Yr5 PACES Flashcards
1
Q
Key Points in Obs Hx
A
Screen: PV bleeding/discharge, pain, fetal movements, rhesus status, ROM, PET, urinary/bowel, FLAWS, PSHx
Current + Past
ICE + Social Hx
2
Q
Key Points in Gynae Hx
A
Screen: PV bleeding/discharge, pain, any chance preg, urinary/bowel, FLAWS, PSHx
MOSS: menstrual, obstetric, sexual, smear
ICE + Social Hx
3
Q
Key Points in Paeds Hx
A
PC SVR Birth Feeding Growth Development Allergies Immunisations School Life Social Worker Siblings
4
Q
Key Points in Psych Hx
A
Affective Psychotic Organic Flaws Tremor Risk ICE PMHx PPHx DHx SHx Forensic Premorbid
5
Q
What are classic ix you don’t want to miss for each speciality?
A
Hx: ICE/SHx/Collateral, Exam, Obvs, Bloods, Imaging
Obs: bimanual, speculum, CTG
Gynae: preg test, speculum, TVUS
Paeds: red book, pews score, urine dipstick, involve parents/school, safetynet/FU
Psych: questionnaires eg PHQ-9 and GAD-7, rule out organics eg urine tox screen, ECG
6
Q
Where can you signpost the pt if they’re having difficulty w employment/landlord?
A
Citizens Advice
7
Q
What do you always forget to do whilst counselling?
A
Check to see their prior knowledge on the dx
8
Q
How do you categorise any mx plan?
A
Conservative Medical Surgical Educate Senior/MDT Safetynet/FU
9
Q
O+G: What is the general structure to obs mx?
A
Preconception eg counselling, antenatal, delivery, postnatal eg F/U and any long term risks
10
Q
O+G: How are the trimesters divided?
A
T1: 0-12
T2: 12-26
T3: 26-37
11
Q
O+G: What is included in the booking bloods?
A
BP GDM FBC ABO RhD IDA HIV Hep B Syphilis Sickle Cell Thalassemia
12
Q
O+G: What is used to date the preg during scans in 1st/2nd trimester?
A
CRL 10-14wks + HC 14-20wks
13
Q
O+G: When is CVS and amniocentesis performed?
A
CVS 11-14wks
Amniocentesis 15-20wks
14
Q
O+G: How do you interpret a CTG?
A
DR C BRAVADO
Define Risk Contractions Baseline Rate: 110-160 bpm Variability: b/w 5-25 bpm Accelerations: >15bpm >15s ✅ Decelerations: >15bpm >15s ❌ Overall Impression
Variable Dec - Cord Compression
Late Dec - Fetal Distress
15
Q
O+G: How to examine the pregnant abdomen?
A
Inspect: general, hands, face, closer
Palpate: nine segments, uterus border, fetal lie, presentation, engagement, SFH
Complete: fetal heartbeat w Pinard/Doppler over ant shoulder, BP, urinalysis, speculum, TAUS
16
Q
O+G: Which medications are teratogenic?
A
Triptans Epileptics Retinoid ACEi/ARB Third Element OCP Warfarin Alcohol
17
Q
O+G: What do you need to give mum if delivery is <34wks?
A
At least 24hrs before delivery steroids + MgSO4
Steroids: lung maturation - 12mg IM bethamethasone x2 w 12-24hrs apart
MgSO4: neuroprotection - 4g IV loading followed by 1g/hr IV maintenance and maternal obs/reflexes monitoring
Temp: optimise metabolic rate - ensure baby stays warm
18
Q
O+G: What is the mechanism of labour?
A
Engagement OT Descent + Flexion Internal Rotation OA Delivery of Head Restitution of Shoulders External Rotation OT Expulsion
19
Q
O+G: What is the order of manoeuvres for shoulder dystocia + breech px?
A
SD: senior help, McRobert’s and suprapubic pressure, consider episiotomy, Rubins/Woods, turn pt to all fours, consider symphysiotomy/cleidotomy
Breech: ECV, consider ELCS, if SVD hands off approach, Pinard, Lovesets, Mauriceau-Smellie-Veit, forceps
20
Q
O+G: Shoulder Dystocia RFs
A
Big Mum, Big Baby, Prolonged Labour
21
Q
O+G: Breech Px RFs
A
Maternal: grand multiparity, placental/uterine abnormalities, obstrc lower segement eg fibroids or pelvic abnormalities
Foetal: multiple pregnancy, oligo/polyhydramnios, prematurity
22
Q
O+G: How would you explain ECV?
A
Bloods: FBC, U+Es, G+S, XM, clotting
Procedure: 1/2 are successful, before/after CTG, offer tocolysis, positioned slight head down, experienced clinician applies pressure
Benefits: avoid c/s and it’s comps
Risks: placental abruption, PROM, EMCS
CIs: c/s required, abnormal CTG, APH within 7d, ruptured membranes, multiple pregnancy, major uterine anomaly
23
Q
O+G: How do you explain a colposcopy?
A
After an abnormal smear result colposcopy is performed to follow it up which usually takes 10-15mins
We use the speculum first to have a closer look at the neck of the womb which will involve you lying on your back with your legs up and a chaperone will be available if you wish
The most you will feel is a bit of cold with the solution and a small pinch with the biopsy
It can be done at any point in the menstrual cycle but you should reschedule if you have heavy bleeding on the day and we need to know if you could be pregnant
If solution was used you may have a couple days of brown discharge and following a biopsy do not use cream/tampons/have sex for 48hrs
If heavy bleeding, lasts >7d, foul smelling discharge, pelvic pain that does not improve w ibuprofen, temp >38° come back to us
24
Q
O+G: SGA vs IUGR
A
We screen using SFH +/- 2cm and perform growth scans: skip to scan if multiple preg, polyhydramnios, fibroids, BMI >35
SGA: constitutionally small where AC <=10th centile for GA eg if have small parents
IUGR: subset which is abnormal where there is red growth rate
25
O+G: RFs for IUGR
Qs: booking, fever, UPSI, PET screen, BP, diabetes, kidneys
Symmetrical: multiple preg, intrauterine infections, chromosomal abnormalities
Asymmetrical: maternal smoking, PET, HTN, diabetes, chronic disease + placental abruption
‘The placenta is becoming tired and not being able to feed the baby as well as it did before’
26
O+G: Workup for SGA
5% of Pregnancies
SFH + AC/EFW
Ix: serial USS and umbilical artery doppler every 2wks from 26-28wks + screen for TORCH and urine tox
Mx: smoking cessation, control maternal disease, inc monitoring to USS wkly and doppler biwkly if PI or RI >2SDs on doppler, seniors consider immediate delivery if AREDV or abnormal CTG, otherwise deliver by 37wks w steroids if <36wks
27
O+G: RFs for LGA
Mod: high BMI, prev DM, GDM
NM: advanced maternal age, multiparity, molar pregnancy, eponymous syndromes eg Sotos
28
O+G: Workup for LGA
10% of Pregnancies
SFH + AC/EFW
Ix: OGTT, serum bHCG, genetic testing
Mx: plan delivery and discuss risk of prolonged labour, shoulder dystocia, nerve injuries -> offer c/s
29
O+G: Def of PET
HTN px >20wks gestation w significant proteinuria ie >0.3g/24hr that can progress to seizures due to impaired trophoblastic invasion of spiral arteries and endothelial cell damage
If px <20wks: chronic HTN
If no proteinuria: gestational HTN
30
O+G: Mx of PET
If at high risk: prev HTN during preg, chronic HTN, CKD, DM, AI disease then 75mg OD aspirin from 12wks
If dx confirmed: 1. Labetalol unless asthmatic 2. Nifedipine unless at term 3. Methyldopa + BP/dip/USS/doppler/CTG every 2wks
Always admit >160/110, measure every 15-30mins until under then x4/day, if sev bloods x3/wk vs mod bloods x2/wk
Intrapartum: continuous CTG, continue antihypertensives and monitor BP, consider epidural and MgSO4, avoid ergometrine
Postpartum: discharge when asx, BP <150/100, stable bloods + F/U until <130/80
31
O+G: Def of GDM
New onset >24wks w comps similar to DM in pregnancy but to a lesser degree
Dx if ‘5678’ fasting plasma glucose >5.6mmol/L or 2hr OGTT >7.8mmol/L
Review at joint diabetes and antenatal clinic within 1wk
32
O+G: Mx of GDM
1. If fasting <7 then 2wk trial of change in diet and exercise
2. If unsuccessful + <7 add metformin
3. If unsuccessful OR >7 add insulin
4. If can’t tolerate metformin or dec insulin consider glibenclamide
5. Offer IOL/ELCS b/w 37-39wks w capillary glucose checked every hr to maintain 4-7mmol/L
6. Check fasting again at 6w postnatal check to assess risk of developing T2DM
33
O+G: What are the main two CIs for a bimanual examination?
Placental Praevia + PROM
34
O+G: Ddx for Bleeding in Late Pregnancy
```
Placental Praevia
Vasa Praevia
Placental Abruption
Uterine Abruption
Vaginal/Cervical
Haematuria/Rectal
```
35
O+G: How would you F/U a low lying placenta at 20wks?
