Random review Q&A Flashcards
Ectopic pregnancy, clinical features-signs and symptoms- just list them out
- Absence of menses
- Irregular vaginal bleeding (spotting)
- Abdominal/shoulder tip pain
- Cervical motion tenderness
- Tachycardia and hypotension
- Palpable adnexal mass (50% of women)
- Absence of IUP on USS, with a positive β-hCG
Risk factors for ectopic pregnancy-5
Anatomic alteration of the fallopian tubes is the main cause of ectopic pregnancy. It may be due to:
A history of PID
Previous ectopic pregnancy
Past surgeries involving the fallopian tubes
Endometriosis
Exposure to DES (diethylstilbestrol) in utero
Bicornuate uterus
Non‑anatomical risk factors
Intrauterine device (IUD)
History of infertility
Hormone therapy
Signs and symptoms of ectopic
Patients usually present with signs and symptoms 4–6 weeks after their last menstrual period.
1) Lower abdominal pain and guarding
2) Vaginal bleeding
3) Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination
4) Tenderness in the area of the ectopic pregnancy
5) Cervical motion tenderness, closed cervix
6) Enlarged uterus
7) Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of myometrial distensibility.
What are the 3 options for ectopic pregnancy
Expectant
Medical
Surgery
Indication for surgery
Procedure
Follow up after surgery
Haemodynamically unstable • Signs of rupture • Any β-hCG level • Persistent excessive bleeding • Heterotopic pregnancy
Laparoscopy method of choice
• Laparotomy if:
o Haemodynamically unstable
o Laparoscopy too difficult
• GP 14 days post-surgery • If salpingo(s)tomy, weekly β-hCG until negative • If salpingectomy, urinary β-hCG 3 weeks after surgery • USS if clinically indicated • Optimal conception interval unknown (0–3 months common)
Post-op care for ectopic
Give written information about: • Management option chosen • Expected bleeding/symptoms • Resumption of menstruation • Contraception • Follow-up arrangements
General care considerations • Review histopathology of POC • If indicated, recommend RhD-Ig • Analgesia as required • Communicate information to other care providers (e.g. GP) • Early USS (5–6 weeks) in next pregnancy
Indication for medical management of ectopic
Indications • Haemodynamically stable • No evidence of rupture • No signs of active bleeding • Normal FBC, ELFT
Indications
Uncomplicated ectopic pregnancies
Hemodynamic stability
β-hCG ≤ 5000 mlU/mL
No renal, hepatic, or hematologic diseases
No fetal heartbeat and ectopic mass size < 4 cm
Treatment of choice: methotrexate (MTX)
Peak Expiratory Flow(PEF)- things to do
why is it useful
how long
To perform a peak flow:
1) Stand up straight.
2) Make sure the indicator is at the bottom of the meter.
3) Take a deep breath, filling your lungs completely.
4) Place the mouthpiece in your mouth; lightly bite with your teeth, and close your lips on it.
5) Blast the air out as hard and as fast as possible in a single blow.
6) Record the number that appears on the meter.
7) Repeat these steps 3 times.
8) Record the highest of the 3 readings in an asthma diary. 9) This reading is your or your child’s peak flow.
10) Peak flow monitoring helps measure how much, and when, the airways are changing.
Each morning and evening, record the highest of three peak flows. Take a deep breath, seal your mouth tightly around the mouthpiece, then blow as hard
and as fast as you can. Check the number, re-set the pointer to zero, and repeat two more times.
To find your personal best peak flow, perform peak flows:
Twice a day for 2 weeks;
At the same time in the morning and in the early evening;
Before taking any inhalers, or as instructed by your caregiver.
