Tuesday 10th Flashcards
High risk of developing pre-eclampsia
- hypertensive disease during previous pregnancies
- chronic kidney disease
- autoimmune disorders such as SLE or antiphospholipid syndrome
- type 1 or 2 diabetes mellitus
Blood pressure in pregnancy
- blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
- after this time the blood pressure usually increases to pre-pregnancy levels by term
Hypertension in pregnancy
- systolic > 140 mmHg or diastolic > 90 mmHg
- an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
- No proteinuria, no oedema
Pseudodementia depression
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss
- less than six months
- rapid onset
- biological symptoms e.g. weight loss, sleep disturbance
- patient worried about poor memory
Evra patch is the only combined contraceptive patch licensed for use in the UK
- The patch cycle lasts 4 weeks
- For the first 3 weeks, the patch is worn everyday and needs to be changed each week.
- During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
- Action required if delayed patch change over 48 hours: barrier protection for 7 days and emergency contraception if required
High-risk HPV (hrHPV)
- If hrHPV positive, cytology is performed; if this shows normal cells then the cervical smear test is repeated in 12 months time.
- If this repeat test is still positive for hrHPV but cytology normal, another repeat test in a further 12 months
Sepsis: RED FLAGs
- Responds only to voice or pain/ unresponsive
- Acute confusional state
- Systolic B.P <= 90 mmHg (or drop >40 from normal)
- Heart rate > 130 per minute
- Respiratory rate >= 25 per minute
- Needs oxygen to keep SpO2 >=92%
- Non-blanching rash, mottled/ ashen/ cyanotic
- Not passed urine in last 18 h/ UO < 0.5 ml/kg/hr
- Lactate >=2 mmol/l
- Recent chemotherapy
Sepsis: fluid resus over 16yr
- use crystalloids that contain sodium in the range 130–154 mmol/litre with a bolus of 500 ml over less than 15 minutes
qSOFA score: Sepsis
- Respiratory rate > 22/min
- Altered mentation
- Systolic blood pressure < 100 mm Hg
Sepsis: Amber flags
- Relatives concerned about mental status
- Acute deterioration in functional ability
- Immunosuppressed
- Trauma/ surgery/ procedure in last 6 weeks
- Respiratory rate 21-24
- Systolic B.P 91-100 mmHg
- Heart rate 91-130 OR new dysrhythmia
- Not passed urine in last 12-18 hours
- Temperature < 36ºC
- Clinical signs of wound, device or skin infection
SEPSIS SIX
- Administer oxygen: Aim to keep saturations > 94% (88-92% if at risk of CO2 retention e.g. COPD)
- Take blood cultures
- Give broad spectrum antibiotics
- Give intravenous fluid challenges: NICE recommend a bolus of 500ml crystalloid over less than 15 minutes
- Measure serum lactate
- Measure accurate hourly urine output
Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA)
- PaO2 /FI O2 <400
- Platelets x103 microlitres <150
- Bilirubin µmol/L >20
- Cardiovascular: MAP <70mmHg
- GCS <15
- Creatinine µmol/L > 110
- Urine output ml/day <500
human papillomavirus (HPV) vaccine
all 12- and 13-year-olds in school Year 8
Suxamethonium
- Depolarising neuromuscular blocker
- Inhibits action of acetylcholine at the neuromuscular junction
- Degraded by plasma cholinesterase and acetylcholinesterase
- Fastest onset and shortest duration of action of all muscle relaxants
- Produces generalised muscular contraction prior to paralysis
- Adverse effects include hyperkalaemia, malignant hyperthermia and lack of acetylcholinesterase
Asthma: diagnosis
Patients >= 17 years
- patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma
- all patients should have spirometry: FEV1/FVC ratio less than 70%
- bronchodilator reversibility (BDR) test: in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more- - all patients should have a FeNO test: >= 40 parts per billion (ppb)
Acute otitis externa
- Boil in external auditory meatus
- Acute pain on moving the pinna
- Conductive hearing loss if lesion is large
- When rupture occurs pus will flow from ear
- Ear packs may be used
- Topical antibiotics
- Operative debridement may be needed in severe cases
Chronic otitis externa
- Chronic combined infection in the external auditory meatus usually combined staphylococcal and fungal infection
- Chronic discharge from affected ear, hearing loss and severe pain rare
- Cleansing of the external ear and treatment with antifungal and antibacterial ear drops
Acute suppurative otitis media
- Viral induced middle ear effusions secondary to Eustacian tube dysfunction
- Most common in children and rare in adults
- May present with symptoms elsewhere (e.g. vomiting) in children
- Severe pain and sometimes fever
- May present with discharge if tympanic rupture occurs
- Antibiotics (usually amoxycillin)
Chronic suppurative otitis media
1) Those without cholesteatoma have a perforation of the pars tensa,
> may complain of intermittent discharge (non offensive),
> Simple pars tensa perforations may be managed non operatively or a myringoplasty considered if symptoms troublesome
2)Those with cholesteatoma have a perforation of the pars flaccida
> impaired hearing and foul smelling discharge
> Pars flaccida perforations will usually require a radical mastoidectomy
Otosclerosis
- Progressive conductive deafness
- Secondary to fixation of the stapes in the oval window
- Treatment is with stapedectomy and insertion of a prosthesis
Acoustic neuroma
- Symptoms of gradually progressive unilateral perceptive deafness and tinnitus
- Involvement of the vestibular nerve may cause vertigo
- Extension to involve the facial nerve may cause weakness and then paralysis.
