Professional Documents
Culture Documents
Contents
Pediatrics - OK .............................................................................................................................................. 6
Digestive problems....................................................................................................................... 12
Immunisation ............................................................................................................................... 23
Orthopedics ................................................................................................................................. 29
Intoxications ................................................................................................................................ 38
Antibiotics ................................................................................................................................... 48
Anticoagulants ............................................................................................................................. 64
Pharmacology .............................................................................................................................. 72
Obstetrics - OK............................................................................................................................................ 76
Pregnancy parameters.................................................................................................................. 76
Amenorrhoea............................................................................................................................. 145
Bleeding..................................................................................................................................... 149
Infertility.................................................................................................................................... 170
TB ...................................................................................................................................................... 256
PE ...................................................................................................................................................... 354
MI ...................................................................................................................................................... 371
DM..................................................................................................................................................... 423
Pediatrics - OK
- By age
o Neonate < 1 mth
o Infant 1 mth – 1 yr
o Toddler 1-3 yrs
o Child
o Puberty
▪ Boys 12 – 16/18
▪ Girls 10 – 15/17
- Neonatal Conjunctivitis:
oImmediately after birth, purulent, sticky
oMarked conjunctival edema = Gonococcal
oIf at 2nd to 3rd wk = Chlamydia
- Umbillical granuloma – Red fleshy tissue at base of umbilicus + discharge
o Topical Silver Nitrate (Caustic pen) ------ for 5 days (MCQ)
o If yellowish (urine) discharge - USG and Surgery (Urachus fistula)
- Umbilical discharge
o types
▪ Mucous
7
▪ Pus
▪ Urine
• before delivery – communication = Urachus; if it remains after delivery =
patent urachus
- Dx
▪ Creatinine and urea levels from discharge -> confirm it’s
a urinary discharge
▪ USG – to rule out patent urachus
- Mx – Refer for surgical correction
▪ Feces
▪ Black----Meconium?
o Dx diff
▪ CA
▪ Fistula
▪ Urachal cyst
▪ Umbilical calculus
o Mx
▪ Clean debris
▪ Apply dressing (wound)
▪ Swab for culture and sensitivity
▪ A/B
- Night terrors and sleep walking have many features in common – Murtagh 789
o Sleep walking: – child not awake
▪ sits up in bed, walks around, don’t acknowledge parents even though eyes
might be open
▪ lasts 10-30 min
▪ 1-8 yrs, (child is neurologically & developmentally normal)
▪ Can’t remember episode next morning
▪ usually within 2 hrs after falling asleep
▪ harmless, benign
▪ inherited – family Hx
▪ 2% of children
▪ usually grow out of it by 12 yrs
▪ Rx
• Reassure and educate parents, protect the child (unaware), self limiting
• wake up the child 15 mins before the usual time of attacks for a few dys
• don’t try to calm the child during attack--> it will aggravate the situation
• no indication for sleeping pills, anti-epileptics or sleep EEG.
• no relation with TV viewing or day’s activity
o Night terror:
▪ Sharp screams, violent thrashing movements, sweating, tachycardia
▪ 3N for night terror and sleep walking. No N for nightmate
Night (sleep) terror Sleep walking Nightmare
2-4 yrs 6-9 yrs 3-6 yrs
First 1/3 of sleep (within 2 hrs of First 1/3 of sleep Last 1/3 of sleep
falling asleep)
Non-REM stage Non-REM stage REM stage
8
▪
▪ Rx:
•O2 by mask
•May intubate or ventilate
•Cricothyrotomy or tracheostomy
•Antibiotics:
- Ceftriaxone
o Croup: (acute laryngo-tracheo-bronchitis)(complications-tracheitis)
▪ Steeple sign on anterior neck X Ray film
10
▪
▪ Most ominous sign of deterioration = Retraction of intercostal spaces and
suprasternal fossi and use of accessory muscles. Rx:
• Nebulized Adrenaline
• Corticosteroid Oral/ IM/ IV
• May do intubation
Croup Epiglottitis Bronchiolitis
(Laryngotracheobronchitis)
Cause Viral – Parainfluenza virus (+ Bacterial – H. influenzae type B RsV
adenov., influenza)
Age 6 mths – (3-) 6 years, 6 mths – 6 yrs 2 wks - 9 mths, < 1 yr
sometimes older may also occur in adults
Onset Slow (usually 2 days) – Rapid (hrs) Slow (usually 2 days) –
prodrome of URTI prodrome of URTI
Fever Low grade High (> 40) yes
Dysphagia None Severe None
Drooling None Present None
Stridor Harsh inspiratory stridor Soft expiratory stridor
Cough Barking, brassy, spontaneous Absent Yes
Voice Hoarse Soft, clear to muffled
Wheeze Bilat. Inspiratpry crackles and
or expiratory wheeze
Posture Recumbent/ lying back Sitting forward, quietly & still,
while his eyes follow you
around the room (limited head
movt. to protect obstructive
airway), sits with neck
hyperextended and chin
protruding (“sniffing dog”
position) & lean forward in a
“tripod” position to maximize
air entry
Toxemia Mild Severe
Other Indication of emergency Cherry-Red epiglottis Resp. distress (tachypnea,
intervention: Child is restless It’s a true emergency and can lead intercostal recession, nasal
& irritable to life-threatening airway flaring) widespread fine
obstruction so time should not inspir. crackles (not in
be wasted on ordering an X asthma) hyperinflated chest –
11
o 3 causes:
Infantile respiratory distress Transient tachypnoea of Meconium aspiration
syndrome (Hyaline membrane newborn (Wet lungs – can’t syndrome (with meconium
disease) eliminate/squeeze fluids from all over his body)
lungs because delivered by C/S)
Premature, usually < 30 wks wt Term baby, C section Post term baby (Jay – in
<2.5kg (can be in term babies too) prolonged labor)
Not improving with O2 < 30% O2 (< 40% other sources) Sympt. from birth
Longer course, worst prognosis Quick recovery within 72 hrs Usually they improve
X-Ray – ground-glass haze, Coarse streaking/ fluid in lung Hyperinflation, bilateral
fine granularity with hypoareated fissures consolidation because of
lung fields, slightly elevated both inspiration of meconium
hemidiaphragms
Rx:
- Betametasone to mothers up to
34 wks (↑secr. of surfactant)
- Surfactant (Survanta) on ETT for
baby
Digestive problems
- Baby vomits after first and each feeding
o Tracheoesophageal fistula - becomes cyanotic
o Esophageal atresia – does NOT become cyanotic
o Dx
▪ chest X Ray
- Tracheoesophageal fistulae (TEF):
o 1 in 3,000 births
o Associated with polyhydramnios (16%), cardiac abnormalities, vestibular abnormalities,
imperforate anus, and genital-urinary abnormalities
o Various types:
▪ Distal TEF with upper esophageal atresia (85%)
▪ Blind upper & lower oesophageal pouches without a connection to the trachea
(9%)
▪ True H-type fistula (6%)
▪ Proximal esophagus empties to trachea (1%)
o Dx
▪ Passage of a NG tube that meets obstruction 9-13 cm from nares suggests
diagnosis
▪ Chest X Ray with catheter in place demonstrates position of pouch as well as
air in stomach and intestine.
o A standard Ba swallow is not recommended because of possibility of spillage into
pulmonary tree.
- If baby vomits, check serum K:
o Low K – Pyloric Stenosis
o High K
▪ Congenital adrenal hyperplasia (salt losing) presents soon after birth
• Baby vomits, marked decr. Na and Cl, K incr.
▪ Salt losing congenital syndrome?
13
▪
- Vomiting in children
o By color
▪ Green (bile stained):
• 1- Duodenal atresia – newborn
- assoc. with Down syndrome
• Small bowel obstruction
• Volvulus – Vomiting and abdominal distension
- Bilious/ green vomiting
- Several small, seedy and yellowish stools (from intestine distal
to point of volvulus)
- Olive shaped mass palpable in epigastrum
- Non-projectile bile-stained vomiting
• Sepsis
• Infection: UTI, Otitis media
▪ Milk stained (Non-bilious), Coffee ground
• 1 - Pyloric Stenosis ----- Projectile
• GERD
• Infection: UTI, Otitis media
o types
▪ 1. 1st day baby vomiting bilious content + baby did not pass meconium
• duodenal or jejunal atresia
- X Ray: Double-bubble sign
• small bowel obstruction or malrotation
• Hirschprung dis.
• imperforated anus
• meconium plug & ileus
• cystic fibrosis
▪ 2. 2-3 wks with projectile vomiting immediately after meal
14
▪ Dx
• On 1st/2nd day – Newborn screening --> looking for
1. Immunoreactive Trypsin (IRT ) – if > 99 percentile = positive => send
for 2. DNA analysis: Check to see if 1 or 2 allels are affected -->
• If both + = Diseased => refer to Cystic Fibrosis Clinic
• If only 1 + = Carrier--> 3. Sweat Cl- Test: 75 g Sweat (> 60 mEq/L =
positive) => Refer to Cystic Fibrosis Clinic.
- 40-60 – Suggestive of healthy carrier
▪ Rx
• Drainage of airway secretions
• Hypertonic saline solution by nebulizer
• A/B for infection
• Oral pancreatic enzymes
• Lung and liver transplant
▪ Survival in developed countries = 31 yrs (in poor countries – 10 yrs)
o Celiac disease: (Fe deficiency is MC than other metabolits)
▪ triad: fatigue + wt. loss + diarrhoea +hyperactive bowel sounds
• loose stools
• wt. loss (failure to thrive)
• fatigue, due to iron/ folate deficiency (due to malabs.) anemia
- Microcytic – iron deficiency
- Normocytic
- Macrocytic – folate deficiency
- ↑INR due to Vit K malabsorption
- Osteoprosis due to Vit D and calcium malabsorption
▪ Irish nurse
▪ Sx
• usually start after gastroenteritis – acid, watery diarrhoea, smells like
vinegar
• cough
• buttock wasting
• bulky stool
• failure to thrive
▪ Dx
• I test - fecal fat estimation (Steathorea)
- ↑fecal fat
- fat crystals in stool
• IgA
- Anti-gliadin AB – Screening only
- Anti-endomysial – 90% sens./specif. (Maria)
- Anti-transglutaminase – 90% sens./specif. (Maria)
• II test - Small bowel biopsy (best)
▪ Cx
• Increased risk of proximal jejunal lymphoma
▪ Rx
• Remove gluten from diet
19
o Toddler’s diarrhea: Hx of loose stools containing undigested food (peas & other
vegetables)
▪ otherwise child is healthy and gaining weight
▪ resolves spontaneously
- Abdominal pain in children
o 3 mths – 1 year (< 2 yrs)
▪ INTUSSUSCEPTION = Distal ileum telescopes into a distal bowel loop.
• usually in the ileocolic region
• also at other ages
• causes
- Metastatic deposit – MC from melanoma
- Enlarged Pyer’s patches – in children
- Crohn’s
- Meckel’s diverticulum
- lymphoma of small bowel
- benign sumbucous fibrolipoma
- Internal hernia
• Sx
- Intestinal obstruction
- Sudden screaming intermittent attacks of pain with vomiting,
drawing legs up
- Sausage mass in the RIF
- Child looks pale, lethargic, anxious and unwell.
- Bleeding (Red Currant Jelly Stool): Late sign.
• Associations:
- Recent viral gastroenteritis (Adenovirus)
- Infantile Spasm.
- H-S Purpura (Arthralgia, skin rash, nephritis)
• Dx:
- Plain X Ray: Normal or bowel obstruction = I step
- Ultrasound: Target sign
- Barium Enema: Claw sign
- Air or Barium enema – best - Hydrostatic reduction under USG
• Rx
- Air or Barium enema
▪ if it fails, repeat for at least 3 times
▪ risk of recurrence
• monitor for 24 hrs in the hospital
- Surgery: If enema failed, peritonitis or septicaemia
o Usually over 5 yrs
▪ Appendicitis
• Any age, rare under 5 years.
• Sx
- Anorexia, vomiting.
- Localized abdominal pain: Epigastrium, periumbilical region, RIF.
- Tenderness and guarding in RIF
20
o Rx
▪ Day 1 – enema to empty bowel
▪ Day 2 – laxatives PR
▪ Day 3 – oral laxatives
▪ then go back to toilet – put child to toilet after breakfast, before going to school
• address constipation: more fiber, more fluids
- Necrotising enterocolitis:--- in premature newborns
o caused by ischemia of the bowel + inf. (Pseudomonas aeruginosa)
o Risk factors
▪ Septicemia
▪ Low apgar scores
▪ Respiratory distress
o Dx
▪ X Ray
• Pneumatosis intestinalis – air cysts in the intestinal wall
• finding of air in the portal vein = severe illness
o Rx
▪ Supportive
▪ if perforation - remove necrotic intestine
- young child 6 wks – no stool up to 7 days - still OK
- Hirschprung disease = Aganglionosis = congenital megacolon
o Narrowed aganglionic portion + proximal distension
o There is just a delay in passing of meconium (usually on 4th day) and bilious vomiting on
7th day.
o MC in male
o Constipation + distension
o Dx
▪ PR
▪ X ray, Barium enema (distended enema)
▪ full thickness biopsy
o Rx
▪ Resection of affected portion of colon
▪ Preliminary colostomy
Immunisation
- Immunisation schedule – additional notes from Neha + Murtagh – p. 79
o Premature baby < 32 wks – additional HBV vaccine at 1 yr
o > 6 mths – can give Influenza vaccine
▪ free for:
• > 65 age
• indigenous population > 50 yrs (+ free pneumococcal vaccine)
• indigenous population 15-49 yrs who have a high risk of complication
and death.
o Pneumococcal vaccine - Indigenous population at 2, 4, 6 mths, 18-24 mths
▪ in chronic heart failure, chronic renal failure, postsplenectomy
▪ not in chronic HT
o Post-splenectomy
▪ H. influenza B – Hib once (if not immunized)
24
-
o Cyanotic (Blue babies) - Shunt Right --> Left 5Ts (TOF, TGA, Tricuspid Atresia, Tingle
Ventricle, Truncus areteriosus)
TGA Hypoplastic left heart TOF
DiGeorge syndrome syndrome (HLHS) MC cyanotic heart disease of
(CATCH 22) childhood (DiGeorge
syndrome) presents e nail
clubbing
26
Sequence in girls:
first telarche (enlargement of breast buds)
then growth spurt
then axillary and pubic hair develops
then menarche occurs (2 years after start of puberty)
Sequence in boys:
Scrotal and testicular growth
Pubic hair (after 6 months)
Penile enlargement (within 12-18 months)
axillary hair (after 2 years)
deepening of voice
Tanner stages
Boys Girls
Prepubescent Basal Growth, No penile/ testicular Basal growth, breast buds
Stage 1 enlargement, No pubic hair
Stage 2 Testicular/ scrotal enlargement (9- Growth spurt (8-13 yrs
11 yrs)
Stage 3 Growth spurt/ Pubic hair Axillary and pubic hair
Stage 4 Penile enlargement,axillary hair Coarse pubic hair and menarche
Stage 5 Deepening of voice and facial hair Adult pubic hair distribution
- Development
o Female
▪ I – Telarche 2 yrs till menarche
▪ II – Adrenarche androgen hormones --> axillary & pubic hair, body odor
▪ III – Menarche influenced by her mother’s menarche
▪ IV – Pubarche pubic hair
o Male
▪ I – Testis
- Simple Tanner scale – printout from Neha
o Boys
▪ Scrotal & testis growth --> 6 mths --> pubic hair --> 12-18 mths --> penile
enlargement --> Axillary hair (whole process 2 yrs)
o Girls
▪ 1st = enlargement of breast buds (9 yrs old) -> growth spurt -> axillary & pubic
hair --> menarche (whole process = 2 yrs)
o Average time for puberty = 3 yrs
o Based on secondary sexual characters
▪ Male
34
• size of testis
• pubic and axillary hair
▪ Female
• breast and nipple dev.
• pubic and axillary hair
o Stages:
▪ 1– Preadolescent, no sec. sexual chars.
▪ 2– 9 - 11
▪ 3– 11-13
▪ 4– 13-15
▪ 5– 15+
- Causes of delayed puberty:
o types
▪ Hypogonadotropic hypogonadism
• ↓FSH ↓ LH → ↓ estrogen
• Pituitary problem
▪ Hypergonadotropic hypogonadism
• ↑FSH ↑LH → ↓ estrogen
o Dx
▪
FSH LH
- Normal percentile: 3 – 97% for height & weight
- Speech problems
o Delay
▪ Causes
• Mental retardation – MC
• Deafness
• Cerebral palsy
• Infantile autism
• Social deprivation
o Stammering
▪ Male 3:1
▪ Genetic factors
▪ Recover spontaneously before age 16
o Elective mutism – occurs only in certain situations
- Developmental problems in kids
o Precocious puberty – early secondary sexual characters in girls < 8 yrs, boys < 9.5 yrs
Investigation of preco. Puberty:
1. FSH, LH and Estradiol (usually raised in precocious puberty)
2. Bone age X Ray (Left wrist and elbow)
3. MRI brain (to exclude pituitary tumor) if FSH and LH are ↑
o Premature telarche – isolated breast dev. in girls < 2 yrs
▪ due to hormonal stimulation from estrogen
▪ sometimes with discharge from nipples
o Pubertal gynecomastia – 40-50% boys, transient
- 1st yr of life weight calculation
o ¾ kg monthly first 4 mths = ¾ x 4 = 3 kg
o ½ kg monthly next 4 mths = ½ x 4 = 2 kg
35
▪ Even below 3rd & above 97th percentile there are normal kids.
o Short Stature:
▪ 1. Familial (Genetic) short stature
• Bone age BA = CA Chronological age
• Grow on 3rd percentile or below but the rate of growth is parallel to 3rd
• Growth velocity = Normal
• Puberty is at appropriate time
▪ 2. Constitutional delay (delayed puberty) MC
• Boys
• Growth velocity is slower bw 6m and 3yrs
• often family Hx of parent being short as a child with delayed puberty
and eventually he caught up ----- “Late bloomers”
• BA < CA
• Puberty is delayed
• 1st bone age then (testosterone & plasma gonadotrophin levels MCQ)
- e.g. in the recalls
▪ Short with CA = 15 but stature of 12 yrs
• good prognosis? if BA = 9 = constitutional delay
▪ 3. Hypopituitrism
• Usually manifests after 2 yrs
• look for relative obesity w/o any other explanation
▪ 4. Chronic illness or malnutrition
• Celiac, Cystic fibrosis, etc.
▪ 5. Iatrogenic
• e.g. C/S
- fusion of epiphysis
▪ 6. Chromosomal abnormality
• MC – Turner Syndrome
- Girl – Short stature -- 45XO
7. Skeletal Dysplasia—Short limbs
o Alena
▪ most kids 25-75 percentile
▪ <10 = Concern
▪ > 95 = Gigantic
▪ important is trend from birth
• if always high or low percentile = normal!
• drop in wt. > 2% at a certain moment, in a short period of time = FTT
- Short stature
o Genetic
o Intrauterine causes
o Intralabor causes
o Postpartum causes
▪ extensive resuscitation
• Growth hormone retardation
▪ Post delivery hypoglycemia
▪ Hypothyroidism
37
▪ Cystic Fibrosis
▪ Celiac disease
▪ Phenylketonuria
o later
▪ child abuse, nutritional defficiences
▪ CRF
▪ Turner syndrome – female (45XO)
o MC = Constitutional delay
o Combinations:
▪ Bone age = Chronological age => Subnormal adult height
• cause
- Genetic short stature
- low birth weight
▪ Bone age < Chronological age + appropriate to height age => Normal adult
height
• Cause = familial maturation delay
• e.g. jul 2009 – q11
▪ Bone age below height age => severe growth retardation (only height is short,
GH is diagnostic)
• cause = endocrine – hypothyr., growth hormone defficiency
o Dx
▪ FBE – anemia, chronic inflammation (ESR, CRP)
▪ Thyroid function
▪ Growth Hormone level
▪ Blood sugar Level
▪ Karyotyping – Turner
▪ X Ray of left wrist -> bone age
• if it’s younger than age of child => room for it to grow
Milestones - TO DO!(MCQ 2145 P 94)
- Asked so far – Murtagh 866
o Social Smile: 2 mths (0-7 wks)
o Roll over from back to front position (prone to supine): 4 months?
o Roll over from front to back position: 5 mths
▪ Both asked – 4-5 mths
o sits with support: 6m
o sits alone: 8m
o standing with support: 5-10 m (10 m)
o walks with support: 7 ½ - 12 ½ (12 m)
o walks without support: 11 ½ - 15 m (15 m)
o walks up steps w/o help: 2 yrs (14-22 m)
▪ Climbs stairs with alternate foot: 30 m
o hops on one foot: 3-5 yrs
o rides a tricycle: 21m – 3 yrs
o reach for an object: 3 – 5½m
o pass object from hand to hand: 4½-7½m
o pincer grip: 9 –15 m
o wave his hand/ wave goodbye around: 12 m ??
