Revision mistakes Flashcards
1
Q
Complication of ectopic
A
- Shoulder tip pain (peritonitis)
- Rupture - bleeding/shock
- Methotrexate - not advised to get pregnant for 3 months.
2
Q
Investigations for Molar pregnancy
A
- very high HCG
- uterus size greater than expected for gestational age
- US: snowstorm appearance
3
Q
Length of UTI tx
A
- Pregnancy: 7 days -> trimetho (avoid 1st tri), nitrofu (avoid 3rd), amoxicillin, cefalexin
- LLTI Women: 3 days
- LLTI children: 3 days -> trimethoprim, nitrofurantoin, cephalosporin or amoxicillin
- UUTI children: 7-10 days -> cephalosporin or co-amoxiclav
(infants less than 3 months old should be referred immediately to a paediatrician)
4
Q
RF for placental abruption
A
Abruption prev. Blood pressure ROM Uterine trauma Polyhydramnios Twins Infection Older age Narcotics
5
Q
When is screening for gestational diabetes and what are RF’s
A
Screened at 24-28 weeks if have RF (prev. macrosomic baby, prev. gestational diabetes, BMI>30, ethnic origin, FH diabetes, glucose in urine dipstick, current polyhydramnios/ big baby).
- OGTT - 5.6 (fasting), 7.8 (2 hours post)
6
Q
Mx of pre-existing diabetes
A
- Aim for good glucose control and high dose folic acid (5mg/day) from 3 months preconception until 12 weeks.
- Retinopathy screening and tx if needed
- Stop other diabetic drugs except metformin and insulin
- Advise a planned delivery between 37-39 weeks
7
Q
Mx of gestational HTN
A
- Aim for BP below 135/85
- Urine dipstick + blood tests weekly with monitoring of ctg
- PIG testing once
- Stop Acei, ARB, thiazides. Use labetalol, ca2+ blockers, alpha-blockers
8
Q
Pre eclampsia RF
A
High: pre-exist HTN, prev HTN in preg, AI, T1/2DM, CKD
Mod: 40+, BMI >35, 10+ years since last preg, 1st preg, FH
9
Q
Mx of pre-eclampsia
A
When pre-eclampsia is diagnosed, the general management is similar to gestational hypertension, except:
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure is monitored closely (at least every 48 hours)
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
- Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Meds: Labetalol/nifedipine/methyldopa/IV hydralazine (severe)
10
Q
Causes of Oligohydramnios
A
decreased fetal urination (fetal renal problems),
decreased production (placental problems, IUGR, pre-eclampsia), PROM, post-term gestation
11
Q
Cause of Polyhydramnios
A
- Most commonly idiopathic
fetal swallowing prob (duofenal atreisa, neuro disorders), fetal urination increase (fetal anaemia, maternal diabetes, microsomic baby), secretions of fetal lung fluid, hydrops fetalis, fetal hypoxia
12
Q
Mx (+length of Mx) of VTE in pregnancy
A
- LMWH -> dalteparin based on weight at booking clinic or early pregnancy. Immediately, before dx confirmed.
- LMWH continued for rest of pregnancy + 6wk post natally or 3 months in total (whichever is longer)
Massive PE: emergency unfractionated heparin, thrombolysis or embolectomy.
13
Q
Where is ectopic most common + most dangerous
A
Tubal - most in ampulla. Most dangerous in isthmus
14
Q
What is PPH defined as
A
500ml loss after vaginal delivery
15
Q
Most common side effect in IUD and IUS
A
IUS - initial spotting/irregular bleeding
IUD - heavier, longer, more painful periods
16
Q
Transgender male w/vagina on testosterone therapy. Is he safe against pregnancy?
A
- Not protected. Testosterone teratogenic and not safe with pregnancy.
- IUD copper coil safe option
17
Q
At what gestation would a referral to the maternal fetal medicine unit be made for a woman who hasnt felt fetal movements
A
24 weeks
18
Q
In a patient with asthma + HTN having a PPH what medical management should be administered and what avoided?
A
- IV oxytocin
- IM carboprost contraindicated in asthma
- IM/IV ergometrine contraindicated in HTN
19
Q
Is methotrexate safe to take preconception/pregnancy
A
Methotrexate: must be stopped at least 6 months before conception in both men and women
20
Q
What is the SSRI of choice in children/adolescents
A
Fluoxetine
21
Q
What are stroke mimics?