Rescan @ 32wks as only 1/10 will still be low lying at bitth
36
O+G: Mx of Placenta Praevia
Confirm dx >32wks then repeat USS at 36wks
Minor Degree: type 1 lateral + type 2 marginal
Major Degree: type 3 partial + type 4 complete
If bleed/pain/contractions attend, if major w prev bleed admit from 34wks, consider booking in an ELCS
37
O+G: Mx of PROM
Ix: speculum for pooling/os, if no pooling IGFBP-1/PAMG-1, if os closed and >30w TVUS cervical length <15mm likely to be PTL, CTG
Mx: PPROM admission and expectant mx until 37wk if no comps and appropriate safety netting w QDS erythromycin 10d/until established labour vs PROM induce if meconium or >24hrs, do NOT use tocolytics
Prevention: vaginal progesterone, cervical cerclage, future preg under obstetrician
38
O+G: Mx of PPH
Classify: SVD minor 0.5-1L and major or C/S >1L plus 1° <24hrs or 2° 24h-12w
The 4T’s: tone, trauma, tissue, thrombin
Mx: A-E, 2222, bimanual compression, IM/IV syntocinon, IM ergometrine, IM carboprost, ballon tamponade, B-lynch suture, hysterectomy, debrief, document, datix
Comps: death, renal failure, VTE, DIC, Sheehan’s syndrome
39
O+G: Bishop’s Score
To assess likelihood of labour: cervical position, consistency, effacement, dilation + fetal station
If <=5 unlikely to start w/o induction therefore use PV prostaglandin gel, 6-8 consider 1. membrane sweep 2. AROM w amnihook 3. oxytocin, >=9 likely to start spontaneously
Indics: prolonged preg, FGR, PROM, GDM, PET
Contras: major placental/vasa praevia, cord prolapse, prev uterine rupture, vertical c/s scar, transverse lie, active genital herpes
Comps: failed IOL, hyperstimulation, fetal distress, uterine rupture, c/s
40
O+G: How do you counsel for a VBAC?
VBAC > ERCS III+IV > EMCA I+II
Indics: singleton, cephalic, >37w, only one prev c/s, if more consultant decision
Contras: major placental/vasa praevia, cord prolapse, prev uterine rupture, vertical c/s scar, transverse lie, active genital herpes
Risks of VBAC: uterine rupture, instruments, EMCS
Risks of ERCS: usual c/s risks eg infection bleed hysterectomy ureteric/bladder injury fetal lacerations + impact on future preg
41
O+G: What are the comps of PTB?
The Big 4: RDS, NEC, IVH, PVL
42
O+G: What are the maternal sepsis RFs?
Fever
PROM
PTB
GBS
43
O+G: TOP
Hx: ask about partner and whether they’ve told anyone, ‘if you didn’t have this abortion how would it affect you’, explain the options
Indics: The Abortion Act 1967 - risk of continuation greater, to prevent grave permanent injury, usually class C ie above and <24wks, existing children, child born would suffer abnormalities, to save life of preg woman
Mx: confirm preg, STI screen, future contraception and compliance, requires two docs to sign, medical <9w home vs >9w in clinic mifepristone -[48h]-> misoprostol, surgical <14w ERPC vs >14w D+C, if >20w feticide, consider anti-D, preg test a mnth after
Comps: infection, bleed, cervical trauma, uterine perforation, RPOC
44
O+G: MOA of Mifepristone and Misoprostol
Mifepristone: anti progesterone - fetus termination
Misoprostol: synthetic prostaglandin - fetus expulsion
45
What are the normal obs for a child <1?
RR 30-40
HR 110-160
SBP 80-90
46
What are the normal obs for a child 1-2?
RR 25-35
HR 100-150
SBP 85-95
47
What are the normal obs for a child 2-5?
RR 25-30
HR 95-140
SBP 85-100
48
What are the normal obs for a child 5-12?
RR 20-25
HR 80-120
SBP 90-110
49
What are the normal obs for a child >12?
RR 15-20
HR 60-100
SBP 100-120
50
Paeds: What does the traffic light system look at?
```
Colour
Activity
Respiratory
Circulation
Other
```
51
Paeds: What are the domains of development?
Gross Motor
Fine Motor + Vision
Hearing + Language
Social Behaviour
52
Paeds: What is the developmental screen for children <5yrs?
By 6wks: Smiling
By 6ms: Turns to Sound
By 9ms: Sitting
By 18ms: Words + Walking
By 3yrs: 3 Word Sentence
53
Paeds: What does the guthrie test at 7d screen for?
Congenital hypothyroid, SCD, CF plus six inherited metabolic disease
54
Paeds: What are the definitions of neonate, infant, toddler?
<1m, 1m-1y, 1-3yrs
55
Paeds: Immunisation Schedule
2/3/4m: 6in1 + rotavirus@2/3 + pneumococcal/MenB@2/4/1yr
1yr: Hib/MenC + MMR
3yrs: 4in1 + MMR
14yrs: 3in1 + MenACWY
The 3in1 is diphtheria, tetanus, pertussis + inactivated polio in the 4in1 + Hib and Hep B in the 6in1
56
Paeds: Viva on MMR
It’s a liver attenuated vaccine like BCG and typhoid
Therefore CI in pregnancy, immunocomp pts, another live vaccine <4w, Ig therapy <3m, neomycin allergy
57
Paeds: How do you counsel for worry surrounding the MMR vaccine?
The link w autism was disproven and Andrew Wakefield is no longer able to practice medicine
They are all high risk viruses that usually px w temp, tiredness, loss of appetite, sore eyes, rash but may cause serious complications: measles (chest infection + progressive brain damage), mumps (deafness + infertility), rubella (easy bruising + bleeding)
Explain herd immunity, recent outbreaks, provide leaflets
58
Paeds: Kawasaki’s Disease vs Scarlet Fever
KD: vasculitis, >5d fever w four of CRASH ie conjunctivitis rash adenopathy strawberry tongue swollen hands/feet, admit for IVIG and high dose aspirin
SF: group A strep, fever rash adenopathy strawberry tongue, penicillin/erythromycin for 10d
Therefore if febrile make sure you check for rash glands tongue
59
Paeds: What is the scoring system for croup?
Westley: chest wall retractions, stridor, cyanosis, consciousness, air entry
If >3 admit and >8 give neb adrenaline
60
Paeds: Croup vs Bronchiolitis
Both px w coryzal sx first
Auscultate: harsh stridor and barking cough in croup + fine bi-basal end insp crackles and high pitch exp wheeze in bronchiolitis
Croup: upper airway, 6m-6y, autumn, parainfluenza, supportive, single dose dexamethasone
Bronchiolitis: lower airway, <1yo, winter, RSV, supportive, palivizumab every m for 6m
61
Paeds: Croup vs Epiglottitis vs Bacterial Tracheitis
All <6yrs
Croup: viral, harsh stridor and barking cough, normally clinically well, onset over days, dexamethasone +/- adrenaline
Epiglottitis: Hib, soft stridor, toxic and drooling, onset over hrs, ceftriaxone + fluid resus as life threatening
Tracheitis: staph/strep/Hib, barking cough, toxic not drooling, longer hx, ceftriaxone +/- intubation
62
Paeds: What should you NOT do in children w epiglottitis?
Lie them down or examine their throat
63
Paeds: Ddx of Wheeze
```
Bronchiolitis
Viral Induced
Asthma
GORD
CF
FB
```
64
Paeds: Mx of Asthma
Hx of bronchiolitis <1yo + viral induced wheeze 1-5yo
Ix: vital signs + PEFR if 50-75% mod, 33-50% sev (SpO2>92), <33% LT (SpO2<92)
Acute Tx: mod salbutamol 4hrly, oral pred 3d, F/U in 48hrs VS sev/LT admit for (1) burst therapy 10x SABA via MDI and spacer OR 3x salbutamol neb 2x ipratropium neb, 1x oral pred (2) IV bolus MgSO4 (3) IV infusion salbutamol/aminophylline (4) PICU
Chronic Tx: 1.SABA 2.Becotide 3.LTRA 4.Flixotide 5.Prednisolone + trigger avoidance, technique, personalised action plan, Asthma UK, itchywheezysneezy.com, safety net
65
Paeds: When can you discharge a pt following an acute asthma attack?
Stable on 4hrly tx, peak flow at 75%+, SpO2>94
Make sure you F/U within 48hrs and educate pt on what when how
66
Paeds: Which medications are CI in asthma?
```
B-B
ACEi
Adenosine
Aspirin
NSAIDs
```
67
Paeds: What should you ask in an asthma history?
Decipher level of control, triggers and current tx: cough, chest tightness, SOB, exercise, cold weather, nighttime, interfere w activities, prev admissions
Screen for allergies: hx of eczema, hay fever, PESTO
68
Paeds: Viva on Cystic Fibrosis
Sx: recurring chest infections, difficulty putting on wt, diarrhoea/constipation
Signs: clubbing, jaundice, easy bruising
Ix: antenatal guthrie testing, sweat test >60mmol/L, CXR
Mx: MDT w regular reviews and specific mx for 1. Resp 2. Infection 3. Nutrition 4. Psych
Comps: diabetes, liver cirrhosis, sterility
69
Paeds: Mx of GORD
GOR: inappropriate relaxation of LOC where most resolve by 12m
Same day referral: dysphagia, haematemesis, melaena
If breast-fed: assessment, alginate therapy, 4wk PPI/H2 antagonist
If formula-fed: review feeding hx, smaller more freq feeds, thicker formula, alginate therapy, 4wk PPI/H2 antagonist
Still sleep on back there’s NO positional mx
70
Paeds: Ddx of Pyloric Stenosis
GOR, Gastroenteritis, UTI
71
Paeds: Ddx of Intussusception
Incarcerated Hernia, Gastroenteritis, UTI
72
Paeds: Pyloric Stenosis vs Intussusception
PS: hypertrophied pyloric muscle results in projectile vomit in 2-8wk w palpable olive mass in RUQ, visible peristalsis, hypoCl hypoK met alkalosis
Mx of PS: test feed, target lesion on US, slow IV fluid resus and correct electrolytes, def lap Ramstedt pyloromyotomy
IN: invagination of ileum->caecum results in bile stained vomit in 3m-2yo w sausage shaped mass in RUQ, emptiness in RLQ ie Dance sign, red currant jelly stool
Mx of IN: target mass on US, analgesia, drip and suck, rectal air insufflation, if perforated surgical reduction, broad spec abx
73
Paeds: Ddx for Neonatal Jaundice
Always abnormal if <24hrs: infection, haemolysis, metabolic
Can be normal if >24hrs: 1d-2w above, physiological, breastfeeding + >2wks uBR above, pyloric stenosis, congenital hypothyroidism vs cBR biliary atresia, ascending cholangitis, CF
74
Paeds: Mx of Jaundice
Ix: <24hrs serum BR, 1d-2w transcutaneous BR, >2w split BR + identify cause w MC+S, FBC, blood film, DAT, G6PD, ABO, TFTs, LFTs
Mx: if uBR use tx threshold chart for phototherapy vs exchange transfusion + if cBR tx cause
75
Paeds: What inc the risk of developing kernicterus? (3)
Serum BR >340 in babies >37wks, rapidly rising BR >8.5/hr, clinical features eg poor feeding, extreme lethargy, hypotonia
76
Paeds: How do you counsel for neonatal jaundice tx?
