Problematic conditions Flashcards
What is the cause of infectious mononucleiosis and what are common features?
- EBV
- Sore throat, Lymphadenopathy, splenomegaly (splenic rupture)
- RASH AFTER TAKING AMOXICILLIN
Mx regarding infectious mononucleiosis
- usually self limiting. The acute illness lasts around 2 – 3 weeks, however it can leave the patient with fatigue for several months once the infection is cleared.
- avoid alcohol, as EBV impacts the ability of the liver to process the alcohol.
- avoid contact sports due to the risk of splenic rupture. Emergency surgery is usually required if splenic rupture occurs.
What is the vaccination schedule?
2mth: 6 in 1 (diphtheria, hep B, Hib, polio, tetanus, whooping cough) Men B, Rotavirus.
3mth: 6 in 1, PCV, Rotavirus.
4mth: 6 in 1, Men B.
1y: Hib/Men C, PCV booster, MMR, Men B booster.
- 3y = 4in1 (dip/tet/whooping/polio), MMR.
- 12-13y = HPV.
- 14y = Tetanus, diphtheria, polio. Men ACWY.
- Influenza vaccine is also offered to all children of primary school age and those in Y7. It is also
offered from 6m to those at high risk.
What is ITP and mx
- autoimmune destruction of platelets (thrombocytopenia)
Often preceded by viral illness - Bleeding, for example from the gums, epistaxis or menorrhagia
- Bruising
- Petechial or purpuric rash, caused by bleeding under the skin
- Mx: usually resolves by itself. If very low:
-> oral/IV corticosteroid
-> IV immunoglobulins
-> platelet transfusions can be used in an emergency (e.g. active bleeding) but are only a temporary measure as they are soon destroyed by the circulating antibodies
Features of haemophilia
- Spontaneous bleeding into joints (haemoathrosis) and muscles - painful, swelling
- Haematoma’s/described as extensive bruising
- Can present as intracranial haemorrhages, cord
Risk factors for DDH
- female sex: 6 times greater risk
- breech presentation
- positive family history
- firstborn children
- oligohydramnios
- birth weight > 5 kg
- congenital calcaneovalgus foot deformity
(Fat, Female, Fanny first, FH, Firstborn, Fluid low, Foot deformity)
Ex drugs + S/E:
SSRI
SNRI
Tricyclics
MOA
Tetracyclics
- SSRI: Sertaline, Fluoxetine, Citalopram (Stomac,sexual,serot, sleep depr, sodium low)
- SNRI: Duloxetine, Venlafaxine
- Tricy: Amitryptiline, Imipramine (Anticholinergic)
- MOA: IproniaZID, Phenelazine, Trancyclpromine (cheese)
- Tetracy: Mirtazapine
Mood stabilising drugs
Lithium or Valproate
Lithium adverse effects and toxicity
- S/E: (lithium + sodium same in periodic table - similar structure and effects) LITHIUM
Lethargy, Insipidus (diabetes) - thirst/urination, Tremor (fine), Hypothyroidism, Impaired memory + cognition, Upset stomach, Muscle weakness - TOXICCC (lithium>1.5mmol/L):
Tremor (coarse), tachycardia/arrhy
Oliguric renal failure
ataXia
Increased reflexes
Convulsions, Coma, Consciousness reduced - Mx: 1. Stop lithium immediately
2. High fluid + IV NACl
3. If severe - renal dialysis
Lithium monitoring
- when checking lithium levels, the sample should be taken 12 hours post-dose
- after starting lithium levels should be performed WEEKLY and after each dose change until concentrations are stable
- once established, lithium blood level should ‘normally’ be checked every 3 MONTHS
- THYROID and RENAL (from diabetes insipidus) function should be checked every 6 MONTHS
Criteria for delirium
ICD-10 criteria for delirium:
1.) Impairment of consciousness and attention
2.) Global disturbance in cognition
3.) Psychomotor disturbance
4.) Disturbance of sleep-wake cycle
5.) Emotional disturbances
Etiology of delirium
D - Drugs and Alcohol
E - Eyes, ears and emotional
L - Low Output state (MI, ARDS, PE, CHF, COPD)
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
Medical problems associated with Down’s syndrome
CHILDHASPROBLEM
Congenital heart disease (VSD,ASD,Fallot)/ Cataracts.
Hypothyroidism / Hypotonia.
Increased gap between 1st and 2nd toe.
Leukemia risk x2 (AML+ALL) / Lung problem.
Duodenal atresia / Delayed development.
Hirschsprung disease / Hearing loss.
Alzheimer disease
Short neck / Squint.
Palmar crease / Protruding tongue.
Round face / Rolling eye (nystagmus).
Occiput flat / Oblique eye fissure.
Brushfield spots / Brachycephaly.
Low nasal bridge / Language problems.
Epicanthic fold / Ears folded.
Mental retardation / Myoclonus.