https://my.clevelandclinic.org/health/articles/4298-peak-flow-meter
Surgery in ectopics
Hemodynamic instability, impending rupture
Risk factors for rupture
Contraindications for MTX treatment: e.g., renal insufficiency
If conservative treatment is unsuccessful
Laparoscopic removal
1) Salpingostomy (tube‑conserving operation)
Risk of persistent ectopic pregnancy
Patients with unruptured tubal pregnancy who do not meet the criteria for conservative treatment
2) Salpingectomy (not function-preserving)
Ruptured tube, heavy bleeding, large ectopic mass
If the patient does not desire future pregnancies → bilateral salpingectomy
PSYCHIATRIC FUNCTIONAL ENQUIRY: MOAPS
M: mood (depression vs euthymia vs mania)
O: organic/substance use, medical illness
A: anxiety (worries, compulsions, obsessions)
P: psychotic symptoms (hallucinations, delusions)
S: safety (risk of suicide: ideation, plan, means)
What is the DERMIS acronym? (definition of Borderline PD)
D: defence mechanisms(i.e. splitting, projecting anger onto all those around them)
E: ego strength lacking, can’t put off instant gratification
R: relationship difficulties
M: mood instability
I: impulsivity
S: ense of self disrupted, suicidality, self harm
Why is it that the negative symptoms are often the most disabling symptoms in the long term picture of schizophrenia?
These are not easily controlled, as anti-psychotic treat the +ve symptoms only.
When is clozapine contraindicated?-5
Previous cardiomyopathy Blood dyscrasias (any pathological condition of blood) Neutropenia Severe renal impairment Liver failure
How do you manage NMS?
- Stop any agents that are thought to be causing
- IV fluids (flush out the CK MM and prevent acute kidney injury)
- O2
- Dantrolene to relieve rigidity
- Anti-pyretics to cool down
…so just think of the symptoms, and how you would individually manage that
What are some differentials for serotonin syndrome?
Neuroleptic malignant syndrome
Substance abuse (cocaine/stimulants)
Infections (sepsis, meningitis)
Malignant hyperthermia
What benzodiazepines bypass the liver and therefore are safer to give without knowing liver function?
LOT
Lorazepam
Oxazepam
Temazepam
Imagine it these benzo are alot for the liver to handle so they bypass it
What is a major distinguishing clinical finding that you have in serotonin syndrome and not in neuroleptic malignant syndrome?
Hyper-reflexia - otherwise it is very similar.
What is the comparison of the therapeutic window of sodium valproate and lithium?
Sodium valproate has a wide therapeutic window - meaning that accidental overdose is uncommon
What diagnoses are important to exclude/consider in somebody presenting with symptoms of panic attack? (Particularly if it is a 1st presentation)
ARDS/pneumonia
PE
Asthma
Diabetic ketoacidosis (kussmaul breathing)
What is a common SSRI used in anxiety?
Escitalopram
What are examples of things that can bring about an adjustment disorder?
What other condition should you keep in mind with Adjustment disorder
Relationship breakdown/divorce
Becoming a parent
Leaving home
Screen for depression and suicide as well
What is the biggest risk with re-feeding syndrome?
Cardiac decompensation, metabolic increase not tolerated by the heart leading to tachycardia and oedema
What is the mechanism of action of EtOH?
Potentiates GABA-A transmission (depressant), increased dopamine in mesolimbic pathway (addictive component)
There are 4 stages of alcohol withdrawal, what are they?
1: ‘shakes’, sweating, cramps, diarrhoea, cramps
2: Seizures (<48 hours)
3. Hallucinations (at 48 hours)
4. DT’s, confusion, delusions, autonomic hyperactivity
When do you give benzos in alcohol withdrawal?
When there is symptomatic withdrawal - i.e. according to the CIWA score
Why is antibiotic therapy not recommended in children with bloody diarrhoea without fever?
If caused by EHEC can lead to haemolytic uremic syndrome
Avoid use of antibiotics and antimotility agents in suspected infection with enterohemorrhagic E. coli, as these agents may increase the likelihood of HUS.
Please discuss the mechanism of citalopram
An SSRI
Block SERT at presynaptic terminal to increase 5-HT at the synaptic cleft.
This increases post synpatic response to serotonin. However, by activating autoreceptors on the presynaptic cleft, it can lead to negative feedback, thus worsening the symptoms iniitally. However, these downregulate eventually, and the response improves.
Note this mechanism is the same for tolerance, except observed on the post synaptic membrane
Foetal and Maternal complications of GDM
Foetal:
Birth trauma (obstructed vaginal delivery) increased need for c-section Macrosomia, organomegaly, polycythaemia, jaundice Hyperinsulinaemia Shoulder dystocia Neonatal hypoglycaemia Increased need for premature delivery ARDS Increased need to c-section IUFD LONG-TERM impaired glucose tolerance, T2DM, obesity
Maternal Miscarriage Preeclampsia Infection Induction of labour Trauma C-section PPH Increased risk of T2DM + HTN Increased risk of hypoglycaemia
Types of rectal prolapse?
