s)

A

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
360
Q

Stages of Labour?

A
  • 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
361
Q

Four main indications for induction??

(P’s)

A
  • 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
362
Q

Methods for Induction of Labour?

A

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
363
Q

Pregnancy-related Pelvic Girdle Pain?

A

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)
364
Q

Pre-existing Diabetes & Pregnancy?

A

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
365
Q

Gestational Diabetes

A
  • 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!!
366
Q

Shoulder Dystocia?

order of manouvres to delivery the baby

(MSE, WBE)

A
  • 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
367
Q

Antenatal Examination of the Abdomen

Check List: SALPINX

A

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

368
Q

Hypertension in Pregnancy

Three categories

Management

A
  • 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)
369
Q

Pre-eclampsia

What is it? Buzz words.

Diagnosis?

Complications?

A
  • 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
370
Q

Indications for prevention dose Aspirin (75mg) from 12/40 weeks gestation??

ECLAMPO

A
  • 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
371
Q

HELLP Syndrome?

A
  • 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.
372
Q

Mx of Pre-eclampsia?

A
  • 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.
373
Q

Predicting Eclampsia: 4 Red Flag Symptoms?

A
  • 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!!
374
Q

Pre-eclampsia: Work-up & Mx?

A

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!!
375
Q

Emergency Mx of Eclampsia?

KNOW THIS!

A
  • 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
376
Q

Twin Pregnancy

Zygosity? Chorionicity?

Types of twin pregnancies?

Principles of antenatal care for twin pregnancies?

A
  • 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!
377
Q

Twin-Twin Transfusion Syndrome (TTTS)

A
  • 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
378
Q

Hormone Replacement Therapy (HRT)

Good or bad?? - lots of conflicting evidence

Main indications for HRT in menopausal women?

A
  • 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
379
Q

Small for Gestational Age (SGA)

Definition?

Causes/Aetiologies? (SWAN)

A
  • 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!
380
Q

Causes of high risk pregnancies for IUGR?

“SHITS! CRAP!”

And how you investigate them?

A

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”
381
Q

Maternal Steroids:

Three indications?

How does it help?

How is it given?

A

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!
382
Q

Magnesium Sulfate in Pre-term Deliveries?

A
  • 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!
383
Q

Obstetric Emergencies: Antepartum Haemorrhage

Definition

Causes

A
  • 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
384
Q

Obstetric Emergencies: Antepartum Haemorrhage

Placentral Abruption vs. Placenta Praevia

A

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!

385
Q

Obstetric Emergencies: Anti-D

A
  • 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
386
Q

Obstetric Emergencies: Post Partum Haemorrhage (PPH)

Definition?

Primary vs. Secondary?

4 T’s of Primary PPH?

Prophylaxis?

Management of PPH?

A
  • 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
387
Q

Key points about STD’s:

Trichomonas Vaginalis

Bacterial Vaginosis

Chlamydia

Gonorrhoea (Neisseria gonorrhoeae)

Thrush (candida albicans

Human Papilloma Virus

Syphillis

DDx for bacterial discharge with “fishy smell”?

A

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
388
Q

Key Points for a STI/Vaginal Discharge OSCE Station?

S.E.X.

Triple testing!

A
  • 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.

389
Q

Red Flag Symptoms in Gynae: Conditions to Exclude

Intermenstrual bleeding?

Post-menopausal bleeding?

Post-coital bleeding?

Missed period?

A

Intermenstrual bleeding?

  • Carcinoma of endometrium!

Post-menopausal bleeding?

  • Carcinoma of endometrium!

Post-coital bleeding?

  • Carcinoma of cervix!

Missed period?

  • Pregnancy, including ectopic etc
390
Q

Female Genital Mutilation

Types?

A
  • Type 1 = excision of clitoris
  • Type 2 = excision of clitoris & labia minora
  • Type 3 = infundibulation (stitching up)
391
Q

Ectropion?

A
  • 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
392
Q

Endometriosis?

A
  • 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!
393
Q

Post Partum Contraception

First 21 days?

Lactational amenorrhoea method?

Concerns about starting COCP?

Post partum options?

A

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)
394
Q

Hormonal Changes Leading to Ovulation?

A
  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
395
Q

Polycystic Ovarian Syndrome (PCOS)

A
  • 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)
396
Q

Secondary Amenorrhoea: The big four causes?

A
  • Pregnancy
  • Prolactinoma
  • Polycystic ovarian syndrome
  • Premature ovarian insufficiency
    • Will have raised gonadotrophins (from pituitary!)
    • stress - women in 20’s with exams / who exercise loads
397
Q

Amenorrhoea

Definitions - Primary vs Secondary

Causes

Ix

Treating

A

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
398
Q

Pelvic Inflammatory Disease

Salpingitis

Work up for both?

A

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
399
Q

Subfertility

Definition?

Causes - 4 categories?

Ix the subfertile couple!

Mx

A
  • 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
400
Q

Assissted Reproduction Treatments - licensed by the HFEA

Intrauterine insemination (IUI)?

In-vitro fertilisation (IVF)?

Intracytoplasmic sperm injection (ICSI)?

A

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%
401
Q

Early Pregnancy Loss: Miscarriage

Definition?

Types?

Management options?

Information to mothers post-miscarriage?

A
  • 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!
402
Q

Pregnancy of Unknown Location (PUL)

A
  • 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
403
Q

Early Pregnancy Loss: Ectopic Pregnancy

Definition?

Risk Factors? (PIPPA)

Presentation & Ix’s?

Management options?

A
  • 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!

404
Q

Heavy Menstrual Bleeding

Definition?

Causes: 4 categories?

The work up for Heavy periods?

Management?

