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PACES specialties Flashcards

1
Q

First rank symptoms of Schizophrenia

A

 Thought insertion
 Thought withdrawal
 Auditory hallucinations
 Delusional Perceptions
 Passivity

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2
Q

Differentials of Psychotic episode

A

 Organic: SoL or Huntington’s
 Drug related: recreational drug-induced psychosis, corticosteroids, levodopa
 Psychotic: Schizophrenia, post-puerperal psychosis
 Affective: Psychotic depression, Schizoaffective disorder

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3
Q

Management of schizophrenia

A

Treated within the multidisciplinary mental health team…

Bio: antipsychotics
 1st: Atypical e.g. Aripiprazole 15mg OD
 2nd: Switch to another atypical agent (if poor adherence – Depot)
 3rd: CLOZAPINE after ~8 week trial.
 +modify cardiac risk factors as higher incidence

Psycho (consider EIP)
 CBT (+ve symptoms)
 Art therapy (-ve symptoms)
 Family therapy

Social
 Key worker appointed under CPA framework (Care Programme Approach)
 Addiction management as needed
 Housing support

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4
Q

Differentials of manic episode

A

 Organic: Hyperthyroidism, fronto-temporal dementia, stroke
 Iatrogenic: Corticosteroids, Levodopa, Substance misuse
 Psychiatric: bipolar disorder, depression, schizoaffective disorder, personality disorder

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5
Q

Acute management of manic episode

A

 Admit
 Cease all offending medications e.g. anti-depressants
 Anti-psychotic e.g. Olazapine (if needed add Lithium or Valproate)

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6
Q

Chronic management of bipolar disorder

A

Bio
 Mood stabilisers: Lithium
Psycho: “Bi-polar specific therapies”
 Psychoeducation
 CBT (for depressive episodes)
 Social Rhythm therapy
Social
 Citizen’s advice bureau (financial advice)
 Housing support

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7
Q

Grading of depression

A

 Mild = triad features only
 Moderate = triad + 3 other features
 Severe = triad + ≥4 other features (marked functional impairment)

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8
Q

Differentials of a depressive episode

A

 Organic: Hypothyroidism, Obstructive Sleep Apnoea, Parkinson’s, dementia
 Drug related: Substance misuse, methyldopa, beta blockers, opioids, racutaine
 Psychiatric: unipolar depression, Grief reaction, SAD, GAD, Bipolar.

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9
Q

Management of depression

A

Bio
 1st: SSRI e.g. Sertraline (at least 6 months)
 2nd: Trial of another SSRI

Psycho
 1st: Sleep Hygiene (i.e. low intensity interventions)
 2nd: Group CBT
 3rd: Individual CBT (IAPT): more sessions
 3rd: Interpersonal therapy
Social
 Crisis planning: Samaritans helpline 116 123
 Alcohol/smoking cessation
 Signposting to charities which can support: MIND

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10
Q

Risk factors for future completed suicide

A

FINAL
 Finances
 Intention & planning
 Noose & violent methods
 Avoid getting caught.
 Letter to loved ones

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11
Q

Risk factors for suicide attempt

A

S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness

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12
Q

Differentials of GAD

A

 Organic: Hyperthyroidism
 Drug-related: Salbutamol, Steroids, Caffeine
 Panic Disorder, Agoraphobia, Depression

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13
Q

Management of GAD

A

Bio (step 3)
 1st: Sertraline
 2nd: other SSRI or SNRI (venlafaxine)
 3rd: Pregabalin
Psycho
 (step 2) Low intensity: individual guided self help e.g. sleep hygiene
 (step 3) High intensity: CBT
Social
 (step 1) education & provision of self-help information + monitoring

Step 4 = refer to psychiatry

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14
Q

Classic features of PTSD

A

 Flashbacks
 Avoidance
 Hypervigilant state
 Emotional numbing

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15
Q

Differentials of PTSD

A

Acute stress reaction (<1m)
Abnormal grief reaction
Adjustment disorder

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16
Q

Treatment of PTSD

A

Bio
 SSRI or SNRI
 Atypical antipsychotics (if non-responsive and disabling)
Psycho
 Trauma-focussed CBT including exposure therapy
 Eye Movement Desensitisation and Reprocessing (EMDR)
Social
 Group therapy (with others who have similar experiences)

Note: In Combat-related PTSD, EMDR is contra-indicated.

