When do we manage an ectopic surgically?
- Haemodynamic instability
- Live ectopic pregnancy (cardiac activity seen)
- hCG greater than 1500 IU/L
- Adnexal mass >35mm
- Significant pain
- Presence of significant haemoperitoneum on ultrasound
- Patient choice/poor compliance with conservative treatment
When do we do a salpingotomy over a salpingectomy
o Previous ectopic pregnancy
o Contralateral tubal damage
o Previous abdominal surgery
o PID
Medical vs Expectant management of ectopic
Medical:
o No significant pain
o Unruptured ectopic pregnancy, mass < 35 mm and no visible heartbeat
o Low serum bHCG < 1500 IU/L
o No intrauterine pregnancy – MUST be confirmed
NB need to Measure bHCG levels on day 4 and 7 post dose administration. If levels decreased by > 15% between day 4 and 7, start weekly measurements until level less than 15 IU/L
Expectant:
- As above
- <30mm mass
- A decreasing bHCG <1,000 followed up until <15
Asthma non-acute diagnosis and management
Code as suspected asthma -> give treatment and good response will confirm diagnosis, poor treatment do spirometry tests.
+ EDUCATION ABOUT TECHNIQUE AND SPACER
Once first beginning symptoms give SABA inhaler prn, if using > 3 times a week we would initiate preventer therapy with a very low dose ICS or if <5 -> LTRA
If that doesn’t control, your initial add on therapy would be adding ICS/LTRA. After that increase very low dose ICS to low dose. Refer after this.
Life threatening vs Severe asthma attack
Both have sats <92%
Severe - PEF 33-50%; Thretening <33%
Severe - can’t complete sentences in one breath, HR/RR depends on age but above 5, RR>30 and HR>125
Threatening - silent chest, NORMAL CO2, exhaustion, cyanosis
How to manage PUL
• Definition: a situation where a pregnancy test is positive but there are no signs of intrauterine or extrauterine pregnancy on ultrasound scan
• This could mean that there is an ectopic pregnancy that cannot be visualised on TVUSS
• Management - should be focussed on pts symptoms
oBalance between not missing an ectopic pregnancy and not ending an early viable pregnancy
oRepeat hCG measurement 48 hourly to assess change:
Increase >63% likely that she has an intrauterine pregnancy and offer TVUSS 7-14days later.
Decrease <50% likely that pregnancy will not continue but this isn’t confirmed. Pregnancy test 14 days later and come back within 24hrs if positive.
If in between refer for clinical review within 24 hours.
When do we do ECV?
<36 weeks many will turn spontaneously
For nulliparous offer ECV at 36 weeks, at 37 for multiparous
CI if C section is required, APH in past week, ROM, multiple pregnancy
ECV successful 60% of time, if fails can go for vaginal delivery with hands off or Cs
How is the antenatal care of multiple pregnancies different?
- First trimester scan 11-13+6 wks to determine GA, chorionicity and screen for DS
- Determine chorionicity (T sign - monochorionic, Lambda - dichorionic)
- FBC at 20-24 wks to identify those who need extra iron/folic acid as there is a higher incidence of anaemia
- Fetal risks: Counsel on higher risk of DS, Monitor for TTTS in 2nd trimester, and IUGR
- Maternal risks: HTN, preterm birth (most before 37 wks)
- Monitoring:
Monochorionic - 2 weekly growth and doppler from 16 weeks
Dichorionic - 4 weekly growth scans and doppler from 20 weeks
GDM diagnosis criteria
• Fasting plasma glucose > 5.6 mmol/L
• 2-hour plasma glucose > 7.8 mmol/L
If risk Factors present (Previous GDM/ macrosomia, > BMI, First-degree relative with diabetes, Asian, black Caribbean or Middle-Eastern origin) woman should be offered a 2-hour 75 g oral glucose tolerance test (OGTT) at 24-28 weeks
USS schedule
10-14 weeks
• Mainly to determine gestational age, detect multiple pregnancy and determine nuchal translucency as part of screening for Down syndrome
18-21 weeks
• Primarily screens for structural anomalies
• Give couples reproductive choice (e.g. termination of pregnancy)
What are sensitising events that would require anti D prophylaxis
- Delivery of RhD+ infant
- Any TOP
- Miscarriage if > 12 weeks
- Ectopic pregnancy (if managed surgically)
- External cephalic version
- Antepartum haemorrhage
- Amniocentesis, CVS, foetal blood sampling
- Abdominal trauma
GDM Mx
o Newly diagnosed women should be seen at a joint diabetes and antenatal clinic within a week
o Women should be taught self-monitoring of BMs
o Advice about diets (low glycaemic index foods) and exs
o Fasting glucose < 7 mmol/L → trial of diet and exs
oIf glucose targets NOT met within 1-2 weeks → metformin
oIf glucose targets still NOT met → add insulin
o If at the time of diagnosis, fasting glucose > 7 mmol/L or if >6 + complications → insulin
o If metformin is not tolerated: glibenclamide
GDM Counselling
o Risk Factors: age, family or personal history, obesity, multiple pregnancy, Asian background
o Explain the diagnosis (diabetes that occurs in pregnancy because the body isn’t able to produce enough insulin to meet the demands of carrying a baby)
o Estimated prevalence: 2-3%
o Explain the risks (MATERNAL: hypertensive disease, traumatic delivery, stillbirth; FOETAL: macrosomia, neonatal hypoglycaemia, congenital abnormalities)
o Treatment options (diet/exercise, metformin, insulin) and the importance of good glycaemic control
oExplain how to monitor blood glucose (using glucometer)
oNeed to be seen at a joint diabetes and antenatal clinic within 1 week (and every 2 weeks thereafter)
oNeed to have 4 weekly ultrasound growth scans from 28-36 weeks
oExplain that medication will be stopped after delivery but that they will be followed up to check if glucose problem continues
Hyperemesis Gravidarum
• Investigations: body weight, U&E, urine dipstick (check ketones), observations, assess severity using PUQE (score < 13 can be managed as an outpatient)
Criteria: > 5% weight loss, dehydration, electrolyte disturbance
• 1st line: antihistamines (promethazine or cyclizine)
• 2nd line: ondansetron or metoclopramide
• Steroids may be used in refractory cases
• Alternative treatment: ginger, P6 (wrist) acupressure
• Admission may be required if severely dehydrated
Pay careful consideration to the psychological impact of hyperemesis gravidarum
COUNSEL: Most patients find that the symptoms improve after about 12-14 weeks and hopefully the medication will lessen the symptoms until they go away by themselves
Stress the importance of adequate fluids (dioralyte) and nutrition
Miscarriage counselling
- Risk Factors: advanced maternal age, previous miscarriages, chronic conditions (e.g. uncontrolled diabetes), uterine or cervical anomalies, smoking, alcohol and illicit drug use, underweight or overweight
- BREAKING BAD NEWS
- Explain the diagnosis
- Reassure that this is common and under-reported (1 in 5 pregnancies)
- Explain that risk increases with age
- If asked about cause: explain that most of the time there is no cause
- Explain the management options (expectant, medical and surgical)
- If medical: explain what to expect (pain, bleeding, nausea)
- Antiemetics and pain relief will be given
- Advise to do a pregnancy test after 3 weeks
- Safety net: return if symptoms get worse, bleeding persists after 7-14 days
Types of miscarriage
Spontaneous miscarriage - fetus dies or delivers dead before 24 weeks. 15% of pregnancies spontaneously miscarry, rate increases with maternal age.
