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Paediatrics (ADHD (Symptoms (3 Core Behaviours: Inattention …
Paediatrics
ADHD
Symptoms
3 Core Behaviours:
Inattention
Hyperactivity
Impulsivity
Consider ADHD:
Sx<12 yo // Developmentally inappropriate // Several symptoms in >2 settings
Who?
4-7% school children
M:F 4:1
RFs: Genetic/ Enviro / Exp abuse / Drug exposure in utero
Ix: In consultation ?impulsivity/innatention ?RFs/SHx, Nurse classroom observation, Connor's/SNAP questionnaire
Tx: Education for parents, School support/Liaison,
ASD
Symptoms:
Communication
Social Interaction
Imagination / Rigidity
Comms: No desire to comm, No social awareness, Repeat speech (echolalia), Delayed language
Social: No desire to interact, no understanding of social rules/norms. don't like unfamiliar people in unfamiliar circumstances
Tx: Education to promote verbal comm
Sickle Cell Disease
Mx: Hydroxyurea
<5yo give penicillin to decrease risk of bacterial infection e.g pneumonia
Haematology
Anaemia
High reticulocyte count--> Haemolysis / Blood Loss
Severe anaemia at birth- Haemolytic disease / Internal Haemorrhage / Bleeding umbilical cord
Erythroblastosis Fetalis:
Rh-ve mother prev sensitised to Rh +ve cells --> Transplacental passage of antibodies--> Haemolysis of Rh+ve fetal cells
S&S- Severe anaemia, enlarged spleen+liver
Tx- Prevent sensitisation with Rh Immune globulin. Intrauterine transfusion
**Iron Deficiency (microcytic) Anaemia
Causes: Low Iron Intake e.g diet/ exclusive cows milk intake // Malabsorption // Increased Req e.g Infections
Milk
Cows milk has reduced iron content and low bioavailability
Breastmilk meets basic iron requirements for first 6mo of life, after this additional supplements/ iron-rich foods required.
Functions of Iron: Haemoglobin--> transport of oxygen, transport electrons in mitochondiria
S&S: Pallor, Irritatbility, Anorexia when Hb<50, Tachycardia
Blood film- Microcytic, Hypochromic, Low/Normal Reticulocytes
Blood result- Los ferritin & serum iron, Increased TIBC (Total Iron Binding Capacity)
Mx: Iron supplement for 3-6mo (6mg/kg/day PO) SE: constipation
Congenital / Acquired
Microcyctic / Normocytic / Macrocytic
Obstetrics
Labour
Cesearean Section
Offered from 39 weeks, before this lungs not fully developed. If ptx had CS<2 years offer CS again, if longer offer NVD.
Can offer to tubal ligation with CS 'tube tie'= sterilisation
CAT 1- deliver now,
CAT 2- no current maternal distress, deliver 24hrs,
CAT3- will be at risk in 72 hrs,
CAT 4- Elective
Placental expulsion
End of pregnancy uterus contracts. Placenta cannot contract or change shape and is therefore sheered from uterus wall.
Cord Prolapse
PPh: Cord descend below presenting part after rupture of membranes, if compressed and spasms baby can become hypoxic
Mx: DO NOT push back inside, keep warm and moist, plan C-section
Partogram
Measures progress of cervical dilation, assessed on vaginal exam and plotted against time
Vaginal tears
1st degree- vaginal musoca only
2nd degree- sub-cutaneous tissue
3rd degree- external anal sphincter
4th degree- through external anal sphincter into rectal mucosa
RFs: macrosomia / shoulder dystocia / primigravida / foreceps delivery
Pre-term labour
(due to polyhydramnios)
Serial monitoring of AFi / foetal growth, maternal steroids, infometacin (limits foetal urination), amnioreduction (draings amniotic fluid), induction of labour if foetal distress
Stages of Labour: (TBC- Grace)
First Stage
Latent Phase- regular rhythmic uterine contractions, 5-10 min intervals.
Active Phase
Cardinal Movements
Descent --> Engagement--> Flexion --> Internal rotation --> Crowning --> Extension of presenting part --> External roration of head --> Delivery
Induction of labour:
(ZtF)
Offered at 41-42 weeks or in prelabour ROM, foteal growth restriction, pre-eclampsia, obstetric cholestasis, existing diabetes, intrauterine feotal death.
Bishop score used to decide whether to induce labour
Mx- membrane sweep, vaginal prostaglandin E2 (dinoprostone), Cervical ripening balloon, artificial rupture of membranes with oxytocin infusion, oral mifepristone+misoprostol (where intrauterine foetal death has occurred)
Pre-eclampsia
Comps
Eclampsia (Pre-eclampsia + Seizures) // AKI
HELLP syndrome (Haemolysis, Elevated liver enzymes, Low platelets) //
Mx
Prevention
Hx DM- give prophylactic aspirin 75mg/day
Treatment
Anti-hypertensives- 1st labetalol (BB), nifedipine (CCB) - note do not give ACEi as CI in pregnancy
PPh
Poor placental perfusion secondary to abnormal placentation (spiral arteries of uterus do not dilate therefore high resistance low flow uteroplacental circulation). Resultant increase BP, hypoxia, oxidative stress leads to systemic inflammatory response
RFs
1st Preg (5%), Prev Pre-Ec, DM, Chronic HTN,
Age>40, BMI>35
Ix
Diagnostic criteria:
Gestation >20wks
HTN >140 / >90
Proteinuria >300mg 24hr urine sample
Staging: Mild 140-149/90-99, Moderate 150-159/100-109, Severe >160/110
S&S
Acute bilateral ankle swelling, Headaches, Blurred vision, Epigastric pain, Hyper-reflexia
Eclampsia Mx: (TBC- Grace) ABCDE, mother left lateral position, magnesium sulphate 1g/hr 24hrs, IV labetalol
Gestational Diabetes
Glucose
Early pregnancy glucose levels low because??
Later pregnancy glucose levels higher due to maternal insulin resistance and foetal glucose sparing
Baby main nutrient supply= glucose
Mx: Fasting glucose<7mmol/L (lifestyle--> metformin-->insulin)
Fasting glucose >7mmol (insulin +/- metformin)
S&S: Polyuria, polydipsia, fatigue
PPh: Reduced insulin sensitivity and subsequent glucose intolerance that occurs during pregnancy and resolves after birth
RFs: BMI>30, prev macrosomic baby, prev GDM, FHx GDM/DM, ethnic minority
Ix: fasting glucose >5.6mmol/l, OGTT glucose >7.8mmol/l at 2 hrs
(5-6-7-8)
Comps: Macrosomia, shoulder dystocia, developing T2DM after pregnancy, preterm labour, pre-eclampsia, miscarriage
Post-partum Haemorrhage (PPH)
ILA!
Causes (4Ts)
Mx (4Rs):
Tissue (retained PoC)
Remove excess tissue
**Tone (Atonic uterus e.g , smoking, large baby, multiparity, long or fast delivery)
Reset- IV Oxytocin + Ergometrin
Thrombin
Reverse defect
Trauma/Tear
Repair- pressure and suture
Complications
DIC
Death
ARDS
Shehans syndrome
PPh:
Primary PPH- loss of blood from genital tract <24hrs after delivery. Minor: 500-1000ml, Major: >1000ml
RFs: 'Big Old Long Bleed' = Big uterus (polyhydramnios, multiple pregnancy, macrosomia), Old (increased maternal age), Long/Complicated labour (induction, CS, instrumetation), Bleed Hx (prev PPH, placena previa / abruption, bleeding disorder)
Secondary PPH
Cause
*Endometritis- inflammation of endometrium due to infection
Ix
?Infection= Vaginal swabs, Blood cultures
?Retained POC- USS
General MX:
ABCDE, Bloods- cross matching, IV fluids
Shoulder dystocia
RFs
Prev SD, >42 weeks, DM, Foetal Macrosomia, Maternal Obesity
Mx (ALARMER)
Ask for help
Leg hyperflexion to abdomen (McRoberts manoeuvre)
Anterior shoulder pressure
Rubin manoeuvre (vaginal approach, shoulder pushed towards chest)
Manual delivery of posterior arm
Episostomy
Roll over on all fours
PPh:
Defined as a delay delay in delivery of shoulders following head
Comp
Delayed delivery causes foetal hypoxia // Brachial plexus injury (erbs palsy)
S&S
Difficult delivery of head // Turtle sign (foetal head retracts into pelvis)
Ectopic Pregnancy
PPh: Implantation outside uterine cavity *fallopian tubes
RFs: Prev ectopic, Adhesion formation (uterine surgery, PID, endometriosis), Contraception (IUD/IUS/POP)
S&S: Abdo pain +/- PV bleed, shoulder tip pain, vaginal discharge (brown 'prune juice'- decidua breakdown). Ruptured- signs of shock.
Mx- termination of pregnancy (ectopic is not viable)- IM methotrexate, laparoscopic salpingectomy (removing ectopic and tube implanted in), salpingotomy (cut ectopic and salvage tube to preserve future fertility
Ix: B-HcG and USS. normal preg (>1500 + intrauterine preg on pelvic US), ectopic preg (>1500 + no intrauterine preg on either pelvic or TVUS).
