1
Q
Which diseases require no school exclusion? (7)
A
Conjunctivitis
Fifth Disease (Slapped Cheek Syndrome)
Infectious Mononucleosis
Roseola
Threadworms
Head Lice
Hand, foot and mouth
2
Q
What are school exclusion rules for scarlet fever?
A
24 hours after commencing antibiotics
3
Q
What are school exclusion rules for whooping cough?
A
2 days after commencing antibiotics (or 21 days from onset of symptoms if no abx)
4
Q
What are school exclusion rules for measles?
A
4 days from onset of rash
5
Q
What are school exclusion rules for rubella?
A
5 days from onset of rash
6
Q
What are school exclusion rules for chickenpox?
A
All lesions crusted over
7
Q
What are school exclusion rules for mumps?
A
5 days from onset of swollen glands
8
Q
What are school exclusion rules for D&V?
A
Until symptoms settled for 48 hours
9
Q
What are school exclusion rules for impetigo?
A
Until lesions crusted and healed, or 48 hours after commencing treatment
10
Q
What are school exclusion rules for scabies?
A
Until treated
11
Q
What are school exclusion rules for influenza?
A
Until recovered
12
Q
When to offer antihypertensives in hypertension?
A
- Offer antihypertensives after ABPM/HBPM for:
o Stage 1 Hypertension (≤80 years) with 1 of following:
Target organ damage, established CVD, renal disease, diabetes, ≥10% QRISK2
Stop taking OCP recommend
Consider in Stage 1 if >80 and >150/90 or <60 with QRISK <10%
o Stage 2 Hypertension - If severe hypertension:
o Start antihypertensive immediately
13
Q
Drug management in hypertension?
A
If <55 or T2DM
ACEi/ARB (ARB for Afro-Caribbean)
If >55, do not have T2DM or Afro-Caribbean or any age without T2DM:
CCB
If still not controlled:
ACEi/ARB + CCB
If still not controlled:
ACEi/ARB + CCB + Thiazide-like diuretic (indapamide)
If still not controlled:
ACEi/ARB + CCB + Thiazide-like diuretic + further diuretic (low-dose spironolactone if K<4.5 or high dose TLD if K>4.5, or alpha or beta blocker)
14
Q
Drug treatments in heart failure with preserved ejection fraction (>40%)?
A
Consider MRA + SGLT2
Loop diuretic (furosemide up to 80mg)
o Specialist advice if does not improve
15
Q
Drug treatments in heart failure with redcued ejection fraction (<40%)?
A
1st line
ACEi/ARB - Hydralazine & Isosorbide dinitrate if not responding to ACEi
Beta-blocker - Start low dose and titrate up
MRA (spironolactone/eplerenone)
SGLT2i
If ongoing symptoms:
- Switch ACE to ARNI (Entresto)
Symptomatic Treatment:
Loop diuretics (furosemide) - For relief of congestive symptoms and fluid retention, titrated according to need
16
Q
Further management of heart failure with reduced ejection fraction (<40%) if 1st line therapy does not work?
A
Ivabradine * Sinus rhythm, HR >75bpm, EF <35%
Hydralazine
- If ACE/ARB/ARNI not tolerated
~~~
Digoxin
- Sinus rhythm, reduced EF, worsening or severe HF
17
Q
Important drug interaction to avoid in chronic heart failure?
A
AVOID NDHP-CCB IN HF WITH REDUCED EF, REDUCES CARDIAC CONTRACTILITY
18
Q
Management of stable angina whilst awaiting diagnosis?
A
o Sublingual GTN spray used to relieve symptoms
If they experience chest pain, stop and rest, use GTN as instructed
Take 2nd dose after 5 mins, if pain still present call 999
o Aspirin (75mg) if likely to be stable angina
19
Q
Initial tests in specialist chest pain service of stable angina??
A
Bloods
• FBC (anaemia), TFTs, HbA1c, Lipids
ECG
• May show ST depression, T wave flattening/inversion, pathological Q waves, LBBB
20
Q
Diagnostic imaging in specialist chest pain service of stable angina??
A
1st line - CT coronary angiography
2nd line - Non-invasive functional imaging, offer when CT angiogram has shown CAD of uncertain functional significance or non-diagnostic
• Myocardial perfusion scintigraphy with SPECT
• Stress Echo
• Contrast MRI
3rd line – Invasive coronary angiography, if results inconclusive
21
Q
Investigations if known CAD in stable angina? Criteria for this?
A
o If known CAD (previous MI, revascularisation, previous angiograpy)
Exercise testing ECG – ST depression <6 mins
22
Q
Drug treatments given in stable angina?
A
o Sublingual GTN spray (sublingual tablets) used to relieve symptoms
If they experience chest pain, stop and rest, use GTN as instructed
Take 2nd dose after 5 mins, if pain still present call 999
o Beta-blocker/CCB (N-DHP) (1st line regular)
Use both if symptoms persist (BB & DHP CCB)
Alternatives if cannot tolerate BB/CCB or both CI: Isosorbide mononitrate, nicorandil, ivabradine, ranolazine
o Monitor 2-4 weeks after starting or changing dose
23
Q
Secondary prevention of CVD in stable angina?