A
HEMI: Hypoglycemia (and hyperglycemia), Epilepsy, Multiple sclerosis + Migraine and Intracranial tumors (or Infections, such as meningitis, encephalitis and abscesses)
22
Q
At what week of pregnancy is HTN classed as gestational/pre-eclampsia rather than pre-exsiting
A
20wk+
23
Q
Regarding temperature in an infant what classes as high and what as medium risk
A
<3 months and temp 38+ degrees = red
3-6 months and temp 39+ degrees = amber
Fever for 5+ days = amber
24
Q
What complication can B19 infection of a pregnant women cause, and treat with what?
A
Hydrops fetalis -> ascites, oedema
Tx: transfusion
25
What is complication of kawasaki and how do investigate for it
Coronary artery aneurysm - echocardiogram
26
What are the signs of congenital varicella syndrome
SMELL
Skin scarring
Microcephaly
Eye problems - cataracts
Limb hypoplasia
Learning difficulties
27
What is the school exclusion period for impetigo + Tx
- 48hrs after abxx or until all crusted over
- Hydrogen peroxide or fusidic acid (topical abx) or flucloxacillin (severe)
28
Tx for oral candidas vs vaginal candidas
ORAL:
1. Miconazole gel
2. Nystatin suspension
3. Flucanozole (severe)
Vaginal:
1. Oral flucanazole single dose
2. Clotrimazole cream
29
Tx for Gram +ve diphtheria bacteria
IM penicillin, diphtheria antitoxin
30
Tx of pyelonephritis
<3 months: immediate IV ceftriaxone. Admission
>3months: cefalexin or co-amoxiclav oral abx for 7-10 days
31
Tx for nocturnal enuresis
1: fluid intake, reward systems, enuresis alarm
2. Desmopressin
3. Oxybutinin
32
What signs may show on an xray for perthes disease and what is the main complication
Widening/irregularity of joint space, crescent sign (osteonecrosis)
Early hip osteoarthritis
33
Signs/symptoms of Osteogenesis imperfecta
- unusual recurrent fractures
- Blue/grey sclera
- Hypermobility
- May have short stature, triangular face, deafness, bone deformities
34
Signs/symptoms of Rickets
- Abnormal fractures
- Poor growth
- Deformities - delayed teeth, swollen/widening of wrist joints, craniotabes (soft skull with frontal bossing), knock knees, bowing of legs
- Colder climate/ low exposure to sunlight
35
Blood results in rickets
- low calcium, phosphate, high PTH, ALP
36
How many joints are affected in oligoarticular JIA
<5 joints
37
Mx of reduced fetal movements
- <24wks: Doppler. If never felt = onward referral to fetal medicine centre for evidence of fetal neuromuscular conditions
- 24-28wks: Doppler. Consider US if clinical suspicion of RFM.
- 28wks+: Doppler.
No FHR = Immediate US
FHR = CTG to monitor + exclude compromise
If normal CTG, but concern remains -> urgent US (within 24hrs)
38
What are the features of Brown-Sequard
- Caused by lateral hemisection of the spinal cord
features:
- ipsilateral weakness below lesion
- ipsilateral loss of proprioception and vibration sensation
- contralateral loss of pain and temperature sensation
39
A 60-year-old man with chronic schizophrenia presented with nausea and vomiting. He receives metoclopramide for his symptoms. Twenty minutes later he becomes agitated and develops marked oculogyric crises and oromandibular dystonia.
What is the most appropriate drug to prescribe?
Acute dystonia secondary to antipsychotics is usually managed with procyclidine
40
Atypical antipsychotic SE's
Weight problems = hyperlipidaemia + glucose intolerance
Immune problems = agranulocytosis + neutropaenia
Cardiac problems = myocarditis + arrhythmias
41
What weight classes as macrosomic
Baby weighing 4.5 kg or more
42
Causes of constipation in children
The vast majority of children have no identifiable cause - idiopathic constipation. Other causes of constipation in children include:
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung's disease
hypercalcaemia
learning disabilities
43
RF's for cervical ectropion
Elevated oestrogen - COCP, ovulatory phase, pregnancy
44
What are the signs of Cushings triad that may occur with raised ICP
hypertension
bradycardia
irregular breathing
= is a late sign indicating impending brain herniation. Systolic hypertension occurs as a reflex to maintain cerebral perfusion pressure in the presence of raised intracranial pressure.
