Emma OSCE guide thingy*

* = specific points from actual past OSCE marking guides I found = other stuff (books, tuts, PBLs, etc)

HypertensionHx:

compliance with medications exercise diet and salt intake 'explore secondary causes” (see below) 'cofactors': weight and alcohol use stress ('how is everything at work/home')

Examination General inspection: cushinoid features, oedema

(nephritic syndrome/HF/pregnant) Eye exam: fundoscopy for grade of hypertensive

retinopathy CVS exam:look for LHF (to assess severity), coarction (radiofemoral delay/weak pulses), renal bruits Abdo exam:masses/palpable kidneys Thyroid exam and lymph nodes

Investigations:If not done, get

U+E U/A (MSU) FBC weight

If those done, then get BSL + insulin (DM) ECG/echo (for hypertrophy, cardiomegaly) protein/creatinine ratio (renal causes) fasting lipids (good for Px) renal U/S (renal causes duh) cardiac stress test (for heart failure) TFTs (thyroid causes) aldosterone/cortisols (endocrine causes)

Ruling out 2ndary causes: are you pregnant? Changes in weight tiredness/lethargy urinary Sx PMHx: DM, lipids, IHD/HF, stroke, renal disease Medications (OCP, steroids, MAOIs) Renal Qs: oedema, blood in urine, urinary Sx, abdo

pain DM Qs: polyuria, nocturia, fatigue, thrush Cancer Qs: night sweats, bone pain Thyroid Qs: cold intolerance, hair/skin changes

Top 5DDx:1 essential (95%)2 Renal:Diabetes!!chronic GN, PCKD (have been in past OSCEs)some renovascular disease 3 endocrine: ↑ aldosterone (conns, adrenal hyperplasia)Pheochromocytoma, Cushings, hypothyroid4 other: coarctation of aortaPregnancysteroids, COC

For Px, look for retinopathy, LHF, proteinuria

Counselling Explain risks Explain treatment goals 140/85 130/80 if DM Lifestyle: Good chance they may

need to lose some fucking weight, you bastards Tell ‘em to quit smoking, start walking and clean up

their diet (salts, alcohol) Then bring ‘em back another day to discuss

lipids/sugars etc

Management:Treat any causes, refer to who ever (diabetes education, endocrinologist, nephrologist, onchologist)Meds: start with a thiazide diuretic

Warn ‘em about: hypoK, ↓ glucose tolerance, cholesterol

Watch out for: goutStart with ACEI if under 55, DM, LHF

Warn ‘em about: cough, postural hypotension, renal failure, ↑K

Watch out for: renal diseaseAdd Ca blocker, thiazide or ACEI as 2nd and 3rd

drugsThen add B-blockers or spiranolactone – B-

blockers good in pregnancy, pheochromoWarn about: hypotensionWatch out for: asthmaIf used as a 1st drug, add Ca-blocker

and NOT THIAZIDE

CXR scriptThis is the PA chest X ray of [name], a [age] [sex]The film is well penetrated + well centred

Lung fieldsLung fields….are clearThere is/are [a/symmetrical]

Infiltration / opacificationPatchy consolidation

of/in the [left / right / bilateral] [upper / lower / mid zones / hemi-thorax]

obscuring the costophrenic angles / left hemi-diaphragmand the presence of air bronchograms

There is/are calcification/plaquesalong the L/R hemi-diaphragm / pleura

There is air visible under the L/R hemi-diaphragm

Heart failure…thickened upper lobe veins……interstitial pulmonary oedema…+ interstitial thickening (Kerly B lines)…alveolar pulmonary oedema patchy consolidation (bats wing consolidation)

There is cardiomegaly (STEMI)signs of [Right / Left] [atrial / ventricular] hypertrophyThe mediastinum is..normal size

…decreased lung volume…

solitary pulmonary noduleThere is a solitary [left / right]…[peripheral / central / hilar] mass … with …

◦ [smooth / irregular] outline◦ satellite nodules◦ [hilar / para-tracheal / mediastinal]

lymphadenopathy◦ associated destruction of the L/R [numbers]

anterior ribs◦ pleural effusion◦ [complete / partial] [L/R] [upper / mid / lower]

lobe collapse

(There are multiple rounded lung lesions)

CXR: positioning, penetration, lung fieldsheart size = enlarged heartabnormal shape of heart – for stemi

Lung Fx guyHxAB man SOB and smokes

if he smokeshow much he smokeshow long he has smoked forWhat medications has he used in the past (no asthma)

Counsel about SOBIs only able to breathe out about half the rate of healthy people his age and heightLungs have become stiff and not as elastic they should beA lot of this is due to his Hx of heavy smokingWhen he had the inhaler/nebuliser this improved his breathing a liitle and it may be worth treating him with medicine similar to the blue inhaler he used beforeMay also be worth trying some other different types of medications to prevent some of his wheezing

Counsel about QUITHis lungs will continue to get worse, possibly quite quickly if he keeps smokingHe will find it harder to exercise and get more chest infectionsIf he stops smoking his lungs should stop getting much worse and should stay about that same for many yearsBecause he has already damaged his lungs, may get slowly worse even if he stops smoking, but if he keeps smoking they will definitely get worse much more quickly.Recognises that is difficult to stop smoking and suggest that there are a number of programs that may help him quit (mention one)

ECG script

This is the ECG of [name], a [age] [sex] Rate is [rate]

'The trace is in [sinus rhythm]

There is/are [no P wave conduction] ◦ [NO P WAVES]◦ with [irregular baseline]

The trace is in [first/second/third] degree heart block

There is a [normal/short/prolonged] PR interval

There is [right / left] axis deviation[normal cardiac axis]

QRS complexes, ST segments and T waves

There normal [QRS complexes, ST segments and T waves]

There are [ir/regular], [broad/widened/narrow] QRS complexes [of ab/normal shape] and rate [rate]

There is/are [normal ST segments]◦ [depressed/raised ST segments] at leads [ ]◦ [ST elevation] at leads [ ]

There are [normal T waves]◦ [inverted T waves]◦ [no identifiable T waves]◦

BBB and heart block There is [RBBB/LBBB]

little square: 40msbig square: 200ms

R-R intervals2 big squares: 150/min3 big squares: 100/min4 big squares: 75/min5 big squares: 60/min6 big squares: 50/min

P wave: 80-100msPR interval: 120-200msQRS complex: <120msQTc interval: 300-440msST segment: 80-120ms

30F with palpitationsECG

name, rate, rhythm, axis VPBs (ventricular extrasystole)

What does it mean – use diagram!! normal heart extra beats are from the ventricle doesn't mean there is a problem but the heart is irritable, from external factors

Ventricular extrasystole

early QRS with no P wave wide, abnormally shaped QRS abnormally shaped T wave Next P wave is on time

Advise about risk factors coffee lack of sleep smoking – give advise for quitting best not to use drugs to suppress them – makes it

worseReassure

no other tests needed

no jargon, but reassure68M past STEMI with palpitations

ECG results: explainAF with rapid ventricular responseProblems associated with AF

Thromboemboliv events like strokeTachycardia

HypotensionAngina with patient has IHDHeart failure

ManagementSlow ventricular rate

B-BlockersCa blockers (verapamil / diltiazem)Digoxin

AnticoagulationHeparin initially (UFH or LMWH)Warfarin

Cardioversion: hazardous if >2 daysmay be able to TOE to exclude intercardiac thrombusfor anticoagulate for 4 weeks first

Counselling for people who fail at lifeA) Big guy with dizzy spells

Assessment for risk factors Smoking

ETOH - quantify caffeine intake Exercise? Overweight?

BP? when last checked?

ECG Name, rate, rhythm axis sinus rhythm with VEB in leads v4, v5 atrial ectopic

Counselling “These extra beats in your heart can be caused by

a number of factors, such as your ◦ weight◦ ETOH and caffeine use◦ your smoking◦ your diet

I'm also concerned that you are at risk of heart problems, like heart attacks and stroke. “

Ventricular extrasystole causesCardiac: IHD, mycarditis, MILifestyle: stress/poor

sleep/caffeine/tobacco/ETOH,Drugs: Digoxin, TCAsElectrolyte imbalance (↓K/MG), thyroid

Mx healthy food – less salt and fats, maybe draw

triangle? - who cooks in the house? Take away? Lose weight reduce ETOH (I'm concerned about the amount

you drink) Quit smoking – bring up quite dates, champix, GP

support exercise – suggestions like parking away from

office and walking a bit, going for walks with family, team sports

coping and relaxation – suggest 'family time', away from phone and computer, baths, yoga

Further Ix Blood tests: fasting cholesterol, glucose exercise ECG echocardiography

Make a follow up plan, bring him back in 2 weeks to discuss lifestyle changes

If dizziness gets worse or chest pains, go to hospital

Refer to dietician

B) 60F with STEMI to assess cardiac statusHx:

chest pain? Describe palpitations? Nocturnal dyspnoea? Orthopnoea? Exercise tolerance? Ankle swelling/weight gain

CXR: positioning, penetration, lung fieldsheart size = enlarged heartabnormal shape of heart

ECG: Name rate rhythm axis Describe ST segments and T waves

Normal ECG → raised ST segments (6 hours) → normalised ST segments → inverted T waves (24 hours)

“persistent ST elevation for >8 weeks is significant”

Top complications of MI

arrhythmiaheart failurerecurring ACS/anginapericarditisLV aneurism and mural thrombusDVT/PEstroke

Dx: left ventricular aneurism Further Ix: echocardiography Mx: ACEI or diuretics refer to cardiologist

Diabetes M (the M stands for MacDonald’s)

Ax of ulcers (PBL) Hx: smokes?

Exam: look for PVD, do neuro exam (esp sensation)

Ix: swab ulcer for micro

Dopplerplain film Xray for OM – bone scan and MRI are much betterRule out other neuro causes - B12, foliate, thyroxin

Mx: dress ulcer and refer to podiatrist Augmentin/cephalexin + metronidazole

Diagnosing DM Sx: thirst, polyuria, weight loss, visual blurring fasting >7 random >11.1 (and later redone)

First round Ix U/A for glucose and proteins random blood glucose → GTT

Further Ix HbA1c (<7%) fasting lipid profile albumin/creatinine ratio on urine podiatrists review or monofilament foot check by

nurse/AHW ophthalmologist review or retinal screen

Ix for autonomic neuropathy (PBL) ECG (loss of beat to beat variation in R-R interval) postural hypotension valsalva ratio

Blurred vision

Top DdxStructural: refraction, cataracts, ulcersDiabetic retinopathy

Leg ulcers

Top Ddx1 venous (70%)2 ischaemic/arterial (5%)3 mixed (20%)4 neurogenic (DM)5 trauma, infection, cancer

Explaining consequences kidney damage heart problems blindness foot problems – numbness, ulcers, risk of

amputationLifestyle issues

Diet – preliminary advice, offer referral to dietician or AHW

exercise- quantify – suggest options smoking and ETOH – Ax risk, quantify use

MedsMetformin – overweight, diet treated patients

NOT in renal/hepatic diseasethen add sulfonylurea

BP control

Screen: >55 or >35 indigenous, islanders, Chineseheart disease, GDM, PCOS, obese>45 if BMI>30, 1st degree FHx, HTN

Counsel for TransfusionPros and cons for low Hb risk of further bleeding still present endoscopy is safer if transfused more rapid recovery against normal vital signs asymptomatic risk of transfusion

Alternatives IV fluids to maintain circulatory volume Reassess Hb: transfuse if dropping Monitor vitals: transfuse if deteriorate Await endoscopy outcome and assess bleeding

risk Discuss with more senior Dr Explains if not transfused, replete bone marrow will

correct anaemia

Explain Correct cross-matching blood and patient checks Close monitoring during transfusion

Safety Australian blood supple one of the safest in the

world but not without risk HIV very rare but possible (1:10000,000) Other risks

Fever / rigors, hives / itch – common often mld Fluid overload – shortness of breath, heart

failure Blood incompatibility – haemolytic reactions,

kidney failure, coagulopathy, anaphylaxis Acute lung injury – respiratory failure Contamination – infections HTLV, HBC, HCV,

CMV, EBV, very rare, or bacterial Delayed haemolysis anaemia’s, jaundice,

delayed thrombocytopenia bruising Consent not obtained, so will not proceed at this

stage

Bleeding ♀

Common bleeding DDx

purpura simplex senile purpura steroid induced

trauma

Hx purpura / bruises (describe)

◦ injuries? Bumps or falls?◦ joint swelling

epistaxis / gum bleeding blood in: urine / stools women

◦ Menorrhagia◦ PPH/surgical bleeding

FHx of bleeding or bleeding disorders medications

◦ aspirin◦ Warfarin / Heparin / Clopidogrel

PMHx:◦ recent viral illness◦ ETOH use◦ dental work◦ liver disease or SLE/RA◦ cancer screen

Examination vitals: haemodynamically stable? haemorrhagic lesions (echymoses, purpura)

◦ senile purpura = hands◦ petechiae = platelet/vascular cause◦ thighs + buttocks = HSP◦ joint swelling

GIT◦ splenomegally◦ lymphadenopathy◦ hepatomegally / jaundice

Vascular disorders HSP

Coagulation Haemophilia A/B vWD DIC liver disease

◦ Vit K deficiency◦ alcoholism

WarfarinThrombocytopenia

ITP drug induced thrombocytopenia

◦ chemotherapy◦ anticonvulsants◦ diuretic (thiazide)

marrow failure TTP

Platelet dysfunction drug induced inherited disorders

Ix Urine U/A (blood) FBC + blood film

◦ platelets <50 = thrombocytopenia coag profile

◦ APTT: ↑ = coagulation cause◦ Prothrombin Time: ↑ = vitamin K deficiency

fibrinogen = DIC, liver disease platelet function analyser

◦ measures time to form platelet plug◦ CEPI: if prolonged then do◦ CADP: if normal = aspirin effect

prolonged = platelet dysfunction

Further Ix coag factor assays

◦ vWD:▪ ristocetin cofactor▪ vWF antigen

◦ Haemophilia: FVIII + FIX◦ APPT 50:50 corrects in vWD, not in drugs

platelet aggregate studies ◦ ADP, collagen, adrenalin, ristocetin

Haemophilia X-linked recessive A factor VIII B factor IX (Christmas)

→ unstable plug + excessive bleeding Sx

◦ haematoma◦ haemarthrosis◦ haematuria

von Willebrands Disease Type 1 autosomal dominant

◦ Type 3 is severe Sx (1/3 no Sx)

◦ easy bruising◦ nose/gum/post dental bleeds◦ menorrhagia◦ haematomas + haemarthrosis

Counselling vWD a bleeding disorder

lack of or poorly functioning vWF milder then haemophilia normal lifestyle and life span can be achieved risk at time of operations, births need specialist care: refer to a HAEMOTOLOGIST

Mx and risks Importance of prophylactic treatment before procedure DDAVP, factor 8 concentrate, TA

Desmopressin (DDAVP): release vWF from cells prophylactic for menstruation + minor ops effective for 2-3 days

Biostate: blood product with FVIII + vWF just recombinant FVIII is useless tranexamic acid: good as mouthwash

If need blood products: risk of HIV Hep B vaccination

Risk to my child Inherited risk uncertain Each pregnancy 50% chance it will be passed to child

(AD) but effects individuals differently (variable penetrance)

Severity varies over time

Been tired lately, is from vWD? Blood from menorrhagia may be causing Fe deficiency Need Fe studies

Young woman with PEHx

Recent travel Recent trauma FHx: thromboembolism OCP or other medications + OTC ETOH Aspirin NSIADs Contraindications

o pregnancyo peptic ulcers / GI bleedso bleeding disorderso liver failure

Ix – Counsel Procoagulant screen Lupus anticoagulant Factor V mutations Protein C + S Anti-thrombin III

What is it? Inhibits reductase enzyme for vit K

regeneration

Mx counselling

Duration and monitoring Start on Heparin + Warfarin Heparin starts acting ASAP, but Warfarin takes 5-7 days to work properly It stops the parts that protect against clots

before the parts that help clots form

Take blood to check your INR (clotting) for 4 days, then we can tweak the amount of Warfarin

AIMS: INR<1.4 before we start, want you between 2-3 once Warfarin is stable

Heparin injection once a day for about a week Warfarin for 6 months

Side effects Bleeding, easy bruising (?aspirin) If blood in cough, stool, urine come back in,

may need to adjust dose Warfarin induced skin necrosis: very rare and

never with Heparin Rarely hypersensitivity reaction, purple toe

Elderly with poor urine output + weakness

Hx Fluid loss

o Urine output Hxo Vomiting, diarrhoea, bleedingo Urinary Sx (blood) or flank pain

Nocturia = CRF Fluid intake dehydration: thirst, postural dizziness, weight loss PMHx:

◦ HTN◦ RF or renal disease◦ HF◦ Prostate or stones or cancers

recent illness?◦ vomiting, diarrhoea◦ fevers, chills◦ GI blood / haematuria◦ HTN??

