Mind Maps for Medical Students

Clinical Specialties

K30033_C000.indd 1 28/02/17 2:09 pm

K30033_C000.indd 2 28/02/17 2:09 pm

iii

Olivia Smith BSc (Hons), MSc (Dist)

Mind Maps for Medical Students

Clinical Specialties

The Hull York Medical SchoolHull and York, UK

K30033_C000.indd 3 28/02/17 2:09 pm

CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2017 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-8219-7 (Paperback)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, n either the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the p atient’s medical history, r elevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For p ermission to p hotocopy o r use ma terial el ectronically f rom this w ork, please access www.copyright.com (http://www.copyright.com/) or c ontact the C opyright C learance C enter, I nc. (CCC), 222 R osewood Dr ive, Da nvers, MA 0192 3, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

K30033_C000.indd 4 28/02/17 2:09 pm

v

Dedication vi

Foreword vii

Preface viii

Abbreviations ix

Chapter 1 Psychiatry 1Chapter 2 Obstetrics 33Chapter 3 Gynaecology 71Chapter 4 Paediatrics 103Chapter 5 Ophthalmology 157Chapter 6 Ear, nose and throat 171Chapter 7 Dermatology 183Chapter 8 Orthopaedics 219

Appendix 1 Useful diagnostic classifications 253Appendix 2 Useful websites 254Index 257

Contents

Please note due to the layout of the maps and tables, some pages within chapters

have been left intentionally blank

K30033_C000.indd 5 28/02/17 2:09 pm

vi

For my father and mother.This book is dedicated to my parents who have been the greatest influence in my life.

For all your unceasing encouragement, love and support I am forever grateful.

Dedication

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vii

Medical students and trainees are faced with a huge volume of facts and knowledge that they must learn, assimilate and understand how to apply. Many hours are spent pouring over text books, online resources, lecture notes and papers. This tsunami of information is often hard to make sense of and the essentials difficult to remember.

Mind maps have become a popular way to help people understand complex interconnected concepts and information. Diagrams are used to visually organise information and show relationships among pieces of the whole. Despite technological advances, when it comes to efficient learning, simple methods, such as that used by Olivia Smith in MindMaps forMedicalStudents:ClinicalSpecialities, can be highly effective.

Mind maps can take a lot of time to create. In this compact volume Olivia Smith, a senior medical student, has helped to do this for readers across eight core clinical specialities essential to the study of medicine. This is a sequel to her successful first book, Mind Maps for Medical Students, which distills a wide range of knowledge according to body systems. Both books organize a large amount of material in a logical, concise and conceptually appealing way to aid learning. By doing so it complements, but does not replace, more exhaustive sources and will also allow readers to position and contextualize new evidence as it emerges, so adding to their knowledge base.

It can be used by medical students, junior doctors and other health care professionals as a brief overview to introduce an area, for intense periods of revision and as an aide-mémoire. I hope this will encourage learners to develop their own mind maps in these or other areas and inspire other medical students to write.

Professor Trevor A Sheldon DSc, FMedSciDean, Hull York Medical School, UK

Foreword

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viii

This book serves as a companion to MindMapsforMedicalStudents. It aims to cover succinctly the main topics in clinical specialties that students and junior doctors are expected to be familiar with. It is a distillation of knowledge that aims to complement larger texts rather than replace them by presenting key facts in a digestible format. Each topic is presented in a logical manner following a design that may be utilized in OSCE assessments covering definitions, causes and investigations as well as treatments and complications. This will aid readers with their revision and consolidation of knowledge prior to examinations.

Wishing you all the very best in your examinations and future careers.

Olivia Smith BSc (Hons), MSc (Dist)Final year medical student, The Hull York Medical School, UK.

Preface

K30033_C000.indd 8 28/02/17 2:09 pm

ix

Abbreviations

ACE angiotensin converting enzyme

ACE-III Addenbrooke’s Cognitive Examination

ACL anterior cruciate ligamentADHD attention deficit hyperactivity

disorderADLs activities of daily livingAIDS acquired immunodeficiency

syndromeALL acute lymphoblastic leukaemiaALT alanine aminotransferaseANCA antineutrophil cytoplasmic

antibodyAP anteroposteriorAPP amyloid precursor proteinARPKD autosomal recessive polycystic

kidney diseaseASD atrial septal defectASO antistreptolysin O AST aspartate aminotransferaseBBPV benign paroxysmal positional

vertigoBMI body mass indexBP blood pressureBUN blood urea nitrogenCADASIL cerebral autosomal

dominant arteriopathy with subcortical infarcts and leukoencephalopathy

CBT cognitive behavioural therapyCF cystic fibrosisCFTR cystic fibrosis transmembrane

conductance regulatorCJD Creutzfeldt–Jakob diseaseCMV cytomegalovirusCOCP combined oral contraceptive

pillCOPD chronic obstructive pulmonary

disease

CRP C-reactive proteinCT computed tomographyCTG cardiotocographyDDH developmental dysplasia of

the hipDIC disseminated intravascular

coagulationDKA diabetic ketoacidosisDLQI Dermatology Life Quality

IndexDM diabetes mellitusDMARD disease modifying

antirheumatic drugDSM-5 Diagnostic and Statistical

Manual of Mental Disorders, 5th Edition

DVT deep venous thrombosisECG electrocardiogram/

electrocardiographyECHO echocardiogramECT electroconvulsive therapyEEG electroencephalogramELISA enzyme linked

immunosorbent assayEPSE extrapyramidal side effectsESR erythrocyte sedimentation

rateFBC full blood countFEV1/FVC forced expiratory volume in

1 second/fixed vital capacityFGFR3 fibroblast growth factor

receptor 3FIGO Fédération Internationale de

Gynécologie et d’ObstétriqueFSH follicle-stimulating hormoneGABA gamma-aminobutyric acidGAD-7 Generalized Anxiety Disorder

(Assessment)GFR glomerular filtration rateGGT gamma glutamyltransferase

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x

GI gastrointestinalGnRH gonadotropin releasing

hormoneHAART highly active anti-retroviral

therapyHADS Hospital Anxiety and

Depression ScalehCG human chorionic gonadotropinHELLP haemolysis, elevated liver

enzymes, low platelet count (syndrome)

HHV human herpesvirusHIV human immunodeficiency virusHPA hypothalamic–pituitary–

adrenal (axis)HPV human papillomavirusHRT hormone replacement therapyHSP Henoch–Schönlein purpuraHSV herpes simplex virus5-HT 5-hydroxytryptamine

(receptors)HUS haemolytic uraemic syndromeIBD inflammatory bowel diseaseICD-10 International Statistical

Classification of Diseases and Related Health Problems, 10th Revision

IL interleukinIM intramuscularIOP intraocular pressureIUD intrauterine deviceIUGR intrauterine growth

restriction IUS intrauterine systemIV intravenousIVF in-vitro fertilizationLABA long-acting beta agonistLCHAD long-chain 3-hydroxyl-

coenzyme A dehydrogenase

LDH lactase dehydrogenaseLFTs liver function testsLH leutinizing hormoneLP lumbar punctureMAO-B monoamine oxidase type B

(inhibitor)MAOI monoamine oxidase inhibitorMCV mean corpuscular volumeMMR measles, mumps, rubellaMND motor neurone diseaseMRI magnetic resonance imagingNAAT nucleic acid amplification testNEC necrotizing enterocolitisNICE National Institute for Health

and Care ExcellenceNICU Neonatal Intensive Care UnitNMS neuroleptic malignant

syndromeNNRTI non-nucleoside reverse

transcriptase inhibitorsNRI noradrenaline reuptake

inhibitorNSAID non-steroidal anti-

inflammatory drugNTD neural tube defectOA osteoarthritisOCD obsessive compulsive disorderPAS pulmonary artery stenosisPASI Psoriasis Area and Severity

IndexPCL posterior cruciate ligamentPCOS polycystic ovary syndromePCR polymerase chain reactionPDA patent ductus arteriosusPEFR peak expiratory flow ratePET positron emission tomographyPHQ-9 Patient Health QuestionnairePID pelvic inflammatory diseasePOP progesterone only pill

Abbreviations

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xi

PPH post-partum haemorrhagePTSD post-traumatic stress

disorderPUVA psoralen + ultraviolet

(A spectrum) light RA rheumatoid arthritisRAST radioallergosorbent testRBC red blood cellRIMA reversible inhibitor of

monoamine oxidase ARMI Risk of Malignancy IndexRUQ right upper quadrantSABA short-acting beta agonistSFH symphysis–fundal heightSHBG sex hormone binding globulinSJS Stevens–Johnson syndrome SNRI serotonin noradrenaline

re-uptake inhibitorSPECT single-photon emission

computed tomographySSRI selective serotonin re-uptake

inhibitorSTI sexually transmitted infectionSUDEP sudden unexplained death in

epilepsy

SUFE slipped upper femoral epiphysis

TB tuberculosisTCA tricyclic antidepressantTEN toxic epidermal necrolysisTNM tumour/nodes/metastases

(staging system)TFTs thyroid function testsTOP termination of pregnancyTSH thyroid stimulating hormoneU&E urine and electrolytesuE3 oestriolUMN upper motor neuronUSS ultrasound scanUTI urinary tract infectionVDRL Venereal Disease Research

Laboratory (test)VEGF vascular endothelial growth

factorVMA/ (urinary) vanillyl mandellic pHVA acid/plasma homovanillic acidVSD ventricular septal defectVZV varicella zoster virus WCC white cell countWHO World Health Organization

Abbreviations

K30033_C000.indd 11 28/02/17 2:09 pm

K30033_C000.indd 12 28/02/17 2:09 pm

MAP

1.1

D

epre

ssio

n

2

TABL

E 1.

1 Tr

eatm

ent

of

dep

ress

ion

4

TABL

E 1.

2 A

nti

dep

ress

ants

6

MAP

1.2

A

nxi

ety

8

MAP

1.3

O

bse

ssiv

e co

mp

uls

ive

dis

ord

er (

OC

D)

10

TABL

E 1.

3 A

nxi

oly

tics

an

d h

ypn

oti

cs

12

MAP

1.4

Sc

hiz

op

hre

nia

14

TABL

E 1.

4 A

nti

psy

cho

tics

16

MAP

1.5

B

ipo

lar

dis

ord

er

18

TABL

E 1.

5 P

erso

nal

ity

dis

ord

ers

20

MAP

1.6

A

no

rexi

a n

ervo

sa

22

MAP

1.7

B

ulim

ia n

ervo

sa

24

MAP

1.8

Att

enti

on

defi

cit

hyp

erac

tivi

ty

dis

ord

er (

AD

HD

)

26

TABL

E 1.

6 D

emen

tia

28

Chap

ter O

ne P

sych

iatr

y

Psyc

hiat

ry1

K30033_C001.indd 1 28/02/17 11:02 am

Psyc

hiat

ry2

Map

1.1

. D

epre

ssio

n

Clas

sifi

cati

on

Mild

(4–5

sym

ptom

s)M

oder

ate

(6–7

sym

ptom

s)

Seve

re (8

–10

sym

ptom

s)U

nabl

e to

com

plet

e da

ily ta

sks

Real

diff

icul

ty in

com

plet

ing

daily

task

sCa

n co

ntin

ue w

ith d

aily

task

s+

/– s

omat

ic s

ympt

oms

+/–

som

atic

sym

ptom

s

+/–

psy

chot

ic s

ympt

oms

Pres

enta

tion

Som

atic

or

psyc

hoti

c sy

mpt

oms

Sym

ptom

sTh

ese

may

be

split

into

thre

e br

oad

cate

gorie

s: co

re s

ympt

oms,

nega

tive

thin

king

and

som

atic

sym

ptom

s:Co

re s

ympt

oms:

dep

ress

ed m

ood,

ane

rgia

, anh

edon

ia.

Neg

ativ

e th

inki

ng: t

houg

hts

of g

uilt,

low

sel

f est

eem

, tho

ught

s of

sui

cide

and

dea

th, p

oor c

once

ntra

tion.

Som

atic

sym

ptom

s: d

ecre

ased

wei

ght (

incr

ease

d w

eigh

t see

n in

aty

pica

l dep

ress

ion)

, sle

ep d

istu

rban

ce w

ith e

arly

mor

ning

wak

ing,

de

crea

sed

libid

o, c

onst

ipat

ion,

psy

chom

otor

reta

rdat

ion

or a

gita

tion.

Thes

e s

ympt

oms

may

be

used

to c

lass

ify d

epre

ssio

n as

mild

, mod

erat

e or

sev

ere:

Psyc

hotic

sym

ptom

s ar

e m

ood

cong

ruen

t or i

ncon

grue

nt:

Moo

d co

ngru

ent:

• De

lusi

ons:

of p

over

ty, g

uilt,

pun

ishm

ent;

if th

e pa

tient

hol

ds th

e de

lusi

on th

at th

ey a

re d

ead,

then

this

is k

now

n as

Cot

ard’

s sy

ndro

me.

• Ha

lluci

natio

ns:

Au

dito

ry: u

sual

ly d

erog

ator

y vo

ices

.

Olfa

ctor

y: ro

ttin

g fru

it/fle

sh.

Vi

sual

: tor

men

tors

.

Moo

d in

cong

ruen

t: th

ough

t ins

ertio

n or

with

draw

al.

Trea

tmen

tDe

pend

s on

the

clas

sific

atio

n of

dep

ress

ion.

It

incl

udes

psy

chol

ogic

al th

erap

ies

such

as

CBT,

antid

epre

ssan

ts a

nd E

CT (s

ee Ta

ble

1.1,

p. 4

)

Inve

stig

atio

nsEn

sure

that

the

patie

nt is

real

ly s

uffe

ring

from

dep

ress

ion

and

not a

nor

gani

c di

sord

er. T

his

invo

lves

taki

ng a

car

eful

his

tory

from

the

patie

ntan

d th

e us

e of

que

stio

nnai

res

such

as

HADS

, PHQ

-9, G

AD-7

follo

wed

by

inve

stig

atio

ns d

epen

ding

on

patie

nt p

rese

ntat

ion.

Alw

ays

asse

ss s

uici

de ri

sk.

• Ba

selin

e bl

oods

: FBC

, U&

E, L

FTs

(incl

udin

g G

GT

and

MCV

for

al

coho

l mis

use)

, TFT

s (h

ypot

hyro

idis

m m

ay c

ause

low

moo

d),E

SR,

gl

ucos

e, c

alci

um, v

itam

in B

12 a

nd fo

late

leve

ls.•

Spec

ific

test

s ar

e on

ly u

sed

if in

dica

ted

by h

isto

ry a

nd e

xam

inat

ion

(e

.g. u

rine

for t

oxic

olog

y, de

xam

etha

sone

sup

pres

sion

test

, syp

hilis

se

rolo

gy e

tc).

• Ra

diol

ogy:

CT

or M

RI m

ay b

e in

dica

ted

in s

ome

case

s.

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mo-

nal a

nd p

sych

osoc

ial f

acto

rs. A

few

exa

mpl

es a

re g

iven

bel

ow:

• G

enet

ic: f

amily

his

tory

of d

epre

ssio

n.•

Neu

roho

rmon

al: t

he m

onoa

min

e hy

poth

esis

of d

epre

ssio

n is

pop

ular

,

whi

ch s

ugge

sts

that

ther

e ar

e lo

w le

vels

of s

erot

onin

, nor

adre

nalin

e

and

dopa

min

e in

the

brai

n. O

ther

theo

ries

incl

ude

the

sugg

estio

n of

in

crea

sed

cort

isol

leve

ls.•

Psyc

hoso

cial

: adv

erse

life

eve

nts

and

nega

tive

child

hood

exp

erie

nces

su

ch a

s ab

use,

the

loss

of a

par

ent a

nd b

ully

ing.

Chr

onic

phy

sica

l

illne

ss, u

nem

ploy

men

t and

the

lack

of a

con

fidin

g re

latio

nshi

p ar

e

linke

d to

incr

ease

d ra

tes

of d

epre

ssio

n.

Wha

t is

dep

ress

ion?

This

is a

con

ditio

n of

per

vasi

ve lo

w m

ood.

It is

dia

gnos

ed u

sing

the

ICD-

10 o

r the

DSM

-5 a

nd th

e fo

llow

ing

crite

ria n

eed

to b

e fu

lfille

d:

1. S

ympt

oms

mus

t be

pres

ent f

or a

t lea

st 2

wee

ks w

ith a

cha

nge

from

n

orm

al m

ood

and

at le

ast t

wo

to th

ree

core

sym

ptom

s.2.

Cha

nge

in m

ood

mus

t not

be

seco

ndar

y to

dru

g or

alc

ohol

mis

use,

a

med

ical

con

ditio

n or

an

adve

rse

life

even

t suc

h as

ber

eave

men

t.3.

The

re m

ust b

e im

pairm

ent o

f soc

ial f

unct

ioni

ng.

MA

P 1.

1. D

epre

ssio

n

K30033_C001.indd 2 28/02/17 11:02 am

Psyc

hiat

ry3

Map

1.1

. D

epre

ssio

n

Clas

sifi

cati

on

Mild

(4–5

sym

ptom

s)M

oder

ate

(6–7

sym

ptom

s)

Seve

re (8

–10

sym

ptom

s)U

nabl

e to

com

plet

e da

ily ta

sks

Real

diff

icul

ty in

com

plet

ing

daily

task

sCa

n co

ntin

ue w

ith d

aily

task

s+

/– s

omat

ic s

ympt

oms

+/–

som

atic

sym

ptom

s

+/–

psy

chot

ic s

ympt

oms

Pres

enta

tion

Som

atic

or

psyc

hoti

c sy

mpt

oms

Sym

ptom

sTh

ese

may

be

split

into

thre

e br

oad

cate

gorie

s: co

re s

ympt

oms,

nega

tive

thin

king

and

som

atic

sym

ptom

s:Co

re s

ympt

oms:

dep

ress

ed m

ood,

ane

rgia

, anh

edon

ia.

Neg

ativ

e th

inki

ng: t

houg

hts

of g

uilt,

low

sel

f est

eem

, tho

ught

s of

sui

cide

and

dea

th, p

oor c

once

ntra

tion.

Som

atic

sym

ptom

s: d

ecre

ased

wei

ght (

incr

ease

d w

eigh

t see

n in

aty

pica

l dep

ress

ion)

, sle

ep d

istu

rban

ce w

ith e

arly

mor

ning

wak

ing,

de

crea

sed

libid

o, c

onst

ipat

ion,

psy

chom

otor

reta

rdat

ion

or a

gita

tion.

Thes

e s

ympt

oms

may

be

used

to c

lass

ify d

epre

ssio

n as

mild

, mod

erat

e or

sev

ere:

Psyc

hotic

sym

ptom

s ar

e m

ood

cong

ruen

t or i

ncon

grue

nt:

Moo

d co

ngru

ent:

• De

lusi

ons:

of p

over

ty, g

uilt,

pun

ishm

ent;

if th

e pa

tient

hol

ds th

e de

lusi

on th

at th

ey a

re d

ead,

then

this

is k

now

n as

Cot

ard’

s sy

ndro

me.

• Ha

lluci

natio

ns:

Au

dito

ry: u

sual

ly d

erog

ator

y vo

ices

.

Olfa

ctor

y: ro

ttin

g fru

it/fle

sh.

Vi

sual

: tor

men

tors

.

Moo

d in

cong

ruen

t: th

ough

t ins

ertio

n or

with

draw

al.

Trea

tmen

tDe

pend

s on

the

clas

sific

atio

n of

dep

ress

ion.

It

incl

udes

psy

chol

ogic

al th

erap

ies

such

as

CBT,

antid

epre

ssan

ts a

nd E

CT (s

ee Ta

ble

1.1,

p. 4

)

Inve

stig

atio

nsEn

sure

that

the

patie

nt is

real

ly s

uffe

ring

from

dep

ress

ion

and

not a

nor

gani

c di

sord

er. T

his

invo

lves

taki

ng a

car

eful

his

tory

from

the

patie

ntan

d th

e us

e of

que

stio

nnai

res

such

as

HADS

, PHQ

-9, G

AD-7

follo

wed

by

inve

stig

atio

ns d

epen

ding

on

patie

nt p

rese

ntat

ion.

Alw

ays

asse

ss s

uici

de ri

sk.

• Ba

selin

e bl

oods

: FBC

, U&

E, L

FTs

(incl

udin

g G

GT

and

MCV

for

al

coho

l mis

use)

, TFT

s (h

ypot

hyro

idis

m m

ay c

ause

low

moo

d),E

SR,

gl

ucos

e, c

alci

um, v

itam

in B

12 a

nd fo

late

leve

ls.•

Spec

ific

test

s ar

e on

ly u

sed

if in

dica

ted

by h

isto

ry a

nd e

xam

inat

ion

(e

.g. u

rine

for t

oxic

olog

y, de

xam

etha

sone

sup

pres

sion

test

, syp

hilis

se

rolo

gy e

tc).

• Ra

diol

ogy:

CT

or M

RI m

ay b

e in

dica

ted

in s

ome

case

s.

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mo-

nal a

nd p

sych

osoc

ial f

acto

rs. A

few

exa

mpl

es a

re g

iven

bel

ow:

• G

enet

ic: f

amily

his

tory

of d

epre

ssio

n.•

Neu

roho

rmon

al: t

he m

onoa

min

e hy

poth

esis

of d

epre

ssio

n is

pop

ular

,

whi

ch s

ugge

sts

that

ther

e ar

e lo

w le

vels

of s

erot

onin

, nor

adre

nalin

e

and

dopa

min

e in

the

brai

n. O

ther

theo

ries

incl

ude

the

sugg

estio

n of

in

crea

sed

cort

isol

leve

ls.•

Psyc

hoso

cial

: adv

erse

life

eve

nts

and

nega

tive

child

hood

exp

erie

nces

su

ch a

s ab

use,

the

loss

of a

par

ent a

nd b

ully

ing.

Chr

onic

phy

sica

l

illne

ss, u

nem

ploy

men

t and

the

lack

of a

con

fidin

g re

latio

nshi

p ar

e

linke

d to

incr

ease

d ra

tes

of d

epre

ssio

n.

Wha

t is

dep

ress

ion?

This

is a

con

ditio

n of

per

vasi

ve lo

w m

ood.

It is

dia

gnos

ed u

sing

the

ICD-

10 o

r the

DSM

-5 a

nd th

e fo

llow

ing

crite

ria n

eed

to b

e fu

lfille

d:

1. S

ympt

oms

mus

t be

pres

ent f

or a

t lea

st 2

wee

ks w

ith a

cha

nge

from

n

orm

al m

ood

and

at le

ast t

wo

to th

ree

core

sym

ptom

s.2.

Cha

nge

in m

ood

mus

t not

be

seco

ndar

y to

dru

g or

alc

ohol

mis

use,

a

med

ical

con

ditio

n or

an

adve

rse

life

even

t suc

h as

ber

eave

men

t.3.

The

re m

ust b

e im

pairm

ent o

f soc

ial f

unct

ioni

ng.

MA

P 1.

1. D

epre

ssio

n

K30033_C001.indd 3 28/02/17 11:02 am

Psyc

hiat

ry4

Tabl

e 1.

1. T

reat

men

t o

f d

epre

ssio

n

TABL

E 1.

1. T

reat

men

t of

dep

ress

ion.

Tre

atm

ent

depe

nds

on t

he c

lass

ifica

tion

of

depr

essi

on.

Clas

sifi

cati

on o

f de

pres

sion

M

etho

d of

tre

atm

ent

Mild

Cons

erva

tive

the

rapy

This

is a

‘wat

chfu

l wai

ting’

app

roac

h an

d in

volv

es:

• An

exe

rcis

e re

gim

e: th

e cu

rren

t rec

omm

enda

tions

are

thre

e tim

es a

wee

k fo

r 45

min

utes

last

ing

10–1

2 w

eeks

• Al

coho

l and

life

styl

e ad

vice

• Sl

eep

hygi

ene

• G

uide

d se

lf he

lp

Mod

erat

e –

seve

re

Cons

erva

tive

the

rapy

:

• An

exe

rcis

e re

gim

e as

abo

ve•

Psyc

holo

gica

l the

rapi

es (e

.g. c

ogni

tive

beha

viou

ral t

hera

py [C

BT],

whi

ch c

halle

nges

the

patie

nt’s

thou

ghts

and

fe

elin

gs in

ord

er to

cha

nge

them

), co

unse

lling

, int

erpe

rson

al p

sych

othe

rapy

, dyn

amic

ther

apy

Med

ical

the

rapy

:

• An

tidep

ress

ants

(see

Tabl

e 1.

2, p

. 6).

Mos

t pat

ient

s ar

e st

arte

d on

an

SSRI

firs

t lin

e•

If th

is in

itial

ther

apy

does

not

wor

k, p

atie

nts

may

be

switc

hed

to a

ltern

ativ

e an

tidep

ress

ants

, hav

e th

eir t

hera

py

augm

ente

d w

ith a

ntip

sych

otic

or a

ntie

pile

ptic

med

icat

ion

by a

spe

cial

ist o

r be

refe

rred

for E

CT (u

sual

ly 6

–12

sess

ions

, tw

ice

wee

kly)

. The

pat

hway

follo

wed

dep

ends

on

NIC

E an

d lo

cal g

uida

nce

K30033_C001.indd 4 28/02/17 11:02 am

K30033_C001.indd 5 28/02/17 11:02 am

Psyc

hiat

ry6

TABL

E 1.

2. A

ntid

epre

ssan

ts.

Clas

s of

ant

idep

ress

ant

Exam

ples

Use

sSi

de e

ffec

ts

Sele

ctiv

e se

roto

nin

reup

take

in

hibi

tors

(SSR

Is)

Cita

lopr

amSe

rtra

line

(ofte

n us

ed in

thos

e w

ho

have

pre

viou

sly

had

a m

yoca

rdia

l in

farc

tion)

Fluo

xetin

e (h

as a

long

hal

f-life

)Pa

roxe

tine

DO

BS:

Dep

ress

ion

OCD

Bulim

ia

Soci

al p

hobi

as

• G

I ups

et•

Sexu

al d

ysfu

nctio

n•

Hypo

natr

aem

ia in

the

elde

rly

• Di

scon

tinui

ty s

yndr

ome:

shi

verin

g, a

nxie

ty, h

eada

che,

na

usea

, diz

zine

ss•

Sero

toni

n sy

ndro

me:

mus

cle

rigid

ity, s

eizu

res,

card

iova

scul

ar c

olla

pse,

hyp

erth

erm

ia. T

reat

ser

oton

in

synd

rom

e w

ith c

ypro

hept

adin

e (a

5-H

T 2A re

cept

or

anta

goni

st)

Tric

yclic

ant

idep

ress

ants

(T

CAs)

Amitr

ipty

line

Imip

ram

ine

Clom

ipra

min

e

DO

BS:

Dep

ress

ion

OCD

(clo

mip

ram

ine)

Bed

wet

ting

(imip

ram

ine)

Som

etim

es n

euro

path

ic

pain

(am

itrip

tylin

e)

• Li

nked

to re

cept

or b

lock

ade:

α 1 a

ntag

onis

t: po

stur

al h

ypot

ensi

on

Antim

usca

rinic

: dry

mou

th, u

rinar

y re

tent

ion,

co

nstip

atio

n, b

lurr

ed v

isio

n

Antih

ista

min

ergi

c: w

eigh

t gai

n, d

row

sine

ss•

Toxi

city

= th

e 3C

s:Co

nvul

sion

sCo

ma

Card

ioto

xici

ty

Sero

toni

n no

radr

enal

ine

reup

take

inhi

bito

rs (S

NRI

s)Ve

nlaf

axin

eDu

loxe

tine

Depr

essi

onG

ener

aliz

ed a

nxie

ty d

isor

-de

r (ve

nlaf

axin

e)Pe

riphe

ral n

euro

path

y (d

ulox

etin

e)

• In

crea

sed

bloo

d pr

essu

re•

Nau

sea

• Se

datio

n

Tabl

e 1.

2. A

nti

dep

ress

ants

K30033_C001.indd 6 28/02/17 11:02 am

Psyc

hiat

ry7

Tabl

e 1.

2. A

nti

dep

ress

ants

Mon

oam

ine

oxid

ase

inhi

bito

rs (M

AOIs

)Se

legi

line

Moc

lobe

mid

e (re

vers

ible

inhi

bito

r of

mon

oam

ine

oxid

ase

A [R

IMA]

)

HA

D:

Hyp

ocho

ndria

sis

Anx

iety

Dep

ress

ion

Sele

gilin

e is

a M

AO-B

in

hibi

tor t

hat i

s lic

ense

d fo

r use

in P

arki

nson

’s di

seas

e

• An

timus

carin

ic: d

ry m

outh

, urin

ary

rete

ntio

n,

cons

tipat

ion,

blu

rred

vis

ion

• Th

e Ch

eese

Rea

ctio

n –

hype

rten

sive

cris

is th

at o

ccur

s w

ith in

gest

ion

of ty

ram

ine

cont

aini

ng s

ubst

ance

s (e

.g. c

hees

e, p

ickl

ed h

errin

g, s

oybe

an p

rodu

cts,

etc.

)

α 2 ant

agon

ist

Mirt

azap

ine

Depr

essi

onPT

SD•

Incr

ease

d ap

petit

e an

d w

eigh

t •

Dry

mou

th•

Seda

tion

Nor

adre

nalin

e re

upta

ke

inhi

bito

rs (N

RIs)

Rebo

xetin

eDA

P:D

epre

ssio

nA

DHD

Pani

c di

sord

er

• An

timus

carin

ic: d

ry m

outh

, urin

ary

rete

ntio

n,

cons

tipat

ion,

blu

rred

vis

ion

• An

tihis

tam

iner

gic:

wei

ght g

ain,

dro

wsi

ness

Tetr

acyc

lics

Map

rotil

ine

Depr

essi

on•

Seda

tion

• Po

stur

al h

ypot

ensi

on

K30033_C001.indd 7 28/02/17 11:02 am

Psyc

hiat

ry8

Map

1.2

. A

nxi

ety

Wha

t is

anx

iety

?An

xiet

y is

a n

orm

al e

mot

ion

that

like

ly h

as b

een

expe

rienc

ed b

ym

ost o

f us

durin

g ou

r liv

es. H

owev

er, w

hen

anxi

ety

is s

uch

that

itin

terfe

res

with

dai

ly fu

nctio

ning

and

per

form

ance

, it i

s co

nsid

ered

to b

e pa

thol

ogic

al. T

his

rela

tions

hip

is c

alle

d Ye

rkes

–Dod

son

law

.

Anxi

ety

may

be

clas

sifie

d in

to m

any

diffe

rent

sub

grou

ps:

Org

anic

cau

ses:

• Hy

pert

hyro

idis

m.

• Hy

pogl

ycae

mia

.•

Phae

ochr

omoc

ytom

a.•

Cere

bral

trau

ma.

• Te

mpo

ral l

obe

epile

psy.

Psyc

hiat

ric

caus

es:

• An

xiet

y di

sord

ers:

Phob

ic d

isor

ders

(e.g

. ago

raph

obia

).

N

on-s

ituat

iona

l dis

orde

rs (e

.g. g

ener

aliz

ed a

nxie

ty

di

sord

er [a

tria

d of

app

rehe

nsio

n, m

otor

tens

ion

and

auto

nom

ic o

vera

ctiv

ity]).

Reac

tion

to s

tres

sful

eve

nts

(e.g

. PTS

D).

OCD

(see

Map

1.3

, p. 1

0).

• Se

cond

ary

to d

epre

ssio

n or

psy

chos

is.•

Seco

ndar

y to

a m

edic

al c

ondi

tion.

• Se

cond

ary

to p

sych

oativ

e su

bsta

nce

abus

e (e

.g. a

lcoh

ol in

take

or

with

draw

al, a

mph

etam

ines

, ben

zodi

azep

ine

with

draw

al).

Sym

ptom

sTh

ese

may

be

gene

raliz

ed o

r par

oxys

mal

.

Rem

embe

r as

PAN

ICS:

P –

Palp

itatio

ns, p

ins

& n

eedl

esA

– A

bdom

inal

dis

com

fort

N –

Nau

sea

and

vom

iting

I –

Inte

nse

fear

of d

ying

(ang

or a

nim

us)

C –

Ches

t pai

n, c

hoki

ngS

– S

wea

ting,

sw

allo

win

g di

fficu

lty (g

lobu

s hy

ster

icus

), sh

ortn

ess

of

bre

ath

Thes

e sy

mpt

oms

may

occ

ur a

t diff

eren

t tim

es a

nd o

f var

ying

inte

nsity

dep

endi

ng o

n th

e un

derly

ing

diso

rder

(e.g

. if a

patie

nt h

ad a

soc

ial p

hobi

a, th

en a

n ex

cess

ive

anxi

ous

resp

onse

wou

ld o

nly

occu

r on

a sp

ecifi

c so

cial

situ

atio

n su

chas

del

iver

ing

a sp

eech

).

Trea

tmen

tDe

pend

s on

the

type

of a

nxie

ty d

isor

der

diag

nose

d, b

ut c

onsi

sts

of p

sych

olog

ical

and

phar

mac

olog

ical

ther

apy.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Be

havi

oura

l the

rapy

suc

h as

gra

ded

ex

posu

re.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Antid

epre

ssan

ts (s

ee Ta

ble

1.2,

p. 6

).•

Anxi

olyt

ics

(see

Tabl

e 1.

3, p

. 12)

.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c in

vest

igat

ion

for a

nxie

tydi

sord

ers,

but i

t is

vita

l to

excl

ude

an o

rgan

icca

use.

The

refo

re, p

erfo

rm in

itial

inve

stig

atio

ns:

• Bl

oods

– F

BC, U

&E,

TFT

s, gl

ucos

e, c

alci

um

leve

ls.•

ECG.

• To

xico

logy

repo

rt if

indi

cate

d.•

Urin

ary

VMA/

pHVA

if in

dica

ted

(for

ph

aeoc

hrom

ocyt

oma)

.

Caus

es

The

gene

tic/

biol

ogic

al m

odel

:•

Inhe

rited

dis

orde

r – m

any

patie

nts

have

a

first

-deg

ree

fam

ily re

lativ

e w

ith th

e di

sord

er.

• Ab

norm

al re

cept

ors

in th

e 5-

HT, n

orad

rena

line

an

d G

ABA

syst

ems.

The

soci

al/p

sych

olog

ical

mod

el:

• Re

spon

se to

str

essf

ul li

fe e

vent

s.•

A ps

ycho

logi

cally

sus

cept

ible

pat

ient

may

m

isin

terp

ret a

nor

mal

bod

y st

imul

us.

MAP

1.2

. Anx

iety

K30033_C001.indd 8 28/02/17 11:02 am

Psyc

hiat

ry9

Map

1.2

. A

nxi

ety

Wha

t is

anx

iety

?An

xiet

y is

a n

orm

al e

mot

ion

that

like

ly h

as b

een

expe

rienc

ed b

ym

ost o

f us

durin

g ou

r liv

es. H

owev

er, w

hen

anxi

ety

is s

uch

that

itin

terfe

res

with

dai

ly fu

nctio

ning

and

per

form

ance

, it i

s co

nsid

ered

to b

e pa

thol

ogic

al. T

his

rela

tions

hip

is c

alle

d Ye

rkes

–Dod

son

law

.

Anxi

ety

may

be

clas

sifie

d in

to m

any

diffe

rent

sub

grou

ps:

Org

anic

cau

ses:

• Hy

pert

hyro

idis

m.

• Hy

pogl

ycae

mia

.•

Phae

ochr

omoc

ytom

a.•

Cere

bral

trau

ma.

• Te

mpo

ral l

obe

epile

psy.

Psyc

hiat

ric

caus

es:

• An

xiet

y di

sord

ers:

Phob

ic d

isor

ders

(e.g

. ago

raph

obia

).

N

on-s

ituat

iona

l dis

orde

rs (e

.g. g

ener

aliz

ed a

nxie

ty

di

sord

er [a

tria

d of

app

rehe

nsio

n, m

otor

tens

ion

and

auto

nom

ic o

vera

ctiv

ity]).

Reac

tion

to s

tres

sful

eve

nts

(e.g

. PTS

D).

OCD

(see

Map

1.3

, p. 1

0).

• Se

cond

ary

to d

epre

ssio

n or

psy

chos

is.•

Seco

ndar

y to

a m

edic

al c

ondi

tion.

• Se

cond

ary

to p

sych

oativ

e su

bsta

nce

abus

e (e

.g. a

lcoh

ol in

take

or

with

draw

al, a

mph

etam

ines

, ben

zodi

azep

ine

with

draw

al).

Sym

ptom

sTh

ese

may

be

gene

raliz

ed o

r par

oxys

mal

.

Rem

embe

r as

PAN

ICS:

P –

Palp

itatio

ns, p

ins

& n

eedl

esA

– A

bdom

inal

dis

com

fort

N –

Nau

sea

and

vom

iting

I –

Inte

nse

fear

of d

ying

(ang

or a

nim

us)

C –

Ches

t pai

n, c

hoki

ngS

– S

wea

ting,

sw

allo

win

g di

fficu

lty (g

lobu

s hy

ster

icus

), sh

ortn

ess

of

bre

ath

Thes

e sy

mpt

oms

may

occ

ur a

t diff

eren

t tim

es a

nd o

f var

ying

inte

nsity

dep

endi

ng o

n th

e un

derly

ing

diso

rder

(e.g

. if a

patie

nt h

ad a

soc

ial p

hobi

a, th

en a

n ex

cess

ive

anxi

ous

resp

onse

wou

ld o

nly

occu

r on

a sp

ecifi

c so

cial

situ

atio

n su

chas

del

iver

ing

a sp

eech

).

Trea

tmen

tDe

pend

s on

the

type

of a

nxie

ty d

isor

der

diag

nose

d, b

ut c

onsi

sts

of p

sych

olog

ical

and

phar

mac

olog

ical

ther

apy.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Be

havi

oura

l the

rapy

suc

h as

gra

ded

ex

posu

re.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Antid

epre

ssan

ts (s

ee Ta

ble

1.2,

p. 6

).•

Anxi

olyt

ics

(see

Tabl

e 1.

3, p

. 12)

.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c in

vest

igat

ion

for a

nxie

tydi

sord

ers,

but i

t is

vita

l to

excl

ude

an o

rgan

icca

use.

The

refo

re, p

erfo

rm in

itial

inve

stig

atio

ns:

• Bl

oods

– F

BC, U

&E,

TFT

s, gl

ucos

e, c

alci

um

leve

ls.•

ECG.

• To

xico

logy

repo

rt if

indi

cate

d.•

Urin

ary

VMA/

pHVA

if in

dica

ted

(for

ph

aeoc

hrom

ocyt

oma)

.

Caus

es

The

gene

tic/

biol

ogic

al m

odel

:•

Inhe

rited

dis

orde

r – m

any

patie

nts

have

a

first

-deg

ree

fam

ily re

lativ

e w

ith th

e di

sord

er.

• Ab

norm

al re

cept

ors

in th

e 5-

HT, n

orad

rena

line

an

d G

ABA

syst

ems.

The

soci

al/p

sych

olog

ical

mod

el:

• Re

spon

se to

str

essf

ul li

fe e

vent

s.•

A ps

ycho

logi

cally

sus

cept

ible

pat

ient

may

m

isin

terp

ret a

nor

mal

bod

y st

imul

us.

MAP

1.2

. Anx

iety

K30033_C001.indd 9 28/02/17 11:02 am

Psyc

hiat

ry10

Map

1.3

. O

bse

ssiv

e co

mp

uls

ive

dis

ord

er (

OC

D)

Wha

t is

OCD

?O

CD is

a p

sych

iatr

ic d

isor

der c

hara

cter

ized

by

obse

ssiv

e th

ough

ts, r

umin

atio

ns a

nd c

ompu

lsiv

e rit

uals.

It a

ffect

s m

en a

nd w

omen

equ

ally.

The

mea

n ag

e of

ons

et is

20 y

ears

.

The

cond

ition

is a

ssoc

iate

d w

ith a

nank

astic

pe

rson

ality

dis

orde

r, G

illes

de

la To

uret

te s

yndr

ome,

de

pres

sion

and

, les

s co

mm

only,

sch

izop

hren

ia a

nd b

asal

ga

nglia

dis

orde

rs.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Re

spon

se p

reve

ntio

n.•

Thou

ght s

topp

ing.

• Co

gniti

ve m

odel

ling.

Phar

mac

olog

ical

the

rapy

:•

Antid

epre

ssan

ts (s

ee Ta

ble

1.2,

p. 6

), pa

rtic

ular

ly

cl

omip

ram

ine,

whi

ch h

as s

tron

g an

ti-ob

sess

iona

l

actio

ns•

Anxi

olyt

ics

(see

Tabl

e 1.

3, p

. 12)

.•

Busp

irone

is u

sed

if m

arke

d an

xiet

y pr

esen

t.

Psyc

hosu

rgic

al:

• Th

is is

rare

and

onl

y co

nsid

ered

for i

ntra

ctab

le c

ases

.

Exam

ples

incl

ude

ster

eota

ctic

cin

gulo

tom

y or

ytt

rium

ra

dioa

ctiv

e im

plan

ts.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c te

st fo

r OCD

.(S

ee M

ap 1

.2, p

. 8, f

or te

sts

requ

ired

to ru

leou

t org

anic

cau

ses

of a

nxie

ty a

nd o

ther

type

sof

anx

iety

dis

orde

r.)

Caus

es•

Gen

etic

fact

ors:

3–7%

of s

uffe

rers

hav

e

a fir

st-d

egre

e re

lativ

e w

ith th

e co

nditi

on.

• Dy

sreg

ulat

ion/

hype

rsen

sitiv

ity o

f 5-H

T

rece

ptor

s.•

Hype

ract

ive

orbi

tofro

ntal

lobe

.•

Basa

l gan

glia

dys

func

tion:

Dysf

unct

iona

l str

iatu

m.

Smal

ler c

auda

te n

ucle

us.

Sym

ptom

sO

bses

sive

thou

ghts

, com

puls

ions

, im

puls

es,

rum

inat

ions

and

ritu

als.

Th

e IC

D-10

hig

hlig

hts

six

feat

ures

that

ar

e hi

ghly

sug

gest

ive

of th

e di

sord

er:

1. O

bses

sion

s an

d co

mpu

lsio

ns th

at h

ave

be

en p

rese

nt fo

r at l

east

2 w

eeks

.2.

The

obs

essi

ons

and

com

puls

ions

dec

reas

e

the

patie

nt’s

func

tion.

3. T

he p

atie

nt is

aw

are

that

thes

e th

ough

ts

are

gene

rate

d fro

m th

eir o

wn

min

d.4.

The

se th

ough

ts a

re u

nple

asan

tly re

petit

ive.

5. A

t lea

st o

ne o

f the

se th

ough

ts is

not

re

sist

ed.

6. T

he c

ompu

lsio

ns a

nd ri

tual

s pe

rform

ed a

re

not,

in th

emse

lves

, ple

asur

able

for t

he

patie

nt.

MAP

1.3

. Obs

essi

ve c

ompu

lsiv

e di

sord

er (O

CD)

K30033_C001.indd 10 28/02/17 11:02 am

Psyc

hiat

ry11

Map

1.3

. O

bse

ssiv

e co

mp

uls

ive

dis

ord

er (

OC

D)

Wha

t is

OCD

?O

CD is

a p

sych

iatr

ic d

isor

der c

hara

cter

ized

by

obse

ssiv

e th

ough

ts, r

umin

atio

ns a

nd c

ompu

lsiv

e rit

uals.

It a

ffect

s m

en a

nd w

omen

equ

ally.

The

mea

n ag

e of

ons

et is

20 y

ears

.

The

cond

ition

is a

ssoc

iate

d w

ith a

nank

astic

pe

rson

ality

dis

orde

r, G

illes

de

la To

uret

te s

yndr

ome,

de

pres

sion

and

, les

s co

mm

only,

sch

izop

hren

ia a

nd b

asal

ga

nglia

dis

orde

rs.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Re

spon

se p

reve

ntio

n.•

Thou

ght s

topp

ing.

• Co

gniti

ve m

odel

ling.

Phar

mac

olog

ical

the

rapy

:•

Antid

epre

ssan

ts (s

ee Ta

ble

1.2,

p. 6

), pa

rtic

ular

ly

cl

omip

ram

ine,

whi

ch h

as s

tron

g an

ti-ob

sess

iona

l

actio

ns•

Anxi

olyt

ics

(see

Tabl

e 1.

3, p

. 12)

.•

Busp

irone

is u

sed

if m

arke

d an

xiet

y pr

esen

t.

Psyc

hosu

rgic

al:

• Th

is is

rare

and

onl

y co

nsid

ered

for i

ntra

ctab

le c

ases

.

Exam

ples

incl

ude

ster

eota

ctic

cin

gulo

tom

y or

ytt

rium

ra

dioa

ctiv

e im

plan

ts.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c te

st fo

r OCD

.(S

ee M

ap 1

.2, p

. 8, f

or te

sts

requ

ired

to ru

leou

t org

anic

cau

ses

of a

nxie

ty a

nd o

ther

type

sof

anx

iety

dis

orde

r.)

Caus

es•

Gen

etic

fact

ors:

3–7%

of s

uffe

rers

hav

e

a fir

st-d

egre

e re

lativ

e w

ith th

e co

nditi

on.

• Dy

sreg

ulat

ion/

hype

rsen

sitiv

ity o

f 5-H

T

rece

ptor

s.•

Hype

ract

ive

orbi

tofro

ntal

lobe

.•

Basa

l gan

glia

dys

func

tion:

Dysf

unct

iona

l str

iatu

m.

Smal

ler c

auda

te n

ucle

us.

Sym

ptom

sO

bses

sive

thou

ghts

, com

puls

ions

, im

puls

es,

rum

inat

ions

and

ritu

als.

Th

e IC

D-10

hig

hlig

hts

six

feat

ures

that

ar

e hi

ghly

sug

gest

ive

of th

e di

sord

er:

1. O

bses

sion

s an

d co

mpu

lsio

ns th

at h

ave

be

en p

rese

nt fo

r at l

east

2 w

eeks

.2.

The

obs

essi

ons

and

com

puls

ions

dec

reas

e

the

patie

nt’s

func

tion.

3. T

he p

atie

nt is

aw

are

that

thes

e th

ough

ts

are

gene

rate

d fro

m th

eir o

wn

min

d.4.

The

se th

ough

ts a

re u

nple

asan

tly re

petit

ive.

5. A

t lea

st o

ne o

f the

se th

ough

ts is

not

re

sist

ed.

6. T

he c

ompu

lsio

ns a

nd ri

tual

s pe

rform

ed a

re

not,

in th

emse

lves

, ple

asur

able

for t

he

patie

nt.

MAP

1.3

. Obs

essi

ve c

ompu

lsiv

e di

sord

er (O

CD)

K30033_C001.indd 11 28/02/17 11:02 am

Psyc

hiat

ry12

Tabl

e 1.

3. A

nxi

oly

tics

an

d h

ypn

oti

cs

TABL

E 1.

3. A

nxio

lyti

cs a

nd h

ypno

tics

.

Dru

g na

me

Mec

hani

sm o

f ac

tion

Use

sSi

de e

ffec

ts

Busp

irone

5-HT

1A p

artia

l ago

nist

Gen

eral

ized

anx

iety

dis

orde

r•

Nau

sea

and

vom

iting

• Di

zzin

ess

• He

adac

he•

Blur

red

visi

on

Amob

arbi

tal

Incr

ease

s th

e in

hibi

tory

act

ion

of G

ABA

by b

indi

ng to

the

barb

itura

te b

indi

ng s

ite o

n th

e G

ABA A r

ecep

tor.

Incr

ease

d in

flux

of C

l- ion

s

Seve

re in

som

nia

• De

pend

ence

•

With

draw

al s

ympt

oms

• Da

ytim

e se

datio

n•

Card

iore

spira

tory

dep

ress

ion

• Dr

ug in

tera

ctio

ns s

ince

it in

duce

s p4

50 s

yste

m

Zolp

idem

Bind

s to

the

benz

odia

zepi

ne

bind

ing

site

on

the

GAB

A A rec

epto

rIn

som

nia

• De

pend

ence

• To

lera

nce

• Se

datio

n•

Drow

sine

ss•

Dizz

ines

s

Diaz

epam

Incr

ease

s th

e in

hibi

tory

act

ion

of G

ABA

by b

indi

ng to

the

benz

odia

zepi

ne b

indi

ng s

ite o

n th

e G

ABA

rece

ptor

. Inc

reas

ed in

flux

of

Cl- i

ons

Anxi

ety

Inso

mni

aSt

atus

epi

lept

icus

• De

pend

ence

• To

lera

nce

• Ca

rdio

resp

irato

ry d

epre

ssio

n •

Drow

sine

ss•

Seda

tion

Flum

azen

ilCo

mpe

tes

at th

e be

nzod

iaze

pine

bi

ndin

g si

te. I

t is

ther

efor

e an

an

tago

nist

to th

e ac

tions

of

zolp

idem

and

dia

zepa

m

Benz

odia

zepi

ne o

verd

ose

• Pa

lpita

tions

• In

som

nia

• Co

nvul

sion

• An

xiet

y

K30033_C001.indd 12 28/02/17 11:02 am

K30033_C001.indd 13 28/02/17 11:02 am

Psyc

hiat

ry14

Caus

esTh

e ex

act c

ause

of s

chiz

ophr

enia

is u

nkno

wn

but t

here

are

man

y th

eorie

s:1.

The

dop

amin

e hy

poth

esis

– d

opam

iner

gic

ov

er a

ctiv

ity.

2. S

erot

oner

gic

over

activ

ity –

due

to th

e

supe

riorit

y of

clo

zapi

ne in

trea

ting

tr

eatm

ent r

esis

tant

sch

izop

hren

ia.

3. G

enet

ics

– hi

gher

inci

denc

e in

thos

e w

ith a

fa

mily

his

tory

. Ass

ocia

tion

with

the

DISC

1

gene

(Dis

rupt

ed In

SCh

izop

hren

ia).

4. D

rug

abus

e –

part

icul

arly

can

nabi

s us

e at

an

ea

rly a

ge.

5. G

roup

A p

erso

nalit

y di

sord

er.

6. I

llnes

s du

ring

preg

nanc

y.7.

Win

ter b

irths

.8.

Adv

erse

life

eve

nts.

Wha

t is

sch

izop

hren

ia?

This

is a

chr

onic

psy

chia

tric

dis

orde

r in

whi

ch

the

patie

nt e

xper

ienc

es d

isto

rted

real

ity. I

t af

fect

s m

en a

nd w

omen

equ

ally,

alth

ough

the

form

er te

nd to

hav

e an

ear

lier o

nset

. The

co

nditi

on is

ass

ocia

ted

with

a h

ighe

r sui

cide

ra

te th

an th

e ge

nera

l pop

ulat

ion

(10–

15%

).

Sym

ptom

sTh

e IC

D-10

sug

gest

s th

at s

ympt

oms

need

to b

e pr

esen

t for

at l

east

1 m

onth

.

Thes

e sy

mpt

oms

may

be

desc

ribed

as

Schn

eide

r’s fi

rst r

ank

sym

ptom

s (re

mem

ber a

s TA

P2) o

r, m

ore

broa

dly,

as p

ositi

ve a

nd n

egat

ive

sym

ptom

s.

Schn

eide

r’s fi

rst

rank

sym

ptom

s:•

T –

Thou

ght d

isor

der –

thou

ght i

nser

tion,

with

draw

al, b

road

cast

ing.

Thi

s m

ay

in

terfe

re w

ith s

peec

h, le

adin

g to

neol

ogis

ms,

thou

ght s

topp

ing

and

knig

ht’s

mov

e th

inki

ng.

• A

– A

udito

ry h

allu

cina

tions

– th

ough

t ech

o,

ru

nnin

g co

mm

enta

ry.

• P

– Pa

ssiv

ity p

heno

men

on –

bel

ief t

hat b

ody

is c

ontr

olle

d by

an

exte

rnal

age

ncy.

• P

– de

lusi

onal

Per

cept

ions

– th

inki

ng a

n

ev

eryd

ay o

bjec

t has

a s

peci

fic m

eani

ng

fo

r the

pat

ient

.

Posi

tive

sym

ptom

s:•

Thou

ght d

isor

der –

thou

ght i

nser

tion,

w

ithdr

awal

, bro

adca

stin

g.•

Delu

sion

s.•

Idea

s of

refe

renc

e.

• Ha

lluci

natio

ns.

• Pa

ssiv

ity p

heno

men

a.

Neg

ativ

e sy

mpt

oms

(ABC

P):

• A

logi

a.•

Anh

edon

ia.

• A

volit

ion.

• B

lunt

ing

of a

ffect

.•

Cat

aton

ia.

• P

over

ty o

f ide

atio

n.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c in

vest

igat

ion

for s

chiz

ophr

e-ni

a. It

is a

clin

ical

dia

gnos

is b

ut it

is v

ital t

o ru

le

out o

ther

cau

ses

of p

sych

osis,

suc

h as

dru

g-in

duce

d ps

ycho

sis,

and

to p

erfo

rm a

risk

as

sess

men

t. M

oreo

ver,

base

line

bloo

ds s

houl

d be

pe

rform

ed a

s w

ell a

s an

ECG

due

to th

e po

ssib

le

side

effe

cts

of a

ntip

sych

otic

med

icat

ion.

Trea

tmen

tDe

pend

s on

whe

ther

it is

an

urge

nt o

r non

-urg

ent s

ituat

ion.

Fol

low

you

r loc

al g

uide

lines

.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

inte

rven

tion

– pr

ogno

sis

is w

orse

in fa

mili

es w

ith h

igh

expr

esse

d em

otio

n.•

Art t

hera

py.

• Li

aise

with

soc

ial w

orke

r reg

ardi

ng h

ousi

ng d

iffic

ultie

s an

d em

ploy

men

t.

Phar

mac

olog

ical

the

rapy

:•

Antip

sych

otic

s (s

ee Ta

ble

1.4,

p. 1

6).

MAP

1.4

. Sch

izop

hren

ia

Map

1.4

. Sc

hiz

op

hre

nia

K30033_C001.indd 14 28/02/17 11:02 am

Psyc

hiat

ry15

Map

1.4

. Sc

hiz

op

hre

nia

Caus

esTh

e ex

act c

ause

of s

chiz

ophr

enia

is u

nkno

wn

but t

here

are

man

y th

eorie

s:1.

The

dop

amin

e hy

poth

esis

– d

opam

iner

gic

ov

er a

ctiv

ity.

2. S

erot

oner

gic

over

activ

ity –

due

to th

e

supe

riorit

y of

clo

zapi

ne in

trea

ting

tr

eatm

ent r

esis

tant

sch

izop

hren

ia.

3. G

enet

ics

– hi

gher

inci

denc

e in

thos

e w

ith a

fa

mily

his

tory

. Ass

ocia

tion

with

the

DISC

1

gene

(Dis

rupt

ed In

SCh

izop

hren

ia).

4. D

rug

abus

e –

part

icul

arly

can

nabi

s us

e at

an

ea

rly a

ge.

5. G

roup

A p

erso

nalit

y di

sord

er.

6. I

llnes

s du

ring

preg

nanc

y.7.

Win

ter b

irths

.8.

Adv

erse

life

eve

nts.

Wha

t is

sch

izop

hren

ia?

This

is a

chr

onic

psy

chia

tric

dis

orde

r in

whi

ch

the

patie

nt e

xper

ienc

es d

isto

rted

real

ity. I

t af

fect

s m

en a

nd w

omen

equ

ally,

alth

ough

the

form

er te

nd to

hav

e an

ear

lier o

nset

. The

co

nditi

on is

ass

ocia

ted

with

a h

ighe

r sui

cide

ra

te th

an th

e ge

nera

l pop

ulat

ion

(10–

15%

).

Sym

ptom

sTh

e IC

D-10

sug

gest

s th

at s

ympt

oms

need

to b

e pr

esen

t for

at l

east

1 m

onth

.

Thes

e sy

mpt

oms

may

be

desc

ribed

as

Schn

eide

r’s fi

rst r

ank

sym

ptom

s (re

mem

ber a

s TA

P2) o

r, m

ore

broa

dly,

as p

ositi

ve a

nd n

egat

ive

sym

ptom

s.

Schn

eide

r’s fi

rst

rank

sym

ptom

s:•

T –

Thou

ght d

isor

der –

thou

ght i

nser

tion,

with

draw

al, b

road

cast

ing.

Thi

s m

ay

in

terfe

re w

ith s

peec

h, le

adin

g to

neol

ogis

ms,

thou

ght s

topp

ing

and

knig

ht’s

mov

e th

inki

ng.

• A

– A

udito

ry h

allu

cina

tions

– th

ough

t ech

o,

ru

nnin

g co

mm

enta

ry.

• P

– Pa

ssiv

ity p

heno

men

on –

bel

ief t

hat b

ody

is c

ontr

olle

d by

an

exte

rnal

age

ncy.

• P

– de

lusi

onal

Per

cept

ions

– th

inki

ng a

n

ev

eryd

ay o

bjec

t has

a s

peci

fic m

eani

ng

fo

r the

pat

ient

.

Posi

tive

sym

ptom

s:•

Thou

ght d

isor

der –

thou

ght i

nser

tion,

w

ithdr

awal

, bro

adca

stin

g.•

Delu

sion

s.•

Idea

s of

refe

renc

e.

• Ha

lluci

natio

ns.

• Pa

ssiv

ity p

heno

men

a.

Neg

ativ

e sy

mpt

oms

(ABC

P):

• A

logi

a.•

Anh

edon

ia.

• A

volit

ion.

• B

lunt

ing

of a

ffect

.•

Cat

aton

ia.

• P

over

ty o

f ide

atio

n.

Inve

stig

atio

nsTh

ere

is n

o sp

ecifi

c in

vest

igat

ion

for s

chiz

ophr

e-ni

a. It

is a

clin

ical

dia

gnos

is b

ut it

is v

ital t

o ru

le

out o

ther

cau

ses

of p

sych

osis,

suc

h as

dru

g-in

duce

d ps

ycho

sis,

and

to p

erfo

rm a

risk

as

sess

men

t. M

oreo

ver,

base

line

bloo

ds s

houl

d be

pe

rform

ed a

s w

ell a

s an

ECG

due

to th

e po

ssib

le

side

effe

cts

of a

ntip

sych

otic

med

icat

ion.

Trea

tmen

tDe

pend

s on

whe

ther

it is

an

urge

nt o

r non

-urg

ent s

ituat

ion.

Fol

low

you

r loc

al g

uide

lines

.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

inte

rven

tion

– pr

ogno

sis

is w

orse

in fa

mili

es w

ith h

igh

expr

esse

d em

otio

n.•

Art t

hera

py.

• Li

aise

with

soc

ial w

orke

r reg

ardi

ng h

ousi

ng d

iffic

ultie

s an

d em

ploy

men

t.

Phar

mac

olog

ical

the

rapy

:•

Antip

sych

otic

s (s

ee Ta

ble

1.4,

p. 1

6).

MAP

1.4

. Sch

izop

hren

ia

K30033_C001.indd 15 28/02/17 11:02 am

Psyc

hiat

ry16

Tabl

e 1.

4. A

nti

psy

cho

tics

TABL

E 1.

4. A

ntip

sych

otic

s.

Clas

sifi

cati

onEx

ampl

esM

echa

nism

of

acti

onU

ses

Side

eff

ects

Typi

cal

Halo

perid

olCh

lorp

rom

azin

eTh

iorid

azin

e

Bloc

k D 2 r

ecep

tors

, th

ereb

y in

crea

sing

co

ncen

trat

ion

of

cAM

P 1

Schi

zoph

reni

aPs

ycho

sis

Man

iaTo

uret

te’s

synd

rom

e

Antip

sych

otic

med

icat

ions

blo

ck s

ever

al re

cept

ors,

whi

ch re

sults

in a

n ar

ray

of s

ide

effe

cts:

• D 2 r

ecep

tors

affe

ct s

ever

al p

athw

ays:

Tu

bero

infu

ndib

ular

pat

hway

: gal

acto

rrho

ea, a

men

orrh

oea,

hy

perp

rola

ctin

aem

ia

N

igro

stria

tal p

athw

ay: e

xtra

pyra

mid

al s

ide

effe

cts

(EPS

E).

Rem

embe

r as

TRA

P:T

– Ta

rdiv

e dy

skin

esia

R

– Re

stle

ss lo

wer

lim

bs (a

kath

esia

)A

– A

cute

dys

toni

aP

– Pa

rkin

soni

sms

M

esoc

ortic

al p

athw

ay: i

ncre

ases

neg

ativ

e sy

mpt

oms

(see

Map

1.

4, p

. 14)

.

Mes

olim

bic

path

way

: dec

reas

es p

ositi

ve s

ympt

oms

(see

Map

1.

4, p

. 14)

.•

α 1 ant

agon

ist:

post

ural

hyp

oten

sion

• An

timus

carin

ic: d

ry m

outh

, urin

ary

rete

ntio

n, c

onst

ipat

ion,

blu

rred

vi

sion

• An

tihis

tam

iner

gic:

wei

ght g

ain,

dro

wsi

ness

• N

euro

lept

ic m

alig

nant

syn

drom

e (N

MS)

– th

is is

a li

fe-t

hrea

teni

ng

reac

tion

that

may

be

caus

ed b

y an

adv

erse

reac

tion

to a

ntip

sych

otic

dr

ugs.

Sym

ptom

s of

NM

S in

clud

e: fe

ver,

mus

cle

rigid

ity, a

ltere

d m

enta

l sta

tus

and

auto

nom

ic d

ysfu

nctio

n

K30033_C001.indd 16 28/02/17 11:02 am

Psyc

hiat

ry17At

ypic

al

Ola

nzap

ine

Cloz

apin

eQ

uetia

pine

Risp

erid

one

Arip

ipra

zole

Bloc

k D 2 r

ecep

tors

th

ereb

y in

crea

sing

co

ncen

trat

ion

of

cAM

P 1 rec

epto

rs,

but a

re a

lso

effe

ctiv

e in

bl

ocki

ng 5

-HT 2,

α 1 an

d H 1 r

ecep

tors

Schi

zoph

reni

a O

lanz

apin

e m

ay a

lso

be u

sed

for a

nxie

ty

diso

rder

s, O

CD, m

ania

, de

pres

sion

and

To

uret

te’s

synd

rom

e

• Si

de e

ffect

s ar

e th

e sa

me

as th

ose

liste

d fo

r typ

ical

age

nts;

how

ever

, th

ere

are

far f

ewer

EPS

E an

d an

ticho

liner

gic

side

effe

cts,

whi

ch is

w

hy a

typi

cal a

gent

s ar

e pr

efer

red

to th

e ol

der,

typi

cal m

edic

atio

ns.

• Sp

ecifi

c si

de e

ffect

s:

Cloz

apin

e (u

sed

in tr

eatm

ent r

esis

tant

sch

izop

hren

ia):

agra

nulo

cyto

sis

O

lanz

apin

e: w

eigh

t gai

n

Moo

d st

abili

zer

Lith

ium

U

nkno

wn.

Tho

ught

to

act

in a

sim

ilar

way

to o

ther

sin

gle

char

ged

catio

ns

by in

terfe

ring

with

mem

bran

e io

n tr

ansp

ort

mec

hani

sms

Bipo

lar d

isor

der

Man

ia•

Com

mon

: tre

mor

, dia

rrho

ea, i

ncre

ased

app

etite

• Th

ose

that

requ

ire b

lood

test

mon

itorin

g: n

ephr

ogen

ic d

iabe

tes

insi

pidu

s, hy

poth

yroi

dism

• In

ove

rdos

e: c

onvu

lsio

ns, c

oma,

dea

th•

Tera

toge

nic:

Ebs

tein

’s ab

norm

ality

• Sp

ecia

l poi

nts:

narr

ow th

erap

eutic

inde

x. M

onito

r ser

um li

thiu

m

conc

entr

atio

n

Tabl

e 1.

4. A

nti

psy

cho

tics

K30033_C001.indd 17 28/02/17 11:02 am

Psyc

hiat

ry18

Map

1.5

. B

ipo

lar

dis

ord

er

Wha

t is

bip

olar

dis

orde

r?M

ajor

dep

ress

ion

alon

gsid

e at

leas

t one

man

ic

(bip

olar

I) o

r one

hyp

oman

ic (b

ipol

ar II

) epi

sode

ch

arac

teriz

es th

is d

isor

der.

Patie

nts

will

ev

entu

ally

suf

fer f

rom

dep

ress

ive

sym

ptom

s. In

so

me

way

s th

is d

isor

der m

ay b

e vi

ewed

as

a cy

clic

al in

terc

hang

ing

betw

een

elev

ated

and

low

moo

d w

here

the

patie

nt is

func

tiona

lly n

orm

al

betw

een

epis

odes

.

M

en a

nd w

omen

are

equ

ally

affe

cted

.

MA

P 1.

5. B

ipo

lar

dis

ord

er

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tic, n

euro

horm

onal

, neu

roan

atom

ical

and

psyc

hoso

cial

fact

ors.

A fe

w e

xam

ples

are

giv

enbe

low

:G

enet

ic: f

amily

his

tory

bip

olar

dis

orde

r.Po

ssib

le in

volv

emen

t of c

hrom

osom

es 6

q an

d8q

21.

Neu

roho

rmon

al: t

he m

onoa

min

e hy

poth

esis.

Neu

roan

atom

ical

: inc

reas

ed s

ize

of la

tera

lve

ntric

les,

abno

rmal

HPA

axi

s.Ps

ycho

soci

al: a

dver

se li

fe e

vent

s an

d ne

gativ

ech

ildho

od e

xper

ienc

es s

uch

as a

buse

, PTS

D.

Trea

tmen

tDe

pend

s on

whe

ther

it is

an

urge

nt o

rno

n-ur

gent

situ

atio

n. F

ollo

w y

our l

ocal

guid

elin

es.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• Li

aise

with

soc

ial w

orke

r reg

ardi

ng h

ousi

ng

diffi

culti

es a

nd e

mpl

oym

ent.

Phar

mac

olog

ical

the

rapy

:•

Antip

sych

otic

s an

d m

ood

stab

ilize

rs (s

ee

Tabl

e 1.

4, p

. 16)

.•

Antie

pile

ptic

med

icat

ions

are

als

o us

ed

eith

er in

depe

nden

tly o

r in

com

bina

tion

with

lit

hium

.

Inve

stig

atio

ns•

Ther

e is

no

spec

ific

inve

stig

atio

n fo

r bip

olar

di

sord

er. I

t is

a cl

inic

al d

iagn

osis

but

it is

vi

tal t

o ru

le o

ut o

ther

cau

ses

of p

sych

osis,

su

ch a

s dr

ug-in

duce

d ps

ycho

sis,

as w

ell a

s

orga

nic

moo

d di

sord

ers

and

to p

erfo

rm a

ris

k as

sess

men

t. M

oreo

ver,

base

line

bloo

ds

shou

ld b

e pe

rform

ed a

s w

ell a

s an

ECG

due

to

the

poss

ible

affe

cts

of a

ntip

sych

otic

m

edic

atio

n. (N

ote:

QTc

pro

long

atio

n m

ay

occu

r with

all

antip

sych

otic

s.)•

Inve

stig

atio

ns a

s fo

r dep

ress

ion

(see

Map

1.

1, p

. 2).

Type

s of

bip

olar

dis

orde

r

Type

sKe

y fe

atur

es

Bipo

lar I

Bipo

lar I

I

Rapi

d cy

clin

g

Cycl

othy

mia

• At

leas

t one

man

ic

epis

ode

last

ing

>1

wee

k.•

Usu

ally

cou

pled

with

pe

riods

of d

epre

ssio

n,

but s

ome

patie

nts

may

on

ly h

ave

man

ic e

piso

des.

• >

1 ep

isod

e of

sev

ere

de

pres

sion

, but

onl

y

coup

led

with

hyp

oman

ia.

• >

4 m

ood

swin

gs w

ithin

a

year

.

• M

ood

swin

gs th

at a

re n

ot

as s

ever

e as

thos

e in

bipo

lar d

isor

der.

Follo

ws

a

cycl

ic p

atte

rn th

at m

ay

last

for l

onge

r per

iods

.

Sym

ptom

s•

Thos

e of

dep

ress

ion

(see

Map

1.1

, p. 2

).•

Thos

e of

man

ia: t

hese

sym

ptom

s m

ust b

e

pres

ent f

or a

t lea

st 1

wee

k. R

emem

ber a

s

DIG

FA

ST:

D

– D

istr

actib

ility

I

– Irr

espo

nsib

le b

ehav

iour

(e.g

. hed

onis

tic

beha

viou

r with

out c

onsi

derin

g th

e

con

sequ

ence

s su

ch a

s bo

rrow

ing

or

spen

ding

vas

t sum

s of

mon

ey a

nd

hav

ing

unpr

otec

ted

sexu

al in

terc

ours

e)

G –

Gra

ndio

sity

with

del

usio

ns o

f

po

wer

/wea

lth

F –

Flig

ht o

f ide

as

A –

Act

ivity

incr

ease

s

S –

Sle

ep d

ecre

ases

T

– T

alka

tiven

ess

K30033_C001.indd 18 28/02/17 11:02 am

Psyc

hiat

ry19

Map

1.5

. B

ipo

lar

dis

ord

er

Wha

t is

bip

olar

dis

orde

r?M

ajor

dep

ress

ion

alon

gsid

e at

leas

t one

man

ic

(bip

olar

I) o

r one

hyp

oman

ic (b

ipol

ar II

) epi

sode

ch

arac

teriz

es th

is d

isor

der.

Patie

nts

will

ev

entu

ally

suf

fer f

rom

dep

ress

ive

sym

ptom

s. In

so

me

way

s th

is d

isor

der m

ay b

e vi

ewed

as

a cy

clic

al in

terc

hang

ing

betw

een

elev

ated

and

low

moo

d w

here

the

patie

nt is

func

tiona

lly n

orm

al

betw

een

epis

odes

.

M

en a

nd w

omen

are

equ

ally

affe

cted

.

MA

P 1.

5. B

ipo

lar

dis

ord

er

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tic, n

euro

horm

onal

, neu

roan

atom

ical

and

psyc

hoso

cial

fact

ors.

A fe

w e

xam

ples

are

giv

enbe

low

:G

enet

ic: f

amily

his

tory

bip

olar

dis

orde

r.Po

ssib

le in

volv

emen

t of c

hrom

osom

es 6

q an

d8q

21.

Neu

roho

rmon

al: t

he m

onoa

min

e hy

poth

esis.

Neu

roan

atom

ical

: inc

reas

ed s

ize

of la

tera

lve

ntric

les,

abno

rmal

HPA

axi

s.Ps

ycho

soci

al: a

dver

se li

fe e

vent

s an

d ne

gativ

ech

ildho

od e

xper

ienc

es s

uch

as a

buse

, PTS

D.

Trea

tmen

tDe

pend

s on

whe

ther

it is

an

urge

nt o

rno

n-ur

gent

situ

atio

n. F

ollo

w y

our l

ocal

guid

elin

es.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• Li

aise

with

soc

ial w

orke

r reg

ardi

ng h

ousi

ng

diffi

culti

es a

nd e

mpl

oym

ent.

Phar

mac

olog

ical

the

rapy

:•

Antip

sych

otic

s an

d m

ood

stab

ilize

rs (s

ee

Tabl

e 1.

4, p

. 16)

.•

Antie

pile

ptic

med

icat

ions

are

als

o us

ed

eith

er in

depe

nden

tly o

r in

com

bina

tion

with

lit

hium

.

Inve

stig

atio

ns•

Ther

e is

no

spec

ific

inve

stig

atio

n fo

r bip

olar

di

sord

er. I

t is

a cl

inic

al d

iagn

osis

but

it is

vi

tal t

o ru

le o

ut o

ther

cau

ses

of p

sych

osis,

su

ch a

s dr

ug-in

duce

d ps

ycho

sis,

as w

ell a

s

orga

nic

moo

d di

sord

ers

and

to p

erfo

rm a

ris

k as

sess

men

t. M

oreo

ver,

base

line

bloo

ds

shou

ld b

e pe

rform

ed a

s w

ell a

s an

ECG

due

to

the

poss

ible

affe

cts

of a

ntip

sych

otic

m

edic

atio

n. (N

ote:

QTc

pro

long

atio

n m

ay

occu

r with

all

antip

sych

otic

s.)•

Inve

stig

atio

ns a

s fo

r dep

ress

ion

(see

Map

1.

1, p

. 2).

Type

s of

bip

olar

dis

orde

r

Type

sKe

y fe

atur

es

Bipo

lar I

Bipo

lar I

I

Rapi

d cy

clin

g

Cycl

othy

mia

• At

leas

t one

man

ic

epis

ode

last

ing

>1

wee

k.•

Usu

ally

cou

pled

with

pe

riods

of d

epre

ssio

n,

but s

ome

patie

nts

may

on

ly h

ave

man

ic e

piso

des.

• >

1 ep

isod

e of

sev

ere

de

pres

sion

, but

onl

y

coup

led

with

hyp

oman

ia.

• >

4 m

ood

swin

gs w

ithin

a

year

.

• M

ood

swin

gs th

at a

re n

ot

as s

ever

e as

thos

e in

bipo

lar d

isor

der.

Follo

ws

a

cycl

ic p

atte

rn th

at m

ay

last

for l

onge

r per

iods

.

Sym

ptom

s•

Thos

e of

dep

ress

ion

(see

Map

1.1

, p. 2

).•

Thos

e of

man

ia: t

hese

sym

ptom

s m

ust b

e

pres

ent f

or a

t lea

st 1

wee

k. R

emem

ber a

s

DIG

FA

ST:

D

– D

istr

actib

ility

I

– Irr

espo

nsib

le b

ehav

iour

(e.g

. hed

onis

tic

beha

viou

r with

out c

onsi

derin

g th

e

con

sequ

ence

s su

ch a

s bo

rrow

ing

or

spen

ding

vas

t sum

s of

mon

ey a

nd

hav

ing

unpr

otec

ted

sexu

al in

terc

ours

e)

G –

Gra

ndio

sity

with

del

usio

ns o

f

po

wer

/wea

lth

F –

Flig

ht o

f ide

as

A –

Act

ivity

incr

ease

s

S –

Sle

ep d

ecre

ases

T

– T

alka

tiven

ess

K30033_C001.indd 19 28/02/17 11:02 am

Psyc

hiat

ry20

Tabl

e 1.

5. P

erso

nal

ity

dis

ord

ers

TABL

E 1.

5. P

erso

nalit

y di

sord

ers.

The

se a

re p

erva

sive

dif

ficu

ltie

s in

per

sona

lity

that

impa

ct u

pon

a pa

tien

t's

soci

al

func

tion

ing

in a

det

rim

enta

l way

. The

y ar

e in

cred

ibly

dif

ficu

lt t

o tr

eat

and

ofte

n re

quir

e ye

ars

of p

sych

othe

rapy

.

Clus

ter

Gen

eral

cha

ract

eris

tics

Spec

ific

subt

ypes

AO

dd e

ccen

tric

beh

avio

urDo

not

form

mea

ning

ful r

elat

ions

hips

Psyc

hosi

s is

not

pre

sent

1. P

aran

oid:

Susp

icio

usDe

fenc

e m

echa

nism

: pro

ject

ion

2. S

chiz

oid:

Soci

al w

ithdr

awal

/like

s so

cial

isol

atio

n 3.

Sch

izot

ypal

:Ec

cent

ric b

ehav

iour

and

bel

iefs

‘Mag

ical

thin

king

’

BTh

e em

otio

nal c

lust

erAs

soci

ated

with

moo

d di

sord

ers

Asso

ciat

ed w

ith s

ubst

ance

abu

se

1. A

ntis

ocia

l:Af

fect

s m

ales

mor

e th

an fe

mal

esCr

imin

al b

ehav

iour

and

dis

rega

rd fo

r oth

er m

embe

rs o

f soc

iety

2.

Bor

derl

ine:

Affe

cts

fem

ales

mor

e th

an m

ales

Asso

ciat

ed w

ith d

epre

ssio

nAs

soci

ated

with

del

iber

ate

self

harm

Feel

ings

of e

mpt

ines

sU

nsta

ble

inte

rper

sona

l rel

atio

nshi

psBl

ack

and

whi

te th

inki

ngIm

puls

ive

beha

viou

rDe

fenc

e m

echa

nism

: spl

ittin

g3.

His

trio

nic:

Atte

ntio

n se

ekin

g, v

ery

flirt

atio

us fe

mal

eSe

xual

ly p

rovo

cativ

e

K30033_C001.indd 20 28/02/17 11:02 am

Psyc

hiat

ry21

Tabl

e 1.

5. P

erso

nal

ity

dis

ord

ers

4. N

arci

ssis

tic:

Af

fect

s m

ales

mor

e th

an fe

mal

esG

rand

iose

del

usio

nsLa

ck o

f em

path

yLo

ves

adm

iratio

n an

d lo

athe

s cr

itici

sm

CTh

e an

xiou

s cl

uste

rAs

soci

ated

with

anx

iety

dis

orde

rs1.

Avo

idan

t:Ve

ry s

ensi

tive

to re

ject

ion

Avoi

ds s

ocia

l situ

atio

ns2.

Ana

nkas

tic:

Asso

ciat

ed w

ith O

CDPe

rfect

ioni

st p

erso

nalit

ies

3. D

epen

dent

: Lo

w s

elf e

stee

m‘C

lingy

’

K30033_C001.indd 21 28/02/17 11:02 am

Psyc

hiat

ry22

Map

1.6

. A

no

rexi

a n

ervo

sa

Sym

ptom

s•

Exce

ssiv

e w

eigh

t los

s.•

Wea

knes

s an

d fa

tigue

.•

Cold

per

iphe

ries.

• Br

adyc

ardi

a.•

Hypo

tens

ion.

• Am

enor

rhoe

a.•

Thin

lanu

go h

air o

ver f

ace

and

body

.•

Inab

ility

to p

erfo

rm s

quat

test

.•

Co-m

orbi

d de

pres

sion

/OCD

.

Sign

s•

Sig

ns o

f ind

uced

pur

ging

:

Ru

ssel

l’s s

ign.

Toot

h en

amel

that

is p

itted

/ero

ded.

Enla

rged

par

otid

gla

nds.

• S

igns

of e

lect

roly

te im

bala

nce:

Card

iac

arrh

ythm

ias.

Trea

tmen

tPs

ycho

educ

atio

n co

ncer

ning

wei

ght a

ndnu

triti

on.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• In

terp

erso

nal t

hera

py.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Corr

ectio

n of

ele

ctro

lyte

imba

lanc

e.•

Rest

ore

heal

thy

wei

ght.

• Pr

escr

ibe

mea

ls th

at a

re n

utrit

iona

lly

appr

opria

te.

Urg

ent s

ituat

ions

may

requ

ire re

feed

ing

unde

r the

Men

tal H

ealth

Act

.

Com

plic

atio

ns•

Deat

h.•

Endo

crin

e dy

sfun

ctio

n

(e.g

. am

enor

rhoe

a).

• M

etab

olic

alk

alos

is –

from

exc

essi

ve

vo

miti

ng.

• M

etab

olic

aci

dosi

s –

from

laxa

tive

abus

e.•

Card

iac

com

plic

atio

ns (e

.g. a

rrhy

thm

ias

and

QT

prol

onga

tion

that

may

lead

to

sudd

en d

eath

).•

Refe

edin

g sy

ndro

me

– re

sults

in

hypo

phos

phat

aem

ia, w

hich

can

lead

to

rhab

dom

yoly

sis,

arrh

ythm

ias,

resp

irato

ry

fa

ilure

, con

vuls

ions

, com

a an

d de

ath.

• El

ectr

olyt

e ab

norm

aliti

es –

hyp

okal

ae-

m

ia, h

ypon

atra

emia

, hyp

ogly

caem

ia,

hy

poca

lcae

mia

, hyp

erch

oles

tero

laem

ia.

• An

aem

ia.

• Pr

oxim

al m

yopa

thy.

Wha

t is

ano

rexi

a ne

rvos

a?Th

is is

an

eatin

g di

sord

er th

at is

char

acte

rized

by

ICD-

10 b

y fo

ur k

ey p

oint

s:1.

BM

I <17

.5.

2. S

elf–

indu

ced

wei

ght l

oss.

3. A

mor

bid

fear

of f

atne

ss.

4. E

ndoc

rine

dysf

unct

ion

(e.g

. am

enor

rhoe

a).

This

con

ditio

n af

fect

s fe

mal

es 1

0–20

tim

es

mor

e th

an m

ales

. It i

s as

soci

ated

with

soc

ial

clas

ses

I and

II a

s w

ell a

s ce

rtai

n pr

ofes

sion

s (e

.g. m

odel

s an

d da

ncer

s).

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mon

al a

ndps

ycho

soci

al fa

ctor

s. A

few

exa

mpl

es a

regi

ven

belo

w:

• G

enet

ic: f

amily

his

tory

of a

nore

xia

ne

rvos

a.•

Neu

roho

rmon

al: a

bnor

mal

ities

in

sero

toni

n m

etab

olis

m.

• Ps

ycho

soci

al: a

dver

se li

fe e

vent

s,

perfe

ctio

nist

per

sona

litie

s, hi

gh

achi

evin

g fa

mili

es, m

edia

exp

ecta

tions

of

thin

ness

rela

ting

to th

e id

eal f

emal

e

form

.

Inve

stig

atio

nsCl

inic

al a

sses

smen

t: ov

eral

l clin

ical

as

sess

men

t inc

ludi

ng th

e us

e of

tool

s su

chas

the

SCO

FF q

uest

ionn

aire

:S

– Ha

ve y

ou e

ver m

ade

your

self

Sick

b

ecau

se y

ou a

re u

ncom

fort

ably

full?

C –

Do y

ou fe

el th

at y

ou h

ave

lost

Con

trol

o

ver h

ow m

uch

you

eat?

O –

Hav

e yo

u lo

st O

ne s

tone

in a

3 m

onth

p

erio

d?F

– Do

you

bel

ieve

you

rsel

f to

be F

at w

hen

o

ther

s sa

y yo

u ar

e th

in?

F –

Does

Foo

d do

min

ate

your

life

?

• BM

I = w

eigh

t (kg

)/hei

ght (

m)2 .

• Bl

oods

– F

BC, U

&E,

LFT

s, TF

Ts, g

luco

se,

ca

lciu

m le

vels.

• EC

G.•

Bloo

d pr

essu

re.

• To

xico

logy

repo

rt if

indi

cate

d.

MAP

1.6

. Ano

rexi

a ne

rvos

a

K30033_C001.indd 22 28/02/17 11:02 am

Psyc

hiat

ry23

Map

1.6

. A

no

rexi

a n

ervo

sa

Sym

ptom

s•

Exce

ssiv

e w

eigh

t los

s.•

Wea

knes

s an

d fa

tigue

.•

Cold

per

iphe

ries.

• Br

adyc

ardi

a.•

Hypo

tens

ion.

• Am

enor

rhoe

a.•

Thin

lanu

go h

air o

ver f

ace

and

body

.•

Inab

ility

to p

erfo

rm s

quat

test

.•

Co-m

orbi

d de

pres

sion

/OCD

.

Sign

s•

Sig

ns o

f ind

uced

pur

ging

:

Ru

ssel

l’s s

ign.

Toot

h en

amel

that

is p

itted

/ero

ded.

Enla

rged

par

otid

gla

nds.

• S

igns

of e

lect

roly

te im

bala

nce:

Card

iac

arrh

ythm

ias.

Trea

tmen

tPs

ycho

educ

atio

n co

ncer

ning

wei

ght a

ndnu

triti

on.

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• In

terp

erso

nal t

hera

py.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Corr

ectio

n of

ele

ctro

lyte

imba

lanc

e.•

Rest

ore

heal

thy

wei

ght.

• Pr

escr

ibe

mea

ls th

at a

re n

utrit

iona

lly

appr

opria

te.

Urg

ent s

ituat

ions

may

requ

ire re

feed

ing

unde

r the

Men

tal H

ealth

Act

.

Com

plic

atio

ns•

Deat

h.•

Endo

crin

e dy

sfun

ctio

n

(e.g

. am

enor

rhoe

a).

• M

etab

olic

alk

alos

is –

from

exc

essi

ve

vo

miti

ng.

• M

etab

olic

aci

dosi

s –

from

laxa

tive

abus

e.•

Card

iac

com

plic

atio

ns (e

.g. a

rrhy

thm

ias

and

QT

prol

onga

tion

that

may

lead

to

sudd

en d

eath

).•

Refe

edin

g sy

ndro

me

– re

sults

in

hypo

phos

phat

aem

ia, w

hich

can

lead

to

rhab

dom

yoly

sis,

arrh

ythm

ias,

resp

irato

ry

fa

ilure

, con

vuls

ions

, com

a an

d de

ath.

• El

ectr

olyt

e ab

norm

aliti

es –

hyp

okal

ae-

m

ia, h

ypon

atra

emia

, hyp

ogly

caem

ia,

hy

poca

lcae

mia

, hyp

erch

oles

tero

laem

ia.

• An

aem

ia.

• Pr

oxim

al m

yopa

thy.

Wha

t is

ano

rexi

a ne

rvos

a?Th

is is

an

eatin

g di

sord

er th

at is

char

acte

rized

by

ICD-

10 b

y fo

ur k

ey p

oint

s:1.

BM

I <17

.5.

2. S

elf–

indu

ced

wei

ght l

oss.

3. A

mor

bid

fear

of f

atne

ss.

4. E

ndoc

rine

dysf

unct

ion

(e.g

. am

enor

rhoe

a).

This

con

ditio

n af

fect

s fe

mal

es 1

0–20

tim

es

mor

e th

an m

ales

. It i

s as

soci

ated

with

soc

ial

clas

ses

I and

II a

s w

ell a

s ce

rtai

n pr

ofes

sion

s (e

.g. m

odel

s an

d da

ncer

s).

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mon

al a

ndps

ycho

soci

al fa

ctor

s. A

few

exa

mpl

es a

regi

ven

belo

w:

• G

enet

ic: f

amily

his

tory

of a

nore

xia

ne

rvos

a.•

Neu

roho

rmon

al: a

bnor

mal

ities

in

sero

toni

n m

etab

olis

m.

• Ps

ycho

soci

al: a

dver

se li

fe e

vent

s,

perfe

ctio

nist

per

sona

litie

s, hi

gh

achi

evin

g fa

mili

es, m

edia

exp

ecta

tions

of

thin

ness

rela

ting

to th

e id

eal f

emal

e

form

.

Inve

stig

atio

nsCl

inic

al a

sses

smen

t: ov

eral

l clin

ical

as

sess

men

t inc

ludi

ng th

e us

e of

tool

s su

chas

the

SCO

FF q

uest

ionn

aire

:S

– Ha

ve y

ou e

ver m

ade

your

self

Sick

b

ecau

se y

ou a

re u

ncom

fort

ably

full?

C –

Do y

ou fe

el th

at y

ou h

ave

lost

Con

trol

o

ver h

ow m

uch

you

eat?

O –

Hav

e yo

u lo

st O

ne s

tone

in a

3 m

onth

p

erio

d?F

– Do

you

bel

ieve

you

rsel

f to

be F

at w

hen

o

ther

s sa

y yo

u ar

e th

in?

F –

Does

Foo

d do

min

ate

your

life

?

• BM

I = w

eigh

t (kg

)/hei

ght (

m)2 .

• Bl

oods

– F

BC, U

&E,

LFT

s, TF

Ts, g

luco

se,

ca

lciu

m le

vels.

• EC

G.•

Bloo

d pr

essu

re.

• To

xico

logy

repo

rt if

indi

cate

d.

MAP

1.6

. Ano

rexi

a ne

rvos

a

K30033_C001.indd 23 28/02/17 11:02 am

Psyc

hiat

ry24

Map

1.7

. B

ulim

ia n

ervo

sa

Sym

ptom

s•

Rem

embe

r tha

t pat

ient

s m

ay a

ctua

lly b

e

over

wei

ght d

ue to

bin

ge e

atin

g be

havi

our.

• Co

-mor

bid

depr

essi

on/O

CD.

Sign

s•

Sign

s of

indu

ced

purg

ing:

Russ

ell’s

sig

n.

To

oth

enam

el th

at is

pitt

ed/e

rode

d.

En

larg

ed p

arot

id g

land

s.

O

esop

hage

al te

ars.

• Si

gns

of e

lect

roly

te im

bala

nce:

Card

iac

arrh

ythm

ias.

Hypo

kala

emia

is a

ssoc

iate

d w

ith v

omiti

ng

as

wel

l as

laxa

tive

abus

e.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• In

terp

erso

nal t

hera

py.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Corr

ectio

n of

ele

ctro

lyte

imba

lanc

e.•

Antid

epre

ssan

ts s

uch

as T

CAs

and

SSRI

s ha

ve

been

sho

wn

to d

ecre

ase

purg

ativ

e be

havi

our.

Urg

ent s

ituat

ions

are

less

com

mon

than

for

anor

exia

ner

vosa

sin

ce p

atie

nts

are

ofte

n of

no

rmal

wei

ght.

MAP

1.7

. Bul

imia

ner

vosa

Wha

t is

bul

imia

ner

vosa

?Th

is is

an

eatin

g di

sord

er th

at is

char

acte

rized

by

ICD-

10 b

y th

ree

key

poin

ts:

1. P

atie

nt e

ngag

es in

bin

ge e

atin

g.2.

The

re is

evi

denc

e of

pur

gativ

e be

havi

our

(e

.g. v

omiti

ng to

cou

nter

act t

he e

ffect

s of

bi

nge

eatin

g an

d in

crea

sed

wei

ght).

3. A

mor

bid

fear

of f

atne

ss.

Caus

esTh

e ca

use

of b

ulim

ia is

unc

lear

, but

it is

thou

ght

to b

e du

e to

com

plex

inte

ract

ions

bet

wee

n ge

netic

, neu

roho

rmon

al a

nd p

sych

osoc

ial f

acto

rs.

A fe

w e

xam

ples

are

giv

en b

elow

.

Gen

etic

: fam

ily h

isto

ry o

f bul

imia

ner

vosa

.

Neu

roho

rmon

al: t

heor

ies

invo

lvin

g al

tera

tion

of

sero

toni

n an

d no

radr

enal

ine

exis

t.

Psyc

hoso

cial

: adv

erse

life

eve

nts,

perfe

ctio

nist

pe

rson

aliti

es, p

ast d

ietin

g be

havi

our,

anor

exia

ne

rvos

a, p

erso

nalit

y di

sord

ers

part

icul

arly

bo

rder

line

patie

nts,

low

sel

f est

eem

and

de

pres

sion

.

Inve

stig

atio

nsLi

ke a

nore

xia

nerv

osa,

ther

e is

no

spec

ific

unde

rlyin

g te

st fo

r bul

imia

ner

vosa

. How

ever

, it i

s im

port

ant t

o ru

le o

ut o

rgan

ic c

ause

s of

wei

ght

gain

and

wei

ght l

oss

as w

ell a

s pe

rform

ing

a ps

ychi

atric

eva

luat

ion.

It is

impo

rtan

t to

perfo

rm

the

inve

stig

atio

ns li

sted

bel

ow, p

artic

ular

ly U

&E,

si

nce

elec

trol

yte

dist

urba

nces

are

com

mon

with

pu

rgat

ive

beha

viou

r.•

BMI =

wei

ght (

kg)/h

eigh

t (m

)2 .•

Bloo

ds –

FBC

, U&

E, L

FTs,

TFTs

, glu

cose

, cal

cium

le

vels.

• EC

G.•

Bloo

d pr

essu

re.

• To

xico

logy

repo

rt if

indi

cate

d.

K30033_C001.indd 24 28/02/17 11:02 am

Psyc

hiat

ry25

Map

1.7

. B

ulim

ia n

ervo

sa

Sym

ptom

s•

Rem

embe

r tha

t pat

ient

s m

ay a

ctua

lly b

e

over

wei

ght d

ue to

bin

ge e

atin

g be

havi

our.

• Co

-mor

bid

depr

essi

on/O

CD.

Sign

s•

Sign

s of

indu

ced

purg

ing:

Russ

ell’s

sig

n.

To

oth

enam

el th

at is

pitt

ed/e

rode

d.

En

larg

ed p

arot

id g

land

s.

O

esop

hage

al te

ars.

• Si

gns

of e

lect

roly

te im

bala

nce:

Card

iac

arrh

ythm

ias.

Hypo

kala

emia

is a

ssoc

iate

d w

ith v

omiti

ng

as

wel

l as

laxa

tive

abus

e.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy.

• In

terp

erso

nal t

hera

py.

• Ps

ycho

dyna

mic

ther

apy.

Phar

mac

olog

ical

the

rapy

:•

Corr

ectio

n of

ele

ctro

lyte

imba

lanc

e.•

Antid

epre

ssan

ts s

uch

as T

CAs

and

SSRI

s ha

ve

been

sho

wn

to d

ecre

ase

purg

ativ

e be

havi

our.

Urg

ent s

ituat

ions

are

less

com

mon

than

for

anor

exia

ner

vosa

sin

ce p

atie

nts

are

ofte

n of

no

rmal

wei

ght.

MAP

1.7

. Bul

imia

ner

vosa

Wha

t is

bul

imia

ner

vosa

?Th

is is

an

eatin

g di

sord

er th

at is

char

acte

rized

by

ICD-

10 b

y th

ree

key

poin

ts:

1. P

atie

nt e

ngag

es in

bin

ge e

atin

g.2.

The

re is

evi

denc

e of

pur

gativ

e be

havi

our

(e

.g. v

omiti

ng to

cou

nter

act t

he e

ffect

s of

bi

nge

eatin

g an

d in

crea

sed

wei

ght).

3. A

mor

bid

fear

of f

atne

ss.

Caus

esTh

e ca

use

of b

ulim

ia is

unc

lear

, but

it is

thou

ght

to b

e du

e to

com

plex

inte

ract

ions

bet

wee

n ge

netic

, neu

roho

rmon

al a

nd p

sych

osoc

ial f

acto

rs.

A fe

w e

xam

ples

are

giv

en b

elow

.

Gen

etic

: fam

ily h

isto

ry o

f bul

imia

ner

vosa

.

Neu

roho

rmon

al: t

heor

ies

invo

lvin

g al

tera

tion

of

sero

toni

n an

d no

radr

enal

ine

exis

t.

Psyc

hoso

cial

: adv

erse

life

eve

nts,

perfe

ctio

nist

pe

rson

aliti

es, p

ast d

ietin

g be

havi

our,

anor

exia

ne

rvos

a, p

erso

nalit

y di

sord

ers

part

icul

arly

bo

rder

line

patie

nts,

low

sel

f est

eem

and

de

pres

sion

.

Inve

stig

atio

nsLi

ke a

nore

xia

nerv

osa,

ther

e is

no

spec

ific

unde

rlyin

g te

st fo

r bul

imia

ner

vosa

. How

ever

, it i

s im

port

ant t

o ru

le o

ut o

rgan

ic c

ause

s of

wei

ght

gain

and

wei

ght l

oss

as w

ell a

s pe

rform

ing

a ps

ychi

atric

eva

luat

ion.

It is

impo

rtan

t to

perfo

rm

the

inve

stig

atio

ns li

sted

bel

ow, p

artic

ular

ly U

&E,

si

nce

elec

trol

yte

dist

urba

nces

are

com

mon

with

pu

rgat

ive

beha

viou

r.•

BMI =

wei

ght (

kg)/h

eigh

t (m

)2 .•

Bloo

ds –

FBC

, U&

E, L

FTs,

TFTs

, glu

cose

, cal

cium

le

vels.

• EC

G.•

Bloo

d pr

essu

re.

• To

xico

logy

repo

rt if

indi

cate

d.

K30033_C001.indd 25 28/02/17 11:02 am

Psyc

hiat

ry26

Map

1.8

. A

tten

tio

n d

efici

t h

yper

acti

ve d

iso

rder

(A

DH

D)

Sym

ptom

s•

Decr

ease

d co

ncen

trat

ion.

• Po

or s

choo

l per

form

ance

.•

Forg

etfu

lnes

s.•

Hype

ract

ive

beha

viou

r.•

Inab

ility

to o

rgan

ize

task

s.•

Fidg

etin

g.•

Very

talk

ativ

e.•

Ofte

n in

terr

upts

.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy

incl

udin

g pa

rent

m

anag

emen

t the

rapy

.•

Educ

atio

nal i

nter

vent

ion.

Phar

mac

olog

ical

the

rapy

:•

Met

hylp

heni

date

(Rita

lin) i

s th

e tr

eatm

ent o

f

choi

ce.

Com

plic

atio

ns•

Subs

tanc

e m

isus

e.•

Diss

ocia

l per

sona

lity

diso

rder

.•

Une

mpl

oym

ent.

• Lo

w s

elf e

stee

m.

• In

crea

sed

rate

of s

uici

de.

Wha

t is

AD

HD

?Th

is is

per

vasi

ve, d

evel

opm

enta

lly in

appr

opria

tebe

havi

our i

n w

hich

the

patie

nt la

cks

conc

entr

atio

nan

d is

hyp

erac

tive.

It is

mor

e co

mm

on in

mal

es

than

fem

ales

and

mus

t be

pres

ent i

n at

leas

t tw

o di

ffere

nt s

ettin

gs (e

.g. a

t hom

e an

d at

sch

ool).

The

sy

mpt

oms

mus

t be

pres

ent f

or a

t lea

st 6

mon

ths.

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mon

al a

nd p

sych

osoc

ial f

acto

rs.

A fe

w e

xam

ples

are

giv

en b

elow

.

Gen

etic

s: p

ossi

ble

invo

lvem

ent o

f chr

omos

omes

5,

6 a

nd 1

1.

Neu

roho

rmon

al: d

ysre

gula

tion

of d

opam

ine

and

nora

dren

alin

e.

Psyc

hoso

cial

: fam

ilial

dys

func

tion,

par

enta

l st

ress

, pot

entia

lly fo

od a

dditi

ves.

Inve

stig

atio

ns•

Ther

e is

no

spec

ific

test

for A

DHD,

but

it is

im

port

ant t

o pe

rform

a fu

ll de

velo

pmen

tal,

m

edic

al a

nd fa

mili

al a

sses

smen

t as

wel

l as

ob

tain

ing

info

rmat

ion

from

the

child

’s sc

hool

co

ncer

ning

thei

r beh

avio

ur.

• Th

e Co

nner

s Co

mpr

ehen

sive

Ass

essm

ent S

cale

may

aid

initi

al a

sses

smen

t and

follo

w-u

p

appo

intm

ents

.

MAP

1.8

. Att

enti

on d

efic

it h

yper

acti

ve d

isor

der

(AD

HD

)

K30033_C001.indd 26 28/02/17 11:02 am

Psyc

hiat

ry27

Map

1.8

. A

tten

tio

n d

efici

t h

yper

acti

ve d

iso

rder

(A

DH

D)

Sym

ptom

s•

Decr

ease

d co

ncen

trat

ion.

• Po

or s

choo

l per

form

ance

.•

Forg

etfu

lnes

s.•

Hype

ract

ive

beha

viou

r.•

Inab

ility

to o

rgan

ize

task

s.•

Fidg

etin

g.•

Very

talk

ativ

e.•

Ofte

n in

terr

upts

.

Trea

tmen

t

Psyc

holo

gica

l the

rapy

:•

CBT.

• Fa

mily

focu

sed

ther

apy

incl

udin

g pa

rent

m

anag

emen

t the

rapy

.•

Educ

atio

nal i

nter

vent

ion.

Phar

mac

olog

ical

the

rapy

:•

Met

hylp

heni

date

(Rita

lin) i

s th

e tr

eatm

ent o

f

choi

ce.

Com

plic

atio

ns•

Subs

tanc

e m

isus

e.•

Diss

ocia

l per

sona

lity

diso

rder

.•

Une

mpl

oym

ent.

• Lo

w s

elf e

stee

m.

• In

crea

sed

rate

of s

uici

de.

Wha

t is

AD

HD

?Th

is is

per

vasi

ve, d

evel

opm

enta

lly in

appr

opria

tebe

havi

our i

n w

hich

the

patie

nt la

cks

conc

entr

atio

nan

d is

hyp

erac

tive.

It is

mor

e co

mm

on in

mal

es

than

fem

ales

and

mus

t be

pres

ent i

n at

leas

t tw

o di

ffere

nt s

ettin

gs (e

.g. a

t hom

e an

d at

sch

ool).

The

sy

mpt

oms

mus

t be

pres

ent f

or a

t lea

st 6

mon

ths.

Caus

esTh

e ca

use

is a

com

plic

ated

inte

ract

ion

betw

een

gene

tics,

neur

ohor

mon

al a

nd p

sych

osoc

ial f

acto

rs.

A fe

w e

xam

ples

are

giv

en b

elow

.

Gen

etic

s: p

ossi

ble

invo

lvem

ent o

f chr

omos

omes

5,

6 a

nd 1

1.

Neu

roho

rmon

al: d

ysre

gula

tion

of d

opam

ine

and

nora

dren

alin

e.

Psyc

hoso

cial

: fam

ilial

dys

func

tion,

par

enta

l st

ress

, pot

entia

lly fo

od a

dditi

ves.

Inve

stig

atio

ns•

Ther

e is

no

spec

ific

test

for A

DHD,

but

it is

im

port

ant t

o pe

rform

a fu

ll de

velo

pmen

tal,

m

edic

al a

nd fa

mili

al a

sses

smen

t as

wel

l as

ob

tain

ing

info

rmat

ion

from

the

child

’s sc

hool

co

ncer

ning

thei

r beh

avio

ur.

• Th

e Co

nner

s Co

mpr

ehen

sive

Ass

essm

ent S

cale

may

aid

initi

al a

sses

smen

t and

follo

w-u

p

appo

intm

ents

.

MAP

1.8

. Att

enti

on d

efic

it h

yper

acti

ve d

isor

der

(AD

HD

)

K30033_C001.indd 27 28/02/17 11:02 am

Psyc

hiat

ry28

Tabl

e 1.

6. D

emen

tia

TABL

E 1.

6. D

emen

tia.

Dem

enti

a is

a s

yndr

ome

of a

pro

gres

sive

glo

bal d

eclin

e in

cog

niti

ve f

unct

ion.

Type

of

dem

enti

aCa

uses

Sign

s an

d sy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Alzh

eim

er’s

dise

ase

Exac

t cau

se u

nkno

wn.

Risk

fact

ors

incl

ude:

• Do

wn’

s sy

ndro

me

due

to ↑

am

yloi

d pr

ecur

sor p

rote

in

(APP

) gen

e lo

ad•

Fam

ilial

gen

e as

soci

atio

ns:

AP

P –

chro

mos

ome

21

Pres

enili

n-1

– ch

rom

osom

e 14

Pr

esen

ilin-

2 –

chro

mos

ome

1

Apol

ipop

rote

in E

4 (A

PoE4

) alle

les

– ch

rom

osom

e 19

•

Hypo

thyr

oidi

sm•

Prev

ious

hea

d tr

aum

a•

Fam

ily h

isto

ry o

f Al

zhei

mer

’s di

seas

e

• Am

nesi

a•

Diso

rient

atio

n•

Chan

ges

in

pers

onal

ity

• De

crea

sing

sel

f car

e•

Apra

xia

• Ag

nosi

a•

Apha

sia

• Le

xial

ano

mia

• Pa

rano

id d

elus

ions

• De

pres

sion

• W

ande

ring

• Ag

gres

sion

• Se

xual

dis

inhi

bitio

n

Men

tal s

tate

exa

min

atio

n an

d m

ini-m

enta

l sta

te

exam

inat

ion

Adde

nbro

oke'

s co

gniti

ve

exam

inat

ion

(ACE

-III)

FBC,

U&

E, L

FTs,

TFTs

, CR

P, ES

R, g

luco

se,

calc

ium

, mag

nesi

um,

phos

phat

e, V

DRL,

HIV

se

rolo

gy, v

itam

in B

12

and

fola

te le

vels,

blo

od

cultu

re, E

CG, c

hest

x-r

ay,

CT, M

RI, S

PECT

Thre

e m

ain

findi

ngs

on

hist

olog

y: B

ATB

– Be

ta a

myl

oid

plaq

ues

A –

↓ A

cety

lcho

line

T –

neur

ofibr

illar

y Ta

ngle

s

• M

eman

tine

– in

hibi

ts g

luta

mat

e by

blo

ckin

g N

MDA

re

cept

ors

• Do

nepe

zil –

ac

etyl

chol

ines

tera

se

inhi

bito

r•

Riva

stig

min

e –

acet

ylch

olin

este

rase

in

hibi

tor

• Am

nesi

a•

Incr

ease

d ris

k of

in

fect

ion

• Dy

spha

gia

• U

rinar

y in

cont

inen

ce•

Incr

ease

d ris

k of

falls

K30033_C001.indd 28 28/02/17 11:02 am

Psyc

hiat

ry29

Tabl

e 1.

6. D

emen

tia

Vasc

ular

dem

entia

• Is

the

seco

nd m

ost

com

mon

cau

se o

f de

men

tia•

Caus

ed b

y in

farc

ts o

f sm

all a

nd m

ediu

m

size

d ve

ssel

s in

the

brai

n•

Gen

etic

ass

ocia

tion

with

cer

ebra

l au

toso

mal

dom

inan

t ar

terio

path

y w

ith s

ubco

rtic

al

infa

rcts

and

le

ukoe

ncep

halo

path

y (C

ADAS

IL) o

n ch

rom

osom

e 19

Follo

ws

a de

terio

ratin

g st

epw

ise

prog

ress

ion.

Th

ere

are

thre

e ty

pes:

1. V

ascu

lar d

emen

tia

follo

win

g st

roke

2. M

ulti-

infa

rct

dem

entia

follo

win

g m

ultip

le s

trok

es3.

Bin

swan

ger

dise

ase

follo

win

g m

icro

vasc

ular

infa

rcts

• Am

nesi

a•

Diso

rient

atio

n•

Chan

ges

in

pers

onal

ity

• De

crea

sing

sel

f car

e•

Depr

essi

on•

Sign

s of

UM

N le

sion

s (e

.g. b

risk

refle

xes)

• Se

izur

es

Men

tal s

tate

exa

min

atio

n an

d m

ini-m

enta

l sta

te

exam

inat

ion

Adde

nbro

oke’

s co

gniti

ve

exam

inat

ion

(ACE

-III)

FBC,

U&

E, L

FTs,

TFTs

, CR

P, ES

R, g

luco

se,

calc

ium

, mag

nesi

um,

phos

phat

e, V

DRL,

HIV

se

rolo

gy, v

itam

in B

12 a

nd

fola

te le

vels,

cho

lest

erol

le

vels,

vas

culit

is s

cree

n,

syph

ilis

sero

logy

, ECG

, ch

est x

-ray

, CT,

MRI

, SP

ECT

• Di

etar

y ad

vice

• Sm

okin

g ce

ssat

ion

• Tr

eat D

M a

nd

hype

rten

sion

• As

pirin

Sign

ifica

nt c

o-m

orbi

dity

(e

.g. c

ardi

ovas

cula

r di

seas

e an

d re

nal

dise

ase)

Cont

inue

d ov

erle

af

K30033_C001.indd 29 28/02/17 11:02 am

Psyc

hiat

ry30

Tabl

e 1.

6. D

emen

tia

TABL

E 1.

6. D

emen

tia.

Dem

enti

a is

a s

yndr

ome

of a

pro

gres

sive

glo

bal d

eclin

e in

cog

niti

ve f

unct

ion

(con

tinue

d ).