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17
Q

Differentials of OCD

A

 Psychotic: psychotic depression, schizophrenia
 Affective: GAD, Depression, Hypochondriasis (if mentions health)
 Personality disorder (OCPD)
 Drug related: drug-induced psychosis – cocaine, cannabis (if bizarre)

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18
Q

Treatment of OCD

A

Bio: 2nd line
 SSRI
 Clomipramine (TCA)
Psycho: 1st line
 Low intensity: IAPT
 High intensity: CBT, ERP, Cognitive therapy.
Social
 Encouragement of support network use.

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19
Q

Treatment of Bulimia nervosa

A

Bio
 Consider admission if extremely low BMI
 Fluoxetine*
Psycho
 Family therapy
 Eating disorder focussed CBT
 MANTRA therapy (Maudsley hospital)
Social
 School support

*not licensed in Anorexia

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20
Q

Differentials of ADHD

A

 Organic: Thyroid disease, Hearing problem (glue ear),
 Neurodevelopmental: ADHD, Autism, Learning Disability,
 Affective: GAD, Depression.
 Drug-related: Substance misuse, Caffeine intake.

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21
Q

What scale can be used to screen for ADHD

A

Connor’s rating scale

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22
Q

Treatment of ADHD

A

Bio
 Methylphenidate (need to check weight every 6 months for both)
 Dexamfetamine
Psycho
 Behavioural management therapy
 Family counselling
 Cognitive behaviour therapy
Social
 Educational support (specialists, contact school)
 Family & patient Education
 Sleep hygiene
 Limit caffeine/stimulant intake