We need to give X light therapy to prevent the chemical in their blood that is causing them to be yellow from getting too high and damaging the brain/hearing
It’s like a tanning bed where we will ensure they are wearing eye protection and you will be able to be w them the whole time ideally breastfeeding them
Afterwards they will need to stay a bit longer so we can ensure the chemical levels don’t rise again
77
Paeds: How do you score the GCS verbal component in children <5yo?
No response, moans, cries, less than usual ability, alert
78
Paeds: Ddx for a Fitting Child
Ddx: epilepsy, febrile convulsion, reflex anoxic seizure, breath holding attack, infantile spasm, hypoglycaemia, hyperNa
You must rule out: meningitis/encephalitis, sepsis, head trauma
79
Paeds: Work up for a Fitting Child
Hx: duration, tongue biting, incontinence, post-ictal, recent illness, rash, head injury, video of event
Bedside: obs, temp, urine dip, fingerprick glucose, ECG, LP
Bloods: FBC, U+E, CRP
Imaging: MRI +/- EEG
80
Paeds: How would you classify epilepsy?
Classify seizures: focal aware/impaired motor/non-motor vs generalised motor/absence/atonic vs unknown
81
Paeds: What is a Jacksonian March?
Focal clonic seizures initiated in the primary motor cortex spreads from distal limb towards ipsilateral face
82
Paeds: What is benign rolandic epilepsy?
Focal myoclonic seizures initiated around the central sulcus are the most common form in childhood and usually outgrown: hemifacial sensorimotor, speech arrest, hypersalivation
83
Paeds: What are potential underlying causes of epilepsy?
Sickle cell disease + genetic disorders eg Down’s syndrome and tuberous sclerosis
84
Paeds: Mx of Epilepsy
Take an MDT approach w paediatrician, specialist nurse, psychologist, school nurse, GP + refer to neuro first fit clinic if appropriate
Consrv: how to recognise seizure and get help, video record, avoid dangerous activities
Medical: generalised valproate->lamotrigine, myoclonic valproate->levetirecetam, absence ethosuximide->valproate, partial carbamezapine/lamotrigine->valproate
Intractable: ketogenic diet, vagal nerve stimulation, surgery
85
Paeds: Mx of Status Epilepticus
A-E: high flow oxygen if required, IV access, blood glucose
5mins: if vasc access lorazepam OR buccal midazolam/PR diazepam
15mins: IV/IO lorazepam again AND call for senior help
25mins: IV/IO phenytoin over 20mins AND call for anaesthetist
45mins: rapid sequence induction of anaesthesia w thiopental
86
Paeds: What are the SEs of the common AEDs?
Valproate: wt gain, hair loss, liver failure
Carbamazepine: N+V, ataxia, SIADH, neutropenia, drug interactions
Lamotrigine: SJS
87
Paeds: Dx of DKA
Confirm: clinical hx, signs, urine dip/biochemistry (D: >11.1, K: >3, A: <7.3)
Call senior + assess severity: mild <7.3 ie 5% fluid deficit, mod <7.2 ie 7% fluid deficit, sev <7.1 ie 10% fluid deficit
88
Paeds: Mx of DKA
A-E: Kussmaul breathing, shock and dehydration, GCS
Fluids, Potassium, Insulin: if shocked 20ml/kg, if not 10ml/kg over 1hr, correct deficit over 48hrs using 0.9% NaCl w 20mmol KCl in every 500ml minus first 1hr plus maintenance, start 0.05-0.1U/kg/hr insulin infusion 1-2hrs after starting IV fluids
Repeat obs: signs of comps (neuro+hyperK), fluid balance (no improvement consider resus and sepsis), glucose (<14 add 5-10% glucose), ketones, weight
Resolution: clinically well, drinking and eating, blood ketones <1 or normal pH, urine ketones may still be +, start S/C insulin and stop IV @ 1hr, pt education, MDT, FU, OOH number
89
Paeds: What are the three main comps of DKA and it’s tx?
Cerebral oedema: assess hrly for headache, irritability, Cushing’s triad, raised ICP - exclude hypoglycaemia - tx w hypertonic saline or mannitol, restrict fluids, involve paediatric critical care specialist
HypoK: if <3 temporarily stop insulin and use a continuous ECG
Aspiration pneumonia: consrv mx +/- abx
90
Paeds: How do you counsel for DKA?
It’s the first manifestation of type 1 diabetes where the body is unable to make enough insulin to control the blood sugar levels
At the moment they are so high they have caused the drowsiness, tummy pain and dehydration which is why we need to admit to give fluids and insulin
It’s a very well known condition with established tx, we’re going to do everything we care to support you and care for your child, there’s good leaflets on diabetes.org and F/U
91
Paeds: Mx of T1DM
Take an MDT approach w paediatrician, specialist nurse, psychologist, school nurse, GP
Consrv: balanced diet w CHO counting, regular exercise, monitor glucose/ketones/comps
Medical: three types of insulin therapy
92
Paeds: How do you counsel for a febrile convulsion?
Reasonably common in toddlers, although quite dramatic short simple seizures have no long term consequence and do not recur past 5yrs, not the same as epilepsy
They occur early on in a viral infection when their temp starts to rise so we’d like to arrange a hosp assessment by paediatrics and keep him here for observation as 1/3 will have another
In the future maintaining adequate fluid intake helps and paracetamol improves sx but ultimately if you’re ever worried always come back to see us
93
Paeds: What is the most common cause of febrile convulsions?
HHV-6 Roseola Infantum
94
Paeds: How would you classify febrile convulsions?
Classify seizures: simple, complex, febrile status epilepticus >30mins
Simple - <15mins, generalised, no recurrence within 24hrs, recovery <1hr
Complex - 15-30mins, focal, may repeat within 24hrs, recovery >1hr
95
Paeds: Mx of Febrile Convulsion
Protect from injury and do not restrain during and if >5mins give buccal midazolam or PR diazepam
Ambulance: first seizure, serious illness, breathing difficulties, no drugs available at 5mins, not responding to drugs at 10mins
Admission: first or complex seizure, diagnostic uncertainty about cause or currently on abx, <18mnths
96
Paeds: What is the pathogenesis of SCD?
Autosomal recessive point mutation at codon 6 on Chr 11, glutamine -> valine, defective beta globin
97
Paeds: Mx of Infantile Spasm
Dx w hypsarrhythmia on EEG + tx w vigabatrin
98
Paeds: Mx of Sickle Cell Disease
Ix: family origins questionnaire, antenatal guthrie testing, FBC, blood film, electrophoresis
Acute: A-E, admit, oxygen, fluids, analgesia, abx, exchange transfusion
Chronic: educate, vaccination vs encapsulated, daily PO penicillin and folic acid, hydroxycarbamide if recurrent crises
99
Paeds: What is one of the earliest signs of sickle cell disease and it’s ddx?
Dactylitis
Ddx: hand and foot syndrome, osteomyelitis, connective tissue disease
100
Paeds: What are the encapsulated bacteria?
NHS: neisseria, Hib, streptococcus
101
Paeds: How does hydroxycarbamide work?
Stimulates HbF production
102
Paeds: What are the acute and chronic comps of sickle cell disease?
Acute: chest syndrome, hoot and foot syndrome, splenic sequestration, painful crisis, priapism, infection
Chronic: anaemia, pain, epilepsy, gallstones, CKD, impaired growth
103
Paeds: Ddx for Failure to Thrive
Constitutional delay: low BW + small parents
Inadequate intake: malnutrition, impaired suck/swallow, eating disorders, neglect, psychosocial deprivation, malabsorption eg CF, coeliac, CMPA/lactose intolerance
Inadequate retention: GORD + vomiting
Increased requirements: recurrent infections, malignancy, hypothyroid
104
Paeds: Mx of FTT
Tx underlying cause, dehydration status, vit defs, developmental assessment, MDT inc SALT, F/U
Mild: feeding or providing eating behaviour recommendations
Mod: above plus refer to specialist
Sev: above plus hospitalisation
105
Paeds: At what age do you start weaning?
6-12m
106
Paeds: At what age do you start adopting a normal adult bowel habit of 3/d-3/wk?
~4yo
107
Paeds: Hx of Abdo Pain
```
Socrates
N+V
Urine
Stool
Fever
Rash
Joints
Fluids
Diet
Allergies
Stress
```
108
Paeds: Ddx for Acute Abdo Pain
Gastroenteritis
Appendicitis
Mesenteric Adenitis
Meckel’s Diverticulum
Plus: ectopic pregnancy, GU, DKA, SCD
109
Paeds: Ddx for Recurrent Abdo Pain
Functional
Constipation
Coeliac Disease
Lactose Intolerance
Plus: Mittelschmerz + GU
110
Paeds: What is an abdominal migraine?