A
  • 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
405
Q

3 indications for “Mirena”?

A
  • Contraception
  • Primary menorrhagia
  • Endometrial protection during HRT
406
Q

Gynae Oncology: Red Flag Symptoms

A
  • 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

407
Q

Gynae Oncology: Carcinoma of the Endometrium

Risk factors?

Ix?

Mx?

A

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
408
Q

​Gynae Oncology: Carcinoma of the Ovary

A

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!
409
Q

​Gynae Oncology: Carcinoma of the Cervix

HPV

Cervical Screening!

A

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!
410
Q

Emergency Contraception Rules!

Levonorgestrel (LNG)

Ulipristal (UPA) - ellaone

Copper coil

KEY POINTS IN THE Hx & Counselling for oral EC!!

A

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
411
Q

Missed Pill Rules!

A

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!!
412
Q

Ix for IMB?

A
  • Pregnancy test
  • Cervical smear & triple swabs!
  • US & endometrial biopsy
  • Imaging if pelvis mass found
413
Q

The Parkland formula for fluid resuscitation in burns is:

A

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

414
Q

Pityriasis versicolour?

A

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

415
Q

CASE: A 32-year-old man presents to the acute surgical unit with acute pancreatitis. Over the next few days he becomes dyspnoeic and his saturations are 89% on air. A CXR shows bilateral pulmonary infiltrates. His pulmonary capillary wedge pressure is normal. What is the most likely diagnosis?

A

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
416
Q

Metabolic derrangement in Cushing’s syndrom?

A
  • Hypokalaemic metabolic alkalosis
417
Q

3 most common primary tumours causing bony metastasis?

A
  • In descending order…
    • prostate
    • breast
    • lung
418
Q

Maternal Infections & Sequelae for foetus?

FAS?

Smoking?

Congenital Rubella?

Congenital Varicella?

Congenital Syphillis?

A

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

419
Q

Most common inherited clotting disorder??

A

von Willerbrand disease! (type 1)

420
Q

CASE: A T2DM who is unwell with D&V - which medicaiton do you want to suspend??

A
  • Metformin increases the risk of lactic acidosis - suspend during intercurrent illness eg. diarrhoea and vomiting
421
Q

Dx & Mx of Kawasaki has been made: what follow up Ix should be organised?

A
  • Cardiac ECHO
  • Coronary artery aneurysms are acknowledged complication of Kawasaki - screened for with an echo
422
Q

Gastroparesis in T1DM?

A
  • 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.
423
Q

Management of patients at risk of corticosteroid-induced osteoporosis

A

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.

424
Q

ETHICS CASE - FGM: While treating a patient for recurrent UTIs she confides in you that she had a female genital mutilation procedure performed when she was 18-year-old, she then also states that she is taking her 20-year-old daughter home to have it done this summer. The patient says this is with her daughter’s consent and asks her not to tell anyone, what do you do?

A
  • 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.’

425
Q

The Rotator Cuff muscles & corresponding shoulder movements!

LEARN THESE

A
  • 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 minor - 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

426
Q

CASE: An 18-month-old boy is brought to the GP by his mother as she is concerned about his breathing. Three days ago he started with fever, cough and rhinorrhoea. For the past 24 hours his mother reports that he has been ‘wheezy’. On examination his temperature is 37.9ºC, heart rate 126/min, respiratory rate 42/min and a bilateral expiratory wheeze is noted. You prescribe a salbutamol inhaler along with a spacer. Two days later the mother represents noting the inhaler has made little difference to the wheeze. Clinical findings are similar, although his temperature today is 37.4ºC. What is the most appropriate next step in management?

A
  • 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.

427
Q

Top Tips for Examining A Child?

A
  • 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!
428
Q

Bronchiolitis Poem?

A

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)

429
Q

Paediatric Cardiology: Cardiac defects & their associated murmurs

ASD?

Pansystolic murmur?

Ejection systolic murmur?

Machinary murmur?

A

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
430
Q

Paediatrics: The 7 S’s of Innocent Murmurs

A
  • 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.

431
Q

Paediatrics: Ventricular Septal Defect (VSD)

A
  • 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
432
Q

Paediatrics: ASD

A
  • 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
433
Q

Paediatrics: Patent ductus arteriosus (PDA)

A
  • 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
434
Q

Paediatrics: Tetralogy of Fallot

A
  • 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
435
Q

Paediatrics: Down Syndrome

ROSEOLA! (just a pneumonic - not associated with Down’s)

A
  • 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
436
Q

Paediatrics: Kawasaki’s Disease

A

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!
437
Q

Paediatrics: Rheumatic Fever

A

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
438
Q

Paediatric: Paediatric Basic Life Support

A

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)
439
Q

Good phrase for NAI Paeds station?

A

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.

440
Q

Paediatrics: Leukaemia

A
  • 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%
441
Q

Paediatrics: Differential Diagnoses for NAI?

A
  • Accidental injury
  • Osteogenesis imperfecta
  • Coagulation disorders eg: ITP
  • Mongolian blue spot!!
  • Scalded skin syndrome
442
Q

Paediatrics: Management of NAI?

SMACK!

A
  • 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!!
443
Q

Paediatrics: UK Vaccination Schedule?

A
444
Q

Paediatrics:Turner Syndrome

Summary?

Phenotypic features?

Associated features?

Management?

A

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!
445
Q

ETHICS CASE: Medical team decides DNACPR would be clinically beneficial for a palliative patient. However on consultaiton of this with him he gets incredible distressed and agitated. He requests that he would still like CPR and feels as if you are giving him a death sentence by suggesting this. He refuses the DNACPR. What do you do?

A
  • 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.