Type one and two. One is just the mucosa protruding past the external anal sphincter. This is more common in children. Two is complete, and involves the full thickness of the wall. and is broken up like this:
First degree: Prolapse includes the mucocutaneous junction.
2nd: Without involvement of the mucocutaneous junction
3rd: Prolapse is internal, concealed or occult. This is otherwise known as an internal intussusception.
What is Hartmann’s Pocuh
This is the junction of the neck of the gallbladder and the cystic duck. THis is where stones fall to be stuck.
Gallstones may lodge in it
What are some risk factors for gallstones you learnt today?
Terminal ileum dmaage, weight loss (learnt why: rapid weight loss leads to excess mobilisation of cholesterol and biliary stassis), TPN (due to impaired gallbladder emptying). I would also imagine dehydration is a risk factor. Remember oestrogen slows the transit of bile in the biliary system which is the pathogenesis of cholestasis in pregnancy.
The patient has a post operative fever,and pain in the RUQ after a cholecystectomy. What is the diagnosis unitl proven otherwise?
Bile duct injury
What is post cholecystectomy syndrome?
Sphincter of Oddi dysfunction. It’s a persistence or recurrence of pain after the cholecystectomy. Alternative explanations include post op adhesions.
Role of USS and CT in pancreatitis?
Role of US is to rule out gallstones, and is commonly used in the first episode of pancreatitis. CT is to assess any complications such as a pseudocyst and to measure the extent of the necrosis. CT best done around the 72 hour mark otherwise it’s known to underestimate the extent of the disease.
how do we divide the management of acute pancreatitis? Describe the steps involved?
→ Treatment with acute pancreatitis is directed four ways: general, local, complications and cause
- General
o Treat fluid loss
• If severe: careful fluid replacement with central venous pressure measurement may be necessary
• Monitor urine output: IDC
o Oxygen, Analgesia
o PPI
o AWS, thiamine
o NBM
o Nutrition- initially fast the patient, enteral nutrition has now been shown to prevent mucosal barrier breakdown and abscess formation → NG feeds if severe
- Local
o There is no specific treatment for the pancreatic inflammation
• Therefore treatment is directed at minimising the progression of the disease and preventing complications
o Antibiotics: imipenem
• Only if they have an infection, not just because they are febrile
• Prophylaxis not shown to be effective
o ERCP
• Early ERCP (<72 hours) versus conservative management extensively studies
• Benefit in cholangitis and obstructive jaundice but there has been conflicting evidence in the remainder of acute pancreatitis
o Laparoscopic cholecystectomy recommended during same admission for all groups
o Necrosectomy
• Indications
• Infected necrosis with septic complications
• Sterile necrosis with progressive deterioration
• Surgical intervention within first 2 weeks carries high mortality
- Complications
o Surgical intervention in pancreatitis is reserved for the treatment of complications and in gallstone pancreatitis for the treatment of the cause
o Severe pancreatitis with infected necrosis: Debriding necrosed tissue necessary
• As seen on a CT or the presence of organisms in tissue that as been aspirated from the pancreas following a percutaneous radiologically guided needle approach
o Pseudocysts: treated via percutaneous or endoscopic techniques or open surgery
o Abscess drainage → percutaneous or open
- Cause
o Gallstones: Cholecystectomy, ERCP
Blood supply of the thyroid gland
Superior thyroid artery is from the external cartoid, the inferior thyroid artery is from the subclavian artery.
Discuss the diabetes cycle of care. What is included in a primary care management plan for T2DM?
Look up guideline
GAD features in DSM?
1) Excessive worry or anixety for most days for more than 6 months which patient finds difficult to control
2) Needs three or more REMDIS features
Restlessness
Easy fatigue
Muscle tension
Difficulty concentrating/ distractibility
Irritability
Sleep disturbance
Causes significant impairment.
Not better explaned by another medical or psyche thin.
Describe refeeding syndrome?