Drugs◦ NSAIDs◦ ACE-I◦ radiocontrast◦ aminoglycosides◦ methotrexate◦ IVDU, opioids (rhabdomyolysis)

Examination vitals hydration infections fundi: retinopathy suggests pre-existing renal insult Chest: heart failure Abdo

o Kidneyso Bruits (RAS)

IxBloods

U+E◦ Hypovolaemia◦ Raised 1:20 ratio◦ Need prior creatinine to Dx CRF

K: the killer in ARF FBC

◦ ↑HB in hypovolaemia◦ normocytic in CRF

ABG◦ ARF metabolic acidosis

◦ Vomiting alkalosis

CK rhabdomyolysis (ATN) Glucose, Ca, LFTs (causes)

Urine U/A + MCS

◦ SG in hypovolaemia), proteinuria, haematuria, culture if septic

◦ Hyaline casts = ATN + hypovolaemia Electrolytes: urine:serum creatinine >10 = pre-renal

Renal U/S Smooth, normal size = acute pre-renal Dilated / calculi = post-renal Small, scarred, echogenic = chronic

o Masses (obstruction)

Pre-renal (50%) hypovolaemia heart failure renal artery insufficiency/stenosis

Intrinsic ATN glomerular

Post-renal urethral / ureter prostate

Mx IV fluid resuscitation Cease NSAIDs, ACEI Hold on K replacement failure to regain OU with fluids = ATN or intrinsic

If oliguria keeps getting worse:

Ruling out ATN (Dx of exclusion) fluid resus → ↑ UO and ↓ creatinine

= pre-renal ARF clear block → dilated pelvises + ↓ creatinine

= post-renal ARF HTN, proteinuria, haematuria

= rapidly progressive GN fever, rash, eosinophilia, HTN, haematuria

= acute interstitial nephritis (NSAIDs, penicillin, strep)

atherosclerosis + vascular bruits + eosinophilia = atheroembolic ARF

Mx for ATN admit + fluid resuscitation stop diuretics, ACEI, NSAIDs

high K foods, K retaining drugs monitor

◦ Hourly: fluid balance, body weight, volume status, U+E

◦ Daily: FBC, Ca, Phos Then add:

◦ inotropes (Dopamine)◦ Frusemide

Fluid restriction: previous day's UO + 500 ml, slight over hydration

If it keeps getting worse:

Uraemiaprogressive accumulation of nitrogenous waste/fluid

↑ K → weakness + arrhythmia metabolic acidosis → Kussmaul resps uraemic encephalopathy → confusion, tremor

◦ ↑ reflexes + upgoing toes platelet dysfunction → bleeding pericarditis ↓↓ BP + ↓↓ temperature

Ix Bloods

◦ FBC (sepsis), CRP◦ cultures◦ U+E

Urine CXR ABG, VQ ECG for arrhythmias CT head, neuro exam, drug screen

Mx needs dialysis

◦ life threatening hyper kalaemia → IV Ca → salbutamol inhaled ± insulin+glucose

Indications for emergency dialysis ↑↑↑K (>7mmol/L) pulmonary oedema worsening metabolic acidosis (<7.2, BE<-10) Uraemia encephalopathy

Counseling dialysis her symptoms are from kidneys being shut down chemicals are building up in her body her kidneys can recover, but will take time the dialysis will remove the bad chemicals and let

the kidneys rest may have to stay on it for 1-2 weeks

JaundiceHx Jaundice: duration, level Fatigue Vomiting and nausea Drugs, medications, ETOH Hep risks

Travel IVDU / tattoos / piercings transfusions

Other Sx Pain Pale stool, dark urine Itching/pruritis

Pre hepatic (haemolytic) Dyserythropoiesis GilbertsHepatic HC damage ± cholestasis Hepatitis (CMV, EBV, AIH) Drugs

Paracetamol Statins Valproate

ETOH / cirrhosis liver mets / abscess haemochromatosis septicaemia RHFCholestatic/post-hepatic/obstructive Conj spills over into blood dark urine, pale

stool, pruritus Gallstones pancreatic cancer drugs

steroids OCP

PSC / PBC

Examination Vitals: temperature, confusion lymphadenopathy General:

jaundice gynaecomastia hepatic flap

Skin: spider naevi palmer erythema scratch marks (obstructive) needle marks

abdo: Liver: large or small, firm, tender splenomegally Masses ascites

IxUrine: no bilirubin = pre-hepatic No urobilinogen = obstructiveBloods FBC, clotting, blood film, retic count, Coombs U+E Hep serology HBV surface antigen = current infection HBV core antibody = any infection HBV Surface antibody = immune HAV IgM = acute IgG = past infection EBV, CMV U/S: dilated ducts (obstruction) ERCP GS, mets, pancreatic masses If not dilated biopsy

LFTsALP = cholestasis = obstruction, cancer GGT = obstruction / ETOH AST = hepatocellular damage – hepatitis, ETOH bilirubin = hepatitis, obstruction unconjugates bilirubin = pre-renal + Gilberts

Young woman with abdo pain + bloody diarrhoeaHx pain Hx travel, shellfish Abx use infected contacts? Sexual Hx animal contacts diarrhoea Hx fever, pain, dehydration duration of illness

Examination general: toxic Vitals hypovolaemia abdo exam

◦ tenderness◦ rebound, guarding◦ masses (ectopics)

DRE Murphy’s sign Rovsing's sign

Ix bloods

◦ FBC: anaemia, WCC (infect or inflamm)◦ U+E (dehydration, renal failure)◦ LFT (albumin + total protein)◦ ESR/CRP/platelets: inflamm

urine: bHCG, U/A + culture stool: leucocytes (IBD), culture (parasites, dificile) plain AXR (obstruction, toxic megacolon,

perforation) plain CXR: perforation (gas under diaphragm)

Mx bowel obstruction admit → decompression with NGT fluid resuscitation analgesics ± antiemetics antibiotics refer surgeon

Acute-on-Chronic abdo pain DDx IBD appendicitis pancreatitis coeliac disease gallbladder stones IBS ectopics UTI

Further Ix abdo CT: for cause of bowel obstruction sigmoidoscopy/colonoscopy: to confirm IBD ± Fe studies

Mx of IBD Truelove regimen

◦ IV steroids acutely 100mg 6hrly to induce remission ~5 days

→ oral pred ~50mg/day◦ Abx: ciprofloxicin + metronidazole

add immunosuppresion: takes 8 weeks for full effect, so need steroids◦ if mild, use sulfasalazine ◦ if sulfur allergy or severe: 6-MP, azathioprine

monitor for bowel obstruction

Counseling Long term: 13% active chronic, 73% intermittent

chronic Half will need surgery at some point pregnancy:

◦ Lower fertility. No increased risks if not active at time of conception

◦ active → PTL, LBW◦ Safe meds in pregnancy: steroids, TPN,

sulfasalazine

ABDO pain Ddx obstruction perforation inflammation

◦ IBD◦ IBS◦ toxic megacolon

infection◦ UTI, PID◦ ABx related◦ appendix, diverticular, abscess

vascular (aneurism) pancreatic / biliary

♀ RIF pain appendix ovarian cyst pregnancy / ectopic intestinal lymphoma UTI

Haemochromatosis

Hx Sx

bronze tired, weight loss swollen fingers / joint pain abdo pain loss of libido itchiness

DM Sx Nocturia polyuria

FHx: Thalassaemia, haemochromatosis Lifestyle

ETOH use Diet: meat, OJ + white wine with meal

PMHx: Anaemias Arthritis Transfusions Liver problems

Examination General

Bronze Pruritus, scratch marks, jaundice Spider angioma Swollen hands

Abdo Hepatomegally (95%) Splenomegally

Portal HTN: Gynaecomastia Palmar erythema Testicular atrophy

CVS/chest: HF (+ crackles), arrhythmias rennin, aldosterone

Ix LFTs Bloods

Transferrin sats >80% Ferritin Phlebotomy requirements Tf receptor HFE genotyping Glucose

Joint Xray Liver biopsy Bone marrow Perl’s stain for Fe loading + severity MRI for Fe loading ECG/Echo

Mx Venesection: ~1 unit/wk until Fe deficient – every

2-3 months AIM: MCV <0.5, ferritin < 100/L, transferrin

sats <40% Monitor: DM: HbA1c – falsely low OTC: NO Fe in vitamins!! Diet: well balanced low-Fe diet. Drink tea, coffee,

red wine with meals ( absorption). Don’t drink fruit juice, white wine with meals

Minimal ETOH, HBV vaccine Screening

Serum ferritin + HFE genotype in 1st degree

Px Normal life expectancy with venesection – if no

cirrhosis or DM Gonadal failure irreversible If cirrhosis, >10% get HCC

Liver problems

Pancreas: acute + chronic pancreatitis, pancreatic cancerBiliary: gallstones, cholecystitis, cholangitis

Hx Drugs and ETOH Sx: itch, pain, jaundice, dark urine, pale stools,

nausea, steatorrhoea

Causes HH type 1 transfusions chronic liver disease Thalassaemia / sideroblastic anaemia Diet + ETOH

Hepcidin Fe absorption, release from Fe + IL6, IL1 Hepcidin Fe absorption + release from hypoxia, erythropoietin, anaemia Type 1 Hereditary haemochromatosis in Europeans: homozygous for C282Y

mutation of HFE males get it earlier, period is protectivePx 70% progressive Fe overload 50% clinical 25% liver injury <10% cirrhosis intestinal Fe absorption deposits in organs: joints, liver, heart,

pancreas, pit, adrenals, skin less Fe in spleen

Signs: painless jaundice, Murphy’s sign, masses, fever

DDX: PUD, oesophageal spasm, GORD, NUD, IBS, renal colic, IHD

Painless jaundice + palpable GB = not stonesIx

FBCU+ELFTsGlucoseINR+coags

Special IxBlood culturesAmylase + lipaseTumour markers Ca19-9Malabsorption: vitamins ADEK, B12Multi-organ failure: Ca, ABG

ImagingAXR: stones, airAbdo U/S: stones/massCT abdo: mall lesions, liver metsCholangiographyBiopsy

Organ Fx testsBiliary isotope scanning HIDA/DISIDAPancreatic Fx tests

SLE and ANA – potential counselling Qs

Explaining ANA to a patient – draw a picture when someone has SLE, their body makes ANA = antinuclear antibodies we take serum from your blood sample and put them on a slide with cells on it If your blood has ANA, they will attach themselves to the cells Then we add another type of antibody that's fluorescent – this one attaches itself to the cells already joined with

the ANA We look at the slide under a UV microscope and if there are fluorescent cells its positive We dilute the sample until negative – we can't find any more cells

1:10 positive1:20 positive1:40 positive1:80 positive1:160 positive1:320 negative

The reported titre would be 1:160

we would call anything above 1:40 a high titre

Does mean I definitely have it? Not a very specific test - there are other things that can cause it – SS, RA, AI hepatitis, scleroderma Even some healthy people without any of these can have a high titre The higher the titre, more accurate it is likely to be We use other tests that are more specific for SLE

◦ Ssa and Ssb for Sjogrens syndrome◦ Sm for SLE◦ dsDNA is found in SLE with kidney involvement

How do we know if I'm getting better? May not go down with remission, so not good for monitoring

◦ we use dsDNA, C3, C4, urinary protein, creatinine and ESR◦ SLE haemolytic anaemia – we use Hb, reticulocytes◦ liver disease- we use LFTs◦ SLE nephritis- we use urine, creatinine

Tiredness

Uber common DDx Depression Post viral (up to 6 months) Sleep apnoea DM

RULE OUT Cancer Arrhythmia Anaemia hypothyroid

Hx Sleep

o How have you been sleepingo Do you snore?o Feel tired when you wake upo Nocturia (DM)

Smoking and ETOH (quantify) medications and allergies

Anaemia screen Heavy periods (menorrhagia) / no periods at all

(pregnant) Diet (meat?) + appetite FHx: pernicious anaemia

Cancer screen WEIGHT LOSS AND NIGHT SWEATS

Shortness of breathChanges to stools

Thyroid screen Unusually cold this winter? Noticed changes to your hair or skin? Weight / appetite

Depression screen How are things at work / home? Sleep / appetite? How’s your mood been?

PMHx D

M

Chronic disease Blood loss Thyroid disease For anaemia: PMHx: liver disease PMHx: chronic pancreatitis PMHx: thyroid disease Surgery: gastrectomy/terminal ileum intestinal bacterial overgrowth – stasis from

intestinal surgery or anatomical lesion /DM/scleroderma/amyloid

Ix: FBC Fe studies TFT U+E BSL LFT

consider bHCG, b12, foliate, no marks though

Anaemia Ix B12 foliate levels (ETOH foliate deficiency) thyroid test – to monitor meds pernicious anaemia = anti-parietal cell

antibody/anti-intrinsic factor intestinal infection = bacterial overgrowth,

tropical sprue, fish tapeworm

Counsel: explain and reassureMx: oral thyroxine – 50-100mcg dailyFurther Ix: recheck TFTs in 6-8 weeks and thyroid ABs

Counsel about folate/B12 intake schillings test/ABs , gastroscopy meds for thyroid Fx ETOH use wont need blood transfusion

microcyticFe deficiencychronic diseaseThalassaemia sideroblastic anaemia

normocyticblood loss chronic diseaserenal failure hypothyroidism haemolysispregnancy

macrocyticB12 / foliate deficiency ETOH/liver disease myelodysplastic syndromes

Ddx of the young tired ♀

1 Fe deficiency/anaemia 2 psychosocial/depression 3 hypothyroid 4 pregnancy

Ddx of the older tired ♀

1 diabetes 2 hypothyroid 3 psychosocial/depression 4 anaemia

Chronic HeadacheHx Pattern of pain Location Aggravating/relieving factors Auras before / during Vision changes FHx: migraines, cancer, HTN, IHD How’s everything at home / work

Ruling out problems When did it start How bad is it Is it getting better or worse

Raised ICP (infection, tumour, space occupying lesion) Disturb sleep or worse on waking Worse on coughing / bending over vomiting Fevers, chills Any neuro changes (confusion/memory loss) Fits, faints, funny turns

Other Happened before Any trauma ETOH Medication (aspirin/codeine)

Counsel Has symptom of a serious underlying disorder A differential is raised intracranial pressure Malignancy is a possibility (space

occupying lesion) Idiopathic intracranial HTN Subdural haematoma

Examination Neuro Examination Fundoscopy for ICP

Further Ix CT/MRI

ESR for temporal arteritisCT for meningitis or SAH

Top DDx URTI Tension Migrane Combination CervicalRULE OUT SAH Temporal arteritis Venous thrombosis Meningitis Subdural haematoma

Migraine Unilateral With prodrome / aura Throbbing Vomiting Worse with ETOH/pill Usually starts <20yo Family Hx

Tension Bilateral No auras Constant No vomiting Better with ETOH Daily No FHx

MigraineCounselling Acknowledge difficulty Gage effect on work / school Identify triggers: choco, citrus, cheese, red wine,

caffeine Stress, lack of sleep

Look after self + relax

Acute attacks Start treatment with earliest sign Dark lights, try to sleep Try ergotamine or sumatriptan (not both)

Aspirin + paracetamol + NSAIDs Antiemetic (metaclopromide)

Cluster Daily like clockwork Over one eye ± lacrimation, horners Reassure that usually resolves 4-6wks Ergotamine / sumatriptan Antiemetics, ± local

Temporal Arteritis OVER 50 Unilateral Daily, constant ache Worse in morning Blurred vision DO ESR IF SUSPICIOUS!

Benign intracranial hypertension = young fat women

Back pain

DDx Vertebral dysfunction Strains/sprains OARULE OUT Cancer OM/abscess/discitis/PID AAA Cauda equina

RED FLAGS Pain

> 1 month: how long had pain? constant?

cancer: weight loss, cough cauda equina:

saddle anaesthesia: numbness between your legs?

recent bladder dysfunction: any changes to your bladder habits ?

severe neuro deficit: legs feeling wobbly or weak?

Hx Pain:

Where? Referral to legs? Deep/surface uni/bilateral?

Onset, frequency, duration Better worse Wake at night? (arthritis, cancer) Worse with sitting = disc

Other Sx Psoriasis Joint pain Fever, rigors

Drugs: steroids / anticoagulants?

Counsel explain advise:

avoid best rest maintain normal activities XRays not routine unless

◦ <25yo◦ red flags

Mx: paracetamol + NSAIDS (GI upset?) Physio can be helpful in the first 6 weeks Depression screen

Knee pain in adult

Top DDx Ligament sprains Osteoarthritis Patellofemoral syndrome (runner’s knee) Prepatellar bursitis (housemaid’s knee)

RULE OUT Crutiate lig tear DVT Cancer (bone) Septic arthritis RA

Hx Happened before? Any past sports injuries? An injury

What happened? Twist? Swelling? Dealing with work?