38
• Admit
o 1 Standard drink = 10g
▪ 250 ml glass of Beer 4.8%
▪ 100 ml glass of Wine 13.5%
▪ 30 ml glass of Spirit 40%
▪ http://www.health.gov.au/internet/alcohol/publishing.nsf/Content/standard
o High risk/ harmful drinking
▪ > 6 standard drinks for men
▪ > 4 standard drinks for women
o Alcohol limit for driving in Australia: < 0.05 g/ 100ml (2.5 g alcohol/ 5L blood volume)
▪ for a 70 kg man, this means not to drink more than:
• 2 std drinks in 1h
• 3 std drinks in 2h
• 4 std drinks in 3h (1 std drink eliminated in 1 h)
o Lethal dose: 0.45-0.5 g/100 ml (%)
o Intoxication
▪ Potentially fatal
▪ BAC is around 0.45% to 0.5%
▪ Use a breath analyzer to estimate BAC & observe pt, until BAC falls below 0.2%.
▪ BAC normally declines at a rate of 0.015% to 0.02%/ hr, although rate of decline
may be ↑in heavy drinkers.
▪ Sx
• hearing voices (like in Schizophrenia)
▪ TREATMENT:
• Supportive and symptomatic
• Careful monitoring of:
- BAC
- Level of consciousness
- Responsiveness
- O2 saturation
o Alcohol withdrawal:
▪ Characterised by:
• Anxiety
• Tremor
• Sweating
• Nausea & vomiting
• Agitation
• Headache and perceptual disturbances
• Seizures: Uncommon
• Alcoholic hallucinosis
- rare complication of alcohol withdrawal in alcoholics. This
develops about 12 to 24 hrs after drinking stops and involves
auditory hallucinations (accusatory or threatening voices).
▪ these begin with simple sounds (whispering, muted
laughter, clink of glasses, simple words)
43
• TREATMENT:
- Hospitalization
- Correct dehydration and infection if any
- Benzodiazepine loading dose technique.
▪ Diazepam 10 to 20 mg orally, 2 hrly until symptoms
subside.
- Thiamine 100 mg IM as a single dose, followed by 300 mg orally,
daily in 3 divided doses.
- Haloperidol 1.5 to 10 mg orally If psychotic features (e.g.
hallucinations and delusions). Add haloperidol– only if
benzodiazepines didn’t work.
- Wernicke’s Encephalopathy:
o in alcoholics due to thiamine defficiency
o Sx – CONA
▪ Confusion
▪ Opthtalmoplegia
▪ Nystagmus
▪ Ataxia
• Nystagmus & Ataxia (DD)
- with alcohol – Wernicke’s encephalopathy
- cerebellar stroke
▪ no tongue fasciculations
▪ Korsakoff amnestic confabulatory syndrome
• Anterograde amnesia
• Retrograde amnesia
• Confabulation – to make up missing details from affected memory
• meager content in conversation
• lack of insight
• apathy
o Rx
▪ Thiamin IV or IM
▪ followed by glucose/ dextrose
• if we administer glucose first, before thiamin, it might cause
dehydrogenation of piruvate, which will consume thiamin
- Drug intox.
o CNS depressors, stupor, coma
▪ miosis, bradycardia, hT
▪ Drugs:
• OPIODS:
- 1. Morphine
▪ SE
• Miosis (pin-point pupils)
• drowsiness & respiratory depression – most
dangerous
o in high single dose adm.
o usually in terminal patients
45
- Effects in prenancy
▪ IUGR
▪ placental abruption
▪ premature labor
▪ intraventricular hemorrhage
▪ developmental delay
▪ stillbirth
▪ teratogenic effect not proven
- Post-withdrawal – can cause depression
- RX Cold blanket and cool normal saline MCQ party intoxication
• Amphetamine
- Sx
▪ rush with grandiosity, feelings of well-being and
overconfidence, heightened sense of sexual feeling
▪ can aggravate or produce a paranoid schizophreniform
psychosis - “stimulant psychosis” (by increasing
dopamine in the synaptic clefts of brain)
• paranoia and persecutory delusions
• ideas of reference
• auditory and visual hallucinations
▪ persecutory auditory hallucinations
▪ visual illusions and hallucinations
▪ tactile hallucinations of bugs or vermin crawling under
the skin (formication) – can lead to scratching
▪ anxiety, hostility, aggressiveness
- Rx
▪ admission
▪ cessation of amphetamines
▪ antipsychotics – haloperidol, phenothiazines
- In pregnancy
▪ amphetamines - MC associated with congenital
anomalies and
• cleft palate
• HT and pre-eclampsia
• IUGR
• preterm labor
- withdrawal – with depression and high suicidal risk
- Ecstasy – type of amphetamine
▪ euphoria, anxiety, agitation
▪ dehydration
• sec. hyponatremia due to excessive water
consumption
▪ muscle jerks
• Marijuana (Cannabis)
- only drug that has its own receptor
- potentiates the effect of sleeping pills – risk of overdose
- mix of stimulant/ depressant / hallucinogen effects
47
▪ Pneumocystic - Cotrimoxazol
▪ Klebsiella - Cefuroxime
o Lung abscess
▪ Cephalosporin (Ceftriaxone) + Clindamycin
▪ Cephalosporin + Flucloxacillin
o Tonsilitis – Penicilin
o Rheumatic fever Penicilin
o Scarlet fever Penicillin
o Impetigo Topical antiseptic – Bactroban (Mupirocin)
▪ if extensive, systemic A/B
• Flucloxacilin
• Cephalexin
o Meningitis - Ceftriaxone (3rd gen) + Benzylpenicillin
▪ Ceftriaxone 2 g IV
• + Benzylpenicillin 2.4 g IV (ampicillin for Listeria) in immune-
compromised or Listeria
▪ if Penicillin/Cephalosporin hypersensitivity:
• Vancomycin + Ciprofloxacin
▪ prophylaxis in contacts: Ciprofloxacin or Rifampicin
o Typhoid fever – Ciprofloxacin
o other diarrhoeas – see Diarrhoea chap.
o Whooping Cough – Clarithromycin/ Erythromycin
o Epiglotitis – Cephalosporin (3rd gen): Ceftriaxone, Cefotaxime
o Infective endocarditis - start ASAP empiric Rx with Benzyl Penicillin + Flucloxacilin +
Gentamycin IV
o Osteomyelitis – (staph.) Flucloxacilin
o Septic arthritis (staph.) Flucloxacilin
▪ in hospital – Ceftriaxone – 3rd gen (covers gram -ve)
o Cholecystitis - Gentamicin, Ampicillin.
o Cholangitis: Ceftriaxone, Penicillin, Aminoglycosides
o Peptic ulcer
▪ 1st line: PPI + Clarythromycin + Amoxycilin
▪ 2nd line: PPI + Metronidazole + Amoxycilin
▪ 3rd line if sensitive to Penicilin: PPI + Clarythromycin + Metronidazole
o Peritonitis (after viscus rupture): Gentamicin 5 mg/kg IV + Ampicillin 1 g IV +
Metronidazole 500 mg IV
o TB
▪ Active TB
• 4 drugs (rifampicin, isoniazid, pyrazinamide, ethambutol) for 2 mths
• then 2 drugs (rifampicin and isoniazid) for 4 mths
- total 6 mths
▪ Latent TB (Mantoux positive, no symptoms, no X Ray findings)
• when active TB is excluded: Isoniazid mono-therapy for 6-9 mths
▪ Pregnant
• Isoniazid, Rifampicin, Ethambutol – 9 mths treatments
▪ Isoniazid resistant TB
52
- strong on gram -ve, moderate on gram +ve, also cover other bact.
- ex. Cefclidine, Cefepime
▪ 3. Imipenam – Very broad spectrum (Gram +ve, Gram -ve, Aerob/Anaerob,
Pseudomonas, most enterobact. etc. – almost all bact.)
▪ 4. Meropenam – also very broad spectrum
o II. Aminoglicosides
▪ Gentamycin, Streptomycin, Amikacin, Kanamycin, Neomycin
▪ spectrum: good for gram -ve, also on gram +v
▪ SE
• Ototoxic - Vit. E should be added to prevent ototoxicity of gentamycin
• Nephrotoxic – monitor renal function
▪ prefered dosage: once daily
o III. Macrolides
▪ Erythromycin, Clarithromycin, Azithromycin
▪ spectrum
• more on gram +, less on gram –
• active on Mycoplasma, Chlamydia, Bordetella
• Azithromycin – very active on legionella
o IV. Tetracyclins
▪ Tetracyclin, Doxycyclin
▪ spectrum:
• Gram +, Gram -, Chlamydia, Mycoplasma
54
• e.g.
- Penicilin
- Cephalosporin (cross-reaction with penicilin)
- Sulphur drugs
- IV contrast mediums (CT, etc.)
▪ type II – Cytotoxic
• sub-types
- hemol. anemia – sulphonamides (sulfur drugs), peniciline – rare,
quinidine (anti-arrhythmic), methyldopa
- Agranulocytosis – clozapine, carbimazole, ACE inh.
- Thrombocytopenia – heparin (HIT), quinidine
▪ type III – Immune-complex mediated
• e.g.
- penicilin
- sulphur drugs
- thiazides
▪ type IV – T-cell mediated
• e.g.
- penicilin
- cephalosporin
- local anesthetics
- phenitoin
- Drugs to be avoided in pregnancy – Murtagh 1063
o A/B
▪ Tetracyclines (e.g. doxycycline) – incorporated into fetal bones and teeth
▪ Aminoglycosides
▪ Trimethoprim
o Anti-HTN
▪ ACE inhibitors
▪ Diuretics – as in pre-eclampsia and pregnancy induced HT the intravasc. volume
is already low.
▪ Beta blockers – have potential problems
▪ (best evaluated to use in pregnancy = Methyldopa)
▪ Verapamil
o C/S systemic
o Anticonvulsants
▪ Phenytoin – hydantoin syndrome (facial, nail and other abnormalities)
o Estrogen
▪ Diethystilbestrol
• causes reproductive tract abnormalities in both genders
• ↑risk of clear cell carcinoma of vagina in female children
• ↑ abortion rate
o Danazol – Androgenisation: Clitoral hypertrophy & labial fusion in female fetuses
- Drugs to be used in Breastfeeding
o Antiphyschotic
▪ Olanzapine
▪ Risperidone
56
▪ No typical antipsychotics
▪ Clozapine – as much as possible avoid but can be given
o Antidepressants
▪ SSRI except fluoxetine
▪ prefer short acting SSRIs (Paroxetine, Sertraline)
o Bipolar drugs
▪ Na valpropate---- Drug of choice
▪ Lithium – CI (blue book), but Shipra said: as much as possible avoid, but can be
given (check level in the infant as well)
o Benzodiazepines
▪ short acting cause sedation and poor sucking in baby
▪ long acting, like diazepam, cause floppy infant syndrome
o Opioids – safe
- Danazol
o Androgenic SE, especially in long term Rx
▪ Weight gain
▪ Fluid retention
▪ Voice change
▪ in pregnancy: androgenisation: clitoral hypertrophy & labial fusion in female
fetuses
- Inotrop drugs
o Positive inotrops
▪ Ca
▪ Ca sensitizer – levosimendan (in CHF)
▪ Cardiac glycosides – Digoxin
▪ Catcholamines – adrenaline, noradrenaline, dopamine, dobutamine
▪ PG
▪ Phosphodiesterase inh. – theophylline
o Negative inotrops
▪ Beta blockers
▪ Ca channel blockers – only diltiazem, verapamil
• amlodpidine (long acting metabolite of nifedipine) – replacing nifedipine
• decr. the afterload resitance (vasodil.)
• SE:
- edema – nifedipine
- reactive tachycardia
- Chronotrop. neg. Drugs (decreasing HR)
o digoxin
o verapamil, diltiazem
o adenosine
o beta blockers
- Antiarrhythmic Drugs - http://en.wikipedia.org/wiki/Antiarrhythmic_agent
Known
Class Examples Mechanism Clinical uses [5]
as
57
• Ventricular arrhythmias
fast- • Quinidine (Na+) channel block • prevention of paroxysmal recurrent
channel • Procainamide (intermediate atrial fibrillation (triggered by vagal
Ia
blockers • Disopyramide association/dissociation) overactivity), *procainamide in
Wolff-Parkinson-White syndrome
▪ verapamil intox.
• AV block I-III
• LBBB, RBBB
- Beta Blockers
o Types
▪ Non-selective: Propranolol (acts on both heart and lung)
▪ Selective: Metoprolol, Atenolol, Sotalol (acts only on heart)
o Indications
▪ HTN
▪ heart failure – decr. Mortality (cardioselective only)
▪ after MI – decr. mortality
▪ rate control
▪ rhythm control – sotalol
o CI
▪ Pregnancy
▪ heart block
▪ Prinzmetal angina (due to coronary spasm)
▪ asthma, COPD (propranolol – neselective)
▪ DM
▪ peripheral vascular disease
o SE
▪ bronchospasm – non-selective
▪ hyperkalemia
▪ hyponatraemia
▪ ↑risk of DM
- ACE inhibitors
o Indications
▪ HTN
▪ Heart failure – ↓mortality
▪ MI – ↓ mortality
• especially with:
- renal condition
- HTA
- DM
▪ Renal condition (renoprotectors)
▪ DM nephropathy in beginning stage (microalbuminuria)
▪ Progressive renal failure
o SE
▪ Dry cough
▪ Angioedema (C1 estrase)
▪ Agranulocytosis (cytotoxic)
▪ Hyperkalemia
▪ Acute renal failure – in (unilateral or bilateral) renal artery stenosis
▪ Orthostatic hypotension
o CI
▪ Pregnancy
59
▪
Renal failure (in advanced stages when creatinine > 3.5 & worsening with their
use)
▪ Renal artery stenosis
▪ Diastolic heart failure (hypertrophic heart) – M 1337
• hypertrophic cardiomyopathy
• aortic stenosis
• HT
• Rx
- Beta blocker
- Calcium antagonists
- Spironolactone (causes hyperkalemia)
o indic.:
▪ Diuretic
• Heart failure
• HTN
▪ Antiandrogen (Aldosterone antagonist) causes gaynocomastia
- Thiazides
o SE
▪ hypokalemia
▪ hyperuricaemia
▪ impaired glucose tolerance –↑risk of DM (like the Beta Blockers)
▪ hypercholestrolemia
o indic.
▪ diuretic
• HTN
• heart failure
▪ protect from oxalate stones (renal stones)
- Nitrates
o Types
o Short acting
▪ GTN – spray, patch
• duration of action – 30 min
▪ Long acting
• isosorbid mononitrate
• isosorbid dinitrate
o SE
▪ Postural hypotension and Headaches – bc of vasodilation
▪ reflex tachycardia (prevent with β blockers)
- Hyperkalemia
o causes
▪ Drugs
• K⁺ sparing diuretics (spironolactone & amiloride)
• ACE inhibitors & AIIRA
• Digoxin
• Beta Blockers
• NSAIDs: Indomethacin, etc.
• IV Benzyl Penicillin (contains K)!
60
- tachycardia
• various arrythmias
- shortened QRS complex, atrial or ventricular extrasystoles,
paroxysmal atrial tachycardia with AV block, heart block
- PR interval prolongation
- Pulses bigeminy, V. tach. or fibrillation
• nodal bradycardia, bradyarrythmia
• ST depression with T negative wave (“sagging” )
• hypokalemia – small T wave, proeminent U wave
- hyperkalemia – tall tented T wave, widened QRS complex, absent
P waves
• hypocalcemia: long QT, small T wave
- hypercalcemia: short QT
• ventricular ectopics
• never prolonged QTc (corrected QT -> predispose to torsade de pointes)
▪ Rx
• Stop digoxin
• Check K+
• Treat arrythmias
• Consider giving digibind IV – AB to digoxin
- NSAIDs:
o not in renal failure/ insufficiency
▪ ↓ GFR
▪ ↑ proximal tubular reabsorption
• can ↓ Lithium clearance -> Lithium toxicity (MCQ)
- Oral antidiabetics
o Glibenclamide
▪ SE
• hypoglycemia
• cholestatic jaundice
o Metformin
▪ GI upset
• diarrhoea, ↑flatulence
▪ no hypoglycemia
- Amphotericin B IV
o only in potentially lethal fungal infection, as a last resort
o SE
▪ Phlebitis at the site of infusion
▪ anemia
▪ hypokalemia
▪ renal problems (irreversible)
• renal failure
• renal tubular necrosis
- Azathioprine
o hepatotoxic
o acute pancreatitis
62
- Phenytoin
SE
o P 450 inducer
o Gum hypertrophy
o Teratogenic --hydantoin syndrome (facial, nail and other abnormalities)
o Osteomalacia & osteopenia (not osteoporosis)
o interferes with folate metabolism – Megaloblastic anemia
o neuropathies (vertigo, headache and nystagmus)
o Yellow-brown pigmentation of skin
o hirsutism
o lymphadenopathy
o risk of cardiac arrythmias when injected rapidly
- Valproate
o Hepatotoxic (monitored in plasma)
o Teratogenic
- Benzodiazepines
o SE
▪ drowsiness, dizziness
▪ upset stomach
▪ blurred vision
▪ dreaming
▪ depression
- Amitryptilline (TCA)
o SE
▪ ED
▪ ↑ QT interval
- Erythromycin:
o Abdominal Pain
o Anorexia
o Loose bowel motions
- CorticoSteroids
o SE – Oxford 371
▪ Short term
• mood changes: euphoria, depressive
• mild hypokalemia
• mild hyperglycemia – counter-insulin effect
▪ Long term (Cushing – like syndrome)
• insomnia, increased appetite
• fluid retention – mineralocorticoid effect
• HTN
▪ adrenal suppression
▪ avascular necrosis of the bone
▪ myopathy
▪ cataract
▪ gynecomastia?
▪ osteoporosis
▪ growth suppression
63
▪ pancreatitis
▪ oesophageal and peptic ulceration
▪ infections – ↑frequency and severity
• candidiasis
• chickenpox
- Teratogenic drugs
o class
▪ A – safe
▪ B – not fully studied, Metronidazole
▪ C
• Lithium – defintely teratogenic in the 1st trimester and should always
be suspended, preferrably before an intended pregnancy!
• Methadone
- should be taken during the 1st trimester
- discontinue gradually in the 2nd trimester
- taken again during breastfeeding to prevent or minimise
withdrawal or abstinence in the neonate
• Phenytoin and all entiepileptics
• Warfarin
• ACE inh.
• Danazol (androgenisation) Clitoral hypertrophy & labial fusion
• Retinoids
• A/B:
- tetracyclines (growth retardation, etc.)
- metronidazole (its now proven to be safe)
- chloramphenicol
- aminoglycozides
- Drugs causing pulmonary infiltration
o Amiodarone -> fibrosis, alveolitis
▪ other SE:
• hypothyroidism (inf. the conversion of T4 -> T3)
• photosensitivity
• skin pigmentation
• peripheral neuropathy
• ARDS
o Bleomycin
o Busulphan
o Gold compounds (rheumatoid arthritis)
o Nitrofurantoin
o Methotrexate
o Methylsergide
- Nephrotoxic drugs
o A/B
▪ Aminoglycosides: gentamycin, etc.