If result <1500 repeat in 48hrs, doubles- viable preg, halves- miscarriage, neither- cannot exclude ectopic
Further reading:
https://zerotofinals.com/obgyn/earlypregnancy/ectopic/
Miscarriage
PPh: Loss of pregnancy <24 weeks. early<13 weeks, late 13-24 weeks, 20-25% pregnancies. RFs: SAD BURTH- SLE, Age>35, DM, BV, Uterine / ceRvical abnormality, THrombophilia e.g. anti-phospholipid syndrome
Types
Recurrent: >3 consecutive
Threatened (Os closed, USS + foetus, PV bleed)
Inevitable (Os open, USS + foetus, PV bleed)
Incomplete (Os open, USS no foetus, PV bleed)
Complete/ Missed (Os closed, USS no foetus, No PV bleed)
S+S: PV bleed> menstrual. Prod of conception, lower back pain
Ix: B-hcG, TVUS, Bloods ?anaemia
Mx:
Conservative- allow POC to pass naturally
Medical- Vaginal misoprostol- myometrial contractions, Mifeprestone- cervical ripening
Surgical- vaccum aspiration or evacuation of retained POC
IUGR (Intrauterine Growth Restriction)
PPh:
RFs
Maternal:
Person: BMI<20, Age<16 / >35,
PMH: Prev SGA newborn. Parity 0 / >5, Inter-pregnancy interval <6mo / >2yrs
SHx: Substance abuse, Infection: Malaria, TB, UTI, TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex)
Fetal: Chromosomal abnormality e.g trisomy 13 / 18 / 21, Infections (as above),
Placental: pre-eclampsia, placental abruption
Defining
IUGR= Only considers clinical features (signs of malnutrition and in-utero growth restriction)
SGA= Only considers birth wt. (pre/post-natal birth weight < 10th percentile for their gestational age)
Classification
Symmetrical
(earlier in pregnancy)
Antenatal
Reduced: head circumference, abdo circumference, biparietal diameter (head), fetal length
Postnatal
Reduced: head circumference, weight, length
Asymmetrical
(later in pregnancy)
Antenatal
Reduced abdominal circumference. Normal head, biparietal
Postnatal
Reduced weight. Normal length/head circumference
Ix: US- ratio of head circumference and abdo circumference
Mx: Smoking cessation, pre-eclampsia prevention 75mg aspirin,
Frequent surveillance e.g uterine artery doppler UAD and SFH measuring
Definitions
Gravidity= Number of times a woman has been pregnant
Primagravida= first pregnancy
Multigravida= been pregnant more than once
Parity=No. Times given birth to a fetus with gestational age of 24 weeks of more, regardless of born alive or stillborn
Nulliparous= not given birth previously (regardless of outcome)
Multiparous= given birth more than once
Pregnancy length
Preterm
Before 37 weeks gestation
Full term
39-40 weeks
Prolonged/post-term
Beyond 42 weeks
Baby sizes
Size for dates
Small= EBW<10th centile. Large= EBW>90th centile
Birth weight
Low <2500g, Large>4000g, Macrosomia >4500g
Random clinic notes
Maternal immune suppression Prevents foetal rejection
Total iron binding capacity increases in pregnancy
from 16-24 weeks baby movement increases
VTE risk >/=3 give dalteparin (LMWH) from 28 weeks, SC OD. If haemorraage on dalteparin give protamine sulphate (antidote)
Placenta
Placenta Praevia
S&S: Painless, bright red bleeding, usually from 20wks when uterus stretches
Ix: TVUS
Mx: Minor bleed- bed rest, Major bleed- blood products and IV fluids
Signs of foetal hypoxia--> emergency caesarean
Planning delivery: Vaginal USS shows PPraevia, admit to hospital, cross-match blood, give anti-D, plan C-section delivery
Comps: Maternal (blood loss), Foetal (hypoxia / preterm delivery)
PPh: "placenta first"
Complete/partial/marginal (<2cm from) covering of internal cervical os by placenta RFs: Multiple placentas (twins), Maternal Age >35, Intrauterine Fibroids, Maternal Smoking
Placenta invasion
Accreta- superficial myometrium
Increta- deeper myetrium
Percreta- nearby organs e.g bladder
Placenta Abruption
S&S: Sudden onset severe continuous abdominal pain, PV bleeding (although may be concealed), haemodynamic instability, CTG shows foetal distress, "Woody" abdomen (muscles tense to stop bleeding),
Mx: IV fluids and blood products, monitor closely, if severe emergency caesarean
Anti-D immunoglobulin given to Rhesus-D negative mothers
Comps:
Maternal: Hypovolaemic shock, Sheehan syndrome (perinatal pituitary necrosis), Renal failure, DIC (disseminated intravascular coagulation)
Fetal: Intrauterine hypoxia, Premature birth
Ix: clinical diagnosis, USS to exclude placenta praevia
PPh: antepartum haemorrhage caused by premature separation of placenta during pregnancy. Can be complete/partial, apparent (PV bleed) or concealed (internal bleeding)
RFs- previous abruption, pre-eclampsia, Age >35, trauma, multiple pregnancy, foetal growth restriction, multi-gravida, smoking, cocaine
Normal- implantation into fundus of uterus
Presentations and DDs
Abdominal pain
Ectopic Pregnancy
Pre-term Labour
Placental Abruption
Ruptured/haemorrhagic ovarian cyst
None O&G
Appendicitis / Cholecystitis / Acute Pancreatitis / Intestinal obstruction
Miscarriage
Hypertension
Pre-eclampsia (>20wks G + HTN + Proteinuria)
Essential HTN (<20wks G)
Pregnancy induced HTN (PIH) (>20wks G, New HTN, no proteinuria)
Eclampsia (pre-eclampsia + seizures)
Antepartum Bleeding
Placenta Praevia
Placental abruption
Vaginal/vulval trauma
Domestic violence
Vasa Preaevia
Uterine Rupture
Dysmenorrhoea
History Qs
(TBC- Grace)
SOCRATES, cycle length/history
Endometriosis
PID
Pelvic adhesions
Fibroids
Copper IUD
Premature Rupture of Membranes
Ix:
USS- ?amniotic fluid volume
Vaginal swabs/CRP/FBC- ?infection.
CTG- ?foetal wellbeing
NOT digital exam (increases Rx infection)
Mx:
Infection--> deliver baby
No infection--> admit mother, IC steroids, close monitoring, induce labour at 36 weeks
PPh:
PROM (Premature rupture of membranes): rupture >37 weeks prior to onset of labour
15% pregnancies, minimal risk
(P-PROM) Pre-term premature rupture of membranes: <37 weeks
2% pregnancies, high risk
Breakdown of foetal membranes normal physiologically in preparation for labour. Early rupture caused by infection / genetics
S&S:
'broken waters' or gradual leakage
Baby Scans and Checks
12 weeks scan: dating scan (crown and rump length used to guide due date), screen for Down's, Edward's, Patau's
18-20 weeks anomaly scan: Check placenta location ?normal ?placenta praevia
SFH: 16-26w height = gestational age. 26-36 weeksL height+2= gestational age
Discrepancy between SFH and Gestational Age: Mutliple preg, polyhydramnios, fibroids, macrosomia
Rheusus Staus
Give Anti-D to any Rh- mother up to 72hrs after a sensisting event e.g miscarriage after 12 weeks, abdo trauma, amniocentesis, bleeding, labour
If both parents Rh- then child should be Rh-.
?Give anti-D anyway incase he isn't the father
Haemolytic disease of newborn:
Anti-D antibodies cross placental membrane, enter foetal circulation, haemolyse RBCs causing increased bilirubin which causes kernicterus
IgM cannot cross placenta, IgG can
Post-Natal Depression (TBC- OS, TMOG)
PPh
RFs: poor social support, relationship with partner, unplanned pregnancy, prev mental health problems, domestic violence
Protective factors: breastfeeding, financial security, supportive family
Ix:
Edinburgh PND
S&S:
Anhedonia, Low mood, Thoughts of self-harm/suicide, Guilt, Loss of appetite, anxiety, loss of libido,
Mx:
Reassurance that PND is not uncommon, Self-help, Baby groups, CBT, Sertraline
"Sweep"
Who? When?
Performed in all Ptx when reaching full term (37-42 weeks) prior to induction
Method
Lubricated gloves, index finger into opening cervix or neck of womb, circular motions to separate membranes from amniotic sac
Purpose
To release prostaglandins which prepare cervix for birth
Fertilisation
Infertility
Laparoscopy and dye test: Gold standard key hole ix.
L= ?endometriosis ?pelvic infection ?adhesions ?ovarian cysts ?fibroids
D= ?fallopian tubes blocked
Investigate fertility after 1 year of trying to conceive
IVF
Funding
Private IVF: £3-5k
NHS: BMI<30 and no children either partner
(lower BMI makes periods more regular)
GTD
Molar pregnancy
Mx (molar)= Suction curettage, chemo
Partial molar= ovum fertilised by 2 sperm (triplody- 69 chromosomes)
Ix: Urine/Blood B-hCG= High, USS- 'snow storm'
Abnormality in chromosomal number during fertilisation, the non-viable egg implants and fails to come to term becomes a mass in the uterus
Complete molar=
S&S: Vaginal Bleeding / Abdo pain (early pregnancy), Hyperemesis / Hyperthyroidism due to B-hCG (late pregnancy)
Definition: Collection of pregnancy related tumours.
Benign= molar disease // Malignant= choriocarcinoma / invasive mole
Amniotic Fluid (TBC)
Polyhydramnios
*Idiopathic, can caused by increased foetal urination or decreased foetal swallowing
RFs: multiple gestation, maternal diabetes, oesophageal atresia, foetal anaemia
50% idiopathic
Ix: identify cause: OFTT, maternal infection, amniocentesis, USS
Amniotic fluid index >95th centile for gestational age
AFI >24cm (2000ml+)
Oligohydramnios
AFI <5cm (<200ml)
Vasa Praevia
PPh: Foetal blood vessels run near to internal vertical os. Rupture of umbilical cord vessels--> membrane rupture and loss of foetal blood --> presents as PV bleed
S&S: Triad= Vaginal bleed, Rupture of membranes, Foetal compromise
Surgery
Episiotomy
Incision of perineum, performed during 2nd stage of labour to enlarge opening for baby to pass through. Common to continue being painful and cause dyspareunia
Malpresentation
*Breech - this is more common in pre-term babies who may have not turned in uterus in preparation for delivery
GI 3a List
Structural
Malrotation
S&S= Dark green vomit
Ix= Upper GI Contrast
Duodenal Atresia
PPh= Congenital absence/complete closure of duodenum
Ix: Abdo XR- double bubble sign
Intussusception
PPh= Telescoping/Invagination of bowel
S&S= Redcurrant jelly stool, Abdo mass, Colicky pain, Vomitting
Ix= US- target sign, AXR
Mx= Gas in anal canal, analgesia, IV fluids (if shocked), surgical reduction if necessary
GORD
PPh: Common in 1st year of life, most resolve by 12mo because of maturation of oesophageal sphincter, upright posture and more solids in diet
Mx: feed thickeners, omeprazole (reduce oesophagitis)
Ix: Clinical diagnosis, 24hr oesophageal pH, contrast studies (?anatomical abnormality)
Pyloric Stenosis
PPh: Congenital hypertrophy of pylorous, M>F
Ix:
US/AXR
Bloods
Metabolic Alkalosis
Hypochloraemia (vomiting)
Hyperkalaemia (dehydration --> retain Na+ and excrete K+)
S&S: Non-bilious projectile vomitting, "olive" in RUQ/Epigastric region, Peristalsis (movement of stomach wall muscles having to work harder),
Mx: rehydration, electrolyte balancing, surgery (pyloromyotomy)
Hernia
Faltering growth
Inadequate intake
Lack of food availability / neglect
Inadequate retention
Vomitting / GORD
Malabsorption
Coeliac / CF / CMPAllergy
Increased requirements
Hyperthyroid / CA / Cong HD
Inflammation
Appendicitis
S&S
Abdo pain central--> R localised, RIF rebound tenderness
Anorexia, Pyrexia, Vomiting,
IBD
Crohn's
Ix:
Stool cultures and faecal calprotectin
Colonoscopy + Biopsy= non-caseating epithelioid cell granulomata
Coeliac
Anti TTG, Antiendomyseal
Biopsy diagnostic- villous atrophy, crypt hyperplasia
Infection
Giardiasis
PPh= Infection of intestine with protozoan
S&S= Intermittent non-bloody diarrhoea and constipation, abdo pain, bloating
Ix: Enzyme immunoassay of stool
Mx= High dose metronidazole
Gastroenteritis
**Rotavirus (vaccine available),
Main problem is dehydration
Campylobacter Jejuni (*bacterial infection)
Salmonellae / Shigella- blood + pus in stool, pain, tenesmus (feeling of incomplete defecation)
Diarrhoea
Acute Diarrhoea
Causes
Antibiotics use
Infection- *Rotavirus
Gastroenteritis- E.coli, Shigeella, Salmonella
Main complication= Dehydration
Chronic / Recurrent Diarrhoea
Causes
Malabsorption- CF / Coealiac / Secondary lactose intolerance
Inflammation- IBD / CMPAllergy
Normal- toddler diarrhoea (thriving, loose stools with undigested food)
Ix
FBC- ?anaemia- blood loss
ESR- ?IBD
Serology- ?Coeliac Abs
Sweat test- ?CF
Endoscopy- ?IBD lesions
Vomitting
Indicators of cause
Transient + fever/ diarrhoea/ cough = ?gastroenteritis / ?resp infection
Projectile= ?pyloric stenosis (at 2-7wks)
Bile stained= ?intestinal obstruction e.g intussusception, malrotation, strangulated hernia
Blood stained= ?oesophagitis ?peptic ulceration
None= ?over-feeding
Types
Posseting (small quantities w/bubbles or wind)
Regurgitation (larger quantities / more freq)
Constipation
Hirshprung's disease
PPh= Nerves missing in some parts of bowel meaning lack of constriction of bowel.
