MSK, Reproduction and Psychiatry Summary COPY Flashcards
What is the management of ectopic pregnancies?
- medical: methotrexate
- surgical: laparoscopic salpingectomy/ salpinotomy for few indications
conservative
+ USS in following pregnancies
What infections might cause reactive arthritis?
Infections include- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci
Infections- throat, urogenital & GI
Gout vs Pseudogout comparison
What is the management of bacterial vaginosis?
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Management
oral metronidazole for 5-7 days
70-80% initial cure rate
relapse rate > 50% within 3 months
the BNF suggests topical metronidazole or topical clindamycin as alternatives
What are risk factrors for stress incontinence?
Age
Parity
Menopause
Smoking
Medical problems
Increased intra abdominal pressure
Pelvic floor trauma
Denervation
Connective tissue disease
Surgery
What is the presentation of breast cancer?
hard lump, fixed mass, tethering to skin, dimpling of skin, often painless lump or thickening in breast, discharge or bleeding, change in size or contours of breast, change in colour of areola, redness or pitting of skin over the breast like the skin of an orange
What are the two ways of assessing osteoporosis fracture risk?
FRAX
Qfracture
How is the diagnosis of PCOS made?
2 of the three
- Polycystic ovaries on USS
- Oligo ovulation or anovulation
- Clinical hirsuitism, acne or biochemical signs of hyperandrogenism
What is the presentation of SLE?
classification criteria (any 4 “ORDER HIS ANA):
Oral ulcers
malar Rash
Discoid rash (raised, scarring, permanent marks, alopecia)
Exaggerated photosensitivity
Renal disorders (significant proteinuria or cellular casts in urine)
Haematological (low WCC, platelets, lymphocytes, haemolytic anaemia)
Immunological (anti ds-DNA, SM ( I think this is anti-smith, cardiolipin, lupus anticoagulant, low complement)
Serositis (pleurisy or pericarditis)
Arthritis/arthralgia (2 joints at least)
Neuro (unexplained seizures or psychosis)
ANA (anti-nuclear Ab)
Also has fever
What is the triad of granulomatosis with polyangitis?
Focal necrotising vasculitis
Necrotizing granulomas in the upper airway, lungs
Necrotizing glomerulonephritis (renal vasculitis)
What are the casues of male infertility?
CF, testicular maldescent, testicular problem, pre-testicular (hypothalamus) or post-testicular. Previously mentioned that there can also be absence of vas deferens
failure of production (35%)
Klinfelter’s syndrome
previous mumps or TB
failure of transport
sterilisation
CF
impotence
What is a bone biopsy finding of pagets disease of the bone?
Mosaic pattern of lamellar bone
Large numerous osteclasts with up to 100 nuclei normal is 5-10)
Affected bone marrow field is filled with highly vascular stroma
What are X ray findings of Paget’s disease of the bone?
Osteoporisis circumscripta (well defined osteolytic lesions of the skull in early course)
Cotton wool appearance
Squaring of vertebrae seen on lateral X-ray
Tam O’shanter sign (enlarged overriding frontal bone)
Bone scan scintigraphy is a potential investigation (focal increased radionuclide uptake)
What medications might predispose you to osteoporosis?
Steroids
PPI - reduced calclium absorption
Enzyme inducting antiepileptic mediations
Aromatase inhibitors
GnRH inhibitors
Warfarin - Vitamin K is an essential factor for carboxylation of bone matrix protein. Low vitamin K may be associated with reduced bone mineral density (BMD)
What are the features of endometrial cancer?
post-menopausal bleeding is most common feature, abnormal vaginal bleeding (change in pre-menstrual bleeding)
How does dupuytrens disease progress?
Starts in the palms causing puckering of the skin. Metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.
What are the relevant investigations for menopause?
DEXA scan for bone density
LH (Increases)
FSH (increases)
Oestrogen (decreases)
Progesterone (decreases)
What is the management for placental abruption?
May have to do immediate C section in worst cases but vaginal delivery may be achieved
What is the presentation of osteoarthritis?
patient over 45 and activity-related joint pain (pain after exertion) plus either morning stiffness < 30 minutes, reduced ROM, deformity
pain after exertion,
IF linked to trauma, prolonged morning-related stiffness, rapid deterioration of symptoms, hot swollen joint then -> gout, other inflammatory arthrides, septic arthritis, malignancy
What would you find in a salivary gland biopsy in sjogren’s?
Focal lymphocyte foci (collections of tightly aggregated lymphocytes)
What is FIGO staging?
Endometrial cancer staging
(FIGO stage 1-4 according to depth of myometrial invasion, cervical involvement and lymph node involvement) and type (1 or 2)
stage 1 (carcinoma strictly confined to the uterus)
stage 2 (carcinoma extended to the endocervix (2A) or cervical stoma (2B))
stage 3 (spread to serosa of uterus, pelvic peritoneum or pelvic lymph nodes)
stage 4 (local metastasis to bladder/bowel (4A) or distant metastasis (4B))
What is the disease mechanism of granulomatosis with polyangitis (wegners)?
B cell mediated release of free radicals from neutrophils
Free radicals damage neighbouring endothelial cells - vasculitits
granulomatosis with polyangitis only affects small vessels (nasopharynx, kidneys and lungs)
What are the causes of pseudogout?
Sporadic
Hereditary component
Secondary to previous joint damage, hyperparathyroidism, haemachromatosis, hypothyroidism, ochronosis, diabetes
What is presentation of RA?