Type

of

dem

enti

aCa

uses

Sign

s an

d sy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Dem

entia

with

Lew

y bo

dies

• As

soci

ated

with

Pa

rkin

son’

s di

seas

e•

Avoi

d an

tipsy

chot

ic

drug

s in

thes

e pa

tient

s

Is a

tria

d of

:1.

Par

kins

onia

nism

–

brad

ykin

esia

, gai

t di

sord

er

2. H

allu

cina

tions

–

pred

omin

atel

y vi

sual

, us

ually

of a

nim

als

and

peop

le3.

Dis

ease

pro

cess

fo

llow

s a

fluct

uatin

g co

urse

Men

tal s

tate

exa

min

atio

n an

d m

ini-m

enta

l sta

te

exam

inat

ion

Adde

nbro

oke’

s co

gniti

ve

exam

inat

ion

(ACE

-III)

CT, M

RI, S

PECT

ApoE

gen

otyp

eLe

wy

bodi

es, u

biqu

itin

prot

eins

and

alp

ha-

synu

clei

n fo

und

on

hist

olog

y

• AV

OID

AN

TIPS

YCHO

TICS

–

caus

e hy

pers

ensi

tivity

to

neu

role

ptic

s•

Levo

dopa

may

be

use

d to

trea

t Pa

rkin

son’

s sym

ptom

s bu

t the

se m

ay

wor

sen

psyc

hotic

sy

mpt

oms

• N

euro

lept

ic

hype

rsen

sitiv

ity•

Auto

nom

ic

dysf

unct

ion

• Fl

uctu

atin

g bl

ood

pres

sure

• Ar

rhyt

hmia

s•

Urin

ary

inco

ntin

ence

• Dy

spha

gia

• In

crea

sed

risk

of fa

lls

Fron

tote

mpo

ral

dem

entia

(Pic

k’s

dise

ase)

• G

enet

ic a

ssoc

iatio

n w

ith c

hrom

osom

e 17

q21–

22 a

nd ta

u ge

ne 3

mut

atio

ns

• Am

nesi

a•

Diso

rient

atio

n•

Chan

ges

in

pers

onal

ity

• De

crea

sing

sel

f car

e•

Mut

ism

• Ec

hola

lia•

Ove

reat

ing

• Pa

rkin

soni

sm

• Di

sinh

ibiti

on

Men

tal s

tate

ex

amin

atio

n an

d m

ini-m

enta

l sta

te

exam

inat

ion

Adde

nbro

oke’

s co

gniti

ve

exam

inat

ion

(ACE

-III)

CT, M

RI, S

PECT

Curr

ently

non

e. O

nly

supp

ortiv

e tr

eatm

ent

avai

labl

e.

• In

crea

sed

risk

of fa

lls•

Incr

ease

d ris

k of

in

fect

ion

K30033_C001.indd 30 28/02/17 11:02 am

Psyc

hiat

ry31

Tabl

e 1.

6. D

emen

tia

Hist

olog

y: d

epen

ds o

n su

btyp

e:1.

Mic

rova

cuol

ar ty

pe –

m

icro

vacu

olat

ion

2. P

ick

type

–

wid

espr

ead

glio

sis,

no m

icro

vacu

olat

ion

3. M

ND

type

–

hist

olog

ical

cha

nges

lik

e M

ND

Hunt

ingt

on’s

dem

entia

• Ca

used

by

Hunt

ingt

on’s

dise

ase,

whi

ch is

an

auto

som

al d

omin

ant

diso

rder

whe

re th

ere

is a

def

ectiv

e ge

ne o

n ch

rom

osom

e 4

• Ca

uses

unc

ontr

olla

ble

chor

eifo

rm

mov

emen

ts a

nd

dem

entia

Unc

ontr

olla

ble

chor

eifo

rm m

ovem

ents

Di

agno

stic

gen

etic

te

stin

gN

o cu

re. T

reat

sym

ptom

s:•

Chor

ea –

an

atyp

ical

an

tipsy

chot

ic a

gent

• O

bses

sive

com

puls

ive

thou

ghts

and

irr

itabi

lity

– SS

RIs

• Dy

spha

gia

• In

crea

sed

risk

of fa

lls•

Incr

ease

d ris

k of

in

fect

ion

Cont

inue

d ov

erle

af

K30033_C001.indd 31 28/02/17 11:02 am

Psyc

hiat

ry32

Tabl

e 1.

6. D

emen

tia

TABL

E 1.

6. D

emen

tia.

Dem

enti

a is

a s

yndr

ome

of a

pro

gres

sive

glo

bal d

eclin

e in

cog

niti

ve f

unct

ion

(con

tinue

d ).

Type

of

dem

enti

aCa

uses

Sign

s an

d sy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Creu

tzfe

ldt–

Jako

b di

seas

e (C

JD)

• Ca

used

by

prio

ns•

Prog

ress

ive

and

with

out c

ure

• Th

ere

is a

lso

varia

nt

CJD

(vCJ

D), w

hich

ha

s an

ear

lier o

nset

of

dea

th

• Ra

pidl

y pr

ogre

ssiv

e de

men

tia (4

–5 m

onth

s)•

Amne

sia

• Di

sorie

ntat

ion

• Ch

ange

s in

pe

rson

ality

• De

pres

sion

• Ps

ycho

sis

• At

axia

• Se

izur

es

EEG

– tr

ipha

sic

spik

es

seen

LP –

for 1

4-3-

3 pr

otei

nCT

, MRI

No

cure

•

Incr

ease

d ris

k of

in

fect

ion

• Co

ma

• He

art f

ailu

re•

Resp

irato

ry fa

ilure

Oth

er c

ause

s•

HIV

• Vi

tam

in B

12 d

efici

ency

• Sy

phili

s•

Wils

on’s

dise

ase

– au

toso

mal

rece

ssiv

e co

nditi

on w

here

co

pper

acc

umul

ates

w

ithin

the

tissu

es•

Dem

entia

pug

ilist

ica

(aka

“pu

nch

drun

k”

synd

rom

e) –

see

n in

bo

xers

and

pat

ient

s w

ho s

uffe

r mul

tiple

co

ncus

sion

s

K30033_C001.indd 32 28/02/17 11:02 am

TABL

E 2.

1 U

K a

nte

nat

al b

oo

kin

g

app

oin

tmen

ts

34

TABL

E 2.

2 T

he

ph

ysio

log

y o

f la

bo

ur

37

TABL

E 2.

3 D

ysto

cia

38

MAP

2.1

P

rob

lem

s in

pre

gn

ancy

39

MAP

2.2

D

iab

etes

mel

litu

s (D

M)

in p

reg

nan

cy

40

MAP

2.3

E

pile

psy

in p

reg

nan

cy

42

MAP

2.4

P

re-e

clam

psi

a 44

MAP

2.5

L

iver

dis

ease

un

iqu

e to

p

reg

nan

cy

46

MAP

2.6

T

OR

CH

ES in

fect

ion

s 50

MAP

2.7

T

oxo

pla

smo

sis

51

MAP

2.8

R

ub

ella

52

MAP

2.9

C

yto

meg

alo

viru

s (C

MV

) 54

MAP

2.1

0 H

erp

es s

imp

lex

viru

s (H

SV)

55

MAP

2.1

1 H

um

an im

mu

no

defi

cien

cy v

iru

s (H

IV)

56

MAP

2.1

2 Sy

ph

ilis

58

MAP

2.1

3 Pl

acen

tal a

bru

pti

on

60

MAP

2.1

4 Pl

acen

ta p

raev

ia

62

MAP

2.1

5 Po

st-p

artu

m h

aem

orr

hag

e (P

PH)

64

MAP

2.1

6 R

hes

us

dis

ease

66

MAP

2.1

7 Sy

mp

hys

is p

ub

is d

ysfu

nct

ion

68

TABL

E 2.

4 B

reas

tfee

din

g

69

Chap

ter T

wo

Obs

tetr

ics

33O

bste

tric

s

K30033_C002.indd 33 28/02/17 11:15 am

34O

bste

tric

sTa

ble

2.1.

UK

an

ten

atal

bo

oki

ng

ap

po

intm

ents

TABL

E 2.

1. U

K a

nten

atal

boo

king

app

oint

men

ts. U

sefu

l web

site

tha

t su

mm

ariz

es t

he c

urre

nt p

rogr

amm

e: h

ttp:

//cpd

. sc

reen

ing.

nhs.

uk/fl

ashv

ideo

/NH

SPre

gnan

cySc

reen

ing.

mp4

.

Ges

tati

onW

hat

happ

ens

duri

ng t

he a

ppoi

ntm

ent?

8–12

wee

ksTh

is is

the

initi

al b

ooki

ng a

ppoi

ntm

ent:

• Ta

ke a

gen

eral

his

tory

enq

uirin

g ab

out p

ast m

edic

al m

ater

nal h

isto

ry a

nd m

ater

nal l

ifest

yle

fact

ors

incl

udin

g al

coho

l, sm

okin

g an

d di

et.

Also

, ask

abo

ut fo

lic a

cid

and

vita

min

D s

uppl

emen

tatio

n. S

tart

thes

e su

pple

men

ts if

they

are

not

bei

ng ta

ken

• M

easu

re b

lood

pre

ssur

e•

Perfo

rm a

urin

e di

p st

ick

and

cultu

re (f

or a

sym

ptom

atic

bac

teriu

ria)

• M

easu

re p

atie

nt’s

BMI

• Ro

utin

e bl

ood

test

s: FB

C, b

lood

gro

up, r

hesu

s st

atus

, red

blo

od c

ell a

lloan

tibod

ies

• Sc

reen

for i

nfec

tious

dis

ease

: HIV

, hep

atiti

s B,

rube

lla, s

yphi

lis

10–1

3 +

6 w

eeks

• Da

te c

onfir

min

g sc

an•

Scre

ens

for m

ultip

le p

regn

ancy

11–1

3 +

6 w

eeks

• Do

wn’

s sy

ndro

me

scre

enin

g: th

e co

mbi

ned

test

is o

ffere

d to

wom

en 1

1–14

wee

ks g

esta

tion.

Thi

s co

nsis

ts o

f the

nuc

hal t

rans

luce

ncy

scan

and

blo

od te

sts

(ser

um b

eta

hum

an c

horio

nic

gona

dotr

opin

and

ser

um p

regn

ancy

-ass

ocia

ted

plas

ma

prot

ein

A)

16 w

eeks

• Ro

utin

e bl

ood

test

: FBC

– g

ive

iron

supp

lem

enta

tion

if an

aem

ic•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

18–2

0 +

6 w

eeks

•

Feta

l ano

mal

y sc

an

25 w

eeks

O

nly

for p

rimip

arou

s m

othe

rs:

• M

easu

re s

ymph

ysis

–fun

dal h

eigh

t (SF

H)•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

K30033_C002.indd 34 28/02/17 11:15 am

35O

bste

tric

sTa

ble

2.1.

UK

an

ten

atal

bo

oki

ng

ap

po

intm

ents

28 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

• Ro

utin

e bl

ood

test

: FBC

– g

ive

iron

supp

lem

enta

tion

if an

aem

ic. C

heck

for a

typi

cal r

ed b

lood

cel

l allo

antib

odie

s•

Giv

e an

ti-D

prop

hyla

xis

to rh

esus

-neg

ativ

e m

othe

rs

31 w

eeks

O

nly

for p

rimip

arou

s m

othe

rs:

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

34 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

• G

ive

anti-

D pr

ophy

laxi

s to

rhes

us-n

egat

ive

mot

hers

• Co

unse

l mot

her a

bout

birt

hing

pla

n an

d sp

ecifi

c w

ishe

s or

con

cern

s

36 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

• Ex

tern

al c

epha

lic v

ersi

on fo

r bre

ech

pres

enta

tions

• Co

unse

l mot

her a

bout

bre

ast f

eedi

ng a

nd p

ost-

nata

l dep

ress

ion/

baby

blu

es

38 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

Cont

inue

d ov

erle

af

K30033_C002.indd 35 28/02/17 11:15 am

36O

bste

tric

sTa

ble

2.1.

UK

an

ten

atal

bo

oki

ng

ap

po

intm

ents

TABL

E 2.

1. U

K a

nten

atal

boo

king

app

oint

men

ts. U

sefu

l web

site

tha

t su

mm

ariz

es t

he c

urre

nt p

rogr

amm

e: h

ttp:

//cpd

. sc

reen

ing.

nhs.

uk/fl

ashv

ideo

/NH

SPre

gnan

cySc

reen

ing.

mp4

(con

tinue

d  ).

Ges

tati

onW

hat

happ

ens

duri

ng t

he a

ppoi

ntm

ent?

40 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

• Co

unse

l mot

her a

bout

indu

ctio

n of

labo

ur

41 w

eeks

• M

easu

re S

FH•

Mea

sure

blo

od p

ress

ure

• Pe

rform

a u

rine

dip

stic

k an

d cu

lture

• Co

unse

l mot

her a

bout

indu

ctio

n of

labo

ur

K30033_C002.indd 36 28/02/17 11:15 am

37O

bste

tric

sTa

ble

2.2.

Th

e p

hys

iolo

gy

of

lab

ou

r

TABL

E 2.

2. T

he p

hysi

olog

y of

labo

ur. T

here

are

thr

ee s

tage

s of

labo

ur a

nd t

he s

ucce

ss o

f ea

ch s

tage

dep

ends

on

mat

erna

l, fe

tal a

nd m

echa

nica

l fac

tors

.

Stag

e of

labo

urSu

bcat

egor

ies

App

roxi

mat

e du

rati

onSp

ecifi

c in

vest

igat

ions

1. O

nset

of c

ontr

actio

ns u

ntil

full

dila

tatio

n of

the

cerv

ix1.

Lat

ent s

tage

– u

ntil

the

cerv

ix

reac

hes

4 cm

2. A

ctiv

e st

age

– fro

m 4

–10

cm

Varia

ble

Mea

sure

feta

l hea

rt ra

te u

sing

CTG

Mea

sure

mat

erna

l hea

rt ra

te, b

lood

pr

essu

re a

nd te

mpe

ratu

re

2. F

rom

full

dila

tatio

n of

the

cerv

ix u

ntil

the

deliv

ery

of

the

fetu

s

May

be

split

into

a p

assi

ve a

nd a

n ac

tive

stag

e.

The

fetu

s m

echa

nica

lly fo

llow

s a

path

way

to

be

expe

lled

from

the

uter

us.

This

pat

hway

is a

s fo

llow

s:

1. T

he h

ead

beco

mes

eng

aged

2. T

he fe

tus

desc

ends

to ‘s

tatio

n ze

ro’ (

the

leve

l of t

he is

chia

l spi

nes)

3. H

ead

flexi

on4.

Hea

d ro

tate

s in

tern

ally

5. H

ead

exte

nds

6. H

ead

rota

tes

exte

rnal

ly7.

Sho

ulde

rs a

nd b

ody

are

subs

eque

ntly

de

liver

ed

2–3

hour

s M

easu

re fe

tal h

eart

rate

usi

ng C

TGM

easu

re m

ater

nal h

eart

rate

, blo

od

pres

sure

and

tem

pera

ture

3. F

rom

del

iver

y of

the

fetu

s un

til d

eliv

ery

of th

e pl

acen

taN

ote

umbi

lical

cor

d le

ngth

enin

g 30

min

utes

M

easu

re fe

tal r

espo

nse

usin

g th

e

APG

AR s

core

Chec

k m

ater

nal v

ital s

igns

K30033_C002.indd 37 28/02/17 11:15 am

38O

bste

tric

sTa

ble

2.3.

Dys

toci

a

TABL

E 2.

3. D

ysto

cia.

In la

yman

’s t

erm

s th

is m

eans

dif

ficu

lt c

hild

birt

h. T

here

are

man

y re

ason

s w

hy c

hild

birt

h m

ay b

e di

fficu

lt a

nd t

hese

may

be

clas

sifi

ed in

to m

ater

nal c

ause

s, f

etal

cau

ses

and

mec

hani

cal c

ause

s. S

ome

exam

ples

are

pr

esen

ted

belo

w.

Mat

erna

l fac

tors

Feta

l fac

tors

Mec

hani

cal f

acto

rs

Inef

fect

ive

uter

ine

cont

ract

ion:

this

ofte

n oc

curs

in

nul

lipar

ous

wom

en w

ho h

ave

had

a pr

olon

ged

labo

ur

Mat

erna

l illn

ess

(e.g

. dia

bete

s m

ellit

us,

pre-

ecla

mps

ia, e

clam

psia

)

Prob

lem

atic

pla

cent

al im

plan

tati

on

(e.g

. pla

cent

a pr

aevi

a)

Feta

l mal

pres

enta

tion

Mac

roso

mia

: ass

ocia

ted

with

mat

erna

l dia

bete

s

Ceph

alop

elvi

c di

spro

port

ion:

ther

e ar

e fo

ur b

road

an

atom

ical

type

s of

fem

ale

pelv

is:

• G

ynec

oid

• An

droi

d•

Anth

ropo

id•

Plat

ypel

loid

Shou

lder

dys

toci

a: th

is h

as a

var

iety

of

asso

ciat

ions

suc

h as

dia

bete

s m

ellit

us, m

acro

som

ia,

smal

l mat

erna

l siz

e an

d a

past

obs

tetr

ic h

isto

ry o

f sh

ould

er d

ysto

cia.

To m

anag

e th

is p

robl

em s

ever

al

man

oeuv

res

may

be

empl

oyed

sta

rtin

g w

ith th

e M

cRob

ert’s

man

oeuv

re. O

ther

s in

clud

e th

e W

ood’

s sc

rew

pro

cedu

re a

nd th

e Za

vane

lli m

anoe

uvre

K30033_C002.indd 38 28/02/17 11:15 am

39O

bste

tric

sM

ap 2

.1.

Pro

ble

ms

in p

reg

nan

cy

Dis

orde

rs r

elat

ing

to h

igh

bloo

dpr

essu

re•

Pre-

ecla

mps

ia (s

ee M

ap 2

.4, p

. 44)

• Ec

lam

psia

Live

r di

seas

e un

ique

to

preg

nanc

y•

Hype

rem

esis

gra

vida

rum

(see

Map

2.5

, p. 4

6)•

Intr

ahep

atic

cho

lest

asis

of p

regn

ancy

(s

ee M

ap 2

.5, p

. 46)

• Ac

ute

fatt

y liv

er o

f pre

gnan

cy (s

ee M

ap

2.5,

p. 4

6)

Infe

ctio

ns•

TORC

HES

(see

Map

2.6

, p. 5

0)

Endo

crin

e di

sord

ers

• Di

abet

es m

ellit

us (s

ee M

ap 2

.2, p

. 40

)N

euro

logi

cal d

isor

ders

• Ep

ileps

y (s

ee M

ap 2

.3, p

. 42)

MAP

2.1

. Pro

blem

s in

pre

gnan

cy

K30033_C002.indd 39 28/02/17 11:15 am

40O

bste

tric

sM

ap 2

.2.

Dia

bet

es m

ellit

us

(DM

) in

pre

gn

ancy

Wha

t is

diab

etes

mel

litus

in p

regn

ancy

?Th

is is

met

abol

ic c

ondi

tion

in w

hich

the

patie

ntha

s hy

perg

lyca

emia

due

to in

sulin

inse

nsiti

vity

or d

ecre

ased

insu

lin s

ecre

tion.

Caus

esTh

ese

may

be:

Pre-

exis

ting

. The

re a

re m

any

– on

ly a

few

com

mon

cau

ses

are

liste

d he

re:

• Ty

pe 1

DM

: thi

s is

an

auto

imm

une

cond

ition

,

whi

ch re

sults

in th

e de

stru

ctio

n of

the

p

ancr

eatic

bet

a ce

lls re

sulti

ng in

no

insu

lin

pro

duct

ion.

Thi

s co

nditi

on h

as a

juve

nile

o

nset

and

is a

ssoc

iate

d w

ith H

LA-D

R3 a

nd

HLA

-DR4

. Pat

ient

s ar

e at

risk

of k

etoa

cido

sis.

• Ty

pe 2

DM

: thi

s oc

curs

whe

n pa

tient

s

gra

dual

ly b

ecom

e in

sulin

resi

stan

t or w

hen

t

he p

ancr

eatic

bet

a ce

lls fa

il to

sec

rete

e

noug

h in

sulin

, or b

oth.

It u

sual

ly h

as a

late

r

life

ons

et; h

owev

er, t

he in

cide

nce

is in

crea

sing

i

n yo

ung

popu

latio

ns d

ue to

env

ironm

enta

l

fac

tors

suc

h as

incr

easi

ng o

besi

ty a

nd

sed

enta

ry li

fest

yle.

Pat

ient

s ar

e at

risk

of

d

evel

opin

g a

hype

rosm

olar

sta

te.

• Ch

roni

c pa

ncre

atiti

s: th

is c

ondi

tion

dest

roys

b

oth

alph

a an

d be

ta p

ancr

eatic

cel

ls s

o th

at

glu

cago

n an

d in

sulin

are

no

long

er p

rodu

ced

a

nd s

ecre

ted.

Sym

ptom

s•

Gen

eral

: pol

yuria

, pol

ypha

gia,

poly

dips

ia, b

lurr

ed v

isio

n, g

lyco

suria

, sig

ns

of

mac

rova

scul

ar a

nd m

icro

vasc

ular

dis

ease

.•

Mor

e co

mm

on in

type

1 D

M: a

ceto

ne

brea

th, w

eigh

t los

s, Ku

ssm

aul

br

eath

ing,

nau

sea

and

vom

iting

.

Trea

tmen

t (g

esta

tion

al D

M s

peci

fic)

Cons

erva

tive

:•

Ensu

re th

at m

othe

r is

unde

r con

sulta

nt

led

care

.•

Ensu

re m

othe

r is

taki

ng a

hig

her d

ose

of

folic

aci

d (5

mg/

day)

due

to a

n in

crea

sed

ris

k of

neu

ral t

ube

defe

cts.

• Di

et c

ontr

ol.

• In

crea

sed

exer

cise

.

Med

ical

:•

Met

form

in.

• In

sulin

.

Inve

stig

atio

ns

Dia

gnos

tic

inve

stig

atio

ns fo

r D

M a

re:

• Fa

stin

g pl

asm

a gl

ucos

e: >

7 m

mol

/L

(12

6 m

g/dL

).•

Rand

om p

lasm

a gl

ucos

e (p

lus

DM s

ympt

oms)

:

>11

.1 m

mol

/L (2

00 m

g/dL

).•

HbA1

C: >

6.5%

.

Oth

er t

ests

incl

ude:

• Im

paire

d gl

ucos

e to

lera

nce

test

(for

bor

derli

ne

case

s):

Fast

ing

plas

ma

gluc

ose:

<7

mm

ol/L

(126

mg/

dL) a

nd a

t 2 h

ours

a le

vel o

f 7.8

–11

mm

ol/L

(140

–200

mg/

dL)

Plas

ma

gluc

ose

at 2

hou

rs: >

11.1

mm

ol/L

(>20

0 m

g/dL

)•

Impa

ired

fast

ing

gluc

ose:

Plas

ma

gluc

ose:

5.6

–6.9

mm

ol/L

(110

–126

mg/

dL).

Spec

ific

to g

esta

tion

al D

M:

• O

ral g

luco

se to

lera

nce

test

at 1

6–18

wee

ks

and

at 2

8 w

eeks

if in

itial

test

is n

orm

al.

• G

esta

tiona

l dia

bete

s m

ay b

e di

agno

sed

whe

n

the

blo

od g

luco

se le

vel i

s >

9 m

mol

/L 2

hou

rs

a

fter a

75

g or

al g

luco

se lo

ad.

Com

plic

atio

ns

Gen

eral

:•

Mac

rova

scul

ar: h

yper

tens

ion,

incr

ease

d ris

k

of s

trok

e, m

yoca

rdia

l inf

arct

ion,

dia

betic

foot

.•

Mic

rova

scul

ar: n

ephr

opat

hy, n

euro

path

y

(glo

ve a

nd s

tock

ing

dist

ribut

ion)

, ret

inop

athy

.•

Psyc

holo

gica

l: de

pres

sion

.

Feta

l:•

Neu

ral t

ube

and

card

iac

defe

cts.

• M

acro

som

ia a

nd s

houl

der d

ysto

cia.

• N

eona

tal h

ypog

lyca

emia

.

Mat

erna

l:•

DM la

ter i

n lif

e.•

Pote

ntia

lly in

stru

men

tal d

eliv

ery

or c

aesa

rean

se

ctio

n.

MAP

2.2

.D

iabe

tes

mel

litus

(DM

) in

preg

nanc

y

Ges

tati

onal

(i.e

. it d

evel

oped

dur

ing

preg

nanc

y). T

his

ofte

n no

rmal

izes

afte

r the

bab

yis

del

iver

ed b

ut m

any

wom

en g

o on

tode

velo

p DM

late

r in

life.

The

exa

ct c

ause

of

gest

atio

nal d

iabe

tes

is u

nkno

wn.

It is

ass

ocia

ted

with

man

y ris

k fa

ctor

s su

ch a

s hi

gh m

ater

nal

BMI,

ethn

ic o

rigin

with

a h

igh

prev

alen

ce in

thos

e w

ith S

outh

Asi

an a

nces

try,

a pr

evio

ushi

stor

y of

ges

tatio

nal d

iabe

tes

or a

mac

roso

mic

baby

(wei

ght >

4.5

kg).

K30033_C002.indd 40 28/02/17 11:15 am

41O

bste

tric

sM

ap 2

.2.

Dia

bet

es m

ellit

us

(DM

) in

pre

gn

ancy

Wha

t is

diab

etes

mel

litus

in p

regn

ancy

?Th

is is

met

abol

ic c

ondi

tion

in w

hich

the

patie

ntha

s hy

perg

lyca

emia

due

to in

sulin

inse

nsiti

vity

or d

ecre

ased

insu

lin s

ecre

tion.

Caus

esTh

ese

may

be:

Pre-

exis

ting

. The

re a

re m

any

– on

ly a

few

com

mon

cau

ses

are

liste

d he

re:

• Ty

pe 1

DM

: thi

s is

an

auto

imm

une

cond

ition

,

whi

ch re

sults

in th

e de

stru

ctio

n of

the

p

ancr

eatic

bet

a ce

lls re

sulti

ng in

no

insu

lin

pro

duct

ion.

Thi

s co

nditi

on h

as a

juve

nile

o

nset

and

is a

ssoc

iate

d w

ith H

LA-D

R3 a

nd

HLA

-DR4

. Pat

ient

s ar

e at

risk

of k

etoa

cido

sis.

• Ty

pe 2

DM

: thi

s oc

curs

whe

n pa

tient

s

gra

dual

ly b

ecom

e in

sulin

resi

stan

t or w

hen

t

he p

ancr

eatic

bet

a ce

lls fa

il to

sec

rete

e

noug

h in

sulin

, or b

oth.

It u

sual

ly h

as a

late

r

life

ons

et; h

owev

er, t

he in

cide

nce

is in

crea

sing

i

n yo

ung

popu

latio

ns d

ue to

env

ironm

enta

l

fac

tors

suc

h as

incr

easi

ng o

besi

ty a

nd

sed

enta

ry li

fest

yle.

Pat

ient

s ar

e at

risk

of

d

evel

opin

g a

hype

rosm

olar

sta

te.

• Ch

roni

c pa

ncre

atiti

s: th

is c

ondi

tion

dest

roys

b

oth

alph

a an

d be

ta p

ancr

eatic

cel

ls s

o th

at

glu

cago

n an

d in

sulin

are

no

long

er p

rodu

ced

a

nd s

ecre

ted.

Sym

ptom

s•

Gen

eral

: pol

yuria

, pol

ypha

gia,

poly

dips

ia, b

lurr

ed v

isio

n, g

lyco

suria

, sig

ns

of

mac

rova

scul

ar a

nd m

icro

vasc

ular

dis

ease

.•

Mor

e co

mm

on in

type

1 D

M: a

ceto

ne

brea

th, w

eigh

t los

s, Ku

ssm

aul

br

eath

ing,

nau

sea

and

vom

iting

.

Trea

tmen

t (g

esta

tion

al D

M s

peci

fic)

Cons

erva

tive

:•

Ensu

re th

at m

othe

r is

unde

r con

sulta

nt

led

care

.•

Ensu

re m

othe

r is

taki

ng a

hig

her d

ose

of

folic

aci

d (5

mg/

day)

due

to a

n in

crea

sed

ris

k of

neu

ral t

ube

defe

cts.

• Di

et c

ontr

ol.

• In

crea

sed

exer

cise

.

Med

ical

:•

Met

form

in.

• In

sulin

.

Inve

stig

atio

ns

Dia

gnos

tic

inve

stig

atio

ns fo

r D

M a

re:

• Fa

stin

g pl

asm

a gl

ucos

e: >

7 m

mol

/L

(12

6 m

g/dL

).•

Rand

om p

lasm

a gl

ucos

e (p

lus

DM s

ympt

oms)

:

>11

.1 m

mol

/L (2

00 m

g/dL

).•

HbA1

C: >

6.5%

.

Oth

er t

ests

incl

ude:

• Im

paire

d gl

ucos

e to

lera

nce

test

(for

bor

derli

ne

case

s):

Fast

ing

plas

ma

gluc

ose:

<7

mm

ol/L

(126

mg/

dL) a

nd a

t 2 h

ours

a le

vel o

f 7.8

–11

mm

ol/L

(140

–200

mg/

dL)

Plas

ma

gluc

ose

at 2

hou

rs: >

11.1

mm

ol/L

(>20

0 m

g/dL

)•

Impa

ired

fast

ing

gluc

ose:

Plas

ma

gluc

ose:

5.6

–6.9

mm

ol/L

(110

–126

mg/

dL).

Spec

ific

to g

esta

tion

al D

M:

• O

ral g

luco

se to

lera

nce

test

at 1

6–18

wee

ks

and

at 2

8 w

eeks

if in

itial

test

is n

orm

al.

• G

esta

tiona

l dia

bete

s m

ay b

e di

agno

sed

whe

n

the

blo

od g

luco

se le

vel i

s >

9 m

mol

/L 2

hou

rs

a

fter a

75

g or

al g

luco

se lo

ad.

Com

plic

atio

ns

Gen

eral

:•

Mac

rova

scul

ar: h

yper

tens

ion,

incr

ease

d ris

k

of s

trok

e, m

yoca

rdia

l inf

arct

ion,

dia

betic

foot

.•

Mic

rova

scul

ar: n

ephr

opat

hy, n

euro

path

y

(glo

ve a

nd s

tock

ing

dist

ribut

ion)

, ret

inop

athy

.•

Psyc

holo

gica

l: de

pres

sion

.

Feta

l:•

Neu

ral t

ube

and

card

iac

defe

cts.

• M

acro

som

ia a

nd s

houl

der d

ysto

cia.

• N

eona

tal h

ypog

lyca

emia

.

Mat

erna

l:•

DM la

ter i

n lif

e.•

Pote

ntia

lly in

stru

men

tal d

eliv

ery

or c

aesa

rean

se

ctio

n.

MAP

2.2

.D

iabe

tes

mel

litus

(DM

) in

preg

nanc

y

Ges

tati

onal

(i.e

. it d

evel

oped

dur

ing

preg

nanc

y). T

his

ofte

n no

rmal

izes

afte

r the

bab

yis

del

iver

ed b

ut m

any

wom

en g

o on

tode

velo

p DM

late

r in

life.

The

exa

ct c

ause

of

gest

atio

nal d

iabe

tes

is u

nkno

wn.

It is

ass

ocia

ted

with

man

y ris

k fa

ctor

s su

ch a

s hi

gh m

ater

nal

BMI,

ethn

ic o

rigin

with

a h

igh

prev

alen

ce in

thos

e w

ith S

outh

Asi

an a

nces

try,

a pr

evio

ushi

stor

y of

ges

tatio

nal d

iabe

tes

or a

mac

roso

mic

baby

(wei

ght >

4.5

kg).

K30033_C002.indd 41 28/02/17 11:15 am

42O

bste

tric

sM

ap 2

.3.

Epile

psy

in p

reg

nan

cy

Com

plic

atio

ns (p

regn

ancy

spe

cific

)

Gen

eral

:•

Inju

ries

whi

le h

avin

g se

izur

e.•

Depr

essi

on.

• An

xiet

y.•

Brai

n da

mag

e.•

Sudd

en u

nexp

lain

ed d

eath

in e

pile

psy

(

SUDE

P).

Feta

l:•

Neu

ral t

ube

defe

cts

(ass

ocia

ted

with

sod

ium

va

lpro

ate

espe

cial

ly).

• Cl

eft p

alat

e (a

ssoc

iate

d w

ith p

heny

toin

).•

Intr

aute

rine

grow

th re

stric

tion.

• De

velo

pmen

tal d

elay

.

Inve

stig

atio

nsN

ote

that

epi

leps

y w

ill o

ften

be d

iagn

osed

befo

re th

e la

dy fa

lls p

regn

ant.

How

ever

, the

fo

llow

ing

test

s ar

e us

ed to

hel

p ai

d th

edi

agno

sis

of e

pile

psy

and

iden

tify

the

caus

e.•

Bloo

ds –

FBC

, U&

E, L

FTs,

CRP,

ESR,

glu

cose

,

cal

cium

leve

ls•

Radi

olog

y –

MRI

• O

ther

– E

CG, L

P, EE

G

Wha

t is

epi

leps

y?Th

is is

a c

ondi

tion

in w

hich

the

brai

n is

affe

cted

by re

curr

ent s

eizu

res.

Caus

esSe

izur

es a

re c

ause

d by

abn

orm

al p

arox

ysm

alne

uron

al d

isch

arge

s in

the

brai

n, w

hich

are

usua

lly a

resu

lt of

som

e fo

rm o

f tra

umat

ic b

rain

inju

ry. T

hese

dis

char

ges

disp

lay

hype

rsyn

chro

niza

tion.

The

cau

ses

of e

pile

psy

may

be

broa

dly

class

ified

into

thre

e ty

pes:

1. I

diop

athi

c –

caus

e fo

r epi

leps

y is

unk

now

n.2.

Cry

ptog

enic

– c

ause

for e

pile

psy

is u

nkno

wn,

b

ut th

ere

are

sign

s th

at s

ugge

st th

at th

e

cau

se m

ay b

e lin

ked

to b

rain

inju

ry (e

.g.

p

atie

nt h

as a

utis

m o

r lea

rnin

g di

fficu

lties

).3.

Sym

ptom

atic

– c

ause

kno

wn.

Som

e ca

uses

of

sy

mpt

omat

ic e

pile

psy

incl

ude:

VIN

DIC

ATE:

V

– Va

scul

ar: h

isto

ry o

f str

oke

I

– In

fect

ion:

hist

ory

of m

enin

gitis

or m

alar

ia

N –

Neo

plas

ms:

brai

n tu

mou

r

D –

Dru

gs: a

lcoh

ol a

nd il

licit

drug

use

I

– Ia

trog

enic

: dru

g w

ithdr

awal

C

– Co

ngen

ital:

fam

ily h

isto

ry o

f epi

leps

y

A –

Aut

oim

mun

e: v

ascu

litis

T

– Tr

aum

a: h

isto

ry o

f bra

in in

jury

E

– En

docr

ine:

¯N

a+, ¯

Ca2+

, ¯ o

r g

luco

se

Trea

tmen

t (p

regn

ancy

spe

cific

)Co

ntin

uing

ant

iepi

lept

ic th

erap

y du

ring

preg

nanc

y is

adv

isab

le s

ince

the

risks

of h

avin

gse

izur

es w

hile

pre

gnan

t out

wei

gh th

e ha

rm o

fth

erap

y on

the

fetu

s.

Cons

erva

tive

:•

Ensu

re th

at m

othe

r is

unde

r con

sulta

nt

led

care

.•

Ensu

re m

othe

r is

taki

ng a

hig

her d

ose

of fo

lic

acid

(5 m

g/da

y) d

ue to

an

incr

ease

d ris

k of

ne

ural

tube

def

ects

.

Med

ical

:•

Neo

nata

l car

e –

vita

min

K in

ject

ion.

• Ca

rbam

azep

ine

is c

onsi

dere

d to

be

the

leas

t

tera

toge

nic

of th

e ol

der a

ntie

pile

ptic

age

nts.

• So

dium

val

proa

te h

as th

e st

rong

est

a

ssoc

iatio

n w

ith n

eura

l tub

e de

fect

s.

Sign

s an

d sy

mpt

oms

Thes

e de

pend

on

the

regi

on o

f the

bra

inaf

fect

ed.

• F

ront

al lo

be: J

AM

:

J –

Jack

soni

an m

arch

.

A –

pA

lsy

(pos

t-ic

tal T

odd’

s pa

lsy)

.

M –

Mot

or fe

atur

es.

• T

empo

ral l

obe:

AD

D F

AT:

A

– A

ura

that

the

epile

ptic

att

ack

will

occ

ur.

D

– D

éjà

vu.

D

– D

elus

iona

l beh

avio

ur.

F

– F

ear/p

anic

– h

ippo

cam

pal i

nvol

vem

ent.

A

– A

utom

atis

ms.

T

– Ta

ste/

smel

l – u

ncal

invo

lvem

ent.

• P

arie

tal a

nd o

ccip

ital

lobe

s:

Visu

al a

nd s

enso

ry d

istu

rban

ces

Oth

ers

incl

ude:

par

tial o

r gen

eral

ized

seiz

ures

with

or w

ithou

t con

vuls

ions

, to

ngue

biti

ng, m

igra

ines

and

dep

ress

ion.

MAP

2.3

. Epi

leps

y in

pre

gnan

cy

K30033_C002.indd 42 28/02/17 11:15 am

Com

plic

atio

ns (p

regn

ancy

spe

cific

)

Gen

eral

:•

Inju

ries

whi

le h

avin

g se

izur

e.•

Depr

essi

on.

• An

xiet

y.•

Brai

n da

mag

e.•

Sudd

en u

nexp

lain

ed d

eath

in e

pile

psy

(

SUDE

P).

Feta

l:•

Neu

ral t

ube

defe

cts

(ass

ocia

ted

with

sod

ium

va

lpro

ate

espe

cial

ly).

• Cl

eft p

alat

e (a

ssoc

iate

d w

ith p

heny

toin

).•

Intr

aute

rine

grow

th re

stric

tion.

• De

velo

pmen

tal d

elay

.

Inve

stig

atio

nsN

ote

that

epi

leps

y w

ill o

ften

be d

iagn

osed

befo

re th

e la

dy fa

lls p

regn

ant.

How

ever

, the

fo

llow

ing

test

s ar

e us

ed to

hel

p ai

d th

edi

agno

sis

of e

pile

psy

and

iden

tify

the

caus

e.•

Bloo

ds –

FBC

, U&

E, L

FTs,

CRP,

ESR,

glu

cose

,

cal

cium

leve

ls•

Radi

olog

y –

MRI

• O

ther

– E

CG, L

P, EE

G

Wha

t is

epi

leps

y?Th

is is

a c

ondi

tion

in w

hich

the

brai

n is

affe

cted

by re

curr

ent s

eizu

res.

Caus

esSe

izur

es a

re c

ause

d by

abn

orm

al p

arox

ysm

alne

uron

al d

isch

arge

s in

the

brai

n, w

hich

are

usua

lly a

resu

lt of

som

e fo

rm o

f tra

umat

ic b

rain

inju

ry. T

hese

dis

char

ges

disp

lay

hype

rsyn

chro

niza

tion.

The

cau

ses

of e

pile

psy

may

be

broa

dly

class

ified

into

thre

e ty

pes:

1. I

diop

athi

c –

caus

e fo

r epi

leps

y is

unk

now

n.2.

Cry

ptog

enic

– c

ause

for e

pile

psy

is u

nkno

wn,

b

ut th

ere

are

sign

s th

at s

ugge

st th

at th

e

cau

se m

ay b

e lin

ked

to b

rain

inju

ry (e

.g.

p

atie

nt h

as a

utis

m o

r lea

rnin

g di

fficu

lties

).3.

Sym

ptom

atic

– c

ause

kno

wn.

Som

e ca

uses

of

sy

mpt

omat

ic e

pile

psy

incl

ude:

VIN

DIC

ATE:

V

– Va

scul

ar: h

isto

ry o

f str

oke

I

– In

fect

ion:

hist

ory

of m

enin

gitis

or m

alar

ia

N –

Neo

plas

ms:

brai

n tu

mou

r

D –

Dru

gs: a

lcoh

ol a

nd il

licit

drug

use

I

– Ia

trog

enic

: dru

g w

ithdr

awal

C

– Co

ngen

ital:

fam

ily h

isto

ry o

f epi

leps

y

A –

Aut

oim

mun

e: v

ascu

litis

T

– Tr

aum

a: h

isto

ry o

f bra

in in

jury

E

– En

docr

ine:

¯N

a+, ¯

Ca2+

, ¯ o

r g

luco

se

Trea

tmen

t (p

regn

ancy

spe

cific

)Co

ntin

uing

ant

iepi

lept

ic th

erap

y du

ring

preg

nanc

y is

adv

isab

le s

ince

the

risks

of h

avin

gse

izur

es w

hile

pre

gnan

t out

wei

gh th

e ha

rm o

fth

erap

y on

the

fetu

s.

Cons

erva

tive

:•

Ensu

re th

at m

othe

r is

unde

r con

sulta

nt

led

care

.•

Ensu

re m

othe

r is

taki

ng a

hig

her d

ose

of fo

lic

acid

(5 m

g/da

y) d

ue to

an

incr

ease

d ris

k of

ne

ural

tube

def

ects

.

Med

ical

:•

Neo

nata

l car

e –

vita

min

K in

ject

ion.

• Ca

rbam

azep

ine

is c

onsi

dere

d to

be

the

leas

t

tera

toge

nic

of th

e ol

der a

ntie

pile

ptic

age

nts.

• So

dium

val

proa

te h

as th

e st

rong

est

a

ssoc

iatio

n w

ith n

eura

l tub

e de

fect

s.

Sign

s an

d sy

mpt

oms

Thes

e de

pend

on

the

regi

on o

f the

bra

inaf

fect

ed.

• F

ront

al lo

be: J

AM

:

J –

Jack

soni

an m

arch

.

A –

pA

lsy

(pos

t-ic

tal T

odd’

s pa

lsy)

.

M –

Mot

or fe

atur

es.

• T

empo

ral l

obe:

AD

D F

AT:

A

– A

ura

that

the

epile

ptic

att

ack

will

occ

ur.

D

– D

éjà

vu.

D

– D

elus

iona

l beh

avio

ur.

F

– F

ear/p

anic

– h

ippo

cam

pal i

nvol

vem

ent.

A

– A

utom

atis

ms.

T

– Ta

ste/

smel

l – u

ncal

invo

lvem

ent.

• P

arie

tal a

nd o

ccip

ital

lobe

s:

Visu

al a

nd s

enso

ry d

istu

rban

ces

Oth

ers

incl

ude:

par

tial o

r gen

eral

ized

seiz

ures

with

or w

ithou

t con

vuls

ions

, to

ngue

biti

ng, m

igra

ines

and

dep

ress

ion.

MAP

2.3

. Epi

leps

y in

pre

gnan

cy

43O

bste

tric

sM

ap 2

.3.

Epile

psy

in p

reg

nan

cy

K30033_C002.indd 43 28/02/17 11:15 am

44O

bste

tric

sM

ap 2

.4.

Pre-

ecla

mp

sia

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

LFT

s, gl

ucos

e

(par

ticul

arly

scr

eeni

ng fo

r HEL

LP

synd

rom

e), u

ric a

cid

leve

l.•

Mea

sure

blo

od p

ress

ure:

>14

0/90

mm

Hg.

• U

rinal

ysis

: pro

tein

uria

.•

Neu

rolo

gy e

xam

inat

ion:

hyp

erre

flexi

a, c

lonu

s.•

Fund

osco

py: p

apill

oede

ma.

Sym

ptom

s•

May

be

asym

ptom

atic

.•

Head

ache

.•

Visu

al d

istu

rban

ce.

• Ab

dom

inal

pai

n (ty

pica

lly ri

ght u

pper

q

uadr

ant o

r epi

gast

ric re

gion

).•

Nau

sea

and

vom

iting

.

Wha

t is

pre

-ecl

amps

ia?

This

is a

mul

tisys

tem

ic d

isor

der c

hara

cter

ized

by

four

fact

ors:

1. H

yper

tens

ion

>14

0/90

mm

Hg.

2. O

ccur

s af

ter 2

0 w

eeks

ges

tatio

n.3.

Pro

tein

uria

>0.

3 g/

24 h

ours

.4.

Nor

mal

izes

afte

r del

iver

y of

fetu

s.

Caus

esIt

is a

pla

cent

al d

isea

se b

ut th

e ex

act

path

ogen

esis

is in

com

plet

ely

unde

rsto

od.

Pre-

ecla

mps

ia is

, how

ever

, ass

ocia

ted

with

num

erou

s ris

k fa

ctor

s su

ch a

s:•

Extr

emes

in a

ge: <

20 o

r >40

yea

rs.

• N

ullip

arity

.•

Mul

tiple

pre

gnan

cy.

• N

ew p

artn

er.

• Pa

st h

isto

ry o

f pre

-ecl

amps

ia.

• Hi

gh m

ater

nal B

MI.

• Pr

evio

us h

yper

tens

ion.

• Pr

evio

us re

nal d

isea

se.

• Pr

evio

us D

M.

• In

terv

al b

etw

een

preg

nanc

ies

>10

yea

rs.

Trea

tmen

tDe

liver

y is

the

defin

itive

trea

tmen

t of

pre-

ecla

mps

ia b

ut o

ther

opt

ions

are

em

ploy

edw

hile

the

fetu

s de

velo

ps. F

ollo

wN

ICE/

cons

ensu

s gu

idel

ines

.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Re

gula

r blo

od p

ress

ure

mon

itorin

g.

Med

ical

:•

Labe

talo

l is

used

firs

t lin

e.•

Oth

er a

gent

s in

clud

e ni

fedi

pine

and

h

ydra

lazi

ne.

• M

agne

sium

sul

phat

e is

als

o us

ed fo

r sei

zure

pr

even

tion.

Com

plic

atio

ns

Feta

l:•

Intr

aute

rine

grow

th re

stric

tion.

• Pr

emat

ure

deliv

ery.

Mat

erna

l:•

Ecla

mps

ia.

• HE

LLP

synd

rom

e.•

Cere

bral

hae

mor

rhag

e.•

Intr

a-ab

dom

inal

hae

mor

rhag

e.

MAP

2.4

. Pre

-ecl

amps

ia

K30033_C002.indd 44 28/02/17 11:16 am

45O

bste

tric

sM

ap 2

.4.

Pre-

ecla

mp

sia

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

LFT

s, gl

ucos

e

(par

ticul

arly

scr

eeni

ng fo

r HEL

LP

synd

rom

e), u

ric a

cid

leve

l.•

Mea

sure

blo

od p

ress

ure:

>14

0/90

mm

Hg.

• U

rinal

ysis

: pro

tein

uria

.•

Neu

rolo

gy e

xam

inat

ion:

hyp

erre

flexi

a, c

lonu

s.•

Fund

osco

py: p

apill

oede

ma.

Sym

ptom

s•

May

be

asym

ptom

atic

.•

Head

ache

.•

Visu

al d

istu

rban

ce.

• Ab

dom

inal

pai

n (ty

pica

lly ri

ght u

pper

q

uadr

ant o

r epi

gast

ric re

gion

).•

Nau

sea

and

vom

iting

.

Wha

t is

pre

-ecl

amps

ia?

This

is a

mul

tisys

tem

ic d

isor

der c

hara

cter

ized

by

four

fact

ors:

1. H

yper

tens

ion

>14

0/90

mm

Hg.

2. O

ccur

s af

ter 2

0 w

eeks

ges

tatio

n.3.

Pro

tein

uria

>0.

3 g/

24 h

ours

.4.

Nor

mal

izes

afte

r del

iver

y of

fetu

s.

Caus

esIt

is a

pla

cent

al d

isea

se b

ut th

e ex

act

path

ogen

esis

is in

com

plet

ely

unde

rsto

od.

Pre-

ecla

mps

ia is

, how

ever

, ass

ocia

ted

with

num

erou

s ris

k fa

ctor

s su

ch a

s:•

Extr

emes

in a

ge: <

20 o

r >40

yea

rs.

• N

ullip

arity

.•

Mul

tiple

pre

gnan

cy.

• N

ew p

artn

er.

• Pa

st h

isto

ry o

f pre

-ecl

amps

ia.

• Hi

gh m

ater

nal B

MI.

• Pr

evio

us h

yper

tens

ion.

• Pr

evio

us re

nal d

isea

se.

• Pr

evio

us D

M.

• In

terv

al b

etw

een

preg

nanc

ies

>10

yea

rs.

Trea

tmen

tDe

liver

y is

the

defin

itive

trea

tmen

t of

pre-

ecla

mps

ia b

ut o

ther

opt

ions

are

em

ploy

edw

hile

the

fetu

s de

velo

ps. F

ollo

wN

ICE/

cons

ensu

s gu

idel

ines

.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Re

gula

r blo

od p

ress

ure

mon

itorin

g.

Med

ical

:•

Labe

talo

l is

used

firs

t lin

e.•

Oth

er a

gent

s in

clud

e ni

fedi

pine

and

h

ydra

lazi

ne.

• M

agne

sium

sul

phat

e is

als

o us

ed fo

r sei

zure

pr

even

tion.

Com

plic

atio

ns

Feta

l:•

Intr

aute

rine

grow

th re

stric

tion.

• Pr

emat

ure

deliv

ery.

Mat

erna

l:•

Ecla

mps

ia.

• HE

LLP

synd

rom

e.•

Cere

bral

hae

mor

rhag

e.•

Intr

a-ab

dom

inal

hae

mor

rhag

e.

MAP

2.4

. Pre

-ecl

amps

ia

K30033_C002.indd 45 28/02/17 11:16 am

46O

bste

tric

sM

ap 2

.5.

Live

r d

isea

se u

niq

ue

to p

reg

nan

cy

Hyp

erem

esis

gra

vida

rum

Wha

t is

hyp

erem

esis

gra

vida

rum

?Th

is is

a c

ompl

icat

ion

of p

regn

ancy

, whi

ch b

egin

s du

ring

the

first

trim

este

r and

usu

ally

reso

lves

by

wee

k 20

. A tr

iad

char

acte

rizes

the

cond

ition

:1.

Nau

sea

and

vom

iting

.2.

Wei

ght l

oss

(5%

or m

ore

of p

re-p

regn

ancy

bod

y w

eigh

t).3.

Deh

ydra

tion.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Sym

ptom

s•

Nau

sea

and

vom

iting

.•

Wei

ght l

oss

(5%

or m

ore

of p

re-p

regn

ancy

bod

y w

eigh

t).•

Dehy

drat

ion

– re

sulti

ng in

ket

osis

and

con

stip

atio

n.•

Met

abol

ic im

bala

nce

– ke

tosi

s an

d th

yrot

oxic

osis.

• Hy

pero

lfact

ion.

• Pt

yalis

m.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

BU

N, T

FTs

(TSH

low

), LF

Ts =

AST

,

ALT

<1,

000

IU/L

, ALT

>AS

T, vi

tam

in B

leve

ls.•

Urin

alys

is.•

USS

– m

onito

r ges

tatio

n an

d ex

clud

e m

olar

pre

gnan

cy

(see

Map

3.3

, p. 7

6).

Trea

tmen

t

Med

ical

:•

IV fl

uid

resu

scita

tion.

• An

tiem

etic

s –

pyrid

oxin

e, p

rom

etha

zine

.•

Nut

ritio

nal s

uppo

rt –

thia

min

e.

Com

plic

atio

ns

Mot

her:

• W

eigh

t los

s.•

Com

plic

atio

ns o

f vom

iting

(e.g

. oes

opha

geal

rupt

ure,

re

nal d

amag

e, v

ascu

lar d

eple

tion,

Wer

nick

e’s

en

ceph

alop

athy

).

Fetu

s:•

Prem

atur

ity.

• Lo

w b

irth

wei

ght.

Intr

ahep

atic

cho

lest

asis

of p

regn

ancy

Wha

t is

intr

a-he

pati

c ch

oles

tasi

s of

pre

gnan

cy?

This

is a

reve

rsib

le h

orm

onal

ly in

fluen

ced

chol

esta

sis,

whi

chty

pica

lly p

rese

nts

durin

g th

e se

cond

trim

este

r and

con

tinue

sin

to th

e th

ird tr

imes

ter.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Stu

dies

hav

e su

gges

ted

that

this

cond

ition

is li

nked

to in

crea

sed

horm

one

leve

ls. In

crea

sed

risk

with

mul

tiple

pre

gnan

cies

. Thi

s co

nditi

on o

ften

recu

rs in

subs

eque

nt p

regn

anci

es.

Sym

ptom

s•

Prur

itus,

typi

cally

com

men

cing

on

the

palm

s of

the

hand

s

and

sole

s of

the

feet

. Itc

hing

then

spr

eads

to th

e fa

ce a

nd

trun

k. W

orse

at n

ight

. No

rash

pre

sent

.•

Jaun

dice

.•

Stea

torr

hoea

.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

BU

N, L

FTs

= A

ST, A

LT <

1,00

0 IU

/L,

G

GT

norm

al, b

ile a

cid

leve

ls (h

igh)

, pro

thro

mbi

n

(nor

mal

), bi

lirub

in <

6 m

g/dL

.•

Urin

alys

is.•

USS

– m

onito

r ges

tatio

n.

Trea

tmen

t•

Med

ical

: urs

odeo

xych

olic

aci

d, a

ntih

ista

min

es.

• De

liver

y of

fetu

s (u

sual

ly a

t 37

wee

ks o

r whe

n fe

tal

di

stre

ss is

imm

inen

t).

Com

plic

atio

ns

Mot

her:

• Se

vere

pru

ritus

– in

terfe

res

with

sle

ep.

• De

rang

ed c

lott

ing

– du

e to

dec

reas

ed v

itam

in K

leve

ls.

Fetu

s:•

Feta

l dis

tres

s.•

Still

birt

h.•

Mec

oniu

m in

gest

ion/

aspi

ratio

n.

MAP

2.5

. Liv

er d

isea

se u

niqu

e to

preg

nanc

y

K30033_C002.indd 46 28/02/17 11:16 am

47O

bste

tric

sM

ap 2

.5.

Live

r d

isea

se u

niq

ue

to p

reg

nan

cy

Hyp

erem

esis

gra

vida

rum

Wha

t is

hyp

erem

esis

gra

vida

rum

?Th

is is

a c

ompl

icat

ion

of p

regn

ancy

, whi

ch b

egin

s du

ring

the

first

trim

este

r and

usu

ally

reso

lves

by

wee

k 20

. A tr

iad

char

acte

rizes

the

cond

ition

:1.

Nau

sea

and

vom

iting

.2.

Wei

ght l

oss

(5%

or m

ore

of p

re-p

regn

ancy

bod

y w

eigh

t).3.

Deh

ydra

tion.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Sym

ptom

s•

Nau

sea

and

vom

iting

.•

Wei

ght l

oss

(5%

or m

ore

of p

re-p

regn

ancy

bod

y w

eigh

t).•

Dehy

drat

ion

– re

sulti

ng in

ket

osis

and

con

stip

atio

n.•

Met

abol

ic im

bala

nce

– ke

tosi

s an

d th

yrot

oxic

osis.

• Hy

pero

lfact

ion.

• Pt

yalis

m.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

BU

N, T

FTs

(TSH

low

), LF

Ts =

AST

,

ALT

<1,

000

IU/L

, ALT

>AS

T, vi

tam

in B

leve

ls.•

Urin

alys

is.•

USS

– m

onito

r ges

tatio

n an

d ex

clud

e m

olar

pre

gnan

cy

(see

Map

3.3

, p. 7

6).

Trea

tmen

t

Med

ical

:•

IV fl

uid

resu

scita

tion.

• An

tiem

etic

s –

pyrid

oxin

e, p

rom

etha

zine

.•

Nut

ritio

nal s

uppo

rt –

thia

min

e.

Com

plic

atio

ns

Mot

her:

• W

eigh

t los

s.•

Com

plic

atio

ns o

f vom

iting

(e.g

. oes

opha

geal

rupt

ure,

re

nal d

amag

e, v

ascu

lar d

eple

tion,

Wer

nick

e’s

en

ceph

alop

athy

).

Fetu

s:•

Prem

atur

ity.

• Lo

w b

irth

wei

ght.

Intr

ahep

atic

cho

lest

asis

of p

regn

ancy

Wha

t is

intr

a-he

pati

c ch

oles

tasi

s of

pre

gnan

cy?

This

is a

reve

rsib

le h

orm

onal

ly in

fluen

ced

chol

esta

sis,

whi

chty

pica

lly p

rese

nts

durin

g th

e se

cond

trim

este

r and

con

tinue

sin

to th

e th

ird tr

imes

ter.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Stu

dies

hav

e su

gges

ted

that

this

cond

ition

is li

nked

to in

crea

sed

horm

one

leve

ls. In

crea

sed

risk

with

mul

tiple

pre

gnan

cies

. Thi

s co

nditi

on o

ften

recu

rs in

subs

eque

nt p

regn

anci

es.

Sym

ptom

s•

Prur

itus,

typi

cally

com

men

cing

on

the

palm

s of

the

hand

s

and

sole

s of

the

feet

. Itc

hing

then

spr

eads

to th

e fa

ce a

nd

trun

k. W

orse

at n

ight

. No

rash

pre

sent

.•

Jaun

dice

.•

Stea

torr

hoea

.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, U

&E,

BU

N, L

FTs

= A

ST, A

LT <

1,00

0 IU

/L,

G

GT

norm

al, b

ile a

cid

leve

ls (h

igh)

, pro

thro

mbi

n

(nor

mal

), bi

lirub

in <

6 m

g/dL

.•

Urin

alys

is.•

USS

– m

onito

r ges

tatio

n.

Trea

tmen

t•

Med

ical

: urs

odeo

xych

olic

aci

d, a

ntih

ista

min

es.

• De

liver

y of

fetu

s (u

sual

ly a

t 37

wee

ks o

r whe

n fe

tal

di

stre

ss is

imm

inen

t).

Com

plic

atio

ns

Mot

her:

• Se

vere

pru

ritus

– in

terfe

res

with

sle

ep.

• De

rang

ed c

lott

ing

– du

e to

dec

reas

ed v

itam

in K

leve

ls.

Fetu

s:•

Feta

l dis

tres

s.•

Still

birt

h.•

Mec

oniu

m in

gest

ion/

aspi

ratio

n.

MAP

2.5

. Liv

er d

isea

se u

niqu

e to

preg

nanc

y

K30033_C002.indd 47 28/02/17 11:16 am

48O

bste

tric

sM

ap 2

.5.

Live

r d

isea

se u

niq

ue

to p

reg

nan

cy

Acu

te fa

tty

liver

of p

regn

ancy

Wha

t is

acu

te fa

tty

liver

of p

regn

ancy

?Th

is is

a s

erio

us c

ompl

icat

ion

of p

regn

ancy

that

typi

cally

occ

urs

in th

e th

ird tr

imes

ter.

It is

cha

ract

eriz

ed b

y m

icro

vesi

cula

r st

eato

sis

(var

iant

form

of h

epat

ic fa

t acc

umul

atio

n) in

the

liver

. Ass

ocia

ted

with

ecl

amps

ia.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Incr

ease

d ris

k in

wom

en w

ho h

ave

a he

tero

zygo

us lo

ng-c

hain

3-h

ydro

xyac

ylco

enzy

me

A de

hydr

ogen

ase

(LCH

AD) d

efic

ienc

y. Th

is c

ondi

tion

is th

ough

t to

be d

ue to

mito

chon

dria

l dys

func

tion.

Dys

func

tion

of th

e m

itoch

ondr

ia re

sults

in th

e dy

sfun

ctio

n of

fatt

y ac

id o

xida

tion

and,

as

such

, an

accu

mul

atio

n of

fat w

ithin

the

hepa

tocy

tes.

Exce

ss fa

t inf

iltra

tion

resu

lts in

acu

te h

epat

ic in

suffi

cien

cy.

Sym

ptom

s•

Non

-spe

cific

– le

thar

gy, n

ause

a an

d vo

miti

ng.

• Hy

pert

ensi

on.

• Ab

dom

inal

pai

n –

epig

astr

ic, R

UQ.

• Sy

mpt

oms

asso

ciat

ed w

ith: u

pper

gas

troi

ntes

tinal

hae

mor

rhag

e, a

cute

kid

ney

inju

ry, p

ancr

eatit

is, h

ypog

lyca

emia

, ful

min

ant

he

patic

failu

re.

• En

ceph

alop

athy

– a

ltere

d m

enta

l sta

tus

and

conf

usio

n.•

Jaun

dice

.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, p

late

lets

<10

0,00

0 m

m3 , f

ibrin

ogen

leve

l (lo

w),

antit

hrom

bin

III, U

&E,

BU

N, L

FTs

= A

ST,

AL

T >

300

IU/L

, pro

thro

mbi

n (in

crea

sed)

, bili

rubi

n (in

crea

sed)

, DIC

, glu

cose

leve

ls (d

ecre

ased

).•

Urin

alys

is.•

Mat

erna

l USS

– li

ver (

incr

ease

d ec

hoge

nici

ty).

• Fe

tal U

SS –

mon

itor g

esta

tion.

Trea

tmen

t

Med

ical

:•

Resu

scita

tion

– IV

flui

ds, I

V gl

ucos

e, fr

esh

froze

n pl

asm

a, c

ryop

reci

pita

te.

• De

liver

y of

fetu

s.

Surg

ical

:•

Live

r tra

nspl

ant m

ay b

e re

quire

d fo

r mot

hers

with

sev

ere

liver

failu

re, e

ncep

halo

path

y or

sev

ere

DIC.

Com

plic

atio

ns

Mot

her:

• Fu

lmin

ant h

epat

ic fa

ilure

.•

DIC.

• En

ceph

alop

athy

.•

Deat

h <

20%

.

Fetu

s:•

Feta

l mor

talit

y ~

45%

.

MAP

2.5

. Liv

er d

isea

se u

niqu

e to

pre

gnan

cy (c

ontin

ued

).

K30033_C002.indd 48 28/02/17 11:16 am

49O

bste

tric

sM

ap 2

.5.

Live

r d

isea

se u

niq

ue

to p

reg

nan

cy

Acu

te fa

tty

liver

of p

regn

ancy

Wha

t is

acu

te fa

tty

liver

of p

regn

ancy

?Th

is is

a s

erio

us c

ompl

icat

ion

of p

regn

ancy

that

typi

cally

occ

urs

in th

e th

ird tr

imes

ter.

It is

cha

ract

eriz

ed b

y m

icro

vesi

cula

r st

eato

sis

(var

iant

form

of h

epat

ic fa

t acc

umul

atio

n) in

the

liver

. Ass

ocia

ted

with

ecl

amps

ia.

Caus

esTh

e ex

act c

ause

is u

nkno

wn.

Incr

ease

d ris

k in

wom

en w

ho h

ave

a he

tero

zygo

us lo

ng-c

hain

3-h

ydro

xyac

ylco

enzy

me

A de

hydr

ogen

ase

(LCH

AD) d

efic

ienc

y. Th

is c

ondi

tion

is th

ough

t to

be d

ue to

mito

chon

dria

l dys

func

tion.

Dys

func

tion

of th

e m

itoch

ondr

ia re

sults

in th

e dy

sfun

ctio

n of

fatt

y ac

id o

xida

tion

and,

as

such

, an

accu

mul

atio

n of

fat w

ithin

the

hepa

tocy

tes.

Exce

ss fa

t inf

iltra

tion

resu

lts in

acu

te h

epat

ic in

suffi

cien

cy.

Sym

ptom

s•

Non

-spe

cific

– le

thar

gy, n

ause

a an

d vo

miti

ng.

• Hy

pert

ensi

on.

• Ab

dom

inal

pai

n –

epig

astr

ic, R

UQ.

• Sy

mpt

oms

asso

ciat

ed w

ith: u

pper

gas

troi

ntes

tinal

hae

mor

rhag

e, a

cute

kid

ney

inju

ry, p

ancr

eatit

is, h

ypog

lyca

emia

, ful

min

ant

he

patic

failu

re.

• En

ceph

alop

athy

– a

ltere

d m

enta

l sta

tus

and

conf

usio

n.•

Jaun

dice

.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s us

ing

CTG.

• Bl

oods

– F

BC, p

late

lets

<10

0,00

0 m

m3 , f

ibrin

ogen

leve

l (lo

w),

antit

hrom

bin

III, U

&E,

BU

N, L

FTs

= A

ST,

AL

T >

300

IU/L

, pro

thro

mbi

n (in

crea

sed)

, bili

rubi

n (in

crea

sed)

, DIC

, glu

cose

leve

ls (d

ecre

ased

).•

Urin

alys

is.•

Mat

erna

l USS

– li

ver (

incr

ease

d ec

hoge

nici

ty).

• Fe

tal U

SS –

mon

itor g

esta

tion.

Trea

tmen

t

Med

ical

:•

Resu

scita

tion

– IV

flui

ds, I

V gl

ucos

e, fr

esh

froze

n pl

asm

a, c

ryop

reci

pita

te.

• De

liver

y of

fetu

s.

Surg

ical

:•

Live

r tra

nspl

ant m

ay b

e re

quire

d fo

r mot

hers

with

sev

ere

liver

failu

re, e

ncep

halo

path

y or

sev

ere

DIC.

Com

plic

atio

ns

Mot

her:

• Fu

lmin

ant h

epat

ic fa

ilure

.•

DIC.

• En

ceph

alop

athy

.•

Deat

h <

20%

.

Fetu

s:•

Feta

l mor

talit

y ~

45%

.

MAP

2.5

. Liv

er d

isea

se u

niqu

e to

pre

gnan

cy (c

ontin

ued

).

K30033_C002.indd 49 28/02/17 11:16 am

50O

bste

tric

sM

ap 2

.6.

TOR

CH

ES in

fect

ion

s

Syph

ilis

(See

Map

2.8

, p. 5

2)TO

– T

Oxo

plas

mos

isR

– R

ubel

laC

– C

MV

HE

– H

Erpe

s an

d H

IVS

– S

yphi

lis

Her

pes

sim

plex

vir

us (H

SV)

(See

Map

2.1

1, p

. 56)

Hum

an im

mun

odef

icie

ncy

viru

s (H

IV)

(See

Map

2.1

0, p

. 55)

Toxo

plas

mos

is(S

ee M

ap 2

.7, p

. 51)

Cyto

meg

alov

irus

(CM

V)(S

ee M

ap 2

.9, p

. 54)

Rube

lla(S

ee M

ap 2

.12,

p. 5

8)

MAP

2.6

. TO

RCH

ES in

fect

ions

K30033_C002.indd 50 28/02/17 11:16 am

51O

bste

tric

s

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

pre

gnan

t wom

en to

avo

id c

ats/

clea

ring

litte

r tra

ys.

• Do

not

allo

w p

et c

at to

sle

ep in

sam

e be

d.•

High

light

han

d hy

gien

e, e

spec

ially

if h

andl

ing

raw

mea

t.

Med

ical

:•

Feta

l:

Py

rimet

ham

ine.

Sulp

hona

mid

e.•

Mat

erna

l:

Sp

iram

ycin

.

Wha

t is

tox

opla

smos

is?

This

is a

n in

fect

ion

caus

ed b

yTo

xopl

asm

a go

ndii,

a p

roto

zoan

. Inf

ectio

n is

mor

e co

mm

on in

imm

unos

uppr

esse

d in

divi

dual

s(e

.g. H

IV, c

ance

r suf

fere

rs).

Tran

smis

sion

:•

Infe

cted

mea

t.•

Cat f

aece

s.

Sym

ptom

s•

Ofte

n as

ympt

omat

ic.

• Fl

u-lik

e sy

mpt

oms

– fa

tigue

, sor

e

thro

at, h

eada

che,

feve

r,

lym

phad

enop

athy

.

Inve

stig

atio

ns•

Bloo

d te

st: m

ater

nal

im

mun

oglo

bulin

M.

• Ra

diol

ogy:

ultr

asou

nd

scan

for f

etal

hyd

roce

phal

us.

• Am

nioc

ente

sis.

• Pe

rform

add

ition

al te

sts

(e

.g. f

or H

IV c

o-in

fect

ion

if

clin

ical

ly re

leva

nt).

Com

plic

atio

ns

Feta

l: Re

mem

ber a

s th

e 3C

s:

C

– C

ereb

ral m

anife

stat

ions

(e.g

. hyd

roce

phal

us, m

icro

ceph

aly)

.

C

– C

onvu

lsio

ns.

C –

Cho

riore

tiniti

s.M

ater

nal:

Rem

embe

r as

ABC

DE:

A

– A

bsce

ss fo

rmat

ion

(cer

ebra

l)

B –

Blu

rred

vis

ion

C

– C

onfu

sion

D

– D

iffic

ulty

bre

athi

ng (p

neum

oniti

s)

E –

Enc

epha

lom

yelit

is

MAP

2.7

. Tox

opla

smos

is

Map

2.7

. To

xop

lasm

osi

s

K30033_C002.indd 51 28/02/17 11:16 am

52O

bste

tric

sM

ap 2

.8.

Ru

bel

la

Sym

ptom

s•

Arth

ralg

ia.

• So

re th

roat

.•

Feve

r.•

Mac

ular

rash

– in

itial

ly o

n fa

ce b

ut s

prea

ds to

tors

o an

d th

en le

gs. D

urat

ion

abou

t 3 d

ays.

• O

ccip

ital l

ymph

aden

opat

hy; t

his

may

be

pa

infu

l and

cau

se d

isco

mfo

rt.

Com

plic

atio

ns

Feta

l:•

Cong

enita

l rub

ella

syn

drom

e - r

emem

ber a

s

ABC

DE:

A

– A

sm

all h

ead

(mic

roce

phal

y) a

nd lo

w b

irth

wei

ght

B

– Bl

uebe

rry

muf

fin ra

sh (e

xtra

med

ulla

ry

ha

emat

opoi

esis

)

C –

Cong

enita

l hea

rt m

alfo

rmat

ions

(PDA

, PAS

)

D –

Dea

fnes

s (s

enso

rineu

ral)

E

– Ey

e ab

norm

aliti

es (c

atar

acts

)

Mat

erna

l: as

in S

ympt

oms

box.

Trea

tmen

tTh

ere

is n

o sp

ecifi

c tr

eatm

ent f

or ru

bella

.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

pre

gnan

t wom

en to

avo

id k

now

n

con

tact

s w

ith ru

bella

(e.g

. kno

wn

case

s at

w

ork)

.

Med

ical

:•

Mat

erna

l:

M

MR

vacc

ine.

Wha

t is

rub

ella

?Th

is is

a s

ingl

e st

rand

ed R

NA

viru

s. It

is a

lso

know

n as

Ger

man

mea

sles

. Gre

ates

t ris

k of

in

fect

ion

and

com

plic

atio

ns is

dur

ing

the

first

few

wee

ks o

f pre

gnan

cy.

Tran

smis

sion

:•

Airb

orne

infe

ctio

n pa

ssed

thro

ugh

re

spira

tory

dro

plet

s.

Inve

stig

atio

ns•

Bloo

d te

st: m

ater

nal a

ntib

odie

s.•

Urin

alys

is: f

or v

irus

in n

eona

te.

MAP

2.8

. Rub

ella

K30033_C002.indd 52 28/02/17 11:16 am

53O

bste

tric

sM

ap 2

.8.

Ru

bel

la

Sym

ptom

s•

Arth

ralg

ia.

• So

re th

roat

.•

Feve

r.•

Mac

ular

rash

– in

itial

ly o

n fa

ce b

ut s

prea

ds to

tors

o an

d th

en le

gs. D

urat

ion

abou

t 3 d

ays.

• O

ccip

ital l

ymph

aden

opat

hy; t

his

may

be

pa

infu

l and

cau

se d

isco

mfo

rt.

Com

plic

atio

ns

Feta

l:•

Cong

enita

l rub

ella

syn

drom

e - r

emem

ber a

s

ABC

DE:

A

– A

sm

all h

ead

(mic

roce

phal

y) a

nd lo

w b

irth

wei

ght

B

– Bl

uebe

rry

muf

fin ra

sh (e

xtra

med

ulla

ry

ha

emat

opoi

esis

)

C –

Cong

enita

l hea

rt m

alfo

rmat

ions

(PDA

, PAS

)

D –

Dea

fnes

s (s

enso

rineu

ral)

E

– Ey

e ab

norm

aliti

es (c

atar

acts

)

Mat

erna

l: as

in S

ympt

oms

box.

Trea

tmen

tTh

ere

is n

o sp

ecifi

c tr

eatm

ent f

or ru

bella

.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

pre

gnan

t wom

en to

avo

id k

now

n

con

tact

s w

ith ru

bella

(e.g

. kno

wn

case

s at

w

ork)

.

Med

ical

:•

Mat

erna

l:

M

MR

vacc

ine.

Wha

t is

rub

ella

?Th

is is

a s

ingl

e st

rand

ed R

NA

viru

s. It

is a

lso

know

n as

Ger

man

mea

sles

. Gre

ates

t ris

k of

in

fect

ion

and

com

plic

atio

ns is

dur

ing

the

first

few

wee

ks o

f pre

gnan

cy.

Tran

smis

sion

:•

Airb

orne

infe

ctio

n pa

ssed

thro

ugh

re

spira

tory

dro

plet

s.

Inve

stig

atio

ns•

Bloo

d te

st: m

ater

nal a

ntib

odie

s.•

Urin

alys

is: f

or v

irus

in n

eona

te.

MAP

2.8

. Rub

ella

K30033_C002.indd 53 28/02/17 11:16 am

54O

bste

tric

sM

ap 2

.9.

Cyt

om

egal

ovi

rus

(CM

V)

Wha

t is

CM

V?Th

is is

an

enve

lope

d vi

rus

belo

ngin

g to

the

Herp

esvi

ridae

fam

ily.

Tran

smis

sion

:•

Airb

orne

infe

ctio

n pa

ssed

thro

ugh

resp

irato

ry

dr

ople

ts.

• Vi

a m

ater

nal g

enito

urin

ary

trac

t.

Inve

stig

atio

ns•

Bloo

d te

st: m

ater

nal a

ntib

odie

s.•

Radi

olog

y: U

SS m

ay s

how

hyp

erec

hoge

nic

bow

el.

• Hy

pere

chog

enic

bow

el is

als

o fo

und

in c

ystic

fibr

osis

and

Dow

n’s

synd

rom

e.

Sym

ptom

s•

Gen

eral

ly a

sym

ptom

atic

.

MAP

2.9

. Cyt

omeg

alov

irus

(CM

V)

Com

plic

atio

nsFe

tal:

rem

embe

r as

ABC

DE:

A –

A s

mal

l hea

d m

icro

ceph

aly)

and

low

birt

h w

eigh

tB

– Bl

indn

ess

(occ

asio

nally

)C

– Ca

uses

neo

nata

l jau

ndic

eD

– D

eafn

ess

(hig

h ris

k)E

– En

larg

ed li

ver a

nd s

plee

n

Mat

erna

l: as

in S

ympt

oms

box.

Trea

tmen

tTh

ere

is n

o sp

ecifi

c tr

eatm

ent f

or C

MV.

Th

e m

edic

atio

ns u

sed

to tr

eat C

MV

ordi

naril

y ar

ete

rato

geni

c.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Mat

erna

l:

Co

nsid

er te

rmin

atio

n of

pre

gnan

cy.

K30033_C002.indd 54 28/02/17 11:16 am

55O

bste

tric

sM

ap 2

.10.

Her

pes

sim

ple

x vi

rus

(HSV

)

Wha

t is

HSV

?Th

is is

a v

irus

belo

ngin

g to

the

Herp

esvi

ridae

fam

ily. T

here

are

man

y di

ffere

nt ty

pes

of h

erpe

svi

rus,

but t

his

min

d m

ap fo

cuse

s on

HSV

-1 a

ndHS

V-2.

Tran

smis

sion

:•

Sexu

al c

onta

ct.

• M

ucou

s m

embr

ane

cont

act (

e.g.

sal

iva)

.

Inve

stig

atio

ns•

Vira

l sw

ab.

• Vi

ral P

CR.

Sym

ptom

s•

Tend

er b

liste

r(s) t

hat o

ccur

eith

er o

n

the

lip o

r in

the

geni

tal r

egio

n. T

hese

m

ay w

eep.

• Ly

mph

aden

opat

hy.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

on

deliv

ery

rout

e (i.

e. c

aesa

rean

se

ctio

n is

pre

fera

ble)

.

Med

ical

:•

Mat

erna

l: ac

iclo

vir.

• Fe

tal:

acic

lovi

r.

Com

plic

atio

ns

Feta

l: re

mem

ber a

s A

BCD

E:

A

– A

sm

all h

ead

(mic

roce

phal

y)

B

– Br

ain

path

olog

y (m

enin

gitis

)

C

– Ch

orio

retin

itis

D –

Dea

th

E

– En

ceph

aliti

s

Mat

erna

l: as

in S

ympt

oms

box.

MAP

2.1

0. H

erpe

s si

mpl

ex v

irus

(HSV

)

K30033_C002.indd 55 28/02/17 11:16 am

56O

bste

tric

sM

ap 2

.11.

Hu

man

imm

un

od

efici

ency

vir

us

(HIV

)

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

dvic

e, p

lann

ed c

aesa

rean

del

iver

y, in

fant

bot

tle fe

edin

g.

Med

ical

:•

High

ly a

ctiv

e an

tiret

rovi

ral t

hera

py (H

AART

):

N

ucle

osid

e re

vers

e tr

ansc

ripta

se in

hibi

tors

(NRT

Is) (

e.g.

zid

ovud

ine

[par

ticul

arly

to re

duce

vert

ical

tran

smis

sion

]). N

ote:

Zid

ovud

ine

is th

e on

ly a

gent

sho

wn

to d

ecre

ase

perin

atal

tran

smis

sion

.

N

on-n

ucle

osid

e re

vers

e tr

ansc

ripta

se in

hibi

tors

(NN

RTIs

) (e.

g. n

evira

pine

).

Pr

otea

se in

hibi

tors

(PIs

) (e.

g. a

taza

navi

r).•

Giv

e ei

ther

:

Tw

o N

RTIs

com

bine

d w

ith o

ne N

NRT

I; or

Two

NRT

Is c

ombi

ned

with

one

PI;

or

Tw

o N

RTIs

com

bine

d w

ith o

ne in

tegr

ase

inhi

bito

r (II;

e.g

. ral

tega

vir).

Spec

ial n

otes

:•

NRT

Is c

ross

the

plac

enta

, the

NN

RTIs

nev

irapi

ne a

nd e

favi

renz

cro

ss th

e pl

acen

ta, b

ut P

Is d

o no

t

cros

s th

e pl

acen

ta e

asily

.•

Zido

vudi

ne is

giv

en in

trav

enou

sly

durin

g la

bour

.•

Neo

nata

l car

e: in

fant

zid

ovud

ine,

initi

ated

as

soon

as

poss

ible

afte

r del

iver

y an

d co

ntin

ued

until

6

wee

ks.

• He

patit

is B

co-

infe

ctio

ns: t

enof

ovir

and

lam

ivud

ine

or e

mtr

icita

bine

.

Wha

t is

HIV

?Th

is is

an

RNA

retr

oviru

s of

the

Lent

iviru

s ge

nus.

Th

is v

irus

caus

es a

cqui

red

imm

unod

efic

ienc

y sy

ndro

me

(AID

S).

Caus

eTh

ere

are

two

type

s of

HIV

:•

HIV-

1:

G

roup

M, s

ubty

pes

A to

J: p

reva

lent

in

Euro

pe, N

orth

Am

eric

a, A

ustr

alia

and

sub-

Saha

ran

Afric

a.

G

roup

O: m

ainl

y in

Cam

eroo

n.•

HIV-

2:

Pr

edom

inan

tly c

onfin

ed to

Wes

t Afri

ca.

Tran

smis

sion

• U

npro

tect

ed s

exua

l int

erco

urse

.•

Shar

ed n

eedl

es (e

.g. d

rug

user

s).

• Co

ntam

inat

ed b

lood

tran

fusi

ons.

• Ve

rtic

al tr

ansm

issi

on –

mot

her t

o ch

ild. T

he

viru

s cr

osse

s th

e pl

acen

ta a

nd is

tran

smitt

ed

th

roug

h br

east

milk

.

Com

plic

atio

ns

Feta

l:•

IUG

R.•

Still

birt

h.

Mat

erna

l:•

Pre-

ecla

mps

ia.

• In

crea

sed

risk

of in

fect

ion:

Toxo

plas

mos

is.

CMV

retin

itis.

Pneu

moc

ystic

jiro

veci

i pne

umon

ia.

Kapo

si’s

sar

com

a.

Cr

ypto

cocc

al m

enin

gitis

.

M

ycob

acte

rium

avi

um c

ompl

ex.

MAP

2.1

1. H

uman

imm

unod

efic

ienc

y vi

rus

(HIV

)

Inve

stig

atio

ns•

Enzy

me-

linke

d im

mun

osor

bent

ass

ay (E

LISA

).•

Wes

tern

blo

t tes

t.•

Imm

unof

luor

esce

nce

assa

y (IF

A).

• N

ucle

ic a

cid

test

ing.

Gen

es r

equi

red

for

vira

l rep

licat

ion

PEG

:P

– po

l: en

code

s re

vers

e tr

ansc

ripta

se a

nd

inte

gras

eE

– en

v: e

ncod

es e

nvel

ope

prot

eins

(e.g

. gp1

20)

G –

gag

: enc

odes

vira

l str

uctu

ral p

rote

ins.

K30033_C002.indd 56 28/02/17 11:16 am

57O

bste

tric

sM

ap 2

.11.

Hu

man

imm

un

od

efici

ency

vir

us

(HIV

)

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

dvic

e, p

lann

ed c

aesa

rean

del

iver

y, in

fant

bot

tle fe

edin

g.

Med

ical

:•

High

ly a

ctiv

e an

tiret

rovi

ral t

hera

py (H

AART

):

N

ucle

osid

e re

vers

e tr

ansc

ripta

se in

hibi

tors

(NRT

Is) (

e.g.

zid

ovud

ine

[par

ticul

arly

to re

duce

vert

ical

tran

smis

sion

]). N

ote:

Zid

ovud

ine

is th

e on

ly a

gent

sho

wn

to d

ecre

ase

perin

atal

tran

smis

sion

.

N

on-n

ucle

osid

e re

vers

e tr

ansc

ripta

se in

hibi

tors

(NN

RTIs

) (e.

g. n

evira

pine

).

Pr

otea

se in

hibi

tors

(PIs

) (e.

g. a

taza

navi

r).•

Giv

e ei

ther

:

Tw

o N

RTIs

com

bine

d w

ith o

ne N

NRT

I; or

Two

NRT

Is c

ombi

ned

with

one

PI;

or

Tw

o N

RTIs

com

bine

d w

ith o

ne in

tegr

ase

inhi

bito

r (II;

e.g

. ral

tega

vir).

Spec

ial n

otes

:•

NRT

Is c

ross

the

plac

enta

, the

NN

RTIs

nev

irapi

ne a

nd e

favi

renz

cro

ss th

e pl

acen

ta, b

ut P

Is d

o no

t

cros

s th

e pl

acen

ta e

asily

.•

Zido

vudi

ne is

giv

en in

trav

enou

sly

durin

g la

bour

.•

Neo

nata

l car

e: in

fant

zid

ovud

ine,

initi

ated

as

soon

as

poss

ible

afte

r del

iver

y an

d co

ntin

ued

until

6

wee

ks.

• He

patit

is B

co-

infe

ctio

ns: t

enof

ovir

and

lam

ivud

ine

or e

mtr

icita

bine

.

Wha

t is

HIV

?Th

is is

an

RNA

retr

oviru

s of

the

Lent

iviru

s ge

nus.

Th

is v

irus

caus

es a

cqui

red

imm

unod

efic

ienc

y sy

ndro

me

(AID

S).

Caus

eTh

ere

are

two

type

s of

HIV

:•

HIV-

1:

G

roup

M, s

ubty

pes

A to

J: p

reva

lent

in

Euro

pe, N

orth

Am

eric

a, A

ustr

alia

and

sub-

Saha

ran

Afric

a.

G

roup

O: m

ainl

y in

Cam

eroo

n.•

HIV-

2:

Pr

edom

inan

tly c

onfin

ed to

Wes

t Afri

ca.

Tran

smis

sion

• U

npro

tect

ed s

exua

l int

erco

urse

.•

Shar

ed n

eedl

es (e

.g. d

rug

user

s).

• Co

ntam

inat

ed b

lood

tran

fusi

ons.

• Ve

rtic

al tr

ansm

issi

on –

mot

her t

o ch

ild. T

he

viru

s cr

osse

s th

e pl

acen

ta a

nd is

tran

smitt

ed

th

roug

h br

east

milk

.

Com

plic

atio

ns

Feta

l:•

IUG

R.•

Still

birt

h.

Mat

erna

l:•

Pre-

ecla

mps

ia.

• In

crea

sed

risk

of in

fect

ion:

Toxo

plas

mos

is.

CMV

retin

itis.

Pneu

moc

ystic

jiro

veci

i pne

umon

ia.

Kapo

si’s

sar

com

a.

Cr

ypto

cocc

al m

enin

gitis

.

M

ycob

acte

rium

avi

um c

ompl

ex.

MAP

2.1

1. H

uman

imm

unod

efic

ienc

y vi

rus

(HIV

)

Inve

stig

atio

ns•

Enzy

me-

linke

d im

mun

osor

bent

ass

ay (E

LISA

).•

Wes

tern

blo

t tes

t.•

Imm

unof

luor

esce

nce

assa

y (IF

A).

• N

ucle

ic a

cid

test

ing.

Gen

es r

equi

red

for

vira

l rep

licat

ion

PEG

:P

– po

l: en

code

s re

vers

e tr

ansc

ripta

se a

nd

inte

gras

eE

– en

v: e

ncod

es e

nvel

ope

prot

eins

(e.g

. gp1

20)

G –

gag

: enc

odes

vira

l str

uctu

ral p

rote

ins.

K30033_C002.indd 57 28/02/17 11:16 am

58O

bste

tric

sM

ap 2

.12.

Syp

hili

s

Wha

t is

syp

hilis

?Th

is is

a s

exua

lly tr

ansm

itted

dis

ease

cau

sed

by

the

spiro

chae

te T

repo

nem

a pa

llidu

m.

Tran

smis

sion

:•

Sexu

al c

onta

ct.

Sym

ptom

sIn

fect

ions

occ

urs

in th

ree

stag

es:

1. C

hanc

re –

pai

nles

s.2.

Dis

sem

inat

ed d

isea

se –

rash

on

palm

s

and

sol

es.

3. C

ardi

ac a

nd n

euro

logi

cal i

nvol

vem

ent.

Inve

stig

atio

ns•

Vene

real

Dis

ease

Res

earc

h La

bora

tory

(

VDRL

) tes

t.•

Rapi

d pl

asm

a re

agin

test

.•

Fluo

resc

ent t

repo

nem

al a

ntib

ody

abso

rptio

n

tes

t (FT

A-AB

S).

• Tr

epon

ema

palli

dum

hae

mag

glut

inat

ion

test

(

TPHA

).•

Trep

onem

a pa

llidu

m p

artic

le a

gglu

tinat

ion

t

est (

TPPA

).•

Trep

onem

al e

nzym

e im

mun

oass

ay (E

IA).

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

on

deliv

ery

rout

e (i.

e. c

aesa

rean

sec

tion

is p

refe

rabl

e)

Med

ical

: (m

any

antib

iotic

s lis

ted

belo

w a

re c

ontr

aind

icat

ed d

urin

g pr

egna

ncy.

Cons

ult l

ocal

gui

delin

es a

nd th

e BN

F). M

othe

r may

nee

d to

co

nsid

er te

rmin

atio

n of

pre

gnan

cy.

• M

ater

nal:

Pr

ocai

ne p

enic

illin

G.

Do

xycy

clin

e.

Eryt

hrom

ycin

.

Azith

rom

ycin

.N

ote:

If p

atie

nt h

as n

euro

syph

ilis,

give

pro

phyl

actic

pre

dnis

olon

e to

avoi

d th

e Ja

risch

–Her

xhei

mer

reac

tion.

Thi

s re

actio

n m

ay o

ccur

afte

ran

tibac

teria

l tre

atm

ent,

whi

ch c

ause

s th

e de

ath

of th

e sp

iroch

aete

and

su

bseq

uent

end

otox

in re

leas

e. E

ndot

oxin

s ca

use

the

Jaris

ch–H

erxh

eim

er

reac

tion.

• F

etal

:

Peni

cilli

n.

Com

plic

atio

ns

Feta

l: A

BCD

ES:

A

– A

sm

all h

ead

(mic

roce

phal

y)

B –

Bra

in p

atho

logy

(men

ingi

tis),

Bloo

d st

aine

d na

sal d

isch

arge

C

– C

horo

iditi

s

D –

Den

tal m

alfo

rmat

ions

, Dea

fnes

s (s

enso

rineu

ral)

E

– E

nlar

ged

liver

and

spl

een

S

– S

kin

lesi

ons,

Seiz

ures

Mat

erna

l: •

Mis

carr

iage

. •

Gum

ma

form

atio

n. •

Men

ingi

tis.

• S

trok

e. •

Hea

rt v

alve

dam

age.

MA

P 2.

12. S

yph

ilis

K30033_C002.indd 58 28/02/17 11:16 am

59O

bste

tric

sM

ap 2

.12.

Syp

hili

s

Wha

t is

syp

hilis

?Th

is is

a s

exua

lly tr

ansm

itted

dis

ease

cau

sed

by

the

spiro

chae

te T

repo

nem

a pa

llidu

m.

Tran

smis

sion

:•

Sexu

al c

onta

ct.

Sym

ptom

sIn

fect

ions

occ

urs

in th

ree

stag

es:

1. C

hanc

re –

pai

nles

s.2.

Dis

sem

inat

ed d

isea

se –

rash

on

palm

s

and

sol

es.

3. C

ardi

ac a

nd n

euro

logi

cal i

nvol

vem

ent.

Inve

stig

atio

ns•

Vene

real

Dis

ease

Res

earc

h La

bora

tory

(

VDRL

) tes

t.•

Rapi

d pl

asm

a re

agin

test

.•

Fluo

resc

ent t

repo

nem

al a

ntib

ody

abso

rptio

n

tes

t (FT

A-AB

S).

• Tr

epon

ema

palli

dum

hae

mag

glut

inat

ion

test

(

TPHA

).•

Trep

onem

a pa

llidu

m p

artic

le a

gglu

tinat

ion

t

est (

TPPA

).•

Trep

onem

al e

nzym

e im

mun

oass

ay (E

IA).

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vise

on

deliv

ery

rout

e (i.

e. c

aesa

rean

sec

tion

is p

refe

rabl

e)

Med

ical

: (m

any

antib

iotic

s lis

ted

belo

w a

re c

ontr

aind

icat

ed d

urin

g pr

egna

ncy.

Cons

ult l

ocal

gui

delin

es a

nd th

e BN

F). M

othe

r may

nee

d to

co

nsid

er te

rmin

atio

n of

pre

gnan

cy.

• M

ater

nal:

Pr

ocai

ne p

enic

illin

G.

Do

xycy

clin

e.

Eryt

hrom

ycin

.

Azith

rom

ycin

.N

ote:

If p

atie

nt h

as n

euro

syph

ilis,

give

pro

phyl

actic

pre

dnis

olon

e to

avoi

d th

e Ja

risch

–Her

xhei

mer

reac

tion.

Thi

s re

actio

n m

ay o

ccur

afte

ran

tibac

teria

l tre

atm

ent,

whi

ch c

ause

s th

e de

ath

of th

e sp

iroch

aete

and

su

bseq

uent

end

otox

in re

leas

e. E

ndot

oxin

s ca

use

the

Jaris

ch–H

erxh

eim

er

reac

tion.

• F

etal

:

Peni

cilli

n.

Com

plic

atio

ns

Feta

l: A

BCD

ES:

A

– A

sm

all h

ead

(mic

roce

phal

y)

B –

Bra

in p

atho

logy

(men

ingi

tis),

Bloo

d st

aine

d na

sal d

isch

arge

C

– C

horo

iditi

s

D –

Den

tal m

alfo

rmat

ions

, Dea

fnes

s (s

enso

rineu

ral)

E

– E

nlar

ged

liver

and

spl

een

S

– S

kin

lesi

ons,

Seiz

ures

Mat

erna

l: •

Mis

carr

iage

. •

Gum

ma

form

atio

n. •

Men

ingi

tis.

• S

trok

e. •

Hea

rt v

alve

dam

age.

MA

P 2.

12. S

yph

ilis

K30033_C002.indd 59 28/02/17 11:16 am

60O

bste

tric

sM

ap 2

.13.

Pla

cen

tal a

bru

pti

on

Wha

t is

pla

cent

al a

brup

tion

?Th

is is

a c

ause

of a

ntep

artu

m h

aem

orrh

age,

whi

chm

ay b

e de

fined

as

vagi

nal b

leed

ing

that

occ

urs

at <

24w

eeks

ges

tatio

n. T

he c

ause

s of

ant

epar

tum

haem

orrh

age

may

be

rem

embe

red

as P

VC2 :

P –

Plac

enta

l abr

uptio

nP

– Pl

acen

ta p

raev

iaV

– Va

sa p

raev

iaV

– Va

gina

l inf

ectio

nC

– Ca

ncer

of t

he c

ervi

xC

– Ce

rvic

itis

Caus

esPl

acen

tal a

brup

tion

occu

rs w

hen

the

plac

enta

sepa

rate

s fro

m th

e w

all o

f the

ute

rus.

It is

subc

lass

ified

as

eith

er a

con

ceal

ed o

r rev

eale

d (m

ore

com

mon

) abr

uptio

n.

Risk

fact

ors

Rem

embe

r as

OH

PIP

S:O

– O

verd

iste

nded

ute

rus

H –

Hyp

erte

nsio

n

P –

Pre-

ecla

mps

iaI –

Int

ra-u

terin

e gr

owth

rest

rictio

nP

– Pa

st h

isto

ry o

f pla

cent

al a

brup

tion

S –

Smok

ing

hist

ory

Sym

ptom

s•

Vagi

nal b

leed

ing.

• Se

vere

abd

omin

al p

ain

out o

f kee

ping

w

ith b

lood

loss

, cou

pled

with

sig

ns o

f

sys

tem

ic s

hock

may

indi

cate

con

ceal

ed

abr

uptio

n.•

Woo

den

uter

us o

n pa

lpat

ion.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

USS

for p

lace

nta

prae

via.

Trea

tmen

t

Med

ical

:•

Emer

genc

y tr

eatm

ent:

adm

issi

on, c

ross

-mat

ch

and

blo

od tr

ansf

usio

n.•

Cons

ider

del

iver

y de

pend

ing

on g

esta

tion.

If

the

fetu

s is

<34

wee

ks, g

ivin

g st

eroi

ds to

the

m

othe

r will

hel

p in

duce

feta

l lun

g

dev

elop

men

t.

Com

plic

atio

ns

Feta

l:•

Deat

h•

Intr

a-ut

erin

e gr

owth

rest

rictio

n

Mat

erna

l: DA

DS:

D –

Dea

th

A

– A

cute

kid

ney

inju

ry

D

– D

isse

min

ated

intr

avas

cula

r

coag

ulat

ion

and

mul

ti-or

gan

failu

re

S

– S

hock

MAP

2.1

3. P

lace

ntal

abru

ptio

n

K30033_C002.indd 60 28/02/17 11:16 am

61O

bste

tric

sM

ap 2

.13.

Pla

cen

tal a

bru

pti

on

Wha

t is

pla

cent

al a

brup

tion

?Th

is is

a c

ause

of a

ntep

artu

m h

aem

orrh

age,

whi

chm

ay b

e de

fined

as

vagi

nal b

leed

ing

that

occ

urs

at <

24w

eeks

ges

tatio

n. T

he c

ause

s of

ant

epar

tum

haem

orrh

age

may

be

rem

embe

red

as P

VC2 :

P –

Plac

enta

l abr

uptio

nP

– Pl

acen

ta p

raev

iaV

– Va

sa p

raev

iaV

– Va

gina

l inf

ectio

nC

– Ca

ncer

of t

he c

ervi

xC

– Ce

rvic

itis

Caus

esPl

acen

tal a

brup

tion

occu

rs w

hen

the

plac

enta

sepa

rate

s fro

m th

e w

all o

f the

ute

rus.

It is

subc

lass

ified

as

eith

er a

con

ceal

ed o

r rev

eale

d (m

ore

com

mon

) abr

uptio

n.

Risk

fact

ors

Rem

embe

r as

OH

PIP

S:O

– O

verd

iste

nded

ute

rus

H –

Hyp

erte

nsio

n

P –

Pre-

ecla

mps

iaI –

Int

ra-u

terin

e gr

owth

rest

rictio

nP

– Pa

st h

isto

ry o

f pla

cent

al a

brup

tion

S –

Smok

ing

hist

ory

Sym

ptom

s•

Vagi

nal b

leed

ing.

• Se

vere

abd

omin

al p

ain

out o

f kee

ping

w

ith b

lood

loss

, cou

pled

with

sig

ns o

f

sys

tem

ic s

hock

may

indi

cate

con

ceal

ed

abr

uptio

n.•

Woo

den

uter

us o

n pa

lpat

ion.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

USS

for p

lace

nta

prae

via.

Trea

tmen

t

Med

ical

:•

Emer

genc

y tr

eatm

ent:

adm

issi

on, c

ross

-mat

ch

and

blo

od tr

ansf

usio

n.•

Cons

ider

del

iver

y de

pend

ing

on g

esta

tion.

If

the

fetu

s is

<34

wee

ks, g

ivin

g st

eroi

ds to

the

m

othe

r will

hel

p in

duce

feta

l lun

g

dev

elop

men

t.

Com

plic

atio

ns

Feta

l:•

Deat

h•

Intr

a-ut

erin

e gr

owth

rest

rictio

n

Mat

erna

l: DA

DS:

D –

Dea

th

A

– A

cute

kid

ney

inju

ry

D

– D

isse

min

ated

intr

avas

cula

r

coag

ulat

ion

and

mul

ti-or

gan

failu

re

S

– S

hock

MAP

2.1

3. P

lace

ntal

abru

ptio

n

K30033_C002.indd 61 28/02/17 11:16 am

62O

bste

tric

sM

ap 2

.14.

Pla

cen

ta p

raev

ia

Wha

t is

pla

cent

a pr

aevi

a?Th

is is

a ‘l

ow ly

ing

plac

enta

’ and

a c

ause

of

ante

part

um h

aem

orrh

age,

whi

ch m

ay b

e de

fined

as

vagi

nal b

leed

ing

that

occ

urs

at <

24 w

eeks

ges

tatio

n.O

ther

cau

ses

of a

ntep

artu

m h

aem

orrh

age

are

liste

d in

Map

2.1

3, p

. 60.

Pl

acen

ta p

raev

ia m

ay b

e cl

assi

fied

as e

ither

min

or o

r maj

or. T

he m

ajor

form

com

plet

ely

cove

rsth

e in

tern

al o

s, w

here

as in

the

min

or fo

rm th

ein

tern

al o

s is

onl

y pa

rtia

lly c

over

ed.

Caus

esPl

acen

ta p

raev

ia is

cau

sed

by lo

w im

plan

tatio

n of

the

embr

yo.

Risk

fact

ors

Rem

embe

r as

MU

MS:

M –

Mat

erna

l age

U –

Ute

rine

abno

rmal

ityM

– M

ultip

arity

S –

Sec

tion

(cae

sare

an)

Sym

ptom

s•

Pain

less

vag

inal

ble

edin

g.•

Abno

rmal

feta

l lie

/failu

re o

f eng

agem

ent.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

abd

omin

al a

nd tr

ansv

agin

al U

SS.

Trea

tmen

t

Med

ical

:•

Emer

genc

y tr

eatm

ent:

adm

issi

on, c

ross

-mat

ch

and

blo

od tr

ansf

usio

n.

• Co

nsid

er e

lect

ive

caes

area

n se

ctio

n de

pend

ing

o

n ge

stat

ion.

If th

e fe

tus

is <

34 w

eeks

, giv

ing

s

tero

ids

to th

e m

othe

r will

hel

p in

duce

feta

l lun

g

dev

elop

men

t.

Com

plic

atio

ns

Feta

l:•

Deat

h•

Prem

atur

e de

liver

y.

Mat

erna

l: •

Mas

sive

hae

mor

rhag

e an

d de

ath.

• H

yste

rect

omy.

• H

igh

risk

of p

ost-

part

um h

aem

orrh

age.

MAP

2.1

4. P

lace

nta

prae

via

K30033_C002.indd 62 28/02/17 11:16 am

63O

bste

tric

sM

ap 2

.14.

Pla

cen

ta p

raev

ia

Wha

t is

pla

cent

a pr

aevi

a?Th

is is

a ‘l

ow ly

ing

plac

enta

’ and

a c

ause

of

ante

part

um h

aem

orrh

age,

whi

ch m

ay b

e de

fined

as

vagi

nal b

leed

ing

that

occ

urs

at <

24 w

eeks

ges

tatio

n.O

ther

cau

ses

of a

ntep

artu

m h

aem

orrh

age

are

liste

d in

Map

2.1

3, p

. 60.

Pl

acen

ta p

raev

ia m

ay b

e cl

assi

fied

as e

ither

min

or o

r maj

or. T

he m

ajor

form

com

plet

ely

cove

rsth

e in

tern

al o

s, w

here

as in

the

min

or fo

rm th

ein

tern

al o

s is

onl

y pa

rtia

lly c

over

ed.

Caus

esPl

acen

ta p

raev

ia is

cau

sed

by lo

w im

plan

tatio

n of

the

embr

yo.

Risk

fact

ors

Rem

embe

r as

MU

MS:

M –

Mat

erna

l age

U –

Ute

rine

abno

rmal

ityM

– M

ultip

arity

S –

Sec

tion

(cae

sare

an)

Sym

ptom

s•

Pain

less

vag

inal

ble

edin

g.•

Abno

rmal

feta

l lie

/failu

re o

f eng

agem

ent.

Inve

stig

atio

ns•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

abd

omin

al a

nd tr

ansv

agin

al U

SS.

Trea

tmen

t

Med

ical

:•

Emer

genc

y tr

eatm

ent:

adm

issi

on, c

ross

-mat

ch

and

blo

od tr

ansf

usio

n.

• Co

nsid

er e

lect

ive

caes

area

n se

ctio

n de

pend

ing

o

n ge

stat

ion.

If th

e fe

tus

is <

34 w

eeks

, giv

ing

s

tero

ids

to th

e m

othe

r will

hel

p in

duce

feta

l lun

g

dev

elop

men

t.

Com

plic

atio

ns

Feta

l:•

Deat

h•

Prem

atur

e de

liver

y.

Mat

erna

l: •

Mas

sive

hae

mor

rhag

e an

d de

ath.

• H

yste

rect

omy.

• H

igh

risk

of p

ost-

part

um h

aem

orrh

age.

MAP

2.1

4. P

lace

nta

prae

via

K30033_C002.indd 63 28/02/17 11:16 am

64O

bste

tric

sM

ap 2

.15.

Po

st-p

artu

m h

aem

orr

hag

e (P

PH)

Wha

t is

PPH

?Th

is is

ble

edin

g th

at o

ccur

s af

ter d

eliv

ery

of th

e fe

tus.

It m

ay b

e de

fined

as

prim

ary,

seco

ndar

y or

m

assi

ve d

epen

ding

on

the

amou

nt o

f blo

od lo

st a

nd th

e tim

e th

at h

as e

laps

ed p

ost d

eliv

ery.

Caus

esPr

imar

y: re

mem

ber a

s th

e 5T

s:

T

– T o

ne o

f ute

rus

lost

(mos

t com

mon

cau

se)

T –

Trau

ma

(e.g

. to

perin

eum

or u

terin

e ru

ptur

e)

T

– To

rn c

ervi

x or

vag

ina

T –

Thro

mbi

n (i.

e. b

leed

ing

diso

rder

s)

T

– Ti

ssue

(i.e

. ret

aine

d pr

oduc

ts o

f con

cept

ion)

Seco

ndar

y:•

Infe

ctio

n –

endo

met

ritis.

• Re

tain

ed p

rodu

cts

of c

once

ptio

n.

Risk

fact

ors:

rem

embe

r as

ABC

D:

A

– A

ntep

artu

m h

aem

orrh

age

B

– B

irthi

ng p

robl

ems

(i.e.

inst

rum

enta

l del

iver

y, in

duce

d la

bour

)

C –

Coa

gula

tion

diso

rder

s (e

.g. v

on W

illeb

rand

dis

ease

)

D –

Dur

atio

n of

labo

ur >

12 h

ours

Type

of

PPH

Bloo

d lo

stTi

me

elap

sed

afte

r bi

rth

Prim

ary

>50

0 m

L<

24 h

ours

Seco

ndar

y>

500

mL

>24

hou

rs to

12

wee

ksM

assi

ve>

1,50

0 m

LN

/A

Sym

ptom

sDe

pend

s on

the

caus

e of

PPH

. All

may

pres

ent w

ith s

hock

:•

Aton

ic u

teru

s: ut

erus

is e

nlar

ged.

• U

terin

e ru

ptur

e: a

bdom

inal

pai

n, v

agin

al

b

lood

loss

.•

Infe

ctio

n: ta

chyc

ardi

a, fe

ver,

abdo

min

al

p

ain,

vag

inal

blo

od lo

ss.

• Re

tain

ed c

once

ptio

n pr

oduc

ts: s

igns

of

i

nfec

tion

(see

abo

ve).

Trea

tmen

t

Emer

genc

y tr

eatm

ent:

• G

ener

ally

resu

scita

tion

man

agem

ent

in

clud

ing

an A

BCDE

app

roac

h w

ith

in

sert

ion

of tw

o w

ide

bore

can

nula

s.•

Bloo

ds: c

ross

-mat

ch a

nd b

lood

tran

sfus

ion.

• Sp

ecifi

c m

anag

emen

t dep

endi

ng o

n ca

use:

Aton

ic u

teru

s: ut

erin

e m

assa

ge.

U

terin

e ru

ptur

e: la

paro

tom

y.

Endo

met

ritis

: ant

ibio

tics

(che

ck lo

cal

g

uide

lines

).

Reta

ined

pro

duct

s of

con

cept

ion:

evac

uatio

n w

ith s

uctio

n cu

rett

e.

Inve

stig

atio

ns•

Trau

ma

ABCD

E w

ith u

rine

outp

ut

mea

sure

men

t.•

Iden

tify

caus

e (e

.g. v

agin

al e

xam

inat

ion)

.•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

abd

omin

al a

nd tr

ansv

agin

al

U

SS.

Com

plic

atio

ns•

Mas

sive

hae

mor

rhag

e.•

Hyst

erec

tom

y.•

Deat

h.

MAP

2.1

5. P

ost-

part

um h

aem

orrh

age

(PPH

)

K30033_C002.indd 64 28/02/17 11:16 am

65O

bste

tric

sM

ap 2

.15.

Po

st-p

artu

m h

aem

orr

hag

e (P

PH)

Wha

t is

PPH

?Th

is is

ble

edin

g th

at o

ccur

s af

ter d

eliv

ery

of th

e fe

tus.

It m

ay b

e de

fined

as

prim

ary,

seco

ndar

y or

m

assi

ve d

epen

ding

on

the

amou

nt o

f blo

od lo

st a

nd th

e tim

e th

at h

as e

laps

ed p

ost d

eliv

ery.