S&S= Constipation--> Abdo distention and pain, Billous vomiting
Ix= XR / barium enema, biopsy
Mx= surgical removal.
Acute Abdo Pain
Causes
Intra-abdominal
Surgical
**Acute Appendicitis, Instestinal obstruction, Inguinal hernia, Peritonitis, Pancreatitis, Trauma
Medical
Gastroenteritis, UTI, DKA, Sickle cell, IBD, Constipation, Gynae problems (pubertal females)
Extra-abdominal
URTI, Pneumonia, Testicular torsion, Hip/spine
Poor Feeding
Failure to Thrive
Gynae
Uterus
Adenomysosis
PPh: invasion of endometrial tissue into myometrium usually following uterine damage.
RFs: multiparitiy, uterine surgery, previous CS
S&S: menorrhagia, dysmenorrhoea, dyspareunia (cyclical)
Ix: TVUS, MRI (imaging usually difficult to diagnose)
Mx: Mirena coil, COCP, GnRH agonist, aromatase inhibitor. Hysterectomy (definitive)
Endometriosis
Comps- Endometriomas 'chocolate cysts'- endometrial tissue cyclically sheds forming cysts of old dark blood, these can rupture causing pain and inflammation
Mx: Lower ovarian function >6/12 e.g COCP/POP/Mierna/Depo/GnRH agonist
Surgery- laparoscopic excision / ablation or hysterectomy
Ix: Laparoscopy + Biopsy, Transvaginal US, MRI
S&S: dysmenorrhoea, deep dyspareunia, chronic pelvic pain, subfertility
Pain is usually cyclical around time of periods
PPh: Growth of endometrial tissue in sites other than uterine cavity e.g ovaries/fallopian tubes
Fibroids
PPh: Benign smooth muscle monoclonal tumours of uterus, produce aromatase which converts androgens to oestrogen leading to growth.
RFs: African, MED 12 gene, Increased oestrogen (pre-menopausal, pregnancy), FHx, Age, Obesity
S&S: *asymptomatic, heavy/prolonged bleeding, abdo pain, infertility, suprapubic mass
Ix: Pelvic exam, USS, Hysteroscopy,
Locations: *intramural, sub-mucosal (grow into uterine cavity), sub-serosal (grow outwards from uterus)
Mx- asymptomatic- nothing. Symptomatic- mirena coil, TXA, myomectomy, hysterectomy, uterine artery embolisation, GnRH agonists
Comps- miscarriage, malpresentation, post-partum haemorrhage
Red degeneration of fibroids- Iscaehma, infarction and necrosis of pre-existing fibroid due to disrupted supply. More common ins 2nd or 3rd trimester due to fibroid raidly outgrowing blood supply or uterus changing shape and kinking arteries.
Endometrial Polyps
PPh: Benign growths on the inner wall of uterus
RFs: Peri/Post-menopausal, HTN, Obese, Tamoxifen
S&S: Irregular menstrual bleeding, Intermenstrual bleeding, Menorrhagia, Post-menopausal bleeding, infertility
Ix: Hysteroscopy
Mx: Surgical removal
Prolapse
PPh- weakness of supporting structures allows pelvic organs to protrude into vagina. RFs- increasing patity, perineal trauma in childbirth, obesity, menopause, surgery obesity, chronic cough, chronic constipation
Sx- usually post-menopausal, mass sensation, dragging, sexual dysfunction. dysuria/incontinence / difficulty defecating depending on type.
Mx- pelvic floor physiotherapy, ring/shelf pessary wt loss, smoking cessation
Surgical- excision of loose tissue, suturing to strengthen or hysterectomy if severe.
Physiology- urinary continence maintained via external urethral sphincter and pelvic floor muscles
Types: cystocele- prolapse of anterior vaginal wall containing bladder (dysuria/incontinence), rectocele- prolapse of posterior vaginal wall containig rectum (difficulty defecating)
Ovulation/ Periods
Menorrhagia
PPh:
Heavy periods that impact on patients life
?Number of tampons/pads ?Doubling protecting
Differentials: Dysfunctional uterine bleeding (DUB- diagnosis of exclusion if no identifiable cause found), Fibroids, Endometriosis, Adenomyosis, PID, Copper coil, PCOS, Endometrial hyperplasia/CA,
Bleeding disorders (VWD), hypothyroidism
Sx:
Cyclical menstrual blood loss, over several consecutive cycles, no IMB/ PCB
Ix:
Abdo + Bimanual exam, FBC- anaemia + iron, TFTs
Mx:
IUS --> COCP / POP --> Mefanamic/Tranexamic acid (1st if ptx not want contraception)
Endometrial ablation / Hysterectomy
Amenorrhoea
Secondary
Stopping for >3mo (after having started)
Physiological- Pregnancy, Menopause,
Hormonal- PCOS, COOP, Hypothyroidism
Lifestyle- Over-exercise, Stress, Rapid wt. loss (e.g anorexia),
Primary
Outlflow obstruction: Mullerian Agenesis, Impeforate hymen
Ovarian: PCOS, Turner's syndrome
Pituitary: Prolactinoma (prolactin inhibits oestrogen which prevents LH surge)
Hypothalamic: Kallman syndrome (GnRH deficiency)
Non at 14 (without signs of puberty)
Non at 16 (with signs of puberty)
Consultation
Ix= Pregnancy test
Primary- ?chromosomal cause = karyotyping
Secondary- LH, FSH, Testosterone, TFTs
O/E= Weight (obese/anorexia), height (turners), cranial nerve defect (pituitary path), acne/hirsutism (PCOS), web neck (turners), hypothyroid signs, breast development, galactorrhoea (prolactinoma), pelvic mass (pregnancy / CA), Vagina (imperforate hymen)
Hx= On contraceptives? Sexually active?
Confirm age and when menses started? LMP character?
Mx
Gonadal failure / hypothalamic disfunction- OCP
Anatomical abnormality / pituitary adenoma- surgery
Ovarian failure- oestrogen replacement
Menopause
Mx:
Lifestyle advice- wt.bearing exercise, reduce modifiable RFs, CBT,
Clonidine (vasomotor/ flushes mx), Venlofaxine (SSRI- hot flushes and mood)
Alendronate, Ca2+, Vit D
HRT
Give progesterone to prevent effects of unopposed oestrogen on endometrium (unless had hysterectomy)
Risks: VTE, CVD, Stroke, Breast CA (CI in ptx with/Hx of BCA),
Benefits: Relieve menopause sx, bone density protection
S&S
Medium term
Urogenital atrophy: dyspareunia, recurrent UTIs, prolapse, vaginal dryness, stress incontinence
Short term
General: mood swings, loos of memory/concentration, headaches, dry/itchy skin, joint pains
Vasomotor e.g sweat, palpitations, hot flushes
Longer term
Osteoporosis, CVD, Dementia
PPh: Diagnosed after 12 months of amenorrhoea, average age 51
Ix: FSH raised
Menarche / Puberty /
Precoicous puberty
Ph:
Secondary sexual characteristic --> peak height velocity --> menarche (12-13)
PPh: Physical / hormonal signs of pubertal development at an age considered earlier than normal (<8F <9M)
Oligomenorrhoea
PPh: menses >35 days apart
Ovary / Ovarian Conditions
Premature Ovarian Failure
(Primary Ovarian Insufficiency)
Ix: Hormone levels (low oestrogen, high LH/FSH), Karyotype (fragile X)
Diagnosis: FSH>25 and 4mo ammenorrhoea
S&S: Infrequent periods/ infertility, Menopause-like sx: hot flushes/night sweats, vaginal dryness etc.
PPh:
Pituitary response to low oestrogen = increased FSH/LH levels
50% retain some ovarian function hence may have spontaneous pregnancy
Premature failure of ovaries before age of 40 (lack of ovulation and subsequent low oestrogen production)
Low number of follicles or follicles unresponsive to FSH
Causes: Idiopathic, Iatrogenic (Chemo/Radiotherapy) Chromosomal (Turners, BRCA1, Fragile X), Autoimmune
Mx: Ovarian hormones= HRT (+progesterone) /COOP, Fertility= IVF / Donor egg
Polycystic Ovarian Syndrome
(PCOS)
Ph: **Endocrine condition in women child-bearing age (5-20%)
Raised LH stimulates excess testosterone production from ovaries
Ix: Diagnosed via Rotterdam criteria (olgiovulation/ anovulation, hyperandrogenism, polycystic ovaries- >12 developing follciles or ovarian volume >10cm3)
TVUS- 'string of pearls' if follicles around periphery of ovary >12 or >10cm3.