Morning stiffness, improves with use
Bilateral symptoms
Systemic upset
Joint swelling (joints are swollen and warm, limitation of movement
Lymphadenopathy
Splenomegaly
Systemic - fatigue/lethargy, weight loss, anaemia
swollen, painful joints in hands and feet
stiffness worse in the morning
gradually gets worse with larger joints becoming involved
presentation usually insidiously develops over a few months
positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints
Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.
What is the definition of primary amenorrhoea?
never had period, either >14 and no secondary sexual characteristics or >16 and sexual characteristics
What is the managment of hallux rigidus?
Non-operative:
- Activity modification, shoe wear with rigid sole, analgesia
Operative:
cheilectomy (remove dorsal bone impingement)
arthrodesis = 1st MTPJ fusion (gold standard, permanent)
arthroplasty
What are the features of dyskariosis?
dyskariosis (abnormal cells may be few, nucleus is increased in size and nuclear/cytoplasmic ratio, variation in size, shape, outline, coarse, irregular chromatin, nucleoli)
Where do ganglia arise from ?
Joint capsule, tendon sheath or ligament
What are the tests for achilles tendon rupture?
Simmonds - squeeze test
Matles test - angle of dangle
What are the investigations for endometriosis?
laparoscopy (gold standard) look for clear, red, bluish lack or with lesions,
pelvic MRI for deep endometriosis, if severe disease is suspected and surgical planning necessary
pelvic USS can diagnose endometrioma (chocolat cyst) or large nodules
What are the stages of cervical cancer?
stage 1 (carcinoma strictly confined to the cervix)
stage 2 (carcinoma that extends into the parametrium or upper 2/3 of vagina)
stage 3 (carcinoma has extended to pelvic side wall, lower 1/3 of vagina or causes hydronephrosis)
stage 4 (carcinoma that has extended beyond the pelvis)
What percentage of CIN 3 progresses to cervical carcinoma?
30-80%
What is the diagnostic criteria for pre-eclampsia?
creatinine ratio >30mg/mmol,
24h urine protein collection >300mg/day,
mild HT on two occasions or more, more than 4 hours apart or moderate to severe HT
What is the presentation for hallux valgus (forefoot problems)
bunions, pressure symptoms from shoe wear, pain from crossing over of toes, metatarsalgia
What is the investigation for vulvovaginal candidosis?
Gram stained preparation, culture
What is the disease process of septic arthritis?
Articular cartilage is attacked by abcterial toxin and cellular enzyme
Complete destruction of the articular cartilage
source of infection can be from blood, adjacent sites (osteomyelitis, bone abscess) or it can be through direct introduction of the organism via trauma / instrumentation
What are the causes of menorrhoagia?
Uterine fibroids
Dysfunctional uterine bleeding
Coagulopathies
Pelvic malignancies
What is the treatment of DDH?
Pavlik harness
Surgery may be needed if your baby is diagnosed with DDH after they’re 6 months old, or if the Pavlik harness has not worked
Surgical options include:
closed reduction – the ball is placed in the socket without making any large cuts (incisions)
open reduction – an incision is made in the groin to allow the surgeon to place the ball in the socket
What are the functions of progesterone?
- Maintenance of endometrium and pregnancy
- Thickens cervical mucous
- Decreases myometrial excitability
- Increases body temperature
- Responsible for spiral artery development
What are the three different types of idiopathic juvenile arthritis?
Polyarticular (5 joints or more)
Pauci articular (4 joints or less)
Stills disease which is systemic onset
What are investigations for polymyalgia rheumatica?
ESR > 40 mm/hr
Increased CRP
note CK and EMG normal
reduced CD8+ T
You tend to find that there is a dramatic response to steroids
What is acute flare therapy for gout?
Anti-inflammatory treatment ASAP
GLucocorticoids (oral and or intraarticular injections)
NSAIDs (naproxen, indomethacin)
Colchicine (inhibits leukocyte migration)
Biological agents (IL-1 inhibitors)
What is stage 2 of labour?
Full cervical dilation to the birth of the baby
Passive second stage of labour - Full dilation of the cervix with or without expulsive contractions
Active second stage - Presenting part is visible, expulsive contractions with full dilatation of the cervix, active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions.
Primagravida = birth would be expected within two hours of active second stage commencing
Multigravida = 1 hour
What is the screening programme for breast cancer in Scotland?
he Scottish Breast Screening Programme invites women aged between 50 and 70 years old for screening every three years. Women over 70 years old are able to attend through self-referral.
What is placental abruption?
Premature separation of the placenta from the uterine wall
What is the presentation of pre-eclampsia?
asymtomatic or headache, blurry vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face and legs, clonus, brisk reflexes, papilloedema, reduced urine output, convulsions, epigastric pain, right upper quadrant pain, visual disturbance, leg swelling
Eclampsia is characterised by tonic clonic seizures
Can also cause pulmonary oedema, cerebral haemorrhage, HELLP syndrome, placental abruption
HELLP syndrome is haemolysis, elevated liver enzymes and low platelets
What causes klumpkes palsy?
breech delivery, T1 damage (upward traction): occurs with shoulder disclocation or cervical rib
What type of HPV virus is most assocaited with cervical cancer?
HPV 16 and 18 are highr risk subtypes
What are investigations for fibroids?
large fibroids are palpable abdominally, uterus may be enlarged on pelvic examination
Transvaginal USS, Pelvic USS, hysteroscopy?
What are potential complications of PID?
infertility (10-20% after first episode), ectopic pregnancies, chronic pelvic pain, Fitz-Hugh-Curtis syndrome (in 10% cases)
What changes would you see in the blood in pre-eclampsia?
High Bp
Raised liver enzymes
Bilirubin
Raised urea and creatinine
Raised urate
Low platelets
Low haemoglobin
Signs of haemolysis
Features of DIC
What is the cause of pathophysiology of osteogenesis imperfecta?