Poorly localised pain interfering w daily activities >1hr >=2/yr a/w N+V, pallor, anorexia, complete resolution b/w attacks, nil sx of other GI disease
111
Paeds: Viva on Functional Abdo Pain
Sx: at least x4/mnth for >=2mnths, ICE and social hx are key, ask about FHx of IBS and migraines
Ix: FBC, ESR, urinalysis, stool microscopy, avoid unnecessary tests
Mx: explain sx, ascertain causes of stress, encourage not to miss school, probiotics, FODMAPs, antispasmodic/antidiarrhoeal agents, safety net if fever/PR bleed
112
Paeds: Ddx for Constipation
Acute: fluid depletion, metabolic, bowel obstruction, neurological, sexual abuse
Chronic: functional, IBD, coeliac disease, Hirschsprung’s disease, hypothyroidism
Mx: pt education, involve dietician/psychologist, adequate fluid/fibre intake, encourage toileting after mealtimes, star charts, analgesia, movicol stool softener, senna stimulant laxative
113
Paeds: What are the red flag sx for a constipated child? (6)
1. Failure to pass meconium in first 24hrs: Hirschsprung’s + cystic fibrosis
2. FTT: coeliac + hypothyroid
3. Gross abdo distension: Hirschsprung’s + other GI dysmotility
4. Abnormal LL neuro: lumbosacral pathology
5. Sacral dimple above gluteal cleft: spina bifida occulta
6. Perianal fistulae, abscess, fissure: crohn’s
114
Paeds: Viva on Coeliac Disease
Sx: bloating, irritable, not dropping down growth centiles
Signs: wasted buttocks, distended abdomen, dermatitis herpetiformis
Ix: FBC, blood film, anti-tTG, HLA DQ2/8, if older biopsy for villous atrophy and crypt hyperplasia
Mx: MDT paediatrician, specialist nurse, psychologist, school nurse, GP + dietician annual review inc BMI and diet adherence
Comps: FFT, IDA, vit B12/D deficiencies, oestoporosis, EATL
115
Paeds: When should you suspect NAI?
High index of suspicion for: non-contact area bruising, high energy fractures, drowsiness, neglect, delay in reporting, recurring, keep prying if inconsistent hx
“When children have similar injuries sometimes they don’t happen by accident and are caused by others”
“It’s a routine requirement to admit, keep them safe and run more tests”
116
Paeds: Mx of NAI
Ix: full body +/- skeletal survey, draw/photo, attachment, growth, hygiene, bloods and bone profile, fundoscopy, CT head, check child protection register
Mx: must admit, involve 1. seniors 2. named doc for child protection 3. social services, formulate a plan, consider if siblings need protection, F/U
117
Paeds: What is the classical triad of shaken baby syndrome?
1. Encephalopathy
2. Retinal Haemorrhages
3. Subdural Haematoma
118
Paeds: Ddx of NAI Drowsy Baby
Sepsis
Hypoglycaemia
Poor Feeding Technique
119
Paeds: Ddx of Floppy Neonate
Congenital hypothyroidism, rickets, sepsis, chromosomal disorder eg Downs, metabolic disorder eg Prader Willi, muscular dystrophy, cerebral palsy
120
Paeds: Workup for Floppy Child
O/E: truncal hypotonia and head lag, dysmorphic features, limb movements
Urine: amino and organic acids, reducing substances, mucopolysaccharides and oligosaccharide screen
Bloods: antenatal guthrie screen, FBC, U+Es, LFTs, TFTs, Vit D, culture, karyotype
121
Paeds: Viva on Obesity
1. Plot findings on growth chart
2. Organic causes: insulin resistance, leptin deficiency, PWS, hypothyroidism, cushings
3. Risk factors: modifiable inc diet, lack of exercise, psychosocial + non-modifiable inc FHx and birth wt
4. MDT approach: paediatrician, specialist nurse, psychologist, school nurse, GP, dietician, family therapy
5. Population approach: public health advertising + education
122
Paeds: What is the usual age toilet trained children become dry by day and by night?
Day <4yrs + Night <5yrs
123
Paeds: RFs for Enuresis
Male
FHx
Obesity
Psych
124
Paeds: How do you classify bedwetting?
Must ascertain whether daytime sx and if prev continence
1°: never achieved sustained continence at night + daytime sx think overactive bladder/ectopic ureter - daytime sx think sleep arousal diff
2°: after achieving six mnths dry at night think diabetes, UTI and constipation
125
Paeds: Mx of Enuresis
Rule out: diabetes, uti, constipation
Ix: urine 1. diary 2. dipstick 3. MC+S, renal USS, MCUG
Consrv: reassure if <5yrs, watch and wait if 5-7yrs <2/wk, alarm and praise success if 5-7yrs >2/wk, optimise weight, avoid caffeine and use toilet before bed, use bed pads
Medical: straight to desmopressin if >7yrs or require short term control
Referral: 1° w daytime sx OR not responded to two courses of tx
126
Paeds: Ddx for Neonatal Breathing Difficulty
More common: transient tachypnoea of the newborn, sepsis, pneumonia
Less common: meconium aspiration, pneumothorax, congenital anomaly eg fistula or diaphragmatic hernia
127
Paeds: Ddx for Jittery Baby
Hypoglycaemia
Drug Withdrawal
Polycythaemia
128
Paeds: Ddx for Postnatal Collapse
Sepsis
Congenital Heart Disease
Congenital Adrenal Hyperplasia
129
Paeds: Ddx for Neonatal Vomiting
Meconium Ileus
Duodenal Atresia
Necrotising Enterocolitis
130
Paeds: When are the different hearing exams done?
Newborn: 1. EOAE 2. AABR
7-9m: Distraction Testing
10-18m: Visual Reinforcement Audiometry
18m-4y: Performance + Speech Discrimination Testing
>4yrs: Pure Tone Audiometry
131
O+G: Workup for Miscarriage
Bleed: when, quantity, colour, clots, discharge, haematuria/PR, prev eps
SVR: abdo pain, N+V, fever, dizzy, sob, falls - think infection, anaemia, trauma
Hx: ICE, PGHx inc sexual and smears, POHx, PMHx, PSHx, DHx, FHx, SHx
Ix: o/e, obs chart, bloods, preg test, speculum, TVUS, must exc ectopic
Mx: admit if ectopic or hemo unstable, <6wk expectant w 1wk preg test or 2wk FU, >6wk 1. expectant 7-14d 2. PO/PV misoprostol 3. MVA under LA or ERPC under GA all w 3wk preg test or 4wk FU and anti-D if surg mx or >12w, MDT w psychologist if appropriate
Couns: anyone you’d like to be here w you, it’s not your fault, they’re common 1/5, won’t affect future chances, the tablet helps the womb to push, leaflets
132
O+G: Miscarriage vs PUV
Miscarriage: either no FH and CRL >7mm or GS >25mm and no foetus confirmed by two clinicians
PUV: either no FH and CRL <7mm or GS <25mm and no foetus therefore TVUS again in 7d
133
O+G: Classification of Miscarriages
Early/Late: <13wks + 13-24wks
Os Open: inevitable + incomplete
Os Closed: threatened, complete, missed
134
O+G: What are the risks a/w surgical mx of miscarriage?
I: cervical trauma, uterine perforation, retained POC
E: haemorrhage + infection
L: adhesions + psych
135
O+G: HIV in Pregnancy
RFs: vertical risk if high viral load/low CD4 count, prolonged ROM, breastfeeding
Monitoring: test at booking, viral load every 2-4wks and at 36wks, CD4 at baseline and delivery
Mx of Mother: continual ART, at 36wks if <50 copies/mL SVD but if >50 copies/mL or hep C coinfection ELCS at 38w, avoid foetal blood sampling and breastfeeding, consider giving mother cabergoline to red lactation, offer guidance about contraception
Mx of Infant: clamp cord asap and bath baby, if low/med risk 2-4w PO zidovudine monotherapy vs high risk 4w PEP combination, PCR @ 6+12 wks
136
O+G: Workup for Headache
Screen for PET, Comps, VIVID
PET: vision, vomiting, swelling
Comps: epigastric/RUQ pain, sob, fatigue, nosebleeds, fits
VIVID: onset, speech, consciousness, head injury, worse lying down, fever, wt loss
137
O+G: Ix for HELLP Syndrome
O/e: tenderness in epigastrium/RUQ
Bloods: FBC for low pl, LFTs for inc br, film for schistocytes
138
O+G: Ddx of Itch
Obs Cholestasis
Plus: eczema, hepatitis, PBC, GS, pancreatic cancer, CMV
Therefore ask about jaundice, rash, dark urine, pale stools, wt loss
139
O+G: Obs Cholestasis
No Rash - itch w excoriations +/- jaundice
RFs: prev OC, FHx, ethnicity, multiple preg, pruritis on COCP
Ix: Raised BR + Bile Acids
Tx: symptoms w loose cotton clothes, topical emollient, ursodeoxycholic acid, sedating antihistamines, monitoring w wkly LFTs and biwkly doppler/CTG, IOL @ 37wks, FU w GP, do NOT use COCP b/w pregnancies
Comps: sev liver impairment, prematurity, stillbirth
140
O+G: Acute Fatty Liver
No Pruritis - abdo pain, N+V, jaundice
RFs: nulliparity, male foetus, multiple preg, obesity, PET
Ix: Raised ALT + Uric Acid
Tx: supportive through third trimester then deliver once stable
Comps: haemorrhage 2° to DIC, renal failure, stillbirth
141
Paeds: Difference b/w Osteochondritidies
Osgood-Schlatter Disease: patellar tendon inflammation
Chondromalacia Patellae: patella posterior surface cartilage degeneration
Osteochondritis Dissecans: AVN causing bone/cartilage fragmentation
142
Paeds: Ddx for Blue Baby
Cardiac: R-L shunt thus dec pulmonary blood flow ie TOF ‘boot shaped heart’, TGA ‘egg on a string’, tricuspid atresia
Resp: surfactant def, meconium aspiration, pulmonary hypoplasia all of which could lead to PPHN
143
Paeds: TOF
VSD
RVH
Pulm Stenosis
Overriding Aorta
144
Paeds: What are the limit ages for gross motor development?
4m - Head Control
9m - Sits Unsupported
12m - Stands Independently
18m - Walks Independently
145
Paeds: What are the limit ages for vision and fine motor development?