446
Q

Triad for Dx of post-partum thyroiditis?

A
  • Patient within 12 months of giving birth
  • Clinical manifestations suggestive of hypothyroidism
  • Thyroid function tests support diagnosis
447
Q

Renal CASE: 45yr old man presents with urinary colic. Hx of reccurrent episodes of frank haematuria over past week. O/E has left loin mass and varicocole. Most likely Dx?

A
  • Renal ADENOCARCINOMA

Renal adenocarcinoma = most common renal malignancy (75% cases)

Way more common than RCC.

448
Q

Urinary Incontinence Studies:

A
  • 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
449
Q

Paediatric CASE: A 5-year-old child presents to the emergency department complaining of right iliac fossa pain. On examination there is no rebound tenderness or guarding. Urine dipstick and routine bloods come back as normal. The mother reports that her daughter had a viral infection a few days ago.

What’s the most likely diagnosis?

A

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

450
Q

Black Hairy Tongue

A
  • 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
451
Q

Diabetic Nephropathy: What will the kidneys look like on US?

A
  • 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!!!

452
Q

HTN Mx CASE: Poorly controlled HTN already on ACEi, thiazide & amlodipine, with a K+ of 4.2mmol/L. What do you add?

A

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

453
Q

NB: Smokers may normally have carboxyhaemoglobin levels up to 10% (normal = 0.5 - 2.5). Dont be fooled by this.

A

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)

454
Q

ENT CASE: A 42-year-old man presents with a 2 week history of a worsening sore throat, is complaining of painful swallowing. On examination you notice that he has difficulty opening his jaw, purulent tonsils and his uvula is deviated to the right. Given the likely diagnosis, how should this condition be managed?

A

IV Abx & surgical drainage

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

455
Q

3 Diagnostic Criteria for Malnutrition?

REMEMBER THIS

A
  • 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
456
Q

3 Indications for Splenectomy?

A
  • Uncontrollable splenic bleeding
  • Hilar vascular injuries
  • Devascularised spleen
457
Q

Orthogerries CASE: A 54-year-old woman who has had two Colle’s fractures in the past three years has a DEXA scan:

T-score

  • L2-4: -1.4
  • Femoral neck: -2.7

What does the scan show?

A

Osteopaenia in vertebrae

Osteoporosis in femoral neck

T score

  • > -1.0 = normal*
  • -1.0 to -2.5 = osteopaenia*

< -2.5 = osteoporosis

458
Q

CASE (that you fucked up): A 32-year-old female intravenous drug user (IVDU) presents to the emergency department demanding analgesia for her back pain. You recognise her as a frequent attender, most recently being treated for a groin abscess.

On examination her heart rate is 124/min, temperature 38.1ºC, respiratory rate is 22/min and she is alert. The patient is lying on her right hand side with her knees slightly flexed and you find tenderness over L3-L4.

Given the examination findings what is the most likely causative organism in this case?

A

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

459
Q

Ankle Injury: Ottawa Rules

REMEMBER THESE

A
  • 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
460
Q

Causes of Ulceration CASES:

1) A 66-year-old female has long standing mixed arteriovenous ulcers of the lower leg. Over the past 6 months one of the ulcers has become much worse and despite a number of different topical therapies is increasing in size.
2) A 28-year-old man undergoes a ileocaecal resection and end ileostomy for Crohn’s disease. One year later he presents with a deep painful ulcer at his stoma site.

A

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.

461
Q

Postnatal Diagnoses:

‘Baby blues’

Postnatal depression

Postnatal psychosis

A

‘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
462
Q

King’s College Hospital criteria for liver transplantation (paracetamol liver failure)

A

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
463
Q

Classifying Bacteria

Gram-positive cocci?

Gram-negative cocci?

A

Gram-positive cocci = staphylococci + streptococci (including enterococci - E. coli)

Gram-negative cocci = Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis

(Neisseria = Negative)

464
Q

Gestation diabetes, now on insulin - does she have to inform DVLA?

A

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

465
Q

Breast CASE: A 38-year-old lady who smokes heavily presents with recurrent episodes of infection in the right breast. On examination, she has an indurated area at the lateral aspect of the nipple areolar complex. Imaging shows no mass lesions. What is the most likely diagnosis?

A

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. It 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.

466
Q

Key thing to remember when interpretting TTG levels when Ix for Coeliac disease?

A
  • 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

467
Q

GI CASE: A 44-year-old obese female is noted to have gallstones during an abdominal ultrasound, which was requested due to repeated urinary tract infections. Apart from the repeated UTIs she is otherwise well. What is the most appropriate management of the gallstones?

A

Asymptomatic gallstones which are located in the gallbladder are common and do not require treatment.

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.

468
Q

Polymyalgia Rheumatica vs. Fibromyalgia

A

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
469
Q

Triad of Paget’s Disease of Bone?

A
  • Old man,
  • bone pain,
  • raised ALP
470
Q

GREAT CASE: An 76-year-old lady has spent a week on the ward following a surgically-repaired neck of femur fracture. Serial blood tests reveal:

Date Platelet Count

10/10 260 * 109/l

14/10 90 * 109/l

18/10 23 * 109/l

On 19/10 she develops a large DVT in her right leg and the consultant believes this series of events may be drug-induced.

Which of the following is the most likely cause of this presentation?

A

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.

471
Q

Assessing the severity of COPD

A

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!)

472
Q

Definition (& pathophys) of Acute Respiratory Distress Syndrome?

A

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
473
Q

Choice of Abx for prophylaxis in Spontaneous Bacterial Peritonitis?

A

Ciprofloxacin PO

474
Q

Neuro: Dx indicated by ISOLATED elevated protein in the LP CSF analysis?

