Specialties Flashcards
Small for Dates
Definition:
Birth weight below 10th centile for gestational age
Aetiology:
Most commonly hypoglycaemia
Asymmetrical (most common) - Placental insufficiency, pre-eclampsia, multipregnancy
Symmetrical - intrinsic fetal (chromosomal, intrauterine infection), maternal eg. alcohol/drug abuse
Clinical Features:
Asymmetrical - brain and head growth relatively spared
Symmetrical - head circumference is proportionally decreased
Investigations:
Simple - immediate BM and monitoring, urine for ketones
Bloods - serum glucose and insulin, venous gases
Imaging -
Other -
Management:
Conservative - Early first feed
Medical - IV dextrose
Surgical -
Physiological Jaundice
Definition:
Jaundice after 24 hours. Usually resolves <2 weeks
Aetiology:
Immature liver. May only be diagnosed after ruling out other causes
Clinical Features:
Jaundice
Investigations:
Simple -
Bloods - FBC, CRP, LFTs, split Bilirubin, TFTs, group & Coombs
Imaging - USS liver for obstruction
Other -
Management:
Conservative - Phototherapy
Medical -
Surgical -
Cerebral Palsy
Definition:
Disorder of movement and tone caused by a non-progressive brain lesion
Aetiology:
Anoxic brain injury - pre/peri/post-natal
Clinical Features:
Spastic (most common 75%) - hypertonic muscles, pathological reflexes (hemi/di/quadraplegic)
Ataxic - balance problems, fine motor problems, tremor, speech difficulties. Can present with hypotonia
Athetoid - damage to extra and/or pyramidal motor tracts and basal ganglia. Involuntary movements worse on movement. Tone is mixed
Associated - learning difficulties, epilepsy, visual, speech disorders, behaviour problems
Investigations:
Simple - clinical diagnosis
Bloods -
Imaging -
Other -
Management:
Conservative - MDT, physio, dierician, orthotics
Medical -
Surgical - correcting malformation, loosening contractures,
Down’s Syndrome
Definition:
Autosomal trisomy 21
Aetiology:
Non-disjunction (95%) - pair of 21 chromosomes fail to separate at meiosis
Robertsonian Translocation (4%) - long arm of 21 is attached to another chromosome
Mosaicism (1%) - non-disjunction in mitosis
Clinical Features:
Mongoloid slant of eyes, large epicanthic folds, brushfield spots, protuberent tongue, round flat face, flat occiput, single palmar crease, short fingers, wide spaced big toe, hypotonia, learning difficulties
Associated - glue ear, URTI, AVSD, hypothyroid
Investigations:
Simple - clinical diagnosis
Bloods - 12 week screening (aFP, oestriol, bHCG, Inhibin A)
Imaging - nuchal translucency
Other -
Management:
Conservative - supportive
Medical -
Surgical -
Chronic Asthma
Definition:
recurrent, reversible airway obstruction
Aetiology:
bronchial hypersensitivity, mucosal swelling, increased mucus secretion
Triggers - exercise, infection, pollution/smoking, allergens, drugs (b-blockers, NSAIDs, aspirin)
RF - atopy, FH, smoking
Clinical Features:
Wheeze
Dry cough
SoB - worse in morning or when triggered
Chest tightness
Investigations:
Simple - sputum C&S, lung function (PEFR low, obstructive pattern)
Bloods - FBC, CRP, U&Es, culture, ABG
Imaging - CXR - hyperinflation
Other -
Management:
Conservative - avoid triggers, inhaler technique, PEFR diary
Medical - see below
Surgical -
UTI
Definition:
Urinary tract infection
Aetiology:
90% E. Coli
DM type1
Obstruction
Idiopathic
Poor nappy hygeine
Clinical Features:
Fever, vomiting, lethargy, abdo pain, collapse, urinary symptoms
Investigations:
Simple - urine dip, C&S, obs
Bloods - FBC, CRP, U&Es
Imaging -
Other - USS, DMSA, MCUG
Management:
Conservative - wipe front to back, avoid bubble bath, cotton underwear
Medical -
<3 yrs - IV amoxicillin + Gentamicin
>3 rs uncomplicated - 3/7 Trimethoprim +- prophylaxis
Complicated - Gentamicin
Prophylaxis - Trimethoprim
Surgical -
Meningitis
Definition:
Bacterial or viral inflammation of the meninges
Aetiology:
Mostly viral - enterovirus, HSV, varicella
Bacterial - Group B strep, E. Coli, strep pneumonia
Non-infective - SLE, sarcoidosis, leukaemia
Clinical Features:
Early - cold peripheries, leg pain, abnormal skin colour, poor feeding,
Classic - fever, neck stiffness, headache, photophobia, irritability, haemorrhagic rash
Late - altered LoC, seizures, confusion, tense fontanelle, increased HR and BP
Investigations:
Simple - urine C&S
Bloods - FBC, CRP, U&Es, C&S, clotting
Imaging - CXR, CT Head
Other - LP if no signs of RICP
Management:
ABCDE approach
Conservative -
Medical - Benzylpenicillin IM until C&S, fluids, paracetamol
Surgical -
Anorexia Nervosa
Definition:
An extreme exaggeration of the widespread habit of dieting. Generally begins with rdinary efforts at dieting in a girl who is somewhat overweight at the time.