Pre auricular sinus
- Common congenital condition in which an epithelial defect forms around the external ear
- Small sinuses require no treatment
- Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise
Risk factors for breech presentation
- uterine malformations, fibroids
- placenta praevia
- polyhydramnios or oligohydramnios
- fetal abnormality (e.g. CNS malformation, chromosomal disorders)
- prematurity (due to increased incidence earlier in gestation)
Delirium tremens - alcohol withdrawal
- coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
- oral Chlordiazepoxide
- Lorazepam may be preferable in patients with hepatic failure
Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score
used for the management of alcohol withdrawal in hospital
Alcohol withdrawal
- Minor alcohol withdrawal symptoms such as tremor, anxiety and headache start approximately 6-12 hours after alcohol is stopped
- alcoholic hallucinosis after 12-24 hours
- withdrawal seizures and delirium tremens from 48 hours onwards
IV levetiracetam
anti-seizure medication
IV pabrinex
prevent the development of Wernicke’s encephalopathy
drug-induced Parkinsonism
- symmetrical tremour
- antipsychotics can precipitate Parkinsonism
- atypical presentation of a younger female
idiopathic Parkinson’s disease
- unilateral resting tremor
- bradykinesia
- other classic symptoms and signs
Causes of Parkinsonism
- Parkinson’s disease
- drug-induced e.g. antipsychotics, metoclopramide*
- progressive supranuclear palsy
- multiple system atrophy
- Wilson’s disease
- post-encephalitis
- dementia pugilistica (secondary to chronic head trauma e.g. boxing)
- toxins: carbon monoxide, MPTP
Antipsychotics: Extrapyramidal side-effects (EPSEs)
- Parkinsonism
- acute dystonia: sustained muscle contraction (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)
- managed with procyclidine
Antipsychotics: Other side-effects
- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- raised prolactin
> may result in galactorrhoea
> due to inhibition of the dopaminergic
tuberoinfundibular pathway - impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
- reduced seizure threshold (greater with atypicals)
- prolonged QT interval (particularly haloperidol)
Antipsychotics
dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
- used in elderly patients:
> increased risk of stroke
> increased risk of venous thromboembolism
clozapine
atypical antipsychotic
Acute pancreatitis: causes
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)
COPD should be suspected in anyone aged over 35, with any risk factors (eg smoking) with:
- exertional dyspnoea
- a chronic cough (3 months +)
- regular sputum production
- regular winter bronchitis
- wheeze
suspected renal colic
Non-contrast CT-KUB
- calcification in the renal collecting system or ureter,
- hydronephrosis
- and/or perinephric stranding.
renal colic
- acute, severe, ‘loin-to-groin’ pain
- nausea and or vomiting
- Obesity risk factor for the development of renal calculi
Renal colic: initial investigations
- urine dipstick and culture
- serum creatinine and electrolytes: check renal function
- FBC / CRP: look for associated infection
- calcium/urate: look for underlying causes
- clotting if percutaneous intervention planned
- blood cultures if pyrexial or other signs of sepsis