A
o Aspirin 75mg OD
o Atorvastatin 80mg OD
o ACEi (if hypertensive/diabetic)
24
Q
When to refer to cardiologist and for what in stable angina?
A
- Referral to cardiologist for angiography (and possible revascularisation) if:
o Extensive ischaemia on ECG
o On optimal drug treatment given (2 drugs max doses)
25
Severity assessment of asthma exacerbation - moderate?
PEFR 50-75% best or predicted
Increasing symptoms
No features of acute severe asthma
26
Severity assessment of asthma exacerbation - severe?
```
Any 1 of:
• PEFR 33-50% best or predicted
• Unable to complete sentences in 1 breath
• RR ≥25
• HR ≥110
```
27
Severity assessment of asthma exacerbation - life-threatening?
```
Patient with severe asthma with any 1 of:
• Altered consciousness
• Cyanosis
• Hypotension
• Exhaustion, poor respiratory effort
• Silent Chest
• Threatening - SpO2<92% (PaO2<8kPa), PEFR <33%
• Bradycardia
• Normal pCO2 (4.6-6)
```
28
Severity assessment of asthma exacerbation - near-fatal asthma?
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
29
Management of asthma exacerbations - moderate asthma attack?
o Treat at home or in surgery and assess response to treatment
o Salbutamol via spacer every 60 seconds up to 10 puffs
o If no improvement – via salbutamol 5mg nebuliser
o Prednisolone 40-50mg for 5 days
o Admit if features of severe, life-threatening asthma or recent nocturnal symptoms/hospital admission
30
Management of asthma exacerbations -acute severe or life-threatening - initial management?
Make sure patient is sitting up
15L/min Oxygen via NRB mask if hypoxic (aim 94-98%)
IV access (FBC, U&E, glucose, CRP, cultures (if septic))
ABG
Salbutamol 5mg (or terbutaline 10mg) nebulised with oxygen
• If does not respond – every 15 mins or continuous nebuliser
Ipratropium Bromide 500mcg (0.5mg) added to nebulisers if poor initial response
• 4-6 hourly
Hydrocortisone IV 100mg every 6 hours (or prednisolone PO 40-50mg for 5 days if can take orally)
Magnesium Sulphate 1.2g-2g IV over 20 mins
31
Investigations of asthma - if suspected asthma?
- If <5 – treat based on symptoms and review child regularly, if still symptoms at 5, carry out objective tests, refer to resp paediatrician any preschool child with admission or 2 or more admissions to an emergency department, with wheeze in a 12m
- If >5 and unable to perform objective tests – continue to treat and try redoing test every 6-12 months
32
Investigations of asthma in children 5-17 years - initial investigations to perform?
1st line - fractional nitric oxide (FeNO) diagnose asthma if: FeNO is ≥ 35 ppb
If FeNO level normal or not available:
- Bronchodilator reversibility (BDR) with spirometry
- diagnose asthma if: FEV1 increase ≥ 12% from the pre-bronchodilator or increase is ≥ 10% of predicted FEV1
If spirometry not available:
- PEFR twice daily for 2 weeks
- diagnose asthma if:
PEF variability ≥ 20%
If asthma is not confirmed by FeNO, BDR or PEF variability but still suspected on clinical grounds:
- skin prick testing to house dust mite
- OR measure total IgE level and blood eosinophil count
exclude asthma if no positive house dust mite or normal IgE
diagnose asthma if there is evidence of sensitisation OR a raised total IgE level and the eosinophil count is > 0.5 x 109/L
If there is still doubt about the diagnosis
- refer
33
Investigations of asthma in children 5-17 years - when to refer to specialist?
o Refer for specialist assessment if negative FeNO, BDR, PEFR and negative IgE and house dust mite
34
Investigations of asthma in adults - objective tests to perform?
1st line
- Eosinophil count
- FeNO
Diagnosed if raised eosinophils or FeNO >50
If not:
- Bronchodilator reversibility (BDR) with spirometry
Diagnose FEV1 increase ≥ 12% and >200 ml from pre-broncho or FEV1 ≥ 10% of predicted FEV1
If not available:
- PEFR twice daily for 2 weeks
Diagnose PEF variability ≥ 20%
If not:
- Refer for bronchial challenge test
35
Management of asthma - general advice?