Pain: After exercise / stairs? Morning / night / wake you from sleep / night

sweats Swelling

Sudden = ACL tear Days = bursitis Chronic = runner’s knee, RA

Weight loss, tired?

Examination: Knee Examination Check other joints Psoriasis Fever

Ix None really needed if not suspicious In OA, Xrays are only useful as baseline reference

Counselling OA Degrading of the cartilage cushions in the joint, and

later bone With mild inflammation Factors make you more likely to develop OA:

overweight + past injuries, DM Weight loss will help pain Refer to physio

Walking sticks, cushioned shoes Drugs:

Glucosamine Analgesia: panadol good, neurofen only when

acute Long term, you will need a knee replacement Steroid injections

Inflammation Sneaks up Throbbing Morning stiffness Better with activity Bilateral Localised Night + morning

mechanical past Hx deep, dull transient stiffness better with rest unilateral diffuse in afternoon

Aboriginal kid with ear painHx

general health◦ URTIs◦ acute OM◦ atopy, allergies

development and schooling, speech◦ Hearing loss?

otalgia? Otorrhoea? irritable? poor feeding?

◦ How long for? sleep: not sleeping?

◦ How is sleep usually? ◦ Snores? (OSA)

Red flags speech delay cranio-facial abnormality neuro deficit febrile convulsions

Ex ENT exam: both ears, throat, teeth, nose,

cervical nodes systemic – CVS and resp – chest, heart, lungs,

pulse, RR, skin, temperature hearing test Webber and rinne observe general appearance: alert, active,

engaging

Examine drum with kid on mums lap ear wash out with 1:20 of dilute betadine and

mop dry ± pneumatic otoscopy

Ix audiology

Mx dry mopping bd ear wash with 1:20 db + dry Abx ear drops bd weekly review for 2 weeks

Counselling 20% of kids at any one time 30-70%: have CSOM with hearing loss affects language, speech, schooling, legals Abx only shortens course by 1 day

Follow up in 4 days. If not better, give ABx

Probable Dx chronic suppurative OM acute OM with perforation foreign body OE cholesteatoma

A acute OM tired, flushed child with pink ear analgesia and follow up Abx if bulging or AB

B acute OM + effusion healthy child analgesia and monitor for 3 months if persists, consider grommet

C recurrent OM 6 in a year

consider 3-4 weeks Abx, grommet

Otitis externa (swimmer’s ear) sore, itchy + discharge pre-auricular tenderness Mx:

Tissue spears Topical Abx IV Abx + admit if cellulitis or severe pain Avoid water in ear

Obstructive sleep disorderHx Repeated episodes of URT airflow in sleep Snoring Trouble sleeping Sleepy, wake up tired rhinorrhoea Daytime mouth breathing School performance

Examination centiles Mouth breathing Lines under eyes Nasal obstruction Tonsils, palate, tongue Speech

Ix Lateral Xray PST Sleep studies

Adeno-tonsillar hypertrophy Common Adenotonsillectomy improves 90-95% Can try allergy Mx, nasal CPAP

Recurrent tonsillitis Viral: Mx: symptomatic Acute follicular: serious Consider adenotonsillectomy

Asthma kid Hx Sx

Wheeze: night, morning, exercise SOB Chest tightness Cough (night-time)

FHx of asthma/allergy/atopy triggers

exercise cold air allergies viral illness dust SMOKING

Hospital visits + days off school attitude towards condition ? Patient understanding of role of preventers vs

relievers adherence to meds

Assess Pattern / Severity infrequent episodic

>2 months apart few Sx / signs between attacks reliever (Ventolin)

frequent episodic <6 weeks apart some Sx between attacks, but Ex normal Preventer + reliever

persistent daytime Sx 2/ week night Sx 1/week attacks <6 weeks apart hospital visits preventer, reliever + controller

Ix Spirometry

If over 6yo Obstruction = FEV1 <80%, FEV1/FVC <75% 12% improvement with SAB (eg 8089)

exercise challenge 70% can be exercise induced look for 15% drop

CXR: Only to exclude DDx

Mx Reliever : Ventolin (Salbutamol) Preventer : Flixotide (steroids) Controller : Seretide: steroids and Salmetarol (LAB) Avoid triggers and SMOKING

Mx arrange follow up safety net – warning signs of severe asthma

and Mx care of device correct dose warn of steroid effects ACTION PLAN FBP / finger prick haemacue

Counselling: about asthma The airways are hyper-sensitive They react to triggers inflammation, airway constriction, mucus production

Counselling: how to use an inhaler able to demonstrate how to use show patient how to use advise use of spacer shake canister hold correctly breathe out breathe in and hold breathe

When to come into hospital Using reliever more than once every 3 hours Sx get worse quickly Sx continue after reliever taken Severe Sx:

Gasping Cannot speak Blue lips

Acute Attack

Vitals: HR, RR, sats O2 via face mask if sats RA <92%

Assess severitymild cough, wheeze relaxed, no muscle use sats >95 in RA PEF >60Moderate Less breath sounds Accessory muscles used Sats 92-95 in RA PEF 40-60Sever Gasping Pale, sweaty, cyanosed O2 sats <92 in RA PEF <40%

Mild SAB 100mcg 3-4 hrly

<6yo = 6 puffs >6yo = 12 puffs

Oral steroid Pred 1mg/kg daily up to 50mg

Moderate SAB 2-4 hrly Steroids (Pred)

Severe SAB ½ - 2 hrly Steroids

Pred oral OR IV hydrocort 4mg/kg 6hrly Switch to nebulised SAB if: Can’t use spacer or spacer not helping

Sexual Hx of male with dischargeHx

urethral discharge + urethral pain on urination sores / ulcers on penis past history of STIs constitutional Sx: fever, joint pain, rash number of sexual partners (in past 3 months)

o last sexual activity? high risk practices + oral sex

o CONDOMSo anal

sexual orientation

Hep vaccines Allergies / meds IVDU / piercings / tattoos

Counselling Explain diagnoses Gonorrhoea Chlamydia

How much do you know about G + C – these are bacterial that can be sexually transmitted

Given what you told me, It’s more than likely you have one or both of these

So I’d like to take some swabs around the tip of the penis and get a urine sample so we can see exactly what the best treatment for you is

Ix Urethral swab First pass urine test (PCR) Serology for baseline status

Mx Antibiotics: Azithromycin + Ceftriaxone Safe sex education

o I’d like to have a talk with you about condoms

o Do you usually use condoms?o Why was this time different?

Contact tracing No sex with partner

o Need to treat all recent partnerso No sex until you and your partner are

clearedo Retest in 7 days

Window period follow up

Probabe DDxUrethritis Gonorrhoea N-G-U: Chlamydia

Vaginal dischargeHx

colour / type

Clear normal / neoplasiaCheese curds: candidaGrey, watery: bacterial vaginosisGreen, purulent: trichomonasBrown: endometriosis, ectopicsBlood: infection, neoplasia,

menstruation, miscarriage

Discharge When did you notice it Has it happened before Pain / Itching Urinary Sx Coital pain / blood

Health generally fever, joint pain, rash ABx

Cause can be sexually transmitted, can I enquire? Number of sexual partners

CONDOMS The pill or Other contraception Anal or oral Past history of STIs

Examination PE: note discharge

Inflamed vagina: thrush, trichomonas Cervix: inflamed, ectropion Abdo / adnexal tenderness

DDx Normal discharge Vaginitis (90%) (BV, candida,

trichomonas) Cancer Infection: G / C PID Herpes? Endometriosis Atrophic vaginitis

Ix STI screen

MCS:◦ Clue cells = BV◦ Hyphae = thrush◦ Motile trichomonads

ECS + HVS Pap smear Vaginal pH

◦ High pH: BV, trichomonas, atrophic

Bacterial vaginosis Too few lactobacilli, too many anaerobes ±itch ± pain whiff test risky in pregnancy Clindamycin / Metronidazole

Yoghurt

Thrush (candidia) Itchy, burning, red With OCP, Abx, pregnancy Mx: Clotrimazole, Nystatin

◦ Treat partner

Trichomonas Red, sore Mx: Tinidazole

◦ Treat partner

ContraceptionCounsel for mirenaHx

contraceptive Hx family size – completed? Medical Hx

contraindications ▪ pelvic infection▪ abnormal bleeding▪ pregnant▪ high risk of infection

Counselling action

▪ prevents implantation▪ releases progesterone▪ thins endometrium▪ efficacy – 99%

benefits – effective, no loss of spontaneity or need to remember, less menstrual blood loss, lasts up to 5 yrs but can be removed at any time

risks – slight risk of infection with insertion, very slight risk of perforation, need condoms for STI

side effects – irregular spotting insertion – ensure not pregnant / via spec in dr

rooms / may be uncomfortable / may need swabs prior to insertion

patients needs to check thread to ensure IUD insitu post menstruation

Communication information clear and sufficient to facilitate choice /

offers written information offers to discuss other choices offers other forms of IUD allows questions

Counsel for OCPHx

previous contraception medical Hx + surgical Hx + allergies menstrual Hx (brief)

Contraindications HTN smoking migraines FHx of clotting prior DVT/PE currently pregnant

Examination BP HCG urine

Counsellingaction

inhibits ovulation cervical mucus changes decreased receptivity of endometrium▪ 95% efficacy

Side effects breakthrough bleeding fluid retention weight gain breast enlargement/tenderness nausea acne depression loss of libido

Instructions importance of taking pill as instructed pill missed within 12hrs can be taken 7 day rule – need contraception for the first 7 days

or if missed for 24 hrs If you miss a pill and there are less than 7 active

pills in the pack, go straight to a new pack reduced efficacy if Abx / other meds / gastro upset COC for contraception only – still need safe sex

practices with unfamiliar partners try linking taking pill with a daily habit

▪ make sure patient understands !!!

Counselling for emergency contraceptive pillHx

how many hours ago had unprotected sex condom use? Usually use condoms? Sexual Hx

◦ do you have a regular sexual partner? ◦ Other sexual partners?

Have you used other contraception? Menstrual Hx

“I'm gonna give it to you, but lets talk”

Counselling Only effective in first 72hrs Not 100% effective Side effects – what to expect

nausea and vomiting – need to take again abdo pain fatigue headache dizziness

Needs follow up Should not be used as a regular contraception

Health promotion STI screen or agree to full screen on follow up don't let them leave without contraception Pap smear

Heavy + Irregular Bleeding

Hx Gyn Hx

LNMP Cycle Volume IMB Pain: related to bleeding? pap smear COC/HRT Post Coital Sx Fe tablets

Contraception STIs + sexual activity PMHx: thyroid, anaemia, bleeding, cancers pelvic operative or problems FHX Meds, allergies

Examination PE for masses / tenderness Spec for infection / trauma

Ix Pap smear for CIN Swabs for C + G HVS for other infections Pelvic U/S: fibroids, pregnancy, polyps, cancer bHCG bloods: FBC (HB, WCC)

Fe studies Clotting studies TFT progesterone

MSU U/A Hysteroscopy, SHG, CT

MenorrhagiaDDx ectopic growths

fibroids / polyps endometriosis tumours

IUD / COC PID Systemic

Polycystic ovaries PCOD Hypothyroid Bleeding diseases

fat fat fat

MetorrhagiaDDx OCP / IUD Fibroids / polyps PID Endometriosis Cancer Pregnant

Perimenopausal irregular bleedingSx of menopause

hot flushes mood changes libido changes poor sleep vaginal dryness, dyspareunia

contraindications to HRT breast cancer liver disease DVT/PE

Ix

oestrogen FSH LH TFTs

screening CVS risk factors mammogram bone density pap smear

DDx HRT break through Atrophic Cancer

Counsel about HRT risks benefits side effects mode of delivery (tablet, patch, cream) oestrogen only vs combined

Counsel about natural therapies phyto-estrogens evening primrose oil

▪ red clover

CIN

BiopsyCIN I: atypical cells in lower third of epitheliumCIN II: lower 2/3CIN II: full thickness / carcinoma in situ

Risk factors: Early first sex Multiple partners A partner with multiple partners SMOKING ICP

Transformation zone: everts in puberty acid columnar becomes squamous

HPV 16, 18, 31, 33 high risk HPV clearance is 8-14months Gardasil does 6, 11, 16, 18

Squamous most low grade lesion regress quickly (10 months) low grade high grade ~8years cancers develop over years from CIN3 many CIN2/3 spontaneously resolve

Glandular very rare leads to adenocarcinoma 26 = atypical glandular cells, no Sx immediate

colposcopy

Post treat follow up of CINII + CIN IIIAfter treatment colposcopy at 4 months paps at 4, 12, 24 months GP HPV typing at 12, 24 months If paps + HPV negative 2yr routine testing

Low grade 30+yr, no negativeCytology in 3yrs = immediate colp or repeat pap in 6m

repeat papin 12m

Negativelow grade high grade

Repeat pap AnyIn 12m Glandular

Colposcopy findings

Negative

Routinescreening

FibroidsCounselling benign smooth muscle tumour in 20% of reproductive women grows with estrogen and shrinks away with

menopause

Hx obesity pregnancy HRT, COC, tumours Sx

Menorrhagia, pain, fullness Urinary Sx Subfertility

Ix Examination: uterus enlargement U/S: if large enough HSG

Mx Watch it Hormones: mirena, Xoledex

But not permanent Myomectomy

Less invasive than hysterectomy Keeps some fertility

EndometriosisHx nullipara 35-45yo European FHx Sx

Pelvic pain back / flank Dysmenorrhoea: starting days before and

worsening Dyspareunia (esp in period) Menorrhagia Urinary + bowel Sx

PMHx: problems conceiving

Examination Abdo: tender abdomen PE:

Nodular utero-sacral ligament Tender uterus + adnexa Fixed, retroverted uterus Adnexal mass = endometrioma

Ix U/S for endometroima (choc cyst) Lap: grey / red lesions

Adhesions Café au lait spots

Mx NSAIDs + analgesia Hormones ( estrogen)

GnRH analogue: Zoledex)◦ Maximum of 6 months

OCP: monophasic Progestin’s: Mirena – effective Danazol (testosterone analogue)

◦ Not very good Surgery:

laproscopic, but relapse is common◦ Very effective in severe cases

hysterectomy

Counsellng lining of uterus develops outside the uterus

◦ 15% of fertile women◦ 40% of subfertile women◦ not everyone with it has problems

Px Watch+wait: conception is 55-75% 1/3 relapse in 5 years lap: 66% show improvement stops with menopause

support groups

Polycystic ovarian syndromeSx virilization

◦ hair: male pattern baldness, hirsutism◦ acne◦ voice changes◦ muscle growth

oligomenorrhoea + infertility insulin + insulin resistance obesity

Examination masculine traits

Ix bloods

LH (but no surge) Normal estrogen, FSH testosterone

U/S Ovaries >8cm >8 cysts echogenic stroma

Mx stimulate ovulation, resect ovaries weight reduction electrolysis + Anti-androgens + Diane-35 Metformin

AmenorrhoeaDDxPregnancy + lactationPrimary or Secondary hypothalamic

anorexia exercise, stress Cushings

Pituitary Sheehans syndrome Adenoma Thyroid

Ovary PCOD Premature ovarian failure XO Tumours

Uterine scarring: Asherman’s syndrome Imperforate hymen

Hx Puberty milestones Gyn Hx if secondary amenorrhoea Thyroid screen

PMHx Thyroid Steroids/pred Radiation / pelvic surgery FHx of menstrual problems

OHx / lactation + pregnancy Menopause? Weight change, exercise, diet

Examination Height + weight Thyroid Examination Cushings: obesity, HTN, striae, thinning hair,

hirsutism Breast + hair development Full PE

Ix TFT Prolactin levels Sex hormones Progestin challenge U/S for pregnancy, mass bHCG!!