▪ Cephalosporins – some
• worst combinations causing ARF (acute tubular necrosis):
- Gentamycin + Cefazolin (1st gen)
64
- Toxoplasmosis
o Pyrimethamine + Sulfadiazine (+ folic acid, to counteract their antifolate activity)
- Clostridium difficile
o 1. Metronidazole
o 2. Vancomycin– if 1 fails
o Antiemetic, nausea:
a. side effect of morphine – haloperidol, prochlorperazine (Stemetil)
b. poor gastric emptying – metclopramide, cisapride, domperidone
c. cytotoxic chomotherapy or radiotherapy – ondansetron (Zofran) = serotonin receptor
antagonist
Antivertigo – Betahistine - dilate blood vessels within middle ear which can relieve pressure from
excess fluid and act on smooth muscle. In Meniere’s syndrome.
Antipsychotics:
- Tranquilizing psychiatric medication primarily used to manage psychosis (including delusions or
hallucinations, as well as disordered thought) particularly in schizophrenia and Bipolar Disorder.
- All antipsychotic drugs tend to block D2 receptors in dopamine pathways of brain. This means
that dopamine released in these pathways has less effect. Excess release of dopamine in
mesolimbic pathway has been linked to psychotic experiences. It is blockade of dopamine
receptors in this pathway that is thought to control psychotic experiences.
- 1st generation (Typical) antipsychotics – 1950 - the first typical antipsychotics to enter clinical
use were the Phenothiazine (Chlorpromazine)
o Butyrophenones
▪ Haloperidol (Haldol, Serenace)
▪ Droperidol (Droleptan)
o Phenothiazines
▪ Chlorpromazine (Thorazine, Largactil)
▪ Fluphenazine (Prolixin) - Available in decanoate (long-acting) form
▪ Perphenazine (Trilafon)
▪ Prochlorperazine (Compazine)
▪ Thioridazine (Mellaril, Melleril)
▪ Trifluoperazine (Stelazine)
▪ Mesoridazine
▪ Periciazine
▪ Promazine
▪ Triflupromazine (Vesprin)
▪ Levomepromazine (Nozinan)
▪ Promethazine (Phenergan)
▪ Pimozide (Orap)
o Thioxanthenes
▪ Chlorprothixene (Cloxan, Taractan, Truxal)
▪ Clopenthixol (Sordinol)
▪ Flupenthixol (Depixol, Fluanxol)
▪ Thiothixene (Navane)
▪ Zuclopenthixol (Cisordinol, Clopixol, Acuphase)
68
o Examples:
▪ Agomelatine (Valdoxan, Melitor, Thymanax)
Lithium:
- A mood stabilizing drug, primarily in treatment of Bipolar Disorder, where it has a role in
treatment of depression and particularly mania, both acutely and in the long term. As a mood
stabilizer, it is probably more effective in preventing mania than depression and may ↓ risk of
suicide in certain bipolar patients. In depression alone (unipolar disorder) Lithium can be used to
augment other antidepressants. Lithium carbonate (Li2CO3), sold under several trade names is
MC prescribed while the citrate salt lithium citrate (Li3C6H5O7) the sulfate salt lithium sulfate
(Li2SO4), lithium aspartate and the orotate salt lithium orotate are alternatives.
- Upon ingestion, it becomes widely distributed in CNS and interacts with a number of
neurotransmitters and receptors, ↓ norepinephrine release and increasing serotonin synthesis.
Parkinson: Levo-dopa (precursor of cathecolamines: dopamine, epinephrine, norepinephrine),
Quetiapine (at night, = antipsychotic,= Seroquel, also used in Schizophrenia, Bipolar syndrome, restless
legs syndrome and chronic insomnia )
Antiepileptics:
- Carbamazepine (+ also used in Trigeminal neuralgia)
- Valproate
- Ethosuximide
- Gabapentin (+ diabetic neuropathy, post-herpetic neuralgia)
- Aspirin
o it has half the effectiveness of warfarin in preventing strokes!!!
- Dypiridamole
- Ticlopidine, Clopidogrel
Thrombolytics:
- These drugs are most effective if administered immediately. The advantage of administration is
highest within first 60 minutes, but may extend up to 6 hrs after start of symptoms.
- examples:
o tissue plasminogen activator - t-PA - alteplase (Activase)
o reteplase (Retavase)
o tenecteplase (TNKase)
o anistreplase (Eminase)
o Streptokinase (Kabikinase, Streptase)
o urokinase (Abbokinase)
- Side-effects:
o Hemorrhagic stroke is a rare but serious complication of thrombolytic therapy.
o If a patient has had thrombolysis before, an allergy against the thrombolytic drug may
have developed (especially after streptokinase).
Antispasmodic – hyoscine
▪ dermatitis
▪ dementia
- Regular monitoring of plasma level of drugs – for:
o Lithium
o Digitalis
o Theophylline
Therapeutic value Toxic value
Digitalis 0.5-1.5 2
Lithium 0.6-1.2 2
Theophylline 10-12 20
o Clozapine
▪ monitor FBE (neutropenia) and glucose tolerance (DM)
o nortryptiline
o (Amit) +
▪ Aminoglycosides: gentamicin
▪ Antiepileptics: phenytoin, valproate, carbamazepine
▪ antiarrhythmics
▪ antidepressants
- Drug interactions
o Erythromycin and Theophylline
o ACE inhibitors and Diuretics
o Amiodarone and Beta Blockers
o NOT - Digoxin and Warfarin
- Drug administration changes in pre-op for elective surgery
o Oral hypoglycemic
▪ No change for minor procedure
▪ Switch over to insulin at least 48 hrs before surgery
o OCP
▪ Combined OCPs: Stop pill 4 weeks before surgery (risk of DVT due to ↑
estrogen in OCP)
▪ Mini-pill: can be continued
o Oral anticoagulants
▪ Warfarin
• Elective surgery
- Stop it 1 week before surgery + start heparin (LMW heparin)
- Stop heparin 12-24 hrs before surgery
- After surgery, start heparin and warfarin
- Stop heparin when desired INR has been achieved
• Emmergency surgery
- Give FFP + prothrombine concentrate + Vit. K
o Aspirin, Clopidogrel - Stop 1 week before surgery
o Antianginal, Anti-HT – continued
o Antidepresants
▪ MAOI – Stop 3 weeks before surgery
▪ Lithium – Stop 48-72 hrs before surgery
o C/S
76
▪ if taken for > 1 week in last year (external C/S have suppressed the endogenous
production of C/S): give hydrocortison supplement before or during surgery to
keep up with the stress of the surgery
- Drugs that can be delivered by endotracheal tube
o O2
o Naloxone
o Lignocaine
o Atropine
o Adrenaline
o Asthma
▪ Beta 2 agonists: Salbutamol (Ventoline)
▪ Cholinergic blockers: Iprotropium bromide (Atrovent)
- Statin (HMG-CoA inh.)
o SE
▪ Hepatotoxic
▪ Myositis
• Statins + fibrates = bad combination -> risk of myopathy (simvastatin
myopathy)
- even worse with erythromycin – liver enzyme inhibitor
- causes rhabdomyolysis:
▪ check serum CK and urine myoglobin
▪ hemoglobinuria (not hematuria) – no RBCs on
microscopy
o CI in pregnancy
o Dx
▪ LFT, CK – follow up for 6 mths
- Follow up LFT test
o Anti-TB drugs
o Anti-epileptics
o Li
o Statins
Obstetrics - OK
Pregnancy parameters
- Implantation:
o 5 days for fertilized egg
o 10 days from ovulation
- Don’t monitor baby up to 24 weeks
o until then – only monitor mother
- Term baby > 37 weeks
- Characteristic of pregnancy
o immunological suppresion
o leucocytosis
- Gestational age - most appropriate examination:
o U/S in first trimester, 8th to 9th week, before 18 wks (not reliable after 18th week)
▪ the earlier the more accurate
▪ measures the crown-rump legnth (CRL)
o if no U/S then pelvic/ bi-manual examination in first trimester
77
Gravida/ para/ abortus (GPA) or sometimes just gravida/ para (GP), is a shorthand notation for a
woman's obstetric history.
- Gravida indicates the total number of times a woman has been pregnant, regardless of whether
these pregnancies were carried to term. A current pregnancy, if any, is included in this count.
- Para indicates the number of viable (>20 wks) births. Pregnancies consisting of multiples, such as
twins or triplets, count as ONE birth for the purpose of this notation.
- Abortus is the number of pregnancies that were lost for any reason, including induced abortions
or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost.
Pregnancy stuff:
duration: 37-42 wks (40 weeks since last normal menstrual period, LNMP or 38 wks from conception)
Prenatal care:
monthly visits during the first two trimesters (from week 1–28)
biweekly from 28 to week 36 of pregnancy
weekly after week 36 (delivery at week 38–40)
total: 14 (can be reduced to 7-10)
Supplimentation:
Folate 0.5 mg last 3 months and first 3 months of the pregnancy
Iron – in vegans/ vegetarians
Calcium and vit. D (10 µgrams/ day) – maybe
Vit. A excess is harmful to the baby!
Screening:
- Chorionic villus sampling: 9-11 weeks, result in 48 hrs
- Amniocentesis: 15 weeks, result in 3 weeks
- Ultrasound
- Immunisations:
78
- Influenza
- Typhoid or cholera – if travelling abroad
- Polio – if not vaccinated yet
Symphisis – Fundal height: approx. match height in cm = No. of weeks (e.g. at 20 weeks – 20 cm)
Evolution:
by 10 weeks (70 days) the placental development is complete
uterus becomes palpable from 12-13 weeks
fetal movements felt after 18 weeks
morphology ultrasound scan at 18-20 weeks
uterine fundus reaches the umbilicus – 20 weeks
Infections in pregnancy
- Pregnancy doesn’t lower the woman’s resistance to inf.?
o exception: poliomyelitis
- baby – immunocompetent at 14 wks, but the efficacy is low till the second ½ of the pregn.
- Mx
o offer mother termination of pregnancy if active infection with:
▪ Erythema infectiosum (Slppped cheek, 5th disease)
▪ Rubella
- Types
o a. Bacterial
▪ 1. Group B Streptococcus:
• (15) 18-27% of mothers are carriers
• during labour > 50% of babies born through an infected vagina are
colonized
- 1% of them will develop early onset GBS neonatal sepsis ->
difficult to treat with high neonatal death
▪ 25-30% of premature babies
▪ 2-8% of term babies
▪ 15-40% neurological sequelae in survivors
• risk incr. in
- PROM – mother can develop chorioamniotitis
- Vaginal delivery – especially in premature babies
• Mx – 2 approaches:
- 1. test for it at 36 weeks
▪ Swab low vagina + rectum
- 2. treat if positive risk factors
▪ premature labor < 37 weeks
▪ when anticipated ROM > 18 hrs before delivery
▪ intrapartum fever > 38o C
▪ previous early onset GBS dis.
▪ GBS bacteriuria during pregnancy
• Rx.
- for mother
▪ come to hospital if early labor
79
• Rx
- Procaine benzylpenicillin or benzathine penicillin
- Non-pregnant: if sensitive to penicillin
▪ Doxycycline
- in case mother was infected and not fully treated -> baby also
treated with procaine benzylpenicillin for 10 days
▪ since baby’s sympt. are non-specific + serology is
inacurate
o b. Viral – smaller than bact. => higher chance of passing through the placenta
▪ most of them infect baby only if very severe infection in mother
• exceptions:
- Rubella
- CMV
- Herpes
▪ 1. Rubella (German Measles)
• very rare now, due to the immunization program
- 85% had the inf. and 90% of them are immune
• if active inf. in first 14 wks => fetus will almost certainly be inf. (90%),
with 40% of them being damaged by virus (5% risk in last trim.)
• causes “Congenital Rubella Syndrome”:
- Prematurity
- "blueberry muffin" rash
- Cataract, blindness
- Deafness
- Heart malformation - PDA
- IUGR
- Thrombocytopenic purpura, hepatosplenomegaly
- Vasculitis, renal artery stenosis
• Prevention
- Immunize all women between 11-13 yrs
- Screening
▪ when she wants to get pregnant
• if not immune – get vaccine and don’t get
pregnant in next 3 months
▪ at first pregnancy test – if vaccinated, extremely small
risk of infection
• Mx in case of inf. (rubelliform rash – 50% of rashes are not due to
rubella) or contact with infected person
- Pregnancy test neg.
▪ IgM neg., IgG neg. -> immunize and don’t get pregnant
in next 3 mths
▪ IgM pos., IgG neg. -> supportive Rx + don’t get
pregnant till sympt. disappear and IgG becomes pos.
▪ IgM neg., IgG pos. = immune, safe to get pregnant
- Pregnancy test pos.
▪ IgM neg., IgG neg. -> do not immunize + avoid contact
with inf. person + repeat test in 3 weeks
81
• D&C
▪ followed by U/S + prophylactic inj. of methotrexate
• FOLLOW –UP: Wkly serum or urine β-hCG.
• They should fall to undetectable levels within
12-16 wks after evacuation
• if not back to normal -> oncology assessment
for possible metastases
o MC location = lung
o brain
o bones
▪ Precaution: no pregnancy for 1 yr (use OCP)
o b. Invasive mole (chorioadenoma destruens).
o c. Choriocarcinoma.
▪ 3. Spontaneous miscarriage
o Intrauterine death – MC cause = Unknown
o Expulsion of products of conception before 24th wks of pregnancy
o Occurs in 10-20% of all early pregnancies
o MC in 1st trimester
o Miscarriage
▪ 1st trimester – Chromosomal (MC - 60%, mostly trisomies) and
fetal abnormalities
▪ MC > 35 yrs
▪ 2 trimester
nd
▪ genetic disease
▪ infection
▪ uterine malformation
▪ Fetal fibronectin test: if + even when cervix is still
closed risk of premature delivery is markedly ↑.
▪ cervical incompetence
• 20% of women with recurrent misscariage
after 12 wks have this (usually at 16 wks)
• gradual dilatation of internal cervical OS ->
intrauterine pressure will break amniotic bag at
cervical OS.
• Sx
o Recurrent miscarriage: painless leaking
of amniotic fluid (PROM)
o painless cervical dilatation + ↑ cervical
mucous discharge
o miscarriage after painless labour
o contractions – only rarely
o usually no or small bleeding – differ
from other type of miscarriages
• Dx
o U/S or vaginal examination – before
• Rx - Cervical Cerclage – sutures like a ring on
outside of cervix at internal OS
88
• Can’t be arrested/stopped
• Bleeding is heavier, abdominal cramps more persistent
(typical here)
• External OS is open (5 mm ≥).
• POC may be found in vagina or protruding from cervical
canal.
▪ 3. Incomplete miscarriage.
• Parts of fetus/placental material retained in uterus
• The bleeding remains heavy.
• Cramps persist even following passage of clots and
POC
▪ 4. Complete miscarriage.
• All fetal and placental material has been expelled from
uterus
• Bleeding and cramps stop.
• Signs of pregnancy disappear.
• Cervical OS is closed.
▪ 5. Silent or missed micarriage.
• All the POC are retained
• Cramps and bleeding are replaced by an asymptomatic
brownish vaginal discharge
• USG fails to detect fetal heart motion.
o Dx
▪ First: Pregnancy test.
• If β-hCG is positive, check β-hCG level to assess
usefulness of ultrasound of USG.
- Β-hCG greater than 1000 U/L: USG.
▪ To confirm the gestation.
▪ To check the sac size.
▪ Liquor volume.
▪ Presence or absence of fetal heart
activity
o MANAGEMENT:
▪ Stable or Unstable?
▪ IV resuscitation
▪ Transfusion if needed
▪ Refer to Gynaecological team for surgical or non-surgical
management
▪ Give Rh negative mothers anti-D immunoglobulin
▪ 4. Septic abortion
• Result of criminal abortion.
• Pelvic infection with salpingitis, peritonitis, pelvic and pulmonary
thrombophlebitis.
• Can lead to septicaemia, DIC, shock and death.
• CLINICAL FEATURES:
- Fever > 37.8
90
- Abdominal pain
- Foul-smelling vaginal discharge and bleeding.
• MANAGEMENT:
- First step: Swabs for microscopic assessment and culture.
- Immediate antibiotic therapy: Gentamicin 5mg/kg IV, ampicillin
2g IV and metronidazole 500 mg IV
- Refer for curettage or emergency hysterectomy
- II. Late pregnancy
o a. Bleeding = ANTEPARTUM HEMORRHAGE = Vaginal bleeding after 24 wks of gestation
▪ 1. Placenta praevia
• The placenta is implanted, either partially or wholly, in the lower uterine
segment and lies below the fetal presenting part.
• incidence – 1%
• MC obstetric cause of coagulopathy
• classif.
- total, complete, central – completely covers the cervical os
- partial
- marginal – edge min. 2 cm away from cervical os
-
• RISK FACTORS:
- Three times as common in multiparous women as in primiparae.
- Cesarian section.
- Submucous fibroids.
- History of placenta praevia.
- Advanced maternal age
• Sx
- PAINLESS vaginal bleeding
▪ may be precipitated by
• trauma
• coitus
• pelvic/ vaginal exam
▪ can stop then resume
- Uterine Hypotonia: Uterus is non tender
- Fetal head is still mobile above the pelvic brim
- Blood loss is MATERNAL.
- Bleeding in 2nd half of pregnancy is placenta praevia until proven
otherwise.
• DIAGNOSIS:
- First: Fetal heart sounds
- Ultrasound: Dx is confirmed only after 30 weeks of pregnancy (at
32-34 weeks)
91
• Dx
- clinical
- Apt test – distinguish between fetal blood and maternal blood
• Mx
- emmergency C-section, otherwise fetus will die
▪ 4. Placenta Accreta
• rare: 1:500 - 1:2500
- incidence is ↑due to↑incidence of C-sections
- risk proportionately increases after multiple C-sections
• risk factors
- previous C-section + anterior low lying placenta
• when placenta implants over a previous C-section scar -> trophoblast
penetrates through scarred decidua and myometrium becoming
morbidly adherent.
• Sx
- Excessive vaginal bleeding leading to frequent DIC
• Mx – Cesaren hysterectomy to preserve mother’s life
▪ 5. Rupture of uterus
• RESULT OF:
- Obstructed labour – during uterine contractions
- Trauma
- Dehiscence of a cesarean scar
- Inappropriate use of oxytocins
• Sx
- Vaginal bleeding
- Abdominal pain which becomes constant
- Shock in some cases
- Some can be asymptomatic
• TREATMENT:
- Hysterectomy
- In few cases uterine tear can be sutured
▪ 6. Polyp
• Sx
- Bleeding can occur after coitus
- More limited bleeding
▪ best way to monitor adequacy of blood volume replacement = urine output
• since body can compensate through vasoconstriction for a while (Pulse,
BP normal) but urinary output will be ↓ in hypovolemia.
o b. HTN in pregnancy – Classification:
▪ 1. Chronic HT
• Essential HT – prior to conception or in 1st ½ of the pregnancy, without
an underlying cause
• Secondary HT – caused by renal, renovasc. or endocrine disorders or
aortic coarctation
▪ 2. Gestational HT
• arises after 20 wks
• without any features of pre-eclampsia
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• Thrombocytopenia
• hemolysis
• DIC
▪ fetal growth restriction
• COMPLICATIONS:
- Mother
▪ HELLP syndrome = severe form of pre-eclampsia
• triad:
o Hemolytic anemia
o Elevated Liver enzyme
o Low Platelets
• Rx – deliver the baby
▪ DIC
▪ Oliguria, ARF
▪ Eclampsia (tonico-clonic seizures and coma)
- Baby
▪ Intrauterine death.
▪ IUGR
▪ Premature delivery.
• MANAGEMENT:
- Admission: BP > 150/100 (twice), maternal symptoms,
compromised fetal well being.
- Treat HTN:
▪ moderate – Oral
• Methyldopa 250 mg two-three times daily.
• Labetalol or atenolol
• Nifedipine
▪ Severe – IV
• Hydralazine 5 mg IV bolus every 20 min
- < 32 wks: try to continue pregnancy until 35 wks
▪ steroids for pulmonary maturity
▪ daily fetal movement count (kick count chart)
▪ 3 CTGs/ week
▪ Doppler umbilical blood flow
▪ Platelet count – to detect HELLP syndrome
• if platelets > 100.000 – keep monitoring
• if platelets < 100.000
o Give C/S – 2 doses, 24 hrs apart -> to
prevent hyaline membrane disease
o Correct thrombocytopenia, then
o induction
- 32-35 wks: Same management, but if delivery is indicated, can
do C-section or induction of labor
- > 35 wks
▪ pregnancy should be terminated rapidly with induction
of labor or C-section, depending on cervix and feto-
maternal situation.