Open os:
Inevitable miscarriage - heavy bleeding, although fetus may still be alive, miscarriage is about to occur. Clots may be present.
Incomplete miscarriage- some fetal parts have passed
Closed os:
Threatened miscarriage- bleeding but fetus is still alive, uterus is expected size. 25% will miscarry
Complete miscarriage - all fetal tissue has passed, bleeding has diminished and uterus is no longer enlarged.
Missed miscarriage - fetus has not developed or died in utero, but this isn’t recognised until bleeding occurs/ discovered incidentally on USS. Uterus is smaller than expected or empty.
Septic miscarriage - uterus contents ar einfected, vaginal loss is offensive, tender uterus, fever can be absent. If pelvic infection occurs there is abdo pain and peritonism.
Miscarriage mx
- If FHB present + Blood -> safety net to return if bleeding gets worse or persists for more than 14 days
- If no FHB + confirmed pregnancy + blood -> first line is expectant management (exceptions are very late first trimester, previous trauma with pregnancy, infection or clotting abnormality/can’t have blood transfusion)
o If bleeding resolves within 7-14 days take p test 3 weeks after and return if positive - Medical: Vaginal misoprostol (repeat day 3 if expulsion not complete) contact healthcare profession if bleeding hasn’t started within 24 hours + pain relief + anti-emetics + p test 3 weeks after
- Surgical: Manual vacuum aspiration under LA ±misoprostol to ripen cervix
What makes a febrile seizure complex?
Focal onset or focal features
Last >15 mins
Recurrence in 24h or same illness
Incomplete recovery within 1h
Febrile seizure counselling about anxiety
- Febrile seizures are not the same as epilepsy
- Short lasting seizures are not harmful to the child (no brain damage)
- They are relatively common – between 2 and 5 in 100 children
- The risk of developing epilepsy later is low but slightly higher than the general population: background risk is ~2%, simple seizure 2-7.5%, complex 10-20%
- Antipyrexials don’t prevent and it isn’t due to the actual temp but the rise in speed
Febrile seizure counselling about what happens if it happens again
1 in 3 will have another seizure – need to know how to manage
Protect from injury (cushion head with hands or soft material), move harmful objects
Do not restrain or put anything in mouth
When seizure stops: check airway is clear and put in recovery position
May be sleepy for 1h after seizure
Call an ambulance if lasts >5 mins and give rescue pack midazolam
How to manage febriel seizure
Rectal diazepam, repeated once after 5 mins OR one dose buccal midazolam
Call ambulance if after 10 mins since first dose:
Still seizing
Ongoing twitching
Another seizure begun before child regains consciousness
Questions to ask if failure to thrive?
Prenatal - SFD? Premature?
Functional issues: having enough time to feed her, good feeding schedule, difficult child
Reduced Appetite? (IDA, chewing on other things)
Feeding difficulties? Ability to latch on? Ability to stay on? swallowing, vomiting after
Malabsorption qs: Diarrhoea? Mucous?
Any G&D concerns?
What have you tried so far and what is it better with?
Failure to thrive definition
TLDR: below 2nd centile for age (no matter bw) or based on fall of 1, 2, 3 weight centile dependent on BW being <9, 9-91, >91
A fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
A fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
A fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
When current weight is below the 2nd centile for age, whatever the birthweight
Generic FTT management
Next steps: further investigation, clinical growth and monitoring, interventions and goals
MDT: Midwife, GP, infant feeding specialist, paediatrician, paediatric dietician.
Conservative advice:
Encouraging relaxed and enjoyable feeding and mealtimes, as a family or with other children
Encouraging young children to feed themselves
Allowing young children to be ‘messy’ with their food
Medical advice:
Short term trial of dietary fortification (superdense energy foods)
2nd line - trial of an oral liquid nutritional supplement for infants or children
Only after MDT discussion, refractory to prev tx and if there are srs concerns about weight gain you can try an eating tube
Referral - if concerns of underlying idsorder
Puberty onset ranges
8-14 in girls and 9-15 in boys
Girls: Breast development is the first sign (8.5 - 12 years) after which there is pubic hair growth and rapid height acceleration almost immediately after. Menarche occurs 2.5 years after the start of puberty.
Boys: testicular enlargement >4ml is the first sign. Pubic hair growth 10-14 yo. Height growth spurt when testicular volume is 12-15ml. Voice breaks ~13yo.
Investigations to order if you’re querying precocious puberty
Height, weight and head circumference
Bone age
Mid parental height
This is calculated as the mean of the father’s and mother’s height with 7 cm added for the mid-parental target height of a boy, and 7 cm subtracted for a girl.
Growth velocity
Pelvic USS in females for endometrial thickness
BMI adjusted to age and gender is used first line to assess obesity
Exam: Tanner staging
Bloods: LH ++ > FSH + (elevated in gonadotrophin dependent PP); TFTs
CAH: 17 hydroxyprogesterone or 11 deoxycortisol which would be raised
Imaging: USS ovaries/uterus (looking for multicystic and enlarged uterus in premature onset of normal puberty)
Types of precocious puberty
PREMATURE ONSET OF NORMAL PUBERTY:
- Will follow the usual sequence of breast enlargement (thelarche) -> pubic hair (pubarche)/growth spurt (gap) -> periods
- Parents might have early puberty
- Associated with obesity
Gonadotrophin dependent PP (PP + growth spurt): This can be idiopathic, familial or less commonly due to CNS abnormalities (intracranial tumours) and hypothyroidism
Gonadotrophin independent PP is due to exogenously raised sex steroids e.g. due to CAH, COCP, ovarian tumour (granulosa) or testosterone (Leydig) tumour. These pts might have isolated PP e.g. isolated pubic hair and virilisation of female genitalia. Ask about episodes of severe sicknesss with lots of vomiting and weight loss in childhood requiring them to go to hopsital and get salt replacement.
How do you treat PP?
Treat the underlying cause
Give GnRH agonists - this arrests the pulsatile release of GnRH, decreasing LH and FSH
Check that the child is not suffering any psychological side effects of early puberty
Delayed puberty ddx
DDx:
- Constitutional Delay
- IUGR at birth and never catch up
- Endocrine e.g. hypothyroid, GH deficiency, panhypopituitarism (craniopharyngioma), iatrogenic cushings
- Psychosocial deprivation
- Syndromic: Downs, Turners (widely spaced nipples, rec otitis media)
- Chronic paeds disease
- Nutritional + EXCESSIVE EXERCISE
Features of consitutional delay + Mx
Delayed puberty
Short during childhood
FHx in parents often of the same sex
Legs may be long compared to back
Androgen and oestrogens can help kick start puberty
Self-esteem and psychological affect
Mx: Reassure puberty will happen, check to see if psychologically they are okay, if they want meds you can give oral oxandrolone in young males (will just help catch up growth) or IM low dose testosterone in older males (will accelerate growth and induce 2ndary) females can be treated with oestradiol.