Pelvic pain + Dysmenorrhoea

Hx menstrual Hx

LMP Regularity Cycle length Duration Relation to pain Pap, post-coital Sx, OCP

Other Sx Urinary Sx / bowel Sx discharge or burning Fevers, sweats, weight loss

OHx Pregnant Subfertile

PMHx Smoking Gyn problems / cancers / operations FHx: gyn cancers

DDxAcute Primary dysmenorrhoea Gyn:

PID Torsion of fibroid / ovarian cyst Pregnancy (ectopic, MC)

Non-gyn: Appendicitis UTI / cystitis Diverticulitis, IBD, IBS etc

chronic 2ndary dysmenorrhoea, IUD Gyn:

Endometriosis PID Cancer Adhesions

Non-gyn: Diverticulitis

Examination Vitals: signs of infection or shock Pelvic Examination GIT Examination Weight + lymphadenopathy

Ix Urine

U/A + Chlamydia culture bHCG

bloods FBC: HB + WCC (left shift etc) ESR Blood cultures

Swabs (Chlamydia, HVS, ECS) for culture and pap Pelvic U/S AXR

Counselling for primary dysmenorrhoea (adolescent) advise that change 5 months after menarche is due

to ovulation and is normal very common at this age, often incapacitating -

>50%, 10% are incapacitated recognise and is sympathetic to nature explains likely to go or improve with first pregnancy

Mx suggest meds taken monthly at onset or just prior

to period name meds: ponstan, aspirin, NSAIDs asks about vomiting – suggest taking meds a day

earlier discuss COC if these don’t work Ask if sexually active and ask about contraception Advise would be good to do a check for STIs, offer

at least PCR screen - urine, vaginal swab for C + G

Early pregnancy bleeding

Hx LNMP Bleeding

Amount, clots, placenta Colour freq, onset pain

Faintness, shoulder tip pain Pregnancy Sx: vomiting, nausea, breast pain CONTRACEPTION

Sexual active PMHx

STIs or PID pelvic surgery, sterilization, IUD Prior pregnancies + OHx Meds, allergies etc

Examination Vitals Abdo palp: for Fundal height vs gestation Spec

Is there cervical dilatation? Fibroids, polyps etc

Bi-manual Doppler

Fetal heart at 5wks Fetal pole at 6wks

Ix U/S

Empty gestation sac: fetus should be visible >25mm

Pseudo sac : ectopic Pole but no FH Empty uterus : ectopic / complete MC

Bloods FBC, G+H, Xmatch, quants, Rhesus

Spec: HVS + ECS for STI/CIN U/S: sac, pole, FH Urine: MSU U/A + bHCG

Mx Expectant Misoprostol D+C Anti-D

HyperemesisSevere N+V in 1-2% of pregnancies peaks at 8-12wks, gone by 20wks mild - <2 vomits/day, some ketones, needs anti-

emetics severe - >2 vomits/day, much ketones, needs IV

hydration Ix: MSU (ketones)

U+E (hydration) U/S: exclude mole / multiples TFT if suspect

Mx: Small meals Multi vitamins IV Hartmann’s if severe Metoclopramide (Maxalon) is category A :

better Stemetil is category C

DDx Miscarriage Ectopic Molar pregnancy Not pregnant: trauma, infection, cancer

Miscarriage <8 weeks

Threatened Sx

Bleeding but FH+ Abdo cramps

Examination CLOSED CERVIX Soft, non-tender uterus Appropriate size

Mx 75% settle: try bed rest watch out for PROM

Inevitable Sx

Bleeds Painful cervical contraction ± ROM

Examination OPEN CERVIX

FH+

Incomplete (some retained products) Sx

Bleeding +++ Pain +++

Mx: expectant ok if <15mm on TVS

Missed (>4 weeks after) Sx

Amenorrhoea / spotting No fetal movements

Examination No uterine growth Regression of hormonal breast changes

Septic (Emergency ) Temp >38 Foul smelling discharge

Molar Benign, proliferative, cystic growth Presents like miscarriage HUGE bHCG No embryo, no sac

Councelling 50% of EPL is for a chromosomal abnormality

Ectopic Pregnancy

Hx Smoke Infectons

STI or PID Endometriosis

Pelvic surgery TOP, D+C Ectopics IUD

Sx before rupture Amenorrhoea / missed period Dull unilateral, colicky pelvic pain PV spotting: brown Examination

Adnexal tenderness + mass

Sx after rupture = EMERGENCY Acute suprapubic / abdo pain chest / shoulder Examination

Peritonism + gaurding Blood loss + shock

◦ Pallor, HR, BP, clamminess, faint

Ix bHCG: high U/S: no gestational sac

Empty uterus ± pseudosac if shocked:

FBC: septic, acidosis

U+E: hypovolaemic

DDx Torted / rupture ovary / fibroid / cyst Threatened miscarriage Appendicits PID salpingitis

Counselling What it is Of early pregnancy bleeding, ~10% have ectopics 10-20% will have another ectopic: more if ‘infertile’ 50% will have a normal pregnancy 30% will become sterile

Mx IM/local Methotrexate if

Tubal <35mm no fetal cardiac activity bHCG <10,000 not ruptured

laparoscopic salpingectomy or salpingotomy

Termination of pregnancy must

be <20wks counselling by 2 medical practitioners if >20wks, needs panel approval if <16yo, one parent must be informed

Hx GHx Support systems

Counselling Discuss the options: keep baby, foster/adopt, TOP Discuss contraception!!! Period may take 4-6wks to return Pregnancy test stays + for 3wks Victims of sexual assault Consent (<16) Less risky <12wks

Ix Confirm pregnancy Confirm dates (LMP / U/S) Rhesus group, G+H

Mx <14wks surgery

suction curette D+C with forceps Risks of surgery

>14wks medical PV Misoprostol SE: vomiting, diarrhoea, abdo pain, fever,

palpitations may need general anaestheic removal of

placenta

Risks failure rate is low haemorrhage infection trauma: cervical tears, uterine perforation, bowel

injury retained products later:

cervical incompetence infertility

psych: grief, regret sexual + relationship difficulties

Follow up: 2 weeks

37F infertility identify importance of both partners acknowledge a stressful issue

Female Hx primary or secondary – for how long contraception timing and frequency of intercourse menstrual Hx: full, with dysmenorrhoea,

dyspareunia galactorrhoea, hirsutism

PHMx: renal disease thyroid disease PID STIs peritonitis endometriosis

Intake: Meds drugs smoking alcohol

Male Hx pregnancies to other partners

PMHx:

STI UTI testicular injury/infection varicocoele undescended testis

Intake: smoking drugs ETOH

CounsellingAge

fertility drops rapidly from 35ys >35 yrs genetic issues like trisomy

Ix semen analysis

◦ 2 types◦ abstain from intercourse for 3 days◦ needs to attend for an appointment

confirm ovulation◦ day 21 progesterone, measure FSH/LH,

serum prolactin, TFTs, basal body temp, cervical mucous change

referral for tubal fx Ax – lap and dye, or a HSG

Antenatal Care

If worried about age, ask about folic acid supplements before/during preg multivitamins during FHx: congenital abnormalities

Booking tests Hb Blood group, Rhesus, antibodies Rubella titre HBV / HCV / HIV Syphilis Chlamydia MSU: U/A

Routine Ax Weight BP U/A Pelvic Examination

fundal height to monitor fetal growth lie to ensure longitudinal presentation to exclude malpresentation liquor volume to ensure adequate fetal back for fetal position (from 36 weeks) descent of presenting part into pelvis fetal movement for wellbeing (from 16 weeks)

When to come to hospital when membranes rupture regular contractions (every 5 minutes) constant abdo pain any PV blood loss baby’s movement pattern changes constant headache / visual disturbances

Scans and screens not all inheritable diseases can be picked up

by the tests – examples and % discuss in a realistic fashion what screen can

and cannot offer

6-7wks : dating scan 11-13wks : first trimester screen

for Downs syndrome nuchal folds : 70-90% sensitive FALSE + 3.8%

11-14wks : chorionic villus sampling optional: for anomalies much more accurate 1-2% MC risk

15-17wks : maternal serum screening “triple test” downs + neural tube defects with age, gestation, bHCG, aFP, oestriol 60% sensitive more sensitive in women >35, so more likely to

pick up abnormalities 15-17wks : amniocentesis

more reliable, but risk is higher 0.5% MC risk

18-20wks : anatomy scan for fetal age + anomalies placenta location

28wks Hb Anti-D + rhesus antibodies GTT / GCT as needed

36wks Anti-D ±Hb LVS + rectal swab for GBS

Rhesus isoimmunisation

Antibodies surface glycoprotein D (and others) No risk = LEB, LEA, LEP Medium risk = other High risk = K (attacks marrow), D, c, E

risk 15% are D negative, but babe is unknown Need group and antibody screen if antibody screen is +

→ type antibodies (take twice as much blood)

First babyFirst, take a Hx

obstetric screen (told N if unimportant) is father neg or pos?

Counselling Rhesus“Your baby's blood group is a combination of the mothers and the fathers blood groups”If babes blood get meets yours, mum's body sees that babe's blood is different, your body makes antibodies to get rid of them.

This won't do much to the first baby, but can hurt the second Positive baby.Mum's antibodies cross the placenta and break down 2nd baby's blood.

Explain the plan..When is prophylactic anti-D needed?

At 28, 34, 36 weeks with any bleeding or trauma with any amnios or CBS with MC or delivery

Routine screen at 28, 34, 36higher risk of sensitisation inCaesarean Sectionmanual removal

abruption needling threatened MC

625U at 28 and 36 weeksWithin 96hr of onset of bleeding1st trimester 250IU2nd/3rd trimesters 625IU

Bleeds occurring soon after Anti-D needle anti-D in maternal circulation depends on what it

has to bind to (babies blood) more babies blood in mum = Anti-D used up

sooner 1 week after Anti-D given: should be fine after 2-3 weeks: will need to retest

◦ + : still in blood, fine◦ - : needs more anti-D◦ +++ : really needs anti-D

Sources of isoimmunisation1 any bleeding in pregnancy

◦ TOP, miscarriage◦ threatened miscarriage◦ ectopic pregnancy◦ delivery◦ PV bleeding >12 weeks◦ amniocentesis, CVS, ECV

2 blood transfusions: organ transplant + trauma3 IVDU

Second baby Anti-D titre 1:32First, take a Hx

first pregnancy – how was it? Any bleeding? ECV? Rhesus of mum, dad, babe Any Mx, when was it given? - during pregnancy or

during birth How was birth? Any phototherapy needed?

Maternal antibodies remain in neonate for 12 weeks

Rh disease therapy by severitymild

fetal anaemia jaundice at delivery

◦ mild use lights◦ severe use many lights and biliblanket◦ can cause kernicterus and CP

exchange transfusion: O neg top up transfusion for 6-8 weeks in utero transfusion (intravascular)

severe: hydrops: dead Most babe have mild disease With each subsequent pregnancy, jaundice

appears 10 weeks earlier

Ix before anti-Dantibody screenKleihauer test: for fetal blood in maternal circulation, and how much Anti-D needed

Screeningbooking and 34/40if <10IU/ml disease unlikely, recheck every 2 weeksif >10IU/ml investigate

Ax severity in uteroAx haemolysis with amniocentesis if titre >1:8

All neonates of Rh- mother need FBC Rh group film bilirubin indirect coombs

HTN in pregnancy<20wks : HTN>20wks : gestational HTN >140/90Pre-eclampsia : >20wks + proteinuria

Pre-eclampsia

CounsellingComplications Mum

CNS◦ Eclampsia◦ CVA

Liver/blood◦ HELLP◦ DIC / bleeding (thrombocytopenia)◦ Liver rupture

Kidneys: renal failure Pulmonary oedema Retinal detachment

babe IUGR Placental abruption Distress + death

Hx Sx

Neuro: headache CLONUS, REFLEXES -- Nausea, vomiting, RUQ pain

Gestation (>20wks) ± multiples

GP (Nuulipara at risk) Prior PE with same partner

Family Hx SMOKING + obesity PMHx

HTN DM, renal Clotting disorders

Examination BP Oedema (may not find) Neuro : clonus + reflexes Fundi Abdo Examination for pain

Ix MSU for U/A Bloods

FBC: platelets + MCV U+E (creatinine, uric acid) LFTs (AST)

CTG + biophysical profile >28wks U/S (AFI, weight)

Mx Can manage as outpatient if mild

BP 140/90 < > 160/110<5g/d proteinuriaAsymptomatic

BP + U/A twice a wk U/S every 2 wks

Admit if: >160/110 >5g/d proteinuria symptoms fetal compromise

1 BP control Nifedipine Hydrazaline

Maintenance = methyldopa Useless for mild PE Keep >140/80 for placental perfusion

2 MgSO4 When: persistently high BP with drugs CNS dysfunction or HELLP Monitor for

Deep tendon reflexes RR <12 UO <30ml/hr

Delivery Waiting is only for fetus Deliver if

>34wks Fetal compromise Uncontrollable HTN Eclampsia DIC HELLP CVA

Eclampsia Tonic-clonic seizure, 60-90 seconds cerebral haemorrhage, renal failure, hepatic

failure pre-eclampsia eclampsia in <1%

Mx ABC, remove danger, don’t restrain IV MgSO4 4g in NS over 5min

Monitor RR Diazepam can depress fetus Hydralazine: boluses PRN every 20min if >160/110 Deliver with epidural

HELLP 1-2% maternal mortality severe if

ANY Haemolysis LFTs: ALT, LDH twice of normal platelets <100

Mx Platelet transfusion antenatal / postnatal Prednisalone

Gestational DMHx Risky people

GP + gestation Age >30yo Obesity Ethnicity (aboriginal, asian, middle eastern) Family Hx of DM or GDM

This pregnancy: HTN before 20wks polyhydramnios

Past pregnancies Unexplained stillbirths Past GDM Macrosomic babies

Sx: Thirst nocturia

Examination BMI Fundi Abdo palp + spec

fetal height (macrosomia) polyhydramnios

Ix MSU U/A for glucose Glucose testing If low risk: 24-28wks : glucose challenge test If high risk:

Random BSL <24wks >5.5 glucose tolerance test ASAP <5.5 GTT can wait until 26wks

Always GTT if symptomatic or macrosomic

Complications Mother

DKA Pre-eclampsia

Pregnancy Polyhydramnios PPROM Preterm labour (50%) Obstructed labour

Fetal Congenital abnormalities

◦ Cardiac + neural IU death

Neonates RDS Hypoglycaemia Hypocalcaemia Fetal hypoxia polycthemia + jaundice

Mx Plan Educate: see DM nurse Diet: 5-6 low GI meals/day

Limit energy if obese Exercise: 30min/day Not working after 2 wks:

Insulin: 4 injections/day, 4-8U Usually before meal or at night

Monitor BGL: self monitoring

Aim: <5.5 fasting <7.0 2hrs post food

Once a trimester bloods HBA1c TFT U+E, LFT Ophthalmologist podiatrist

U/S 1st trimester screen ~11wks anatomy ~18-22wks fetal growth/AFI scan ~34 ± ~37 if suspect macrosomic

Thromboembolic diseaseHyper-coagulable state

clotting factors fibrinogen fibrinolysis

stasis in lower limbstrauma to pelvic veins at delivery

Risks12x in pregnancy10-20x in caesarean

Hxage >35obesityPregnancy:

GDMPre-eclampsiacurrent infectiongrand multiparaemergency CS in labour3 days of bed rest

PMHx:ThrombophiliaPrevious TEDFamily Hx of clots

SxRed, swollen legLower abdo pain (iliac v)PE (SOB, cough, pleuritic pain)

IxDuplex doppler for femoral vVenography has radiation – only use if doppler failsVQ scan for PE (even with the risks) – good negative value

MxSC Heparin, 20-40mg/dayTED stockings6-12 wks anticoagulation then screen for thrombophilia

Caesarean sectionIndicationsObstructed labour, Cephalopelvic disproportionPlacenta previaFetal distressSevere PE or DMIUGRMalpresentationsFTPDystociaProlapsed cordTwins / higher order multiplesPrior CSSome congenital malformations: hydrocephalusMaternal HIV, herpes

The procedure: yeah, that’s not happening

ConsentingThere are some risks with any surgery.They’re very unlikely, but I want to let you knowInfection

EndometritisWound infection

Bleeding: PPH

Injury to pelvic structuresBladderUterusColonureters

ThromboembolismBoth epidurals + general have risksRisks to fetus

Cut by scalpel transient tachypnoea of the newborn

It will have an effect on delivery of the next pregnancyLong term risksAbnormal placentationScar complicationsUterus Rupture

Post operative instructionsEarly mobilisationEarly oral intakeWatch for oliguriaMonitor BPOpioids analgesia NSAIDsStaples out 3-7 days laterNo heavy lifting/squatting for first 2 weeks

VBAC counselling

Benefits Less incidence of

◦ tranfusions◦ bleeding◦ hysterectomy◦ infection

shorter hospital stay

Riskshigher incidence of rupture: 1 in 200

higher with assymptomatic deherence0.5% hysterectomy rate0.07% perinatal death rate stillbirth

Complications of surgery (very uncommon)infectionbleedingorgan damageanaesthetics

Success rate 55% at KEMH↑ success elective ceasareans for non-recurring problems

o breecho cord prolapse

prior vaginal deliveries normal BMI smaller baby size spontaneous labour

↓ success cephalopelvic disproportion obstructed labour induction of labour malposition high BMI

Contraindications >2 CS placenta previa malpresentation CPD classical CS prior rupture uterine surgery- hysterotomy, myomectomy high BMI >35 ?twins

Trial of Labour: Only 1 previous LUSCS Adequate pelvis No other uterine scars or previous rupture

Physician immediately available Anaesthesia and personnel available for

emergency c-section

MxCTG, esp IOLEpidural is safe (can still feel rupture)Manage prolonged labour

Antepartum haemorrhagePV bleeding >24wks

DDxPlacenta previaPlacental abruptionShowCervicitistrauma

HxBleeding

OnsetAmount (pads?)Trauma, post-coitalBright, dark, clots, wateryHas it settled

Pain or tighteningsFetal movement: normal or reducedHappened before?Placenta previaPast pregnancies: APH, other problems, CS

ExaminationABCDs Haemodynamically stable?