Aetiology:
More common in young females of higher socio-economic class.
Clinical Features:
Low body weight, amenorrhoea, persuit of thinness, low BP, brady, constipation, electrolyte imbalances, hormonal disturbance
Investigations:
Simple - obs, urine dip, BM, ECG
Bloods - FBC, CRP, U&Es, TFTs
Imaging -
Other -
Management:
Conservative - Supportive therapy, patient education, build a good relationship, weight control, MDT
Medical - Possible use of chlorpromazine or TCAs to promote weight gain.
Surgical -
Bulimia Nervosa
Definition:
Episodes of uncontrollable overeating (bulimia or binge eating), followed by compensatory behaviours (vomiting, abuse of purgatives)
Aetiology:
Clinical Features:
Binge eating of high calorie foods covertly, vomiting and its complications - arrhythmias, renal injury, UTI, pitted teeth, epileptic fits, tetany, weakness
Investigations:
Simple - Obs, urine dip, ECG, BM
Bloods - FBC, CRP, U&Es, Glucose
Imaging -
Other -
Management:
Conservative - Build relationship with the patient, MDT, supportive, therapy (group or CBT)
Medical - SSRIs - Fluoxetine. TCAs produce immediate reduction in bingeing but unknown long term.
Surgical -
Deliberate self harm
Definition:
A deliberate non-fatal act done in the knowledge that is was potentially harmful.
Risk Factors:
Planning, carried out alone, violent method, note or will, Hx, Male, >45, psychiatric illness
Clinical Features:
Investigations:
Simple -
Bloods -
Imaging -
Other -
Management:
Conservative - Suicide risk assessment, MDT, support
Medical - Treat underlying cause if any
Surgical -
Mental Health Act
Section 2
Section 3
Section 4
Section 5(2)
Section 5(4)
Section 136
Section 2 - Admission for assessment (& treatment)
Application by approved social worker or closest relative on the advice of two doctors.
Lapses after 28 days patient appeal must be within 14 days
Section 3 - Admission for treatment
Exact disorder must be stated and the forms completed by two doctors.
Lapses after 6 months, renewable for 6 months and then for 12 months thereafter
Section 4 - Admission for urgent treatment
Approved social worker or closest relative applies on recommendation of one doctor (usually GP).
Lapses after 72 hours but is usually converted to Section 2 when admitted to hospital.
Section 5(2) - Detention of a patient already in hospital
The doctor in charge applies to the hospital administrator day or night. Cannot be done in A&E as it is not a ward.
Lapses after 72 hours
Section 5(4) - Nurses’ holding powers
An authorized psychiatric nurse may detain a voluntary ‘mental’ patient from self-discharging if there is a risk to self or others.
Lapses after 6 hours and the nurse must find the staff to complete a Section 5(2) or allow the patient’s discharge.
Section 136 - Police arrest in a public place
Allows Police to arrest and convey to a place of safety someone who is believed to be suffering from a mental disorder.
Lapses after 72 hours and the patient must be discharged after assessment or detained under Section 2 or 3.
Alcohol Dependence
Definition:
The 7 essential elements in alcohol dependence syndrome are:
- Subjective awareness of compulsion to drink
- Stereotyped pattern of drinking
- Increased tolerance to alcohol
- Primacy of drinking over other activities
- Repeated withdrawal symptoms
- Relief drinking
- Reinstatement after abstinence
Aetiology:
Genetic factors, learned behaviour, personality disorder, psychiatric illness
Clinical Features:
Intoxication or liver disease
Symptoms of withdrawal - delerium tremens, inc.HR, low BP, tremor, fits, visual or tactile hallucinations. Treat with chlordiazepoxide
Investigations:
Simple - Obs, ECG, BM
Bloods - FBC, CRP, U&Es, LFTs, clotting
Imaging - USS liver is indicated
Other -
Management:
Conservative - MDT, goal orientated treatment plan, address social problems
Medical - Treat withdrawal, detox, vitamin replacement, rehydration, treat underlying medical issues
SSRIs have some evidence in reducing cravings
Acamprosate - maintenance of abstinence
Surgical -
Bipolar Disorder
Definition:
A disorder characterised by mood disturbance (inappropriate dpression or elation in recurring attacks). Usually accompanied by abnormalities in thinking and perception.