3m - Fixes + Follows
6m - Reaches for Objects
9m - Transfers
12m - Pincer Grip
146
Paeds: What are the limit ages for hearing, speech and language development?
7m - Polysyllabic Babble
10m - Consonant Babble
18m - 6 Words w Meaning
2y - Joins Words Together
2.5y - 3 Words Sentences
147
Paeds: What are the limit ages for social, emotional and behavioural development?
8w - Smiles
10m - Fear of Strangers
18m - Can Self Feed
2. 5y - Symbolic Play
3. 5y - Interactive Play
148
O+G: What are the RFs for an ectopic pregnancy?
```
Inc Age
Smoker
Chlamydia
IUD
IVF
Prev Ectopic
Prev Abdo/Pelvic Surgery
```
149
O+G: What are the key points to a contraception hx?
Screen for any UKMEC health problems in PMHx
Explain the pros and cons of each form of contraception
Refer for sexual health screening if appropriate
Safetynet eg if period >7d late or lower abdo pain
150
O&G: Placental Praevia vs Abruption
Extent of abdo pain + if any signs of shock
151
O&G: Ddx for PV Bleeding
Non-Preg: menstrual, PCB (cervical polyp/ectropion/malignancy), PMB (atrophic vaginitis and endometrial polyp/hyperplasia/malignancy)
Early Preg: above plus miscarriage (pain precedes bleeding), ectopic (bleeding precedes pain), molar preg
Late Preg: vasa previa, placenta previa/accreta, placental abruption, uterine rupture, bloody show, PPH
Kleihauer Test, Hb Electrophoresis, Anti-D
152
O&G: Ddx for PV Discharge
High Vaginal Swab:
Candidiasis
Bacterial Vaginosis
Trichomonas Vaginitis
Endocervical Swab:
Chlamydia
Gonorrhoea
Physiological
153
O&G: Ddx for Abdo Pain
Non-Preg: GI, UTI, tubo-ovarian pathology, PID, fibroids, endometriosis
Early Preg: above plus miscarriage (pain precedes bleeding), ectopic (bleeding precedes pain), molar preg
Late Preg: labour, placental abruption, uterine rupture, HELLP, AFLP
154
O&G: Ddx for Red Fetal Movements
TORCH, IUGR, Miscarriage/SB
155
O&G: Rashes
Infectious: MMR, VZV, syphilis
Non Inf: linea nigra, striae gravidarum, acne flares, atopic eczema, psoriasis, pruritis folliculitis, pemphigoid gestations, prurigo, PUPPP
156
Paeds: ASD vs VSD
ASD
O/e: raised JVP, thrill, ESM
A/w: pulm HTN, CCF, Downs
VSD
O/e: SOB, thrill, PSM
A/w: TOF, coarctation, PDA
157
Paeds: SRV
```
Fever
Rash
Fits
Cough
SOB
Vomit
Blood
Bile
Pain
Urine
Stool
Blood
Mucus
Lumps
Joints
Injury
Colour
Activity
```
Plus: bulging fontanelle, feeding, nappies in infants
158
Paeds: Ddx for Fever
Make sure you do SRV + FLAWS
Infection: work through the systems - sepsis, meningitis, ENT, croup, bronchiolitis, pneumonia, bronchiectasis, gastroenteritis, UTI, transient synovitis, scarlet fever, HIV
Inflammation: kawasaki disease, JIA, SLE
Malignancy: ALL, lymphoma, ewing’s sarcoma
159
Paeds: Ddx for Rash
Make sure you ask about itch + SRV
Infection: bacterial/viral/fungal/parasitic - impetigo, meningitis, lyme disease, HHV, MMR, poxvirus, parvovirus, enterovirus, tinea, scabies
Inflammation: kawasaki disease, JIA, HSP
Dermatological: dermatitis, CMPA, eczema +/- herpeticum, psoriasis, acne
Haematological: vascular birthmarks, ITP/DIC, NAI/trauma
Systemic: urticaria, jaundice, erythema nodosum/multiforme
160
Paeds: Ddx for Vomiting
Emergencies: sepsis, meningitis, DKA
Gastro Medical: gastroenteritis, GORD, CMPA
Gastro Surgical: pyloric stenosis, intussusception, malrotation, volvulus, appendicitis
Misc: raised ICP, torsion, bulimia
161
Paeds: Ddx for Abdo Mass
```
Constipation
Hepatomegaly
Splenomegaly
Pyloric Stenosis
Intussusception
Neuroblastoma
Wilm Tumour
```
162
Paeds: Ddx for Headache
Sinister: infection, raised ICP, haematoma, trauma
Non-Sinister: tension, migraine, sinusitis, dehydration
163
Paeds: Ddx for Diarrhoea
Infection, Inflammation, Food Intolerance, Overflow, Anxiety
164
Paeds: Ddx for Encoporesis
Chronic Constipation + Anxiety
Plus: Hirschsprungs, imperforate anus, anal trauma
165
Paeds: Ddx for Developmental Delay
Specific: LD + impairments
Global: cerebral palsy, ASD, ADHD, genetic syndromes, neglect
166
Paeds: Ix for DD
Bedside: developmental history, RFs, MH screen, bloods for genetic testing, vision/hearing
Referral: developmental paediatrician + CAMHS
167
Paeds: Cardiac Arrest Algorithm
Five initial breaths then 15:2
168
Paeds: List the Autistic Spectrum Disorders
1. PDD-NOS
2. Autism
3. Asperger’s
4. Rett Syndrome
5. Childhood Disintegrative Disorder
169
Paeds: Autistic Spectrum Disorder Triad + Mx
Triad of: impaired social interaction, speech and language disorder, routine w ritualistic and repetitive behaviours
Ix: physical exam to exclude Down syndrome and establish baseline, autism diagnostic interview, autism diagnostic observation schedule, WPSSI/WISC
Tx: MDT approach inc SALT, education health and care plan, applied behavioural analysis
170
Paeds: ADHD Triad + Mx
Triad of: hyperactivity, impulsivity, inattention
Ix: conners rating scale, classroom observation, educational psychological assessment
Tx: refer, parent training, behavioural and educational interventions, 6w methylphenidate, 6w lisdexamphetamine, atomoxetine
171
Paeds: WAGR Syndrome
Wilms Tumour
Aniridia
GU Malformations
Retardation
172
Paeds: Ix for Recurrent UTIs
US: structural abnormalities
MCUG: VUR + PUV
DMSA: renal scarring
173
Paeds: Sepsis 6
1. Oxygen
2. Bloods
3. IV/IO Abx
4. Fluids
5. Senior
6. Inotropes
174
Paeds: Red Flags of Sepsis
```
Hypotension
Lactate >2
Inc HR/RR
SpO2 <90
AVPU P/U
Immunocomp
Rash/Mottled
```
175
Paeds: Mx of OSD
Reassure + Consrv: analgesia, intermittent ice packs, protective knee pads, red sporting activity until sx dec, encourage stretching
176
Paeds: Mx of TGA
Set up a prostaglandin infusion, call seniors and paediatric surgery, hyperoxia test, CXR, echo
177
Paeds: Up to what age would hand dominance be considered pathological?
12m
178
Paeds: Primitive Reflexes
If absent at birth = abnormal
2m - StePPing
4m - Root + Moro
5m - Palmar/Plantar Grasp
179
Paeds: What is a devastating long term consequence of a VSD that may present in early adulthood?
Eisenmenger Syndrome: L-R Shunt -> R-L Shunt
180
Paeds: Precocious Puberty Ages
Girls <8y
Boys <9y
True - GnRH dependent: idiopathic, CNS tumour/injury, congenital anomaly
Pseudo - GnRH independent: congenital adrenal hyperplasia, Leydig cell/ovarian tumours, McCune-Albright syndrome
181
Paeds: Pubertal Delay Ages
Girls >13.5y
Boys >14y
Central - hypogonadotrophic hypogonadism: Kallmann syndrome, chronic illness, anorexia nervosa
Peripheral - hypergonadotrophic hypogonadism: Klinefelter’s/Turner’s, gonadotropin resistance, acquired
182
Paeds: Down Syndrome
Facies: upslanting palpebral fissures, epicanthal folds, brushfield spots in iris, flattened nasal bridge, low set small folded ears, small mouth, macroglossia, short neck, flat occiput
Associations: heart defects, resp infections, Hirschprung, coeliac, duodenal atresia, obstructive sleep apnoea, dental problems, short stature, developmental delay, epilepsy, ALL/germ cell tumour, early onset Alzheimer’s
183
O+G: Fetal Screening
Combined @ 10-14w: Nuchal Transluceny + b-hCG/PAPP-A
Quadruple Test @ 14-20w: b-hCG, AFP, unconjugated oestriol, inhibin A
184
O+G: Which vaccinations are offered in pregnancy?
Influenza + Pertussis
185
O+G: When should you induce labour in multiple pregnancies?
MCMA: 32-34w
MCDA: 36-37w
DCDA: 37-38w
186
O+G: What are the criteria for IVF on the NHS?