45
What drugs do SSRI's interact with
- NSAIDS/aspirin -> if have to then give PPI
- Warfarin/heparin
- Triptans -> increased risk of serotonin syndrome
46
How long to keep person on SSRI for if responding well
6 months, then wean off
47
Risks of SSRI's during pregnancy
- 1st trimester: increased risk of congenital problems. Particularly with Paroxetine.
- 3rd trimester: persistent pulmonary HTN of newborn
48
What should be investigated in a woman with recurring vaginal candidadis
- diabetes (HBA1c), Immunosupression (HIV testing), pregnancy test
49
What is Steven Johnson syndrome + Mx
- It's usually a reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters.
-The patient may present with Nikolsky's sign, where the epidermal layer easily sloughs off when pressure is applied to the blistered or erythematous area.
- emergency referral to burns unit -
Cease all medications, obtain IV access and begin fluid hydration
-> steroids, immunosupressants, supportive care
50
What sign may show up on a CXR for a child with respiratory distress syndrome/SDLD
Ground glass
51
What is the sarnat scoring for HIE
Conscious level: Irritable/hyper alert (mild), Lethargy (Mod), Comatose/reduced (severe)
Tone: mildly abnormal (mild), hypo/hypertonic (mod), flaccid (severe)
Seizures: absent (mild), present (mod,severe)
Reflexes: Exaggerated (mild), Depressed (mod), absent (severe)
Mild: Resolves within 24 hr
Mod: Weeks. 40% risk of CP
Severe: 90% CP, 50% mortality.
52
Why is therapeutic cooling used in HIE
The intention of therapeutic hypothermia is to reduce the inflammation and neurone loss after the acute hypoxic injury. It reduces the risk of cerebral palsy, developmental delay, learning disability, blindness and death.
53
RFs for neonatal hypoglycaemia
- Prematurity, maternal diabetes, IUGR, sepsis
54
What does APGAR stand for
appearance (color), pulse, grimace (reflex), Activity (muscle tone), RR
55
What do you see on pelvic US with a patient with ovarian torsion
Whirlpool sign or free fluid
56
What are the features of noonan syndrome
Short stature, Low set ears, Webbed neck, Sunken chest, Pulmonary stenosis, Bleeding disorders
(think Turners but also in males)
57
Features of Williamsssss
smiley, sociable, short, supravalvular aortic stenosis, star-shaped eyes
58
Features of Angelmanns
Seizures, Ataxia, Intellectual disabilities, Laughter (inappropriate), fascination with water
59
Breastfeeding - mx to suppress lactation
- stop the lactation reflex i.e. stop suckling/expressing
- supportive measures: well-supported bra and analgesia
- cabergoline is the medication of choice if required
60
SSRI if breastfeeding
sertaline or paroxetine
61
When to take 5mg folic acid
Metabolic disease - diabetes/coeliac, Obesity, Relative of neural tube defects, Epilepsy. + sickle cell/thalassemia
62
Differential diagnosis for peripheral sensory neuropathy
ABCDE Mnemonic
Alcohol
B12/Folate
Chronic Renal Failure
Diabetes Mellitus
Everything Else (!) - Vasculitis and Paraneoplastic
63
Breast Cancer Question: Management of HER2 positive tumours
Receive Trastuzumab (otherwise known as Herceptin) which is a monoclonal antibody against the extracellular domain of the HER2 receptor
64
Optic neuritis Question: Clinical features
The clinical diagnosis of ON consists of the classic triad of:
Visual loss
Periocular pain
Dyschromatopsia
65
What are the most common sites affected by osteosarcoma?
Distal femur and proximal tibia, humerus
66
Which routine investigations should be ordered in patients with suspected dementia?
Full blood count, biochemistry tests (electrolytes, calcium, glucose, and renal and liver function), thyroid function tests, serum vitamin B12 and folate levels.
6CIT, 10-CS,
67
What does Section 136 of the Mental Health Act involve?
The police can bring someone from a public place who appears to have a mental disorder to a Place of Safety (either the police station or more commonly A&E)
68
What is defintion of anorexia nervosa
Anorexia Nervosa is a disorder characterised by deliberate weight loss, induced and sustained by the patient. There must be clear concerns from the individual regarding their weight and shape, with a fear of becoming fat as an intrusive overvalued idea.
It is important to keep in mind weight control by other compensatory measures, such as excessive exercise, laxative use, or vomiting.