Delayed puberty things to ask:
History things to ask:
- Malabsorptive screen -> stools
- Constitional screen -> parents
- Nutrition and exercise
- Psych -> anorexia, emotional neglect
- Iatrogenic -> steroids, chemotherapy
- Congenital -> turners (rec ear infections, widely spaced nipples)
- Hypothalamic /pituitary disorders (changes to vision)
- Endocrine (tiredness, weight gain)
- Systemic disease (unlikely more FTT) - CKD, CCHD
Delayed puberty investigations
Examination + Tanner staging
Bedside obs + weight and height plotting
Bloods: usuals + screen for chronic disorders + genetic screen
Chronic: TFTs, LH FSH, Oestrogen/Testosterone, IGF-1 (GH is pulsatile), Growth hormone provocation test
+ KARYOTYPING (45XO)
Imaging: Bone age, MRI if cranio
Delayed puberty investigations
Examination + Tanner staging
Bedside obs + weight and height plotting
Bloods: usuals + screen for chronic disorders + genetic screen
Chronic: TFTs, LH FSH, Oestrogen/Testosterone, IGF-1 (GH is pulsatile), Growth hormone provocation test
+ KARYOTYPING (45XO)
Imaging: Bone age, MRI if cranio
Hyperemesis Gravidarum
Criteria: > 5% weight loss, dehydration, electrolyte disturbance
Investigations: body weight, U&E, urine dipstick (check ketones), observations, assess severity using PUQE (score < 13 can be managed as an outpatient)
Mx:
• 1st line: antihistamines (promethazine or cyclizine)
• 2nd line: ondansetron or metoclopramide
• Steroids may be used in refractory cases
If admitted:
Admission may be required if severely dehydrated
o IV normal saline with KCl (monitor U&E)
o Thiamine supplementation
o Offer thromboprophylaxis
• Pay careful consideration to the psychological impact of hyperemesis gravidarum
Counsel:
Explain that it a very severe form of morning sickness
Medication should help reduce the nausea
Most patients find that the symptoms improve after about 12-14 weeks and hopefully the medication will lessen the symptoms until they go away by themselves
Stress the importance of adequate fluids (dioralyte) and nutrition
Risk Factors: previous hyperemesis, multiple pregnancy, first pregnancy, obesity
TOP (things to ask in history, next steps and options)
Things to ask in history:
Need to explore sexual history ?Long term partner ?Coercion/ rape ?happened before
Ensure this is her own (not the father’s) decision
Need to determine gestation
Ask who they’ve told so far, would they consider telling anyone else if no one, will they come to the clinic with them etc
Next steps: Urine and blood pregnancy test, blood group status, determine GA and TVUSS/TA USS
Options: Depends on women choice and GA
SURGICAL options: Aspiration (7-13) done under LA/GA (takes about 10 min then recovery room) or D&E (>13) (done under LA, GA, or spinal, takes about 30 min discharge same day, requires dilator beforehand e.g. mifepristone). Both require Abx and Rhesus cover.
MEDICAL: Antiprogesterone (mifepristone) given first + prostaglandin (misoprostol) given 24-48 hrs after up to 9 weeks, most effective <7.
9 weeks +1 - 13 weeks + 6 can do inpatient medical
mifepristone 200 mg orally, followed 24–48 hours later by misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, followed by misoprostol 400 micrograms every 3 hours until abortion occurs.
FETICIDE: If > 22 weeks to prevent live birth
KCl pumped into umbilical vein or fetal heart
Selective abortion - may be performed if high order pregnancy
Urge incontinence questions
FUNDHIPS + Cancer screen
Nocturia? If nocturia isn’t present or if transient consider other causes such as constipation, atrophic vaginitis and prolapse -> ask about heaviness throughout the day + sex symptoms
Gynae screen: discharge, PV bleeds, dysapareunia
uterine prolapse symptoms, counselling and manageen
symptoms of heaviness worsen on standing, throughout the day urinary symptoms (stress and/or urge incontinence), constipation, disordered defecation sexual symptoms (dyspareunia)
Counselling:
caused by weakening of your pelvic floor this is a muscle that keeps all of your organs in your pelvis in the right place. Usually we try to avoid treating this condition unless it’s having an impact on your daily life. Your urinary symptoms may be caused by a part of your vaginal wall pressing on your bladder.
C:
Weight reduction
Avoiding heavy lifting and high impact exercise
Pelvic floor exercises - can see a physio to help you with this esp since you are experience some incontinence with this prolapse
Vaginal hormone treatment (oestrogen creams etc)
M:
Insert a ring pessary or a shelf pessary into the vagina that acts as an artificial pelvic floor
Changed every 6-9 months
Requires oestrogen replacement post menopausally to prevent vaginal ulceration - using topical or standard HRT
S: If your symptoms worsen, or the prolapse becomes more severe, there are some surgical options, and we can refer you to a specialists gynae surgeons
Hysteropexy: open/laparoscopic, uterus + cervix attached to sacrum using bifurcated mesh.
How to describe PEMPT
Close up your bottom, as if you’re trying to stop yourself going to the toilet
at the same time, draw in your vagina as if you’re gripping a tampon, and your urethra as if to stop the flow of urine
at first, do this exercise quickly, tightening and releasing the muscles immediately
then do it slowly, holding the contractions for as long as you can before you relax: try to count to 10
try to do 3 sets of 8 squeezes every day: to help you remember, you could do a set at each meal
If you are having trouble trying to do this, I can refer you to a specialist physio who will help identify if you are using the right technique and give you some tips to help you along the way.
Types of prolapse
Urethrocele -Prolapse of ant vaginal wall w urethra only
Cytocele - Prolapse of upper ant vaginal wall, inc bladder. Often assoc prolapse of urethra = cytourethrocoele
Apical prolapse - Prolapse of uterus, cervix + upper vagina.
Rectal prolapse - Prolapse of lower post wall of vagina, involving ant wall of rectum
Other management of TOP
Blood tests: Hb, blood group, Rhesus status
Rhesus negative should receive anti-D within 72h of TOP.
Surgical -> consider in rhesus negative regardless of GA
Medical -> consider after 10 weeks if Rhesus negative
STI screen - chlamydia, HIV, gonorrhea, syphilis
Surgical Abx
200mg doxy/ 500mg azithromycin within 2 hours of procedure
PAIN MANAGEMENT FOR BOTH MEDICAL AND SURGICAL
NSAIDS, local anaesthesia eg lidocaine for cervical dilation, paracetamol
Discussion of contraception options if not on contraception
Can be administered at time of surgical TOP
Oral pills, condoms, injections, implants can be started on day of misoprostol administration
Or after next menstrual cycle: IUD, sterilization
Discussion of contraception ‘health’ - not forgetting pill etc
Must always read the leaflet in the pill packet
Psychological input Eg if raped - victim support
What will happen on the day?