LH/FSH ratio (increased), Insulin (increased), Testosterone (increased),
DDs/Exl- DDs / Excl: TFTs- Thyroid dysfunction, Prolactin- Hyperprolactinaemia, Testosterone/Cortisol- CAH, Cortisol- Cushing's syndrome,
Sx: Olgio/Amenorrhoea, hirsutism, acne, obesity, male pattern baldness, insulin resistance (acanthosis nigracans), infertility
Mx: Wt. loss, Monitor/control T2DM.
Clomefine citrate (induces ovulation)
COCP (control bleeding, tx acne and lower risk endometrial CA)
Needle drilling (diathermy into 4 points of ovary to lower steroid production)
Ovarian Cyst
PPh: fluid-filled sac. Pre-menopausal functional cysts (related to fluctuating hormones of menstrual cycle) are v.common. Postmenopausal cysts more concerning of CA. Not PCOS unless >2 of anovulation, hyperandrogenism polycystic on US.
Sx: asymptomatic, incidental finding. Vague sx e.g pain, bloating. Palpable pass if v.large. Acute presentation if lead to torsion, haemorrhage. rupture.
Ix: risk of malignancy index (RMI)- USS, menopausal status, CA125 .
Mx: simple ovarian cyst in premenopausal: <5cm resolve themselves, 5-7cm annual US, >7cm MRI scan and surgical assessment.
Persistent, enlarging or high RMI scoring cysts- laparoscopy to remove cyst (cystectomy) or ovary (oophorectomy)
Comps: torsion, haemorrhage, rupture
Ovarian Torsion
PPh: ovary twists in relation to connective tissue, fallopian tube and blood supply (adnexa). Usually due to ovarian mass >5cm (cyst or tumour). Can lead to ischaemia and necrosis- emergency!
Sx: unilateral pelvic pain, sudden onset, severe, N+V, may be palpable mass
Ix: pelvic/ TVUS- 'whirlpool sign' (free fluid in pelvis, oedema of ovary), doppler may show lack of blood flow. Laproscopyic surgery definitive ix
Mx: laproscopic surgery- untwist (detorsion) or remove (oophorectomy)
Comps: may become infected causing sepsis, may rupture causing peritonitis
Ovarian Rupture
Gynae Cancers
Endometrial
Ix:
FIGO Staging
1= confined to uterus. 2= extends to cervix. 3= beyond uterus but confined to pelvis. 4= bladder / bowel / mets
O/E Abdo- ?masses, Speculum- ?vulval/vaginal atrophy, Bimanual- size/axis of uterus prior to sampling
TVUS- >5mm thick, hysteroscopy+ biopsy, MRI/CT for staging
S&S: *post-menopausal bleeding, (advanced= abdo pain/wt. loss)
PPh:
Adenocarcinoma, majority caused by stimulation of endometrium by 'unopposed oestrogen' e.g no progesterone from corpus luteum after ovulation
RFs: Age, Obesity, Anovulation (early menarche/ late menopause, low parity, PCOS, HRT)
*Gynae CA in developed world. 65-75
Mx: (depends on stage) Hysterectomy +/- lymph node removal
Adjuvant radio and progesterone
Ovarian CA
Mx: total abdominal hysterectomy and bilateral salpingo-oophorectomy + adjuvant chemo
Ix: CA125 test, Abdo/Pelvic USS, Risk Malignancy Index 1
Staging: 1 (ovary only), 2 (beyond ovary, within pelvis), 3 (beyond ovary, within abdomen), 4 (distant metastases)
S&S: Asymptomatic / vague sx, abdo pain, abdo distension bloating, change in bowel habit, bowel obstruction, urinary frequency
PPh: >50 post-menopausal, poor prognosis as usually late presentation
*Epithelial / Sex Cord / Germ cell
RFs: Many ovulations (early menarche, late menopause, nulliparity) BRCA1/2
Vulval (TBC)
Mx:
Ix:
S&S: lump, ulceration, bleeding, pain, itching, lymphadenopathy of groin
PPh: 90% squamous cell carcinoma *labia majora
RFs: >75, immunosuppression, HPV, Lichen sclerosus
Cervical
PPh:
Screening: 25-49 every 3 years, 50-64 every 5 years.
Smears collect cervical cells for dyskariosis (abnormalities suggestive of cervical intra-epithelial neoplasia- CIN)--> borderline/mild/severe--> colposcopy
Human papillomavirus (HPV)-vaccine available. Bad HPV is 16 and 18.
squamous,
25-29yo
RFs: Smoking, Intercourse<16yo, STIs, OCP, Multiparity, NOT GENETIC
Mx: <2cm= loop resection (remove part of cervical) >2cm= radical hysterectomy
4cm= chemo, radio, palliative
S&S: Red Flag= Post-coital bleeding. PV discharge (blood-stained/foul smelling) Dyspareunia, Wt.loss. (Advanced= rectal bleed / haematuria as it invades)
Ix
Staging FIGO
0- in situ. 1= cervix. 2= beyond cervix but NOT pelvic side wall / lower third vag.
3= pelvic wall / lower third vag. 4= bladder / rectum / mets
Speculum exam, bimanual exam, ?bleeding ?mass
Colposcopy (acetic acid staining) and biopsy
CT chest/abdo ?mets
Gynae Syndromes
Turner's syndrome (45XO)
Female only, only 1 X chromosome, underdeveloped ovoaries hence amenorrhoea
Asherman's syndrome (TBC)
Sheehan's syndrome
Pituitary infarction following PPH
Androgen Insensitivity Syndrome
Genetically male but phenotypically female, intra-abdominal gonads and cells don't respond to male hormones e.g androgens
Angelmans syndrome (TBC- ?Gynae/other)
Presentations and DDs
Post-Menopausal bleeding
Cervical CA / polyp
Vulval CA
Endometrial CA / polyp
History Qs
Bleeding: duration, timing, volume, colour
Trauma, Assoc pain, Vag dryness, Wt loss
Sexual Hx, Pregnancy Hx, Age of Menopause, HRT use
Abnormal vaginal bleeding
Cervical ectropion
Cervical CA
STIs
Chronic pelvic pain
Endometriosis
Ruptured ectopic
IBS/IBD, Interstitial cystitis
PID
Fibroids
Adhesions
Vaginal Discharge
Bacterial Vaginosis
thin white/grey discharge, offensive smell, no itching/soreness
STIs (gonorrhoea, chlamydia)
Trichomonas vaginalis
thin, frothy, offensive discharge with irritation, dysuria, vaginal inflammation
Vaginal Candidiasis
Profuse thick white, itchy, curd-like discharge
Pelvic Pain
PID
PPh:
Infective inflammation spread from vagina/cervix to upper genital tract.
15-24
Chalmydia/Gonorrhoea
RFs: sexual activity, recent partner change, Hx STIs/PID, sex without barrier protection
S&S
Dyspareunia, PV Bleed (post-coital, IMB, menorrhagia)
Ix:
Endocevical swabs (gon/chlam), High Vag swabs (trichomonas vaginalis/BV), Full STI screen, Urine dipstick (UTI), Pregnancy test, TVUS/Laparoscopy
Mx:
Ceftriaxone (IM500mg) and14 days of Doxycycline (100mgPOBD) + Metronidazole (400mgPOBD).
Keep in a recently inserted coil, if no improvement after 72hrs remove.
Comps
Ectopic preg and infertility due to tubular scarring
Chronic Pelvic Pain
PPh:
Pain >6mo not occuring exclusively with menstruation, intercourse or pregnancy (Period, Pussy, Preggers)
Differentials
Endometriosis, fibroids, adhesions, PID, ovarian cyst (Gynae)
IBS, IBD, constipation (GI)
Interstitial cystitis (GU)
Acute Pelvic Pain
PPh:
Pain <6mo
Differentials
Ectopic, Miscarriage, Prem labour Ovarian cyst/haemorrage/torsion/rupture (Obs)
PID, Abscess, Ovarian cyst/haemorrhage/torsion/rupture(Gynae)
Appendicitis, bowel obstruction, constipation (GI)
UTI, renal stones, urinary retention (GU)
(Infection/inflammation / blockage / voiding)
Clinic notes
Cervical Ectropion = when glandular cells of cervical canal spread to outer surface of cervix
Vulval/Vaginal
Bartholins cyst
PPh: Bartholin's glands (4 and 8 o'clock to vestibule) lubricate the vagina. Blockage of duct causes small fluid-filled cyst to form
Ix: swab, differentials - STIs, sebaceous cyst, histology >40 ?CA
Mx: if small then conservative. warm baths aid spontaneous rupture and symptom relief. Marsupilation- incision and stitch flaps open so can drain
Paeds Cardio
Infective endocarditis :smiley:
RFs
Turbulent blood flow causes e.g VSD, coarctation of aorta, PDA, prosthetic valve
Sx:
Fever, Anaemia, Pallor, Splinter haemorrhages, Cluubing, Haematuria
Ix:
Blood cultures, Echo
PPhy
Strep Viridans
Mx:
Penicillin + aminoglycoside, surgery
Prophylaxis- good dental hygiene
Rheumatic Fever :smiley:
PPhy:
Group A B-Haemolytic strep
5-15 yrs
S&S:
Hx Pharyngeal infection--> 2-6 weeks--> polyarthritis, fever, malaise
Jones criteria diagnosis (1 major, 2 minor + Hx Group A B-haemolytic strep)
Major:
Polyarthritis,
Endocarditis / Myocarditis / Pericarditis
Involuntary movements/Emotional liability
Minor
Fever, Polyarthalgia, Hx RF, Prolonged P-R
Mx:
Bed rest, anti-inflamm, aspirin,
corticosteroids if severe
Sx HF: Acei / Diuretics
Prophylactic benzathine penicillin / erythromycin
Complication
Reccurent RF--> Mitral stensosis
Innocent murmurs
(4 S's)
aSymptomatic patient
Soft blowing murmur
left Sternal edge
Systolic murmur only
Kawasaki disease :smiley:
PPh:
Vasculitis of sml-med arteries causing aneurysms in coronary arteries. >myocardial iscahemia
Japanese, 6mo-4yrs
Unknown cause
Sx:
Crash and Burn
(C)onjunctivitis, (R)ash, (A)denopathy-cerivical ,unilateral, (S)trawberry tongue, (H)ands-palmar peeling/erythema/swelling.