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
What are potential ectopic sites for ectopic pregnancy?
Fallopian tube is the most common (especially ampullary region)
Cervical
Abdominal
Ovarian
Uterine cesarean scar
What is managment of endometriosis?
medical:
NSAIDs, COCP, danazol/gestrinone, mirena IUS, GnRH agonist (leuprorelin), progesterone, levonorgestrel (LNG), GnRH analogues
surgical:
remove endometriosis, goes from laparoscopic ablation of lesions to hysterectomy and bilateral salpingo-oophorectomy
pain management
What are the characteristic features of Ewings sarcoma on x-ray?
Ewings sarcoma - forms lytic bone lesions that look like an onion ring appearance
What is the presentation of hallux rigidus?
Stiff big toe
Asymptomatic
Pain (often at extreme of dorsiflexion)
Limited ROM
What is operative treatment of lesser toe deformities?
flexor to extensor transfer
fusion of interphalageal joint
release of metatarsophalangeal joint
shortening osteotomy of metatarsal
What are potential causes for raised CA125?
CA 125 (glyco-protein antigen) can indicate malignancies (ovary, colon/pancreas and breast) and benign conditions such as menstruation, PID, endometriosis, liver disease, recent surgery, effusions
What are risk factors fordupuytrens disease?
Male
Old age
Alcohol
Diabetes
Tobacco
HIV
Epilepsey
Which fingers are most commonly affected by dupuytrens diusease?
Ring finger follwed by little and middle fingers
What are risk factors for ovarian cancer?
Passmedicine:
family history: mutations of the BRCA1 or the BRCA2 gene
many ovulations*: early menarche, late menopause, nulliparity
FH, >30 y/o, FH (2 or more relatives), cancer gene mutation carriers)
for risk (combines menopausal status, ultrasound score and CA 125) use RMI I score (if 250 or greater then referral to specialist team)
What are the complications of scaphoid fracture?
avascular necrosis in proximal part of scaphoid (AVN) (because blood supply is distal to proximal), non-union
What is the presentation of base of thumb OA?
pain (opening jars, pinching), stiffness, swelling, deformity, loss of function
What is Amsel’s diagnostic criteria for diagnosing bacterial vaginosis?
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
What are the complications of gout?
Stone passage causing renal colic
Renal failure - death in 20% of individuals with chronic gout
What drug can be used to treat HER 2 positive breast cancer?
Some breast cancers have high numbers of receptors for the protein HER2 (human epidermal growth factor 2). They are called HER2 positive breast cancers. About 1 in 7 women (15%) with early breast cancer have HER2 positive cancer. A drug called trastuzumab (Herceptin®) is an effective treatment for this type of breast cancer.
What is the largest cause of mortality in pregnancy women?
VTE/PE
What is the difference between a complete and an incomplete hydatiform mole?
Complete = single sperm fertalises enucleate egg, this means that the moile only contains paternal DNA. There are no fetal cells and there is a risk of GTN (gestational trophoblastic neoplasia) - this includes invasive mole, choriocarcinoma and placental site trophoblastic tumour.
Partial = One normal egg cell fertilised by two normal sperm cells, usually triploid. Some fetal cells are evident such as amnion and RBC,s there isn’t really an association with choriocarcinoma.
What type of autoantibody may be present in JIA?
ANA
What are the complications of pre-eclampsia on the fetus?
IUGR
Intrauterine death
Iatrogenic preterm delivery
What is a complication of chlamydia?
Peri-hepatitis (fitz hugh-curtis syndrome)
How long is a cast recquired for the following tpes of fractures?
Buckle
Green stick
Complete
Buckle = 3/4 weeks
Greenstick = 4-6 weeks
Complete = 6 weeks
What are the symptoms of PID?
constant lower abdominal pain, purulent vaginal discharge, deep dyspareunia, pyrexia, irregular PV bleeding, adnexal tenderness
dysuria, irregular periods
What diseases might predispose you to enteropathic arthritis?
Commonly associated with inflammatory bowel disease (Crohn’s or UC)
Rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease
What are risk factors for breast cancer?
Female sex
Age
Family history (BRCA1 and BRCA2)
Early menarche late menopause
Nullparity, higher age at first pregnancy
Higher socioeconomic group
HRT
Why can hyperprolactinaemia cause infertility|?
Becasue prolactin inhibits GnRH
What are complications of perthes disease?
Premature fusion of growth plates
OA
Phases =
Avascular necrosis
Fragmentation - revascularisation (pain)
Reossification - bony healing
Residual deformity
What is the most common benign bone tumour?
Osteochondroma
What are findings on imaging of gout? (US, radiographical, CT)
Joint destruction, bony erosions (rarely present on the first acute episode)
Imaging findings tend to become more likely with disease duration
X-Ray - radiolucent uric acid nephrolithiasis
Which disc when prolapsed would cause :
sensory loss on the little toe and sole of foot
Motor weakness in plantar felxion of the foot
Reflex change in ankle jerk
Disc = L5/S1
Actual root value = S1
What is management for urge incontinence and overactive bladder?
conversative: physiotherapy, bladder retaining, lifestyle modifications, normalise fluid intake, reduce caffeine, fizzy drinks, chocolate, stop smoking, weight loss,
medical:
anticholinergics (oral or transdermal antimuscarinic), tri-cyclic antidepressants,
surgical:
Botox injections, clam cystoplasty, urinary diversion
What are the complications of placental abruption?
complications include maternal shock, collapse, fetal death, maternal DIC (disseminated intravascular coagulation), renal failure, postpartum haemorrhage, ‘couvelaire uterus’
How is histological diagnosis of CIN achieved?