69
What is Parkinsonism
Parkinsonism is an umbrella term for the clinical syndrome involving bradykinesia together with at least one of the following: rigidity, tremor, and postural instability.
70
What is Reyes syndrome
Aspirin is usually avoided in children due to the risk of Reyes syndrome (liver and brain damage).
71
Absolute contraindications to External Cephalic Version
Caesarean section is already indicated for other reason
Ante-partum haemorrhage has occurred in the last 7 days
Non-reassuring cardiotocograph
Major uterine abnormality
Placental abruption or placenta praevia
Membranes have ruptured
Multiple pregnancy (but may be considered for delivery of the second twin)
72
Mx of JIA
- NSAIDs
- Steroids
- Immunotherapy -> TNF inhibitors, methotrexate
73
What are the types of facial nerve palsy
- UMN: Unilateral facial weakness, Forehead spared, drooping of eye, loss of nasolabial fold. SUSPECT STROKE
- LMN: Forehead not spared, unilateral facial weakness, drooping of eye...
74
Causes of LMN facial nerve palsy and Tx
- Bells -> idiopathic. Prednisolone (<72hrs) + lubricating eye drops. Paralysis no improvement after 3 weeks, then refer urgently to ENT.
- Ramsey Hunt -> VZV. Vesicular rash around their ear, hearing loss/tinnitus/vesicles in ear and a facial nerve palsy. prednisolone + aciclovir + eye lubricating drops
75
When is surgical referral indicated in Vesico-ureteric reflux?
Surgery is indicated for grade IV or V (reflex through to the calyces of the kidneys) or if there is a history of recurrent UTIs.
76
Combined Hormonal Contraception Question: Side effects
Breast tenderness, enlargement
Headache
Changes to mood and libido
Nausea and vomiting
Irregular menstrual bleeding, spotting, amenorrhoea
Ovarian cysts
Venous thromboembolism
77
Breast cancer staging
TNM Staging
T1 <2cm
T2 2-5cm
T3 >5cm
T4 Spread to the chest wall, skin or inflammatory breast cancer
N0 No node metastasis
N1 1-3 ipsilateral nodes
N2 4-9 ipsilateral nodes
N3 10 or more ipsilateral nodes
M0 No metastasis
M1 Metastasis
78
Presentation of Wilm's tumour/Nephroblastoma
- Under 5 w/ mass in abdomen
- Ballotable mass in kidney/flank
- Abdo pain, haematuria, fever, weight loss, HTN
79
Ix of Wilms
- initially US.
- But CT/MRI to stage
- Biopsy = definitive
80
Diagnosis of Guillain barre
A diagnosis of Guillain-Barré syndrome is made clinically. The Brighton criteria can be used for diagnosis.
Diagnosis can be supported by investigations:
Nerve conduction studies (reduced signal through the nerves)
Lumbar puncture for CSF (raised protein with a normal cell count and glucose)
81
How should children be monitored after an episode of henoch-schonlein purpura?
After an episode of HSP, children should have regular urine dips for 12 months to check for renal impairment.
82
Most common type of hernia in paediatrics and why
- indirect inguinal hernia, patent processus vaginalis
83
What are examples of sensitisation events?
Examples of sensitisation events include:
- delivery of a Rh +ve infant, whether live or stillborn
- any termination of pregnancy
- miscarriage if gestation is > 12 weeks
- ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
- external cephalic version
- antepartum haemorrhage
- amniocentesis, chorionic villus sampling, fetal blood sampling
- abdominal trauma
84
Features of haemolytic disease of the newborn
Hydrops foetalis appearing as foetal oedema in at least two compartments (for example pericardial effusion, pleural effusion, ascites), seen on antenatal ultrasound
Yellow coloured amniotic fluid due to excess bilirubin
Jaundice and kernicterus in the neonate
Foetal anaemia causing skin pallor
Hepatomegaly or splenomegaly
85
What is infectious mononucleiosis and what is the px
Infectious mononucleosis (glandular fever) is caused by the Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4)
- The classic triad of sore throat, pyrexia and lymphadenopathy
-> palatal petichae
-> may be hard to distinguish from tonsilitis (which is less severe + shorter)
- Advise against contact sports and heavy lifting for 1 month to minimise risk of SPLENIC RUPTURE
86
What is the main Ix for infectious mononucleoisis
- Heterophil antibody test (Monospot test) - NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
87
Breast fibroadenoma/ breast cyst
- Fibroadenoma basics:
Develop from a whole lobule + common in younger women
MOBILE, firm, SMOOTH breast lump - a 'breast mouse'
No increase in risk of malignancy
If >3cm surgical excision is usual
88
Cord Prolapse Question: Management
The foetus should be delivered as rapidly as possible, e.g. via an instrumental delivery, or if the cervix is not fully dilated, caesarean section
While preparing for delivery, prevent further prolapse by adopting a 'knees-to-chest' position
Filling the bladder with 500ml warmed saline can aid in preventing further prolapse
Avoid exposure and handling of the cord, reduce cord into the vagina
Tocolytics e.g. terbutaline to stop uterine contractions
89
What is the mechanism of action of Lorazepam?