If <40yo offered three cycles if: unable to get pregnant through regular UPSI for 2yrs OR after 12 cycles of artificial insemination
If 40-42yo offered one cycle if: above AND first time, no evidence of low ovarian reserve, informed of comps w pregnancy at this age
187
O+G: Ddx for Subfertility
Anovulation: ovarian failure, PCOS, AN, Kallmann, Sheehan’s, hyperprolactinaemia
Plus: tubal pathology, endometriosis, male infertility, unexplained
188
O+G: Menorrhagia Qs
Anaemia + Bleeding Disorders
189
O+G: Mx of Menorrhagia
Ddx: physiological, cervical pathology, fibroids (TVUS), endometriosis (diagnostic lap), adenomyosis (MRI)
Ix: hx, abdo exam, preg test, bloods for FBC TFTs G+S clotting, bimanual/speculum/special tests if suspect ddx
Tx: establish if they’re trying to conceive, mirena/COCP vs MFA/TXA, ferrous sulphate, endometrial ablation/hysterectomy
190
O+G: Naegele’s Rule
EDD = LMP - 3m + 1w
191
O+G: Ddx for Hyperemesis
O+G:
Morning Sickness
Gravidarum
Molar Preg
GI/GU:
Gastroenteritis
Bowel Obstrc
UTI
192
O+G: Morning Sickness vs Hyperemesis Gravidarum
MS: common, tends to improve after first trimester, none of below
HG: >5% wt loss, dehydration, electrolyte imbalances
RFs: modifiable smoker/high BMI + NM nulliparous, prev hx, multiple preg, molar preg
PUQE: assess severity if >13 admit vs <13 but cannot tolerate oral mx ambulatory day case
Ix: obs/assess dehydration, body wt, urine dipstick infection/DKA, bloods for FBC U+Es LFTs TFTs VBG +/- US exclude other causes
Tx: antihistamine eg promethazine/cyclizine, antiemetic eg metoclopramide/ondansetron, steroids, IV fluids w KCL and thiamine, LMWH
193
O+G: GTD
Complete: empty egg fertilised by two sperm/one which duplicates ie 46XY/XX - snowstorm
Partial: normal egg fertilised by two sperm/one which duplicates ie 69XXX/XXY - fetal parts
Malignancy: invasive moles, choriocarcinoma, placental site trophoblastic tumour
RFs: extremes of reproductive age, ethnicity, prev GTD, low beta carotene/saturated fat diet
Px: usually painless irregular PV bleeding, hyperemesis, XS uterine enlargement
Mx: serum b-hCG/TFTs, pelvic US/histology, cancer screen, ERPC +/- methotrexate, avoid pregnancy until 6m of normal b-hCG
194
O+G: Amsel Criteria
To dx BV require >=3 of: discharge, whiff test, vaginal pH >4.5, clue cells on microscopy
195
O+G: Rotterdam Criteria
To dx PCOS require >=2 of: 2y oligo/anovulation, clinical/biochem features of hyperandrogenism eg hirsutism/LH>FSH, polycystic ovaries on TVUS ie >12 in >=1 ovary OR volume >=10cm^3
Ix: above plus monitoring for DM and CVD
Tx: optimise wt, oligo/anovulation and hyperandrogenism w COCP, infertility w endogenous clomiphene +/- metformin, exogenous gonadotrophins/IVF, lap ovarian drilling
196
O+G: Tx/Comps of Chlamydia/Gonorrhoea
Chlamydia: 7d doxycyline/3d azithromycin - PID, fitz-hugh-curtis, Reiter’s syndrome
Gonorrhoea: single dose of IM ceftriaxone/PO ciprofloxacin - PID, Skene/Bartholin abscess, disseminated gonorrhoea
197
O+G: Def of Labour
Painful uterine contractions + cervical dilatation and effacement +/- rom
NB: Braxton-Hicks contractions are painless and there’s no cervical change
198
O+G: Mx of Cord Prolapse
1. Help
2. Prevent further cord compression: avoid handling, elevate the presenting part/fill maternal bladder, tocolytics
3. Place mother in either: all fours, left lateral position, knees to chest
4. Deliver
199
O+G: Menopause
If <45 take FSH twice a mnth apart to see if elevated vs >45 clinical retrospective diagnosis
1. Lifestyle: regular exercise, red stress, sleep hygiene
2. HRT: establish whether they still have a uterus, Elleste Solo if no, Elleste Duet if yes, both carry risk of breast cancer and VTE, FU @ 3m then annually for effectiveness/SEs/BP
3. Alternatives: CBT/SSRI, lubricants, bisphosphonates
200
O+G: Amenorrhoea
1°: no menstruation by >16y in those w secondary sexual characteristics or >14y in those w/o
2°: cessation of regular menses for >3m or if irregular menses for >6m
201
O+G: DVT
RFs + Wells <=1 DD vs >=2 US
Tx: start s/c LMWH and continue until >6w postnatally or >3m of tx whichever is greater, do NOT use DOAC/warfarin in pregnancy, discontinue LMWH 24hrs before delivery, if VTE at term use IV unfractionated heparin which can be reversed w protamine sulphate
202
O+G: The FIGO Stages
Ovarian: confined, pelvis, abdomen, beyond
Endometrial: confined, cervix, local, bladder/bowel/distant mets
Cervical: confined, upper vagina, lower vagina, bladder/bowel/distant mets
203
O+G: Incontinence
Types: stress, urge, mixed, overflow, functional
Both: exclude DM/UTI, bladder diaries, urodynamic testing, encourage reduction of caffeine/fizzy drinks, optimise wt
Stress RFs: age, obesity, children, traumatic delivery, pelvic surgery
Stress Mx: 1. 3m pelvic floor exercises 2. SNRI eg duloxetine OR surgical eg burch colposuspension
Urge RFs: age, obesity, smoking, DM, FHx
Urge Mx: 1. 6w bladder training 2. antimuscarinic eg oxybutynin 3. beta-3 agonist eg mirabegron 4. surgical eg botox injection
204
O+G: Threatened Miscarriage vs APH
> 20wks
205
O+G: RFs for Placental Abruption
Prev, C/S, PET, smoking, cocaine
206
O+G: What US finding is suggestive of a MCDA pregnancy?
T-sign
207
O+G: Cervical Cancer Screening
25 -[3]- 49 -[5]- 64
208
O+G: Mx of Ectopic
It depends on pt sx, stable, adnexal size, fetal heartbeat, serum hCG
Expectant: serial hCG
Medical: IM methotrexate
Surgical: salpingectomy 3w FU vs salpingotomy wkly FU both +/- anti-D
If accidental discuss contraception and STI screen
209
O+G: Breast Cancer Screening
50 -[3]- 71
210
O+G: RFs for PPROM
Maternal: smoker, prev PROM/PTL, APH, trauma, cervical incompetence
Fetal: multiple preg + polyhydramnios
211
O+G: Levator Ani
Puborectalis
Pubococcygeus
Iliococcygeus
212
O+G: What are the four categories of uterine prolapse?
1. Cervix is in the upper half of the vagina
| 2. Introitus 3. Protrudes 4. Procidentia
213
O+G: Tx of PID
Tx Comps + Remove IUD
IM Ceftriaxone x1
PO Doxycycline 14d
PO Metronidazole 14d
If sys unwell, tubo-ovarian abscess, signs of peritonitis, unable to rule out other surgical causes, unable to tolerate oral abx - inpatient
214
O+G: Gardasil
6
11
16
18
215
O+G: Ddx for Dysmenorrhoea
```
Primary
Endometriosis
Adenomyosis
Fibroids
PID
```
216
Psych: Depression Hx
How long
Tell me about whats been going on
Would it be okay for me to ask you some more details qs about how you’ve been feeling
How have you been feeling in yourself
What about feeling tearful - things that wouldn’t ordinarily bother you
What about your energy levels
How have you been managing at work
With all this going on how are you sleeping
How long does it take you to fall asleep
Are you waking up much in the night
And able to get back to sleep
Appetite
Concentration
Memory
Are there still things in your life that you still enjoy
How old are your children
Looking after children takes up a lot of time, how are you coping with that feeling as low as you do
What about looking after yourself
When pple feel down it can have an impact on their relationship w close ones ...
It can also affect everything in the relationship including their sex life, have you noticed any changes there
Every had episodes in the past where you feel like this
217
Psych: Mania Hx
Has long has this been going on for
Am I right in thinking you normally do a different job
Can I take you back a step you said God tells you, can you tell me a bit more about that
Does the voice come through the ears or from inside your head
Who have you shown it to
Sorry to interrupt, it sounds like this has been keeping you really busy, have you been sleeping much at all
How are your thoughts
How do you feel about yourself and you self esteem
Have you ever had anything like this before in your life where you feel full of energy
...
And any times where it’s been the opposite, where you’ve feel low and lacked energy
Anyone in the family w things like this
How have you been feeling phsyically
Taking any prescribed medication, over the counter, recreational drugs
It sounded like your friend/family didn’t think you were very well atm, what do you think about that
218
Psych: ‘Can we talk about this now you seem to be going off on one’ - Mania
I would like to hear about it but before we get back into that
What I’m wondering is this might be a sign that you’re not very well atm
219
Psych: Anxiety Hx
Take your time
How long has this been going on for
Before this had you had anything similar
Can you remember what happened to start it all off
What did you think was going on
Are you finding yourself avoiding situations
How is it affecting your relationship w pple close to you
Have you had a heart trace done - what were you told about the results
Even though you’ve been told nothings wrong w the heart, do you still worry there might be
220
Psych: ‘What do you think it is’ - Anxiety
I’d agree that there doesn’t seem to be anything wrong w the heart
I say this because of the ECG and no RFs
Justify: normal ECG + no RFs
What I’m wondering is if it’s the anxiety giving you a lot of these symptoms
Have you ever thought this might be the case
Has anyone ever explained anxiety and panic attacks to you - talk about adrenaline, fight or flight, hypervigilance, our heart rate goes up and down throughout the day but most of us don’t notice us but because you’ve had a prev panic attack it makes you more aware of it
221
Psych: Psychosis Hx
How long has it been going on for
How did you first notice this was happening
I’ve noticed while we’ve been talking you’ve been looking around the room as if you’re checking for something, could I ask you whats happening at those times
```
Who is it you can hear/recognise
How many voices
Can you hear what they’re saying
Do they talk to each other
Why do you think they’re doing that
```
Has there been any other changes, perhaps to the way you’re thinking, sometimes pple tell us they’re getting thoughts put into their head that aren’t their own
Do you have any idea how that’s happening
What about the experience that somehow other pple are able to know what you’re thinking even though you haven’t told them
And that your thoughts stop all together
Any problems w the rest of your body, changes in sensation
Has it had any other affect on your life
Any problems watching the tv or listening to the radio
222
Psych: ‘Do you believe me?’ - Psychosis
I certainly believe that you’re having a really difficult time atm and this is all very real for you I guess what I’m not so sure about is what’s causing this
223
Psych: Def of Depression
>2wks
Low mood, Anhedonia, Anergia
224
Psych: Beck’s Negative Triad
All w/o Reason:
Worthless - how is your self esteem?