Pallor, vitals, CRTAbdo palp

Fundal height, lie, presentationDescent (for PP)Tenderness, tone (for abruption)Fetal heart (BAD abruption)

NO VE or SPEC UNTIL PLACENTA FOUND

Ix U/S for fetus and placenta location CTG (will be in abruption) Speculum + swab IV access

o G+Ho Coags, FBC, Rhesus ABso Fluid resuscitationo analgesia

Placenta PreviaSmall bleed = small shockNo painNon-tenderNormal fetal heartSmall bleed large bleedAbnormal lieNon-engagement

Placenta AbruptionHuge shock for small lossConstant painTender uterusFetus distressedBeware of DICCan be concealed

MxPlacental abruption

Syntocinon IV or ceaser Transfusion / platelets / FFP IDC

Placenta previaIf LLP at 24wks : rescan at 30wks, 34wksCan discharge if no further bleeding

If stable, can go to 36wksVaginal delivery ok if placenta is >2cm from margin

Placenta Previa Minor

o Lower segmento Marginal: of internal os

Majoro Partial: partially covers oso Complete

At 24wks: 5% have low lying placenta 9 in 10 move away when lower segment forms PP grows too quickly for the isthmus and shearsRisk Factors

Multipara, multiplesVBAC

AbruptionRisk FactorsSMOKINGPE/eclampsiaRenal diseaseRapid uterine growth: polyhydramnios, twinsInfectionTraumaVBAC

Post termPost term = >42weeks5-10%RFsNulliparaPrevious post termFHx

ComplicationsMaternal

Difficult labourPerineal tears CS

fetusmacrosomiaplacental insufficiencyfetal distressprolonged labourmeconium

Mxget accurate gestational agebiophysical profilefetal HRcontraction stress testTiming: 38-39wks if high risk, look at

fetal Ax: fetal compromise, AFI, oligohydramniosCervix favourability: Bishops

Station-3

0

-2

1

-1

2

Dilation0cm

0

1 -2cm

1

3-4cm

2

Length3

0

2

1

1

2

ConsistencyFirm

0

Medium

1

Soft

2

PositionPosterior

0

Mid-position

1

Anterior

2

Favourable>7 : low risk of IOL failure membrane sweep then IOL when readygood fetal monitoring

Unfavourable<7use cervical ripening agentsIOL with Foleys catheter or PG-E2Good fetal monitoring

Induction of labourIndications41 +3 wksIUGRPEHydropsTTTSSevere HLASevere maternal medical condition

Contraindications CPD (absolute) Malpresentation (not breech/face) Fetal distress Placenta previa tumour cervical surgery

Risks Infection Bleeding Cord prolapse Uterine rupture PPH CS + instrumental delivery

Ripen Cervix95% of term cervixes are ripeIOL with unripe cervix: prolonged labour, distress, CSUse Foley catheter unless medical reason for using PG-E2Monitor

Foleys:Check every 2hoursIf falls out after 12 hours – reviewMaternal: vitals 4hrlyFetus 4hrly, CTG only if concerned

PG:Every4 hrsNeeds CTG!!

DO NOT use PGE2 ifVBACGrand multipCephalopelvic disproportionHigh fetal headAbnormal traceSevere asthma (constricts)

Mx of HyperstimulationStop oxytocinRemove catheter / gelTocolysis (Terbutaline)

Artificial Rupture of MembranesCTG monitoring neededSyntocinon 10mg, start at 6/hr, double every 30 minsUntil contractions 4:10

Breech presentations

50-70% extended5-10% flexed10-40% footling

Risk Factors prematurity extended legs uterine anomolies placenta previa, fibroid, twins fetal anomoly – hydrocephalus, anacephalus

Counselling may still turn itself

16% at 32/40 3-4% at term

Risks of a breech delivery cord prolapse entrapment of head behind cervix asphyxia intracranial haemorrhage trauma to spleen etc

External Cephalic Version – 36-37 weeks

success rates about 50% CTG + U/S

Tocolytics + anti-emetic + anti-D Monitoring

can’t do it if Absolute

◦ Multiples◦ APH◦ ROM◦ Placenta previa◦ Concerning trace

Relative◦ Pre-eclampsia◦ VBAC (lower segment only)◦ Rhesus –ve◦ Anterior placenta / obese

Can you have a breech vaginal birth? Adequate pelvis 37-42wks EFW 2500-3700g Extened or flexed breech only Flexed head Normal labour ±VBAC

Tears + episiotomyRisks macrosomia precipitant labours poor head flexion dystocia forceps narrow arch

1st degree: superficial only2nd degree: involve perineal muscle: suture in delivery

suite3rd degree: involve anal sphincter: send to theatre,

needs GA + ABx4th degree: rectal mucosaPost-op: high fibre diet + faecal softeners for 10 days

Prevention massage episiotomy

Problems with episiotomy

bleeding infection + tissue breakdown haematoma pain

TwinsAntenatal care U/S at 11wks

To confirm Viability Chorionicity Nuchal folds

Regular ANC more frequent

TTTS MC twins

AnalgesiaNitrous

Preterm labourLabour = coordinated uterine contraction + cervical dilation + effacement fetus + placenta expelled1/3 from wrong dates

Hx GP Confirm gestation (by dates / U/S) Contractions

Onset Duration + Frequency in 10 minutes abdo tightening / lower back pain / pelvic

pressure PROM or APH

Rhesus status Placenta previa

Infection fever urinary Sx Abdo tenderness

PMHx / Meds / FHx HTN obesity anaemia

Social risk factors Age <18 or >40 SMOKING ETOH

ExamVitals: BP, pulse, tempAbdo palpation

FH, lie, pres, liquor, uterus toneDoppler for fetal heart + wellbeingCTG if

More than 1 : 10>30 weekswant pain relief

Spec: >1cm dilation, >2cm effacedLook for ROM / bloodSwabs

VE ONLY IF CANT SEE CERVIX

DDx of TPLCervical incompetence : no contractionsPreterm uterine contractions : no cervical change, self limiting

IxSwabsFibronectin (good if negative)HVS, LVS, ARS for cultureOtherUrine: U/A, MCSU/S: fetal size, position, placenta

Mx50% cease spontaneously1 expectant (>34 wks)Maternal / fetal need

ChorioamnionitisGBS +APHIUGR

Labour gone to far

2 intervention (24-34 wks)SteroidsBetamethasone IM at 0 + 24hrsTocolysislow success if ROM or >4cmNifedipine

Blocks oxytocin + PGsNot with MgSO4, low BP

SalbutamolMonitor

U+E, LFTs30minly BP, HR, RRCTG continuous

AbxGBS = PenUTI = Cephalexin

PROM2-3% of deliveriesprolonged PPROM >18 hrs until labour

Hx gestation GP (multigravids) Rh status Hx of fluid

Sudden Gush of fluid / bloody show Sensation of wetness Blood

Contractions / tightenings infection

fever PV/PU blood Abdo tenderness

Cervical surgery/incompetence Status of mum + fetus (Hydramnios) FHx/PMHx or PROM

Examination Abdo palp: FH, lie, presentation, position, FMF

o Uterine tenderness, irritability, contractions

Doppler: Fetal Heart Temp, BP, pulse

Confirm ROMNO VE Speculum:

o Pooling of amniotic fluid in posterior fornixo Fluid with valsalva manoeuvreo Dilation / effacement of cervix

Swab:o Amnicator + fibronectin: only negative is

useful

o Fern test

Ix U/S: AFI Fetal wellbeing Infection:

FBC (WCC, CRP) Genito: LVS (GBS), HVS (if purulent) ± urine for U/A, MCS

Complications Preterm delivery (most deliver in 48hrs) Infection (chorioamnionitis) Cord prolapse Placental abruption

Mx Give antibiotics (IM erythromycin) >34/40 Induce labour after 12 hours

expectant Mx 24-32 Abx + steroids ± tocolytics

(Nefidipine) 18-22 Waiting can risk infection

Chorioamnionitise.coli, GBS, anaerobesSx Fever Uterine tenderness HR (mum>100 or fetus >160) leukocytosis: daily (also rises from steroids, labour) offensive liquor Mx Bloods, IV Abx, Labour ASAP

Post Partum Haemorrhage

Top Ddx retained placenta atonic uterus vaginal tear ruptured uterus

If not given, ask for: name G&P gestation PMHx meds allergies

Essential info to ask for is placenta delivered and complete estimate of blood loss asks if syntocinon / ergotamine

Hx Risk factors:

past caesarean prolonged labour – how long was labour 2nd degree tear – any tears

Assessment

vital signs amount of blood lost

Mx of PPH shock call for help (Dr or midwife) recognise that this is a medical emergency

(hypovolaemic shock) airway, breathing, circulation

give oxygen elevate legs ask about IV access + organise large bore

cannulas order IV fluids, crystalloid, rapid infusion/bolus

Specific Mx of PPH massages uterus or organises it empty bladder: IDC insertion blood for Xmatch + FBC orders misoprostol 1000mcg / syntocinon infusion

gentle traction to deliver placenta pad + pressure to vaginal tear repair

Further measures bimanual compression, P F2a, balloon catheter,

laparotomy (B-Lynch suture), internal iliac ligation

Neonate first aidPredictors

fetal distress on CTG mec low scalp pH preterm instrumental delivery

Ax of baby colour: pink / blue / pale breathing: adequate? Heart rate: should be >60/min – umbilicus or apex

Pink, regular breathing, HR>100 keep warm + dry pass to folks

Blue, breathing, HR<100 rub + dry Reassess ± open + clear airway bag and mask 30 breaths in 30 seconds reassess after 30 seconds

Blue, inadequate breaths, HR>100 rub + dry ± suction to open + clear airway CALL FOR HELP no response → ventilate

Meconium + non-vigorous, HR<100 DO NOT rub or dry assess airway intubate and suction (or suction under direct vision) THEN rub and dry reassess ventilation

Pale, shocked, apnoeic, HR<60 maintain airway reassess HR no response to ventilation → add cardiac

compressions no improvement → adrenalin

◦ >34/40 1ml of 1:10,000◦ <34/40 0.5ml of 1:10,000

blood loss or poor perfusion → 10ml/kg in 1-2min via UV

Neonatal respiratory distressClinical features General wellness: colour Signs of infection

or temperature Tachytachyhypo

Resp distress: RR>60 Central cyanosis Recession Flaring Grunting

Ix bloods

U+E FBC (Hb, WCC) BGL Culture

Gastric aspirate MC/S Ear swab MC/S CXR

HMD: ‘ground glass’ + bronchograms◦ Pneumonia looks the same

TTN: ‘streaking, wet’ lung Mec: hyperinflation, consolidation

HMD few T2 pneumocytes for surfactant, small lung volume,

causes collapse and shunt In:

<30wks GDM Twin 2 FHx of HMD

over 12-24hrs hypothermia Mx: O2 + assisted ventilation (CPAP, IPPV)

Surfactant therapy Keep sweet + warm

DDx Hyaline membrane disease Transient tachypnoea of the newborn GBS pneumonia Mec aspiration Pneujmothorax

TTN In caesareans + maternal analgesia Mild resp distress, not ‘ill’ looking Lasts 1-2 days Mx: ± 30% O2

GBS/E. coli pneumonia Severe, rapid Mx: Amoxycillin + Gentamicin

Mec aspiration Pulmonary HTN R-L shunting Mx: O2 ± CPAP

Abx

Pneumothorax Worsens if not treated Mx: intercostal catheter + underwater drain

chronic lung disease 28 days on ventilation + CXR changes caused by

◦ high volume and pressure◦ O2 concentration >40%◦ inflammation◦ poor nutrition

Linked to HMD Presents with

◦ becoming O2 dependent on ventilator◦ respiratory distress: recession◦ FTT

First day check observe infant + comment on colour (jaundice /

pallor / plethora) and posture

discuss taking weight, length, head circumference, importance of plotting these on percentile chart

checks anterior fontanelle

observes face – notes symmetrical / position of ears / shape of eyes

looks inside mouth for cleft of hard or soft palate

ascultate heart and comment on heart sounds and murmurs

observe chest / check for respiratory distress

palpate abdomen for liver, spleen, kidneys and hernias. Check umbilicus for infection

examines genitalia

checks femoral pulses

examines for developmental dysplasia of hips

checks tone of infant including head lag

turns infant over / checks spine. Checks patent anus

Prematurity <37 weeks low birth weight <2500g very low birthweight <1500g extremely LBW <1000g

50% survival at 24wks90% survival at 27wks

Thermoregulation have

high surface area:weight ratio brown fat stores non-keratinised skin glycogen supply

Mx: warmers/incubator, head coverings

Hypoglycaemia Have

stresses glycogen stores

Mx: check BGL before each 3hrly feed <2.5 needs dextrose infusion + maintenance

Fluids + electrolytes have

immature renal function Mx:

Daily U+E, urine output Day 1-2 : 100ml/kg/day Day 3-7 : 150ml/kg/day Day >8 : 200ml/kg/day

Breastfeeding Within 90minutes of delivery 8 feeds/day otherwise use NGT or IV weigh daily

DDx of SGA wrong dates constitutional IUGR Oligohydramnios

Small for gestational age

Wrong dates 6wk scan ±1 day 12wk ± 1 week 20wk ± 2 weeks

Hx double check dates OHx:

SGA in other pregnancies Smoker, drug use HTN, autoimmune disease

Ix Fundal height AFI: should be 5-24 S:D ratio of umbilical artery: high means babe is

unhappy Biophysical profile U/S (BPD, HC, Abdo C, femur

length, EFW) Symmetrical: small, but head and abdo

circumference are in proportion Asymmetrical: blood shunted to brain instead

of liver (abdo circ)

1 well + small symmetrical check ethnicity

2 sick + small preplacental

maternal cyanotic heart defect anaemia high altitude

placental IUGR: assymetrical

◦ Maternal HTN / pre-eclampsia◦ Smoking◦ Multiple gestation

Post-placental Infection: TORCH ± hydrocephaly Aneuploidy: trisomy 13 / 18

◦ Symmetrical Structural: gastroschesis

Neonatal jaundice

24hrs to 2 weeks, can be physiologicalAll develop SB in first week

A Unconjugated Haemolytic (pre-hepatic)

o Breast feedingo Haemolytic anaemia – ABO, Rh, drugso Sepsis

Non-haemolytico Hypothyroidism o Sepsiso Gilbertso Pyloric stenosis

B Conjugated (BAD) Hepatic

o Hepatitis + cholestasiso TORCHo Sepsiso CF

Post-hepatico Biliary atresiao Obstruction

Hx onset (not first day)

Early day 1-2o Haemolytic jaundiceo sepsis

Normal day 3-10 Prolonged >2wks

o Breast milko Conjugated (sepsis, CF, cholestasis)o Inherited enzyme deficiency (G6PD)

mother’s blood group FHx of blood disorders / CF ? birth trauma / swallowed blood peripartum mode of feeding, feeding problems, engorgement,

let down weight loss, bowel/bladder output

Ix heel prick SBR with unconj/conj ratio BSL (consider hypoglycaemia) FBC + Blood film Blood grouping for rarer incompatibility Direct Coombs for rhesus Syphilis / TORCH screen

Mx Treat cause Phototherapy

o Check charto Naked, no nappyo Give 30ml/kg/day more watero Harms: temperature, eye damage,

diarrhoea, separation, fluid losso Stop when levels fall >25umol/L below

threshold IV immunoglobulin Exchange transfusion

o Warmed blood 160ml/kg over 2 hrso Removes bilirubin + Abs, corrects

anaemiao Only in severe disease or G6PD

Counselling Explains reasoning to mother Improve feeding – express and feed, S26, top

ups etc phototherapy

Sequelae kernicterus

Neonatal sepsisMostly GBS, E.coli, Listeria

GBS: 10-15% death 50% start in utero

In utero or on deliveryPrematurity risks nosocomial infection

Hx, Ex Respiratory distress / apnoea Temperature instability Irritability Poor feeding / vomiting / diarrhoea / jaundice Bloods: neutrophils, thrombocytopenia,

coagulopathy

First.. Clear airway, intubate + ventilate (should correct

acidosis) IV access colloid 20ml/kg

Ix Bloods

FBC + CRP Culture BGL, ABG

SPU urine culture LP for culture + film CXR ± stool, PNA for viral PCR

Mx <48hrs = GBS+E.coli = BenPen + Gentamicin Late onset infection >48hrs = coag neg staph =

vancomycin

Hypoxic ischaemic encephalopathy

Diseases in pregnancy

Epilepsy Pregnancy epilepsy: 10% gets worse, 50%

unchaged Medication adherence Altered drug metabolism Vomiting

Epilepsy pregnancy: mostly has no effects Drugs can be teratogenic ( risk of malformation) population malformation rate is 4%

◦ anti-epileptic drugs is 19%◦ depends on drug◦ monotherapy is better◦ as low a dose as possible◦ NO VALPROATE spina bifida, clefts, heart

disease, short limbs Seizure risks: dual hypoxia

Recurrent fits fetal intracranial haemorrhages

Counselling Stay on your meds Routine screening Monitor drug levels in 1st and 2nd trimesters

Twice in 3rd

Supplements Folate before 13wks Vitamin K from 36wks

Delivery Recommend epidural

◦ Pain, emotion, RR seizure risk Seizure rate is 1-2%

Post natal Recheck drug levels and gradually reduce Need estrogen in contraception: mirena is good

Breastfeeding Drugs can accumulate, but not usually a problem

HBV Vertical transmission Fetal: 90-95% become chronic Vaccinate neonate: offer everyone in first 5 days

+ Ig if mum is positive 95% protective with both

HCV no interferon / riboviron only 2-8% vertical transmission with positive maternal

RNA labour:

keep membrane intact till last minute no fetal scalp electrode check RNA viral load

neonate: yes to breastfeeding◦ not if cracked nipples or mastitis

HIV HIV mother 1/10,000 LB risk

preterm labour low birth weight vertical transmission (IU, birth, breastfeeding)

Mx: refer, monitor viral load, CD4 counts Labour: membranes intact

◦ No instrumental◦ Usually CS◦ Give IV Zidovudine

Neonate: no breastfeeding◦ Check loads

UTI Uterus presses bladder Smooth muscle relaxation stasis + reflux Can cause

PROM ± chorio Preterm labour Low birth weight

Mx: Cefelexin / Nitrofuintoin NO Trimethoprim

Large head circumferenceDDx Familial Skull bones Subdural: haematome, emphyema Brain: metabolic disturbance, neurofibromatosis Ventricles: hydrocephalus

Meningitis, obstruction, congenital

Hx: FHx of large heads Examination

Centiles Setting sun sign: loss of upward gaze (hydrocephalus, 3rd ventricle swelling) Fundi + fontanelles

Ix: head U/S / CT if fontanelle closed Refer!!!