Histological diagnosis is achieved with biopsies of abnormal area
What are the features of osteogenesis imperfecta?
fragile bones from mild trauma or even daily acts of life
other non-bone clinical features
growth deficiency
defective tooth formation (dentigenesis imperfecta)
hearing loss
blue sclera
scoliosis/barrel chest
ligamentous laxity (Beighton score)
easy bruising
What are genes associated with ovarian cancer?
genes associated: BRAC1, BRAC2, HNPCC/Lynch type 2 familial cancer syndrome
Which nerve is likely to be affected in fracture of humeral condyles?
Ulnar nerve
What are the findings in the urine for sjogren’s?
Proteinuria/haematuria reflecting glomerulonephritis
What is the management for psoriatic arthritis?
sulfasalazine, methotrexate, leflunomide, cyclosporine, anti-TNF therapy, anti-IL-17 and IL-23, steroids, physiotherapy and occupational therapy, axial disease treated similar to ankylosing spondylitis
NSAIDs, DMARD
What is the definition of primary and secondary postpartum haemorrhage?
primary PPH :>500 mL blood loss within first 24h delivery
secondary PPH: >500 mL blood loss after 24h of delivery
What are the mechanisms of labour?
Descent
Flexion
Internal rotation of the head
Crowning and extension of the head
Restitution
Internal rotation of the shoulders
External rotation of the head
Lateral flexion
What are the causes of sjogrens?
Primary = sicca syndrome
Secondary (to other autoimmune diseases, RA is the most common)
What is the management for stress incontinence?
conservative: pelvic floor exercises, lifestyle changes (smoking cessation, lose weight, eat more healthily to avoid constipation, stop drinking alcohol or caffeine) tension free vaginal tape (for suburethral hammock theory) (TVT) or colposuspension but TVT is now 1st choice, physiotherapy (pelvic floor muscle training),
medical:
duloxetine
surgery:
tension-free vaginal tape, colposuspension, urethral bulking agents
What is the tool which calculates prognosis for breast cancer?
Nottingham prognosis index
This accounts for tumour size, lymph node score and grade score
What is the investigation for osteomyelitis?
MRI
Others include:
US, aspiration (swelling?), isotope bone scan, labelled white cell scan, MRI, FBC + WBC, ESR, CRP, CK, 3x blood cultures at peak of temperature, U&Es if ill dehydrated, bone biopsy, tissue swabs from up to 5 sites around implant at debridement in prosthetic infections but sinus tract and superficial swab results may be misleading (skin contaminants)
What is the gene assocaited with Ewings sarcoma?
associated with t(11;22) translocation which results in an EWS-FLI1 gene product
What are the differences between acute slip and chronic slip?
Acute Slip:
In an acute slip, pain in the hip is so severe that your child is unable to walk or stand. You may notice that one leg seems shorter than the other. They won’t want to move their hip because it is painful. You may notice that their leg is turned outwards.
Chronic Slip:
Limping
Walking may be painful
Pain worse on excersize
Stiffness
Leg on affected side may be shorter
Muscle wasting on affected side
What are the features of Pelvic Inflammatory Disease?
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in around 10% of cases. It is characterised by right upper quadrant pain and may be confused with cholecystitis
What is managment for male infertility?
surgical sperm retrieval,
reversal of vasectomy,
donor insemination,
intra-uterine insemination,
IVF/ICSI (intracytoplasmic sperm injection,
injection of mature egg with single sperm,
overnight incubation), DI (?)
sperm donation
What is the definition of adenomyosis?
Presence of endometrial tissue in the myometrium
What is the blood marker for granulomatosis with polyangitis?
c-ANCA
What is the managment for adenomyosis?
Hormonal contraception for heavy/painful periods (mirena US, progestogens, combined OCP)
What would separate transient synovitis from septic arthritis?
apyrexial, allowing joint to be examined, low CRP, normal WCC, not that unwell (as opposed to septic artheritis and osteomyelitis)
What is the management of tibialis posterior tendon dysfunction?
orthoses or surgery (reconstruction of tendon (tendon transfer), triple fusion (subtalar, talonavicular and calcaneocuboid)
How do anti-psychotics work?
Antipsychotics act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
What is the sign for tibialis posterior tendon dysfunction?
clinical diagnosis (double & single heel raise; heel should swing for valgus to varus as heel rises)
What are the extrapyramidal side effects caused by traditional anti-psychotics?
Extrapyramidal side-effects
Parkinsonism
acute dystonia (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)
What are serological tests for Sjogren’s?
rheumatoid factor (RF) positive in nearly 100% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS
also: hypergammaglobulinaemia, low C4
What is the aetiology of hallux valgus?
Genetic foot wear
What is the presentation of septic arthritis?
fever, warm, red, swollen, painful joint, may also be an erythematous rash
in adults: acute pain in single large joint, limping, swollen red joint, refusal to move joint (knee, ankle, wrist) (reluctancy to make any movement, increase T° and pulse, increase tenderness)
What are the characteristic features of osteosarcoma on x-ray?
Lytic bone lesions which form a sunburts effect
Osteosarcomas often cause the periosteum to lift and this is called codman’s triangle
What are imaging findings in psoriatic arthritis?
imaging: XR (para-marginal erosions, fluffy periosteal bone formation, bony ankylosis, asymmetrical sacroiliitis
What is the presentation of radial nerve palsy?
Motor wasting (wrist drop - extensors)
Sensory deficit - 1st web space dorsally
What is the investigation / diagnosis for ectopic pregnancy?