Burn= fever>5 days
Mx:
IV Immunoglobulins & aspirin
Arrhythmias :smiley:
Supraventricular tachycardia
PPhy
HR 250-300bpm
Premature activation of atrium via accessory pathway (re-entry)
S&S:
Reduced CO, Pulm Oedema, Sx HF
ECG
Narrow complex tachycardia
Severe- Myocaridal ischaemia = T wave inversion lat leads
Wolf-Parkinson-White= Short P-R interval, Delta wave
Mx:
Vagal Stimulation
IV Adenosine (AV block that breaks re-entry)
Electrical cardioversion
Digoxin to maintain
Long QT syndrome
PPhy:
Autosomal Dominant
S&S:
Assoc with sudden LOC OE/Stress/Emotion
Assoc with erythromycin
Cyanosis :smiley:
Types
Peripheral
blue hands or feet
Central
blue tongue and slate blue colour (reduced arterial blood O2 tension)
Diagnosis
Nitrogen washout
place in 100% O2 for 10 mins
PaO2 remains low <15kPa= cyanotic
PaO2 >20kPa= not cyanotic
Heart Failure
S&S
Symptoms
Breathlessness
Sweating
Poor feeding
Recurrent chest infection
Signs
Failure to thrive
Tachypnoea & Tachycardia
Murmur- Gallop Rhythm
Enlarged Heart
Hepatomegaly
Cool peripheries
Congenital Heart Disease :smiley:
Categories of cause
Acyanotic (L-->R shunts)
Persistent ductus arteriosus
Connects PA to descending aorta. PDA= failed to close by 1mo.
Blood flows from aorta to PA
S&S: Continuous murmur beneath left clavicle collapsing/bounding pulse
Ix: Echo, (CXR/ECG normal)
Mx: Closure with coil via catheter
Septal defects
ASD
Types
Secundum (complete)- 80%- involves foramen ovale
Partial atrioventricular septal defect
S&S
none (commonly)
HF
arrhythmias
Ejection systolic murmer, upper left sternal edge- increased flow across right ventricular outflow tract
Ix
CXR-Cardiomegaly, Enlarged pulmonary arteries
ECG-partial RBBB, right axis deviation
Echo
Mx
Cardiac catheter- occlusion device
*VSD
Large >3mm
S&S
Signs of HF
Soft/No pansystolic murmur , Loud P2 from raised PA disolic pressure
Ix
CXR (ABCDE HF), ECG (biventriular hypertrophy / PH), Echo
Mx
Surgery, Diuretics, Additional calories intake (F2Thrive)
Small VSD < 3mm
Most close spontaneously, good dental hygiene to avoid bacterial endocarditis
Asymptomatic, Loud Pansystolic murmur
Outflow obstructions
Pulmonary stenosis
S&S
Asymptomatic
Ejection systolic (ULSE)
Ix: CXR (Dilated PA), ECG (RVH)
Mx: Balloon dilatation
Aortic Stenosis
S&S
Carotid thrill, Ejection systolic (URSE)
Asymptomatic / CPoE, Syncope
Ix: CXR (LVH, Dilated ascending aorta), ECG (LVH),
Mx: Aortic valvuloplasty (balloon) / valve replacement
Coarctation of Aorta
diminished femoral pulses
Cyanotic
Tetralogy of Fallot
Four features
VSD
Causes systolic pressures between ventricles to equalise / in severe, increased RV pressure by PS causes right to left shunt
Overriding aorta
Aorta dilated (received blood from both ventricles via VSD) and displaced (over intraventricular septum)
RVOTO
Right ventricular outflow tract obstruction (Septum/valvular stenosis)
RVH
S&S:Clubbing. Loud ejection systolic LSE. Rare= Hypercyanotic spells- rapid increase cyanosis assoc. inconcolable crying due to hypoxia + pallor due to tissue acidosis.
Ix: Echo
Mx: corrective surgery 6 mo- close VSD, relieve RVTO
Transposition of great arteries (TGA)
S&S: Cyanosis at day 1-2 when DA closes
Ix: Echo
Mx: Prostaglandin Infusion (maintain a PDA) //Balloon atrial septostomy (catheter through FO to LA, inflate balloon, pull back to RA to rip septum allowing mixing) // surgical switch procedure
Atrioventricular Septal Defect (complete) (AVSDc)
PPh: Downs syndrome, single five-leaflet valve between atria and ventricles stretching entire AV junction
S&S: Cyanosis at birth / 2-3wks
Ix: Echo
Mx: Tx HF medically // Surgical repair 3-6mo
Sexual Health
Contraception (TBC)
Ix pregnancy
B-HCG >25 = pregnancy (could be normal/ectopic)
IUS
Mirena- puts progesterone into uterus thinning endometrium
COCP
SEs: spotting, breast tenderness, mood swings
Risks: VTE, MI, Stroke, Breast CA
CI: Migraine.
No protection against STIs
Suppresses FSH/LH to prevent development of follicles and ovulation. Thickens cervical mucus and reduces implantation.
Adv: effective, non-invasive, easily reversible, helps regulate periods
Reduced risik of ovarian/endometrial CA
1/day 3 weeks, 1 week off
Or back to back
Avoid: >35 smoking >15/day, migraine with aura, uncontrolled HTN, Hx VTE, vascular disease, stroke, breast CA, prolonged immobility, major surery
Further reading: (not used)
https://zerotofinals.com/obgyn/contraception/cocp/
IUD
(copper coil)
IUD contraception prevents implantation in womb NOT fallopian tubes so possible ectopic on IUD
Fraser Guidelines
Give contraceptive tx if ptx:
understands advice,
cannot be persuaded to inform parents,
likely to have sex +/- contraceptive,
physical/mental health will suffer,
in best interests of ptx
POP
(mini pill)
1/day for 4 weeks, meticulously taken same time every day, 3 hours window
Suppresses ovulation, thins endometrium, thickens cervical mucus, reduces tubal motility,
Easily reversible, avoids CV risks of oestrogen, used if CI to COCP e.g migraine
SEs: spotting, amenorrhoea, IMB, breast tenderness, headaches
Must be taken meticulously- same time every day within 3hr window. Pregnancy occurs- more likely to be ectopic
Progesterone depot
(depo-provera)
1/12 weeks injection,
Suppresses ovulation, prevents implantation, thickens cervical mucus
SEs: OP, wt gain, not quickly reversible (delayed return to fertility of up to 1 year)
Implant
(Nexplanon)
Long acting, reversible, inhibits ovulation, thickens cervical mucus, thins endometrium
Most effective contraception (<0.05% pregnancy rate)
SEs: Irregular periods / light spotting, changes in wt, mood, libido. Local adverse effect e.g infection/expulsion, no protection from STIs
Teenage Pregnacny
Dropped, now at lower levels
Law= sex<12 is rape // Offence to have sex <16 // Offence for >18 in position of trust to have sex with <18
Emergency Contraception
NCKS
Levonorgestrel (Kyleena)- <72hrs, progestogen, one dose 1.5mg
Ulipristal acetate (ellaOne)- <120hrs progesterone receptor modulator- one dose 30mg,
IUD (copper voil)- <120hrs, also provides ongoing contraceptive
Pregnancy should be excluded
Risk assess for STIs and investigate if appropriate
Menopausal
Continue contraception 12 months after last period in women >50
Continue contraception 24 months after last period in women <50
STIs
Chlamydia
Gonorrhoea
Herpes
Syphilis
Genital Warts
HIV
Candidiasis
(thrush)
S&S- Cottage cheese discharge, itching, sore, red- S&S
RFs- Preg, DM, recent Abx- RFs
Ix- MC&S (mycelia spores)- Ix
Clotrimazole cream / oral fluconazole -Mx
Trichomoniasis
Bacterial Vaginosis
Mx: Metronidazole or Clindamycin
Ix: Microscopy of a HSV (high vaginal smear)- ?clue cells, ?reduced lactobacilli ?absence of pus cells, positive whiff test
S&S: Offensive fishy smelling thin white/grey vaginal discharge, NO itching or soreness
RFs: Sexual activity, IUD, STI, Recent Abx use, Smoking
PPh: Normally lactobacilli bacteria in vagina maintain acidic pH <4.5 to prevent bacterial growth. When these are reduced other bacteria can grow. *Gardnerella vaginalis
Sexual Disorders
PPh: Persistent + cause marked distress
Causes: Chronic disease (CVD, T2DM, Obesity), Hormonal, Iatrogenic, Psychiatric
Ix: Sex Hx & Exam, Bloods (testosterone, TSH, GnRH, Oestrogen)
Types: Desire, Arousal, Pain/resolution, Finishing/orgasm
Desire
Hypoactive sexual desire disorder= decreased sexual desire, normal arousal + pleasure
Causes: (CHIP) Chronic Disease= CVD, DM, Anaeamia. Hormonal= hypothyroid, hyperprolactinaemia. Iatrogenic= SSRI, OCP. Psychiatric= Depression/anxiety
Mx: Psychosexual therapy, CBT, testosterone injections
Arousal
Erectile Dysfunction
Causes: (CHIP)
Mx: 1) Sildenafil, 2) Alprostadil Injections 3) Vaccum/prosthesis
Female Sexual Arousal Dis.
Failure of genital response (*Vag dryness), decreased interest in sex/physical response to sex/sexual please
Causes (CHIP): H-oestrogen deficiency
Mx: Behavioural (senate focus). Psychosexual couples therapy
Orgasm
Rapid ejaculation
Ej <1min , uncontrolled ejaculation preventing both partners from enjoying sex
Causes: genetic, performance anxiety, hypersensitive penis, hyperthyroid
Mx: SSRIs, topical anaesthetic, psychosexual therapy
Female Orgasmic Dis.