Pregnancy test
USS
Pain relief will be given before and after
Medical - Take first pill in clinic, Then either have a second appointment (24-48 hours later) or sent home with a different pill
Surgical - An appointment will be booked
LA - area numbed + some sedation so you are awake but relaxed Or may have GA (unusual)
Vacuum takes 5-10 minutes and most people go home a few hours after
D&E - dilation for several hours/ day before hand - procedure 20 minutes some go home the same day
Likely to experience stomach cramps so need to take regular pain relief such as ibuprofen
It’s also likely that you will have some bleeding, which may be quite heavy with medical so it’s recommended you bring sanitary towels (not tampons) with you on the day and also have a good stock at home.
Can have sex when you feel ready - CONTRACEPTION
If on going bleeding, severe pain, smelly discharge, temperature or ongoing signs of pregnancy the clinic will have a 24 hour helpline.
Exercising in pregnancy
- Avoid sports that involve you being on your back for long periods after 16 weeks
- Avoid contact sports, risks of fall, scuba diving or high altitude sports
- As a general rule, you should be able to hold a conversation as you exercise when pregnant.
- no more than 15 minutes of continuous exercise, 3 times a week. Increase this gradually to daily 30-minute sessions.
Abdomen Pain in kids questions
- Obstruction -> N&V (colour), flatus, distension
1b. Appendicitis/Meckels -> anorexia, pain, vomiting - Constipation -> PR blood, dietary fibre, stools
- Infection -> UTI -> Urinary changes, fevers / Gastroenteritis - contacts
- Hirschsprungs -> delayed meconium
- Malabsorptive -> weight loss, greasy stools, diarrhoea, ulcers (IBD)
- Psych -> stressed, IBS, abdominal migraine (midline pain lasting 1-72hr, well between episodes) (RAP)
Extra abdominal: - DKA -> increased frequency
- Torsion
Fatigue ddx in kids
- Sleeping well? Enuresis? Insomnia?
- Psych? Depression? anxiety?
- Infectious? URTI? EBV? UTI?
- IDA? SOB? Pallor? Chewing on funny objects?
- Asthma? Wheeze, worse in cold air?
- Malignancy? Bruises? Bleeding? Rash? Bone pain? Glands?
- Chronic disease? Weight loss? Stools? Blood in urine? CF?
Cervical cancer screening
- 25 years – first smear invite
- 25-49 – every three years
- 50-64 – every five years
- 65+ - no screening (unless abnormal recall/no previous tests)
When do we refer for colposcopy?
- High-grade cytology – referred to colposcopy
* Low-grade cytology with High Risk -HPV – referred to colposcopy
LLETZ counselling
Indicated in patients with high grade CIN
The patient may have light bleeding for several days.
• If heavy bleeding occurs she should return as secondary infection may occur and needs treatment.
• She should avoid sexual intercourse and tampon use for 4 weeks, to allow healing of the cervix.
• Fertility is generally unaffected by the procedure, though cervical stenosis leading to infertility has been reported, and mid-trimester loss from cervical weakness
is rare. Although there is a risk of premature birth
o Patients who undergo treatment for CIN will receive a TEST OF CURE 6 months late
Cervical cancer treatment
C
Depends on staging and whether they’re pregnancy:
1- Confined to cervix 2 – Invaded into to vagina, 2B – Invaded into parametrium
1A 1 Microinvasive -> Cone biopsy
1A 2 – IIA Early stage disease -> Radical hysterectomy + lymphadenectomy or chemoradiation
2B-4A – Locally advanced -> Chemoradiation
4b – Mets -> Chemo ± immunotherapy with bevacizumab
PID causes
It is most commonly caused by STIs but can also happen after miscarriage/termination/IUD insertion.
Chlamydia trachomatis and neisseria gonorrhoea cause ¼ of cases in the UK, and are more commonly seen in younger women presenting with PID. Mycoplasma genitalium, anaerobes and gardnerella vaginalis may also occur, so broad spectrum antibiotics are needed. (Moxifloxacin is recommended as 1st line in M.Genitalium PID).
PID Mx
• Ceftriaxone 500 mg IM (single dose)
• Doxycycline 100 mg BD (oral) for 14 days
• Metronidazole 400 mg BD (oral) for 14 days
If pyrexial or oral management has failed
• 1st line: IV cefoxitin + doxycycline
+ STI contact tracing
+ Advise about: barrier contraception, no sex until meds finished, about risks* and safety net to come back
FOLLOW UP:
- If managed as output, assess within 72 hours (admit if no improvement)
- Again at 2-4 wks to ensure resolution, reassure if compliant fertility isn’t affected reiterate importance of STI
VIVA: C (Advice and counsel risks) M Abx + anagelsia S - removal of IUD, if necessary adhesiolysis /salpingectomy
*Following treatment fertility is usually maintained but there remains a risk of future infertility, chronic pelvic pain or ectopic pregnancy
Repeat episodes of PID are associated with an exponential increase in the risk of infertility
The earlier treatment is given the lower the risk of future fertility problems
Features of PID and which would prompt admission?
Lower abdominal pain which is typically bilateral (but can be unilateral)
Abnormal vaginal or cervical discharge which is often purulent
Deep dyspareunia
Abnormal vaginal bleeding, including post coital bleeding, intermenstrual bleeding and menorrhagia
Secondary dysmenorrhoea
High fever (>38), signs of peritonism, abscesses (tubo-ovarian) or sepsis - IV antibiotics indicated
(Pregnancy, lack of improvement with oral therapy would also prompt admission)
Fever in paeds history / mx
>38 and under 3 months -> admit Characterise source and then how un well Eye discharge Ear tugging Coughing or grunting Vomiting or diarrhoea Less wet nappies Abdo pain and posturing Bone pain New Rashes or Red skin How unwelll: Drowsy, seizure, playing activities, appetite, inconsolable
Returning traveller paeds ddx
Malaria - swinging fevers
Typhoid - constipation, myalgia, Rose spots
Dengue - myalgia, retro orbital headache, facial flushing, macpap rash, DIC
Sepsis red flags
Red flags: Mottled/blue colour Unrousable or high pitched continuous cry Grunting, RR >60, chest indrawing decreased skin turgor Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurology/seizures
Baby has rash
questiosn you should ask
Non-blanching? Start and move somewhere? Lymphadenopathy Sparing of nasolabial folds? mouth? Desquamate? Tongue? Conjunctivitis? Prodrome? Vaccination status?
Measles: Fever conjunctivitis
Rash starts behind ears/hairline > body.
Initially morbilliform discrete > confluent, can desquamate. Lasts 4 days. Koplik spots precede rash.