Caus

esPr

imar

y: re

mem

ber a

s th

e 5T

s:

T

– To

ne o

f ute

rus

lost

(mos

t com

mon

cau

se)

T –

Trau

ma

(e.g

. to

perin

eum

or u

terin

e ru

ptur

e)

T

– To

rn c

ervi

x or

vag

ina

T –

Thro

mbi

n (i.

e. b

leed

ing

diso

rder

s)

T

– Ti

ssue

(i.e

. ret

aine

d pr

oduc

ts o

f con

cept

ion)

Seco

ndar

y:•

Infe

ctio

n –

endo

met

ritis.

• Re

tain

ed p

rodu

cts

of c

once

ptio

n.

Risk

fact

ors:

rem

embe

r as

ABC

D:

A

– A

ntep

artu

m h

aem

orrh

age

B

– B

irthi

ng p

robl

ems

(i.e.

inst

rum

enta

l del

iver

y, in

duce

d la

bour

)

C –

Coa

gula

tion

diso

rder

s (e

.g. v

on W

illeb

rand

dis

ease

)

D –

Dur

atio

n of

labo

ur >

12 h

ours

Type

of

PPH

Bloo

d lo

stTi

me

elap

sed

afte

r bi

rth

Prim

ary

>50

0 m

L<

24 h

ours

Seco

ndar

y>

500

mL

>24

hou

rs to

12

wee

ksM

assi

ve>

1,50

0 m

LN

/A

Sym

ptom

sDe

pend

s on

the

caus

e of

PPH

. All

may

pres

ent w

ith s

hock

:•

Aton

ic u

teru

s: ut

erus

is e

nlar

ged.

• U

terin

e ru

ptur

e: a

bdom

inal

pai

n, v

agin

al

b

lood

loss

.•

Infe

ctio

n: ta

chyc

ardi

a, fe

ver,

abdo

min

al

p

ain,

vag

inal

blo

od lo

ss.

• Re

tain

ed c

once

ptio

n pr

oduc

ts: s

igns

of

i

nfec

tion

(see

abo

ve).

Trea

tmen

t

Emer

genc

y tr

eatm

ent:

• G

ener

ally

resu

scita

tion

man

agem

ent

in

clud

ing

an A

BCDE

app

roac

h w

ith

in

sert

ion

of tw

o w

ide

bore

can

nula

s.•

Bloo

ds: c

ross

-mat

ch a

nd b

lood

tran

sfus

ion.

• Sp

ecifi

c m

anag

emen

t dep

endi

ng o

n ca

use:

Aton

ic u

teru

s: ut

erin

e m

assa

ge.

U

terin

e ru

ptur

e: la

paro

tom

y.

Endo

met

ritis

: ant

ibio

tics

(che

ck lo

cal

g

uide

lines

).

Reta

ined

pro

duct

s of

con

cept

ion:

evac

uatio

n w

ith s

uctio

n cu

rett

e.

Inve

stig

atio

ns•

Trau

ma

ABCD

E w

ith u

rine

outp

ut

mea

sure

men

t.•

Iden

tify

caus

e (e

.g. v

agin

al e

xam

inat

ion)

.•

Mon

itor f

etal

dis

tres

s w

ith C

TG.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave.

• Ra

diol

ogy:

abd

omin

al a

nd tr

ansv

agin

al

U

SS.

Com

plic

atio

ns•

Mas

sive

hae

mor

rhag

e.•

Hyst

erec

tom

y.•

Deat

h.

MAP

2.1

5. P

ost-

part

um h

aem

orrh

age

(PPH

)

K30033_C002.indd 65 28/02/17 11:16 am

66O

bste

tric

sM

ap 2

.16.

Rh

esu

s d

isea

se

Wha

t is

rhe

sus

dise

ase?

This

dis

ease

is o

ne c

ause

of h

aem

olyt

ic d

isea

seof

the

new

born

. Ant

ibod

ies

from

arh

esus

-neg

ativ

e m

othe

r des

troy

feta

l blo

odce

lls, r

esul

ting

in h

aem

olyt

ic d

isea

se.

Caus

esRh

esus

dis

ease

occ

urs

as a

dire

ct re

sult

ofm

ater

nal a

ntib

odie

s at

tack

ing

feta

l blo

od c

ells.

This

hap

pens

whe

n th

e m

othe

r is

rhes

usne

gativ

e bu

t the

fetu

s is

rhes

us p

ositi

ve.

The

mot

her m

ust h

ave

been

pre

viou

sly

sens

itize

d (b

y ex

posu

re to

rhes

us-p

ositi

ve b

lood

[e.g

. dur

ing

a pr

evio

us p

regn

ancy

]).

Inve

stig

atio

ns•

Rhes

us s

tatu

s is

diag

nose

d du

ring

the

rout

ine

U

K sc

reen

ing

prog

ram

me

(see

Tabl

e 2.

1, p

. 34)

.•

Coom

bs te

st –

blo

od s

ampl

ing

from

the

u

mbi

lical

cor

d as

sess

es b

aby’

s bl

ood

type

as

w

ell a

s w

heth

er a

nti-D

ant

ibod

ies

have

p

asse

d in

to th

e ba

by’s

bloo

d.

Sym

ptom

sSy

mpt

oms

depe

nd o

n th

e se

verit

y of

rhes

us

dise

ase.

Gen

eral

sym

ptom

s:•

Hypo

toni

a.•

Off

feed

s.•

Haem

olyt

ic a

naem

ia (o

f var

ying

sev

erity

).•

Jaun

dice

(of v

aryi

ng s

ever

ity).

Mild

ana

emia

Mod

erat

e ja

undi

ce

Mod

erat

e

Seve

re a

naem

iaHy

drop

s fo

etal

isHy

pogl

ycae

mia

Mod

erat

e an

aem

iaM

oder

ate–

seve

re ja

undi

ce

Mild

Seve

re

Bloo

d lo

stTi

me

elap

sed

afte

r bi

rth

Trea

tmen

t

Med

ical

:•

Prev

entin

g rh

esus

dis

ease

:

Ro

utin

e an

tena

tal a

nti-D

pro

phyl

axis

:

1.

Si

ngle

dos

e tr

eatm

ent –

at 2

8–30

wee

ks.

2.

Doub

le d

ose

trea

tmen

t – a

t 28

wee

ks a

nd 3

4 w

eeks

.

An

ti-D

imm

unog

lobu

lin g

iven

at a

ny

sen

sitiz

ing

even

t (e.

g. a

ny b

leed

ing)

.

Anti-

D im

mun

oglo

bulin

giv

en w

ithin

72 h

ours

afte

r birt

h if

mot

her h

as

not

bee

n se

nsiti

zed.

• Tr

eatin

g rh

esus

dis

ease

:

Ph

otot

hera

py.

In

trav

enou

s im

mun

oglo

bulin

.

Bloo

d tr

ansf

usio

ns.

Com

plic

atio

ns•

Haem

olyt

ic d

isea

se o

f the

new

born

.•

Still

birt

h.•

Lear

ning

diff

icul

ties.

• De

afne

ss.

• Bl

indn

ess.

MAP

2.1

6. R

hesu

s di

seas

e

K30033_C002.indd 66 28/02/17 11:16 am

67O

bste

tric

sM

ap 2

.16.

Rh

esu

s d

isea

se

Wha

t is

rhe

sus

dise

ase?

This

dis

ease

is o

ne c

ause

of h

aem

olyt

ic d

isea

seof

the

new

born

. Ant

ibod

ies

from

arh

esus

-neg

ativ

e m

othe

r des

troy

feta

l blo

odce

lls, r

esul

ting

in h

aem

olyt

ic d

isea

se.

Caus

esRh

esus

dis

ease

occ

urs

as a

dire

ct re

sult

ofm

ater

nal a

ntib

odie

s at

tack

ing

feta

l blo

od c

ells.

This

hap

pens

whe

n th

e m

othe

r is

rhes

usne

gativ

e bu

t the

fetu

s is

rhes

us p

ositi

ve.

The

mot

her m

ust h

ave

been

pre

viou

sly

sens

itize

d (b

y ex

posu

re to

rhes

us-p

ositi

ve b

lood

[e.g

. dur

ing

a pr

evio

us p

regn

ancy

]).

Inve

stig

atio

ns•

Rhes

us s

tatu

s is

diag

nose

d du

ring

the

rout

ine

U

K sc

reen

ing

prog

ram

me

(see

Tabl

e 2.

1, p

. 34)

.•

Coom

bs te

st –

blo

od s

ampl

ing

from

the

u

mbi

lical

cor

d as

sess

es b

aby’

s bl

ood

type

as

w

ell a

s w

heth

er a

nti-D

ant

ibod

ies

have

p

asse

d in

to th

e ba

by’s

bloo

d.

Sym

ptom

sSy

mpt

oms

depe

nd o

n th

e se

verit

y of

rhes

us

dise

ase.

Gen

eral

sym

ptom

s:•

Hypo

toni

a.•

Off

feed

s.•

Haem

olyt

ic a

naem

ia (o

f var

ying

sev

erity

).•

Jaun

dice

(of v

aryi

ng s

ever

ity).

Mild

ana

emia

Mod

erat

e ja

undi

ce

Mod

erat

e

Seve

re a

naem

iaHy

drop

s fo

etal

isHy

pogl

ycae

mia

Mod

erat

e an

aem

iaM

oder

ate–

seve

re ja

undi

ce

Mild

Seve

re

Bloo

d lo

stTi

me

elap

sed

afte

r bi

rth

Trea

tmen

t

Med

ical

:•

Prev

entin

g rh

esus

dis

ease

:

Ro

utin

e an

tena

tal a

nti-D

pro

phyl

axis

:

1.

Si

ngle

dos

e tr

eatm

ent –

at 2

8–30

wee

ks.

2.

Doub

le d

ose

trea

tmen

t – a

t 28

wee

ks a

nd 3

4 w

eeks

.

An

ti-D

imm

unog

lobu

lin g

iven

at a

ny

sen

sitiz

ing

even

t (e.

g. a

ny b

leed

ing)

.

Anti-

D im

mun

oglo

bulin

giv

en w

ithin

72 h

ours

afte

r birt

h if

mot

her h

as

not

bee

n se

nsiti

zed.

• Tr

eatin

g rh

esus

dis

ease

:

Ph

otot

hera

py.

In

trav

enou

s im

mun

oglo

bulin

.

Bloo

d tr

ansf

usio

ns.

Com

plic

atio

ns•

Haem

olyt

ic d

isea

se o

f the

new

born

.•

Still

birt

h.•

Lear

ning

diff

icul

ties.

• De

afne

ss.

• Bl

indn

ess.

MAP

2.1

6. R

hesu

s di

seas

e

K30033_C002.indd 67 28/02/17 11:16 am

68O

bste

tric

sM

ap 2

.17.

Sym

ph

ysis

pu

bis

dys

fun

ctio

n

Wha

t is

sym

phys

is p

ubis

dys

func

tion

?Th

is is

a c

ondi

tion

of p

ain

and

disc

omfo

rt th

atoc

curs

in s

ome

preg

nant

wom

en d

ue to

incr

ease

d m

ovem

ent a

nd m

isal

ignm

ent o

f the

pelv

ic b

ones

at t

he p

ubis

sym

phys

is. S

ympt

oms

tend

to w

orse

n as

the

preg

nanc

y pr

ogre

sses

and

ther

e is

an

incr

ease

d ris

k w

ith m

ultip

arity

.

Caus

esDu

e to

incr

ease

d la

xity

of t

he p

elvi

c lig

amen

ts.

This

occ

urs

due

to in

crea

sed

rela

xin

horm

one

leve

ls.

Inve

stig

atio

ns•

Usu

ally

a c

linic

al d

iagn

osis.

• Ra

diol

ogy

– U

SS m

ay b

e us

ed to

ass

ess

the

d

egre

e of

sep

arat

ion

at th

e pu

bic

sym

phys

is.

9 m

m is

con

side

red

phys

iolo

gica

l in

p

regn

ancy

; >10

mm

in p

regn

ancy

is

con

side

red

path

olog

ical

.

Sym

ptom

s•

Pain

and

pel

vic

disc

omfo

rt (t

ypic

ally

at t

he

p

ubic

sym

phys

is b

ut m

ay a

lso

occu

r at t

he

s

acro

iliac

join

ts).

• Pa

in w

orse

ns w

ith m

ovem

ent a

nd c

erta

in

a

ctiv

ities

suc

h as

clim

bing

sta

irs.

• W

addl

ing

gait.

• Pa

lpat

ion

– te

nder

ness

ove

r the

pub

ic

sym

phys

is; a

gap

may

be

felt.

Trea

tmen

t

Cons

erva

tive

:•

Phys

ioth

erap

y.•

Plac

e a

pillo

w b

etw

een

the

legs

whi

le in

bed

r

estin

g.•

Avoi

d ac

tiviti

es th

at w

orse

n th

e pa

in.

Med

ical

:•

Anal

gesi

a: p

arac

etam

ol.

Com

plic

atio

ns•

Dias

tasi

s of

the

sym

phys

is p

ubis.

MAP

2.1

7. S

ymph

ysis

pubi

s dy

sfun

ctio

n

K30033_C002.indd 68 28/02/17 11:16 am

69O

bste

tric

sTa

ble

2.4.

Bre

astf

eed

ing

TABL

E 2.

4. B

reas

tfee

ding

.

Adv

anta

ges

Dis

adva

ntag

esA

bsol

ute

cont

rain

dica

tion

s

Bene

fits

for

bab

y:•

Decr

ease

d ris

k of

infe

ctio

n (e

.g. c

hest

infe

ctio

n,

ear i

nfec

tion,

urin

ary

trac

t inf

ectio

n)•

Decr

ease

d ris

k of

ast

hma

• De

crea

sed

risk

of e

czem

a•

Decr

ease

d ris

k of

dia

bete

s m

ellit

us

• De

crea

sed

risk

of d

iarr

hoea

and

vom

iting

Bene

fits

for

mot

her:

• De

crea

sed

risk

of c

ance

r: br

east

and

ova

rian

• De

crea

sed

risk

of o

steo

poro

sis

• In

crea

sed

bond

ing

with

chi

ld

• Ve

rtic

al tr

ansm

issi

on•

Risk

of m

astit

is•

Mot

her r

equi

res

addi

tiona

l cal

orie

s

• Ve

rtic

al in

fect

ions

(e.g

. HIV

)•

Gal

acto

saem

ia•

Drug

s: re

mem

ber A

BCS:

A –

Ant

ibio

tics

(e.g

. tet

racy

clin

es)

A –

Asp

irin

A –

Am

ioda

rone

B –

Benz

odia

zepi

ne

C –

Cyto

toxi

c dr

ugs

C –

Carb

imaz

ole

S –

Sulp

hony

lure

as

K30033_C002.indd 69 28/02/17 11:16 am

K30033_C002.indd 70 28/02/17 11:16 am

Chap

ter T

hree

Gyn

aeco

logy

MAP

3.1

E

cto

pic

pre

gn

ancy

72

MAP

3.2

M

isca

rria

ge

74

MAP

3.3

M

ola

r p

reg

nan

cies

76

TABL

E 3.

1 S

exu

ally

tra

nsm

itte

d in

fect

ion

s 78

TABL

E 3.

2 N

on

-sex

ual

ly t

ran

smit

ted

infe

ctio

ns

80

TABL

E 3.

3 M

eno

rrh

agia

81

MAP

3.4

A

men

orr

ho

ea

82

MAP

3.5

P

oly

cyst

ic o

vary

sy

nd

rom

e (P

CO

S)

84

TABL

E 3.

4 Te

rmin

atio

n o

f p

reg

nan

cy (

TOP)

86

MAP

3.6

I

nfe

rtili

ty

88

MAP

3.7

C

ervi

cal c

ance

r 90

MAP

3.8

V

agin

al c

ance

r 92

MAP

3.9

E

nd

om

etri

al c

ance

r 94

MAP

3.1

0 O

vari

an c

ance

r 96

TABL

E 3.

5 O

vari

an c

ysts

98

TABL

E 3.

6 I

nco

nti

nen

ce

99

TABL

E 3.

7 C

on

trac

epti

on

10

0

Gyn

aeco

logy

71

K30033_C003.indd 71 28/02/17 11:17 am

Gyn

aeco

logy

72M

ap 3

.1.

Ecto

pic

pre

gn

ancy

Wha

t is

an

ecto

pic

preg

nanc

y?Th

is is

whe

n th

e em

bryo

impl

ants

out

side

the

uter

us. T

he e

mbr

yo m

ay im

plan

t in

the

abdo

men

but

mor

e of

ten

it is

a tu

bal p

regn

ancy

m

ost c

omm

only

loca

ted

in th

e am

pulla

regi

on

of th

e fa

llopi

an tu

be (8

0%).

Caus

esAn

ythi

ng th

at n

arro

ws

or d

amag

es th

e fa

llopi

an tu

be m

ay re

sult

in a

n ec

topi

c pr

egna

ncy.

Rem

embe

r as

TIPS

:T

– Th

e pr

oges

tero

ne o

nly

pill

– re

sults

in

thic

kene

d se

cret

ions

.I

– In

fect

ion

and

IVF

trea

tmen

t.P

– Pe

lvic

infla

mm

ator

y di

seas

e.S

– Su

rgic

al p

roce

dure

s –

resu

lt in

adh

esio

ns.

Inve

stig

atio

ns•

Preg

nanc

y te

st a

nd b

-hCG

leve

ls.•

Bloo

d te

sts:

FBC,

U&

E, g

roup

and

sav

e.•

Radi

olog

y: tr

ansv

agin

al U

SS.

Com

plic

atio

nsRe

mem

ber a

s TU

BE:

T –

Tuba

l rup

ture

.U

– s

Ubf

ertil

ity.

B –

Blue

s (i.

e. p

sych

olog

ical

impl

icat

ions

rela

ted

to c

hild

loss

and

pos

sibl

e su

bfer

tility

).E

– Ec

topi

c pr

egna

ncy

risk

incr

ease

s fo

r

su

bseq

uent

pre

gnan

cies

.

Trea

tmen

t

Emer

genc

y tr

eatm

ent

Depe

nds

on in

itial

pre

sent

atio

n:•

Gen

eral

resu

scita

tion

man

agem

ent

in

clud

ing

an A

BCDE

app

roac

h w

ith in

sert

ion

of

two

wid

e bo

re c

annu

las.

• Bl

oods

: cro

ss-m

atch

and

blo

od tr

ansf

usio

n.

• Co

nsid

er a

nti-D

pro

phyl

axis.

Med

ical

:•

Met

hotr

exat

e.

Surg

ical

:•

Lapa

rosc

opic

sal

ping

otom

y/sa

lpin

gect

omy.

• If

this

fails

, the

n co

nsid

er la

paro

tom

y.

MAP

3.1

. Ect

opic

pre

gnan

cy

Sym

ptom

sCo

nsid

er in

any

sex

ually

act

ive

fem

ale

who

has

abdo

min

al p

ain

and

who

has

mis

sed

a pe

riod:

• Ab

dom

inal

pai

n –

usua

lly in

the

low

er ri

ght

o

r low

er le

ft qu

adra

nts

and

colic

ky in

nat

ure.

• Va

gina

l ble

edin

g –

dark

col

oure

d an

d

lik

ened

to ‘p

rune

juic

e’.

• N

ause

a an

d vo

miti

ng.

• Si

gns

of s

hock

: cla

mm

y ap

pear

ance

, pal

e,

tac

hyca

rdic

, hyp

oten

sive

.•

Vag

inal

exa

min

atio

n: c

ervi

cal e

xcita

tion.

K30033_C003.indd 72 28/02/17 11:17 am

Wha

t is

an

ecto

pic

preg

nanc

y?Th

is is

whe

n th

e em

bryo

impl

ants

out

side

the

uter

us. T

he e

mbr

yo m

ay im

plan

t in

the

abdo

men

but

mor

e of

ten

it is

a tu

bal p

regn

ancy

m

ost c

omm

only

loca

ted

in th

e am

pulla

regi

on

of th

e fa

llopi

an tu

be (8

0%).

Caus

esAn

ythi

ng th

at n

arro

ws

or d

amag

es th

e fa

llopi

an tu

be m

ay re

sult

in a

n ec

topi

c pr

egna

ncy.

Rem

embe

r as

TIPS

:T

– Th

e pr

oges

tero

ne o

nly

pill

– re

sults

in

thic

kene

d se

cret

ions

.I

– In

fect

ion

and

IVF

trea

tmen

t.P

– Pe

lvic

infla

mm

ator

y di

seas

e.S

– Su

rgic

al p

roce

dure

s –

resu

lt in

adh

esio

ns.

Inve

stig

atio

ns•

Preg

nanc

y te

st a

nd b

-hCG

leve

ls.•

Bloo

d te

sts:

FBC,

U&

E, g

roup

and

sav

e.•

Radi

olog

y: tr

ansv

agin

al U

SS.

Com

plic

atio

nsRe

mem

ber a

s TU

BE:

T –

Tuba

l rup

ture

.U

– s

Ubf

ertil

ity.

B –

Blue

s (i.

e. p

sych

olog

ical

impl

icat

ions

rela

ted

to c

hild

loss

and

pos

sibl

e su

bfer

tility

).E

– Ec

topi

c pr

egna

ncy

risk

incr

ease

s fo

r

su

bseq

uent

pre

gnan

cies

.

Trea

tmen

t

Emer

genc

y tr

eatm

ent

Depe

nds

on in

itial

pre

sent

atio

n:•

Gen

eral

resu

scita

tion

man

agem

ent

in

clud

ing

an A

BCDE

app

roac

h w

ith in

sert

ion

of

two

wid

e bo

re c

annu

las.

• Bl

oods

: cro

ss-m

atch

and

blo

od tr

ansf

usio

n.

• Co

nsid

er a

nti-D

pro

phyl

axis.

Med

ical

:•

Met

hotr

exat

e.

Surg

ical

:•

Lapa

rosc

opic

sal

ping

otom

y/sa

lpin

gect

omy.

• If

this

fails

, the

n co

nsid

er la

paro

tom

y.

MAP

3.1

. Ect

opic

pre

gnan

cy

Sym

ptom

sCo

nsid

er in

any

sex

ually

act

ive

fem

ale

who

has

abdo

min

al p

ain

and

who

has

mis

sed

a pe

riod:

• Ab

dom

inal

pai

n –

usua

lly in

the

low

er ri

ght

o

r low

er le

ft qu

adra

nts

and

colic

ky in

nat

ure.

• Va

gina

l ble

edin

g –

dark

col

oure

d an

d

lik

ened

to ‘p

rune

juic

e’.

• N

ause

a an

d vo

miti

ng.

• Si

gns

of s

hock

: cla

mm

y ap

pear

ance

, pal

e,

tac

hyca

rdic

, hyp

oten

sive

.•

Vag

inal

exa

min

atio

n: c

ervi

cal e

xcita

tion.

73M

ap 3

.1.

Ecto

pic

pre

gn

ancy

Gyn

aeco

logy

K30033_C003.indd 73 28/02/17 11:17 am

Gyn

aeco

logy

74M

ap 3

.2.

Mis

carr

iag

e

Trea

tmen

t•

Depe

nds

on c

linic

al p

rese

ntat

ion

and

the

ty

pe o

f mis

carr

iage

.

Emer

genc

y tr

eatm

ent:

• M

ay b

e re

quire

d if

mot

her i

s ha

emor

rhag

ing.

Med

ical

:•

Pros

tagl

andi

ns +

/– m

ifepr

isto

ne

(a

nti-p

roge

ster

one)

.

Surg

ical

:•

Suct

ion

cure

ttag

e.

Com

plic

atio

ns•

Infe

ctio

n an

d py

rexi

a.•

Psyc

holo

gica

l im

plic

atio

ns in

clud

ing

de

pres

sion

.•

Com

plic

atio

n of

sur

gica

l cur

etta

ge (e

.g. t

he

risk

asso

ciat

ed w

ith g

ener

al a

naes

thet

ic,

ut

erin

e pe

rfora

tion,

Ash

erm

an’s

synd

rom

e

[intr

aute

rine

adhe

sion

s]).

Inve

stig

atio

ns•

b-hC

G le

vels.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave,

rh

esus

sta

tus.

• Ra

diol

ogy:

tran

svag

inal

USS

.

MAP

3.2

. Mis

carr

iage

Wha

t is

a m

isca

rria

ge?

This

is w

hen

the

fetu

s is

spon

tane

ously

abo

rted

<24

wee

ksge

stat

ion,

with

the

maj

ority

bei

ng<1

2 w

eeks

ges

tatio

n. Th

ere

are

man

y di

ffere

nt ty

pes

ofm

iscar

riage

. The

se m

ay b

e de

fined

as e

ither

com

plet

e or

inco

mpl

ete ,

or c

lass

ified

acc

ordi

ng to

thei

rpr

esen

tatio

n , s

uch

as in

evita

ble,

thre

aten

ed, m

issed

and

recu

rrent

.

Caus

esM

ostly

the

caus

e is

unkn

own

but

broa

d ca

uses

, par

ticul

arly

of r

ecur

rent

m

iscar

riage

, may

be

rem

embe

red

as A

BC:

A –

Antip

hosp

holip

id s

yndr

ome,

incr

easin

g Ag

eB

– Bl

eedi

ng d

isord

ers

(e.g

. von

Will

ebra

nd d

iseas

e)C

– Ch

rom

osom

al a

bnor

mal

ity,

Cerv

ical

inco

mpe

tenc

e

Type

of

mis

carr

iage

Sym

ptom

sCe

rvic

al o

sop

en o

r cl

osed

Inev

itabl

e

Thre

aten

ed

Mis

sed

Heav

y va

gina

l ble

edin

gAb

dom

inal

pai

n

Ligh

t vag

inal

ble

edin

gFe

tus

may

sur

vive

No

vagi

nal b

leed

ing

Fetu

s is

no

long

er v

iabl

e

Ope

n

Clos

ed

Clos

ed

Sym

ptom

sSy

mpt

oms

depe

nd o

n th

e ty

pe o

f mis

carr

iage

.

K30033_C003.indd 74 28/02/17 11:17 am

Gyn

aeco

logy

75M

ap 3

.2.

Mis

carr

iag

e

Trea

tmen

t•

Depe

nds

on c

linic

al p

rese

ntat

ion

and

the

ty

pe o

f mis

carr

iage

.

Emer

genc

y tr

eatm

ent:

• M

ay b

e re

quire

d if

mot

her i

s ha

emor

rhag

ing.

Med

ical

:•

Pros

tagl

andi

ns +

/– m

ifepr

isto

ne

(a

nti-p

roge

ster

one)

.

Surg

ical

:•

Suct

ion

cure

ttag

e.

Com

plic

atio

ns•

Infe

ctio

n an

d py

rexi

a.•

Psyc

holo

gica

l im

plic

atio

ns in

clud

ing

de

pres

sion

.•

Com

plic

atio

n of

sur

gica

l cur

etta

ge (e

.g. t

he

risk

asso

ciat

ed w

ith g

ener

al a

naes

thet

ic,

ut

erin

e pe

rfora

tion,

Ash

erm

an’s

synd

rom

e

[intr

aute

rine

adhe

sion

s]).

Inve

stig

atio

ns•

b-hC

G le

vels.

• Bl

ood

test

s: FB

C, U

&E,

gro

up a

nd s

ave,

rh

esus

sta

tus.

• Ra

diol

ogy:

tran

svag

inal

USS

.

MAP

3.2

. Mis

carr

iage

Wha

t is

a m

isca

rria

ge?

This

is w

hen

the

fetu

s is

spon

tane

ously

abo

rted

<24

wee

ksge

stat

ion,

with

the

maj

ority

bei

ng<1

2 w

eeks

ges

tatio

n. Th

ere

are

man

y di

ffere

nt ty

pes

ofm

iscar

riage

. The

se m

ay b

e de

fined

as e

ither

com

plet

e or

inco

mpl

ete,

or c

lass

ified

acc

ordi

ng to

thei

rpr

esen

tatio

n, s

uch

as in

evita

ble,

thre

aten

ed, m

issed

and

recu

rrent

.

Caus

esM

ostly

the

caus

e is

unkn

own

but

broa

d ca

uses

, par

ticul

arly

of r

ecur

rent

m

iscar

riage

, may

be

rem

embe

red

as A

BC:

A –

Antip

hosp

holip

id s

yndr

ome,

incr

easin

g Ag

eB

– Bl

eedi

ng d

isord

ers

(e.g

. von

Will

ebra

nd d

iseas

e)C

– Ch

rom

osom

al a

bnor

mal

ity,

Cerv

ical

inco

mpe

tenc

e

Type

of

mis

carr

iage

Sym

ptom

sCe

rvic

al o

sop

en o

r cl

osed

Inev

itabl

e

Thre

aten

ed

Mis

sed

Heav

y va

gina

l ble

edin

gAb

dom

inal

pai

n

Ligh

t vag

inal

ble

edin

gFe

tus

may

sur

vive

No

vagi

nal b

leed

ing

Fetu

s is

no

long

er v

iabl

e

Ope

n

Clos

ed

Clos

ed

Sym

ptom

sSy

mpt

oms

depe

nd o

n th

e ty

pe o

f mis

carr

iage

.

K30033_C003.indd 75 28/02/17 11:17 am

Gyn

aeco

logy

76M

ap 3

.3.

Mo

lar

pre

gn

anci

es

Wha

t is

a m

olar

pre

gnan

cy?

Mol

ar p

regn

anci

es, a

lso

know

n as

ges

tatio

nal t

roph

obla

stic

dise

ase,

are

due

to e

xces

sive

unc

ontr

olle

d pr

olife

ratio

n of

trop

hobl

astic

tiss

ue. T

hey

may

be

char

acte

rized

as

eith

erpa

rtia

l or c

ompl

ete

mol

ar p

regn

anci

es a

nd fu

rthe

rch

arac

teriz

ed a

s be

nign

or m

alig

nant

.

Type

of

mol

ar p

regn

ancy

Hyda

tidifo

rm m

ole

Inva

sive

mol

e

Beni

gn o

r m

alig

nant

?

Chor

ioca

rcin

oma

Beni

gn

Mal

igna

nt

Mal

igna

nt

Caus

es•

Part

ial m

oles

are

mad

e fro

m b

oth

mat

erna

l and

pat

erna

l

gene

tic m

ater

ial.

• Co

mpl

ete

mol

es a

re m

ade

from

onl

y pa

tern

al g

enet

ic

mat

eria

l.

Risk

fact

ors

• Ex

trem

es o

f mat

erna

l age

.•

Mor

e co

mm

on in

wom

en o

f Asi

an a

nces

try.

Inve

stig

atio

ns•

b-hC

G le

vels

: exc

essi

vely

hig

h.•

Bloo

d pr

essu

re.

• Bl

ood

test

s: FB

C, U

&E,

TFT

s (g

roup

and

sa

ve, r

hesu

s st

atus

if e

xces

sive

bl

eedi

ng).

• Ra

diol

ogy:

tran

svag

inal

USS

– a

‘sno

w

sto

rm’ a

ppea

ranc

e is

pat

hogn

omon

ic.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Co

ntac

t spe

cial

ist c

entr

es fo

r tro

phob

last

ic d

isea

se.

Med

ical

:•

Pros

tagl

andi

ns +

/– m

ifepr

isto

ne (a

nti-p

roge

ster

one)

so

met

imes

use

d to

aid

rem

oval

of t

roph

obla

stic

tiss

ue.

• Ch

emot

hera

py m

ay b

e re

quire

d.

Surg

ical

:•

Suct

ion

cure

ttag

e.

Com

plic

atio

ns•

Incr

ease

d ris

k of

trop

hobl

astic

dis

ease

in s

ubse

quen

t

preg

nanc

ies.

• Tr

opho

blas

tic d

isea

se m

ay b

ecom

e pe

rsis

tent

and

requ

ire

chem

othe

rapy

.•

Chor

ioca

rcin

oma

may

met

asta

size

.

MAP

3.3

. M

olar

pre

gnan

cies

Sym

ptom

s•

Ute

rus

larg

e fo

r dat

es.

• Va

gina

l ble

edin

g.•

Hype

rem

esis.

• Ra

re s

ympt

oms:

pre-

ecla

mps

ia,

hy

pert

hyro

idis

m.

K30033_C003.indd 76 28/02/17 11:17 am

Gyn

aeco

logy

77M

ap 3

.3.

Mo

lar

pre

gn

anci

es

Wha

t is

a m

olar

pre

gnan

cy?

Mol

ar p

regn

anci

es, a

lso

know

n as

ges

tatio

nal t

roph

obla

stic

dise

ase,

are

due

to e

xces

sive

unc

ontr

olle

d pr

olife

ratio

n of

trop

hobl

astic

tiss

ue. T

hey

may

be

char

acte

rized

as

eith

erpa

rtia

l or c

ompl

ete

mol

ar p

regn

anci

es a

nd fu

rthe

rch

arac

teriz

ed a

s be

nign

or m

alig

nant

.

Type

of

mol

ar p

regn

ancy

Hyda

tidifo

rm m

ole

Inva

sive

mol

e

Beni

gn o

r m

alig

nant

?

Chor

ioca

rcin

oma

Beni

gn

Mal

igna

nt

Mal

igna

nt

Caus

es•

Part

ial m

oles

are

mad

e fro

m b

oth

mat

erna

l and

pat

erna

l

gene

tic m

ater

ial.

• Co

mpl

ete

mol

es a

re m

ade

from

onl

y pa

tern

al g

enet

ic

mat

eria

l.

Risk

fact

ors

• Ex

trem

es o

f mat

erna

l age

.•

Mor

e co

mm

on in

wom

en o

f Asi

an a

nces

try.

Inve

stig

atio

ns•

b-hC

G le

vels

: exc

essi

vely

hig

h.•

Bloo

d pr

essu

re.

• Bl

ood

test

s: FB

C, U

&E,

TFT

s (g

roup

and

sa

ve, r

hesu

s st

atus

if e

xces

sive

bl

eedi

ng).

• Ra

diol

ogy:

tran

svag

inal

USS

– a

‘sno

w

sto

rm’ a

ppea

ranc

e is

pat

hogn

omon

ic.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Co

ntac

t spe

cial

ist c

entr

es fo

r tro

phob

last

ic d

isea

se.

Med

ical

:•

Pros

tagl

andi

ns +

/– m

ifepr

isto

ne (a

nti-p

roge

ster

one)

so

met

imes

use

d to

aid

rem

oval

of t

roph

obla

stic

tiss

ue.

• Ch

emot

hera

py m

ay b

e re

quire

d.

Surg

ical

:•

Suct

ion

cure

ttag

e.

Com

plic

atio

ns•

Incr

ease

d ris

k of

trop

hobl

astic

dis

ease

in s

ubse

quen

t

preg

nanc

ies.

• Tr

opho

blas

tic d

isea

se m

ay b

ecom

e pe

rsis

tent

and

requ

ire

chem

othe

rapy

.•

Chor

ioca

rcin

oma

may

met

asta

size

.

MAP

3.3

. M

olar

pre

gnan

cies

Sym

ptom

s•

Ute

rus

larg

e fo

r dat

es.

• Va

gina

l ble

edin

g.•

Hype

rem

esis.

• Ra

re s

ympt

oms:

pre-

ecla

mps

ia,

hy

pert

hyro

idis

m.

K30033_C003.indd 77 28/02/17 11:17 am

Gyn

aeco

logy

78Ta

ble

3.1.

Sex

ual

ly t

ran

smit

ted

infe

ctio

ns

TABL

E 3.

1. S

exua

lly t

rans

mit

ted

infe

ctio

ns.

Dis

ease

Caus

ativ

e or

gani

smSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Chla

myd

ia

Chla

myd

ia

trac

hom

atis

• As

ympt

omat

ic (t

here

is c

urre

ntly

an

oppo

rtun

istic

scr

eeni

ng p

rogr

amm

e in

the

UK

for u

nder

25’

s)•

Fem

ales

: vag

inal

dis

char

ge, i

nter

-men

stru

al

or p

ost-

coita

l ble

edin

g, c

ervi

citis

•

Mal

es: u

reth

ritis,

dys

uria

• It

is th

e m

ost c

omm

on c

ause

of p

elvi

c in

flam

mat

ory

dise

ase

Nuc

leic

aci

d am

plifi

catio

n te

st (N

AAT)

from

eith

er

endo

cerv

ical

sw

abs/

urin

e sa

mpl

e fo

r wom

en a

nd a

ur

ine

sam

ple

for m

en

• Do

xycy

clin

e (7

day

s)•

Azith

rom

ycin

(sin

gle

dose

)

Tric

hom

onia

sis

Tric

hom

onas

va

gina

lis•

Asym

ptom

atic

•

Fem

ales

: vag

inal

dis

char

ge (g

reen

and

of

fens

ive)

, vul

vova

gini

tis, ‘

stra

wbe

rry

cerv

ix’,

supe

rfici

al d

yspa

reun

ia, p

H >

4.5

• M

ales

: ure

thrit

is

Wet

mou

nt m

icro

scop

y to

vi

sual

ize

mot

ile tr

opho

zoite

s •

Met

roni

dazo

le

Gon

orrh

oea

Nei

sser

ia

gono

rrho

eae

• Fe

mal

es: g

ener

ally

asy

mpt

omat

ic, v

agin

al

disc

harg

e, c

ervi

citis

•

Mal

es: u

reth

ritis

Endo

cerv

ical

sw

abs

• az

ithro

myc

in a

nd IM

ce

ftria

xone

Gen

ital w

arts

(con

dylo

mat

a ac

cum

inat

a)

Hum

an

papi

llom

aviru

s (H

PV)

• Pa

pilli

form

or fl

at w

arts

•

May

be

pigm

ente

d•

May

ble

ed•

May

itch

Clin

ical

pre

sent

atio

n•

Firs

t lin

e –

topi

cal

podo

phyl

lum

or c

ryot

hera

py•

Seco

nd li

ne –

imiq

uim

od

crea

m

K30033_C003.indd 78 28/02/17 11:17 am

Gyn

aeco

logy

79Ta

ble

3.1.

Sex

ual

ly t

ran

smit

ted

infe

ctio

ns

Gen

ital h

erpe

sHe

rpes

sim

plex

vi

rus

(HSV

) 1 a

nd 2

• Pa

infu

l, ul

cera

ted

lesi

ons

• Dy

suria

• Ly

mph

aden

opat

hy

Vira

l sw

ab•

Acic

lovi

r

Syph

ilis

Trep

onem

a pa

llidu

m

See

Map

2.1

2 (p

. 58)

Split

into

:

• Pr

imar

y sy

phili

s –

chan

cre

• Se

cond

ary

syph

ilis

– ra

sh

• Te

rtia

ry s

yphi

lis –

car

diac

and

neu

rolo

gica

l in

volv

emen

t. G

umm

ata

form

atio

n

See

Map

2.1

2 (p

. 58)

VDRL

test

ing

• Pe

nici

llin

K30033_C003.indd 79 28/02/17 11:17 am

Gyn

aeco

logy

80Ta

ble

3.2.

No

n-s

exu

ally

tra

nsm

itte

d in

fect

ion

s

TABL

E 3.

2. N

on-s

exua

lly t

rans

mit

ted

infe

ctio

ns.

Dis

ease

Caus

ativ

e or

gani

smSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Cand

idia

sis

Cand

ida

albi

cans

•

Typi

cal d

isch

arge

(‘co

ttag

e ch

eese

’)•

Itchi

ng

• Vu

lviti

s

• M

icro

scop

y an

d cu

lture

• To

pica

l pre

para

tions

(e

.g. i

mid

azol

es)

• O

ral p

repa

ratio

ns

(e.g

. fluc

onaz

ole)

Bact

eria

l vag

inos

isG

ardn

erel

la

vagi

nalis

• M

ay b

e as

ympt

omat

ic•

Amse

l’s c

riter

ia –

thre

e of

the

four

crit

eria

list

ed b

elow

mus

t be

met

:1.

Whi

te h

omog

eneo

us d

isch

arge

2. C

lue

cells

vis

ible

on

mic

rosc

opy

3. V

agin

al p

H >

4.5

4. P

ositi

ve w

hiff

test

– a

fish

y od

our i

s cr

eate

d on

add

ition

of

pota

ssiu

m h

ydro

xide

• Re

fer t

o Am

sel’s

crit

eria

: m

icro

scop

y, in

crea

sed

vagi

nal p

H, a

dditi

on o

f po

tass

ium

hyd

roxi

de

• O

ral m

etro

nida

zole

(5

–7 d

ays)

• Se

cond

line

– to

pica

l met

roni

dazo

le o

r cl

inda

myc

in

K30033_C003.indd 80 28/02/17 11:17 am

Gyn

aeco

logy

81

TABL

E 3.

3. M

enor

rhag

ia. I

n la

yman

’s t

erm

s, m

enor

rhag

ia is

hea

vy m

enst

rual

ble

edin

g. P

revi

ousl

y it

was

defi

ned

obje

ctiv

ely

as >

80 m

L bl

ood

loss

; how

ever

, the

re h

as b

een

a sh

ift

to t

he s

ubje

ctiv

e w

here

hea

vy m

enst

rual

bl

eedi

ng is

defi

ned

by w

hat

the

wom

an f

eels

is e

xces

sive

.

Caus

esIn

vest

igat

ions

Trea

tmen

t

Rem

embe

r as

U B

LEED

:

U –

Ute

rine

poly

ps/U

terin

e fib

roid

sB

– B

leed

ing

diso

rder

s (e

.g. v

on W

illeb

rand

di

seas

e)L

– L

ikel

y no

und

erly

ing

path

olog

y (5

0%)

E –

End

omet

riosi

sE

– E

ndom

etria

l car

cino

ma/

hype

rpla

sia

D –

pel

vic

infla

mm

ator

y D

isea

se/

intr

aute

rine

Dev

ices

Depe

nds

on th

e ca

use

of m

enor

rhag

ia. I

t is

esse

ntia

l to

per

form

an

FBC

in e

ach

case

to e

xclu

de a

naem

ia.

Som

e in

vest

igat

ions

are

list

ed b

elow

:

• G

ener

al b

lood

test

s: FB

C, U

&E,

TFT

s•

Radi

olog

y: U

SS, h

yste

rosc

opy,

endo

met

rial b

iops

y if

indi

cate

d

Refe

r to

appr

opria

te lo

cal a

lgor

ithm

s.

Trea

tmen

t is

a st

epw

ise

appr

oach

.

Med

ical

:

• Fi

rst-

line:

Mire

na in

trau

terin

e sy

stem

• Se

cond

-line

: mef

enam

ic a

cid

(par

ticul

arly

if c

o-m

orbi

d dy

smen

orrh

oea)

, tra

nexa

mic

aci

d, c

ombi

ned

oral

co

ntra

cept

ive

pill

• Th

ird-li

ne: l

ong

actin

g pr

oges

toge

ns (o

ral o

r inj

ecte

d).

Cons

ider

GnR

H an

alog

ues

if th

is fa

ils

Surg

ical

:

• En

dom

etria

l abl

atio

n•

Hyst

erec

tom

y •

Not

e: S

urgi

cal i

nter

vent

ion

can

caus

e in

fert

ility

Tabl

e 3.

3. M

eno

rrh

agia

K30033_C003.indd 81 28/02/17 11:17 am

Gyn

aeco

logy

82M

ap 3

.4.

Am

eno

rrh

oea

Wha

t is

am

enor

rhoe

a?Th

is m

ay b

e de

fined

as

eith

er p

rimar

y or

seco

ndar

y am

enor

rhoe

a:•

Prim

ary:

men

stru

atio

n ha

s no

t com

men

ced

by

the

age

of 1

6.•

Seco

ndar

y: th

e ab

senc

e of

men

stru

atio

n fo

r

6 m

onth

s in

a w

oman

who

pre

viou

sly

had

no

rmal

men

stru

atio

n.

Caus

esTh

ese

are

split

into

prim

ary

and

seco

ndar

yca

uses

.

Prim

ary

caus

es (2

T 2C

):•

Turn

er s

yndr

ome

(45,

X).

• Te

stic

ular

fem

iniz

atio

n.•

Cong

enita

l mal

form

atio

ns (e

.g. M

ayer

–

Roki

tans

ky–K

üste

r–Ha

user

syn

drom

e

[Mül

leria

n ag

enes

is],

impe

rfora

te h

ymen

).•

Cong

enita

l adr

enal

hyp

erpl

asia

.

Seco

ndar

y ca

uses

(4P

3H):

• Pr

egna

ncy

– th

e m

ost c

omm

on c

ause

.•

Poly

cyst

ic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• Pr

emat

ure

ovar

ian

failu

re.

• Pi

tuita

ry n

ecro

sis

– Sh

eeha

n’s

synd

rom

e

afte

r PPH

.•

Hyp

erpr

olac

tinae

mia

.•

Hyp

otha

lam

ic d

isor

der (

e.g.

ano

rexi

a

nerv

osa,

exc

essi

ve e

xerc

ise,

str

ess)

.•

Hyp

er/H

ypot

hyro

idis

m.

Sym

ptom

sDe

pend

s on

the

caus

e of

am

enor

rhoe

a.So

me

exam

ples

are

list

ed b

elow

:•

Poly

cyst

ic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• Tu

rner

syn

drom

e –

web

bed

neck

, sho

rt

stat

ure.

• Pr

emat

ure

ovar

ian

failu

re –

ass

ocia

ted

with

ot

her a

utoi

mm

une

cond

ition

s su

ch a

s

Addi

son’

s di

seas

e an

d hy

poth

yroi

dism

.•

May

er–R

okita

nsky

–Küs

ter–

Haus

er

synd

rom

e –

vary

ing

degr

ees

of u

tero

vagi

nal

ap

lasi

a or

hyp

opla

sia.

Inve

stig

atio

ns•

b-hC

G le

vels

(urin

e or

ser

um) t

o ex

clud

e

preg

nanc

y.•

Bloo

d te

sts:

FBC,

U&

E, T

FTs,

gona

dotr

opin

le

vels,

pro

lact

in le

vels,

and

roge

n le

vels,

oe

stra

diol

.•

Radi

olog

y: m

ay b

e re

quire

d to

vis

ualiz

e

susp

ecte

d tu

mou

rs if

clin

ical

ly in

dica

ted.

Trea

tmen

tDe

pend

s on

the

caus

e of

am

enor

rhoe

a. S

ome

exam

ples

are

list

ed b

elow

.

Cons

erva

tive

:•

Pat

ient

edu

catio

n.

Med

ical

:•

Pol

ycys

tic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• P

rem

atur

e ov

aria

n fa

ilure

– h

orm

one

re

plac

emen

t the

rapy

.

Surg

ical

:•

Dep

ends

on

unde

rlyin

g pa

thol

ogy

(e

.g. M

ayer

–Rok

itans

ky–K

üste

r–Ha

user

sy

ndro

me

– th

e us

e of

vag

inal

dila

tors

and

su

rgic

al p

roce

dure

s su

ch a

s th

e Ve

cchi

etti

pr

oced

ure.

Com

plic

atio

ns•

Infe

rtili

ty.

• O

steo

poro

sis.

MAP

3.4

. Am

enor

rhoe

a

K30033_C003.indd 82 28/02/17 11:17 am

Gyn

aeco

logy

83M

ap 3

.4.

Am

eno

rrh

oea

Wha

t is

am

enor

rhoe

a?Th

is m

ay b

e de

fined

as

eith

er p

rimar

y or

seco

ndar

y am

enor

rhoe

a:•

Prim

ary:

men

stru

atio

n ha

s no

t com

men

ced

by

the

age

of 1

6.•

Seco

ndar

y: th

e ab

senc

e of

men

stru

atio

n fo

r

6 m

onth

s in

a w

oman

who

pre

viou

sly

had

no

rmal

men

stru

atio

n.

Caus

esTh

ese

are

split

into

prim

ary

and

seco

ndar

yca

uses

.

Prim

ary

caus

es (2

T 2C

):•

Turn

er s

yndr

ome

(45,

X).

• Te

stic

ular

fem

iniz

atio

n.•

Cong

enita

l mal

form

atio

ns (e

.g. M

ayer

–

Roki

tans

ky–K

üste

r–Ha

user

syn

drom

e

[Mül

leria

n ag

enes

is],

impe

rfora

te h

ymen

).•

Cong

enita

l adr

enal

hyp

erpl

asia

.

Seco

ndar

y ca

uses

(4P

3H):

• Pr

egna

ncy

– th

e m

ost c

omm

on c

ause

.•

Poly

cyst

ic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• Pr

emat

ure

ovar

ian

failu

re.

• Pi

tuita

ry n

ecro

sis

– Sh

eeha

n’s

synd

rom

e

afte

r PPH

.•

Hyp

erpr

olac

tinae

mia

.•

Hyp

otha

lam

ic d

isor

der (

e.g.

ano

rexi

a

nerv

osa,

exc

essi

ve e

xerc

ise,

str

ess)

.•

Hyp

er/H

ypot

hyro

idis

m.

Sym

ptom

sDe

pend

s on

the

caus

e of

am

enor

rhoe

a.So

me

exam

ples

are

list

ed b

elow

:•

Poly

cyst

ic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• Tu

rner

syn

drom

e –

web

bed

neck

, sho

rt

stat

ure.

• Pr

emat

ure

ovar

ian

failu

re –

ass

ocia

ted

with

ot

her a

utoi

mm

une

cond

ition

s su

ch a

s

Addi

son’

s di

seas

e an

d hy

poth

yroi

dism

.•

May

er–R

okita

nsky

–Küs

ter–

Haus

er

synd

rom

e –

vary

ing

degr

ees

of u

tero

vagi

nal

ap

lasi

a or

hyp

opla

sia.

Inve

stig

atio

ns•

b-hC

G le

vels

(urin

e or

ser

um) t

o ex

clud

e

preg

nanc

y.•

Bloo

d te

sts:

FBC,

U&

E, T

FTs,

gona

dotr

opin

le

vels,

pro

lact

in le

vels,

and

roge

n le

vels,

oe

stra

diol

.•

Radi

olog

y: m

ay b

e re

quire

d to

vis

ualiz

e

susp

ecte

d tu

mou

rs if

clin

ical

ly in

dica

ted.

Trea

tmen

tDe

pend

s on

the

caus

e of

am

enor

rhoe

a. S

ome

exam

ples

are

list

ed b

elow

.

Cons

erva

tive

:•

Pat

ient

edu

catio

n.

Med

ical

:•

Pol

ycys

tic o

vary

syn

drom

e (s

ee M

ap

3.5,

p. 8

4).

• P

rem

atur

e ov

aria

n fa

ilure

– h

orm

one

re

plac

emen

t the

rapy

.

Surg

ical

:•

Dep

ends

on

unde

rlyin

g pa

thol

ogy

(e

.g. M

ayer

–Rok

itans

ky–K

üste

r–Ha

user

sy

ndro

me

– th

e us

e of

vag

inal

dila

tors

and

su

rgic

al p

roce

dure

s su

ch a

s th

e Ve

cchi

etti

pr

oced

ure.

Com

plic

atio

ns•

Infe

rtili

ty.

• O

steo

poro

sis.

MAP

3.4

. Am

enor

rhoe

a

K30033_C003.indd 83 28/02/17 11:17 am

Gyn

aeco

logy

84M

ap 3

.5.

Poly

cyst

ic o

vary

syn

dro

me

(PC

OS)

Wha

t is

pol

ycys

tic

ovar

y sy

ndro

me?

This

is w

hen

a w

oman

has

pol

ycys

tic o

varie

s. It

is

diag

nose

d us

ing

the

Roth

erha

m c

riter

ia w

here

two

out o

f the

thre

e cr

iteria

list

ed b

elow

mus

t be

met

:1.

Rad

iolo

gica

l fea

ture

s: a

USS

vi

sual

izin

g m

ultip

le (>

12) s

mal

l fol

licle

s

mea

surin

g ~

2–9

mm

+/–

an

ovar

ian

volu

me

>

10 m

L.2.

Men

stru

al ir

regu

larit

y: p

erio

ds th

at a

re >

5

wee

ks a

part

.3.

End

ocrin

e ph

enom

ena:

•

Hype

rand

roge

nism

– h

irsut

ism

, acn

e.

Caus

esTh

e ex

act c

ause

of P

COS

is u

nkno

wn.

Fac

tors

incl

ude

insu

lin re

sist

ance

and

hor

mon

al im

bala

nce

caus

ing

incr

ease

d an

drog

en le

vels,

dec

reas

ed

leve

ls o

f sex

hor

mon

e bi

ndin

g gl

obul

in (S

HBG

), ra

ised

LH

leve

ls a

nd s

omet

imes

rais

ed p

rola

ctin

le

vels.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

par

ticul

arly

wei

ght l

oss.

Med

ical

: thi

s ai

ms

to t

reat

sym

ptom

s•

Hirs

utis

m: o

ral c

ontr

acep

tive

pills

with

an

an

tiand

roge

n ef

fect

(e.g

. Yas

min

or D

iane

tte)

.•

Subf

ertil

ity: m

etfo

rmin

may

hel

p.•

Indu

cing

ovu

latio

n: c

lom

ifene

.

Surg

ical

:•

Not

indi

cate

d. IV

F m

ay b

e re

quire

d la

ter.

Sym

ptom

sM

ay b

e as

ympt

omat

ic b

ut o

ther

feat

ures

may

be

rem

embe

red

as H

AIR

:H

– H

irsut

ism

A –

Am

enor

rhoe

aI

– Irr

egul

ar p

erio

ds/In

crea

sed

wei

ght

R –

Redu

ced

fert

ility

and

mis

carr

iage

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, T

FTs.

• Sp

ecifi

c bl

ood

test

s: an

drog

en le

vels,

SHB

G, L

H,

FSH,

pro

lact

in.

• Ra

diol

ogy:

tran

svag

inal

USS

for s

peci

fic

feat

ures

(see

Rot

herh

am c

riter

ia).

Com

plic

atio

ns•

Infe

rtili

ty.

• Ty

pe 2

dia

bete

s m

ellit

us.

• G

esta

tiona

l dia

bete

s.•

Depr

essi

on.

• In

crea

sed

wei

ght,

whi

ch le

ads

to

co

mpl

icat

ions

suc

h as

:

Sl

eep

apno

ea.

Met

abol

ic s

yndr

ome.

Incr

ease

d ris

k of

dia

bete

s.

Hi

gh b

lood

pre

ssur

e.

MAP

3.5

. Pol

ycys

tic

ovar

y sy

ndro

me

(PCO

S)

K30033_C003.indd 84 28/02/17 11:17 am

Gyn

aeco

logy

85M

ap 3

.5.

Poly

cyst

ic o

vary

syn

dro

me

(PC

OS)

Wha

t is

pol

ycys

tic

ovar

y sy

ndro

me?

This

is w

hen

a w

oman

has

pol

ycys

tic o

varie

s. It

is

diag

nose

d us

ing

the

Roth

erha

m c

riter

ia w

here

two

out o

f the

thre

e cr

iteria

list

ed b

elow

mus

t be

met

:1.

Rad

iolo

gica

l fea

ture

s: a

USS

vi

sual

izin

g m

ultip

le (>

12) s

mal

l fol

licle

s

mea

surin

g ~

2–9

mm

+/–

an

ovar

ian

volu

me

>

10 m

L.2.

Men

stru

al ir

regu

larit

y: p

erio

ds th

at a

re >

5

wee

ks a

part

.3.

End

ocrin

e ph

enom

ena:

•

Hype

rand

roge

nism

– h

irsut

ism

, acn

e.

Caus

esTh

e ex

act c

ause

of P

COS

is u

nkno

wn.

Fac

tors

incl

ude

insu

lin re

sist

ance

and

hor

mon

al im

bala

nce

caus

ing

incr

ease

d an

drog

en le

vels,

dec

reas

ed

leve

ls o

f sex

hor

mon

e bi

ndin

g gl

obul

in (S

HBG

), ra

ised

LH

leve

ls a

nd s

omet

imes

rais

ed p

rola

ctin

le

vels.

Sym

ptom

sM

ay b

e as

ympt

omat

ic b

ut o

ther

feat

ures

may

be

rem

embe

red

as H

AIR

:H

– H

irsut

ism

A –

Am

enor

rhoe

aI

– Irr

egul

ar p

erio

ds/In

crea

sed

wei

ght

R –

Redu

ced

fert

ility

and

mis

carr

iage

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, T

FTs.

• Sp

ecifi

c bl

ood

test

s: an

drog

en le

vels,

SHB

G, L

H,

FSH,

pro

lact

in.

• Ra

diol

ogy:

tran

svag

inal

USS

for s

peci

fic

feat

ures

(see

Rot

herh

am c

riter

ia).

MAP

3.5

. Pol

ycys

tic

ovar

y sy

ndro

me

(PCO

S)

K30033_C003.indd 85 28/02/17 11:17 am

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

par

ticul

arly

wei

ght l

oss.

Med

ical

: thi

s ai

ms

to t

reat

sym

ptom

s•

Hirs

utis

m: o

ral c

ontr

acep

tive

pills

with

an

an

tiand

roge

n ef

fect

(e.g

. Yas

min

or D

iane

tte)

.•

Subf

ertil

ity: m

etfo

rmin

may

hel

p.•

Indu

cing

ovu

latio

n: c

lom

ifene

.

Surg

ical

:•

Not

indi

cate

d. IV

F m

ay b

e re

quire

d la

ter.

Com

plic

atio

ns•

Infe

rtili

ty.

• Ty

pe 2

dia

bete

s m

ellit

us.

• G

esta

tiona

l dia

bete

s.•

Depr

essi

on.

• In

crea

sed

wei

ght,

whi

ch le

ads

to

co

mpl

icat

ions

suc

h as

:

Sl

eep

apno

ea.

Met

abol

ic s

yndr

ome.

Incr

ease

d ris

k of

dia

bete

s.

Hi

gh b

lood

pre

ssur

e.

Gyn

aeco

logy

86

TABL

E 3.

4. T

erm

inat

ion

of p

regn

ancy

(TO

P).

Curr

ent

lega

l sta

ndin

gM

etho

ds u

sed

Com

plic

atio

ns

Base

d on

the

Abor

tion

Act 1

967;

am

ende

d 19

90 b

y th

e Hu

man

Fer

tiliz

atio

n an

d Em

bryo

logy

Ac

t. Re

quire

s th

e si

gnat

ures

of t

wo

regi

ster

ed

prac

titio

ners

. Ful

l det

ails

of t

he H

uman

Fer

tiliz

a-tio

n an

d Em

bryo

logy

Act

may

be

foun

d at

: htt

p://

ww

w.le

gisl

atio

n.go

v.uk

/ukp

ga/1

990/

37/c

onte

nts

Key

feat

ures

of t

he A

ct:

• M

ust b

e no

gre

ater

than

24

wee

ks g

esta

tion

• M

ay b

e co

nsid

ered

>24

wee

ks g

esta

tion

if th

e lif

e of

the

mot

her i

s at

gre

at ri

sk•

Cons

ider

in c

ases

whe

re th

ere

may

be

grea

t ris

k to

the

mot

her’s

exi

stin

g ch

ildre

n •

Cons

ider

whe

n th

e ph

ysic

al o

r men

tal h

ealth

of

the

mot

her i

s in

gre

at je

opar

dy

• Co

nsid

er if

the

child

is h

ighl

y lik

ely

to b

e bo

rn

with

a s

ever

e m

enta

l or p

hysi

cal h

andi

cap

The

met

hod

used

for T

OP

depe

nds

on th

e ge

stat

ion

of th

e pr

egna

ncy.

Gen

eral

ly, th

e m

etho

ds u

sed

are

as fo

llow

s.

1. <

9 w

eeks

ges

tatio

n:

Mife

pris

tone

48

hou

rs a

fter d

ose

of m

ifepr

isto

ne

give

pro

stag

land

in (e

.g. m

isop

rost

ol).

Pros

tagl

andi

ns s

timul

ate

uter

ine

cont

ract

ion

2. <

13 w

eeks

ges

tatio

n:

Surg

ical

dila

tatio

n an

d va

cuum

asp

iratio

n 3.

15

wee

ks g

esta

tion:

Su

rgic

al d

ilata

tion

and

evac

uatio

n

Gen

eral

com

plic

atio

ns:

• Th

ose

of g

ener

al a

naes

thet

ic•

Haem

orrh

age

• In

fect

ion

• Re

tain

ed p

rodu

cts

of c

once

ptio

n•

Psyc

hiat

ric c

ompl

icat

ions

(e.g

. dep

ress

ion)

Spec

ific

com

plic

atio

ns:

• Tr

aum

a to

the

geni

tal t

ract

• As

herm

an’s

synd

rom

e•

Perfo

ratio

n of

pel

vic

orga

ns (i

.e. u

teru

s, bo

wel

an

d bl

adde

r)

Tabl

e 3.

4. T

erm

inat

ion

of

pre

gn

ancy

(TO

P)

K30033_C003.indd 86 28/02/17 11:17 am

Tabl

e 3.

4. T

erm

inat

ion

of

pre

gn

ancy

(TO

P)

K30033_C003.indd 87 28/02/17 11:17 am

Gyn

aeco

logy

88M

ap 3

.6.

Infe

rtili

ty

Wha

t is

infe

rtili

ty?

Infe

rtili

ty is

the

failu

re to

con

ceiv

e af

ter r

egul

ar

unpr

otec

ted

inte

rcou

rse

for 2

yea

rs in

the

abse

nce

of k

now

n re

prod

uctiv

e pa

thol

ogy.

This

m

ay b

e ca

tego

rized

as

bein

g ei

ther

prim

ary

or

seco

ndar

y. In

the

form

er th

e co

uple

hav

e ne

ver

conc

eive

d, w

here

as in

sec

onda

ry in

fert

ility

the

coup

le h

as p

revi

ousl

y co

ncei

ved.

Fe

rtili

ty re

quire

s a

norm

al s

perm

to re

ach

a no

rmal

egg

and

then

fert

ilize

it. T

his

fert

ilize

d eg

g th

en n

eeds

to im

plan

t suc

cess

fully

into

the

endo

met

rium

. Any

hin

dran

ce in

this

pro

cess

m

ay c

ause

infe

rtili

ty.

Caus

esTh

ese

are

clas

sifie

d in

to m

ale

and

fem

ale

caus

es. S

ome

exam

ples

are

list

ed b

elow

:•

Mal

e: o

ccur

s w

hen

ther

e is

a p

robl

em w

ith

sper

m v

olum

e, p

H, c

once

ntra

tion,

mor

phol

ogy,

mot

ility

or v

italit

y. Th

is m

ay b

e du

e to

sm

okin

g,

alco

hol u

se, s

tero

ids

or S

TIs.

• Fe

mal

e: th

ink

of th

e hy

poth

alam

ic o

varia

n ax

is to

rem

embe

r the

cau

ses:

Hypo

thal

amic

dys

func

tion:

– Hy

perp

rola

ctin

aem

ia.

– Hy

poth

alam

ic h

ypog

onad

ism

.

–

Hypo

thyr

oidi

sm.

– Hy

pert

hyro

idis

m.

Ova

rian

dysf

unct

ion:

– PC

OS.

– Pr

emat

ure

ovar

ian

failu

re.

Tuba

l dys

func

tion:

– PI

D.

–

Adhe

sion

s fro

m p

revi

ous

pelv

ic

sur

gery

.

–

Cyst

ic fi

bros

is.

Im

plan

tatio

n fa

ilure

:

–

Fibr

oids

.

An

atom

ical

abn

orm

ality

:

–

Bico

rnat

e ut

erus

.

–

May

er–R

okita

nsky

–Küs

ter–

Haus

er

sy

ndro

me.

Trea

tmen

tDe

pend

s on

the

caus

e of

infe

rtili

ty.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Re

gula

r int

erco

urse

3–4

tim

es a

wee

k.•

Life

styl

e ad

vice

– p

artic

ular

ly w

eigh

t los

s.

Med

ical

:•

Clom

ifene

.•

Gon

adot

ropi

n th

erap

y.

Surg

ical

:•

Ova

rian

diat

herm

y.•

IVF.

• In

tra-

uter

ine

inse

min

atio

n.•

Tuba

l sur

gery

.

Inve

stig

atio

ns•

Sem

en a

naly

sis.

Nor

mal

resu

lts a

re:

Volu

me

>1.

5 m

L.

pH

>7.

2.

Sper

m c

once

ntra

tion

>15

mill

ion/

mL.

Mor

phol

ogy

>4%

nor

mal

form

s.

M

otili

ty >

32%

pro

gres

sive

mot

ility

.

Vi

talit

y >

58%

live

spe

rmat

ozoa

.•

Bloo

d te

sts:

FBC,

U&

E, T

FTs,

andr

ogen

leve

ls,

SHBG

, LH,

FSH

, pro

lact

in, 2

1-da

y

prog

este

rone

(>30

nm

ol/L

= o

vula

tion)

.•

Radi

olog

y: tr

ansv

agin

al U

SS,

hy

ster

osal

ping

ogra

m.

• L

apar

osco

py a

nd d

ye te

sts.

Sym

ptom

s•

Prim

ary

or s

econ

dary

infe

rtili

ty.

• Th

ose

of u

nder

lyin

g ca

use.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Side

effe

cts

of tr

eatm

ents

incl

udin

g:

O

varia

n hy

pers

timul

atio

n sy

ndro

me.

Ecto

pic

preg

nanc

y.

M

ultip

le p

regn

ancy

.

Map

3.6

. Inf

erti

lity

K30033_C003.indd 88 28/02/17 11:17 am

Wha

t is

infe

rtili

ty?

Infe

rtili

ty is

the

failu

re to

con

ceiv

e af

ter r

egul

ar

unpr

otec

ted

inte

rcou

rse

for 2

yea

rs in

the

abse

nce

of k

now

n re

prod

uctiv

e pa

thol

ogy.

This

m

ay b

e ca

tego

rized

as

bein

g ei

ther

prim

ary

or

seco

ndar

y. In

the

form

er th

e co

uple

hav

e ne

ver

conc

eive

d, w

here

as in

sec

onda

ry in

fert

ility

the

coup

le h

as p

revi

ousl

y co

ncei

ved.

Fe

rtili

ty re

quire

s a

norm

al s

perm

to re

ach

a no

rmal

egg

and

then

fert

ilize

it. T

his

fert

ilize

d eg

g th

en n

eeds

to im

plan

t suc

cess

fully

into

the

endo

met

rium

. Any

hin

dran

ce in

this

pro

cess

m

ay c

ause

infe

rtili

ty.

Caus

esTh

ese

are

clas

sifie

d in

to m

ale

and

fem

ale

caus

es. S

ome

exam

ples

are

list

ed b

elow

:•

Mal

e: o

ccur

s w

hen

ther

e is

a p

robl

em w

ith

sper

m v

olum

e, p

H, c

once

ntra

tion,

mor

phol

ogy,

mot

ility

or v

italit

y. Th

is m

ay b

e du

e to

sm

okin

g,

alco

hol u

se, s

tero

ids

or S

TIs.

• Fe

mal

e: th

ink

of th

e hy

poth

alam

ic o

varia

n ax

is to

rem

embe

r the

cau

ses:

Hypo

thal

amic

dys

func

tion:

– Hy

perp

rola

ctin

aem

ia.

– Hy

poth

alam

ic h

ypog

onad

ism

.

–

Hypo

thyr

oidi

sm.

– Hy

pert

hyro

idis

m.

Ova

rian

dysf

unct

ion:

– PC

OS.

– Pr

emat

ure

ovar

ian

failu

re.

Tuba

l dys

func

tion:

– PI

D.

–

Adhe

sion

s fro

m p

revi

ous

pelv

ic

sur

gery

.

–

Cyst

ic fi

bros

is.

Im

plan

tatio

n fa

ilure

:

–

Fibr

oids

.

An

atom

ical

abn

orm

ality

:

–

Bico

rnat

e ut

erus

.

–

May

er–R

okita

nsky

–Küs

ter–

Haus

er

sy

ndro

me.

Trea

tmen

tDe

pend

s on

the

caus

e of

infe

rtili

ty.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Re

gula

r int

erco

urse

3–4

tim

es a

wee

k.•

Life

styl

e ad

vice

– p

artic

ular

ly w

eigh

t los

s.

Med

ical

:•

Clom

ifene

.•

Gon

adot

ropi

n th

erap

y.

Surg

ical

:•

Ova

rian

diat

herm

y.•

IVF.

• In

tra-

uter

ine

inse

min

atio

n.•

Tuba

l sur

gery

.

Inve

stig

atio

ns•

Sem

en a

naly

sis.

Nor

mal

resu

lts a

re:

Volu

me

>1.

5 m

L.

pH

>7.

2.

Sper

m c

once

ntra

tion

>15

mill

ion/

mL.

Mor

phol

ogy

>4%

nor

mal

form

s.

M

otili

ty >

32%

pro

gres

sive

mot

ility

.

Vi

talit

y >

58%

live

spe

rmat

ozoa

.•

Bloo

d te

sts:

FBC,

U&

E, T

FTs,

andr

ogen

leve

ls,

SHBG

, LH,

FSH

, pro

lact

in, 2

1-da

y

prog

este

rone

(>30

nm

ol/L

= o

vula

tion)

.•

Radi

olog

y: tr

ansv

agin

al U

SS,

hy

ster

osal

ping

ogra

m.

• L

apar

osco

py a

nd d

ye te

sts.

Sym

ptom

s•

Prim

ary

or s

econ

dary

infe

rtili

ty.

• Th

ose

of u

nder

lyin

g ca

use.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Side

effe

cts

of tr

eatm

ents

incl

udin

g:

O

varia

n hy

pers

timul

atio

n sy

ndro

me.

Ecto

pic

preg

nanc

y.

M

ultip

le p

regn

ancy

.

Map

3.6

. Inf

erti

lity

Gyn

aeco

logy

Map

3.6

. In

fert

ility

89

K30033_C003.indd 89 28/02/17 11:17 am

Gyn

aeco

logy

90

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Spec

ific

bloo

d te

sts:

colp

osco

py w

ith

biop

sy o

f cer

vix.

• Ra

diol

ogy:

MRI

of p

elvi

s.•

Stag

e us

ing

the

Fédé

ratio

n In

tern

atio

nale

de

G

ynéc

olog

ie e

t d’O

bsté

triq

ue (F

IGO

) sys

tem

.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

anxi

ety.

• G

ener

al a

nd s

peci

fic c

ompl

icat

ions

of

ch

emot

hera

py a

nd ra

diot

hera

py.

• Ly

mph

oede

ma

if ly

mph

nod

es a

re re

mov

ed.

• Fi

stul

a fo

rmat

ion.

• M

etas

tase

s.•

Deat

h.

Sym

ptom

s•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Post

-men

opau

sal b

leed

ing.

• Ab

norm

al v

agin

al d

isch

arge

.•

Gen

eral

sym

ptom

s of

mal

igna

ncy

(e.g

.

fatig

ue, c

ache

xia,

wei

ght l

oss)

.•

Asym

ptom

atic

– a

bnor

mal

ities

pic

ked

up b

y

the

Nat

iona

l Scr

eeni

ng P

rogr

amm

e (N

SP) U

K.

The

NSP

for c

ervi

cal c

ance

r use

s liq

uid-

base

d

cyto

logy

to c

lass

ify c

ervi

cal i

ntra

epith

elia

l

neop

lasi

a as

wel

l as

iden

tify

HPV

infe

ctio

n.

This

occ

urs

3 ye

arly

age

d 25

–49

and

5 ye

arly

ag

ed 5

0–64

, pro

vidi

ng th

at re

sults

are

no

rmal

.

Wha

t is

cer

vica

l can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

d pr

olife

ratio

n of

cel

ls li

ning

the

cerv

ix. I

t may

be

cate

goriz

ed in

to tw

o di

ffere

nt c

ell t

ypes

:1.

Squ

amou

s ce

ll ca

rcin

oma

(80%

).2.

Ade

noca

rcin

oma

(20%

).

Caus

esTh

e ex

act c

ause

of c

ervi

cal c

ance

r rem

ains

un

know

n bu

t it i

s as

soci

ated

with

sev

eral

risk

fa

ctor

s, th

e m

ost p

rom

inen

t bei

ng th

e hu

man

pa

pillo

mav

irus

(HPV

) (se

e be

low

).

Risk

fact

ors

• HP

V –

type

s 16

, 18

and

33.

• HI

V.•

Mul

tiple

pre

gnan

cies

.•

Mul

tiple

sex

ual p

artn

ers.

• Ea

rly a

ge o

f firs

t sex

ual i

nter

cour

se.

• Co

mbi

ned

oral

con

trac

eptiv

e pi

ll (C

OCP

).•

Incr

easi

ng a

ge.

• Lo

w s

ocio

econ

omic

sta

tus.

• Sm

okin

g.

Cerv

ical

ect

ropi

onDo

es n

ot c

ause

cer

vica

l can

cer b

ut is

incl

uded

in

the

diffe

rent

ial d

iagn

osis

of v

agin

al b

leed

ing.

Wha

t is

cer

vica

l ect

ropi

on?

This

is w

hen

a gr

eate

r pro

port

ion

of c

olum

nar

epith

eliu

m c

ross

es th

e tr

ansi

tion

zone

and

is

pres

ent o

n th

e ec

toce

rvix

rath

er th

an s

trat

ified

sq

uam

ous

cell

epith

eliu

m. C

olum

nar e

pith

eliu

m

is th

inne

r and

far m

ore

fragi

le th

an s

trat

ified

squa

mou

s ce

ll ep

ithel

ium

, the

refo

re it

is m

ore

pron

e to

ble

edin

g.

Caus

es: a

nyth

ing

that

incr

ease

s oe

stro

gen

leve

ls (e

.g. C

OCP

, pre

gnan

cy).

Sym

ptom

s: p

ost-

coita

l ble

edin

g, a

bnor

mal

va

gina

l ble

edin

g, b

leed

ing

on c

onta

ct (e

.g. a

t co

lpos

copy

).

Trea

tmen

t: ab

lativ

e co

ld c

oagu

latio

n.

Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot

met

asta

ses

are

pres

ent.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

sm

okin

g ce

ssat

ion.

• Pr

even

tion

(UK)

: HPV

vac

cina

tion

offe

red

to

scho

olgi

rls a

ged

12.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

re

quire

d.

Surg

ical

:•

Cone

bio

psy.

• Hy

ster

ecto

my.

MAP

3.7

. Cer

vica

l can

cer

Map

3.7

. C

ervi

cal c

ance

r

K30033_C003.indd 90 28/02/17 11:17 am

Gyn

aeco

logy

91

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Spec

ific

bloo

d te

sts:

colp

osco

py w

ith

biop

sy o

f cer

vix.

• Ra

diol

ogy:

MRI

of p

elvi

s.•

Stag

e us

ing

the

Fédé

ratio

n In

tern

atio

nale

de

G

ynéc

olog

ie e

t d’O

bsté

triq

ue (F

IGO

) sys

tem

.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

anxi

ety.

• G

ener

al a

nd s

peci

fic c

ompl

icat

ions

of

ch

emot

hera

py a

nd ra

diot

hera

py.

• Ly

mph

oede

ma

if ly

mph

nod

es a

re re

mov

ed.

• Fi

stul

a fo

rmat

ion.

• M

etas

tase

s.•

Deat

h.

Sym

ptom

s•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Post

-men

opau

sal b

leed

ing.

• Ab

norm

al v

agin

al d

isch

arge

.•

Gen

eral

sym

ptom

s of

mal

igna

ncy

(e.g

.

fatig

ue, c

ache

xia,

wei

ght l

oss)

.•

Asym

ptom

atic

– a

bnor

mal

ities

pic

ked

up b

y

the

Nat

iona

l Scr

eeni

ng P

rogr

amm

e (N

SP) U

K.

The

NSP

for c

ervi

cal c

ance

r use

s liq

uid-

base

d

cyto

logy

to c

lass

ify c

ervi

cal i

ntra

epith

elia

l

neop

lasi

a as

wel

l as

iden

tify

HPV

infe

ctio

n.

This

occ

urs

3 ye

arly

age

d 25

–49

and

5 ye

arly

ag

ed 5

0–64

, pro

vidi

ng th

at re

sults

are

no

rmal

.

Wha

t is

cer

vica

l can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

d pr

olife

ratio

n of

cel

ls li

ning

the

cerv

ix. I

t may

be

cate

goriz

ed in

to tw

o di

ffere

nt c

ell t

ypes

:1.

Squ

amou

s ce

ll ca

rcin

oma

(80%

).2.

Ade

noca

rcin

oma

(20%

).

Caus

esTh

e ex

act c

ause

of c

ervi

cal c

ance

r rem

ains

un

know

n bu

t it i

s as

soci

ated

with

sev

eral

risk

fa

ctor

s, th

e m

ost p

rom

inen

t bei

ng th

e hu

man

pa

pillo

mav

irus

(HPV

) (se

e be

low

).

Risk

fact

ors

• HP

V –

type

s 16

, 18

and

33.

• HI

V.•

Mul

tiple

pre

gnan

cies

.•

Mul

tiple

sex

ual p

artn

ers.

• Ea

rly a

ge o

f firs

t sex

ual i

nter

cour

se.

• Co

mbi

ned

oral

con

trac

eptiv

e pi

ll (C

OCP

).•

Incr

easi

ng a

ge.

• Lo

w s

ocio

econ

omic

sta

tus.

• Sm

okin

g.

Cerv

ical

ect

ropi

onDo

es n

ot c

ause

cer

vica

l can

cer b

ut is

incl

uded

in

the

diffe

rent

ial d

iagn

osis

of v

agin

al b

leed

ing.

Wha

t is

cer

vica

l ect

ropi

on?

This

is w

hen

a gr

eate

r pro

port

ion

of c

olum

nar

epith

eliu

m c

ross

es th

e tr

ansi

tion

zone

and

is

pres

ent o

n th

e ec

toce

rvix

rath

er th

an s

trat

ified

sq

uam

ous

cell

epith

eliu

m. C

olum

nar e

pith

eliu

m

is th

inne

r and

far m

ore

fragi

le th

an s

trat

ified

squa

mou

s ce

ll ep

ithel

ium

, the

refo

re it

is m

ore

pron

e to

ble

edin

g.

Caus

es: a

nyth

ing

that

incr

ease

s oe

stro

gen

leve

ls (e

.g. C

OCP

, pre

gnan

cy).

Sym

ptom

s: p

ost-

coita

l ble

edin

g, a

bnor

mal

va

gina

l ble

edin

g, b

leed

ing

on c

onta

ct (e

.g. a

t co

lpos

copy

).

Trea

tmen

t: ab

lativ

e co

ld c

oagu

latio

n.

Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot

met

asta

ses

are

pres

ent.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

sm

okin

g ce

ssat

ion.

• Pr

even

tion

(UK)

: HPV

vac

cina

tion

offe

red

to

scho

olgi

rls a

ged

12.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

re

quire

d.

Surg

ical

:•

Cone

bio

psy.

• Hy

ster

ecto

my.

MAP

3.7

. Cer

vica

l can

cer

Map

3.7

. C

ervi

cal c

ance

r

K30033_C003.indd 91 28/02/17 11:17 am

Gyn

aeco

logy

92 Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot m

etas

tase

s ar

e pr

esen

t.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

sm

okin

g ce

ssat

ion.

• Pr

even

tion

(UK)

: HPV

vac

cina

tion

offe

red

to s

choo

lgirl

s ag

ed 1

2.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

requ

ired.

Surg

ical

:•

Part

ial o

r rad

ical

vag

inec

tom

y.•

Radi

cal v

agin

ecto

my

plus

radi

cal h

yste

rect

omy.

• Pe

lvic

exe

nter

atio

n.

Sym

ptom

s•

Asym

ptom

atic

.•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Post

-men

opau

sal b

leed

ing.

• Ab

norm

al v

agin

al d

isch

arge

.•

Dysp

areu

nia.

• G

ener

al s

ympt

oms

of m

alig

nanc

y

(e.g

. fat

igue

, cac

hexi

a, w

eigh

t los

s)

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Spec

ific

bloo

d te

sts:

colp

osco

py w

ith b

iops

y.•

Radi

olog

y: M

RI p

elvi

s.•

Stag

e us

ing

the

FIG

O s

yste

m o

r the

TN

M

stag

ing

syst

em.

MAP

3.8

. Vag

inal

can

cer

Wha

t is

vag

inal

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

d pr

olife

ratio

n of

cel

ls li

ning

the

vagi

na. I

t may

be

cate

goriz

ed in

to d

iffer

ent c

ell t

ypes

:•

Squa

mou

s ce

ll ca

rcin

oma

(mos

t com

mon

).•

Aden

ocar

cino

ma.

• Cl

ear c

ell a

deno

carc

inom

a.•

Ger

m c

ell t

umou

rs (e

.g. t

erat

omas

).•

Mel

anom

a.

Caus

esTh

e ex

act c

ause

of v

agin

al c

ance

r rem

ains

un

know

n bu

t it i

s as

soci

ated

with

sev

eral

risk

fa

ctor

s (s

ee b

elow

).

Risk

fact

ors

Rem

embe

r the

se a

s VA

GIN

A:

V –

Viru

ses

(e.g

. HPV

, HIV

)A

– in

crea

sing

Age

G –

Gen

eral

fact

ors

such

as

smok

ing

and

alco

hol

I –

chro

nic

Irrita

tion

(e.g

. fro

m p

rolo

nged

pes

sary

use)

N –

Neo

plas

ms

(e.g

. hav

ing

cerv

ical

can

cer

in

crea

ses

the

risk

of v

agin

al s

quam

ous

cell

c

arci

nom

a)A

– v

agin

al A

deno

sis

Map

3.8

. V

agin

al c

ance

r

K30033_C003.indd 92 28/02/17 11:17 am

Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot m

etas

tase

s ar

e pr

esen

t.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Li

fest

yle

advi

ce –

sm

okin

g ce

ssat

ion.

• Pr

even

tion

(UK)

: HPV

vac

cina

tion

offe

red

to s

choo

lgirl

s ag

ed 1

2.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

requ

ired.

Surg

ical

:•

Part

ial o

r rad

ical

vag

inec

tom

y.•

Radi

cal v

agin

ecto

my

plus

radi

cal h

yste

rect

omy.

• Pe

lvic

exe

nter

atio

n.

Sym

ptom

s•

Asym

ptom

atic

.•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Post

-men

opau

sal b

leed

ing.

• Ab

norm

al v

agin

al d

isch

arge

.•

Dysp

areu

nia.

• G

ener

al s

ympt

oms

of m

alig

nanc

y

(e.g

. fat

igue

, cac

hexi

a, w

eigh

t los

s)

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Spec

ific

bloo

d te

sts:

colp

osco

py w

ith b

iops

y.•

Radi

olog

y: M

RI p

elvi

s.•

Stag

e us

ing

the

FIG

O s

yste

m o

r the

TN

M

stag

ing

syst

em.

MAP

3.8

. Vag

inal

can

cer

Wha

t is

vag

inal

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

d pr

olife

ratio

n of

cel

ls li

ning

the

vagi

na. I

t may

be

cate

goriz

ed in

to d

iffer

ent c

ell t

ypes

:•

Squa

mou

s ce

ll ca

rcin

oma

(mos

t com

mon

).•

Aden

ocar

cino

ma.

• Cl

ear c

ell a

deno

carc

inom

a.•

Ger

m c

ell t

umou

rs (e

.g. t

erat

omas

).•

Mel

anom

a.

Caus

esTh

e ex

act c

ause

of v

agin

al c

ance

r rem

ains

un

know

n bu

t it i

s as

soci

ated

with

sev

eral

risk

fa

ctor

s (s

ee b

elow

).

Risk

fact

ors

Rem

embe

r the

se a

s VA

GIN

A:

V –

Viru

ses

(e.g

. HPV

, HIV

)A

– in

crea

sing

Age

G –

Gen

eral

fact

ors

such

as

smok

ing

and

alco

hol

I –

chro

nic

Irrita

tion

(e.g

. fro

m p

rolo

nged

pes

sary

use)

N –

Neo

plas

ms

(e.g

. hav

ing

cerv

ical

can

cer

in

crea

ses

the

risk

of v

agin

al s

quam

ous

cell

c

arci

nom

a)A

– v

agin

al A

deno

sis

93G

ynae

colo

gyM

ap 3

.8.

Vag

inal

can

cer

K30033_C003.indd 93 28/02/17 11:17 am

Gyn

aeco

logy

94 Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot m

etas

tase

s ar

e pr

esen

t.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

requ

ired.

Surg

ical

:•

Tota

l abd

omin

al h

yste

rect

omy

with

bila

tera

l sal

ping

o-oo

phor

ecto

my

+

/– ly

mph

aden

ecto

my.

Sym

ptom

s•

A w

oman

with

pos

t-m

enop

ausa

l ble

edin

g is

co

nsid

ered

to h

ave

endo

met

rial c

ance

r unt

il

prov

en o

ther

wis

e.•

Prem

enop

ausa

l wom

en: i

nter

men

stru

al

blee

ding

, pos

t-co

ital b

leed

ing.

• G

ener

al s

ympt

oms

of m

alig

nanc

y (e

.g. f

atig

ue,

ca

chex

ia, w

eigh

t los

s)

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Radi

olog

y: fi

rst l

ine

– tr

ansv

agin

al U

SS

(<4

mm

= n

orm

al).

• Th

is m

ay b

e fo

llow

ed b

y hy

ster

osco

py w

ith

endo

met

rial b

iops

y.•

MRI

of p

elvi

s –

for s

tagi

ng a

nd m

etas

tase

s.•

Stag

e us

ing

the

FIG

O s

yste

m o

r the

TN

M

stag

ing

syst

em.

MAP

3.9

. End

omet

rial

can

cer

Wha

t is

end

omet

rial

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

dpr

olife

ratio

n of

the

endo

met

rium

.It

may

be

cate

goriz

ed in

to d

iffer

ent c

ell t

ypes

, m

ost o

f whi

ch a

re a

deno

carc

inom

as.

Caus

esIt

is d

ue to

the

unop

pose

d ac

tion

of o

estr

ogen

on

the

endo

met

rium

. Ris

k fa

ctor

s ar

e lis

ted

belo

w.

Risk

fact

ors

Rem

embe

r the

se a

s EN

DO

MET

RIU

M:

E –

Early

men

arch

eN

– N

ullip

arity

D –

Dia

bete

s m

ellit

usO

– p

olyc

ystic

Ova

ry s

yndr

ome

M –

Men

opau

se (l

ate)

E T –

Tam

oxife

nR

– H

RTI

– In

crea

sed

risk

with

oth

er c

ance

rs (e

.g. b

reas

t

an

d ov

aria

n)U

– U

nopp

osed

oes

trog

en (e

.g. a

novu

latio

n, H

RT)

M –

Men

stru

al ir

regu

larit

y

Map

3.9

. En

do

met

rial

can

cer

K30033_C003.indd 94 28/02/17 11:17 am

Gyn

aeco

logy

95Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot m

etas

tase

s ar

e pr

esen

t.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

may

be

requ

ired.

Surg

ical

:•

Tota

l abd

omin

al h

yste

rect

omy

with

bila

tera

l sal

ping

o-oo

phor

ecto

my

+

/– ly

mph

aden

ecto

my.

Sym

ptom

s•

A w

oman

with

pos

t-m

enop

ausa

l ble

edin

g is

co

nsid

ered

to h

ave

endo

met

rial c

ance

r unt

il

prov

en o

ther

wis

e.•

Prem

enop

ausa

l wom

en: i

nter

men

stru

al

blee

ding

, pos

t-co

ital b

leed

ing.

• G

ener

al s

ympt

oms

of m

alig

nanc

y (e

.g. f

atig

ue,

ca

chex

ia, w

eigh

t los

s)

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

and

an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Radi

olog

y: fi

rst l

ine

– tr

ansv

agin

al U

SS

(<4

mm

= n

orm

al).

• Th

is m

ay b

e fo

llow

ed b

y hy

ster

osco

py w

ith

endo

met

rial b

iops

y.•

MRI

of p

elvi

s –

for s

tagi

ng a

nd m

etas

tase

s.•

Stag

e us

ing

the

FIG

O s

yste

m o

r the

TN

M

stag

ing

syst

em.

MAP

3.9

. End

omet

rial

can

cer

Wha

t is

end

omet

rial

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

dpr

olife

ratio

n of

the

endo

met

rium

.It

may

be

cate

goriz

ed in

to d

iffer

ent c

ell t

ypes

, m

ost o

f whi

ch a

re a

deno

carc

inom

as.

Caus

esIt

is d

ue to

the

unop

pose

d ac

tion

of o

estr

ogen

on

the

endo

met

rium

. Ris

k fa

ctor

s ar

e lis

ted

belo

w.

Risk

fact

ors

Rem

embe

r the

se a

s EN

DO

MET

RIU

M:

E –

Early

men

arch

eN

– N

ullip

arity

D –

Dia

bete

s m

ellit

usO

– p

olyc

ystic

Ova

ry s

yndr

ome

M –

Men

opau

se (l

ate)

E T –

Tam

oxife

nR

– H

RTI

– In

crea

sed

risk

with

oth

er c

ance

rs (e

.g. b

reas

t

an

d ov

aria

n)U

– U

nopp

osed

oes

trog

en (e

.g. a

novu

latio

n, H

RT)

M –

Men

stru

al ir

regu

larit

y

Map

3.9

. En

do

met

rial

can

cer

K30033_C003.indd 95 28/02/17 11:17 am

Gyn

aeco

logy

96 Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot

met

asta

ses

are

pres

ent.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Chem

othe

rapy

usu

ally

requ

ired

and

ra

diot

hera

py m

ay b

e re

quire

d.

Surg

ical

:•

Depe

nds

on th

e in

divi

dual

cas

e an

d m

ay

incl

ude

ooph

orec

tom

y, sa

lpin

gect

omy,

hy

ster

ecto

my,

omen

tect

omy.

Sym

ptom

sSy

mpt

oms

are

gene

rally

real

ly v

ague

, whi

ch is

why

ov

aria

n ca

ncer

can

be

so d

iffic

ult t

o di

agno

se.

Sym

ptom

s in

clud

e:•

Abdo

min

al p

ain.

• Ab

dom

inal

blo

atin

g.•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Early

sat

iety

.•

Sym

ptom

s of

bla

dder

dys

func

tion

or

irrita

tion

such

as

frequ

ency

and

urg

ency

.•

Gen

eral

sym

ptom

s of

mal

igna

ncy

(e.g

. fat

igue

,

cach

exia

, wei

ght l

oss)

.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

an

d an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Tum

our m

arke

r: CA

125

(dia

gnos

is a

nd

follo

w-u

p).

• Ra

diol

ogy:

tran

svag

inal

USS

.•

CT o

r MRI

of p

elvi

s –

for s

tagi

ng a

nd

met

asta

ses.

• Su

rger

y: d

iagn

ostic

lapa

roto

my

with

bio

psy.

• St

age

usin

g th

e FI

GO

sys

tem

or t

he T

NM

sy

stem

.•

Risk

of M

alig

nanc

y In

dex

(RM

I) m

ay b

e us

ed to

ca

lcul

ate

the

risk

of h

avin

g a

mal

igna

nt

ovar

ian

tum

our =

ultr

asou

nd s

core

×

men

opau

sal s

core

× C

A 12

5 m

easu

rem

ent.

MAP

3.1

0. O

vari

an c

ance

r

Wha

t is

ova

rian

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

dpr

olife

ratio

n of

ova

rian

tissu

e. A

ppro

xim

atel

y90

% a

rise

from

epi

thel

ial t

issu

e. M

ay o

ccur

se

cond

arily

(e.g

. met

asta

sis

from

ano

ther

site

, us

ually

the

GI t

ract

, whe

re it

is k

now

n as

a

Kruk

enbe

rg tu

mou

r).

Caus

esTh

e ex

act c

ause

of o

varia

n ca

ncer

is u

nkno

wn;

ho

wev

er, i

t is

stro

ngly

ass

ocia

ted

with

mul

tiple

ov

ulat

ions

and

oth

er ri

sk fa

ctor

s (s

ee b

elow

).

Risk

fact

ors

Rem

embe

r the

se a

s A

BCD

E:A

– in

crea

sing

Age

B –

BRC

A1 a

nd B

RCA2

gen

esC

– CO

CP is

pro

tect

ive!

!D

– D

urat

ion

of o

vula

tion

(i.e.

nul

lipar

ity, e

arly

men

arch

e an

d la

te m

enop

ause

)E

– En

dom

etrio

sis

Map

3.1

0. O

vari

an c

ance

r

K30033_C003.indd 96 28/02/17 11:17 am

Trea

tmen

tDe

pend

s on

FIG

O s

tage

and

whe

ther

or n

ot

met

asta

ses

are

pres

ent.

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Chem

othe

rapy

usu

ally

requ

ired

and

ra

diot

hera

py m

ay b

e re

quire

d.

Surg

ical

:•

Depe

nds

on th

e in

divi

dual

cas

e an

d m

ay

incl

ude

ooph

orec

tom

y, sa

lpin

gect

omy,

hy

ster

ecto

my,

omen

tect

omy.

Sym

ptom

sSy

mpt

oms

are

gene

rally

real

ly v

ague

, whi

ch is

why

ov

aria

n ca

ncer

can

be

so d

iffic

ult t

o di

agno

se.

Sym

ptom

s in

clud

e:•

Abdo

min

al p

ain.

• Ab

dom

inal

blo

atin

g.•

Inte

rmen

stru

al b

leed

ing.

• Po

st-c

oita

l ble

edin

g.•

Early

sat

iety

.•

Sym

ptom

s of

bla

dder

dys

func

tion

or

irrita

tion

such

as

frequ

ency

and

urg

ency

.•

Gen

eral

sym

ptom

s of

mal

igna

ncy

(e.g

. fat

igue

,

cach

exia

, wei

ght l

oss)

.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns –

dep

ress

ion

an

d an

xiet

y.•

Gen

eral

and

spe

cific

com

plic

atio

ns o

f

chem

othe

rapy

and

radi

othe

rapy

.•

Lym

phoe

dem

a if

lym

ph n

odes

are

rem

oved

.•

Fist

ula

form

atio

n.•

Met

asta

ses.

• De

ath.

Inve

stig

atio

ns•

Gen

eral

blo

od te

sts:

FBC,

U&

E, L

FTs,

TFTs

.•

Tum

our m

arke

r: CA

125

(dia

gnos

is a

nd

follo

w-u

p).

• Ra

diol

ogy:

tran

svag

inal

USS

.•

CT o

r MRI

of p

elvi

s –

for s

tagi

ng a

nd

met

asta

ses.

• Su

rger

y: d

iagn

ostic

lapa

roto

my

with

bio

psy.

• St

age

usin

g th

e FI

GO

sys

tem

or t

he T

NM

sy

stem

.•

Risk

of M

alig

nanc

y In

dex

(RM

I) m

ay b

e us

ed to

ca

lcul

ate

the

risk

of h

avin

g a

mal

igna

nt

ovar

ian

tum

our =

ultr

asou

nd s

core

×

men

opau

sal s

core

× C

A 12

5 m

easu

rem

ent.

MAP

3.1

0. O

vari

an c

ance

r

Wha

t is

ova

rian

can

cer?

This

is u

ncon

trol

led

diffe

rent

iatio

n an

dpr

olife

ratio

n of

ova

rian

tissu

e. A

ppro

xim

atel

y90

% a

rise

from

epi

thel

ial t

issu

e. M

ay o

ccur

se

cond

arily

(e.g

. met

asta

sis

from

ano

ther

site

, us

ually

the

GI t

ract

, whe

re it

is k

now

n as

a

Kruk

enbe

rg tu

mou

r).

Caus

esTh

e ex

act c

ause

of o

varia

n ca

ncer

is u

nkno

wn;

ho

wev

er, i

t is

stro

ngly

ass

ocia

ted

with

mul

tiple

ov

ulat

ions

and

oth

er ri

sk fa

ctor

s (s

ee b

elow

).

Risk

fact

ors

Rem

embe

r the

se a

s A

BCD

E:A

– in

crea

sing

Age

B –

BRC

A1 a

nd B

RCA2

gen

esC

– CO

CP is

pro

tect

ive!

!D

– D

urat

ion

of o

vula

tion

(i.e.

nul

lipar

ity, e

arly

men

arch

e an

d la

te m

enop

ause

)E

– En

dom

etrio

sis

97G

ynae

colo

gyM

ap 3

.10.

Ova

rian

can

cer

K30033_C003.indd 97 28/02/17 11:17 am

Gyn

aeco

logy

98Ta

ble

3.5.

Ova

rian

cys

ts

TABL

E 3.

5. O

vari

an c

ysts

. Ova

rian

cys

ts m

ay b

e be

nign

or

mal

igna

nt. U

ltra

soun

d is

use

d to

ass

ess

whi

ch is

mor

e lik

ely.

U

nilo

cula

r cy

sts

are

likel

y ph

ysio

logi

cal/b

enig

n, w

here

as m

ulti

locu

lar

com

plex

cys

ts r

aise

sus

pici

on o

f a

mal

igna

nt le

sion

.

Type

of

cyst

Key

feat

ures

Folli

cula

r cys

tTh

e m

ost c

omm

on ty

pe o

f phy

siol

ogic

al c

yst

Corp

us lu

teum

cys

tHi

gher

tend

ency

to c

ause

intr

aper

itone

al b

leed

ing

Derm

oid

cyst

Beni

gn g

erm

cel

l tum

our

Tors

ion

mor

e lik

ely

Epith

elia

l tum

ours

1. S

erou

s cy

stad

enom

a:

Com

mon

est

M

ay m

imic

feat

ures

of s

erou

s ca

rcin

oma

2. M

ucin

ous

cyst

aden

oma:

M

ay b

e m

assi

ve in

siz

e

Endo

met

riom

aAl

so k

now

n as

‘cho

cola

te c

ysts

’Co

mpl

icat

ion

of e

ndom

etrio

sis

Wha

t is

end

omet

rios

is?

A co

nditi

on w

here

end

omet

rial t

issu

e oc

curs

out

side

the

uter

ine

cavi

ty.

Caus

es: T

he e

xact

cau

se is

unk

now

n bu

t the

pre

sent

theo

ry re

gard

s re

trog

rade

men

stru

atio

n as

the

mos

t lik

ely

fact

or.

Sym

ptom

s: C

hron

ic p

elvi

c pa

in, r

etro

vert

ed u

teru

s, dy

smen

orrh

oea,

dee

p dy

spar

euni

a.In

vest

igat

ions

: Bim

anua

l and

spe

culu

m e

xam

inat

ion

follo

wed

by

lapa

rosc

opy.

Trea

tmen

t:

• Co

nser

vativ

e: p

atie

nt e

duca

tion.

• M

edic

al: a

ste

pwis

e ap

proa

ch is

em

ploy

ed. F

irst l

ine:

NSA

IDs.

Seco

nd li

ne: p

arac

etam

ol. T

hird

line

: cod

eine

. Hor

mon

al

ther

apy

such

as

the

COCP

may

be

used

if th

ese

pain

med

icat

ions

fail.

• Su

rgic

al: l

aser

abl

atio

n, a

dhes

ioly

sis,

tota

l abd

omin

al h

yste

rect

omy.

K30033_C003.indd 98 28/02/17 11:17 am

Gyn

aeco

logy

99Ta

ble

3.6.

In

con

tin

ence

TABL

E 3.

6. In

cont

inen

ce.

Type

Wha

t is

it?

Inve

stig

atio

nsTr

eatm

ent

Stre

ss in

cont

inen

ce•

Urin

e is

lost

by

any

mov

emen

t tha

t in

crea

ses

intr

a-ab

dom

inal

pre

ssur

e (e

.g. s

neez

ing

and

coug

hing

) •

Aggr

avat

ing

fact

ors

incl

ude

preg

nanc

y, ob

esity

, CO

PD

• U

rinal

ysis

•

Post

-voi

d re

sidu

al v

olum

e•

Uro

dyna

mic

test

ing

• En

dosc

ope

test

s•

Radi

olog

y: x

-ray

, USS

• Co

nser

vativ

e: p

atie

nt e

duca

tion,

lif

esty

le a

dvic

e su

ch a

s sm

okin

g ce

ssat

ion,

wei

ght l

oss

• Fi

rst l

ine:

Keg

el p

elvi

c flo

or e

xerc

ises

•

Med

ical

: oes

trog

en m

ay b

e gi

ven

to

post

-men

opau

sal w

omen

•

Surg

ery:

ure

thro

pexy

, bla

dder

nec

k su

spen

sion

sur

gery

(Bur

ch a

nd s

ling

proc

edur

es)

Urg

e in

cont

inen

ce•

Too

muc

h co

ntra

ctio

n •

Urin

e is

lost

by

inap

prop

riate

det

ruso

r m

uscl

e co

ntra

ctio

n •

Caus

e: m

ay b

e du

e to

neo

plas

ms

or

nerv

e da

mag

e (e

.g. m

ultip

le s

cler

osis,

Pa

rkin

son’

s di

seas

e, s

trok

e)

• U

rinal

ysis

•

Post

-voi

d re

sidu

al v

olum

e•

Uro

dyna

mic

test

ing

• En

dosc

ope

test

s•

Radi

olog

y: x

-ray

, USS

• An

ticho

liner

gic

med

icat

ions

(e

.g. o

xybu

tyni

n th

erap

y)•

Trea

tmen

t of u

nder

lyin

g co

nditi

on

Ove

rflow

inco

ntin

ence

• To

o lit

tle c

ontr

actio

n •

This

hap

pens

due

to a

mar

ked

incr

ease

d in

bla

dder

resi

dual

vol

ume;

th

eref

ore,

the

blad

der i

s us

ually

full

and

thus

freq

uent

ly le

aks

urin

e

• U

rinal

ysis

•

Post

-voi

d re

sidu

al v

olum

e•

Uro

dyna

mic

test

ing

• En

dosc

ope

test

s•

Radi

olog

y: x

-ray

, USS

• Co

nser

vativ

e: p

atie

nt e

duca

tion,

sto

p m

edic

atio

ns if

they

are

the

caus

e•

Inte

rmitt

ent c

athe

teriz

atio

n•

Beth

anec

hol (

chol

iner

gic)

may

impr

ove

detr

usor

mus

cle

activ

ity

K30033_C003.indd 99 28/02/17 11:17 am

Gyn

aeco

logy

100

Tabl

e 3.

7. C

on

trac

epti

on

TABL

E 3.

7. C

ontr

acep

tion

. Con

sult

the

UK

MEC

gui

delin

es r

egar

ding

con

trac

epti

ve c

hoic

es

(htt

p://w

ww

.fsr

h.or

g/pd

fs/U

KM

EC20

09.p

df).

Effic

acy

of c

ontr

acep

tion

depe

nds

on th

e Pe

arl I

ndex

(the

num

ber o

f uni

nten

ded

preg

nanc

ies

per 1

00 w

oman

yea

rs).

A

high

Pea

rl In

dex

equa

tes

to a

hig

her c

hanc

e of

an

unin

tend

ed p

regn

ancy

.

Type

Exam

ples

Barr

ier m

etho

dsCo

ndom

– m

ale

and

fem

ale

Diap

hrag

mCa

p

Horm

onal

con

trac

eptio

nCO

CP:

• M

echa

nism

of a

ctio

n: p

reve

nts

ovul

atio

n an

d pr

even

ts im

plan

tatio

n by

thin

ning

the

endo

met

rial l

inin

g•

Man

y co

ntra

indi

catio

ns. R

efer

to U

KMEC

gui

delin

es. T

here

are

four

cat

egor

ies

in th

e U

KMEC

gui

delin

es; 1

– g

ener

ally

saf

e;

2 –

bene

fits

outw

eigh

the

risks

; 3 –

risk

s ou

twei

gh th

e be

nefit

s; 4

– un

safe

•

Effe

ctiv

e co

ntra

cept

ion:

afte

r 7 d

ays

POP:

• M

echa

nism

of a

ctio

n: th

icke

ns th

e ce

rvic

al m

ucus

and

sec

retio

ns m

akin

g it

inho

spita

ble

to s

perm

• Ef

fect

ive

cont

race

ptio

n: a

fter 2

day

s

Cont

race

ptiv

e in

ject

ion:

• De

po-P

rove

ra is

mai

nly

used

in th

e U

K•

Giv

en 1

2 w

eekl

y•

Dela

y in

retu

rn o

f fer

tility

onc

e st

oppi

ng th

e in

ject

ion.

Mak

e ta

ke u

p to

12

mon

ths

to re

turn

• Ef

fect

ive

cont

race

ptio

n: a

fter 7

day

s

K30033_C003.indd 100 28/02/17 11:17 am

Gyn

aeco

logy

101

Tabl

e 3.

7. C

on

trac

epti

on

Cont

race

ptiv

e im

plan

t:•

The

radi

opaq

ue im

plan

t (N

expl

anon

) is

inse

rted

sub

derm

ally

in th

e no

n-do

min

ant a

rm•

Is th

e lo

ng-a

ctin

g co

ntra

cept

ion

of c

hoic

e in

you

ng p

eopl

e w

ho m

ay n

ot re

liabl

y ta

ke th

e pi

ll •

Effe

ctiv

e co

ntra

cept

ion:

afte

r 7 d

ays

Emer

genc

y co

ntra

cept

ive

pill:

• 1.

5 m

g le

vono

rges

trel

take

n w

ithin

72

hour

s of

unp

rote

cted

inte

rcou

rse

Intr

aute

rine

cont

race

ptio

nIn

trau

terin

e de

vice

(IU

D):

• IU

D al

so k

now

n as

the

copp

er c

oil

• M

echa

nism

of a

ctio

n: th

e co

pper

ions

are

thou

ght t

o cr

eate

a h

ostil

e en

viro

nmen

t for

spe

rm

• Ef

fect

ive

cont

race

ptio

n: im

med

iate

ly

Inte

rute

rine

syst

em (I

US)

:•

IUS,

als

o kn

own

as th

e M

irena

sys

tem

, rel

ease

s le

vono

rges

trel

•

Mec

hani

sm o

f act

ion:

thic

kens

cer

vica

l muc

us a

nd s

ecre

tions

. Pre

vent

s en

dom

etria

l pro

lifer

atio

n•

Effe

ctiv

e co

ntra

cept

ion:

afte

r 7 d

ays

Irrev

ersi

ble

cont

race

ptio

nM

ale

ster

iliza

tion:

•

An e

asie

r pro

cedu

re to

per

form

than

fem

ale

ster

iliza

tion

• M

ay b

e do

ne a

s an

out

patie

nt p

roce

dure

und

er lo

cal a

naes

thes

ia•

Two

sem

en s

ampl

es m

ust b

e su

pplie

d af

ter t

he p

roce

dure

at 1

6 an

d 20

wee

ks to

ens

ure

that

it h

as w

orke

d

Fem

ale

ster

iliza

tion:

•

Perfo

rmed

und

er g

ener

al a

naes

thes

ia•

Man

y di

ffere

nt m

etho

ds m

ay b

e us

ed (e

.g. F

ilshi

e cl

ips

or F

alop

e rin

gs)

K30033_C003.indd 101 28/02/17 11:17 am

K30033_C003.indd 102 28/02/17 11:17 am

Chap

ter F

our P

aedi

atri

cs

MAP

4.1

N

eon

atal

jau

nd

ice

104

MAP

4.2

N

ecro

tizi

ng

en

tero

colit

is (

NEC

) 10

6

MAP

4.3

H

yper

tro

ph

ic p

ylo

ric

sten

osi

s 10

8

MAP

4.4

H

irsc

hsp

run

g’s

dis

ease

10

9

MAP

4.5

In

tuss

usc

epti

on

11

0

TABL

E 4.