Lack or delayed orgasm
Causes CHIP: H- low prolactin/thyroid, P- Psychological & Pelvic floor weakness
Mx: topical oestrogen, masturbation/vibrators
Pain/Resolution
Vaginismus
Spasm of pelvic floor muscles- penile entry painful/ impossible
Causes: Psychological trauma / fear of partner +/- preg, FGM, Thrush
Mx: Psychosexual therapy, vaginal dilators, graded penetration
Dyspareunia
(TBC)
Vuvlodynia
Vaginismus= involuntary contraction of pelvic floor muscles making it difficult for penetration
Superficial
Genital herpes, lichen clerosus, vaginismus, thrush
Deep
Endometriosis, PID
FGM
PPh:
Procedures involving partial/total removal of female external genitalia for non-medical reasons
WHO Categories:
1- clitoridectimy, 2-excision (clit+labia minora), 3-infibulation (narrowing vaginal orifice by creating a covering seal cutting and appositioning labia minora) 4- all other procedures
Law- illegal to perform or assist in carrying out FGM in UK (FGM act 2003)
S&S: Sex (Dyspareunia, anorgasmia, difficulty conceiving) Periods (Dysmenorrhoea), GU ( urinary outflow obstruction) Physical (chronic pain, scarring) Psychological (PTSD)
Mx: surgical de-infibulation
Scabies
Red S shape
Paeds Neuro
Primitive Reflexes
Moro Reflex- When dropped , spread arms, pull arms in, cry
Palmar reflex
Rooting
Tonic neck reflex
Paracute
Epileptic Seizure
Excessive, unsynchronised neuronal discharge in brain causing paroxysmal changes to behaviour, sensation or cognitive processes
30 seconds - 2 minutes
S&S= Jerky movements, tongue biting, head turning, muscle pains
Mx: Focal- 1st line Carbamazepine / Sodium Valproate (!)Teratogenic
Seizure
Convulsion caused by paroxysmal discharge of cerebral neurones
1-20 minutes
S&S= Eyes closed, Talking/Crying, Pelvic thrusting
Cerebral Palsy
Permenant, non-progressive disorder of movement and posture, often assoc. w/ epilepsy and abnormal speech, vision & intellect
Caused by lesion/defect in brain- congenital, infection, hypoxia, trauma
**Spastic (70%)- presents earl with hypotonia (hemiplegic / quadriplegic / diplegic)
Ataxic hypotonia (10%)
Dyskinetic (10%)
Mixed (10%)
Strabismus (squint)
Paralytic / Non-paralytic
**1 in 20 children
Non-paralytic normally due to refractory error- correct with glasses or eye patch
Ix
Eye account/ Video, ECG (?Prolonged QT), EEG, MRI/CT
O+G ILAs
Chronic Pelvic Pain
Obstetric Haemorrheage
Foetal growth restriction / macrosomia
Malpresentation- failure to progress in labour
Early pregnancy problems
Amenorrhoea
Paeds Resp
Respiratory Infections :smiley:
Lower airways infections
Bronchitis (whooping cough)
Mx: Clarithromycin, Prophylactic Eryhtromycin close contacts
S&S: Normal resp infection e.g malaise, runny nose, fever (1-2 wks) --> Hacking cough followed by 'whoop' on startling/ post-vomit.
Ix: Culture organism on pre-nasal swab. Lymphocytosis on blood film
Caused by bordatella pertussis- vaccine DTaP
Bronchiolitis
Commonest serious respiratory condition.
Caused by RSV.
S&S: Apnoea in infants< 4 mo, Sharp dry cough, Cyanosis/Pallor, Hyperinflation of chest, Fine end-inspiratory crackles
Ix: PCR nasopharyngeal secretions
Mx: Supportive- O2, NG/IV Fluids, Infection control measures. Recovery in 2 weeks.
Pneumonia
Viral (younger children), Bacterial (older children)
Prevenar vaccine against 13 common serotypes of streptococcus pneumonia
S&S: Difficulty breathing and fever. Dulllness to percussion= consolidation,
Mx: Newborns: Iv broad spec Abx. Older children oral amoxicillin/ Co-amoxiclav (severe). ?drainage of epyema.
Laryngeal and Tracheal Infections
Croup
S&S- Fever/Coryza --> Barking cough, coryza, progressive stridor. Worse at night.
Mx: Dexamethasone/prednisolone PO and nebulised steroids (budesonide). Severe= nebulised adrenaline.
PP: Mucosal inflammation, increased secretion, subglottic oedema
Pop: 6mo - 6yo (*2yr)
Cause- Viral- *Parainfluenza, RSV rhinovirus
Bacterial Tracheitis
Rare- Staph Aureus--> thick secretions --> High Fever & Rapid UAO --> Tx IV Abx and Intubation (if req.)
Acute Epiglottitis
Rare- H.Influenza type B (immunised in children)
Very acute onset & Life-threatening
Intense swelling of epiglottis, assoc. septicaemia
High fever, toxic, absent cough, intensely painful throat (cannot speak, drools)
Senior anaesthetitis, ENT surgeon, intubated under GA, tracheostomy, IV Cefuroxime
Upper Respiratory Tract Infection (URTI) 80%
Coryza
(Cold
Viral- Rhino
Paracetamol/Ibruprofen
Pharyngitis
(sore throat)
Viral- adeno/entero/rhino
Phayrnx / Soft palate inflamed
Acute Otitis Media
Diagnosis- O/E tympanic membrane bright, red, bulging, loss of normal light reflection
V- RSV / Rhino
B- Pneumococcus / Moroxella Catarrhalis
Paracetamol / Ibruprofen. Ammoxicillin shortens duration of pain but do not reduce hearing loss.
Recurrent--> OM+effusion --> **conductive hearing loss --> speech development problems
Tonsilitis
Tonsil inflammation with purulent exudate
*Epstein Barr virus / Group A B-Haemolytic strep.
V/B cannot be distinguished clinically
Penicillin / Erythromycin (if Alg)
Tonsilectomy if severe / obstructive sleep apnoea
Upper Airways Obstruction
Causes:
*Croup
Epiglottitis, Bacterial Tracheitis, Laryngeal foreign body, Trauma
Characteristics
Stridor- inspiratory rasping
Hoarsness due to inflammation of vocal cords
Barking cough
Dyspnoea
Management
Don't examine, reduce ptx anxiety
?hypoxia/deterioration
Severe= nebulised adrenaline
V.Severe= tracheal intubation
Asthma
Asthma Attack
High Flow O2--> Salbutamol nebs--> Prednisolone PO--> Ipratropium bromide
(IV) --> Hydrocortisone --> Salbutamol --> Aminophylline--> MgSO4
Severity
Moderate
Sats > 92%
Severe
Sats<92%, High RR, High HR,
Life-threatening
Sats <92%, Cyanosis, Decreased Resp effort, Altered consciousness,
Questions
How often using reliever?
Unscheduled visits to GP? A&E? HDU? Venitalated?
Noctural waking?
Chronic Asthma
Age <5yrs
SABA--> Corticosteroid --> LTRA
Age > 5yrs
SABA--> Corticosteroid --> LABA --> Increase Corticosteroid --> LTRA
Pathogens
Viruses (cause 80-90%)
Respiratory syncytial virus (RSV)
Rhinoviruses
Influenza
Parainfluenza
Bacteria
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Bordetela pertussis, Mycoplasma pneumoniae
Breath Sounds
Wheeze- polyphonic expiratory sound
Stridor= harsh high pitched inspiratory monophonic sound
Paeds MSK
Rickets
Disorder of bone mineralisation--> bone weakness
Cause: Vit D deficiency
S&S
Rachitic Rosary (boney knobs at the costochondral joints on ribs)
Bowing of legs / knock-knees
Weakness
Ix:
Vit D , ALP, PTH
Bone profile and XR
Mx: Adcal D3 (Ca2+ and Vit D)
The limping child
3-10
Transient
synovitis
PPh: AKA irritable hip, temporary irritation and inflammation to synovial membrane of joint. Assoc with recent URTI.
Sx- limp, groin/hip pain, systemically well (usually no fever)
if there is fever think septic arthritis!
Mx: analgesia, safety net advice around fever, follow-up
Sx usually fully resolve 1-2 weeks,
Perthe's disease
PPh- Idiopathic self-limiting disruption of blood to femoral head causing avascular necrosis
RFs- Passive smoking, Boys>girls, ADHD, Social deprivation, LBW & short stature
Mx: contain hip e.g with brace, physio, sugery
Sx: Limp, pain in hip/grain, restricted hip movement +/- referred pain to knee
Ix- Technetium bone scan, MRI
Trauma
Oestomyelitis
PPh: infection of bone and bone marrow, *metaphysis of long bone, usually staph aureus. Direct (open fracture) or haematogenous infection (skin/gums)
RFs- boys, <10, bone fractures, immunocompromise,
Sx: unwell child, not weight bearing, pain, swelling, tenderness.
Afebrile or low grade fever, high fever if it spreads to joint and causes septic arthritis!
Ix: XR (may be normal), MRI gold standard
Bloods- raised ESR/CRP, WCC, blood culture, bone marrow aspiration/biopsy
Mx: IV abx, surgery for drainage and debridement
0-3
DDH
PPh: developmental dysplasia of hip- abnormal relationship of femoral head to acetabulum, instability of hip and tendency for dislocation
RFs: female, first born, breech, first degree FHx, multiple pregnancy, prematurity
Usually picked up on neonatal examination at birth (NIPE) and at 6-8wks check
Ix: Ortolani test / Barlow manoeuvre --> US
O/E different leg length, different knee level when flexed, restricted abduction
Mx: Pavlik harness <6mo- permanent harness adjusted with growth, keeps hips flexed and abducted, surgical reduction
Infection
Septic arthritis
Infection of joint- systemically unwell
Osteomyelitis
Infection of bone
NAI
10-15
Trauma
Osteomyelitis
Slipped Upper
Femoral Epiphysis (SUFE)
PPh: Slipped upper femoral epiphysis AKA slipped capital femoral epiphysis
Fracture through the growth plate leads to slippage of femoral head
Boys>girls, typically ~12, obesity
S&S: several weeks vague groin/thigh pain, waddling gait, decreased range of hip movement, painful limp
Hx minor trauma, pain disproportionate to trauma,
Mx: surgical pinning of hip
Ix: XR, blood tests (normal), technetium bone scan, MRI scan
O/E limited internal rotation, prefer to keep hip externally rotated
Perthe's disease
Osteogenesis Imperfecta
PPh
Autosomal Dominant
Defect in type 1 collagen
Causes weak, brittle bones
S&S
Bone fragility
Fractures
Deformity
Pain
Poor growth
Deafness - ear bones
Mx
MDT- Physio, surgeons, OT's
Bisphosphonates e.g pamidronate
Dextrocardia
Heart points right not left
Kocher's Criteria Septic Joint
T>38.5, CRP>20, ESR>40, WCC>12, Cannot weight bear
3/4= septic joint
Dehydration
Red flags
Appears unwell / deteriorating
Altered responsiveness
Sunken eyes
Reduced skin turgor
Tachycardia
Tachypnoea
History
Fluid losses- recent / ongoing e.g D+V, sweat, polyuria
Quantity of loss e.g. no. episodes / volume of vomit
Rough estimate of current fluid status
Urinating? Quantity? Concentrated/dilute?