Aetiology:
Genetic and environmental factors
Clinical Features:
Depressive - sleep disturbance, reduced weight & appetite, neglect, poverty of speech, low mood, morbid thoughts, delusions, hallucinations
Mania - sleep disturbance, inc. appetite, inc. energy, bright clothing, pressured speech, euphoria, flight of ideas, grandiose delusions, hallucinations
Investigations:
Simple - Obs, urine dip, BM, ECG
Bloods - FBC, CRP, U&Es, TFTs
Imaging -
Other -
Management:
Conservative - MDT, education, community support
Medical - Lithium for prophylaxis (monitor weekly at first) be aware interactions!
Surgical -
Schizophrenia
Definition:
Chronic relapsing condition often presenting with psychotic, disorganisation and negative symptoms with cognitive impairment.
Aetiology:
Genetic, biochemical, psychological, social, family and neurological processes
Clinical Features:
ICD-10
- Thought insertion
- Delusions of control, influence or passivity
- Hallucinatory voices giving running commentary
- Persistant delusions that are inappropriate and impossible
- Persistant hallucinations in any modality
- Interruptions in train of thought “knight’s move”
- Catatonic behaviour
- Negative symptoms - apathy, paucity of speech resulting in social withdrawal
Investigations:
Simple - Obs, urine dip, BM, ECG
Bloods - FBC, CRP, U&Es, LFTs, TFTs
Imaging - ?CTHead
Other -
Management:
Conservative - MDT, social support, education, risk reduction, psychotherapy
Medical - Atypical antipsychotics in new diagnoses eg Risperidone, Clozapine
Surgical -
Antenatal Care
Nulliparous - 10 appointments
Parous - 7 appointments
All appointments include BP measurement & urine dip for proteinuria
Booking visit before 12 weeks of pregnancy. The information is offered verbally and backed up in writing with an opportunity to discuss and ask questions.
Information given covers lifestyle advice and initial measurements of weight, BMI and BP.
The clinician offers screening tests for:
- Anaemia
- RhD and blood group
- Hep B
- HIV
- Rubella susceptibility
- Syphilis
- Bacteriuria
- Sickle cell and thalassaemia (in certain cases)
The clinician also offers scans for:
- Assessment of gestational age (10-13)
- Screening for Down’s (combined 10-14 or quad test <20)
- Anomaly scan (18-20)
Further appointments:
16 weeks - review tests and discuss further or additional care. Iron if Hb <11 g/dL
18-20 weeks - for women who agree to anomaly scan. Further scan at 36 weeks if praevia.
25 weeks - (nulliparous) routine examination with BP, urine, S-F height
28 weeks - routine exam plus anaemia and RhD screen. Offered iron, anti-D and pertussis
31 weeks - (nulliparous) routine plus review 28 weeks tests and identify those needing extra care
36 weeks - routine plus external cephalic version if indicated and follow up of praevia from anomaly scan
38 weeks - routine
40 weeks - routine
41 weeks - routine plus offer membrane sweep and/or induction
NB - Combined or quadruple test for Down’s Syndrome both give a risk of Down’s NOT a diagnosis.
Combined (10-14 weeks) - nuchal translucency plus blood tests for PAPP-A and ß-hCG. Recommended by NHS Fetal Anomaly Screening Programme.
Quadruple if missed USS (14-20 weeks) - AFP, ß-hCG, inhibin-A and oestriol
Anti-D
Definition:
The development of anti-D antibodies occurs as a result of fetomaternal haemorrhage (FMH) in a rhesus D (RhD)-negative woman with an Rh-D-positive fetus.
Indications
Postnatal
A Kleihauer screening test should beperformed within 2 hours of delivery to identify RhD-negative women with a large FMH who require additional anti-D Ig.
For successful immunoprophylaxis, anti-D Ig should be given as soon as possible after the potentially sensitising event but always within 72 hours. Ideally, anti-D Ig should be administered into the deltoid muscle.
Miscarriage
Anti-D Ig should be given to all non-sensitised RhD-negative women who have a spontaneous complete or incomplete miscarriage at or after 12+0 weeks of gestation.