Hopeless - how do you feel about the world?
Helpless - what are your feelings towards the future?
225
Psych: Sx of Depression
Core: low mood, anhedonia, anergia
Biological: sleep, appetite, libido
Cognitive: concentration + Beck’s Triad of worthlessness, hopelessness, helplessness
Always ask about elevated mood too
226
Psych: Ddx for Depression
```
Pseudo
Bipolar
Dysthymia
Cyclothymia
Hypothyroid
Substances
Postnatal
Dementia
GAD
```
Adjustment
Grief Reaction
227
Psych: Mx of Depression
U+Es
ECG
PHQ-9
Self referral to CBT - computerised cbt
‘The positive side is you’ve done something about it by coming in today and there’s certainly a range of things we can put in place to support you and treatments available - can we spend a few minutes going through those options’
Mild-Mod: CBT or IPT
Mod-Sev: above + antidepressants +/- augmentation
ECT
Support groups/charities
228
Psych: What should you check before starting antidepressants?
Any periods of elevated mood + ECG for long QT syndrome
229
Psych: Ddx of Mania
Tbc
230
Psych: PTSD
>1m
1. Trauma Focused CBT + EMDR
2. SSRI - Paroxetine
3. NaSSA - Mirtazapine
231
Psych: Grief Reaction vs ASR vs PTSD
GR: can be normal
232
Psych: Monitoring of Lithium
Tbc
233
Psych: Def of GAD
Tbc
234
Psych: GAD
>6m
‘React more easily’
‘If we start to tackle this as if it’s more anxiety we have talking therapies and tablets - theres pros and cons to both which we’ll need to run through’
235
Psych: What are the two types of bipolar affective disorder?
Type I: >=1 Manic Ep >1w
Type II: >=1 Hypomanic Ep >4d AND >=1 Major Depressive Ep >2w
236
Psych: OCD
>2w
Recurrent obsessional thoughts or compulsive repeated acts
1. Exposure + Response Prevention CBT
2. SSRI - Fluoxetine
3. TFA - Clomipramine
237
Psych: Ddx of GAD
Tbc
238
Psych: Physical Sx of Anxiety
```
Dizzy
Sweating
Palpitations
Hyperventilation
Loose Bowels
```
239
Psych: Def of Schizophrenia
Typically starts in 20s for males and 30s for females
>6m
Make sure you acknowledge the pt ‘I know these are real for you’
```
>=1sx >=1m
Third person auditory hallucinations
Delusions of thought
Delusions of control
Delusional perception
```
OR
```
>=2
Paranoid
Hebephrenic
Catatonic
Simple
AND
present most time >=1m
AND
not caused by substance/oganic
```
240
Psych: Schizo vs OCD
Whether the thoughts were put there or originated from their own head
241
Psych: Mx of Schizophrenia
Bio-Psycho-Social
U+Es
ECG
CBT
Family Therapy
Art Therapy
Atypical Antipsychotics - queutapine +/- CBT
Do prolactin and CVD rfs inc lipids and HbA1c, measure wt, before starting antipsychotic, optimise cv rfs
Smoking/substance support
Clozapine - neutropenia, NMS - raised CK and AKI, rlly high fever, muscle stiffness - stop offending drug, dantrolene, bromocriptine, benzos
Support groups/charities
242
Psych: How to ask the first rank sx?
Auditory Hallucinations: ‘Do you ever hear noises or voices?’ ‘Do you recognise them?’ ‘What do they say?’ ‘Do they tell you to do things and you obey?’
Somatic Hallucinations: ‘Do you ever feel that something is touching you when there’s nobody there?’
Thought Abnormalities: ‘Do you experience your thoughts suddenly stopping?’ ‘Do you ever feel like anyone is taking thoughts out of your head?’ ‘Are your thoughts your own?’ ‘Can other people hear your thoughts?’
Delusional Perception: ‘Do you ever feel that specific events in the world or on TV are related to you in some way?’
Passivity: ‘Do you ever feel as though you are being controlled?’
243
Psych: Ddx for Schizophrenia
```
Psychosis
Schizophreniform
Schizoaffective
Postnatal
Cluster A
Thyrotoxicosis
Substances
OCD
```
Delusional Disorder
Hepatic Encephalopathy
244
Psych: What are the SEs of atypical antipsychotics?
Typicals - Extra-pyramidal: tardive dyskinesia, acute dystonia, parkinsonism
Atypicals - Metabolic: sedation, wt gain, dyslipidaemia, hyperprolactinaemia
245
Psych: How to px the MSE?
ASEPTIC
Appearance + Behaviour: dress, hygiene, eye contact, rapport, concentration
Speech: rate rhythm tone volume quantity, poverty, pressured
Emotion: subj mood/season now + obj affect/weather then
Perception: illusions + hallucinations
Thought: formal thought abnormality, alogia, clanging, neologism, perseveration, derailment, depersonalisation, delusions, possession
Insight: preserved, partial, nil
Cognition: time, place, person - what’s the date, where are we now, who am I
246
Psych: Depression MSE
A: signs of neglect, dehydration, miserable, disinterested, anxious movements, poor eye contact, looking down, posture, tearful
S: slow, quiet, mute
E: constricted affect, nihilism
P: severe, nihilistic delusions, persecutory delusions, evil images, guilt ‘feel they have harmed someone/done something bad’
T: Beck’s Triad
I: nil
C: psychomotor retardation mimics cognitive impairment
247
Psych: Mania MSE
A: excitable, irritable, distracted, inappropriate clothing
S: pressured
E: inc self esteem, grandiose, labile mood, irritable, insomnia, loss of inhibition, inc appetite, inc libido, exaggerated and euphoric affect
P: grandiose delusions
Feel like they are destined for something special/have special abilities’, paranoia, catatonic stupor
T: flight of ideas, racing thought, suicidal ideas, third person auditory hallucinations
I: minimal
C: nil impact
248
Psych: Schizophrenia MSE
A: disheveled, dec eye contact, agitated, suspicious
S: disorganised, word salad
E: blunted and inappropriate affect
P: paranoid ‘sometimes have the feeling that a person/group wants to harm them’
T: procress: block, insertion, broadcasting, derailment + content: delusional?
I: variable
C: deficit
249
Psych: Def of AN
BMI <17.5 OR Wt Loss >15%
250
Psych: Personality Disorders
Cluster A - odd: paranoid, schizoid, schizotypal
Cluster B - dramatic: histrionic, EUPD, antisocial
Cluster C - anxious: avoidant, anankastic, dependent
251
Psych: SEs of Antipsychotics
Typicals - early acute dystonia (procyclidine), late tardive dyskinesia (tetrabenazine), parkinsonism, akathisia
Atypicals - wt gain, dyslipidaemia, hyperprolactinaemia, sedation
Clozapine - agranulocytosis + neuroleptic malignant syndrome
252
Psych: Emergencies
SS
NMS
Psychosis
Delirium
253
Psych: Risk Assessment
It sounds like a very difficult time for you, can I ask you how you’re coping with all of this
It sounds like you don’t feel very safe have I got that right
Have you felt the need to take steps to protect yourself in any way
Has it got so bad that you’re felt the need to hurt yourself or kill yourself as the only way out
In the past ever had problems w your temper, getting in fights
Can I double check you haven’t been in trouble w the police before
With all of this going on, is their anywhere you feel safe
It’s a difficult q to ask but one we ask everybody in your situation, have things ever been so bad that you not only thought about harming yourself but also to take the children with you
What about the other side of that, things to live for
Are there pple that can be supportive
Do you feel able to keep yourself safe atm from hurting yourself
Do you think if that was to change, you’d be able to let anyone know
254
Psych: Suicide Risk Assessment
Before-During-After
Before: careful planning, writing a note, sorting will/finances, isolation, mental illness, prev act
During: method (drugs, alcohol, violent) + purpose (intent to die)
After: route to hospital, any regret, future risk
Assess capacity and admit if high risk, at the greatest risk during first wk of admission, formulate 1. crisis plan 2. coping strategies 3. F/U <1wk
255
Psych: Suicide RFs
SAD PERSONS
Sex Male
Age Extremities <25/>45
Depression + Others
```
Prev Act
Excessive Alcohol/Drugs
Rational Thinking Loss
Social Support Lacking
Organised Plan
No Partner
Sickness
```
256
Psych: Mx of EUPD
Bio-Psycho-Social
Refer for dialectical behavioural therapy first line and consider mentalisation-based therapy, art therapy, SSRIs
Formulate short/long term goals and a crisis plan inc providing contact numbers for local crisis resolution team, community mental health nurse, OOH social worker
Educate pt on dx and identify triggers, seek senior and MDT input, F/U
257
Psych: How would you explain EUPD?
It’s often undiagnosed and characterised by an inc sensitivity to emotions and is likely linked to stressful life circumstances
258
Psych: What does the total score on the PHQ-9, GAD-7, HADS reflect?