A

Guillain-Barre

475
Q

Kartagener’s syndrome?

A

Recurrent chest infections + subfertility - think primary ciliary dyskinesia syndrome (Kartagener’s syndrome)

476
Q

Coeliac disease pt w/ anaemia - what could she be deficient in?

A

Iron AND B12 AND folate

Coeliac can cause you to be deficient in any/ALL of these

477
Q

CASE: A 72-year-old man who is known to have chronic kidney disease stage 4 is admitted to the Emergency Department. Since yesterday he has felt short-of-breath on exertion and has been coughing up blood. On examination, he is tachycardic at 110/min with a normal chest examination.

What is the most suitable initial imaging investigation to exclude a pulmonary embolism in this patient?

A

Pulmonary embolism and renal impairment

→ V/Q scan is the investigation of choice

478
Q

vW Disease - bleeding time/clotting studies?

A

Bleeding time is a marker of primary haemostasis and so is raised in vWD, but normal in haemophilia

479
Q

HbA1c needed to Dx diabetes??

A

>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.

480
Q

Triad for Chorioamnitis?

A

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

481
Q

Blood Transfusion Reactions

Transfusion-Related Associated Lung Injury (TRALI)

Transfusion Associated Circulatory Overload (TACO)

Graft vs Host Disease

Acute or Delayed Haemolysis

Allergic

A

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.
482
Q

Effects of Carcinoid Syndrome on the Heart?

A

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.

483
Q

4 Causes of Renal Impairment in Multiple Myeloma?

A
  • 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.

484
Q

Imaging Modality to Ix Osteomyelitis??

A

MRI

485
Q

Paediatrics: GORD

(vs. Posseting)

A

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!
486
Q

Paediatrics:Gastroenteritis

A
  • 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
487
Q

Paediatrics: Haemolytic Uraemic Syndrome (HUS)

A
  • 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)

488
Q

Paediatrics: Pyloric Stenosis

A
  • 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
489
Q

Paediatrics:Intussusception

A
  • 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
490
Q

Paediatrics: Coeliac Disease

A

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
491
Q

Paediatrics: Inflammatory Bowel Disease

A

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
492
Q

Paediatrics: Respiratory Illnesses in Children - by age?

Neonates

Infants

Under 5’s

Over 5’s

A

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
493
Q

Paediatrics: Respiratory Signs

What are they & what can cause each…?

Stridor

Stertor

Grunting

Wheeze

A

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
494
Q

Paediatrics: Bronchiolitis

Red flags for parents to look for?

Admit if “DRAMAS”?

A
  • 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!!

495
Q

Paediatrics: Asthma

A
  • 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
496
Q

Paediatrics: Viral-induced Wheeze

A
  • 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
497
Q

Paediatrics: Croup

A
  • 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
498
Q

Paediatrics: Stridor

Croup vs. Epiglottitis

(Both cause stridor!!)

A

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
499
Q

Paediatrics: Respiratory Illnessses compared

Bronchiolitis vs. Croup vs. Viral-induced wheeze

A
  • 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
500
Q

Paediatrics:Cystic Fibrosis

A
  • 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
501
Q

What are the criteria to be able to call it a miscarriage?

A
  • Crown-rump length >7mm
  • Presence of a foetal heart
502
Q

Ix for intermenstrual bleeding or postcoital bleeding?

A

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!
503
Q

Ix for Post menopausal women ?

A

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
504
Q

Key things to ask for gynae cancers?

A
  • Endometrial
    • FHx of bowel cancer?? Lynch & HNPCC
  • Ovarian
    • Increased risk with increased ovulations (nulliparous, no COCP use etc)
    • FHx - BRCA 1 & 2??
  • Cervical
    • HPV
505
Q

Paediatrics: Nephrotic Syndrome

A
  • 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.

506
Q

Paediatrics: Acute Nephritic Syndrome

Abnormal “HOST” response

A
  • 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
507
Q

Paediatrics: DDx for non-blanching rash

A
  • 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
508
Q

Paediatrics: Non-blanching Rash

ALL vs. ITP vs. HSP vs. Meningococcal sepsis vs. HUS

A

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
509
Q

Paediatrics: Henoch-Schonlein Purpura

A
  • 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!
510
Q

Paediatrics: Idiopathic Thrombocytopaeniac Purpura (ITP)

A
  • 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
511
Q

Paediatrics: Causes of a childhood limp

Age 1 - 3 yrs?

Age 3 - 10 yrs?

Age 10-16 yrs?

A

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
512
Q

Paediatrics: Childhood Limp DDx

Transient Synovitis

Septic arthritis

Perthes’ disease

Slipped upper femoral epiphysis

Juvenile idiopathic arthritis

A

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)
513
Q

Paediatrics: Common Childhood Infectious Disease

Measles

Mumps

Rubella

Chickenpox

Slapped Cheek Disease / Erythema Infectiosum

Scarlet Fever

A

Measles

Mumps

Rubella

Chickenpox

Slapped Cheek Disease / Erythema Infectiosum

Scarlet Fever

514
Q

Paediatrics: Neonatal Examination Findings

“Port wine stain”

Cavernous Haemangioma

Absent red reflex

Talipes equinovarus

A

“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
515
Q

Paediatrics: Complications of preterm delivery/prematurity?

“HEADS & HEARTS & LUNGS & GUTS, LUNGS & GUTTTS”

A
  • Heads - intraventricular haemorrhage
  • Hearts - patent ductus arteriosus
  • Lungs - respiratory distress syndrome
  • Guts - NEC
  • Eyes - retinitis of prematurity
516
Q

Paediatrics: Neurological Examination in Children

A
  • 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
517
Q

Paediatrics: Epilepsy in Children

A
  • 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
518
Q

Paediatrics: West’s Syndrome

Triad of…?