Benzodiazepine: increased activity at GABA-A receptors
90
What is myotonic dystrophy
Increase in muscle tone/tension, leading to degeneration of muscle fibres. Inherited autosomal dominant condition - trinucleotide repeat
91
What are the clinical features of myotonic dystrophy?
It is useful to think of the clinical features from head to toe:
Typically present in their 20s: (20s + balding = unusual)
Features in the face: frontal balding, myopathic facies (a long and thin face), bilateral ptosis, cataracts.
Features in speech: dysarthria (caused by a myotonic tongue and pharyngeal muscles).
Features in the neck: wasted sternocleidomastoid muscles.
Features in the hands: distal wasting and weakness, slow relaxing grip (when shaking hand takes a while to let go), percussion myotonia (thumb flexion on percussion of the thenar eminence).
Internal features: insulin resistance/metabolic syndrome - type 2 diabetes, cardiomyopathy/arrhythmia, testicular atrophy.
92
What is anticipation phenomenon
A phenomenon in which the signs and symptoms of some genetic conditions tend to become more severe and/or appear at an earlier age as the disorder is passed from one generation to the next
93
What are Duchenne and Beckers dystrophy
degeneration of muscle fibres. Mutation of dystrophin gene
- More severe Duchenne than Beckers, symptoms by age 5.
- More common in males
94
A 25 year old male patient presents to the general practitioner with gradually worsening weakness in his hands.
On physical examination there is frontal balding. At the end of the consultation the GP notices that the patient has difficulty letting go when he shakes his hand.
what is condition?
Myotonic dystrophy
95
Duchenne dystrophy presentation, Dx, Tx
Muscle wasting and weakness in early childhood
SIGNS:
- Progressive proximal muscle weakness from 5,
- Gowers sign positive (walk their arms up their legs when getting up from the floor),
- Calf pseudohypertrophy,
- Bulky appearing muscles, slip through parents hands
- associated with dilated cardiomyopathy
- Usually wheelchair-bound before puberty and die from respiratory failure by their early twenties.
Dx:
- raised creatinine kinase
- genetic testing has now replaced muscle biopsy as the way to obtain a definitive diagnosis
Tx: None, supportive
96
Beckers dystrophy
- Muscle wasting and weakness presents in late childhood - Usually become wheelchair-bound in their teens commonly survive into their thirties.
97
What is mammary duct ectasia
Mammary duct ectasia is a palpable, peri-areolar breast mass caused by inflammation and dilation of the large breast ducts. It commonly presents with thick, green/yellow/white nipple discharge. It may mimic the appearance of cancer on mammography.
98
Features of mastitis
- Inflammation of breast tissue +/- infection.
- Localised symptoms include a painful, tender, red and hot breast
- Systemic symptoms include fever, rigors, myalgia, fatigue, nausea and headache
- development of a breast abscess which presents as a fluctuant, tender mass with overlying erythema.
99
Mx of mastitis
Reassure lactating women that they can continue to breastfeed
Advise on methods to facilitate milk removal e.g. manual expression
Analgesia
Consider a course of oral antibiotics according to local protocol
If condition does not improve, may require intravenous antibiotics or surgical management, particularly if a breast abscess develops
100
Mx of necorotising enterocolitis (PREMATURE NEONATES)
-Necrotising enterocolitis is managed with broad-spectrum antibiotics (to cover both anaerobic and aerobic bacteria) and parenteral nutrition (to rest the bowel). - Supportive treatment with IV fluids and ventilation are also crucial.
- Surgery to resect necrotic sections of bowel may be necessary, and is essential in cases of bowel perforation.
101
What is idiopathic intracranial hypertension
= chronic ICP with unknown etiology. Most common in young, obese women
Px = Classical clinical features include headache and visual disturbance.