- Weight loss
- Stop smoking
- Avoid triggers
- Annual flu vaccine
- Check inhaler technique and PEFR 2x a day
36
Management of asthma - medications - under 5s - step 1?
o SABA with 8-12 week trial of paediatric low dose ICS BD
| If symptoms >3x per week, causing waking at night or not controlled on SABA alone
37
Management of asthma - medications - under 5s - step 2?
o After 8 weeks, stop ICS treatment:
If symptoms resolved then reoccurred within 4 weeks of stopping ICS – restart at paediatric low dose maintenance therapy
If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS – repeat 8-week trial of paediatric moderate dose of ICS
38
Management of asthma - medications - under 5s - step 3?
o If unresolved on paediatric low dose maintenance therapy:
- Titrate up to paediatric moderate dose ICS BD
o If uncontrolled on moderate dose ICS
- Add LRTA trial for 8-12 weeks (stop if ineffective)
| Add LTRA
39
Management of asthma - medications - under 5s - step 4?
o If unresolved on ICS and LTRA:
- Stop LTRA and referral to respiratory paediatric asthma specialist
| Stop LTRA and refer to specialist
40
Management of asthma - medications - child 12 and over and adults - step 1?
o Step 1
- Low dose ICS/LABA (ICS/formoterol) AIR therapy
- If highly symptomatic (regular night waking, symptoms or not controlled on AIR) - low dose MART therapy
41
Management of asthma - medications - child >11 and adults - step 2?
- Moderate dose MART
42
Management of asthma - medications - child >5 and adults - step 3?
```
Step 3 (if >3 doses PRN SABA in week, drugs not working, woken)
- Measure FeNO and Eosinophil count
- If either raised - referral to respiratory
- If both normal - 8-12 week trial of LRTA or LAMA in addition
After 8-12 weeks:
- If controlled - continue
- If improved but inadequate - continue and trial other medication
- If not improved - stop and trial other
- If not improved and tried both - refer
43
Management of asthma - medications - child >5 and adults - step 5?
o Step 5 (if >3 doses PRN SABA, drugs not working, woken)
Referral to specialist
Oral prednisolone
Steroid sparing – methotrexate, ciclosporin
44
Management of asthma - when to refer immediately?
- Immediately if occupational asthma suspected
45
Management of asthma - follow up?
- Annually
- 4-8 weeks after medication change or start
- Long-term/Frequent steroid tablets need BP, HbA1c, cholesterol and vision tested every 3 months
46
Management of asthma - self-management plan?
- Increased dose of ICS for 7 days when asthma deteriorates (quadruple dose)
47
Doses of ICS in asthma - adults?
o < or equal 400mcg budesonide or equivalent = low dose
o 400mcg – 800mcg budesonide or equivalent = moderate dose
o >800mcg budesonide or equivalent = high
dose
48
Doses of ICS in asthma - child <16?
o < or equal 200mcg budesonide or equivalent = low dose
o >200mcg – 400mcg budesonide or equivalent = medium dose
o >400mcg budesonide or equivalent = high dose
49
Asssessment of COPD?
- MRC Dyspnoea scale
o 1 – not troubled by breathlessness except strenuous
o 2 – SOB when hurrying or walking up slight hill
o 3 – Walks slower than contemporaries due to breathlessness, must stop when at own pace
o 4 – stops for breath about 100m or few minutes
o 5 – Too breathless to leave house, breathless when dressing
- Symptoms of anxiety or depression
- Calculate BMI
- Arrange spirometry, CXR, FBC
50
Investigations to perform in COPD?
Post-bronchodilator spirometry
- Reduced FEV1, FEV1/FVC <0.7, PEFR
- Reversibility <20% post-bronchoscopy
CXR
o Hyperinflation (>6 anterior ribs seen above diaphragm MCL)
o Flat hemidiaphragm
FBC
BMI
51
Classification criteria in COPD?
Diagnosis – GOLD Criteria
- Mild – FEV1 ≥80% of predicted
- Moderate – FEV1 50-79% of predicted
- Severe – FEV1 30-49% of predicted
- Very Severe – FEV1 <30% of predicted
52
Management of COPD -pulmonary rehab?
- Pulmonary rehabilitation if MRC dyspnoea scale grade 3 or more
o Do not offer if unable to walk or have unstable angina or recent MI
- Chest physio if lots of sputum
53
Management of COPD - when to step up from SABA to Step 2?
Remain breathless or exacerbations depite:
Offered smoking cessation advice
Optimal non-pharmacological management and relevant vaccines
Using SABA
54
Management of COPD - when to step up from Step 2 to triple therapy?
Acute episodes of worse symptoms caused by COPD exacerbations (hospitalisation or 2 moderate exacerbations per year)
Adversely impacting on QoL
55
Management of COPD -step 1?
o PRN SABA (salbutamol) or SAMA (ipratropium bromide)
56
Management of COPD - step 2 if no asthmatic features or not steroid responsive?
o Add LABA + LAMA
| o Discontinue SAMA if having LAMA
57
Management of COPD - step 2 if asthmatic features (previous asthma diagnosis, high blood eosinophils, FEV1 variation over time >400mls, >20% PEFR variability)?
o Add LABA plus ICS combination (never just ICS, Seretide (salmeterol & fluticasone)/Symbicort(formoterol & budesonide)
58
Management of COPD - step 3?
o Add LABA + LAMA + ICS
| If no asthmatic features – trial 3 month and if no improvement, move back to LABA + LAMA
59
Management of COPD - oral therapy?