Brushfield spots = white/grey spots in iris
Heart defects associated with different genetic conditions
- Down’s: ASD, VSD, Tetralogy of Fallot, AVSD
- Turner’s: Bicuspid aortic valve, Aortic coarctation
- Fragile X: Mitral valve prolapse
- Edwards: VSD
- William’s: Aortic stenosis
- Noonan’s: pulmonary stenosis (opposite to Turner’s)
Barbituate vs Benzo’s mechanism of action
GABAA drugs:
- benzodiazipines increase the frequency of chloride channels
- barbiturates increase the duration of chloride channel opening
(Barbidurates increase duration & Frendodiazepines increase frequency)
Indications for benzodiazapines
Alcohol withdrawal, Seizures, Severe Anxiety, Severe insomnia
RF’s for ovarian, endometrial, cervical, vulval cancer
- Ovarian: Age>60, clomifene, early menarche, nulliparity, BRCA1/2
- Endometrial: obesity, nulliparity, early menarche, late menopause, diabetes mellitus, tamoxifen, PCOS, HNPCC
- Cervical: HPV 16,18,
smoking, HIV, early first intercourse, many sexual partners, high parity, lower socioeconomic status, COCP - Vulval: - 65 years+, HPV, infection, VIN, Immunosuppression, Lichen sclerosus
Common antibacterials contraindicated in pregnancy
iM FAST of these drugs
- Metronidazole
- Fluoroquinolones
- Aminoglycoside
- Sulfonamides
- Tetracyclines
Ix for a pregnancy of unknown location + bleeding but less than 6wk
- Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy:
- If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage
- If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy
- A normal increase in B-hCG suggests the foetus is growing normally, but does not exclude an ectopic pregnancy
A transvaginal ultrasound may help to identify the location of the pregnancy, but in the early days of gestation the foetus may be too small to be accurately identified by ultrasound. In this instance it may be best to repeat the scan at a later date.
- If the pregnancy is < 6 weeks gestation and women have bleeding, but NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
to return if bleeding continues or pain develops
to repeat a urine pregnancy test after 7–10 days and to return if it is positive
a negative pregnancy test means that the pregnancy has miscarried
Causes of placental abruption
Abruption prev., Blood pressure, Ruptured membranes, Uterine trauma, Polyhydramnios, Twins, Infection, Older age, Narcotics
RF for gestational diabetes + Mx
Prev macrosomic baby, prev gestational diabetes, BMI >30, ethnic origin, FH Diabetes
Mx: if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with SHORT ACTING ONLY
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
High and mod risks for pre-eclampsia
- High risk: pre-exis HTN, prev. HTN in preg, AI, T1/2DM, CKD
- Mod risk: 40+ age, BMI >35, 10+ years since last pregnancy, 1st preg, FH
Investigations for gestational HTN vs Pre-eclampsia
Gestational (>20wk):
- BP -> weekly measurement (until 135/85mmHg)
- Urine dipstick -> weekly
- PIGF -> once
(If >160/110 then admit, BP every 15 mins, urine dipstick daily)
Pre-eclampsia:
- BP -> Every 48 hrs
- Urine dipstick -> only if new sx
- CTG/US fetus -> 2 weeks
Mx for gestational HTN
- Stop ACEi, ARB, Thiazides
- Change to labetalol (CI if asthmatic)/nifedipine/methyldopa, alpha-blockers
Mx for pre-eclampsia
- Prophylaxis: Aspirin from 12 weeks gestation until birth
- Labetalol (CI in asthma)/nifedipine/methyldopa
- IV hydralazine (if severe)
- If severe pre-eclampsia bp or sx (vomiting, blurred vision, papilloedema) then give IV magnesium (if concern may develop eclampsia) and plan immediate delivery, within 24-48hrs, if after 37 weeks gestation. MAGNESIUM SULPHATE FOR 24 HOURS AFTER DELIVERY OR AFTER LAST SEIZURE
- If before 37 weeks, then consider surveillance and early delivery.
RF for ectopic pregnancy
smoking, multiple sexual partners/PID,
use of IUD, prior fallopian tube surgery, infertility and using in vitro fertilisation, age <18 at first sexual
intercourse, black race, and age >35 at presentation.
What is Mx following preterm premature rupture of membranes
- Following RCOG guidelines, antibiotics (erythromycin) should be given for 10 DAYS following premature preterm rupture
of membranes, or until the woman is in established labour, whichever is sooner. - The presence of a pool of
fluid in the vagina at sterile speculum examination is highly suggestive of membrane rupture, and when
this is clearly observed no further diagnostic tests are required - antenatal corticosteroids
- delivery considered at 34 weeks of gestation -> trade-off between increased risk of maternal chorioamnionitis with a decreased risk of respiratory distress syndrome as the pregnanct continues
Dx of chlamydia
- Vaginal swab - microscopy, culture, sensitivities
- First catch urine sample for NAAT
What are the complications of gp B strep, chlamydia, syphillis, VZV during pregnancy
- ALL: chorioamnionitis, PROM, Preterm labour, miscarriage, stillbirth
- Chlamydia: neonate conjunctivitis, pneumonia
- Gp B strep: Meningitis, Encephalitis, Sepsis, Pneumonia (B=Brain, blood, breathing)
- Syphillis: (face) Keratitis, Deafness, Blunted teeth/palate defect, Saddle shaped nose, frontal bossing. (2 L’s): Lower extremity problems, bleeding into lungs
- VZV: SMELL - Skin scarring, Microcephaly, Eye problems, Limb hypoplasia, Learning difficulties
Tx of Chlamydia + GpB strep in pregnancy
CHLAMYDIA: Erythromycin or amoxicillin
GBS: intrapartum BENZYLPENICILLIN or ampicillin
Mx of bacterial meningitis
- Community: benzylpenicillin
- Hospital: Under 3 months = cefotaxime plus amoxicillin (the amoxicillin is to cover listeria contracted during pregnancy), above 3 months = ceftriaxone
- Prophylaxis within 7 days exposure = Ciprofloxacin
Non-epileptic attack disorder
- arms flexing/extending or pelvic thrusting
- eyes are usually closed, which may also be the case in syncope; eyes are typically open in epilepsy
- prolonged seizures (often >30 minutes) are common in NEAs; epileptic seizures and syncope typically
do not last >5 minutes - symptoms wax and wane in NEAs, as opposed to epilepsy, which typically follow set patterns (e.g.
tonic-clonic)