Refeeding ysndrome is when we have a low phosphate level in the body. There is a low amount intracellularly, because a lot of this is shunted to the serum to bring the levels back up. However, when we give insulin, it cannot be compensated, and all the phosphate is driven intracellularly (we get an exacerbated insulin response with long term starvation). Thus, we get hypophosphataemia. Please note that we can also get hypokalaemia with this
Mechanism of SSRI’s
4 ways it works. It inihibits pre ysnaptic uptake of serotonin. And postsynaptic. First step.
2: Increases serotonin in the synaptic cleft. More serotonin to bind to post synaptic receptors.
3: increased binding at post synapse. this is the antidepressant effect. Pre synaptic receptors get downregulated.
4: Post synaptic receptors also become downregulated which is when side effects decrease.
What are some symptoms aside from cardiac and respiratory symptoms in congenital heart defects? Note remember that they can get a cardiac wheeze
Failure to thrive Poor feeding Developmental delay Diaphoresis Easily fatigued Poor exercise tolerance
You know the management of Kawasaki. Why do we delay the MMR vaccine by 3-6 months?
2% rate of recurrence is something I also need to remember.
We delay it because the immunoglobulins can reduce the effectiveness of the MMR vaccine.
What is Nokolsky sign? What other features are typical of SSSS
How do differentiate from TENS?
When you rub the skin it disintegrates.
They will be in a lot of pain, and they won’t like being in contact with Mum.
It starts as exudation and crusting, which progresses to wrinkling, bullae formation and the exfoliation.
TENS will have mucosal involvement (they have eye involvement). Also note SSSS does not scar because it’s only the epidermis.
Discuss the clinical features of HSP
Palpable purpura with arthritis, arthralgia, abdo pain and / or renal involvement (haematuria, proteinuria, HTN)
Pulmonary + neuro involvement are both rare but may be life threatening if present.
PAAR
HSP and abdominal pain
Remember the abdo pain is in intussuseption.
How would you manage the HSP
Depends if there is mild or moderate/ severe pain.
Mild: subcut oedema managed by bed rest + elevation of the affected area. Paracetamol and NSAID’s.
Mod/ severe: glucocorticoids reduce the duration of joint pain and abdo pain. No impact on long term kidneys.
If there is significant renal, pulmonary, neurological or abdo comp, refer to paeds and consider admission.
Follow up is referral to the GP or paediatrician to identify subsequent renal involvement, monitoring for HTN, proteinuria or macroscopic haematuria.
In symptoms/sign is seen in delirium tremens, however not see in the minor, major and seizure stages of alcohol withdrawal
FEVER
Down syndrome causes in the chromosomal, what are 2 processes in the chromosome
1) Non-disjunction-90%
2) Balanced Robertsonian translocation
scaphoid abdomen and respiratory distress in an infant
Congenital diaphragmatic hernia
What are the other names for erythema infectiousum
Fifth disease/parvovirus/slapped cheek syndrome
What Ix is the most important test for urinary incontinence
Post-voidal residual volume(PVRV)–> normally after peeing 50ml of urine is left in the bladder
Urge incontinence- what is the drug
Oxybutynin- anticholinergic
Helps to calm the overactive bladder- detrusor muscle overactivity
Overflow incontinence
-what happens
Urinary retention
Need a catheter
PVRV- high
Men–> due to BPH
The child presents with bloody diarrhea + NO FEVER
parents say he ate some funny
Diagnosis?
- what should you avoid
- what do you see on the blood film
HUS
Abx should be avoided in HUS
treatment is IV fluids, conservative management
RBC transfusion if needed
Dialysis if renal failure
On blood film, you will see schistocytes due to the Shiga toxins effects
PID think?
Ectopic
Do a beta-hCG as well
Needle decompression of pneumothorax- a landmark for insertion
2nd intercoastal space, midclavicular line
SAH- what kind of CT would you do
NON-contrast
Blood appears white
Contrast appears white
So do a NON-CONTRAST
SAH are given CCB why?
Vasospasm of the blood vessels
Acute pancreatitis criteria
Ranson’s criteria
Treatment-
IV fluid, NBM and morphine
Low-fat diet after getting well
The renal stone best test?
-which drug can be given
CT scan
NOT X-RAY
Thiazide diuretic can help- reabsorption of calcium in the urine
What happens to the estrogen and FSH during ovarian failure
Can because of amenorrhea
and seen in MENOPAUSE
FSH is increased due to the negative feedback mechanisms