US scan (no intrauterine gestational sac, may see adnexal masses, fluid in pouch of Douglas), serum Beta HCG levels, serum progesterone levels, FBC, diagnostic laparoscopy
What are the investigations for hallux valgus?
clinical, XR (determine severity of underlying bony deformity, exclude associated degenerate change)
When are posterior disocations more likely to happen?
Secondary to epileptic seizures
What is SICCA syndrome?
Sicca syndrome is a variant of Sjögren syndrome characterized by xerostomia and keratoconjunctivitis without previous rheumatoid arthritis.
(dry mouth, dry eyes and RA)
What is the disease mechanism for trigger finger?
Trigger finger occurs if there’s a problem with the tendon or sheath, such as inflammation and swelling. The tendon can no longer slide easily through the sheath and can bunch up to form a small lump (nodule). This makes bending the affected finger or thumb difficult. If the tendon gets caught in the sheath, the finger can click painfully as it’s straightened.
What are the risk factors for breast cancer?
BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
1st degree relative premenopausal relative with breast cancer (e.g. mother)
nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
early menarche, late menopause
combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral contraceptive use
past breast cancer
not breastfeeding
ionising radiation
p53 gene mutations
obesity
previous surgery for benign disease (?more follow-up, scar hides lump)
What are signs and symptoms of Pagets diseas of the bone?
Affects femur, lumbar vertebrae and the skull
Bone pain
Pathological fractures
Bony malformations (enlarged skull, bowing of long bones)
Increased temperature (hypervascularity)
Arthritis in assocaited joints
Hearing impairment (sclerosis of the skull bones, cranial nerve compression)
Decreased ROM
Where does primary bone cancer often spread to?
primary bone cancer spreads to breast, bronchus, prostate, kidney, thyroid
What are the investigations for Pelvic Inflammatory Disease?
FBC, CRP, hCG (ensure negative), MSU, high vaginal swab, endocervical swabs, blood cultures if febrile, pelvic USS, screen for chlamydia and gonorrhoea (low vaginal swabs)
When would you refer someone to colposcopy?
Three consecutive inadequate smear samples
Three borderline dmears (squamous)
Mild, moderate or severe dyskariosis
Suspected invasive disease
Dyskariosis (this is when the squamous epithelial cells have abnormal cytologic changes as well as charactersitic hyperchromatic nuclei and/or irregular nuclear chromatin). Another word for dyskariosis is dysplasia
What is the presentation for shoulder dyslocation?
Pain
Decreased movement
Loss of deltoid coutour
Arm held internally rotated and adducted
What is the disease process of Perthes disease?
Part or all of the femoral head (top of the thigh bone: the ball part of the ball-and-socket hip joint) loses its blood supply and may become misshapen. This may lead to arthritis of the hip in later years.
How is colposcopy carried out?
colposcopy involves inspection of ectocervix under magnification. Acetic acid and Lugol’s iodine is applied to identify abnormality.
What is management of chronic osteomyelitits?
long term AB (local: gentamicin cement, systemic: IV AB)
surgery (mutliple ops to eradicate)
deformity correction, massive reconstruction, amputation
What is the management for shoulder dyslocation?
Firstly consider anaesthesia / sedation
Closed reduction (e.g Kocher’s)
Open reduction if closed reduction techniques fail
Immobalise the arm for 3 weeks
Physiotherapy
Surgery
What is the difference in crystal histology for gout and pseudogout?
Gout = needle shaped, negatively birefringent
Pseudogout = Rhomboid, positively birefringent
What causes female pelvico organ prolapse?
Caused by weakening of pelvic floor normally secondary to child birth
What are X-ray findings in osteoarthritis?
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
What are the investigations for pre-eclampsia?
Serial blood pressure
Urinalysis
Urine protein/creatinine ratio
FBC
U and E
LFT
Coagualtion
Group and save if delivery thought to be likely
CTG to assess fetal well-being
What are different types of cephalic presentation?
Vertex
Sinciput (forehead)
Brow
Face Chin
How is diagnosis of perthes disease achieved?
plain x-ray
technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist
What is the potential complication assocaited with placenta praevia?
Post-partum haemorrhage
What condition is polymyalgia rheumatic closely related to?
Giant cell arteritis
What are the types of osteomalacia?
vitamin D deficiency e.g. malabsorption, lack of sunlight, diet
renal failure
drug induced e.g. anticonvulsants
vitamin D resistant; inherited
liver disease, e.g. cirrhosis
What is the crystal in both gout and pseudogout?
Gout = monosodium urate
Pseudogout = Calcium pyrophosphate
What mood stabilsing agent can cause hypothyroidism?
Lithium
What are risk factors for ectopic pregnancy?
Pelvic inflammatory disease
Chlamydia
Gonorrhoea
Previous tubal surgery
Previous ectopic
Assisted conception
What muscles are contained in the sheath which is inflamed in de quervain’s tenosynovitis?
extensor pollicis brevis and abductor pollicis longus tendons
What does CIN grading measure?
Grading is determined by how abnormal the cells look under a microscope as well as how much of the cervical tissue is affected.
Epithelial lining of the transdformation zone of the cervix is the part that is affected
What are the complications of fibroids?