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23
Q

Causes of hyperemesis gravidarum

A

 Hyperthyroid
 Multip
 Trophoblastic disease

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24
Q

Grounds for admission in hyperemesis gravidarum

A

 Inability to keep down PO anti-emetics
 Ketonuria
 Weight loss >5%

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25
Treatment of hyperemesis gravidarum
Conservative  IV fluids  Thiamine Medicals: anti-emetics  1st: Cyclizine or Promethiazine (a TCA)  2nd: Metoclopramide or Ondansetron  3rd: Corticosteroids
26
Diagnostic threshold of GDM on testing
 Fasting ≥ 5.6 mmol/l  2 hour OGTT ≥ 7.8 mmol/l
27
Treatment of GDM
Conservative  Consultant-led care  Education on regular BM measurement  Diet: low glycaemic index foods  Exercise Medical:  1st: consider trial of lifestyle  2nd: consider trial of metformin  3rd: short acting insulin therapy
28
Complications of GDM
Maternal  Recurrent GDM / T2DM development  Pre-eclampsia Fetal  Macrosomia (increases risk of shoulder dystocia)  Polyhydramnios  Pre-term delivery  Caesarean section  Neonatal hypoglycaemia
29
Definition of Pre-eclampsia
Pre-eclampsia: Gestational HTN + significant proteinuria* OR organ dysfunction** *Significant Proteinuria: After a +ve Urine dip: 1+ proteinuria.  Protein:Creatinine (PCR) ratio >30mg  Albumin:Creatinine (ACR) ratio >8mg ** Other organ dysfunction:  Renal: Creatinine elevated  Neuro (Eclampsia, headaches, AMS)  Placental: (IUGR, Stillbirth)  Liver (HELLP)  Haematological (HELLP, DIC)
30
Risk factors for pre-eclampsia
1 = treat Past medical factors: DM, CKD, Chronic Hypertension/PMHx, Auto-immune disease 2 = treat Pregnancy factors: >40, Primip, Multiple pregnancy, >35 BMI.
31
Pre-eclampsia management
Conservative  Monitoring: every week BP, protein ratio measurements  Blood tests: HELLP check at time of presentation.  Safety netting: features of eclampsia = headache, visual changes, swelling Medical  1st: Labetalol PO  2nd: Nifedipine PO (if asthmatic)
32
Eclampsia treatment
Conservative:  Admit, Resusitate as needed  Call for Help  Monitoring: mother (neuro-obs) and fetus (CTG)  Consider delivery: Steroids Medical:  1st: Magnesium Sulphate 4g IV bolus -> infusion  If resp depression occurs due to Mg: Calcium Gluconate Note: HELLP treatment = Urgent delivery
33
Differentials of obstretric cholestasis
Obstetric: Intrahepatic cholestasis, Acute fatty liver, HELLP, PUPPPs. Non-Obstetric: Gilbert’s, Acute hepatitis, Cholecystitis, drug related
34
Differentials of antepartum haemorrhage
 Obstetric: Bloody show, Placental Abruption, Placenta Praevia, Vasa Previa, Uterine rupture  Gynaecological: Cervical ectropion, Cervical polyp, idiopathic
35
Treatment of placental abruption/praevia at >34 weeks
Conservative  Call for help: alarm + Major Obstretric Haemorrhage  Resuscitation: wide bore cannulae  Admit Medical  Dexamethasone: Abruption - if <37 weeks. Praevia if <35 weeks.  Blood products  Consider Anti-D prophylaxis Surgical  For expedited delivery (could need hysterectomy)
36
Risk factors for PPH
 Previous  Prolonged labour  Pre-eclampsia  Polyhydramnios  Placenta Praevia
37
Causes of PPH
 Tone  Trauma  Tissue  Thrombin (coagulopathy)
38
Acute management of PPH
Conservative  Call for help: alarm + major obstetric haemorrhage  Lie flat + uterine massage/bimanual compression  Resuscitation: two wide bore cannulae + blood tests  Catheterise Medical  Oxytocin 10 units IV  Ergometrin 500mcg IM (NOT IN HTN)  Tranexamic Acide 1g  Blood products Surgical  1st: Intrauterine balloon  2nd: B-lynch suture  3rd: Ligation of uterine arteries  Last: Hysterectomy
39
Differentials of post menopausal bleeding
 Age related: Climacteric period, Atrophic vaginitis  Malignant: Endometrial, Cervical, Ovarian, Vulval  Inflammatory: endometrial hyperplasia, endometrial or cervical polyps  STI: chlamydia
40
Risk factors for endometrial cancer
All increased levels of oestrogen exposure:  Oestrogen/anovulation: Early Menarche, Late Menopause, Nulliparous,  Metabolic: Obesity, PCOS, DM  Genetic: FHx, Lynch syndrome  Medications: tamoxifen, unopposed HRT
41
Treatment for endometrial cancer
Non-invasive  Psychologist referral  Follow up with specialist cancer nurse Invasive treatment FIGO staging: 1 Confined to uterus (on microscope) Total hysterectomy + BSO 2 Extends to cervix Radical hysterectomy 3 Extends into pelvis Maximal debulking surgery + chemotherapy 4 Metastases (bladder, rectal involvement) Maximal debulking surgery + rad/chemotherapy