Drug users in pregnancy1-2% of pregnant women are IVDU

Social risksTend to present lateLow socioeconomic statusNo social supportPolydrug useSmokingLess STI screensPsychiatric HxPoor diet: anaemia, folate

Risks to babyInfectionIUGR/SGAFetal alcohol syndromePreterm labourIVDU abruptionNeonatal abstinance syndrome (esp opiates)Congenital abnormalitiesMiscarriageFetal distressSIDS

Smoking in pregnancy Preterm labour IUGR Adult disease: allergy, asthma, DM Stillbirth Abruption PE

ETOH in pregnancy: fetal alcohol syndrome animal facies: flat nose, cheek hypertrophy IUGR Neonatal IQ CNS: microcephaly

Hx OHx + GHx

LMP Other kids?

Pap smears Drug Hx (specific)

What taken, when, how often, route, needle use Pattern of use

Screening Hx: STIs, rhesus, BBV Social Hx + supports Is she functional enough to look after kids PMHx: DVT, jaundice, liver disease

MxWANDAS: non judgemental, with links to other groups Aim is to make them stable Everyone in one place

Nutritionist, Social worker, Clinical psychologist, Parent education, Home midwife

Screening STIs Pap smear Anatomy scan LFTs

Birth Pain relief: no morphine

Respiratory depression – can’t give naloxone on babe of IVDU

Aggression High or withdrawling during labour Continuous monitoring

Neonatal withdrawal Up to 10 days Irritable, jittery Poor feeding High pitched cry (benzos, morphine) Yes to breastfeeding!

The always crying child

Top Ddx1 colic2 reflux3 constipation4 lactose intolerance / cow's milk allergy5 infection(6 pyloric stenosis)

Hx crying pattern feeds vomiting, stool frequency and consistency noticed anything sets her off?

◦ Position◦ foods

weight gain otherwise well?

◦ allergy Sx◦ fever

Parent response and support◦ who looks after bub?◦ Any one who could baby sit?◦ Mother's groups or Ngala

Examination centiles + development localised infections

◦ ear◦ fontanelles for ICP◦ UTI◦ sepsis

Ix stool: clinitest tablet U/S (pyloric stenosis) AXR (constipation) skin prick / RAST

Mx change of position or thickened feeds for GOR removing lactose

Counselling (colic) reassure: common, but don't minimise usually resolves around 3 months motion might help baby might cry no matter what its ok to take a break refer to Ngala or hospital for respite

Baby vomiting (GORD)

DDx GOR Pyloric stenosis UTI URTI

Hx fever or infection vomiting – freq, amount, colour, timing to feeds,

projection constipation/diarrhoea position – worse prone, more irritable lying down complications – cough weight gain

FHx of pyloric stenosis

social Hx maternal support how are you coping?

Examination centiles general:

febrile Active / quiet / lethargic

Hydration: Pink + well perfused Fontanelles abdo

Pyloric stenosis◦ Abdo distended◦ Olive in midline◦ Peristalsis

Ix U/S

GOR (lower oesophageal sphincter relaxation) 60% have GOR vomiting from 2-3 weeks GOR resolves by 9 monthsPyloric stenosis Dramatic onset in 2-6 weeks Low K, high Cl = met alk + dehydration Family Hx FTT suddenly Projectile vomiting ± blood

Counselling reassure – should resolve with time pyloric stenosis is unlikely

Ix – U/S and blood test

Mx GOR – none is fine, or Positioning (30o) thickening feeds

◦ less volume more often omeprazole now/later

Need to return for follow up

Mx pyloric stenosis Rehydrate Correct met alkalosis surgery

GOR varied volumes Sooner or later after

some feeds Thrive Not dehydrated

PS Large volume Straight away after

every feed FTT dehydrated

Failure To ThriveHx

chronic conditions◦ CP◦ seizures

Pregnancy Hx◦ smoking/ETOH◦ medications/illness

nutritional assessment Family Hx: siblings social Hx

DdxA non-organic constitutional feeding problem psychosocial !!B organic congenital: CHD, cleft chronic illness: CF, asthma, chronic infection (TB,

HIV, UTI) losses:

vomiting: PS/GOR/coeliac/hirschprung stool: diarrhoea urine: polyuria and metac - DM

Metabolic (galactoseamia, PKU)

Exam Weight, height, Hc General: HR, BP, RR, chest+heart Any systemic disease? Body

◦ Muscle◦ Fats (buttox folds) and subcut◦ Hydration◦ Anaemia◦ Teeth

Nutritional Ax

IntakeMilk

Breast or bottle? What type of formula? How often? (on demand or 2-5hrs) How long? (5-30minutes) How much? (bottle 60-80ml/kg/day on day 1

-> 100 -> 120 -> 140 -> 160 -> 180 -> 200/kg/day)

What do they eat on a normal day? Solids – from 6/12 (blended cereal, veg, fruit) Meat: from 6/12 Cup drinking from 7/12 Semi-solids from 8/12 Normal food from a year – also milk down to

600ml/day

Output 4 wet nappies/day Bowel: with feeds Vomits

Birth Hx Gestation Birth weight Complications

History Illnesses Infections

Family Hx Growth pattern Illnesses

Short boyHx

height compared to other kids how long has he been shorter? Impact – r\teasing at school, performance? Birth Hx PMHx development height and puberty in siblings?

Examination centile of child and parents growth velocity puberty signs skeletal proportions- lower segment >50% inspection

◦ turners, downs◦ cafe au lait spots◦ thyroid

Ix bone age Xray TFTs FBC/ESR (IDB), UAE urine culture LFT

Ca, Phosphate girls get chromosomes

Ddx emotional chronic illness

length > weight nutritional

length < weight bone (bone dysplasia, rickets) endocrine (thyroid, GH, PHT)

length = weight constitutional short family stature chromosomal (metabolism errors,

turners)

Then coeliac tests TTG GH test

Anaemia / pale child

DDxmicrocytic Fe deficiency chronic disease Thalassaemia normocytic blood loss renal disease hypothyroidism haemolysis: sicle cell, G6PD, rhesusmacrocytic B12 / foliate deficiency Marrow failure

Hx Duration, speed of onset (blood loss, infection) Lethargy Otherwise well?

Weight loss (coeliac, cancer) Bruising / bleeding Jaundice infections medication

Diet (meat, green veg, legumes) Birth Hx FHx bleeding, G6PD

Examination General: pallor, sepsis

Weight loss, skin folds, bruising, jaundice

Ix FBC + film + differentials + retic count Fe studies Hb electrophoresis (thalassemia)

TFT, U+E

ThalassemiaIx Hb, MCV, ferritin, microcytic Dx: Hb electrophoresis

B Thalassemia minor: HbA mild pallor, splenomegally

B Thalassemia major (2 minor parents): HbF a chains shortened RBC survival, marrow over

function Sx

presents 3mths – 1yo pallor hepatosplenomegally abdo distension jaundice

Exam: growth retardation poor muscle development Fe skin pigment

Mx 3-4 weekly transfusions to suppress haemopoiesis Aim: keep Hb above 100mg/L Leads to Fe loading needs chelation Folic acid HBV vaccine

Counselling Disorder of gene for B globin, part of Hb in your red

blood cells Recessive: ¼ risk if both are carriers Px: Death in 10yr from HF, arrhythmia, infection

Cancers

Leukemia75% ALL, 2-5yomore in downsTumour lysis syndrome: tumour cell breakdown products can be toxicMx: hyperhydrate + bicarb to clear toxins

Allopurinol

Hx Pallor, fatigue, nausea, bleeding Lymph invasion mediastinal mass Extra-medulary haematopoiesis organomegally, bone pain, neuro involvement

Examination General: bruising, pallor, petichiae CVS: murmurs (anaemia) Resp + lymph nodes Abdo: organomegally Fundi for ICP

Ix Bloods

FBC + film + retics Blood culture U+E LDH (high cell turnover)

CXR (thymic mass) Bone marrow: L1 blasts), LPRespiratory infection

Hx Cough

Duration + Onset Pattern:

◦ Fits (pertusis, bronchiolitis, FB)◦ night (asthma, croup), morning (GOR)◦ Barking (croup)

Sputum / blood◦ Wheeze or Stridor

What’s the general state of him? Feeding, sleeping, irritable Stupor

Other Sx Fever Vomiting Rhinorrhoea Rash

What was his health like before? Allergy, asthma GORD, CF Developing in track General wellness

Infectious contacts / smokers Vaccinations HIB FOR EPIGLOTTITIS FHx : asthma, CF, CHD

Examination Centiles General: AVPU, distress, colour Vitals: fever, RR, HR, hydration Chest: respiratory distress

Crackles, wheeze, stridor ENT: obstruction

Ix FBC (WCC, left shift), CRP, cultures, U+E Sputum culture PNA CXR

Bronchiolitis (respiratory syncitical virus) Risks

<1 year SMOKERS Prematurity CHD CF

Sx coryza Cough + wheeze Low grade fever Tired, poor feeding, not sleeping

Examination Vitals: febrile, HR, RR Chest: nasal flare, recession, inspiratory crackles

Admit if Cyanotic, stupor, sats <92

DDxCough + unwell URTI croup bronchiolitis pneumonia foreign body pertusisCough but well GOR Post-nasal drip CF Passive smoking Post viral, habitChronic cough Asthma CF IFB Chronic Infections TB

Croup (parainfluenza) Sx

1-3 days fever, flu-like barking seal cough stridor irritable, not sleeping

Examination unwell, upset inspiratory stridor RR, HR

Mx steroids nebulised adrenalin in short term if severe, admit + intubate

Pneumonia Sx

Respiratory distress (GRUNT) Fever, tired Productive cough Vomit, abdo pain Not eating, not sleeping, miserable

Neonates GBSRapid, VERY unwell S.aureusFAST, URTI Sx in under 3s Strep pneumoniaeOthers: Hib, mycoplasma, viral (flu)

Mx admit if: <3months old, very sick, consolidation O2 if sats <92 Abx

amoxy + gent fluclox is severe roxithromycin if atypical

DDxAcute stridor croup tonsillar abscess anaphylaxis epiglottitis FB

Chronic stridor Laryngomalacia Subglottic stenosis Vascular rings, webs

Wheeze Asthma Bronchiolitis Pertusis Transient viral wheeze

Resp scriptOpeners X is a Xxyears old B/G who was brought in.....

S/He appears alert restless drowsy pale, limp toxic crying/ smiling colour: pink, blue, pale, yellow, dusky, mottled with tubes / oxygen mask / ventilation / sputum

cups / IV access

Hydration appears well hydrated Signs of mild / moderate / severe dehydration

◦ skin turgur◦ sunken fontanelles◦ low urine output◦ CRT >3 (poor peripheral perfusion)◦ high RR, HR, low BP◦ dry mucosa

Breathing

X is tachypnoeic / breathing comfortably There are signs of respiratory distress:

◦ sternal / subcostal / intracostal recession◦ nasal flaring◦ grunting

With:◦ inspiratory / expiratory stridor◦ inspiratory / expiratory wheeze◦ cough: barking (croup), whooping (pertusis),

breaths40-60 in neonatefirst 3 months = 30-503 months to 2 years = 20-402-10 years = 14-24>10 yrs = 12-20

AllergyUrticaria + AngioedemaHx Sx:

Rash Itching Swollen eyelids, lips, tongue Breathing problems

FHx of allergy, atopy, asthma triggers illnesses medications foods eaten contacts – plants, soap, wool recent infectious illness

Examinspect

angioedema lips, mouth, throat eye for rhinoconjunctivitis lymph glands

Fever joints chest – stridor and wheeze heart

Favoured Dx: urticaria

Counselling a reaction to an allergen or recent viral illness is not an Abx allergy maybe a food testing is not usually helpful may help to keep a food diary

Mx non-sedating anti histamine (Claratine) Sx treatment

calamine lotion tepid baths

oral steroids – if all else fails be aware of possibility of anaphylaxis

Food hypersensitivity Most lost with age : egg, milk, soya

Persistant : peanut, nut, shellfish Sx

Urticaria, angioedema Abdo distension, D+V Laryngeal oedema, asthma Anaphylaxis

Delayed onset: diarrhoea + AD

IxRAST vs skin prick Skin prick is

Cheap and faster Less error Antihistamine false negatives AD false positives

Anaphylaxis Mx

ABC IM adrenalin 0.01ml/kg 1:1,000

◦ Epi jr = 1:10,000◦ Every 10-15 min

IV access, O2, intubate? Mx for future

Immunotherapy reduces risk to <1%◦ Expose to tiny amount of antigen, gradual add

to it◦ Maintenance once a month

avoid food Food challenge: in hospital School liaison - Dietician Refer for fluvax safety

Counsel Risk of a major future reaction

<1% if was small s50% if major systemic reaction

EPIPEN: don’t leave without one Have one at school + ACTION PLAN

Medical alert bracelet

Allergic rhinitis ‘hay fever’Hx Sx

Blocked nose, rhinorrhoea Morning sneezes

Allergic ‘salute’ Link to seasons Specific triggers

Snoring / poor sleep / sleepiness School performance FHx of allergy, atopy, asthma SMOKERS in the house PMHx

Atopy medications

Examination Centiles Face

Allergic shiners (under eyes) Mouth breathing Tender sinus

Nose Nasal crease Pale, swollen nasal turbines Nasal discharge

Eyes: conjunctivitis Throat: enlarged tonsils, secretions

Counselling Over active immune system in URT Seasonal : older kids, from pollens etc Year round: kids under 10 Most grow out of it or to milder form

Mx Infants: saline nose drops Kids: steroid nasal spray (most respond)

Rhinocort, Becanase Mat cause nose bleeds

Non-sedating Antihistamines for flares (Clarytine) NO decongestants NO SMOKING

Atopic DermatitisHx

Sx Lesion: site, duration

◦ Has it moved◦ Itchy, pain

Rhinorrhoea, sneezing Swelling, breathing probs Triggers: water, plants, soap, wool Link to foods or drugs

General health recent infectious illness

FHx of allergy, atopy, asthma

Examination Centiles Skin:

Dry lichenified dermatitis Face, trunk, limbs Bacterial infection, weeping Xerosis Pruritic, scaly

Ix High total IgE + specific IgE to allergens SPT only useful if negative

Counselling Over active immune system in the skin We don’t know why, but we do know there is a broad

range of triggers So we need to take a many-faceted approach Has triggers + irritants Steroid phobia

MxStop the itch-scratch cycle Remove trigger + irritants (food, dust mites) Prevent dryness: emolients (sorbeline)

Ointment steroids, not creams!! Inflammation: topical steroids/antihistamines

Sigmacort for face Celestone for body

Infection: ceflex Stress management Serious flare ups can admit to hospital

Paediatric resuscitation

Correct airway, breathing, circulation approach 1 Check response, call for help 0.5 Airway opening manoeuvres, chin lift, jaw thrust, no

sweep mouth 1 Look, listen, feel 0.5 2 rescue breaths, gentle rise and fall of chest noted