A
  • Infantile spasms (“flexor spasms”)
  • Development delay
  • Hypsarrhythmia on EEG (“choatic” pattern)

Poor prognosis.

519
Q

Paediatrics: Type of epilepsy & 1st line Rx?

Generalised tonic-clonic (GTC)

Focal

Absence

Infantile spasms

A

Generalised tonic-clonic (GTC)

  • Lamotrigine
  • Valproate - avoid in girls of reproductive age

Focal

  • Carbamazepine
  • Lamotrigine

Absence

  • Ethosuximide
  • Valproate

Infantile spasms

  • Prednisolone
  • Vigabatrin
520
Q

Paediatrics: Cerebral Palsy

A
  • 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)
521
Q

Paediatrics: Breath Holding Attacks & Reflex Anoxic Seizures

A

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
522
Q

Paediatrics: Autistic Spectrum Disorder

A

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)
523
Q

Paediatrics: Attention Deficit Hyperactivity Disorder

A

Characterised by:

  • Inattentiveness
  • Hyperactivity
  • Impulsiveness
524
Q

Paediatrics:Conduct Disorder

A
  • 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
525
Q

Paediatrics: Functional Abdo Pain

A

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..?”
526
Q

SGH GREY BOOK: Empirical Abx for Infections

Community Acquired Pneumonia (CAP)

Hospital Acquired Pneumonia (HAP)

Infective Exacerbation of COPD and LRTI

Aspiration Pneumonia

Urinary Tract Infection

Intra-abdominal Sepsis

Cellulitis

Osteomyelitis / Septic arthritis

Infection - unknown source (w/out sepsis)

Suspected sepsis - site & organism unknown

Meningitis

C. Diff

A

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.
527
Q

Common Rx cause of erectile dysfunction?

A

Beta blockers & SSRI’s

528
Q

DDx for cervical excitation O/E?

A

PID or Ectopic Pregnancy!

529
Q

Achalasia leads to increased risk of which type of oesophageal cancer??

A

Squamous cell carcinoma

(NOT adenocarcinoma - this is GORD/Barrett’s!)

530
Q

Paracetamol Overdose: Picture for liver ezymes?

ALT? ALP? ALT:ALP ratio?

A

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.

531
Q

Epstein’s Anomaly

A
  • 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
    *
532
Q

Mx of Beta thalassaemia major?

A
  • Life-long blood transfusions!

PLUS iron-chelation therapy to reduce risk of iron-overload

533
Q

Paediatrics CASE: A 6-year-old boy is found unconscious in the bath. He is brought into the emergency department as a paediatric cardiac arrest. The nurse attempts to insert a cannula into his hand and fails three times. What is the most appropriate next step in obtaining access?

A
  • Get the registrar to obtain intraosseous access

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

534
Q

Management of Mastitis in a breastfeeding woman?

A
  • 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.
535
Q

MOA of clomifene?

(Used to treat infertilify in PCOS)

A

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

536
Q

Metabolic abnormalities characteristic of ASA overdose?

A

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

537
Q

Paediatrics CASE: A neonate who was born prematurely at 35 weeks gestation is registered at the Practice. He was very well after delivery, without any notable complications such as respiratory problems. How should his routine childhood immunisations be given?

A

Give according to chronological age

REMEMBER THIS YOU FUCKING SPAZOID

538
Q

1st line testing for Acromegaly??

A

Serum IGF-1

539
Q

Management of Sinusitis?

A
  • 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)
540
Q

Key features of a Myxoedemic Coma??

(Myoedemic coma = severe hypothyroidism!!)

A
  • Hypothermia,
  • hyporeflexia,
  • bradycardia
  • seizures
541
Q

NB I thought that Uvula deviation = quinsy (NOT tonsillitis) but have a look at the question attached…

A

I guess you need to consider..

  • Where it is, this is clearly on the tonsills
  • Quinsy would be anterior and unilateral
542
Q

Paediatrics HARD CASE: A 14-year-old child attends the emergency department following a bout of haemoptysis. He has been a well child with no regular contact with his doctor other than for vaccinations, which are up to date.

The only finding of note in his past history is the documentation of a harsh, blowing, pansystolic murmur noted during routine examination as a baby. There has never been any follow up of this and today on examination you cannot hear this murmur.

Additionally on examination you note loss of the nail fold angle and a blue tinge to the lips.

Given the likely diagnosis, what investigation findings would you expect?

A

The ECG in Eisenmenger’s syndrome shows right ventricular hypertrophy

This is a VSD (pansystolic, blowing murmur!) which now demonstrates Eisenmenger’s syndrome!

543
Q

Roseola infantum - what is the typical pathopneumonic presentation??

A

​Roseola infantum - fever followed later by rash

544
Q

DKA - Typical management of Insulin??

YOU COMPLETELY FUCKED THIS UP YOU SPAZ

A

In the acute management of DKA, insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin

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

545
Q

Ix PE??

A
  • Well’s score!
  • 1st line with Well’s score <4 = D-Dimer
  • Positive D-dimer –> CTPA to look for the PE!!
546
Q

Derm: Blisters/Bullae

Bullous Pemphigoid vs. Pemphigus Vulgaris

A
  • no mucosal involvement: bullous pemphigoid
  • mucosal involvement: pemphigus vulgaris

think of the VULVA as a mucosal surface (or entrance to one)

547
Q

Mx of Slow heart rhythms??

A
  • IV atropine - 6 doses
  • External heart pacing - if not improved w/ 6 doses of atropine
548
Q

Contraindications for VBAC?