Pain
Malpresentation/obstruction of labour
Menorrhagia
Subfertility
Red degeneration - haemorrhage into the tumour - commonly happens as a result of pregnancy
What are risk factors for DVT/PE?
older mothers, increasing parity, increased BMI, smokers, IV drug users, PET, dehydration (due to hyperemesis), decreased mobility, infections, operative delivery, prolonged labour, haemorrhage, blood loss >2L, previous VTE, FH of VTE, sickle cell disease
What is the presentation of menopause?
lack of menstruation for >1 year
hot flushes and night sweats (vasomotor symptoms)
vaginal dryness/soreness (vasomotor symptoms)
dyspareunia (vasomotor symptoms)
atrophy and thinning of vaginal epithelium
overactive bladder symptoms (urgency, frequency)
mood changes,
loss of libido
osteoporosis
increase in cardiovascular risk
What is management of osteogenesis imperfecta?
surgical: treat fractures
medical: IV bisphosphonates (to prevent fractures)
social: education and social adaptations
genetic: genetic counselling for parents and next generation
What is the managment of dupytrens disease?
non-operative: radiotherapy
operative: partial fasciectomy (+ physio), dermo-fasciectomy (+ intense physio, no recurrence), arthodesis, amputation, percutaneous needle fasciotomy (potential recurrence, risk of nerve injury), collagenase (30% recurrence, radical, cost)
What might be in a males history for pirmary infertility?
change in shaving frequency (testosterone), mumps infection, STI (chlamydia/gonorrhoea), history of varicoceal repair, vasectomy, Klinfelter’s
What is the presentation of chlamydia?
female: usually none, sometime cervicitis/cystitis, lower abdominal pain, intermenstrual bleeding
male: often asymptomatic discharge, dysuria
asymptomatic in around 70% of women and 50% of men
women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria
What are the risk factors for vulvovaginal candidosis?
risk factors: diabetes, oral steroids, immune suppression including HIV, pregnancy, reproductive age group
What is the managment of preterm labour?
The mother should deliver the baby in a unit where adequate facilities to care for the neonate are available
Medical = corticosteroids associated with significant reduction in neonatal death, respiratory distress syndrome and intraventricular haemorrhage in the newborn
Tocolytics = atosiban, nifedipine
Surgical = cervical cerclage for those at risk or identified as having a short cervix
Which is more common, primary or secondary bone tumour?
secondary bone tumour 25x commoner than primary
What is the bacterial change assocaited with bacterial vaginosis?
increased gardnerella, ureaplasma, mycoplasma, anaerobes, reduced lactobacilli
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH
What is low does amitryptiline used for?
low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)
What is the presentation of ovarian cancer?
Pass Medicine:
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
non-speciifc bowel symptoms (indigestion, early satiety, loss of appetite, altered bowel habit/pain, bloating, discomfort, weight loss)
overlap with IBS symptoms
pelvic mass (asymptomatic or pressure symptoms), adnexal mass on pelvic examination,
late-stage disease may present as a large pelvic mass, ascites, palpable lymph nodes and pleural effusion
What is the definition of menorrhagia?
Heavy menstrual bleeding (more than 80ml per cycle)
What are the subtypes of breats cancer?
Non-invasive = Ductal carcinoma in situ, lobular carcinoma in situ
Invasive = Invasive ductal carcinoma (most common)
Invasive lobular carcinoma and its variants
What causes erbs palsy?
birth injury or fall on side of neck (downward traction): forced contralateral neck adbuction
Shoulder dystocia
What is the management of PID?
medical:
- mild: oral ofloxacin + metronidazole for 14 days
- moderate: intramuscular ceftriaxone + oral doxycycline + metronidazole for 14 days
severe: inpatient IV therapy if clinically unwell and severe
surgical:
may be indicated in severe cases with evidence of pelvic abscess
prevention: contact tracing for sexual partners
What does HRT increase the risk of?
VTE
Breast cancer
Endometrial cancer
Gall bladder disease
Vascular disease
What are investigations for Traumatic subarachnoid haemorrhae?
CT
Cerebral angiogram
What is the pathogenesis of osteosarcoma?
assocaited mutations include abnormal pRB protein which is associated with retinoblastoma, also the p53 protein which is associated with li-fraumeni syndrome which is a multi - system cancer syndrome. Osteosarcoma is caused by osteoblast cells which are pleomorphic and produce too much osteoid tissue
What is the management of plantar fasciitis/fasciosis?
rest, change training, streching of Achilles, ice, NSAIDs, orthoses (heel pads), physiotherapy, weight loss, injections (corticosteroid (good in short term but may make conditon worse long term), night splinting
newer/3rd line treatment:
extracorporeal shockwave therapy
topaz plasma coblation
nitric oxide
platelet rich plasma
endoscopic/open surgery
What causes fibroids?
Benign tumour arising from the myometrium
What are the complications of pre-exiswting diabetes in pregnancy?
increased risk of congenital fetal abnormalities (especially if blood sugars high peri-conception), miscarriage, pre-eclampsia, fetal macrosomia, polyhydramnios, operative delivery, shoulder dystocia, worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia, infections, stillbirth, increased perinatal mortality, neonatal death (impaired lung activity, neonatal hypoglycaemia, jaundice, obstruction of labour)
What are the causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of the genital tract
Vasa praevia (very rare)
What is the mean age of osteomyelitis?
6 years old
What are the effects of gestational diabetes on the mother?
on mother: diabetic nephropathy and retinopathy may deteriorate. Increased risk of miscarriage, pre-eclampsia and operative delivery
What is the management of septic arthritis?
fluid and pain control, AB, surgical drainage lavage, infected joint replacement, arthroscopy (knee, shoulder, ankle), arthrotomy, physiotherapy
Passmedicine:
synovial fluid should be obtained before starting treatment
intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin or clindamycin if penicillin allergic
antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks)
needle aspiration should be used to decompress the joint
arthroscopic lavage may be required
What is the treatment of Paget’s disease?
don’t treat if asymptomatic uness in skull or area needing surgery
do not treat based on raised alkaline phosphatase alone
use IV bisphosphonate therapy and one-off zoledronic acid infusion
calcitonin for severe pain/extensive lytic disease
Who usually receives chemotherapy for breast cancer?