Scarlette fever: pinpoint sandpaper rash (torso, spares palms/soles).
Desquamation of fingers/toes, strawberry tongue, sore throat, fever lasts 24-48h. Flushed cheeks with circumoral pallor
Rubella - Prodrome - mild fever
Rash - starts face > body, lymphadenopathy (suboccipital/postauricular), lasts 3-5 days
B19
Erythema infectiosum, slapped cheek syndrome
Bilat bright red rash cheeks, sparing nasal ridge/periorbital areas (lasts 2-4 days) > lace like reticular rash on limbs +/- trunk
How to counsel anti-vacs
Explore what parent already knows about the vaccination programme
“I’d really encourage you to take up the … vaccine for your child. This vaccination is very safe and almost every baby born in the UK receives it. It is protect both your child and the community as a whole. These infections are typically picked up around school so it really is important that [Abc] gets vaccinated as soon as possible.
There is NO evidence that the MMR vaccine is linked to autism. The paper that suggested this has been discredited and the doctor who published it is no longer allowed to work in the UK as a doctor
Causes no delay in development
Contains no mercury
Given as 3 vaccines in 1 injection is just as safe, doesn’t ‘overload’ immune system and makes sure the baby goes through as little pain as possible
- 3 separate vaccines have no safety evidence.
- Only a tiny amount of your Charles’ immune system will be used to develop a response to this vaccine, the rest will be used to fight off the many bugs they come into contact with every day!
- The vaccines work at different times so won’t be overloaded
6-10 days measles
2-3 weeks mumps
12-14 days rubella
- Is grown on egg cells but contains no egg proteins so will not cause Charles to have an allergic reaction
NOTE: flu vaccine is grown on hens’ eggs and can trigger a reaction if individuals are allergic to eggs
What to expect on the day:
- Common Side effects: crying, irritability, fever, muscle/joint pain, swollen glands, rash, loss of appetie (Increase fluid intake
and give Paracetamol/ibuprofen if needed)
- Rare but severe reaction: erythema at site of injection or elsewhere/anaphylaxis → contact the doctor immediately
These complications are rare and are much less severe than the consequences of catching MMR so we feel it is best to immunise children
If mum is persistent that she wouldn’t want the vaccination safety net against the signs of MMR so that she knows to come into A&E asap.
Enuresis management
Dry by day + night by 5 years .dry by day only by 4 years
Primary enuresis
<5 -> reassure
>5 -> once per week -> reassure, watch and see approach. If > once per week:
1st line: enuresis alarm with positive reward system
2nd line: desmopressin
NOTE: fluid should be restricted 1 hour before desmopressin until 8 hours after
> 7 years old - desmopressin can be used first line.
If rapid or short-term control is required (e.g. school trips), offer desmopressin
If bedwetting has NOT responded to two courses of treatment, refer to secondary care, enuresis clinic or community paediatrician. TCAs and antimuscarinics can be considered.
What is autism
Pervasive developmental disorder defined by abnormal or impaired development before age 3 years. Abnormal functioning in: social interaction, communication and restricted/repetitive behaviour. Affects 1-2% children.
What signs of autism would you expect to see in a 1 year old child and what tests would you do
Clumsy walking, minimal babbling, avoid eye contact, no smiling, avoids hugs, plays alone and exhibits repetitive behaviour, doesn’t respond to name being called, disturbed sleep pattern
Hearing and sight test, SALT assessment, Assess IQ, M-CHAT score (modified checklist for autism in toddlers)
How do you manage Autism
Collateral history from rest of family/nursery teachers, advice family on sleep hygiene, methods of countering challenging behaviour, care plan approach with a key worker for family,
MDT approach: Community paediatrician, Autism team/CAMHS, Clinical psychologist, Occupational therapist, SALT
- Psychological interventions to reduce ritualistic behaviours
- Speech and language therapy (with a focus on social skills)
- Educational assessment and plan ±special school
Counsel:
o Explain that autism is a spectrum, so it is difficult to predict the extent of the impact on the child’s life
o Explain that it is characterised by difficulties in social interaction, language impairment and ritualistic behavioural tendencies
Cow’s milk intolerance PC Ix Mx
Feeding difficulty, vomiting, PR bleeding, wt loss
Ix: clinical diagnosis, consider referral for skin prick and/or specific IgE
Mx: Implement strict cows’ milk elimination diet for at least 6 months or until the child is 9-12 months
• Breastfed Babies: advise mother to exclude cow’s milk protein from her diet (Consider calcium and vitamin D, use extensively hydrolysed formula for at least 6 months)
• Formula-fed Babies: advise replacement of cows’ milk-based formula with hypoallergenic infant formula (e.g. extensively hydrolysed formula or if severe a/acid formula)
Cow milk intolerance counselling
Very common (5-15% of infants) and not srs
Eliminate cows milk (takes 2-3 wks to eliminate from breast milk)
Other: 1) Offer nutritional counselling with a paediatric dietician 2) Regularly monitor growth 3) Re-evaluate the child to assess for tolerance to cows’ milk protein (every 6-12 months) - this involves re-introducing cows’ milk protein into the diet
• If tolerance is established, greater exposure of less processed milk is advised following a ‘Milk Ladder’ (available from Allergy UK)
SUPPORT: British Dietetic Association (BDA) has produced a useful fact sheet
Cow milk intolerance counselling
Very common (5-15% of infants) and not srs
Eliminate cows milk (takes 2-3 wks to eliminate from breast milk)
Other: 1) Offer nutritional counselling with a paediatric dietician 2) Regularly monitor growth 3) Re-evaluate the child to assess for tolerance to cows’ milk protein (every 6-12 months) - this involves re-introducing cows’ milk protein into the diet
• If tolerance is established, greater exposure of less processed milk is advised following a ‘Milk Ladder’ (available from Allergy UK)
SUPPORT: British Dietetic Association (BDA) has produced a useful fact sheet
Enuresis counselling
Screen for constipation, thirst, UTI, psych issues
• Explain that bedwetting is NOT the child or the parents’ fault
• Occurs because the volume of urine produced at night exceeds the capacity of the bladder to hold it, and the sensation of a full bladder does NOT wake the child
• Reassure that pretty much all children become dry with time as their bladder capacity increases and they learn to wake at the sensation of a full bladder
Advice:
• There should be easy access to the toilet
• Waterproof mattress or bed pads could be used
• Parents and carers should take a neutral attitude towards bedwetting so that they don’t embarrass the children
• Lifting or waking during the night does not promote long-term dryness. Just urinating regularly throughout the day and before bed.
• Positive reward systems can be used (e.g. rewards for going to the toilet before bed, drinking the recommended amount of fluid during the day)
• SUPPORT: ERIC (Education and Resources for Improving Childhood Continence)
A 5-year-old boy presents with a short history of facial oedema that has now progressed to total body swelling involving the face, abdomen, scrotum, and feet. Other symptoms include nausea, vomiting, and abdominal pain.