- Oral theophylline or aminophylline if still symptomatic or cannot use inhalers
- Mucolytic if chronic cough with sputum
- If cor pulmonale – furosemide diuretic
- Prophylactic antibiotics (azithromycin)
- Long-term oral corticosteroids
60
Management of asthma - medications - Aged 5-11 - Step 1?
BD Paediatric low dose ICS with SABA
If uncontrolled then either:
- MART
- (paediatric low dose then increased to moderate dose if needed)
- Conventional:
- Add in LTRA if unable to manage MART (trial 8-12 weeks then stop if ineffective)
- ICS/LABA + SABA, up to moderate dose as needed
- Then refer
61
Management of Asthma - adults - how to change medication over from old regimen - SABA only?
Low dose ICS/formoterol AIR therapy
62
Management of Asthma - adults - how to change medication over from old regimen - low dose ICS and SABA or low dose ICS with LABA/LRTA?
Low dose MART
63
Management of Asthma - adults - how to change medication over from old regimen - moderate dose ICS and SABA or moderate dose ICS with LABA/LRTA?
Moderate dose MART
64
Management of recurrent UTIs - definiton of recurrent?
at least 2 episodes within 6 months, or 3 or more within 12 months
65
Management of recurrent UTIs - when to refer?
Men >16
People with recurrent upper UTI
People with recurrent lower UTI when underlying cause unknown
Pregnant women
66
Management of recurrent UTIs - general measures?
Non-pregnant women may wish to try D-mannose or cranberry products
Avoid douching
Wipe from front to back after defaecation
Avoid delay in post-coital urination
Hydration important
67
Management of recurrent UTIs - antibiotic prophylaxis - men and pregnant women?
First choice
o Trimethoprim 200mg when exposed to trigger or 100mg at night
o Nitrofurantoin 100mg when exposed to trigger or 50mg at night
Second choice
o Amoxicillin 500mg when exposed to trigger or 250mg at night
o Cefalexin 500mg when exposed to trigger or 125mg at night
• Review in 6 months
68
Further investigations needed in children with UTI - When to arrange US of UT?
During acute infection in all children with atypical infection:
• Poor urine flow, abdominal/bladder mass, raised creatinine, sepsis, failure to respond to antibiotics within 48 hours, non-E.coli organism
During acute infection if child <6 months with recurrent UTI
Within 6 weeks if child >6 months with recurrent UTI
Within 6 weeks if <6 months with first-time UTI that responds to treatment
69
Further investigations needed in children with UTI - other tests needed and when?
o Dimercaptosuccinic acid scintigraphy (DMSA) carried out within 4-6 months of acute infection if:
All children <3 years with atypical or recurrent UTI
All children >3 years or over with recurrent UTIs
70
When to refer CKD to nephrologist?
- eGFR <30
- ACR >70mg/mmol
- ACR >30mg/mmol with haematuria
- Decrease by >25% in year or decrease GFR >15ml/min/1.73 in year
- Poorly controlled BP on 4 antihypertensives
- Suspected genetic causes or renal artery stenosis
71
Management of CKD - antihypertensives?
o If hypertensive and ACR <30 – follow guidelines
o If hypertension and ACR >30 – ACEi/ARB
o If ACR >70 and normotensive OR CKD and diabetic – ACEi/ARB (aim <130/80)
72
Management of CKD -aim of antihypertensives?
Aim <140/90 in hypertensive + CKD + ACR <70
Aim <130/80 in ACR>70 + normotensive or CKD + diabetes
73
Management of CKD -monitoring of antihypertensives?
Measure serum potassium and eGFR before ACEi, 1-2 weeks later and at any dose change (before starting K<5, otherwise don’t start ACE/ARB, stop if K>6 after 1-2 weeks)
If eGFR decreased by >25% then repeat test 1-2 weeks – if <25% then continue and repeat test in 1-2 weeks, if >25% investigate causes and stop drug
74
Management of CKD - statin therapy?
- Atorvastatin 20mg daily (if eGFR <60 and ACR >3)
o Baseline lipids, CK, LFTs
o Can increase dose if not >40% reduction in non-HDL cholesterol and eGFR >30 in 3 months
o Repeat lipids at 3 months
75
Management of CKD -antiplatelets and anticoagulants?
- Antiplatelets
o Secondary prevention only
- Anticoagulant
o Secondary prevention of CVD – Apixaban used if eGFR 30-50 and non-valvular AF and 1 of: Hx of TIA/stroke, >75, HTN, DM, HF
76
Management of CKD - complications - anaemia?
o Check Hb in people with eGFR <45
o Offer iron tablet if deficient – if Hb level not reached within 3 months, offer IV therapy
o If on dialysis – offer IV iron first
o EPO may be needed
77
Management of CKD - complications - bone complications?
o Measure serum Ca, phosphate, PTH and Vit D when eGFR <30
If needed – cholecalciferol
o Bisphosphonates for prevention of osteoporosis when eGFR >30, if indicated only
78
Management of CKD - complications - bicarbonate level?