Node posistive
Stage 3
What are diseases that increase the chances of osteoporosis?
Endocrine: glucocorticoid excess (e.g. Cushing’s, steroid therapy), hyperthyroidism, hypogonadism (e.g. Turner’s, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus
Multiple myeloma, lymphoma
Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs), gastrectomy, liver disease
Rheumatoid arthritis
Long term heparin therapy
Chronic renal failure
Osteogenesis imperfecta, homocystinuria
Another list from Laszlo’s table:
risk factor endocrine:
thyrotoxicosis, hyper and hypoparathyroidism, Cushings, hyperprolactinaemia, hypopituitarism, low sex hormone levels (
rheumatic:
rheumatoid arthritis, ankylosing spondylitis, polymyalgia rheumatica, osteomalacia
GI:
inflammatory- UC and Crohns
liver- PBC, CAH, alcoholic cirrhosis, viral cirrhosis (hepC)
malabsorption- CF, chronic pancreatitis, coeliac disease, Whipple’s disease, short gut syndromes, ischaemic bowel
medication, chronic renal failure
medications, steroids, PPI, enzyme inducting antiepileptic medications, aromatase inhibitors, GnRH inhibitors, warfarin
What are the investigations for adenomyosis?
MRI, hysterectomy and histological diagnosis as diagnostic is often flawed
What is the presentation of syphillis?
primary: chancre lesion, raised painless papule with ulcerated centre, usually found at the site of inoculation; lymphadenopathy
secondary: widepsread mucocutaneous lesions, fever, malaise, headache, lymphadenopathy, sore throat
tertiary: characteised by gumma, usually found in liver, bone and testes
What is the mechanism of osteoporosis?
metabolic bone disease characterised by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk
Mastectomy vs wide local excision?
What are the different forms of hormone replacement therapy?
Combined (oestrogen and progestogen) for a women with a uterus
Oestrogen alone for those with hysterectomy
Can be given sequentially (monthly withdrawal bleeding) or can be given continuously (period free)
What can predispose you to osteomyelitis?
Pathogenesis:
Haematogenous spread in children and elderly
Local spread from site of infection (trauma in open fracture, bone surgery or joint replacement)
Secondary to vascular insufficiency
Predisposing conditions
diabetes mellitus
sickle cell anaemia
intravenous drug user
immunosuppression due to either medication or HIV
alcohol excess
How do we diagnose giant cell arteritis?
Extremely elevated ESR (over 100mm/hr)
Temporal artery biopsy
What is the effect of gestational diabetes on a baby?
on fetus: increased risk of congenital anomalies, perinatal mortality, macrosomial, shoulder dystocia, polyhydramnios
What are other side-effects of anti-psychotics?
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin: galactorrhoea, impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (greater with atypicals)
sprolonged QT interval (particularly haloperidol)
What is the most common type of dislocatation?
Antero-inferiorly
What are casues of amenorrhoea?
Pregnancy
PCOS
Hypothalamic disorders
Hyperprolactinaemia
Ovarian failure / menopause
Thyroid disease
Anatomical disorders of outflow
What causes OA?
Inflamatory process
Progressive cartilage loss
Subchondral bone formation and bony osteophytes
May be secondary to trauma, infection or ceongenital conditions such as developmental dysplasia of the hip.
What are risk factors for osteoporosis?
Family history
Female sex
Increasing age
Deficient diet
Sedentary lifestyle
Smoking
Premature menopause
Low body weight
Caucasians and Asians
What are the sypmtoms of ectopic pregnancy rupture?
Severe abdominal pain (may refer to shoulder with phrenic nerve irritation)
Rebound tenderness
Guarding indicates peritoneal irritation
Haemodynamic instability (feeling faint, syncope, tachycardia, hypotension, diaphoresis)
What is the cause of plantar fibromatosis?
Progressive connsctive tissue build up
What is the management of molar pregnancy?
remove tissue by curretage, if beta hCG returns to normal then no further treatment, if beta hCG stays high (persistent disease) then cure by methotrexate
What are blood findings in psoriatic arthritis?
Raised ESR
RhF negative
ANA negative
What is the presenation of ulnar nerve palsy?
•motor deficit - claw hand, hypothenar & 1st dorsal interosseous wasting
Sendory deficit is in little finger
What are the risk factors for plantar fasciitis/fasciosis?
athletes associated with high intensity or rapid increase in training, running with poorly padded shoes or hard surfaces, obesity, occupations involving prolonged standing, foot/lower limb rotational deformities, tight gastro-soleus complex
What are investigations for SCFE?
Physical examination
X-Ray
CT scan
If avascular necrosis is suspected then an MRI or a bone scan may be necessary
What is the presentation of erb’s palsy?
waiter’s tip position, arm is adducted and IR, elbow is extended and pronated, wrist is flexed, decreased sensation over C5, C6 dermatomes
What is the outcome of congenital syphillis?
Spontaneous abortion, birth defects
What are potential complications of fractures?
Compartment syndrome
Refracture
Non-union
Superficial radial nerve injury
Posterior interosseous nerve injury
What is the management of PPH?
obstetric emergency, resuscitation and treat cause (fluids, uterine massage, drugs to stimulate contractility (oxytocin, ergometrine)
if still bleeding then insertion of intrauterine balloon, uterine artery embolisation, uterine artery ligation, hysterectomy
What is management of primary amenorrhoea?
Gradual build up with estrogen
Effect on breast development
Add progesterone
Once maximum height potential is reached
At least 20 mg of estrogen dose
What is the management of osteomyelitis?
hydration and analgesia,
rest & splintage,
AB (choice depends on microbiology), IV AB for children,
surgery is indicated for abscess drainage, debridement of dead/infected tissue, drainage of subperiosteal abscess, drainage of joint sepsis,
Antibiotic therapy is usually:
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
What is a classical presentation of ankylosing spondylitis?