On examination, he has facial oedema, ascites, scrotal oedema, and pitting oedema of both legs up to the knees.
Management?
IN THIS HISTORY ASK ABOUT PREVIOUS URTI
• Initially give oral steroids (60 mg/m2 per day of prednisolone)
• After 4 weeks, the dose should be reduced or alternate days for 4 weeks
• Then it should be weaned or stopped
• Children who DO NOT RESPOND after 4-6 weeks of corticosteroid therapy or have atypical features may have a more complex diagnosis and need a renal biopsy
• NOTE: renal histology of steroid-sensitive nephrotic syndrome is usually NORMAL on light microscopy, but fusion of podocytes is seen on electron microscopy (minimal change disease)
Complications
• Hypovolaemia
• Thrombosis
• Infection
• Hypercholesterolaemia
HSP Mx
- Most cases will resolve spontaneously within 4 weeks
- Joint pain can be managed using paracetamol or ibuprofen
- If there is scrotal involvement or severe oedema or severe abdominal pain, oral prednisolone may be given
- IV corticosteroids are recommended in patients with nephrotic-range proteinuria and those with declining renal function
- Renal transplant may be considered in end-stage renal disease
- Follow-up to check blood pressure and renal function
Placenta praevia
Praevia
• Placenta/ p: placenta lies directly over the internal os
• Low-Lying Placenta: placental edge is < 2 cm from the internal os on USS
Ix:
Bloods – FBC, clotting studies, G&S, Rh status, Kleihauer test, U&E, LFT
TVUSS & CTG (>27wks) !Do NOT perform a bimanual !
Mx: ABC approach & Establish IV access and give fluids
Admit for 48hrs/until bleeding settles and give Anti-D if Rhesus -ve. If >34 wks admit until delivery.
Long term:
• Growth scan and umbilical artery dopplers (every 2 weeks)
• Consultant led antenatal care
• Final ultrasound at 36-37 weeks to determine method of delivery (C-section if grade III/IV at 37 weeks, vaginal delivery if grade I)
• Consider IOL if early foetal compromise
• If major placenta praevia with bleeding: admit from 34 weeks
Comms: Risks and increased monitoring
Risks:
o Major blood loss
o May require a blood transfusion
o May require a hysterectomy
Why has this happened?
previous placenta praevia, multiple pregnancy, previous C-section, smoking and drug use, advanced maternal age
Low lying plaenta counsellinh
Presenting with Asymptomatic Low-Lying Placenta (<2cm)
o Explain the importance of the finding (increases risk of bleeding)
o Explain that 90% of placentas will move away from the os
o Rescan at 32 weeks and then go from there
o Avoid having sex
Eclapsia
o Risk Factors: history of hypertensive disease, first pregnancy, new paternity, advanced maternal age, obesity, multiple pregnancy
o Call senior help emergency alert team (2222)
o Secure the airway
o Magnesium sulphate is the first-line anticonvulsant - should be administered ASAP either in women at risk of eclampsia or when eclampsia occurs
• Loading dose of 4 g over 5-10 mins
• Maintenance infusion of 1 g/hour for 24 hours after delivery
o Eclamptic seizures tend to self-terminate within 2-3 mins
o WARNING: magnesium sulphate has a narrow therapeutic range and overdose can cause respiratory depression and cardiac arrest
• Monitor: reflexes, respiratory rate, oxygen saturation, urine output
• Antidote: 10 ml 10% calcium gluconate (slow IV infusion)
o Once the seizure has terminated, take an ABCDE approach
o Discuss delivery
• It is likely they will need an urgent delivery (likely by C-section)
• Give steroids if necessary
• HDU care
• Watch out for issues with fluid balance (pulmonary oedema)
ED questions
How do you feel about yourself?
How do you feel about your weight?
Are you trying to lose weight at the moment?
How are you doing that (cal count, vomit, exercise, laxatives)? Freq? Triggers?
Ideal weight?
IF POSS - current weight and height?
Tell me about a typical day of eating [be really sensitive as concept of food makes them really anxious]
Check physical symptoms
Periods - last period? Are your periods regular?
Libido
Anaemic symptoms - dizziness/ SOB/ tiredness
Fevers
Weakness
Cold sensitively
Other gut problems eg bloating
Constipation
Skin/hair changes
Often co-exists with anxiety/depression
Depression screen: mood, motivation, energy, sleep
Anxiety/OCD screen: rituals, fear something bad will happen
PMHx AN/BN
DHx OTC!
SCOFF screening tool
SCOFF Screening Tool (think scoffing food)
Do you makes yourself SICK because you feel uncomfortably full?
Do you worry you’ve lost CONTROL over how much you eat?
Have you recently lost more than ONE stone in a 3 month period?
Do you believe yourself to be FAT when others say you are too thin?
Would you say FOOD dominates your life?
One point for every ‘yes’: a score =/> 2 indicated a likely dx of AN/ BN
ED physical health problems
Cardio - bradycardia, low BP, arrthymia,
GI - constipation, distension, ulcers, erosion of dental carries (BN) oesophageal tears
MSK -osteoporosis and #
Reproductive - Amenorrhoea, Infertility
Neuro - Peripheral Neuropathy,
What requires admission
Rapid weight loss BMI <13 Purpuric rash Cold peripheries Core body temperature <34.5 hypotension < 80/50 Bradycardia <40 with prolonged QT on ECG Inability to stand from squatting without using arms for leverage Electrolyte imbalance K< 2.5, Na < 130, PO4 < 0.5
ED Management
BSP
B-
Treat underlying conditions eg depression/anxiety with approach stepwise approach
Fluoxetine - Antidepressant that may help in BN - enhances impulse control
Nutritional management and weight restoration
Realistic weekly weight gain (0.5-1 kg/week) - to be measured in OP
Beware of false weight gain - water loading etc
Establish target weight and long term plan
Treatment of physical health symptoms → warn patient these should get better if weight is addressed
Laxatives
Cream for dry skin
Social
Constructing eating plan
OT - Teaching shopping/ cooking skills
PT if muscle weakness etc
Psych Psychoeducation About condition, nutrition and health Mindful eating CBT Find out about deeper issues Reduced stress/anxiety around meal times Address perfectionism Address low self esteem Family therapies
ED pt in A&E Ix
Bloods - electrolytes (may need admission), TFTs (exclude hypothyroidism), FBC (anaemia), ESR normally low/normal. LFTs creatinine kinase, phosphate, albumin, glucose - evaluate nutritional state and risk.
ECG (hypokalaemia) - arrhythmias, prolonged QT
Fluids
Pain relief
When would you consider sectioning a patient for an ED?
Obviously we would first try and convince patient to go to hospital
BMI <13.5, rapid weight loss, severe electrolyte abnormalities, syncope, risk of self harm/suicide, social crisis.
MHA - may be used in severe cases to commence NG feed or IV bolus if there is high risk of death from refusing to eat (eg hypokalemia, arrhythmias). Restraint may be needed.