- Oral sodium bicarbonate
| o eGFR<30 or sodium bicarbonate <20
79
Management of chlamydia - contact tracing?
o Four weeks prior to developing symptoms where a male has urethral symptoms and all contacts since
o All contacts in last six months of asymptomatic individuals and symptomatic women and men other than urethral
o Inform of risk and offer treatment, tracing and STI testing
80
Management of chlamydia - antibiotic management?
- Doxycycline 100mg BD for 7 days (CI in pregnancy) OR Azithromycin 1g single dose (4 tablets taken at once, >90% affective)
o Alternatives: Erythromycin, oflaxacin
- In pregnancy – azithromycin 1g stat then 500mg for 2 days OR erythromycin 500mg QDS for 7 or BD for 14 days
o Test 3 weeks later
81
Management of chlamydia - test of cure?
- Performed on pregnant patient, persistent symptoms, non-compliance or re-exposed
- 3 weeks later
- In screening programme, <25 should repeat at 3 months
82
Management of gonorrhoea - contact tracing?
o Men with symptomatic anogenital gonorrhoea, all partners within 2 weeks notified or most recent if longer than 2 weeks
o All others, partners within 3 months
o Inform of risk and offer treatment, tracing and STI testing
83
Management of gonorrhoea - antibiotics?
When susceptibility not known prior to treatment:
- single dose of IM ceftriaxone 1g
- if ceftriaxone is refused (e.g. needle-phobic) then PO cefixime 400mg (single dose) + oral azithromycin 2g (single dose)
When susceptibility known prior to treatment:
o Ciprofloxacin 500mg PO single-dose
84
Management of gonorrhoea - antibiotics in ophthalmia neonatorum?
- Opthalmia neonatorum – IV benzylpenicillin or cephalosporing with saline lavage and topical erythromycin
85
Management of gonorrhoea -test of cure?
Test of cure follow up
| - With culture >72h or with NAAT >2 weeks following antibiotic treatment
86
Investigations in menorrhagia?
```
Pregnancy test
Bloods – FBC, (TFTs, clotting (if indicated))
Smear if due & STI screen
USS
Hysteroscopy
Endometrial sampling
```
87
When to refer to secondary care in menorrhagia? Investigations?
• Criteria
o Persistent IMB
o Symptoms failed to improve on medical management
o Women >45 with heavy bleeding, endometrial pathology
o Abnormal examination
o Risk factors for endometrial cancer
• TVUS and hysteroscopy if abnormal
88
1st line medical management of menorrhagia?
Mirena IUS
Release levonorgestrel – leading to atrophy of endometrium
Reduces bleeding and 30% amenorrhoeic at 12 months
SE – irregular bleeding for 1st 4-6 months and progestogenic effects
89
2nd line medical management of menorrhagia?
NSAIDs (mefenamic acid)
Taken during days of bleeding
Tranexamic Acid
Useful in those trying to conceive as non-hormonal
CI – thromboembolic disease
COCP
Effective but think CIs
90
3rd line medical management of menorrhagia?
Progestogens
Medroxyprogesterone acetate (IM every 12 weeks)
Norethiserone PO (Used short-term to stop heavy bleeding)
GnRH rarely used, only in secondary care
91
When to use surgical management of menorrhagia?
2 drugs tried and failed
92
Surgical management of menorrhagia? When performed? SE?
Endometrial ablation
o 1st line, if uterus is <10 weeks of gestation on palpation
o Removing the full thickness of endometrium with superficial myometrium and basal glands using diathermy/thermal balloon
o Performed with hysteroscopy
o SE – bleeding, infection, uterine perforation, vaginal discharge, infertility
o Need contraception post-operation
93
Alternative surgical managements and when performed?
Uterine Artery Embolisation or Myomectomy
o If uterus is >10 weeks in size or fibrois >3cm, retain ferility
Hysterectomy
o Women not wishing to retain fertility, who have fibroids >3cm
o Vaginal hysterectomy preferred, may need abdominal
94
Pharmacological management in dysmenorrhoea?
```
• NSAIDs (mefenamic acid) during menstruation
• Paracetamol
• If not wanting to conceive:
o COCP
o POP
o Depot medroxyprogesterone acetate
o Mirena IUS
```
95
Surgical management in dysmenorrhoea?
• If women completed family – hysterectomy in severe, refractory cases
96
General measures in PMS?
• Improve Healthy Diet
o Less fat, sugar, salt, caffeine and alcohol.
o Regular, frequent small balanced meals rich in complex carbohydrates
• Increase exercise
• Stop smoking
• Schedule stressful tasks to better half of month if needed
• Stress reduction
o Relaxation techniques
o Yoga
o Meditation
o Breathing techniques
97
1st line management in moderate PMS?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
98
1st line management in severe PMS?
• COCP (Yasmin, good if wanting contraception too)
o Used cyclically or continuously
• Cognitive behavioural therapy.