The headache is classically non-pulsatile, bilateral, and worse in the morning (after lying down or bending forwards). Papilloedema (most signif - can lead to progressive optical atrophy, visual field loss)
102
Mx of idiopathic intracranial HTN
First line management of idiopathic intracranial hypertension (and the only intervention supported by good evidence) is weight loss.
Failing this, patients often try carbonic anhydrase inhibitors, such as ACETAZOLAMIDE, but its extensive profile of side effects (peripheral paraesthesia, anorexia and metallic dysgeusia) mean that it is poorly tolerated.
More invasive strategies to lower CSF pressure including therapeutic lumbar punctures and surgical CSF shunting are tried in resistant cases.
103
What are the sx of Meniere's
Vertigo - episodic + sudden onset, Ataxia, Unilateral Sensorineural hearing loss, Tinnitus
104
Tx of Meniere's
Management relies on prophylactic use of betahistine to reduce the frequency of attacks, and the acute use of prochlorperazine.
Surgical approaches lack a strong evidence base.
105
What are the sx of Vestibular schwannoma (acoustic neuroma)
Vertigo - usually comes on slowly and gradually gets worse over time, Unilateral Sensorineural hearing loss, ataxia, tinnitus, absent corneal reflex.
Any patients with unilateral tinnitus + sensoneural deafness = MRI to rule out malignancy
106
What is the presentation of benign paroxysmal positional vertigo
- elderly, calcium deposits within semicircular canals
- BPPV is provoked by movements of the head usually to one side when turning in bed or on looking upwards.
- These sudden attacks of rotational vertigo last for 30s to 1 minute and are provoked the changing position of the head.
- There are no auditory symptoms for BPPV.
- Episodes will usually disappear within a few weeks or months, but they often recur.
107
Ix and Mx of benign paroxysmal positional vertigo
The diagnostic test is the Dix-Hallpike manoeuvre
The therapeutic manoeuvre is the Epley manoeuvre.
108
Complications of twin to twin transfusion syndrome
One fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the fetuses.
109
What is Centor score used for
- likelihood of bacterial group A strep as being cause of sore throat (3or4/4)
110
Mx of bacterial tonsilitis
centor score of 3/4 -> 1st line penicillin V. Penicillin allergy = macrolide
111
Indications for tonsillectomy in recurrent tonsilitis
7+ episodes in one year, 5+/year in two years, 3+/year in 3 years
112
Features of pseudobulbar palsy
Clinical signs include a spastic tongue, a slow thick ("hot-potato") speech, a brisk jaw jerk reflex, and emotional lability. Other upper motor neurone features in the limbs may be present e.g. spastic hypertonia, pyramidal weakness, and hyper-reflexia.
113
Causes of pseudobulbar palsy
Vascular - stroke, degenerative - MND, brainstem tumours, MS, traumatic causes
114
Features of bulbar palsy
Clinical signs include an absent or normal jaw jerk reflex, an absent gag reflex, a flaccid fasciculating tongue, nasal quiet speech, and signs suggestive of the cause e.g. limb fasciculations of motor neurone disease.
115
Causes of bulbar palsy
motor neurone disease (in particular the progressive bulbar palsy variant), myasthenia gravis, Guillain-Barré syndrome, brainstem stroke (the lateral medullary syndrome), and syringobulbia.
116
Classic featuers of Stills disease
- salmon-pink rash, high swinging fevers and joint pain.
(In children that have fevers for more than 5 days, the key non-infective differentials to remember are Kawasaki disease, Still’s disease, rheumatic fever and leukaemia.)
117
Classic features of rheumatic fever + mx
- AI disease triggered by Gp A strep:
-> 2 – 4 weeks following a streptococcal infection, such as tonsillitis
Px: JONES (major) PEACE (minor)
- Joints - arthritis, O - heart -> myocarditis/valvitis, Nodules, Erythema marginatum (pink rings), Sydenhams chorea
- Previous RF, ECG with PR prolongation, Arthralgia, CRP+ESR elevated, Elevated temp/fever
Tx: phenoxymethylpenicillin (penicillin V) for 10 days.
118
First line tx of nocturnal enuresis in under 5 year old
Children under the age of 5 years who have nocturnal enuresis can be managed with reassurance and advice
119
Difference between MS and peripheral neuropathy
-MS produces a wider range of symptoms than peripheral neuropathy does.