PHQ-9: 0-4 none, 5-9 mild, 10-14 mod, 15-19 mod/sev, 20-27 sev
GAD-7: 0-4 none, 5-9 mild, 10-14 mod, 15-21 sev
HADS: 7Qs for Depression + 7Qs for Anxiety each scores 0-7 norm, 8-10 borderline, 11-21 abnormal
259
Psych: Mx of Alcohol Withdrawal
Tx if CIWA-Ar >8: oral lorazepam/chlordiazepoxide + parenteral thiamine
Bio-Psycho-Social: detox and then acamprosate/disulfiram, motivational interviewing, alcoholics anonymous
260
Postnatal Depression
Bio-Psycho-Social: sertraline/paroxetine, CBT, involve home tx team or if severe admit to MBU
Screen for neglect by ascertaining feelings towards baby
It usually takes <1m to recover, explain it’s normal to feel low after giving birth but do not expect to continue past 2wks, likely due to hormonal changes
261
Puerperal Psychosis
Admit to MBU and depending on px: antipsychotics/antidepressants/lithium, if agitated benzos, if severe ECT
Screen for neglect by ascertaining feelings towards baby
It usually takes 6-12wks to recover and you must F/U as 1/3 recur
262
Psych: Tx of Paracetamol OD
Admit and establish exact time taken:
If <1hr give activated charcoal
If 4-8hrs measure serum paracetamol, plot on nomogram and if over tx line commence NAC infusion
If >8hrs/OD was staggered commence NAC infusion, measure serum paracetamol and ALT, if over tx line or raised ALT continue
263
Psych: How would you explain dialectical behavioural therapy?
It helps you understand your thought process and shows you things are rarely black and white and skills to cope w difficult emotions
264
Psych: CAGE + FAST
CAGE >=2: cut down, annoyed, guilty, eye opener
FAST >=3: predominantly used in A+E
265
Psych: How is psychosis in depression different from psychosis in schizophrenia?
It’s mood congruent in depression vs not in schizophrenia due to their blunted affect
266
Psych: Dependence Syndrome Classification
>=3 present together within prev yr: compulsion, difficulty controlling, physiological withdrawal or use to relieve/avoid, tolerance, progressive neglect, persistent use despite overt harmful consequences
267
Psych: Wernicke’s + Korsakoff’s
W: ataxia, ophthalmoplegia, acute confusion - reversible
K: plus anterograde amnesia w confabulation - irreversible
268
Psych: Ddx for Puerperal Psychosis
Schizophrenia
BPAD w Psychosis
Psychotic Depression
269
Psych: Mx of Opiate Withdrawal
Tx if COWS >5: naloxone + lofexidine for sx relief
Bio-Psycho-Social: involve crisis assessment team followed by CMHT/primary care plus + harm reduction approaches eg needle exchange and vaccinations
270
Psych: Def of Dementia
An acquired progressive degenerative disorder giving global impairment of all mental functions in clear consciousness
271
Psych: What is the def/causes of delirium?
State of mental confusion that starts suddenly and is caused by a physical condition ie PInCH ME: pain, infection, constipation, dehydration and urinary retention, medications esp anticholinergics, electrolytes
Mx: admit, MCA, tx underlying cause, safe low stimulation environment, de-escalation techniques, seek advice from elderly care, low dose lorazpem/haloperidol w senior input
272
Psych: What screening tests assess cognitive function?
```
AMTS
MMSE
ACE-III
MoCA
Rudas
```
273
Psych: How do you do a quick mental state assessment?
This is a shorter MMSE w/o the attention or language
Registration: Apple, Table, Penny
Orientation: What year is this? (1) What month is this? (1) What day of the wk is this? (1)
Recall: What were the three objects? (1)
>3 high likelihood of dementia
274
Psych: MCA
Tbc
275
Psych: MHA
Tbc
As an F1 wouldn’t be doing myself
2 (28d) - assessment
3 (6m) - treatment
4 (72h) - emerg tx
5(2) - holding for 72h
276
Psych: Sx of Parkinson’s
Tremor
Rigidity
Bradykinesia
Always ask if they’re on antipsychotics
277
Psych: CBT
The ABC of CBT: there’s an activating event, that’s mediated by beliefs (thoughts, attitudes, assumptions) and results in consequences (emotions/behaviour)
Aim to understand the link b/w thoughts and emotions
Formulation: rationale for pts problem - origin, current status, maintenance
Map out the links b/w thoughts, emotions, bodily sensations, behaviour
Session: set an agenda, homework from prev session, specific interventions
Depression - activity schedule to link mood and activities - build in activities that bring pleasure
Negotiate behavioural targets
Identify the negative automatic thoughts - thought record, identify cognitive disorders (allow events to fit in with underlying assumptions and beliefs), challenge (thought records, socratic questioning)
Push pt to think about their thoughts/behaviours and design experiments to disprove the negative ones
278
Psych: ECT
T
279
Psych: CBT Anxiety Model
Anxiety
Adrenaline + Hyperventilation
Physical Sx
Catastrophic Thoughts
Safety Behaviours
Anxiety
280
Psych: CBT Depression Model
T
281
Psych: What are the SEs of SSRIs?
```
The Five S’s:
Suicide
Stomach
Sexual
Sleep
Serotonin
```
282
O+G: What are the urodynamics of a normal bladder function?
Voiding Detrusor Pressure <70 cm H2O
Peak Flow Rate >15 mL/s
283
Depression sx screen
Core: low mood, anhedonia, anergia
Biological: appetite/wt change, low libido, sleep disturbance
Cognitive: memory impairment, beck’s triad, suicidal
PLUS hx of hypomania, psychosis, mood incongruence
284
Schizophrenic sx screen
ICD-10 states >=1 of Schneider’s first rank sx OR >=2 ABCD
285
Duration of schizophrenia to dx
>=1m
286
What are Schneider’s first rank sx?
Auditory Hallucinations: thought echo, third person voices, running commentary
Abnormal Thoughts: insertion, withdrawal, broadcasting
Delusion of Control: SIVA
Delusional Perception
287
What does the SIVA in delusion of control stand for?
Somatic
Impulse
Volition
Affect
288
What is a hallucination?
Perception in the absence of a stimulus
289
What is a delusion?
Fixed false belief
290
What is the ABCD part of the schizophrenia screen?
Always present hallucinations in any modality every day for a mnth
Breaks in train of thought, incoherent speech, neologisms
Caratonic behaviours: WRENCHES
Defeatist sx: 5A’s
291
What are the WRENCHES of catatonic behaviours?
```
Waxy Flexibility
Rigidity
Echopraxia
Negativism
Catalepsy
Hyperactive
Echolalia
Stupor
```
292
What are the five A’s of the negative sx?
```
Apathy
Anhedonia
Affect Blunted
Asociality
Alogia
```
293
What are the acute and chronic sx of schizophrenia?
Acute, +ve sx, hallucinations, thought interference, delusions
Chronic, -ve sx, 5A’s
294
What is the cause of these acute and chronic sx?
Acute: XS dopamine in mesolimbic tracts
Chronic: def dopamine in mesocortical tracts
295
Outline the MSE
ASEPTIC
Appearance + Behaviour
Speech: rate, quantity, tone, volume, fluency
Emotion: Mood + Affect
Perceptions: Hallucinations + Illusions
Thoughts: Form, Content, Possession
Insight + Judgement
Cognition: oritentation, attention, memory
296
Outline the capacity assessment
Understand
Retain
Weighup
Communicate
297
How is one orientated?
Time, place, person
298
What is inc in appearance + behaviour during the MSE?
Kempt, eye contact, distracted
299
What is inc in insight + judgement during the MSE?
Tbc
300
What is mood + affect?
Mood - generally (flat/labile)
Vs
Affect - currently (blunted/elevated)
Ask to rate their mood on a scale of 1-10
301
What is an illusion?
Misinterpreted perception
302
What are the different types of depression?
Unipolar
Bipolar
Psychotic
Psychosocial
Ddx: dysthymia, pseudo, adjustment disorder, hypothyroidism
303
Which drugs shouldn’t you give to a bipolar entering hypomanic state?
Antidepressants w/o mood stabilisers
304
What drugs shouldn’t you give to a Parkinson’s pt?
Antipsychotics
305
Depression vs Adjustment Disorder
Depression may not necessarily have a preceding event and is likely to be more severe
306
Biological vs Psychosocial
If it was: spontaneous, episodic, responded to prev tx, strong fhx etc all point towards a biological cause
307
The sensitivity and specificity of the depression screen
Core+Bio - sensitive but not specific
Cognitive - specific but not sensitive
308
What is typical thought broadcasting?
They’re in the newspapers/TV
309
Which screening tools are their for alcohol misuse/dependency?
CAGE, AUDIT, SADQ
310
What are the four CAGE qs?
Have you ever felt you need to cut down on your drinking?
Have people annoyed you by criticising your drinking?
Have you ever felt guilty about drinking?
Have you ever felt you needed a drink first thing in the morning to steady your nerves or to get rid of a hangover?
311
What is considered a positive CAGE?
>=2
312
What are the seven DSM-IV criteria for alcohol dependence?
```
Restricted
Cravings
Primacy
Tolerance
Withdrawal
Relief Drinking
Reinstatement
```
313
How could you word asking about primacy?
Do you find yourself neglecting other aspects of your life because of alcohol
314
What should you briefly ask about after screening for alcohol dependency?
Ascertain what exactly they’re drinking
Ask about smoking and drugs
Anything they see the GP for reg
Ask for them to fill in AUDIT whilst you liaise w the rest of the team
315
How could you word asking about tolerance?
Do you find you have to drink more to reach the same affect
316
How many of the DSM-IV criteria are required for alcohol dependence?
>=3 occurring at any time in the same twelve mnth period
317
How are non-fatal offences sentenced?
Offences Against the Person Act 1861:
Assault + Battery - 6m
S47 ABH + S20 GBH - 5y
S18 GBH w Intent - up to life
318
How often should pts in isolation be checked?
2hrly by nurse + 4hrly by dr
319
What are T2 (consent form), T3 (certificate of second opinion) and S62 forms?
Apply to meds used to alleviate sx of mental disorder and their SEs after the initial 3m w/o consent period
320
When does the T2 become invalid?
If the pt loses capacity to consent or withdraws consent -> SOAD
If the tx changes or additional meds are prescribed -> new form
321
SSRI SEs
GI disturbance, drowsiness, fatigue, dry mouth, sexual dysfunction
322
What is the Braak staging for Alzheimer’s disease?
Stage I+II: transentorhinal - autonomic and olfactory disturbances
Stage III+IV: limbic - sleep and motor disturbances
Stage V+VI: neocortical - emotional and cognitive disturbances