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
What clinical test could be used to show reduced forward flexion in ankylosing spondylitis?
Schober’s test
OA and RA comparison
What are the signs and symptoms of scleroderma?
Raynaud phenomenon
Cutaneous changes of face, extremities:
Skin thickening, tightening, sclerosis (most common); edema, erythema (precede sclerosis)
GI involvement
▫
Esophageal fibrosis
→
dysphagia, GI reflux
Small intestine involvement
→
abdominal pain, obstructions,
constipation, diarrhea, malabsorption syndrome (weight loss, anemia)
▪
Pulmonary involvement with interstitial
fibrosis
Right-sided cardiac dysfunction/
pulmonary hypertension
▪
Cardiac involvement
▫
Pericardial effusions, myocardial fibrosis
→
congestive heart failure, arrhythmias
Renal involvement (diffuse disease)
→
fatal hypertensive crisis (rare)
What are the risk factors for endometrial cancer?
obesity
nulliparity
early menarche
late menopause
unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously
diabetes mellitus
tamoxifen
polycystic ovarian syndrome
hereditary non-polyposis colorectal carcinoma
What is the most common type of fracture in a child?
Forearm fracture - 80% of which occur in the distal third
What is the treatment for chlamydia?
The two most commonly prescribed antibiotics for chlamydia are:
azithromycin – given as 2 or 4 tablets at once
doxycycline – given as 2 capsules a day for a week
Your doctor may give you different antibiotics, such as amoxicillin or erythromycin, if you have an allergy or are pregnant or breastfeeding. A longer course of antibiotics may be used if your doctor is concerned about complications of chlamydia.
What is the pathophysiology associated with lupus?
There is environmental damage of DNA - release of nuclear antibodies. Antinuclear antibodies and antigens form immune complexes (this is a type 3 hypersensitivity reaction, these immune complexes deposit themselves in tissues)
Organs affected = kidneys, skin, joints and heart
Individuals may develop antibodies which target certain molecules such as phosphilipids on red or white blood cells marking them for phagocytosis (this is a type 2 hypersensitivity reaction)
What are the symptoms of plantar fasciitis/fasciosis?
pain first thing in the morning, pain on weight bearing after rest (post-static dyskinesia), pain located at origin of plantar fascia, frequently long-lasting (2 years or more)
What is the 3rd stage of labour?
Birth of the baby to the expulsion of the placenta and membranes
Active management management includes:
Routine use of uterotonic drugs
Deferred clamping and cutting of the cord
Controlled cord traction after signs of separation of the placenta.
Physiological management includes:
No routine use of uterotonic drugs
No clamping of the cord until pulsation has stopped
Delivery of the placenta by maternal effort.
Prolonged in:
Active management over 30 mins
Physiological management after 60 mins
What is a monteggia fracture?
Fracture of proximal ulna with dislocation of radial head
What is the presentation of rheumatoid arthritis?
joint pain exacerbated by movement, morning stiffness, immobility, poor function, , joint swelling, affects various joints,
systemic symptoms, non-specific: fatigue/lethargy (secondary fibromyalgia due to dysregulation of the HPA axis), weight loss, anaemia, anorexia, mild fever
specific: eyes, lungs (interstitial lung disease, fibrosis), nerves, skin, kidneys, muscles (sarcopenia), bones (osteoporosis), secondary Sjogren’s syndrome, liver (elevated acute-phase response, anaemia of chronic disease (IL6 increases hepatocyte production of hepcidin, an iron-regulatory hormone)
long term: CVS (altered lipid metabolism, elevated acute-phase reactants, increased endothelial activation), malignancy
2010 EULAR/ACR RA classification depends on joint involvement, serology, acute-phase reactants, duration of symptoms
disease activity score:
DAS 2,4 represents clinical remission
DAS >5,1 represents eligibility for biologic therapy
joints: swollen, warm, tender joints, limitation of movement
joint deformities: swan neck, boutonniere, subluxation
lymphadenopathy, splenomegaly, rheumatoid nodules, muscle weakness, evidence of amyloidosis and vasculitis
diagnosis criteria: need 4 out of 7 (RF RISES)
Rheumatoid factor
Finger/hand joint involvement
Rheumatoid nodules
Involvement of 3 or more joints
Stiffness - early morning
Erosions/decalcification on XR
Symmetrical arthritis
What is the cassical sign of PID?
Cervical excitation
What is the management of base of thumb OA?
non op: NSAIDs, splint, steroid injection
op: trapeziectomy (gold standard), fusion, replacement
What are investigations for septic arthritis?
bloods:
FBC, WCC, ESR, CRP, blood cultures, XR, US, uric acid (exclude gout), Ab (exclude RA),
synovial fluid:
aspiration, culture (cloudy?), increased leucocytes
urine:
MC&S (microscopy, culture, sensitivity)
microbiology:
urethral, cervical and anorectal swabs
XR: soft tissue swelling, joint distension, later juxta-articular osteoporosis, periosteal elevation, joint space narrowing, bony erosions and possible osteomyelitis
What is the cause of sjogren’s syndrome?
Chronic autoimmuned infalmmatory disease
Lymphocytic infiltration
Destruction of exocrine glandsof eyes and mouth
What is the general treatment for multi-system autoimmune diseases?
What is the treatment for scleroderma?
CIN staging
CIN 1: low grade dysplasia–will regress
CIN 2: moderate dysplasia – may regress
CIN 3: severe dysplasia – unlikely to regress