• Simple analgesia for pain if needed
• SSRI (fluoxetine/sertraline/citalopram)
o Continuous or just for luteal phase of menstruation
o Give 3 months, if benefit then continue for 6-12 months
99
Secondary care medical management of PMS?
- Progesterone or progestogens used alone.
- Antidepressants other than SSRIs
- Alprazolam.
- Diuretics
- Danazol
- Transdermal oestrogen
- GnRH analogues +/- addback HRT
100
Complementary therapies in PMS treatment?
o Vitamin B6, calcium and vitamin D, magnesium, evening primrose oil
101
Investigations performed in PCOS?
```
o Bloods:
Total testosterone (normal or slightly raised)
Free testosterone (may be raised if >5nmol/L – exclude androgen-secreting tumours and CAH – 17-hydroxyprogesterone)
SHBG (normal or low in PCOS)
LH (elevated) & FSH (normal)
TFTs
Prolactin
Lipids
• To exclude a prolactinoma
o Ovarian USS
o Screen for diabetes
o BMI
```
102
What is the criteria for PCOS?
Rotterdam criteria for diagnosing PCOS:
- Requires the presence of 2 out of 3 of:
• Polycystic ovaries on US
• 12 or more follicles or ovarian volume >10 on USS
• Oligo-ovulation or anovulation
• Clinical/biochemical features of hyperandrogenism
Acne, excess body hair, alopecia
Raised serum testosterone
103
General management of PCOS?
```
o Weight loss
o Diet
o Exercise
o Stop smoking
o Sleep apnoea advice
• Psychological support
```
104
If not planning pregnancy, management of PCOS?
```
o Improving insulin resistance:
Metformin (not licensed so risks and benefits weighed up)
o Ensuring withdrawal bleeds every 3-4 months: (reduces endometrial cancer risk)
COCP cyclical
IUS
If not taking pill (norethisterone 5mg TDS PO for 10 days)
o Hirsutism
Co-cyprindol 2mg/d
Waxing, shaving
Eflornithine facial cream
Spironolactone
• Avoid in pregnancy, teratogenic
```
105
If presenting with subfertility and wanting to conceive, management of PCOS?
```
o Clomifene citrate
Induces ovulation
Use for <6 cycles
Need US monitoring
o Metformin added on
o Laparoscopic Ovarian Drilling
Needlepoint diathermy in 4 places per ovary to reduce steroid production
When clomifene not working
```
106
Investigations in endometriosis? When to avoid? Signs present?
• Transvaginal USS
- Identifies endometriosis + deep into bowel//bladder & endometriomas
- If not appropriate, can use transabdominal USS
• Laparoscopy with biopsy (gold standard)
o Histological verification
Positive is confirmative
Endometriomas >3cm should be resected to rule out malignancy (rare)
o If normal – woman does not have endometriosis
o Avoid within 3 months of hormonal treatment (leads to underdiagnosis)
o Signs present – red dots, black ‘powder burn’ dots, large raised red/black vesicles, white area of scarring with surrounding abnormal blood vessels.
107
Other investigations that can be performed in endometriosis?
• Pelvic MRI
| - Used to assess extent of deep endometriosis involving bowel/urinary tract
108
General treatment of endometriosis?
• Analgesia
o Paracetamol/NSAIDs 1st line
Naproxen
o If inadequate, consider other analgesia/referral
• Neuropathic Pain
o Amitryptiline/gabapentin/pregabalin
109
Hormonal management of endometriosis?
- COCP
• Cyclically or continuous PO/IM/SC
• Effect = ovarian suppression
• SE = headaches, N&V, diarrhoea, stroke.
- Medroxyprogesterone acetate or other progestagens
• Effect = ovarian suppression
• SE = weight gain, bloating, acne, irregular bleeding, depression
110
Secondary care hormonal management of endometriosis if other do not work?
* GnRH analogues
* Effect = ovarian suppression
* Mirena IUS
* Effect = Endometrial suppression (sometimes ovarian)
* Danazol (anti-androgenic)
* Effect = ovarian suppression
* SE= Irreversible voice changes, hirsutism, acne
111
Surgical management of endometriosis?
- Laparoscopic ablation/resection/cystectomy
• Coagulation, excision or ablation
- Hysterectomy
• Last resort for severe endometriosis, not suitable if wanting to get pregnant
112
Subfertility treatment in endometriosis?
- Surgical ablation plus adhesiolysis
| - In moderate to severe disease, IVF needed
113
What management of ectopic pregnancies are there?
Offer expectant or medical
| Surgical
114
When to offer expectant or medical treatment in ectopic pregnancy?
* Asymptomatic/Mild symptoms
* hCG<1500IU
* Ectopic pregnancy <3cm on scan and no fetal heart activity
* No haemoperitoneum on TVS
115
Expectant management of ectopic pregnancy?
• If clinically well
- Test hCG day 2, 4 & 7
- Falling hCG >15% and above criteria
• Take serum hCG weekly
116
Medical management of ectopic pregnancy?