Mx Dehydration
Clinically dehydrated, able to tolerate PO/NG fluids
Oral Rehydration Solution (ORS) - diarolyte.
50ml/kg AND maintenance fluids given over 4 hours as an ORS.
Severe dehydration (shock)
rapid 20ml/kg bolus 0.9% normal saline
no improvement= repeat bolus
still no improvement= call ICU
Fluid deficit correction=
% dehydration x weight (kg) x 10
% dehydration is assumed to be 10% if dehydrated
Given over 48 hours in DKA
Causes
Inadequate Intake
Structural malformation= tongue tie / cleft lip
Pain = oral ulcers, tonsillitis
Respiratory disress therefore unable to stop to drink
Neglect
Excessive loss
D+V= gastritis, gastroenteritis, pyloric stenosis, acute appendicitis, DKA
Sweat= fever, hot weather, prolonged exercise
Polyuria= T1DM, DI
Burns
Maintenance fluids
100ml/kg first 10kg,
50ml/kg for second 10kg
20ml/kg for every kg above 20kg
given over 24hrs
Paeds GI
Abdominal Mass
Wilms Tumor= Kidney CA
Neuroblastoma= CA of neuronal blast cells normally in adrenals
Polycystic Kidneys
Constipation
Bowel Obstruction
Newborn Jaundice
RBC lifespan shorter, hepatic bilirubin metabolism less efficient
<24hrs likely haemolytic jaundice e.g rhesus haemolytic disease, GP6D deficiency
High levels unconjugated bilirubin--> kernicterus
Mx: Phototherapy, exchange transfusions
Differentials
Melaena
Gastrisits / Duodenal Ulcer
Abdo pain + rectal bleeding
Anal fissures / Haemorrhoids / Polyp / Prolapse / Infective cause
Vomitting
Food- over feeding, allergy, intolerance // Structural- obstruction, malrotation // Infection e.g gastroenteritis // Inflammation- appendicitis or coeliac disease
Nutrirition
Lactose intollerance
Hydrogen breath test
PPh= Deficiency of intestinal lactase prevents hydrolysis of lactose. Osmotic load of unabsorbed lactose causes secretion of fluid and electrolytes--> Diarrhoea
Cows Milk Protein Allergy
Skin prick test
Diet
Vit B12= found in animal products, vegetarian/vegan mothers who breast-feed exclusively may have B12 deficient children
B1= Thiamine- found in many vegetables, cereals, fruits
Indicators for Abdo XR
Constipation, Distention, Pain of unknown cause
O+G Pharm
Syntocinon
Oxytocin analogue
Induction of labour, PPH
Misoprostol
Prostaglandin analogue
Miscarriage, PPH
Clonidine
Anti-hypertensive
Menopausal vasomotor sx e.g flushes
Methotrexate
Ectopic Preg
Labatolol= Tx BP > 150/100
Paeds Infection & Immunity
MMR
Measles
Droplet spread, highly infectious
4Cs (Coryza, Cough, Conjuctivitis, temp'C)
Koplik spots- pathopneumonic white spots on buccal mucosa
Rash
Behind ears--> whole body
Maculopapular
Discrete--> blotchy and confluent
Complications- pneumonia, encephalitis, diarrhoea
Mx:
Tx Sx, Isolate Pt
Immunocomprimised- Ribavirin
Mumps
Droplet spread to resp tract
Fever, malaise, parotitis (unilateral--> bilateral)
O/E parotid ducts are red
Ix- increased amylase
Comp- unilateral, transient hearing loss, unilateral orchitis (rare infertility)
Tx: None (self-limiting)
Rubella
Spread via resp tract
Low-grade fever, prominent lymphadenopathy
Rash- maculopapular face--> body for 3-5 days
Comp- severe damage to foetus- keep away from non-immune pregnant mothers
Ix: Serology
Human Herpes Simplex
Herpes Zoster (chickenpox)
Spread via resp --> blood/lymphatics--> vesicular rash
Rash
on head+trunk --> peripheries
clusters of papules--> vesicles ---> pustules --> crusts
Comp
Encephalitis, Second bacterial infection--> toxic shock syndrome / necrotising fasciitis
Latent varicella zoster reactivation (shingles)- most commonly in thoracic dermatome.
Tx: Immunocomprimised- Human varicella zoster immunoglobulin. Note- acyclovir in adults not children.
Rashes
Raised hemisphere lesions
Solid
Blanch on pressure
Papules = measles/ enterovirus / enterovirus / scarlet fever/ Kawasaki's disease
Contain fluid/pus
Under 0.5cm
Vesicular= chicken pox, shingles, herpes simplex, hand,foot&mouth disease
Over 0.5cm
Pustular/Bullous= impetigo, scalded skin syndrome
Non-raised lesions
Blanch on pressure
Red/pink discrete flat areas
Macules = *rubella / measles / enterovirus / scarlet fever / Kawasaki's disease
Dry, flaky, loss of dermis
Desquamation = post-scarlet fever / Kawasaki's disease
Non-blanching w/glass
Red/purple spots
Purpuria/Petichial= Meningococcal
Meningitis
Cause
*Viral
Bacterial
Neonates: Group B Strep/ E.Coli/ Listeria monocytogenes
Children: Neisseria Meningitidis, strep pneumoniae
S&S
Early
fever, poor feeding, vomitting, irritability, lethargy, seizures, reduced consciousness
Late
bulging fontanelle, neck stiffness, lying with arched back
Mening. Septicaemia
tachycardia, prolonged cap refill, oliguria, hypotension,
Purpuric non-blanching rash, irregular outline, necrotic center.
Ix
LP
CSF- Cloudy Yellow, Raised Protein, Low Glucose= Bacterial
CSF- Clear, Normal/raised protein, Normal/low glucose= viral
Blood cultures, rapid antigen screening, PCR
Mx
Cefotaxime/Ceftriaxone
In GP= IM Benzylpenicillin
Add Amoxicillin if <3mo
Rifampicin to close contacts
PP
Vaccine for group C meningoccal meningitis
Inflam of meninges--> rinflam mediators, activated leucocytes, endothelial damage--> cerebral oedema, raised ICP, decreased cerebral blood flow
Transmission- resp/saliva secretions
Childhood Development
Cerebral Palsy
Permanent, non-progressive cerebral pathology leading to handicap and disability, notably of movement and posture
Caused by hypoxia, infection, haemorrhage or trauma ante/peri/postnatally
Mx: Physio, SALT, Feeding/Sleeping support
Heel Prick Test
5 days old
Sickle cell disease, Cystic Fibrosis, Congenital Hypothyroidism,
Phenylketonuira (PKA), Homocystinuria (HCU), Maple syrup urine disease (MSUD), Glutaric aciduria type 1 (GA1), Isovaleric acidaemia (IVA)
Downs' Syndrome
S&S
Learning delay, hypotonia, short stature, CHD, Brushfield spots
Brushfield spots= white / greyish, brown spots at the periphery of the eye due to accumulation of connective tissue
Increased risk of leukaemia
Developmental concers
Not walking by 18mo- check creatinine Kinase- ?Duchenne
CAH
ABG
Metablolic Acidosis
Hyponatraemia, Hyperkalaemia
Autosomal recessive 21-hydroxylase deficiency
Tx: IV Hydrocortisone, IV Fludrocortisone
Low cortisol, Low Aldosterone, High testosterone
Paeds GU
Presentations and differentials
Acute Scrotum
Epidiymo-orchitis
Discomfort and swelling at the back of scrotum, possible discharge, usually caused by STI
Trauma
Acute Hydrocele
Testicular torsion
Severe, Sudden pain. Vomiting.
Red, Swollen, Tender. Surgical emergency
Groin Pain
Hernia
Inguinal: reducible, often indirect. need surgical repair
Hydrocele
Proteinuria
Exercise / Postural / UTI
Nephrotic syndrome / CKD
Other scrotum
Varicocele- enlargement of pampniform plexus (drains testicle), 'bag of worms'
Testicular CA- firm, painless, non-cystic lump
Nephrotic Syndrome
Diagnosis
Proteinuria >1mg/m2/24hrs
Hypoalbuminaemia <25
Peripheral Oedema
Cause
Minimal change disease
S&S
Peripheral oedema (ankles/facial/scrotal swelling), frothy urine, occasionally infection
Mx
Fluids
Prednisolone
Penicillin prophylaxis
Pneumococcal vaccination
?albumin infusion
UTI
Normally E.Coli
If <6mo do renal USS +/- DMSA
Wilm's tumour
Kidney CA- Haematuria, Abdo pain, palpable mass
Sexual Health
History Taking
Female SH Hx
Pain
Genital, pelvic, abdominal- SOCRATES
Dysuria- character, freq of urination (UTI, chlamydia, gonorrhoea, trichomoniasis, herpes)
Dyspareunia- superficial (herpes) / deep (gonorrhoea, chlamydia). Qs: location, duration, character, timing
Vaginal Discharge
Volume, Colour, Consistency, Smell
Gonorrhoea, Chlamydia, Trichomonas Vaginalis (yellow frothy), BV (offensive fishy-smelling no soreness/irritation)
Vaginal Bleeding
Post-coital (chlamydia, gonorrhoea, cervical CA)
Intermenstrual (chlamydia, gonorrohoea, cervical/endometrial CA, fibroids, endometriosis)
Itching/soreness
(thrush, BV, herpes, gonorrhoea, chalmydia, PM vaginal atrophy, lichen sclerosis- white patches)
Skin changes
Painful blisters/ulcers (herpes)
Non-painful lesions- anywhere vagina to anus (genital warts)
Systemic sx
Fever (PID), malaise, wt. loss, rash, joint swelling (reactive arthritis/reiter's syndrome)
Menstrual Hx
Duration, Freq,
Heavy? Flooding? Pain?
Past Gynae Hx
Last cervical screen+outcome,
Ectopic preg? STIs? Endometriosis? CA?