1 A

nte

rio

r ab

do

min

al w

all d

efec

ts

111

MAP

4.6

C

on

gen

ital

car

dia

c d

efec

ts

112

MAP

4.7

G

enit

ou

rin

ary

abn

orm

alit

ies

114

TABL

E 4.

2 N

euro

cuta

neo

us

syn

dro

mes

11

6

MAP

4.8

N

eura

l tu

be

def

ects

(N

TDs)

11

8

MAP

4.9

C

ereb

ral p

alsy

12

0

MAP

4.1

0 M

enin

git

is

122

MAP

4.1

1 Fa

ilure

to

th

rive

12

4

MAP

4.1

2 B

ron

chio

litis

12

6

MAP

4.1

3 C

rou

p

128

Paed

iatr

ics

MAP

4.1

4 C

ysti

c fi

bro

sis

(CF)

13

0

MAP

4.1

5 A

sth

ma

132

TABL

E 4.

3 Fl

ow

ch

art

sum

mar

izin

g t

he

B

riti

sh T

ho

raci

c So

ciet

y g

uid

elin

es

134

MAP

4.1

6 R

heu

mat

ic f

ever

13

6

MAP

4.1

7 U

rin

ary

trac

t in

fect

ion

(U

TI)

138

MAP

4.1

8 H

aem

oly

tic

ura

emic

syn

dro

me

(HU

S)

140

MAP

4.1

9 H

eno

ch–S

chö

nle

in p

urp

ura

(H

SP)

142

TABL

E 4.

4 C

hild

ho

od

ep

ilep

sy s

ynd

rom

es

144

MAP

4.2

0 D

iab

etic

ket

oac

ido

sis

(DK

A)

146

FIG

URE

4.1

Path

op

hys

iolo

gy

of

dia

bet

ic

keto

acid

osi

s 14

8

TABL

E 4.

5 Tr

iso

mie

s 14

9

MAP

4.2

1 K

awas

aki’s

dis

ease

15

0

TABL

E 4.

6 C

hild

ho

od

can

cers

15

2

103

K30033_C004.indd 103 28/02/17 11:43 am

Paed

iatr

ics

104 Wha

t is

neo

nata

l jau

ndic

e?Ja

undi

ce, a

lso

know

n as

icte

rus,

is th

e ye

llow

dis

colo

urat

ion

of m

ucou

s m

embr

anes

, scl

era

and

skin

. Thi

s oc

curs

due

to th

e ac

cum

ulat

ion

of

bilir

ubin

. Jau

ndic

e m

ay b

e se

en a

t a b

iliru

bin

conc

entra

tion

>42.

8 µm

ol/L

(2

.5 m

g/dL

).

Caus

esTh

e ca

uses

of j

aund

ice

may

be

split

into

thre

e ca

tego

ries:

1. P

re-h

epat

ic ja

undi

ce.

2. In

tra-

hepa

tic ja

undi

ce.

3. P

ost-

hepa

tic ja

undi

ce.

For n

eona

tes

it m

ay b

e fu

rthe

r sub

divi

ded

into

a ti

me

scal

e: <

24 h

ours

, 24

hou

rs to

3 w

eeks

, and

>3

wee

ks. S

ee Ta

ble

oppo

site

for m

ore

deta

ils.

Sym

ptom

sPo

or fe

edin

g, fa

ilure

to th

rive

and

yello

w d

isco

lour

atio

n as

wel

l as

SICK

:S

– Se

izur

esI

– Irr

itabi

lity,

Incr

ease

d m

uscl

e to

neC

– Co

ma

K –

Kern

icte

rus

MA

P 4.

1. N

eona

tal j

aund

ice

Inve

stig

atio

nsM

ust d

eter

min

e un

derly

ing

caus

e.

Use

thes

e te

sts

to d

eter

min

e th

e ty

pe o

f jau

ndic

e:•

Appe

aran

ce o

f urin

e an

d st

ool.

• LF

Ts.

• Bi

lirub

in le

vels.

• Al

kalin

e ph

osph

atas

e le

vels.

Tabl

e to

sho

w t

he d

iffer

ent

bloo

d re

sult

s fo

r di

ffer

ent

type

s of

ja

undi

ce:

Pre-

hepa

tic

jaun

dice

Inve

stig

atio

nIn

tra-

hepa

tic

jaun

dice

Post

-hep

atic

jaun

dice

Appe

aran

ce o

fur

ine

Nor

mal

Dark

Dark

Dark

Dark

Appe

aran

ce o

fst

ool

Nor

mal

Nor

mal

or p

ale

Pale

Conj

ugat

edbi

lirub

inN

orm

al

Unc

onju

gate

dbi

lirub

inN

orm

al o

r N

orm

al

Tota

l bili

rubi

nN

orm

al o

r

Alka

line

phos

phat

ase

Nor

mal

<24

hou

rs

>3

wee

ksU

ncon

juga

ted

caus

es: i

nfec

tion,

a p

hysi

olog

ical

cau

se, h

aem

olyt

ic c

ause

s. Co

njug

ated

cau

ses:

hepa

titis,

obs

truc

ted

bile

duc

t.

Infe

ctio

n (e

.g. T

ORC

HES

[see

Map

2.6

, p. 5

0])

Haem

olyt

ic d

isor

ders

:•

ABO

inco

mpa

tibili

ty.

• Rh

esus

inco

mpa

tibili

ty.

• G

6PD

defic

ienc

y:

X-

linke

d co

nditi

on.

Defic

ienc

y in

glu

cose

-6-p

hosp

hate

deh

ydro

gena

se. R

esul

tant

effe

ct is

a d

ecre

ase

in a

ntio

xida

nt N

ADPH

mea

ning

that

RBC

s ar

e

mor

e su

scep

tible

to o

xida

tive

stre

ss (e

.g. i

nfec

tion/

cert

ain

food

s su

ch a

s fa

va b

eans

). Bl

ood

smea

r: He

inz

bodi

es, b

ite c

ells.

• Sp

hero

cyto

sis:

Auto

som

al d

omin

ant c

ondi

tion.

Caus

ed b

y fu

nctio

nal a

bnor

mal

ity o

f str

uctu

ral R

BC m

embr

ane

prot

eins

(e.g

. spe

ctrin

, ank

yrin

)

Bl

ood

smea

r: sp

hero

cyte

s.

24 h

ours

to

3 w

eeks

Rem

embe

r as

ABC

:A

– A

phy

siol

ogic

al c

ause

B –

Brea

st m

ilk ja

undi

ceC

– Cr

igle

r–N

ajja

r syn

drom

e: a

utos

omal

rece

ssiv

e co

nditi

on. T

wo

type

s: ty

pe 1

: abs

ence

of U

DP g

lucu

rono

syl t

rans

fera

se 1

-A1;

t

ype

2: re

duce

d le

vels

of U

DP g

lucu

rono

syl t

rans

fera

se 1

-A1.

Haem

olys

isIn

fect

ion

Caus

eTi

me

elap

sed

post

nata

lly

Trea

tmen

tTr

eat u

nder

lyin

g ca

use

Com

plic

atio

ns•

Live

r fai

lure

.

• Pa

ncre

atiti

s.

• Re

nal f

ailu

re.

• Se

psis.

• Ch

olan

gitis

.•

Bilia

ry c

irrho

sis.

Map

4.1

. N

eon

atal

jau

nd

ice

K30033_C004.indd 104 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

. N

eon

atal

jau

nd

ice

Wha

t is

neo

nata

l jau

ndic

e?Ja

undi

ce, a

lso

know

n as

icte

rus,

is th

e ye

llow

dis

colo

urat

ion

of m

ucou

s m

embr

anes

, scl

era

and

skin

. Thi

s oc

curs

due

to th

e ac

cum

ulat

ion

of

bilir

ubin

. Jau

ndic

e m

ay b

e se

en a

t a b

iliru

bin

conc

entra

tion

>42.

8 µm

ol/L

(2

.5 m

g/dL

).

Caus

esTh

e ca

uses

of j

aund

ice

may

be

split

into

thre

e ca

tego

ries:

1. P

re-h

epat

ic ja

undi

ce.

2. In

tra-

hepa

tic ja

undi

ce.

3. P

ost-

hepa

tic ja

undi

ce.

For n

eona

tes

it m

ay b

e fu

rthe

r sub

divi

ded

into

a ti

me

scal

e: <

24 h

ours

, 24

hou

rs to

3 w

eeks

, and

>3

wee

ks. S

ee Ta

ble

oppo

site

for m

ore

deta

ils.

Sym

ptom

sPo

or fe

edin

g, fa

ilure

to th

rive

and

yello

w d

isco

lour

atio

n as

wel

l as

SICK

:S

– Se

izur

esI

– Irr

itabi

lity,

Incr

ease

d m

uscl

e to

neC

– Co

ma

K –

Kern

icte

rus

MA

P 4.

1. N

eona

tal j

aund

ice

Inve

stig

atio

nsM

ust d

eter

min

e un

derly

ing

caus

e.

Use

thes

e te

sts

to d

eter

min

e th

e ty

pe o

f jau

ndic

e:•

Appe

aran

ce o

f urin

e an

d st

ool.

• LF

Ts.

• Bi

lirub

in le

vels.

• Al

kalin

e ph

osph

atas

e le

vels.

Tabl

e to

sho

w t

he d

iffer

ent

bloo

d re

sult

s fo

r di

ffer

ent

type

s of

ja

undi

ce:

Pre-

hepa

tic

jaun

dice

Inve

stig

atio

nIn

tra-

hepa

tic

jaun

dice

Post

-hep

atic

jaun

dice

Appe

aran

ce o

fur

ine

Nor

mal

Dark

Dark

Dark

Dark

Appe

aran

ce o

fst

ool

Nor

mal

Nor

mal

or p

ale

Pale

Conj

ugat

edbi

lirub

inN

orm

al

Unc

onju

gate

dbi

lirub

inN

orm

al o

r N

orm

al

Tota

l bili

rubi

nN

orm

al o

r

Alka

line

phos

phat

ase

Nor

mal

<24

hou

rs

>3

wee

ksU

ncon

juga

ted

caus

es: i

nfec

tion,

a p

hysi

olog

ical

cau

se, h

aem

olyt

ic c

ause

s. Co

njug

ated

cau

ses:

hepa

titis,

obs

truc

ted

bile

duc

t.

Infe

ctio

n (e

.g. T

ORC

HES

[see

Map

2.6

, p. 5

0])

Haem

olyt

ic d

isor

ders

:•

ABO

inco

mpa

tibili

ty.

• Rh

esus

inco

mpa

tibili

ty.

• G

6PD

defic

ienc

y:

X-

linke

d co

nditi

on.

Defic

ienc

y in

glu

cose

-6-p

hosp

hate

deh

ydro

gena

se. R

esul

tant

effe

ct is

a d

ecre

ase

in a

ntio

xida

nt N

ADPH

mea

ning

that

RBC

s ar

e

mor

e su

scep

tible

to o

xida

tive

stre

ss (e

.g. i

nfec

tion/

cert

ain

food

s su

ch a

s fa

va b

eans

). Bl

ood

smea

r: He

inz

bodi

es, b

ite c

ells.

• Sp

hero

cyto

sis:

Auto

som

al d

omin

ant c

ondi

tion.

Caus

ed b

y fu

nctio

nal a

bnor

mal

ity o

f str

uctu

ral R

BC m

embr

ane

prot

eins

(e.g

. spe

ctrin

, ank

yrin

)

Bl

ood

smea

r: sp

hero

cyte

s.

24 h

ours

to

3 w

eeks

Rem

embe

r as

ABC

:A

– A

phy

siol

ogic

al c

ause

B –

Brea

st m

ilk ja

undi

ceC

– Cr

igle

r–N

ajja

r syn

drom

e: a

utos

omal

rece

ssiv

e co

nditi

on. T

wo

type

s: ty

pe 1

: abs

ence

of U

DP g

lucu

rono

syl t

rans

fera

se 1

-A1;

t

ype

2: re

duce

d le

vels

of U

DP g

lucu

rono

syl t

rans

fera

se 1

-A1.

Haem

olys

isIn

fect

ion

Caus

eTi

me

elap

sed

post

nata

lly

Trea

tmen

tTr

eat u

nder

lyin

g ca

use

Com

plic

atio

ns•

Live

r fai

lure

.

• Pa

ncre

atiti

s.

• Re

nal f

ailu

re.

• Se

psis.

• Ch

olan

gitis

.•

Bilia

ry c

irrho

sis.

105

K30033_C004.indd 105 28/02/17 11:43 am

Paed

iatr

ics

Map

4.2

. N

ecro

tizi

ng

en

tero

colit

is (

NEC

)

Wha

t is

nec

roti

zing

ent

eroc

olit

is?

This

is a

n in

flam

mat

ory

bow

el n

ecro

sis.

Caus

esTh

e ex

act c

ause

of N

EC is

unk

now

n, b

ut th

e pr

esen

t the

ory

conc

erni

ng th

e pa

thop

hysi

olog

y of

NEC

invo

lves

a h

ypox

ic

insu

lt th

at o

ccur

s in

a p

rem

atur

e in

fant

bec

ause

thei

r im

mun

e sy

stem

is n

ot fu

lly d

evel

oped

. Hyp

oxia

occ

urs

and

this

cau

ses

inte

stin

al s

loug

hing

. Thi

s al

low

s ba

cter

ia to

inva

de th

e in

test

inal

w

all a

nd c

ause

infla

mm

atio

n. T

his

even

tual

ly le

ads

to g

angr

ene,

ris

k of

per

fora

tion

and

NEC

.

Trea

tmen

t

Cons

erva

tive

:•

Info

rmat

ion

prov

ided

to p

aren

ts.

• St

op b

ottle

feed

ing.

• Ad

mit

to N

ICU

and

take

ser

ial x

-ray

s

look

ing

for p

erfo

ratio

n.•

Cont

inua

lly m

onito

r girt

h m

easu

rem

ent.

Med

ical

: onl

y co

nsid

er if

no

perfo

ratio

n ev

iden

t:•

Deco

mpr

ess

the

larg

e bo

wel

.•

Prov

ide

broa

d-sp

ectr

um a

ntib

iotic

s

(che

ck h

ospi

tal g

uide

lines

).•

Intr

aven

ous

fluid

s an

d nu

triti

on.

Surg

ical

:•

Man

age

surg

ical

ly if

per

fora

ted.

Sym

ptom

s•

Into

lera

nt o

f fee

ds.

• Ab

dom

inal

dis

tens

ion.

• De

crea

sed

bow

el s

ound

s.•

Bloo

dy s

tool

s.•

Vom

iting

(may

be

bile

sta

ined

).•

Shoc

k.

Com

plic

atio

ns•

Deat

h.•

Shor

t bow

el s

yndr

ome.

• Bo

wel

obs

truc

tion.

• An

aem

ia.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E (th

ere

may

be

a m

etab

olic

aci

dosi

s).

• Ra

diol

ogy:

abd

omin

al x

-ray

(pne

umat

osis

in

test

inal

is/p

erfo

ratio

n). M

ay s

how

oth

er

sign

s (e

.g. f

ootb

all s

ign

[mas

sive

pn

eum

oper

itone

um],

th

umbp

rintin

g [la

rge

bow

el o

edem

a]).

MAP

4.2

. Nec

roti

zing

ent

eroc

olit

is (N

EC)

106

K30033_C004.indd 106 28/02/17 11:43 am

Paed

iatr

ics

Map

4.2

. N

ecro

tizi

ng

en

tero

colit

is (

NEC

)

Wha

t is

nec

roti

zing

ent

eroc

olit

is?

This

is a

n in

flam

mat

ory

bow

el n

ecro

sis.

Caus

esTh

e ex

act c

ause

of N

EC is

unk

now

n, b

ut th

e pr

esen

t the

ory

conc

erni

ng th

e pa

thop

hysi

olog

y of

NEC

invo

lves

a h

ypox

ic

insu

lt th

at o

ccur

s in

a p

rem

atur

e in

fant

bec

ause

thei

r im

mun

e sy

stem

is n

ot fu

lly d

evel

oped

. Hyp

oxia

occ

urs

and

this

cau

ses

inte

stin

al s

loug

hing

. Thi

s al

low

s ba

cter

ia to

inva

de th

e in

test

inal

w

all a

nd c

ause

infla

mm

atio

n. T

his

even

tual

ly le

ads

to g

angr

ene,

ris

k of

per

fora

tion

and

NEC

.

Trea

tmen

t

Cons

erva

tive

:•

Info

rmat

ion

prov

ided

to p

aren

ts.

• St

op b

ottle

feed

ing.

• Ad

mit

to N

ICU

and

take

ser

ial x

-ray

s

look

ing

for p

erfo

ratio

n.•

Cont

inua

lly m

onito

r girt

h m

easu

rem

ent.

Med

ical

: onl

y co

nsid

er if

no

perfo

ratio

n ev

iden

t:•

Deco

mpr

ess

the

larg

e bo

wel

.•

Prov

ide

broa

d-sp

ectr

um a

ntib

iotic

s

(che

ck h

ospi

tal g

uide

lines

).•

Intr

aven

ous

fluid

s an

d nu

triti

on.

Surg

ical

:•

Man

age

surg

ical

ly if

per

fora

ted.

Sym

ptom

s•

Into

lera

nt o

f fee

ds.

• Ab

dom

inal

dis

tens

ion.

• De

crea

sed

bow

el s

ound

s.•

Bloo

dy s

tool

s.•

Vom

iting

(may

be

bile

sta

ined

).•

Shoc

k.

Com

plic

atio

ns•

Deat

h.•

Shor

t bow

el s

yndr

ome.

• Bo

wel

obs

truc

tion.

• An

aem

ia.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E (th

ere

may

be

a m

etab

olic

aci

dosi

s).

• Ra

diol

ogy:

abd

omin

al x

-ray

(pne

umat

osis

in

test

inal

is/p

erfo

ratio

n). M

ay s

how

oth

er

sign

s (e

.g. f

ootb

all s

ign

[mas

sive

pn

eum

oper

itone

um],

th

umbp

rintin

g [la

rge

bow

el o

edem

a]).

MAP

4.2

. Nec

roti

zing

ent

eroc

olit

is (N

EC)

107

K30033_C004.indd 107 28/02/17 11:43 am

Paed

iatr

ics

Map

4.3

. H

yper

tro

ph

ic p

ylo

ric

sten

osi

s

Wha

t is

hyp

ertr

ophi

c py

lori

c st

enos

is?

This

is w

hen

the

mus

cula

r lay

er o

f the

pyl

oris

hype

rtro

phie

s, re

sulti

ng in

a g

astr

ic o

utle

tob

stru

ctio

n by

nar

row

ing

the

outle

t fro

m th

est

omac

h to

the

duod

enum

. It p

rese

nts

arou

nd2–

8 w

eeks

of a

ge.

Caus

esHy

pert

roph

y of

the

mus

cula

r lay

er o

f the

pyl

oris.

The

exac

t rea

son

why

this

hap

pens

rem

ains

uncl

ear b

ut th

ere

are

som

e as

soci

ated

risk

fact

ors

(see

bel

ow).

Risk

fact

ors

(rem

embe

r as

the

3Fs

):Fi

rst-

born

mal

esFa

mily

his

tory

of t

he d

isor

der

Fair

skin

Inve

stig

atio

ns•

Feed

ing

test

may

sho

w p

eris

talti

c w

ave.

• Bl

ood

test

s: FB

C, W

CC, U

&E,

LFT

s (th

ere

may

be

a

hypo

chlo

raem

ic a

lkal

osis

).•

Mon

itor u

rine

outp

ut.

• Ra

diol

ogy:

USS

con

firm

s di

agno

sis

Com

plic

atio

ns•

Elec

trol

yte

imba

lanc

es.

• Du

oden

al p

erfo

ratio

n.•

Apno

ea.

• As

pira

tion

pneu

mon

ia.

Sym

ptom

sRe

mem

ber a

s PY

LORI

C:P

– Pr

ojec

tive

vom

iting

(non

-bili

ous)

wor

seni

ng w

ith ti

me

Y –

Yelli

ng, u

nhap

py c

hild

L –

Leth

argi

c ch

ild, L

oss

of w

eigh

tO

– ‘O

live’

(pyl

oric

mas

s) p

rese

nt in

the

RUQ

R –

Rum

blin

g tu

mm

y (i.

e. g

astr

ic p

eris

tals

is fr

om le

ft to

righ

t

see

n on

feed

ing

test

)I

– Irr

itabl

eC

– Co

nstip

ated

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

Med

ical

:•

Corr

ect e

lect

roly

te im

bala

nce.

Surg

ical

:•

Ram

sted

t’s p

ylor

omyo

tom

y.

MAP

4.3

. Hyp

ertr

ophi

cpy

lori

c st

enos

is

108

K30033_C004.indd 108 28/02/17 11:43 am

Paed

iatr

ics

Map

4.4

. H

irsc

hsp

run

g’s

dis

ease

Wha

t is

Hir

schs

prun

g’s

dise

ase?

This

is a

con

geni

tal a

bsen

ce o

f gan

glio

n ce

lls fr

om th

em

uscu

lar a

nd m

ucos

al la

yers

of t

he c

olon

. The

regi

onus

ually

affe

cted

is th

e re

ctum

sin

ce, d

urin

g de

velo

pmen

t,th

e ce

lls m

igra

te c

rani

ocau

dally

. The

loss

of t

hese

gang

lion

cells

resu

lts in

con

stip

atio

n, o

bstr

uctio

n an

d,po

tent

ially

, meg

acol

on. T

his

cond

ition

affe

cts

mal

es m

ore

than

fem

ales

.

Caus

esAs

abo

ve –

def

ectiv

e cr

anio

caud

al m

igra

tion

of th

ene

urob

last

cel

ls o

ccur

ring

at 1

2 w

eeks

ges

tatio

n.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

Surg

ical

:•

Surg

ery

is th

e de

finiti

ve tr

eatm

ent.

Rem

ove

the

af

fect

ed s

ectio

n of

bow

el +

/– c

olos

tom

y. Ex

ampl

es o

f

proc

edur

es u

sed

are

liste

d be

low

:

So

ave–

Bole

y pr

oced

ure.

Duha

mel

pro

cedu

re.

Com

plic

atio

ns•

Ente

roco

litis.

• Ac

ute

obst

ruct

ion.

• Co

mpl

icat

ions

of s

urge

ry a

nd

gene

ral c

ompl

icat

ions

.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E, L

FTs.

• Re

ctal

suc

tion

biop

sy s

how

ing

agan

glio

nic

se

ctio

n of

bow

el is

gol

d st

anda

rd

inve

stig

atio

n.

Sym

ptom

s•

Failu

re to

pas

s m

econ

ium

.•

Abdo

min

al d

iste

nsio

n.•

Vom

iting

.•

Decr

ease

d fe

edin

g.•

Irrita

bilit

y.•

Empt

y re

ctal

vau

lt.•

Poss

ible

sig

ns o

f ent

eroc

oliti

s.

MAP

4.4

. Hir

schs

prun

g’s

dise

ase

109

K30033_C004.indd 109 28/02/17 11:43 am

Paed

iatr

ics

Map

4.5

. In

tuss

usc

epti

on

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E, L

FTs

(usu

ally

un

rem

arka

ble

bloo

d re

sults

).•

Radi

olog

y: a

bdom

inal

x-r

ay –

may

vi

sual

ize

dila

ted

loop

s of

bow

el o

r

perfo

ratio

n.•

USS

– ‘t

arge

t sig

n’

Not

e: A

ir/co

ntra

st e

nem

a m

ay b

e us

ed a

s it

isbo

th d

iagn

ostic

and

ther

apeu

tic.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

Radi

olog

ical

(see

inve

stig

atio

ns s

ecti

on):

• Hy

dros

tatic

redu

ctio

n us

ing

enem

a.

Surg

ical

:•

May

be

requ

ired

if ot

her m

easu

res

fail.

Wha

t is

intu

ssus

cept

ion?

This

is w

hen

a po

rtio

n of

the

inte

stin

e be

com

es in

vagi

nate

d in

to it

sow

n lu

men

to a

var

iabl

e de

gree

by

peris

tals

is.

Caus

esTh

ese

may

be

split

into

pae

diat

ric a

nd a

dult

caus

es.

Paed

iatr

ic:

• M

ecke

l’s d

iver

ticul

um. T

his

is th

e re

mna

nt o

f the

vite

lline

duc

t

(join

s yo

lk s

ac to

the

mid

gut l

umen

) tha

t usu

ally

obl

itera

tes

du

ring

9th w

eek

of g

esta

tion.

It is

ass

ocia

ted

with

the

rule

of 2

s:

It

affe

cts

2% o

f the

pop

ulat

ion.

2 ti

mes

mor

e co

mm

on in

mal

es.

It is

2 in

ches

long

.

It

is lo

cate

d 2

feet

from

the

ilioc

aeca

l val

ve (a

lthou

gh, i

n

re

ality

, thi

s m

ay b

e an

y di

stan

ce).

It co

ntai

ns 2

typ

es o

f tis

sues

, gas

tric

and

pan

crea

tic, w

hich

is w

hy a

tech

netiu

m-9

9m s

can

is th

e in

vest

igat

ion

of c

hoic

e.•

Hype

rtro

phie

d Pe

yer’s

pat

ches

Adu

lts

• Tu

mou

r. Sy

mpt

oms

Sym

ptom

s pr

esen

t in

a cl

assi

c tr

iad:

1. P

ain

– se

vere

, col

icky

abd

omin

al p

ain.

2. B

lood

in s

tool

– o

ften

desc

ribed

as ‘

redc

urra

nt je

lly’.

3. V

omiti

ng –

non

-bili

ous

initi

ally

but

may

bec

ome

bilio

us.

Com

plic

atio

ns•

Perfo

ratio

n.•

Shoc

k.•

Perit

oniti

s.

MAP

4.5

. In

tuss

usce

ptio

n

110

K30033_C004.indd 110 28/02/17 11:43 am

Paed

iatr

ics

Tabl

e 4.

1. A

nte

rio

r ab

do

min

al w

all d

efec

ts

TABL

E 4.

1. A

nter

ior

abdo

min

al w

all d

efec

ts. T

he d

iffe

renc

es b

etw

een

an o

mph

aloc

oele

and

a g

astr

osch

isis

ar

e ou

tlin

ed b

elow

.

Om

phal

ocoe

leG

astr

osch

isis

Loca

tion

Mid

line

defe

ct. I

t is

a ve

ntra

l def

ect o

f the

um

bilic

al ri

ngPa

raum

bilic

al d

efec

t due

to in

com

plet

e fu

sion

of t

he

abdo

min

al w

all

Cove

red

by v

isce

raYe

sN

o

Ass

ocia

ted

wit

h ot

her

defe

cts

Yes.

Gen

eral

ly, m

idlin

e de

fect

s ar

e as

soci

ated

with

oth

er a

bnor

mal

ities

su

ch a

s ca

rdia

c, g

enito

urin

ary

or c

hrom

osom

al a

bnor

mal

ities

No.

How

ever

, thi

s co

nditi

on h

as a

n as

soci

atio

n w

ith c

ocai

ne u

se a

nd b

abie

s w

ho a

re s

mal

l for

ge

stat

iona

l age

Inve

stig

atio

nsDe

tect

ed a

nten

atal

ly v

ia s

onog

raph

yDe

tect

ed a

nten

atal

ly v

ia s

onog

raph

y

Trea

tmen

tSe

vera

l ste

ps n

eed

to b

e fo

llow

ed:

1. T

he a

bdom

inal

con

tent

s m

ust b

e pr

otec

ted.

Thi

s m

ay b

e ac

hiev

ed

usin

g m

oist

ened

, ste

rile

gauz

e 2.

Flu

ids

and

elec

trol

ytes

mus

t be

mon

itore

d an

d co

rrec

ted

if ne

cess

ary

3. T

he le

sion

mus

t be

clos

ed (e

.g. u

sing

a s

ilo).

This

mus

t be

done

slo

wly

be

caus

e if

clos

ed to

o qu

ickl

y, th

e su

dden

add

ition

of t

he a

bdom

inal

co

nten

ts m

ay c

ause

hae

mod

ynam

ic c

ompr

omis

e an

d de

crea

se v

enou

s re

turn

to th

e he

art

Seve

ral s

teps

nee

d to

be

follo

wed

:1.

The

abd

omin

al c

onte

nts

mus

t be

prot

ecte

d. T

his

may

be

achi

eved

usi

ng m

oist

ened

, ste

rile

gauz

e2.

Flu

ids

and

elec

trol

ytes

mus

t be

mon

itore

d an

d co

rrec

ted

if ne

cess

ary

3. P

rovi

de b

road

-spe

ctru

m a

ntib

iotic

s.4.

Sur

gery

is n

eces

sary

usu

ally

with

in 2

4–48

hou

rs

111

K30033_C004.indd 111 28/02/17 11:43 am

Paed

iatr

ics

Map

4.6

. C

on

gen

ital

car

dia

c d

efec

ts

Atr

ial s

epta

l def

ects

(ASD

s):

Ost

ium

pri

mum

:•

Caus

ed b

y a

failu

re o

f the

sep

tum

prim

um to

join

the

endo

card

ial c

ushi

on.

• As

soci

ated

with

oth

er n

eura

l cre

st m

igra

tion

defe

cts

sinc

e th

e en

doca

rdia

l cus

hion

is p

rimar

ily fo

rmed

fro

m n

eura

l cre

st c

ells

that

hav

e m

igra

ted

to th

e

en

doca

rdia

l tub

e du

ring

embr

yolo

gica

l dev

elop

men

t.

Ost

ium

sec

undu

m:

• Ei

ght t

imes

mor

e co

mm

on th

an th

e pr

imum

type

.•

Caus

ed b

y ex

cess

ive

abso

rptio

n of

the

sept

um p

rimum

o

r inc

ompl

ete

grow

th o

f the

sep

tum

sec

undu

m.

Cond

itio

n

Mur

mur

s

Mur

mur

MAP

4.6

. Con

geni

tal c

ardi

ac d

efec

ts

Acy

anot

ic d

efec

ts

Dext

rapo

sitio

n of

the

aort

icop

ulm

onar

yse

ptum

(aka

the

spira

lse

ptum

)

Pers

iste

nt tr

uncu

sar

terio

sis

Tran

spos

ition

of t

hegr

eat v

esse

ls

The

spira

l sep

tum

fails

to fo

rmA

VSD

form

s si

nce

the

spira

l sep

tum

is th

eso

urce

of t

hem

embr

anou

sin

trav

entr

icul

ar s

eptu

m

Asso

ciat

ed w

ith o

ther

defe

cts

that

allo

w th

esh

untin

g of

blo

od,

othe

rwis

e th

e ne

onat

ew

ould

die

Durin

g de

velo

pmen

tth

e ao

rtico

pulm

onar

yse

ptum

spira

ls th

roug

h a

180

degr

ee a

nticl

ockw

ise ro

tatio

n,

henc

e its

nam

e th

e sp

iral

sept

um. T

his p

lace

s the

gre

at

vess

els i

nto

thei

r app

ropr

iate

an

atom

ical p

ositi

on (i

.e. t

he

aorta

pos

terio

r and

to th

e rig

ht, t

he p

ulm

onar

y tru

nk

ante

rior a

nd to

the

left)

. In

this

cond

ition

the

aorti

copu

lmo-

nary

sept

um fa

ils to

spira

l

Rem

embe

r as

PRO

V:P

– Pu

lmon

ary

sten

osis

R –

Righ

t ven

tric

ular

h

yper

trop

hyO

– O

verr

idin

g ao

rta

V –

VSD

Type

Caus

eFe

atur

es

Tetr

alog

y of

Fal

lot

Loca

tion

bes

t he

ard

VSD

ASD

PDA

Tetr

alog

y of

Fal

lot

Tran

spos

ition

of t

hegr

eat v

esse

ls

Pans

ysto

lic. S

mal

ler

lesi

ons

are

loud

est

Low

er le

ft st

erna

l edg

e

Syst

olic

eje

ctio

n

Mac

hine

ry m

urm

ur

Syst

olic

eje

ctio

n

No

mur

mur

Upp

er le

ft st

erna

l edg

e

Upp

er le

ft st

erna

l edg

e

Upp

er le

ft st

erna

l edg

e

N/A

Wha

t ar

e co

ngen

ital

car

diac

def

ects

?Th

is is

whe

n th

e he

art f

ails

to d

evel

op n

orm

ally.

The

y m

ay b

e br

oadl

y ca

tego

rized

as

cyan

otic

and

acy

anot

ic.

Cyan

otic

def

ects

: •

Trun

cus

arte

riosu

s.•

Tran

spos

ition

of t

he g

reat

ves

sels.

• Tr

icus

pid

insu

ffici

ency

.•

Tetr

alog

y of

Fal

lot.

Acy

anot

ic d

efec

ts: l

eft ®

righ

t shu

nt•

Rem

embe

r as

the

3Ds:

VS

D –

mos

t com

mon

def

ect

AS

D

PDA

Caus

esDe

pend

s on

the

spec

ific

defe

ct, b

ut th

ere

are

man

y ris

k fa

ctor

s as

soci

ated

with

them

:•

Unk

now

n.•

Mat

erna

l fac

tors

: e.g

. TO

RCHE

S in

fect

ion

(see

Map

2.6

, p. 5

0), d

iabe

tes

mel

litus

and

sys

tem

ic lu

pus

eryt

hem

atos

us.

• Te

rato

gens

:

Al

coho

l.

Li

thiu

m.

War

farin

.

Ph

enyt

oin.

• Ch

rom

osom

al a

bnor

mal

ities

.

right

® le

ft sh

unt

112

K30033_C004.indd 112 28/02/17 11:43 am

Atr

ial s

epta

l def

ects

(ASD

s):

Ost

ium

pri

mum

:•

Caus

ed b

y a

failu

re o

f the

sep

tum

prim

um to

join

the

endo

card

ial c

ushi

on.

• As

soci

ated

with

oth

er n

eura

l cre

st m

igra

tion

defe

cts

sinc

e th

e en

doca

rdia

l cus

hion

is p

rimar

ily fo

rmed

fro

m n

eura

l cre

st c

ells

that

hav

e m

igra

ted

to th

e

en

doca

rdia

l tub

e du

ring

embr

yolo

gica

l dev

elop

men

t.

Ost

ium

sec

undu

m:

• Ei

ght t

imes

mor

e co

mm

on th

an th

e pr

imum

type

.•

Caus

ed b

y ex

cess

ive

abso

rptio

n of

the

sept

um p

rimum

o

r inc

ompl

ete

grow

th o

f the

sep

tum

sec

undu

m.

Acy

anot

ic d

efec

ts

Dext

rapo

sitio

n of

the

aort

icop

ulm

onar

yse

ptum

(aka

the

spira

lse

ptum

)

Pers

iste

nt tr

uncu

sar

terio

sis

Tran

spos

ition

of t

hegr

eat v

esse

ls

The

spira

l sep

tum

fails

to fo

rmA

VSD

form

s si

nce

the

spira

l sep

tum

is th

eso

urce

of t

hem

embr

anou

sin

trav

entr

icul

ar s

eptu

m

Asso

ciat

ed w

ith o

ther

defe

cts

that

allo

w th

esh

untin

g of

blo

od,

othe

rwis

e th

e ne

onat

ew

ould

die

Durin

g de

velo

pmen

tth

e ao

rtico

pulm

onar

yse

ptum

spira

ls th

roug

h a

180

degr

ee a

nticl

ockw

ise ro

tatio

n,

henc

e its

nam

e th

e sp

iral

sept

um. T

his p

lace

s the

gre

at

vess

els i

nto

thei

r app

ropr

iate

an

atom

ical p

ositi

on (i

.e. t

he

aorta

pos

terio

r and

to th

e rig

ht, t

he p

ulm

onar

y tru

nk

ante

rior a

nd to

the

left)

. In

this

cond

ition

the

aorti

copu

lmo-

nary

sept

um fa

ils to

spira

l

Rem

embe

r as

PRO

V:P

– Pu

lmon

ary

sten

osis

R –

Righ

t ven

tric

ular

h

yper

trop

hyO

– O

verr

idin

g ao

rta

V –

VSD

Type

Caus

eFe

atur

es

Tetr

alog

y of

Fal

lot

K30033_C004.indd 113 28/02/17 11:43 am

Paed

iatr

ics

Map

4.6

. C

on

gen

ital

car

dia

c d

efec

ts

Cond

itio

n

Mur

mur

s

Mur

mur

MAP

4.6

. Con

geni

tal c

ardi

ac d

efec

ts

Loca

tion

bes

t he

ard

VSD

ASD

PDA

Tetr

alog

y of

Fal

lot

Tran

spos

ition

of t

hegr

eat v

esse

ls

Pans

ysto

lic. S

mal

ler

lesi

ons

are

loud

est

Low

er le

ft st

erna

l edg

e

Syst

olic

eje

ctio

n

Mac

hine

ry m

urm

ur

Syst

olic

eje

ctio

n

No

mur

mur

Upp

er le

ft st

erna

l edg

e

Upp

er le

ft st

erna

l edg

e

Upp

er le

ft st

erna

l edg

e

N/A

Wha

t ar

e co

ngen

ital

car

diac

def

ects

?Th

is is

whe

n th

e he

art f

ails

to d

evel

op n

orm

ally.

The

y m

ay b

e br

oadl

y ca

tego

rized

as

cyan

otic

and

acy

anot

ic.

Cyan

otic

def

ects

: •

Trun

cus

arte

riosu

s.•

Tran

spos

ition

of t

he g

reat

ves

sels.

• Tr

icus

pid

insu

ffici

ency

.•

Tetr

alog

y of

Fal

lot.

Acy

anot

ic d

efec

ts: l

eft ®

righ

t shu

nt•

Rem

embe

r as

the

3Ds:

VS

D –

mos

t com

mon

def

ect

AS

D

PDA

Caus

esDe

pend

s on

the

spec

ific

defe

ct, b

ut th

ere

are

man

y ris

k fa

ctor

s as

soci

ated

with

them

:•

Unk

now

n.•

Mat

erna

l fac

tors

: e.g

. TO

RCHE

S in

fect

ion

(see

Map

2.6

, p. 5

0), d

iabe

tes

mel

litus

and

sys

tem

ic lu

pus

eryt

hem

atos

us.

• Te

rato

gens

:

Al

coho

l.

Li

thiu

m.

War

farin

.

Ph

enyt

oin.

• Ch

rom

osom

al a

bnor

mal

ities

.

right

® le

ft sh

unt

113

Paed

iatr

ics

Map

4.7

. G

enit

ou

rin

ary

abn

orm

alit

ies

Hor

sesh

oe k

idne

y

Wha

t is

a h

orse

shoe

kid

ney?

This

occ

urs

durin

g de

velo

pmen

t whe

n th

e up

per a

nd lo

wer

pol

es o

f the

kid

neys

fuse

and

cann

ot a

scen

d to

thei

r nor

mal

an

atom

ical

pos

ition

due

to th

e in

ferio

r m

esen

teric

art

ery.

This

resu

lts in

aho

rses

hoe

shap

e.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

• As

ympt

omat

ic.

• Re

curr

ent u

rinar

y tr

act i

nfec

tions

.•

Rena

l cal

culi.

• O

bstr

uctiv

e ur

opat

hy.

Inve

stig

atio

ns: U

SS is

dia

gnos

tic.

Trea

tmen

t: tr

eatm

ent o

f com

plic

atio

ns.

Com

plic

atio

ns:

• Su

scep

tible

to tr

aum

a.•

Rena

l cal

culi

form

atio

n.•

Incr

ease

d ris

k of

tran

sitio

nal c

ell

c

arci

nom

a of

the

rena

l pel

vis.

Gen

itour

inar

y ab

norm

aliti

es a

re

asso

ciat

ed w

ith C

HA

RGE:

C –

Colo

bom

aH

– H

eart

def

ects

A –

Atr

esia

of t

he n

asal

cho

anae

R –

Reta

rded

gro

wth

/dev

elop

men

tG

– G

enito

urin

ary

abno

rmal

ities

E –

Ear a

bnor

mal

ities

/dea

fnes

s

Aut

osom

al r

eces

sive

pol

ycys

tic

kidn

ey d

isea

se

Wha

t is

aut

osom

al r

eces

sive

pol

ycys

tic

kidn

ey d

isea

se(A

RPKD

)?Th

is is

a re

cess

ivel

y in

herit

ed p

olyc

ystic

dis

ease

foun

d in

chi

ldre

n.

Caus

es:

• PK

HD1

on c

hrom

osom

e 6.

Sign

s an

d sy

mpt

oms:

• Hy

pert

ensi

on.

• Th

ose

of c

hron

ic k

idne

y in

jury

.•

Chro

nic

resp

irato

ry in

fect

ions

.•

Thos

e of

por

tal h

yper

tens

ion:

asc

ites,

capu

t med

usae

and

oes

opha

geal

varic

es (v

omiti

ng b

lood

).•

Failu

re to

thriv

e.•

Recu

rren

t urin

ary

trac

t inf

ectio

ns.

• Po

lyur

ia.

Inve

stig

atio

ns: a

nten

atal

scr

eeni

ng is

dia

gnos

tic. S

how

sen

larg

ed k

idne

y w

ith o

r with

out o

ligoh

ydra

mni

os.

Trea

tmen

t: no

spe

cific

trea

tmen

t. M

anag

e hy

pert

ensi

on.

Dial

ysis

and

kid

ney

tran

spla

ntat

ion

shou

ld b

e co

nsid

ered

. Lon

g-te

rmox

ygen

ther

apy

is o

ften

requ

ired

due

to c

hron

ic re

spira

tory

infe

ctio

ns.

Com

plic

atio

ns:

• He

patic

cys

ts.

•

Con

geni

tal h

epat

ic fi

bros

is.

• P

rolif

erat

ive

bile

duc

ts.

Blad

der

exst

roph

y

Wha

t is

bla

dder

exs

trop

hy?

This

is a

con

geni

tal m

alfo

rmat

ion

whe

re th

e bl

adde

r pro

trud

es th

roug

h an

abd

omin

al w

all d

efec

t.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

rem

embe

r as

ABC

DES

:A

– A

bdom

inal

wal

l def

ect

B –

Boys

als

o ha

ve e

pisp

adia

sC

– Cl

itoris

is b

ifid

in g

irls

affe

cted

D –

Div

erge

nt la

bia

may

als

o be

pre

sent

E –

Exte

rnal

ly ro

tate

d pe

lvis

S –

Shor

tene

d pu

bic

ram

i

Inve

stig

atio

ns: c

linic

al d

iagn

osis

aid

ed w

ith U

SS.

Trea

tmen

t: su

rger

y.

Com

plic

atio

ns:

• Ve

sico

uret

eral

reflu

x (d

iagn

osed

afte

r a m

ictu

ratin

g cy

stou

reth

rogr

am).

• U

rinar

y tr

act i

nfec

tions

.•

Blad

der s

pasm

.

Hyp

ospa

dias

Wha

t is

hyp

ospa

dias

?Th

is is

a c

onge

nita

l mal

form

atio

n of

the

uret

hral

gro

ove,

mea

ning

that

the

uret

hral

op

enin

g oc

curs

on

the

vent

ral a

spec

t of t

he p

enis.

The

hyp

ospa

dias

is c

lass

ified

by

the

loca

tion

of th

e ur

ethr

al o

peni

ng. E

pisp

adia

s is

whe

n th

e ur

ethr

al o

peni

ng o

ccur

s on

the

dors

al a

spec

t of t

he p

enis.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

Clas

sic

tria

d of

:1.

Abn

orm

al u

reth

ral o

peni

ng.

2. C

hord

ee (b

end

of p

enis

).3.

Hoo

ded

fore

skin

.

Inve

stig

atio

ns: c

linic

al d

iagn

osis.

Trea

tmen

t: su

rger

y.

Com

plic

atio

ns:

• In

fect

ion.

• H

aem

atom

a.•

Fist

ula.

• St

enos

is.

MAP

4.7

. Gen

itou

rina

ry a

bnor

mal

itie

s

114

K30033_C004.indd 114 28/02/17 11:43 am

Paed

iatr

ics

Map

4.7

. G

enit

ou

rin

ary

abn

orm

alit

ies

Hor

sesh

oe k

idne

y

Wha

t is

a h

orse

shoe

kid

ney?

This

occ

urs

durin

g de

velo

pmen

t whe

n th

e up

per a

nd lo

wer

pol

es o

f the

kid

neys

fuse

and

cann

ot a

scen

d to

thei

r nor

mal

an

atom

ical

pos

ition

due

to th

e in

ferio

r m

esen

teric

art

ery.

This

resu

lts in

aho

rses

hoe

shap

e.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

• As

ympt

omat

ic.

• Re

curr

ent u

rinar

y tr

act i

nfec

tions

.•

Rena

l cal

culi.

• O

bstr

uctiv

e ur

opat

hy.

Inve

stig

atio

ns: U

SS is

dia

gnos

tic.

Trea

tmen

t: tr

eatm

ent o

f com

plic

atio

ns.

Com

plic

atio

ns:

• Su

scep

tible

to tr

aum

a.•

Rena

l cal

culi

form

atio

n.•

Incr

ease

d ris

k of

tran

sitio

nal c

ell

c

arci

nom

a of

the

rena

l pel

vis.

Gen

itour

inar

y ab

norm

aliti

es a

re

asso

ciat

ed w

ith C

HA

RGE:

C –

Colo

bom

aH

– H

eart

def

ects

A –

Atr

esia

of t

he n

asal

cho

anae

R –

Reta

rded

gro

wth

/dev

elop

men

tG

– G

enito

urin

ary

abno

rmal

ities

E –

Ear a

bnor

mal

ities

/dea

fnes

s

Aut

osom

al r

eces

sive

pol

ycys

tic

kidn

ey d

isea

se

Wha

t is

aut

osom

al r

eces

sive

pol

ycys

tic

kidn

ey d

isea

se(A

RPKD

)?Th

is is

a re

cess

ivel

y in

herit

ed p

olyc

ystic

dis

ease

foun

d in

chi

ldre

n.

Caus

es:

• PK

HD1

on c

hrom

osom

e 6.

Sign

s an

d sy

mpt

oms:

• Hy

pert

ensi

on.

• Th

ose

of c

hron

ic k

idne

y in

jury

.•

Chro

nic

resp

irato

ry in

fect

ions

.•

Thos

e of

por

tal h

yper

tens

ion:

asc

ites,

capu

t med

usae

and

oes

opha

geal

varic

es (v

omiti

ng b

lood

).•

Failu

re to

thriv

e.•

Recu

rren

t urin

ary

trac

t inf

ectio

ns.

• Po

lyur

ia.

Inve

stig

atio

ns: a

nten

atal

scr

eeni

ng is

dia

gnos

tic. S

how

sen

larg

ed k

idne

y w

ith o

r with

out o

ligoh

ydra

mni

os.

Trea

tmen

t: no

spe

cific

trea

tmen

t. M

anag

e hy

pert

ensi

on.

Dial

ysis

and

kid

ney

tran

spla

ntat

ion

shou

ld b

e co

nsid

ered

. Lon

g-te

rmox

ygen

ther

apy

is o

ften

requ

ired

due

to c

hron

ic re

spira

tory

infe

ctio

ns.

Com

plic

atio

ns:

• He

patic

cys

ts.

•

Con

geni

tal h

epat

ic fi

bros

is.

• P

rolif

erat

ive

bile

duc

ts.

Blad

der

exst

roph

y

Wha

t is

bla

dder

exs

trop

hy?

This

is a

con

geni

tal m

alfo

rmat

ion

whe

re th

e bl

adde

r pro

trud

es th

roug

h an

abd

omin

al w

all d

efec

t.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

rem

embe

r as

ABC

DES

:A

– A

bdom

inal

wal

l def

ect

B –

Boys

als

o ha

ve e

pisp

adia

sC

– Cl

itoris

is b

ifid

in g

irls

affe

cted

D –

Div

erge

nt la

bia

may

als

o be

pre

sent

E –

Exte

rnal

ly ro

tate

d pe

lvis

S –

Shor

tene

d pu

bic

ram

i

Inve

stig

atio

ns: c

linic

al d

iagn

osis

aid

ed w

ith U

SS.

Trea

tmen

t: su

rger

y.

Com

plic

atio

ns:

• Ve

sico

uret

eral

reflu

x (d

iagn

osed

afte

r a m

ictu

ratin

g cy

stou

reth

rogr

am).

• U

rinar

y tr

act i

nfec

tions

.•

Blad

der s

pasm

.

Hyp

ospa

dias

Wha

t is

hyp

ospa

dias

?Th

is is

a c

onge

nita

l mal

form

atio

n of

the

uret

hral

gro

ove,

mea

ning

that

the

uret

hral

op

enin

g oc

curs

on

the

vent

ral a

spec

t of t

he p

enis.

The

hyp

ospa

dias

is c

lass

ified

by

the

loca

tion

of th

e ur

ethr

al o

peni

ng. E

pisp

adia

s is

whe

n th

e ur

ethr

al o

peni

ng o

ccur

s on

the

dors

al a

spec

t of t

he p

enis.

Caus

es: c

onge

nita

l abn

orm

ality

.

Sign

s an

d sy

mpt

oms:

Clas

sic

tria

d of

:1.

Abn

orm

al u

reth

ral o

peni

ng.

2. C

hord

ee (b

end

of p

enis

).3.

Hoo

ded

fore

skin

.

Inve

stig

atio

ns: c

linic

al d

iagn

osis.

Trea

tmen

t: su

rger

y.

Com

plic

atio

ns:

• In

fect

ion.

• H

aem

atom

a.•

Fist

ula.

• St

enos

is.

MAP

4.7

. Gen

itou

rina

ry a

bnor

mal

itie

s

115

K30033_C004.indd 115 28/02/17 11:43 am

Paed

iatr

ics

Tabl

e 4.

2. N

euro

cuta

neo

us

syn

dro

mes

TABL

E 4.

2. N

euro

cuta

neou

s sy

ndro

mes

.

Cond

itio

nG

enet

ics

Not

es

Neu

rofib

rom

atos

isAu

toso

mal

dom

inan

t Ty

pe 1

: neu

rofib

rom

in d

efec

t chr

omos

ome

17q1

1Ty

pe 2

: mer

lin d

efec

t chr

omos

ome

22q1

2

Type

1:

• Ak

a vo

n Re

cklin

ghau

sen

dise

ase

• Sk

in m

anife

stat

ions

:

Café

au

lait

spot

s

Axill

ary

freck

ling

N

euro

fibro

mas

Li

sch

nodu

les

(ham

arto

mas

on

the

iris)

• In

crea

sed

risk

of o

ptic

glio

ma

Type

2:

• Sk

in m

anife

stat

ions

are

mor

e m

ild th

an ty

pe 1

• As

soci

ated

with

aco

ustic

neu

rom

as a

nd d

eafn

ess

Tube

rous

scl

eros

isAu

toso

mal

dom

inan

t Ty

pe 1

: ham

artin

def

ect c

hrom

osom

e 9

Type

2: t

uber

in d

efec

t chr

omos

ome

16

• Sk

in m

anife

stat

ions

:

Ash

leaf

spo

ts

Shag

reen

pat

ches

Ad

enom

a se

bace

um•

Asso

ciat

ed w

ith e

pile

psy

and

beni

gn tu

mou

rs

Here

dita

ry h

aem

orrh

agic

tela

ngie

ctas

ia

Auto

som

al d

omin

ant c

ondi

tion

Mos

t due

to m

utat

ions

of:

•EN

G c

hrom

osom

e 9

•AC

VRL1

chr

omos

ome

12

• Ak

a O

sler

–Web

er–R

endu

syn

drom

e•

Asso

ciat

ed w

ith te

lang

iect

asia

, epi

stax

is a

nd v

ascu

lar

diso

rder

s of

the

cent

ral n

ervo

us s

yndr

ome

116

K30033_C004.indd 116 28/02/17 11:43 am

Paed

iatr

ics

Tabl

e 4.

2. N

euro

cuta

neo

us

syn

dro

mes

Stur

ge–W

eber

syn

drom

eM

utat

ion

of th

e G

NAQ

gen

e ca

uses

abn

orm

ality

of

mes

oder

m a

nd e

ctod

erm

dev

elop

men

t•

Skin

man

ifest

atio

n: fa

cial

por

t win

e st

ain

• Ra

diol

ogic

al a

ppea

ranc

e: in

trac

rani

al le

sion

s an

d ty

pica

l tr

am tr

ack

calc

ifica

tions

• As

soci

ated

with

epi

leps

y, he

mip

legi

a, g

lauc

oma

and

men

tal r

etar

datio

n

117

K30033_C004.indd 117 28/02/17 11:43 am

Paed

iatr

ics

Map

4.8

. N

eura

l tu

be

def

ects

(N

TDs)

Wha

t ar

e ne

ural

tub

e de

fect

s?Th

ese

are

cong

enita

l abn

orm

aliti

es in

the

deve

lopm

ent o

f th

e sp

ine,

spi

nal c

ord

and

brai

n. T

hey

occu

r to

vary

ing

degr

ees

but t

he m

ost c

omm

on is

spi

na b

ifida

, a d

isor

der

in w

hich

the

spin

al c

olum

n do

es n

ot c

ompl

etel

y cl

ose.

Caus

esTh

e ex

act c

ause

of N

TDs

is n

ot k

now

n. H

owev

er,

they

are

ass

ocia

ted

with

tera

toge

ns s

uch

asan

tiepi

lept

ic m

edic

atio

n, m

ater

nal d

iabe

tes

mel

litus

and

hig

h m

ater

nal B

MI.

Com

plic

atio

ns•

Decr

ease

d bl

adde

r con

trol

.•

Incr

ease

d ris

k of

UTI

.•

Decr

ease

d m

obili

ty.

• Le

arni

ng d

iffic

ultie

s.•

Hydr

ocep

halu

s.•

Com

plic

atio

ns o

f sur

gery

and

gen

eral

ana

esth

etic

.

Sym

ptom

sVa

ry d

epen

ding

on

type

of N

TD. A

brie

fou

tline

is p

rovi

ded

belo

w:

• An

ence

phal

y: th

e br

ain

and

cran

ium

fail

to

deve

lop

resu

lting

in fe

tal d

eath

.•

Ence

phal

ocoe

le: a

ka c

rani

um b

ifidu

m. T

his

is a

co

nditi

on w

here

the

brai

n, c

over

ed b

y its

m

enin

ges,

prot

rude

s th

roug

h a

mid

line

cran

ial d

efec

t.•

Spin

a bi

fida:

this

occ

urs

whe

n th

e sp

inal

col

umn

or

vert

ebra

l arc

h fa

ils to

clo

se. T

he s

pina

l col

umn

may

be

teth

ered

, whi

ch le

ads

to p

robl

ems

with

bla

dder

co

ntro

l. O

n ex

amin

atio

n, th

ere

is o

ften

hair

ov

erly

ing

the

defe

ct.

• M

enin

goco

ele:

is a

ssoc

iate

d w

ith s

pina

bifi

da.

Th

e m

enin

ges

prot

rude

thro

ugh

the

defe

ct b

ut it

doe

s

not c

onta

in th

e sp

inal

cor

d.•

Men

ingo

mye

loco

ele:

is a

ssoc

iate

d w

ith s

pina

bifi

da.

Th

e m

enin

ges

and

spin

al c

ord

prot

rude

thro

ugh

the

defe

ct.

Trea

tmen

tDe

pend

s on

the

type

of N

TD.

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Fo

lic a

cid

supp

lem

enta

tion

– hi

gher

dos

e to

mot

hers

at r

isk

(

e.g.

thos

e ta

king

ant

iepi

lept

ic m

edic

atio

n).

• Br

aces

, cru

tche

s an

d ot

her w

alki

ng a

ids

to h

elp

child

’s m

obili

ty.

Med

ical

:•

Trea

tmen

t of s

ympt

oms

(e.g

. UTI

s an

d di

fficu

lty

with

bla

dder

con

trol

).

Surg

ical

:•

Rele

ase

teth

ered

cor

d.•

Shun

ts fo

r hyd

roce

phal

us.

• Cl

osur

e if

spin

al c

ord

expo

sed.

MAP

4.8

. Neu

ral t

ube

defe

cts

(NTD

s)

Inve

stig

atio

ns•

Ante

nata

lly o

n ul

tras

ound

.•

Trip

le m

arke

r tes

t at 1

6–18

wee

ks:

1.

Alp

ha fe

topr

otei

n le

vels

(α-F

P).

2.

Oes

trio

l lev

els

(uE3

).

3. H

uman

cho

rioni

c go

nado

trop

in (h

CG).

Cond

itio

n

Spin

a bi

fida

Anen

ceph

aly

α-FP

uE3

hCG

Nor

mal

Nor

mal

¯¯

118

K30033_C004.indd 118 28/02/17 11:43 am

Paed

iatr

ics

Map

4.8

. N

eura

l tu

be

def

ects

(N

TDs)

Wha

t ar

e ne

ural

tub

e de

fect

s?Th

ese

are

cong

enita

l abn

orm

aliti

es in

the

deve

lopm

ent o

f th

e sp

ine,

spi

nal c

ord

and

brai

n. T

hey

occu

r to

vary

ing

degr

ees

but t

he m

ost c

omm

on is

spi

na b

ifida

, a d

isor

der

in w

hich

the

spin

al c

olum

n do

es n

ot c

ompl

etel

y cl

ose.

Caus

esTh

e ex

act c

ause

of N

TDs

is n

ot k

now

n. H

owev

er,

they

are

ass

ocia

ted

with

tera

toge

ns s

uch

asan

tiepi

lept

ic m

edic

atio

n, m

ater

nal d

iabe

tes

mel

litus

and

hig

h m

ater

nal B

MI.

Com

plic

atio

ns•

Decr

ease

d bl

adde

r con

trol

.•

Incr

ease

d ris

k of

UTI

.•

Decr

ease

d m

obili

ty.

• Le

arni

ng d

iffic

ultie

s.•

Hydr

ocep

halu

s.•

Com

plic

atio

ns o

f sur

gery

and

gen

eral

ana

esth

etic

.

Sym

ptom

sVa

ry d

epen

ding

on

type

of N

TD. A

brie

fou

tline

is p

rovi

ded

belo

w:

• An

ence

phal

y: th

e br

ain

and

cran

ium

fail

to

deve

lop

resu

lting

in fe

tal d

eath

.•

Ence

phal

ocoe

le: a

ka c

rani

um b

ifidu

m. T

his

is a

co

nditi

on w

here

the

brai

n, c

over

ed b

y its

m

enin

ges,

prot

rude

s th

roug

h a

mid

line

cran

ial d

efec

t.•

Spin

a bi

fida:

this

occ

urs

whe

n th

e sp

inal

col

umn

or

vert

ebra

l arc

h fa

ils to

clo

se. T

he s

pina

l col

umn

may

be

teth

ered

, whi

ch le

ads

to p

robl

ems

with

bla

dder

co

ntro

l. O

n ex

amin

atio

n, th

ere

is o

ften

hair

ov

erly

ing

the

defe

ct.

• M

enin

goco

ele:

is a

ssoc

iate

d w

ith s

pina

bifi

da.

Th

e m

enin

ges

prot

rude

thro

ugh

the

defe

ct b

ut it

doe

s

not c

onta

in th

e sp

inal

cor

d.•

Men

ingo

mye

loco

ele:

is a

ssoc

iate

d w

ith s

pina

bifi

da.

Th

e m

enin

ges

and

spin

al c

ord

prot

rude

thro

ugh

the

defe

ct.

Trea

tmen

tDe

pend

s on

the

type

of N

TD.

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Fo

lic a

cid

supp

lem

enta

tion

– hi

gher

dos

e to

mot

hers

at r

isk

(

e.g.

thos

e ta

king

ant

iepi

lept

ic m

edic

atio

n).

• Br

aces

, cru

tche

s an

d ot

her w

alki

ng a

ids

to h

elp

child

’s m

obili

ty.

Med

ical

:•

Trea

tmen

t of s

ympt

oms

(e.g

. UTI

s an

d di

fficu

lty

with

bla

dder

con

trol

).

Surg

ical

:•

Rele

ase

teth

ered

cor

d.•

Shun

ts fo

r hyd

roce

phal

us.

• Cl

osur

e if

spin

al c

ord

expo

sed.

MAP

4.8

. Neu

ral t

ube

defe

cts

(NTD

s)

Inve

stig

atio

ns•

Ante

nata

lly o

n ul

tras

ound

.•

Trip

le m

arke

r tes

t at 1

6–18

wee

ks:

1.

Alp

ha fe

topr

otei

n le

vels

(α-F

P).

2.

Oes

trio

l lev

els

(uE3

).

3. H

uman

cho

rioni

c go

nado

trop

in (h

CG).

Cond

itio

n

Spin

a bi

fida

Anen

ceph

aly

α-FP

uE3

hCG

Nor

mal

Nor

mal

¯¯

119

K30033_C004.indd 119 28/02/17 11:43 am

Paed

iatr

ics

Map

4.9

. C

ereb

ral p

alsy

Wha

t is

cer

ebra

l pal

sy?

This

is a

non

-pro

gres

sive

insu

lt th

at o

ccur

s on

the

deve

lopi

ng b

rain

. It r

esul

ts in

a d

isor

der o

f mov

emen

tan

d po

stur

e as

wel

l as

othe

r neu

rolo

gica

l com

plai

nts

such

as e

pile

psy,

depe

ndin

g on

the

loca

tion

of th

e le

sion

.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

cer

ebra

l pal

syin

clud

ing:

• In

fect

ion

– m

enin

gitis

and

TORC

HES.

• Tr

aum

a –

in e

arly

chi

ldho

od y

ears

or a

t birt

h.•

Hypo

xia.

• Pr

emat

urity

– in

crea

ses

risk.

• Va

scul

ar m

alfo

rmat

ion

(e.g

. art

erio

veno

us

mal

form

atio

ns, s

trok

e).

• Tu

mou

rs.

Inve

stig

atio

nsG

ener

ally

this

is a

clin

ical

dia

gnos

is, b

ut id

entif

ying

the

caus

e m

ay b

e ai

ded

byra

diol

ogic

al in

vest

igat

ion

such

as

CT a

nd M

RI. I

t is

also

impo

rtan

t to

perfo

rm a

n au

diol

ogic

al a

sses

smen

t as

wel

l as

an o

phth

alm

olog

ical

eva

luat

ion.

Com

plic

atio

ns•

Ort

hopa

edic

com

plic

atio

ns: m

uscl

e sh

orte

ning

, abn

orm

al p

ostu

ring.

• N

euro

logi

cal c

ompl

icat

ions

: epi

leps

y.•

Resp

irato

ry c

ompl

icat

ions

: asp

iratio

n pn

eum

onia

, res

tric

tive

lung

dis

ease

.•

Gas

troi

ntes

tinal

com

plic

atio

ns: g

astr

o-oe

soph

agea

l ref

lux

dise

ase,

con

stip

atio

n.•

Urin

ary

com

plic

atio

ns: U

TI, b

ladd

er c

ontr

ol is

sues

.•

Derm

atol

ogic

al c

ompl

icat

ions

: dec

ubitu

s ul

cers

.•

Psyc

holo

gica

l com

plic

atio

ns: d

epre

ssio

n.•

Slee

p di

sord

ers.

• Le

arni

ng d

iffic

ultie

s.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt a

nd p

atie

nt e

duca

tion.

• Ac

cess

to s

uppo

rt s

ervi

ces.

Med

ical

:•

Man

age

com

plic

atio

ns.

• An

tiepi

lept

ic m

edic

atio

n.•

Oth

ers

such

as

benz

odia

zepi

nes

and

bacl

ofen

may

be

r

equi

red.

Surg

ical

:•

Mus

cle

leng

then

ing.

• O

rtho

paed

ic s

urge

ry (e

.g. s

pina

l fus

ion)

.•

Sele

ctiv

e do

rsal

rhiz

otom

y.

MAP

4.9

. Cer

ebra

l pal

sy

Sym

ptom

sTh

e sy

mpt

oms

depe

nd o

n th

e su

btyp

e of

cer

ebra

l pal

sy (r

emem

ber a

s SA

D).

Split

sym

ptom

s in

to:

1. M

otor

abn

orm

ality

.

Subt

ype

Not

es

Ata

xic

Dys

kine

tic

Spas

tic

Abno

rmal

sen

se o

f bod

y in

spa

ce

Mos

t com

mon

~80

%Sc

isso

ring

post

ure

sinc

e fle

xors

, add

ucto

rs a

nd in

tern

alro

tato

rs a

re la

rgel

y af

fect

edPa

tient

may

pre

sent

with

dip

legi

a, h

emip

legi

a or

quad

riple

gia

Abno

rmal

, inv

olun

tary

pos

turin

g

2. L

earn

ing

diffi

culti

es.

3. N

euro

logi

cal a

bnor

mal

ities

: pat

ient

s m

ay s

uffe

r with

epi

leps

y.4.

Beh

avio

ural

abn

orm

aliti

es: d

isor

dere

d sl

eep

and

self-

inju

rious

beh

avio

ur.

5. S

enso

ry im

pairm

ent:

visu

al im

pairm

ent i

nclu

ding

refra

ctor

y er

rors

as

wel

l as

stra

bism

us.

I

ncre

ased

risk

of d

eafn

ess.

Esse

ntia

l to

scre

en fo

r bot

h.6.

Pse

udob

ulba

r pal

sy: p

rese

nt in

som

e pa

tient

s. Af

fect

s sp

eech

and

sw

allo

win

g.

120

K30033_C004.indd 120 28/02/17 11:43 am

Paed

iatr

ics

Map

4.9

. C

ereb

ral p

alsy

Wha

t is

cer

ebra

l pal

sy?

This

is a

non

-pro

gres

sive

insu

lt th

at o

ccur

s on

the

deve

lopi

ng b

rain

. It r

esul

ts in

a d

isor

der o

f mov

emen

tan

d po

stur

e as

wel

l as

othe

r neu

rolo

gica

l com

plai

nts

such

as e

pile

psy,

depe

ndin

g on

the

loca

tion

of th

e le

sion

.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

cer

ebra

l pal

syin

clud

ing:

• In

fect

ion

– m

enin

gitis

and

TORC

HES.

• Tr

aum

a –

in e

arly

chi

ldho

od y

ears

or a

t birt

h.•

Hypo

xia.

• Pr

emat

urity

– in

crea

ses

risk.

• Va

scul

ar m

alfo

rmat

ion

(e.g

. art

erio

veno

us

mal

form

atio

ns, s

trok

e).

• Tu

mou

rs.

Inve

stig

atio

nsG

ener

ally

this

is a

clin

ical

dia

gnos

is, b

ut id

entif

ying

the

caus

e m

ay b

e ai

ded

byra

diol

ogic

al in

vest

igat

ion

such

as

CT a

nd M

RI. I

t is

also

impo

rtan

t to

perfo

rm a

n au

diol

ogic

al a

sses

smen

t as

wel

l as

an o

phth

alm

olog

ical

eva

luat

ion.

Com

plic

atio

ns•

Ort

hopa

edic

com

plic

atio

ns: m

uscl

e sh

orte

ning

, abn

orm

al p

ostu

ring.

• N

euro

logi

cal c

ompl

icat

ions

: epi

leps

y.•

Resp

irato

ry c

ompl

icat

ions

: asp

iratio

n pn

eum

onia

, res

tric

tive

lung

dis

ease

.•

Gas

troi

ntes

tinal

com

plic

atio

ns: g

astr

o-oe

soph

agea

l ref

lux

dise

ase,

con

stip

atio

n.•

Urin

ary

com

plic

atio

ns: U

TI, b

ladd

er c

ontr

ol is

sues

.•

Derm

atol

ogic

al c

ompl

icat

ions

: dec

ubitu

s ul

cers

.•

Psyc

holo

gica

l com

plic

atio

ns: d

epre

ssio

n.•

Slee

p di

sord

ers.

• Le

arni

ng d

iffic

ultie

s.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt a

nd p

atie

nt e

duca

tion.

• Ac

cess

to s

uppo

rt s

ervi

ces.

Med

ical

:•

Man

age

com

plic

atio

ns.

• An

tiepi

lept

ic m

edic

atio

n.•

Oth

ers

such

as

benz

odia

zepi

nes

and

bacl

ofen

may

be

r

equi

red.

Surg

ical

:•

Mus

cle

leng

then

ing.

• O

rtho

paed

ic s

urge

ry (e

.g. s

pina

l fus

ion)

.•

Sele

ctiv

e do

rsal

rhiz

otom

y.

MAP

4.9

. Cer

ebra

l pal

sy

Sym

ptom

sTh

e sy

mpt

oms

depe

nd o

n th

e su

btyp

e of

cer

ebra

l pal

sy (r

emem

ber a

s SA

D).

Split

sym

ptom

s in

to:

1. M

otor

abn

orm

ality

.

Subt

ype

Not

es

Ata

xic

Dys

kine

tic

Spas

tic

Abno

rmal

sen

se o

f bod

y in

spa

ce

Mos

t com

mon

~80

%Sc

isso

ring

post

ure

sinc

e fle

xors

, add

ucto

rs a

nd in

tern

alro

tato

rs a

re la

rgel

y af

fect

edPa

tient

may

pre

sent

with

dip

legi

a, h

emip

legi

a or

quad

riple

gia

Abno

rmal

, inv

olun

tary

pos

turin

g

2. L

earn

ing

diffi

culti

es.

3. N

euro

logi

cal a

bnor

mal

ities

: pat

ient

s m

ay s

uffe

r with

epi

leps

y.4.

Beh

avio

ural

abn

orm

aliti

es: d

isor

dere

d sl

eep

and

self-

inju

rious

beh

avio

ur.

5. S

enso

ry im

pairm

ent:

visu

al im

pairm

ent i

nclu

ding

refra

ctor

y er

rors

as

wel

l as

stra

bism

us.

I

ncre

ased

risk

of d

eafn

ess.

Esse

ntia

l to

scre

en fo

r bot

h.6.

Pse

udob

ulba

r pal

sy: p

rese

nt in

som

e pa

tient

s. Af

fect

s sp

eech

and

sw

allo

win

g.

121

K30033_C004.indd 121 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

0. M

enin

git

is

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Let

harg

y.

Cry

ing.

O

ff fe

eds.

• S

igns

of i

ncre

ased

intr

acra

nial

pre

ssur

e:

Dec

reas

ed le

vel o

f con

scio

usne

ss.

P

apill

oede

ma.

H

eada

che.

• S

peci

fic s

igns

:

Pur

puric

non

-bla

nchi

ng ra

sh (N

eiss

eria

m

enin

gitid

is).

N

eck

stiff

ness

.

Ker

nig’

s si

gn.

F

ocal

neu

rolo

gica

l sig

ns (e

.g. c

rani

al

n

erve

invo

lvem

ent).

Inve

stig

atio

ns•

Blo

od te

sts:

FBC

, WCC

, U&

E, L

FTs,

glu

cose

,

gro

up a

nd s

ave,

clo

ttin

g st

udie

s, b

lood

cul

ture

s an

d PC

R fo

r N. m

enin

gitid

is.

• G

ener

al in

vest

igat

ions

: thr

oat s

wab

,

urin

alys

is m

icro

scop

y an

d cu

lture

,

sto

ol s

ampl

e.•

Lum

bar p

unct

ure:

con

trai

ndic

ated

if ra

ised

i

ntra

cran

ial p

ress

ure

or m

enin

goco

ccal

s

eptic

aem

ia. V

alue

s sh

own

belo

w. P

CR

req

uire

d fo

r vira

l dia

gnos

is.

Org

anis

mW

CCPr

otei

nG

luco

se

Bact

eria

lN

eutr

ophi

ls

Vira

lLy

mph

ocyt

esN

orm

alN

orm

al

¯

• R

adio

logy

: CT

if in

dica

ted.

Com

plic

atio

nsM

enin

gitis

cau

ses

seve

ral c

ompl

icat

ions

.So

me

are

liste

d be

low

.Re

mem

ber a

s th

e 5C

s:C

– Ce

rebr

al p

alsy

C –

Conv

ulsi

ons

C –

Circ

ulat

ory

shoc

kC

– Ce

rebr

al a

bsce

ssC

– Cr

ania

l ner

ve p

alsi

es

Trea

tmen

t

Cons

erva

tive

:•

Par

ent e

duca

tion.

• C

onta

ct p

ublic

hea

lth c

onsu

ltant

sin

ce it

is a

n

otifi

able

dis

ease

.

Med

ical

:•

GP

may

giv

e IM

ben

zylp

enic

illin

in th

eir

pr

actic

e to

pre

vent

del

ay.

• I

V an

tibio

tics

depe

nd o

n ag

e:

<3

mon

ths:

am

oxic

illin

and

cef

otax

ime.

>

3 m

onth

s: c

efot

axim

e.•

Dex

amet

haso

ne if

>1

mon

th a

nd c

ausa

tive

or

gani

sm is

Hae

mop

hilu

s in

fluen

zae.

• A

ntib

iotic

pro

phyl

axis

for c

lose

men

ingo

cocc

al c

onta

cts

with

rifa

mpi

cin.MAP

4.10

. Men

ingi

tis

Wha

t is

men

ingi

tis?

This

is a

n in

fect

ion

of th

e su

bara

chno

id s

pace

by

an o

rgan

ism

that

sub

sequ

ently

cau

ses

infla

mm

atio

n of

the

men

inge

s.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

men

ingi

tis(s

ee b

elow

).

Cate

gory

Age

aff

ecte

dO

rgan

ism

s

Gro

up B

st

rept

ococ

cus

Esch

eric

hia

coli

List

eria

m

onoc

ytog

enes

Nei

sser

ia

men

ingi

tidis

Stre

ptoc

occu

spn

eum

onia

eHa

emop

hilu

s in

fluen

zae

type

B

Nei

sser

ia

men

ingi

tidis

Stre

ptoc

occu

s pn

eum

onia

eM

umps

Myc

obac

teriu

mtu

berc

ulos

is

Ente

rovi

rus

Cyto

meg

alov

irus

Arbo

viru

s

Any

age

Any

age

Ove

r6

year

s

1 m

onth

to6

year

s

Neo

nate

to2

mon

ths

Bact

eria

l

Vira

l

Risk

fact

ors:

rem

embe

r as

ABC

S:

A –

Age

(you

ng)

B

– Be

ing

of lo

w s

ocio

econ

omic

sta

tus

C

– Co

mpl

emen

t def

ects

S

– Si

ckle

cel

l dis

ease

122

K30033_C004.indd 122 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

0. M

enin

git

is

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Let

harg

y.

Cry

ing.

O

ff fe

eds.

• S

igns

of i

ncre

ased

intr

acra

nial

pre

ssur

e:

Dec

reas

ed le

vel o

f con

scio

usne

ss.

P

apill

oede

ma.

H

eada

che.

• S

peci

fic s

igns

:

Pur

puric

non

-bla

nchi

ng ra

sh (N

eiss

eria

m

enin

gitid

is).

N

eck

stiff

ness

.

Ker

nig’

s si

gn.

F

ocal

neu

rolo

gica

l sig

ns (e

.g. c

rani

al

n

erve

invo

lvem

ent).

Inve

stig

atio

ns•

Blo

od te

sts:

FBC

, WCC

, U&

E, L

FTs,

glu

cose

,

gro

up a

nd s

ave,

clo

ttin

g st

udie

s, b

lood

cul

ture

s an

d PC

R fo

r N. m

enin

gitid

is.

• G

ener

al in

vest

igat

ions

: thr

oat s

wab

,

urin

alys

is m

icro

scop

y an

d cu

lture

,

sto

ol s

ampl

e.•

Lum

bar p

unct

ure:

con

trai

ndic

ated

if ra

ised

i

ntra

cran

ial p

ress

ure

or m

enin

goco

ccal

s

eptic

aem

ia. V

alue

s sh

own

belo

w. P

CR

req

uire

d fo

r vira

l dia

gnos

is.

Org

anis

mW

CCPr

otei

nG

luco

se

Bact

eria

lN

eutr

ophi

ls

Vira

lLy

mph

ocyt

esN

orm

alN

orm

al

¯

• R

adio

logy

: CT

if in

dica

ted.

Com

plic

atio

nsM

enin

gitis

cau

ses

seve

ral c

ompl

icat

ions

.So

me

are

liste

d be

low

.Re

mem

ber a

s th

e 5C

s:C

– Ce

rebr

al p

alsy

C –

Conv

ulsi

ons

C –

Circ

ulat

ory

shoc

kC

– Ce

rebr

al a

bsce

ssC

– Cr

ania

l ner

ve p

alsi

es

Trea

tmen

t

Cons

erva

tive

:•

Par

ent e

duca

tion.

• C

onta

ct p

ublic

hea

lth c

onsu

ltant

sin

ce it

is a

n

otifi

able

dis

ease

.

Med

ical

:•

GP

may

giv

e IM

ben

zylp

enic

illin

in th

eir

pr

actic

e to

pre

vent

del

ay.

• I

V an

tibio

tics

depe

nd o

n ag

e:

<3

mon

ths:

am

oxic

illin

and

cef

otax

ime.

>

3 m

onth

s: c

efot

axim

e.•

Dex

amet

haso

ne if

>1

mon

th a

nd c

ausa

tive

or

gani

sm is

Hae

mop

hilu

s in

fluen

zae.

• A

ntib

iotic

pro

phyl

axis

for c

lose

men

ingo

cocc

al c

onta

cts

with

rifa

mpi

cin.MAP

4.10

. Men

ingi

tis

Wha

t is

men

ingi

tis?

This

is a

n in

fect

ion

of th

e su

bara

chno

id s

pace

by

an o

rgan

ism

that

sub

sequ

ently

cau

ses

infla

mm

atio

n of

the

men

inge

s.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

men

ingi

tis(s

ee b

elow

).

Cate

gory

Age

aff

ecte

dO

rgan

ism

s

Gro

up B

st

rept

ococ

cus

Esch

eric

hia

coli

List

eria

m

onoc

ytog

enes

Nei

sser

ia

men

ingi

tidis

Stre

ptoc

occu

spn

eum

onia

eHa

emop

hilu

s in

fluen

zae

type

B

Nei

sser

ia

men

ingi

tidis

Stre

ptoc

occu

s pn

eum

onia

eM

umps

Myc

obac

teriu

mtu

berc

ulos

is

Ente

rovi

rus

Cyto

meg

alov

irus

Arbo

viru

s

Any

age

Any

age

Ove

r6

year

s

1 m

onth

to6

year

s

Neo

nate

to2

mon

ths

Bact

eria

l

Vira

l

Risk

fact

ors:

rem

embe

r as

ABC

S:

A –

Age

(you

ng)

B

– Be

ing

of lo

w s

ocio

econ

omic

sta

tus

C

– Co

mpl

emen

t def

ects

S

– Si

ckle

cel

l dis

ease

123

K30033_C004.indd 123 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

1. F

ailu

re t

o t

hri

ve

Wha

t is

failu

re t

o th

rive

?Th

is is

whe

n th

e ch

ild’s

wei

ght o

r rat

e of

wei

ght g

ain

is s

igni

fican

tly le

ss

than

thei

r ide

ntic

ally

mat

ched

pee

rs.

Caus

esTh

ere

are

man

y ca

uses

of f

ailu

re to

thriv

e, w

hich

may

be

cong

enita

l or

acqu

ired.

Som

e ar

e ca

tego

rized

bel

ow:

• N

ot e

noug

h di

etar

y in

take

:

Ab

use

and

negl

ect.

Anor

exia

ner

vosa

.

Po

or p

aren

tal d

ieta

ry u

nder

stan

ding

.•

Diffi

culty

feed

ing:

Clef

t pal

ate.

Oes

opha

geal

atr

esia

/trac

heo-

oeso

phag

eal a

tres

ia.

Neu

rolo

gica

l dis

orde

rs (e

.g. c

ereb

ral p

alsy

).•

Mal

abso

rptio

n:

Co

elia

c di

seas

e.

In

flam

mat

ory

bow

el d

isea

se (I

BD).

Lact

ose

into

lera

nce.

• Ch

roni

c di

seas

e:

Cy

stic

fibr

osis.

Asth

ma.

Gro

wth

hor

mon

e de

ficie

ncy.

Hypo

thyr

oidi

sm.

• Ch

rom

osom

al a

bnor

mal

ities

:

Tu

rner

syn

drom

e.•

Gen

etic

abn

orm

aliti

es:

Acho

ndro

plas

ia.

Inbo

rn e

rror

s of

met

abol

ism

.

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Le

thar

gy.

Decr

ease

d w

eigh

t.

O

ff fe

eds.

• Si

gns

and

sym

ptom

s of

und

erly

ing

dise

ase

(see

bel

ow):

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

TFTs

, glu

cose

.•

Urin

alys

is.•

Stoo

l mic

rosc

opy

and

cultu

re.

• Sp

ecifi

c te

st (e

.g. s

wea

t tes

t for

cys

tic fi

bros

is,

endo

mes

ial a

nd g

liadi

n an

tibod

ies

for c

oelia

c

dise

ase)

.•

Chro

mos

omal

ana

lysi

s if

indi

cate

d.•

Radi

olog

y: m

ay b

e re

quire

d in

cer

tain

ci

rcum

stan

ces

(e.g

. cer

ebra

l pal

sy m

ay re

quire

CT

or M

RI).

Com

plic

atio

ns•

Psyc

holo

gica

l iss

ues

(e.g

. dep

ress

ion)

.•

Decr

ease

d gr

owth

.•

Deve

lopm

enta

l del

ay.

• Sp

ecifi

c pr

oble

ms

rela

ted

to c

ause

.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• In

volv

e so

cial

wor

kers

if n

eces

sary

.•

Ensu

re c

hild

has

an

appr

opria

te d

iet a

nd is

re

ceiv

ing

the

nece

ssar

y ca

lorie

s.

Med

ical

:•

Trea

t the

und

erly

ing

caus

e.

Surg

ical

:•

If in

dica

ted.

MAP

4.1

1. F

ailu

re t

o th

rive

Cond

itio

nN

otes

Anor

exia

ner

vosa

Cere

bral

pal

sy

Abus

e

Cyst

ic fi

bros

is

Asth

ma

See

Map

1.6

(p. 2

2)

See

Map

4.9

(p. 1

20)

See

Map

4.1

4 (p

. 130

)

See

Map

4.1

5 (p

. 132

)

Brui

sing

of v

aryi

ng a

ge. C

hang

ing

hist

ory

not i

n ke

epin

g w

ith in

jurie

s

Hypo

thyr

oidi

smCo

ld in

tole

ranc

e, c

onst

ipat

ion,

dry

ski

n/ha

ir,hy

pore

flexi

a, b

rady

card

ia

Acho

ndro

plas

iaAu

toso

mal

dom

inan

t inh

erita

nce.

A c

ause

of

dwar

fism

. Due

to m

utat

ion

of fi

brob

last

grow

th fa

ctor

rece

ptor

3 (F

GFR

3)

Coel

iac

dise

ase

Prox

imal

sm

all i

ntes

tine

mai

nly

affe

cted

.As

soci

ated

with

oth

er a

utoi

mm

une

cond

ition

san

d de

rmat

itis

herp

etifo

rmis

124

K30033_C004.indd 124 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

1. F

ailu

re t

o t

hri

ve

Wha

t is

failu

re t

o th

rive

?Th

is is

whe

n th

e ch

ild’s

wei

ght o

r rat

e of

wei

ght g

ain

is s

igni

fican

tly le

ss

than

thei

r ide

ntic

ally

mat

ched

pee

rs.

Caus

esTh

ere

are

man

y ca

uses

of f

ailu

re to

thriv

e, w

hich

may

be

cong

enita

l or

acqu

ired.

Som

e ar

e ca

tego

rized

bel

ow:

• N

ot e

noug

h di

etar

y in

take

:

Ab

use

and

negl

ect.

Anor

exia

ner

vosa

.

Po

or p

aren

tal d

ieta

ry u

nder

stan

ding

.•

Diffi

culty

feed

ing:

Clef

t pal

ate.

Oes

opha

geal

atr

esia

/trac

heo-

oeso

phag

eal a

tres

ia.

Neu

rolo

gica

l dis

orde

rs (e

.g. c

ereb

ral p

alsy

).•

Mal

abso

rptio

n:

Co

elia

c di

seas

e.

In

flam

mat

ory

bow

el d

isea

se (I

BD).

Lact

ose

into

lera

nce.

• Ch

roni

c di

seas

e:

Cy

stic

fibr

osis.

Asth

ma.

Gro

wth

hor

mon

e de

ficie

ncy.

Hypo

thyr

oidi

sm.

• Ch

rom

osom

al a

bnor

mal

ities

:

Tu

rner

syn

drom

e.•

Gen

etic

abn

orm

aliti

es:

Acho

ndro

plas

ia.

Inbo

rn e

rror

s of

met

abol

ism

.

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Le

thar

gy.

Decr

ease

d w

eigh

t.

O

ff fe

eds.

• Si

gns

and

sym

ptom

s of

und

erly

ing

dise

ase

(see

bel

ow):

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

TFTs

, glu

cose

.•

Urin

alys

is.•

Stoo

l mic

rosc

opy

and

cultu

re.

• Sp

ecifi

c te

st (e

.g. s

wea

t tes

t for

cys

tic fi

bros

is,

endo

mes

ial a

nd g

liadi

n an

tibod

ies

for c

oelia

c

dise

ase)

.•

Chro

mos

omal

ana

lysi

s if

indi

cate

d.•

Radi

olog

y: m

ay b

e re

quire

d in

cer

tain

ci

rcum

stan

ces

(e.g

. cer

ebra

l pal

sy m

ay re

quire

CT

or M

RI).

Com

plic

atio

ns•

Psyc

holo

gica

l iss

ues

(e.g

. dep

ress

ion)

.•

Decr

ease

d gr

owth

.•

Deve

lopm

enta

l del

ay.

• Sp

ecifi

c pr

oble

ms

rela

ted

to c

ause

.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• In

volv

e so

cial

wor

kers

if n

eces

sary

.•

Ensu

re c

hild

has

an

appr

opria

te d

iet a

nd is

re

ceiv

ing

the

nece

ssar

y ca

lorie

s.

Med

ical

:•

Trea

t the

und

erly

ing

caus

e.

Surg

ical

:•

If in

dica

ted.

MAP

4.1

1. F

ailu

re t

o th

rive

Cond

itio

nN

otes

Anor

exia

ner

vosa

Cere

bral

pal

sy

Abus

e

Cyst

ic fi

bros

is

Asth

ma

See

Map

1.6

(p. 2

2)

See

Map

4.9

(p. 1

20)

See

Map

4.1

4 (p

. 130

)

See

Map

4.1

5 (p

. 132

)

Brui

sing

of v

aryi

ng a

ge. C

hang

ing

hist

ory

not i

n ke

epin

g w

ith in

jurie

s

Hypo

thyr

oidi

smCo

ld in

tole

ranc

e, c

onst

ipat

ion,

dry

ski

n/ha

ir,hy

pore

flexi

a, b

rady

card

ia

Acho

ndro

plas

iaAu

toso

mal

dom

inan

t inh

erita

nce.

A c

ause

of

dwar

fism

. Due

to m

utat

ion

of fi

brob

last

grow

th fa

ctor

rece

ptor

3 (F

GFR

3)

Coel

iac

dise

ase

Prox

imal

sm

all i

ntes

tine

mai

nly

affe

cted

.As

soci

ated

with

oth

er a

utoi

mm

une

cond

ition

san

d de

rmat

itis

herp

etifo

rmis

125

K30033_C004.indd 125 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

2. B

ron

chio

litis

MAP

4.1

2.Br

onch

iolit

is

Wha

t is

bro

nchi

olit

is?

This

is a

low

er re

spira

tory

trac

t inf

ectio

n th

at is

ch

arac

teriz

ed b

y pr

ogre

ssiv

e sy

mpt

oms

from

co

ryza

to a

per

sist

ent c

ough

, bre

athl

essn

ess

and

poss

ible

resp

irato

ry d

istr

ess.

This

con

ditio

n of

ten

affe

cts

child

ren

<1

year

of a

ge s

ince

thei

r airw

ays

are

so n

arro

w.

Caus

esRe

mem

ber a

s RI

P:R

– Re

spira

tory

syn

cytia

l viru

s (m

ost c

omm

on

cau

se)

I –

Influ

enza

P –

Para

influ

enza

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

• Hi

gh-r

isk

infa

nts

may

requ

ire p

roph

ylac

tic

paliv

izum

ab (e

.g. i

nfan

ts w

ho a

re p

rem

atur

e or

ha

ve c

onge

nita

l hea

rt d

efec

ts).

Med

ical

:•

Hum

idifi

ed o

xyge

n de

liver

ed v

ia a

nas

al

cann

ula.

• Ve

ntila

tion

requ

ired

if sy

mpt

oms

are

seve

re.

• Br

onch

odila

tors

may

be

used

but

thei

r ben

efit

is

unp

rove

n.

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Br

eath

less

ness

.

Pe

rsis

tent

cou

gh.

Leth

argy

.

O

ff fe

eds.

• Si

gns

of re

spira

tory

dep

ress

ion:

Nas

al fl

arin

g.

Su

bcos

tal a

nd in

terc

osta

l rec

essi

on.

Low

Gla

scow

Com

a Sc

ale

scor

e.

Cy

anos

is.•

Sign

s of

hyp

erin

flatio

n:

Do

wnw

ard

disp

lace

men

t of l

iver

.•

On

ausc

ulta

tion:

Expi

rato

ry w

heez

e.

Fi

ne e

nd in

spira

tory

cra

ckle

s.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs.

• Ca

pilla

ry b

lood

gas

.•

Spec

ific

test

s: na

sal a

spira

tes

with

imm

uno-

flu

ores

cent

sta

inin

g fo

r res

pira

tory

syn

cytia

l viru

s.•

Radi

olog

y: c

hest

x-r

ay

Com

plic

atio

ns•

Vent

ilatio

n m

ay b

e re

quire

d (th

is m

ay

inc

reas

e th

e ris

k of

pne

umon

ia).

• Re

spira

tory

failu

re.

• Ca

rdia

c fa

ilure

.•

Pneu

mot

hora

x.

126

K30033_C004.indd 126 28/02/17 11:43 am

Paed

iatr

ics

MAP

4.1

2.Br

onch

iolit

is

Wha

t is

bro

nchi

olit

is?

This

is a

low

er re

spira

tory

trac

t inf

ectio

n th

at is

ch

arac

teriz

ed b

y pr

ogre

ssiv

e sy

mpt

oms

from

co

ryza

to a

per

sist

ent c

ough

, bre

athl

essn

ess

and

poss

ible

resp

irato

ry d

istr

ess.

This

con

ditio

n of

ten

affe

cts

child

ren

<1

year

of a

ge s

ince

thei

r airw

ays

are

so n

arro

w.

Caus

esRe

mem

ber a

s RI

P:R

– Re

spira

tory

syn

cytia

l viru

s (m

ost c

omm

on

cau

se)

I –

Influ

enza

P –

Para

influ

enza

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

• Hi

gh-r

isk

infa

nts

may

requ

ire p

roph

ylac

tic

paliv

izum

ab (e

.g. i

nfan

ts w

ho a

re p

rem

atur

e or

ha

ve c

onge

nita

l hea

rt d

efec

ts).

Med

ical

:•

Hum

idifi

ed o

xyge

n de

liver

ed v

ia a

nas

al

cann

ula.

• Ve

ntila

tion

requ

ired

if sy

mpt

oms

are

seve

re.

• Br

onch

odila

tors

may

be

used

but

thei

r ben

efit

is

unp

rove

n.

Sym

ptom

s•

Gen

eral

sym

ptom

s:

Br

eath

less

ness

.

Pe

rsis

tent

cou

gh.

Leth

argy

.

O

ff fe

eds.

• Si

gns

of re

spira

tory

dep

ress

ion:

Nas

al fl

arin

g.

Su

bcos

tal a

nd in

terc

osta

l rec

essi

on.

Low

Gla

scow

Com

a Sc

ale

scor

e.

Cy

anos

is.•

Sign

s of

hyp

erin

flatio

n:

Do

wnw

ard

disp

lace

men

t of l

iver

.•

On

ausc

ulta

tion:

Expi

rato

ry w

heez

e.

Fi

ne e

nd in

spira

tory

cra

ckle

s.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs.

• Ca

pilla

ry b

lood

gas

.•

Spec

ific

test

s: na

sal a

spira

tes

with

imm

uno-

flu

ores

cent

sta

inin

g fo

r res

pira

tory

syn

cytia

l viru

s.•

Radi

olog

y: c

hest

x-r

ay

Com

plic

atio

ns•

Vent

ilatio

n m

ay b

e re

quire

d (th

is m

ay

inc

reas

e th

e ris

k of

pne

umon

ia).

• Re

spira

tory

failu

re.

• Ca

rdia

c fa

ilure

.•

Pneu

mot

hora

x. Map

4.1

2. B

ron

chio

litis

127

K30033_C004.indd 127 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

3. C

rou

p

Wha

t is

cro

up?

This

is a

vira

l inf

ectio

n th

at c

ause

spr

ogre

ssiv

e in

flam

mat

ion

of th

ere

spira

tory

trac

t com

men

cing

with

the

lary

nx a

nd s

prea

ding

dist

ally

to th

e br

onch

i. Th

is is

why

it is

als

o kn

own

as a

cute

lary

ngot

rach

eobr

onch

itis.

Tend

sto

affe

ct c

hild

ren

aged

6 m

onth

sto

6 y

ears

.

Caus

esRe

mem

ber a

s RI

P:R

– Re

spira

tory

syn

cytia

l viru

sI

– In

fluen

zaP

– Pa

rain

fluen

za (m

ost

c

omm

on c

ause

)

Com

plic

atio

ns•

Deat

h.•

Trac

heiti

s.•

Pneu

mon

ia.

Sym

ptom

sTe

nd to

be

wor

se a

t nig

ht

• G

ener

al s

ympt

oms:

Br

eath

less

ness

.

Pers

iste

nt c

ough

.

Leth

argy

.

Off

feed

s.•

Typi

cal f

eatu

res:

wor

sen

with

pr

ogre

ssio

n of

infla

mm

atio

n:

Cory

za +

/– fe

ver (

prod

rom

e).

‘B

arki

ng’ c

ough

.

Hoar

sene

ss.

St

ridor

.•

Sign

s of

res

pira

tory

dep

ress

ion:

N

asal

flar

ing.

Su

bcos

tal a

nd in

terc

osta

l rec

essi

on.

Lo

w G

lasc

ow C

oma

Scal

e sc

ore.

Cy

anos

is.•

On

ausc

ulta

tion

:

St

ridor

– h

eard

in m

oder

ated

crou

p w

ith a

ste

thos

cope

. It i

s po

ssib

le

to

hea

r str

idor

with

out a

ste

thos

cope

in s

ever

e ca

ses. M

AP 4

.13.

Cro

up

Inve

stig

atio

ns•

Bloo

d te

sts

and

an e

xam

inat

ion

of th

e ch

ild’s

th

roat

is u

sual

ly n

ot u

nder

take

n si

nce

this

may

di

stre

ss th

e ch

ild a

nd in

adve

rten

tly c

lose

thei

r

airw

ay, l

eadi

ng to

an

emer

genc

y si

tuat

ion

in

whi

ch in

vasi

ve a

cces

s to

the

airw

ay m

ust b

e

esta

blis

hed.

• He

art r

ate,

resp

irato

ry ra

te a

nd o

xyge

n sa

tura

tion.

• As

sess

sev

erity

usi

ng th

e W

estle

y Cr

oup

Scor

e:

Cate

gory

Wes

tley

scor

eFe

atur

es

Mild

Mod

erat

e

Seve

re

0–2

3–5

6–11

Freq

uent

cou

gh.

Mar

ked

strid

or. M

arke

dst

erna

l wal

l ret

ract

ion.

Resp

irato

ry d

istr

ess

Freq

uent

cou

gh. S

trid

or.

Ster

nal w

all r

etra

ctio

n at

rest

Occ

asio

nal c

ough

. No

strid

or.

No

sign

s of

resp

irato

ryde

pres

sion

Trea

tmen

tDe

pend

s on

the

seve

rity

of c

roup

.

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

Med

ical

:

Mild

Mos

t may

be

man

aged

at h

ome

with

par

acet

amol

,ne

w g

uida

nce

reco

mm

ends

giv

ing

a si

ngle

dos

e of

ora

lde

xam

etha

sone

to a

ll ch

ildre

n re

gard

less

of s

ever

ity.

Seve

re

Mod

erat

e

1. S

tero

ids,

e.g.

:- O

ral d

exam

etha

sone

or p

redn

isol

one

- Neb

uliz

ed b

udes

onid

e2.

Neb

uliz

ed a

dren

alin

e (5

mL

of 1

:1,0

00 w

ith o

xyge

n)

Ster

oids

, e.g

.:- O

ral d

exam

etha

sone

or p

redn

isol

one

- Neb

uliz

ed b

udes

onid

e

128

K30033_C004.indd 128 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

3. C

rou

p

Wha

t is

cro

up?

This

is a

vira

l inf

ectio

n th

at c

ause

spr

ogre

ssiv

e in

flam

mat

ion

of th

ere

spira

tory

trac

t com

men

cing

with

the

lary

nx a

nd s

prea

ding

dist

ally

to th

e br

onch

i. Th

is is

why

it is

als

o kn

own

as a

cute

lary

ngot

rach

eobr

onch

itis.

Tend

sto

affe

ct c

hild

ren

aged

6 m

onth

sto

6 y

ears

.

Caus

esRe

mem

ber a

s RI

P:R

– Re

spira

tory

syn

cytia

l viru

sI

– In

fluen

zaP

– Pa

rain

fluen

za (m

ost

c

omm

on c

ause

)

Com

plic

atio

ns•

Deat

h.•

Trac

heiti

s.•

Pneu

mon

ia.

Sym

ptom

sTe

nd to

be

wor

se a

t nig

ht

• G

ener

al s

ympt

oms:

Br

eath

less

ness

.

Pers

iste

nt c

ough

.

Leth

argy

.

Off

feed

s.•

Typi

cal f

eatu

res:

wor

sen

with

pr

ogre

ssio

n of

infla

mm

atio

n:

Cory

za +

/– fe

ver (

prod

rom

e).

‘B

arki

ng’ c

ough

.

Hoar

sene

ss.

St

ridor

.•

Sign

s of

res

pira

tory

dep

ress

ion:

N

asal

flar

ing.

Su

bcos

tal a

nd in

terc

osta

l rec

essi

on.

Lo

w G

lasc

ow C

oma

Scal

e sc

ore.

Cy

anos

is.•

On

ausc

ulta

tion

:

St

ridor

– h

eard

in m

oder

ated

crou

p w

ith a

ste

thos

cope

. It i

s po

ssib

le

to

hea

r str

idor

with

out a

ste

thos

cope

in s

ever

e ca

ses. M

AP 4

.13.

Cro

up

Inve

stig

atio

ns•

Bloo

d te

sts

and

an e

xam

inat

ion

of th

e ch

ild’s

th

roat

is u

sual

ly n

ot u

nder

take

n si

nce

this

may

di

stre

ss th

e ch

ild a

nd in

adve

rten

tly c

lose

thei

r

airw

ay, l

eadi

ng to

an

emer

genc

y si

tuat

ion

in

whi

ch in

vasi

ve a

cces

s to

the

airw

ay m

ust b

e

esta

blis

hed.

• He

art r

ate,

resp

irato

ry ra

te a

nd o

xyge

n sa

tura

tion.

• As

sess

sev

erity

usi

ng th

e W

estle

y Cr

oup

Scor

e:

Cate

gory

Wes

tley

scor

eFe

atur

es

Mild

Mod

erat

e

Seve

re

0–2

3–5

6–11

Freq

uent

cou

gh.

Mar

ked

strid

or. M

arke

dst

erna

l wal

l ret

ract

ion.

Resp

irato

ry d

istr

ess

Freq

uent

cou

gh. S

trid

or.

Ster

nal w

all r

etra

ctio

n at

rest

Occ

asio

nal c

ough

. No

strid

or.

No

sign

s of

resp

irato

ryde

pres

sion

Trea

tmen

tDe

pend

s on

the

seve

rity

of c

roup

.

Cons

erva

tive

:•

Pare

nt e

duca

tion.

• Co

ntin

ual m

onito

ring.

Med

ical

:

Mild

Mos

t may

be

man

aged

at h

ome

with

par

acet

amol

,ne

w g

uida

nce

reco

mm

ends

giv

ing

a si

ngle

dos

e of

ora

lde

xam

etha

sone

to a

ll ch

ildre

n re

gard

less

of s

ever

ity.

Seve

re

Mod

erat

e

1. S

tero

ids,

e.g.

:- O

ral d

exam

etha

sone

or p

redn

isol

one

- Neb

uliz

ed b

udes

onid

e2.

Neb

uliz

ed a

dren

alin

e (5

mL

of 1

:1,0

00 w

ith o

xyge

n)

Ster

oids

, e.g

.:- O

ral d

exam

etha

sone

or p

redn

isol

one

- Neb

uliz

ed b

udes

onid

e

129

K30033_C004.indd 129 28/02/17 11:43 am

Paed

iatr

ics

Map

4.1

4. C

ysti

c fi

bro

sis

(CF)

Inve

stig

atio

nsDe

pend

on

age

of p

atie

nt a

nd w

hen

the

dise

ase

pres

ents

.•

Spec

ific

test

s:

N

ewbo

rn b

lood

spo

t:

im

mun

orea

ctiv

e tr

ypsi

noge

n (IR

T)

Sw

eat t

est:

– Cl

– >50

mm

ol/L

– N

a+ >

60 m

mol

/L•

Bloo

d te

sts

with

eve

ry a

cute

ex

acer

batio

n: F

BC, U

&E,

LFT

s.•

Iden

tify

caus

e of

infe

ctio

n us

ing

sput

um

anal

ysis,

che

st x

-ray

and

blo

od

cultu

re. C

omm

on o

rgan

ism

s in

clud

e

Stap

hylo

cocc

us a

ureu

s, Ha

emop

hilu

s

influ

enza

e, P

seud

omon

as a

erug

inos

a.•

Radi

olog

y:

Ch

est x

-ray

:

–

Bron

chie

ctas

is: ‘

tram

trac

ks’.

– Co

nsol

idat

ion.

– Fi

bros

is.

Sym

ptom

sSy

mpt

oms

and

how

the

dise

ase

man

ifest

s its

elf m

ay v

ary

depe

ndin

g on

the

age

of th

e ch

ild.

Neo

nate

:•

Mec

oniu

m il

eus.

Youn

g ch

ild:

• Fa

ilure

to th

rive.

• Fr

eque

nt c

hest

infe

ctio

ns.

• St

eato

rrho

ea.

• Si

gns

of c

lubb

ing

com

men

ce.

Old

er c

hild

:•

Freq

uent

che

st in

fect

ions

.•

Asth

ma.

• Al

lerg

ic b

ronc

hopu

lmon

ary

aspe

rgill

osis.

• St

eato

rrho

ea.

Adu

ltho

od:

• As

abo

ve.

• Br

onch

iect

asis.

• In

fert

ility

.•

Diab

etes

.•

Cor p

ulm

onal

e.•

Depr

essi

on.

• Ci

rrho

sis.

Com

plic

atio

ns•

Incr

ease

d fre

quen

cy o

f

resp

irato

ry tr

act i

nfec

tions

.•

Bron

chie

ctas

is.•

Resp

irato

ry fa

ilure

.•

Infe

rtili

ty.

• Di

abet

es.

• G

alls

tone

s.•

Cor p

ulm

onal

e.•

Mal

nutr

ition

.•

Nas

al p

olyp

s.•

Depr

essi

on.

Wha

t is

cys

tic

fibro

sis?

This

is a

n au

toso

mal

rece

ssiv

e co

nditi

on th

at o

ccur

s in

1 in

2,50

0 liv

e bi

rths

and

has

a c

arrie

r rat

e of

1 in

25.

It o

ccur

s du

e to

a d

elet

ion

in p

heny

lala

nine

, mea

ning

that

an

abno

rmal

cys

tic fi

bros

is tr

ansm

embr

ane

cond

ucta

nce

regu

lato

r (CF

TR) p

rote

in is

then

cre

ated

. Thi

s in

turn

dec

reas

es

Cl– io

n tr

ansp

ort r

esul

ting

in th

icke

ned

dehy

drat

ed s

ecre

tions

.

Caus

esIt

is c

ause

d by

a d

elet

ion

in p

heny

lala

nine

, mos

t com

mon

ly a

t pos

ition

508

on

chr

omos

ome

7.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion

(e.g

. kee

p ch

ildre

n w

ith C

F se

para

te to

av

oid

cros

s-in

fect

ion)

.•

Cont

inua

l mon

itorin

g w

ith m

ultid

isci

plin

ary

team

in

volv

emen

t.•

Up

to d

ate

imm

uniz

atio

ns.

• Ph

ysio

ther

apy

(e.g

. Flu

tter

®, a

muc

us c

lear

ance

dev

ice

use

d by

resp

irato

ry p

hysi

othe

rapi

sts)

.

Med

ical

:•

Trea

t inf

ectio

ns a

ccor

ding

to c

ultu

ral s

ensi

tiviti

es.

Co

nsul

t mic

robi

olog

y an

d ho

spita

l gui

delin

es. S

ome

ex

ampl

es a

re g

iven

bel

ow:

Pipe

raci

llin

in c

ombi

natio

n w

ith ta

zoba

ctam

.

To

bram

ycin

.

M

erop

enem

.

Im

ipen

em.

• Pa

ncre

atic

enz

yme

supp

lem

ents

(e.g

. Cre

on).

• Fa

t sol

uble

vita

min

s.

MAP

4.1

4.Cy

stic

fib

rosi

s (C

F)

130

K30033_C004.indd 130 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

4. C

ysti

c fi

bro

sis

(CF)

Inve

stig

atio

nsDe

pend

on

age

of p

atie

nt a

nd w

hen

the

dise

ase

pres

ents

.•

Spec

ific

test

s:

N

ewbo

rn b

lood

spo

t:

im

mun

orea

ctiv

e tr

ypsi

noge

n (IR

T)

Sw

eat t

est:

– Cl

– >50

mm

ol/L

– N

a+ >

60 m

mol

/L•

Bloo

d te

sts

with

eve

ry a

cute

ex

acer

batio

n: F

BC, U

&E,

LFT

s.•

Iden

tify

caus

e of

infe

ctio

n us

ing

sput

um

anal

ysis,

che

st x

-ray

and

blo

od

cultu

re. C

omm

on o

rgan

ism

s in

clud

e

Stap

hylo

cocc

us a

ureu

s, Ha

emop

hilu

s

influ

enza

e, P

seud

omon

as a

erug

inos

a.•

Radi

olog

y:

Ch

est x

-ray

:

–

Bron

chie

ctas

is: ‘

tram

trac

ks’.

– Co

nsol

idat

ion.

– Fi

bros

is.

Sym

ptom

sSy

mpt

oms

and

how

the

dise

ase

man

ifest

s its

elf m

ay v

ary

depe

ndin

g on

the

age

of th

e ch

ild.

Neo

nate

:•

Mec

oniu

m il

eus.

Youn

g ch

ild:

• Fa

ilure

to th

rive.

• Fr

eque

nt c

hest

infe

ctio

ns.

• St

eato

rrho

ea.

• Si

gns

of c

lubb

ing

com

men

ce.

Old

er c

hild

:•

Freq

uent

che

st in

fect

ions

.•

Asth

ma.

• Al

lerg

ic b

ronc

hopu

lmon

ary

aspe

rgill

osis.

• St

eato

rrho

ea.

Adu

ltho

od:

• As

abo

ve.

• Br

onch

iect

asis.

• In

fert

ility

.•

Diab

etes

.•

Cor p

ulm

onal

e.•

Depr

essi

on.

• Ci

rrho

sis.