A
  • 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

549
Q

CASE: A 36 year old man presents to the Emergency Department with a 2 day history of painful left knee. There is no history of trauma. He has been well except for a bout of food poisoning after eating a kebab 2 weeks ago. He reports no personal or family history of rheumatological conditions and has never had any sexually transmitted infections either. On examination, the knee is swollen, erythematous and tender. Aspiration reveals clear fluid which contains no white cells or crystals. What is the most likely diagnosis?

A

REITER’s SYNDROME (Reactive arthritis)

NB: The absence of white cells and crystals immediately rules out septic arthritis and gout or pseudo-gout.

550
Q

Timings for transfusion of 1unit of RBC’s?

A
  • Normal = 90-120mins
  • Pt. w/ HF = 3hrs (to reduce chance of circulatory overload)
  • Trauma/major haemorrhage scenarious - blood may be transfused STAT
551
Q

With respect to the NICE Chronic Obstructive Pulmonary Disease guidelines (COPD), what criteria should be used to determine whether patients who are having an excerbation of COPD require antibiotics?

A

Purulent sputum + clinical signs of pneumonia

552
Q

1st line Mx of Fissure in ano??

A
  • Laxatives + topical vasodialtor (eg: GTN)
553
Q

“CRAB” Features of multiple myeloma?

A
  • C - hypercalcaemia
  • R - renal insufficiency
  • A - anaemia (& thrombocytopaenia)
  • B - Bence-Jones proteins / bone lesions!
554
Q

Poor Prognostic Factors for Hodkin’s Lymphoma?

A
  • B-symptoms
  • Older patient
  • Male sex
  • Stage IV disease - extranodal sites involves
  • Lymphocyte-deplete subtype
555
Q

Sickle Cell Crises - 4 types?

A

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
556
Q

MOA of Rivaroxaban?

A

Direct FXa inhibitor!

557
Q

MOA of Heparin vs. Warfarin?

A

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)
558
Q

Sickle cell patient w/ sudden anaemia & low reticulocyte count - Dx?

A

Parvovirus B19 infection!

NB: Acute sequestriation & acute haemolysis –> increased corrected reticulocyte count (>3%)

559
Q

Most common pathophysiology of abdominal aortic aneurysms??

A

Atherosclerosis!

Atherosclerosis –> thickened intima (endothelium) –> increased diffusion barrier –> vessel wall weakens

560
Q

Rx for angina?

A

1st line: GTN, aspirin, statin

2nd line: add CCB (eg: verapamil) or beta-blocker

3rd line: add ivabradine or nicoradil (K+ channel agonist)

561
Q

Criteria for posterior MI on ECG?

A

ST depression in 2 or more leads V1 - V4 should be considered a posterior MI

and therefore treated as a STEMI

562
Q

Significance of a Left Bundle Branch Block on an ECG?

A

LBBB on ECG = MI until proven otherwise!

William = Left bundle branch block

Correlate with clinical history obviously

563
Q

?MI - when do you take the troponin level?

A

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!)

564
Q

Paediatrics: Things to ask in a headache Hx?

A
  • Hydration
  • Eyesight ?glasses
  • Screen time
  • Sleep
  • Sinus things - hayfever, recurrent URTI’s
  • Nutrition
  • Reduce stress
  • ?analgesia overuse headaches
565
Q

Paediatrics: Sepsis

A

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

566
Q

Paediatrics: DKA

A
  • 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
567
Q

Ix work-up for haematuria?

A
  • Urine dip
  • Urine MC&S - ?UTI
  • Bloods - U&E’s ?renal function

Microscopic haematuria:

  • US +/- Xray

Frank haematuria:

  • CT scan

BOTH types

  • Flexi cystoscopy!
568
Q

Causes of dilated cardiomyopathy?

A
  • Genetic
  • Myocarditis - eg: coxsackie A or B –> lymphocytic infiltrate in myocardium
  • Alcohol abuse!!
  • Drugs - doxorubicin, cocaine
  • Pregnancy
  • Haemochromatosis!
569
Q

Organisms causing pneumonias?

A

HAP

  • Pseudomonas
  • MRSA

CAP

  • Strep pneumoniae = commonest
  • H influenzae = smokers/COPD
  • Klebsiella = aspiration
  • Staph aureus = secondary pneumonia (after viral infection)
  • Legionella = immunocompromised
570
Q

3 Key Causes of Pulmonary HTN?

A
  • Hypoxaemia - eg: COPD, interstitial lung disease
  • Increased volume in pulmonary circuit - eg: HF, congenital heart disease
  • Recurrent PE’s
571
Q

Triple therapy for H. pylori gastritis?

A

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

572
Q

Considering IBD as a diagnosis, what do you need to exclude first?

A

Infective & ischaemic causes of bloody diarrhoea!

573
Q

Extra-intestinal manifestations of IBD - Crohn’s vs. UC?

A

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
574
Q

Difference between ischaemic colitis & mesenteric ischaemia?

A

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

575
Q

RUQ pain - Acute pancreatitis vs. acute cholecystitis?

A

Ix

acute pancreatitis = serum amylase!

acute cholecystitis = alkaine phosphatase!

576
Q

Hepatitis B virus - Serology!!

Hep B surface antigen:

Hepatitis B core antibody:

Hepatitis B surface antibody:

Hep B envelope antigen (HbeAg)

A

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
577
Q

Complications of Liver Cirrhosis:

Decreased toxification…

Decreased protein synthesis…

Portal HTN…

A

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!
578
Q

What will you Rx before chemotherapy to reduce chance of tumour lysis syndrome??