GEEKY MEDICS SHX
https://geekymedics.com/sexual-history-taking/
Male SH Hx
Testicular pain/swelling
SOCRATES- ?epididymo-orchitis 2nd to chlamydia/gonorrhoea
Itching/soreness
candida, herpes, genital warts
Skin lesions
*HPV genital warts (painless), herpes (crops, painful)
Urethral discharge
chlamydia / gonorrhoea
Dysuria
UTI / Chlamydia / Gonorrhoea
Systemic Sx
Fever (PID), Malaise, wt loss, rash, joint swelling (reactive arthritis/reiter's syndrome)
Other questions
Last sexual encounter
Timing, type of sex (oral, vaginal, anal, >2 people),
Contraception used
Regular/casual partner, partner gender/origin, other partners last 3mo
PMH
Medical/surgical diagnosis
Prev STIs
Immunisations- HepA/B and HPV vaccines (important in gay men)
DHx
Regular medications & allergies
Recent Abx
SHx
Smoking, alcohol, drugs (IV)
HIV Risk
partner known to be HIV+
sex with bisexual/homosexual man
sex abroad / someone born different country
you or partner IVDU
sex workers
SMILE Paeds
Didn't Know That
Imaging
Commonest abdo imaging in children is US
ITU
Level 1 care- multi-organ failure, require special levels of care, nursed 1:1 care
HDU
Level 2 care. ptx typically have single-organ failure, nurse at nurse:ptx 2:1
Septic arhtiris
Kocher count- (1 point for each) non-weight bearing, temp >38.5, ESR>40mm/hr, WBC>12,000 cells/mm3
Likelihood of SA- 1= 3%, 2=40%, 3=93%, 4=99%
Sepsis
Definition= life-threatening organ dysfunction caused by dysregulated host response to infection
Examine testicles
In abdominal pain always examine testicles to check for testicular torsion
Torn frenulum
NAI- rammed bottle into mouth
Petechiae vs purpura
Petechiae= small 1-3mm red non-blanching macular lesions caused by intradermal capillary bleeding
Purpura= larger, typically raised lesions resulting from bleeding under the skin
Greenstick fracture
fracture in young, soft bone in which the bone bends and breaks, occur most commonly in infacny/childhood
Septic arthritis
If high likelihood of SA aspirate joint under GA
PCs
Fever
Case
1yo F, 48hr fever, won't come down with calpol, generally miserable, won't drink much, cough/coryzyzal
Child grizzly, snot pouring from nose, drinking cup of juice, mild cough, no increased work of breathing, bright red tonsils with pus, RR 28, CRT<2 seconds, O2 100%, Temp 38, HR 190
Action- probably URTI so probably going to discharge but first keep in for further observation because tachycardic.
Is this... sepsis, meningitis, pneumonia, UTI, leukaemia,
Abdo Pain
Case
5yo M, tummy pain, bowels not open for 2 days, 3x vomit, 1x diarrhoea, not eating/drinking
Abdo generally sore, RR 26, HR 120, CRT<2, Temp 37.8, not keen to walk, seems very sore, urine dip negative, vomit not bilious, no hernia, testes normal
Action- review, analgesia, likely send home with safety netting
Is this... appendicitis, intussusception, mecke's, hernia, torsion, something not in abdomen
Difficulty Breathing
Case
10 day old boy, born 36wk gest, 24hr worsening difficulty breathing, cough, not really fed last 8 hrs
Clearly unwell, pale, RR 70, marked work of breathing but with intermitten apnoea, HR 180, CRT 5 seconds, sats difficult to record, cool peripheries
Action- escalate, oxygen.airway.breathing support, IV access, bloods/gas, fluid bolus resuc, inotrope support, abx, CXR, prostin/cardiology
Is this...sepsis, bronchiolitis/oneumonia, cardiac lesion (duct-dependent), metabolic, NAI- shaken baby
Rash
Case
3yo M, 24hr worsening rash starting on legs, now spots on torso/arms, not going away with glass test, otherwise ok
Well-looking child, playful, no sig hix, non-lanching petechiae over both legs and few spors on tose, afebrile, sats normal, urine dip normal
Action- refer/admit for observation +/- do bloods
Tip- note that it's very very unlikely to be meningococcal sepsis if afebrile with normal sats in a well-looking child
Likely to be non-specific viral illness.
Is this... sepsis (non-meningitis) ITP, Leukaemia HSP, HUS, NAI
Top tip: "if i took the rash away how worried would you be about your child?"
Fallen on arm
Case
7yo F, fall from trampoline, severe pain right arm, cannot fully extend elbow
Commonest upper limb orthopaedic injuries- pulled elbow, distal radius fracture (buckle), mid-shaft radius/ulna fracture, supracondylar fracture (garland classifications)
Limping
Case
2yo M, woke up this morning not able to weight bear, recent viral illeness, parents unsure where pain coming from
No prev PMH, RR 22, HR 120, CRT<2 secs, Temp 38, not keen to walk, pain coming from right hip
Action- refer, need bloods +/- XR hip +/- ortho review.
Is this... septic arthritis, *irritable hip- AKA transient synovitis
osteomyelitis, CA (bone/blood), perthe's (avascular necrosis femoral head), SUFE (slipped upper femoral epiphysis), trauma, something not in hip e.g back problem
Vomiting
Case
6yo F, 2 days vomiting, not keeping anything down, PU normal, parents want IV fluids
No diarrhoea, no PMH, BM normal, looks well dehydrated, examination otherwise unremarkable, RR 20, HR 120, CRT<2
Action- with/without urine sample would refer/admit for observation to make sure they are not vomiting / tolerating fluids. Oral rehydration fluids.
Is this... intracranial pathology (tumour/infection), intususception, appendicitis, UTI, sepsis, pneumonia, DKA, hypogylcaemia
NAI
Head injuries- CT brain- subdural haemorrhage
Bruising, fractures,
Emotional abuse/neglect
Think about safeguarding for every single child
Trauma
Riding bike, hit handle bars, abdo brusing- ?splenic laceration
Refreshed That
HSP
Check renal function
Bronchiolitis
RSV infection
Meningitis vs meningococcal sepsis
Meningitis- localised infection to meninges
Meningococcal septicaemia- infection that is spread in blood from meningococcal source
Note that you can have both
Good phrase
100% certain safe for you to go home
90% certain you won't worsen and need to see us again in next 24hrs
Contact information- Twitter
Drdanmagnus
dan.magnus@uhbw.nhs.uk
O&G Hormones and Ovarian Cycle (Physiology)
Key Hormones
HcG (human chorionic gonadotrophin)
prevents corpus luteum regression
signals presence of blastocyst hence marker of pregnancy
produced by syncytiotrophoblast of embryo then by placenta after implantation
Progestins
Produced by corpus luteum then placenta after 7 weeks
Prepares endometrium for implanataion e.g stimulate proliferation of cells, vascularisation and differentiation of endometrial stroma
promotes myometrial quiescence, increases maternal ventilation
Oestrogen
E3 (oestriol)- indicates foetal wellbeing
E2 (oestradiol)- proliferation endometrial epithelium and facilitates progesterone action
High levels of oestrogen cause a surge of LH which then causes ovulation
hPL (human placental lactogen)
Mobilises glucose from fat
Acts as insulin antagonist
Converts mammary glands into milk-secreting tissues
Prolactin
Milk production
Oxytocin
Milk secretion
Uterine contractions
Hypothalamic-Pituitary-Gonadal (HPG) Axis
Hypothalamus releases GnRH
Anterior pituitary releases
FSH + LH
FSH
Binds to granulosa cells to stimulate follicle growth
Permits conversion of androgens (from theca cells) to oestrogen
Stimulates inhibin secretion (which neg feedbacks against FSH)
LH
Acts on theca cells to stimulate production and secretion of androgens
HPG +/- feedback
Oestrogen
Moderate levels= negative feedback
High levels (no progesterone)= positive feedback
Presence progesterone= negative feedback
Inhibin
Selectively inhibits FSH
Ovarian Cycle
Follicular Phase
Follicles mature and prepare to release oocyte
FSH and LH levels rise stimulating follicle growth and oesotrogen production
As oestrogen levels rise, neg feedback reduces FSH levels meaning only one dominant follicle survives, others form polar bodies
Follicular oestrogen eventually becomes high enough to initiate positive feedback on HPG axis increasing GnRH
This causes LH surge (no change in FSH due to follicular inhibin)
Follicle ruptures and mature oocyte enters fallopian tube, viable for fertilisation for 24hrs
GnRH stimulates the release of FSH and LH
Luteal Phase
Corupus Luteum
No fertilisation
CL spontaneously regresses after 14 days.
Fall in hormones relieves neg feedback on HPG resetting it for a new cycle to begin
Fertilisation
Follicle supported by placental HcG to produce hormones for supporting pregnancy
Synctiotrophoblast of embryo procudes HcG which maintains the CL
Corpus Luteum is tissue in ovary that forms at the site of a ruptured follicle.
Corpus Luteum produces oestrogens, progesterone and inhibin to maintain conditions for fertilisation and implantation
Breast Disease
Breast
Examination
Technique
Ptx at 45 degrees, arms above head to spread tissue
Always examine both sides!
Lift arms- ?tethering
Axilla- arms at 90, muscle relaxed, feel fatty tissue between pec major and lat dorsi.
Lumps
Describing lumps:
(5Ss) Shape?, Size?, Site?, Smooth? Single/lobulated?
Hard? Fixed to Skin/muscle
Scaling lumps:
1- Benign. 2-Probably benign. 3- Indeterminate 4- Suspicious. 5-Malignant.
Presentations and Differentials
Discharge
Green/Brown- ?Ductectasia
Spontaneous bilateral lactating - ?Prolactinoma
!Blood- ?CA
Pain
Lumps
Skin changes
Breast Cancer
(See Breast Notes, History, Examiantion document)
O+G Random Clinic Notes
Thrombocytopenia= Platelets<150
Heartburn--> Omeprazole fine, lansoprazole CI
Growth, Endocrine, Metabolic
(at a glance 15-18)
Weight faltering
Causes
*Environmental/Psychosocial - ?Neglect ?Eating Difficulty ?Maternal depression
Genetic: CF
GI: Coeliac, GORD
Endo: Hypothyroidism, GH deficiency
Paeds definitionss
Trisomies
13: Patau's syndrome
18: Edwards syndrome
21: Down's syndrome
Chromosomal
Kleinfelters (XXY)
Paediatric Syndromes
Kallmann's Syndrome
PPh: Hypogonadotropic hypogonadism
S&S: No smell, No/delayed secondary sex characteristics (DD delayed puberty), Amenorrhoea, Infertile, OP
Ix: M: Low testosterone. F: Low oestrogen + progesterone
Mx: HRT, Fertility support
O+G
PassMedicine
Didn't Know That
Choanal atresia
Episodes of cyanosis (baby) usually worst during feeding, improved when baby crying
Asthma