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- Eclampsia
▪ delivery
▪ prevent convulsions with MgSO4
• can be used in first 48-72 hrs after delivery
• Initial dose of 4g IV over 5-10 min then infusion
1g/ h for at least 24 hrs.
• if woman has eclampsia, hyperreflexia, fits or
headache
• monitor tendon reflexes, resp. rate (>16/min)
and urine output (>25 ml/h)
• SE/toxicity
o diminished or abolished reflexes (knee
jerk = patellar reflex) – first sign
o decr. resp. rate -> resp. paralysis
o decreased urinary output
• Rx
o stop MgSO4
o give antidote – Cal. Gluconate
▪ if convulsions occur, treat with Diazepam 0.1-0.2
mg/kg IV or Phenytoin
▪ 4. Pre-eclampsia superimposed on chronic HT
• after 20 wks
• systemic features of pre-eclampsia develop on top of existing chronic HT
o c. PROM
▪ in most cases (80-90%) the baby is born within 7 days
▪ for best prognosis of baby, most important is administartion of C/S
▪ Mx
• lithmus paper test (Nitrizine test) – is there amniotic fluid in discharge?
• monitor for signs of Chorioamniotitis
- cause: anaerobes, GSE
- Sx
▪ fever
▪ tachycardia
▪ abd. pain, tenderness
▪ offensive vaginal discharge
- Dx
▪ FBE: incr. WBC, CRP – every 2-3 days
- Rx
▪ A/B
▪ expedite the delivery
• Sterile speculum exam. – under strict sterile conditions
• NO PV!! – risk of inf.
• U/S – amount of amniotic fluid around the baby (oligohydramnios?)
• Doppler for umbilical blood flow: is the baby receiving enough blood?
• CTG – every 2-3 days
• WBC and C reactive protein every 2-3 days.
• high and low vaginal swab, rectal swab
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• Week 35-36
• Sx
- nausea, anorexia, vomiting
- jaundice and fever
• Cx
- renal failure
- fulminant hepatitis with hepatic encephalopathy
- pancreatitis
- DIC
• Dx
- liver and renal failure (urea and uric acid ↑)
- AST and ALT ↑(but not as high as in viral hepatitis: 200 not 400)
- Bilirubin ↑
- ALP usually normal
- liver biopsy – confirms Dx
• Rx
- urgent admission to ICU
- urgent termination of pregnancy (life-saving for mother and
baby)
- prevent/ treat DIC
- may require liver transplant
▪ 2. Intrahepatic cholestasis of pregnancy (hepatosis)
• MC in 3rd trimester, but can start anytime
- usually in second ½ of pregnancy
• due to estrogen sensitivity
• Cx
- fetal distress
- fetal death
- preterm delivery
- meconium ingestion
- meconium aspiration syndrome
• Sx
- intense itching, usually without a rash
▪ Generally, itching is localized to abdomen, legs, palms,
and soles, but can be generalized.
▪ Itching that increases in evening
▪ Itching that doesn’t respond favorably to anti-
histamines or other remedies
- Often, elevated LFTs and serum bile acid counts
- Less common:
▪ Darker urine
▪ Lighter stools
▪ ↑ clotting time (due to associated vitamin K deficiency)
▪ Fatigue
▪ Increased nausea
▪ Decrease in appetite
▪ Jaundice - only in relatively small subset of cases
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o 2. Gestational DM
▪ screening test is glucose challenge test (non-fasting) at 26-28 wks (not OGTT)
• N = 8 mmol/l
• > 8 abnormal -> then do OGTT (fasting)
• Criteria for diagnosis of gestational DM: Fasting > 5.5mmol/l and >
8mmol/l 2hrs after 75gms oral glucose.
- also do OGTT if high risk:
▪ previous Hx of gestational DM
▪ DM
▪ family Hx of DM or gestational DM
▪ Hx of macrosomia
▪ PCOS
▪ glycosuria
• common in pregnancy – 25-50%
• only 2-3% of them have DM
• if present on 2 occasions, should do OGTT
▪ Rx – like in pre-gestational DM
▪ follow up with OGTT at 6 weeks and then every 5 yrs
• likely to recur in subsequent pregnancies
• 30% developing DM later in life
- Vomiting
o causes
▪ normal pregnancy
▪ multiple pregnancy
▪ hydatiform mole
▪ UTI
▪ intestinal obstruction
o Dx
▪ U&E and creatinine – to assess the dehydration
▪ U/S – multiple pregnancy? hydatiform mole?
▪ urine culture – UTI?
▪ single erect abd. X-ray – intest. obstr.?
- Acute pancreatitis in pregn. is assoc. with:
o cholelithiasis – MC
o alcohol intake
o cocaine use
o hyperparathyroidism
o abdominal trauma
- pain in lumber area while walking, 3rd trimester - refer to physiotherapy
- fetal movements felt by
o 18 wks –multigravida
o 20 wks - primigravida
- can’t feel fetal movement
o 1st step – intermittent auscultation
▪ don’t hear anything -> 2nd step = U/S
▪ hear something that worries you (bradycardia, etc.) -> II step = CTG
• CTG normal
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- Mx
▪ < 32 wks – U/S
▪ > 32 wks – repeat CTG
o (another approach) if normal auscultation (hypoxia)
▪ CTG
• if ok discharge + do kick count chart (normal: 10 movements/day)
▪ if abnormal auscultation
• CTG + U/S
- Multiple pregnancies
o assoc. with
▪ ↑perinatal morbidity and mortality (5-10x)
▪ ↑post-partum hemorrhage (uterine atony)
▪ ↑IUGR of one or both twins
▪ ↑umbilical cord prolapse (esp. for 2nd twin)
o not associated with feto-maternal hemorrhage
- Oligohydroamnios
o Mx
▪ U/S
▪ RFT
▪ regular CTG
▪ lupus AB
- Polyhydroamnios
o risks
▪ PROM
▪ preterm labor
▪ cord prolapse
▪ APH
▪ malpresentation
- Pubic symphysis diastasis (pelvic osteoarthropathy)
o separation of pubic bones (due to relaxation of ligaments during pregnancy)
o II-III trim or early postparthum
o Sx
▪ pubic pain aggravated by walking/ moving
▪ pubic joint is very tender
o Dx
▪ confirmed by U/S
▪ post-partum – X Ray
o Rx
▪ bed rest on firm mattress
- Abdomen big for date (fundus > age)
o wrong date
o polyhydramnios
▪ fetal malformations
▪ multiple pregnancy (twins)
▪ DM
▪ infection: CMV, toxoplasmosis
▪ chorioangioma of placenta
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o DM – macrosomia
o fibroids
o twins
o Rh incompat. – MC cause of hydrops fetalis
o ABO incompatibility
- Abdomen small for date (fundus < age)
o Wrong date
o Small baby – in fetal malformation
o Oligohydramnios– in fetal malformation
o IUGR
- CTG:
o usually performed after 26 weeks (before not very accurate)
o not usually done
▪ not superior to intermittent auscultation
▪ has not ↓ incidence of cerebral palsy or other neonatal developm. anomalies
▪ rarely a predictor of previous fetal oxygenation – unless profoundly abnormal
▪ poor predictor of current fetal oxygenation - unless profoundly abnormal
o Indications
▪ high risk pregnancy: HT and DM mom, etc.
▪ overdue pregnancy > 40 wks (2 times/ week)
▪ on Oxytocin
▪ color of water is brown or green
▪ bad baby heart beats
o Side Effects
▪ ↑ risk of obstetric intervention (instrumental delivery or C-section)
o 2 lines:
▪ above - baby’s heart
▪ below - uterus contractions
o we check fetal heart rate, fetal movements and uterine contractions to identify the
presence of fetal hypoxia
▪ 1. Baseline FHR = mean level of FHR when this is stable (excluding accelerations
and decelerations)
• Normal: 110-160 (150?)
• < 110 Bradycardia
- ↑ vagal heart tone
- fetal heart block
- cord compression
- fetal hypoxia
• >150 Tachycardia
- fetal inf.
- fetal hypoxia
- maternal fever
• > 200 – fetal arrhythmia
▪ 2. Baseline variability – minor fluctuations of baseline
• normal: 5-15 (10-15?)
• reduced or incr = fetal distress
• lost:
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- Mx
▪ non-reassuring pattern in I stage of labor
• reposition woman (left, right position)
• give O2 via face mask
• if she was on oxytocin, slow it or stop it
• -> then check CTG again
o if it didn’t improve -> perform fetal
scalp blood sampling (with
amniotomy)
▪ if Ph <7.2 -> C-section
• Abnormal CTG – 2 of the following features in the non-reassuring type
are present or
- baseline FHR < 100 or > 170
- variability is absent (<3) = monotonous trace
- late decelerations (especially prolonged > 3 min)
▪ => immediate delivery
• vaginal – if cervix is fully dilated
• C-section – if cervix is not fully dilated
• Most ominous – indicating severe fetal compromise
- 1. persistent late decelerations - worst
- 2. severe variable decelerations
- Appendicitis in pregnancy:
o Dx
▪ difficult, due to:
• the displacement of appendix by enlarged uterus – higher the later the
condition occurs during pregnancy
• tenderness more difficult to localize, since appendix is behind large
uterus
• confusion with other diseases
- UTI
- hyperemesis gravidarum
- right ovarian cyst complication
- red degeneration of fibroid
- small concealed placental abruption
o Rx – Appendicectomy
- DVT in pregnancy
o Anticoagulant throughout pregnancy
▪ use Heparin instead of Warfarin (therapeupric doses for 3 months then prophylactic
doses for remainder of pregnancy until 6 wks postpartum)
• Heparin = Large molecule size => can’t cross placenta (no anticoagulant
effect on baby). Therapeutic dose = 2 times prophylactic dose.
• reversal of anticoagulant effects can be achieved faster than warfarin
▪ Warfarin
• SE
- Can’t be used in 1st trimester (Teratogenic)
▪ can be given during 13-36 wks but its effect is slower
to reverse
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-miscarriage risk
-stillbirth
-neurological problems in baby
-crosses placenta and has anticoagulant effects on baby as well ->
hemorrhg. in mother and baby
o 6 wks post-partum heparin
- Impaction of a retroverted uterus (e.g. 16 wks - MCQ)
o Sx
▪ lower abd. pain, urinary retention
- Thrombocytopenia
o causes
▪ incidental thrombocytopenia of pregnancy– MC
• not significant unless < 50x109/L
▪ pre-eclampsia – when severe = HELLP syndrome
▪ immune thrombocytopenia
▪ SLE
- Maternal mortality
o 1:10.000 in Aus.
o causes
▪ Primary pulmonary HT – 50% die during pregnancy or puerperium
▪ Severe pre-eclampsia and eclampsia
▪ PE
▪ Postpartum hemorrhage
▪ Amniotic fluid embolism
▪ Anesthetic accidents
- IUGR
o viscera least affected is the brain
o can be
▪ Asymmetric
• MC- AC is affected
• due to placental dysfunction
• Biparietal head diameter (BPD) is last one to be affected
▪ Symmetric
• more rare
• causes
- intrauterine infections
- other intrauterine abnormalities
• All parameters are reduced, BPD is reduced alongwith others
- Premature delivery
o causes
▪ increased uterine size
• macrosomia
• polyhydroamnios
• multiple pregnancy
▪ shortened cervix < 1.5 cm
▪ open cervix especially if:
• internal OS is open
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• Lochia rubra (or cruenta) is the 1st discharge, red in color because of
large amount of blood it contains.
- It typically lasts no longer than 3 to 5 days after birth.
• Lochia serosa is the term for lochia which has thinned and turned
brownish or pink in color. It contains serous exudate, erythrocytes,
leukocytes and cervical mucus.
- This stage continues until around the 10th day after delivery.
• Lochia alba (or purulenta) is the name for lochia once it has turned
whitish or yellowish-white. It contains fewer red blood cells and is
mainly made up of leukocytes, epithelial cells, cholesterol, fat & mucus.
- It typically lasts from 2nd through 3rd to 6th week after delivery
- Puerperial fever/ sepsis (1 to 10th day after delivery)
o > 38OC
o > 24 hrs
o causes
▪ 3 Bs
• Birth canal – endometritis (MC, 75%, with high grade fever)
- post-partum endometritis or pyrexia (fever, tender uterus, foul
smelling lochia):
▪ Ampicilin (or amoxycylin) and metronidazole
• if not improving add Gentamycin
• Breast - mastits
• Bladder – UTI
• + DVT
▪ MC
• UTI – E.coli
• breast inf – Staph. aureus
• wound inf. – if C-section
▪ less common
• Genital – endometritis – strepto.
• DVT?
o Dx
▪ U/S: bulky uterus
▪ inspection of lower tract for infected tears or lacerations
▪ MSU for microscopy, culture, sensitivity
▪ vaginal swab
▪ signs of mastitis
o Rx
▪ 1 - init. empirical: penicilin + metronidazole + gentamycin
▪ after result, adjust for sensitivity
- After birth - http://en.wikipedia.org/wiki/Fetal_circulation
o Umbilical vein closes and becomes ligamentum teres
o Closure of ductus venosus
o Lateral umbilical artery becomes lateral umbilical ligament
o Ductus arteriosus is closing due to increased local PG
o increased venous return from the lungs causes pressure to increase in the left atrium,
which closes the foramen ovale flap valve
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o MC cranio-facial malformation
o causes
▪ Benzodiazepine
▪ Antiepileptics - carbamazepine
▪ Amphetamines
▪ Rubella
▪ Genetic factors
• Kalman syndrome
▪ Smoking
▪ Alcohol
- Alcohol abuse:
o from 80 g alcohol/ day => Fetal alcoholic syndrome
▪ Microcephaly
▪ Mental retardation
▪ Poor muscle tone
▪ short palpebral fissure
▪ long and smooth philtrum
▪ underweight till puberty
▪ short stature
▪ septal defect
▪ facial hypoplasia
▪ joint deformities
▪ low IQ
▪ attention deficit
▪ forebrain malformation
- Cocaine abuse:
o IUGR
o Placenta abruption
o Premature labour
o Intraventricular hemorrhage
o Developmental delay
o Stillbirth
o Teratogenic effect not proven
- fetal malformations can be assoc. with umbilical cord vessel anomalies
o Normal – 2 arteries & 1 vein (3 vessels cord)
o MC anomaly assoc. with fetal malformation = only 2 vessels in cord
▪ 1 artery + 1 vein – baby can survive
▪ otherwise – stillbirth in 1st trimester
Antenatal care
o 1st antenatal checkup
▪ Confirm pregnancy
▪ FBE
▪ Blood group, Rh, Coomb’s test
▪ Blood sugar level
• Random
• Fasting
▪ MSU, urine analysis, electrolytes
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▪ LFT
▪ Infections
• Rubella
• Hep. B
• HIV
• Syphillis - VDRL
• CMV
- consider Varicella, Hep. C
o Hb electrophoresis – Thalassemia
o for Gestational DM
▪ Screening test is Glucose challenge test (non-fasting) at 26-28 wks (not OGTT)
• Normal = 8
• > 8 is abnormal -> then do OGTT (fasting)
- also do OGTT if high risk: Previous Hx of gestational DM, DM,
family Hx of DM or Gestational DM, Hx of macrosomia, PCOS,
Glycosuria.
▪ Insulin requirements
• ↑ in last trimester
• ↓ immediately after delivery
▪ Fetal hypoglycemia
• should be checked @ 4 hrs after delivery or after second feeding,
whatever comes first
o International travel/ flight
▪ after 28 wks – Better to avoid
▪ after 36 wks – Prohibited
o Pregnancy + cardiac disease
▪ never give ergometrine
▪ don’t put in lithotomy position
▪ watch for fluid balance
o VSD in pregnancy
▪ if only VSD – can go for vaginal delivery
▪ if VSD + transverse lie – C-section
o ≥ 42 wks (41 wks + 6 days) = Postdated pregnancy
▪ Induction and C/S then
• U/S – check amniotic fluid index – N > 5
• CTG – if CTG abnormal, do pH test (fetal scalp)
▪ Meconium stained indicates fetal distress
• We have to do CTG before Dx of fetal distress
• pH < 7.2 = fetal hypoxia
- have to check cord prolapse too
o after ROM – check for cord prolapse
o C/S in
▪ Breech presentation
▪ Fetal distress
▪ Labour progress is slow
Labour:
Contractions:
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< 30 weeks: small localized contractions every 1 min + higher amplitude contraction every 30-30 min
after 30 weeks: more intense (Braxton Hicks contractions)
after 36 weeks: increasing progressively until labour starts
labour starts: 1 contraction every 10 min, lasts 20 sec
late labour: 2-4 contractions every 10 min (1 every 2-4 min), last 40-90 sec
contractions still occur for 48 hrs after delivery with decreased frequency
Cervix dilatation:
anytime after 34 weeks, but usually later (especially in primigravida)
dilatation of min. 1 cm/h during labor
Onset of labour: dilatation of cervix more than 2 cm + painful contractions at least every 10 min with
increasing frequency
Duration of labor: 6 (multipara) – 9 (nullipara) hrs (90% within 12 – multiparae to 16 – nulliparae – hrs)
Stage I – till complete cervical dilatation (10 cm); only passive uterine contractions
- has a:
o passive phase
o active phase – from cervix dilated 3-4 cm to fully dilated; cervix dilates faster,
contractions become more painful
Stage II – till birth: passive uterine contractions + active abdominal contractions
- if it lasts more than 2 hrs -> vacuum extraction or forceps
Stage III: placenta expulsion: 15-30 min after birth of baby. Wait 2-3 min after birth before clamping the
umbilical cord
- Labour
o epidural – up to 7 cm dilatation
o monitoring of fetal well being
▪ uncomplicated labor – intermittent auscultation (stethoscope with Doppler)
▪ complication - CTG
o There are 3 signs of onset of labor:
▪ A bloody show
• passage of a small amount of blood or blood-tinged mucus through
vagina near the end of pregnancy
• It can occur just before labor or in early labor as the cervix changes
shape, freeing mucus and blood that occupied the cervical glands or
cervical OS
▪ Rupture of membranes (waters breaking)
▪ Onset of contractions
o 1st stage
116
▪starts when
• cervix is at least 2 cm dilated
• contr. become painful and regular, at progressively shorter intervals (3-
5 min), and lasting > 1 min
▪ Duration
• average 8.25 hrs in nulliparae, 5.5 hrs in multipare
▪ Phases
• a. latent: onset -> 4 cm dilat.
• b. active: 4 cm -> 10 cm dilat.
- 1 cm/ hr dilatation
▪ Pulse, temp., BP every 2 hrs
▪ monitor contr.
▪ monitor FHR every 15 min
▪ PV exam every 4 hrs
• if ROM – check for cord prolapse
▪ every woman should receive Syntometrine (ergometrine + oxytocin), to
• promote contr.
• minimize bleeding (16 x less)
nd
o 2 stage – begins when cervix is fully dilated
▪ duration
• < 45 min – multiparous (average 15 min)
• < 2 hrs – nulliparous (average 1 hr)
• > 2 hrs – can be:
- 1. Obstructed labor - very low chance woman will deliver
naturally
▪ if on epidural (no urge to push) we can wait up to 3 hrs
▪ causes:
• Pelvic swellings: Ovarian tumors, fibroids,
ectopic pelvic kidney, very distended urinary
bladder
o (not cystocele or rectocele – are soft,
can easily be pushed out of the way)
• Cephalopelvic disproportion
• Large baby: DM, hydrops fetalis, etc.
• Postterm pregnancy
▪ MCQ: MC finding = 4 cm of head is palpable in abd.,
although bony head is at ischial spines on pelvic
assessment.