Amenorrhoea ddx
Low FSH on day2-5 of the cycle
Hypothalamic - anorexia, exs/diet, stress, idiopathic
Pituitary causes - tumour, post op (Sheehan), hypothyroidism and hyperprolactinaemia e.g. - drugs, pituitary tumour
High FSH Ovarian causes PCOS POI Primary causes e.g. Kallman's
Premature menopause definition
menopause occurring before the age of 40 – effect 1% women
Ammenhoea ix
Gynae Basic obs + pregnancy test Blood - FSH, LH, other thalamic hormones, prolactin, day 21 progesterone, anti mullerian hormones, TFTs, other pit hormones Karyotyping - Turners DEXA scan Ultrasound CT
POI management
C - counselling about family (having children now/preserving eggs)
M - HRT (until natural menopause age, re-assess every 5 years)
S- Hysterectomy (due to the side effect of long term oestrogen causing CVSD)
Suicide History
Nice starter questions
You’ve really gone through a lot today. Would you mind telling me what happened?
I can see that you’re angry and upset. I’d like to try and help you, and part of that is understanding what’s made you feel like this
Ask about before during after
BEFORE - What made you first think about taking your life? Multiple drugs/alcohol? Planned/unplanned?
DURING - What did you think would happen? Was there a small part of you that thought you might live? How did you end up in hospital
AFTER - How do you feel now? Do you regret whats happened? How do you see the future?
Suicide Mx
Medically - deal with drug OD treat underlying psych disorders
Biological therapies: antidepressants (short prescription and regular review to avoid stockpiling)
Psychological therapies: IAPT self referral, CBT
Social therapies: sick note for time off work, support groups, family support
1. Make a crisis plan (if this happens again)
2.F/U in one week time with community mental health team /GP
Talk through coping strategies e.g. distraction techniques and mood lifting techniques
First episode of psychosis ix/mx
Collateral History Physical Examination Bloods • FBC, U&E, lipids, LFT, VDRL o Urine Drugs Screen oRating Scale – Brief Psychiatric Rating Scale oADL Assessment and Housing and Finance
First rank symptoms and how to ask them
Thought: insertion or withdrawal
Auditary Hallucination
Passivity phenomena
Delusional Perception
I’d like to ask you some questions. Some of them might sound a little strange, but please don’t worry—these are routine questions that I ask all my patients.
“Do you feel in complete control of your thoughts”
“Have you heard people talking, but can’t work out where they are?”
“Do you ever feel as though you are being controlled by someone or something?”
Delusions:
“How do you see the future?”
“Do you ever feel that somebody or something is paying particular attention to you and what you are doing?”
Schizophrenia counsellling (explain diagnosis and steps)
Condition where your brain processes information in a different way to others. This can result in you having experiences that other people don’t have, like some of the voices or feeling like you are being controlled by an outside source. It can also make you have feelings where you don’t want to be around other people or that you lose interest in work or relationships.
We don’t know why this is but there is evidence that it is partly down to your genes. People also think it could be due to some of the chemicals in your brain being over or under active in different areas of the brain.
Some of the things you might experience can be quite scary or make you feel quite down, so it is important that you have a good social support and if you feel low you know you can contact health services or there is a charity Samaritans (116 123) that are available 24/7.
Moving forward, I am going to refer you to a service that is a specialist in this condition.
Phases of schizphrenia
Prodrome (at risk mental state)
High risk but not inevitable to develop into psychosis
Social withdrawal, loss of interest in work/school/relationships w/o frank psychotic symptoms
Acute
Acute psychosis, thinking disturbed, can result in muddled speech, behaviour can be withdrawn, overactive or bizarre
Chronic
Prominent negative Sx, can last indefinitely, disabling
Apathy - loss of motivation
Blunted affect - dec reactivity to mood
Anhedonia
Social withdrawal
Poverty of thought and speech
Might manifest as personal hygiene neglect, limited repertoire of daily activities
+/- residual, less prominent +ve Sx - might just be less distressed by delusional thoughts
Schizophrenia management
MDT approach such as specialist psych nurse to help with education and advice. Psychologist to run the CBT sessions.
Refer to EIS - early intervention service - aim to keep DUP <3months
B
Antipsychotics - (wait 2-4weeks)
2nd line - switch antipsychotic
Treatment resistant - clozapine - bloods every week, then two weeks, then monthly
DON’T give if epileptic - lowers epileptic threshold
P
CBT - reality testing, improve awareness of illogical thinking, think about evidence against a belief, improves self esteem, help cope with hallucinations/delusions
Family therapy - communication skills training, education about disorder, expand social network
S
Psycho-education
Career support, housing/benefits support
Social skills training - improve interpersonal skills, role play, improve confidence in their skills and day to day functioning in the community
OT - skills, budgeting, cooking
Rehabilitation - courses for education, personal development (eg creative writing), accessing social activities
COCP CI
>35 + Smoker Migraines Previous clots Breast feeding Risks: Thrombosis and breast cancer Benefits: Lightens periods and PMS
Progesterone only pill
Suitable for those who are breastfeeding/don’t tolerate COCP
Needs careful compliance (<3hrs or <12 for cerazette)
Can cause irregular bleeding (1/3 it stops, 1/3 become irregular and 1/3
Takes up to a year for periods to return
Progesterone implant called Nexplanon- quickly reversible for fertility, irregular bleeding, lasts 3 years
Progesterone injection every 12 wks - can cause weight gain, not quickly reversible for fertility
LP indication in paeds
infants younger than 1 month
all infants aged 1–3 months who appear unwell
infants aged 1–3 months with a white blood cell count < 5 × 109/litre or >5 × 109/litre.
IUD vs IUS
IUD
- lasts 5 years, can be up to 10
- effective immediately
- heavier more painful bleeds
IUS
- 7 days to be effective
- mirena lasts 5 years
- spotting then lighter/amennhorea
Both:
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
Who is VBAC offered to and why?
- Singleton pregnancy cephalic at 37+0.
- Successful VBAC has the fewest complications and shorter hospital stay
- After 1 c-s, about ¾ of women with straightforward pregnancy will give birth vaginally
CI to VBAC
- Previous rupture
- Classical Caesarean scar
- Normal CI for vaginal delivery e.g. placenta praevia
- 3 or more C-Ss: can consider VBAC (need experienced obstetrician to counsel and in attendance) if 2 C-S
What are pros and risks of VBAC
Successful VBAC and fewest complications and shorter hospital stay. 3/4 women with straigthforward pregnancy will give birth vaginally after 1 c section
75% success rate (higher if previous vaginal birth)
Risks:
Maternally - rupture 1 in 200, increased risk of ERCS, increased risk of instrumental delivery
Fetal - very slight increased risk of baby having brain damage due to lack of oxygen (instead of 1 in 10,000 with ERCS this is 8 in 10,000)
ERCS pros and cons
Pros - Cons - Increased hospital stay - Increased risk of clot - Small increased risk of placental issues / adhesions in future pregnancies
Oligomenorrhoea invesitgations
Bedside: BMI
PCOS:
Hormone Profile: oestrogen, day 21 progesterone, FSH and LH (days 2-5), free testosterone (raised)
o LH: FSH index (greater than 1:1, ideally >3)
To rule out other causes of oligomenohhorea:
• Prolactin – to rule out hyperprolactinaemia
• TFTs – to rule out hypothyroidism
• NCAH- non-classic CAH, adult onset, give ACTH challenge and measure 17OHprogesterone after. If high consider adult onset CAH.