Anti-D Ig is not required for spontaneous miscarriage before 12+0 weeks of gestation, provided there is no instrumentation of the uterus.
Anti-D Ig should be giventonon-sensitisedRhD-negative womenundergoing surgical evacuation of the uterus, regardless of gestation.
Anti-D Ig should be considered for non-sensitised RhD-negative women undergoing medical evacuation of the uterus, regardless of gestation.
Threatened miscarriage
Anti-D Ig should be givento all non-sensitised RhD-negative women witha threatened miscarriage after 12+0
weeks of gestation. In women in whom bleeding continues intermittently after 12+0 weeks of gestation, anti-D Ig should be given at 6-weekly intervals.
Anti-D Ig should be considered in non-sensitised RhD-negative women if there is heavy or repeated bleeding or associated abdominal pain as gestation approaches 12+0 weeks.
Ectopic pregnancy
Anti-D Ig should be given to all non-sensitised RhD-negative women who have an ectopic pregnancy, regardless of management.
Therapeutic termination of pregnancy
Anti-D Ig should be given to all non-sensitised RhD-negative women having a therapeutic termination of pregnancy, whether by surgical or medical methods,
regardless of gestational age.
Routine antenatal prophylaxis
RAADP should be offered to all non-sensitised RhD-negative women.
RAADP is a completely separate entity from the anti-D Ig required for potentially sensitising events.
The routine 28-week antibody screening sample must be taken before administrationofthe first dose of anti-D. This meets the British Committee for Standards in Haematology requirement for a second antibody screen during pregnancy
Gestational Diabetes
Definition:
GD is any degree of glucose intolerance with its onset (or first diagnosis) during pregnancy and usually resolving shortly after delivery.
WHO definitions:
- Fasting venous plasma glucose >7mmol/L
- Plasma glucose >7.8mmol/L 2 hours post 75g glucose load (OGTT)
Aetiology:
Pregnancy hormones decrease fasting glucose levels, increase fat deposition, delay gastric emptying and increase appetite. However, over the course of pregnancy insulin resistnace increases. In women with GD there is an insufficient compensatory rise in insulin production.
RF: >age, high BMI, smoking, previous macrosomia, FH
Women with RFs prompt an OGTT at 24-28 weeks
The risk of perinatal mortality is not increased but there are
Increased perinatal risks of:
Macrosomia
Shoulder dystocia
Birth injuries such as bone fractures and nerve palsies
Hypoglycaemia
Long-term adverse health outcomes in infants born to mothers with gestational diabetes include:
Sustained impairment of glucose tolerance Subsequent obesity (although not when adjusted for size) Impaired intellectual achievement
For the women themselves, gestational diabetes is a strong risk factor for diabetes and metabolic syndrome.
Management:
Conservative - MDT follow up, monitoring, BMs, urinalysis, BP, monthly USS, Dietry advice
Medical - Insulin and/or metformin
Surgical - C-section offered at 38 weeks with hourly BM monitoring (4-7mmol/L), feed baby early (<30mins)
Postpartum - stop drug therapy and check BMs, follow up OGTT at 6 weeks
Pre-eclampsia & Eclampsia
Definition:
Pregnancy-induced hypertension with proteinuria +/- oedema. A multisytem disorder originating in the placenta which also affects hepatic, renal and coagulation systems.
Eclampsia is progression of pre-eclampsia to a seizure. This is a medical emergency
Aetiology:
Primary defect is failure of trophoblastic invasion of spiral arteries.
Risk Factors:
Maternal - previous or FH
Fetal - hydratidiform mole, multiple pregnancy, placental hydrops
Clinical Features:
HPT + proteinuria +/- oedema
Red. plasma volume, inc. peripheral resistance, placental ischaemia (fetal asphyxia), DIC
Investigations:
Simple - routine antenatal screening (BP, urinalysis)
Bloods -
Imaging - Uterine artery doppler may identify at risk women
Other -
Management:
Conservative - Admission if BP is -
>30/20 over booking BP or
>160/100 or
>140/90 + proteinuria
Medical - low-dose aspirin for at risk women. Prophylactic MgSO4 halves risk of eclampsia
Surgical - May have to deliver
Endometriosis
Definition:
Chronic oestrogen-dependent condition characterised by the growth of endometrial tissue in sites other than the uterine cavity.
Aetiology:
Theories include retrograde menstruation, lymphatic spread or metaplasia.
Risk Factors include FH, inc oestrogen exposure.