1

Compressions pulse check<10 seconds brachial or femoral chest compressions

hand position lower half of sternum, 2 fingers 1 depth, one third chest of wall1 rate, achieving close to 100 compressions per

minute 1

Ventilation Ventilation technique, notes and achieves good rise

and fall of chest 2 High flow oxygen used or requested 1 Ratio 15:2, accept 30:2, approx 2 cycles per minute

1 Continues for 2 minutes (accept check after 1

minute) 1

Drugs IV fluid normal saline bolus given 10-20 ml/kg 0.5 Adrenaline IV given, correct dose of 10 mcg/kg 0.51000mcg = 1mg

Congenital heart check Asymptomatic murmur – 30-50% have murmur at

some point

Hx Cyanosis (onset, duration) Generally well? FTT

Feeing problems Shortness of breath on excersion

Squatting to breathe Chest infections Heart failure, arrhythmias

Examination CVS

Pulse: collapsing / femorals Radio-femoral delay Displaced apex Heart + maneuvers

Resp: RR Abdo: hepatomegally Diagnosed clinically, CXR, ECG, echo

Innocent Vibratory “stills” murmur ES pulmonary flow murmur

quiet or vibratory position dependent otherwise well heard with bell

Sinister Thrill or loud murmur Pansystolic BAD NO FEMORAL PULSES Displaced apex

Cyanotic (R L shunts) Tetrology of fallot1 VSD2 Pulmonary stenosis3 over-riding aorta4 right ventricular hypertrophy

Hx low sats cyanosis develops over months with crying + excersion (squatting) hypoxic

ejection systolic murmur on left sternal edge back spells (SOB, pallor) FTT Clubbing

Ix: ECG: RV hypertrophy Mx

Repair VSD + PS early as possible◦ Create systemic to pulmonary shunt B-blockers

Px: MI, CVA, death

Transposition of great arteries Hx

Cyanosis within a few hours met acidosis Survive via foramen ovale + ductus (up to a month)

left sternal heave Ix: CXR: normal size, egg on side shape

◦ ECG: abnormal T wave

Mx: create ASD surgical correction

AcyanoticVSDPerimembranous or muscularA Small VSD Pan-systolic murmur over left sternal edge

High pitched ± thrill May not hear for 6 weeks

B Large VSD Displaced apex FTT SOB Hepatomegally RR

Ix CXR: cardiomegaly, pulmonary vascular markings ECG: ventricular hypertrophy

Px: 50% resolve, some pulmonary HTN

ASDForemen ovale primum / secondum No Sx in chilhood

Adult: FTT, AF Ejection systolic, pulmonary flow murmur

parasternal heave no pulmonary HTN Ix: CXR: cardiomegaly, pulmonary markings

ECG: RBBB Mx: good surgical options

PDAA Small PDA Continuous murmur in pulmonary / sternal area

Starts like VSDB Large PDA

Collapsing pulse Displaced apex FTT SOB Chest infection

Ix: cardiomegaly, LV hypertrophy Mx

Premature: Indomethicin (too young to respond to O2)

Term: ligation, low risk

Pulmonary stenosisThickened leaflets + partially fused commisures No Sx in childhood Ejection systolic murmur at pulmonary area back

± thrill Ix: convex upper left heart border (pulm A.) Mx: mostly benign, or use balloon catheter

Coarctation of the AortaA early + severe shock, no flow to lower half of body (pink vs blue)

femoral pulses Ix: cardiomegaly + pulmonary congestion Mx: PGE (keep PDA) urgent surgery

B late + mild (PDA remains) Systolic murmur Radio-femoral delay Ix: rib notching (intercostal collaterals) intracranial haemorrhage

Seizures

establish report, be understanding to his anxieties

Hx Seizure

LOC / staring / awake Jerking / stiffening / face gestures Duration Happened before?

Post-ictal: recovery Pre-ictal

sleeping Generally well

Fever N+V+D, cough, headache, ear pain Injury / operations

FHx: seizures / epilepsy

Age 0-4wks: neonatal seizure 0-1: infantile spasms 1-2: breath holding, benign focal (occipital) 4-10: absence, benign focal (rolandic), tempral lobe puberty: IGT-CE

Examination Vitals: fever or sepsis neuro focal decifits (ICP) fundi + fontanelles, stiff neck, rash source of fever

Ix: not routine, use to find source of fever FBC (WCC, ESR), BSL Clean catch urine U/A EEG: developmental delay, focal signs

Can’t predict epilepsy

DDxNon-epileptic

sleep jerks day dreaming breath holding

Parasomnias night terrors sleep walking

ICP/sepsis

Other syncope migraine benign par-

oxysmal vertigo pseudo-seizures

Neonatal seizures focal or generalised causes: HIE

metabolic (glucose) infection: Neiserria, TORCH cerebral malformation

Mx: treat cause + Phenobarbitone

Infantile spasms causes: infection, malformation, injury 1-2 min of slow myoclonic jerk) EEG: disorganised, high voltage

Absence epilepsies 4-12 years <15 seconds of staring, blinking, fidgeting

1) typical: 3Hz spike and wave 2) teens: faster spike EEG Mx: Na Valproate, Ethosuximide, Lamotragine Most have remission

Benign Focal Epilepsy (25%)1) Rolandic: During SLEEP

orofacial movements drooling, choking hand/arm jerks EEG: centrotemporal spikes

2) Occipital: stares, eye deviation

Idiopathic generalised Tonic-Clonic epilepsy Fhx: seizures EEG: spike-wave or polyspike PMHx: absence or febrile convulsions Type: tonic → stop breathing → fall → clonic jerks

Lasts minutes Recovery: post-ictal drowsiness

no memory Mx: Na Valproate

Temporal Lobe epilepsyCauses: developmental lesions simple / complex partial

starring, fear expressionsFebrile convulsions Generalised tonic-clonic <5mins rapidly rising fever Post-ictal period 30min

Counselling NOT epilepsy common: 3% of kids 5months – 5years connected to a viral infection, especially when

rapid fever can be scary to watch, but are benign, usually no serious complications repeated in 30-40% risk of epilepsy in 2-7%, similar to population

Fever care minimal clothing, keep cool do not recommend

◦ sponging, baths: don't help◦ paracetamol – only for pain

First aid stay calm! Do

◦ Place child on soft surface, on side or back◦ time convulsion

do not◦ restrain◦ put anything in mouth (even fingers) they wont

swallow their tongue call 000 if

◦ last more than 5 minutes◦ doesn't wake up afterwards◦ looks very ill afterwards

Hospital care place in recovery position maintain airway, give )2 if needed >5, can give diazepam monitor consciousness, vitals Ix: BSL, UAE, Ca, FBC, blood culture

Vomiting ± diarrhoea

Ddx: diarrhoea + vomiting gastro / any systemic infection

/ UTI antibiotic induced surgical

◦ Appendicitis◦ onstruction

DKA

Hx Duration, frequency, colour

◦ Drinking / eating◦ Keeping anything down

Diarrhoea Fever localising signs (ENT, chest, urine)

◦ cough, rash, runny nose, stiff neck risk factors

◦ Infectious contacts◦ PMHx + general state of health◦ vaccines

if ~7yo, DM screen

Examination Quantify dehydration

◦ weight loss◦ AVPU◦ pallor◦ turgor◦ RR, HR◦ perfusion◦ BP◦ dry membranes

identifies abnormal and worrying signs of sepsis◦ BP ◦ CRT >3 (perfusion)◦ ↑HR, ↑RR (acidosis)◦ confusion◦ fever◦ respiratory distress◦ hydration

localizing signs stiff neck, rash resp Examination ENT exam

Limp and pale 2 year old

Ddx hypoglycaemia infection

◦ respiratory◦ GIT◦ UTI◦ pyelonephritis

anaemia

Ix RECOGNISE SEPTIC BOY suggest septic screen

Blood culture (+ meningococcal PCR) CXR urine (clean catch: U/a + MC/S) ±LP, PNA

insert IV/IO

Mx of sepsis oxygen NS bolus 20ml/kg empirical Abx

◦ Ceftriaxone ± Amoxycillin◦ Amoxycillin + Gentamycin if <6weeksold

plan transfer to larger centre (PMH/joondie)

Hydration at the hospital IV bolus 20ml/kg normal saline Continuing fluids

(eg. 10kg kid, 7.5% loss) Deficit = weight x %loss x 10

(10 x 7.5 x 10 = 750) Maintenance = 100ml/kg for first 10kg

◦ 50ml/kg for nest 10kg◦ 20ml/kf for any extra kg

(100 x 10 = 1000)

Continuing Fluids = maintenance + deficit (1000 + 750 = 1750ml/24hrs)

Oral: given over 6 hrs instead (1000/4 + 750 = 1000ml/6hrs)

Counselling for hydration at home probably gastro, the main problem is dehydration vomiting and diarrhoea in kids can have other

causes Mx

water / oral rehydration fluid + reason why frequent small sips avoid hypertonic fluids (sprite/juice) +

reason what to watch out for

poor fluid intake or still vomiting pallor / lethargy / drowsy / sunken eyes poor urine output high fever / headache / urinary Sx bile stained vomit / abdo pain

he has enough energy reserves to carry him through fasting

early introduction of food promotes recovery antiemetics not good in kids: cause dystonic

reactions careful hand washing to stop spread

Fever and rash

Hx Rash: duration, site, appearance

Come and go? pain Itch (scabies, AD)

Sx: fever sore throat, URTI Vomiting Stiff neck, meningism Focal neuro

Eating + sleeping Infectious contacts PMHx:

Past rashes allergies, psoriasis, SLE Generally well? Medications, vaccinations

Examination General: febrile / drowsy / well Sepsis: fever, BP

◦ cushing reflex: BP, HR, irregular breathing Rash: maculopapular, vesicular, purpuric

Blanching! Scattered / clusters

Neuro Meningism, ICP fundi (pappiloedema) focal changes (6th N palsy) Kernig’s sign

Lymphadenopathy / Splenomegally

Ix Septic screen

Blood cultures, FBC Urine U/A, MC/S CXR LP if no signs of ICP

Meningococcal PCR

DDx thrombocytopenia

Sepsis: MENINGOCOCCAL leukemia ITP TTP Drugs

Trauma Viral + post viral (HSP) venous return (coughing)

Neonates TORCH HLA Cancer trauma

Meningitis Neonates = GBS, E.coli S. pneuoniae N. meningitides Enteroviruses Hib etc

Infants Fever, irritability, drowsy vomit, seizures, poor feeding bulging fontanelles

Kids fever, headache, vomiting, photophobia stiff neck, rash delirium, seizure

Mx IV access, O2, fluid resus Ceftriaxone admit

Idiopathic thrombocytopenia purpuraHx acute bruising + petechiae mucosal bleeding post viral infection / URTI

Ix platellets, but no good test WCC, RBC normal

Mx benign, 80% resolve in 6 months steroids may help to platelets ±splenectomy if doesn’t resolve

Diabetes Mellitus type 1 and DKAHx of DKA nature of vomiting – freq, colour presence of diarrhoea fever diarrhoea infectious contacts and recent illness

Hx of diabetes polyuria + nocturia eating and drinking (polydypsia) energy (fatigue) weight loss funny smell on breath (ketotic) abdo pain General state of health

Steroids Resp distress thrush

Ddx juvenile onset DM steroid use UTI + sepsis Gastro DM2 (rare)

Examination dehydration assessment consciousness temperature look for sepsis

Ix U/A: glucose, ketones Bloods

Random BGL >11.0 fasting BGL >7.0 U+E ABG Septic screen (FBC, cultures) HbA1c To Dx: islet cell Abs, insulin Abs, TFT

Counsel explain JODM to parents explain DKA: convey urgency of initial Mx

Mx of DKA initial resuscitation and paediatrician r/v at PMH IV access + O2 fluid : NS 20ml/kg bolus

◦ oral after 24hrs if stable insulin: aim for BGL 10-12mmol/L

◦ 0.1unit/kg/hr◦ Aim for 5mmol/L drop per hour

K: start with insulin Bicarb: if still acidotic will need specialist input (peads, endocrine, DM

edu nurse) – get to PMH

Mx plan refer to paediatrician DM education nurse

Acute abdo painHx duration, pattern, location, colicky Sx

fever Vomit / bile Stools: diarrhoea, blood Dysuria (UTI) Cough (pneumonia)

What was his health like before? HSD, GORD, CF Developing on track General wellness Feeding + sleeping

Infectious contacts Vaccinations (rota)

Examination centiles Sepsis Hydration Fever Abdo : RUQ sausage

Peritonism Intussusception: RUQ masses, distention Malrotation: distention, tinkling BS

◦ Feaces felt in HSD Bowel sounds Jaundice

Chest : pneumonia, CF testes

Ix bloods

FBC, culture, CRP U+E if vomit BGL

Urine: U/A + MC/S AXR, U/S

Double bubble sign of obstruction Barium enema (intussusception, HSD)

Hirschsprung’s diseaseCongenital abscense of ganglia in segment of colon infrequent, narrow stools, obstruction, megacolon Causes ulcers, bleeds, enterocolitis DRE: thin pellets only Ix: sigmoidoscopy + barium enema Mx: remove segment ± colostomy

Acute colic gastro intussusception appendicitis obstruction (malrotation, constipation) testes torsion pneumonia, UTI HSP DMRecurrent IBD HSP Menstruation functional

Malrotation w volvulusIncomplete or non-rotation of mid-gut around SMA Hx

1 week – 1 month with other GIT malformations malabsorption

Sx Bilious vomit Distension+ colicky pain PR blood = necrosis from volvulus

IMMEDIATE SURGICAL REFERRAL Fluid/electrolytes, Abx, NGT LADD procedure

IntussusceptionDistal ileum into distal bowel Hx

Male 2 months – 2 years PMHx: Hirschsprungs, CF

Sx Colicky pain every 3min drawn up legs Vomiting ++ bilious ‘red current’ stools Tired, not feeding

Mx theraputic barium enema Correct dehydration Surgery

Torsion of testes Painful, enlarged Black swelling VV painful RIF Ix: theatre within 6 hours ± MSU

Chronic diarrhoeaHx

duration, frequency of bowel motions Stools

◦ watery/frothy (milk) with raw buttocks◦ offensive and fatty (coeliac)◦ bloody (IBD)

vomiting Abdo pain and fever (IBD, infection) feeding

◦ started any new foods?◦ Added milk add into diet? Diarrhoea when milk

still given? weight loss (coeliac, IBD, infection) FHx: IBD, coeliac, CF, allergy

Ddx sugar intolerance cows milk allergy CF coeliac infection: giardia (mimmicks

coeliac), salmonella, campylobacter, yersinia, entamoeba H

IBD

Exam abdo exam

◦ tender? Masses? Distension?◦ Rectal exam

general◦ pale? Ill? Wasting? Skin folds?

Chest exam (CF)

Ix bloods

◦ FBC + ESR/CRP◦ LFT◦ coeliac screening serology◦ cultures

stool ◦ microscopy + cultures (aerobic and anaerobic)◦ feacal fat test◦ lactose/glucose clinitest tablet (sugar/lactose

intolerance)

Further Ix as needed biopsy sigmoidoscopy trial lactose restriction

Coeliac disease

permanent sensitivity to a-gliadin of gluten → mucosal damage and loss of villi of proximal small bowel → malabsorption

presents usually between 9 + 18 months

Presents with: FTT after weaning (cereal in diet) poor feeding and weight loss chromic diarrhoea + steatorrhoea irritability vomiting late childhood:

◦ anaemia◦ FTT without GIT Sx◦ delayed puberty, short stature

Examination miserable + pale abdo distension, but wasted buttock wasting and skin folds

Ix FBC:

◦ microcytic (Fe deficiency) or ◦ macrocytic (B12, foliate)

Ca (low) LFTs: hypoalbuminaemia serology (screening only)

◦ antiendomysial and antigliadin antibodies: IgA: 95% specific

◦ antibody of tissue transglumaninase = v v good

stool: faecal fat test

Further Ix (If serology is suggestive) small bowel biopsy: gold standard Dx

◦ before diet change◦ ± retest after diet changes

± gluten challenge

Counselling body decides that gluten is harmful and wants to

destroy it. It destroys cells n your bowel that have the gluten. It makes it hard for your body to absorb the nutrients it needs.

Life long, will go into remission many gluten free products available now pregnancy: risk of fetal loss and abnormalities

Mx strict lifelong gluten-free diet: wheat, barley, rye oats are ok vitamin and Fe supplements pancreatic enzyme supplements may help with

weight gain

Swollen joint child

Hx PMHx and general growth limp:

◦ onset◦ trauma?◦ Duration◦ pattern◦ triggers/relievers

Pain:◦ where does it hurt most◦ diurnal pattern?◦ Night (bone tumour)◦ non-weight bearing?

JIA Hx◦ rash?◦ psoriasis/ itching◦ Eye inflammation◦ neck/back pain

Septic Hx◦ fever

Juvenile idiopathic arthritis common 6 weeks of pain before 16 years old

A systemic arthritis 2 weeks fever + arthritis + rash (maculopapular)

/organomegally high ESR, CRP, WCC

B polyarthritis RF+ in teen girls 4 or more joints treat hard and fast to prevent erosion

C polyarthritis RF- more common ?