• OGTT usually needed once a year if PCOS and obese. If normal, rescreen every 2 years. If not normal, scan annually.
• TVUSS: look for polycystic ovaries
PCOS counselling Mx
- Explain the diagnosis (a disease with no clear cause that leads to abnormalities in hormone levels (which, in turn, result in the symptoms experienced))
- Explain that it is very common (1 in 10 in the UK (many are unaware))
- Explain the main consequences (irregular periods, subfertility, metabolic syndrome, cardiovascular disease, acne)
PCOS questions to ask
Irregular periods Weight changes Hirsuitism Acne Metabolic syndrome and CVS Disease
Hair loss: COCP, or Topical Eflornithine or Dianette
Periods: COCP or progestogens (aiming for at least 3-4 bleeds per year)
Fertility: recommend weight loss → clomiphene +/- metformin → consider LOD
Metabolic Syndrome: check for DM, high cholesterol, heart disease (manage accordingly)
Depression sx and classification
ICD 10 criteria these symptoms for 2 weeks Core • Low mood • Anergia • Anhedonia Biological • Sleep disturbance • Appetite/weight disturbance • Low libido • Psychomotor agitation or retardation Cognitive • Low concentration and attention • Low self-esteem and confidence • (bad) Impaired memory • ASK ABOUT Bleak view of the future • Guilt and worthlessness • self-harm or suicide (ideas or acts of) • hallucinations
Mild - 2C + 2
Moderate - 2C + 3/4 - considerable difficulty doing day to day things
Severe - 3C + 4 -major impact of qol
Depression ix:
o Collateral history o Physical examination o Bloods: FBC, TFT, U&E o Rating Scale: PHQ9, HAD, CDI (children) o Risk Assessment
Depression Mx:
Moderate:
BPS
B - Antidepressant e.g. SSRI + f/u within a week if <30, if not 2 and advise that it takes 6 months for them to work
P - CBT (weekly sessions over 3-4 months)
S- Family therapy, social services to arrange a package of care
Mild - CBT r/w in 2 weeks
Severe - use crisis resolution and home treatment and consider inpatient
Counselling:
o Explain the diagnosis of depression (persistently low mood that impacts on day to day functioning)
o Explain that it is very common (each year 1 in 4 people suffer a mental health problem)
Doses:
Sertraline increase from 50 mg to 200 mg (in steps of 50 mg every couple of weeks
2nd line Taper down SSRI and start SNRI e.g. Venlafaxine: 37.5 mg BD (up to 225mg per day)
After this: check compliance, check for underlying diagnoses, check for perptuating factors
3rd line augmentation with quietiapine or another antidpressant
Serotonin Syndrome
OD or SSRI + MAOi
o Clinical Features: fever, agitation, confusion, hypertension, hyperreflexia, clonus, tremor, diarrhoea, dilated pupils (onset within hours)
o Withdraw offending drug
o Supportive care
o Mild cases will resolve within 1-3 days
o Benzodiazepines can be used to control agitation
GAD ix
Collateral history from wife
TFTs (palps etc)
Urine drug screen
24h urinary catecholamines (phaeo)
ECG and blood pressure (might omit as done by A&E)
Might mention formal evaluation using GAD-2/-7 questionnaires
Oligomennhorea ddx
Hypothalamic - HH, hypothalamic lesion, Kallman’s
Pituitary - Prolactinoma, Sheehan’s
Ovarian - PCOS, POF, ovarian cyst
Uterine - fibroids, Asherman’s syndrome
Congenital - uterine malformation, imperforate hymen, chromosomal abnormality (Turner’s)
Physiological - pregnancy
Iatrogenic - progestogens, HRT, dopamine antagonists, mirena
GAD symptoms
Apprehension (worries about future misfortunes, feeling ‘on edge’, difficulty concentrating, etc.); Motor tension (restless fidgeting, tension headaches, trembling, inability to relax); Autonomic overactivity (lightheadedness, sweating, tachycardia or tachypnoea, epigastric discomfort, dizziness, dry mouth, etc.).
Schizophrenia Ix & mx
Ix: collateral history, bedside obs, FBC, UEs, TFTs, urine dip and drug screen, lipids, glucose
Mx: MDT + EIS DUP<3 months
Bio - Antipsychotics - require careful monitoring (2-4wks before changing)
Psychologically - CBT and reality testing and improve awareness of illogical thinking
Social - Psychoeducation, Family therapy, support for their career /housing, and signpost them to local help groups, social skills training and OTfor budggeting etc
Pre-eclampsia sx ix mx
Oedema of face hands feet Headache Seizures (eclampsia) Visual disturbances Reduced fetal movements O/E: Hyper refflexia and clonus
ix: Urine dip, obstetric and neuro exam, BP, FBC, P:CR
Criteria: New onset BP >140 + proteinuria after 20 wks
Mx:
Admit if BP >140 for observation and monitor BP 4x/d and kidney function twice a week
>150 - Oral Labetalol to keep BP <150 and 80-100, kidney function three times a week
2ndline Nifedipine and 3rd line Methyldopa
Regular fetal surveillance
If HTN refractory and severe -> offer steroids and birth
Controlled, severe -> birth at 34 + steroids
Mild/Moderate -> 34-36+6 wks
After 37 wks recommend birth 24-48hrs
Indications for delivery in pre-eclampsia
- Uncontrollable BP
- Rapidly worsening biochemistry/haematology
- Eclampsia
- Maternal symptoms
- Foetal distress, severe IUGR, reduced UA EDF
Pre-eclampsia counselling
Pre-eclampsia is a condition that affects some pregnant women and causes them to have a high blood pressure, usually during the second half of pregnancy. We don’t know what causes it, but we think it is something to do with the placenta. Often causes no symptoms but sometimes can cause headaches. It is very common 2-8 per 100.
Risks to mum: eclampsia (Seizures), stroke, affect your liver
Risks to baby: SGA/IUGR, Pre-term, hypoxia
o Explain that admission is needed (at least until blood pressure can be controlled)
o Explain pre-eclampsia and the risks (early delivery, reduced placental function, IUGR, risks to mother)
oExplain treatment (labetalol)
oExplain that blood pressure will be monitored closely (~4/day) with regular blood tests (3/week if moderate or severe, 2/week if mild
o Explain that early delivery may be necessary
o If safe for discharge: explain that they need twice-weekly BP and CTG and once weekly bloods
o Risk of Recurrence: ~15%