42
Treatment for endometrial hyperplasia
 Treatment with atypia: Hysterectomy + BSO  Treatment without atypia: Progesterone therapy – IUS + resample in 3 months.
43
Differentials of Menorrhagia
Structural  Polyps  Adenomyosis  Leiomyoma  Malignancy Systemic  Coagulopathy  Ovulatory disorders  Endometrial disorders: endometriosis, abnormal uterine bleeding  Iatrogenic (contraceptives)  Not otherwise classified (hypothyroidism, PID)
44
What is the most common cause of menorrhagia
Abnormal Uterine Bleeding
45
Treatment for menorrhagia
Conservative  Reassurance and education Medical If she wants contraception…  1st: LNG-IUS insertion  2nd: COCP  3rd: Depo-Provera (long acting progesterone) If she does not want contraception  Mefenamic acid or Tranexamic acid
46
Differentials of post-coital bleeding
 Infectious: Chlamydia, PID  Inflammatory: Cervical polyps, ectropion, trauma, Atrophic vaginitis  Malignancy: Cervical cancer
47
Risk factors for cervical cancer
 HPV infection  Precancerous smears: CIN & CGIN  Smoking  COCP  Multiparity
48
Treatment of cervical cancer
Non-invasive  Psychologist referral  Fertility counselling  Follow up with specialist cancer nurse Invasive Dependant on FIGO cancer stage… 1a Confined to cervix (on microscope) Cone biopsy (fertility sparing), Wertheim’s Hysterectomy 1b(ig) Confined to cervix (macroscopic lesions) Wertheim’s Hysterectomy (radical) 2 Beyond cervix, spares lower 1/3 vagina Wertheim’s Hysterectomy, Radio-chemotherapy 3 Beyond cervix, involves lower 1/3 vagina Radio-chemotherapy 4 Metastases (bladder, rectal involvement) Radial Pelvic exenteration
49
Differentials of an ovarian mass
 Physiological cysts: follicular, corpus luteal  Epithelial (surface): Serous, mucinous, Brenner  Germ cell (interesting bit): Teratoma, dysgerminoma  Stromal (middle): thecoma, granulosa  Metastatic: Krukenberg
50
How can the risk of ovarian malignancy be quantified
Risk of Malignancy Index  Ultrasound findings  Menopausal status  CA125 score >250 = refer to secondary care.
51
What tumour markers should be ordered for a patient <40 suspected of ovarian cancer?
 CA125  LDH  AFP  hCG
52
Risk factors for ovarian cancer
 FHx: BRCA1/2  Ovulations: early menarche, late menopause, nulliparous, PCOS  Smoking
53
Management of ovarian cancer
Conservative  Monitoring CA125 for 5 years.  Fertility counselling  Follow up with specialist cancer nurse Medical  Adjuvant Chemotherapy Surgical  RMI >25 = bilateral oophorectomy, if cancer found then see below  RMI >250 = staging laparotomy & debulking
54
Risk factors for ovarian torsion
 Young (reproductive age)  Pregnant  OHSS  Ovarian mass/cyst
55
Treatment of ovarian torsion
Conservative  Admit  Refer to Gynae  NBM Medical  IV fluids  Analgesia  Anti-emetics Surgical  1st: Surgical reversal +/- cystectomy +/- oophropexy  2nd: salpingo-oophorectomy
56
Risk factors for ectopic pregnancy
 Tubal: defect (e.g. salpingotomy), PID/previous STI, Smoking  Uterine: copper IUD in situ, IVF
57
Management of ectopic pregnancy
Expectant  Stable + pain free + tubal ectopic <35mm + no FHB + Serum hCG <1000 + will follow up.  Consider if <1500 hCG Treatment…  Repeat serum hCGs on Day, 2, 4, 7 (think: 24/7) after first test  Education Medical  No significant pain + tubal ectopic unruptured >35mm + no FHB + <1500 + will return to follow up  Consider if 5000 > x < 1500  Note: must have no confirmed intrauterine pregnancy Treatment…  IM Methotrexate  Repeat serum hCGs (4, 7 + weekly until negative) + FBC & LFTs on day 7.  Education (no pregnancies for next 3 months) Surgical (any)  Significant pain  >35 mm  FHB visible  >5000 serum hCG Treatment…  Laparoscopic > open  1st: Salpingectomy  2nd: Salpingotomy IF infertility risk factors  IF RHESUS NEGATIVE: 250IU (no kleihauer)  Education  Advise to take urine pregnancy test after 3 weeks.
58
Complications of ectopic
Disease related  Rupture -> internal bleeding -> hypovolaemic shock -> death Treatment related  Treatment failure (95% success in methotrexate)  Future infertility
59
Management of miscarriage
Expectant  Discharge with safety netting  To return if lasts >14 days  Urine pregnancy test after 3 weeks Note: 1st line but consider other if any of…  Increased risk of haemorrhage or its effects (inc. late first trimester, sickle cell)  Previous traumatic pregnancy experience  Infection Medical  PV Misoprostol 800 micrograms if missed, 600 if incomplete  Education about what to expect  Urine pregnancy test after 3 weeks Surgical  Manual vacuum aspiration under local  Surgical removal under general  Misoprostol often given neo-adjuvantly to aid cervix ripening  No follow up usually needed