Com

plic

atio

ns•

Incr

ease

d fre

quen

cy o

f

resp

irato

ry tr

act i

nfec

tions

.•

Bron

chie

ctas

is.•

Resp

irato

ry fa

ilure

.•

Infe

rtili

ty.

• Di

abet

es.

• G

alls

tone

s.•

Cor p

ulm

onal

e.•

Mal

nutr

ition

.•

Nas

al p

olyp

s.•

Depr

essi

on.

Wha

t is

cys

tic

fibro

sis?

This

is a

n au

toso

mal

rece

ssiv

e co

nditi

on th

at o

ccur

s in

1 in

2,50

0 liv

e bi

rths

and

has

a c

arrie

r rat

e of

1 in

25.

It o

ccur

s du

e to

a d

elet

ion

in p

heny

lala

nine

, mea

ning

that

an

abno

rmal

cys

tic fi

bros

is tr

ansm

embr

ane

cond

ucta

nce

regu

lato

r (CF

TR) p

rote

in is

then

cre

ated

. Thi

s in

turn

dec

reas

es

Cl– io

n tr

ansp

ort r

esul

ting

in th

icke

ned

dehy

drat

ed s

ecre

tions

.

Caus

esIt

is c

ause

d by

a d

elet

ion

in p

heny

lala

nine

, mos

t com

mon

ly a

t pos

ition

508

on

chr

omos

ome

7.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt e

duca

tion

(e.g

. kee

p ch

ildre

n w

ith C

F se

para

te to

av

oid

cros

s-in

fect

ion)

.•

Cont

inua

l mon

itorin

g w

ith m

ultid

isci

plin

ary

team

in

volv

emen

t.•

Up

to d

ate

imm

uniz

atio

ns.

• Ph

ysio

ther

apy

(e.g

. Flu

tter

®, a

muc

us c

lear

ance

dev

ice

use

d by

resp

irato

ry p

hysi

othe

rapi

sts)

.

Med

ical

:•

Trea

t inf

ectio

ns a

ccor

ding

to c

ultu

ral s

ensi

tiviti

es.

Co

nsul

t mic

robi

olog

y an

d ho

spita

l gui

delin

es. S

ome

ex

ampl

es a

re g

iven

bel

ow:

Pipe

raci

llin

in c

ombi

natio

n w

ith ta

zoba

ctam

.

To

bram

ycin

.

M

erop

enem

.

Im

ipen

em.

• Pa

ncre

atic

enz

yme

supp

lem

ents

(e.g

. Cre

on).

• Fa

t sol

uble

vita

min

s.

MAP

4.1

4.Cy

stic

fib

rosi

s (C

F)

131

K30033_C004.indd 131 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

5. A

sth

ma

Wha

t is

ast

hma?

Asth

ma

is a

chr

onic

, inf

lam

mat

ory

dise

ase

that

is c

hara

cter

ized

by

reve

rsib

le a

irway

obs

truc

tion.

In

chi

ldre

n it

affe

cts

boys

mor

e th

angi

rls, b

ut in

adu

lts, f

emal

es a

re m

ore

grea

tly a

ffect

ed.

Caus

esTh

e ca

use

of a

sthm

a is

mul

tifac

toria

l en

com

pass

ing

both

gen

etic

and

envi

ronm

enta

l ele

men

ts:

• G

enet

ic:

Pers

onal

/fam

ily h

isto

ry o

f

at

opy

– in

volv

emen

t of

chro

mos

ome

11.

Fam

ily h

isto

ry o

f ast

hma.

• En

viro

nmen

tal:

Indo

or a

llerg

ens:

–

Hou

se d

ust m

ite.

–

Pet

s.

– F

unga

l spo

res.

Out

door

alle

rgen

s:

– P

olle

n.

– C

old

air.

Sym

ptom

s•

Resp

irato

ry fe

atur

es: w

heez

e, c

ough

, sho

rtne

ss

of

bre

ath.

• Sy

mpt

oms

wor

se a

t nig

ht o

r ear

ly m

orni

ng.

• Sy

mpt

oms

may

occ

ur a

fter e

xerc

ise

or a

trig

gerin

g

fac

tor s

uch

as c

old

wea

ther

.•

Sym

ptom

s m

ay o

ccur

afte

r bet

a bl

ocke

rs.

• De

crea

sed

peak

exp

irato

ry fl

ow ra

te (P

EFR)

and

forc

ed e

xpira

tory

vol

ume

in 1

sec

ond.

• Pe

rson

al/fa

mily

his

tory

of a

sthm

a/at

opy.

• U

nexp

lain

ed b

lood

eos

inop

hilia

.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

eosi

noph

ils.

• Sp

utum

sam

ple

if in

dica

ted.

• Pu

lmon

ary

func

tion

test

s:

PEFR

: din

ural

var

iatio

n.

Spiro

met

ry: F

EV1/

FVC

<0.

7

(o

bstr

uctiv

e de

fect

).•

Radi

olog

y:

Ches

t x-r

ay: o

nly

if re

quire

d/in

ac

ute

sett

ing.

May

sho

w

pn

eum

otho

rax

or c

onso

lidat

ion.

Com

plic

atio

ns•

Deat

h.•

Dist

urbe

d sl

eep.

• Pe

rsis

tent

cou

gh.

• Si

de e

ffect

s of

ste

roid

s, e.

g.:

W

eigh

t gai

n.

Thin

ning

of t

he s

kin.

St

riae

form

atio

n.

Cata

ract

s.

Cush

ing’

s sy

ndro

me.

G

row

th d

istu

rban

ce.

Occ

upat

iona

l alle

rgen

s:

– I

socy

anat

es.

–

Epo

xyre

sins

.

Oth

er fa

ctor

s:

– S

mok

ing.

–

Infe

ctio

n.

– E

mot

ion.

–

Dru

gs (e

.g. b

eta

bloc

kers

).

The

abov

e tr

igge

ring

fact

ors

caus

e th

e cl

assi

c tr

iad

that

cha

ract

eriz

es a

sthm

a:1.

Cop

ious

muc

us s

ecre

tion.

2. In

flam

mat

ion

of th

e ai

rway

s.3.

Con

trac

tion

of b

ronc

hial

sm

ooth

mus

cle.

This

tria

d oc

curs

due

to th

e ac

tivat

ion

of T

h2 c

ells,

w

hich

upr

egul

ate

the

imm

une

resp

onse

. Th2

cel

ls

stim

ulat

e th

e re

leas

e of

the

follo

win

g:•

Inte

rleuk

in (I

L)-4

: stim

ulat

es e

osin

ophi

ls a

nd B

lym

phoc

ytes

.•

IL-5

: stim

ulat

es e

osin

ophi

ls.•

IL-1

3: s

timul

ates

muc

us p

rodu

ctio

n.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

on

inha

ler t

echn

ique

, use

of s

pace

r

dev

ices

and

avo

idan

ce o

f trig

gerin

g fa

ctor

s.•

Annu

al a

sthm

a re

view

and

influ

enza

vac

cine

r

equi

red.

Med

ical

:•

Refe

r to

Briti

sh T

hora

cic

Soci

ety

Gui

delin

es (s

ee

Tab

le 4

.3, p

. 134

).

MAP

4.1

5. A

sthm

a

132

K30033_C004.indd 132 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

5. A

sth

ma

Wha

t is

ast

hma?

Asth

ma

is a

chr

onic

, inf

lam

mat

ory

dise

ase

that

is c

hara

cter

ized

by

reve

rsib

le a

irway

obs

truc

tion.

In

chi

ldre

n it

affe

cts

boys

mor

e th

angi

rls, b

ut in

adu

lts, f

emal

es a

re m

ore

grea

tly a

ffect

ed.

Caus

esTh

e ca

use

of a

sthm

a is

mul

tifac

toria

l en

com

pass

ing

both

gen

etic

and

envi

ronm

enta

l ele

men

ts:

• G

enet

ic:

Pers

onal

/fam

ily h

isto

ry o

f

at

opy

– in

volv

emen

t of

chro

mos

ome

11.

Fam

ily h

isto

ry o

f ast

hma.

• En

viro

nmen

tal:

Indo

or a

llerg

ens:

–

Hou

se d

ust m

ite.

–

Pet

s.

– F

unga

l spo

res.

Out

door

alle

rgen

s:

– P

olle

n.

– C

old

air.

Sym

ptom

s•

Resp

irato

ry fe

atur

es: w

heez

e, c

ough

, sho

rtne

ss

of

bre

ath.

• Sy

mpt

oms

wor

se a

t nig

ht o

r ear

ly m

orni

ng.

• Sy

mpt

oms

may

occ

ur a

fter e

xerc

ise

or a

trig

gerin

g

fac

tor s

uch

as c

old

wea

ther

.•

Sym

ptom

s m

ay o

ccur

afte

r bet

a bl

ocke

rs.

• De

crea

sed

peak

exp

irato

ry fl

ow ra

te (P

EFR)

and

forc

ed e

xpira

tory

vol

ume

in 1

sec

ond.

• Pe

rson

al/fa

mily

his

tory

of a

sthm

a/at

opy.

• U

nexp

lain

ed b

lood

eos

inop

hilia

.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

eosi

noph

ils.

• Sp

utum

sam

ple

if in

dica

ted.

• Pu

lmon

ary

func

tion

test

s:

PEFR

: din

ural

var

iatio

n.

Spiro

met

ry: F

EV1/

FVC

<0.

7

(o

bstr

uctiv

e de

fect

).•

Radi

olog

y:

Ches

t x-r

ay: o

nly

if re

quire

d/in

ac

ute

sett

ing.

May

sho

w

pn

eum

otho

rax

or c

onso

lidat

ion.

Com

plic

atio

ns•

Deat

h.•

Dist

urbe

d sl

eep.

• Pe

rsis

tent

cou

gh.

• Si

de e

ffect

s of

ste

roid

s, e.

g.:

W

eigh

t gai

n.

Thin

ning

of t

he s

kin.

St

riae

form

atio

n.

Cata

ract

s.

Cush

ing’

s sy

ndro

me.

G

row

th d

istu

rban

ce.

Occ

upat

iona

l alle

rgen

s:

– I

socy

anat

es.

–

Epo

xyre

sins

.

Oth

er fa

ctor

s:

– S

mok

ing.

–

Infe

ctio

n.

– E

mot

ion.

–

Dru

gs (e

.g. b

eta

bloc

kers

).

The

abov

e tr

igge

ring

fact

ors

caus

e th

e cl

assi

c tr

iad

that

cha

ract

eriz

es a

sthm

a:1.

Cop

ious

muc

us s

ecre

tion.

2. In

flam

mat

ion

of th

e ai

rway

s.3.

Con

trac

tion

of b

ronc

hial

sm

ooth

mus

cle.

This

tria

d oc

curs

due

to th

e ac

tivat

ion

of T

h2 c

ells,

w

hich

upr

egul

ate

the

imm

une

resp

onse

. Th2

cel

ls

stim

ulat

e th

e re

leas

e of

the

follo

win

g:•

Inte

rleuk

in (I

L)-4

: stim

ulat

es e

osin

ophi

ls a

nd B

lym

phoc

ytes

.•

IL-5

: stim

ulat

es e

osin

ophi

ls.•

IL-1

3: s

timul

ates

muc

us p

rodu

ctio

n.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

on

inha

ler t

echn

ique

, use

of s

pace

r

dev

ices

and

avo

idan

ce o

f trig

gerin

g fa

ctor

s.•

Annu

al a

sthm

a re

view

and

influ

enza

vac

cine

r

equi

red.

Med

ical

:•

Refe

r to

Briti

sh T

hora

cic

Soci

ety

Gui

delin

es (s

ee

Tab

le 4

.3, p

. 134

).

MAP

4.1

5. A

sthm

a

133

K30033_C004.indd 133 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

3. F

low

ch

art

sum

mar

izin

g t

he

Bri

tish

Th

ora

cic

Soci

ety

gu

idel

ines

Age

<5

year

s5–

12 y

ears

>12

yea

rsLi

fe-t

hrea

teni

ng a

sthm

a

Step

1: S

ABA

(sho

rt-a

ctin

g be

ta a

goni

st) (

e.g.

sal

buta

mol

)

Step

2: I

nhal

ed co

rtico

ster

oid

or

leuk

otrie

ne re

cept

or a

ntag

onist

Step

3: C

onsi

der l

euko

trie

ne

rece

ptor

ant

agon

ist i

n ch

ildre

n ta

king

inha

led

ster

oid.

Con

side

r inh

aled

st

eroi

d in

chi

ldre

n al

read

y ta

king

leuk

otrie

ne re

cept

or

anta

goni

st

Step

1: S

ABA

Step

2: I

nhal

ed c

ortic

oste

roid

Step

3: A

dd L

ABA

(long

-act

ing

beta

ago

nist

) (e

.g. s

alm

eter

ol)

Asse

ss c

ontr

ol:

• If

wel

l con

trol

led:

con

tinue

regi

me

• If

part

ial i

mpr

ovem

ent:

cont

inue

regi

me

but i

ncre

ase

inha

led

cort

icos

tero

id d

ose

Step

1: S

ABA

Step

2: I

nhal

ed c

ortic

oste

roid

Step

3: A

dd L

ABA

(long

-act

ing

beta

ago

nist

) (e

.g. s

alm

eter

ol)

Asse

ss c

ontr

ol:

• If

wel

l con

trol

led:

con

tinue

regi

me

• If

part

ial i

mpr

ovem

ent:

cont

inue

regi

me

but i

ncre

ase

inha

led

cort

icos

tero

id d

ose

Be a

war

e of

nat

iona

l and

lo

cal g

uide

lines

rega

rdin

g lif

e-th

reat

enin

g as

thm

a. G

ener

al

prot

ocol

may

incl

ude:

1. A

BCDE

app

roac

h. C

all f

or

assi

stan

ce2.

Hig

h flo

w o

xyge

n vi

a m

ask

3. N

ebul

ized

bro

ncho

dila

tors

su

ch a

s sa

lbut

amol

and

an

timus

carin

ics

such

as

ipra

trop

tium

bro

mid

e.

Mon

itor r

espo

nse.

4. S

ecur

e IV

acc

ess

and

cons

ider

hyd

roco

rtis

one

5. F

urth

er m

etho

ds s

houl

d be

in

itiat

ed u

nder

spe

cial

ist

supe

rvis

ion

and

incl

ude

amin

ophy

lline

bol

us o

r m

agne

sium

sul

phat

e IV

TABL

E 4.

3. F

low

cha

rt s

umm

ariz

ing

the

Brit

ish

Thor

acic

Soc

iety

gui

delin

es.

http

s://w

ww

.brit

-tho

raci

c.or

g.uk

/doc

umen

t-lib

rary

/clin

ical

-info

rmat

ion/

asth

ma/

btss

ign-

asth

ma-

guid

elin

e-qu

ick-

refe

renc

e-gu

ide-

2014

/

134

K30033_C004.indd 134 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

3. F

low

ch

art

sum

mar

izin

g t

he

Bri

tish

Th

ora

cic

Soci

ety

gu

idel

ines

Step

1: S

ABA

(sho

rt-a

ctin

g be

ta a

goni

st) (

e.g.

sal

buta

mol

)

Step

2: I

nhal

ed co

rtico

ster

oid

or

leuk

otrie

ne re

cept

or a

ntag

onist

Step

3: C

onsi

der l

euko

trie

ne

rece

ptor

ant

agon

ist i

n ch

ildre

n ta

king

inha

led

ster

oid.

Con

side

r inh

aled

st

eroi

d in

chi

ldre

n al

read

y ta

king

leuk

otrie

ne re

cept

or

anta

goni

st

Step

4: R

efer

to s

peci

alis

t

• N

o im

prov

emen

t: st

op L

ABA

and

incr

ease

in

hale

d co

rtic

oste

roid

dos

e•

Cons

ider

theo

phyl

line

(pho

spho

dies

tera

se

inhi

bito

r) or

mon

telu

kast

(leu

kotr

iene

re

cept

or a

ntag

onis

t)

Step

4: I

ncre

ase

inha

led

cort

icos

tero

id d

ose

Step

5:

• St

eroi

d ta

blet

(pre

dnis

olon

e)•

High

est d

ose

inha

led

cort

icos

tero

id•

Refe

r to

spec

ialis

t

• N

o im

prov

emen

t: st

op L

ABA

and

incr

ease

in

hale

d co

rtic

oste

roid

dos

e•

Cons

ider

theo

phyl

line

(pho

spho

dies

tera

se

inhi

bito

r) or

mon

telu

kast

(leu

kotr

iene

re

cept

or a

ntag

onis

t)

Step

4:

• In

crea

se in

hale

d co

rtic

oste

roid

dos

e•

Cons

ider

theo

phyl

line

(pho

spho

dies

tera

se

inhi

bito

r), m

onte

luka

st (l

euko

trie

ne

rece

ptor

ant

agon

ist)

or b

eta

2 ag

onis

t ta

blet

Step

5:

• St

eroi

d ta

blet

(pre

dnis

olon

e)•

High

est d

ose

inha

led

cort

icos

tero

id•

Refe

r to

spec

ialis

t

135

K30033_C004.indd 135 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

6. R

heu

mat

ic f

ever

Wha

t is

rhe

umat

ic fe

ver?

Rheu

mat

ic fe

ver i

s a

rare

infla

mm

ator

y di

sord

er th

at is

now

mor

e co

mm

on

in th

ose

from

the

Asia

n su

bcon

tinen

t. Te

nds

to a

ffect

chi

ldre

n ag

ed 5

–15

year

s ol

d.

Caus

es•

Gro

up A

bet

a ha

emol

ytic

str

epto

cocc

us (e

.g. S

trep

toco

ccus

pyo

gene

s).

• Rh

eum

atic

feve

r is

prec

eded

by

a st

rept

ococ

cal p

hary

ngiti

s an

d th

en

affe

cts

all l

ayer

s of

the

hear

t, cr

eatin

g a

path

olog

ical

lesi

on c

alle

d an

As

chof

f bod

y.•

Oth

er re

gion

s of

the

body

as

wel

l as

the

hear

t are

affe

cted

, suc

h as

the

sk

in, c

entr

al n

ervo

us s

yste

m a

nd th

e m

uscu

losk

elet

al s

yste

m.

Sym

ptom

sDi

agno

sed

usin

g th

e Jo

nes

crite

ria: 2

maj

or o

r 1 m

ajor

and

1 m

inor

crite

ria P

LUS

a pr

eced

ing

stre

ptoc

occa

l thr

oat i

nfec

tion.

Rem

embe

r maj

or c

riter

ia a

s A

BCD

:A

– A

rthr

itis

(pol

yart

hriti

s)B

– Be

atin

g he

art (

card

itis)

C –

Synd

enha

m’s

Chor

eaD

– D

erm

atol

ogic

al m

anife

stat

ions

(e.g

. sub

cuta

neou

s no

dule

s an

d

ery

them

a m

argi

natu

m)

Rem

embe

r min

or c

riter

ia a

s FA

T PA

D:

F –

Feve

rA

– A

rthr

algi

aT

– Th

roat

sw

ab p

ositi

ve fo

r Gro

up A

bet

a ha

emol

ytic

Str

epto

cocc

usP

– Pr

evio

us rh

eum

atic

feve

r/pro

long

ed P

R in

terv

alA

– A

cute

pha

se re

acta

nts

(e.g

. CRP

/ESR

/leuc

ocyt

osis

)D

– N

/A

Inve

stig

atio

ns•

Thro

at s

wab

s.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

ASO

titr

es o

r

DNAa

se.

• EC

G: p

rolo

nged

PR

inte

rval

.•

ECHO

: vis

ualiz

e he

art v

alve

affe

cted

.

Com

plic

atio

ns•

Chro

nic

rheu

mat

ic h

eart

dis

ease

: mitr

al

valv

e af

fect

ed in

50%

.•

Atria

l fib

rilla

tion.

• He

art f

ailu

re.

• Pr

edis

posi

tion

for i

nfec

tive

endo

card

itis.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

Aspi

rin is

the

initi

al tr

eatm

ent o

f cho

ice

for

in

flam

mat

ion

but i

s co

ntra

indi

cate

d in

chi

ldre

n

due

to R

eye

synd

rom

e, w

hich

is a

rapi

dly

pr

ogre

ssiv

e en

ceph

alop

athy

.•

Cort

icos

tero

ids

may

be

used

for i

nfla

mm

atio

n.•

Antib

iotic

s (e

.g. p

enic

illin

). Ch

eck

sens

itivi

ties

w

ith m

icro

biol

ogy

and

hosp

ital g

uide

lines

.

MAP

4.1

6. R

heum

atic

fev

er

136

K30033_C004.indd 136 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

6. R

heu

mat

ic f

ever

Wha

t is

rhe

umat

ic fe

ver?

Rheu

mat

ic fe

ver i

s a

rare

infla

mm

ator

y di

sord

er th

at is

now

mor

e co

mm

on

in th

ose

from

the

Asia

n su

bcon

tinen

t. Te

nds

to a

ffect

chi

ldre

n ag

ed 5

–15

year

s ol

d.

Caus

es•

Gro

up A

bet

a ha

emol

ytic

str

epto

cocc

us (e

.g. S

trep

toco

ccus

pyo

gene

s).

• Rh

eum

atic

feve

r is

prec

eded

by

a st

rept

ococ

cal p

hary

ngiti

s an

d th

en

affe

cts

all l

ayer

s of

the

hear

t, cr

eatin

g a

path

olog

ical

lesi

on c

alle

d an

As

chof

f bod

y.•

Oth

er re

gion

s of

the

body

as

wel

l as

the

hear

t are

affe

cted

, suc

h as

the

sk

in, c

entr

al n

ervo

us s

yste

m a

nd th

e m

uscu

losk

elet

al s

yste

m.

Sym

ptom

sDi

agno

sed

usin

g th

e Jo

nes

crite

ria: 2

maj

or o

r 1 m

ajor

and

1 m

inor

crite

ria P

LUS

a pr

eced

ing

stre

ptoc

occa

l thr

oat i

nfec

tion.

Rem

embe

r maj

or c

riter

ia a

s A

BCD

:A

– A

rthr

itis

(pol

yart

hriti

s)B

– Be

atin

g he

art (

card

itis)

C –

Synd

enha

m’s

Chor

eaD

– D

erm

atol

ogic

al m

anife

stat

ions

(e.g

. sub

cuta

neou

s no

dule

s an

d

ery

them

a m

argi

natu

m)

Rem

embe

r min

or c

riter

ia a

s FA

T PA

D:

F –

Feve

rA

– A

rthr

algi

aT

– Th

roat

sw

ab p

ositi

ve fo

r Gro

up A

bet

a ha

emol

ytic

Str

epto

cocc

usP

– Pr

evio

us rh

eum

atic

feve

r/pro

long

ed P

R in

terv

alA

– A

cute

pha

se re

acta

nts

(e.g

. CRP

/ESR

/leuc

ocyt

osis

)D

– N

/A

Inve

stig

atio

ns•

Thro

at s

wab

s.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

ASO

titr

es o

r

DNAa

se.

• EC

G: p

rolo

nged

PR

inte

rval

.•

ECHO

: vis

ualiz

e he

art v

alve

affe

cted

.

Com

plic

atio

ns•

Chro

nic

rheu

mat

ic h

eart

dis

ease

: mitr

al

valv

e af

fect

ed in

50%

.•

Atria

l fib

rilla

tion.

• He

art f

ailu

re.

• Pr

edis

posi

tion

for i

nfec

tive

endo

card

itis.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

Aspi

rin is

the

initi

al tr

eatm

ent o

f cho

ice

for

in

flam

mat

ion

but i

s co

ntra

indi

cate

d in

chi

ldre

n

due

to R

eye

synd

rom

e, w

hich

is a

rapi

dly

pr

ogre

ssiv

e en

ceph

alop

athy

.•

Cort

icos

tero

ids

may

be

used

for i

nfla

mm

atio

n.•

Antib

iotic

s (e

.g. p

enic

illin

). Ch

eck

sens

itivi

ties

w

ith m

icro

biol

ogy

and

hosp

ital g

uide

lines

.

MAP

4.1

6. R

heum

atic

fev

er

137

K30033_C004.indd 137 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

7. U

rin

ary

trac

t in

fect

ion

(U

TI)

Wha

t is

a u

rina

ry t

ract

infe

ctio

n?Th

is is

an

infe

ctio

n of

the

urin

ary

trac

t with

ty

pica

l sig

ns a

nd s

ympt

oms.

It m

ay b

e cl

assi

fied

as e

ither

low

er o

r upp

er (a

cute

py

elon

ephr

itis)

.

In c

hild

ren,

UTI

s ar

e m

ore

com

mon

in

boys

unt

il th

e ag

e of

3 m

onth

s. Af

ter t

his

time

the

inci

denc

e is

hig

her i

n gi

rls.

Caus

es

UTI

s ar

e ge

nera

lly c

ause

d by

infe

ctio

n of

the

urin

ary

trac

t with

Esc

heric

hia

coli.

How

ever

, th

ere

are

seve

ral r

isk

fact

ors

that

may

pr

edis

pose

to in

fect

ion

(see

bel

ow).

Risk

fact

ors

• Fe

mal

e ge

nder

.•

Gen

itour

inar

y m

alfo

rmat

ions

.•

Vesi

cour

eter

ic re

flux

(VU

R).

• Di

abet

es.

• Im

mun

osup

pres

sion

.•

Cond

ition

s th

at p

redi

spos

e to

sto

ne

fo

rmat

ion

and

ther

efor

e ur

inar

y tr

act

ob

stru

ctio

n.•

Cath

eter

izat

ion.

Inve

stig

atio

ns•

Urin

e di

pstic

k: p

ositi

ve fo

r leu

cocy

tes

and

nitr

ites.

The

prob

lem

in p

aedi

atric

s is

colle

ctin

g th

e ur

ine

sam

ple

and

the

met

hod

varie

s de

pend

ing

on th

e ag

e of

the

child

. Som

e ex

ampl

es in

clud

e: c

lean

catc

h m

etho

d, c

olle

ctio

n pa

ds a

nd

supr

apub

ic a

spira

tion.

U

rine

cultu

re: >

105 o

rgan

ism

s pe

r mL

of

m

idst

ream

urin

e.•

Radi

olog

y:

Ki

dney

s, ur

eter

and

bla

dder

USS

for

anat

omic

al a

bnor

mal

ities

.

Ve

sico

uret

eric

reflu

x: m

ictu

ratin

g

cyst

oure

thro

gram

.

Re

nal s

carr

ing:

dim

erca

ptos

ucci

nic

ac

id s

can.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt a

nd p

atie

nt e

duca

tion.

Med

ical

:•

Depe

nds

on th

e ag

e of

the

child

and

type

of i

nfec

tion.

• Tr

eat a

ccor

ding

to c

ultu

ral s

ensi

tiviti

es a

fter c

onta

ctin

g

mic

robi

olog

y an

d co

nsul

ting

loca

l gui

delin

es.

Age

Act

ion

<3

mon

ths

>3

mon

ths

with

low

er U

TIRe

fer

Antib

iotic

s (e

.g. t

rimet

hopr

im o

r nitr

ofur

anto

in)

>3

mon

ths

with

upp

er U

TIAd

mit

and

antib

iotic

s (e

.g. c

o-am

oxic

lav)

Com

plic

atio

ns•

Pyel

onep

hriti

s.•

Hydr

onep

hros

is.•

Rena

l fai

lure

.•

Rena

l abs

cess

.•

Seps

is.

MAP

4.1

7. U

rina

ry t

ract

infe

ctio

n (U

TI)

Sym

ptom

sG

ener

ally

dep

end

on th

e ag

e of

the

child

.

Neo

nate

s:•

Off

feed

s.•

Irrita

ble

• Fo

ul s

mel

ling

urin

e

Youn

g ch

ildre

n:•

Feve

r.•

Dysu

ria.

• Su

prap

ubic

pai

n.

Old

er c

hild

ren

(mor

e lik

e ad

ult

sym

ptom

s):

• Fe

ver.

• Dy

suria

.•

Freq

uenc

y.•

Urg

ency

.•

Supr

apub

ic p

ain.

Upp

er U

TI:

• Fe

ver/c

hills

.•

Flan

k pa

in.

• Ha

emat

uria

.

138

K30033_C004.indd 138 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

7. U

rin

ary

trac

t in

fect

ion

(U

TI)

Wha

t is

a u

rina

ry t

ract

infe

ctio

n?Th

is is

an

infe

ctio

n of

the

urin

ary

trac

t with

ty

pica

l sig

ns a

nd s

ympt

oms.

It m

ay b

e cl

assi

fied

as e

ither

low

er o

r upp

er (a

cute

py

elon

ephr

itis)

.

In c

hild

ren,

UTI

s ar

e m

ore

com

mon

in

boys

unt

il th

e ag

e of

3 m

onth

s. Af

ter t

his

time

the

inci

denc

e is

hig

her i

n gi

rls.

Caus

es

UTI

s ar

e ge

nera

lly c

ause

d by

infe

ctio

n of

the

urin

ary

trac

t with

Esc

heric

hia

coli.

How

ever

, th

ere

are

seve

ral r

isk

fact

ors

that

may

pr

edis

pose

to in

fect

ion

(see

bel

ow).

Risk

fact

ors

• Fe

mal

e ge

nder

.•

Gen

itour

inar

y m

alfo

rmat

ions

.•

Vesi

cour

eter

ic re

flux

(VU

R).

• Di

abet

es.

• Im

mun

osup

pres

sion

.•

Cond

ition

s th

at p

redi

spos

e to

sto

ne

fo

rmat

ion

and

ther

efor

e ur

inar

y tr

act

ob

stru

ctio

n.•

Cath

eter

izat

ion.

Inve

stig

atio

ns•

Urin

e di

pstic

k: p

ositi

ve fo

r leu

cocy

tes

and

nitr

ites.

The

prob

lem

in p

aedi

atric

s is

colle

ctin

g th

e ur

ine

sam

ple

and

the

met

hod

varie

s de

pend

ing

on th

e ag

e of

the

child

. Som

e ex

ampl

es in

clud

e: c

lean

catc

h m

etho

d, c

olle

ctio

n pa

ds a

nd

supr

apub

ic a

spira

tion.

U

rine

cultu

re: >

105 o

rgan

ism

s pe

r mL

of

m

idst

ream

urin

e.•

Radi

olog

y:

Ki

dney

s, ur

eter

and

bla

dder

USS

for

anat

omic

al a

bnor

mal

ities

.

Ve

sico

uret

eric

reflu

x: m

ictu

ratin

g

cyst

oure

thro

gram

.

Re

nal s

carr

ing:

dim

erca

ptos

ucci

nic

ac

id s

can.

Trea

tmen

t

Cons

erva

tive

:•

Pare

nt a

nd p

atie

nt e

duca

tion.

Med

ical

:•

Depe

nds

on th

e ag

e of

the

child

and

type

of i

nfec

tion.

• Tr

eat a

ccor

ding

to c

ultu

ral s

ensi

tiviti

es a

fter c

onta

ctin

g

mic

robi

olog

y an

d co

nsul

ting

loca

l gui

delin

es.

Age

Act

ion

<3

mon

ths

>3

mon

ths

with

low

er U

TIRe

fer

Antib

iotic

s (e

.g. t

rimet

hopr

im o

r nitr

ofur

anto

in)

>3

mon

ths

with

upp

er U

TIAd

mit

and

antib

iotic

s (e

.g. c

o-am

oxic

lav)

Com

plic

atio

ns•

Pyel

onep

hriti

s.•

Hydr

onep

hros

is.•

Rena

l fai

lure

.•

Rena

l abs

cess

.•

Seps

is.

MAP

4.1

7. U

rina

ry t

ract

infe

ctio

n (U

TI)

Sym

ptom

sG

ener

ally

dep

end

on th

e ag

e of

the

child

.

Neo

nate

s:•

Off

feed

s.•

Irrita

ble

• Fo

ul s

mel

ling

urin

e

Youn

g ch

ildre

n:•

Feve

r.•

Dysu

ria.

• Su

prap

ubic

pai

n.

Old

er c

hild

ren

(mor

e lik

e ad

ult

sym

ptom

s):

• Fe

ver.

• Dy

suria

.•

Freq

uenc

y.•

Urg

ency

.•

Supr

apub

ic p

ain.

Upp

er U

TI:

• Fe

ver/c

hills

.•

Flan

k pa

in.

• Ha

emat

uria

.

139

K30033_C004.indd 139 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

8. H

aem

oly

tic

ura

emic

syn

dro

me

(HU

S)

Wha

t is

hae

mol

ytic

ura

emic

syn

drom

e?Th

is is

a s

yndr

ome

that

pre

dom

inan

tly a

ffect

sch

ildre

n.

Caus

esU

sual

ly E

sche

richi

a co

li O

157:

H7 o

r Shi

gella

ent

eriti

s. Th

ese

orga

nism

s en

ter t

he b

ody

via

cont

amin

ated

food

or

wat

er. T

hen

they

exp

ress

vira

toxi

ns, w

hich

cau

seda

mag

e by

bin

ding

to g

lom

erul

ar e

ndot

helia

l cel

ls,re

sulti

ng in

rena

l ins

uffic

ienc

y, de

stro

ying

red

bloo

dce

lls a

nd c

ausi

ng a

naem

ia a

nd p

late

let d

amag

e.

Sym

ptom

sHU

S is

com

pris

ed o

f a tr

iad.

Rem

embe

r as

MAT

:1.

M –

Mic

roan

giop

athi

c ha

emol

ytic

ana

emia

2. A

– A

cute

kid

ney

inju

ry3.

T –

Thr

ombo

cyto

peni

a

Oth

er s

ympt

oms

incl

ude:

• N

ause

a•

Vom

iting

• Bl

oody

dia

rrho

ea•

Abdo

min

al p

ain

• N

O F

EVER

Inve

stig

atio

ns•

Stoo

l cul

ture

.•

Urin

alys

is a

nd e

stim

ated

GFR

.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

Cr:B

UN,

LDH

.•

Perip

hera

l blo

od s

mea

r: sc

hist

ocyt

es.

Com

plic

atio

nsRe

mem

ber a

s A

BCS:

A –

Acu

te k

idne

y in

jury

B –

incr

ease

d Bl

ood

pres

sure

C –

Chro

nic

kidn

ey in

jury

C –

Card

iac

com

plic

atio

ns (e

.g. h

eart

failu

re)

C –

Com

aS

– St

roke

Trea

tmen

t

Cons

erva

tive

:•

Invo

lve

the

neph

rolo

gist

s an

d ha

emot

olog

ists

• HU

S is

a n

otifi

able

dis

ease

in th

e U

K.•

Patie

nt a

nd p

aren

t edu

catio

n.•

Mon

itor B

P.

Med

ical

:•

Trea

tmen

t is

gene

rally

sup

port

ive.

• Hy

drat

e pa

tient

with

IV fl

uids

.•

If hy

pert

ensi

on p

rese

nt, t

hen

cons

ider

cal

cium

c

hann

el b

lock

ers.

• Co

nsid

er d

ialy

sis

and

RBC

tran

sfus

ion

i

f nee

ded.

MAP

4.1

8. H

aem

olyt

ic u

raem

icsy

ndro

me

(HU

S)

140

K30033_C004.indd 140 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

8. H

aem

oly

tic

ura

emic

syn

dro

me

(HU

S)

Wha

t is

hae

mol

ytic

ura

emic

syn

drom

e?Th

is is

a s

yndr

ome

that

pre

dom

inan

tly a

ffect

sch

ildre

n.

Caus

esU

sual

ly E

sche

richi

a co

li O

157:

H7 o

r Shi

gella

ent

eriti

s. Th

ese

orga

nism

s en

ter t

he b

ody

via

cont

amin

ated

food

or

wat

er. T

hen

they

exp

ress

vira

toxi

ns, w

hich

cau

seda

mag

e by

bin

ding

to g

lom

erul

ar e

ndot

helia

l cel

ls,re

sulti

ng in

rena

l ins

uffic

ienc

y, de

stro

ying

red

bloo

dce

lls a

nd c

ausi

ng a

naem

ia a

nd p

late

let d

amag

e.

Sym

ptom

sHU

S is

com

pris

ed o

f a tr

iad.

Rem

embe

r as

MAT

:1.

M –

Mic

roan

giop

athi

c ha

emol

ytic

ana

emia

2. A

– A

cute

kid

ney

inju

ry3.

T –

Thr

ombo

cyto

peni

a

Oth

er s

ympt

oms

incl

ude:

• N

ause

a•

Vom

iting

• Bl

oody

dia

rrho

ea•

Abdo

min

al p

ain

• N

O F

EVER

Inve

stig

atio

ns•

Stoo

l cul

ture

.•

Urin

alys

is a

nd e

stim

ated

GFR

.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

Cr:B

UN,

LDH

.•

Perip

hera

l blo

od s

mea

r: sc

hist

ocyt

es.

Com

plic

atio

nsRe

mem

ber a

s A

BCS:

A –

Acu

te k

idne

y in

jury

B –

incr

ease

d Bl

ood

pres

sure

C –

Chro

nic

kidn

ey in

jury

C –

Card

iac

com

plic

atio

ns (e

.g. h

eart

failu

re)

C –

Com

aS

– St

roke

Trea

tmen

t

Cons

erva

tive

:•

Invo

lve

the

neph

rolo

gist

s an

d ha

emot

olog

ists

• HU

S is

a n

otifi

able

dis

ease

in th

e U

K.•

Patie

nt a

nd p

aren

t edu

catio

n.•

Mon

itor B

P.

Med

ical

:•

Trea

tmen

t is

gene

rally

sup

port

ive.

• Hy

drat

e pa

tient

with

IV fl

uids

.•

If hy

pert

ensi

on p

rese

nt, t

hen

cons

ider

cal

cium

c

hann

el b

lock

ers.

• Co

nsid

er d

ialy

sis

and

RBC

tran

sfus

ion

i

f nee

ded.

MAP

4.1

8. H

aem

olyt

ic u

raem

icsy

ndro

me

(HU

S)

141

K30033_C004.indd 141 28/02/17 11:44 am

Paed

iatr

ics

Map

4.1

9. H

eno

ch–S

chö

nle

in p

urp

ura

(H

SP)

Wha

t is

Hen

och–

Schö

nlei

n pu

rpur

a?Th

is is

a s

yste

mic

vas

culit

is th

at p

rese

nts

with

typi

cal s

igns

and

sym

ptom

s.

Caus

esHS

P is

cau

sed

by Ig

A co

mpl

ex d

epos

ition

in th

eca

pilla

ries,

arte

riole

s an

d ve

nule

s in

org

ans

such

as th

e sk

in a

nd th

e ki

dney

s, w

hich

cau

ses

sym

ptom

s vi

a th

e ac

tivat

ion

of c

ompl

emen

t.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

Trea

tmen

t is

gene

rally

sup

port

ive

due

to h

igh

rate

s of

spo

ntan

eous

rem

issi

on.

• An

alge

sia.

• St

eroi

ds m

ay s

omet

imes

be

used

in s

ever

e

cas

es.

Sym

ptom

sHS

P is

com

pris

ed o

f a tr

iad.

Rem

embe

r as

RAP:

1. R

– R

enal

man

ifest

atio

ns:

•

Haem

atur

ia –

mic

rosc

opic

/mac

rosc

opic

.

• AN

CA n

egat

ive

glom

erul

onep

hriti

s.

• N

ephr

otic

syn

drom

e (ra

re).

2. A

– A

rthr

algi

a an

d ab

dom

inal

pai

n.3.

P –

Pur

pura

:

• Th

is ty

pica

lly a

ffect

s th

e bu

ttoc

ks a

nd th

e

lo

wer

lim

bs. H

owev

er, i

t may

affe

ct th

e

ar

ms.

Inve

stig

atio

ns•

Urin

alys

is a

nd e

stim

ated

GFR

.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

Cr:B

UN,

LDH

, CRP

,

ESR

.•

IgA

leve

ls.•

Skin

bio

psy

if in

dica

ted

or if

ther

e is

dia

gnos

tic

unc

erta

inty

: im

mun

oflu

ores

cenc

e sh

ows

IgA

d

epos

its a

nd C

3.

Com

plic

atio

nsRe

mem

ber a

s A

BC:

A –

Acu

te k

idne

y in

jury

B –

Bow

el o

bstr

uctio

n: in

tuss

usce

ptio

nC

– Ch

roni

c ki

dney

inju

ry

MAP

4.1

9.H

enoc

h–Sc

hönl

ein

purp

ura

(HSP

)

142

K30033_C004.indd 142 28/02/17 11:44 am

143

Paed

iatr

ics

Wha

t is

Hen

och–

Schö

nlei

n pu

rpur

a?Th

is is

a s

yste

mic

vas

culit

is th

at p

rese

nts

with

typi

cal s

igns

and

sym

ptom

s.

Caus

esHS

P is

cau

sed

by Ig

A co

mpl

ex d

epos

ition

in th

eca

pilla

ries,

arte

riole

s an

d ve

nule

s in

org

ans

such

as th

e sk

in a

nd th

e ki

dney

s, w

hich

cau

ses

sym

ptom

s vi

a th

e ac

tivat

ion

of c

ompl

emen

t.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

Trea

tmen

t is

gene

rally

sup

port

ive

due

to h

igh

rate

s of

spo

ntan

eous

rem

issi

on.

• An

alge

sia.

• St

eroi

ds m

ay s

omet

imes

be

used

in s

ever

e

cas

es.

Sym

ptom

sHS

P is

com

pris

ed o

f a tr

iad.

Rem

embe

r as

RAP:

1. R

– R

enal

man

ifest

atio

ns:

•

Haem

atur

ia –

mic

rosc

opic

/mac

rosc

opic

.

• AN

CA n

egat

ive

glom

erul

onep

hriti

s.

• N

ephr

otic

syn

drom

e (ra

re).

2. A

– A

rthr

algi

a an

d ab

dom

inal

pai

n.3.

P –

Pur

pura

:

• Th

is ty

pica

lly a

ffect

s th

e bu

ttoc

ks a

nd th

e

lo

wer

lim

bs. H

owev

er, i

t may

affe

ct th

e

ar

ms.

Inve

stig

atio

ns•

Urin

alys

is a

nd e

stim

ated

GFR

.•

Bloo

d te

sts:

FBC,

U&

E, L

FTs,

Cr:B

UN,

LDH

, CRP

,

ESR

.•

IgA

leve

ls.•

Skin

bio

psy

if in

dica

ted

or if

ther

e is

dia

gnos

tic

unc

erta

inty

: im

mun

oflu

ores

cenc

e sh

ows

IgA

d

epos

its a

nd C

3.

Com

plic

atio

nsRe

mem

ber a

s A

BC:

A –

Acu

te k

idne

y in

jury

B –

Bow

el o

bstr

uctio

n: in

tuss

usce

ptio

nC

– Ch

roni

c ki

dney

inju

ry

MAP

4.1

9.H

enoc

h–Sc

hönl

ein

purp

ura

(HSP

)

Map

4.1

9. H

eno

ch–S

chö

nle

in p

urp

ura

(H

SP)

K30033_C004.indd 143 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

4. C

hild

ho

od

ep

ilep

sy s

ynd

rom

es

TABL

E 4.

4. C

hild

hood

epi

leps

y sy

ndro

mes

.

Type

of

epile

psy

Feat

ures

Inve

stig

atio

nsTr

eatm

ent

Abse

nce

Caus

e: e

xact

cau

se is

unk

now

n bu

t is

thou

ght t

o in

volv

e T-

type

Ca2+

cha

nnel

s. Se

izur

es m

ay b

e tr

igge

red

by h

yper

vent

ilatio

nFe

atur

es:

• Ak

a pe

tit m

al s

eizu

res

• Co

nsci

ousn

ess

is im

paire

d•

Ofte

n pi

cked

up

as d

ay d

ream

ing

in s

choo

l•

Mor

e co

mm

on fe

mal

es•

May

be

asso

ciat

ed w

ith a

utom

atis

ms

(e.g

. lip

sm

acki

ng)

EEG

: 3Hz

spi

ke a

nd

wav

e Et

hosu

xim

ide

Beni

gn ro

land

ic e

pile

psy

Caus

e: u

nkno

wn

Feat

ures

:•

Occ

urs

at n

ight

tim

e•

Abno

rmal

sen

satio

n (e

.g. p

arae

sthe

sia

of th

e co

rner

of

the

patie

nt’s

mou

th a

nd to

ngue

)•

Droo

ling

and

bed

wet

ting

may

occ

ur•

Tend

s to

rem

it by

pub

erty

EEG

: cen

trot

empo

ral

spik

esO

ften

not u

sed

sinc

e th

e co

nditi

on is

be

nign

Antie

pile

ptic

s: ca

rbam

azep

ine

is u

sed

first

line

144

K30033_C004.indd 144 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

4. C

hild

ho

od

ep

ilep

sy s

ynd

rom

es

Lenn

ox–G

asta

ut s

yndr

ome

Caus

e: o

vera

ll th

e ca

use

is u

nkno

wn

but i

t may

occ

ur

seco

ndar

y to

con

geni

tal o

r acq

uire

d ca

uses

. Con

geni

tal

caus

es in

clud

e tu

bero

us s

cler

osis

and

inhe

rited

m

etab

olic

dis

orde

rs. A

cqui

red

caus

es in

clud

e in

fect

ion,

tr

aum

a an

d tu

mou

rs

Feat

ures

: •

Vary

ing

type

s of

sei

zure

s•

Stat

us e

pile

ptic

us m

ay o

ccur

• As

soci

ated

with

dro

p at

tack

s•

Asso

ciat

ed w

ith le

arni

ng d

ifficu

lties

and

de

velo

pmen

tal d

elay

• Pe

rsis

ts in

to a

dult

life

EEG

: Slo

w s

pike

and

w

ave

Diffi

cult

to tr

eat

Antie

pile

ptic

: sod

ium

val

proa

te is

ofte

n us

ed fi

rst l

ine

Pred

niso

lone

is s

omet

imes

use

d

Wes

t’s s

yndr

ome

Caus

e: e

xact

cau

se is

unk

now

n. H

owev

er, t

here

are

th

eorie

s th

at s

ugge

st th

e in

volv

emen

t of a

bnor

mal

G

ABA

neur

otra

nsm

itter

or t

he e

xces

sive

pro

duct

ion

of

cort

icot

ropi

n-re

leas

ing

horm

one

Feat

ures

:•

Ther

e ar

e th

ree

diffe

rent

type

s of

att

ack:

1. L

ight

ning

att

acks

2. N

oddi

ng a

ttac

ks3.

Jac

kkni

fe a

ttac

ks

• As

soci

ated

with

: ABC

D:A

– A

icar

di s

yndr

ome

B –

Brai

n da

mag

eC

– C

ereb

ral a

trop

hyD

– D

yspl

asia

of t

he c

orex

EEG

: hyp

sarr

hyth

mia

Di

fficu

lt to

trea

tAn

tiepi

lept

ic: v

igab

atrin

is o

ften

used

fir

st li

nePr

edni

solo

ne is

som

etim

es u

sed

145

K30033_C004.indd 145 28/02/17 11:44 am

Paed

iatr

ics

Map

4.2

0. D

iab

etic

ket

oac

ido

sis

(DK

A)

Wha

t is

dia

beti

c ke

toac

idos

is?

This

is a

n em

erge

ncy

that

is a

ssoc

iate

d w

ithty

pe 1

dia

bete

s (s

ee M

ap 2

.2, p

. 40)

. It i

s a

stat

e of

unc

ontr

olle

d ca

tabo

lism

in w

hich

ket

one

bodi

es a

re fo

rmed

. The

ket

one

bodi

es a

re

acet

one,

ace

toac

etat

e an

d be

ta-h

ydro

xybu

tyra

te.

This

may

be

the

patie

nt’s

first

pre

sent

atio

n to

em

erge

ncy

serv

ices

prio

r to

a di

abet

ic d

iagn

osis

or

it m

ay b

e br

ough

t on

by th

e pa

tient

mis

sing

th

eir i

nsul

in d

ose

or b

ecau

se o

f str

ess

(e.g

. ill

ness

)

Caus

es•

Non

-del

iber

ate

omis

sion

of i

nsul

in

(e.g

. illn

ess)

.•

Delib

erat

e om

issi

on o

f ins

ulin

(e.g

. chi

ldre

n

w

ith u

nsta

ble

fam

ily c

ircum

stan

ces,

co

-mor

bid

psyc

hiat

ric d

isor

der s

uch

as

eatin

g di

sord

ers

or d

epre

ssio

n, p

sych

osoc

ial

im

pact

of h

avin

g a

chro

nic

illne

ss re

sulti

ng in

mis

sed

dose

s at

sch

ool o

r uni

vers

ity).

The

path

ophy

siol

ogy

of D

KA is

sum

mar

ized

in

Figu

re 4

.1 (p

. 148

).

Trea

tmen

t

Resu

scit

atio

n:•

Airw

ay –

+/–

nas

ogas

tric

tube

.•

Brea

thin

g –

100%

oxy

gen.

• Ci

rcul

atio

n –

IV s

alin

e so

lutio

n.

Clin

ical

ly a

cido

tic

but

not

in s

hock

:•

IV th

erap

y –

salin

e so

lutio

n an

d ad

ditio

nal

K

Cl th

erap

y (m

onito

r ECG

).•

Fixe

d ra

te in

sulin

infu

sion

of 0

.1un

it/kg

/h IV

(

typi

cally

50

units

Act

rapi

d® in

50m

l 0.9

%

sal

ine)

.•

Cons

tant

pat

ient

obs

erva

tions

(e.g

. glu

cose

leve

ls, u

rine

outp

ut, f

luid

inpu

t, ne

urol

ogic

al

st

atus

, ele

ctro

lyte

s an

d EC

G).

• St

art b

road

-spe

ctru

m a

ntib

iotic

s if

infe

ctio

n

s

uspe

cted

.

Clin

ical

ly w

ell a

nd t

oler

atin

g or

al fl

uids

:•

Star

t sub

cuta

neou

s in

sulin

.•

Cont

inue

ora

l hyd

ratio

n th

erap

y.

Inve

stig

atio

ns•

Bloo

ds: g

luco

se le

vels,

U&

E, b

lood

gas

es.

• U

rinal

ysis

: for

ket

ones

.•

If in

fect

ion

susp

ecte

d, th

en o

btai

n cu

lture

s

(blo

od, u

rine,

thro

at) a

nd p

erfo

rm th

e

'sep

tic s

ix'.

• EC

G –

tent

ed T-

wav

es a

nd b

road

enin

g of

the

Q

RS c

ompl

ex m

ay b

e se

en in

hyp

erka

laem

ia

a

ssoc

iate

d w

ith p

otas

sium

ther

apy

• AB

G: a

sses

s th

e de

gree

of a

cido

sis.

• Am

ylas

e: a

bdom

inal

pai

n an

d vo

miti

ng is

als

o as

soci

ated

with

pan

crea

titis.

• Ra

diol

ogy:

che

st x

-ray

may

be

requ

ired

to

l

ocat

e so

urce

of i

nfec

tion.

Sym

ptom

s

Gen

eral

sym

ptom

s:•

Poly

uria

/enu

resi

s.•

Poly

dips

ia.

• W

eigh

t los

s.•

Abdo

min

al p

ain.

• Le

thar

gy.

• Vo

miti

ng.

• Co

nfus

ion.

Clin

ical

sig

ns o

f DKA

:•

Dehy

drat

ion.

• Po

lyur

ia.

• Po

lydi

psia

.•

Tach

ycar

dia.

• Hy

pote

nsio

n.•

Kaus

smau

l bre

athi

ng (t

o ex

hale

exc

essi

ve

CO2)

.•

Acet

one

swee

t sm

ellin

g br

eath

.•

Conf

usio

n.•

Com

a.

Bioc

hem

ical

sig

ns:

• Ke

tonu

ria.

• In

crea

sed

bloo

d gl

ucos

e le

vel.

• Ac

idae

mia

.

Com

plic

atio

ns•

Com

a.•

Com

plic

atio

ns o

f tre

atm

ent,

e.g.

:

Ce

rebr

al o

edem

a.

Hy

poka

laem

ia.

Hypo

glyc

aem

ia.

MAP

4.2

0. D

iabe

tic

keto

acid

osis

(DK

A)

146

K30033_C004.indd 146 28/02/17 11:44 am

Paed

iatr

ics

Map

4.2

0. D

iab

etic

ket

oac

ido

sis

(DK

A)

Wha

t is

dia

beti

c ke

toac

idos

is?

This

is a

n em

erge

ncy

that

is a

ssoc

iate

d w

ithty

pe 1

dia

bete

s (s

ee M

ap 2

.2, p

. 40)

. It i

s a

stat

e of

unc

ontr

olle

d ca

tabo

lism

in w

hich

ket

one

bodi

es a

re fo

rmed

. The

ket

one

bodi

es a

re

acet

one,

ace

toac

etat

e an

d be

ta-h

ydro

xybu

tyra

te.

This

may

be

the

patie

nt’s

first

pre

sent

atio

n to

em

erge

ncy

serv

ices

prio

r to

a di

abet

ic d

iagn

osis

or

it m

ay b

e br

ough

t on

by th

e pa

tient

mis

sing

th

eir i

nsul

in d

ose

or b

ecau

se o

f str

ess

(e.g

. ill

ness

)

Caus

es•

Non

-del

iber

ate

omis

sion

of i

nsul

in

(e.g

. illn

ess)

.•

Delib

erat

e om

issi

on o

f ins

ulin

(e.g

. chi

ldre

n

w

ith u

nsta

ble

fam

ily c

ircum

stan

ces,

co

-mor

bid

psyc

hiat

ric d

isor

der s

uch

as

eatin

g di

sord

ers

or d

epre

ssio

n, p

sych

osoc

ial

im

pact

of h

avin

g a

chro

nic

illne

ss re

sulti

ng in

mis

sed

dose

s at

sch

ool o

r uni

vers

ity).

The

path

ophy

siol

ogy

of D

KA is

sum

mar

ized

in

Figu

re 4

.1 (p

. 148

).

Trea

tmen

t

Resu

scit

atio

n:•

Airw

ay –

+/–

nas

ogas

tric

tube

.•

Brea

thin

g –

100%

oxy

gen.

• Ci

rcul

atio

n –

IV s

alin

e so

lutio

n.

Clin

ical

ly a

cido

tic

but

not

in s

hock

:•

IV th

erap

y –

salin

e so

lutio

n an

d ad

ditio

nal

K

Cl th

erap

y (m

onito

r ECG

).•

Fixe

d ra

te in

sulin

infu

sion

of 0

.1un

it/kg

/h IV

(

typi

cally

50

units

Act

rapi

d® in

50m

l 0.9

%

sal

ine)

.•

Cons

tant

pat

ient

obs

erva

tions

(e.g

. glu

cose

leve

ls, u

rine

outp

ut, f

luid

inpu

t, ne

urol

ogic

al

st

atus

, ele

ctro

lyte

s an

d EC

G).

• St

art b

road

-spe

ctru

m a

ntib

iotic

s if

infe

ctio

n

s

uspe

cted

.

Clin

ical

ly w

ell a

nd t

oler

atin

g or

al fl

uids

:•

Star

t sub

cuta

neou

s in

sulin

.•

Cont

inue

ora

l hyd

ratio

n th

erap

y.

Inve

stig

atio

ns•

Bloo

ds: g

luco

se le

vels,

U&

E, b

lood

gas

es.

• U

rinal

ysis

: for

ket

ones

.•

If in

fect

ion

susp

ecte

d, th

en o

btai

n cu

lture

s

(blo

od, u

rine,

thro

at) a

nd p

erfo

rm th

e

'sep

tic s

ix'.

• EC

G –

tent

ed T-

wav

es a

nd b

road

enin

g of

the

Q

RS c

ompl

ex m

ay b

e se

en in

hyp

erka

laem

ia

a

ssoc

iate

d w

ith p

otas

sium

ther

apy

• AB

G: a

sses

s th

e de

gree

of a

cido

sis.

• Am

ylas

e: a

bdom

inal

pai

n an

d vo

miti

ng is

als

o as

soci

ated

with

pan

crea

titis.

• Ra

diol

ogy:

che

st x

-ray

may

be

requ

ired

to

l

ocat

e so

urce

of i

nfec

tion.

Sym

ptom

s

Gen

eral

sym

ptom

s:•

Poly

uria

/enu

resi

s.•

Poly

dips

ia.

• W

eigh

t los

s.•

Abdo

min

al p

ain.

• Le

thar

gy.

• Vo

miti

ng.

• Co

nfus

ion.

Clin

ical

sig

ns o

f DKA

:•

Dehy

drat

ion.

• Po

lyur

ia.

• Po

lydi

psia

.•

Tach

ycar

dia.

• Hy

pote

nsio

n.•

Kaus

smau

l bre

athi

ng (t

o ex

hale

exc

essi

ve

CO2)

.•

Acet

one

swee

t sm

ellin

g br

eath

.•

Conf

usio

n.•

Com

a.

Bioc

hem

ical

sig

ns:

• Ke

tonu

ria.

• In

crea

sed

bloo

d gl

ucos

e le

vel.

• Ac

idae

mia

.

Com

plic

atio

ns•

Com

a.•

Com

plic

atio

ns o

f tre

atm

ent,

e.g.

:

Ce

rebr

al o

edem

a.

Hy

poka

laem

ia.

Hypo

glyc

aem

ia.

MAP

4.2

0. D

iabe

tic

keto

acid

osis

(DK

A)

147

K30033_C004.indd 147 28/02/17 11:44 am

Paed

iatr

ics

FIG

URE

4.1.

Pat

ho

ph

ysio

log

y o

f d

iab

etic

ket

oac

ido

sis

Stat

e of

unc

ontr

olle

d ca

tabo

lism

Diab

etic

ket

oaci

dosi

s

Lipo

lysi

s In

crea

sed

bloo

d gl

ucos

e le

vels

Osm

otic

diu

resi

s

Rena

l hyp

oper

fusi

on

Stat

e of

unc

ontr

olle

d ca

tabo

lism

Keto

nes

man

ufac

ture

d

The

kidn

ey, b

ecau

se o

f ren

al h

ypop

erfu

sion

and

the

anti-

insu

lin a

ctio

n of

gluc

agon

, cor

tisol

and

cat

echo

lam

ines

,ca

nnot

exc

rete

ket

ones

pro

ficie

ntly

FIG

URE

4.1

. Pat

hoph

ysio

logy

of d

iabe

tic k

etoa

cido

sis

148

4.5.

Tri

som

ies

K30033_C004.indd 148 28/02/17 11:44 am

149

Paed

iatr

ics

TABL

E 4.

5. T

riso

mie

s.

Tris

omy

Synd

rom

e na

me

Sym

ptom

sIn

vest

igat

ions

Com

plic

atio

ns

21Do

wn’

s sy

ndro

me

• Le

arni

ng d

ifficu

lties

• Sh

ort s

tatu

re•

Flat

tene

d no

se•

Slan

ted

eyes

• Si

mia

n cr

ease

• G

ap b

etw

een

1st a

nd 2

nd to

e

Ante

nata

l tes

ting

– U

SS fo

r nuc

hal

tran

sluc

ency

(see

Tabl

e 2.

1, p

. 34)

Radi

olog

y –

pelv

ic x

-ray

sho

ws

dysp

last

ic p

elvi

s

• At

rial s

epta

l def

ects

• Ve

ntric

ular

sep

tal d

efec

ts•

Duod

enal

atr

esia

• Ac

ute

lym

phob

last

ic le

ukae

mia

• Al

zhei

mer

’s di

seas

e•

Hypo

thyr

oidi

sm

18Ed

war

d’s

synd

rom

e•

Rock

er b

otto

m fe

et•

Lear

ning

diffi

culti

es•

Clen

ched

han

ds•

Low

set

ear

s•

Mic

rogn

athi

a•

Clef

t lip

or c

left

pala

te•

Und

esce

nded

test

icle

s

Chro

mos

omal

ana

lysi

s co

nfirm

s di

agno

sis

ECG

and

ECH

O –

for c

ardi

ac

com

plic

atio

ns

• Co

arct

atio

n of

the

aort

a •

Atria

l sep

tal d

efec

ts•

Ingu

inal

her

nia

• O

mph

aloc

oele

• Re

nal a

gene

sis

13Pa

tau’

s sy

ndro

me

• Le

arni

ng d

ifficu

lties

• Co

ngen

ital h

eart

dis

ease

• Cl

eft l

ip/p

alat

e•

Mic

roce

phal

y •

Poly

dact

yly

• Ro

cker

bot

tom

feet

Chro

mos

omal

ana

lysi

s co

nfirm

s di

agno

sis

ECG

and

ECH

O –

for c

ardi

ac

com

plic

atio

ns

• O

mph

aloc

oele

• Po

lycy

stic

kid

neys

• Ve

ntric

ular

sep

tal d

efec

ts•

Ingu

inal

her

nia

Tabl

e 4.

5. T

riso

mie

s

4.5.

Tri

som

ies

K30033_C004.indd 149 28/02/17 11:44 am

Paed

iatr

ics

Map

4.2

1. K

awas

aki’s

dis

ease

Wha

t is

Kaw

asak

i’s d

isea

se?

This

is a

rare

form

of a

utoi

mm

une

vasc

uliti

s;al

so k

now

n as

lym

ph n

ode

synd

rom

e.It

is v

ital t

o di

agno

se d

ue to

its

seve

reco

mpl

icat

ions

.

Caus

esEx

act c

ause

is n

ot k

now

n. It

is th

ough

t to

bean

aut

oim

mun

e va

scul

itis.

Sym

ptom

sRe

mem

ber a

s A

BCD

ES:

A –

A h

igh

feve

r >5

days

B –

Brig

ht re

d lip

sC

– Ce

rvic

al ly

mph

aden

opat

hyD

– D

esqu

amat

ion

of h

ands

and

feet

E –

Eyes

: non

-pur

ulen

t bila

tera

l

con

junc

tiviti

sS

– St

raw

berr

y to

ngue

Inve

stig

atio

nsKa

was

aki’s

dis

ease

is a

clin

ical

dia

gnos

is a

ndth

ere

is n

o sp

ecifi

c te

st; h

owev

er, i

t is

vita

l to

perfo

rm a

n EC

HO lo

okin

g fo

r cor

onar

yan

eury

sms,

whi

ch a

re a

ser

ious

com

plic

atio

n.

• Bl

ood

test

s: FB

C, W

CC, U

&E,

LFT

s, ES

R, C

RP.

• U

rinal

ysis.

• EC

G.•

Radi

olog

y:

EC

HO.

USS

/CT

if in

dica

ted:

may

sho

w

ga

llbla

dder

enl

arge

men

t.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

IV im

mun

oglo

bulin

ther

apy.

• As

pirin

(Kaw

asak

i’s d

isea

se is

the

only

ex

cept

ion

for t

he u

se o

f asp

irin

in c

hild

ren

d

ue to

the

risk

of R

eye

synd

rom

e).

Com

plic

atio

ns•

Coro

nary

ane

urys

ms.

• Dy

srhy

thm

ias.

• M

yoca

rditi

s.•

Valv

ular

abn

orm

aliti

es.

MAP

4.2

1. K

awas

aki’s

dis

ease

150

K30033_C004.indd 150 28/02/17 11:44 am

Paed

iatr

ics

Map

4.2

1. K

awas

aki’s

dis

ease

Wha

t is

Kaw

asak

i’s d

isea

se?

This

is a

rare

form

of a

utoi

mm

une

vasc

uliti

s;al

so k

now

n as

lym

ph n

ode

synd

rom

e.It

is v

ital t

o di

agno

se d

ue to

its

seve

reco

mpl

icat

ions

.

Caus

esEx

act c

ause

is n

ot k

now

n. It

is th

ough

t to

bean

aut

oim

mun

e va

scul

itis.

Sym

ptom

sRe

mem

ber a

s A

BCD

ES:

A –

A h

igh

feve

r >5

days

B –

Brig

ht re

d lip

sC

– Ce

rvic

al ly

mph

aden

opat

hyD

– D

esqu

amat

ion

of h

ands

and

feet

E –

Eyes

: non

-pur

ulen

t bila

tera

l

con

junc

tiviti

sS

– St

raw

berr

y to

ngue

Inve

stig

atio

nsKa

was

aki’s

dis

ease

is a

clin

ical

dia

gnos

is a

ndth

ere

is n

o sp

ecifi

c te

st; h

owev

er, i

t is

vita

l to

perfo

rm a

n EC

HO lo

okin

g fo

r cor

onar

yan

eury

sms,

whi

ch a

re a

ser

ious

com

plic

atio

n.

• Bl

ood

test

s: FB

C, W

CC, U

&E,

LFT

s, ES

R, C

RP.

• U

rinal

ysis.

• EC

G.•

Radi

olog

y:

EC

HO.

USS

/CT

if in

dica

ted:

may

sho

w

ga

llbla

dder

enl

arge

men

t.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt a

nd p

aren

t edu

catio

n.

Med

ical

:•

IV im

mun

oglo

bulin

ther

apy.

• As

pirin

(Kaw

asak

i’s d

isea

se is

the

only

ex

cept

ion

for t

he u

se o

f asp

irin

in c

hild

ren

d

ue to

the

risk

of R

eye

synd

rom

e).

Com

plic

atio

ns•

Coro

nary

ane

urys

ms.

• Dy

srhy

thm

ias.

• M

yoca

rditi

s.•

Valv

ular

abn

orm

aliti

es.

MAP

4.2

1. K

awas

aki’s

dis

ease

151

K30033_C004.indd 151 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

6. C

hild

ho

od

can

cers

TABL

E 4.

6. C

hild

hood

can

cers

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Acut

e ly

mph

obla

stic

le

ukae

mia

(ALL

)

A ra

re n

eopl

asm

of t

he

bloo

d/bo

ne m

arro

w. T

he

exac

t cau

se is

unk

now

n bu

t it

is li

kely

due

to a

gen

etic

su

scep

tibili

ty c

oupl

ed w

ith

an e

nviro

nmen

tal t

rigge

r. It

is th

e co

mm

ones

t can

cer

in c

hild

ren.

Ass

ocia

ted

with

Do

wn’

s sy

ndro

me

• Bo

ne m

arro

w fa

ilure

•

Brui

sing

•

Shor

tnes

s of

bre

ath

• Pu

rpur

a •

Mal

aise

•

Wei

ght l

oss

• N

ight

sw

eats

Bloo

ds: F

BC, W

CC,

plat

elet

s, U

&E,

LF

Ts, E

SR, C

RPBo

ne m

arro

w

biop

sy, l

ymph

nod

e bi

opsy

Radi

olog

y: x

-ray

, USS

, CT

, MRI

ALL

is c

lass

ified

us

ing

the

Fren

ch–

Amer

ican

–Brit

ish

(FAB

) cla

ssifi

catio

n

To in

duce

rem

issi

on:

• De

xam

etha

sone

• Vi

ncris

tine

• An

thra

cycl

ine

antib

iotic

s•

Cycl

opho

spha

mid

e

Mai

nten

ance

:•

Met

hotr

exat

e•

Mer

capt

opur

ine

• Cy

tara

bine

• Hy

droc

ortis

one

• De

ath

• O

ften

spre

ads

to th

e ce

ntra

l ne

rvou

s sy

stem

• In

crea

sed

risk

of

infe

ctio

n•

Haem

orrh

age

• De

pres

sion

• Co

mpl

icat

ions

of

chem

othe

rapy

Neu

robl

asto

ma

This

is a

neu

roen

docr

ine

tum

our a

risin

g fro

m

neur

obla

st c

ells

with

in

the

sym

path

etic

ner

vous

sy

stem

. Neu

robl

asto

mas

m

ostly

orig

inat

e in

the

adre

nal g

land

s bu

t may

de

velo

p an

ywhe

re a

long

the

sym

path

etic

ner

vous

sys

tem

.

Sym

ptom

s di

ffer d

epen

ding

on

the

loca

tion

of th

e le

sion

. G

ener

al s

ympt

oms:

• W

eigh

t los

s•

Anor

exia

• Em

esis

Bloo

ds: F

BC, W

CC,

plat

elet

s, U

&E,

LFT

s, TF

Ts, E

SR, C

RP,

calc

ium

, mag

nesi

um,

phos

phor

us, u

ric a

cid,

LD

H, Ig

G le

vels

Trea

tmen

t dep

ends

on

the

stag

e of

the

tum

our a

nd is

de

liver

ed b

y a

mul

tidis

cipl

inar

y te

am.

• Re

laps

e an

d re

curr

ent d

isea

se•

Met

asta

sis

152

K30033_C004.indd 152 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

6. C

hild

ho

od

can

cers

It is

the

mos

t com

mon

ex

trac

rani

al s

olid

tum

our o

f in

fanc

y. Th

e ex

act c

ause

of

neur

obla

stom

a is

unk

now

n bu

t ALK

mut

atio

ns h

ave

been

iden

tified

in fa

mili

al

case

s. Fi

fty to

60%

pre

sent

w

ith m

etas

tase

s

Abdo

men

:•

Abdo

min

al p

ain

• Sw

ellin

gCh

est:

• Re

spira

tory

diffi

culty

Bone

/bon

e m

arro

w:

• Bo

ne p

ain

• Li

mp

Para

spin

al c

ord

gang

lia

resu

lts in

neu

rolo

gica

l sy

mpt

oms

such

as:

• W

eakn

ess

• Pa

raly

sis

• Bl

adde

r dys

func

tion

• Bo

wel

dys

func

tion

Rare

sym

ptom

s:•

Hype

rten

sion

(ren

al a

rter

y co

mpr

essi

on)

• Ch

roni

c di

arrh

oea

(vas

oact

ive

inte

stin

al

pept

ide

secr

etio

n)

Incr

ease

d le

vels

of

urin

e ca

tech

olam

ines

(o

r the

ir m

etab

olite

s [e

.g. h

omov

anill

ic

acid

/van

illyl

man

delic

ac

id])

Radi

olog

y: C

T, m

eta-

iodo

benz

ylgu

anid

ine

scan

Hist

olog

y: H

omer

W

right

rose

ttes

.N

euro

blas

tom

as

are

clas

sifie

d us

ing

the

Inte

rnat

iona

l N

euro

blas

tom

a St

agin

g Sy

stem

(IN

SS)

Med

ical

: com

mon

ch

emot

hera

py c

ombi

natio

ns

incl

ude:

• Vi

ncris

tine,

cy

clop

hosp

ham

ide

and

doxo

rubi

cin

• Ci

spla

tin a

nd e

topo

side

• Ca

rbop

latin

and

eto

posi

de•

Ifosf

amid

e an

d et

opos

ide

• Cy

clop

hosp

ham

ide

and

topo

teca

n

Surg

ical

: •

Surg

ical

rese

ctio

n in

lo

caliz

ed d

isea

se is

cur

ativ

e•

Surg

ery

post

che

mot

hera

py

may

be

seen

as

a de

bulk

ing

proc

edur

e

• Pa

rane

opla

stic

sy

ndro

mes

(e.g

. op

socl

onus

m

yocl

onus

sy

ndro

me)

• Co

mpl

icat

ions

of

chem

othe

rapy

Cont

inue

d ov

erle

af

153

K30033_C004.indd 153 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

6. C

hild

ho

od

can

cers

Wilm

s’ tu

mou

r(a

ka

neph

robl

asto

ma)

Is a

form

of r

enal

can

cer

that

occ

urs

in c

hild

ren.

It

is a

ssoc

iate

d w

ith a

nirid

ia.

Nep

hrob

last

omas

are

mos

tly

unila

tera

l. It

is a

ssoc

iate

d w

ith W

T1 g

ene

mut

atio

ns

(chr

omos

ome

11p1

3) in

20

% o

f cas

es.

Synd

rom

es a

ssoc

iate

d w

ith

Wilm

s’ tu

mou

rs:

• De

nys–

Dras

h sy

ndro

me

• Fr

asie

r syn

drom

e•

Spor

adic

ani

ridia

• Li

–Fra

umen

i syn

drom

e

• Ab

dom

inal

sw

ellin

g•

Abdo

min

al p

ain

• Ha

emat

uria

• N

ause

a •

Vom

iting

Bloo

ds: F

BC, W

CC,

plat

elet

s, U

&E,

LFT

s, ES

R, C

RP, B

UN

U

rinal

ysis

Radi

olog

y: a

bdom

inal

U

SS, a

bdom

inal

x-

ray,

ches

t x-r

ay, C

T ab

dom

en, M

RI, I

V py

elog

ram

Trea

tmen

t dep

ends

on

the

stag

e an

d si

ze o

f the

tum

our a

s w

ell a

s hi

stop

atho

logi

cal a

nd

mol

ecul

ar tu

mou

r fea

ture

s.

Chem

othe

rapy

: som

e st

anda

rd c

hem

othe

rapy

re

gim

ens

are

liste

d be

low

:•

Vinc

ristin

e an

d da

ctin

omyc

in•

Vinc

ristin

e, d

actin

omyc

in

and

doxo

rubi

cin

• Vi

ncris

tine,

dox

orub

icin

, cy

clop

hosp

ham

ide

and

etop

osid

e

Radi

othe

rapy

Surg

ical

: nep

hrec

tom

y

• M

etas

tasi

s•

Hype

rten

sion

, pa

rtic

ular

ly if

bi

late

ral r

enal

in

volv

emen

t

TABL

E 4.

6. C

hild

hood

can

cers

(con

tinue

d).

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

154

K30033_C004.indd 154 28/02/17 11:44 am

Paed

iatr

ics

Tabl

e 4.

6. C

hild

ho

od

can

cers

Ewin

g’s

sarc

oma

This

is a

rare

, mal

igna

nt

smal

l, ro

und,

blu

e ce

ll tu

mou

r affe

ctin

g th

e bo

ne/

soft

tissu

e. It

typi

cally

affe

cts

teen

ager

s an

d yo

ung

adul

ts.

Usu

ally

a re

sult

of t(

11;2

2)

tran

sloc

atio

ns re

sulti

ng in

a

EWSR

1/FL

I1 fu

sion

gen

e.

The

mos

t com

mon

regi

ons

affe

cted

are

:

• Pe

lvis

• Fe

mur

• Hu

mer

us•

Ribs

• Cl

avic

le

• Pa

in in

the

loca

tion

of th

e tu

mou

r, w

hich

wor

sens

ov

er ti

me

• A

swel

ling

in th

e lo

catio

n of

the

tum

our

• Sw

ellin

g an

d de

crea

sed

rang

e of

mov

emen

t of t

he

affe

cted

join

t•

Feve

r of u

nkno

wn

orig

in•

Unp

rovo

ked

bone

frac

ture

• G

ener

al s

ympt

oms

such

as

leth

argy

and

wei

ght l

oss

Bloo

ds: F

BC, W

CC,

plat

elet

s, U

&E,

LFT

s, TF

Ts, E

SR, C

RPRa

diol

ogy:

x-r

ays

(sho

w ‘m

oth-

eate

n’

radi

oluc

enci

es),

CT, M

RI, P

ET, b

one

scin

tigra

phy

Hist

olog

y: s

mal

l, ro

und,

blu

e ce

ll tu

mou

r. Cl

ear

cyto

plas

m w

ith H

&E

stai

ning

Trea

tmen

t dep

ends

on

the

stag

e an

d si

ze o

f the

tum

our

as w

ell a

s hi

stop

atho

logi

cal

feat

ures

.

Chem

othe

rapy

: som

e ch

emot

hera

py re

gim

ens

are

liste

d be

low

:•

Ifosf

amid

e an

d et

opos

ide

• Vi

ncris

tine,

dox

orub

icin

and

cy

clop

hosp

ham

ide

Radi

othe

rapy

Surg

ical

: lim

b am

puta

tion

• M

etas

tasi

s•

Lim

b am

puta

tion

155

K30033_C004.indd 155 28/02/17 11:44 am

K30033_C004.indd 156 28/02/17 11:44 am

Chap

ter F

ive

Oph

thal

mol

ogy

Oph

thal

mol

ogy

TABL

E 5.

1 S

ud

den

pai

nle

ss v

isu

al lo

ss

158

MAP

5.1

M

acu

lar

deg

ener

atio

n

162

MAP

5.2

G

lau

com

a 16

4

MAP

5.3

Cat

arac

ts

166

TABL

E 5.

2 R

ed e

ye

168

TABL

E 5.

3 D

iab

etic

eye

dis

ease

17

0

157

K30033_C005.indd 157 28/02/17 11:10 am

Oph

thal

mol

ogy

158

Tabl

e 5.

1. S

ud

den

pai

nle

ss v

isu

al lo

ss

TABL

E 5.

1. S

udde

n pa

inle

ss v

isua

l los

s.

Ther

e ar

e m

any

caus

es o

f pai

nles

s lo

ss o

f vis

ion.

The

y m

ay b

e re

mem

bere

d by

the

mne

mon

ic O

IRO

V:

Opt

ical

– o

cclu

sion

of t

he re

tinal

vei

n; Is

sues

– is

chae

mic

opt

ic n

euro

path

y; R

eally

– re

tinal

det

achm

ent;

Obs

cure

– o

cclu

sion

of t

he

retin

al a

rter

y; V

isio

n –

vitr

eous

hae

mor

rhag

e.

Dis

ease

Caus

eFe

atur

esIn

vest

igat

ions

Trea

tmen

t

Occ

lusi

on o

f the

re

tinal

vei

n•

Hype

rten

sion

• G

lauc

oma

• Po

lycy

thae

mia

• Su

dden

pai

nles

s m

onoc

ular

vis

ion

loss

or d

ense

cen

tral

sco

tom

a•

Isch

aem

ic s

ubty

pe is

ass

ocia

ted

with

acu

te p

rese

ntat

ion,

whe

reas

no

n-is

chae

mic

sub

type

may

pr

esen

t mor

e su

btly

• Vi

sual

acu

ity•

Pupi

l ana

lysi

s: m

ay s

how

an

ipsi

late

ral a

ffere

nt p

upill

ary

defe

ct•

Intr

aocu

lar p

ress

ure

(IOP)

: us

ually

nor

mal

• An

terio

r slit

lam

p ex

amin

atio

n: n

orm

al•

Fund

osco

py: d

iagn

ostic

. Vi

sual

izes

retin

al

haem

orrh

age

and

oede

ma

(aka

‘blo

od a

nd th

unde

r fu

ndus

’)•

Fluo

resc

ein

angi

ogra

phy:

re

tinal

cap

illar

y is

chae

mia

, m

acul

ar o

edem

a,

neov

ascu

lariz

atio

n

Emer

genc

y ca

re

Med

ical

:•

No

exac

t tre

atm

ent.

Man

age

risk

fact

ors

and

com

plic

atio

ns

as th

ey o

ccur

• M

acul

ar o

edem

a: in

trav

itrea

l an

ti-VE

GF

or s

tero

ids

• N

eova

scul

ariz

atio

n: la

ser

phot

ocoa

gula

tion

Surg

ical

:

• Vi

trec

tom

y

K30033_C005.indd 158 28/02/17 11:10 am

159

Oph

thal

mol

ogy

Tabl

e 5.

1. S

ud

den

pai

nle

ss v

isu

al lo

ss

Isch

aem

ic o

ptic

ne

urop

athy

• Te

mpo

ral a

rter

itis

• At

hero

scle

rosi

s•

Non

-mod

ifiab

le ri

sk fa

ctor

s: ag

e, m

ale

gend

er, p

ositi

ve

fam

ily h

isto

ry•

Mod

ifiab

le ri

sk fa

ctor

s: di

abet

es m

ellit

us,

hype

rten

sion

, sm

okin

g,

obes

ity, l

ipid

and

cho

lest

erol

le

vels

• Vi

sual

loss

: usu

ally

on

w

akin

g•

Tem

pora

l art

eriti

s:

Gen

eral

sym

ptom

s: w

eigh

t los

s, m

uscl

e ac

hes

(ass

ocia

ted

with

pol

ymya

lgia

rh

eum

atic

a), s

calp

tend

erne

ss,

tem

pora

l art

ery

is th

icke

ned,

te

nder

but

non

pul

satil

e, ja

w

clau

dica

tion

Vi

sual

sym

ptom

s: op

tic

neur

opat

hy, b

lindn

ess,

di

plop

ia

Neu

rolo

gy s

ympt

oms:

stro

ke, m

yelo

path

y, ne

urop

athy

• Sp

ecifi

c bl

ood

test

s: ES

R in

crea

sed

mar

kedl

y in

te

mpo

ral a

rter

itis

and

is th

e fir

st-li

ne in

vest

igat

ion

• O

ther

blo

od te

sts:

FBC,

CRP

• Bi

opsy

: of t

empo

ral a

rter

y if

indi

cate

d. S

how

s gi

ant c

ell

infil

trat

ion

Pred

niso

lone

for t

empo

ral

arte

ritis

Cont

inue

d ov

erle

af

K30033_C005.indd 159 28/02/17 11:10 am

Oph

thal

mol

ogy

160

Tabl

e 5.

1. S

ud

den

pai

nle

ss v

isu

al lo

ss

TABL

E 5.

1. S

udde

n pa

inle

ss v

isua

l los

s (c

ontin

ued

).

Dis

ease

Caus

eFe

atur

esIn

vest

igat

ions

Trea

tmen

t

Retin

al

deta

chm

ent

• Tr

aum

a –

part

icul

arly

ac

cele

ratio

n–de

cele

ratio

n in

jurie

s •

Retin

al te

ars

• Po

sitiv

e fa

mily

his

tory

• Co

mpl

icat

ion

of c

atar

act

surg

ery

• M

yopi

a (h

igh

leve

l)

• Th

ere

are

thre

e di

ffere

nt w

ays

in

whi

ch re

tinal

det

achm

ent m

ay

man

ifest

. Rem

embe

r as

RETi

nal:

R –

Rheg

mat

ogen

ous

E –

Exud

ativ

eT

– Tr

actio

nal

• Sy

mpt

oms

may

be

rem

embe

red

as th

e 4F

s:F

– Fl

oate

rsF

– Fl

ashe

s (p

hoto

psia

) F

– Fi

eld

loss

F –

Fall

in a

cuity

occ

urs

whe

n m

acul

a de

tach

es•

Supe

rior t

empo

ral q

uadr

ant m

ost

com

mon

ly a

ffect

ed

• Vi

sual

acu

ity

• Pu

pil a

naly

sis:

may

de

mon

stra

te a

rela

tive

affe

rent

pup

illar

y de

fect

or

a M

arcu

s G

unn

pupi

l if n

ot

cons

ensu

al

• Vi

sual

fiel

d an

alys

is•

Ante

rior s

lit la

mp

exam

inat

ion

• Fu

ndos

copy

: vis

ualiz

es

deta

ched

por

tion

of th

e re

tina

(gre

y op

ales

cent

)

Emer

genc

y ca

re

Surg

ical

:

• Re

atta

ch th

e re

tina

(e.g

. vitr

ecto

my

with

gas

ta

mpo

nade

)

K30033_C005.indd 160 28/02/17 11:10 am

Oph

thal

mol

ogy

161

Tabl

e 5.

1. S

ud

den

pai

nle

ss v

isu

al lo

ss

Occ

lusi

on o

f the

re

tinal

art

ery

• Te

mpo

ral a

rter

itis

• At

hero

scle

rosi

s•

Risk

fact

ors

incr

ease

w

ith a

tria

l fibr

illat

ion,

co

agul

opat

hies

and

sic

kle

cell

dise

ase

• Su

dden

pai

nles

s ce

ntra

l vis

ual

loss

• Pe

rform

blo

od te

sts

to

dete

ct th

e un

derly

ing

caus

e (e

.g. F

BC, s

ickl

e ce

ll st

udie

s, ES

R, C

RP, p

roth

rom

bin

time,

act

ivat

ed p

artia

l th

rom

bopl

astin

tim

e,

chol

este

rol a

nd tr

igly

cerid

e le

vels

)•

ECG

: for

atr

ial fi

brill

atio

n•

Full

opht

halm

olog

y as

sess

men

t as

abov

e

Trea

tmen

t dep

ends

on

the

time

elap

sed

sinc

e vi

sual

loss

det

ecte

d.

Retin

al a

rter

y oc

clus

ion

requ

ires

prom

pt e

mer

genc

y tr

eatm

ent:

• Lo

wer

IOP:

ocu

lar m

assa

ge,

ante

rior c

ham

ber p

arac

ente

sis

• O

ther

med

icat

ions

: tim

olol

, ac

etaz

olam

ide,

man

nito

l, th

rom

boly

tics

may

be

usef

ul,

hype

rbar

ic o

xyge

n th

erap

y (w

ithin

2–1

2 ho

urs

of o

nset

)

Vitr

eous

ha

emor

rhag

e•

Diab

etes

mel

litus

• Co

agul

atio

n di

sord

ers

• Su

dden

pai

nles

s vi

sual

loss

: ‘c

obw

ebs

and

float

ers’

• Ph

otop

hobi

a •

Phot

opsi

a

Trea

t und

erly

ing

caus

e

Cons

erva

tive

:•

Bed

rest

with

the

head

of t

he

bed

elev

ated

30–

45°

Med

ical

:•

Depe

nds

on u

nder

lyin

g ca

use

Surg

ical

:•

Lase

r the

rapy

•

Cryo

ther

apy

• Vi

trec

tom

y

K30033_C005.indd 161 28/02/17 11:10 am

Oph

thal

mol

ogy

162

MAP

5.1

. M

acu

lar

deg

ener

atio

n

Com

plic

atio

ns•

Blin

dnes

s.•

Depr

essi

on.

Wha

t is

mac

ular

deg

ener

atio

n?Th

is is

a c

hron

ic o

cula

r con

ditio

n, w

hich

is

mor

e co

mm

on in

old

er p

atie

nts.

Ther

e ar

e th

ree

diffe

rent

type

s:

1. D

ry (g

eogr

aphi

c) m

acul

ar d

egen

erat

ion:

•

Char

acte

ristic

yel

low

dru

sen.

•

Mos

t com

mon

type

.

2. W

et (e

xuda

tive)

mac

ular

deg

ener

atio

n:

• Se

vere

and

acc

eler

ativ

e.

• As

soci

ated

with

neo

vasc

ular

izat

ion

of

the

cho

roid

and

, the

refo

re,

haem

orrh

age.

3. S

targ

ardt

mac

ular

deg

ener

atio

n:

• O

ccur

s in

teen

ager

s.

• Ra

re.

Caus

esU

nkno

wn.

The

re a

re th

eorie

s w

hich

sug

gest

th

at V

EGF

play

s a

role

in th

e pa

thop

hysi

olog

y of

the

dise

ase

and

ther

e is

a li

nk w

ith

smok

ing

(incr

ease

s th

e ris

k by

3.6

).

Risk

fact

ors:

rem

embe

r as

ABC

S:A

– A

ge: g

ener

ally

ove

r 60

B –

high

Blo

od p

ress

ure

C –

incr

ease

d Ch

oles

tero

l lev

els/

Cauc

asia

n et

hnic

ityS

– Sm

okin

g/Su

nlig

ht (U

V) e

xpos

ure

Sym

ptom

s•

Prog

ress

ive

cent

ral v

isua

l los

s.•

Scot

omas

.•

Visu

al a

cuity

: dec

reas

ed.

• M

etam

orph

opsi

a.

Trea

tmen

t

Trea

tmen

tD

ryW

et

Cons

erva

tive

Med

ical

Patie

nt e

duca

tion

Refe

rral

to o

ccup

atio

nal

ther

apy

to im

prov

e qu

ality

of li

fe (e

.g. a

dapt

ed h

ouse

aids

suc

h as

mag

nifie

dho

me

appl

ianc

es)

No

effe

ctiv

e tr

eatm

ent

As w

ith d

ry m

acul

arde

gene

ratio

n

Ora

l vita

min

s an

d an

tioxi

dant

s An

ti-VE

GF

ther

apy

(e.g

. ran

ibiz

umab

)Su

rgic

alN

o ef

fect

ive

trea

tmen

tPh

otod

ynam

ic th

erap

y

MAP

5.1

. Mac

ular

deg

ener

atio

n

Inve

stig

atio

ns•

Oph

thal

mol

ogy

exam

inat

ion:

Visu

al a

cuity

.

Vi

sual

fiel

ds.

Amsl

er g

rid: m

etam

orph

opsi

a.

Fl

uore

scei

n an

giog

raph

y: w

et m

acul

ar

de

gene

ratio

n (n

eova

scul

ariz

atio

n).

• Bl

ood

test

s: FB

C, U

&E,

glu

cose

, cho

lest

erol

an

d lip

id le

vels.

K30033_C005.indd 162 28/02/17 11:10 am

Oph

thal

mol

ogy

163

Com

plic

atio

ns•

Blin

dnes

s.•

Depr

essi

on.

Wha

t is

mac

ular

deg

ener

atio

n?Th

is is

a c

hron

ic o

cula

r con

ditio

n, w

hich

is

mor

e co

mm

on in

old

er p

atie

nts.

Ther

e ar

e th

ree

diffe

rent

type

s:

1. D

ry (g

eogr

aphi

c) m

acul

ar d

egen

erat

ion:

•

Char

acte

ristic

yel

low

dru

sen.

•

Mos

t com

mon

type

.

2. W

et (e

xuda

tive)

mac

ular

deg

ener

atio

n:

• Se

vere

and

acc

eler

ativ

e.

• As

soci

ated

with

neo

vasc

ular

izat

ion

of

the

cho

roid

and

, the

refo

re,

haem

orrh

age.

3. S

targ

ardt

mac

ular

deg

ener

atio

n:

• O

ccur

s in

teen

ager

s.

• Ra

re.

Caus

esU

nkno

wn.

The

re a

re th

eorie

s w

hich

sug

gest

th

at V

EGF

play

s a

role

in th

e pa

thop

hysi

olog

y of

the

dise

ase

and

ther

e is

a li

nk w

ith

smok

ing

(incr

ease

s th

e ris

k by

3.6

).

Risk

fact

ors:

rem

embe

r as

ABC

S:A

– A

ge: g

ener

ally

ove

r 60

B –

high

Blo

od p

ress

ure

C –

incr

ease

d Ch

oles

tero

l lev

els/

Cauc

asia

n et

hnic

ityS

– Sm

okin

g/Su

nlig

ht (U

V) e

xpos

ure

Sym

ptom

s•

Prog

ress

ive

cent

ral v

isua

l los

s.•

Scot

omas

.•

Visu

al a

cuity

: dec

reas

ed.

• M

etam

orph

opsi

a.

Trea

tmen

t

Trea

tmen

tD

ryW

et

Cons

erva

tive

Med

ical

Patie

nt e

duca

tion

Refe

rral

to o

ccup

atio

nal

ther

apy

to im

prov

e qu

ality

of li

fe (e

.g. a

dapt

ed h

ouse

aids

suc

h as

mag

nifie

dho

me

appl

ianc

es)

No

effe

ctiv

e tr

eatm

ent

As w

ith d

ry m

acul

arde

gene

ratio

n

Ora

l vita

min

s an

d an

tioxi

dant

s An

ti-VE

GF

ther

apy

(e.g

. ran

ibiz

umab

)Su

rgic

alN

o ef

fect

ive

trea

tmen

tPh

otod

ynam

ic th

erap

y

MAP

5.1

. Mac

ular

deg

ener

atio

n

Inve

stig

atio

ns•

Oph

thal

mol

ogy

exam

inat

ion:

Visu

al a

cuity

.

Vi

sual

fiel

ds.

Amsl

er g

rid: m

etam

orph

opsi

a.

Fl

uore

scei

n an

giog

raph

y: w

et m

acul

ar

de

gene

ratio

n (n

eova

scul

ariz

atio

n).

• Bl

ood

test

s: FB

C, U

&E,

glu

cose

, cho

lest

erol

an

d lip

id le

vels.

MAP

5.1

. M

acu

lar

deg

ener

atio

n

K30033_C005.indd 163 28/02/17 11:10 am

Oph

thal

mol

ogy

164

MAP

5.2

. G

lau

com

a

Sym

ptom

s•

Gla

ucom

a m

ay b

e pi

cked

up

on ro

utin

e op

htha

lmol

ogy

exam

inat

ion.

• Di

min

ishe

d vi

sion

.•

Clos

ed a

ngle

gla

ucom

a: h

azy

corn

ea, s

emid

ilate

d pu

pil.

• Pa

in.

• Ke

y tr

iad:

1, v

isua

l fie

ld lo

ss;

2,

alte

ratio

n to

the

optic

nerv

e cu

p; a

nd 3

, alte

ratio

n

to

the

optic

dis

c.

Com

plic

atio

n•

Blin

dnes

s.

Inve

stig

atio

ns•

Tono

met

ry: m

easu

res

IOP.

• Fu

ndos

copy

.•

Visu

al fi

eld

asse

ssm

ent.

• Cu

p-to

-dis

c ra

tio.

• G

onio

scop

y: a

sses

ses

the

i

ridoc

orne

al a

ngle

.•

Scan

ning

lase

r oph

thal

mos

copy

.•

Scan

ning

lase

r pol

arim

etry

.

Wha

t is

gla

ucom

a?G

lauc

oma

com

pris

es a

gro

up o

f ocu

lar d

isor

ders

cha

ract

eriz

ed b

y th

e fo

llow

ing

tria

d:•

Visu

al fi

eld

loss

(nas

al a

nd s

uper

ior f

ield

s af

fect

ed fi

rst).

• O

ptic

dis

c cu

ppin

g.•

Opt

ic n

erve

dam

age.

IOP

is o

ften

rais

ed b

ut it

may

be

norm

al.

Caus

esTh

ere

are

two

type

s of

gla

ucom

a: o

pen

angl

e (m

ost c

omm

on) a

nd c

lose

d an

gle.

The

follo

win

g ta

ble

expl

ores

the

diffe

renc

es b

etw

een

the

two.

Drai

nage

of a

queo

us h

umou

rth

roug

h th

e tr

abec

ular

mes

hwor

kis

rest

ricte

d

Feat

ure

Ope

n an

gle

Clos

ed a

ngle

Caus

e

Path

olog

y

Prim

ary:

• M

YOC

mut

atio

nSe

cond

ary:

• Tr

aum

a –

obst

ruct

ion

to th

e

trab

ecul

ar m

eshw

ork

Prim

ary:

• Sh

allo

w a

nter

ior c

ham

bers

Seco

ndar

y:•

Trau

ma

• Tu

mou

r of t

he c

iliar

y bo

dy

Out

flow

of a

queo

us h

umou

r is

obst

ruct

ed s

ince

iris

bow

s ag

ains

tth

e tr

abec

ular

mes

hwor

k

Pain

ful

No

Yes

Asso

ciat

ions

Myo

pia

Hype

rmet

ropi

a

Trea

tmen

t

Cons

erva

tive

: pat

ient

edu

catio

n an

d an

nual

ass

essm

ent

Med

ical

:

Brim

onid

ine

Clas

sEx

ampl

e

Beta

blo

cker

s

Sym

path

omim

etic

s

Beta

xolo

l

Carb

onic

anh

ydra

se in

hibi

tors

Acet

azol

amid

e

Mio

tics

Pilo

carp

ine

MO

ASi

de e

ffec

ts

¯ IO

P by

slo

win

g th

e ra

te o

f aqu

eous

hum

our

prod

uctio

n

Sele

ctiv

e a

2-ad

reno

rece

ptor

ago

nist

; ¯ IO

P by

slow

ing

the

rate

of a

queo

us h

umou

r pro

duct

ion

and

by in

crea

sing

uve

oscl

eral

out

flow

Lata

nopr

ost

Pros

tagl

andi

n an

alog

ues

¯ IO

P by

incr

easi

ng u

veos

cler

al o

utflo

w

Inhi

bits

car

boni

c an

hydr

ase,

ther

efor

e ¯

IOP

bysl

owin

g th

e ra

te o

f aqu

eous

hum

our p

rodu

ctio

n

¯ IO

P by

ope

ning

dra

inag

e ch

anne

ls in

trab

ecul

arm

eshw

ork

Cont

rain

dica

ted

in a

sthm

a, h

eart

blo

ckan

d br

adyc

ardi

a

¯ vi

sual

acu

ity, i

tchi

ng, d

iplo

pia,

redn

ess

of th

eey

elid

, exc

essi

ve te

arin

g, tu

nnel

vis

ion

Brow

n pi

gmen

tatio

n of

iris,

¯ v

isua

l acu

ity

Wea

k sy

stem

ic d

iure

tic. I

s a

sulp

hona

mid

ede

rivat

ive,

ther

efor

e su

lpho

nam

ide

side

effe

cts

(e.g

. ras

hes)

Blur

red

visi

on, c

iliar

y sp

asm

, itc

hing

and

lens

chan

ges

(with

chr

onic

use

)

MAP

5.2

. Gla

ucom

a

K30033_C005.indd 164 28/02/17 11:10 am

Oph

thal

mol

ogy

165

Sym

ptom

s•

Gla

ucom

a m

ay b

e pi

cked

up

on ro

utin

e op

htha

lmol

ogy

exam

inat

ion.

• Di

min

ishe

d vi

sion

.•

Clos

ed a

ngle

gla

ucom

a: h

azy

corn

ea, s

emid

ilate

d pu

pil.

• Pa

in.

• Ke

y tr

iad:

1, v

isua

l fie

ld lo

ss;

2,

alte

ratio

n to

the

optic

nerv

e cu

p; a

nd 3

, alte

ratio

n

to

the

optic

dis

c.

Com

plic

atio

n•

Blin

dnes

s.

Inve

stig

atio

ns•

Tono

met

ry: m

easu

res

IOP.

• Fu

ndos

copy

.•

Visu

al fi

eld

asse

ssm

ent.

• Cu

p-to

-dis

c ra

tio.

• G

onio

scop

y: a

sses

ses

the

i

ridoc

orne

al a

ngle

.•

Scan

ning

lase

r oph

thal

mos

copy

.•

Scan

ning

lase

r pol

arim

etry

.

Wha

t is

gla

ucom

a?G

lauc

oma

com

pris

es a

gro

up o

f ocu

lar d

isor

ders

cha

ract

eriz

ed b

y th

e fo

llow

ing

tria

d:•

Visu

al fi

eld

loss

(nas

al a

nd s

uper

ior f

ield

s af

fect

ed fi

rst).

• O

ptic

dis

c cu

ppin

g.•

Opt

ic n

erve

dam

age.

IOP

is o

ften

rais

ed b

ut it

may

be

norm

al.

Caus

esTh

ere

are

two

type

s of

gla

ucom

a: o

pen

angl

e (m

ost c

omm

on) a

nd c

lose

d an

gle.

The

follo

win

g ta

ble

expl

ores

the

diffe

renc

es b

etw

een

the

two.

Drai

nage

of a

queo

us h

umou

rth

roug

h th

e tr

abec

ular

mes

hwor

kis

rest

ricte

d

Feat

ure

Ope

n an

gle

Clos

ed a

ngle

Caus

e

Path

olog

y

Prim

ary:

• M

YOC

mut

atio

nSe

cond

ary:

• Tr

aum

a –

obst

ruct

ion

to th

e

trab

ecul

ar m

eshw

ork

Prim

ary:

• Sh

allo

w a

nter

ior c

ham

bers

Seco

ndar

y:•

Trau

ma

• Tu

mou

r of t

he c

iliar

y bo

dy

Out

flow

of a

queo

us h

umou

r is

obst

ruct

ed s

ince

iris

bow

s ag

ains

tth

e tr

abec

ular

mes

hwor

k

Pain

ful

No

Yes

Asso

ciat

ions

Myo

pia

Hype

rmet

ropi

a

Trea

tmen

t

Cons

erva

tive

: pat

ient

edu

catio

n an

d an

nual

ass

essm

ent

Med

ical

:

Brim

onid

ine

Clas

sEx

ampl

e

Beta

blo

cker

s

Sym

path

omim

etic

s

Beta

xolo

l

Carb

onic

anh

ydra

se in

hibi

tors

Acet

azol

amid

e

Mio

tics

Pilo

carp

ine

MO

ASi

de e

ffec

ts

¯ IO

P by

slo

win

g th

e ra

te o

f aqu

eous

hum

our

prod

uctio

n

Sele

ctiv

e a

2-ad

reno

rece

ptor

ago

nist

; ¯ IO

P by

slow

ing

the

rate

of a

queo

us h

umou

r pro

duct

ion

and

by in

crea

sing

uve

oscl

eral

out

flow

Lata

nopr

ost

Pros

tagl

andi

n an

alog

ues

¯ IO

P by

incr

easi

ng u

veos

cler

al o

utflo

w

Inhi

bits

car

boni

c an

hydr

ase,

ther

efor

e ¯

IOP

bysl

owin

g th

e ra

te o

f aqu

eous

hum

our p

rodu

ctio

n

¯ IO

P by

ope

ning

dra

inag

e ch

anne

ls in

trab

ecul

arm

eshw

ork

Cont

rain

dica

ted

in a

sthm

a, h

eart

blo

ckan

d br

adyc

ardi

a

¯ vi

sual

acu

ity, i

tchi

ng, d

iplo

pia,

redn

ess

of th

eey

elid

, exc

essi

ve te

arin

g, tu

nnel

vis

ion

Brow

n pi

gmen

tatio

n of

iris,

¯ v

isua

l acu

ity

Wea

k sy

stem

ic d

iure

tic. I

s a

sulp

hona

mid

ede

rivat

ive,

ther

efor

e su

lpho

nam

ide

side

effe

cts

(e.g

. ras

hes)

Blur

red

visi

on, c

iliar

y sp

asm

, itc

hing

and

lens

chan

ges

(with

chr

onic

use

)

MAP

5.2

. Gla

ucom

a

MAP

5.2

. G

lau

com

a

K30033_C005.indd 165 28/02/17 11:10 am

Oph

thal

mol

ogy

166

MAP

5.3

. C

atar

acts

Wha

t ar

e ca

tara

cts?

A ca

tara

ct is

opa

city

of t

he c

ryst

allin

e le

ns

and

is a

lead

ing

wor

ldw

ide

caus

e of

bl

indn

ess.

Ther

e ar

e m

any

diffe

rent

type

s of

cata

ract

s an

d th

ese

may

be

defin

ed b

ased

on

loca

tion

or c

ausa

tive

dise

ase.

Som

e ex

ampl

es a

re p

rovi

ded

belo

w.

Loca

tion

:•

Nuc

lear

cat

arac

t.•

Subc

apsu

lar c

atar

act.

• Co

rtic

al c

atar

act.

Ass

ocia

ted

wit

h di

seas

e:•

Diab

etes

: sno

wfla

ke c

atar

act.

• W

ilson

’s di

seas

e: s

unflo

wer

cat

arac

t.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s an

d ris

k fa

ctor

s fo

r the

dev

elop

men

t of c

atar

acts

. Th

ese

may

be

cong

enita

l or a

cqui

red.

Cong

enit

al:

• TO

RCHE

S in

fect

ions

(see

Map

2.6

, p. 5

0).

• G

enet

ic c

ause

s:

Tr

isom

ies.

Gal

acto

saem

ia.

Low

e’s

synd

rom

e.

Acq

uire

d: re

mem

ber

VITA

MIN

D:

V –

Vas

cula

r com

plic

atio

ns

(e.

g. h

yper

tens

ion)

.I

– In

fect

ion

(e.g

. onc

hoce

rcia

sis

[rive

r

blin

dnes

s]).

T –

Tra

uma

(e.g

. UV

expo

sure

, blu

nt fo

rce)

.A

– A

utoi

mm

une

(e.g

. hyp

opar

athy

roid

ism

),

Age

M –

Met

abol

ic (e

.g. d

iabe

tes

mel

litus

,

W

ilson

’s di

seas

e).

I –

Irra

diat

ion

N –

Nev

er fo

rget

dru

gs (e

.g. s

ide

effe

ct o

f

cor

ticos

tero

ids)

D –

Der

mat

olog

y (e

.g. e

czem

a).

Sym

ptom

s•

Leuk

ocor

ia.

• De

crea

sed

visu

al a

cuity

.•

Dipl

opia

.•

Gla

re.

• M

yopi

c sh

ift.

• N

ysta

gmus

(con

geni

tal c

atar

acts

).

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

and

annu

al o

phth

alm

ic

rev

iew

.

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use

(

e.g.

pen

icill

amin

e fo

r Wils

on’s

dis

ease

).

Surg

ical

:•

Phac

oem

ulsi

ficat

ion

may

onl

y be

per

form

ed

on

ripe

cat

arac

ts a

nd th

en a

n in

trao

cula

r

l

ens

is im

plan

ted.

Com

plic

atio

ns•

Blin

dnes

s.•

Com

plic

atio

ns o

f cat

arac

t sur

gery

(e

.g. r

etin

al d

etac

hmen

t).

MAP

5.3

. Cat

arac

ts

Inve

stig

atio

ns•

Oph

thal

mic

exa

min

atio

n.•

Bloo

d te

sts:

to u

ncov

er th

e un

derly

ing

caus

e;

FBC

, U&

E, L

FTs,

gluc

ose,

cho

lest

erol

leve

ls

+/–

spe

cific

test

s (e

.g. c

oppe

r stu

dies

for

W

ilson

’s di

seas

e or

urin

e am

ino

acid

s,

pho

spha

te a

nd c

alci

um fo

r Low

e’s

synd

rom

e).

K30033_C005.indd 166 28/02/17 11:10 am

Oph

thal

mol

ogy

167Wha

t ar

e ca

tara

cts?

A ca

tara

ct is

opa

city

of t

he c

ryst

allin

e le

ns

and

is a

lead

ing

wor

ldw

ide

caus

e of

bl

indn

ess.

Ther

e ar

e m

any

diffe

rent

type

s of

cata

ract

s an

d th

ese

may

be

defin

ed b

ased

on

loca

tion

or c

ausa

tive

dise

ase.

Som

e ex

ampl

es a

re p

rovi

ded

belo

w.

Loca

tion

:•

Nuc

lear

cat

arac

t.•

Subc

apsu

lar c

atar

act.

• Co

rtic

al c

atar

act.

Ass

ocia

ted

wit

h di

seas

e:•

Diab

etes

: sno

wfla

ke c

atar

act.

• W

ilson

’s di

seas

e: s

unflo

wer

cat

arac

t.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s an

d ris

k fa

ctor

s fo

r the

dev

elop

men

t of c

atar

acts

. Th

ese

may

be

cong

enita

l or a

cqui

red.

Cong

enit

al:

• TO

RCHE

S in

fect

ions

(see

Map

2.6

, p. 5

0).

• G

enet

ic c

ause

s:

Tr

isom

ies.

Gal

acto

saem

ia.

Low

e’s

synd

rom

e.

Acq

uire

d: re

mem

ber

VITA

MIN

D:

V –

Vas

cula

r com

plic

atio

ns

(e.

g. h

yper

tens

ion)

.I

– In

fect

ion

(e.g

. onc

hoce

rcia

sis

[rive

r

blin

dnes

s]).

T –

Tra

uma

(e.g

. UV

expo

sure

, blu

nt fo

rce)

.A

– A

utoi

mm

une

(e.g

. hyp

opar

athy

roid

ism

),

Age

M –

Met

abol

ic (e

.g. d

iabe

tes

mel

litus

,

W

ilson

’s di

seas

e).

I –

Irra

diat

ion

N –

Nev

er fo

rget

dru

gs (e

.g. s

ide

effe

ct o

f

cor

ticos

tero

ids)

D –

Der

mat

olog

y (e

.g. e

czem

a).

Sym

ptom

s•

Leuk

ocor

ia.

• De

crea

sed

visu

al a

cuity

.•

Dipl

opia

.•

Gla

re.

• M

yopi

c sh

ift.

• N

ysta

gmus

(con

geni

tal c

atar

acts

).

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

and

annu

al o

phth

alm

ic

rev

iew

.

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use

(

e.g.

pen

icill

amin

e fo

r Wils

on’s

dis

ease

).