▪ Rx
• if good contr. -> assisted delivery
o Forceps
▪ more traumatic for mother not
for baby
▪ ↑in vaginal tears
▪ ↑need for episiotomy
o Vacuum extraction
▪ more traumatic for baby
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▪
118
Erb's Palsy - Paralysis of arm caused by injury to upper group of arm's main nerves,
specifically if upper trunk C5-C6 is severed - loss of sensation in arm, paralysis and atrophy of
deltoid, biceps & brachialis muscles. Position of limb under such condition is characteristic:
arm hangs by side and is rotated medially; forearm is extended and pronated. Arm can’t be
raised from side. All power of flexion of elbow is lost as is also supination of forearm.
Resulting biceps damage is main cause of this classic physical position commonly called
"waiter's tip." Risk factors – breech presentation, shoulder dystocia
▪
- 2. Inefficient or incoordinated labor
Feature on PV examination Obstructed labor Inefficient/ incoordinate labor
Moulding of fetal head ++ Usually none
Caput formation on fetal head ++ ±
Cervical oedema Anterior lip oedema Usually none
Fetal tachycardia ++ and progressive +
Station of fetal head – relation Just at or above ischial Can be above or below ischial
of lowest part to ischial spines spines spines
Amount of head palpable above > 2 finger breadths Usually < 1 finger breadth
pelvic brim when lower point of (most important feature)
head is at ischial spines
▪ monitor FHR every 5 min
• if FHR falls < 100 + for > 2 min => PV (cord prolapse?)
▪ monitor contr. – normal: 60-90 seconds every 2-4 min
• if not good give oxytocin
o 3rd stage:
▪ duration
• 15 min in both nullipara and multipara (90%)
• If placenta still not delivered after 15 min
- encourage contraction by rubbing uterine fundus
- no effect => manual removal
▪ MC SE = Uterine inversion
o total duration of labor:
▪ 9.5 hrs in nullipara
▪ 6 hrs in multipara
o Cardinal movements of labor:
▪ engagement
▪ descent
▪ flexion
• first 3 occur simultaneously
▪ internal rotation
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▪ extension
▪ external rotation
▪ expulsion
o sign of progress of labor
▪ incr. strength, duration and frequency of uterine contraction
▪ descent of fetal head into pelvis
▪ rotation of fetal head (occipito-transverse to occipito-anterior) on abd.
palpation
▪ best sign of progress – progressive increase in cervical dilatation (1cm/hr)
• with effacement (shortening) of the cervix
▪ rotation of fetal head (occipito-transverse to occipito-anterior) on pelvic exam.
▪ descent of head within and through the pelvis
▪ above spines -> spines level -> below spines -> coccyx -> vulva
- Induction of labor
o indic.
▪ Prolonged pregnancy > 42 weeks
▪ Hypertensive disorders in pregnancy
• Pregn. induced HTN
• Pre-eclampsia
• Eclampsia
▪ PROM
▪ Intrauterine fetal death (IUD)
▪ IUGR
▪ Antepartum hemor.
▪ Isoimunisation
• ABO incompat.
• Rh incompat.---Hydrops fetalis
o CI
▪
absolute
• Cephalopelvic disproportion
• Placenta praevia
• Vasa praevia
• Fetal distress
• previous classical C-section (not low segmental)
• invasive cervical CA
• cord presentation
• some abnormal presentations
- Breech pres.
▪ complete – ok (bent knee)
▪ frank – ok (knee extended)
▪ incomplete – NOT OK (with feet down)
o when to start: when cervix is ready/ favorable -> assesed with Bishop score
▪ 1. Cervix dilatation
▪ 2. Cervix length
▪ 3. Cervix consistency
▪ 4. Cervix position
▪ 5. Head station (in raport to ischial spines)
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0 1 2 3
Dilatation (cm) <1 2 3 >4
Length (cm) >4 3 2 <1
Consistency Firm Mild Soft
Position Post. Ant. Central
Head station -3 -2 -1 >0
▪ score 0-4 – cervix not ready for induction (very high risk to fail induction)
▪ score at least 5 to start induction (with amniotomy)
o Procedure:
▪ start with intravaginal PG gel
• PG E2 – Dynoprostone – for alive baby
• PG F2 alpha – Dynoprost
- indic.
▪ dead fetus
▪ missed abortion
▪ termination of pregnancy
▪ evac. of hydatidiform mole
▪ wait until cervix will be ready (if no fetal distress) with Bishop score ≥ 5
▪ then do amniotomy
• SE
- cord prolapse
- inf.
▪ after amniotomy, deliver within 5-8 hrs
▪ after amniotomy, use oxytocin infusion (drips) to promote contr.
▪ then proceed with normal delivery
Preterm premature rupture of membranes: rupture of membranes before 37 wks
Premature rupture of membranes: rupture of membranes after 37 wks without onset of labor.
Position of baby: important after 28 wks
Lie:
- longitudinal (99%)
- cephalic – 95%
- breech – 4%
- oblique
- transversal
Presentation:
- Cephalic – 95%
- Vertex – head flexed, occiput leads
- Face - head extended, face leads
- Brow – head slightly extended (between vertex and face)
- Breech (buttocks down) – 3.5%
- Shoulder – 0.5%
- Malpresentations
o Breech presentation
▪ 15% at 30 weeks, but only 3% at birth
▪ ↑ risk for fetus
- due to
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▪ intracranial hemor.
▪ asphyxia
▪ fractues of humerus, femur or clavicle
- preterm and late post term babies – mortality 12%
- term babies – mortality 1%
▪ Types
- with extended legs (frank) – 65-70%
- with flexed legs (complete)- NVD can be attempted
- footling (incomplete) – one foot comes first (rare)
▪ Rx
▪ if still breech pres. at 37 wks, attempt cephalic version - easier if the baby has
flexed legs
• Ext. cephalic version @ 36 wks or end of 37 week + tocolytic
▪ CI
• Cephalopelvic disproportion
• Placenta praevia
• Multiple pregnancies
• Antepartum bleeding
• Hx of uterine scar, HTN, bad obstetric Hx
• PE
• Hx of unstable lie
• Small for date baby
▪ absolute indic.
• shoulder presentation
• face presentation
• Risk of cord prolapse: first do PV to exclude cord prolapse
- Rx
▪ if the cord is still puslating, push the presenting part
and cord as far in as possible (MCQ).
▪ place mother in knee – chest position
▪ urgent delivery
• C-section – preferred
• Vaginal delivery with forceps or vacuum
extraction avoiding cord pressure
- C-section – preferred, with decr. perinatal mortality (from 1.15% to 0.6%)
- normal delivery can also be used
• baby with normal size
• complete breech or extended legs
• eyebrow presentation
• head flexed
• CPD excluded
• labor onset spontaneously
• e.g. if unexpected breech presentation with full cervical dilatation with
insufic. time to organize a C-section
o Transverse or oblique presentation
▪ may convert to a longitudinal one later on
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▪ Dx – 1st - U/S to rule out placenta previa (this is what might be causing the baby
to have this presentation, prevents him from having a cephalic presentation)
▪ Mx
- at 36 weeks – Cephalic version
- > 36 weeks: wait for normal labor
▪ if beyond 37 wks (term) best Mx is C-Section
- Malpositions
o types
▪ Occipito-posterior – MC
• 11 cm (vs. 9.5 for normal position)
• assoc. with poor quality uterine contraction
- if this is excluded – Cephalopelvic disproportion
• incoordinate uterine action -> ↑ intrauterine pressure -> incr. fetal
distress (MCQ).
- CTG is recommended for monitoring
- even more common when oxytocin and epidural were used
▪ in this case CTG is mandatory
• slow labor
- Rx
▪ labor can be stimulated with
• amniotomy
• oxytocin
▪ epidural is often necessary
▪ C-section may be necessary in case of obstructed
labour or fetal distress
▪ occipito-transverse
▪ (occipito-ant. = N)
▪ face
▪ brow
o Rx
▪ if no other problems – vaginal delivery in most of them (especially in occipito-
post. and occipito-transverse)
• exception: Face – vaginal delivery may be impossible => C-section
▪ C-section – in prolonged labor with maternal exhaustion, obstructed labor, CPD,
fetal distress, selected primigravida, face and brow (only in nulliparous not
multiparous) presentation .
Post partum depression occurs in 30% of women in first 6-12months postpartum
Post partum Blues occur during first 2 weeks after delivery.
- Anesthesia
o Epidural:
▪ Anaesthetist conducting an epidural places catheter in the mid-lumbar, or lower
back region of spine.
▪ In adults, spinal cord terminates around the level of disc between L1 and L2 (in
neonates it extends to L3 but can reach as low as L4), below which lies a bundle
of nerves known as cauda equina ("horse's tail"). Hence, lumbar epidurals carry
a very low risk of injuring the spinal cord.
123
o at 1 and 5 min
0 1 2
Appearance/ color Absolutely blue Centrally pink, Pink
peripherally blue
Pulse/ heart rate Absent < 100 > 100
Grimace/ response to No response Some facial grimace Cries
stimulation (place
suction catheter in
nose of child)
Activity/ muscle tone Floppy, flaccid & Some flexion Good active
hypotonic limbs movement
Respiration effort Absent Gasping, irregular & slow Normal good crying
▪ Good > 7
▪ How ready is this child =
• heart rate
• resp. effort
• irritability
• tone
• colour
▪ low score at 1 and 5 min => child needs resuscitation
▪ causes
• significant hypoxia
• perinatal asphyxia
Apgar score
The test is generally done at 1 and 5 min after birth and may be repeated later if score is and
remains low.
- Scores 3 and below are generally regarded as critically low.
- 4 to 6 fairly low
- 7 to 10 generally normal.
A low score @ 1min indicates neonate requires medical attention[3] but is not necessarily an
indication that there will be long-term problems, particularly if there is an improvement @
5min. If Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, there is a risk
that child will suffer longer-term neurological damage.
Gynecology - OK
Breast pathology
- Mastalgia:
o 30-50 yrs (MC 35-45 yrs)
o Causes:
▪ MC – Cyclical mastalgia
▪ Pregnancy
▪ Caffeine
▪ Breast CA
• risk is < 10%
• e.g. mastitis carcinomatosa – red and hot breast, during lactation
▪ Fibroadenoma
▪ Mastitis
125
▪ Drugs
• OCP
• HRT – Diffuse bilateral pain
- Rx – ↓ estrogen dose
• Theophylline
o Types
▪ diffuse, bilateral and cyclical = Cyclical mastalgia
• 30-50 (35) yrs
• hormonal basis
• causes
- MC = benign mammary dysplasia (fibroadenosis, chronic
mastitis, cystic hyperplasia, fibrocystic breast dis.)
▪ 30-50 yrs
▪ Dx
• mammogram – if diffuse lumpiness > 40 yrs
o shows calcifications
• U/S
• biopsy
▪ Mx
• large cysts - aspiration
• Sx
- pain in breasts (mid-cycle till end of period) & feeling of lumpy
breasts
▪ pain extend down inner aspect of upper arm
- possible - straw-like or green grey discharge from the nipple
- breasts diffusely nodular or lumpy
• Rx – Murtagh 969
- Mild
▪ reassurance
• rule out fear of CA in patient
▪ analgesic (paracetamol)
▪ lifestyle advice
• low fat, eliminate caffeine
• wear good quality, comfortable bra
• lose weight
- Moderate
▪ Mefenamic acid (NSAID - inh. of PG synthesis)
▪ add Vit B1, Vit B6
▪ (Primrose oil – contains an essential fatty acid - Awad)
- No response
▪ Danazol (progestogen = modified testosterone –
inhibits ovarian synthesis of estrogen)
▪ norethisterone – progestogen
▪ Diffuse, bilat. non-cyclical mastalgia
• poorly understood
• causes (may be)
- duct ectasis
126
- periductal mastitis
• Rx
- much more difficult to treat
- exclude caffeine & lose weight
- Vit B1, Vit B6
- norethisterone – progestogen
▪ Unilateral difuse non-cyclical
• Mastitis – cellulits of interlobular connective tissue
- in lactating women with
▪ cracked nipple
▪ poor milk drainage
- causes
▪ bact
• MC cause – Staph. aureus (coagulase-positive)
o Rx
▪ Flucloxacilin
▪ Erythromycin
• E. coli
▪ Candida – after A/B
• severe breast pain (hot knife, hot shooting
pains)
- Sx
▪ a sore lump at first
• then red tender area
▪ fever
- Cx – Breast abscess
▪ if persisting > 48 hrs + area of tense induration
develops
▪ Rx
• surgical drainage (under GA) or aspiration with
a large bore needle (under LA)
• A/B
- Rx
▪ Breast feeding should continue from both sides (milk
production not affected)
• empty the breast well
▪ flucloxacilin
• or cephalexin
▪ for candida – fluconazole
• or nystatin
▪ localised
• Costochondritis (Tietze’s syndrome)
- constochondral junction becomes strained in persistent cough
- palpable swelling about 4 cm from sternal edge (enlargement of
costochondral cartilage)
- initiated or aggravated by deep breathing and coughing
- Self-limiting – may take a few mths
127
o Carcinoma – 22%
o Cysts – 10%
▪ 40-50 yrs, painful solid lumps.
▪ associated with mammary dysplasia
▪ regress after menopause
▪ Dx
• for breast cyst – 1st test is always U/S!
• mammography
• FNAC
▪ MCQ: 45 yrs, painful solid lump in the breast – breast cyst (tense)
• rapid growth – pain
o Breast abscess - 2%
o Duct ectasia
▪ Looks like CA
▪ A whole breast quadrant is indurated and tender
▪ Green toothpaste-like nipple discharge
▪ Dx – widespread linear and globular calcifications on mammography
▪ Rx - Surgery
o Duct papilloma
▪ Benign-----not premalignant
▪ Bloody discharge
▪ Rx – excision of duct and affected breast segment
o Lactation cyst (Galactocele)
▪ Rx - Aspiration
o Paget’s syndrome of nipple
o Fat necrosis (traumatic)
▪ after large bruise or trauma (e.g. protracted breast feeding)
▪ with skin and nipple retraction
• looks like CA
▪ it usually disappears
▪ Dx – excision biopsy
- Breast CA
o MC CA in women
o Lifetime risk: 1 in 11 women in Aus.
▪ 1 in 11 women will develop CA by age 75 – max around 60 yrs
o 1 in 25 women die of breast CA
o incidence rises with age and incr. in higher socioeconomic class
o Types:
▪ MC - non-invasive: intraductal CA
▪ invasive
• invasive duct CA – 90%
• lobular CA
o risk factors
▪ Sex -100 x MC in women
▪ Caucasian race
• low in Asian countries
▪ Age:
129
• solid lumps
▪ FNAC: 90-95% accuracy – better than mammography
▪ indications for biopsy or excision of lump:
• cyst fluid is blood stained
• lump dn’t dissapear completely with aspiration
• swelling recurs within 1 mth
- unsure/suspicion of CA: core biopsy -> histology (can Dx CA) –
radiologists do this under U/S guidance
▪ FNAC can’t distinguish between CA in situ & invasive!
• core biopsy can do that
▪ tumor markers
• estr. receptors – in 2/3 of breast CA
- good prognostic factor
• progesterone receptors
o Staging
▪ Manchester
• I - Confined to breast
• II - Confined to breast + palpable mobile axillary lymph nodes
• III - Skin changes (fixation, cutaneous ulcers, peau d’orange) + fixed
axillary nodes, supraclavicular nodal involvement
• IV - Distant metastasis
o Rx
▪ workflow (dr. Gaya)
• a. for younger women - wide local excision (quadrantectomy), with a 1
cm margin
- “sentinel node” procedure to detect if first node draining from
the breast (sentinel node) is involved
▪ single most powerful predictor of subsequent
metastases and death = lymph node involvment
▪ radiopharmaceutical injected at nuclear medicine
centre a day before surgery + on the day of surgery we
inject some blue dye close to the nipple:
• we remove sentinel node during surgery, send it
to pathology & check it
o if not affected, we don’t remove lymph
nodes
o if affected, we remove all nodes
(axillary disection)
▪ if more nodes are involved, we
do chemotherapy
- plus Radiotherapy – otherwise 40% chance of recurrence
▪ indications
• tumor > 5 cm
• axillary node involvement > 3 nodes
• positive of close tumor margins
132
▪ COCP
▪ Barrier methods
• condoms
- < 5 pregnancies/ 100 women/ yr
• diaphragms
▪ IUD (can be inserted any time within first 12 days of start of menstrual bleeding)
• with
- copper – affect sperm motility and transport
- progest. (Mirena – with levonorgestrel)
• 96-99% pregnancy protection
• Post-partum
- 6 wks after vaginal delivery
- 12 wks after C-section
• CI
- absolute
▪ pregnancy
▪ active PID
▪ undiagnosed abnormal genital tract bleeding
▪ previous ectopic pregnancy
▪ severe uterine cavity distortion
- in nulliparous women?
▪ Cx
• risk of infection
• bleeding
• Side Effects:
- risk of ectopic pregnancy 10x > than with COC
- if pregnancy occurs, 40-50% risk of abortion or intraut. sepsis in
2nd trimester
- incr. risk of PID in 1st 30 days after insertion -> prophylactic
doxycycline (especially if having multiple sexual partners)
- extrusion, perforation and translocation of uterus
- may incr. bleeding for 2-3 mths, then disappears
▪ if it persists, remove IUD
▪ – Mirena reduces or stops bleeding
- lower abd. cramp-like pains
▪ Spermicidal agents
• adjuvants
• when used alone < 10 pregnancies per 100 women/ yrs
▪ Rhythm
• coitus interruptus
• calendar method
- facts
▪ ovulation occurs always 14 days before her period
(luteal phase is always 14 days)
▪ sperm survival is up to 6 days
▪ ovulated egg can be fertilized during 24-36 hrs following
ovulation
135
- method
▪ keep track of length of cycles: e.g. between 26-29 days
=> ovulation between day 12-15
▪ safe periods -
• up to 12-6 (how much sperm survives) =1st 6dys
• after day 15 + 2 (how much time ovum can be
fertilized) = day 17
• unsafe from day 6 to 17
• Basal body temp.
- 2-3 days after ovulation, body temp.↑0.3o C for the rest of cycle
(over temp. of previous 6 days) -> safe from 2 dys after rise of
temp. (4-5 dys after ovulation) until next period.
- + calendar method for safe period at the beginning of her cycle
• Billing method
- fertile mucus – clear, watery, stringy, incr. in amount, feels
lubricative
▪ on ovulation – highest secretion
• ovum survives for 2 days + 1-2 days extra for
safety => safe = 4 days after maximal mucus
secretion (spinbarkiet phenomenon)
(ovulation) MCQ
▪ then abrupt change to non fertile mucus
- not fertile mucus – more whitish, thick, sticky
- failure rate: 1-2 (average 3) / 100 women/ yrs
• Lactational amenorrhoea - Awad
- during breastfeeding
- < 1% risk of pregnancy (90% safety – Awad)
- conditions
▪ exclusive breastfeeding
▪ < 6 months
▪ mother didn’t get her period yet
▪ + Progest. Only Pill (POP) (main action is thickening of cervical mucus)
• mini-pill
- not as efficacious as OCP bc it doesn’t inhibit ovulation (but
almost same) and are taken regularly for 28 days of cycle (no
inactive pills).
- pregnancy rate 3/ 100 women/ yr
- contains
▪ lovenorgestrel 30 µgms/ day
▪ norethisterone
- Side Effects (only few)
▪ cycle irregularity (oligomenorrhea, irregular bleeding
or amenorrhea) and weight gain
• reduces cycle to < 25 days
- Indications
▪ > 45 yrs
▪ smokers > 35 yrs
136
- Essure procedure
▪ introduction of microinsert in tubes-> occulsion of tubes
▪ + Yasmin contraceptive pills (Awad)
• can also help for wt. loss
• decr. fluid retention
• decr. acne formation, decr. greasy skin
- Post-partum contraception
o C.I. - OCPs or NUVA ring – combined estr. or prog. (estr. would suppress lactation)
o can give any progesteron
- Combined Oral Contraceptive Pills: (act on hypothalamus MCQ)
o inhibits hypothalamic and pitutary function => Anovulation
o risk of pregnancy: 1-3 ideally (2-6 in practice)/ 100 women/yr
o OCP – safe to be used for 10 yrs, up to the age of 50 yrs
o contain
▪ estr – MC ethinyl estradiol (20-30ug)
▪ prog.– MC levonorgestrel
o types
▪ microgynon 30 – first line
▪ microgynon 50 – indic:
• in epileptics and other enzyme inductors
• if with microgynon 30 she has breakthrough bleeding that doesn’t
resolve in time
• for control of menorrhagia
• failure of microgynon 30
o Woman > 35 yrs
▪ smoker -> mini-pill (POP)
▪ non-smoker -> mono-phasic OCPs
o Advantages
▪ effective Rx for most menstrual cycle disorders
• primary dysmenorrhoea & menorrhagia
▪ ↓ Fe-deficiency anemia
▪ ↓ benign breast dis.