Both MS and PN can cause tingling, pain, or decreased sensation of the hands, arms, feet, or legs, but patterns and timing differ.
- The tingling and other sensory problems of MS tend to affect one side of the body, while both sides generally are affected in peripheral neuropathy in what is described as a "stocking-glove" pattern.
- MS is more likely than PN to cause muscle weakness, but some types of peripheral neuropathy can make you weak as well. MS is also much more likely than peripheral neuropathy to cause:
Bowel and bladder control problems
Sexual difficulties
Visual problems
Slurred speech
Trouble swallowing
- Cognitive (thinking and problem solving) difficulties are only seen in MS patients.
120
RF's for endometrial cancer
- extra oestrogen: obesity, nulliparity, early menarche, late menopause, unopposed oestrogen, PCOS
- diabetes mellitus
- tamoxifen
121
A 24-year-old man is brought in by his family out of concern about his 'personality change'. He talks about an interesting television programme that tells him about his secretive role.
What is the most likely psychopathology described by the patient?
Delusional perception (not grandiosity) - as theres a real stimulus. Delusion formed from perception of a real stimulus.
122
A 27 year old woman attends for colposcopy after a high-risk HPV and abnormal cells are found on routine smear. She receives the results and she is found to have low grade CIN (CIN 1). Her previous smears have all been normal.
What is the most appropriate management?
Conservative mx and repeat cytology in 6 months.
- If persistent CIN1 or higher grade, then large loop excision of transformation zone
123
Why shouldn't give dextrose solution + cyclizine to a pateint with hyperemesis graviradum?
Mx options for hyperemeis graviradum?
Can precipitate Wernicke's encelalopathy
- Mx: Antihistamines - oral CYCLIZINE OR PROMETHAZINE (1st line). METOCLOPRAMIDE (2nd - not used for 5+ day). ONDANSETRON during first trimester small risk of baby having cleft lip/palate. NORMAL SALINE IV hydration.
124
What factor may cause a rise/decrease in clozapine blood levels?
Smoking cessation/starting smoking
125
What is necrotising fascilitis and which condition associated with
- chicken pox
- a rare bacterial infection that spreads quickly in the body and can cause death.
- NSAIDs can increase risk
126
MRI with or without contrast
Reason not to do contrast: pregnancy or renal disease
Then assuming they are safe to have contrast;
Contrast is used to look for something, for example a mass if your thinking brain tumour or you want to look more in detail at the tissues. So in this case where it could be MS you want to look at the tissue and see if there are plaques which would be consistent with MS.
Non-contrast is more suitable if you just need to look at the area rather than FOR something or at the specific tissue. So an example would be looking at a brain haemorrhage or ischaemic stroke. You dont need to look specificaly AT the nature of the tissue, you just need to look at the area for any changes
127
What factors during pregnancy require a routine neonate hip ultrasound exam
- first degree FH of hip problems in early life
- BREECH AT OR AFTER 36 wks
- Multiple pregnancy
128
What is a quick and easy bedside test to perform to confirm that the fluid is CSF?
- Glucose
- Beta-2-transferrin (gold standard but wouldnt be quick)
129
Mx of PPH
1. ABC approach
-lie the woman flat
-bloods
-commence warmed crystalloid infusion
2. mechanical
- palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- catheterisation to prevent bladder distension and monitor urine output
3.medical
- IV oxytocin: slow IV injection followed by an IV infusion
- Ergometrine slow IV or IM (unless there is a history of hypertension)
- Carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- tranexamic acid may play in PPH
4. surgical: if medical options fail to control the bleeding then surgical options will need to be urgently considered
- intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
- other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
5. severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
130
What are cut offs for down syndrome screening
Combined: 11 - 13+6 weeks -> ↑ HCG, ↓ PAPP-A, thickened nuchal translucency
Quadruple: ↓ AFP↓ oestriol ↑ hCG ↑ inhibin A
131
Mx of GAD
Education+monitoring/Low intensity intervention/high intensity or CBT
SSRI/SNRI/Pregablin
132
Mx of chicken pox in pregnancy
Prophylaxis:
- Any doubt about having chicken pox: varicella Ab check
- <20wk: VZIG immediately
- >20wk: VZIG or Aciclovir 7- 14 days POST EXPOSURE
Present w/rash:
- If <24hrs post rash and >20wk: aciclovir
- If <20wk: consider aciclovir w/ caution