Surg

ical

:•

Phac

oem

ulsi

ficat

ion

may

onl

y be

per

form

ed

on

ripe

cat

arac

ts a

nd th

en a

n in

trao

cula

r

l

ens

is im

plan

ted.

Com

plic

atio

ns•

Blin

dnes

s.•

Com

plic

atio

ns o

f cat

arac

t sur

gery

(e

.g. r

etin

al d

etac

hmen

t).

MAP

5.3

. Cat

arac

ts

Inve

stig

atio

ns•

Oph

thal

mic

exa

min

atio

n.•

Bloo

d te

sts:

to u

ncov

er th

e un

derly

ing

caus

e;

FBC

, U&

E, L

FTs,

gluc

ose,

cho

lest

erol

leve

ls

+/–

spe

cific

test

s (e

.g. c

oppe

r stu

dies

for

W

ilson

’s di

seas

e or

urin

e am

ino

acid

s,

pho

spha

te a

nd c

alci

um fo

r Low

e’s

synd

rom

e).

MAP

5.3

. C

atar

acts

K30033_C005.indd 167 28/02/17 11:10 am

Oph

thal

mol

ogy

168

Tabl

e 5.

2. R

ed e

ye

TABL

E 5.

2. R

ed e

ye. T

here

are

man

y ca

uses

of

red

eye.

The

se a

re o

utlin

ed b

elow

.

Dis

ease

Caus

eFe

atur

esIn

vest

igat

ions

Trea

tmen

t

Acut

e an

gle

clos

ure

glau

com

aSe

e M

ap 5

.2 (p

. 164

)Se

e M

ap 5

.2 (p

. 164

)Se

e M

ap 5

.2 (p

. 164

)Se

e M

ap 5

.2 (p

. 164

)

Ante

rior u

veiti

s As

soci

ated

with

HLA

-B27

Som

e ex

ampl

es in

clud

e: A

BCS:

A –

Ank

ylos

ing

spon

dylit

is, ju

veni

le

idio

path

ic A

rthr

itis,

psor

iatic

Art

hriti

s, re

activ

e A

rthr

itis

B –

Behç

et’s

dise

ase

C –

Croh

n’s

dise

ase

S –

Sarc

oido

sis, S

yste

mic

lupu

s ery

them

atos

us

• Pa

infu

l red

eye

• Ac

ute

onse

t•

Phot

opho

bia

• Bl

urre

d vi

sion

• Fi

xed

oval

pup

il

Inve

stig

atio

ns to

est

ablis

h un

derly

ing

caus

e

Fund

osco

py

Radi

olog

y: x

-ray

may

be

usef

ul in

cas

es o

f art

hriti

s

Cons

erva

tive

:•

Patie

nt e

duca

tion

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use

• Sp

ecifi

c tr

eatm

ent o

f ant

erio

r uv

eitis

: cor

ticos

tero

ids

and

cycl

ople

gics

may

be

used

Scle

ritis

Asso

ciat

ed w

ith a

utoi

mm

une

dise

ases

su

ch a

s rh

eum

atoi

d ar

thrit

is a

nd S

jögr

en’s

synd

rom

e

• Pa

infu

l red

eye

• Pa

in w

orse

on

mov

emen

t•

Dim

inis

hed

visu

al

acui

ty

Inve

stig

atio

ns to

est

ablis

h un

derly

ing

caus

e

Full

opht

halm

ic

exam

inat

ion

Diffe

rent

iate

scle

ritis

from

ep

iscle

ritis

by a

dmin

ister

ing

phen

ylep

hrin

e ey

e dr

ops.

In e

pisc

lerit

is bl

ood

vess

els

turn

pal

e

Cons

erva

tive

:•

Patie

nt e

duca

tion

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use

• Sp

ecifi

c tr

eatm

ent o

f scl

eriti

s: N

SAID

s, co

rtic

oste

roid

s

K30033_C005.indd 168 28/02/17 11:10 am

Oph

thal

mol

ogy

169Conj

unct

iviti

s Ba

cter

ial:

•St

aphy

loco

ccus

spp

.•

Stre

ptoc

occu

s sp

p.•

Chla

myd

iatr

acho

mat

is

Vira

l:•

Influ

enza

• HS

V•

VZV

Alle

rgic

Aut

oim

mun

e:

• As

soci

ated

with

con

ditio

ns s

uch

as

reac

tive

arth

ritis

Occ

upat

iona

l exp

osur

e:•

Expo

sure

to c

hem

ical

s

• Itc

hy, r

ed e

ye•

Bact

eria

l: pu

rule

nt, s

ticky

di

scha

rge

• Vi

ral:

clea

r di

scha

rge

Clin

ical

dia

gnos

is

Cons

erva

tive

:•

Patie

nt e

duca

tion

Med

ical

:•

Bact

eria

l: an

tibio

tic e

ye d

rops

• Vi

ral:

self-

limiti

ng

• Al

lerg

ic: a

ntih

ista

min

es•

Auto

imm

une:

art

ifici

al te

ars

and

trea

tmen

t of u

nder

lyin

g ca

use

• O

ccup

atio

nal e

xpos

ure:

irr

igat

ion

of c

hem

ical

with

sa

line

solu

tion

Subc

onju

nctiv

al

haem

orrh

age

Rem

embe

r as

ABC

DE:

A –

Acu

te h

aem

orrh

agic

con

junc

tiviti

sB

– in

crea

sed

Bloo

d pr

essu

reC

– Co

ughi

ng

D –

Dis

orde

rs o

f coa

gula

tion

E –

Eye

trau

ma

• Re

d ey

eCl

inic

al d

iagn

osis

Cons

erva

tive

:•

Patie

nt e

duca

tion

• Ad

vise

that

it lo

oks

mor

e al

arm

ing

than

it is

Med

ical

:•

Self-

limiti

ng c

ondi

tion

• Ar

tifici

al te

ars

may

som

etim

es

be g

iven

Tabl

e 5.

2. R

ed e

ye

K30033_C005.indd 169 28/02/17 11:10 am

Oph

thal

mol

ogy

170

Tabl

e 5.

3. D

iab

etic

eye

dis

ease

TABL

E 5.

3. D

iabe

tic

eye

dise

ase.

Thi

s is

a m

icro

vasc

ular

com

plic

atio

n of

dia

bete

s m

ellit

us.

Path

ophy

siol

ogy:

hyp

ergl

ycae

mia

⇒ v

ascu

lar p

eric

yte

loss

and

end

othe

lial d

amag

e ⇒

mic

roan

eury

sm fo

rmat

ion

⇒ re

tinal

isch

aem

ia ⇒

st

imul

atio

n of

gro

wth

fact

ors

⇒ n

eova

scul

ariz

atio

n.Th

e fe

atur

es th

at a

re c

hara

cter

istic

of e

ach

phas

e of

dia

betic

retin

opat

hy a

re e

xplo

red

belo

w.

Phas

eFe

atur

e

Back

grou

ndRe

mem

ber a

s A

BCD

E:A

– m

icro

Ane

urym

s (d

ots)

B –

Blot

hae

mor

rhag

es <

3C

– Co

tton

woo

l spo

ts (o

edem

a fro

m re

tinal

infa

rcts

)D

– v

enou

s D

ilata

tion

E –

har

d Ex

udat

es

Pre-

prol

ifera

tive

Rem

embe

r as

ABC

D:

A –

mic

roA

neur

yms

(dot

s). M

ore

than

bac

kgro

und

retin

opat

hy

B –

veno

us B

eadi

ng a

nd lo

opin

gC

– Co

tton

woo

l spo

ts >

5D

– D

ark

clus

ter h

aem

orrh

ages

Prol

ifera

tive

Neo

vasc

ular

izat

ion

Fibr

ous

prol

ifera

tion

Haem

orrh

ages

Adva

nced

Retin

al d

etac

hmen

tRu

beos

is ir

idis

Neo

vasc

ular

gla

ucom

a

Mac

ulop

athy

As a

bove

but

invo

lves

the

mac

ular

K30033_C005.indd 170 28/02/17 11:10 am

Chap

ter S

ix E

ar, n

ose

and

thro

at

MAP

6.1

a H

eari

ng

loss

(fl

ow

ch

art)

17

2

MAP

6.1

b H

eari

ng

loss

(sp

ecifi

c co

nd

itio

ns)

17

4

MAP

6.2

B

enig

n p

aro

xysm

al p

osi

tio

nal

ve

rtig

o (

BPP

V)

176

MAP

6.3

Ep

ista

xis

178

MAP

6.4

N

aso

ph

aryn

gea

l can

cer

180

MAP

6.5

O

rop

har

yng

eal c

ance

r 18

1

MAP

6.6

La

ryn

gea

l can

cer

182

Ear,

nose

and

thr

oat

171

K30033_C006.indd 171 28/02/17 11:13 am

172

Ear,

nose

and

thr

oat

MAP

6.1

a. H

eari

ng

loss

(fl

ow

ch

art)

Caus

esM

ay b

e su

bdiv

ided

into

con

geni

tal a

nd a

cqui

red.

Cong

enit

al:

• In

fect

ion

(e.g

. rub

ella

).•

Gen

etic

s (e

.g. A

lpor

t’s s

yndr

ome)

.

Acq

uire

d•

Pres

bycu

sis.

• In

fect

ion

(e.g

. men

ingi

tis, m

easl

es).

• Tr

aum

a (e

.g. n

oise

inju

ry, h

ead

trau

ma)

.•

Tum

our (

e.g.

aco

ustic

neu

rom

a).

• O

toto

xic

drug

s (e

.g. g

enta

mic

in, f

uros

emid

e,

cisp

latin

).•

Mén

ière

’s di

seas

e (s

ee M

ap 6

.1b,

p. 1

74).

MAP

6.1

a. H

eari

ng lo

ss (f

low

cha

rt)

Cond

uctiv

e he

arin

g lo

ss

Inne

r ear

Caus

esM

ay b

e su

bdiv

ided

into

con

geni

tal a

nd a

cqui

red.

Cong

enit

al:

• At

resi

a.•

Abno

rmal

ities

of t

he o

ssic

les.

• O

tosc

lero

sis.

Acq

uire

d•

Wax

.•

Otit

is e

xter

na.

• G

lue

ear (

see

Map

6.2

, p. 1

76).

• Pe

rfora

ted

drum

.

Sens

orin

eura

l hea

ring

loss

Out

er e

arM

iddl

e ea

r

K30033_C006.indd 172 28/02/17 11:13 am

Ear,

nose

and

thr

oat

173

MAP

6.1

a. H

eari

ng

loss

(fl

ow

ch

art)

Caus

esM

ay b

e su

bdiv

ided

into

con

geni

tal a

nd a

cqui

red.

Cong

enit

al:

• In

fect

ion

(e.g

. rub

ella

).•

Gen

etic

s (e

.g. A

lpor

t’s s

yndr

ome)

.

Acq

uire

d•

Pres

bycu

sis.

• In

fect

ion

(e.g

. men

ingi

tis, m

easl

es).

• Tr

aum

a (e

.g. n

oise

inju

ry, h

ead

trau

ma)

.•

Tum

our (

e.g.

aco

ustic

neu

rom

a).

• O

toto

xic

drug

s (e

.g. g

enta

mic

in, f

uros

emid

e,

cisp

latin

).•

Mén

ière

’s di

seas

e (s

ee M

ap 6

.1b,

p. 1

74).

MAP

6.1

a. H

eari

ng lo

ss (f

low

cha

rt)

Cond

uctiv

e he

arin

g lo

ss

Inne

r ear

Caus

esM

ay b

e su

bdiv

ided

into

con

geni

tal a

nd a

cqui

red.

Cong

enit

al:

• At

resi

a.•

Abno

rmal

ities

of t

he o

ssic

les.

• O

tosc

lero

sis.

Acq

uire

d•

Wax

.•

Otit

is e

xter

na.

• G

lue

ear (

see

Map

6.2

, p. 1

76).

• Pe

rfora

ted

drum

.

Sens

orin

eura

l hea

ring

loss

Out

er e

arM

iddl

e ea

r

K30033_C006.indd 173 28/02/17 11:13 am

Ear,

nose

and

thr

oat

174

MAP

6.1

b. H

eari

ng

loss

(sp

ecifi

c co

nd

itio

ns)

Glu

e ea

r

Wha

t is

glu

e ea

r?G

lue

ear,

also

kno

wn

as o

titis

med

ia w

ith

effu

sion

, is

a co

llect

ion

of fl

uid

with

in th

e m

iddl

e ea

r. Th

is fl

uid

is th

ough

t to

occu

r due

to

dysf

unct

iona

l Eus

tach

ian

tube

s, w

hich

cre

ate

nega

tive

pres

sure

. It o

ccur

s in

mal

es m

ore

than

fe

mal

es.

Caus

eTh

e ex

act c

ause

is u

nkno

wn.

It o

ften

occu

rs

seco

ndar

y to

a v

iral u

pper

resp

irato

ry tr

act

infe

ctio

n or

acu

te b

acte

rial o

titis

med

ia.

Risk

fact

ors:

rem

embe

r as

EARS

:E

– Eu

stac

hian

tube

abn

orm

aliti

es

(e.g

. in

Dow

n’s

synd

rom

e)A

– A

deno

ids

(enl

arge

d)R

– Re

spira

tory

infe

ctio

nsS

– Sm

okin

g (u

sual

ly p

aren

ts),

Seas

on (w

inte

r)

Sym

ptom

sM

ay v

ary

depe

ndin

g on

age

of c

hild

/adu

lt.

Bulg

ing

drum

of v

aryi

ng c

olou

r. A

fluid

leve

l m

ay b

e pr

esen

t.

Inve

stig

atio

nsAu

diog

ram

s (c

ondu

ctiv

e de

fect

s), i

mpe

danc

e au

diom

etry

.

Trea

tmen

tCo

nser

vati

ve:

• O

ften

self-

limiti

ng.

• He

arin

g ai

ds o

nly

if bi

late

ral s

ympt

oms.

Med

ical

:•

NIC

E do

es n

ot re

com

men

d an

tibio

tics.

Surg

ical

:•

Myr

ingo

tom

y.•

Gro

mm

ets

+/–

ade

noid

ecto

my.

Mén

ière

’s d

isea

se

Wha

t is

Mén

ière

’s d

isea

se?

Mén

ière

’s di

seas

e, a

lso

know

n as

end

olym

phat

ic h

ydro

ps, i

s a

caus

e of

sen

sorin

eura

l hea

ring

loss

. It i

s th

ough

t to

be c

ause

d by

the

dila

tatio

n an

d ex

cess

ive

fluid

colle

ctio

n w

ithin

the

endo

lym

phat

ic s

pace

s. It

is m

ore

com

mon

in fe

mal

es th

an m

ales

and

pre

sent

s m

ore

com

mon

ly in

mid

dle

aged

adu

lts.

Caus

e. T

he e

xact

cau

se is

unk

now

n.

Sym

ptom

s. P

rese

nts

with

a c

hara

cter

istic

tria

d:1.

Ver

tigo.

2. L

ow p

itch

tinni

tus.

3. S

enso

rineu

ral h

earin

g lo

ss.

Oth

er fe

atur

es in

clud

e au

ral f

ulln

ess,

a po

sitiv

e Ro

mbe

rg te

st a

nd n

ysta

gmus

.

Inve

stig

atio

ns. C

linic

al d

iagn

osis

but

als

o pe

rform

MRI

of h

ead

to ru

le o

ut s

pace

-occ

upyi

ng le

sion

.

Trea

tmen

tCo

nser

vati

ve: p

atie

nt e

duca

tion.

Med

ical

: acu

te a

ttac

ks –

cyc

lizin

e or

pro

chlo

rper

azin

e; lo

ng-t

erm

trea

tmen

t – b

etah

istin

e or

thia

zide

dr

ugs;

trea

t sym

ptom

s (e

.g. v

omiti

ng w

ith p

roch

lorp

eraz

ine)

.

Surg

ical

: end

olym

phat

ic s

hunt

s; ot

otox

ic d

rugs

.

Oto

scle

rosi

s

Wha

t is

oto

scle

rosi

s? T

his

is a

n au

toso

mal

dom

inan

t con

ditio

n th

at ty

pica

lly a

ffect

s fe

mal

es a

ged

20–4

0 ye

ars.

Caus

es. H

ered

itary

. Nor

mal

oss

icle

bon

e is

repl

aced

by

vasc

ular

bon

e, w

hich

is s

pong

y.

Sym

ptom

s. Co

nduc

tive

hear

ing

loss

, tin

nitu

s, fla

min

go ti

nge

appe

aran

ce to

the

tym

pani

c m

embr

ane

(Sch

war

t’s s

ign)

.

Inve

stig

atio

n. A

udio

met

ry.

Trea

tmen

t:•

Cons

erva

tive:

pat

ient

edu

catio

n.•

Med

ical

: sod

ium

fluo

ride.

• Su

rgic

al: s

tape

dect

omy.MAP

6.1

b. H

eari

ng lo

ss (s

peci

fic

cond

itio

ns)

K30033_C006.indd 174 28/02/17 11:13 am

Ear,

nose

and

thr

oat

175

MAP

6.1

b. H

eari

ng

loss

(sp

ecifi

c co

nd

itio

ns)

Glu

e ea

r

Wha

t is

glu

e ea

r?G

lue

ear,

also

kno

wn

as o

titis

med

ia w

ith

effu

sion

, is

a co

llect

ion

of fl

uid

with

in th

e m

iddl

e ea

r. Th

is fl

uid

is th

ough

t to

occu

r due

to

dysf

unct

iona

l Eus

tach

ian

tube

s, w

hich

cre

ate

nega

tive

pres

sure

. It o

ccur

s in

mal

es m

ore

than

fe

mal

es.

Caus

eTh

e ex

act c

ause

is u

nkno

wn.

It o

ften

occu

rs

seco

ndar

y to

a v

iral u

pper

resp

irato

ry tr

act

infe

ctio

n or

acu

te b

acte

rial o

titis

med

ia.

Risk

fact

ors:

rem

embe

r as

EARS

:E

– Eu

stac

hian

tube

abn

orm

aliti

es

(e.g

. in

Dow

n’s

synd

rom

e)A

– A

deno

ids

(enl

arge

d)R

– Re

spira

tory

infe

ctio

nsS

– Sm

okin

g (u

sual

ly p

aren

ts),

Seas

on (w

inte

r)

Sym

ptom

sM

ay v

ary

depe

ndin

g on

age

of c

hild

/adu

lt.

Bulg

ing

drum

of v

aryi

ng c

olou

r. A

fluid

leve

l m

ay b

e pr

esen

t.

Inve

stig

atio

nsAu

diog

ram

s (c

ondu

ctiv

e de

fect

s), i

mpe

danc

e au

diom

etry

.

Trea

tmen

tCo

nser

vati

ve:

• O

ften

self-

limiti

ng.

• He

arin

g ai

ds o

nly

if bi

late

ral s

ympt

oms.

Med

ical

:•

NIC

E do

es n

ot re

com

men

d an

tibio

tics.

Surg

ical

:•

Myr

ingo

tom

y.•

Gro

mm

ets

+/–

ade

noid

ecto

my.

Mén

ière

’s d

isea

se

Wha

t is

Mén

ière

’s d

isea

se?

Mén

ière

’s di

seas

e, a

lso

know

n as

end

olym

phat

ic h

ydro

ps, i

s a

caus

e of

sen

sorin

eura

l hea

ring

loss

. It i

s th

ough

t to

be c

ause

d by

the

dila

tatio

n an

d ex

cess

ive

fluid

colle

ctio

n w

ithin

the

endo

lym

phat

ic s

pace

s. It

is m

ore

com

mon

in fe

mal

es th

an m

ales

and

pre

sent

s m

ore

com

mon

ly in

mid

dle

aged

adu

lts.

Caus

e. T

he e

xact

cau

se is

unk

now

n.

Sym

ptom

s. P

rese

nts

with

a c

hara

cter

istic

tria

d:1.

Ver

tigo.

2. L

ow p

itch

tinni

tus.

3. S

enso

rineu

ral h

earin

g lo

ss.

Oth

er fe

atur

es in

clud

e au

ral f

ulln

ess,

a po

sitiv

e Ro

mbe

rg te

st a

nd n

ysta

gmus

.

Inve

stig

atio

ns. C

linic

al d

iagn

osis

but

als

o pe

rform

MRI

of h

ead

to ru

le o

ut s

pace

-occ

upyi

ng le

sion

.

Trea

tmen

tCo

nser

vati

ve: p

atie

nt e

duca

tion.

Med

ical

: acu

te a

ttac

ks –

cyc

lizin

e or

pro

chlo

rper

azin

e; lo

ng-t

erm

trea

tmen

t – b

etah

istin

e or

thia

zide

dr

ugs;

trea

t sym

ptom

s (e

.g. v

omiti

ng w

ith p

roch

lorp

eraz

ine)

.

Surg

ical

: end

olym

phat

ic s

hunt

s; ot

otox

ic d

rugs

.

Oto

scle

rosi

s

Wha

t is

oto

scle

rosi

s? T

his

is a

n au

toso

mal

dom

inan

t con

ditio

n th

at ty

pica

lly a

ffect

s fe

mal

es a

ged

20–4

0 ye

ars.

Caus

es. H

ered

itary

. Nor

mal

oss

icle

bon

e is

repl

aced

by

vasc

ular

bon

e, w

hich

is s

pong

y.

Sym

ptom

s. Co

nduc

tive

hear

ing

loss

, tin

nitu

s, fla

min

go ti

nge

appe

aran

ce to

the

tym

pani

c m

embr

ane

(Sch

war

t’s s

ign)

.

Inve

stig

atio

n. A

udio

met

ry.

Trea

tmen

t:•

Cons

erva

tive:

pat

ient

edu

catio

n.•

Med

ical

: sod

ium

fluo

ride.

• Su

rgic

al: s

tape

dect

omy.MAP

6.1

b. H

eari

ng lo

ss (s

peci

fic

cond

itio

ns)

K30033_C006.indd 175 28/02/17 11:13 am

Ear,

nose

and

thr

oat

176

MAP

6.2

. B

enig

n p

aro

xysm

al p

osi

tio

nal

ver

tig

o (

BPP

V)

Com

plic

atio

n•

Dizz

ines

s, th

eref

ore

incr

ease

d ris

k of

fa

lls.

Sym

ptom

s•

Vert

igo.

• N

ause

a.•

Ligh

thea

dedn

ess.

• Im

bala

nce.

• N

ysta

gmus

.

The

abov

e sy

mpt

oms

are

near

ly a

lway

s pr

ecip

itate

d by

a s

udde

n ch

ange

in h

ead

posi

tion,

suc

h as

lyin

g do

wn.

Inve

stig

atio

nsA

diag

nosi

s is

mad

e de

pend

ing

on

sym

ptom

s, pa

tient

his

tory

and

exa

min

atio

n.

• Di

x–Ha

llpik

e te

st –

a p

ositi

ve te

st

stim

ulat

es b

urst

s of

nys

tagm

us.

• U

nder

take

ves

tibul

ar a

nd a

udito

ry te

sts.

Trea

tmen

tCo

nser

vati

ve:

• Pa

tient

edu

catio

n –

said

to b

e a

self-

limiti

ng c

ondi

tion

that

may

reso

lve

in ~

2 m

onth

s af

ter o

nset

.•

Eple

y m

anoe

uvre

– a

ttem

pts

to re

posi

tion

the

disp

lace

d ot

ocon

ia.

Med

ical

:•

Anti-

emet

ics

for n

ause

a if

seve

re.

Surg

ical

:•

Very

rare

ly p

erfo

rmed

and

sho

uld

not b

e co

nsid

ered

un

less

the

abov

e m

etho

ds h

ave

faile

d. E

xam

ples

incl

ude

po

ster

ior c

anal

plu

ggin

g.

Wha

t is

ben

ign

paro

xysm

al p

osit

iona

l ver

tigo

?Th

is p

atho

logy

of t

he in

ner e

ar re

sults

in th

e su

dden

ons

et o

f na

usea

, ver

tigo

and

nyst

agm

us fo

llow

ing

cert

ain

mov

emen

ts

of th

e he

ad.

Caus

esBP

PV is

thou

ght t

o be

cau

sed

by th

e di

spla

cem

ent o

f ot

ocon

ia (s

mal

l cal

cium

car

bona

te c

ryst

als)

from

the

utric

le

into

the

sem

icirc

ular

can

als.

Mov

emen

t of t

hese

cry

stal

s al

ong

the

cana

l in

ques

tion

stim

ulat

es th

e se

nsat

ion

of

rota

tion.

Risk

fact

ors

Ther

e ar

e m

any

fact

ors

that

con

trib

ute

to th

e di

spla

cem

ent o

f ot

ocon

ia. T

he c

omm

ones

t is

head

inju

ry, b

ut o

ther

s in

clud

e in

fect

ion

and

dege

nera

tion

attr

ibut

ed to

old

age

.

MAP

6.2

. Ben

ign

paro

xysm

al p

osit

iona

l ver

tigo

(BPP

V)

K30033_C006.indd 176 28/02/17 11:13 am

Ear,

nose

and

thr

oat

177

MAP

6.2

. B

enig

n p

aro

xysm

al p

osi

tio

nal

ver

tig

o (

BPP

V)

Com

plic

atio

n•

Dizz

ines

s, th

eref

ore

incr

ease

d ris

k of

fa

lls.

Sym

ptom

s•

Vert

igo.

• N

ause

a.•

Ligh

thea

dedn

ess.

• Im

bala

nce.

• N

ysta

gmus

.

The

abov

e sy

mpt

oms

are

near

ly a

lway

s pr

ecip

itate

d by

a s

udde

n ch

ange

in h

ead

posi

tion,

suc

h as

lyin

g do

wn.

Inve

stig

atio

nsA

diag

nosi

s is

mad

e de

pend

ing

on

sym

ptom

s, pa

tient

his

tory

and

exa

min

atio

n.

• Di

x–Ha

llpik

e te

st –

a p

ositi

ve te

st

stim

ulat

es b

urst

s of

nys

tagm

us.

• U

nder

take

ves

tibul

ar a

nd a

udito

ry te

sts.

Trea

tmen

tCo

nser

vati

ve:

• Pa

tient

edu

catio

n –

said

to b

e a

self-

limiti

ng c

ondi

tion

that

may

reso

lve

in ~

2 m

onth

s af

ter o

nset

.•

Eple

y m

anoe

uvre

– a

ttem

pts

to re

posi

tion

the

disp

lace

d ot

ocon

ia.

Med

ical

:•

Anti-

emet

ics

for n

ause

a if

seve

re.

Surg

ical

:•

Very

rare

ly p

erfo

rmed

and

sho

uld

not b

e co

nsid

ered

un

less

the

abov

e m

etho

ds h

ave

faile

d. E

xam

ples

incl

ude

po

ster

ior c

anal

plu

ggin

g.

Wha

t is

ben

ign

paro

xysm

al p

osit

iona

l ver

tigo

?Th

is p

atho

logy

of t

he in

ner e

ar re

sults

in th

e su

dden

ons

et o

f na

usea

, ver

tigo

and

nyst

agm

us fo

llow

ing

cert

ain

mov

emen

ts

of th

e he

ad.

Caus

esBP

PV is

thou

ght t

o be

cau

sed

by th

e di

spla

cem

ent o

f ot

ocon

ia (s

mal

l cal

cium

car

bona

te c

ryst

als)

from

the

utric

le

into

the

sem

icirc

ular

can

als.

Mov

emen

t of t

hese

cry

stal

s al

ong

the

cana

l in

ques

tion

stim

ulat

es th

e se

nsat

ion

of

rota

tion.

Risk

fact

ors

Ther

e ar

e m

any

fact

ors

that

con

trib

ute

to th

e di

spla

cem

ent o

f ot

ocon

ia. T

he c

omm

ones

t is

head

inju

ry, b

ut o

ther

s in

clud

e in

fect

ion

and

dege

nera

tion

attr

ibut

ed to

old

age

.

MAP

6.2

. Ben

ign

paro

xysm

al p

osit

iona

l ver

tigo

(BPP

V)

K30033_C006.indd 177 28/02/17 11:13 am

Ear,

nose

and

thr

oat

178

MAP

6.3

. Ep

ista

xis

Trea

tmen

t

Cons

erva

tive

:•

ABCD

E –

emer

genc

y ca

re.

• Pi

nch

flesh

y pa

rts

of th

e no

se to

geth

er a

nd

tilt h

ead

forw

ard.

Pla

ce a

n ic

e pa

ck o

n th

e

brid

ge o

f the

nos

e or

the

back

of t

he n

eck.

Do

this

for 2

0–30

min

utes

.

Med

ical

:•

Ante

rior e

pist

axis

:

Ad

rena

line

solu

tion

to c

lean

the

nose

and

caus

e va

soco

nstr

ictio

n. R

eass

ess

to

id

entif

y bl

eed.

Silv

er n

itrat

e st

icks

– u

sed

for n

asal

caut

ery

if bl

eedi

ng p

oint

cle

arly

iden

tifie

d. A

pply

to th

is p

oint

and

a

sm

all a

rea

arou

nd it

. Cau

tion

: do

not

use

bila

tera

lly s

ince

ther

e is

a ri

sk o

f

na

sal p

erfo

ratio

n. A

lway

s pr

escr

ibe

Nas

eptin

cre

am a

fter c

aute

ry. T

his

cons

ists

of n

eom

ycin

and

chlo

ram

phen

icol

. Con

trai

ndic

atio

ns:

pean

ut a

llerg

y.

If

blee

ding

stil

l per

fuse

afte

r cau

tery

,

th

en c

onsi

der n

asal

pac

king

with

eith

er

(1

) Rap

id R

hino

®, (

2) M

eroc

el®

or

(3) B

IPP

gauz

e.

• Po

ster

ior e

pist

axis

ENT

team

requ

ired

to p

oste

riorly

pack

age

the

nasa

l cav

ity w

ith a

Fol

ey

ca

thet

er. A

nter

ior p

acki

ng is

app

lied

as

w

ell.

Surg

ical

:•

Refe

r to

ENT

team

for s

phen

opal

atin

e ar

tery

a

blat

ion.

Sym

ptom

s•

Haem

orrh

age

of v

aryi

ng s

ever

ity fr

om o

ne o

r

both

nos

trils

.•

Pres

ence

of b

lood

in th

e or

opha

rynx

.

Com

plic

atio

ns•

Com

prom

ise

to a

irway

.•

Anae

mia

.

Inve

stig

atio

nsIt

is e

ssen

tial i

n al

l cas

es to

exa

min

e bo

th n

ostr

ils w

ith a

nas

al s

pecu

lum

and

a p

en to

rch

to id

entif

y w

heth

er b

leed

ing

is u

nila

tera

l or b

ilate

ral,

as w

ell a

s id

entif

ying

the

sour

ce o

f the

ble

ed. I

t is

also

vita

l to

asse

ss w

heth

er p

ost-

nasa

l ble

edin

g ha

s co

mpr

omis

ed b

reat

hing

.

In m

ost a

cute

cas

es s

peci

fic te

sts

are

unne

cess

ary.

How

ever

, rec

urre

nt c

ases

requ

ire:

• Bl

ood

test

s: FB

C, c

oagu

latio

n st

udie

s.•

Radi

olog

y: C

T (if

mal

igna

ncy

susp

ecte

d).

• O

ther

: nas

opha

ryng

osco

py (i

f mal

igna

ncy

susp

ecte

d).

Wha

t is

epi

stax

is?

Epis

taxi

s is

the

term

use

d fo

r nos

eble

ed. I

t is

very

co

mm

on a

nd th

ere

are

two

maj

or ty

pes:

1. A

nter

ior e

pist

axis

: mos

t com

mon

. Ofte

n

pres

ents

as

unila

tera

l nas

al b

leed

ing

and

oc

curs

from

Kie

ssel

bach

’s pl

exus

(a

lso

know

n as

Litt

le’s

area

).2.

Pos

terio

r epi

stax

is: l

ess

com

mon

but

mor

e

diffi

cult

to m

anag

e. P

rese

nts

with

bila

tera

l

nasa

l ble

edin

g an

d al

so p

ost-

nasa

l ble

edin

g

into

the

orop

hary

nx.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

nos

eble

eds

rang

ing

from

the

idio

path

ic to

fore

ign

bodi

es a

nd

tum

ours

. Som

e ca

uses

are

list

ed b

elow

. Re

mem

ber a

s EP

ISTA

XIS:

E –

Epis

taxi

s pa

st h

isto

ry (e

.g. a

nato

mic

al

defo

rmiti

es o

r her

edita

ry h

aem

orrh

agic

tela

ngie

ctas

ia)

P –

Punc

h to

the

face

/trau

ma

I –

Infla

mm

ator

y re

actio

ns (e

.g. r

ecen

t upp

er

resp

irato

ry tr

act i

nfec

tion)

S –

Syst

emic

fact

ors

(e.g

. hyp

erte

nsio

n)T

– Th

rom

bocy

tope

nia

A –

Alc

ohol

– c

ause

s va

sodi

latio

nX

– fa

ctor

X d

efic

ienc

yI

– In

tran

asal

tum

ours

S –

Spra

ys (e

.g. p

rolo

nged

use

of n

asal

ste

roid

s)

Risk

fact

ors

• Tr

aum

a.•

Antic

oagu

latio

n m

edic

atio

n.•

Hype

rten

sion

.•

Rece

nt u

pper

resp

irato

ry tr

act i

nfec

tion.

• Hi

stor

y of

epi

stax

is.•

Drug

s –

coca

ine

use.

MAP

6.3

. Epi

stax

is

ppyy

ggpp

gg

K30033_C006.indd 178 28/02/17 11:13 am

Ear,

nose

and

thr

oat

179

MAP

6.3

. Ep

ista

xis

Trea

tmen

t

Cons

erva

tive

:•

ABCD

E –

emer

genc

y ca

re.

• Pi

nch

flesh

y pa

rts

of th

e no

se to

geth

er a

nd

tilt h

ead

forw

ard.

Pla

ce a

n ic

e pa

ck o

n th

e

brid

ge o

f the

nos

e or

the

back

of t

he n

eck.

Do

this

for 2

0–30

min

utes

.

Med

ical

:•

Ante

rior e

pist

axis

:

Ad

rena

line

solu

tion

to c

lean

the

nose

and

caus

e va

soco

nstr

ictio

n. R

eass

ess

to

id

entif

y bl

eed.

Silv

er n

itrat

e st

icks

– u

sed

for n

asal

caut

ery

if bl

eedi

ng p

oint

cle

arly

iden

tifie

d. A

pply

to th

is p

oint

and

a

sm

all a

rea

arou

nd it

. Cau

tion

: do

not

use

bila

tera

lly s

ince

ther

e is

a ri

sk o

f

na

sal p

erfo

ratio

n. A

lway

s pr

escr

ibe

Nas

eptin

cre

am a

fter c

aute

ry. T

his

cons

ists

of n

eom

ycin

and

chlo

ram

phen

icol

. Con

trai

ndic

atio

ns:

pean

ut a

llerg

y.

If

blee

ding

stil

l per

fuse

afte

r cau

tery

,

th

en c

onsi

der n

asal

pac

king

with

eith

er

(1

) Rap

id R

hino

®, (

2) M

eroc

el®

or

(3) B

IPP

gauz

e.

• Po

ster

ior e

pist

axis

ENT

team

requ

ired

to p

oste

riorly

pack

age

the

nasa

l cav

ity w

ith a

Fol

ey

ca

thet

er. A

nter

ior p

acki

ng is

app

lied

as

w

ell.

Surg

ical

:•

Refe

r to

ENT

team

for s

phen

opal

atin

e ar

tery

a

blat

ion.

Sym

ptom

s•

Haem

orrh

age

of v

aryi

ng s

ever

ity fr

om o

ne o

r

both

nos

trils

.•

Pres

ence

of b

lood

in th

e or

opha

rynx

.

Com

plic

atio

ns•

Com

prom

ise

to a

irway

.•

Anae

mia

.

Inve

stig

atio

nsIt

is e

ssen

tial i

n al

l cas

es to

exa

min

e bo

th n

ostr

ils w

ith a

nas

al s

pecu

lum

and

a p

en to

rch

to id

entif

y w

heth

er b

leed

ing

is u

nila

tera

l or b

ilate

ral,

as w

ell a

s id

entif

ying

the

sour

ce o

f the

ble

ed. I

t is

also

vita

l to

asse

ss w

heth

er p

ost-

nasa

l ble

edin

g ha

s co

mpr

omis

ed b

reat

hing

.

In m

ost a

cute

cas

es s

peci

fic te

sts

are

unne

cess

ary.

How

ever

, rec

urre

nt c

ases

requ

ire:

• Bl

ood

test

s: FB

C, c

oagu

latio

n st

udie

s.•

Radi

olog

y: C

T (if

mal

igna

ncy

susp

ecte

d).

• O

ther

: nas

opha

ryng

osco

py (i

f mal

igna

ncy

susp

ecte

d).

Wha

t is

epi

stax

is?

Epis

taxi

s is

the

term

use

d fo

r nos

eble

ed. I

t is

very

co

mm

on a

nd th

ere

are

two

maj

or ty

pes:

1. A

nter

ior e

pist

axis

: mos

t com

mon

. Ofte

n

pres

ents

as

unila

tera

l nas

al b

leed

ing

and

oc

curs

from

Kie

ssel

bach

’s pl

exus

(a

lso

know

n as

Litt

le’s

area

).2.

Pos

terio

r epi

stax

is: l

ess

com

mon

but

mor

e

diffi

cult

to m

anag

e. P

rese

nts

with

bila

tera

l

nasa

l ble

edin

g an

d al

so p

ost-

nasa

l ble

edin

g

into

the

orop

hary

nx.

Caus

esTh

ere

are

man

y di

ffere

nt c

ause

s of

nos

eble

eds

rang

ing

from

the

idio

path

ic to

fore

ign

bodi

es a

nd

tum

ours

. Som

e ca

uses

are

list

ed b

elow

. Re

mem

ber a

s EP

ISTA

XIS:

E –

Epis

taxi

s pa

st h

isto

ry (e

.g. a

nato

mic

al

defo

rmiti

es o

r her

edita

ry h

aem

orrh

agic

tela

ngie

ctas

ia)

P –

Punc

h to

the

face

/trau

ma

I –

Infla

mm

ator

y re

actio

ns (e

.g. r

ecen

t upp

er

resp

irato

ry tr

act i

nfec

tion)

S –

Syst

emic

fact

ors

(e.g

. hyp

erte

nsio

n)T

– Th

rom

bocy

tope

nia

A –

Alc

ohol

– c

ause

s va

sodi

latio

nX

– fa

ctor

X d

efic

ienc

yI

– In

tran

asal

tum

ours

S –

Spra

ys (e

.g. p

rolo

nged

use

of n

asal

ste

roid

s)

Risk

fact

ors

• Tr

aum

a.•

Antic

oagu

latio

n m

edic

atio

n.•

Hype

rten

sion

.•

Rece

nt u

pper

resp

irato

ry tr

act i

nfec

tion.

• Hi

stor

y of

epi

stax

is.•

Drug

s –

coca

ine

use.

MAP

6.3

. Epi

stax

is

ppyy

ggpp

gg

K30033_C006.indd 179 28/02/17 11:13 am

Ear,

nose

and

thr

oat

180

MAP

6.4

. N

aso

ph

aryn

gea

l can

cer

Wha

t is

nas

opha

ryng

eal c

ance

r?N

asop

hary

neal

can

cer i

s ty

pica

lly a

squ

amou

s ce

ll ca

rcin

oma

(85%

). O

ther

cel

l typ

es in

clud

e ad

enoc

arci

nom

a, ly

mph

oma

and

mel

anom

a.It

is m

ore

com

mon

in A

sian

pop

ulat

ions

and

in

mal

es.

Caus

esTh

e ex

act c

ause

of n

asop

hary

ngea

l tum

ours

is

unkn

own

but r

isk

fact

ors

incl

ude:

• G

enet

ics:

HLA-

A2.

• In

fect

ion:

Eps

tein

–Bar

r viru

s.•

Diet

: nitr

osam

ines

and

vita

min

C d

efic

ienc

y.

Sym

ptom

sRe

mem

ber a

s N

OSE

:N

– N

eck

lum

pO

– O

talg

ia, n

asal

Obs

truc

tion

S –

Sym

ptom

s of

spr

ead

(e.g

. ner

ve p

alsi

es –

m

andi

bula

r ner

ve; c

rani

al n

erve

s –

mos

t

com

mon

ly C

Ns V

, VI a

nd X

II; H

orne

r’s

syn

drom

e).

E –

Epis

taxi

s.

Com

plic

atio

ns•

Met

asta

sis.

• In

vasi

on o

f loc

al s

truc

ture

s.•

Deat

h.

Trea

tmen

tCo

nser

vati

ve:

• Pa

tient

edu

catio

n, M

acm

illan

nur

ses

refe

rral

.

Med

ical

:•

Chem

othe

rapy

and

radi

othe

rapy

.

Surg

ical

:•

For a

ngio

fibro

ma.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E, L

FTs,

ESR,

Ep

stei

n–Ba

rr v

irus

and

vira

l cap

sid

antig

en.

• Sp

ecifi

c te

sts:

audi

ogra

m, t

ympa

nogr

am a

nd

visu

al fi

elds

.•

Radi

olog

y: C

T, M

RI w

ith T

NM

cla

ssifi

catio

n.

Angi

ogra

phy

for a

ngio

fibro

ma.

MAP

6.4

. Nas

opha

ryng

eal c

ance

r

K30033_C006.indd 180 28/02/17 11:13 am

Ear,

nose

and

thr

oat

181

MAP

6.5

. O

rop

har

yng

eal c

ance

r

Wha

t is

oro

phar

ynge

al c

ance

r?M

ost o

roph

aryn

geal

can

cers

are

squ

amou

s ce

ll ca

rcin

omas

(85%

). Ap

prox

imat

ely

8% o

f the

se

pres

ent w

ith d

ista

nt m

etas

tasi

s. O

ther

cel

l ty

pes

incl

ude

non-

Hodg

kin’

s ly

mph

oma

and

rhab

dom

yosa

rcom

a. It

is m

ore

com

mon

in

mal

es.

Caus

esTh

e ex

act c

ause

of o

roph

aryn

geal

tum

ours

is

unkn

own

but r

isk

fact

ors

incl

ude:

• Sm

okin

g/to

bacc

o ch

ewin

g.•

Alco

hol.

• HP

V in

fect

ion

(type

s 8

and

16).

• Io

nizi

ng ra

diat

ion.

Sym

ptom

s•

Ody

noph

agia

.•

Ota

lgia

.•

Nec

k lu

mp.

• Tr

ism

us.

• So

re th

roat

.•

Leuk

opla

kia.

Com

plic

atio

ns•

Met

asta

sis.

• In

vasi

on o

f loc

al s

truc

ture

s.•

Deat

h.

Trea

tmen

tTr

eatm

ent d

epen

ds o

n th

e ce

ll ty

pe a

nd th

e TN

M g

radi

ng.

• Sq

uam

ous

cell

carc

inom

a: ra

diot

hera

py a

nd s

urge

ry.

• Ca

rcin

oma

of th

e so

ft pa

late

: T1/

T2 –

radi

othe

rapy

; T3/

4 –

rese

ctio

n.•

Post

erio

r pha

ryng

eal w

all c

arci

nom

a: T

1/2

– ra

dica

l rad

ioth

erap

y, re

sect

ion.

• To

nsil

carc

inom

a: T

1/2

– ra

dica

l rad

ioth

erap

y, tr

anso

ral s

urge

ry;

T3

/4 –

rese

ctio

n +

/– d

isse

ctio

n an

d re

cons

truc

tion.

• Po

stop

erat

ive

radi

othe

rapy

requ

ired

for n

odal

invo

lvem

ent.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E, L

FTs,

ESR,

Ep

stei

n–Ba

rr v

irus

and

vira

l cap

sid

antig

en.

• Sp

ecifi

c te

sts:

audi

ogra

m, t

ympa

nogr

am a

nd

visu

al fi

elds

.•

Radi

olog

y: C

T, M

RI w

ith T

NM

cla

ssifi

catio

n.

Angi

ogra

phy

for a

ngio

fibro

ma.

MAP

6.5

. Oro

phar

ynge

al c

ance

r

K30033_C006.indd 181 28/02/17 11:13 am

Ear,

nose

and

thr

oat

182

MAP

6.6

. La

ryn

gea

l can

cer

Wha

t is

lary

ngea

l can

cer?

Lary

ngea

l tum

ours

may

be

beni

gn o

r mal

igna

nt:

• M

alig

nant

: squ

amou

s ce

ll ca

rcin

omas

, ade

noca

rcin

omas

, sar

com

a, v

erru

cous

car

cino

ma,

un

diffe

rent

iate

d.•

Beni

gn: p

apill

omas

, cho

ndro

mas

, lip

omas

.

Caus

esTh

e ex

act c

ause

of l

aryn

geal

tum

ours

is u

nkno

wn

but r

isk

fact

ors

incl

ude:

• Ag

e.•

Mal

e.•

Smok

ing.

• Al

coho

l.

Sym

ptom

s•

Coug

h.•

Hoar

se v

oice

– re

curr

ent l

aryn

geal

ner

ve

invo

lvem

ent.

• Ly

mph

aden

opat

hy.

• St

ridor

.

Com

plic

atio

ns•

Met

asta

sis.

• In

vasi

on o

f loc

al s

truc

ture

s.•

Deat

h.•

Voca

l cor

d pa

raly

sis.

Trea

tmen

tCo

nser

vati

ve:

• Pa

tient

edu

catio

n, M

acm

illan

nur

ses

refe

rral

.•

Spee

ch th

erap

y af

ter c

hem

othe

rapy

, rad

ioth

erap

y an

d su

rger

y.

Med

ical

:•

Trea

tmen

t of l

aryn

geal

can

cer i

s di

ctat

ed b

y th

e TM

N s

tage

.•

Radi

othe

rapy

and

che

mot

hera

py.

Surg

ical

:•

Lary

nx s

parin

g su

rger

y (e

.g. e

ndos

copi

c la

ser r

esec

tion,

lary

ngof

issu

re,

co

rdec

tom

y, ve

rtic

al p

artia

l lar

ynge

ctom

y).

• To

tal o

r par

tial l

aryn

gect

omy.

• N

eck

diss

ectio

n.

Inve

stig

atio

ns•

Bloo

d te

sts:

FBC,

WCC

, U&

E,

LFTs

, ESR

.•

Spec

ific

test

s: ex

amin

atio

n

unde

r ana

esth

esia

and

bi

opsy

.•

Radi

olog

y: c

hest

x-r

ay, C

T,

MRI

.

MAP

6.6

. Lar

ynge

al c

ance

r

K30033_C006.indd 182 28/02/17 11:13 am

Chap

ter S

even

Der

mat

olog

y

MAP

7.1

A

top

ic e

czem

a 18

4

MAP

7.2

Se

bo

rrh

oei

c d

erm

atit

is

186

MAP

7.3

Ps

ori

asis

18

8

MAP

7.4

Pi

tyri

asis

19

0

MAP

7.5

Er

yth

emat

ou

s le

sio

ns

192

MAP

7.6

Li

chen

oid

lesi

on

s 19

4

MAP

7.7

B

ullo

us

dis

ord

ers

196

MAP

7.8

A

cne

vulg

aris

19

8

MAP

7.9

R

osa

cea

200

MAP

7.1

0 A

lop

ecia

are

ata

202

TABL

E 7.

1 V

iral

ski

n in

fect

ion

s 20

4

TABL

E 7.

2 Pa

rasi

tic

skin

infe

ctio

ns

207

TABL

E 7.

3 B

acte

rial

ski

n in

fect

ion

s 20

8

TABL

E 7.

4 Fu

ng

al s

kin

infe

ctio

ns

210

TABL

E 7.

5 Sk

in lu

mp

s 21

2

TABL

E 7.

6 Sk

in t

um

ou

rs

216

Der

mat

olog

y18

3

K30033_C007.indd 183 28/02/17 11:21 am

184

Der

mat

olog

yM

ap 7

.1.

Ato

pic

ecz

ema

MAP

7.1

. Ato

pic

ecze

ma

Wha

t is

ato

pic

ecze

ma?

Ecze

ma

is a

com

mon

chr

onic

infla

mm

ator

y sk

in

cond

ition

that

pre

sent

s w

ith it

chy,

dry

, sca

lyle

sion

s. A

topi

c ec

zem

a is

the

mos

t com

mon

type

of

ecz

ema,

but

ther

e ar

e ot

her v

aria

tions

, suc

h as

con

tact

der

mat

itis,

as

wel

l as

thos

e th

at a

re

defin

ed b

y ap

pear

ance

suc

h as

dis

coid

ecze

ma

and

veno

us e

czem

a.

Caus

esTh

e ex

act c

ause

of a

topi

c ec

zem

a is

not

kno

wn.

It

is th

ough

t to

be m

ultif

acto

rial a

nd is

gen

eral

lyco

nsid

ered

to b

e an

inte

ract

ion

betw

een

gene

ticco

mpo

nent

s an

d th

e im

mun

e sy

stem

.

• G

enet

ic: i

ncre

ased

risk

with

a p

ositi

ve

fam

ily h

isto

ry. F

ilagg

rin g

ene

mut

atio

ns

pred

ispo

se to

ecz

ema.

• A

llerg

en e

xpos

ure:

e.g

. cer

tain

was

hing

de

terg

ents

, per

fum

es, f

ood

alle

rgie

s.•

Exac

erba

ting

fact

ors:

em

otio

nal s

tres

s,

tem

pera

ture

fluc

tuat

ion.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

and

avoi

danc

e of

tr

igge

ring

fact

ors.

Med

ical

:•

Emol

lient

s –

wet

wra

ps m

ay b

e us

ed to

aid

ab

sorp

tion.

• To

pica

l ste

roid

s –

use

low

est p

oten

cy fi

rst.

• An

tibio

tics

– fo

r sec

onda

ry b

acte

rial

in

fect

ion.

• An

ti-vi

rals

– a

cicl

ovir

is u

sed

in e

czem

a

herp

etic

um.

• PU

VA tr

eatm

ent m

ay b

e us

ed in

resi

stan

t

case

s.

Com

plic

atio

ns•

Chro

nic

dry

skin

.•

Supe

radd

ed in

fect

ion:

Usu

ally

Sta

phyl

ococ

cus

aure

us re

sulti

ng

in

impe

tigin

ized

ecz

ema.

Herp

es s

impl

ex v

irus

may

cau

se e

czem

a

herp

etic

um.

• Ey

e pr

oble

ms

such

as

conj

unct

iviti

s an

d

blep

harit

is.

• De

crea

sed

qual

ity o

f sle

ep.

Inve

stig

atio

ns•

Alw

ays

ask

abou

t oth

er a

topi

c co

nditi

ons

su

ch a

s as

thm

a an

d ha

y fe

ver a

s w

ell a

s fo

od

alle

rgy.

• Bl

ood

test

s: s

erum

IgE

(hig

h).

• O

ther

: ski

n pr

ick

or R

AST.

• Sw

ab –

to id

entif

y ca

usat

ive

orga

nism

if

infe

ctio

n pr

esen

t.

Sym

ptom

s•

Xero

sis

(gen

eral

ized

dry

ski

n).

• Er

ythe

mat

ous

lesi

ons.

• Ex

coria

tion.

• Li

chen

ifica

tions

.•

Sign

s of

sup

erad

ded

infe

ctio

n (e

.g. v

esic

les)

.•

Itchi

ng.

• N

ote

dist

ribut

ion:

Face

– o

ften

in b

abie

s.

An

tecu

bita

l fos

sa.

Popl

iteal

foss

a.

W

rists

.

An

kles

.•

Nai

ls –

pol

ishe

d fro

m s

crat

chin

g.

K30033_C007.indd 184 28/02/17 11:21 am

185

Der

mat

olog

yM

ap 7

.1.

Ato

pic

ecz

ema

MAP

7.1

. Ato

pic

ecze

ma

Wha

t is

ato

pic

ecze

ma?

Ecze

ma

is a

com

mon

chr

onic

infla

mm

ator

y sk

in

cond

ition

that

pre

sent

s w

ith it

chy,

dry

, sca

lyle

sion

s. A

topi

c ec

zem

a is

the

mos

t com

mon

type

of

ecz

ema,

but

ther

e ar

e ot

her v

aria

tions

, suc

h as

con

tact

der

mat

itis,

as

wel

l as

thos

e th

at a

re

defin

ed b

y ap

pear

ance

suc

h as

dis

coid

ecze

ma

and

veno

us e

czem

a.

Caus

esTh

e ex

act c

ause

of a

topi

c ec

zem

a is

not

kno

wn.

It

is th

ough

t to

be m

ultif

acto

rial a

nd is

gen

eral

lyco

nsid

ered

to b

e an

inte

ract

ion

betw

een

gene

ticco

mpo

nent

s an

d th

e im

mun

e sy

stem

.

• G

enet

ic: i

ncre

ased

risk

with

a p

ositi

ve

fam

ily h

isto

ry. F

ilagg

rin g

ene

mut

atio

ns

pred

ispo

se to

ecz

ema.

• A

llerg

en e

xpos

ure:

e.g

. cer

tain

was

hing

de

terg

ents

, per

fum

es, f

ood

alle

rgie

s.•

Exac

erba

ting

fact

ors:

em

otio

nal s

tres

s,

tem

pera

ture

fluc

tuat

ion.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

and

avoi

danc

e of

tr

igge

ring

fact

ors.

Med

ical

:•

Emol

lient

s –

wet

wra

ps m

ay b

e us

ed to

aid

ab

sorp

tion.

• To

pica

l ste

roid

s –

use

low

est p

oten

cy fi

rst.

• An

tibio

tics

– fo

r sec

onda

ry b

acte

rial

in

fect

ion.

• An

ti-vi

rals

– a

cicl

ovir

is u

sed

in e

czem

a

herp

etic

um.

• PU

VA tr

eatm

ent m

ay b

e us

ed in

resi

stan

t

case

s.

Com

plic

atio

ns•

Chro

nic

dry

skin

.•

Supe

radd

ed in

fect

ion:

Usu

ally

Sta

phyl

ococ

cus

aure

us re

sulti

ng

in

impe

tigin

ized

ecz

ema.

Herp

es s

impl

ex v

irus

may

cau

se e

czem

a

herp

etic

um.

• Ey

e pr

oble

ms

such

as

conj

unct

iviti

s an

d

blep

harit

is.

• De

crea

sed

qual

ity o

f sle

ep.

Inve

stig

atio

ns•

Alw

ays

ask

abou

t oth

er a

topi

c co

nditi

ons

su

ch a

s as

thm

a an

d ha

y fe

ver a

s w

ell a

s fo

od

alle

rgy.

• Bl

ood

test

s: s

erum

IgE

(hig

h).

• O

ther

: ski

n pr

ick

or R

AST.

• Sw

ab –

to id

entif

y ca

usat

ive

orga

nism

if

infe

ctio

n pr

esen

t.

Sym

ptom

s•

Xero

sis

(gen

eral

ized

dry

ski

n).

• Er

ythe

mat

ous

lesi

ons.

• Ex

coria

tion.

• Li

chen

ifica

tions

.•

Sign

s of

sup

erad

ded

infe

ctio

n (e

.g. v

esic

les)

.•

Itchi

ng.

• N

ote

dist

ribut

ion:

Face

– o

ften

in b

abie

s.

An

tecu

bita

l fos

sa.

Popl

iteal

foss

a.

W

rists

.

An

kles

.•

Nai

ls –

pol

ishe

d fro

m s

crat

chin

g.

K30033_C007.indd 185 28/02/17 11:21 am

186

Der

mat

olog

yM

ap 7

.2.

Seb

orr

ho

eic

der

mat

itis

Wha

t is

seb

orrh

oeic

der

mat

itis

?Th

is is

a c

hron

ic in

flam

mat

ory

skin

con

ditio

n re

sulti

ng in

der

mat

itis

in a

reas

rich

in s

ebac

eous

gl

ands

, suc

h as

the

naso

labi

al fo

lds.

Caus

esTh

e ex

act c

ause

of s

ebor

rhoe

ic d

erm

atiti

s is

not

kn

own

but c

urre

nt th

eorie

s su

gges

t tha

t the

yeas

t Mal

asse

zia

furfu

r pla

ys a

role

. Add

ition

ally,

se

borr

hoei

c de

rmat

itis

is m

ore

com

mon

in

patie

nts

suffe

ring

with

HIV

and

, the

refo

re, a

w

eake

ned

imm

une

syst

em m

ay p

lay

a ro

le.

Sym

ptom

s•

Red/

whi

te/y

ello

w, s

caly

lesi

ons

pres

ent

us

ually

aro

und

the

naso

labi

al fo

lds,

eyeb

row

s,

ches

t and

sca

lp. M

ay a

lso

occu

r in

othe

r hai

r

bear

ing

area

s an

d in

flex

ural

fold

s.•

Itchi

ng.

• Cr

adle

cap

– s

een

in b

abie

s.

Inve

stig

atio

nsSe

borr

hoei

c de

rmat

itis

tend

s to

be

a cl

inic

aldi

agno

sis.

• Sk

in s

crap

ing

mic

rosc

opy

– m

ay s

how

M

alas

sezi

a fu

rfur.

• Sk

in s

wab

s fo

r sup

erad

ded

infe

ctio

n, u

sual

ly

Stap

hylo

cocc

us a

ureu

s.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Was

h w

ith a

nti-d

andr

uff s

ham

poo

cont

aini

ng

antif

unga

l age

nts,

such

as

keto

cona

zole

,

or a

ker

atol

ytic

suc

h as

sal

icyl

ic a

cid

• In

term

itten

t use

of a

mild

topi

cal s

tero

id.

Com

plic

atio

ns•

Supe

radd

ed in

fect

ion.

• Ps

ycho

logi

cal e

ffect

s re

latin

g to

app

eara

nce.

MAP

7.2

. Seb

orrh

oeic

der

mat

itis

K30033_C007.indd 186 28/02/17 11:21 am

187

Map

7.2

. Se

bo

rrh

oei

c d

erm

atit

isD

erm

atol

ogy

Wha

t is

seb

orrh

oeic

der

mat

itis

?Th

is is

a c

hron

ic in

flam

mat

ory

skin

con

ditio

n re

sulti

ng in

der

mat

itis

in a

reas

rich

in s

ebac

eous

gl

ands

, suc

h as

the

naso

labi

al fo

lds.

Caus

esTh

e ex

act c

ause

of s

ebor

rhoe

ic d

erm

atiti

s is

not

kn

own

but c

urre

nt th

eorie

s su

gges

t tha

t the

yeas

t Mal

asse

zia

furfu

r pla

ys a

role

. Add

ition

ally,

se

borr

hoei

c de

rmat

itis

is m

ore

com

mon

in

patie

nts

suffe

ring

with

HIV

and

, the

refo

re, a

w

eake

ned

imm

une

syst

em m

ay p

lay

a ro

le.

Sym

ptom

s•

Red/

whi

te/y

ello

w, s

caly

lesi

ons

pres

ent

us

ually

aro

und

the

naso

labi

al fo

lds,

eyeb

row

s,

ches

t and

sca

lp. M

ay a

lso

occu

r in

othe

r hai

r

bear

ing

area

s an

d in

flex

ural

fold

s.•

Itchi

ng.

• Cr

adle

cap

– s

een

in b

abie

s.

Inve

stig

atio

nsSe

borr

hoei

c de

rmat

itis

tend

s to

be

a cl

inic

aldi

agno

sis.

• Sk

in s

crap

ing

mic

rosc

opy

– m

ay s

how

M

alas

sezi

a fu

rfur.

• Sk

in s

wab

s fo

r sup

erad

ded

infe

ctio

n, u

sual

ly

Stap

hylo

cocc

us a

ureu

s.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Was

h w

ith a

nti-d

andr

uff s

ham

poo

cont

aini

ng

antif

unga

l age

nts,

such

as

keto

cona

zole

,

or a

ker

atol

ytic

suc

h as

sal

icyl

ic a

cid

• In

term

itten

t use

of a

mild

topi

cal s

tero

id.

Com

plic

atio

ns•

Supe

radd

ed in

fect

ion.

• Ps

ycho

logi

cal e

ffect

s re

latin

g to

app

eara

nce.

MAP

7.2

. Seb

orrh

oeic

der

mat

itis

K30033_C007.indd 187 28/02/17 11:21 am

188

Der

mat

olog

yM

ap 7

.3.

Pso

rias

is

Wha

t is

pso

rias

is?

Psor

iasi

s is

a c

hron

ic, n

on-in

fect

ious

in

flam

mat

ory

skin

con

ditio

n ch

arac

teriz

ed b

y w

ell-d

emar

cate

d sa

lmon

pin

k pl

aque

s w

ith

silv

ery

scal

es. I

t is

very

com

mon

and

may

oc

cur a

t any

age

. Tw

o pe

aks

have

bee

n id

entif

ied

– in

the

20s

and

50s.

Mal

es a

nd

fem

ales

are

equ

ally

affe

cted

. Thi

s co

nditi

on

caus

es h

yper

prol

ifera

tion

of th

e ep

ider

mis,

in

flam

mat

ion

of th

e ep

ider

mis

and

der

mis

as

wel

l as

rete

ntio

n of

nuc

lei i

n ke

ratin

ocyt

es in

th

e ho

rny

laye

r (pa

rake

rato

sis)

.

Caus

esTh

e ex

act c

ause

of p

soria

sis

is u

nkno

wn

but

broa

dly

it is

thou

ght t

o be

due

to a

com

plex

in

tera

ctio

n be

twee

n ge

netic

s an

d en

viro

nmen

-ta

l trig

gers

.•

Gen

etic

fact

ors:

Mut

atio

ns o

f PSO

RS1

on c

hrom

osom

e

6

– as

soci

ated

mor

e w

ith g

utta

te

ps

oria

sis.

Poly

mor

phis

ms

in g

enes

for I

L-12

and

IL

-23.

• En

viro

nmen

tal t

rigge

rs:

Infe

ctio

n, p

artic

ular

ly

st

rept

ococ

cal i

nfec

tion

(gut

tate

pso

riasi

s).

Stre

ss.

Drug

s (e

.g. b

eta

bloc

kers

,

AC

E in

hibi

tors

,

an

timal

aria

ls a

nd li

thiu

m).

Trau

ma

– Ko

ebne

r

ph

enom

enon

.

Sm

okin

g.

Al

coho

l.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Avo

id tr

igge

ring

fact

ors

(e

.g. s

mok

ing

is s

tron

gly

linke

d w

ith

palm

opla

ntar

pso

riasi

s)•

Prov

ide

info

rmat

ion

on tr

eatm

ent o

ptio

ns

and

mon

itor b

lood

s re

gula

rly, e

spec

ially

w

hen

patie

nts

are

taki

ng s

yste

mic

ther

apy

or

bio

logi

cal a

gent

s. Al

so, b

e aw

are

of

tera

toge

nici

ty in

wom

en o

f chi

ld-b

earin

g

age.

• As

sess

sev

erity

:

Pa

tient

’s pe

rspe

ctiv

e: a

sses

sed

usin

g

th

e De

rmat

olog

y Li

fe Q

ualit

y

In

dex

(DLQ

I).

Ph

ysic

ian’

s pe

rspe

ctiv

e: a

sses

sed

usin

g

th

e Ps

oria

sis A

rea

and

Seve

rity

Inde

x

(P

ASI).

Med

ical

:•

Topi

cal t

hera

py: e

mol

lient

s, ke

rato

lytic

ag

ents

, Goe

cker

man

trea

tmen

t (co

al ta

r and

U

VB),

dith

rano

l tre

atm

ent (

shor

t con

tact

th

erap

y), t

opic

al s

tero

ids

(e.g

. bet

amet

ha-

so

ne o

intm

ent,

calc

ipot

riol w

ith a

nd

with

out b

etam

etha

sone

).

• Ph

otot

hera

py: U

VB o

r PU

VA. W

ith P

UVA

pa

tient

mus

t tak

e ps

oral

en e

ither

ora

lly o

r

in a

bat

h so

lutio

n.•

Syst

emic

ther

apy

(e.g

. met

hotr

exat

e,

cicl

ospo

rin)

• Bi

olog

ical

age

nts

(e.g

. eta

nerc

ept,

ad

alim

umab

, inf

lixim

ab a

nd u

stek

inum

ab).

Inve

stig

atio

nsDi

agno

sis

is u

sual

ly b

ased

on

clin

ical

exa

min

atio

n.•

Wel

l-dem

arca

ted

salm

on p

ink

plaq

ues

with

silv

ery

whi

te s

cale

s.•

Usu

ally

ove

r ext

enso

r sur

face

s bu

t als

o m

ay b

e pr

esen

t on

the

scal

p an

d na

vel.

• W

hite

bla

nchi

ng ri

ng p

rese

nt o

n sk

in s

urro

undi

ng p

laqu

e. T

his

is c

alle

d W

oron

off’s

ring

.•

Nai

l cha

nges

: (se

e sy

mpt

oms)

.•

Spec

ial s

igns

:

Au

spitz

’s si

gn: c

apill

ary

blee

ding

whe

n in

divi

dual

sca

les

rem

oved

from

pla

que.

Koeb

ner’s

phe

nom

enon

: new

lesi

ons

at s

ite o

f tra

uma.

Bulk

eley

’s m

embr

ane:

moi

st re

d su

rface

on

rem

oval

of s

cale

s.

Sym

ptom

s•

Gen

eral

sym

ptom

s: itc

hing

, pai

n, d

ecre

ased

de

xter

ity.

• Le

sion

type

:

1.

Chro

nic

plaq

ue p

soria

sis

– ex

tens

or

su

rface

s.

•

Psor

iasi

s gy

rate

– c

urve

d lin

ear

pa

tter

ns.

• An

nula

r pso

riasi

s –

ring-

like

lesi

ons,

ce

ntra

l cle

arin

g.

•

Psor

iasi

s fo

llicu

laris

– s

caly

pap

ules

at

pilo

seba

ceou

s fo

llicl

es.

2.

Ru

pioi

d pl

aque

s –

limpe

t she

ll

ap

pear

ance

, 2–5

cm

.

3.

Ost

race

ous

psor

iasi

s –

oyst

er s

hell

appe

aran

ce.

4.

In

vers

e ps

oria

sis

– in

tert

rigin

ous

area

s.

5.

Gut

tate

pso

riasi

s –

rain

drop

app

eara

nce

over

bod

y. As

soci

ated

with

prio

r

st

rept

ococ

cal p

hary

ngiti

s. U

sual

ly

yo

unge

r pat

ient

s.

6.

Pust

ular

pso

riasi

s –

palm

s an

d so

les

usua

lly.

7.

Er

ythr

oder

mic

pso

riasi

s –

derm

atol

ogic

al

em

erge

ncy.

• N

ail c

hang

es:

Pitt

ing.

Yello

win

g.

Su

bung

ual k

erat

osis.

Ony

chol

ysis.

• Jo

int p

ain

– ps

oria

tic a

rthr

itis

is p

rese

nt in

10

–15%

of p

atie

nts.

Com

plic

atio

ns•

Psor

iatic

art

hriti

s.•

Eye

dise

ase

(e.g

. ble

phar

itis

and

co

njun

ctiv

itis)

.•

Incr

ease

d ris

k of

:

Ca

rdio

vasc

ular

dis

ease

.

M

etab

olic

syn

drom

e.

De

pres

sion

.

MAP

7.3

. Pso

rias

is

K30033_C007.indd 188 28/02/17 11:21 am

189

Der

mat

olog

yM

ap 7

.3.

Pso

rias

is

Wha

t is

pso

rias

is?

Psor

iasi

s is

a c

hron

ic, n

on-in

fect

ious

in

flam

mat

ory

skin

con

ditio

n ch

arac

teriz

ed b

y w

ell-d

emar

cate

d sa

lmon

pin

k pl

aque

s w

ith

silv

ery

scal

es. I

t is

very

com

mon

and

may

oc

cur a

t any

age

. Tw

o pe

aks

have

bee

n id

entif

ied

– in

the

20s

and

50s.

Mal

es a

nd

fem

ales

are

equ

ally

affe

cted

. Thi

s co

nditi

on

caus

es h

yper

prol

ifera

tion

of th

e ep

ider

mis,

in

flam

mat

ion

of th

e ep

ider

mis

and

der

mis

as

wel

l as

rete

ntio

n of

nuc

lei i

n ke

ratin

ocyt

es in

th

e ho

rny

laye

r (pa

rake

rato

sis)

.

Caus

esTh

e ex

act c

ause

of p

soria

sis

is u

nkno

wn

but

broa

dly

it is

thou

ght t

o be

due

to a

com

plex

in

tera

ctio

n be

twee

n ge

netic

s an

d en

viro

nmen

-ta

l trig

gers

.•

Gen

etic

fact

ors:

Mut

atio

ns o

f PSO

RS1

on c

hrom

osom

e

6

– as

soci

ated

mor

e w

ith g

utta

te

ps

oria

sis.

Poly

mor

phis

ms

in g

enes

for I

L-12

and

IL

-23.

• En

viro

nmen

tal t

rigge

rs:

Infe

ctio

n, p

artic

ular

ly

st

rept

ococ

cal i

nfec

tion

(gut

tate

pso

riasi

s).

Stre

ss.

Drug

s (e

.g. b

eta

bloc

kers

,

AC

E in

hibi

tors

,

an

timal

aria

ls a

nd li

thiu

m).

Trau

ma

– Ko

ebne

r

ph

enom

enon

.

Sm

okin

g.

Al

coho

l.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Avo

id tr

igge

ring

fact

ors

(e

.g. s

mok

ing

is s

tron

gly

linke

d w

ith

palm

opla

ntar

pso

riasi

s)•

Prov

ide

info

rmat

ion

on tr

eatm

ent o

ptio

ns

and

mon

itor b

lood

s re

gula

rly, e

spec

ially

w

hen

patie

nts

are

taki

ng s

yste

mic

ther

apy

or

bio

logi

cal a

gent

s. Al

so, b

e aw

are

of

tera

toge

nici

ty in

wom

en o

f chi

ld-b

earin

g

age.

• As

sess

sev

erity

:

Pa

tient

’s pe

rspe

ctiv

e: a

sses

sed

usin

g

th

e De

rmat

olog

y Li

fe Q

ualit

y

In

dex

(DLQ

I).

Ph

ysic

ian’

s pe

rspe

ctiv

e: a

sses

sed

usin

g

th

e Ps

oria

sis A

rea

and

Seve

rity

Inde

x

(P

ASI).

Med

ical

:•

Topi

cal t

hera

py: e

mol

lient

s, ke

rato

lytic

ag

ents

, Goe

cker

man

trea

tmen

t (co

al ta

r and

U

VB),

dith

rano

l tre

atm

ent (

shor

t con

tact

th

erap

y), t

opic

al s

tero

ids

(e.g

. bet

amet

ha-

so

ne o

intm

ent,

calc

ipot

riol w

ith a

nd

with

out b

etam

etha

sone

).

• Ph

otot

hera

py: U

VB o

r PU

VA. W

ith P

UVA

pa

tient

mus

t tak

e ps

oral

en e

ither

ora

lly o

r

in a

bat

h so

lutio

n.•

Syst

emic

ther

apy

(e.g

. met

hotr

exat

e,

cicl

ospo

rin)

• Bi

olog

ical

age

nts

(e.g

. eta

nerc

ept,

ad

alim

umab

, inf

lixim

ab a

nd u

stek

inum

ab).

Inve

stig

atio

nsDi

agno

sis

is u

sual

ly b

ased

on

clin

ical

exa

min

atio

n.•

Wel

l-dem

arca

ted

salm

on p

ink

plaq

ues

with

silv

ery

whi

te s

cale

s.•

Usu

ally

ove

r ext

enso

r sur

face

s bu

t als

o m

ay b

e pr

esen

t on

the

scal

p an

d na

vel.

• W

hite

bla

nchi

ng ri

ng p

rese

nt o

n sk

in s

urro

undi

ng p

laqu

e. T

his

is c

alle

d W

oron

off’s

ring

.•

Nai

l cha

nges

: (se

e sy

mpt

oms)

.•

Spec

ial s

igns

:

Au

spitz

’s si

gn: c

apill

ary

blee

ding

whe

n in

divi

dual

sca

les

rem

oved

from

pla

que.

Koeb

ner’s

phe

nom

enon

: new

lesi

ons

at s

ite o

f tra

uma.

Bulk

eley

’s m

embr

ane:

moi

st re

d su

rface

on

rem

oval

of s

cale

s.

Sym

ptom

s•

Gen

eral

sym

ptom

s: itc

hing

, pai

n, d

ecre

ased

de

xter

ity.

• Le

sion

type

:

1.

Chro

nic

plaq

ue p

soria

sis

– ex

tens

or

su

rface

s.

•

Psor

iasi

s gy

rate

– c

urve

d lin

ear

pa

tter

ns.

• An

nula

r pso

riasi

s –

ring-

like

lesi

ons,

ce

ntra

l cle

arin

g.

•

Psor

iasi

s fo

llicu

laris

– s

caly

pap

ules

at

pilo

seba

ceou

s fo

llicl

es.

2.

Ru

pioi

d pl

aque

s –

limpe

t she

ll

ap

pear

ance

, 2–5

cm

.

3.

Ost

race

ous

psor

iasi

s –

oyst

er s

hell

appe

aran

ce.

4.

In

vers

e ps

oria

sis

– in

tert

rigin

ous

area

s.

5.

Gut

tate

pso

riasi

s –

rain

drop

app

eara

nce

over

bod

y. As

soci

ated

with

prio

r

st

rept

ococ

cal p

hary

ngiti

s. U

sual

ly

yo

unge

r pat

ient

s.

6.

Pust

ular

pso

riasi

s –

palm

s an

d so

les

usua

lly.

7.

Er

ythr

oder

mic

pso

riasi

s –

derm

atol

ogic

al

em

erge

ncy.

• N

ail c

hang

es:

Pitt

ing.

Yello

win

g.

Su

bung

ual k

erat

osis.

Ony

chol

ysis.

• Jo

int p

ain

– ps

oria

tic a

rthr

itis

is p

rese

nt in

10

–15%

of p

atie

nts.

Com

plic

atio

ns•

Psor

iatic

art

hriti

s.•

Eye

dise

ase

(e.g

. ble

phar

itis

and

co

njun

ctiv

itis)

.•

Incr

ease

d ris

k of

:

Ca

rdio

vasc

ular

dis

ease

.

M

etab

olic

syn

drom

e.

De

pres

sion

.

MAP

7.3

. Pso

rias

is

K30033_C007.indd 189 28/02/17 11:21 am

190

Der

mat

olog

yM

ap 7

.4.

Pity

rias

is

Pity

rias

is r

osea

Wha

t is

pit

yria

sis

rose

a?Th

is is

a b

enig

n, s

elf-l

imiti

ng b

ran-

like

scal

y ra

sh th

at o

ccur

s on

the

trun

k.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn,

but

HHV

-7 h

as b

een

impl

icat

ed.

Sym

ptom

s•

Itchi

ng.

• 70

% o

f pat

ient

s ha

ve a

n up

per r

espi

rato

ry tr

act i

nfec

tion

befo

re

derm

atol

ogic

al s

ympt

oms

pres

ent.

• He

rald

pat

ch –

a s

ingl

e, la

rger

lesi

on p

rece

des

smal

ler o

val p

laqu

es. I

t is

pi

nk in

app

eara

nce

and

has

a ce

ntra

l cle

arin

g.•

Smal

ler o

val l

esio

ns fo

llow

a ‘C

hris

tmas

tree

’ dis

trib

utio

n.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is.

Trea

tmen

tO

ften

no tr

eatm

ent i

s re

quire

d si

nce

it is

a s

elf-l

imiti

ng c

ondi

tion.

Cons

erva

tive

:•

Patie

nt e

duca

tion

that

con

ditio

n is

ben

ign.

M

edic

al:

• An

ti-hi

stam

ines

or s

tero

id to

aid

itch

ing.

Pity

rias

is v

ersi

colo

r

Wha

t is

pit

yria

sis

vers

icol

or?

This

is a

com

men

sal y

east

infe

ctio

n of

the

skin

that

cau

ses

num

erou

sle

sion

s of

var

ying

col

ours

on

the

trun

k an

d ba

ck.

Caus

esTh

e ye

asts

Mal

asse

zia

glob

osa

and

Mal

asse

zia

furfu

r. Tr

igge

ring

fact

ors

incl

ude

exce

ssiv

e sw

eatin

g an

d liv

ing

in h

ot c

limat

es a

s w

ell a

s im

mun

osup

pres

sion

.

Sym

ptom

s•

Mild

itch

ing.

• Br

an-li

ke s

cale

s of

var

ying

col

our.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is.•

Fung

al c

ultu

res

for M

alas

sezi

a.•

Woo

d la

mp

exam

inat

ion

– ye

llow

-gre

en fl

uore

scen

ce in

affe

cted

regi

ons.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Topi

cal a

nti-f

unga

l age

nts/

sham

poos

.•

Prop

ylen

e gl

ycol

sol

utio

n.•

Sodi

um th

iosu

lpha

te s

olut

ion.

• O

ral a

nti-f

unga

l age

nts

in e

xten

sive

dis

ease

.

MAP

7.4

. Pit

yria

sis

K30033_C007.indd 190 28/02/17 11:21 am

191

Der

mat

olog

yM

ap 7

.4.

Pity

rias

is

Pity

rias

is r

osea

Wha

t is

pit

yria

sis

rose

a?Th

is is

a b

enig

n, s

elf-l

imiti

ng b

ran-

like

scal

y ra

sh th

at o

ccur

s on

the

trun

k.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn,

but

HHV

-7 h

as b

een

impl

icat

ed.

Sym

ptom

s•

Itchi

ng.

• 70

% o

f pat

ient

s ha

ve a

n up

per r

espi

rato

ry tr

act i

nfec

tion

befo

re

derm

atol

ogic

al s

ympt

oms

pres

ent.

• He

rald

pat

ch –

a s

ingl

e, la

rger

lesi

on p

rece

des

smal

ler o

val p

laqu

es. I

t is

pi

nk in

app

eara

nce

and

has

a ce

ntra

l cle

arin

g.•

Smal

ler o

val l

esio

ns fo

llow

a ‘C

hris

tmas

tree

’ dis

trib

utio

n.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is.

Trea

tmen

tO

ften

no tr

eatm

ent i

s re

quire

d si

nce

it is

a s

elf-l

imiti

ng c

ondi

tion.

Cons

erva

tive

:•

Patie

nt e

duca

tion

that

con

ditio

n is

ben

ign.

M

edic

al:

• An

ti-hi

stam

ines

or s

tero

id to

aid

itch

ing.

Pity

rias

is v

ersi

colo

r

Wha

t is

pit

yria

sis

vers

icol

or?

This

is a

com

men

sal y

east

infe

ctio

n of

the

skin

that

cau

ses

num

erou

sle

sion

s of

var

ying

col

ours

on

the

trun

k an

d ba

ck.

Caus

esTh

e ye

asts

Mal

asse

zia

glob

osa

and

Mal

asse

zia

furfu

r. Tr

igge

ring

fact

ors

incl

ude

exce

ssiv

e sw

eatin

g an

d liv

ing

in h

ot c

limat

es a

s w

ell a

s im

mun

osup

pres

sion

.

Sym

ptom

s•

Mild

itch

ing.

• Br

an-li

ke s

cale

s of

var

ying

col

our.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is.•

Fung

al c

ultu

res

for M

alas

sezi

a.•

Woo

d la

mp

exam

inat

ion

– ye

llow

-gre

en fl

uore

scen

ce in

affe

cted

regi

ons.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

Med

ical

:•

Topi

cal a

nti-f

unga

l age

nts/

sham

poos

.•

Prop

ylen

e gl

ycol

sol

utio

n.•

Sodi

um th

iosu

lpha

te s

olut

ion.

• O

ral a

nti-f

unga

l age

nts

in e

xten

sive

dis

ease

.

MAP

7.4

. Pit

yria

sis

K30033_C007.indd 191 28/02/17 11:21 am

192

Der

mat

olog

yM

ap 7

.5.

Eryt

hem

ato

us

lesi

on

s

Eryt

hem

a no

dosu

m

Wha

t is

ery

them

a no

dosu

m?

This

is a

n im

mun

e-m

edia

ted

diso

rder

resu

lting

in a

pan

nicu

litis.

Caus

esTh

ere

are

man

y va

ryin

g ca

uses

of e

ryth

ema

nodo

sum

. Rem

embe

r as

NO

DO

SUM

:N

– N

o ca

use

foun

dO

– O

ccul

t mal

igna

ncy

D –

Dru

gs (e

.g. s

ulph

onam

ides

, ora

l con

trac

eptiv

e pi

ll)O

– O

ther

infe

ctio

ns (e

.g. s

trep

toco

ccal

pha

ryng

itis)

S –

Sarc

oido

sis

U –

Ulc

erat

ive

colit

is/C

rohn

’s di

seas

eM

– M

ycob

acte

rium

Sym

ptom

sPa

infu

l red

nod

ules

on

the

ante

rior s

urfa

ce o

f the

shi

n.

Inve

stig

atio

nsId

entif

y th

e un

derly

ing

caus

e.•

Thro

at s

wab

.•

Acid

fast

bac

illus

sta

inin

g (Z

iehl

–Nie

lsen

) if T

B su

spec

ted.

• Bl

ood

test

s –

FBC,

WCC

, U&

E, L

FTs,

CRP,

ASO

titr

es, v

iral s

tudi

es.

• Ra

diol

ogy

– ch

est x

-ray

.

Trea

tmen

t

Cons

erva

tive

:•

Com

pres

sion

sto

ckin

gs.

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use.

• An

alge

sia.

Com

plic

atio

nsSe

rious

com

plic

atio

ns a

re ra

re.

Eryt

hem

a m

ulti

form

e

Wha

t is

ery

them

a m

ulti

form

e?Th

is is

a s

kin

cond

ition

that

is c

ause

d by

a h

yper

sens

itivi

ty re

actio

n. T

here

are

va

ryin

g de

gree

s of

sev

erity

:1.

Ery

them

a m

ultif

orm

e m

inor

– le

ast s

ever

e.2.

Ery

them

a m

ultif

orm

e m

ajor

.3.

Ste

vens

–Joh

nson

syn

drom

e (S

JS) <

10%

bod

y su

rface

are

a; to

xic

ep

ider

mal

nec

roly

sis

(TEN

) >30

% b

ody

surfa

ce a

rea

– po

tent

ially

lif

e-th

reat

enin

g.

Caus

esTh

e ex

act c

ause

rem

ains

unk

now

n in

50%

of c

ases

. Som

e sp

ecifi

c ca

uses

in

clud

e:•

Bact

eria

l inf

ectio

ns (e

.g. S

trep

toco

ccus

, Nei

sser

ia m

enin

gitid

is).

• Vi

ral i

nfec

tions

(e.g

. her

pes

sim

plex

viru

s).

• Fu

ngal

(e.g

. Coc

cidi

odes

imm

itis)

.•

Para

sitic

infe

ctio

n (e

.g. T

oxop

lasm

a go

ndii)

.•

Adve

rse

drug

reac

tions

(e.g

. pen

icill

in, s

ulph

onam

ides

, asp

irin,

al

lopu

rinol

).•

Mal

igna

ncie

s –

non-

Hodg

kin’

s ly

mph

oma,

mul

tiple

mye

lom

a, le

ukae

mia

.

Sym

ptom

s•

Mul

tiple

ery

them

atou

s pl

aque

s ap

pear

ing

as c

once

ntric

ring

s in

a

sym

met

rical

dis

trib

utio

n.•

SJS:

feve

r >39

°C; f

atig

ue; l

esio

ns in

the

muc

ous

mem

bran

es; c

onju

nctiv

itis.

Inve

stig

atio

nsN

ot e

ssen

tial t

o m

ake

the

diag

nosi

s, bu

t vita

l for

mon

itorin

g, e

spec

ially

in S

JS.

• Bl

ood

test

s –

FBC

(¯),

WCC

(¯),

eosi

noph

ils (

), LF

Ts (

), vi

ral t

itres

.•

Urin

alys

is –

mild

pro

tein

uria

.

Trea

tmen

t

Cons

erva

tive

:•

Rem

ove

caus

ativ

e ag

ent.

• U

se th

e SC

ORT

EN s

core

to p

redi

ct m

orta

lity

in S

JS a

nd T

EN.

• In

cise

and

dra

in la

rge

bulla

e.

Med

ical

:•

Eryt

hem

a m

ultif

orm

e m

inor

– to

pica

l ste

roid

s an

d or

al a

ntih

ista

min

es•

Eryt

hem

a m

ultif

orm

e m

ajor

– in

trav

enou

s flu

ids,

mou

thw

ash

(a

ntis

eptic

and

ana

lges

ic).

• SJ

S –

intr

aven

ous

fluid

s, m

outh

was

h (a

ntis

eptic

and

ana

lges

ic),

op

htha

lmol

ogy

revi

ew, g

enita

l car

e w

ith c

athe

teriz

atio

n, a

sses

smen

t and

tr

eatm

ent o

f sup

erad

ded

infe

ctio

n.

Com

plic

atio

ns•

Dehy

drat

ion

and

elec

trol

yte

imba

lanc

e.•

Acut

e re

spira

tory

dis

tres

s sy

ndro

me.

• Ey

e pr

oble

ms

(e.g

. con

junc

tiviti

s, co

rnea

l ulc

ers,

sym

blep

haro

n).

• Re

nal f

ailu

re.

MAP

7.5

. Ery

them

atou

s le

sion

s

K30033_C007.indd 192 28/02/17 11:21 am

193

Der

mat

olog

yM

ap 7

.5.

Eryt

hem

ato

us

lesi

on

s

Eryt

hem

a no

dosu

m

Wha

t is

ery

them

a no

dosu

m?

This

is a

n im

mun

e-m

edia

ted

diso

rder

resu

lting

in a

pan

nicu

litis.

Caus

esTh

ere

are

man

y va

ryin

g ca

uses

of e

ryth

ema

nodo

sum

. Rem

embe

r as

NO

DO

SUM

:N

– N

o ca

use

foun

dO

– O

ccul

t mal

igna

ncy

D –

Dru

gs (e

.g. s

ulph

onam

ides

, ora

l con

trac

eptiv

e pi

ll)O

– O

ther

infe

ctio

ns (e

.g. s

trep

toco

ccal

pha

ryng

itis)

S –

Sarc

oido

sis

U –

Ulc

erat

ive

colit

is/C

rohn

’s di

seas

eM

– M

ycob

acte

rium

Sym

ptom

sPa

infu

l red

nod

ules

on

the

ante

rior s

urfa

ce o

f the

shi

n.

Inve

stig

atio

nsId

entif

y th

e un

derly

ing

caus

e.•

Thro

at s

wab

.•

Acid

fast

bac

illus

sta

inin

g (Z

iehl

–Nie

lsen

) if T

B su

spec

ted.

• Bl

ood

test

s –

FBC,

WCC

, U&

E, L

FTs,

CRP,

ASO

titr

es, v

iral s

tudi

es.

• Ra

diol

ogy

– ch

est x

-ray

.

Trea

tmen

t

Cons

erva

tive

:•

Com

pres

sion

sto

ckin

gs.

Med

ical

:•

Trea

tmen

t of u

nder

lyin

g ca

use.

• An

alge

sia.

Com

plic

atio

nsSe

rious

com

plic

atio

ns a

re ra

re.

Eryt

hem

a m

ulti

form

e

Wha

t is

ery

them

a m

ulti

form

e?Th

is is

a s

kin

cond

ition

that

is c

ause

d by

a h

yper

sens

itivi

ty re

actio

n. T

here

are

va

ryin

g de

gree

s of

sev

erity

:1.

Ery

them

a m

ultif

orm

e m

inor

– le

ast s

ever

e.2.

Ery

them

a m

ultif

orm

e m

ajor

.3.

Ste

vens

–Joh

nson

syn

drom

e (S

JS) <

10%

bod

y su

rface

are

a; to

xic

ep

ider

mal

nec

roly

sis

(TEN

) >30

% b

ody

surfa

ce a

rea

– po

tent

ially

lif

e-th

reat

enin

g.

Caus

esTh

e ex

act c

ause

rem

ains

unk

now

n in

50%

of c

ases

. Som

e sp

ecifi

c ca

uses

in

clud

e:•

Bact

eria

l inf

ectio

ns (e

.g. S

trep

toco

ccus

, Nei

sser

ia m

enin

gitid

is).

• Vi

ral i

nfec

tions

(e.g

. her

pes

sim

plex

viru

s).

• Fu

ngal

(e.g

. Coc

cidi

odes

imm

itis)

.•

Para

sitic

infe

ctio

n (e

.g. T

oxop

lasm

a go

ndii)

.•

Adve

rse

drug

reac

tions

(e.g

. pen

icill

in, s

ulph

onam

ides

, asp

irin,

al

lopu

rinol

).•

Mal

igna

ncie

s –

non-

Hodg

kin’

s ly

mph

oma,

mul

tiple

mye

lom

a, le

ukae

mia

.

Sym

ptom

s•

Mul

tiple

ery

them

atou

s pl

aque

s ap

pear

ing

as c

once

ntric

ring

s in

a

sym

met

rical

dis

trib

utio

n.•

SJS:

feve

r >39

°C; f

atig

ue; l

esio

ns in

the

muc

ous

mem

bran

es; c

onju

nctiv

itis.

Inve

stig

atio

nsN

ot e

ssen

tial t

o m

ake

the

diag

nosi

s, bu

t vita

l for

mon

itorin

g, e

spec

ially

in S

JS.

• Bl

ood

test

s –

FBC

(¯),

WCC

(¯),

eosi

noph

ils (

), LF

Ts (

), vi

ral t

itres

.•

Urin

alys

is –

mild

pro

tein

uria

.

Trea

tmen

t

Cons

erva

tive

:•

Rem

ove

caus

ativ

e ag

ent.

• U

se th

e SC

ORT

EN s

core

to p

redi

ct m

orta

lity

in S

JS a

nd T

EN.

• In

cise

and

dra

in la

rge

bulla

e.

Med

ical

:•

Eryt

hem

a m

ultif

orm

e m

inor

– to

pica

l ste

roid

s an

d or

al a

ntih

ista

min

es•

Eryt

hem

a m

ultif

orm

e m

ajor

– in

trav

enou

s flu

ids,

mou

thw

ash

(a

ntis

eptic

and

ana

lges

ic).

• SJ

S –

intr

aven

ous

fluid

s, m

outh

was

h (a

ntis

eptic

and

ana

lges

ic),

op

htha

lmol

ogy

revi

ew, g

enita

l car

e w

ith c

athe

teriz

atio

n, a

sses

smen

t and

tr

eatm

ent o

f sup

erad

ded

infe

ctio

n.

Com

plic

atio

ns•

Dehy

drat

ion

and

elec

trol

yte

imba

lanc

e.•

Acut

e re

spira

tory

dis

tres

s sy

ndro

me.

• Ey

e pr

oble

ms

(e.g

. con

junc

tiviti

s, co

rnea

l ulc

ers,

sym

blep

haro

n).

• Re

nal f

ailu

re.

MAP

7.5

. Ery

them

atou

s le

sion

s

K30033_C007.indd 193 28/02/17 11:21 am

194

Der

mat

olog

yM

ap 7

.6.

Lich

eno

id le

sio

ns

Lich

en s

cler

osus

Wha

t is

lich

en s

cler

osus

?It

is a

chr

onic

ski

n co

nditi

on th

at re

sults

in th

inni

ng o

f the

epi

thel

ium

,pa

rtic

ular

ly in

the

geni

tal r

egio

n of

wom

en.

Caus

esTh

e ex

act c

ause

of l

iche

n sc

lero

sus

is u

nkno

wn

but s

ever

al ri

sk fa

ctor

s ha

vebe

en p

ropo

sed

such

as:

• G

enet

ic p

redi

spos

ition

.•

Prev

ious

his

tory

of a

utoi

mm

une

cond

ition

s (e

.g. t

hyro

id d

isea

se, t

ype

1

diab

etes

mel

litus

, viti

ligo)

.•

Low

oes

trog

en s

tatu

s –

due

to h

ighe

r pre

vale

nce

in p

ost-

men

opau

sal

w

omen

.

Sym

ptom

s•

Anog

enita

l les

ions

– a

trop

hic

whi

te m

acul

es.

• Fi

ssur

es.

• Ex

coria

tions

.

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is. A

bio

psy

may

be

need

ed to

con

firm

dia

gnos

isan

d as

sess

for c

ance

r.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

– w

ash

regu

larly

, wea

r loo

se c

loth

ing.

• Ph

otog

raph

ic m

onito

ring

of le

sion

.

Med

ical

:•

Topi

c tr

eatm

ents

– e

mol

lient

s, st

eroi

ds, c

alci

neur

in in

hibi

tors

,

tacr

olim

us o

intm

ent,

retin

oids

.•

Syst

emic

– o

ral p

redn

isol

one,

retin

oids

, met

hotr

exat

e, c

iclo

spor

in.

Com

plic

atio

ns•

Incr

ease

d ris

k of

squ

amou

s ce

ll ca

rcin

oma.

• Ad

hesi

ons

and

scar

ring:

Phim

osis.

Intr

oita

l ste

nosi

s.

La

bia

min

ora

shrin

kage

.

Lich

en p

lanu

s

Wha

t is

lich

en p

lanu

s?Li

chen

pla

nus

is a

chr

onic

infla

mm

ator

y sk

in c

ondi

tion

char

acte

rized

by

wel

l-dem

arca

ted

purp

le p

apul

es p

rese

nt o

n m

ucou

s m

embr

anes

, fle

xor

surfa

ces

and

the

geni

tal a

rea.

It h

as a

sym

met

rical

dis

trib

utio

n.

Ther

e ar

e m

any

clin

ical

cla

ssifi

catio

ns o

f lic

hen

plan

us in

clud

ing,

bu

t not

lim

ited

to, c

utan

eous

lich

en p

lanu

s, m

ucos

al li

chen

pla

nus,

liche

n pl

anop

ilaris

and

lich

en p

lanu

s of

the

nails

.

Caus

esLi

chen

pla

nus

is th

ough

t to

be a

T-ce

ll m

edia

ted

auto

imm

une

dise

ase.

Re

sear

ch h

as s

ugge

sted

som

e co

ntrib

utin

g fa

ctor

s su

ch a

s:•

Gen

etic

pre

disp

ositi

on –

HLA

-DR1

.•

Trau

ma.

• Vi

ral i

nfec

tion

– HS

V, h

epat

itis

C.

Sym

ptom

s•

Poly

gona

l pur

ple

papu

les

in s

peci

fic re

gion

s su

ch a

s th

e w

rists

, shi

ns,

lo

wer

bac

k an

d ge

nita

l reg

ion.

• O

ral m

ucos

al in

volv

emen

t – W

ickh

am’s

stria

e.•

Scar

ring

alop

ecia

.•

Nai

l les

ions

– o

nych

olys

is, th

inni

ng, r

idgi

ng, p

tery

gium

, ano

nych

ia.

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is. A

bio

psy

may

be

need

ed to

con

firm

dia

gnos

is

and

asse

ss fo

r can

cer.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r lic

hen

plan

us-li

ke re

actio

n

(e.g

. ant

ibio

tics

[tetr

acyc

line]

, ant

i-rhe

umat

ic d

rugs

[pen

icill

amin

e]).

Med

ical

:•

Topi

c tr

eatm

ents

– s

tero

ids,

calc

ineu

rin in

hibi

tors

, tac

rolim

us o

intm

ent,

re

tinoi

ds.

• Sy

stem

ic –

ora

l pre

dnis

olon

e, m

etho

trex

ate,

aza

thio

prin

e.

Com

plic

atio

ns•

Incr

ease

d ris

k of

squ

amou

s ce

ll ca

rcin

oma.

MAP

7.6

. Lic

heno

id le

sion

s

K30033_C007.indd 194 28/02/17 11:21 am

195

Der

mat

olog

yM

ap 7

.6.

Lich

eno

id le

sio

ns

Lich

en s

cler

osus

Wha

t is

lich

en s

cler

osus

?It

is a

chr

onic

ski

n co

nditi

on th

at re

sults

in th

inni

ng o

f the

epi

thel

ium

,pa

rtic

ular

ly in

the

geni

tal r

egio

n of

wom

en.

Caus

esTh

e ex

act c

ause

of l

iche

n sc

lero

sus

is u

nkno

wn

but s

ever

al ri

sk fa

ctor

s ha

vebe

en p

ropo

sed

such

as:

• G

enet

ic p

redi

spos

ition

.•

Prev

ious

his

tory

of a

utoi

mm

une

cond

ition

s (e

.g. t

hyro

id d

isea

se, t

ype

1

diab

etes

mel

litus

, viti

ligo)

.•

Low

oes

trog

en s

tatu

s –

due

to h

ighe

r pre

vale

nce

in p

ost-

men

opau

sal

w

omen

.

Sym

ptom

s•

Anog

enita

l les

ions

– a

trop

hic

whi

te m

acul

es.

• Fi

ssur

es.

• Ex

coria

tions

.

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is. A

bio

psy

may

be

need

ed to

con

firm

dia

gnos

isan

d as

sess

for c

ance

r.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion

– w

ash

regu

larly

, wea

r loo

se c

loth

ing.

• Ph

otog

raph

ic m

onito

ring

of le

sion

.

Med

ical

:•

Topi

c tr

eatm

ents

– e

mol

lient

s, st

eroi

ds, c

alci

neur

in in

hibi

tors

,

tacr

olim

us o

intm

ent,

retin

oids

.•

Syst

emic

– o

ral p

redn

isol

one,

retin

oids

, met

hotr

exat

e, c

iclo

spor

in.

Com

plic

atio

ns•

Incr

ease

d ris

k of

squ

amou

s ce

ll ca

rcin

oma.

• Ad

hesi

ons

and

scar

ring:

Phim

osis.

Intr

oita

l ste

nosi

s.

La

bia

min

ora

shrin

kage

.

Lich

en p

lanu

s

Wha

t is

lich

en p

lanu

s?Li

chen

pla

nus

is a

chr

onic

infla

mm

ator

y sk

in c

ondi

tion

char

acte

rized

by

wel

l-dem

arca

ted

purp

le p

apul

es p

rese

nt o

n m

ucou

s m

embr

anes

, fle

xor

surfa

ces

and

the

geni

tal a

rea.

It h

as a

sym

met

rical

dis

trib

utio

n.

Ther

e ar

e m

any

clin

ical

cla

ssifi

catio

ns o

f lic

hen

plan

us in

clud

ing,

bu

t not

lim

ited

to, c

utan

eous

lich

en p

lanu

s, m

ucos

al li

chen

pla

nus,

liche

n pl

anop

ilaris

and

lich

en p

lanu

s of

the

nails

.

Caus

esLi

chen

pla

nus

is th

ough

t to

be a

T-ce

ll m

edia

ted

auto

imm

une

dise

ase.

Re

sear

ch h

as s

ugge

sted

som

e co

ntrib

utin

g fa

ctor

s su

ch a

s:•

Gen

etic

pre

disp

ositi

on –

HLA

-DR1

.•

Trau

ma.

• Vi

ral i

nfec

tion

– HS

V, h

epat

itis

C.

Sym

ptom

s•

Poly

gona

l pur

ple

papu

les

in s

peci

fic re

gion

s su

ch a

s th

e w

rists

, shi

ns,

lo

wer

bac

k an

d ge

nita

l reg

ion.

• O

ral m

ucos

al in

volv

emen

t – W

ickh

am’s

stria

e.•

Scar

ring

alop

ecia

.•

Nai

l les

ions

– o

nych

olys

is, th

inni

ng, r

idgi

ng, p

tery

gium

, ano

nych

ia.

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is. A

bio

psy

may

be

need

ed to

con

firm

dia

gnos

is

and

asse

ss fo

r can

cer.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r lic

hen

plan

us-li

ke re

actio

n

(e.g

. ant

ibio

tics

[tetr

acyc

line]

, ant

i-rhe

umat

ic d

rugs

[pen

icill

amin

e]).

Med

ical

:•

Topi

c tr

eatm

ents

– s

tero

ids,

calc

ineu

rin in

hibi

tors

, tac

rolim

us o

intm

ent,

re

tinoi

ds.

• Sy

stem

ic –

ora

l pre

dnis

olon

e, m

etho

trex

ate,

aza

thio

prin

e.

Com

plic

atio

ns•

Incr

ease

d ris

k of

squ

amou

s ce

ll ca

rcin

oma.

MAP

7.6

. Lic

heno

id le

sion

s

K30033_C007.indd 195 28/02/17 11:21 am

196

Der

mat

olog

yM

ap 7

.7.

Bu

llou

s d

iso

rder

s

Bullo

us p

emph

igoi

d

Wha

t is

bul

lous

pem

phig

oid?

Bullo

us p

emph

igoi

d is

a c

hron

ic a

utoi

mm

une,

blis

terin

g co

nditi

on. I

t is

twic

eas

com

mon

as

bullo

us p

emph

igus

and

tend

s to

pre

sent

in e

lder

ly p

atie

nts.

Caus

esIt

is th

ough

t to

be a

n au

toim

mun

e co

nditi

on in

whi

ch p

atie

nts

prod

uce

IgG

antib

odie

s an

d so

met

imes

als

o Ig

E an

tibod

ies

agai

nst s

peci

fic b

asem

ent

mem

bran

e gl

ycop

rote

ins.

Thes

e ar

e:•

BP18

0 (m

ost c

omm

on),

aka

type

XVI

I col

lage

n.•

BP23

0, a

ka p

laki

n.

Sym

ptom

s•

Wid

espr

ead

itchy

blis

ters

, typ

ical

ly in

flex

ural

are

as, w

hich

hea

l with

out

sc

arrin

g (th

e ex

cept

ion

to th

is is

cic

atric

ial p

emph

igoi

d, w

hich

doe

s sc

ar

and

also

affe

cts

the

orop

hary

nx).

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is c

onfir

med

with

pun

ch b

iops

y fo

llow

ed b

yim

mun

oflu

ores

cenc

e –

visu

aliz

es Ig

G a

nd C

3 at

der

moe

pide

rmal

junc

tion.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r pem

phig

oid-

like

reac

tion

(e

.g. f

uros

emid

e an

d pe

nici

llam

ine)

.

Med

ical

:•

Topi

cal t

reat

men

ts –

ste

roid

s in

mod

erat

e ca

ses.

• O

ral c

ortic

oste

roid

s.•

Imm

unos

uppr

essa

nts

(e.g

. aza

thio

prin

e an

d m

etho

trex

ate)

.•

Antib

iotic

s if

supe

radd

ed in

fect

ion

pres

ent.

Com

plic

atio

ns•

Usu

ally

a s

elf-l

imiti

ng c

ondi

tion

that

rem

its a

fter 1

–2 y

ears

.•

Supe

radd

ed in

fect

ion.

• Si

de e

ffect

s as

soci

ated

with

long

-ter

m s

tero

id o

r im

mun

osup

pres

sant

use

.

Bullo

us p

emph

igus

Wha

t is

bul

lous

pem

phig

us?

Bullo

us p

emph

igus

is a

gro

up o

f aut

oim

mun

e su

perfi

cial

ski

n di

sord

ers.

They

m

ay b

e cl

assi

fied

into

pem

phig

us v

ulga

ris, p

emph

igus

folia

ceus

and

pa

rane

opla

stic

pem

phig

us, w

ith p

emph

igus

vul

garis

bei

ng th

e m

ost

com

mon

.

Caus

esIt

is th

ough

t to

be a

n au

toim

mun

e co

nditi

on w

here

pat

ient

s pr

oduc

e Ig

G

antib

odie

s ag

ains

t des

mog

lein

(typ

ical

ly ty

pes

1 an

d 3)

. Des

mog

lein

is a

n ad

hesi

on m

olec

ule

that

is re

spon

sibl

e fo

r glu

ing

epid

erm

al c

ells

toge

ther

.

Sym

ptom

s•

Pain

ful s

uper

ficia

l blis

ters

– m

ay b

e er

ythe

mat

ous.

• In

itial

ly in

volv

es th

e or

opha

rynx

but

then

spr

eads

to o

ther

regi

ons

such

as

the

face

, che

st a

nd g

enita

l are

a.•

Nik

olsk

y’s

sign

may

be

appa

rent

.

Inve

stig

atio

nsPu

nch

biop

sy w

ith im

mun

oflu

ores

cenc

e –

visu

aliz

es a

cant

holy

sis.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r pem

phig

us-li

ke re

actio

n (e

.g. a

ntib

iotic

s

[pen

icill

in] a

nd o

ther

med

icat

ions

suc

h as

cap

topr

il an

d pe

nici

llam

ine)

.

Med

ical

:•

Ora

l cor

ticos

tero

ids.

• Im

mun

osup

pres

sant

s (e

.g. a

zath

iopr

ine

and

met

hotr

exat

e)•

Plas

map

here

sis

cons

ider

ed in

refra

ctor

y ca

ses.

Com

plic

atio

ns•

Seps

is.•

Side

effe

cts

asso

ciat

ed w

ith lo

ng-t

erm

ste

roid

use

.

MAP

7.7

. Bul

lous

dis

orde

rs

K30033_C007.indd 196 28/02/17 11:21 am

197

Der

mat

olog

yM

ap 7

.7.

Bu

llou

s d

iso

rder

s

Bullo

us p

emph

igoi

d

Wha

t is

bul

lous

pem

phig

oid?

Bullo

us p

emph

igoi

d is

a c

hron

ic a

utoi

mm

une,

blis

terin

g co

nditi

on. I

t is

twic

eas

com

mon

as

bullo

us p

emph

igus

and

tend

s to

pre

sent

in e

lder

ly p

atie

nts.

Caus

esIt

is th

ough

t to

be a

n au

toim

mun

e co

nditi

on in

whi

ch p

atie

nts

prod

uce

IgG

antib

odie

s an

d so

met

imes

als

o Ig

E an

tibod

ies

agai

nst s

peci

fic b

asem

ent

mem

bran

e gl

ycop

rote

ins.

Thes

e ar

e:•

BP18

0 (m

ost c

omm

on),

aka

type

XVI

I col

lage

n.•

BP23

0, a

ka p

laki

n.

Sym

ptom

s•

Wid

espr

ead

itchy

blis

ters

, typ

ical

ly in

flex

ural

are

as, w

hich

hea

l with

out

sc

arrin

g (th

e ex

cept

ion

to th

is is

cic

atric

ial p

emph

igoi

d, w

hich

doe

s sc

ar

and

also

affe

cts

the

orop

hary

nx).

Inve

stig

atio

nsTy

pica

lly a

clin

ical

dia

gnos

is c

onfir

med

with

pun

ch b

iops

y fo

llow

ed b

yim

mun

oflu

ores

cenc

e –

visu

aliz

es Ig

G a

nd C

3 at

der

moe

pide

rmal

junc

tion.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r pem

phig

oid-

like

reac

tion

(e

.g. f

uros

emid

e an

d pe

nici

llam

ine)

.

Med

ical

:•

Topi

cal t

reat

men

ts –

ste

roid

s in

mod

erat

e ca

ses.

• O

ral c

ortic

oste

roid

s.•

Imm

unos

uppr

essa

nts

(e.g

. aza

thio

prin

e an

d m

etho

trex

ate)

.•

Antib

iotic

s if

supe

radd

ed in

fect

ion

pres

ent.

Com

plic

atio

ns•

Usu

ally

a s

elf-l

imiti

ng c

ondi

tion

that

rem

its a

fter 1

–2 y

ears

.•

Supe

radd

ed in

fect

ion.