▪ ↓ Ovarian cysts
▪ 50% ↓ in PID
▪ ↓incidence of ovarian, endometrial and colorectal CA.
• does NOT protect from cervical CA (slightly ↑ probably due to ↑ sexual
activity)
▪ + decr. sebacous disorders
▪ + decr. thyroid disorders
▪ + decr. endometriosis, fibroids?
o SE
▪ Thromboembolic dis.
• Venous:
- DVT
▪ PE
- rarely mesenteric, hepatic and kidney thrombosis
• Arterial:
138
- MI
- stroke
▪ thrombotic
▪ hemorrhagic
- rarely retinal and mesenteric thrombosis
▪ CAs
• possible incr. In
- Cervical CA {Breast CA minimal (has no effect latest research
shows)}
• protective in
- endometrial, ovarian and colorectal CA
▪ OCP are not recommended with any antihypertensives. Condoms can be used.
▪ Migraine – Rx: discontinue COC and give POP
▪ depression – Rx: decr. or change the progest.
▪ Acne – Rx: ↑ estr. dose (estr. will clean acne)
▪ Breast feeding, DM and smoking >35 yrs: POP
▪ Chloasma – Rx: POP
▪ Amenorrhoea – Rx: incr. estr. and decr. progest.
▪ PCOS: An OCP containing ethinyl estrsadiol + cyproterone acetate
▪ Excessive fluid retention: ethinyl estrsadiol + drospirenone
▪ Dysmenorrhoea or menorrhagia – Rx: increase progest.
▪ Breakthrough bleeding
• 20% at beginning
• 3% after 3-6 mths
- Rx - keep using OCPs at same day, every day at same time
▪ if persists after 3 mths, ↑ dose or change to different
type
• early to mid cycle bleeding – ↑ estr. –
Microgynon 50
• late cycle – incr. prog. or change type
▪ Breast problems
• fullness/ tenderness: decr. estr.
• mastalgia: decr. progest.
▪ Libido loss: incr. estr.
▪ Weight gain
• constant – decr. or change progest.
• cyclic – decr. estr.
▪ nausea, vomiting – decr./change/stop estrogen
▪ post-pill amenorrhoea
▪ delayed onset of ovulation after stopping OCPs (Usually periods resumes 2–3 days
after stopping tablets).
• 50% - after 2 weeks
• 90% - after 6 weeks
• 1% - hasn’t occurred after 12 mths
▪ HTN? (blue book 3.201)
• stop OCP, use a different contraception method & reassess in 3 months
- HT will usually settle
139
o Special interactions:
▪ warfarin and oral hypoglycemics doses have to be adjusted
• if using warfarin – STOP OCPs (warfarin is more important)?
▪ High doses of Vit. C, griseofulvin, rifampicin, anticonvulsants (except Sod.
valproate) interact with COCs. Phenobarbitone, phenytoin, primidone,
carbamazepine, oxacarbezepine, topiramate all are enzyme inducing anti-
epileptics. If we have to use these drugs along with hormonal contraceptive
methods either ↑ dose of estrogen in pill or use mirena or barrier method.
▪ Following anti-epileptic drugs are non inducers and don’t effect efficacy of
hormonal contraceptives. Valproic acid, gabapentin, levetricetam , pregabalin,
vogabatrin.
▪ if using A/B or if vomiting/ diarrhea: they might inh. the effect of OCPs -> use
another contraceptive method beside OCPs (condoms)
o Contraindications:
▪ Absolute – Murtagh 961
• 1
- Pregnancy
- First 2 wks post-partum/ post abortion – there’s still bleeding
happening and OCPs would increase risk of clots, thrombosis
• 2
- Thrombembolic Hx
▪ DVT
▪ PE
▪ Thrombophilia
- Coronary artery disease
- Cerebrovascular history
- Migraine
• 3 Estrogen dependant tumors
- Breast
- Cervix
- Ovarian
- Uterus
• 4
- Active liver diseases
- Polycythemia vera
▪ Relative
• heavy smoking/ smoker > 35 yrs old (prescribe POP)
• diagnosed abnormal vaginal bleeding
• HTN
• DM
• hyperlipidemia
• long term immobilisation
• complicated valvular heart disease
• breast feeding – mini-pill (progest)
• 4 wks before surgery and 2 wks after
• gall blader or liver dis.
• Chloasma (prescribe POP)
140
• cardiac disease
o Protective for:
▪ Bowel CA but not for ovarian CA
▪ Cardiac dis.
▪ Alzhimer dis.
• if given from time of menopause
- decline in cognitive fc. (= early manifestation of Alzhimer)
- BUT
▪ doesn’t decr. the rate of progression of Alzheimer
▪ doesn’t make advanced Alzhimer less severe
• if started at 60-65 yrs, incidence of Alzheimer is ↑
o SE
▪ Premenstrual syndrome
▪ Nausea and breast disorders
▪ Bleeding problems
• ↑ risk of Breast CA
• after 5 yrs of combined estrogen + progesteron
• after 7.2 yrs of estrogen only
▪ ↑risk of stroke!
o CI
▪ estr.-dep. CAs (Estrogen containing HRT is CI in Breast CA)
• Breast CA
- Rx just Biphosphonates to prevent osteoporosis
• Endometrial CA
▪ recurrent thrombembolism
▪ Hx of coronary artery disease
▪ uncontrolled HT
▪ undiagnosed vaginal bleeding
▪ active liver disease
▪ active SLE
▪ otosclerosis
▪ acute intermittent porphyria
▪ smoking?
o Rx
▪ with uterus present, no CI
• first 2 yrs after LMP
- Best choice: Cyclical HRT: Continous daily estr. + cyclical
progest.(MPA) (12 dys/ mth)
▪ need to add progesteron (min. 12 dys/ cycle) to protect
uterus.
▪ usually causes predictable periods, generally
comencing 2 days after progesteron course was
completed.
▪ can cause breakthrough bleeding -> is she can’t tolerate
it -> continuous estr. + progest.
• 2 yrs after LMP – Continuous HRT: continuous estr. + progest (MPA).
143
•other SERMs
- Tamoxifen
- Clomiphene
▪ Calcitriol = Vit. D metabolite
• if using this, don’t use Ca
▪ Good dietary intake of Ca
• 800 mg/ day premenopause
• 1000 - 1500 mg/day postmenopause
- 1.5 glass of milk = 1.5 g Ca = enough/ day in osteoporosis (Calin)
• Ca supplementation is poorly absorbed after menopause => inefficient in
preventing bone loss, even when combined with vit. D, unless estrogen
suplementation is given. Ca citrate is better absorbed than carbonate.
o Prevention:
▪ Menopause – patches of HRT, for 2-3 yrs
▪ increased dietary intake of Ca
▪ incr. exercise
▪ decr. smoking, alcohol, coffee
▪ monitor with regular bone density scans
Amenorrhoea
- Primary amenorrhoea
o types
▪ Sexually infantile
• Short stature and non functioning ovaries (streak gonads)
- Turner syndrome – 45X0
▪ gonadal dysfunc. – infertility, lack of breast develop.
▪ Non functioning ovaries, uterus and vagina normal
▪ web neck (cystic hygroma)
▪ wide carrying angle, widely spaced nipples
▪ low ear insertion & low hairline
▪ vision and hearing problems
▪ lymphedema, chromatin negative buccal smear
▪ coarctation of aorta, bicuspid aortic valve
▪ horseshoe kidney
- hypothyroidism
• Normal stature
- Kalman Syndrome – hypothalamo-hypogonadism
▪ deficit of GnRH => lack of FSH and LH
▪ anosmia, hyposmia
▪ optic problems: color blindness or optic atrophy
▪ cleft palate
- true gonadal agenesis
▪ Masculinized
• Congenital adrenal hyperplasia
- 95% due to 21-hydroxylase defic. - AR
▪ normal male genitalia , ambiguous female genitalia /
enlarged clitoris
▪ baby vomits, decr. Na, K incr. – salt-wasting
146
PCOS
PCOS POF Ovarian resistant syndr. Menopause
FSH slightly ↑ or normal Very incr. Incr. Incr.
LH Very incr. Very incr. Incr. Increase
(LH:FSH = 2:1/3:1)
Estr. N Decr. Incr. Decr.
Testosterone Incr.-->
(free, DHEA) Hirsutism
U/S > 10 cysts <10 cysts 3-4 cysts
o Sx
▪ irreg. cycles (anovulatory), oligo- or amenorrhoea, infertility
▪ obesity
▪ hirsutism, acne
▪ ± DM
o MC cause of anovulatory infertility
o causes
▪ insulin resistance
▪ incr. androgens (LH and FSH)
o risk of endometrial hyperplasia -> endomet. CA (unopposed estrogen)
o Dx.
▪ Very high LH (LH > FSH, LH:FSH = 2:1/3:1) – normally FSH > LH
148
▪ estr. N
▪ ↑ Androstendione (testosterone)
▪ ± insulin incr., blood sugar level incr.
▪ sex hormone binding globulin decr.
▪ transvaginal U/S
• if thickness > 5 mm
- hysteroscopy + biopsy
• if thickness < 5 mm – CA very unlikely
▪ Rostterdam Dx criteria – at least 2 of the following:
• 1. Oligo- or amenorrhoea
• 2. Signs of hyperandrogenism:
- Clinical: Acne, hirsutism, deepening of voice, clitoromegaly
- Labs.: ↑ Testosterone & DHEA
• 3. U/S ≥ 10 (12) cysts in any of ovaries or both (at the periphery)
o Rx
▪ lifestyle modification
▪ Metformin – Best Rx
▪ OCP
• ↓ Cyst formation, acne & testosterone
▪ for hirsutism
• wax
• laser
▪ wants to get pregnant: metformin and clomiphene have equal efficacy, but:
• BMI > 25 – Metformin
• BMI normal – Clomiphene
• Blue book p. 527 says:
- 1. Metformin &
- 2. Clomiphene but both are equally effective
- 3. Laparoscopic ovarian drilling, IVF, gonadotrophin therapy –
when 1. and 2. have failed
▪ PCOS with normal prolactin:
• Rx – Clomiphene citrate
- SERM
- stimulates pituitary gland to produce more (mainly FSH) & LH =>
ovulation and superovulation
- effects
▪ Excessive estrogen
• fluid retention, breast enlargement
• hot flushes (vasomotor sympt.)
o cold and warm feeling on face, neck
and upper thorax
• dev. of more than 1 follicle and release of
more than 1 ovum => multiple pregnancy (5-
10% risk)
• inadequate ovulation (corpus luteum dysfc.)
• enlarged ovaries with multiple cysts, pain and
↑risk of torsion
149
• Physiological - DUB
- ovulatory (regular cycle)
- anovulatory cycles (irregular cycle)
▪ MCQ: MC cause of menorrhagia (irregular cycles)
suddenly occuring in a 45 yrs old woman, previously
OK (disorder of ovulation)
▪ Iatrogenic
• hormonal – HRT
• non-hormonal – IUD
• anticoagulants
- Uterine fibroids: (Regular cycle + enlarged uterus)
o encapsulated uterine smooth muscle fiber tumors (leiomyoma – pl. is leiomyomata)
o types
▪ intramural - MC
▪ submucosal (in muscle beneath the endometrium) – MC to cause menorrahgia
▪ subserosal (underneath the peritoneal surface of uterus)
▪ intrauterine – pedunculated causes continuous bleeding
o Estrpgen dependat decrease by menopause
o in fertile women, especially in obese women
o Sx
▪ totally asympt or
▪ menorrhagia
▪ dysmenorrhea, pelvic discomfort (if big)
▪ dysuria, constipation, back pain
▪ if pedunculated – torsion
▪ infertility
▪ calcification
▪ in pregnancy
• red degeneration of fibroid
- mostly in 2nd trimester of pregnancy
- low grade fever, severe abd. pain, local tenderness, guarding
- but no shock (no blood loss)
- Dx diff. with
▪ torsion of ovarian cyst
▪ placental abruption
▪ appendicitis (if right sided)
• effects of pregnancy on fibroid:
- incr. in size
- softens
• effects of fibroid on baby:
- incr. risk of miscarriage
- premature labor
- malposition
- post-partum hemorrhage – lack of contraction
- may prevent vaginal labour (if big and located near internal OS)
o Dx
▪ U/S
151
o types:
▪ extension of squamous CA spread from cervix - MC
▪ metastatic adenoCA from endometrium
▪ primary invasive squamous cell CA of vagina
▪ clear cell CA following diethylstilbestrol Rx
▪ CA of the urethra, Bartholin gland, Gartner duct
- Cyclical (recurrent) vulvitis
o MC cause – Candida
o exacerbates premenstrually
o Sx – chronic vulvar itch, burning, swelling, dyspareunia, aggravated with systemic A/C
▪ with or without discharge
o Dx
▪ low vaginal swab
o Rx
▪ topical antifungal: Imidazole, Nystatin
▪ oral antifungal: Ketokonazol, fluconazol, itroconazole
▪ severe itching – C/S
▪ Pregnancy – Nystatin pessaries
- Sebaceous cysts – in labia majora
Endometriosis & adenomyosis
- Endometriosis
o 10% incidence.
o Ectopically loca ted endometrial tissue responds to sex hormones.
▪ locations:
• MC - ovary (60%), uterosacral ligament (60%)
• 28% - cul de sac of Douglas
• 15% - broad ligament
• 15% - bladder
• 12% - rectum
• 7% - sigmoid colon
• 5% - round ligament
• 2% - appendix
o Puberty to menopause: Peak 25-35 yrs.
o MC in nulliparous women and resolves with pregnancy
o CLINICAL FEATURES:
▪ most patients are asymptomatic
• Dx made when a laparoscopy is done to investigate infertility
▪ pain
• Secondary dysmenorrhoea.
- painful period
- pain usually starts before period and continues through the
period, then ↓
• Acute pain with rupture of endometrioma.
• Dyspareunia
• Non-specific pelvic pain or dyscomfort, low back pain
• pain at urination and or defecation
▪ abnormal bleeding
161
• Menorrhagia
• Premenstrual spotting
• irregular spotting
▪ Infertility
▪ diarrhoea/ constipation, bloating
▪ (almost) never undergoes malignant change
o DIAGNOSIS:
• The most suggestive sign is tenderness, mass or nodularity in the pouch
of Douglas or uterosacral ligaments. MCQ
• cervical excitation (motion tenderness)
▪ 1st exam. – U/S
• rule out: ovarian cysts, fibroids, etc.
▪ Gold stand. of Dx: direct visual inspection at laparoscopy or laparotomy
o Rx
▪ Analgesics.
▪ MEDICAL:
• 1. OCP: once daily for 6 mnths
• 2. Progestogens
• 3. GnRH analogues (treatment of choice)
• 4. Danazol
▪ SURGICAL:
• indic
- if medical Rx fails
- causing infertility
- if significant impact on patient’s life
• Laser or microsurgery
- removal of tissue
- endometrial ablation or electrodiathermy excision
- hysterectomy
- Adenomyosis:
o invasion of the myometrum by the basal endometrium of the uterine cav., with ectopic
glandular tissue (adenomyotic glands) found in the muscle
o 35-50 yrs
o not MC in nulliparous (diff. from endometriosis)
o Sx
▪ dysmenorrhoea
▪ menorrhagia
▪ dyspareunia
▪ slightly enlarged (bulky) and tender uterus
o Dx
▪ D&C not helpful
▪ core biopsy of myometrum
▪ removed uterine specimen (after hysterectomy)
o Rx
▪ if severe sympt. -> hysterectomy (adenomyotic glands repond poorly to
hormonal suppression)
162
▪ color Doppler
o Rx
▪ laparotomy and surgical correction
- Ovarian CA – M 998
o often Dx late (not many Sx), usually an incidental finding
o > 45 yrs, peak 60-65 yrs
o risk factors
▪ nulliparity
▪ age
▪ family Hx
▪ hereditary breast - ovarian CA syndrome – BRCA1, BRCA2
o protective factors
▪ pregnancies
▪ OCP (they suppress/ shut down ovaries)
o Sx
▪ non-specific: lower abd. pain or discomfort, bloating, constipation, pelvic
heaviness, urine frequency, dysuria, vaginal bleeding, menstr. dysfc.
(dyspareunia, dysmenorrhoea)
▪ ascites
▪ adnexal mass on physical or bi-manual exam.
• any ovarian enlargement detected after menopause must be
considered malignant until proven otherwise!
• large adnexal mass developed in a postmenopausal woman – e.g. 60
yrs (+vaginal bleeding) – MC cause = Ovarian CA (Ovarian cysts or
benign tumors are unusual at this age)
o Dx
▪ 1. Pelvic Doppler U/S
▪ No FNAC – risk of spreading the CA!
▪ 2. tumor markers:
• CA-125 – most specific
- (still not very specific) also ↑ in follicular cyst & endometriosis
• AFP
• Beta HCG
• CEA
o Dx and Sx
▪ 3. urgent referal to gynecologist: excision (Oophorectomy)
- CA metastases in ovaries (blue book p. 531) – only 5% of the CA in the ovaries
o in Aus. MC from colon CA -----Colonoscopy is advised for screening
o in underdev. countries – MC from breast CA
o in Japan (with a very high incidence of stomach CA) – MC from stomach CA (Krukenburg
tumor in both ovaries)
Endometrial CA
o Risk factors
▪ Anovulatory cycles
▪ Old age
▪ Obesity
▪ nulliparity
164
▪ late menopause
▪ DM
▪ PCOS
▪ NOT - smoking
o Dx
▪ U/S
• if thickness > 5 mm
- hysteroscopy + biopsy
• if thickness < 5 mm – CA very unlikely
Cervical CA
o risk factors
▪ all women who were sexually active
▪ higher risk
• Early age at 1st intercourse
• Multiple partners or partner who had multiple partners
• Smoking
• OCP
• Radiotherapy
• Diethylstilbestrol (DES)
• HPV – especially with high risk strains (16, 18)
- 4 of 5 women get HPV after they start sexual life, most clear
infection in 1-2 yrs
- condoms give limited protection from transmitting disease
o Prevention
▪ Vaccine = Gardasil – for types 6, 11, 16, 18
• 6, 11 – anogenital warts
• 16, 18 - cervical cancer
• also prevents some vulval and vaginal cancers
• admin. 0, 1-2 mths, 4-6 mths IM
• Girls – any age (9-26 yrs)
- in school free, then they have to buy it
• Boys – 9-15 yrs, safe but not proven to be effective
• useful until 26 yrs
• not in pregnant women
- always do a pregnancy test first
• S.E. - mild fever, allergy
• useful in existing warts
• after admin., continue with PAP smears as usually
o Screening
▪ PAP smears (cellular level) – every 2 yrs until 70 yrs
• if (LSIL CIN I) -> repeat PAP in 12 mths
- -> if normal -> repeat in 12 mths
▪ -> if normal -> normal screening every 2 yrs
- if LSIL CIN I-> colposcopy + biopsy (tisular level – how deep and
extensive is the lesion)
▪ -> if LSIL -> ablation
165
• cryo
• laser
• sugical
• if HSIL (CIN II or CIN III) -> Colposcopy + biopsy
- if HSIL -> ablation
▪ cryo
▪ laser
▪ sugical
- if invasive -> Cone biopsy
▪ SE
• bleeding
• cervix incompetence
• cervix stenosis
• premature labor in future
• PROM
▪ in Pregnancy – cone biopsy and vaginal delivery are CI
• IF LSIL – follow same 12 months protocol
• If HSIL-- first Colposcopy then
< 20 wks – termination of pregnancy + Rx the CA
> 20 wks – discuss with mother:
o terminate pregnancy
o continue but risk of advanced CA
▪ best to wait till 36 wks, then C-
Section (vaginal delivery is CI)
o Stages
▪ I – limited to cervix
▪ II
• IIa – upper 2/3 of vagina
• IIb – upper 2/3 of vagina + parameters
▪ III – lower vagina
▪ IV
• IVa - bladder and rectum
• IVb – distant metastases
o Rx
▪ I – Cervical conization
▪ II – Radiation + chemotherapy
▪ III, IV – radiation + chemotherapy
Uterovaginal (genital) prolapse
o 50% of parous women
o Risk factors/ causes
▪ multiparity – after long 2nd stage labor
▪ obesity
▪ old women at menopause/ post-menopausal – decr. estr. -> decr. collagen
strenght -> weak vaginal muscles
▪ delivering large baby
▪ smoking
o types:
166
o
▪ vaginal hernia, which occurs when small intestine (small bowel) descends into
lower pelvic cavity and pushes at the top of vagina, creating a bulge.