A

FLUIDS + allopurinol

579
Q

4 Complications from Nephrotic syndromes?

A
  • 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
580
Q

Nephrotic Syndromes & their associations

Minimal change disease

Focal segmental glomerulosclerosis (FSGS)

Membranous Nephopathy

Membranoproliferative Glomerulonephritis

A

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
581
Q

Glomerulonephritis: Poststreptococcal Glomerulonephritis vs. IgA Nephropathy?

A

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
582
Q

Alport Syndrome

PC - triad?

A
  • Isolated haematuria
  • Sensoryneural hearing loss
  • Ocular disturbances

Due to inherited defect in type IV collagen - problems with basement membranes

583
Q

Management of ?testicular tumour ?

A

Do NOT biopsy - risk of seeding the scrotum

Definitive Mx = radical orchidectomy

584
Q

PC for Sheehan Syndrome?

A

PC: Poor lactation, loss of pubic hair, fatigue

In a woman who is post-partum and had a PPH after labour!!

585
Q

Complications of Hyperparathyoidism (ie. of hypercalcaemia)?

A
  • 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
586
Q

Pathophysiology of secondary hyperparathyroidism?

A
  • 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)
587
Q

Ix for Cushing syndrome?

A
  • 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
588
Q

Which CAH enzymatic defect will cause ambiguous genitalia & undescended testes in a male & primary ammenorrhoea and lack of pubic hair in a female

A

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

589
Q

Waterhouse-Friderichsen syndrome?

A

Haemorrhagic necrosis of adrenal glands - classically due to sepsis & DIC in young childrne with Neisseria meningitidis infection

–> acute adrenal insufficiency –> weakness and shock

590
Q

Addison disease?

A

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!!
591
Q

Broken bones in a child - DDx?

A
  • 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
592
Q

Osteomalacia vs. Osteoporosis?

A

Osteomalacia

  • Defective Mineralisation 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.
593
Q

Paget Disease of Bone

A
  • 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
594
Q

Which disease causes Heberden’s nodes & Bouchard’s nodes?

A

Osteoarthritis!

These are osteophytes formed (reactive bony outgrowths)

Outer Hebredes! (DIP)

595
Q

Key concepts when managing a rheumatoid arthritis patient?

A

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.
596
Q

Ankylosing Spondylotitis - Treatment Algorhythm?

A
  • NSAIDs - Naproxen 500mg BD!
  • Intra-articular corticosteroid injection (hydrocortisone)
  • Sufasalazine - for peripheral joint involvement
597
Q

Reiter’s Syndrome / Reactive Arthritis

TRIAD of symptoms

Joint aspirate culture ?

Common causative organisms?

A

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!!
598
Q

Gout

Presents as? - Acute vs. Chronic

Primary vs. Secondary Gout?

Synovial fluid aspirate?

A

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
599
Q

CASE: Patient presents with malar rash - bloods reveal a positive ANA - what are your DDx?

A
  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)
600
Q

Antibodies in each disease:

Myasthenia gravis?

Lambert-Eaton syndrome?

A

Myasthenia gravis = Ab against post-synaptic Ach receptor of NMJ

Lambert-Eaton syndrome = Ab against presynaptic Ca2+ channels of NMJ

601
Q

Erythema Mutiforme?

Stevens-Johnson syndrome (SJS)?

Toxic Epidermal Necrolysis?

A

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)
602
Q

Impetigo vs. Cellulitis?

A

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!
603
Q
A
604
Q

Mx of STEMI

A
  1. Pain relief - morphine & metoclopromide
  2. Platelets - aspirin loading dose 300mg & clopidogrel/ticagrelor & LMWH (realistically after coronary angio)
  3. Perfusion of myocardium - Coronary angiography (PCI) ideally within 2hrs of symptoms but ultimately within 12hrs if ongoing chest pain
  4. Plaque 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
605
Q

3 drugs to improve prognosis in heart failure?

A
  • 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)

606
Q

When would you stop an ACEi?

A
  • AKI
  • Angioedema! (closed throat)
  • Documented bilateral renal artery stenosis
  • Hyperkalaemia >6
  • Hypotension
  • Severe aortic stenosis
  • Dry cough –> swap to ARB
607
Q

Mx of chronic heart failure?

A
  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!!

608
Q
A
609
Q

Which cardiac drug can exacerbate psoriasis?

A

Beta blockers

610
Q

Which cardiac drug can cause angioedema?

A

ACEi !!

611
Q

4 Secondary Causes of HTN?

A

Phaeo, Conn’s, Cushing’s, Renal artery stenosis

612
Q

Causes of a big R wave in V1 & V2

A
  • 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
613
Q

Chronology of ECG changes with Hyperkalaemia?

A

flattened P waves

Tall tented T waves

Sagging of the ST segments

Widening of the QRS

Flatline…

614
Q

Which drugs do you NOT give in Wolff Parkinson White which has developed into an SVT / AV re-entry tachycardia?

A

Digoxin & verapamil

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

615
Q

What is the significance of ST segment elevation in V1?

A

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!
616
Q

Based on pretest probablities for coronary artery disease, which Ix would you do?

A

10-30% –> Offer CT calcium scoring

30-60% –> dobutamine stress echo

>60% –> coronary angio

617
Q

Brugada syndrome

A

Young person who dies at rest - often during their sleep?

ECG: Small R, big S, downsloping ST segment!

618
Q

What Ix is key for anyone who has a LOC episode?

Even if it obviously a syncope episode..?

A

ECG!

Looking for cardiac arrythmia or silent infarction

You will get this in A&E before you let little old Doris go home…

619
Q

Which Rx’s can cause Torsades de Pointes in someone who has an underlying long QT?