If hCG fallen <15% from day 2, 4 & 7
• Methotrexate - single dose, followed by hCG on day 4 and 7
• If hCG fallen by <15% then second dose given
• Need reliable contraception for 3 months afterwards - teratogenic
117
Surgical management of ruptured ectopic pregnancy?
Laparoscopy
Laparotomy if haemodynamically unstable
If contralateral tube healthy then salpingectomy, if not then salpingotomy
118
Expectant management of unruptured ectopic pregnancy?
If asymptomatic, hCG <1500IU/l, <3cm on scan
| Take serum hCG day 2, 4 & 7 then weekly until <15IU
119
Medical management of unruptured ectopic pregnancy?
Methotrexate
• Offer if can return for follow up with no pain, adnexal mass <35mm, no heartbeat, serum hCG<1500IU/l, no intrauterine pregnancy
• Measure serum hCG at day 4, 7 and then weekly until negative result attained
• Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months after as methotrexate is teratogenic.
120
Surgical management of unruptured ectopic pregnancy?
• If unable to return to follow-up or significant pain, adnexal mass 35mm, foetal heartbeat, serum hCG >5000
• Performed laparoscopically
o Offer salpingectomy unless other risk factors for infertility
Take urine pregnancy test after 3 weeks, return if positive
o Salpingotomy alternative if risk factors
• Measure serum hCG at 7 days and weekly until negative
• Anti-D rhesus 250UIU to all Rh negative women
121
Initial management of stress urinary incontinence?
```
Lifestyle interventions
• Weight reduction if BMI >30
• Smoking cessation
• Reduce caffeine and fizzy drinks
• Treatment of chronic cough and constipation
```
Pelvic floor muscle training
• For at least 3 months
• Exercises continued long-term.
• 8-12 slow maximal contractions sustained for 6-8 seconds each, 3x per day
Follow up 3 months
122
Follow up management of stress urinary incontinence?
Urodynamics
MDT Meeting
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
Transvaginal tape
123
Pharmacological management of stress urinary incontinence?
Duloxetine
• SNRI enhances urethral striated sphincter activity via a centrally mediated pathway.
• Dose-dependent decreases in frequency of incontinence episodes
124
Surgical management of stress urinary incontinence ? When considered and what types?
Considered when other measures failed
Transvaginal Tape
• Polypropylene mesh tape placed under mid-urethra via small vaginal incision
• Risks – bladder injury, voiding difficulty, tape erosion
Periuretheral injections
• Bulking agents, better for older, frail or young women
125
Initial management of urge urinary incontinence?
Lifestyle advice
* Weight reduction if BMI >30, smoking cessation, reduce caffeine and fizzy drinks, treatment chronic cough and constipation
Refer to Continence service for Bladder Training (6 weeks)
* Ability to suppress urinary urge and extend the intervals between voiding
Anticholinergics - Oxybutynin (+/- vaginal oestrogen if vaginal atrophy)
Follow up 3 months
If nocturia - consider desmopressin
If vaginal atrophy - topical oesotrgen vaginally
126
Describe properties of initial pharmacological management of urge urinary incontinence? SE? CI?
When is botox used?
Anticholinergic (antimuscarinic) agents (oxybutynin)
• Block the sympathetic nerves thereby relaxing the detrusor muscle
• Side effects = dry mouth (up to 30%), constipation, nausea, dyspepsia, flatulence, blurred vision, dizziness, insomnia, palpitation, arrhythmias.
• Contraindications = acute (narrow angle) glaucoma, myaesthenia gravis, urinary retention or outflow obstruction, severe UC, GI obstruction.
Oestrogens
• In women with vaginal atrophy, intravaginal oestrogens may be tried
Botulinum Toxin A
• Blocks neuromuscular transmission – causing the muscle to become weak.
• Used in follow up and injected cystoscopically into the detrusor, usually under local anaesthetic.
127
Follow up management of urge urinary incontinence?
Try 2nd anticholinergic (tolterodine)
Urodynamic study (increased detrusor pressure upon voiding)
MDT meeting
Cystoscopy & Botox (botulinum toxin A)
Nerve stimulation - percutaneous posterior nerve/percutaneous sacral nerve
Augmentation cystoplasty - if small bladder
Urinary diversion
128
Management of overflow incontinence?
o Treat with catheter
• Can cause urinary retention in 5-20% of cases, in which intermittent self catherterisation may be required.
o Surgical
Reserved as last resort for debilitating symptoms, failed therapies
Bladder distension, sacral neuromodulation, detrusor myomectomy have limited efficacy
129
Management of mastitis in lactating women - initial management?
• PRN paracetamol + ibuprofen
• Warm compress on breast, or bathe in warm water, to relieve pain and help with milk flow
• Continue breastfeeding if possible (if not then express milk until resume)
• Avoid wearing a bra, especially at night
• If symptoms not improved after 12-24 hours despite milk removal or breast culture positive, give antibiotics
o Oral flucloxacillin 500mg QDS for 10-14 days (erythromycin)
o Seek advice if Abx not settling symptoms
130
Management of mastitis in lactating women - advice to prevent recurrence?