▪ Enteroceles MC occur in women who have hysterectomy done
▪ Rx – Surgery
- Rectocele:
o
▪ If muscles of posterior wall of vagina are damaged, rectum will begin pressing
into vagina. This is called a rectocele.
167
• FSH, LH
▪ testosterone
o Rx
▪ Inj. with FSH – if sperm analysis isn’t very bad (can improve it)
▪ Regular IVF - if sperm analysis isn’t very bad (5-20 mill/ml)
• if very bad – 2%/ cycle treated success rate
▪ IVF with ICSI – if severe Oilgospermia
• 20% per cycle treated success rate
o MCQ
▪ no fructose = no sperm coming from testicles
▪ 0-3 ml – coming from prostate
- Female infertility
o Dx
▪ Ovulating?
▪ Patency of tubes?
▪ Cervical factor?
• Post-coital test – 2 hrs after check:
- spermatozoids
- cervix – mucus consistency
- IVF
o indic.
▪ Male
• Oligospermia (5-20 mill/ml)
• Presence of sperm AB
▪ Female
• endometriosis
• damaged or absent fallopian tubes
• unexplained infertility
- ICSI (Intracytoplasmic sperm injection)
o indication
▪ severe oligospermia or azoospermia (<5mill/ml)
▪ failure of IVF
- Fertility treatment – Monash IVF
o infertility rate – 15%
o cause of infertility
▪ 1/3 woman
▪ 1/3 man
▪ 1/3 man and woman
o Safety Net – out of 7500 you get 5000 back
o in Vivo:
▪ Ovulation induction – Clomiphene (only if FSH not raised)
▪ Intrauterine insemination (IUI) – 2000 AUD
• 10% success rate
• risk of multiple pregnancies
o in Vitro:
▪ IVF – try this first
• no good sperm
172
• donor program
- donor types
▪ Known
▪ Unknown =altruistic – when child becomes 18 has the
right to find who is biological mother/ father
- for
▪ Sperm
▪ Ovum
• Method: Put sperm and ovum together for (short insemination protocol)
2 or 16 hrs (long)
▪ Intra Cytoplasmic Sperm Injection – if IVF failed or we need to do testicular
aspiration, go for this one
• low sperm count
• inject sperm
o Overall success rate is 90% in 3 attempts.
Orthopedics - OK
Trauma and fractures
General stuff
- MC causes of post-traumatic arterial thrombosis
o 1. fracture of femur
o knee dislocation
o hip fracture
- MC cause of artery injury – posterior knee dislocation (Popliteal A.)
- nerves that regenerate most after traumatic laceration:
o Digital N.
o Sural N.
- after visit to chiropractor = dissection of vertebral artery: neck pain, facial hemisensory loss,
ataxia
- Compartment syndrome – haematoma within a fascia, compressing on close structues
(nerves, arteries, etc.)
o Sx – e.g. leg swollen, post. tibial pulse not felt, pain on moving toes
o Rx - fasciotomy
- MVA
o thoracolumbar pain – transport in supine position on a flat surface
o with blood in urethra -> retrograde urethrogram
o main cause of death after MVA - disruption of great vessels, hypoperfusion and shock
- Compound/ open fracture – first step = debridement
- internal organ rupture in trauma
o MC source of air under diaphragm = ruptured intestine
o blow in the abdomen – Organ least often to rupture = Stomach
o MC organ injured in abd. trauma – Spleen 45%
▪ 2 – Liver: 40%
- Splenic rupture
o Mx
▪ Stable pat.
• U/S and CT scan
▪ isolated splenic rapture
173
• conservative Rx
- if it fails -> splenectomy
▪ hT -> splenectomy
▪ other organs are affected -> splenectomy
- Greenstick fracture
o Hx of trauma
o usually occur most often during infancy and childhood when one's bones are soft
o Because a child's bones are much more pliable than adult bone, an incomplete, or
'greenstick,' fracture may occur. A "greenstick fracture" means that one side of bone is
broken and one side is bent; therefore it is classified as an incomplete break.
o The name for a greenstick fracture comes from the analogy of breaking a young, fresh tree
branch. The broken branch snaps on one side (the outer side of the bend), while the inner
side is bent and still in continuity.
o Rx: Most often greenstick fracture must be bent back into the proper position (called a
"reduction") and then casted for about 6 weeks. Greenstick fractures can take a long time
to heal because they tend to occur in the middle and slower growing parts of bone.
- Stress fractures
o normal bone but repeated stresses/ injury on it
▪ diff. from
• pathol. fractures
• acute traumatic fractures
o Athletes, soldiers
o locations
▪ MC – neck and shaft of 2nd metatarsal bone----March troopers
▪ Spinal vertebra in cricket players
▪ Neck of 1st rib in COPD (coughing)
▪ neck of fibula and proximal tibia in runners
• perpendicular fracture starts from the cortical in -> advances till it
becomes transversal
• Rx – rest!
o Sx – pain worse on weight bearing, point tenderness
o Dx
▪ 1. X Rray – Usually normal
▪ 2. Nuclear bone scan – ↑uptake at the point of fracture
o Mx
▪ rest
▪ healing takes 6-8 wks
▪ walking boots
- Insufficiency fractures
o anorexia
o women from Middle East all covered (insuf. Vit. D)
- Flail chest
o 3 or more ribs broken
o Sx
▪ Paradoxical resp. -> gas exchanage impaired -> resp. distress
o Rx
174
-
▪ External Auditive Conduct laceration with bony debris in the canal
▪ Haemotympanum
175
o
o Longitudinal Fractures
▪ 70-90% of temporal bone fractures
▪ Extending to EAC, ME, ET, & foramen lacerum
▪ Presentation: bleeding from EAC, CHL, CSF otorrhea, facial paralysis
o Transverse Fractures
▪ 20-30% of temporal bone fractures, usually more severe occipital bone injury
▪ Presentation: hemotympanum, CSF rhinorrhea, SNHL, facial paralysis in 50% of
cases
o Treatment
▪ Stabilize for other neurologic & life-threatening injuries
▪ Observation
▪ Antibiotic coverage
▪ Surgery for persistent Tympanic Membrane perforation – paper patch
myringoplasty or standard tympanoplasty
▪ CHL – hemotympanum resolves in 3-4 weeks with no sequaelae
▪ Facial paralysis – facial nerve decompression & exploration
▪ CSF leak – head elevation, stool softeners, acetazolamide (to decrease CSF
production), placement of a lumbar drain, repair of CSF leak
• fracture of the base of skull – CSF leak
- don’t touch the nose (use orogastric tube)
- AB prophylaxis to prevent meningitis
- Orbital floor (blow-out) fractures
o Fracture of the orbital floor caused by blunt, non-penetrating force
o Direct blunt trauma to the globe causes ↑ intraorbital pressure, causing thin bones of the
orbit to “blow out”
o Inferior orbital wall is most commonly involved
o Ocular globe is protected by the orbital fat
o Forced duction testing is done to evaluate possible muscle/ nerve entrapment
o Inferior oblique muscle is tested, other muscles tested if necessary
o Plain films (tear drop sign on Water’s view)
176
o
o CT scan
Clinical features
Enophthalmos MC sign
• Swelling of cheek
• Circumocular haematoma
• Subconjunctival haemorrhage
• Palpable step in infraorbital margin
• Flat malar eminence when viewed from above
• Paraesthesia/diplopia due to infraorbital nerve injury
o • Loss of function (i.e. difficulty opening mouth
o Indications for surgical repair of orbital floor (blow-out) fracture
▪ Rapid onset of intraorbital bleeding & decreased visual acuity
▪ Entrapment (diplopia)
▪ Enophthalmos
o infraorbital nerve entrapment -> diplopia with restricted upward gaze
- Zygomatic fracture
o enophtalmos
Arm
- Lateral epicondylitis = Tennis elbow = Source of extensor tendons (M 714)
On examination the elbow looks normal, and flexion and extension are painless
o pain on pressing on lateral epicondyle
o pronated forearm inc pain (MCQ) + extended wrist (MCQ)-> pain
o resisting extension of wrist -> pain
o Rx
▪ Dumbell exercise with palm facing down
▪ RICE (rest, ice, compression, elevation)
▪ C/S local inj. (1-2)
- Medial epicondylitis = Golf elbow = Source of flexor tendons
o pain on pressing on medial epicondyl
o resisting flexion of wrist -> pain
o Rx
▪ Dumbell exercise with palm facing up
▪ RICE (rest, ice, compression, elevation)
▪ Brace below elbow
▪ C/S local inj. (1-2)
- De Quervain tenosynovitis = Washerwoman’s sprain– M 689
177
▪ Splinting
▪ C/S infiltration
▪ Surgery
- Injuries to the wrist and hand
o Colle’s fracture
▪ Fracture of distal radius usually within 2.5 cm of wrist.
▪ MC of wrist fractures.
▪ Elderly women with osteoporosis
▪ Fall on outstretched hand
▪ Dorsal angulation and dorsal displacement of the distal radial fragment or
radial displacement.
▪ CLINICAL FEATURES:
• Swelling, ecchymosis & tenderness.
• ‘Dinner fork’ deformity.
• ASSESS neurovascular status: Acute carpal tunnel syndrome.
• Common association
- Ulna
- Scaphoid
- Radial or ulnar styloid fracture
▪ X-Ray: distal fragment is:
• Dorsally displaced with dorsal comminution
• Dorsally tilted fragment with apex or fracture volar
• Supinated
• Radially deviated
• Shortened
▪ Cx
• 1. Stiffness of wrist and fingers (MCQ)
- + Most frequent LATE complication of a Colle’s facture in an
elderly woman
• 2. Osteoarthritic changes
• 3. Malunion
• 4. Non-union – Rx: internal fixation
• 5. Delayed union
▪ MANAGEMENT:
• Colles’ backslab: Permit full elbow flexion & thumb movements
extends from below elbow to metacarpal heads (thumb not included)
- include thumb if associated scaphoid fracture
• Types:
- Undisplaced or minimally displaced (stable):
▪ Colle’s backslab
▪ No manipulation (reduction)
▪ 7-10 days
- Displaced, angulated fractures with radial deviation:
▪ Reduction (Bier’s block = regional nerve block for all the
wrist and hand fractures using a blood pressure cough
on the arm + injection with anestetic in hand).
▪ Circumferential plaster cast for 6-8 wks
179
-
▪The wrist should be (like holding an apple – Awad):
• Fully pronated
• Radially deviated
• Partially dorsiflexed
• Thumb held in mid-abduction
- displacement > 2 mm and or angulation – open reduction &
fixation
▪ COMPLICATIONS:
• Non union.
• Avascular necrosis of proximal half of bone.
- circulation (sama as for femoral head)
▪ central to periphearl – usually closes
▪ periphearal to center – from the capsule (main one)
• Osteoarthritis.
o MALLET FINGER:
▪ Injury to extensor digitorum tendon at DIP joint
▪ It results from hyperflexion of extensor digitorum tendon.
▪ Sx
• Full passive but incomplete active extension at DIP joint
▪ TREATMENT:
• Mallet splint for 6-8 wks.
• Elevate hand
• Analgesics
181
- Injuries to elbow
o Pulled elbow - Subluxation of radial head
▪ Children 2-6 years.
▪ Axial traction applied to an extended arm.
▪ The radial head is subluxed out of annular ligament.
▪ CLINICAL FEATURES:
• Anxious child
• Local pain
• Loss of use of arm, particularly supination
• Elbow semi-flexed and pronated on examination.
• There is no neurovascular compromise
• Motor activity is normal
▪ X RAY:
• Only to exclude a fracture if extensive swelling.
• Reduction is not successful after two or 3 attempts.
▪ MANAGEMENT:
• Reduction
- Apply pressure to the region of the radial head with one hand.
- Apply axial compression at the wrist.
- Supinate the forearm.
- Gently flex the elbow with other hand.
▪ supination + force flexion of elbow while holding the
thumb over radial head, to feel it move into position, in
the anular ligament-> moves into position
• No immobilization is required.
- Injuries to shoulder & upper arm
o Acromioclavicular dislocation
▪ Fall on to the apex of shoulder with arm held in adduction
▪ types
• Subluxation: Causes local tenderness to palpation with minimal
deformity.
• Full dislocation: Prominent outer end of clavicle (step deformity)
▪ CLINICAL FEATURES:
• Local tenderness and swelling.
• Palpable step between distal clavicle and acromion.
• Pain with adduction.
• Assess the clavicle and scapula for associated fractures.
▪ DIAGNOSIS:
• X Ray: Apparent on stress view. Patient holding a weight in each hand,
compare the shoulders.
▪ TREATMENT:
• Minor: Ice, oral analgesics sling immobilization, daily range of motion
exercises.
• Complete: Same initial treatment, refer to Orthopedic team for possible
operative intervention.
o Glenohumeral joint dislocation
182
▪ ANTERIOR DISLOCATION - MC
• Caused by forced abduction and external rotation of shoulder
• Young adults from sports, traffic crashes or elderly from a fall.
• It tends to become recurrent.
• CLINICAL FEATURES:
- ‘Squared off’ shoulder: arm held in slight abduction & external
rotation.
- Loss of deltoid contour (MCQ)
- Humeral head can be palpated anteriorly
- Loss of internal rotation
- Pt can’t rise arm above head (but can move his head to that
position)
▪ most specific – can’t scratch in interscapular region
with his hand
- All shoulder movements are painful.
• ASSOCIATED WITH (These result in recurrent dislocations)
- Hill-Sachs lesion: Flattening or a wedge-shaped defect in
posterolateral aspect of humeral head.
- Bankart lesion – after the first dislocation: Avulsion of capsule
when shoulder dislocates. Occurs in 85% of all anterior shoulder
dislocations.
• COMPLICATIONS:
- Look for complications before any attempt of manipulation
- Axillary N damage:
▪ Check sensation over lateral deltoid (police patch)
▪ check motor function with isometric contractions of
deltoid muscle – Murtagh 1394
- Posterior cord of brachial plexus.
- Axillary artery damage.
- Fracture of the upper humerus.
• DIAGNOSIS:
- X Ray: Always to rule out associated humeral head fracture
▪ Mercedes Benz sign on lateral oblique view – normal
• humeral head displaced anterior or posterior
• ant dislocation – humeral head under coracoid
process of scapula
• post dislocation – humeral head over coracoid
process of scapula
- Humeral head is displaced anteromedially with loss of contact
with glenoid fossa
• TREATMENT:
- Pain relief: Morphine 2.5-5 mg IV
- Conscious sedation with fentanyl (analgesic) and midazolam
(sedative, muscle relaxant)
▪ or fentanyl and propofol (used currently)
- Perform the reduction:
▪ Kocher’s manoeuvre
183
▪ Hippocratic method
▪ Jay: straight arm, pull forward (in axul bratului) +
upward (flexion) + abduction + supination
- Sling
- Test again for neurovascular damage
- X Ray to confirm reduction
o Fractures of upper humerus
▪ location:
• Greater tuberosity
• Lesser tuberosity
• Surgical neck of humerus
• Supracondylar
▪ Usually in elderly patients
▪ CLINICAL FEATURES:
• Localized pain.
• Loss of movements.
• Swelling and tenderness.
▪ COMPLICATIONS:
• Dislocation of humeral head.
• Complete distraction of the humeral head from the shaft.
• Axillary N damage -> anaesthesia over lateral deltoid & loss of deltoid
movement.
• Axillary (circumflex) vessel damage.
• in supracondylar fracture (just above epicondyles)
- Sx – huge hematoma
- Cx = Brachial A. injury => Volkmann's ischemic contracture
▪ Permanent flexion contracture of hand at wrist,
resulting in a claw-like deformity of hand and fingers.
It is more common in children. Passive extension of
fingers is restricted and painful. On examination fingers
are white or blue, cold and Radial pulse is absent.
▪ It’s caused by obstruction of brachial artery near elbow
• results from acute ischaemia/ necrosis of
muscle fibres of flexor group of muscles of
forearm, specially flexor digitorum profundus
and flexor pollicis longus which become fibrotic
and short.
▪ Causes:
• Any fracture at elbow or upper arm may lead
to Volkmann's ischemic contracture but
commonly caused by supracondylar fracture of
humerus.
• improper use of a tourniquet
• improper use of a plaster cast – too tight
• compartment syndrome.
▪ Rx
• surgery to fix the damaged tissues
184
Leg
- Dislocation of hip
o Occurs in violent trauma such as:
▪ Traffic crash.
• knee strikes dashboard w/ thigh abducted
▪ Blow from back while in squatting position
▪ Fall from height.
▪ Direct fall on hip.
o location
▪ The MC is posterior dislocation (85%)
• The posterior capsular ligaments are weaker than anterior
▪ Central and anterior dislocation are rare
o CLINICAL FEATURES:
▪ The hip is held slightly flexed
▪ Adducted
▪ Internally rotated
• externally rotated – for anterior dislocation (rotation is more specific in
determining whether anterior or posterior dislocation)
o DIAGNOSIS:
▪ X Ray of pelvis, hip and shaft of femur in all cases.
o Cx:
▪ Avascular necrosis of fem. head: ↑dramatically after 6 hrs of hip dislocation
▪ Assess L5 & S1 of ankle: Sensation over medial side of ankle (L5) and lateral
border of foot (S1).
▪ Sciatic nerve neuropraxia: 15%
o MANAGEMENT:
185
• children
- do nothing till 8 yrs
- refer if inter medial malleloar space > 8 cm
▪ Genu varum (bowed legs)
• where is my horse?
• stress test
• children
- up to 3 yrs normal
- Mx
▪ reassurance
▪ 3 yrs – observe
▪ refer if intercondylar dist. > 6 cm
▪ Genu recurvatum
o Cruciate ligament
▪ Ant (ACL) – MC than post.
• Soccer player accident – MC = Injury to anterior cruciate ligament
• Knee giving way
• tests
- Ant drawer test – with knee at 90 degrees (> 10 degree pathol.)
- Lachmann’s test – with knee at 15-20 degrees (> 5 mm pathol.)
- Pivot shift test
▪ Post (PCL)
• tests
- post drawer test
- post. sac test?
o Meniscus – in twisting movts.
▪ Medial
• more frequent (75%) than lateral
• most common knee injury
• Sx
- giving away sensation
- locking of joint – MC cause of locking
▪ Knee locking in flexion
▪ lateral
▪ tests
• Apply grind/ distraction test
• McMurray test
- Knee pain – frequent in hip problems, with knee joint being normal
- Fractures of patella
o Usually by direct trauma:
▪ Traffic crash
▪ Fall
▪ Indirect force from violent quadriceps contraction
o CLINICAL FEATURES:
▪ Acute knee pain.
▪ Swelling and bruising.
▪ Loss of function, especially inability to extend knee.
187
o DIAGNOSIS:
▪ 1st: X Ray of both knees.
• Confusion may arise from congenital bipartite or tripartite patella but
these are BILATERAL.
▪ Consider CT scan when a suspected fracture is not seen on X-ray.
o MANAGEMENT:
▪ Refer immediately: Distracted or comminuted fractures.
▪ Stable: Aspiration of haemarthrosis.
▪ Place the leg in a padded plaster cylinder from the thigh to the ankle.
▪ Refer to fracture clinic.