• Si

de e

ffect

s as

soci

ated

with

long

-ter

m s

tero

id o

r im

mun

osup

pres

sant

use

.

Bullo

us p

emph

igus

Wha

t is

bul

lous

pem

phig

us?

Bullo

us p

emph

igus

is a

gro

up o

f aut

oim

mun

e su

perfi

cial

ski

n di

sord

ers.

They

m

ay b

e cl

assi

fied

into

pem

phig

us v

ulga

ris, p

emph

igus

folia

ceus

and

pa

rane

opla

stic

pem

phig

us, w

ith p

emph

igus

vul

garis

bei

ng th

e m

ost

com

mon

.

Caus

esIt

is th

ough

t to

be a

n au

toim

mun

e co

nditi

on w

here

pat

ient

s pr

oduc

e Ig

G

antib

odie

s ag

ains

t des

mog

lein

(typ

ical

ly ty

pes

1 an

d 3)

. Des

mog

lein

is a

n ad

hesi

on m

olec

ule

that

is re

spon

sibl

e fo

r glu

ing

epid

erm

al c

ells

toge

ther

.

Sym

ptom

s•

Pain

ful s

uper

ficia

l blis

ters

– m

ay b

e er

ythe

mat

ous.

• In

itial

ly in

volv

es th

e or

opha

rynx

but

then

spr

eads

to o

ther

regi

ons

such

as

the

face

, che

st a

nd g

enita

l are

a.•

Nik

olsk

y’s

sign

may

be

appa

rent

.

Inve

stig

atio

nsPu

nch

biop

sy w

ith im

mun

oflu

ores

cenc

e –

visu

aliz

es a

cant

holy

sis.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Dr

ug c

essa

tion

if re

spon

sibl

e fo

r pem

phig

us-li

ke re

actio

n (e

.g. a

ntib

iotic

s

[pen

icill

in] a

nd o

ther

med

icat

ions

suc

h as

cap

topr

il an

d pe

nici

llam

ine)

.

Med

ical

:•

Ora

l cor

ticos

tero

ids.

• Im

mun

osup

pres

sant

s (e

.g. a

zath

iopr

ine

and

met

hotr

exat

e)•

Plas

map

here

sis

cons

ider

ed in

refra

ctor

y ca

ses.

Com

plic

atio

ns•

Seps

is.•

Side

effe

cts

asso

ciat

ed w

ith lo

ng-t

erm

ste

roid

use

.

MAP

7.7

. Bul

lous

dis

orde

rs

K30033_C007.indd 197 28/02/17 11:21 am

198

Der

mat

olog

yM

ap 7

.8.

Acn

e vu

lgar

is

Wha

t is

acn

e vu

lgar

is?

Acne

vul

garis

is a

com

mon

con

ditio

n th

at re

sults

in a

ser

ies

of s

kin

lesi

ons

rang

ing

from

co

meo

dom

es to

pus

tule

s, pa

pule

s an

d sc

arrin

g. It

may

be

clas

sifie

d as

mild

, mod

erat

e or

se

vere

.•

Mild

– c

omeo

dom

es (o

pen

and

clos

ed),

som

e pa

pule

s, so

me

pust

ules

.•

Mod

erat

e –

incr

easi

ng n

umbe

r of p

apul

es a

nd p

ustu

les,

mild

sca

rrin

g.•

Seve

re –

com

eodo

mes

, pap

ules

, pus

tule

s pl

us m

ore

exte

nsiv

e sc

arrin

g an

d no

dula

r

absc

esse

s.Ac

ne fu

lmin

ans

is a

rare

but

ver

y se

vere

form

of a

cne

seen

exc

lusi

vely

in a

dole

scen

t mal

es.

It is

cau

sed

by a

n im

mun

e re

actio

n to

Pro

pion

obac

teriu

m a

cnes

.

Caus

esFo

llicu

lar k

erat

iniz

atio

n, s

ebor

rhoe

a an

d co

loni

zatio

n of

the

pilo

seba

ceou

s un

it w

ithP.

acne

s ar

e ce

ntra

l to

the

deve

lopm

ent o

f acn

e sk

in le

sion

s.

Rese

arch

has

sho

wn

that

hor

mon

al fa

ctor

s an

d ge

netic

com

pone

nts

may

als

o pl

ay a

ro

le s

ince

they

may

faci

litat

e an

env

ironm

ent p

rovi

ding

opt

imal

con

ditio

ns fo

r the

gro

wth

of P

. acn

es a

s w

ell a

s im

pact

ing

on th

e su

bseq

uent

infla

mm

ator

y re

actio

n.Ex

acer

batin

g fa

ctor

s in

clud

e:•

Cosm

etic

s –

part

icul

arly

oily

cre

ams.

• Ce

rtai

n cl

othi

ng (e

.g. h

igh

colla

red

shirt

s)•

Exce

ssiv

e sw

eatin

g.•

Exce

ssiv

e an

drog

en p

rodu

ctio

n (e

.g. p

olyc

ystic

ova

ry s

yndr

ome

[PCO

S]).

Sym

ptom

sAl

l or s

ome

of th

e fo

llow

ing

lesi

ons

may

be

pres

ent:

• Co

meo

dom

es.

• Pa

pule

s.•

Pust

ules

.•

Cyst

s.•

Pseu

docy

sts.

• Sc

arrin

g (ic

e pi

ck s

carr

ing)

.•

Exco

riatio

ns.

• Er

ythe

mat

ous

or p

igm

ente

d m

acul

es.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

rega

rdin

g sk

in h

ygie

ne.

Med

ical

:•

Mild

: bla

ckhe

ads

and

whi

tehe

ads:

Topi

cal r

etin

oid

(e.g

. iso

tret

inoi

n).

Benz

oyl p

erox

ide.

Cons

ider

com

bine

d or

al c

ontr

acep

tive

pill

(CO

CP).

• M

oder

ate:

pap

ules

and

pus

tule

s:

To

pica

l ant

ibio

tic w

ith to

pica

l ret

inoi

d or

ben

zoyl

per

oxid

e.

O

ral a

ntib

iotic

(e.g

. lym

ecyc

line

com

bine

d w

ith to

pica

l age

nt).

Cons

ider

CO

CP.

• Se

vere

: pap

ulop

ustu

lar w

ith n

odul

es +

/– s

carr

ing:

Refe

r to

derm

atol

ogy

for t

reat

men

t with

isot

retin

oin.

Prov

ide

mod

erat

e le

vel a

cne

man

agem

ent w

hile

wai

ting

for

refe

rral

.

Co

nsid

er C

OCP

, spe

cific

ally

Dia

nett

e.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is; h

owev

er, i

n so

me

case

s if

hype

rand

roge

nism

is s

uspe

cted

in

fem

ales

, fur

ther

test

s sh

ould

be

unde

rtak

en.

(See

Map

3.5

[PCO

S], p

. 84.

)

Com

plic

atio

ns•

Scar

ring.

• Ps

ycho

logi

cal (

e.g.

dep

ress

ion)

.•

Side

effe

cts

of tr

eatm

ent (

e.g.

isot

retin

oin

–

chei

litis,

incr

ease

d ris

k of

sun

burn

,

tera

toge

nic,

mya

lgia

).

MAP

7.8

. Acn

e vu

lgar

is

K30033_C007.indd 198 28/02/17 11:21 am

199

Der

mat

olog

yM

ap 7

.8.

Acn

e vu

lgar

is

Wha

t is

acn

e vu

lgar

is?

Acne

vul

garis

is a

com

mon

con

ditio

n th

at re

sults

in a

ser

ies

of s

kin

lesi

ons

rang

ing

from

co

meo

dom

es to

pus

tule

s, pa

pule

s an

d sc

arrin

g. It

may

be

clas

sifie

d as

mild

, mod

erat

e or

se

vere

.•

Mild

– c

omeo

dom

es (o

pen

and

clos

ed),

som

e pa

pule

s, so

me

pust

ules

.•

Mod

erat

e –

incr

easi

ng n

umbe

r of p

apul

es a

nd p

ustu

les,

mild

sca

rrin

g.•

Seve

re –

com

eodo

mes

, pap

ules

, pus

tule

s pl

us m

ore

exte

nsiv

e sc

arrin

g an

d no

dula

r

absc

esse

s.Ac

ne fu

lmin

ans

is a

rare

but

ver

y se

vere

form

of a

cne

seen

exc

lusi

vely

in a

dole

scen

t mal

es.

It is

cau

sed

by a

n im

mun

e re

actio

n to

Pro

pion

obac

teriu

m a

cnes

.

Caus

esFo

llicu

lar k

erat

iniz

atio

n, s

ebor

rhoe

a an

d co

loni

zatio

n of

the

pilo

seba

ceou

s un

it w

ithP.

acne

s ar

e ce

ntra

l to

the

deve

lopm

ent o

f acn

e sk

in le

sion

s.

Rese

arch

has

sho

wn

that

hor

mon

al fa

ctor

s an

d ge

netic

com

pone

nts

may

als

o pl

ay a

ro

le s

ince

they

may

faci

litat

e an

env

ironm

ent p

rovi

ding

opt

imal

con

ditio

ns fo

r the

gro

wth

of P

. acn

es a

s w

ell a

s im

pact

ing

on th

e su

bseq

uent

infla

mm

ator

y re

actio

n.Ex

acer

batin

g fa

ctor

s in

clud

e:•

Cosm

etic

s –

part

icul

arly

oily

cre

ams.

• Ce

rtai

n cl

othi

ng (e

.g. h

igh

colla

red

shirt

s)•

Exce

ssiv

e sw

eatin

g.•

Exce

ssiv

e an

drog

en p

rodu

ctio

n (e

.g. p

olyc

ystic

ova

ry s

yndr

ome

[PCO

S]).

Sym

ptom

sAl

l or s

ome

of th

e fo

llow

ing

lesi

ons

may

be

pres

ent:

• Co

meo

dom

es.

• Pa

pule

s.•

Pust

ules

.•

Cyst

s.•

Pseu

docy

sts.

• Sc

arrin

g (ic

e pi

ck s

carr

ing)

.•

Exco

riatio

ns.

• Er

ythe

mat

ous

or p

igm

ente

d m

acul

es.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

rega

rdin

g sk

in h

ygie

ne.

Med

ical

:•

Mild

: bla

ckhe

ads

and

whi

tehe

ads:

Topi

cal r

etin

oid

(e.g

. iso

tret

inoi

n).

Benz

oyl p

erox

ide.

Cons

ider

com

bine

d or

al c

ontr

acep

tive

pill

(CO

CP).

• M

oder

ate:

pap

ules

and

pus

tule

s:

To

pica

l ant

ibio

tic w

ith to

pica

l ret

inoi

d or

ben

zoyl

per

oxid

e.

O

ral a

ntib

iotic

(e.g

. lym

ecyc

line

com

bine

d w

ith to

pica

l age

nt).

Cons

ider

CO

CP.

• Se

vere

: pap

ulop

ustu

lar w

ith n

odul

es +

/– s

carr

ing:

Refe

r to

derm

atol

ogy

for t

reat

men

t with

isot

retin

oin.

Prov

ide

mod

erat

e le

vel a

cne

man

agem

ent w

hile

wai

ting

for

refe

rral

.

Co

nsid

er C

OCP

, spe

cific

ally

Dia

nett

e.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is; h

owev

er, i

n so

me

case

s if

hype

rand

roge

nism

is s

uspe

cted

in

fem

ales

, fur

ther

test

s sh

ould

be

unde

rtak

en.

(See

Map

3.5

[PCO

S], p

. 84.

)

Com

plic

atio

ns•

Scar

ring.

• Ps

ycho

logi

cal (

e.g.

dep

ress

ion)

.•

Side

effe

cts

of tr

eatm

ent (

e.g.

isot

retin

oin

–

chei

litis,

incr

ease

d ris

k of

sun

burn

,

tera

toge

nic,

mya

lgia

).

MAP

7.8

. Acn

e vu

lgar

is

K30033_C007.indd 199 28/02/17 11:21 am

200

Der

mat

olog

yM

ap 7

.9.

Ro

sace

a

Wha

t is

ros

acea

?Ro

sace

a is

a c

hron

ic in

flam

mat

ory

eryt

hem

atou

s de

rmat

osis

typi

cally

invo

lvin

g th

e ce

ntra

l fa

ce. I

t is

mor

e co

mm

on in

wom

en a

nd g

ener

ally

affe

cts

thos

e ag

ed 3

0–60

yea

rs.

Caus

esTh

e ex

act c

ause

of r

osac

ea is

unk

now

n bu

t it i

s th

ough

t to

invo

lve

both

gen

etic

and

en

viro

nmen

tal f

acto

rs. P

oten

tial i

nflu

enci

ng fa

ctor

s in

clud

e:•

Skin

type

– m

ore

com

mon

in fa

ir sk

inne

d in

divi

dual

s w

ith C

eltic

orig

in.

• Hi

gh le

vels

of c

athe

licid

ins

(ant

imic

robi

al p

eptid

es).

• Va

sodi

latio

n of

blo

od v

esse

ls c

oupl

ed w

ith fa

ctor

s in

fluen

cing

hyp

erpl

asia

of t

he

se

bace

ous

glan

ds.

• In

volv

emen

t of m

atrix

met

allo

prot

eina

ses

(e.g

. ela

stas

e an

d co

llage

nase

).Ex

acer

batin

g fa

ctor

s in

clud

e:•

Cosm

etic

s –

part

icul

arly

oily

cre

ams.

• Sp

icy

food

s.•

Alco

hol.

• He

at (e

.g. h

ot s

how

ers

or h

ot ro

oms)

.•

UV

expo

sure

.•

Topi

cal s

tero

ids.

Sym

ptom

sAl

l or s

ome

of th

e fo

llow

ing

lesi

ons

may

be

pres

ent:

• Do

me

shap

ed p

apul

es +

/– p

ustu

les.

• Fa

cial

flus

hing

.•

Tela

ngie

ctas

ia.

• Dr

y an

d se

nsiti

ve s

kin.

• Se

bace

ous

hype

rpla

sia.

• Rh

inop

hym

a (w

hisk

ey n

ose)

.•

Blep

haro

phym

a.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

to a

void

exa

cerb

atin

g fa

ctor

s.

Med

ical

:•

Mild

:

To

pica

l met

roni

dazo

le (1

st li

ne).

Azel

aic

acid

(alte

rnat

ive)

.•

Mod

erat

e –

seve

re:

Ora

l tet

racy

clin

es o

r ery

thro

myc

in.

• O

cula

r ros

acea

:

O

cula

r lub

rican

ts.

Ora

l tet

racy

clin

es.

Inve

stig

atio

nsTh

is is

a c

linic

al d

iagn

osis.

If a

ski

n bi

opsy

is

perfo

rmed

, it w

ill d

emon

stra

te v

ascu

lar a

nd

chro

nic

infla

mm

ator

y ch

ange

s.

Com

plic

atio

ns•

Psyc

holo

gica

l (e.

g. d

epre

ssio

n).

• O

cula

r ros

acea

.

MAP

7.9

. Ros

acea

K30033_C007.indd 200 28/02/17 11:21 am

201

Der

mat

olog

yM

ap 7

.9.

Ro

sace

a

Wha

t is

ros

acea

?Ro

sace

a is

a c

hron

ic in

flam

mat

ory

eryt

hem

atou

s de

rmat

osis

typi

cally

invo

lvin

g th

e ce

ntra

l fa

ce. I

t is

mor

e co

mm

on in

wom

en a

nd g

ener

ally

affe

cts

thos

e ag

ed 3

0–60

yea

rs.

Caus

esTh

e ex

act c

ause

of r

osac

ea is

unk

now

n bu

t it i

s th

ough

t to

invo

lve

both

gen

etic

and

en

viro

nmen

tal f

acto

rs. P

oten

tial i

nflu

enci

ng fa

ctor

s in

clud

e:•

Skin

type

– m

ore

com

mon

in fa

ir sk

inne

d in

divi

dual

s w

ith C

eltic

orig

in.

• Hi

gh le

vels

of c

athe

licid

ins

(ant

imic

robi

al p

eptid

es).

• Va

sodi

latio

n of

blo

od v

esse

ls c

oupl

ed w

ith fa

ctor

s in

fluen

cing

hyp

erpl

asia

of t

he

se

bace

ous

glan

ds.

• In

volv

emen

t of m

atrix

met

allo

prot

eina

ses

(e.g

. ela

stas

e an

d co

llage

nase

).Ex

acer

batin

g fa

ctor

s in

clud

e:•

Cosm

etic

s –

part

icul

arly

oily

cre

ams.

• Sp

icy

food

s.•

Alco

hol.

• He

at (e

.g. h

ot s

how

ers

or h

ot ro

oms)

.•

UV

expo

sure

.•

Topi

cal s

tero

ids.

Sym

ptom

sAl

l or s

ome

of th

e fo

llow

ing

lesi

ons

may

be

pres

ent:

• Do

me

shap

ed p

apul

es +

/– p

ustu

les.

• Fa

cial

flus

hing

.•

Tela

ngie

ctas

ia.

• Dr

y an

d se

nsiti

ve s

kin.

• Se

bace

ous

hype

rpla

sia.

• Rh

inop

hym

a (w

hisk

ey n

ose)

.•

Blep

haro

phym

a.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• Ad

vice

to a

void

exa

cerb

atin

g fa

ctor

s.

Med

ical

:•

Mild

:

To

pica

l met

roni

dazo

le (1

st li

ne).

Azel

aic

acid

(alte

rnat

ive)

.•

Mod

erat

e –

seve

re:

Ora

l tet

racy

clin

es o

r ery

thro

myc

in.

• O

cula

r ros

acea

:

O

cula

r lub

rican

ts.

Ora

l tet

racy

clin

es.

Inve

stig

atio

nsTh

is is

a c

linic

al d

iagn

osis.

If a

ski

n bi

opsy

is

perfo

rmed

, it w

ill d

emon

stra

te v

ascu

lar a

nd

chro

nic

infla

mm

ator

y ch

ange

s.

Com

plic

atio

ns•

Psyc

holo

gica

l (e.

g. d

epre

ssio

n).

• O

cula

r ros

acea

.

MAP

7.9

. Ros

acea

K30033_C007.indd 201 28/02/17 11:21 am

202

Der

mat

olog

yM

ap 7

.10.

Alo

pec

ia a

reat

a

Wha

t is

alo

peci

a ar

eata

?Ha

ir gr

owth

con

sist

s of

four

sta

ges:

1. A

nage

n –

the

grow

th p

hase

.2.

Cat

agen

– th

e in

volu

tion

phas

e.3.

Tel

ogen

– th

e re

stin

g ph

ase.

4. R

elea

se –

the

rele

ase

of th

e ha

ir sh

aft.

Alop

ecia

are

ata

is a

chr

onic

rela

psin

g au

toim

mun

e co

nditi

on w

here

the

anag

en p

hase

is

prem

atur

ely

arre

sted

. It i

s a

loca

lized

non

-sca

rrin

g al

opec

ia. B

road

ly s

peak

ing,

alo

peci

a m

ay b

e de

fined

as

diffu

se n

on-s

carr

ing,

loca

lized

sca

rrin

g, a

nd s

carr

ing.

Eac

h ca

tego

ry h

as

a di

ffere

nt c

ause

:•

Diffu

se n

on-s

carr

ing:

dru

g in

duce

d, m

etab

olic

.•

Loca

lized

sca

rrin

g: a

lope

cia

area

ta, t

raum

a, ri

ngw

orm

.•

Scar

ring:

trau

ma

(bur

ns),

liche

n pl

anus

, dis

coid

lupu

s.

Caus

esTh

e ex

act c

ause

and

mec

hani

sm o

f alo

peci

a ar

eata

is u

nkno

wn.

In s

ome

case

s th

e au

toim

mun

e co

nditi

on m

ay b

e tr

igge

red

by tr

aum

a, s

tres

s or

vira

l inf

ectio

n. T

hose

with

a

first

-deg

ree

rela

tive

suffe

ring

with

alo

peci

a ar

eata

are

mor

e lik

ely

to b

e af

fect

ed.

Sym

ptom

sHa

ir lo

ss m

ay in

volv

e th

e sc

alp,

eye

brow

s,ey

elas

hes

or b

eard

.•

Circ

ular

regi

ons

of h

air l

oss.

• N

on-s

carr

ing.

• Ex

clam

atio

n m

ark

hairs

.•

Nai

l cha

nges

are

app

aren

t in

10–1

5%

o

f pat

ient

s an

d in

clud

e Be

au's

line

s,

onyc

holy

sis

and

koilo

nych

ia.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• As

sess

the

exte

nt o

f hai

r los

s us

ing

scal

es

such

as

the

Lugw

ig S

cale

and

the

Nor

woo

d

Scal

e.•

Cons

ider

the

use

of w

igs

or p

artia

l wig

s.

Med

ical

:•

Evid

ence

of h

air r

egro

wth

:

N

o tr

eatm

ent.

• N

o ha

ir re

grow

th a

nd <

50%

hai

r los

s:

Di

scus

s w

atch

ful w

aitin

g an

d pa

tient

pref

eren

ce.

If tr

eatm

ent p

refe

rred

, ref

er to

derm

atol

ogy

whe

re tr

eatm

ent w

ith

in

tral

esio

nal c

ortic

oste

roid

s m

ay b

e

co

mm

ence

d.•

No

hair

regr

owth

and

>50

% h

air l

oss:

Derm

atol

ogy

refe

rral

whe

re to

pica

l

im

mun

othe

rapy

may

be

com

men

ced.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is. Tr

icho

scop

y is

use

dto

exa

min

e th

e ha

ir an

d sc

alp.

Com

plic

atio

ns•

Psyc

holo

gica

l (e.

g. d

epre

ssio

n).

• In

crea

sed

risk

of o

ther

aut

oim

mun

e

cond

ition

s (e

.g. d

iabe

tes

and

thyr

oid

dise

ase)

.

MAP

7.1

0. A

lope

cia

area

ta

K30033_C007.indd 202 28/02/17 11:21 am

203

Der

mat

olog

yM

ap 7

.10.

Alo

pec

ia a

reat

a

Wha

t is

alo

peci

a ar

eata

?Ha

ir gr

owth

con

sist

s of

four

sta

ges:

1. A

nage

n –

the

grow

th p

hase

.2.

Cat

agen

– th

e in

volu

tion

phas

e.3.

Tel

ogen

– th

e re

stin

g ph

ase.

4. R

elea

se –

the

rele

ase

of th

e ha

ir sh

aft.

Alop

ecia

are

ata

is a

chr

onic

rela

psin

g au

toim

mun

e co

nditi

on w

here

the

anag

en p

hase

is

prem

atur

ely

arre

sted

. It i

s a

loca

lized

non

-sca

rrin

g al

opec

ia. B

road

ly s

peak

ing,

alo

peci

a m

ay b

e de

fined

as

diffu

se n

on-s

carr

ing,

loca

lized

sca

rrin

g, a

nd s

carr

ing.

Eac

h ca

tego

ry h

as

a di

ffere

nt c

ause

:•

Diffu

se n

on-s

carr

ing:

dru

g in

duce

d, m

etab

olic

.•

Loca

lized

sca

rrin

g: a

lope

cia

area

ta, t

raum

a, ri

ngw

orm

.•

Scar

ring:

trau

ma

(bur

ns),

liche

n pl

anus

, dis

coid

lupu

s.

Caus

esTh

e ex

act c

ause

and

mec

hani

sm o

f alo

peci

a ar

eata

is u

nkno

wn.

In s

ome

case

s th

e au

toim

mun

e co

nditi

on m

ay b

e tr

igge

red

by tr

aum

a, s

tres

s or

vira

l inf

ectio

n. T

hose

with

a

first

-deg

ree

rela

tive

suffe

ring

with

alo

peci

a ar

eata

are

mor

e lik

ely

to b

e af

fect

ed.

Sym

ptom

sHa

ir lo

ss m

ay in

volv

e th

e sc

alp,

eye

brow

s,ey

elas

hes

or b

eard

.•

Circ

ular

regi

ons

of h

air l

oss.

• N

on-s

carr

ing.

• Ex

clam

atio

n m

ark

hairs

.•

Nai

l cha

nges

are

app

aren

t in

10–1

5%

o

f pat

ient

s an

d in

clud

e Be

au's

line

s,

onyc

holy

sis

and

koilo

nych

ia.

Trea

tmen

t

Cons

erva

tive

:•

Patie

nt e

duca

tion.

• As

sess

the

exte

nt o

f hai

r los

s us

ing

scal

es

such

as

the

Lugw

ig S

cale

and

the

Nor

woo

d

Scal

e.•

Cons

ider

the

use

of w

igs

or p

artia

l wig

s.

Med

ical

:•

Evid

ence

of h

air r

egro

wth

:

N

o tr

eatm

ent.

• N

o ha

ir re

grow

th a

nd <

50%

hai

r los

s:

Di

scus

s w

atch

ful w

aitin

g an

d pa

tient

pref

eren

ce.

If tr

eatm

ent p

refe

rred

, ref

er to

derm

atol

ogy

whe

re tr

eatm

ent w

ith

in

tral

esio

nal c

ortic

oste

roid

s m

ay b

e

co

mm

ence

d.•

No

hair

regr

owth

and

>50

% h

air l

oss:

Derm

atol

ogy

refe

rral

whe

re to

pica

l

im

mun

othe

rapy

may

be

com

men

ced.

Inve

stig

atio

nsU

sual

ly a

clin

ical

dia

gnos

is. Tr

icho

scop

y is

use

dto

exa

min

e th

e ha

ir an

d sc

alp.

Com

plic

atio

ns•

Psyc

holo

gica

l (e.

g. d

epre

ssio

n).

• In

crea

sed

risk

of o

ther

aut

oim

mun

e

cond

ition

s (e

.g. d

iabe

tes

and

thyr

oid

dise

ase)

.

MAP

7.1

0. A

lope

cia

area

ta

K30033_C007.indd 203 28/02/17 11:21 am

204

Der

mat

olog

yTa

ble

7.1.

Vir

al s

kin

infe

ctio

ns

TABL

E 7.

1. V

iral

ski

n in

fect

ions

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Herp

es

sim

plex

vi

rus

(HSV

)

Type

1: H

SV ty

pe 1

Type

2: H

SV ty

pe 2

Spre

ad v

ia d

irect

con

tact

as

wel

l as

drop

let s

prea

d. M

ay

reac

tivat

e w

ith tr

igge

ring

fact

ors

such

as

stre

ss a

nd

trau

ma

Both

form

s of

HSV

may

pr

esen

t with

a b

urni

ng

or ti

nglin

g se

nsat

ion

befo

re th

e ou

tbre

ak o

f vi

sual

lesi

ons

Type

1: p

erio

ral l

esio

ns –

pa

infu

l ves

icle

s an

d ul

cers

. May

man

ifest

as

her

petic

whi

tlow

on

infe

cted

fing

er

Type

2: p

enile

lesi

ons,

vulv

ovag

initi

s, an

al

lesi

ons

Cultu

re/P

CR o

f vira

l sw

ab•

Acic

lovi

r•

Vala

cicl

ovir

• Fa

mci

clov

ir

• En

ceph

aliti

s•

Ocu

lar i

nfec

tion

• Ec

zem

a he

rpet

icum

•

Recu

rren

t ery

them

a m

ultif

orm

e

K30033_C007.indd 204 28/02/17 11:21 am

205

Der

mat

olog

yTa

ble

7.1.

Vir

al s

kin

infe

ctio

ns

Herp

es

zost

er

(shi

ngle

s)

Varic

ella

zos

ter v

irus

(VZV

)

Initi

al in

fect

ion

caus

es c

hick

-en

pox.

Thi

s re

mai

ns d

orm

ant

in a

sen

sory

root

gan

glio

n.

Whe

n re

activ

ated

, shi

ngle

s oc

curs

Pain

and

par

aest

hesi

a de

velo

p al

ong

a de

rmal

di

strib

utio

n up

to 5

da

ys b

efor

e th

e on

set

of v

esic

le d

evel

opm

ent.

Thes

e ve

sicl

es e

vent

ually

cr

ust o

ver

• U

sual

ly a

clin

ical

di

agno

sis

• VZ

V sp

ecifi

c Ig

M

antib

ody

• El

ectr

on m

icro

scop

y

• An

tivira

l age

nt:

acic

lovi

r sho

uld

be

give

n w

ithin

72

hour

s of

rash

ons

et•

Anal

gesi

a:M

ild to

mod

erat

e –

para

ceta

mol

alo

ne o

r in

com

bina

tion

with

an

NSA

ID o

r cod

eine

.Se

vere

– if

the

abov

e m

etho

ds h

ave

faile

d an

d pa

in is

sev

ere,

co

nsid

er a

mitr

ipty

line

or p

rega

balin

• Sc

arrin

g•

Post

-her

petic

ne

ural

gia

• Ra

msa

y Hu

nt

synd

rom

e (c

rani

al n

erve

VII

invo

lvem

ent)

• Zo

ster

oph

thal

mic

us

(oph

thal

mic

div

isio

n of

the

trig

emin

al

nerv

e af

fect

ed)

Cont

inue

d ov

erle

af

K30033_C007.indd 205 28/02/17 11:21 am

206

Der

mat

olog

yTa

ble

7.1.

Vir

al s

kin

infe

ctio

ns

TABL

E 7.

1. V

iral

ski

n in

fect

ions

(con

tinue

d ).

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Vira

l war

tsHu

man

pap

illom

aviru

s (H

PV) –

a d

oubl

e-st

rand

ed

DNA

viru

s. Th

ere

are

man

y di

ffere

nt ty

pes

invo

lved

with

w

art f

orm

atio

n in

diff

eren

t re

gion

s of

the

body

:

• Ty

pe 1

: pla

ntar

war

ts•

Type

2: p

lant

ar w

arts

and

co

mm

on w

arts

• Ty

pe 4

: com

mon

war

ts•

Type

s 6

& 1

1: a

noge

nita

l w

arts

•

Type

16:

oro

phar

ynge

al

canc

er•

Type

16

& 1

8: c

ervi

cal

canc

er

Dom

e-sh

aped

pap

ules

/no

dule

s w

ith a

n irr

egul

ar

papi

llife

rous

sur

face

• Cl

inic

al d

iagn

osis

•

Mic

rosc

opy

– hy

perk

erat

otic

ep

ider

mis

• Ce

rvic

al s

mea

r w

ith li

quid

-bas

ed

cyto

logy

– fo

r cer

vica

l HP

V

• HP

V va

ccin

atio

n pr

ogra

mm

e ai

min

g to

re

duce

the

prev

alen

ce

of c

ervi

cal c

ance

r•

For w

arts

:

Salic

ylic

aci

d

Imiq

uim

od c

ream

Cryo

ther

apy

with

liq

uid

nitr

ogen

• Pa

in (e

.g. p

lant

ar w

art

affe

ctin

g ga

it cy

cle)

• Sp

read

• Lo

cal i

nfec

tion

• M

alig

nant

cha

nge

K30033_C007.indd 206 28/02/17 11:21 am

207

TABL

E 7.

2. P

aras

itic

ski

n in

fect

ions

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Head

lice

Pe

dicu

losi

s hu

man

us c

apiti

s•

May

be

asym

ptom

atic

• Itc

hing

Vi

sual

izat

ion

of

infe

stat

ion.

A fi

ne

toot

hcom

b is

ofte

n us

ed

Inse

ctic

idal

sha

mpo

o co

ntai

ning

per

met

hrin

or

mal

athi

on. T

reat

ho

useh

old

mem

bers

and

cl

ose

cont

acts

if in

fest

ed

Infe

ctio

n se

cond

ary

to

scra

tchi

ng

Scab

ies

Sarc

opte

s sc

abie

i•

Itchi

ng

• Sm

all p

apul

es w

here

the

mite

ha

s bu

rrow

ed b

enea

th th

e sk

in –

ofte

n at

the

web

s of

fin

gers

, the

wris

t and

in th

e ge

nita

l reg

ion

• Li

near

trac

ks o

f the

bu

rrow

ing

mite

Clin

ical

dia

gnos

isM

ite m

ay b

e vi

sual

ized

on

der

mat

osco

py

• Pe

rmet

hrin

or

mal

athi

on s

houl

d be

ap

plie

d to

the

entir

e bo

dy e

xcep

t the

face

• Al

l hou

seho

ld

mem

bers

and

clo

se

cont

acts

requ

ire

trea

tmen

t•

Bed

linen

etc

. req

uire

s th

orou

gh w

ashi

ng o

n hi

gh h

eat

Nor

weg

ian

crus

ted

scab

ies

in

imm

unos

uppr

esse

d pa

tient

s

Tabl

e 7.

2. P

aras

itic

skin

infe

ctio

nsD

erm

atol

ogy

K30033_C007.indd 207 28/02/17 11:21 am

208

Der

mat

olog

yTa

ble

7.3.

Bac

teri

al s

kin

infe

ctio

ns

TABL

E 7.

3. B

acte

rial

ski

n in

fect

ions

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Impe

tigo

Stap

hylo

cocc

us

aure

us (c

omm

on-

est)

Stre

ptoc

occi

• Er

ythe

mat

ous

eros

ions

with

ye

llow

cru

stin

gBa

cter

ial s

wab

s•

Topi

cal f

ucid

in

crea

m•

Fluc

loxa

cilli

n

(S. a

ureu

s)•

Peni

cilli

n (s

trep

toco

cci)

• Er

ythr

omyc

in if

al

lerg

ic to

pen

icill

in

• Sc

arrin

g•

Post

-str

epto

cocc

al

glom

erul

onep

hriti

s•

Scar

let f

ever

• Se

ptic

aem

ia

• St

aphy

loco

ccal

sca

lded

sk

in s

yndr

ome

Cellu

litis

Beta

-hae

mol

ytic

st

rept

ococ

ci

Stap

hylo

cocc

us

aure

us

• Te

nder

ness

on

palp

atio

n•

Eryt

hem

atou

s le

sion

• Ca

rdin

al s

igns

of i

nflam

mat

ion

• Ly

mph

aden

opat

hy•

Feve

r •

Mal

aise

Ofte

n a

clin

ical

di

agno

sis.

Follo

w lo

cal

hosp

ital g

uide

lines

an

d ta

ke b

lood

cu

lture

s

• Fl

uclo

xaci

llin

(S

. aur

eus)

• Pe

nici

llin

(str

epto

cocc

i )•

Eryt

hrom

ycin

if

alle

rgic

to p

enic

illin

• Se

ptic

aem

ia•

Absc

ess

form

atio

n –

requ

ires

surg

ical

dr

aina

ge•

Toxi

c sh

ock-

like

synd

rom

e

K30033_C007.indd 208 28/02/17 11:21 am

209

Der

mat

olog

yTa

ble

7.3.

Bac

teri

al s

kin

infe

ctio

ns

Gas

ga

ngre

neCl

ostr

idiu

m

perfr

inge

ns•

Sym

ptom

s oc

cur a

t the

site

of

trau

ma

• In

flam

mat

ion

• Pa

in•

Indu

ratio

n•

In a

dvan

ced

dise

ase

– cr

epitu

s fe

lt in

mus

cle

and

dist

al p

ulse

s ar

e lo

st

• Sw

abs

– G

ram

st

ain

• Bl

ood

test

s –

FBC,

WCC

, LDH

, bl

ood

cultu

res,

bioc

hem

istr

y pr

ofile

• Im

agin

g –

radi

ogra

phy

and

CT s

cann

ing

• W

ound

de

brid

emen

t •

Skin

gra

fting

may

be

requ

ired

in

seve

re c

ases

• Pe

nici

llin

• Sc

arrin

g –

may

requ

ire

reco

nstr

uctiv

e su

rger

y•

Mul

ti-or

gan

failu

re

Lepr

osy

(Han

sen’

s di

seas

e)

Myc

obac

teriu

m

lepr

ae, a

n in

trac

ellu

lar

acid

–fas

t bac

illus

(g

ranu

lom

atou

s di

seas

e)

• Sk

in le

sion

s –

eryt

hem

atou

s or

hy

popi

gmen

ted

• Pe

riphe

ral n

erve

invo

lvem

ent

– m

otor

wea

knes

s an

d se

nsor

y im

pairm

ent

• Sa

ddle

nos

e•

Loss

of d

igits

/lim

bs d

ue to

se

cond

ary

infe

ctio

ns

Ther

e ar

e th

ree

diffe

rent

form

s of

le

pros

y:

• Tu

berc

uloi

d: m

ildes

t for

m

• Le

prom

atou

s: m

ost s

ever

e fo

rm

and

very

con

tagi

ous

• Bo

rder

line:

mix

ed p

ictu

re o

f tu

berc

uloi

d an

d le

prom

atou

s fo

rms

Skin

bio

psy

– ac

id–f

ast

baci

llus

• Da

pson

e•

Rifa

mpi

cin

• Sc

arrin

g an

d di

sfigu

ratio

n•

Mal

e in

fert

ility

and

er

ectil

e dy

sfun

ctio

n•

Gla

ucom

a•

Kidn

ey fa

ilure

• Pe

rman

ent p

erip

hera

l ne

rve

inju

ry

K30033_C007.indd 209 28/02/17 11:21 am

210

Der

mat

olog

yTa

ble

7.4.

Fu

ng

al s

kin

infe

ctio

ns

TABL

E 7.

4. F

unga

l ski

n in

fect

ions

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Cand

idia

sis

Cand

ida

albi

cans

, a

com

men

sal

yeas

t

Risk

fact

ors

incl

ude

anyt

hing

th

at c

ause

s im

mun

o-su

ppre

ssio

n,

for e

xam

ple:

• HI

V

• Di

abet

es

• Ca

ncer

• An

aem

ia

Depe

nds

on lo

catio

n:

1. S

kin

– so

re, i

tchy

ski

n.

Com

mon

ly a

ffect

s fle

xure

s, w

here

lesi

ons

appe

ar

eryt

hem

atou

s2.

Ora

l can

didi

asis

– p

ain,

di

fficu

lty e

atin

g/sw

allo

win

g,

alte

red

tast

e, w

hite

ps

eudo

mem

bran

e m

ay b

e pr

esen

t3.

Can

dida

l oes

opha

gitis

–

odyn

opha

gia,

wei

ght l

oss

4. B

alan

itis

– pe

nile

itch

ing

and

sore

ness

, dys

uria

5. V

ulvo

vagi

nal c

andi

dias

is –

vu

lval

itch

ing

and

sore

ness

, va

gina

l dis

char

ge, d

ysur

ia,

supe

rfici

al d

yspa

reun

ia

Tend

s to

be

a cl

inic

al d

iagn

osis

bu

t it i

s im

port

ant

to s

wab

the

lesi

on

if th

ere

is a

ny

unce

rtai

nty,

if th

ere

is a

sup

erad

ded

bact

eria

l inf

ectio

n or

if th

e pa

tient

is

imm

unoc

ompr

o-m

ised

.

1. S

kin: Ad

ult,

not i

mm

unoc

ompr

omis

ed –

topi

cal

imid

azol

e

Child

, not

imm

unoc

ompr

omis

ed –

topi

cal

clot

rimaz

ole,

mic

onaz

ole,

eco

nazo

le

Adul

t, im

mun

ocom

prom

ised

– o

ral fl

ucon

azol

e

Child

, im

mun

ocom

prom

ised

– s

eek

spec

ialis

t ad

vice

, con

side

r ora

l fluc

onaz

ole

2. O

ral:

Ad

ults

and

chi

ldre

n, n

ot im

mun

ocom

prom

ised

–

mic

onaz

ole

gel o

r nys

tatin

sus

pens

ion

Ad

ults

, im

mun

ocom

prom

ised

– o

ral fl

ucon

azol

e

3. C

andi

dal o

esop

hagi

tis:

O

ral fl

ucon

azol

e

4. B

alan

itis:

Ad

ults

– im

idaz

ole

crea

m (o

r ora

l fluc

onaz

ole,

si

ngle

dos

e fo

r tho

se o

ver 1

6 ye

ars)

Ch

ildre

n –

a to

pica

l im

idaz

ole

crea

m

5. V

ulvo

vagi

nal c

andi

dias

is

Adul

ts, n

ot im

mun

ocom

prom

ised

– in

trav

agin

al

fluco

nazo

le o

r itr

acon

azol

e. V

ulva

l sym

ptom

s m

ay b

e tr

eate

d w

ith a

topi

cal i

mid

azol

e cr

eam

. If

seve

re, c

lotr

imaz

ole

crea

m m

ay b

e us

ed

Adul

ts, i

mm

unoc

ompr

omis

ed –

ora

l fluc

onaz

ole

or it

raco

nazo

le

• Su

pera

dded

infe

ctio

n

• Sp

ecifi

c com

plica

tions

de

pend

ing

on

loca

tion;

for e

xam

ple,

od

ynop

hagi

a or

supe

rficia

l dy

spar

euni

a

K30033_C007.indd 210 28/02/17 11:21 am

211

Der

mat

olog

yTa

ble

7.4.

Fu

ng

al s

kin

infe

ctio

ns

Ring

wor

mDe

rmat

o-ph

yte

fung

i1.

Bod

y an

d gr

oin

– tin

ea

crur

is

Eryt

hem

atou

s, fla

t or

pote

ntia

lly m

ildly

rais

ed

ring

shap

ed le

sion

s w

ith

a ce

ntra

l cle

arin

g

2. S

calp

– ti

nea

capi

tis

Itchi

ng

Scal

p sc

arrin

g

Patc

hy h

air l

oss

3. F

oot –

tine

a pe

dis

Ty

pica

l whi

te, c

rack

ed

inte

rdig

ital l

esio

ns

1. B

ody

and

groi

n –

tinea

cru

ris

Usua

lly

a cli

nica

l di

agno

sis b

ut

if th

ere

is an

y do

ubt,

send

a

sam

ple

for

micr

osco

py

and

cultu

re

2. S

calp

– ti

nea

capi

tis

Scal

p sc

rapi

ng fo

r m

icro

scop

y an

d cu

lture

3. F

oot –

tine

a pe

dis

Us

ually

a

clini

cal

diag

nosis

but

if

ther

e is

any

doub

t, se

nd

a sa

mpl

e fo

r m

icros

copy

an

d cu

lture

1. B

ody

and

groi

n –

tinea

cru

ris

Mild

– to

pica

l ant

ifung

al c

ream

s

Seve

re –

ora

l ant

ifung

al a

gent

s

2. S

calp

– ti

nea

capi

tis

Adul

ts –

ora

l ant

ifung

als

Ch

ildre

n –

cons

ider

ora

l ant

ifung

als

or re

fer t

o sp

ecia

list

If

kerio

n pr

esen

t – re

fer t

o de

rmat

olog

y

3. F

oot –

tine

a pe

dis

M

ild –

topi

cal c

lotr

imaz

ole,

mic

onaz

ole

or

econ

azol

e

Seve

re –

ora

l ant

ifung

al a

gent

s

• Po

tent

ially

ser

ious

an

d re

fract

ory

case

s in

thos

e w

ho a

re im

mun

o-co

mpr

omis

ed

K30033_C007.indd 211 28/02/17 11:21 am

212

Der

mat

olog

yTa

ble

7.5.

Ski

n lu

mp

s

TABL

E 7.

5. S

kin

lum

ps.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Sebo

rrho

eic

kera

tosi

sPr

olife

ratio

n of

the

basa

l lay

er o

f epi

derm

is.

Incr

ease

d ris

k w

ith s

un

expo

sure

and

age

• Fl

at/ra

ised

pap

ules

/pla

ques

•

War

t-lik

e, p

edun

cula

ted

yello

w-b

row

n ap

pear

ance

• Le

sion

may

itch

and

ble

ed•

Typi

cally

aris

es o

n th

e tr

unk

• Cl

inic

al d

iagn

osis

• De

rmat

osco

py m

ay b

e us

eful

• Cr

yoth

erap

y •

Cure

ttag

eSk

in c

ance

r may

ar

ise

from

or

be d

ifficu

lt to

di

stin

guis

h fro

m

thes

e le

sion

s

Sola

r ker

atos

isSc

aly

plaq

ues

that

occ

ur a

s a

resu

lt of

UVB

dam

age

• W

ell-d

emar

cate

d ye

llow

–br

own,

ery

them

atou

s hy

perk

erat

otic

sca

ly le

sion

• Le

sion

may

itch

and

ble

ed

• Cl

inic

al d

iagn

osis

• De

rmat

osco

py m

ay b

e us

eful

• Bi

opsy

may

be

used

to

rule

out

squ

amou

s ce

ll ca

rcin

oma

• Cr

yoth

erap

y•

Cure

ttag

e•

Crea

ms

– 5-

fluor

oura

cil

(cyt

otox

ic),

imiq

uim

od

Squa

mou

s ce

ll ca

rcin

oma

Derm

atofi

brom

aA

beni

gn n

odul

e th

at ty

pi-

cally

aris

es o

n th

e lo

wer

leg

but m

ay a

rise

else

whe

re.

Mor

e co

mm

on in

wom

en

than

in m

en

• Fi

rm, p

igm

ente

d no

dule

s us

ually

pre

sent

on

the

low

er le

g •

Betw

een

1 an

d 15

in

num

ber

• M

obile

ove

r sub

cuta

neou

s tis

sue

• N

odul

e(s)

may

be

itchy

or

asym

ptom

atic

• Cl

inic

al d

iagn

osis

• De

rmat

osco

py m

ay b

e us

eful

• Bi

opsy

take

n if

ther

e is

any

unc

erta

inty

co

ncer

ning

dia

gnos

is

Onl

y re

mov

e if

caus

ing

trou

ble

to

patie

nts

Blee

ding

if

trau

mat

ized

K30033_C007.indd 212 28/02/17 11:21 am

213

Der

mat

olog

yTa

ble

7.5.

Ski

n lu

mp

s

Haem

angi

oma

This

is a

ben

ign

cond

ition

of

cut

aneo

us b

lood

ves

sels

ca

used

by

arte

riove

nous

m

alfo

rmat

ion

or a

bnor

mal

ve

ssel

pro

lifer

atio

n.Th

ere

are

man

y di

ffere

nt

type

s. So

me

exam

ples

are

lis

ted

belo

w:

1. S

traw

berr

y na

evus

–

this

reso

lves

with

tim

e.

Trea

tmen

t is

gene

rally

no

t req

uire

d un

less

su

pera

dded

infe

ctio

n oc

curs

or i

t dev

elop

s in

a

prob

lem

atic

regi

on

(e.g

. the

eye

lid)

2. P

ort-

win

e st

ain

– as

soci

ated

with

Stu

rge–

Web

er s

yndr

ome

3. C

aver

nous

ha

eman

giom

a –

asso

ciat

ed w

ith

Kasa

bach

–Mer

ritt

synd

rom

e4.

Pyo

geni

c gr

anul

oma

– fo

llow

s tr

aum

a

• De

pend

s on

the

type

of

haem

angi

oma

• Le

sion

s m

ay b

e si

ngul

ar b

ut

in s

ome

case

s m

ultip

le•

The

lesi

ons

are

eryt

hem

atou

s an

d m

ay b

e fla

t or r

aise

d•

Ther

e m

ay b

e th

icke

ning

of

the

over

lyin

g ep

ider

mis

• U

sual

ly a

clin

ical

dia

gnos

is•

USS

is u

sed

to

inve

stig

ate

deep

infa

ntile

ha

eman

giom

as

• M

RI a

nd a

ngio

grap

hy

may

be

requ

ired

in m

ore

com

plex

cas

es

• So

met

imes

no

trea

tmen

t is

requ

ired

• Pr

opan

olol

• Co

mpr

essi

ve

ther

apy

• La

ser t

hera

py•

Intr

ales

iona

l st

eroi

d in

ject

ions

• Ps

ycho

logi

cal

impl

icat

ions

(e

.g.

depr

essi

on)

• U

lcer

atio

n•

Blee

ding

Cont

inue

d ov

erle

af

K30033_C007.indd 213 28/02/17 11:21 am

214

Der

mat

olog

yTa

ble

7.5.

Ski

n lu

mp

s

TABL

E 7.

5. S

kin

lum

ps (c

ontin

ued ).

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Lipo

ma

Beni

gn s

low

gro

win

g tu

mou

r com

pris

ed o

f lo

bula

ted

fat c

ells.

A th

in

fibro

us c

apsu

le e

ncas

es th

e tu

mou

r. It

affe

cts

mal

es a

nd

fem

ales

equ

ally

; how

ever

, m

ultip

le le

sion

s ar

e m

ore

com

mon

in m

en

Smoo

th, s

oft,

rubb

ery

swel

ling

~2–

10 c

m in

dia

met

er•

Usu

ally

a c

linic

al d

iagn

osis

• Sk

in b

iops

y m

ay b

e pe

rform

ed if

ther

e is

any

do

ubt o

f the

dia

gnos

is.

This

will

vis

ualiz

e a

thin

fib

rous

cap

sule

and

ca

pilla

ries

with

fibr

ous

stra

nds

Ofte

n tr

eatm

ent

is n

ot re

quire

d.

If pr

oble

mat

ic,

surg

ical

exc

isio

n m

ay b

e re

quire

d

Inte

rfere

nce

with

ad

jace

nt m

uscl

e m

ovem

ent

Epid

erm

oid

cyst

Epith

eliu

m li

ned

cavi

ty

fille

d w

ith s

emi-s

olid

m

ater

ial.

Mos

tly o

ccur

in

hair

bear

ing

area

s

Derm

al lu

mp

with

cha

ract

eris

tic

cent

ral p

unct

um

Usu

ally

a c

linic

al d

iagn

osis

Surg

ical

exc

isio

n•

Rupt

ure

• In

fect

ion

• Sk

in c

ance

r

Derm

oid

cyst

Cyst

aris

ing

from

epi

derm

al

cells

, lin

ed b

y sq

uam

ous

epith

eliu

m

Smoo

th, s

oft,

rubb

ery

swel

ling.

Two

diffe

rent

type

s:

1. I

mpl

anta

tion

cyst

s –

aris

e fo

llow

ing

trau

ma

2. C

onge

nita

l cys

ts –

aris

e fro

m e

mbr

yoni

c fu

sion

site

s

Usu

ally

a c

linic

al d

iagn

osis

Surg

ical

exc

isio

nRu

ptur

e In

fect

ion

Tors

ion

K30033_C007.indd 214 28/02/17 11:21 am

K30033_C007.indd 215 28/02/17 11:21 am

216

Der

mat

olog

yTa

ble

7.6.

Ski

n t

um

ou

rs

TABL

E 7.

6. S

kin

tum

ours

. Ris

k fa

ctor

s in

clud

e: s

kin

type

1, h

isto

ry o

f su

n bu

rn/s

un e

xpos

ure

(par

ticu

larl

y in

chi

ldho

od),

prec

ance

rous

ski

n le

sion

s, p

erso

nal o

r fa

mily

his

tory

of

skin

can

cer,

radi

atio

n ex

posu

re, m

ulti

ple

mol

es,

gene

tics

– f

amili

al d

yspl

asti

c na

evus

syn

drom

e (c

hrom

osom

e 1)

.

Dis

ease

Caus

eSy

mpt

oms

Inve

stig

atio

nsTr

eatm

ent

Com

plic

atio

ns

Basa

l cel

l car

cino

ma

Sun

expo

sure

, par

ticul

arly

pr

eval

ent i

n sk

in ty

pe 1

an

d ex

cess

ive

child

hood

su

n ex

posu

re

Asso

ciat

ed w

ith

mut

atio

ns o

f the

tu

mou

r sup

pres

sor g

ene

(chr

omos

ome

9)

Depe

nds

on th

e ty

pe o

f bas

al

cell

carc

inom

a:

1. N

odul

ar ty

pe: c

omm

ones

t, pi

gmen

ted

nodu

le w

ith

tela

ngie

ctas

ia

2. S

uper

ficia

l typ

e: ir

regu

lar

pigm

ente

d pl

aque

s3.

Mor

phoe

ic ty

pe: fl

esh

colo

ured

pla

ques

• De

rmat

osco

py•

Exci

sion

bio

psy

Surg

ical

exc

isio

nLo

cal i

nvas

ion

– ro

dent

ulc

er

Squa

mou

s ce

ll ca

rcin

oma

Refe

r to

abov

e ris

k fa

ctor

sA

loca

lly in

vasi

ve tu

mou

r th

at ty

pica

lly u

lcer

ates

with

ro

lled

edge

s.

Two

type

s:

1. B

owen

’s di

seas

e –

squa

mou

s ce

ll ca

rcin

oma

in s

itu2.

Ker

atoa

cant

hom

a –

cent

ral k

erat

in p

lug

• De

rmat

osco

py•

Exci

sion

bio

psy

• Bo

wen

’s di

seas

e –

cryo

ther

apy,

cure

ttag

e or

topi

cal

5-flu

orou

raci

l

• Su

rgic

al

exci

sion

Spre

ad to

lym

ph

node

s

K30033_C007.indd 216 28/02/17 11:21 am

217

Der

mat

olog

yTa

ble

7.6.

Ski

n t

um

ou

rs

Mal

igna

nt m

elan

oma

Refe

r to

abov

e ris

k fa

ctor

sRe

mem

ber t

o as

sess

the

lesi

on A

BCD

E, w

hich

dire

ctly

re

late

s to

the

sym

ptom

s of

th

is m

alig

nanc

y:

A –

Asy

mm

etric

al le

sion

B –

Bord

ers

are

irreg

ular

C –

Colo

ur h

as c

hang

edD

– D

iam

eter

incr

ease

dE

– Ev

olvi

ng le

sion

The

lesi

on m

ay a

lso

itch

and

blee

d

• De

rmat

osco

py•

Asse

ssm

ent u

sing

Cl

ark

leve

ls a

nd

Bres

low

’s th

ickn

ess

Clar

k le

vels

:

1. M

elan

oma

in s

itu2.

Inv

asio

n of

the

papi

llary

der

mis

3. I

nvas

ion

into

the

junc

tion

of th

e pa

pilla

ry a

nd re

ticul

ar

derm

is4.

Inv

asio

n of

the

retic

ular

der

mis

5. I

nvas

ion

of th

e su

bcut

aneo

us fa

t

Bres

low

’s th

ickn

ess:

Thin

: <1

mm

Inte

rmed

iate

: 1–4

mm

Thic

k: >

4 m

m

• W

ide

surg

ical

ex

cisi

on•

If m

etas

tasi

s, th

en

chem

othe

rapy

an

d ra

diot

hera

py is

re

quire

d

• M

etas

tasi

s•

Deat

h

K30033_C007.indd 217 28/02/17 11:21 am

K30033_C007.indd 218 28/02/17 11:21 am

Chap

ter E

ight

Ort

hopa

edic

s

TABL

E 8.

1a

Gen

eral

co

mp

licat

ion

s o

f fr

actu

res

220

TABL

E 8.

1b

Spec

ific

com

plic

atio

ns

of

frac

ture

s 22

1

MAP

8.1

N

eck

pat

ho

log

y 22

2

MAP

8.2

Sh

ou

lder

pat

ho

log

y 22

4

FIG

URE

8.1

The

bra

chia

l ple

xus

227

MAP

8.3

A

rth

riti

s 22

8

MAP

8.4

El

bo

w p

ath

olo

gy

230

MAP

8.5

H

and

pat

ho

log

y 23

2

MAP

8.6

Sp

inal

pat

ho

log

y 23

6

MAP

8.7

H

ip p

ath

olo

gy

240

TABL

E 8.

2 K

nee

pat

ho

log

y 24

4

TABL

E 8.

3 Fo

ot

pat

ho

log

y 24

8

MAP

8.8

O

rth

op

aed

ic in

fect

ion

s 25

0

FIG

URE

8.2

The

lum

bar

ple

xus

252

Ort

hopa

edic

s21

9

K30033_C008.indd 219 28/02/17 11:26 am

Ort

hopa

edic

s22

0Ta

ble

8.1a

. G

ener

al c

om

plic

atio

ns

of

frac

ture

s

TABL

E 8.

1a. G

ener

al c

ompl

icat

ions

of

frac

ture

s.

Com

plic

atio

nCo

mm

ents

Gen

eral

• Ha

emor

rhag

e•

Shoc

k•

Infe

ctio

n•

Fat e

mbo

lus

resu

lting

in p

ulm

onar

y em

bolis

m a

nd re

spira

tory

dis

tres

s sy

ndro

me

• Rh

abdo

myo

lysi

s

Asso

ciat

ed w

ith p

rolo

nged

be

d re

st•

Deep

vei

n th

rom

bosi

s an

d pu

lmon

ary

embo

lism

• Pr

essu

re s

ores

• M

uscl

e w

astin

g•

Infe

ctio

n

Asso

ciat

ed w

ith p

last

er c

asts

• Re

mem

ber a

s SP

AN

:S

– S

tiffn

ess

P –

Pre

ssur

eA

– A

llerg

yN

– N

erve

and

circ

ulat

ory

dist

urba

nce

Asso

ciat

ed w

ith a

naes

thes

ia•

Anap

hyla

xis

• As

pira

tion

Frac

ture

s Th

ere

are

man

y di

ffere

nt ty

pes o

f fra

ctur

e an

d th

ey m

ay b

e de

fined

(1) b

y lo

catio

n, (2

) as o

pen

(com

poun

d) o

r clo

sed,

(3) a

s int

ra- o

r ext

ra-a

rtic

ular

, (4)

as d

ispl

aced

or n

ot

disp

lace

d, (5

) by

type

: (a)

com

plex

– c

omm

inut

ed, s

egm

enta

l, (b

) non

-com

plex

– tr

ansv

erse

, obl

ique

, spi

ral,

avul

sion

etc

., (c

) spe

cific

(e.g

. gre

enst

ick)

, and

(6) b

y di

seas

e in

volv

emen

t (e.

g. o

steo

poro

sis)

. Fr

actu

res m

ust b

e fu

rthe

r ass

esse

d us

ing

radi

ogra

phy,

and

a de

scrip

tion

of im

pact

ion,

ang

ulat

ion

and

tran

sloc

atio

n m

ust b

e re

port

ed. T

he m

any

com

plic

atio

ns a

ssoc

i-at

ed w

ith fr

actu

res

are

outli

ned

belo

w.

K30033_C008.indd 220 28/02/17 11:26 am

221

Ort

hopa

edic

sTa

ble

8.1b

. Sp

ecifi

c co

mp

licat

ion

s o

f fr

actu

res

TABL

E 8.

1b. S

peci

fic

com

plic

atio

ns o

f fr

actu

res.

Com

plic

atio

nCo

mm

ents

Imm

edia

te•

Haem

orrh

age

• N

euro

vasc

ular

com

plic

atio

ns

Early

• In

fect

ion

• Co

mpa

rtm

ent s

yndr

ome:

Fr

actu

res

caus

e sw

ellin

g, w

hich

incr

ease

s th

e pr

essu

re w

ithin

the

com

part

men

t. Th

is re

sults

in d

ecre

ased

cap

illar

y bl

ood

flow

. Isc

haem

ia

deve

lops

whe

n ca

pilla

ry p

ress

ure

is le

ss th

an th

at o

f the

com

part

men

t pre

ssur

e. Ir

reve

rsib

le c

hang

e re

sults

afte

r 6 h

ours

Sym

ptom

s in

clud

e pa

in, w

hich

is o

ut o

f pro

port

ion

with

pre

sent

ing

sym

ptom

s. Th

is p

ain

is p

rese

nt/w

orse

ned

on p

assi

ve s

tret

chin

g.

Para

esth

esia

and

tigh

tnes

s m

ay a

lso

be p

rese

nt

Late

• M

alun

ion

Tw

o di

ffere

nt fo

rms:

1. H

yper

trop

hic

– pl

enty

of n

ew b

one

grow

th b

ut th

ese

fail

to u

nite

2. A

trop

hic

– la

ck o

f new

bon

e gr

owth

. Ost

eope

nic

in a

ppea

ranc

e•

Avas

cula

r nec

rosi

s•

Com

plex

regi

onal

pai

n sy

ndro

me

Tw

o di

ffere

nt fo

rms:

1. N

o un

derly

ing

nerv

e pr

oble

m2.

Und

erly

ing,

dem

onst

rabl

e ne

rve

prob

lem

• M

yosi

tis o

ssifi

cans

– c

alci

ficat

ion

of th

e so

ft tis

sues

, whi

ch o

ccur

s af

ter s

urge

ry o

r inj

ury

• G

row

th d

istur

banc

e –

occu

rs a

fter d

amag

e to

the

grow

th p

late

. Thi

s is

desc

ribed

usin

g th

e Sa

lter-H

arris

cla

ssifi

catio

n. R

emem

ber a

s SA

LT C

:S

– Se

para

te (f

ract

ure

occu

rs th

roug

h th

e gr

owth

pla

te)

A –

Abo

ve (a

bove

the

grow

th p

late

. Mos

t com

mon

type

)L

– L

ower

(bel

ow th

e gr

owth

pla

te)

T –

Thr

ough

(bot

h up

per a

nd lo

wer

. Com

mon

est c

ause

of p

rem

atur

e gr

owth

arr

est)

C –

Crus

hed

phys

is (w

orst

inju

ry)

K30033_C008.indd 221 28/02/17 11:26 am

Ort

hopa

edic

s22

2 Cerv

ical

spo

ndyl

osis

Wha

t is

cer

vica

l spo

ndyl

osis

?De

gene

rativ

e ar

thrit

is o

f the

cer

vica

l ver

tebr

ae. T

here

is in

crea

sed

risk

with

age

.

Caus

es•

Ost

eoar

thrit

is re

sulti

ng in

bon

y sp

urs.

This

may

resu

lt in

a c

ervi

cal

ra

dicu

lopa

thy

or m

yelo

path

y.•

Trau

ma.

Sym

ptom

s•

May

be

asym

ptom

atic

.•

Redu

ced

rang

e of

mov

emen

t.•

Pain

.•

Para

esth

esia

follo

win

g a

derm

atom

al d

istr

ibut

ion.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Lher

mitt

e’s

sign

.•

Radi

olog

y –

CT/M

RI.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: N

SAID

s, co

dein

e et

c.; f

ollo

w W

HO a

nalg

esic

ladd

er.

• Su

rgic

al: a

nter

ior c

ervi

cal d

isce

ctom

y, ce

rvic

al la

min

ecto

my.

Com

plic

atio

ns•

Vert

ebro

basi

lar i

nsuf

ficie

ncy.

Cerv

ical

spo

ndyl

olis

thes

is

Wha

t is

cer

vica

l spo

ndyl

olis

thes

is?

This

is w

hen

a su

perio

rly lo

cate

d ce

rvic

al v

erte

bra

is d

ispl

aced

ant

erio

rly

rela

tive

to th

e ve

rteb

ra b

elow

. Thi

s m

ay n

arro

w th

e ve

rteb

ral c

anal

and

resu

lts

in d

efor

mity

.

Caus

es•

Cong

enita

l: fa

ilure

of o

ndon

toid

pro

cess

fusi

on.

• Tr

aum

a: re

sults

in in

stab

ility

.•

Softe

ning

of t

he tr

ansv

erse

liga

men

t due

to in

flam

mat

ion.

Sym

ptom

s•

Pain

– m

ay b

e ra

dicu

lar o

r may

radi

ate

betw

een

the

shou

lder

bla

des

and

t

o th

e ba

ck o

f the

hea

d.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y: C

T/M

RI.

• M

eyer

ding

gra

ding

sys

tem

– d

escr

ibes

per

cent

age

slip

page

.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: N

SAID

s, co

dein

e et

c.; f

ollo

w W

HO a

nalg

esic

ladd

er. C

onsi

der

co

rtic

oste

roid

inje

ctio

ns.

• Su

rgic

al: m

icro

disc

ecto

my,

hem

ilam

inec

tom

y, an

terio

r cer

vica

l dis

cect

omy

+/–

fusi

on.

Cerv

ical

dis

c pr

olap

se

Wha

t is

a c

ervi

cal d

isc

prol

apse

?Th

is o

ccur

s w

hen

the

nucl

eus

pulp

osus

her

niat

es th

roug

h a

tear

in th

e an

nulu

s fib

rosu

s. Ty

pica

lly a

ffect

sC5

/6 a

nd C

6/7

sinc

e th

ese

are

the

mos

t mob

ile s

egm

ents

. Pro

laps

es m

ay b

e ce

ntra

l or l

ater

al.

Sym

ptom

s•

Brac

halg

ia w

ith a

ssoc

iate

d ra

dicu

lopa

thy.

• Pa

in, p

arae

sths

ia, w

eakn

ess.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y –

MRI

.

Trea

tmen

tDe

pend

s on

the

exte

nt o

f the

pro

laps

e an

d th

e pr

esen

ce o

r abs

ence

of n

euro

logi

cal s

ympt

oms.

• M

ild –

no

neur

olog

ical

sym

ptom

s. Ph

ysio

ther

apy

and

anal

gesi

a m

ay s

uffic

e.•

Mod

erat

e –

only

radi

cula

r sym

ptom

s. Su

rger

y m

ay b

e re

quire

d (e

.g. d

isce

ctom

y or

lam

inec

tom

y).

• Se

vere

– u

rgen

t sur

gica

l dec

ompr

essi

on.MAP

8.1

. Nec

k pa

thol

ogy

Map

8.1

. N

eck

pat

ho

log

y

K30033_C008.indd 222 28/02/17 11:26 am

Ort

hopa

edic

s22

3Cerv

ical

spo

ndyl

osis

Wha

t is

cer

vica

l spo

ndyl

osis

?De

gene

rativ

e ar

thrit

is o

f the

cer

vica

l ver

tebr

ae. T

here

is in

crea

sed

risk

with

age

.

Caus

es•

Ost

eoar

thrit

is re

sulti

ng in

bon

y sp

urs.

This

may

resu

lt in

a c

ervi

cal

ra

dicu

lopa

thy

or m

yelo

path

y.•

Trau

ma.

Sym

ptom

s•

May

be

asym

ptom

atic

.•

Redu

ced

rang

e of

mov

emen

t.•

Pain

.•

Para

esth

esia

follo

win

g a

derm

atom

al d

istr

ibut

ion.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Lher

mitt

e’s

sign

.•

Radi

olog

y –

CT/M

RI.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: N

SAID

s, co

dein

e et

c.; f

ollo

w W

HO a

nalg

esic

ladd

er.

• Su

rgic

al: a

nter

ior c

ervi

cal d

isce

ctom

y, ce

rvic

al la

min

ecto

my.

Com

plic

atio

ns•

Vert

ebro

basi

lar i

nsuf

ficie

ncy.

Cerv

ical

spo

ndyl

olis

thes

is

Wha

t is

cer

vica

l spo

ndyl

olis

thes

is?

This

is w

hen

a su

perio

rly lo

cate

d ce

rvic

al v

erte

bra

is d

ispl

aced

ant

erio

rly

rela

tive

to th

e ve

rteb

ra b

elow

. Thi

s m

ay n

arro

w th

e ve

rteb

ral c

anal

and

resu

lts

in d

efor

mity

.

Caus

es•

Cong

enita

l: fa

ilure

of o

ndon

toid

pro

cess

fusi

on.

• Tr

aum

a: re

sults

in in

stab

ility

.•

Softe

ning

of t

he tr

ansv

erse

liga

men

t due

to in

flam

mat

ion.

Sym

ptom

s•

Pain

– m

ay b

e ra

dicu

lar o

r may

radi

ate

betw

een

the

shou

lder

bla

des

and

t

o th

e ba

ck o

f the

hea

d.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y: C

T/M

RI.

• M

eyer

ding

gra

ding

sys

tem

– d

escr

ibes

per

cent

age

slip

page

.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: N

SAID

s, co

dein

e et

c.; f

ollo

w W

HO a

nalg

esic

ladd

er. C

onsi

der

co

rtic

oste

roid

inje

ctio

ns.

• Su

rgic

al: m

icro

disc

ecto

my,

hem

ilam

inec

tom

y, an

terio

r cer

vica

l dis

cect

omy

+/–

fusi

on.

Cerv

ical

dis

c pr

olap

se

Wha

t is

a c

ervi

cal d

isc

prol

apse

?Th

is o

ccur

s w

hen

the

nucl

eus

pulp

osus

her

niat

es th

roug

h a

tear

in th

e an

nulu

s fib

rosu

s. Ty

pica

lly a

ffect

sC5

/6 a

nd C

6/7

sinc

e th

ese

are

the

mos

t mob

ile s

egm

ents

. Pro

laps

es m

ay b

e ce

ntra

l or l

ater

al.

Sym

ptom

s•

Brac

halg

ia w

ith a

ssoc

iate

d ra

dicu

lopa

thy.

• Pa

in, p

arae

sths

ia, w

eakn

ess.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y –

MRI

.

Trea

tmen

tDe

pend

s on

the

exte

nt o

f the

pro

laps

e an

d th

e pr

esen

ce o

r abs

ence

of n

euro

logi

cal s

ympt

oms.

• M

ild –

no

neur

olog

ical

sym

ptom

s. Ph

ysio

ther

apy

and

anal

gesi

a m

ay s

uffic

e.•

Mod

erat

e –

only

radi

cula

r sym

ptom

s. Su

rger

y m

ay b

e re

quire

d (e

.g. d

isce

ctom

y or

lam

inec

tom

y).

• Se

vere

– u

rgen

t sur

gica

l dec

ompr

essi

on.MAP

8.1

. Nec

k pa

thol

ogy

Map

8.1

. N

eck

pat

ho

log

y

K30033_C008.indd 223 28/02/17 11:26 am

Ort

hopa

edic

s22

4 Shou

lder

dis

loca

tion

Wha

t is

a s

houl

der

disl

ocat

ion?

This

is w

hen

ther

e is

a lo

ss o

f con

grui

ty b

etw

een

the

head

of t

he h

umer

us

and

the

glen

oid

foss

a. T

here

are

two

type

s –

ante

rior a

nd p

oste

rior.

Caus

es•

Ante

rior –

com

mon

est.

Trau

ma.

Incr

ease

d ris

k in

thos

e w

ith c

onne

ctiv

e

tis

sue

diso

rder

s or

thos

e w

ith p

rior s

houl

der d

islo

catio

ns.

• Po

ster

ior –

rare

. Sei

zure

s an

d el

ectr

ocut

ion.

Sym

ptom

s•

Pain

.•

Decr

ease

d ra

nge

of m

ovem

ent.

• A

nter

ior –

hum

eral

hea

d is

pro

min

ent a

nd h

eld

in a

n ab

duct

ed,

e

xter

nally

rota

ted

posi

tion.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y (la

tera

l and

AP

view

s).

Trea

tmen

t•

Clos

ed re

duct

ion

and

slin

g im

mob

iliza

tion.

• Ad

equa

te a

nalg

esia

.

Com

plic

atio

ns•

Axill

ary

nerv

e or

art

ery

dam

age.

• Da

mag

e to

the

brac

hial

ple

xus.

• In

crea

sed

risk

of re

curr

ence

.•

Spec

ific

lesi

ons:

Bank

art l

esio

n: a

vuls

ion

of a

nter

o-in

ferio

r gle

noid

labr

um.

Hill–

Sach

s le

sion

: ind

enta

tion

fract

ure

of th

e po

ster

olat

eral

hum

eral

he

ad.

Rota

tor

cuff

tea

rs

Wha

t ar

e ro

tato

r cu

ff t

ears

?Th

e ro

tato

r cuf

f com

pris

es fo

ur te

ndon

s an

d m

uscl

es th

at a

im to

pro

vide

stab

ility

to th

e hi

ghly

mob

ile s

houl

der j

oint

. The

four

mus

cles

(rem

embe

red

as S

ITS)

are

the

Supr

aspi

natu

s (m

ost c

omm

only

torn

), In

frasp

inat

us, T

eres

min

or a

nd S

ubsc

apul

aris.

Fur

ther

impo

rtan

t ana

tom

ical

det

ails

abo

ut th

ese

mus

cles

are

pro

vide

d be

low

:

Caus

es•

Dege

nera

tion.

• Tr

aum

a.•

Wei

ght l

iftin

g.

Sym

ptom

s•

Part

ial t

ears

resu

lt in

a p

ainf

ul a

rc s

yndr

ome.

• Co

mpl

ete

tear

s lim

it sh

ould

er a

bduc

tion.

• Pa

in to

a v

aria

ble

degr

ee d

epen

ding

on

the

sign

ifica

nce

of th

e te

ar.

• Sh

ould

er te

nder

ness

on

palp

atio

n.•

Wea

knes

s.

Inve

stig

atio

ns•

Thor

ough

exa

min

atio

n w

ith s

peci

fic te

sts

as o

utlin

ed in

Tabl

e ab

ove.

• Ra

diol

ogy

– x-

ray,

MRI

.

Trea

tmen

t•

Cons

erva

tive:

rest

and

phy

siot

hera

py.

• M

edic

al: a

dequ

ate

pain

relie

f.•

Surg

ical

: art

hros

copy

+/−

repa

ir if

indi

cate

d.

Com

plic

atio

ns•

Decr

ease

d ra

nge

of m

ovem

ent,

whi

ch m

ay in

hibi

t dai

ly a

ctiv

ities

suc

h as

ge

ttin

g dr

esse

d.•

Com

plic

atio

ns a

ssoc

iate

d w

ith s

urge

ry in

clud

e ge

nera

l ris

ks fr

om

anae

sthe

sia

and

infe

ctio

n as

wel

l as

spec

ific

com

plic

atio

ns s

uch

as

dam

age

to th

e ax

illar

y ne

rve.

Exte

rnal

ly ro

tate

shu

mer

us

Mus

cle

Act

ion

Supr

aspi

natu

s

Tere

s m

inor

Abdu

cts

hum

erus

Subs

capu

laris

Inte

rnal

ly ro

tate

shu

mer

us

Inne

rvat

ion

Supr

asca

pula

rne

rve

(C5)

Axill

ary

nerv

e(C

5)

Exte

rnal

ly ro

tate

shu

mer

usIn

frasp

inat

usSu

pras

capu

lar

nerv

e (C

5–6)

Upp

er a

nd lo

wer

subs

capu

lar n

erve

(C5–

6)

Empt

y be

er c

ante

st (e

limin

ates

delto

id)

-Resi

sted

ext

erna

lro

tatio

n

Lift-

off t

est

Spec

ific

test

MAP

8.2

. Sho

ulde

r pa

thol

ogy

Map

8.2

. Sh

ou

lder

pat

ho

log

y

K30033_C008.indd 224 28/02/17 11:26 am

Ort

hopa

edic

s22

5Shou

lder

dis

loca

tion

Wha

t is

a s

houl

der

disl

ocat

ion?

This

is w

hen

ther

e is

a lo

ss o

f con

grui

ty b

etw

een

the

head

of t

he h

umer

us

and

the

glen

oid

foss

a. T

here

are

two

type

s –

ante

rior a

nd p

oste

rior.

Caus

es•

Ante

rior –

com

mon

est.

Trau

ma.

Incr

ease

d ris

k in

thos

e w

ith c

onne

ctiv

e

tis

sue

diso

rder

s or

thos

e w

ith p

rior s

houl

der d

islo

catio

ns.

• Po

ster

ior –

rare

. Sei

zure

s an

d el

ectr

ocut

ion.

Sym

ptom

s•

Pain

.•

Decr

ease

d ra

nge

of m

ovem

ent.

• A

nter

ior –

hum

eral

hea

d is

pro

min

ent a

nd h

eld

in a

n ab

duct

ed,

e

xter

nally

rota

ted

posi

tion.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y (la

tera

l and

AP

view

s).

Trea

tmen

t•

Clos

ed re

duct

ion

and

slin

g im

mob

iliza

tion.

• Ad

equa

te a

nalg

esia

.

Com

plic

atio

ns•

Axill

ary

nerv

e or

art

ery

dam

age.

• Da

mag

e to

the

brac

hial

ple

xus.

• In

crea

sed

risk

of re

curr

ence

.•

Spec

ific

lesi

ons:

Bank

art l

esio

n: a

vuls

ion

of a

nter

o-in

ferio

r gle

noid

labr

um.

Hill–

Sach

s le

sion

: ind

enta

tion

fract

ure

of th

e po

ster

olat

eral

hum

eral

he

ad.

Rota

tor

cuff

tea

rs

Wha

t ar

e ro

tato

r cu

ff t

ears

?Th

e ro

tato

r cuf

f com

pris

es fo

ur te

ndon

s an

d m

uscl

es th

at a

im to

pro

vide

stab

ility

to th

e hi

ghly

mob

ile s

houl

der j

oint

. The

four

mus

cles

(rem

embe

red

as S

ITS)

are

the

Supr

aspi

natu

s (m

ost c

omm

only

torn

), In

frasp

inat

us, T

eres

min

or a

nd S

ubsc

apul

aris.

Fur

ther

impo

rtan

t ana

tom

ical

det

ails

abo

ut th

ese

mus

cles

are

pro

vide

d be

low

:

Caus

es•

Dege

nera

tion.

• Tr

aum

a.•

Wei

ght l

iftin

g.

Sym

ptom

s•

Part

ial t

ears

resu

lt in

a p

ainf

ul a

rc s

yndr

ome.

• Co

mpl

ete

tear

s lim

it sh

ould

er a

bduc

tion.

• Pa

in to

a v

aria

ble

degr

ee d

epen

ding

on

the

sign

ifica

nce

of th

e te

ar.

• Sh

ould

er te

nder

ness

on

palp

atio

n.•

Wea

knes

s.

Inve

stig

atio

ns•

Thor

ough

exa

min

atio

n w

ith s

peci

fic te

sts

as o

utlin

ed in

Tabl

e ab

ove.

• Ra

diol

ogy

– x-

ray,

MRI

.

Trea

tmen

t•

Cons

erva

tive:

rest

and

phy

siot

hera

py.

• M

edic

al: a

dequ

ate

pain

relie

f.•

Surg

ical

: art

hros

copy

+/−

repa

ir if

indi

cate

d.

Com

plic

atio

ns•

Decr

ease

d ra

nge

of m

ovem

ent,

whi

ch m

ay in

hibi

t dai

ly a

ctiv

ities

suc

h as

ge

ttin

g dr

esse

d.•

Com

plic

atio

ns a

ssoc

iate

d w

ith s

urge

ry in

clud

e ge

nera

l ris

ks fr

om

anae

sthe

sia

and

infe

ctio

n as

wel

l as

spec

ific

com

plic

atio

ns s

uch

as

dam

age

to th

e ax

illar

y ne

rve.

Exte

rnal

ly ro

tate

shu

mer

us

Mus

cle

Act

ion

Supr

aspi

natu

s

Tere

s m

inor

Abdu

cts

hum

erus

Subs

capu

laris

Inte

rnal

ly ro

tate

shu

mer

us

Inne

rvat

ion

Supr

asca

pula

rne

rve

(C5)

Axill

ary

nerv

e(C

5)

Exte

rnal

ly ro

tate

shu

mer

usIn

frasp

inat

usSu

pras

capu

lar

nerv

e (C

5–6)

Upp

er a

nd lo

wer

subs

capu

lar n

erve

(C5–

6)

Empt

y be

er c

ante

st (e

limin

ates

delto

id)

-Resi

sted

ext

erna

lro

tatio

n

Lift-

off t

est

Spec

ific

test

MAP

8.2

. Sho

ulde

r pa

thol

ogy

Cont

inue

d ov

erle

af

Map

8.2

. Sh

ou

lder

pat

ho

log

y

K30033_C008.indd 225 28/02/17 11:26 am

Ort

hopa

edic

s22

6 Adh

esiv

e ca

psul

itis

Wha

t is

adh

esiv

e ca

psul

itis

?Ad

hesi

ve c

apsu

litis

is a

lso

know

n as

froz

en s

houl

der.

Typi

cally

the

path

olog

y en

com

pass

es th

ree

phas

es:

1. P

ain

with

free

zing

.2.

Tha

win

g.3.

Res

olut

ion

– m

ay ta

ke u

p to

and

pos

sibl

y m

ore

than

2 y

ears

.

Caus

es•

The

exac

t aet

iolo

gy o

f thi

s co

nditi

on is

unk

now

n bu

t it i

s lin

ked

to

trau

ma

and

past

sho

ulde

r sur

gery

.

Risk

fact

ors

• In

crea

sed

age.

• Fe

mal

e.•

Diab

etes

mel

litus

.•

Rheu

mat

oid

arth

ritis.

Sym

ptom

s•

Pain

– o

n ac

tive

and

pass

ive

mov

emen

t.•

Rest

ricte

d ra

nge

on m

ovem

ent –

act

ivel

y an

d pa

ssiv

ely.

Exte

rnal

ro

tatio

n is

ofte

n af

fect

ed fi

rst.

• O

ften

no m

ovem

ent a

t the

gle

nohu

mer

al jo

int.

• Di

fficu

lty s

leep

ing

on th

e af

fect

ed s

ide.

MAP

8.2

. Sho

ulde

r pa

thol

ogy

(con

tinue

d )

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y: U

SS a

nd M

RI.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: a

dequ

ate

anal

gesi

a, s

tero

id in

ject

ions

.•

Surg

ery:

onl

y pe

rform

ed in

sev

ere

case

s (e

.g. c

apsu

lar r

elea

se v

ia

arth

rosc

opy)

.

Com

plic

atio

ns•

Stiff

ness

.•

Loss

of f

unct

ion.

Map

8.2

. Sh

ou

lder

pat

ho

log

y

K30033_C008.indd 226 28/02/17 11:26 am

Ort

hopa

edic

s22

7Fi

gure

8.1

. The

bra

chia

l ple

xus

FIG

URE

8.1

. The

bra

chia

l ple

xus

Dor

sal s

capu

lar

nerv

e:Rh

ombo

id m

ajor

and

min

or,

Leva

tor s

capu

lae

Supr

asca

pula

r ne

rve:

Supr

aspi

natu

s, In

frasp

inat

usLa

tera

l pec

tora

l ner

ve:

Pect

oral

is m

ajor

Low

er s

ubsc

apul

ar n

erve

:Su

bsca

pula

ris, T

eres

maj

or

Upp

er s

ubsc

apul

ar n

erve

:Su

bsca

pula

ris

Long

tho

raci

c ne

rve:

Serr

atus

ant

erio

rTh

orac

odor

sal n

erve

:La

tissi

mus

dor

si

Med

ial p

ecto

ral n

erve

:Pe

ctor

alis

maj

or a

nd m

inor

Axi

llary

ner

ve:

Delto

id, T

eres

min

or

Uln

ar n

erve

:Fl

exo

r ca

rpi u

lnar

isU

lnar

hal

f o

f th

e fl

exo

rd

igit

oru

m p

rofu

nd

us

Med

ian

nerv

e:Fl

exor

s of

the

fore

arm

EXCE

PT fl

exor

car

piul

naris

. The

med

ian

nerv

e in

nerv

ates

th

e LO

AF m

uscl

es:

L –

Late

ral l

umbr

ical

sO

– O

ppon

ens

polli

cis

A –

Abd

ucto

r pol

licis

brev

isF

– Fl

exor

pol

licis

bre

vis

Radi

al n

erve

:Tr

icep

s br

achi

iAn

cone

usEx

tens

or m

uscl

es

Mus

culo

cuta

neou

sne

rve:

Cora

cobr

achi

alis

Bice

ps b

rach

iiBr

achi

alis

C5 C6 C7 C8 T1

K30033_C008.indd 227 28/02/17 11:26 am

Ort

hopa

edic

s22

8 Rheu

mat

oid

arth

riti

s

Wha

t is

rhe

umat

oid

arth

riti

s (R

A)?

This

is a

chr

onic

, aut

oim

mun

e ty

pe II

I hyp

erse

nsiti

vity

reac

tion

that

prin

cipa

lly

affe

cts

the

syno

vium

but

may

als

o af

fect

oth

er o

rgan

s. Jo

int i

nvol

vem

ent i

s ch

arac

teriz

ed b

y sy

mm

etric

al d

efor

mat

ion

with

pai

n th

at is

wor

se in

the

mor

ning

. Thi

s co

nditi

on is

ass

ocia

ted

with

HLA

-DR4

and

HLA

-DR1

.

Caus

eTh

e ex

act c

ause

of R

A is

unk

now

n, b

ut it

is th

ough

t to

invo

lve

a ty

pe II

Ihy

pers

ensi

tivity

reac

tion.

Sign

s an

d sy

mpt

oms

• Ha

nds

– Z

defo

rmity

, bou

tonn

ière

def

orm

ity, s

wan

nec

k de

form

ity, u

lnar

de

viat

ion,

sub

luxa

tion

of th

e fin

gers

, Ray

naud

’s as

soci

atio

n.•

Wris

t – c

arpa

l tun

nel s

yndr

ome.

• Fe

et –

sub

luxa

tion

of th

e to

es, h

amm

er to

e de

form

ity.

• Sk

in –

rheu

mat

oid

nodu

le, v

ascu

litis.

• Ca

rdio

vasc

ular

– a

ther

oscl

eros

is is

incr

ease

d in

RA.

• Re

spira

tory

– p

ulm

onar

y fib

rosi

s.•

Bone

s –

oste

opor

osis.

• Pa

in a

nd s

tiffn

ess.

Inve

stig

atio

ns•

Bloo

ds:

80%

test

pos

itive

for r

heum

atoi

d fa

ctor

.

ES

R an

d CR

P ra

ised

.

Cy

clic

citr

ullin

ated

pep

tide.

If p

ositi

ve, s

ugge

stiv

e of

ero

sive

dis

ease

.•

Radi

olog

y: ra

diol

ogic

al s

igns

of R

A ar

e vi

sual

ized

on

plai

n fil

m:

Bony

ero

sion

, sub

luxa

tion,

car

pal i

nsta

bilit

y.

In

volv

emen

t of m

etac

arpo

- and

met

atar

soph

alan

geal

join

ts.

Peria

rtic

ular

ost

eopo

rosi

s.

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. E

ncou

rage

exe

rcis

e. R

efer

to p

hysi

othe

rapy

an

d as

sess

act

iviti

es o

f dai

ly li

ving

(ADL

s).

• M

edic

al: g

luco

cort

icoi

ds, d

isea

se m

odify

ing

antir

heum

atic

dru

gs (D

MAR

Ds)

(e

.g. g

old

salts

, met

hotr

exat

e, s

ulph

asal

azin

e). A

ntic

ytok

ine

ther

apie

s m

ay b

e

cons

ider

ed in

pat

ient

s in

tole

rant

to m

etho

trex

ate.

• Su

rger

y: e

xcis

ion

arth

ropl

asty

or r

epla

cem

ent m

ay b

e co

nsid

ered

in

seve

rely

affe

cted

join

ts.

Com

plic

atio

ns•

Carp

al tu

nnel

syn

drom

e.•

Peric

ardi

tis.

• Sj

ögre

n’s

synd

rom

e.•

Cerv

ical

myo

path

y.•

Tend

on ru

ptur

e.

Ost

eoar

thri

tis

Wha

t is

ost

eoar

thri

tis

(OA

)?Th

is is

a d

egen

erat

ive

arth

ritis

affe

ctin

g sy

novi

al jo

ints

and

isch

arac

teriz

ed b

y ca

rtila

ge d

egen

erat

ion,

ass

ocia

ted

resp

onse

of t

hepe

riart

icul

ar ti

ssue

and

pai

n th

at is

typi

cally

wor

se a

t the

end

of t

he d

ay.

Caus

eDa

mag

e to

the

join

ts a

nd g

ener

al w

ear a

nd te

ar o

f the

join

t ove

r tim

e is

thou

ght t

o be

the

prim

ary

caus

e of

OA.

The

re a

re c

erta

in fa

ctor

s th

atin

crea

se th

e ris

k of

OA

such

as:

• In

crea

sed

age.

• O

besi

ty.

• Tr

aum

a to

the

join

t.•

Cond

ition

s su

ch a

s ha

emoc

hrom

atos

is a

nd E

hler

s–Da

nlos

syn

drom

e.

Sign

s an

d sy

mpt

oms

• Pa

in a

nd s

tiffn

ess.

• Sw

ellin

g ar

ound

join

t inv

olve

d.•

Crep

itus.

• He

berd

en’s

node

s (d

ista

l int

erph

alan

geal

join

ts).

• Bo

ucha

rd’s

node

s (p

roxi

mal

inte

rpha

lang

eal j

oint

s).

Inve

stig

atio

ns•

Bloo

ds: u

sual

ly n

ot d

iagn

ostic

but

may

be

rele

vant

whe

n O

A is

rela

ted

to

ano

ther

con

ditio

n su

ch a

s ha

emoc

hrom

atos

is.•

Radi

olog

y: ra

diol

ogic

al s

igns

(LO

SS):

L

– Lo

ss o

f joi

nt s

pace

O

– O

steo

phyt

es

S –

Subc

hond

ral c

ysts

S

– Sc

lero

sis

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. E

ncou

rage

exe

rcis

e an

d w

eigh

t los

s.•

Med

ical

: ana

lges

ia (e

.g. p

arac

etam

ol o

r NSA

IDs)

. Gel

s su

ch a

s

caps

aici

n m

ay b

e us

eful

. Ste

roid

inje

ctio

ns.

• Su

rgic

al: a

rthr

opla

sty.

Com

plic

atio

ns•

Incr

ease

d ris

k of

gou

t.•

Chon

droc

alci

nosi

s.

MAP

8.3

. Art

hrit

is

Map

8.3

. A

rth

riti

s

K30033_C008.indd 228 28/02/17 11:26 am

Ort

hopa

edic

s22

9Rheu

mat

oid

arth

riti

s

Wha

t is

rhe

umat

oid

arth

riti

s (R

A)?

This

is a

chr

onic

, aut

oim

mun

e ty

pe II

I hyp

erse

nsiti

vity

reac

tion

that

prin

cipa

lly

affe

cts

the

syno

vium

but

may

als

o af

fect

oth

er o

rgan

s. Jo

int i

nvol

vem

ent i

s ch

arac

teriz

ed b

y sy

mm

etric

al d

efor

mat

ion

with

pai

n th

at is

wor

se in

the

mor

ning

. Thi

s co

nditi

on is

ass

ocia

ted

with

HLA

-DR4

and

HLA

-DR1

.

Caus

eTh

e ex

act c

ause

of R

A is

unk

now

n, b

ut it

is th

ough

t to

invo

lve

a ty

pe II

Ihy

pers

ensi

tivity

reac

tion.

Sign

s an

d sy

mpt

oms

• Ha

nds

– Z

defo

rmity

, bou

tonn

ière

def

orm

ity, s

wan

nec

k de

form

ity, u

lnar

de

viat

ion,

sub

luxa

tion

of th

e fin

gers

, Ray

naud

’s as

soci

atio

n.•

Wris

t – c

arpa

l tun

nel s

yndr

ome.

• Fe

et –

sub

luxa

tion

of th

e to

es, h

amm

er to

e de

form

ity.

• Sk

in –

rheu

mat

oid

nodu

le, v

ascu

litis.

• Ca

rdio

vasc

ular

– a

ther

oscl

eros

is is

incr

ease

d in

RA.

• Re

spira

tory

– p

ulm

onar

y fib

rosi

s.•

Bone

s –

oste

opor

osis.

• Pa

in a

nd s

tiffn

ess.

Inve

stig

atio

ns•

Bloo

ds:

80%

test

pos

itive

for r

heum

atoi

d fa

ctor

.

ES

R an

d CR

P ra

ised

.

Cy

clic

citr

ullin

ated

pep

tide.

If p

ositi

ve, s

ugge

stiv

e of

ero

sive

dis

ease

.•

Radi

olog

y: ra

diol

ogic

al s

igns

of R

A ar

e vi

sual

ized

on

plai

n fil

m:

Bony

ero

sion

, sub

luxa

tion,

car

pal i

nsta

bilit

y.

In

volv

emen

t of m

etac

arpo

- and

met

atar

soph

alan

geal

join

ts.

Peria

rtic

ular

ost

eopo

rosi

s.

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. E

ncou

rage

exe

rcis

e. R

efer

to p

hysi

othe

rapy

an

d as

sess

act

iviti

es o

f dai

ly li

ving

(ADL

s).

• M

edic

al: g

luco

cort

icoi

ds, d

isea

se m

odify

ing

antir

heum

atic

dru

gs (D

MAR

Ds)

(e

.g. g

old

salts

, met

hotr

exat

e, s

ulph

asal

azin

e). A

ntic

ytok

ine

ther

apie

s m

ay b

e

cons

ider

ed in

pat

ient

s in

tole

rant

to m

etho

trex

ate.

• Su

rger

y: e

xcis

ion

arth

ropl

asty

or r

epla

cem

ent m

ay b

e co

nsid

ered

in

seve

rely

affe

cted

join

ts.

Com

plic

atio

ns•

Carp

al tu

nnel

syn

drom

e.•

Peric

ardi

tis.

• Sj

ögre

n’s

synd

rom

e.•

Cerv

ical

myo

path

y.•

Tend

on ru

ptur

e.

Ost

eoar

thri

tis

Wha

t is

ost

eoar

thri

tis

(OA

)?Th

is is

a d

egen

erat

ive

arth

ritis

affe

ctin

g sy

novi

al jo

ints

and

isch

arac

teriz

ed b

y ca

rtila

ge d

egen

erat

ion,

ass

ocia

ted

resp

onse

of t

hepe

riart

icul

ar ti

ssue

and

pai

n th

at is

typi

cally

wor

se a

t the

end

of t

he d

ay.

Caus

eDa

mag

e to

the

join

ts a

nd g

ener

al w

ear a

nd te

ar o

f the

join

t ove

r tim

e is

thou

ght t

o be

the

prim

ary

caus

e of

OA.

The

re a

re c

erta

in fa

ctor

s th

atin

crea

se th

e ris

k of

OA

such

as:

• In

crea

sed

age.

• O

besi

ty.

• Tr

aum

a to

the

join

t.•

Cond

ition

s su

ch a

s ha

emoc

hrom

atos

is a

nd E

hler

s–Da

nlos

syn

drom

e.

Sign

s an

d sy

mpt

oms

• Pa

in a

nd s

tiffn

ess.

• Sw

ellin

g ar

ound

join

t inv

olve

d.•

Crep

itus.

• He

berd

en’s

node

s (d

ista

l int

erph

alan

geal

join

ts).

• Bo

ucha

rd’s

node

s (p

roxi

mal

inte

rpha

lang

eal j

oint

s).

Inve

stig

atio

ns•

Bloo

ds: u

sual

ly n

ot d

iagn

ostic

but

may

be

rele

vant

whe

n O

A is

rela

ted

to

ano

ther

con

ditio

n su

ch a

s ha

emoc

hrom

atos

is.•

Radi

olog

y: ra

diol

ogic

al s

igns

(LO

SS):

L

– Lo

ss o

f joi

nt s

pace

O

– O

steo

phyt

es

S –

Subc

hond

ral c

ysts

S

– Sc

lero

sis

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. E

ncou

rage

exe

rcis

e an

d w

eigh

t los

s.•

Med

ical

: ana

lges

ia (e

.g. p

arac

etam

ol o

r NSA

IDs)

. Gel

s su

ch a

s

caps

aici

n m

ay b

e us

eful

. Ste

roid

inje

ctio

ns.

• Su

rgic

al: a

rthr

opla

sty.

Com

plic

atio

ns•

Incr

ease

d ris

k of

gou

t.•

Chon

droc

alci

nosi

s.

MAP

8.3

. Art

hrit

is

Map

8.3

. A

rth

riti

s

K30033_C008.indd 229 28/02/17 11:26 am

Ort

hopa

edic

s23

0 Tenn

is e

lbow

Wha

t is

ten

nis

elbo

w?

Tenn

is e

lbow

is a

lso

know

n as

late

ral e

pico

ndyl

itis

and

is th

em

ost c

omm

on e

lbow

ove

ruse

inju

ry. T

he la

tera

l epi

cond

yle

isth

e or

igin

of t

he c

omm

on e

xten

sor t

endo

n an

d in

tenn

is e

lbow

it be

com

es in

flam

ed a

nd c

ause

s el

bow

pai

n.

Caus

esTe

nnis

elb

ow is

a fo

rm o

f rep

etiti

ve s

trai

n in

jury

(e.g

. pla

ying

spor

ts s

uch

as te

nnis,

squ

ash)

or u

nder

taki

ng o

ther

act

iviti

essu

ch a

s ga

rden

ing

and

pain

ting.

Thi

s re

sults

inm

icro

rupt

ure/

mic

rote

ars

and

dege

nera

tive

chan

ges

in th

ete

ndon

as

wel

l as

infla

mm

atio

n, p

artic

ular

ly a

t the

mus

cula

ror

igin

of e

xten

sor c

arpi

radi

alis

bre

vis.

Sym

ptom

s•

Achi

ng e

lbow

pai

n, ty

pica

lly o

ver t

he la

tera

l epi

cond

yle,

w

hich

wor

sens

with

act

ivity

.•

Typi

cally

affe

cts

the

dom

inan

t arm

.•

Wor

se d

urin

g si

mpl

e da

ily ta

sks

utili

zing

ext

enso

rs, s

uch

as

liftin

g a

cup

of c

offe

e.•

Decr

ease

d po

wer

grip

in a

ffect

ed a

rm.

Inve

stig

atio

ns•

No

spec

ific

test

s or

imag

ing

requ

ired.

• Cl

inic

al d

iagn

osis.

• M

ill's

test

and

Coz

en’s

test

.

Trea

tmen

t•

Cons

erva

tive:

usu

ally

a s

elf-l

imiti

ng c

ondi

tion,

sto

p/de

crea

se

activ

ity th

at tr

igge

red

tenn

is e

lbow

, ice

elb

ow, u

tiliz

e an

elb

ow

stra

p, p

hysi

othe

rapy

may

be

requ

ired.

• M

edic

al: p

aink

iller

s (e

.g. p

arac

etam

ol a

nd N

SAID

s), l

ocal

st

eroi

d in

ject

ions

if s

ever

e an

d ot

her m

etho

ds h

ave

faile

d.•

Surg

ery:

onl

y co

nsid

ered

if a

bove

met

hods

hav

e fa

iled

and

if

pain

last

s fo

r up

to 4

mon

ths.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Ch

roni

c pa

in.

Gol

fer’s

elb

ow

Wha

t is

gol

fer’s

elb

ow?

Gol

fer’s

elb

ow is

als

o kn

own

as m

edia

l epi

cond

yliti

s an

d is

a ty

pe o

f el

bow

ove

ruse

inju

ry. T

he m

edia

l epi

cond

yle

is th

e or

igin

of t

he c

omm

on

flexo

r ten

don

and

in g

olfe

r’s e

lbow

it b

ecom

es in

flam

ed a

nd c

ause

s el

bow

pai

n.

Caus

esG

olfe

r’s e

lbow

is a

form

of r

epet

itive

str

ain

inju

ry (e

.g. p

layi

ng s

port

s su

ch

as g

olf,

bow

ling,

bas

ebal

l, ro

ck c

limbi

ng) o

r und

erta

king

oth

er a

ctiv

ities

su

ch a

s ga

rden

ing,

pai

ntin

g an

d us

ing

tool

s lik

e sc

rew

driv

ers.

This

resu

lts

in m

icro

rupt

ure/

mic

rote

ars

and

dege

nera

tive

chan

ges

in th

e te

ndon

as

wel

l as

infla

mm

atio

n.

Sym

ptom

s•

Achi

ng e

lbow

pai

n, ty

pica

lly o

ver t

he m

edia

l epi

cond

yle,

whi

ch

wor

sens

with

act

ivity

.•

Typi

cally

affe

cts

the

dom

inan

t arm

.•

Wor

se d

urin

g si

mpl

e da

ily ta

sks

utili

zing

flex

ors.

• De

crea

sed

pow

er g

rip in

affe

cted

arm

.

Inve

stig

atio

ns•

No

spec

ific

test

s or

imag

ing

requ

ired.

• Cl

inic

al d

iagn

osis.

• G

olfe

r’s e

lbow

test

.

Trea

tmen

t•

Cons

erva

tive:

usu

ally

a s

elf-l

imiti

ng c

ondi

tion,

sto

p/de

crea

se

activ

ity th

at tr

igge

red

golfe

r’s e

lbow

, ice

elb

ow, u

tiliz

e an

elb

ow

stra

p, p

hysi

othe

rapy

may

be

requ

ired.

• M

edic

al: p

aink

iller

s (e

.g. p

arac

etam

ol a

nd N

SAID

s), l

ocal

ste

roid

in

ject

ions

if s

ever

e an

d ot

her m

etho

ds h

ave

faile

d.•

Surg

ery:

onl

y co

nsid

ered

if a

bove

met

hods

hav

e fa

iled

and

if

pain

last

s fo

r up

to 4

mon

ths.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Ch

roni

c pa

in.

• As

soci

ated

uln

ar n

euro

path

y.

Rem

embe

r th

e di

ffer

ence

bet

wee

n te

nnis

elbo

w a

nd g

olfe

r’s e

lbow

as:

Tenn

is is

pla

yed

on th

e La

wn

(i.e.

Ten

nis

elbo

w is

Lat

eral

epi

cond

yliti

s)

Gol

f is

play

ed o

n th

e M

eado

w (i

.e. G

olfe

r’sel

bow

is M

edia

l epi

cond

yliti

s)

MAP

8.4

. Elb

ow p

atho

logy

Map

8.4

. El

bo

w p

ath

olo

gy

K30033_C008.indd 230 28/02/17 11:26 am

Ort

hopa

edic

s23

1Tenn

is e

lbow

Wha

t is

ten

nis

elbo

w?

Tenn

is e

lbow

is a

lso

know

n as

late

ral e

pico

ndyl

itis

and

is th

em

ost c

omm

on e

lbow

ove

ruse

inju

ry. T

he la

tera

l epi

cond

yle

isth

e or

igin

of t

he c

omm

on e

xten

sor t

endo

n an

d in

tenn

is e

lbow

it be

com

es in

flam

ed a

nd c

ause

s el

bow

pai

n.

Caus

esTe

nnis

elb

ow is

a fo

rm o

f rep

etiti

ve s

trai

n in

jury

(e.g

. pla

ying

spor

ts s

uch

as te

nnis,

squ

ash)

or u

nder

taki

ng o

ther

act

iviti

essu

ch a

s ga

rden

ing

and

pain

ting.

Thi

s re

sults

inm

icro

rupt

ure/

mic

rote

ars

and

dege

nera

tive

chan

ges

in th

ete

ndon

as

wel

l as

infla

mm

atio

n, p

artic

ular

ly a

t the

mus

cula

ror

igin

of e

xten

sor c

arpi

radi

alis

bre

vis.

Sym

ptom

s•

Achi

ng e

lbow

pai

n, ty

pica

lly o

ver t

he la

tera

l epi

cond

yle,

w

hich

wor

sens

with

act

ivity

.•

Typi

cally

affe

cts

the

dom

inan

t arm

.•

Wor

se d

urin

g si

mpl

e da

ily ta

sks

utili

zing

ext

enso

rs, s

uch

as

liftin

g a

cup

of c

offe

e.•

Decr

ease

d po

wer

grip

in a

ffect

ed a

rm.

Inve

stig

atio

ns•

No

spec

ific

test

s or

imag

ing

requ

ired.

• Cl

inic

al d

iagn

osis.

• M

ill's

test

and

Coz

en’s

test

.

Trea

tmen

t•

Cons

erva

tive:

usu

ally

a s

elf-l

imiti

ng c

ondi

tion,

sto

p/de

crea

se

activ

ity th

at tr

igge

red

tenn

is e

lbow

, ice

elb

ow, u

tiliz

e an

elb

ow

stra

p, p

hysi

othe

rapy

may

be

requ

ired.

• M

edic

al: p

aink

iller

s (e

.g. p

arac

etam

ol a

nd N

SAID

s), l

ocal

st

eroi

d in

ject

ions

if s

ever

e an

d ot

her m

etho

ds h

ave

faile

d.•

Surg

ery:

onl

y co

nsid

ered

if a

bove

met

hods

hav

e fa

iled

and

if

pain

last

s fo

r up

to 4

mon

ths.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Ch

roni

c pa

in.

Gol

fer’s

elb

ow

Wha

t is

gol

fer’s

elb

ow?

Gol

fer’s

elb

ow is

als

o kn

own

as m

edia

l epi

cond

yliti

s an

d is

a ty

pe o

f el

bow

ove

ruse

inju

ry. T

he m

edia

l epi

cond

yle

is th

e or

igin

of t

he c

omm

on

flexo

r ten

don

and

in g

olfe

r’s e

lbow

it b

ecom

es in

flam

ed a

nd c

ause

s el

bow

pai

n.

Caus

esG

olfe

r’s e

lbow

is a

form

of r

epet

itive

str

ain

inju

ry (e

.g. p

layi

ng s

port

s su

ch

as g

olf,

bow

ling,

bas

ebal

l, ro

ck c

limbi

ng) o

r und

erta

king

oth

er a

ctiv

ities

su

ch a

s ga

rden

ing,

pai

ntin

g an

d us

ing

tool

s lik

e sc

rew

driv

ers.

This

resu

lts

in m

icro

rupt

ure/

mic

rote

ars

and

dege

nera

tive

chan

ges

in th

e te

ndon

as

wel

l as

infla

mm

atio

n.

Sym

ptom

s•

Achi

ng e

lbow

pai

n, ty

pica

lly o

ver t

he m

edia

l epi

cond

yle,

whi

ch

wor

sens

with

act

ivity

.•

Typi

cally

affe

cts

the

dom

inan

t arm

.•

Wor

se d

urin

g si

mpl

e da

ily ta

sks

utili

zing

flex

ors.

• De

crea

sed

pow

er g

rip in

affe

cted

arm

.

Inve

stig

atio

ns•

No

spec

ific

test

s or

imag

ing

requ

ired.

• Cl

inic

al d

iagn

osis.

• G

olfe

r’s e

lbow

test

.

Trea

tmen

t•

Cons

erva

tive:

usu

ally

a s

elf-l

imiti

ng c

ondi

tion,

sto

p/de

crea

se

activ

ity th

at tr

igge

red

golfe

r’s e

lbow

, ice

elb

ow, u

tiliz

e an

elb

ow

stra

p, p

hysi

othe

rapy

may

be

requ

ired.

• M

edic

al: p

aink

iller

s (e

.g. p

arac

etam

ol a

nd N

SAID

s), l

ocal

ste

roid

in

ject

ions

if s

ever

e an

d ot

her m

etho

ds h

ave

faile

d.•

Surg

ery:

onl

y co

nsid

ered

if a

bove

met

hods

hav

e fa

iled

and

if

pain

last

s fo

r up

to 4

mon

ths.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Ch

roni

c pa

in.

• As

soci

ated

uln

ar n

euro

path

y.

Rem

embe

r th

e di

ffer

ence

bet

wee

n te

nnis

elbo

w a

nd g

olfe

r’s e

lbow

as:

Tenn

is is

pla

yed

on th

e La

wn

(i.e.

Ten

nis

elbo

w is

Lat

eral

epi

cond

yliti

s)

Gol

f is

play

ed o

n th

e M

eado

w (i

.e. G

olfe

r’sel

bow

is M

edia

l epi

cond

yliti

s)

MAP

8.4

. Elb

ow p

atho

logy

Map

8.4

. Elb

ow p

atho

logy

K30033_C008.indd 231 28/02/17 11:26 am

Ort

hopa

edic

s23

2M

AP 8

.5. H

and

pat

ho

log

y

Dup

uytr

en’s

con

trac

ture

Wha

t is

Dup

uytr

en’s

con

trac

ture

?Du

puyt

ren’

s co

ntra

ctur

e is

a p

rolif

erat

ive

fibro

plas

ia o

f the

pal

mar

an

d di

gita

l fas

cia.

Ove

r tim

e th

is le

ads

to th

e fo

rmat

ion

of

nodu

les

and

cord

s, w

hich

in tu

rn re

sult

in fi

nger

flex

ion.

The

ring

fin

ger i

s m

ost c

omm

only

affe

cted

.