60
Differentials of incontinance (in woman)
 Urge incontinence  Stress incontinence  Mixed incontinence  Functional incontenence  Dietary: related (caffeine intake)  Neurological: stroke-related  Malignancy: bladder, prostate
61
Urge incontenance management
Conservative  Pads & packs  BLADDER RETRAINING for 6 weeks at minimum (hold it for as long as you can) Medical:  Oxybutynin (leads to cant see, cant pee, cant spit, cant shit.)  mirabegron (a beta-3 agonist) can be used in elderly afraid of these side effects. Surgical:  Colposuspension (Birch’s procedure: where suture support the vaginal wall by attaching them to Cooper’s ligament)
62
Stress incontinance management
Conservative:  Kegels – pelvic floor exercises Medical:  Duloxetine (noradrenaline and serotonin reuptake inhibitor) if surgery is not appropriate. Enhances contraction of the pelvic muscle by stimulating the pudendal nerve. Surgical:  Mid-urethral tape surgery.
63
Key features of Endometriosis
 Cyclical pelvic pain  Dysmenorrhoea  Deep Dyspareunia  Subfertility
64
Treatment of endometriosis
Conservative  Analgesia: NSAIDs, Paracetamol  Counselling on subfertility Medical  COCP  GnRH analogues (pseudomenopause) Surgery  Laparoscopic excision  Laser treatment
65
Differentials of dyspareunia
 Infectious: STI, PID, Candida, BV, TV, Bartholin’s Cyst  Non-infectious: Endometriosis, Vulvodynia  Age related: atrophic vaginitis Note: Superficial is suggestive of acquired STI, Bartholin’s & vulvodynia Deep is suggestive of PID, Endometriosis.
66
Causes of amenorrhoea
Primary  Endocrine: Turner’s syndrome, Kallmann syndrome, CAH  Obstetric: Imperforate hymen & other genital tract abnormalities Secondary  PREGNANCY  Hypothalamic: stress, exercise, anorexia  Pituitary: Hyperprolactinaemia, thyroid disease  Gonadal: PCOS, premature ovarian insufficiency, Fibroids
67
Infertility causes
 Idiopathic  Lifestyle: obesity, smoking In women…  Ovary: PCOS, premature ovarian insufficiency  Tubal: PID, STI, post-ectopic pregnancy  Uterine: Fibroids, Endometriosis/Adenomyosis  Endocrine: hyperprolactinaemia, thyroid disease In men…  Endocrine: Kleinefelter’s, Kallmans, Hyperprolactinaemia  Gonadal: CBAVD, Cystic fibrosis  Acquired: torsion, chemotherapy
68
Investigations for infertility
In women… Bloods  Day ~21 serum progesterone  LH & FSH  Prolactin  TFTs Imaging  Hysterosalpingogram (tubal pathology)  TVUSS (fibroids) In men…  Semen analysis  Prolactin
69
Treatment for infertility
Conservative  Family planning: increased sex frequency during ovulation  Weight loss  Smoking/alcohol cessation  Disease optimisation (e.g. DM) Medical  Clomiphene  IVF  ICSI
70
Criteria for diagnosing PCOS
Rotterdam Criteria needs 2 out of 3:  USS showing ovarian cysts (12+ in one ovary)  Evidence of oligo/anovulation (>2 years)  Hyperandrogenism
71
Management of PCOS
Not hoping to conceive… Conservative  Patient education: cardiovascular & metabolic risk  Diet & Exercise  Family planning counselling: infertility, miscarriage  Hair removal Medical  Metformin  COCP*  Co-cypyrindiol (dianette) *note: prolonged anovulation leads to endometrial hyperplasia – withdrawal bleed can be induced using a progestogen for 14 days. Hoping to conceive… Medical  Clomiphene (Multip pregnancy risk↑ : SERM – increases GnRH pulsatility)  Metformin Surgical  Laparoscopic ovarian drilling
72
Risk factors of PCOS
 Early menarche  Obese  Age  Afro-Caribbean
73
Treatment of fibroids
Conservative: symptom control  LNG-IUS  Analgesia: NSAIDs – mefanmenic acid  COCP Medical:  GnRH agonists (short term) Surgical  Fertility preserving: Myomectomy.  Endometrial ablation  Hysterectomy
74
Complications of fibroids
 Sub/infertility  Iron deficiency anaemia  Red degeneration (during pregnancy)
75
UKMEC4 contraindications to the COCP
 B: Breastfeeding < 6 weeks, Breast cancer  A: Migraine with aura  S: Smoker >15 a day, >35 y/o, Stroke/IHD/VTE history, Surgery (during), Severe DM.  H: uncontrolled hypertension.
76
Treatment for menopause
Conservative  Weight loss: D&E  Sleep hygiene  Cognitive behaviour therapy Medical  SSRIs  HRT

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