Multiparity and OCP are protective
Clinical Features:
Dysmenorrhoea, dyspareunia, cyclical or chronic pelvic pain, subfertility, bloating menorrhagia
Investigations:
Simple - pregnancy test, obs, urine dip
Bloods - FBC, CRP, U&Es, amylase
Imaging - USS or MRI
Other - laproscopy is gold standard
Management:
Conservative - education, reassurance,
Medical - COCP, Mirena coil, pain relief
Surgical - excision
Fibroids
Definition:
“uterine leiomyomas” are benign tumours of the smooth muscle cells of the uterus. Their growth is through stimulation by oestrogens.
Aetiology:
Clinical Features:
Menorrhagia, anaemia, discomfort, urinary symptoms, recurrent miscarriage
Investigations:
Simple - pregnancy test, Obs, urine dip
Bloods - FBC
Imaging - USS pelvis
Other - Hysteroscopy +- biopsy
Management:
Conservative - education, reassurance
Medical - NSAIDs (mefenamic acid) and antifibrinolytics (tranexamic acid) reduce menorrhagia
GnRH reduce size of fibroids but have SE (amenorrhoea, menopausal symtoms)
Surgical - Myomectomy, total hysterectomy, uterine artery embolisation
PCOS
Definition:
Systemic disturbance in the metabolism of sex hormones. It causes menstrual dysfunction and signs of androgen excess.
Aetiology:
Inc. LH secretion - inc. androgen - dec. FSH - ovulatory impairment and unruptured cysts.
Clinical Features:
hirsutism, alopecia, deep voice, obesity in 50%, acanthosis nigricans
Investigations:
Simple - obs, BM
Bloods - LH, FSH, TFTs, glucose, lipids
Imaging - USS
Other -
Management:
Conservative - education, lifestyle, MDT
Medical - metformin, glitazones (unlicensed)
Surgical - laproscopic ovarian electrocautery
Acute Lymphoblastic Leukaemia
Definition:
Malignancy of lymphoid cells affecting either B or T cell lines, arresting maturation and promoting proliferation of immature blast cells with bone marrow failure and tissue infiltration.
Aetiology:
Environmental and genetic factors
Clinical Features:
BM failure - anaemia, infection, bleeding
Infiltration - organomegaly, lymphadenopathy, CNS involvement
Investigations:
Simple - obs, BM, urine dip
Bloods - FBC, CRP, U&Es, LFTs, clotting
Imaging - CXR & CT for lymphadenopathy
Other - Blood & BM film, LP
Philadelphia Chromosome = bad prognosis (9:22)
Management: Expert help asap
Conservative - supportive (fluids etc)
Medical - Chemotherapy
Surgical - BM Tx
Acute Myeloid Leukaemia
Definition:
Neoplastic proliferation of blast cells, rapidly progressing with death in ~ 2/12 if untreated.
Aetiology:
Associated with long-term chemo, myelodysplasia, ionising radiation and syndromes (eg Down’s)
Clinical Features:
Marrow failure - anaemia, infection, bleeding
Infiltration - organomegaly, gum hypertrophy, skin involvement
Investigations:
Simple - obs, BM, urine dip
Bloods - FBC, U&Es, CRP, LFTs, clotting
Imaging -
Other - BM biopsy (auer rods), blood film
Management: Expert help asap
Conservative - supportive (fluids etc)
Medical - Chemotherapy
Surgical - BM Tx
Chronic Myeloid Leukaemia
Definition:
Uncontrolled clonal proliferation of myeloid cells
Aetiology:
Philadelphia Chromosome present in >80%
Clinical Features:
Dec. weight, tiredness, fever, sweats, gout, bleeding, hepato-splenomegaly, anaemia
Investigations:
Simple - obs, urine dip, BM
Bloods - FBC, CRP, U&Es, LFTs, clotting
Imaging -
Other - cytogenic analysis of blood or BM
Management:
Conservative - supportive
Medical - Chemotherapy
Surgical - Stem cell Tx
Chronic Lymphocytic Leukaemia
Definition:
Monoclonal proliferation of non-functional B cells. Staging predicts prognosis.
Aetiology:
Clinical Features:
none in 25%, infection, anaemia, dec. weight, sweats, anorexia
Non-tender lymphadenopathy, organomegaly
Investigations:
Simple - obs, urine dip, BM
Bloods - FBC, CRP, U&Es, LFTs, clotting
Imaging -
Other -
Management:
Conservative - monitoring if asymptomatic, supportive
Medical - Chlorambucil to dec. lymphoctye count
Surgical - radiotherapy for symptomatic relief of lymphad. splenomegaly