D oligoarthritis less than 4 joints (extending into more is BAD px)

fat toes and knees + eye inflammation! + limb overgrowth!

E psoriatic with psoriasis (dactylitis, nail abnormalities, 1st

degree relative) bad eye inflammation, variable px

F enthesitis related boys over 8 years old with enthesitis link to B27+ + ankylosing spondylitis feet, neck or back + iritis treat hard and fast for back

Mx physiotherapy and OT NSAIDS – DMARDS and cytotoxics

steroids – local, IV, low dose oral, eye drops

Examination gait skin

◦ signs of trauma◦ rash (maculopapular)◦ psoriasis

joints◦ inflammation◦ number of joints

muscles lymph glands / organomegally fever eye exam for iritis

Ix CRP/ESR, RF, FBC Xray, bone scan MRI for tumour

Developmental dysplasia of the hip Clicky hips, be suspicious if:

Abnormal femoral head movement Limited hip movement FHx Breech

Ix: hip U/S

Risk factors for DDH First born Female Breech CS FHx Foot abnormalities

Screening General: barlows + ortolani Selective screening: hip U/S

◦ Exams in the first year◦ Xray if >3months

Counselling 1 in 80 have clicky hips in first few days 1 in 800 will need some management caught early enough, will walk normally, fully functioning

hip refer to paediatric orthopod

Mx The earlier the better 0-6months: Brace in abduction with a Pavlick harness 8-18months: will need open reduction + osteotomy

Child with Limp

Limp of DDx DDH Perthes SCFE Transient sinovitis Septic arthritis Trauma, OM, cancer

Hx Sx

Pain◦ Location knee, thigh◦ Pain with walking, exercise◦ Affect on school/home

Limp: when? Trauma

Generally well? DDH Steroids Recent illness Weight loss, pain at night

Examination gait General: septic?

Fever, pallor Rash Lymphadenopathy / organomegally

Limb length: true + apparent Limb

Red, swollen, tender, hot Atrophy movement

Ix Xray (SCFE, trauma, infection, tumours, perthes) ±bone scan (OM, stress) FBC + film, ESR

Transient sinovitis 2-8yo benign, common sudden onset limp + pain otherwise well, recent URTI Ix normal Mx: bed rest, analgesia

Septic arthritis + Osteomyelitis red, swollen, hot, tender joint can not weight bear all movements painful septic child Ix: ESR, WCC

Xray, bone scan

Mx: admit, culture (blood, joint fluid), ABx

Perthes disease inadequate growth of blood supply avascular necrosis capital femoral epiphysis f femoral

headHx male ~7yo Sx

Painless limp on exercise Hip/groin pain knee / thigh antalgic gait

cause idiopathic DDH steroids trauma

Examination general: wasted quads on one side

legs unequal move: internal rotationIx : XrayMx: splint, osteotomy

SCFE (slipped capital femoral epiphysis) in fat teenage boys Sx

Gradual Pain + limp knee / thigh / groinExamination Antalgic gait internal rotation joint irritabilityIx: Xray in frog lateral viewMx: surgical screws to stop slip

don’t push back (vessel damage)

Headache childHx pain

◦ location◦ onset◦ duration◦ frequency◦ pattern

Red flags◦ worse at night, on waking◦ vomiting and visual changes◦ progressive◦ cognitive change◦ weight loss◦ under 5 years

state between attacks head trauma development + schooling FHx of migraines, cancers

Examination vitals: BP, HR, temperature inspect: toxic? Unwell? Rash? ENT: cervical nodes, teeth, sinus, ears centiles neuro exam

◦ fundi◦ confusion◦ visual fields◦ tender / stiff neck◦ tense fontanelle

cranial bruits

First acute headacheDdx

first migraine tension / cluster headache viral illness / sinusitis / OM CNS infections (men, enceph, ICPup) Pneumonia HTN / vascular minor trauma exertional hypoglycaemia

MigraineCounselling

education simple analgesia ± metaclopromide ± cyproheptadine nasal sumatriptan sleep

Prevention avoid triggers cyproheptadine, pizotifen, B-blockers, amitryptiline

Head trauma child Hx

What happened? Falls

◦ What surface? What part of body?◦ How high?

Before:◦ black out / fitting◦ did they roll / crawl / climb

during:◦ witnessed?◦ NAI?

After:◦ concussion signs (few hours only)

▪ loss of consciousness▪ confusion▪ vomiting▪ amnesia

◦ Worry about cerebral contusion if▪ drowsy▪ headache or vomiting▪ focal neuro signs

◦ worry about epidural haematoma if▪ hit from side▪ fluctuating confusion and lucidity

◦ worry about subdural haematoma if▪ shaking baby▪ intact consciousness▪ seizures

any other injuries?

ExaminationVitals

breathing: Cheyne-Stokes respirations (Midbrain herniation)

HR + BP in Cushings triad of high ICP AVPU, confusion, drowsiness

Head trauma racoon eyes and battle's sign (basilar skull fracture) depressed skull

Eyes epidural

◦ ipsilateral dilatation ◦ papilloedema

subdural: retinal haemorrhageENT

CSF otorrhoea + rhinorrhoea (basilar skull fracture)Neck/chest

immobilise cervical spine → palpate spinous processes

soft tissue / rib traumaNeuro

focal signs = contusion, haematoma unilateral = epidural bilateral = subdural reflexes

Ix cervical spine films contrast CT (ICP, fracture, penetrating injury)

Fracture Hx How did it happen? Any blood Other injuries – hit his head?

Examination General: distressed

Signs of shock or occult blood loss, confusion Limb

Closed or open Deformity / swelling (acute = #) Neuro distal – sensation, movement Pulses distal to injury

Ix Xray

Site + section (diaphyseal, metaphyseal, epiphyseal

Fracture line: transverse, oblique, spiral, comminuted

Displacement

Mx Analgesia Spling Xray Plaster At home: written instructions

Limb elevation, wear sling for 48hrs Xray at 1 weeks Plaster for 3-6 wks No contact sports for 8-12wks after plaster

BurnsFirst Aid Stop burning: run under cool water for 20 minutes,

no ice. Carefully remove jewellery + clothes

SurveyABCDEF + vitals O2 mask Pulse + BP Elevate burned areas Hx: how + when PMHx: allergies, tetanus status, medical problems

Mx Fluid resus

IV access + bloods Hartmann’s : % x weight x 2

◦ <18months >8%body area◦ >18months >10% body area

elevate burn area monitor UO tetanus prophylaxis IV morphine

Examination Extent

Teens can use rule of 9s, younger kids can’t Distribution

Concern for ◦ Face◦ Neck◦ Hands◦ Feet◦ Perineum◦ joints

depth superficial: dry, red, blister (sun, splash) superficial partial thickness: moist, red, broken

blisters (spills, oil, flame) deep partial: moist, red-white slough, pressure

but no pain (spill, oil, flame) deep full thckness: whyte, dry, charred, no

pain (flame, steam, chemical, electrical)

Ix FBC, U+E, G+H, albumin, BGL urine

Teenagers

Get parents out of roomConfidentialityI write confidential medical notesEverything you say will stay between you + me.I won’t tell your parents and I won’t tell anyone else unless you tell me its ok I think that someone’s going to get hurt.

Issues

HHow is everything at homeGetting along with everyoneEHows everything at schoolWhats your favourite subjectAD

Has anyone in your been using drugs. Have your friends. Have you?SS

3 0M with testicular lump – U/S and counselling BBN

setting scene: seating, no interuptions telling news: direct and honest manner

advise that further Ix in tertiary centre will be needed

CT blood tests (AFP, HCG, LDH) surgery

advise of possible treatment options depending on tumour type: surgery, chemo, radio

ends consultation with good closure and offer some hope of cure

Further Ix blood tests

▪ FBP▪ aFP▪ HCG▪ LDH

CT CXR

Counsel prognosis

◦ seminoma is good (highly radiosensitive)▪ 95% 5yr survival

◦ non-seminomas less good▪ depends on grade + stage

Further Mx refer to consultant surgeon

◦ orchidectomy ▪ ± prosthesis ▪ ± cryo=preservation of sperm

adjuvant treatment◦ seminoma radio

Testicular cancer Germ cell tumours= Teratoma: most common 15-30 Seminoma: 30-50 – most common Non-germ cell tumours = lymphomaRisk factors FHx XXY + feminisation ? exogenous oestrogensHx scrotal mass – firm painless teste enlargement, tender, assymetrical lymph node spread back pain or mets (SOB)

◦ Non-seminoma chemo◦ Depends on stage and grade

▪ size, LN, mets

counselling for chemotherapypreventing nausea in ppl having chemo therapy

Instructions Ondansetron: 1 capsule each morning and night before eating Dexamethasone: 1 tab 2x/ day with food, about 4pm for 2nd

Metoclopramide: 1 or 2 as needed Maxalon: if need extra help

when to start? Ondansetron and Dexamethasone the morning after chemo will be given anti-nausea meds with chemo at hospital on the first day

Should take if feeling ok? Yes, they are to prevent nausea, so should keep using Ondansetron and Dexamethasone even if you feel ok. If

feeling well, dont have to add metoclopramide.side effects

Ondansetron ▪ constipation▪ headache▪ dry mouth

Dexamethasone: short term toxicities▪ heartburn▪ more appetite▪ insomnia▪ high blood sugar

Metoclopramide

▪ restlessness▪ dystonia

Student with lymphoma

Hodgkin’s Lymphoma: Reed-Steinberg cellsTypes Nodular sclerosis (70%)lymphocyte richlymphocyte depletedmixed cellularity Nodular lymphocyte predominantHxPainless, rubbery cervical lymphadenopathyConstitutional SxTiredness, weight lossFever, night sweatsPruritusETOH induced LN painExaminationlymphadenopathy±organomegally

IxBloods

FBC + differentialsESR, LDH, LFTs

FNA of nodeStaging:

CXR, CT all overMarrow biopsy

Dx with LN biopsy + histology

Staging (Ann-Arbor)I : one node areaII : 2 or more nodes on same side of diaphragmIII : both sides of diaphragmIV : disseminated / extra-nodal, or in liver / marrow

Counselling BBN: points for setting the scene, empathy nature of diagnosis further mx:

onchology referral

regular follow upSupport structures

letter of support to university discussion with family counselling

Non-Hodgkin’s LymphomaTypesMostly B cellNodular bestDiffuse worstAlso NK cell and T cellHxpainless lymphadenopathyextranodal sites: skin, GITconstitutional Sxsweating± organomegallyExaminationadenopathy, organomegallymasses: testes, abdo, skin, liver

Treatment outline likely scenario of staging disease,

chemotherapy, DXRTHL: Curable

Radio/chemo: ABVDNHL: varies greatly

usually radio ± chemo (CHOP)

Prognosis overall px depending on staging HL has best overall px

HL: very predictableStage I 90%Stage IV 65%Relapse common

NHL: unpredictable + variable

Skin cancer consultPresents with:A Asymmetry: usually asymmetricalB Borders: well defined + irregularC Colour: blue-black / multicolouredD Diameter: >7mm usuallyE Elevation = invasionBleeding / ulcerationLymphadenopathy5% amelanitic = BAD

Hx previous sun exposure previous skin problems/operations spot changes

o bleedingo itchingo change in size

duration of lesionoutdoor job or hobbiesdo you use sun screen

Examinationdermoscopylymph node exam

IxDermoscopy + excision of lesion2mm marginlymph node sampling – sentinal node biopsy if tumour >1mm

Treatmentexcise with 2-3mm margins ± dissection of lymph nodes for biopsy

if <1mm depth: recut 1cmif >1mm depth: recut 2cm

adjuvant: interferon or combination chemo

PrognosisOverall Australian survival >80%Poorer PX inthickness (Breslow classification)

up to 0.75mm 100% 5YS0.76mm – 1.5mm 80%>1.5mm <40%

depth: levels 4 or 5 = BAD (into reticular dermis + subcutaneous tissue)head, trunk, neckmen >50 yearsamelanoticulcerated

By stage

stage 1/II: localised 89-96%stage III: regional spread 60%mets 14%

Counselling advises patient of Dx of melanoma

o breaking bad news need for review and seriousness of lesion urgency of this review!!

Cough and weight loss in smoker with CXR

Introduction: set the scene for breaking bad news break news in a direct and honest manner

◦ “the report says it’s likely to be cancer, but need more tests to confirm. Not good news but not certain at this stage and not taking away all hope”

Allow time for the patient to respond opportunity to return and discuss again with partner and family member

Ix Advise about further Ix in a tertiary centre CT sputum cytology bronchoscopy

For tissue diagnosis

Melanomaages 30-50pale skin, blondes, redheadscommon locations: lower limbs + upper back

Typessuperficial spreading (70%) takes months to yearslentigo: old: slow growingnodular (2%) = BAD – trunk and limbs of youngAcral: palms and soles – in dark skin

52F with lump in breast

Hx aware of

▪ lump▪ pain▪ nipple discharge

does she do her own breast self examination has she had regular mammograms/paps Past history

▪ breast lumps▪ breast cancers / other cancers

oestrogen risk factors▪ age at menarche and menopause▪ use of HRT or OCP▪ Did she breastfeed? How many kids?

FHx of breast cancer smoking and ETOH

Examination counsellingInspection:

arms by side hands on hips hands up in the air look for skin: irregularities, dimpling, peau d'orange, nipple inversion

Palpation: systemic, plus palpate for nipple discharge exam of lymph nodes: axillary and supraclavicular

Explanation raise issue of breast cancer offer hope

Further Ix “this may or may not be breast cancer, so we need to arrange further definitive testing” mammogram and ultrasound FNA or core biopsy – TODAY IF SERIOUS referral to breast surgeon or breast clinic

“this must be shock for you, if you need time for this to sink in, I suggest we meet again in a few days so I can answer all you questions. You can bring your partner or relative, whichever you choose”(If it is cancer question, you need to cover tests to confirm, treatment, and prognosis)

▪ Oncology Had to describe the CXR in an orderly manner (you should know this from 4th/5th year gen med!!!) – If you do,

you should pick up the missing breast shadow in seconds. There is a complete whiteout of the left, lower segment. We were expected to discuss differentials including malignant pleural effusions, discuss management and investigations. That is if you got that far. you had to request MC+S(microbiol)/biochem/cytology/immuology of pleural aspirate, cytology would show up malignant cells. Rx of underlying cause, plus drain effusion if symptomatic. [Cancer]

Look at and comment on a CT chest and abdomen with primary lung cancer, nodal involvement and liver metastases then discuss TNM classification and treatment options.

Breaking bad news – Tell patient that they have a meningioma and counsel them about the prognosis.Large masses in pancreas BBN

CT – lung cancer with met to liver TNM stage, Mx options, discuss/define performance status Oncology: a discussion with the consultant of a 42 year old woman with moderate to poor prognosis breast

cancer and how you would treat her (including surgery, chemo, radio, treatment for nausea) Giving bad news. 49yr old woman presents wanting to know the results of a CT scan, which revealed multiple

large masses in the head of pancrease, scan inconclusive but highly suspicious of malignancy 65yr old woman presents with a lump in breast which after investigation was T3N2M0, how would you treat her,

what is involved in her management? Must discuss everything, then they start firing well what if she was 70,

what if she was ER negative, what if she was M1, how about T4? What antinauseant do you know

Chesna’s family recipe for key word circling

Demographics

female, childbearing age => LMP, bHCG

child => immunisation, hydration

Comorbidities

diabetes => glucose & medical manamgent

ETOH => thiamine

Presentation

pain => analgesia

fever => septic screen

SOB / chest pain / collapse => consider PE

hypotension/hypovolaemia => always check postural BP first

pregnancy + bleed => anti-D

abdo pain => remember lipase (pancreatitis) & ECG (cardiac causes)

surgical => DVT prophyalxis + coags, G&H, X match (if bleeding/risk of) + AB prophy-laxis + anticoagulation issues

DM/HT => endorgan damage (inc fun-doscopy)

ARF => acute/chronic/a-on-c + baseline/daily weight + when rehydrate “aim to maintain urine output at 0.5-1.0 mL/kg/hr)

COPD => ? CO2 retention (ABG: HCO3- will be increased in chronic retention, other-wise titrate O2)

ulcers/bone related => exclude osteomyelitis

Critical Care

ABCDE => tube in every hole (including 2x wide bore cannulas) => AMPLE => critcal Ix => detailed Hx => secondary survey

****never forget C-spine or glucose****

increased RR => O2 and ABG (exclude resp failure)

bradycardia + hypotension + not responding to IVF => ? inotropes

GCS < 9 => call anaesthetist + intubate

asthma => CXR (exclude pneumothorax)

Drugs

opiods => anti-emetics

insulin => check K

salbutamol => check K, check glucose