* Make sure infant attached correctly
* Feed on demand, both for frequency and duration
* Avoid missed feeds
* Finish first breast before offering other
* Hygiene measures – hand washing, rinse nipple before use
131
Management of mastitis in lactating women - if treatment failure or recurrent?
Treatment failure or recurrence (if not settled in 48 hours)
• Send sample of breast milk for M,C&S
• Co-amoxiclav 500/125mg TDS for 10-14 days
132
Management of mastitis in non-lactating women -initial management?
* PRN paracetamol + ibuprofen
* Warm compress on breast, or bathe in warm water, to relieve pain and help with pain
* Co-amoxiclav 500/125mg TDS for 10-14 days (erythromycin plus metronidazole)
133
Treatment of cervical ectropion?
o None if asymptomatic, pregnant or pubertal
o If taking COCP, change to non-hormonal methods
o If woman wishes, cautery as outpatient
134
Aetiology of trichomonas?
* Trichomonas vaginalis – flagellate protozoan.
| * Transmitted through sex and infects vagina, urethra and paraurethral glands
135
Symptoms of trichomonas in women?
o Frothy green/yellow, offensive smelling discharge.
o Vulval itching and soreness.
o Dysuria
o Superficial dyspareunia.
o Cervix may have a ‘strawberry appearance’ from punctate haemorrhages
136
Symptoms of trichomonas in men?
o Usually asymptomatic
o Non-gonococcal urethritis
o Dysuria, urethral discharge
137
Investigations of trichomonas?
• High vaginal swabs on wet mount microscopy
• Referral to GUM clinic
o Wet smear and culture (Diamond’s) – motile flagellates
o NAAT testing
138
Management of trichomonas?
• Contact tracing
• Treat partners at same time
• Avoid sexual intercourse for >1 week following treatment & until partner treated
• Abx
o Metronidazole 2g orally in a single dose or Metronidazole 400mg twice daily for 5-7 days (latter in pregnancy)
139
Causes of bacterial vaginosis?
o Overgrowth of mixed anaerobes, including Gardnerella and Mycolplasma hominis, which replace the usually dominant vaginal lactobacilli.
o pH <4.5 normally – in BV pH >4.5-6
140
Symptoms of bacterial vaginosis?
- May be asymptomatic
- Profuse, whitish grey, offensive smelling vaginal discharge.
- Characteristic ‘fishy’ smell is due to the presence of amines released by bacterial proteolysis
141
Diagnosis in GP of bacterial vaginosis?
o Typical symptoms
o pH >4.5
o Low vaginal swab in transport medium
142
Management of bacterial vaginosis - general advice?
o Avoid vaginal douching, shower gels, shampoo
| o No treatment if asymptomatic, unless pregnant
143
Management of bacterial vaginosis - treatments?
o Metronidazole 2g PO (single dose), gel PV OR
Use metronidazole 400mg/12h PO for 5 days
SE: Disulfiram-like reaction
o Clindamycin 2% cream vaginally at night for 7 days
o Can buy OTC medications
144
Management of thrush - drug treatment?
• Chronic carriers, candidiasis should only be treated if symptomatic
• Topical/Oral azole therapy
o Clotrimazole 500mg pessary ± topical clotrimazole cream (if vulval symptoms) or
o Fluconazole 150mg PO (single dose) (contraindicated in pregnancy)
o Can be bought OTC so encourage self-treatment in uncomplicated patients
o 7-14 days if immunocompromised
• Return if symptoms not resolved in 7-14 days
145
Management of thrush - severe infection?
- Vaginal swabs for M, C &S
- Two doses of fluconazole (150mg) three days apart
o OR 500mg pessary clotrimazole two doses three days apart
146
What form is used for paternity leave request?
SC3 form
AKT Flashcards
flashcards
Decks in class (37)
# Cards
-
Last Minute . com146
-
DVLA Advice63
-
Statistics86
-
Organisation and Management152
-
Developmental Milestones44
-
School Exclusion Illnesses11
-
Immunisation Programme44
-
2-Week Cancer Pathways34
-
Questions I Got Wrong243
-
Learning Points from Questions96
-
Notifiable Diseases5
-
BP & Diabetes Targets9
-
CYP450 DRUGS5
-
DRUGS IN PREGNANCY AND BREASTFEEDING3
-
Haematology273
-
Cardiovascular516
-
Endocrine454
-
ENT313
-
Gastrointestinal 1402
-
Gastrointestinal 2513
-
Infectious Diseases335
-
MSK370
-
Neurology 1250
-
Neurology 2242
-
Ophthalmology & Skin353
-
Psychiatry345
-
Reproductive System 1232
-
Reproductive System 2280
-
Respiratory411
-
Urinary System368
-
Gynaecology357
-
Fertility72
-
Antenatal Obstetrics399
-
Postnatal Obstetrics75
-
Contraception Drugs212
-
General Paediatrics424
-
General Paediatrics 2530