Caus

esTh

e ex

act c

ause

of t

his

path

olog

y is

unk

now

n. It

is k

now

n th

at it

is

mor

e co

mm

on in

mal

es th

an fe

mal

es a

s w

ell a

s in

thos

e w

ith a

po

sitiv

e fa

mily

his

tory

. It i

s as

soci

ated

with

the

follo

win

g:•

Diab

etes

mel

litus

.•

Hepa

tic c

irrho

sis.

• Ce

rtai

n dr

ugs

(e.g

. phe

nyto

in)

• Tr

aum

a.

The

aggr

essi

ve fo

rm o

f the

dis

ease

is c

alle

d Du

puyt

ren’

s di

athe

sis

and

is a

ssoc

iate

d w

ith P

eyro

nie’

s di

seas

e (p

enile

fibr

omat

osis

) an

d Le

dder

hose

’s di

seas

e (p

lant

ar fa

scia

fibr

omat

osis

).

Sym

ptom

s•

Flex

ion

cont

ract

ure

of th

e fin

gers

.•

Nod

ular

thic

keni

ng o

f pal

mar

fasc

ia a

nd c

ord

deve

lopm

ent.

Inve

stig

atio

ns•

No

spec

ific

test

but

can

test

for u

nder

lyin

g as

soci

atio

ns.

• Pe

rform

Hue

ston

’s ta

blet

op te

st.

Trea

tmen

t•

Surg

ical

– o

nly

perfo

rm fa

scio

tom

y, fa

scie

ctom

y or

de

rmof

asci

ecto

my

if co

ntra

ctur

e is

caus

ing

func

tiona

l pro

blem

s.

Phys

ioth

erap

y an

d sp

lintin

g re

quire

d af

ter t

reat

men

t.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Co

mpl

icat

ions

ass

ocia

ted

with

sur

gery

(e.g

. hae

mat

oma

fo

rmat

ion,

infe

ctio

n, n

erve

inju

ry a

nd re

curr

ence

).

de Q

uerv

ain’

s sy

ndro

me

Wha

t is

de

Que

rvai

n’s

synd

rom

e?de

Que

rvai

n’s

synd

rom

e, a

lso

know

n as

was

herw

oman

’s sp

rain

, is

a st

enos

ing

teno

syno

vitis

of t

he e

xten

sor p

ollic

is b

revi

s an

d th

e ab

duct

or p

ollic

is te

ndon

s.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn

but i

t is

asso

ciat

ed w

ithov

erus

e/re

petit

ive

task

s.

Sym

ptom

s•

Wris

t pai

n (ra

dial

sid

e), w

hich

is w

orse

on

mov

emen

t.

Inve

stig

atio

ns•

Fink

elst

ein’

s te

st –

pai

n on

pas

sive

uln

ar d

evia

tion

(fist

form

ed o

ver t

hum

b).

• Ra

diol

ogy

– x-

ray

to ru

le o

ut o

ther

con

ditio

ns s

uch

as o

steo

arth

ritis.

Trea

tmen

t•

Cons

erva

tive:

rest

and

avo

idan

ce o

f pre

cipi

tatin

g fa

ctor

s.•

Med

ical

: ana

lges

ia, s

tero

id in

ject

ions

.•

Surg

ical

: las

t res

ort f

or s

ever

e ca

ses

– re

leas

e of

firs

t ext

enso

r com

part

men

t.

Com

plic

atio

ns•

Decr

ease

d ra

nge

of m

ovem

ent o

f the

wris

t.

Sten

osin

g te

nosy

novi

tis

Wha

t is

ste

nosi

ng t

enos

ynov

itis

?Th

is is

als

o kn

own

as tr

igge

r fin

ger.

The

flexo

r ten

don

shea

th n

arro

ws

due

toth

icke

ning

of t

he te

ndon

she

ath,

usu

ally

due

to tr

aum

a. T

he ri

ng a

nd m

iddl

e fin

ger a

re m

ost c

omm

only

affe

cted

.

Caus

es•

Typi

cally

trau

ma.

• As

soci

ated

with

dia

bete

s m

ellit

us, r

heum

atoi

d ar

thrit

is a

nd g

out.

Sym

ptom

s•

Trap

ped

flexo

r ten

don,

usu

ally

rela

ted

to th

e A1

pul

ley.

• Di

git l

ocke

d in

flex

ion

and

mus

t be

pass

ivel

y re

leas

ed.

Inve

stig

atio

ns: c

linic

al d

iagn

osis.

Trea

tmen

t•

Cons

erva

tive:

imm

obili

zatio

n.•

Med

ical

: ana

lges

ia, s

tero

id in

ject

ions

.•

Surg

ery:

intr

acta

ble

case

s m

ay re

quire

sur

gica

l rel

ease

.

Com

plic

atio

ns•

Rela

ted

to s

urge

ry (e

.g. i

nfec

tion,

ner

ve in

jury

, ten

don

bow

strin

ging

).

MAP

8.5

. Han

d pa

thol

ogy

StStiii

ttiii

ititi

K30033_C008.indd 232 28/02/17 11:26 am

Ort

hopa

edic

s23

3M

AP 8

.5. H

and

pat

ho

log

y

Dup

uytr

en’s

con

trac

ture

Wha

t is

Dup

uytr

en’s

con

trac

ture

?Du

puyt

ren’

s co

ntra

ctur

e is

a p

rolif

erat

ive

fibro

plas

ia o

f the

pal

mar

an

d di

gita

l fas

cia.

Ove

r tim

e th

is le

ads

to th

e fo

rmat

ion

of

nodu

les

and

cord

s, w

hich

in tu

rn re

sult

in fi

nger

flex

ion.

The

ring

fin

ger i

s m

ost c

omm

only

affe

cted

.

Caus

esTh

e ex

act c

ause

of t

his

path

olog

y is

unk

now

n. It

is k

now

n th

at it

is

mor

e co

mm

on in

mal

es th

an fe

mal

es a

s w

ell a

s in

thos

e w

ith a

po

sitiv

e fa

mily

his

tory

. It i

s as

soci

ated

with

the

follo

win

g:•

Diab

etes

mel

litus

.•

Hepa

tic c

irrho

sis.

• Ce

rtai

n dr

ugs

(e.g

. phe

nyto

in)

• Tr

aum

a.

The

aggr

essi

ve fo

rm o

f the

dis

ease

is c

alle

d Du

puyt

ren’

s di

athe

sis

and

is a

ssoc

iate

d w

ith P

eyro

nie’

s di

seas

e (p

enile

fibr

omat

osis

) an

d Le

dder

hose

’s di

seas

e (p

lant

ar fa

scia

fibr

omat

osis

).

Sym

ptom

s•

Flex

ion

cont

ract

ure

of th

e fin

gers

.•

Nod

ular

thic

keni

ng o

f pal

mar

fasc

ia a

nd c

ord

deve

lopm

ent.

Inve

stig

atio

ns•

No

spec

ific

test

but

can

test

for u

nder

lyin

g as

soci

atio

ns.

• Pe

rform

Hue

ston

’s ta

blet

op te

st.

Trea

tmen

t•

Surg

ical

– o

nly

perfo

rm fa

scio

tom

y, fa

scie

ctom

y or

de

rmof

asci

ecto

my

if co

ntra

ctur

e is

caus

ing

func

tiona

l pro

blem

s.

Phys

ioth

erap

y an

d sp

lintin

g re

quire

d af

ter t

reat

men

t.

Com

plic

atio

ns•

Loss

of f

unct

ion.

• Co

mpl

icat

ions

ass

ocia

ted

with

sur

gery

(e.g

. hae

mat

oma

fo

rmat

ion,

infe

ctio

n, n

erve

inju

ry a

nd re

curr

ence

).

de Q

uerv

ain’

s sy

ndro

me

Wha

t is

de

Que

rvai

n’s

synd

rom

e?de

Que

rvai

n’s

synd

rom

e, a

lso

know

n as

was

herw

oman

’s sp

rain

, is

a st

enos

ing

teno

syno

vitis

of t

he e

xten

sor p

ollic

is b

revi

s an

d th

e ab

duct

or p

ollic

is te

ndon

s.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn

but i

t is

asso

ciat

ed w

ithov

erus

e/re

petit

ive

task

s.

Sym

ptom

s•

Wris

t pai

n (ra

dial

sid

e), w

hich

is w

orse

on

mov

emen

t.

Inve

stig

atio

ns•

Fink

elst

ein’

s te

st –

pai

n on

pas

sive

uln

ar d

evia

tion

(fist

form

ed o

ver t

hum

b).

• Ra

diol

ogy

– x-

ray

to ru

le o

ut o

ther

con

ditio

ns s

uch

as o

steo

arth

ritis.

Trea

tmen

t•

Cons

erva

tive:

rest

and

avo

idan

ce o

f pre

cipi

tatin

g fa

ctor

s.•

Med

ical

: ana

lges

ia, s

tero

id in

ject

ions

.•

Surg

ical

: las

t res

ort f

or s

ever

e ca

ses

– re

leas

e of

firs

t ext

enso

r com

part

men

t.

Com

plic

atio

ns•

Decr

ease

d ra

nge

of m

ovem

ent o

f the

wris

t.

Sten

osin

g te

nosy

novi

tis

Wha

t is

ste

nosi

ng t

enos

ynov

itis

?Th

is is

als

o kn

own

as tr

igge

r fin

ger.

The

flexo

r ten

don

shea

th n

arro

ws

due

toth

icke

ning

of t

he te

ndon

she

ath,

usu

ally

due

to tr

aum

a. T

he ri

ng a

nd m

iddl

e fin

ger a

re m

ost c

omm

only

affe

cted

.

Caus

es•

Typi

cally

trau

ma.

• As

soci

ated

with

dia

bete

s m

ellit

us, r

heum

atoi

d ar

thrit

is a

nd g

out.

Sym

ptom

s•

Trap

ped

flexo

r ten

don,

usu

ally

rela

ted

to th

e A1

pul

ley.

• Di

git l

ocke

d in

flex

ion

and

mus

t be

pass

ivel

y re

leas

ed.

Inve

stig

atio

ns: c

linic

al d

iagn

osis.

Trea

tmen

t•

Cons

erva

tive:

imm

obili

zatio

n.•

Med

ical

: ana

lges

ia, s

tero

id in

ject

ions

.•

Surg

ery:

intr

acta

ble

case

s m

ay re

quire

sur

gica

l rel

ease

.

Com

plic

atio

ns•

Rela

ted

to s

urge

ry (e

.g. i

nfec

tion,

ner

ve in

jury

, ten

don

bow

strin

ging

).

MAP

8.5

. Han

d pa

thol

ogy

StStiii

ttiii

ititi

Cont

inue

d ov

erle

af

K30033_C008.indd 233 28/02/17 11:26 am

Ort

hopa

edic

s23

4 Carp

al t

unne

l syn

drom

e

Wha

t is

car

pal t

unne

l syn

drom

e?Ca

rpal

tunn

el s

yndr

ome

may

be

defin

ed a

s th

e co

mpr

essi

on o

f th

e m

edia

n ne

rve

as it

pas

ses

thro

ugh

the

carp

al tu

nnel

, ben

eath

th

e fle

xor r

etin

acul

um. I

t is

mor

e co

mm

on in

fem

ales

than

mal

es.

Caus

esRe

mem

ber a

s M

EDIA

N T

RAP:

M –

Myx

oede

ma

E –

oEd

ema

D –

Dia

bete

s m

ellit

usI

– Id

iopa

thic

A –

Acr

omeg

aly

N –

Neo

plas

m

T –

Tra

uma

R –

Rhe

umat

oid

arth

ritis

A –

Am

yloi

dosi

sP

– P

regn

ancy

Sym

ptom

sRe

mem

ber a

s 3P

s•

Pain

– in

the

med

ian

nerv

e di

strib

utio

n, w

orse

at n

ight

.

• Pa

raes

thes

ia –

in th

e m

edia

n ne

rve

dist

ribut

ion,

relie

ve b

y

shak

ing

hand

s.•

Patc

h –

on th

enar

em

inen

ce is

pre

serv

ed s

ince

the

supe

rfici

al

bran

ch o

f the

med

ian

nerv

e su

pplie

s th

is a

rea.

The

nar m

uscl

e

may

hav

e w

aste

d in

adv

ance

d di

seas

e.

Inve

stig

atio

ns•

Usu

ally

a c

linic

al d

iagn

osis

cou

pled

with

a th

orou

gh p

hysi

cal

ex

amin

atio

n in

clud

ing

spec

ific T

inel

’s an

d Ph

alen

’s te

sts.

• N

erve

con

duct

ion

stud

ies

– di

ffere

ntia

tes

from

cer

vica

l

spon

dylo

sis

(C6/

7).

Trea

tmen

t•

Cons

erva

tive:

spl

intin

g.•

Med

ical

: ste

roid

inje

ctio

n.•

Surg

ical

: car

pal t

unne

l rel

ease

.

Scap

hoid

frac

ture

Wha

t is

a s

caph

oid

frac

ture

?Th

e sc

apho

id is

the

mos

t com

mon

ly fr

actu

red

wris

t bon

e. T

he re

ason

this

frac

ture

is s

o im

port

ant t

o as

sess

fund

amen

tally

rest

s in

the

bloo

d su

pply

to th

is b

one.

The

blo

od

supp

ly e

nter

s th

e di

stal

par

t of t

he s

caph

oid

bone

and

runs

pro

xim

ally.

Thi

s m

eans

that

th

ere

is a

risk

of p

roxi

mal

ava

scul

ar n

ecro

sis

if fra

ctur

ed.

Caus

es•

Trau

ma

– ty

pica

lly ‘f

all o

n ou

tstr

etch

ed h

and’

(FO

OSH

).

Sym

ptom

s•

Pain

ove

r the

sca

phoi

d bo

ne (i

.e. o

n pa

lpat

ion

of th

e an

atom

ical

snu

ff bo

x).

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. Fr

actu

re m

ay n

ot b

e se

en in

itial

ly. If

not

see

n bu

t it i

s su

spec

ted

cl

inic

ally,

imm

obili

ze in

a s

caph

oid

splin

t and

repe

at th

e x-

ray

in 1

0 da

ys to

2 w

eeks

.

Trea

tmen

t•

Scap

hoid

pla

ster

.

Com

plic

atio

ns•

Avas

cula

r nec

rosi

s (p

roxi

mal

third

).•

Ost

eoar

thrit

is.•

Mal

unio

n.

MAP

8.5

. Han

d pa

thol

ogy

(con

tinue

d )

MAP

8.5

. Han

d p

ath

olo

gy

K30033_C008.indd 234 28/02/17 11:26 am

Ort

hopa

edic

s23

5Carp

al t

unne

l syn

drom

e

Wha

t is

car

pal t

unne

l syn

drom

e?Ca

rpal

tunn

el s

yndr

ome

may

be

defin

ed a

s th

e co

mpr

essi

on o

f th

e m

edia

n ne

rve

as it

pas

ses

thro

ugh

the

carp

al tu

nnel

, ben

eath

th

e fle

xor r

etin

acul

um. I

t is

mor

e co

mm

on in

fem

ales

than

mal

es.

Caus

esRe

mem

ber a

s M

EDIA

N T

RAP:

M –

Myx

oede

ma

E –

oEd

ema

D –

Dia

bete

s m

ellit

usI

– Id

iopa

thic

A –

Acr

omeg

aly

N –

Neo

plas

m

T –

Tra

uma

R –

Rhe

umat

oid

arth

ritis

A –

Am

yloi

dosi

sP

– P

regn

ancy

Sym

ptom

sRe

mem

ber a

s 3P

s•

Pain

– in

the

med

ian

nerv

e di

strib

utio

n, w

orse

at n

ight

.

• Pa

raes

thes

ia –

in th

e m

edia

n ne

rve

dist

ribut

ion,

relie

ve b

y

shak

ing

hand

s.•

Patc

h –

on th

enar

em

inen

ce is

pre

serv

ed s

ince

the

supe

rfici

al

bran

ch o

f the

med

ian

nerv

e su

pplie

s th

is a

rea.

The

nar m

uscl

e

may

hav

e w

aste

d in

adv

ance

d di

seas

e.

Inve

stig

atio

ns•

Usu

ally

a c

linic

al d

iagn

osis

cou

pled

with

a th

orou

gh p

hysi

cal

ex

amin

atio

n in

clud

ing

spec

ific T

inel

’s an

d Ph

alen

’s te

sts.

• N

erve

con

duct

ion

stud

ies

– di

ffere

ntia

tes

from

cer

vica

l

spon

dylo

sis

(C6/

7).

Trea

tmen

t•

Cons

erva

tive:

spl

intin

g.•

Med

ical

: ste

roid

inje

ctio

n.•

Surg

ical

: car

pal t

unne

l rel

ease

.

Scap

hoid

frac

ture

Wha

t is

a s

caph

oid

frac

ture

?Th

e sc

apho

id is

the

mos

t com

mon

ly fr

actu

red

wris

t bon

e. T

he re

ason

this

frac

ture

is s

o im

port

ant t

o as

sess

fund

amen

tally

rest

s in

the

bloo

d su

pply

to th

is b

one.

The

blo

od

supp

ly e

nter

s th

e di

stal

par

t of t

he s

caph

oid

bone

and

runs

pro

xim

ally.

Thi

s m

eans

that

th

ere

is a

risk

of p

roxi

mal

ava

scul

ar n

ecro

sis

if fra

ctur

ed.

Caus

es•

Trau

ma

– ty

pica

lly ‘f

all o

n ou

tstr

etch

ed h

and’

(FO

OSH

).

Sym

ptom

s•

Pain

ove

r the

sca

phoi

d bo

ne (i

.e. o

n pa

lpat

ion

of th

e an

atom

ical

snu

ff bo

x).

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. Fr

actu

re m

ay n

ot b

e se

en in

itial

ly. If

not

see

n bu

t it i

s su

spec

ted

cl

inic

ally,

imm

obili

ze in

a s

caph

oid

splin

t and

repe

at th

e x-

ray

in 1

0 da

ys to

2 w

eeks

.

Trea

tmen

t•

Scap

hoid

pla

ster

.

Com

plic

atio

ns•

Avas

cula

r nec

rosi

s (p

roxi

mal

third

).•

Ost

eoar

thrit

is.•

Mal

unio

n.

MAP

8.5

. Han

d pa

thol

ogy

(con

tinue

d )

MAP

8.5

. Han

d p

ath

olo

gy

K30033_C008.indd 235 28/02/17 11:26 am

Ort

hopa

edic

s23

6

Kyph

osis

Wha

t is

kyp

hosi

s?Th

is is

an

exag

gera

ted

ante

rior c

urva

ture

of t

he th

orac

ic s

pine

. Kyp

hosi

s m

ay b

e cl

assi

fied

as fi

xed,

as

in a

nkyl

osin

g sp

ondy

litis,

or m

obile

as

in p

ostu

ral k

ypho

sis.

It m

ay a

lso

be d

efin

ed re

late

d to

sha

pe (i

.e. r

egul

ar o

r ang

ular

[gib

bus]

).

Ther

e ar

e m

any

diffe

rent

type

s of

kyp

hosi

s. Re

mem

ber a

s PO

ND

S:P

– Po

stur

al –

mor

e co

mm

on in

ado

lesc

ent g

irls

O –

Ost

eopo

rotic

N –

Neu

rom

uscu

lar

D –

Deg

ener

ativ

eS

– Sc

heue

rman

n’s

dise

ase

– al

so k

now

n as

spi

nal o

steo

chon

dros

is. D

efin

edas

kyp

hosi

s >

40°

and

wed

ging

of i

ndiv

idua

l ver

tebr

a of

5°

(sin

ce th

eve

rteb

ra g

row

s m

ore

thic

kly

post

erio

rly th

an a

nter

iorly

)

Caus

esCa

uses

incl

ude:

• In

fect

ion

– TB

, pol

io.

• M

alig

nanc

y.•

Bone

dis

ease

– o

steo

poro

sis,

Page

t’s d

isea

se.

• An

kylo

sing

spo

ndyl

itis.

• Ca

lvé’

s di

seas

e.

Sym

ptom

s•

Cosm

etic

def

orm

ity.

• Ac

hing

, but

not

sev

ere,

pai

n. If

pai

n is

ver

y se

vere

, the

n m

ust e

xclu

de s

pina

l

tum

ours

/ost

eoid

ost

eom

as.

• Sy

mpt

oms

of u

nder

lyin

g co

nditi

on.

Inve

stig

atio

ns•

Thor

ough

spi

nal e

xam

inat

ion.

• Ra

diol

ogy

– x-

ray

(AP

and

late

ral v

iew

s) a

nd C

obb

angl

e m

easu

rem

ent.

• In

vest

igat

ions

con

cern

ing

an u

nder

lyin

g ca

use

if su

spec

ted.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, e

xerc

ise,

par

ticul

arly

sw

imm

ing.

• M

edic

al: a

dequ

ate

anal

gesi

a.•

Surg

ery:

onl

y in

sev

ere

case

s.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns (e

.g. d

epre

ssio

n)•

Rest

rictiv

e lu

ng d

isea

se.

• Ca

rdia

c co

mpl

icat

ions

.•

Cord

com

pres

sion

.•

Para

pleg

ia.

Scol

iosi

s

Wha

t is

sco

liosi

s?Th

is is

a la

tera

l cur

vatu

re o

f the

spi

ne th

at is

>10

° (C

obb

angl

e). I

t may

be

stru

ctur

al o

r non

-str

uctu

ral a

nd b

road

ly s

peak

ing

ther

e ar

e fiv

e di

ffere

ntty

pes.

Rem

embe

r as

PON

DS:

P –

Post

ural

: non

-str

uctu

ral c

ompe

nsat

ory

scol

iosi

sO

– O

steo

path

ic: s

truc

tura

l abn

orm

ality

. Mos

tly c

onge

nita

l but

som

e ca

ses

m

ay b

e as

soci

ated

with

bon

e di

seas

eN

– N

euro

mus

cula

r: as

soci

ated

with

cer

ebra

l pal

sy, F

riedr

eich

’s at

axia

etc

.D

– D

egen

erat

ive:

ass

ocia

ted

with

face

t joi

nt fa

ilure

S –

Stru

ctur

al id

iopa

thic

: may

be

subd

ivid

ed in

to fi

ve ty

pes:

1

. Tho

raco

lum

bar –

usu

ally

cur

ves

to th

e rig

ht

2. L

umba

r – u

sual

ly c

urve

s to

the

left

3

. Inf

antil

e th

orac

ic –

usu

ally

cur

ves

to th

e le

ft

4. A

dole

scen

t tho

raci

c –

usua

lly c

urve

s to

the

right

5

. Dou

ble

maj

or –

two

curv

es in

eac

h di

rect

ion

Caus

esSe

e ab

ove.

Rem

embe

r to

ask

abou

t fam

ily h

isto

ry a

nd p

regn

ancy

.

Sym

ptom

s•

Cosm

etic

def

orm

ity.

• Ac

hing

, but

not

sev

ere,

pai

n. If

pai

n is

ver

y se

vere

, the

n m

ust e

xclu

de

spin

al tu

mou

rs/o

steo

id o

steo

mas

.

Inve

stig

atio

ns•

Thor

ough

spi

nal e

xam

inat

ion.

• Ra

diol

ogy

– x-

ray

(AP

and

late

ral v

iew

s) a

nd C

obb

angl

e m

easu

rem

ent.

• In

vest

igat

ions

con

cern

ing

an u

nder

lyin

g ca

use

if su

spec

ted.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, e

xerc

ise

(par

ticul

arly

sw

imm

ing)

, bra

ce –

Bo

ston

or M

ilwau

kee.

• M

edic

al: a

dequ

ate

anal

gesi

a.•

Surg

ical

: onl

y in

sev

ere

case

s.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns (e

.g. d

epre

ssio

n).

• Re

stric

tive

lung

dis

ease

.•

Card

iac

com

plic

atio

ns.

• N

erve

com

pres

sion

.

MAP

8.6

. Spi

nal p

atho

logy

MAP

8.6

. Sp

inal

pat

ho

log

y

K30033_C008.indd 236 28/02/17 11:26 am

Ort

hopa

edic

s23

7

Kyph

osis

Wha

t is

kyp

hosi

s?Th

is is

an

exag

gera

ted

ante

rior c

urva

ture

of t

he th

orac

ic s

pine

. Kyp

hosi

s m

ay b

e cl

assi

fied

as fi

xed,

as

in a

nkyl

osin

g sp

ondy

litis,

or m

obile

as

in p

ostu

ral k

ypho

sis.

It m

ay a

lso

be d

efin

ed re

late

d to

sha

pe (i

.e. r

egul

ar o

r ang

ular

[gib

bus]

).

Ther

e ar

e m

any

diffe

rent

type

s of

kyp

hosi

s. Re

mem

ber a

s PO

ND

S:P

– Po

stur

al –

mor

e co

mm

on in

ado

lesc

ent g

irls

O –

Ost

eopo

rotic

N –

Neu

rom

uscu

lar

D –

Deg

ener

ativ

eS

– Sc

heue

rman

n’s

dise

ase

– al

so k

now

n as

spi

nal o

steo

chon

dros

is. D

efin

edas

kyp

hosi

s >

40°

and

wed

ging

of i

ndiv

idua

l ver

tebr

a of

5°

(sin

ce th

eve

rteb

ra g

row

s m

ore

thic

kly

post

erio

rly th

an a

nter

iorly

)

Caus

esCa

uses

incl

ude:

• In

fect

ion

– TB

, pol

io.

• M

alig

nanc

y.•

Bone

dis

ease

– o

steo

poro

sis,

Page

t’s d

isea

se.

• An

kylo

sing

spo

ndyl

itis.

• Ca

lvé’

s di

seas

e.

Sym

ptom

s•

Cosm

etic

def

orm

ity.

• Ac

hing

, but

not

sev

ere,

pai

n. If

pai

n is

ver

y se

vere

, the

n m

ust e

xclu

de s

pina

l

tum

ours

/ost

eoid

ost

eom

as.

• Sy

mpt

oms

of u

nder

lyin

g co

nditi

on.

Inve

stig

atio

ns•

Thor

ough

spi

nal e

xam

inat

ion.

• Ra

diol

ogy

– x-

ray

(AP

and

late

ral v

iew

s) a

nd C

obb

angl

e m

easu

rem

ent.

• In

vest

igat

ions

con

cern

ing

an u

nder

lyin

g ca

use

if su

spec

ted.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, e

xerc

ise,

par

ticul

arly

sw

imm

ing.

• M

edic

al: a

dequ

ate

anal

gesi

a.•

Surg

ery:

onl

y in

sev

ere

case

s.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns (e

.g. d

epre

ssio

n)•

Rest

rictiv

e lu

ng d

isea

se.

• Ca

rdia

c co

mpl

icat

ions

.•

Cord

com

pres

sion

.•

Para

pleg

ia.

Scol

iosi

s

Wha

t is

sco

liosi

s?Th

is is

a la

tera

l cur

vatu

re o

f the

spi

ne th

at is

>10

° (C

obb

angl

e). I

t may

be

stru

ctur

al o

r non

-str

uctu

ral a

nd b

road

ly s

peak

ing

ther

e ar

e fiv

e di

ffere

ntty

pes.

Rem

embe

r as

PON

DS:

P –

Post

ural

: non

-str

uctu

ral c

ompe

nsat

ory

scol

iosi

sO

– O

steo

path

ic: s

truc

tura

l abn

orm

ality

. Mos

tly c

onge

nita

l but

som

e ca

ses

m

ay b

e as

soci

ated

with

bon

e di

seas

eN

– N

euro

mus

cula

r: as

soci

ated

with

cer

ebra

l pal

sy, F

riedr

eich

’s at

axia

etc

.D

– D

egen

erat

ive:

ass

ocia

ted

with

face

t joi

nt fa

ilure

S –

Stru

ctur

al id

iopa

thic

: may

be

subd

ivid

ed in

to fi

ve ty

pes:

1

. Tho

raco

lum

bar –

usu

ally

cur

ves

to th

e rig

ht

2. L

umba

r – u

sual

ly c

urve

s to

the

left

3

. Inf

antil

e th

orac

ic –

usu

ally

cur

ves

to th

e le

ft

4. A

dole

scen

t tho

raci

c –

usua

lly c

urve

s to

the

right

5

. Dou

ble

maj

or –

two

curv

es in

eac

h di

rect

ion

Caus

esSe

e ab

ove.

Rem

embe

r to

ask

abou

t fam

ily h

isto

ry a

nd p

regn

ancy

.

Sym

ptom

s•

Cosm

etic

def

orm

ity.

• Ac

hing

, but

not

sev

ere,

pai

n. If

pai

n is

ver

y se

vere

, the

n m

ust e

xclu

de

spin

al tu

mou

rs/o

steo

id o

steo

mas

.

Inve

stig

atio

ns•

Thor

ough

spi

nal e

xam

inat

ion.

• Ra

diol

ogy

– x-

ray

(AP

and

late

ral v

iew

s) a

nd C

obb

angl

e m

easu

rem

ent.

• In

vest

igat

ions

con

cern

ing

an u

nder

lyin

g ca

use

if su

spec

ted.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, e

xerc

ise

(par

ticul

arly

sw

imm

ing)

, bra

ce –

Bo

ston

or M

ilwau

kee.

• M

edic

al: a

dequ

ate

anal

gesi

a.•

Surg

ical

: onl

y in

sev

ere

case

s.

Com

plic

atio

ns•

Psyc

holo

gica

l im

plic

atio

ns (e

.g. d

epre

ssio

n).

• Re

stric

tive

lung

dis

ease

.•

Card

iac

com

plic

atio

ns.

• N

erve

com

pres

sion

.

MAP

8.6

. Spi

nal p

atho

logy

Cont

inue

d ov

erle

af

MAP

8.6

. Sp

inal

pat

ho

log

y

K30033_C008.indd 237 28/02/17 11:26 am

Ort

hopa

edic

s23

8 Ank

ylos

ing

spon

dylit

is

Wha

t is

ank

ylos

ing

spon

dylit

is?

This

is a

chr

onic

infla

mm

ator

y di

seas

e of

the

spin

e an

d sa

croi

liac

join

ts. T

here

is

pre

dom

inan

ce in

you

ng m

ales

and

the

cond

ition

is a

ssoc

iate

d w

ith H

LA-B

27

(pos

itive

in 9

5%).

Caus

esTh

e ex

act c

ause

and

pat

hoph

ysio

logy

of t

his

cond

ition

are

unk

now

n.Ho

wev

er, i

t is

thou

ght t

o be

ass

ocia

ted

with

HLA

-B27

.

Sign

s an

d sy

mpt

oms

Sym

ptom

s im

prov

e w

ith e

xerc

ise.

• Q

uest

ion

mar

k po

stur

e.•

Pain

and

stif

fnes

s.•

Extr

a-ar

ticul

ar fe

atur

es:

Iritis

.

Ao

rtiti

s.

Ap

ical

pul

mon

ary

fibro

sis.

Amyl

oido

sis

(sec

onda

ry).

Card

iac

cond

uctio

n de

fect

s.•

Spec

ific

spin

al s

ympt

oms:

Bam

boo

spin

e –

due

to c

alci

ficat

ion

of li

gam

ents

.

Lo

w b

ack

pain

and

stif

fnes

s.

Lo

ss o

f lum

bar l

ordo

sis.

Com

pens

ator

y fix

ed k

ypho

sis.

Spin

al s

teno

sis

Wha

t is

spi

nal s

teno

sis?

This

is a

nar

row

ing

of th

e sp

inal

can

al, w

hich

resu

lts in

com

pres

sion

of t

he

spin

al c

ord

and

corr

espo

ndin

g ne

rves

.

Caus

es•

Arth

ritis.

• Ag

e.•

Trau

ma.

• Sp

ace-

occu

pyin

g le

sion

.•

Spon

dylo

listh

esis.

Sym

ptom

s•

Uni

late

ral o

r bila

tera

l leg

pai

n +

/– b

ack

pain

that

is u

sual

ly

of g

radu

al o

nset

.•

Num

bnes

s an

d w

eakn

ess

that

wor

sens

with

wal

king

.•

Pain

relie

ved

by s

ittin

g an

d le

anin

g fo

rwar

ds.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y –

MRI

.

Inve

stig

atio

ns•

Wal

l tes

t – d

imin

ishe

d sp

ine

exte

nsio

n m

eans

that

the

pa

tient

's o

ccip

ut, s

capu

la, b

utto

cks

and

heel

s ca

nnot

con

tact

th

e w

all s

imul

tane

ousl

y.•

Bloo

ds –

ser

oneg

ativ

e fo

r rhe

umat

oid

fact

or.

• Ra

diol

ogy

– ch

est x

-ray

and

MRI

to a

sses

s ch

ange

s in

the

spin

e.

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. R

efer

to p

hysi

othe

rapy

.•

Med

ical

: ana

lges

ia (N

SAID

s) a

nd D

MAR

Ds (e

.g. s

ulph

asal

azin

e [fi

rst l

ine]

).•

Surg

ical

: cor

rect

ive

spin

al s

urge

ry.

Com

plic

atio

ns•

Ost

eopo

rosi

s.•

Spin

al fr

actu

res.

• In

crea

sed

risk

of c

ardi

ovas

cula

r dis

ease

(e.g

. str

oke

and

m

yoca

rdia

l inf

arct

ion)

.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: e

ffect

ive

anal

gesi

a.•

Surg

ical

: lam

inec

tom

y.

Com

plic

atio

ns•

Para

lysi

s.•

Inco

ntin

ence

.•

Diffi

culty

bal

anci

ng.

MAP

8.6

. Spi

nal p

atho

logy

(con

tinue

d )

MAP

8.6

. Sp

inal

pat

ho

log

y

K30033_C008.indd 238 28/02/17 11:26 am

Ort

hopa

edic

s23

9Ank

ylos

ing

spon

dylit

is

Wha

t is

ank

ylos

ing

spon

dylit

is?

This

is a

chr

onic

infla

mm

ator

y di

seas

e of

the

spin

e an

d sa

croi

liac

join

ts. T

here

is

pre

dom

inan

ce in

you

ng m

ales

and

the

cond

ition

is a

ssoc

iate

d w

ith H

LA-B

27

(pos

itive

in 9

5%).

Caus

esTh

e ex

act c

ause

and

pat

hoph

ysio

logy

of t

his

cond

ition

are

unk

now

n.Ho

wev

er, i

t is

thou

ght t

o be

ass

ocia

ted

with

HLA

-B27

.

Sign

s an

d sy

mpt

oms

Sym

ptom

s im

prov

e w

ith e

xerc

ise.

• Q

uest

ion

mar

k po

stur

e.•

Pain

and

stif

fnes

s.•

Extr

a-ar

ticul

ar fe

atur

es:

Iritis

.

Ao

rtiti

s.

Ap

ical

pul

mon

ary

fibro

sis.

Amyl

oido

sis

(sec

onda

ry).

Card

iac

cond

uctio

n de

fect

s.•

Spec

ific

spin

al s

ympt

oms:

Bam

boo

spin

e –

due

to c

alci

ficat

ion

of li

gam

ents

.

Lo

w b

ack

pain

and

stif

fnes

s.

Lo

ss o

f lum

bar l

ordo

sis.

Com

pens

ator

y fix

ed k

ypho

sis.

Spin

al s

teno

sis

Wha

t is

spi

nal s

teno

sis?

This

is a

nar

row

ing

of th

e sp

inal

can

al, w

hich

resu

lts in

com

pres

sion

of t

he

spin

al c

ord

and

corr

espo

ndin

g ne

rves

.

Caus

es•

Arth

ritis.

• Ag

e.•

Trau

ma.

• Sp

ace-

occu

pyin

g le

sion

.•

Spon

dylo

listh

esis.

Sym

ptom

s•

Uni

late

ral o

r bila

tera

l leg

pai

n +

/– b

ack

pain

that

is u

sual

ly

of g

radu

al o

nset

.•

Num

bnes

s an

d w

eakn

ess

that

wor

sens

with

wal

king

.•

Pain

relie

ved

by s

ittin

g an

d le

anin

g fo

rwar

ds.

Inve

stig

atio

ns•

Thor

ough

phy

sica

l exa

min

atio

n.•

Radi

olog

y –

MRI

.

Inve

stig

atio

ns•

Wal

l tes

t – d

imin

ishe

d sp

ine

exte

nsio

n m

eans

that

the

pa

tient

's o

ccip

ut, s

capu

la, b

utto

cks

and

heel

s ca

nnot

con

tact

th

e w

all s

imul

tane

ousl

y.•

Bloo

ds –

ser

oneg

ativ

e fo

r rhe

umat

oid

fact

or.

• Ra

diol

ogy

– ch

est x

-ray

and

MRI

to a

sses

s ch

ange

s in

the

spin

e.

Trea

tmen

t•

Cons

erva

tive:

pat

ient

edu

catio

n. R

efer

to p

hysi

othe

rapy

.•

Med

ical

: ana

lges

ia (N

SAID

s) a

nd D

MAR

Ds (e

.g. s

ulph

asal

azin

e [fi

rst l

ine]

).•

Surg

ical

: cor

rect

ive

spin

al s

urge

ry.

Com

plic

atio

ns•

Ost

eopo

rosi

s.•

Spin

al fr

actu

res.

• In

crea

sed

risk

of c

ardi

ovas

cula

r dis

ease

(e.g

. str

oke

and

m

yoca

rdia

l inf

arct

ion)

.

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py.

• M

edic

al: e

ffect

ive

anal

gesi

a.•

Surg

ical

: lam

inec

tom

y.

Com

plic

atio

ns•

Para

lysi

s.•

Inco

ntin

ence

.•

Diffi

culty

bal

anci

ng.

MAP

8.6

. Spi

nal p

atho

logy

(con

tinue

d )

MAP

8.6

. Sp

inal

pat

ho

log

y

K30033_C008.indd 239 28/02/17 11:26 am

Ort

hopa

edic

s24

0 Prox

imal

fem

oral

frac

ture

Wha

t is

a p

roxi

mal

fem

oral

frac

ture

?Fr

actu

res

may

be

defin

ed a

s a

disc

ontin

uity

of b

one

and,

whe

re th

epr

oxim

al fe

mur

is c

once

rned

, it u

sual

ly o

ccur

s in

the

elde

rly a

nd is

mor

eco

mm

on in

wom

en.

Th

e fra

ctur

e m

ay b

e de

fined

as

extr

acap

sula

r or i

ntra

caps

ular

.In

trac

apsu

lar f

ract

ures

are

furt

her s

ubdi

vide

d in

to s

ub-c

apita

l and

tr

ans-

cerv

ical

type

s, w

here

as e

xtra

caps

ular

frac

ture

s m

ay b

e ca

tego

rized

as

basi

-cer

vica

l, in

ter-t

roch

ante

ric a

nd s

ub-t

roch

ante

ric. T

here

is a

hig

h ris

k of

av

ascu

lar n

ecro

sis

with

intr

acap

sula

r fra

ctur

es. T

he b

lood

sup

ply

of th

e pr

oxim

al fe

mur

is fr

om:

1. T

he m

edia

l fem

oral

circ

umfle

x ar

tery

.2.

The

late

ral f

emor

al c

ircum

flex

arte

ry.

3. T

he a

rter

y of

the

ligam

entu

m te

res.

Caus

es•

Path

olog

ical

frac

ture

– o

steo

poro

sis,

met

asta

ses

to b

one.

• Tr

aum

a.

Sym

ptom

s•

Pain

.•

Shor

teni

ng o

f the

affe

cted

leg.

• Ex

tern

al ro

tatio

n of

the

affe

cted

leg.

Inve

stig

atio

ns•

Rout

ine

pre-

oper

ativ

e bl

ood

test

s.•

Radi

olog

y –

x-ra

y. Th

e G

arde

n cl

assi

ficat

ion

is u

sed

to d

escr

ibe

pr

oxim

al in

trac

apsu

lar f

emor

al fr

actu

res:

Type

I: u

ndis

plac

ed.

Type

II: u

ndis

plac

ed b

ut c

ompl

ete

fract

ure.

Type

III:

disp

lace

d fra

ctur

e bu

t stil

l bon

y co

ntac

t.

Ty

pe IV

: com

plet

ely

disp

lace

d.

Trea

tmen

t•

Extr

acap

sula

r fra

ctur

es:

Dyna

mic

hip

scr

ew.

• In

trac

apsu

lar f

ract

ures

:

U

ndis

plac

ed: i

nter

nal f

ixat

ion

or h

emia

rthr

opla

sty.

Disp

lace

d: h

emia

rthr

opla

sty

or to

tal h

ip re

plac

emen

t.

Com

plic

atio

ns•

Avas

cula

r nec

rosi

s.•

Thro

mbo

embo

lism

.•

Com

plic

atio

ns a

ssoc

iate

d w

ith fr

actu

res

(see

Tabl

es 8

.1a,

b,

pp

. 220

, 221

).

Slip

ped

uppe

r fe

mor

al e

piph

ysis

Wha

t is

slip

ped

uppe

r fe

mor

al e

piph

ysis

(SU

FE)?

This

is a

rare

con

ditio

n in

whi

ch th

e up

per f

emor

al e

piph

ysis

slip

s po

ster

oinf

erio

rly fr

om th

e fe

mor

al n

eck.

It m

ay o

ccur

bila

tera

lly in

20%

of

case

s. It

is v

ery

diffi

cult

to d

iagn

ose.

Caus

es•

Cart

ilagi

nous

phy

sis

failu

re.

Risk

fact

ors

Incl

ude:

• O

besi

ty.

• M

ale

sex.

• En

docr

ine

imba

lanc

es (e

.g. h

ypot

hyro

idis

m, d

ecre

ased

sex

hor

mon

es).

Sym

ptom

s•

Pain

– te

nds

to b

e lo

caliz

ed to

the

knee

and

thig

h.•

Decr

ease

d le

g ab

duct

ion,

incr

ease

d ad

duct

ion,

slig

ht le

g sh

orte

ning

and

ex

tern

al ro

tatio

n. L

oss

of in

tern

al ro

tatio

n.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. Se

verit

y is

ass

esse

d us

ing

the

Sout

hwic

k an

gle.

Trea

tmen

t•

Exte

rnal

in-s

itu p

inni

ng o

r ope

n re

duct

ion

and

pinn

ing.

Com

plic

atio

ns•

Chon

drol

ysis.

• De

form

ity.

• O

steo

arth

ritis.

• Av

ascu

lar n

ecro

sis

– hi

gh ri

sk fr

om re

duct

ion

of S

UFE

.

MAP

8.7

. Hip

pat

holo

gy

Map

8.7

. H

ip p

ath

olo

gy

K30033_C008.indd 240 28/02/17 11:26 am

Ort

hopa

edic

s24

1Prox

imal

fem

oral

frac

ture

Wha

t is

a p

roxi

mal

fem

oral

frac

ture

?Fr

actu

res

may

be

defin

ed a

s a

disc

ontin

uity

of b

one

and,

whe

re th

epr

oxim

al fe

mur

is c

once

rned

, it u

sual

ly o

ccur

s in

the

elde

rly a

nd is

mor

eco

mm

on in

wom

en.

Th

e fra

ctur

e m

ay b

e de

fined

as

extr

acap

sula

r or i

ntra

caps

ular

.In

trac

apsu

lar f

ract

ures

are

furt

her s

ubdi

vide

d in

to s

ub-c

apita

l and

tr

ans-

cerv

ical

type

s, w

here

as e

xtra

caps

ular

frac

ture

s m

ay b

e ca

tego

rized

as

basi

-cer

vica

l, in

ter-t

roch

ante

ric a

nd s

ub-t

roch

ante

ric. T

here

is a

hig

h ris

k of

av

ascu

lar n

ecro

sis

with

intr

acap

sula

r fra

ctur

es. T

he b

lood

sup

ply

of th

e pr

oxim

al fe

mur

is fr

om:

1. T

he m

edia

l fem

oral

circ

umfle

x ar

tery

.2.

The

late

ral f

emor

al c

ircum

flex

arte

ry.

3. T

he a

rter

y of

the

ligam

entu

m te

res.

Caus

es•

Path

olog

ical

frac

ture

– o

steo

poro

sis,

met

asta

ses

to b

one.

• Tr

aum

a.

Sym

ptom

s•

Pain

.•

Shor

teni

ng o

f the

affe

cted

leg.

• Ex

tern

al ro

tatio

n of

the

affe

cted

leg.

Inve

stig

atio

ns•

Rout

ine

pre-

oper

ativ

e bl

ood

test

s.•

Radi

olog

y –

x-ra

y. Th

e G

arde

n cl

assi

ficat

ion

is u

sed

to d

escr

ibe

pr

oxim

al in

trac

apsu

lar f

emor

al fr

actu

res:

Type

I: u

ndis

plac

ed.

Type

II: u

ndis

plac

ed b

ut c

ompl

ete

fract

ure.

Type

III:

disp

lace

d fra

ctur

e bu

t stil

l bon

y co

ntac

t.

Ty

pe IV

: com

plet

ely

disp

lace

d.

Trea

tmen

t•

Extr

acap

sula

r fra

ctur

es:

Dyna

mic

hip

scr

ew.

• In

trac

apsu

lar f

ract

ures

:

U

ndis

plac

ed: i

nter

nal f

ixat

ion

or h

emia

rthr

opla

sty.

Disp

lace

d: h

emia

rthr

opla

sty

or to

tal h

ip re

plac

emen

t.

Com

plic

atio

ns•

Avas

cula

r nec

rosi

s.•

Thro

mbo

embo

lism

.•

Com

plic

atio

ns a

ssoc

iate

d w

ith fr

actu

res

(see

Tabl

es 8

.1a,

b,

pp

. 220

, 221

).

Slip

ped

uppe

r fe

mor

al e

piph

ysis

Wha

t is

slip

ped

uppe

r fe

mor

al e

piph

ysis

(SU

FE)?

This

is a

rare

con

ditio

n in

whi

ch th

e up

per f

emor

al e

piph

ysis

slip

s po

ster

oinf

erio

rly fr

om th

e fe

mor

al n

eck.

It m

ay o

ccur

bila

tera

lly in

20%

of

case

s. It

is v

ery

diffi

cult

to d

iagn

ose.

Caus

es•

Cart

ilagi

nous

phy

sis

failu

re.

Risk

fact

ors

Incl

ude:

• O

besi

ty.

• M

ale

sex.

• En

docr

ine

imba

lanc

es (e

.g. h

ypot

hyro

idis

m, d

ecre

ased

sex

hor

mon

es).

Sym

ptom

s•

Pain

– te

nds

to b

e lo

caliz

ed to

the

knee

and

thig

h.•

Decr

ease

d le

g ab

duct

ion,

incr

ease

d ad

duct

ion,

slig

ht le

g sh

orte

ning

and

ex

tern

al ro

tatio

n. L

oss

of in

tern

al ro

tatio

n.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. Se

verit

y is

ass

esse

d us

ing

the

Sout

hwic

k an

gle.

Trea

tmen

t•

Exte

rnal

in-s

itu p

inni

ng o

r ope

n re

duct

ion

and

pinn

ing.

Com

plic

atio

ns•

Chon

drol

ysis.

• De

form

ity.

• O

steo

arth

ritis.

• Av

ascu

lar n

ecro

sis

– hi

gh ri

sk fr

om re

duct

ion

of S

UFE

.

MAP

8.7

. Hip

pat

holo

gy

Map

8.7

. H

ip p

ath

olo

gy

Cont

inue

d ov

erle

af

K30033_C008.indd 241 28/02/17 11:26 am

Ort

hopa

edic

s24

2 Dev

elop

men

tal d

yspl

asia

of t

he h

ip

Wha

t is

dev

elop

men

tal d

yspl

asia

of t

he h

ip (D

DH

)?Th

is ra

nges

from

mild

dys

plas

ia to

irre

duci

ble

disl

ocat

ion

due

to a

de

velo

pmen

tal d

efor

mat

ion

of th

e hi

p jo

int.

Fem

ales

are

affe

cted

mor

e th

an m

ales

. The

con

ditio

n m

ay b

e bi

late

ral.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn

but s

ever

al ri

sk fa

ctor

s ha

ve

been

iden

tifie

d su

ch a

s:•

Fem

ale

sex.

• Fi

rst b

orn

child

.•

Bree

ch d

eliv

ery.

• O

ligoh

ydra

mni

os.

• Po

sitiv

e fa

mily

his

tory

.•

Ethn

icity

: Cau

casi

an a

nd N

orth

Am

eric

an In

dian

s.

DDH

is a

ssoc

iate

d w

ith:

• Co

ngen

tial t

alip

es e

quin

ovar

us.

• To

rtic

ollis

.•

Met

atar

sus

addu

ctus

.

Sym

ptom

s•

Asym

ptom

atic

.•

Asym

met

ric g

lute

al s

kin

fold

s.•

Lim

p.

Inve

stig

atio

ns•

DDH

scre

enin

g.•

Ort

olan

i’s a

nd B

arlo

w’s

test

.•

Radi

olog

y –

USS

.

Trea

tmen

tDe

pend

s on

age

of d

iagn

osis

• Cl

osed

redu

ctio

n: P

avlik

har

ness

, hip

spi

ca.

• O

pen

redu

ctio

n: d

erot

atio

n va

rus

oste

otom

y, Sa

lter o

steo

tom

y.

Com

plic

atio

ns•

Gai

t abn

orm

aliti

es.

• Li

mb

shor

teni

ng.

• Ex

tern

al ro

tatio

n of

the

foot

.

Pert

hes

dise

ase

Wha

t is

Per

thes

dis

ease

?Th

is is

als

o kn

own

as L

egg-

Calv

é-Pe

rthe

s di

seas

e an

d is

ost

eone

cros

is o

fth

e fe

mor

al h

ead

resu

lting

in d

efor

mat

ion

of th

e ep

iphy

sis

(frag

men

tatio

n an

d fla

tten

ing)

. The

re a

re th

ree

phas

es in

the

dise

ase

proc

ess:

1. I

nitia

l – c

resc

ent s

hape

d fe

mor

al h

ead.

2. R

esor

ptio

n –

rare

fact

ion

(Gag

e’s

sign

on

x-ra

y –

a V

shap

ed lu

cenc

y).

3. R

epar

ativ

e.

Caus

esU

nkno

wn

Sym

ptom

s•

Child

with

a li

mp

(boy

s af

fect

ed m

ore

than

girl

s).

• Hi

p pa

in, w

hich

may

radi

ate

to th

e kn

ee a

nd g

roin

.•

Decr

ease

d ra

nge

of h

ip m

ovem

ent.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. M

ay s

how

sev

eral

feat

ures

(e.g

. ABC

):

A –

Abn

orm

al p

hyse

al g

row

th

B –

Bone

den

sity

incr

ease

d at

epi

phys

is

C –

Calc

ifica

tion

late

ral t

o ep

iphy

sis

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, b

race

, tra

ctio

n.•

Med

ical

: ade

quat

e an

alge

sia.

• Su

rgic

al: f

emor

al +

/- pe

lvic

ost

eoto

my.

Com

plic

atio

ns•

Gai

t abn

orm

aliti

es.

• Ar

thrit

is.

MAP

8.7

. Hip

pat

holo

gy (c

ontin

ued

)

Map

8.7

. H

ip p

ath

olo

gy

K30033_C008.indd 242 28/02/17 11:26 am

Ort

hopa

edic

s24

3Dev

elop

men

tal d

yspl

asia

of t

he h

ip

Wha

t is

dev

elop

men

tal d

yspl

asia

of t

he h

ip (D

DH

)?Th

is ra

nges

from

mild

dys

plas

ia to

irre

duci

ble

disl

ocat

ion

due

to a

de

velo

pmen

tal d

efor

mat

ion

of th

e hi

p jo

int.

Fem

ales

are

affe

cted

mor

e th

an m

ales

. The

con

ditio

n m

ay b

e bi

late

ral.

Caus

esTh

e ex

act c

ause

of t

his

cond

ition

is u

nkno

wn

but s

ever

al ri

sk fa

ctor

s ha

ve

been

iden

tifie

d su

ch a

s:•

Fem

ale

sex.

• Fi

rst b

orn

child

.•

Bree

ch d

eliv

ery.

• O

ligoh

ydra

mni

os.

• Po

sitiv

e fa

mily

his

tory

.•

Ethn

icity

: Cau

casi

an a

nd N

orth

Am

eric

an In

dian

s.

DDH

is a

ssoc

iate

d w

ith:

• Co

ngen

tial t

alip

es e

quin

ovar

us.

• To

rtic

ollis

.•

Met

atar

sus

addu

ctus

.

Sym

ptom

s•

Asym

ptom

atic

.•

Asym

met

ric g

lute

al s

kin

fold

s.•

Lim

p.

Inve

stig

atio

ns•

DDH

scre

enin

g.•

Ort

olan

i’s a

nd B

arlo

w’s

test

.•

Radi

olog

y –

USS

.

Trea

tmen

tDe

pend

s on

age

of d

iagn

osis

• Cl

osed

redu

ctio

n: P

avlik

har

ness

, hip

spi

ca.

• O

pen

redu

ctio

n: d

erot

atio

n va

rus

oste

otom

y, Sa

lter o

steo

tom

y.

Com

plic

atio

ns•

Gai

t abn

orm

aliti

es.

• Li

mb

shor

teni

ng.

• Ex

tern

al ro

tatio

n of

the

foot

.

Pert

hes

dise

ase

Wha

t is

Per

thes

dis

ease

?Th

is is

als

o kn

own

as L

egg-

Calv

é-Pe

rthe

s di

seas

e an

d is

ost

eone

cros

is o

fth

e fe

mor

al h

ead

resu

lting

in d

efor

mat

ion

of th

e ep

iphy

sis

(frag

men

tatio

n an

d fla

tten

ing)

. The

re a

re th

ree

phas

es in

the

dise

ase

proc

ess:

1. I

nitia

l – c

resc

ent s

hape

d fe

mor

al h

ead.

2. R

esor

ptio

n –

rare

fact

ion

(Gag

e’s

sign

on

x-ra

y –

a V

shap

ed lu

cenc

y).

3. R

epar

ativ

e.

Caus

esU

nkno

wn

Sym

ptom

s•

Child

with

a li

mp

(boy

s af

fect

ed m

ore

than

girl

s).

• Hi

p pa

in, w

hich

may

radi

ate

to th

e kn

ee a

nd g

roin

.•

Decr

ease

d ra

nge

of h

ip m

ovem

ent.

Inve

stig

atio

ns•

Radi

olog

y –

x-ra

y. M

ay s

how

sev

eral

feat

ures

(e.g

. ABC

):

A –

Abn

orm

al p

hyse

al g

row

th

B –

Bone

den

sity

incr

ease

d at

epi

phys

is

C –

Calc

ifica

tion

late

ral t

o ep

iphy

sis

Trea

tmen

t•

Cons

erva

tive:

phy

siot

hera

py, b

race

, tra

ctio

n.•

Med

ical

: ade

quat

e an

alge

sia.

• Su

rgic

al: f

emor

al +

/- pe

lvic

ost

eoto

my.

Com

plic

atio

ns•

Gai

t abn

orm

aliti

es.

• Ar

thrit

is.

MAP

8.7

. Hip

pat

holo

gy (c

ontin

ued

)

Map

8.7

. H

ip p

ath

olo

gy

K30033_C008.indd 243 28/02/17 11:26 am

Ort

hopa

edic

s24

4Ta

ble

8.2.

Kn

ee p

ath

olo

gy

TABL

E 8.

2. K

nee

path

olog

y. T

he k

nee

is s

usce

ptib

le t

o bo

th p

rim

ary

and

seco

ndar

y os

teoa

rthr

itis

, but

the

sta

bilit

y of

the

kn

ee r

ests

upo

n in

tra-

and

ext

ra-a

rtic

ular

liga

men

ts a

nd m

enis

ci, w

hich

are

sus

cept

ible

to

inju

ry.

Path

olog

yCa

use

Sym

ptom

sIn

vest

igat

ions

Trea

tmen

tCo

mpl

icat

ions

Ante

rior

cruc

iate

lig

amen

t (A

CL) t

ear

The

func

tion

of th

e AC

L is

to:

1. P

reve

nt a

nter

ior d

ispl

acem

ent o

f th

e tib

ia o

ff th

e fe

mur

2. P

reve

nt ro

tatio

n 3.

Pre

vent

hyp

erex

tens

ion

Any

type

of t

raum

a th

at in

volv

es

twis

ting

of a

slig

htly

flex

ed k

nee

(e.g

. foo

tbal

l inj

urie

s, or

ove

r-ex

tens

ion

of th

e kn

ee) c

an d

amag

e th

e AC

L

Fem

ales

(pos

t pub

erty

) are

mor

e lik

ely

to d

amag

e th

eir A

CL th

an

mal

es. T

he re

ason

for t

his

is

deba

ted

but i

s po

tent

ially

due

to:

• Ho

rmon

es –

whi

ch c

ause

laxi

ty

of li

gam

ents

• A

narr

ower

inte

rcon

dyla

r not

ch•

A la

rger

Q a

ngle

in w

omen

• Pa

in

• Kn

ee s

wel

ling

• He

arin

g or

fe

elin

g a

‘pop

’

• An

terio

r dra

w te

st

posi

tive/

Lach

man

te

st p

ositi

ve•

Pivo

t shi

ft te

st•

Radi

olog

y:

x-ra

y –

rule

out

fra

ctur

e

MRI

– c

onfir

ms

diag

nosi

s

Cons

erva

tive

: Em

ploy

RIC

E te

chni

ques

(R

est,

Ice,

Com

pres

sion

and

El

evat

ion)

, phy

siot

hera

py, k

nee

brac

e

Med

ical

: ana

lges

ia

Surg

ical

: ACL

reco

nstr

uctio

n

• Kn

ee in

stab

ility

• O

steo

arth

ritis

• Co

mpl

icat

ions

re

latin

g to

su

rger

y su

ch

as th

e ge

nera

l co

mpl

icat

ions

of

ana

esth

esia

, in

fect

ion,

DVT

, da

mag

e to

su

rrou

ndin

g st

ruct

ures

K30033_C008.indd 244 28/02/17 11:26 am

Ort

hopa

edic

sTa

ble

8.2.

Kn

ee p

ath

olo

gy

Post

erio

r cr

ucia

te li

ga-

men

t (PC

L)

tear

The

func

tion

of th

e PC

L is

to p

reve

nt

post

erio

r dis

plac

emen

t of t

he ti

bia

off t

he fe

mur

Inju

ry to

the

PCL

is v

ery

rare

. It t

ends

to

occ

ur in

road

traf

fic a

ccid

ent

dash

boar

d in

jurie

s

• Pa

in•

Knee

sw

ellin

g•

Posi

tive

post

erio

r dr

aw te

st

• Ra

diol

ogy:

x-

ray

– ru

le o

ut

fract

ure

M

RI –

con

firm

s di

agno

sis

Cons

erva

tive

: Em

ploy

RIC

E te

chni

ques

(Res

t, Ic

e, C

ompr

essi

on a

nd E

leva

tion)

, ph

ysio

ther

apy,

knee

bra

ce

Med

ical

: ana

lges

ia

Surg

ical

: PCL

reco

nstr

uctio

n

• Kn

ee in

stab

ility

• O

steo

arth

ritis

• Co

mpl

icat

ions

re

latin

g to

sur

gery

su

ch a

s th

e

gene

ral

com

plic

atio

ns

of a

naes

thes

ia,

infe

ctio

n, D

VT,

dam

age

to

surr

ound

ing

stru

ctur

es

Cont

inue

d ov

erle

af

245

K30033_C008.indd 245 28/02/17 11:26 am

Ort

hopa

edic

s24

6Ta

ble

8.2.

Kn

ee p

ath

olo

gy

TABL

E 8.

2. K

nee

path

olog

y. T

he k

nee

is s

usce

ptib

le t

o bo

th p

rim

ary

and

seco

ndar

y os

teoa

rthr

itis

, but

the

sta

bilit

y of

the

kn

ee r

ests

upo

n in

tra-

and

ext

ra-a

rtic

ular

liga

men

ts a

nd m

enis

ci, w

hich

are

sus

cept

ible

to

inju

ry ( c

ontin

ued 

 ).

Path

olog

yCa

use

Sym

ptom

sIn

vest

igat

ions

Trea

tmen

tCo

mpl

icat

ions

Men

isca

l te

ars

The

med

ial m

enis

cus

is to

rn m

ore

ofte

n th

en th

e la

tera

l men

iscu

s. Th

e re

ason

for t

his

rest

s in

ana

tom

ical

di

ffere

nces

. The

med

ial m

enis

cus

is

firm

ly a

ttac

hed

to b

oth

the

med

ial

colla

tera

l lig

amen

t and

join

t cap

sule

. It

is a

lso

mor

e C

shap

ed in

con

tras

t with

th

e la

tera

l men

iscu

s, w

hich

is ro

und

in

appe

aran

ce

Trau

ma

as a

resu

lt of

twis

ting

is th

e co

mm

on m

echa

nism

of i

njur

y. Te

ars

may

be

cate

goriz

ed a

s co

mpl

ete

or

inco

mpl

ete

The

com

bina

tion

of a

med

ial m

enis

cus

tear

, med

ial c

olla

tera

l lig

amen

t te

ar a

nd a

torn

ACL

is k

now

n as

O

’Don

oghu

e’s

unha

ppy

tria

d

• Kn

ee lo

ckin

g•

Giv

ing

way

of t

he k

nee

• Pa

in

• Sw

ellin

g•

Decr

ease

d ra

nge

of

mov

emen

t

• Po

sitiv

e M

cMur

ray

test

•

Radi

olog

y:

x-ra

y –

rule

ou

t fra

ctur

e

MRI

–

confi

rms

diag

nosi

s

Cons

erva

tive

: Em

ploy

RIC

E te

chni

ques

(Res

t, Ic

e, C

ompr

essi

on a

nd E

leva

tion)

, ph

ysio

ther

apy,

knee

bra

ce

Med

ical

: ana

lges

ia

Surg

ical

: dep

ends

on

the

loca

-tio

n an

d th

e ex

tent

of t

he te

ar.

If lo

cate

d in

the

oute

r thi

rd o

f th

e m

enis

cus,

also

kno

wn

as th

e ‘re

d zo

ne’,

the

tear

will

hea

l on

its o

wn

sinc

e th

is is

a re

gion

of

copi

ous

bloo

d su

pply.

How

ever

, if

loca

ted

in th

e in

ner t

wo

third

s, th

e ‘w

hite

zon

e’, p

atie

nts

may

re

quire

sur

gica

l int

erve

ntio

n

• Kn

ee in

stab

ility

• O

steo

arth

ritis

K30033_C008.indd 246 28/02/17 11:26 am

247

Ort

hopa

edic

sTa

ble

8.2.

Kn

ee p

ath

olo

gy

Osg

ood–

Schl

atte

r di

seas

e

This

is a

tibi

al tu

bero

sity

apo

phys

itis

that

typi

cally

affe

cts

athl

etic

mal

es

aged

10–

15 y

ears

The

exac

t cau

se is

not

kno

wn

but

over

use

is th

ough

t to

play

a ro

le

• Pa

in, s

wel

ling

and

tend

erne

ss o

f the

tibi

al

tube

rosi

ty

• U

sual

ly

a cl

inic

al

diag

nosi

s•

Radi

olog

y –

x-ra

y m

ay

show

sig

ns

of tu

bero

sity

en

larg

emen

t

Cons

erva

tive

: res

t, ph

ysio

ther

apy,

knee

bra

ce

Med

ical

: ana

lges

ia

• U

nlik

ely

to

caus

e se

rious

co

mpl

icat

ions

bu

t pai

n m

ay

pers

ist

Ost

eo-

chon

driti

s di

ssec

ans

This

is a

par

tial o

r com

plet

e de

tach

-m

ent o

f eith

er b

one

or a

rtic

ular

ca

rtila

ge th

at is

cau

sed

by a

vasc

ular

ne

cros

is o

f the

sub

chon

dral

bon

e.

This

resu

lts in

mic

rofra

ctur

e w

ithou

t re

mod

ellin

g

Oth

er c

ause

s in

clud

e:•

Gen

etic

s•

Repe

titiv

e m

inor

trau

ma

• Dr

ugs

(e.g

. ste

roid

s)

• Pa

in –

wor

sens

with

ex

erci

se•

Swel

ling

• Lo

ckin

g an

d gi

ving

way

• Ra

diol

ogy:

x-

ray

– ru

le o

ut

fract

ure

M

RI –

co

nfirm

s di

agno

sis

The

Ande

rson

st

agin

g cr

iteria

ar

e em

ploy

ed

Cons

erva

tive

: wat

chfu

l wai

t-in

g, re

st

Med

ical

: ana

lges

ia

Surg

ical

: art

hros

copy

, ost

eo-

chon

dral

aut

ogra

ft tr

ansp

lan-

tatio

n

• O

steo

arth

ritis

Pate

llar

sub-

luxa

tion

synd

rom

e

Exac

t cau

se is

unk

now

n bu

t som

e fa

ctor

s ha

ve b

een

sugg

este

d su

ch a

s:

• G

ait a

bnor

mal

ities

• Sh

allo

w p

atel

lar g

roov

e

• W

ide

pelv

is

This

con

ditio

n is

mor

e co

mm

on in

w

omen

• Kn

ee th

at g

ives

way

or

lock

s du

ring

mov

emen

t

• Sl

idin

g an

d hi

ghly

m

obile

pat

ella

• Pa

in –

whe

n si

ttin

g an

d w

orse

ns w

ith

mov

emen

t

• Sw

ellin

g

• Ra

diol

ogy:

x-

ray,

MRI

Cons

erva

tive

: phy

siot

hera

py,

brac

es, o

rtho

tics

Med

ical

: ana

lges

ia

Surg

ical

: med

ial p

atel

lofe

mor

al

ligam

ent r

econ

stru

ctio

n. Th

is lig

amen

t may

tear

whe

n th

e pa

tella

disl

ocat

es o

utw

ards

• Kn

ee in

stab

ility

• Re

curr

ent

subl

uxat

ion

or

disl

ocat

ion

K30033_C008.indd 247 28/02/17 11:26 am

Ort

hopa

edic

s24

8Ta

ble

8.3.

Fo

ot

pat

ho

log

y

TABL

E 8.

3. F

oot

path

olog

y.

Path

olog

yCa

use

Sym

ptom

sIn

vest

igat

ions

Trea

tmen

tCo

mpl

icat

ions

Hallu

x va

lgus

(b

unio

n)Th

e ex

act c

ause

is

unkn

own

but i

t is

asso

ci-

ated

with

:

• Fe

mal

e se

x•

Posi

tive

fam

ily h

isto

ry•

Incr

ease

d ag

e•

Wea

ring

heel

s

• Th

e ha

llux

devi

ates

la

tera

lly a

t the

m

etat

arso

phal

ange

al

join

t •

Pain

• Er

ythe

mat

ous,

irrita

ted

skin

ove

rlyin

g th

e bu

nion

• Th

orou

gh

phys

ical

ex

amin

atio

n in

clud

ing

an

asse

ssm

ent o

f ga

it•

Radi

olog

y: x

-ray

w

ill v

isua

lize

the

defo

rmity

Cons

erva

tive

: app

ropr

i-at

e fo

otw

ear

Med

ical

: ana

lges

ia

Surg

ical

: onl

y in

dica

ted

if th

ere

is s

ever

e pa

in

or if

the

defo

rmity

si

gnifi

cant

ly im

pact

s on

w

alki

ng/li

fest

yle

• O

steo

arth

ritis

•

Com

plic

atio

ns re

latin

g to

sur

gery

suc

h as

in

fect

ion,

DVT

, dam

age

to s

urro

undi

ng

stru

ctur

es

Pes

plan

usCo

llaps

e of

the

med

ial

long

itudi

nal a

rch

• As

ympt

omat

ic

• Pa

in –

ove

r the

tibi

alis

po

ster

ior t

endo

n •

Prog

ress

ed d

isea

se –

in

abili

ty to

rais

e he

el.

Fore

foot

– a

bduc

ted;

hi

ndfo

ot –

val

gus

• Pa

edia

tric

s –

foot

pr

ofor

ma

• Th

orou

gh

phys

ical

ex

amin

atio

n in

clud

ing

an

asse

ssm

ent o

f ga

it•

Radi

olog

y:

x-ra

y m

ay h

elp

eval

uate

the

exte

nt o

f the

de

form

ity

Mos

t are

asy

mpt

omat

ic

and

do n

ot re

quire

tr

eatm

ent

Cons

erva

tive

: ort

hotic

s, ph

ysio

ther

apy

(e.g

. Ach

il-le

s te

ndon

str

etch

ing)

Surg

ical

: in

seve

re c

ases

an

d ai

ms

to re

alig

n th

e fo

ot. E

xam

ple

oper

atio

ns

incl

ude

Achi

lles

tend

on

leng

then

ing,

tibi

alis

pos

-te

rior t

endo

n re

cons

truc

-tio

n an

d re

cons

truc

tive

oste

otom

ies

• Ti

bial

is p

oste

rior

tend

on d

ysfu

nctio

n•

May

con

trib

ute

to

othe

r foo

t con

ditio

ns

such

as

hallu

x va

lgus

an

d pl

anta

r fas

ciiti

s

K30033_C008.indd 248 28/02/17 11:26 am

249

Ort

hopa

edic

sTa

ble

8.3.

Fo

ot

pat

ho

log

y

Pes

cavu

sTh

e ex

act c

ause

of t

he

acce

ntua

ted

long

itudi

nal

arch

in th

is c

ondi

tion

is

unkn

own,

but

is a

ssoc

iate

d w

ith c

ondi

tions

suc

h as

:

• Ce

rebr

al p

alsy

• Sp

ina

bifid

a•

Mus

cula

r dys

trop

hy•

Char

cot–

Mar

ie–T

ooth

di

seas

e

• Pa

in o

n w

alki

ng

• Cl

aw to

es•

Ankl

e in

stab

ility

• Pa

edia

tric

s –

foot

pr

ofor

ma

• Th

orou

gh

phys

ical

ex

amin

atio

n in

clud

ing

an

asse

ssm

ent o

f ga

it•

Radi

olog

y:

x-ra

y m

ay h

elp

eval

uate

the

exte

nt o

f the

de

form

ity

Cons

erva

tive

: ort

hotic

s, ph

ysio

ther

apy

Surg

ical

: pla

ntar

fasc

ia

rele

ase,

Jone

s pr

oced

ure,

ex

tens

or s

hift

proc

edur

e,

Gird

lest

one-

Tayl

or

tran

sfer

, per

oneu

s lo

ngus

to

per

oneu

s br

evis

te

node

sis

• Co

mpl

icat

ions

rela

ting

to s

urge

ry s

uch

as

infe

ctio

n, D

VT, d

amag

e to

sur

roun

ding

st

ruct

ures

, mal

unio

n

Stre

ss fr

actu

reFr

actu

res

tend

to a

ffect

th

e sh

aft o

f the

2nd

or 3

rd

met

atar

sal s

ince

thes

e ar

e le

ss ro

bust

than

the

othe

r m

etat

arsa

l bon

es

• Pa

in o

n w

alki

ng a

nd

over

the

met

atar

sal

• Ra

diol

ogy:

x-r

ayCo

nser

vati

ve: r

est,

plas

ter c

ast m

ay b

e re

quire

d

Med

ical

: ana

lges

ia

• Co

mpl

icat

ions

of

fract

ure

(see

Tabl

es

8.1a

, b, p

p. 2

20, 2

21)

• O

steo

arth

ritis

Talip

es e

quin

o-va

rus

(clu

b fo

ot)

The

exac

t cau

se o

f thi

s co

nditi

on is

unk

now

n bu

t it

is a

ssoc

iate

d w

ith:

• A

posi

tive

fam

ily h

isto

ry•

DDH

• O

ligoh

ydra

mni

os•

Spin

a bi

fida

• In

vert

ed a

nd s

upin

ated

fo

ot•

Addu

cted

fore

foot

• In

war

dly

rota

ted

heel

he

ld in

pla

ntar

flexi

on

• U

SS s

cree

ning

du

ring

preg

nanc

y •

Diag

nosi

s ba

sed

on ty

pica

l ap

pear

ance

• In

vest

igat

e un

derly

ing

caus

e

Pons

eti m

etho

d•

Gai

t abn

orm

ailit

y •

Arth

ritis

•

Smal

ler s

hoe

size

of

affe

cted

foot

K30033_C008.indd 249 28/02/17 11:26 am

Ort

hopa

edic

s25

0 Sept

ic a

rthr

itis

Wha

t is

sep

tic

arth

riti

s?Th

is is

infe

ctio

n of

any

join

t by

a m

icro

orga

nism

. It i

s a

surg

ical

em

erge

ncy.

Caus

esTh

e ex

act m

echa

nism

by

whi

ch th

e or

gani

sm in

vade

s th

e jo

int i

s un

know

n.Sp

read

may

be

syst

emic

, fro

m a

pen

etra

ting

wou

nd o

r fro

m p

rior

oste

omye

litis.

Caus

ativ

e or

gani

sms

incl

ude:

• St

aphy

loco

ccus

aur

eus

(com

mon

est).

• N

eiss

eria

gon

orrh

oea.

• Ha

emop

hilu

s in

fluen

zae.

• Pn

eum

ococ

cus

sp.

• G

roup

B s

trep

toco

cci.

• Es

cher

ichi

a co

li.•

Pseu

dom

onas

sp.

• Pr

oteu

s sp

.•

Fung

i.

Sept

ic a

rthr

itis

is a

ssoc

iate

d w

ith:

• Di

abet

es m

ellit

us.

• IV

dru

g ab

use.

• Ex

trem

es o

f age

(i.e

. the

ver

y yo

ung/

old)

.

Sym

ptom

s•

Gen

eral

feat

ures

of i

nfec

tion:

spi

king

pyr

exia

, mal

aise

• De

crea

sed

rang

e of

mov

emen

t of a

ffect

ed jo

int

• In

flam

mat

ion

and

pain

of a

ffect

ed jo

int

Inve

stig

atio

ns•

Bloo

d te

sts

– FB

C, W

CC, U

&E,

CRP

, blo

od c

ultu

res,

uric

aci

d to

exc

lude

gou

t.•

Spec

ific

test

s –

join

t asp

iratio

n an

d cu

lture

, gon

orrh

oea

swab

s.•

Radi

olog

y:

x-

ray

of jo

int (

and

ches

t if T

B su

spec

ted)

.

U

SS –

allo

ws

diag

nost

ic jo

int a

spira

tion.

Trea

tmen

tTh

is m

ust b

e do

ne w

ithou

t del

ay s

ince

sep

tic a

rthr

itis

is a

n em

erge

ncy.

Surg

ical

: joi

nt a

spira

tion

and

surg

ical

was

hout

follo

wed

by

antib

iotic

sse

nsiti

ve to

cau

sativ

e or

gani

sm.

Com

plic

atio

ns•

Join

t des

truc

tion.

• Se

cond

ary

oste

oart

hriti

s.•

Fibr

ous

anky

losi

s.•

In c

hild

ren

– gr

owth

dis

rupt

ion

from

gro

wth

pla

te d

amag

e.

Ost

eom

yelit

is

Wha

t is

ost

eom

yelit

is?

This

is a

bac

teria

l inf

ectio

n of

the

bone

, whi

ch m

ay b

e sp

read

to th

e bo

neha

emat

ogen

ousl

y, tr

aum

atic

ally

or f

rom

infe

ctio

n of

sof

t tis

sue.

It m

ay

have

an

acut

e or

chr

onic

pre

sent

atio

n.

Caus

esCa

usat

ive

orga

nism

s in

clud

e:•

Stap

hylo

cocc

us a

ureu

s (c

omm

ones

t).•

Haem

ophi

lus

influ

enza

e (m

ore

com

mon

in c

hild

ren)

.•

Salm

onel

la s

p. (m

ore

com

mon

in p

atie

nts

with

sic

kle

cell

dise

ase)

.O

steo

mye

litis

is a

ssoc

iate

d w

ith:

• Di

abet

es m

ellit

us.

• IV

dru

g ab

use.

• Ex

trem

es o

f age

(i.e

. the

ver

y yo

ung/

old)

.•

Sick

le c

ell d

isea

se.

• Im

mun

ocom

prom

ise.

• Ch

roni

c os

teom

yelit

is –

sm

okin

g, s

tero

id u

se a

nd v

ascu

lar d

isea

se.

Sym

ptom

s•

Gen

eral

feat

ures

of i

nfec

tion:

pyr

exia

, mal

aise

.•

Decr

ease

d ra

nge

of m

ovem

ent o

f affe

cted

join

t.•

Infla

mm

atio

n an

d pa

in o

f affe

cted

join

t.

Inve

stig

atio

ns•

Bloo

d te

sts

– FB

C, W

CC, U

&E,

CRP

, ESR

, blo

od c

ultu

res,

uric

aci

d to

ex

clud

e go

ut.

• Sp

ecifi

c te

sts

– jo

int a

spira

tion

and

cultu

re.

• Ra

diol

ogy:

x-ra

y of

join

t (no

abn

orm

al fe

atur

es in

the

first

10–

14 d

ays)

.

U

SS –

allo

ws

diag

nost

ic jo

int a

spira

tion.

CT –

may

be

used

to g

uide

nee

dle

aspi

ratio

n.

M

RI.

Trea

tmen

t•

Cons

erva

tive:

spl

inta

ge, r

ehab

ilita

tion

and

phys

ioth

erap

y.•

Med

ical

: IV

antib

iotic

s.•

Surg

ical

: gui

ded

aspi

ratio

n an

d su

rgic

al e

vacu

atio

n.

Com

plic

atio

ns•

Join

t des

truc

tion.

• Ch

roni

c os

teoa

rthr

itis.

• Se

ptic

art

hriti

s.•

Path

olog

ical

frac

ture

.•

In c

hild

ren

– gr

owth

dis

rupt

ion

from

gro

wth

pla

te d

amag

e.

MAP

8.8

. Ort

hopa

edic

infe

ctio

ns

SSSySySySySym

pm

pm

pm

pm

pttototototo

ms

ms

ms

ms

ms

MAP

8.8

. O

rth

op

aed

ic in

fect

ion

s

K30033_C008.indd 250 28/02/17 11:26 am

251Se

ptic

art

hrit

is

Wha

t is

sep

tic

arth

riti

s?Th

is is

infe

ctio

n of

any

join

t by

a m

icro

orga

nism

. It i

s a

surg

ical

em

erge

ncy.

Caus

esTh

e ex

act m

echa

nism

by

whi

ch th

e or

gani

sm in

vade

s th

e jo

int i

s un

know

n.Sp

read

may

be

syst

emic

, fro

m a

pen

etra

ting

wou

nd o

r fro

m p

rior

oste

omye

litis.

Caus

ativ

e or

gani

sms

incl

ude:

• St

aphy

loco

ccus

aur

eus

(com

mon

est).

• N

eiss

eria

gon

orrh

oea.

• Ha

emop

hilu

s in

fluen

zae.

• Pn

eum

ococ

cus

sp.

• G

roup

B s

trep

toco

cci.

• Es

cher

ichi

a co

li.•

Pseu

dom

onas

sp.

• Pr

oteu

s sp

.•

Fung

i.

Sept

ic a

rthr

itis

is a

ssoc

iate

d w

ith:

• Di

abet

es m

ellit

us.

• IV

dru

g ab

use.

• Ex

trem

es o

f age

(i.e

. the

ver

y yo

ung/

old)

.

Sym

ptom

s•

Gen

eral

feat

ures

of i

nfec

tion:

spi

king

pyr

exia

, mal

aise

• De

crea

sed

rang

e of

mov

emen

t of a

ffect

ed jo

int

• In

flam

mat

ion

and

pain

of a

ffect

ed jo

int

Inve

stig

atio

ns•

Bloo

d te

sts

– FB

C, W

CC, U

&E,

CRP

, blo

od c

ultu

res,

uric

aci

d to

exc

lude

gou

t.•

Spec

ific

test

s –

join

t asp

iratio

n an

d cu

lture

, gon

orrh

oea

swab

s.•

Radi

olog

y:

x-

ray

of jo

int (

and

ches

t if T

B su

spec

ted)

.

U

SS –

allo

ws

diag

nost

ic jo

int a

spira

tion.

Trea

tmen

tTh

is m

ust b

e do

ne w

ithou

t del

ay s

ince

sep

tic a

rthr

itis

is a

n em

erge

ncy.

Surg

ical

: joi

nt a

spira

tion

and

surg

ical

was

hout

follo

wed

by

antib

iotic

sse

nsiti

ve to

cau

sativ

e or

gani

sm.

Com

plic

atio

ns•

Join

t des

truc

tion.

• Se

cond

ary

oste

oart

hriti

s.•

Fibr

ous

anky

losi

s.•

In c

hild

ren

– gr

owth

dis

rupt

ion

from

gro

wth

pla

te d

amag

e.

Ost

eom

yelit

is

Wha

t is

ost

eom

yelit

is?

This

is a

bac

teria

l inf

ectio

n of

the

bone

, whi

ch m

ay b

e sp

read

to th

e bo

neha

emat

ogen

ousl

y, tr

aum

atic

ally

or f

rom

infe

ctio

n of

sof

t tis

sue.

It m

ay

have

an

acut

e or

chr

onic

pre

sent

atio

n.

Caus

esCa

usat

ive

orga

nism

s in

clud

e:•

Stap

hylo

cocc

us a

ureu

s (c

omm

ones

t).•

Haem

ophi

lus

influ

enza

e (m

ore

com

mon

in c

hild

ren)

.•

Salm

onel

la s

p. (m

ore

com

mon

in p

atie

nts

with

sic

kle

cell

dise

ase)

.O

steo

mye

litis

is a

ssoc

iate

d w

ith:

• Di

abet

es m

ellit

us.

• IV

dru

g ab

use.

• Ex

trem

es o

f age

(i.e

. the

ver

y yo

ung/

old)

.•

Sick

le c

ell d

isea

se.

• Im

mun

ocom

prom

ise.

• Ch

roni

c os

teom

yelit

is –

sm

okin

g, s

tero

id u

se a

nd v

ascu

lar d

isea

se.

Sym

ptom

s•

Gen

eral

feat

ures

of i

nfec

tion:

pyr

exia

, mal

aise

.•

Decr

ease

d ra

nge

of m

ovem

ent o

f affe

cted

join

t.•

Infla

mm

atio

n an

d pa

in o

f affe

cted

join

t.

Inve

stig

atio

ns•

Bloo

d te

sts

– FB

C, W

CC, U

&E,

CRP

, ESR

, blo

od c

ultu

res,

uric

aci

d to

ex

clud

e go

ut.

• Sp

ecifi

c te

sts

– jo

int a

spira

tion

and

cultu

re.

• Ra

diol

ogy:

x-ra

y of

join

t (no

abn

orm

al fe

atur

es in

the

first

10–

14 d

ays)

.

U

SS –

allo

ws

diag

nost

ic jo

int a

spira

tion.

CT –

may

be

used

to g

uide

nee

dle

aspi

ratio

n.

M

RI.

Trea

tmen

t•

Cons

erva

tive:

spl

inta

ge, r

ehab

ilita

tion

and

phys

ioth

erap

y.•

Med

ical

: IV

antib

iotic

s.•

Surg

ical

: gui

ded

aspi

ratio

n an

d su

rgic

al e

vacu

atio

n.

Com

plic

atio

ns•

Join

t des

truc

tion.

• Ch

roni

c os

teoa

rthr

itis.

• Se

ptic

art

hriti

s.•

Path

olog

ical

frac

ture

.•

In c

hild

ren

– gr

owth

dis

rupt

ion

from

gro

wth

pla

te d

amag

e.

MAP

8.8

. Ort

hopa

edic

infe

ctio

ns

SSSySySySySym

pm

pm

pm

pm

pttototototo

ms

ms

ms

ms

ms

Ort

hopa

edic

sM

AP 8

.8.

Ort

ho

pae

dic

infe

ctio

ns

K30033_C008.indd 251 28/02/17 11:26 am

Ort

hopa

edic

s25

2Fi

gure

8.2

. The

lum

bar p

lexu

s

Med

ial p

lant

ar n

erve

:Ab

duct

or h

allic

usFl

exor

dig

itoru

m b

revi

sFl

exor

hal

licus

bre

vis

Fem

oral

ner

ve:

ante

rior c

ompa

rtm

ent o

f thi

gh

Obt

urat

or n

erve

:m

edia

l com

part

men

t of t

high

Supe

rfic

ial f

ibul

ar n

erve

:Fi

bula

ris lo

ngus

and

bre

vis

Late

ral p

lant

ar n

erve

:Th

ose

not s

uppl

ied

by m

edia

lpl

anta

r ner

ve

Dee

p fib

ular

ner

ve:

Tibi

alis

ant

erio

rEx

tens

or h

allic

us lo

ngus

Fibu

laris

tert

ius

Exte

nsor

dig

itoru

m lo

ngus

and

brev

is

L2 L3 L4 L5 S1 S2 S3 S4

FIG

URE

8.2

. The

lum

bar

plex

us

Peri

neal

ner

ve:

Perin

eum

K30033_C008.indd 252 28/02/17 11:26 am

253

Appendix One Useful diagnostic classifications

Classification Name of disease

DSM-5, ICD-10 Psychiatric disorders

HADS, PHQ-9, GAD-7 Depression

SCOFF questionnaire Anorexia nervosa/bulimia

ACE-III Dementia

Amsel’s criteria Bacterial vaginosis

Rotherham criteria Polycystic ovary syndrome

FIGO Obstetric malignancy staging system

Jones criteria Rheumatic fever

Duke criteria Infective endocarditis

Psoriasis Area and Severity Index Psoriasis

Ludwig scale/Norwood scale Alopecia

Clark levels and Breslow’s thickness Malignant melanoma

Salter–Harris classification Growth plate fracture

Garden classification Proximal femur fracture

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; ICD-10, International Statistical Classification of Diseases and Related Health Problems, 10th Revision; HADS, Hospital Anxiety and Depression Scale; PHQ-9, Patient Health Questionnaire; GAD-7, Generalized Anxiety Disorder 7; SCOFF, Sick, Control, One stone, Fat, Food; ACE-III, Addenbrooke’s Cognitive Examination; FIGO, Fédération Internationale de Gynécologie et d’Obstétrique.

K30033_Appendices.indd 253 28/02/17 11:51 am

Appendix Two Useful websites

Disease Website

Acne vulgaris http://cks.nice.org.uk/acne-vulgaris

Age-related macular degeneration

https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-SCI-318-RCOphth-AMD-Guidelines-Sept-2013-FINAL-2.pdf

Alopecia areata http://cks.nice.org.uk/alopecia-areata

Amenorrhoea http://cks.nice.org.uk/amenorrhoea

Antepartum haemorrhage

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg63_05122011aph.pdf

Anxiety disorders https://www.nice.org.uk/guidance/qs53

Bacterial meningitis http://pathways.nice.org.uk/pathways/bacterial-meningitis-and-meningococcal-septicaemia

Benign paroxysmal positioning disorder

http://cks.nice.org.uk/benign-paroxysmal-positional-vertigo

http://www.aafp.org/dam/AAFP/documents/patient_care/ clinical_recommendations/RecToBOD-020810-Attachment1BPPV-Jan2010Cluster.pdf

Bipolar disorder https://www.nice.org.uk/guidance/cg38

Borderline personality disorder

https://www.nice.org.uk/guidance/cg78

Bronchiolitis https://www.nice.org.uk/guidance/ng9

Cataracts https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0741

https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2010-SCI-069-Cataract-Surgery-Guidelines-2010-SEPTEMBER-2010.pdf

Cervical cancer http://cks.nice.org.uk/cervical-cancer-and-hpv

Cervical screening http://cks.nice.org.uk/cervical-screening

Childhood cancers http://cks.nice.org.uk/childhood-cancers-recognition-and-referral

Cough in children http://cks.nice.org.uk/cough-acute-with-chest-signs-in-children

Croup http://cks.nice.org.uk/croup

Depression https://www.nice.org.uk/guidance/cg90

Eating disorders https://www.nice.org.uk/guidance/cg9

Ectopic pregnancy and miscarriage

https://www.nice.org.uk/guidance/cg154

Eczema http://cks.nice.org.uk/eczema-atopic

Endometrial cancer http://www.esmo.org/Guidelines/Gynaecological-Cancers/ Endometrial-Cancer

254

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Useful websites

Disease Website

Endometriosis http://cks.nice.org.uk/endometriosis

Epilepsy http://cks.nice.org.uk/epilepsy

Epistaxis http://cks.nice.org.uk/epistaxis-nosebleeds

Gestational trophoblastic disease

https://www.rcog.org.uk/globalassets/documents/guidelines/gt38managementgestational0210.pdf

Glaucoma https://www.nice.org.uk/guidance/cg85

Hearing loss https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0833

Hip fracture https://www.nice.org.uk/guidance/cg124

https://www.nice.org.uk/guidance/cg124/evidence/full- guideline-183081997

Hot swollen joints/septic arthritis

http://bestpractice.bmj.com/best-practice/monograph/486/ treatment/guidelines.html

Infertility http://cks.nice.org.uk/infertility

Ménière’s disease http://cks.nice.org.uk/menieres-disease

Menorrhagia http://cks.nice.org.uk/menorrhagia

Non-complex fractures https://www.nice.org.uk/guidance/NG38/documents/fractures-full-guideline2

Osteomyelitis http://bestpractice.bmj.com/best-practice/monograph/354/ diagnosis.html

Paediatric diabetes https://www.nice.org.uk/guidance/ng18

Paediatric urinary tract infection

https://www.nice.org.uk/guidance/cg54

Pityriasis rosea http://cks.nice.org.uk/pityriasis-rosea

Pityriasis versicolor http://cks.nice.org.uk/pityriasis-versicolor

Polycystic ovarian syndrome

http://cks.nice.org.uk/polycystic-ovary-syndrome

Postpartum haemorrhage

https://www.rcog.org.uk/globalassets/documents/guidelines/gt52postpartumhaemorrhage0411.pdf

Psoriasis http://cks.nice.org.uk/psoriasis

Rosacea http://cks.nice.org.uk/rosacea-acne

Schizophrenia https://www.nice.org.uk/guidance/cg82

Shoulder dystocia https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_42.pdf

Vaginal discharge http://cks.nice.org.uk/vaginal-discharge

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257

abdominal wall defects 111abortion (miscarriage) 74–5abortion (termination) 86absence epilepsy 144achondroplasia 124acne vulgaris 198–9acute fatty liver of

pregnancy 48–9acute lymphoblastic leukaemia

(ALL) 152adhesive capsulitis 226allergy

asthma 132–5eczema 184–5

alopecia areata 202–3α-2 antagonists 7Alzheimer’s disease 28amenorrhoea 82–3amobarbital 12Amsel’s criteria 80anankastic personality

disorder 21anencephaly 118ankylosing spondylitis 238–9anorexia nervosa 22–3antenatal booking

appointments 34–6, 67antepartum haemorrhage

60–3, 74anterior cruciate ligament 244anterior uveitis 168antibiotics

cystic fibrosis 131meningitis 123sexually transmitted

infections 78skin infections 208, 209syphilis 59, 78urinary tract infections 139

anti-D prophylaxis 35, 67antidepressants 4, 6–7, 10antiepileptics 43, 144, 145antifungals 80, 210antihypertensives 45

antipsychotics 16–17, 30antisocial personality

disorder 20antivirals

human immunodeficiency virus (HAART) 57

herpes simplex virus 55, 79, 204

varicella zoster virus 205anxiety 8–9, 12, 21

obsessive compulsive disorder 10–11

anxiolytics 12arthritis

ankylosing spondylitis 238–9

osteoarthritis 222, 228–9rheumatoid 228–9septic 250–1

arthropod parasites 207aspirin 137, 151asthma 132–5atopic eczema 184–5atrial septal defects

(ASDs) 112–13attention deficit hyperactive

disorder (ADHD) 26–7autosomal recessive polycystic

kidney disease (ARPKD) 114avoidant personality

disorder 21

bacterial vaginosis 80balanitis 210barrier contraception 100basal cell carcinoma 216bed rest, prolonged 220benign paroxysmal positional

vertigo 176–7benign rolandic epilepsy 144benign tumours

ovarian cysts 98of the skin 212–14

benzodiazepines 12

beta blockers 45, 165bipolar disorder 18–19bladder exstrophy 115blindness see vision, loss ofblistering disorders 196–7bone

Ewing’s sarcoma 155infections 250–1see also fractures

borderline personality disorder 20

Bowen’s disease 216brachial plexus 227breastfeeding 69Breslow’s thickness 217bronchiolitis 126–7bulimia nervosa 24–5bullous pemphigoid 196–7bullous pemphigus 196–7bunion 248buspirone 12

cancercervical 90–1choriocarcinoma 76–7endometrial 94–5laryngeal 182nasopharyngeal 180oropharyngeal 181ovarian 96–7paediatric 152–5skin 216–17vaginal 92–3

candidiasis 80, 210carbonic anhydrase

inhibitors 165cardiovascular system

congenital defects 112–13

rheumatic fever 136–7carpal tunnel syndrome 234–5cataracts 166–7cavernous haemangioma 213cellulitis 208

Index

K30033_Index.indd 257 28/02/17 2:24 pm

258

cephalopelvic disproportion 38cerebral palsy 120–1cerebrovascular disease 29cervical cancer 90–1cervical disc prolapse 223cervical ectropion 91cervical spondylolisthesis 222cervical spondylosis 222chemotherapy, paediatric

cancers 152, 153, 154, 155child abuse 124childbirth

dystocia 38physiology of labour 37post-partum

haemorrhage 64–5chlamydia 78chocolate cyst

(endometrioma) 98cholestasis (of pregnancy) 46–7choriocarcinoma 76–7chromosomal abnormalities

34, 149Clark levels 217closed angle glaucoma

164, 168Clostridium perfringens 209clozapine 17club foot 249COCP (combined oral

contraceptive pill) 100coeliac disease 124cognitive dysfunction 28–32cold sores 204compartment syndrome 221complex regional pain

syndrome 221condylomata accuminata

(genital warts) 78congenital defects

cardiovascular 112–13cataracts 166genitourinary 114–15hearing loss 172

neural tube defects 43, 118–19

rubella syndrome 53conjunctivitis 169contraception 100–1Coombs test 66corticosteroids see steroidsCotard’s syndrome 3Creutzfeldt–Jakob disease

(CJD) 32Crigler–Najjar syndrome 105croup 128–9cruciate ligament

tears 244–5cyclothymia 18cystadenoma 98cystic fibrosis (CF) 130–1cysts

ovarian 98skin 214

cytomegalovirus (CMV) 54

D2 (dopamine) receptor 16de Quervain’s syndrome 232deafness 172–5dementia 28–32dependent personality

disorder 21depression 2–7dermatitis

atopic eczema 184–5seborrhoeic 186–7

dermatofibroma 212dermoid cyst 98, 214developmental dysplasia of

the hip 242–3diabetes mellitus

eye disease 170in pregnancy 40–1

diabetic ketoacidosis (DKA) 146–8

diagnostic classifications 253diazepam 12disc prolapse, cervical 223

Down’s syndrome (trisomy 21) 34, 149

dry macular degeneration 162, 163

Dupuytren’s contracture 232–3dystocia 38

earhearing loss 172–5vertigo 176–7

eating disordersanorexia 22–3bulimia 24–5

ectopic pregnancy 72–3eczema, atopic 184–5Edward’s syndrome (trisomy

18) 149elbow 230–1emergency contraception 101encephalocoele 118endolymphatic hydrops 174endometrial cancer 94–5endometrioma/endometriosis

98epidermoid cyst 214epilepsy

childhood 144–5in pregnancy 42–3

episcleritis 168epistaxis 178–9erythema multiforme 192–3erythema nodosum 192–3Ewing’s sarcoma 155eye

diabetic retinopathy 170glaucoma 164–5, 168red eye 168–9see also vision, loss of

failure to thrive 124–5Fallot’s tetralogy 112–13fatty liver, in pregnancy

48–9femur, proximal see hip

Index

K30033_Index.indd 258 28/02/17 2:24 pm

259

fetusanti-D status 66–7antiepileptic drugs 43complications of maternal

infections 51, 53, 54, 55, 59

flat foot 248flumazenil 12foot

orthopaedic conditions 248–9tinea pedis 211

fracturescomplications 220–1hip 240–1metatarsal 249scaphoid 234

frontal lobe epilepsy 42frontotemporal dementia 30–1frozen shoulder 226fungal infections 80, 210–11

G6PD (glucose-6-phosphate dehydrogenase) deficiency 105

gangrene 209Garden classification 241Gardnerella vaginalis 80gas gangrene 209gastrointestinal tract

candidiasis 210Hirschsprung’s disease 109intussusception 110necrotizing enterocolitis

106–7pyloric stenosis 108

gastroschisis 111generalized anxiety disorder

8–9, 12genital herpes 79genital warts 78genitourinary system

abnormalities 114–15infections 58–9, 78–80,

138–9

see also kidneyGerman measles 52–3gestational diabetes

mellitus 41gestational trophoblastic

disease 76–7glaucoma 164–5, 168glucose tolerance test 40glue ear 174–5golfer’s elbow 230–1gonorrhoea 78groin 211

haemangioma 213haemolytic disease of the

newborn 66–7haemolytic uraemic syndrome

(HUS) 140–1haemorrhage

antepartum 60–3, 74epistaxis 178–9menorrhagia 81post-partum 64–5

hair lossalopecia areata 202–3tinea capitis 211

hallucinations 3hallux valgus 248hand

carpal tunnel syndrome 234–5

de Quervain’s syndrome 232Dupuytren’s contracture

232–3scaphoid fracture 234stenosing tenosynovitis 233

Hansen’s disease (leprosy) 209head lice 207hearing loss 172–5heart

congenital defects 112–13rheumatic fever 136–7

Henoch–Schönlein purpura (HSP) 142–3

hepatic diseaseneonatal jaundice 104–5in pregnancy 46–9

hereditary haemorrhagic telangiectasia 116

herpes simplex virus (HSV) 55, 204genital 79

herpes zoster 205highly active antiretroviral

therapy (HAART) 57hip

developmental dysplasia 242–3

fracture 240–1Perthes disease 242–3Slipped upper femoral

epiphysis 240–1Hirschsprung’s disease 109histrionic personality

disorder 20hormonal contraception 100–1horseshoe kidney 114human immunodeficiency virus

(HIV) 56–7human papillomavirus (HPV)

78, 90, 206Huntington’s dementia 31hydatidiform mole 76–7hyperemesis gravidarum 46–7hypertension in pregnancy 44–5hypertrophic pyloric

stenosis 108hypospadias 115hypothyroidism 124

impetigo 208implants, contraceptive 101incontinence 99infertility 88–9

amenorrhoea 82–3infraspinatus 224injections, contraceptive 100insomnia 12

Index

K30033_Index.indd 259 28/02/17 2:24 pm

260

intra-hepatic cholestasis of pregnancy 46–7

intra-hepatic jaundice 104intraocular pressure (IOP),

raised 164–5intrauterine contraception

(IUD/IUS) 101intussusception 110

Jarisch–Herxheimer reaction 59jaundice, neonatal 104–5jock itch (tinea cruris) 211Jones criteria 136

Kawasaki’s disease 150–1keratoacanthoma 216ketoacidosis, diabetic 146–8kidney

autosomal recessive polycystic kidney disease 114

horseshoe 114Henoch– Schönlein

purpura 142haemolytic uraemic

syndrome 140–1Wilms’ tumour 154

kneecruciate ligament tears

244–5meniscal tears 246other pathology 247

kyphosis 236–7

labour 37dystocia 38

laryngeal cancer 182lateral epicondylitis 230–1Legg–Calvé–Perthes

disease 242–3Lennox–Gastaut syndrome 145leprosy 209leukaemia (ALL) 152

Lewy body dementia 30lichen planus 194–5lichen sclerosus 194–5lipoma 214lithium 17liver disease

neonatal jaundice 104–5in pregnancy 46–9

lumbar plexus 252lumbar puncture (in

meningitis) 122lymph node syndrome 150–1

macular degeneration 162–3Malassezia spp. 186, 190malignant disease see cancermania 19Meckel’s diverticulum 110medial epicondylitis 230–1melanoma 217Ménière’s disease 174meningitis 122–3meningocoele 118meningomyelocoele 118meniscal tears 246menorrhagia 81menstrual disorders 81–3metatarsal fracture 249miotic drugs 165miscarriage 74–5molar pregnancy 76–7monoamine oxidase inhibitors

(MAOIs) 7montelukast 135mood disorders

bipolar disorder 18–19depression 2–7

morning-after pill 101murmurs, cardiac 113Mycobacterium leprae 209

nails 189, 202narcissistic personality

disorder 21

nasopharyngeal cancer 180neck

disc prolapse 223spondylolisthesis 222spondylosis 222

necrotizing enterocolitis 106–7Neisseria gonorrhoeae 78neonates

jaundice 104–5rhesus disease 66–7

nephroblastoma 154nerves

brachial plexus 227lumbar plexus 252

neural tube defects (NTDs) 43, 118–19

neuroblastoma 152–3neurocutaneous syndromes

116–17neurofibromatosis 116neuroleptic drugs 16–17, 30neuroleptic malignant

syndrome 16noradrenaline reuptake

inhibitors (NRIs) 7nosebleeds 178–9

obsessive compulsive disorder (OCD) 10–11

oesophagitis, candidal 210olanzapine 17omphalocoele 111open angle glaucoma 164optic neuropathy 159oral candidiasis 210oral contraception 100oropharyngeal cancer 181Osgood–Schlatter disease 247Osler–Weber–Rendu

syndrome 116osteoarthritis 228–9

cervical spondylosis 222osteochondritis dissecans 247

Index

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261

osteomyelitis 250–1osteonecrosis of the femoral

head 242–3ostium primum 112ostium secundum 112otitis media 174–5otosclerosis 175ovary

cancer 96–7cysts 98polycystic ovary syndrome

84–5overflow incontinence 99

pancreatitis, chronic 40paranoid personality disorder 20parasites, skin 207Parkinson’s disease 30Patau’s syndrome (trisomy 13) 149patellar subluxation

syndrome 247Pearl Index 100pemphigus 196–7personality disorders 20–1Perthes disease 242–3pes cavus 249pes planus 248petit mal (absence)

epilepsy 144Pick’s disease 30–1pityriasis rosea 190–1pityriasis versicolor 190–1placenta praevia 62–3placental abruption 60–1plaster casts 220polycystic ovary syndrome

(PCOS) 84–5POP (progesterone only

pill) 100port-wine stain 213post-hepatic jaundice 104post-partum haemorrhage

(PPH) 64–5

posterior cruciate ligament 245pre-eclampsia 44–5pre-hepatic jaundice 104pregnancy 39

antenatal care 34–6, 67diabetes 40–1ectopic 72–3epilepsy 42–3liver disease 46–9miscarriage 74–5molar 76–7placenta praevia 62–3placental abruption 60–1pre-eclampsia 44–5symphysis pubis

dysfunction 68TORCHES infections 50–9see also childbirth

primary amenorrhoea 82prion disease 32prostaglandin analogues 165psoriasis 188–9psychosis 14–17punch drunk syndrome 32pyloric stenosis 108pyogenic granuloma 213

red eye 168–9refeeding syndrome 23renal disorders

autosomal recessive polycystic kidney disease 114

horseshoe kidney 114Henoch– Schönlein

purpura 142haemolytic uraemic

syndrome 140–1Wilms’ tumour 154

respiratory tractasthma 132–5bronchiolitis 126–7croup 128–9

retinal artery occlusion 161retinal detachment 160retinal vein occlusion 158retinopathy, diabetic 170Reye syndrome 137rhesus disease 66–7rheumatic fever 136–7rheumatoid arthritis 228–9ringworm 211Risk of Malignancy Index 96rosacea 200–1rotator cuff tears 224–5Rotherham criteria 84rubella 52–3

salbutamol 134salmeterol 134Salter-Harris classification 221scabies 207scalp

alopecia areata 202–3head lice 207tinea capitis 211

scaphoid fracture 234Scheuermann’s disease 236schizoid personality

disorder 20schizophrenia 14–17schizotypal personality

disorder 20Schneider’s first rank

symptoms 14scleritis 168SCOFF questionnaire 23scoliosis 236–7seborrhoeic dermatitis 186–7seborrhoeic keratosis 212secondary amenorrhoea 83seizures see epilepsyselective serotonin reuptake

inhibitors (SSRIs) 6, 10semen analysis 88septic arthritis 250–1

Index

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262

serotonin noradrenaline reuptake inhibitors (SNRIs) 6–7

sexually transmitted infections (STIs) 58–9, 78–9see also human

immunodeficiency virusshingles 205shoulder

adhesive capsulitis 226dislocation 224–5rotator cuff tears 224–5

shoulder dystocia 38sight, loss of see vision,

loss ofsilver nitrate cautery 178skin

benign lumps 212–14bullous disorders 196–7infections 204–11lichenoid lesions 194–5malignancies 216–17neurocutaneous syndromes

116–17rashes 184–93, 198–201

slipped upper femoral epiphysis (SUFE) 240–1

solar keratosis 212spherocytosis 105spina bifida 43, 118–19spine

ankylosing spondylitis 238–9

cervical 222–3curvature 236–7stenosis of the spinal

canal 238–9spondylolisthesis, cervical 222spondylosis, cervical 222squamous cell carcinoma 216Staphylococcus aureus 208stenosing tenosynovitis 233

sterilization 101steroids

asthma 134–5croup 129side effects 133

Stevens–Johnson syndrome 192, 193

strawberry naevus 213Streptococcus spp. 136, 208stress incontinence 99stridor 128Sturge–Weber syndrome 117subconjunctival

haemorrhage 169subscapularis 224supraspinatus 224sweat test 131sympathomimetics 165symphysis pubis dysfunction 68syphilis 58–9, 79

talipes equinovarus 249temporal arteritis 159temporal lobe epilepsy 42tennis elbow 230–1teres minor 224termination of pregnancy 86tetracyclic antidepressants 7tetralogy of Fallot 112–13theophylline 135thyroid disorders 124tinea cruris/tinea capitis/tinea

pedis 211TORCHES infections 50–9

HSV 55, 79, 204syphilis 58–9, 79

toxoplasmosis 51transposition of the great

vessels 112–13Treponema pallidum 58–9, 79trichomoniasis 78tricyclic antidepressants 6

trigger finger 233trisomy 149

Down’s syndrome 34, 149

truncus arteriosis 112–13tubal (ectopic) pregnancy 72–3tubal ligation 101tuberous sclerosis 116tumours see benign tumours;

cancer

urge incontinence 99urinary incontinence 99urinary tract

congenital defects 114–15infections (UTIs) 138–9

uterine (endometrial) cancer 94–5

vaginableeding per 60–5, 81, 90,

92, 94cancer 92–3infections 78–80lichen sclerosus 194–5

varicella zoster virus (VZV) 205

vascular dementia 29vasculitis

Henoch– Schönlein purpura 142–3

Kawasaki’s disease 150–1vasectomy 101ventricular septal defects

(VSDs) 112–13vertigo 176–7vision, loss of

cataracts 166–7glaucoma 164–5macular degeneration 162–3sudden 158–61

vitreous haemorrhage 161

Index

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263

vomiting, hyperemesis gravidarum 46–7

von Recklinghausen disease 116

vulvovaginal candidiasis 80, 210

wall test 239warts 206

genital 78

washerwoman’s sprain 232

websites 34, 100, 134, 254–5

Westley Croup Score 128West’s syndrome 145wet macular degeneration

162, 163

Wilms’ tumour 154Wilson’s disease 32wrist fracture 234

Yerkes–Dodson law 8

zidovudine 57zolpidem 12

Index

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