A

Marcolides (Erythromycin, Clarithromycin)

Quinolones

Trimethprim

620
Q

PY450 enzyme inducers

A

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
621
Q

Ovarian Torsion

A
  • 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
622
Q

Type 1 vs Type 2 Hepatorenal Syndrome?

A

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.

623
Q

Blood film findings consistent with G6PD?

A

Bite and blister cells!

624
Q

Typhoid Fever

A

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.

625
Q

What type of hearing loss does this audiogram show?

A

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!)

626
Q

Retinopathy of prematurity

A

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

627
Q

CASE: A 19-year-old woman is on the Specialist Surgical Ward recovering from a tonsillectomy. She returned from theatre 4 hours ago. Nurses report that there appears to be a small amount of bleeding from the wound.

After your initial assessment, what is your next management step?

A

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.
628
Q

Blood film findings consistent with Pyruvate kinase deficiency?

A

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

629
Q

A normal PaCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening

A

Escalate to the ITU team !

630
Q

Neuroleptic Malignant Syndrome

A

Four main features:

  • rigidity,
  • hyperthermia,
  • autonomic instability (hypotension, tachycardia)
  • altered mental status (confusion)

Can also cause an AKI –> derranged U&E’s!

631
Q

CASE: A 48-year-old woman presents with progressively worsening pain in the right shoulder over the past few weeks. She is generally fit and well but smokes 20 cigarettes/day.

On examination there is diffuse mild tenderness over the lateral aspect of the right shoulder. The pain is recreated when abducting the shoulder to around 70-80 degrees.

A shoulder x-ray is requested:

A

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.

632
Q

Lung cancers and their paraneoplastic syndromes

A

Small cell lung cancer:

  • ADH –> siAHD
  • ACTH –> Cushingoid
  • Lambert-Eaton syndrome

Squamous Cell Carcinoma:

  • PTHrP –> hypercalcaemia!
633
Q

CASE: A 55-year-old woman presents to the emergency department with a sudden onset of central chest pain while she was at rest. The pain was not relieved by her glyceryl trinitrate spray. She has a past history of angina and hypertension. ECG and cardiac biomarkers were positive for an ST-elevation myocardial infarction (STEMI).

A few minutes later, she complained of worsening shortness of breath. On examination, her pulse was weak and thready. Her jugular venous pressure is increased. On chest auscultation, there was a new systolic murmur. Her pulse rate was 130 beats per minute and blood pressure was 80/55 mmHg. There were no new acute changes to the ECG.

Which of the following is the most likely diagnosis?

A

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

634
Q

Follow up imaging modality for unruptured AAA’s under 5.5cm??

A

ULTRASOUND 3monthly

635
Q

Risk factors for pseudogout??

A
  • haemochromatosis
  • hyperparathyroidism
  • acromegaly
  • low magnesium, low phosphate
  • Wilson’s disease
636
Q

Methanol poisoning!

Sx?

Rx?

A

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
637
Q

Rx to correct low calcium from renal failure?

A

Alfacalcidol

This is activated vit D

638
Q

Consequences of renal failure?

A
  • 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
639
Q

Give IV calcium gluconate in someone with a serum potassium > 6.5…

Or treat if ECG changes or if general floppiness (skeletal muscle has become affected)

A

This buys you one hour to give IV insulin & salbutamol

Definitive treatment may be dialysis

640
Q

Abx of choice to treat UTI in pregnancy?

A

NITROFURANTOIN

NOT Trimethoprim (folate antagonist)

641
Q

Lithium toxicity - can affect which part of the brain?

A

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,

642
Q

COntraindicatiosn to diabetic medications?

A
  • Metformin - chronic renal failure (creatinine >150)
  • Pioglitazone - heart failure or liver failure
643
Q

Causes of SiADH?

A

Brain - TBI, SOL (infective, malignant), haemorrhage

Lung - TBI, SOL (infective, malignant), haemorrhage

Pills:

  • SSRI’s
  • TCA’s
  • chemotherapeutic agents
  • Cyclophosphamide
  • Carbamazepine
644
Q

One of the key most likely complications of rheumatoid arthritis?

A

Ishcaemic heart disease!

Remember rasied CRP –> inflammation –> MI etc

645
Q

Triad of Lewy Body Dementia?

A

Memory loss

Hallucinations

Parkinsonism

646
Q

Patient with DIC - which blood products do you give?

A

Cryoprecipitate (or FFP)

647
Q

What is Klebsiella indicated in?

A
  • Aspiration pneumonias
  • Pleural empyema
  • Ascneding cholangitis
648
Q

Management of HTN in diabetics?

A

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

649
Q

When would you use oxycodone?

A

Safe strong opioid to use in patients with renal failure!

650
Q

Rheumatoid Arthritis - poor prognostic factors?

A
  • 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
651
Q

Charcot’s triad?

Reynold’s pentad?

Beck’s triad?

Cushing’s triad?

A

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.

652
Q

Which type of inguinal hernia are kids more likely to get?

A

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

653
Q

Two aims of treatment in acute glaucoma?

A
  • Reducing aqueous secretion
  • Inducing pupillary constriction

Overall to reducing intraoccular pressure

654
Q

Mx order in someone who is both B12 AND folate deficient?

A

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

655
Q

Pregnant lady give IV magnesium sulfate for fits - then experiences respiratory depression due to magnesium sulfate toxicity…

Rx of choice for magnesium sulfate induced respiratory depression?

A

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

656
Q

ABC of IBS?

A

Abdominal pain, Bloating and Change in bowel habit

657
Q

TURP syndrome

A
  • 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
658
Q

The Key Willy diagnoses??

Peyronies Disease

Balanitis Xerotica Obliterans

Balanitis

Paraphimosis

Phimosis

A

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”)

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