- Flat feet (pes plano valgus)
o painless, asympt.
o refer if painful, stiff
o majority: Physiological
o by 6th birthday: 80% resolve
Bone pathology
- Osteosarcoma
o primary – in adolescents: knee (in the metaphysis)
o sec. – metastases to lungs
o Sx
▪ Pain + swelling
▪ Stress fractures
o Dx
▪ X Ray typical:
• Sunburst appearance
• Codman’s triangle – due to periosteal elevation
• + new bone formation
o Rx
▪ surgery
▪ chemotherapy
- Paget’s disease of bone
o Normal bone replaced by new soft (medullary) bone:
▪ Osteoclastic activity then osteoblastic activity
o 10% at 90 yrs
o Sx
▪ Male 2:1
▪ 95% asymptomatic
• Dx. during X Ray or incr. ALP level
▪ Bone pain, joint pain, stiffness and waddling gait,
• MC bones affected: pelvis, femur, skull
• his hat don’t fit him anymore!
▪ deafness
▪ hyperdynamic circ. -> heart failure (hight output cardiac fail)
o Dx
▪ Marked incr. of ALP (asympt. incr. of ALP)
▪ Normal Ca and Phosphate
▪ X Ray – dense, expanded bone (bigger, thicker bone)
188
• X Ray features
- larger bone/ bony extension
- thickened cortex
- coarse/ thicker trabeculation
• Metastases of prostate CA and transitional cell CA of bladder =
Osteosclerotic -> have to be excluded (Do PSA)
o Cx
▪ Fractures
▪ Cardiac failure – in bones more AV shunts, bypassing capillaries (more input
blood coming back to heart => High output cardiac failure)
▪ Osteogenic sarcoma – rarely
▪ Deafness----Cranial nerve involvement
▪ Deformities
o Rx
▪ 1. Bisphosphonates
• SE – Oesophagitis (don’t go to sleep right after taking it)
Neurology - OK
- Cranial nerves
o Only 1st and 2nd pair emerge from cerebrum; remaining 10 pairs emerge from brainstem.
-
Sensory,
Name Motor Origin Nuclei Function
or Both
Cranial nerve zero olfactory trigone, New research indicates CN 0 may
(CN0 is not medial olfactory play a role in detection of
0 Sensory
traditionally gyrus, and lamina pheromones. Linked to olfactory
recognized.)[1] terminalis system in human embryos[4]
▪ Acute mastoiditis
▪ Malignant otitis externa
▪ Acute suppurative otitis media
▪ Tuberculosis
▪ Lyme disease
▪ AI+DS
▪ Infectious mononucleosis
▪ Influenza
▪ Encephalitis
▪ Sarcoidosis
o NEOPLASIA
▪ Cholesteatoma
▪ Carcinoma (primary or metastatic)
▪ Acoustic neuroma
▪ Meningioma
▪ Facial Neuroma
▪ Ossifying hemangioma
▪ Glomus jugulare or tympanicum
▪ Schwannoma of lower cranial nerves
▪ Benign and malignant parotid tumors
▪ Leukemia
▪ Hemangioblastoma
▪ Histiocytosis
▪ Rhabdomyosarcoma
o METABOLIC/ SYSTEMIC
▪ Diabetes mellitus
▪ Hyperthyroidism/hypothyroidism
▪ Pregnancy
▪ Autoimmune disorders
o NEUROLOGIC
▪ Guillain-Barre’ syndrome
▪ Multiple sclerosis
▪ Millard-Gubler syndrome
- Bell’s palsy – idiopathic
o MC cause of acute facial paralysis (70% of cases)
o LMN
o Can occur in any age group, prevalent in 3rd decade of life
o Recurrent paralysis in 10-12% of cases, more often on contralateral side
o Positive family history in 14% of cases
o Association - Type I Herpes virus (HSV-1)
▪ Viral infection induces an inflammatory response resulting in neural edema and
vascular compromise of facial nerve
o Sx
▪ paralysis of all facial muscles, including frontalis (MCQ)
▪ can’t close eye (NOT PTOSIS – Horner)
▪ mouth pulled to opposite direction and up when opening it
▪ unilat. loss of taste (ant 2/3rd of tongue)
o isolated, with no other sympt. (e.g. dysphagia – brainstem infarct)
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o Treatment is controversial
o Treatment options:
▪ Steroid therapy (Prednisolone) – always, 7 days
▪ artificial tears (can’t blink or close eyes)
▪ surgical decompression – if steriods dn’t help
▪ antivirals – sometimes
-
- Herpes zoster oticus – Ramsay Hunt syndrome
o Vesicular eruptions on ear or ear canal (crusts) + ipsilateral facial paralysis
o Other symptoms:
▪
o Nerve degeneration is more progressive and severe than Bell’s palsy!
o Prognosis for recovery is worse!
o Treatment:
▪ antivirals – within first 72 hrs.
▪ steroids
▪ pain management – very painful
- Trigeminal neuralgia
o males > 40 yrs
o paroxystic burning pain in the maxillary and mandibulary region (nerve V distribution)
▪ no Ophtalmic N involv.
o lasts seconds – 1-2 min
o recurs many times during day and night
o triggered by
▪ touching of skin of affected area
▪ washing
▪ shaving
▪ eating
▪ talking
o Unilateral
▪ 2nd mandibular division of Vth nerve
▪ 3rd maxillar division of Vth nerve
o cause
▪ local pressure on nerve root entry zone by tortuous pulsatile dilated small
vessels – 75%
▪ MS
▪ neurosyphillis
▪ tumor in posterior fossa
o Rx
193
▪ Carbamazepine
▪ (amytriptiline)
▪ Phenytoin
▪ Gabapentin
▪ Surgery
- Postherpetic neuralgia
o Unilateral or bilateral
o Ophtalmic area involved
o Rx
▪ Amytriptiline – Murtagh, we used to be told to select this
▪ Carbamazepine – less SE
▪ Gabapentin
Nerve traumatic pathology
- Hand
o Brachial plexus C5-T1 - http://en.wikipedia.org/wiki/Brachial_plexus
▪ Axillary nerve
• Deltoid muscle
• Small area of overlying skin – “police patch”
▪ Musculocutaneous nerve
• Biceps brachii
▪ Radial nerve C5-C8 (goes more towards back of arm-forarm-hand)
• all extensors: triceps = elbow extension, wrist extension
- Injury
▪ above elbow: dropped elbow and wrist (can’t extend)
▪ elbow level: dropped wrist (can’t extend)
- Rotation of thumb (thumb up – antenna, 90 degrees to Palm, in
same plane as palm) – Alena
• Post. interosseous n. (branch of radial n.) – extension of finger lost but
hand extension intact
▪ Median nerve C6-T1
• Motor – grasp (hand) and flexors + thenar muscles (under thumb)
• tests
- above elbow (cubital fossa)
▪ Clasping test (Ochsner’s test) – can’t flex index finger
on affected side when asked to clasp hands firmly
together.
- below elbow (wrist)
▪ Pen touch test – can’t do flexion of thumb, 90o
perpendicular on palm’s plane
• injury -> median claw affecting fingers 2-3
• opposition (adduction OK) of thumb to index finger (OK – O –
Opposition) alena
▪ Ulnar nerve C8-T1
• Ulnar paradox: higher the lesion, less sever the injury
- high – flexor digitorum profundus paralized => less severe “Claw
hand” affecting fingers 4-5
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- low – flexor digitorum not paralized => more severe “Claw hand”
affecting fingers 4-5
• can’t adduct (opposition) thumb (can’t hold a piece of paper between
thumb & index finger = Froment’s sign)
• all small muscles of hand except thenar: interosseus + hypothenar
(under fingers 2-5) (sparing thenar muscles) + abduction and adduction
of fingers (spread fingers) – alena
▪ C8
• Loss of sensation of ring finger, may be extending to little finger
• Weakness of extensors of wrist.
▪ T1 (both Ulnar & Median N)
• all small muscles of hand, including thenar and hypothenar eminences
including all fingers (1-5)
- diff. from medial or ulnar injury
• difficulty of precision grip and opposition of thumb to fingers,
weakness spreading and bringing together fingers
• in time – claw hand
o Sensory
▪ Palm
• 3 ½ median (fingers 1-3.5)
• 1 ½ ulnar (fingers 3.5-5)
▪ Dorsum
• 3 ½ radial (fingers 1-3.5)
• 1 ½ ulnar (fingers 3.5-5)
o Erb's Palsy - Paralysis of arm caused by injury to upper group of arm's main n,
specifically upper trunk C5-C6 is severed- loss of sensation in arm, paralysis and atrophy
of Deltoid, Biceps and Brachialis muscles. The position of limb, under such conditions is
characteristic: arm hangs by side and is rotated medially; forearm is extended and
pronated. The arm can’t be raised from side; all power of flexion of elbow is lost, as is
also supination of forearm. The resulting “Biceps” damage is main cause of this classic
physical position commonly called "Waiter's tip."
▪ Risk factors – breech presentation, Shoulder dystocia due to macrosomia
materanal or gestational DM.
o Klumpke palsy- Paralysis involving muscles of forearm and hand, resulting from a lower
brachial plexus injury (C8-T1 severed)- affects principally intrinsic muscles of hand and
flexors of wrist and fingers".± dilators of iris and elevators of eyelid (both of which may
be seen in case of associated Horner's Syndrome). The classic presentation of Klumpke's
palsy is “Claw Hand” where forearm is supinated, wrist and fingers are hyperextended.
If Horner syndrome is present there is miosis (constriction of pupils) in affected eye
(Complete claw).
195
o
o
Syringomyelia
- Leg – Murtagh 714, Blue book 190-191
o Sciatic N, coming from sacral (or lumbosacral) plexus – branches above popliteal fossa
into: Common peroneal and tibial N
▪ PED: P = Common Peroneal n (at front of leg) damaged => E = Eversion, D =
Dorsiflexion
• L5-S1
• Complic. of lithotomy position -> compression of common peroneal n
• branches:
- deep peroneal N – dorsiflexors: tibialis ant., extensor hallucis
longus, extensor digitorum longus, fibularis brevis
- superf. peroneal N – eversion muscles: fibularis longus, fibularis
brevis
- L4-L5-S1-S2
• Muscles supplied by P:
- Extensor hallucis longus
- Extensor digitorum longus
- Tibialis anterior
- Peroneus brevis
- Short head of biceps femoris
▪ TIP: T= Tibial n (at back of leg) damaged => I= Inversion, P= Plantar flexion
• L4-L5
▪ SEDIP => Sciatic n damaged (peroneal n and tibial n are branches)
Power loss Reflex Sensory loss
C5 Abduction of arm Biceps
C6 Elbow flexion, extension of wrist Biceps
C7 Elbow extension Triceps
C8 Hand grip
T1 Finger spread (abduction / adduction of fingers)
L3 Extension of knee Knee jerk Ant. Aspect of thigh
L4 Inversion of foot Knee jerk Medial aspect of ankle
L5 Dorsiflexion of great toe Dorsum of foot
S1 Plantar flexion & eversion Ankle Plantar Lateral aspect of ankle
- Nerve roots asked in MCQs – Oxford p. 457
o Biceps jerk: C5-C6 (Erb’s palsy)
o Triceps jerk: C7
o Hip flexion L1-L2
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Upper limb: Biceps reflex C5/C6 · Brachioradialis reflex C6 · Extensor digitorum reflex
Tendon reflexes C6/C7 · Triceps reflex C7/C8
Lower limb: Patellar reflex L2-L4 · Ankle jerk reflex S1/S2 · Plantar reflex L5-S2
- Corneal reflex
o V – afferent
o VII – efferent
- Gag reflex
o Glossopharyngeal IX - afferent –
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o Vagus X – efferent
- Oculocephalic reflex (doll’s reflex) – Brainstem integrity
Motor neurone lesions and back pain
o types:
UMN LMN
Weakness Yes Yes
Power Decr. Decr.
Muscle Wasting Absent/mild Marked
Tone Incr. (spasticity) Absent or decr. (flaccid)
Fasciculations No May be present
Reflexes Brisk Absent or diminished
▪ UMN – above anterior horn cell: cerebral cortex, internal capsule, brain stem,
spinal cord (stroke, tumors, MS, etc.)
▪ LMN – lesion from anterior horn cell = spinal reflex arc (peripheral neuropathy,
Bell’s palsy, GBS, motor neuron dis., poliomyelitis, etc.)
o Motor neuron dis. (MND)
▪ progressive neuromusc. disorder due to death of motor neurons in brain, brain
stem and spinal cord.
▪ no sensory loss (MCQ)
▪ no sphincter involvment
▪ cause
• 5-10% inherited AD
• rest – sporadic
▪ types
• amyotrophic lateral sclerosis (ALS)
- LMN muscle atrophy + UMN hyper-reflexia (progressive
spasticity)
• progressive muscle atrophy
• progressive bulbar and pseudobulbar palsy
▪ Sx
• Triad: LMN + fasciculations (in hands – wasting of all muscles) and UMN
signs (hyper reflexia in legs)
• weakness or muscle wasting
• difficulty with swallowing, speech
• fasciculations & cramps
▪ Dx
• clinical
• neurophysiological tests
▪ no Rx
▪ incurable – death in 3-5 yrs from respiratory failure/ aspiration pneumonia
- Back pain:
Without neurological sympt. With neurological sympt.
1. Muscular spasm 1. Disc prolapse – compress on nerve roots
After heavy weight lifting Limited neurol sympt. = sensory abnormality (no motor) –
Diffuse tenderness numbness, shooting pain in leg
2. Vertebral crush/ collapse 2. Cauda equina syndrome (L1-5, S1-5)
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Old lady with osteoporosis Urinary retention (> 500 ml after urination) Saddle shape
Point tenderness paresthesia (numbness in groin area) +↓ anal tone (ask
patient to squeeze + do you feel my finger in your anus?)
LMN only
3. Spinal canal stenosis 3. Spinal cord compression
Pain relieved by trunk flexion Urinary & fecal retention/ incontinence
LMN + UMN
- Examples:
Spinal cord compression/ lesion:
▪MCQ: Pain in mid-thoracic region & spastic paraparesis progressing over last 2
mths.
▪ Sx
• Above lesion - normal
• At the level of lesion - ipsilateral LMN signs
• below lesion – ipsilateral UMN signs + ipsilateral loss of position
- this is after a few wks; initially we have flaccid motor paralysis +
loss of all sensory modalities
• contralat. sensory loss, temperature and pain
• + spinal root pain, precedes weakness
▪ Rx
• Acute – high dose steroids to lower edema!
o Cauda equina syndr. – Murtagh p.37
▪ pain at back of thigh and legs, shooting to leg
▪ saddle anesthesia (numbness of inner buttocks, perineum and upper medial
thigh), back of legs, soles of feet,
▪ bowel and bladder involvement (urinary retention)
▪ weakness of legs and feet
▪ atrophy of calves
▪ Rx – Surgical decompression
o Spinal canal stenosis – neurogenic claudication: Murtagh p. 710
▪ pain in buttocks related to walking, relived by trunk flexion or rest
▪ pain relieved when going up hill and amplified when extending spinal column
(going down hill)
• Dx diff from vascular claudication = pain relieved at rest or going down
hill
▪ Bowel/ bladder involvement
Tremor
o Types
▪ Resting – Parkinsonism
▪ Action or postural
• Benign Essential tremor (MCQ)
- AD in 50% of cases
- can be present in Parkinson
- Sx
▪ Triad: tremor with little disability + normal gait +
family Hx
▪ tremor
199
▪ cogwheel ridigity
▪ slow and shuffling gait with flexed trunk and short steps
• no arm swing
▪ bradykinesia
• slowness to start movements
• micrographia
• ↓ blinking
• slow monotonous speech
▪ progressive forward flexion of trunk
▪ poor balance – suspect Parkinson in a fractured hip
▪ constipation (common)
▪ congnitive impairment – due to:
• progressive Parkinson-associated dementia in 30-40% usually after 10
yrs
• Alzhimer
• medication
▪ normal reflexes
o Dx
▪ clinical!
▪ Dx. diff.
• Parkinsonism – doesn’t respond to levodopa
▪ Lewy bodies in the neurons – pathognomonic
o Rx
▪ 1. drugs:
• types:
- Dopaminergic
▪ Levodopa – best drug, baseline and gold standard of Rx
• initiate Rx ASAP
• start low: 100 mg/day
• ↑if needed:Max. tolerated dose = 450-600
mg/day
▪ + Carbidopa or Benserazide – with onset of disability
(motor disturbances)
▪ improves rigidity, dyskinesia, gait disorder but not
tremors
- Dopamine agonists
▪ Bromocriptine
• SE - severe psychiatric disturbances -> not in
elderly with confusion or dementia
▪ Pergolide – assoc. in Rx for levodopa “on-off”
phenomenon
• SE - severe psychiatric disturbances -> not in
elderly with confusion or dementia
▪ Cabergoline
- Anticholinergic – for tremor (in young people)
▪ benztropine
▪ benzhexol
201
- COMT inhibitors
▪ entacapone – levodopa potentiation
- others
▪ amantadine
▪ selegiline
• approach:
- Mild (minimal disability)
▪ levodopa + carbidopa or
▪ selegiline (can be use as first line monotherapy)
▪ amantadine
- Moderate (disabled but independent)
▪ levodopa
▪ + dopamin agonist: pergolide or bromocriptine or
cabergoline
- Severe (disabled, dependent on others)
▪ levodopa + pergolide or cabergoline
▪ + entacapone
• Long term problems – after 3-5 yrs of Rx with levodopa
- Dyskinesia: Choreiform, involuntary flickering movt. of mouth
(lips, tongue), face, eyelids, cheeks, limbs, trunk – 80-100% of
patients.
▪ Rx: ↓ Levodopa and carbidopa + add pergolide or
cabergoline
- end of dose failure (effect lasts for only 2-3 hrs)
▪ Rx:
• Add entacapone
• dosages closer together
- “on-off” phenomenon (sudden inability to move – recovery in 30-
90 min)
▪ Rx:
• Apomorphine (+ domperidone to prevent
vomiting) for off phase
• add pergolide
- early morning dystonia (clawing of toes)
▪ Rx – slow release levodopa
- nocturnal akinesia
▪ Rx – slow release levodopa
- sundown effect: pts often go psychotic as sun goes down
▪ 2. Surgery:
• Alleviates only tremor and rigidity
• Does not prevent progression to bradykinesia, dysarthria and dementia
• types:
- Pallidotomy
- Stereotactic thalamotomy
• indic:
- tremor or rigidity not responding to drugs
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-
▪ types:
• Partial (non-convulsive, no loss of consciousness)
- Simple
▪ e.g. Jacksonian march: starts from a part of body and
moves to other area of body
- Complex
▪ with impaired (altered or cloudy but not lost)
consciousness
• e.g. temporal lobe epilepsy – with olfactory
hallucinations.
• Generalized (convulsive, with loss of consciousness)
- Grand-mal (tonic – clonic)
▪ Sx
• usually last 1-2 min
• loss of consciousness
tonico-clonic contractions: This is a generalized
seizure with varying phases of muscular rigidity
(tonic) followed by jerking of muscles of body
for several minutes (clonic).
• tongue-biting
• incontinence
• post-ictal confusion
▪ Dx diff with functional or pseudo-seizures = means of
coping with stress (exams, etc.)
• Atypical: no loss of consciousness, no tongue-
biting, no incontinence, etc.
▪ Nocturnal epilepsy – Involuntary vocalisation
followed by grand-mal.
• blood on pillow & enuresis noticed in morning
- Petit-mal (absence) Consciousness is impaired only briefly (few
seconds). Pt often remains upright and gives a normal appearance
or seems to be staring into space. Absence seizures occur more
often in children.
203
▪ > 10 min
▪ multiple convulsions during 1 episode (complex)
▪ family Hx of epilepsy
o prognosis – excellent
o Mx
▪ reassurance
▪ control temperature - Paracetamol
▪ > 10 min -> rectal diazepam (0.2-0.4-0.5 mg/kg)
• if seizures during examination: Observe -> if not improving in 5-10 min -
> rectal diazepam
• Oral or nasal midazolam 0.3-0.5 mg/ kg
▪ recurrance > 30-40%
• 30% in first 24 hrs
- Infantile spasm = Sallam attacks = West syndrome = hypsarrythmia (high amplitude irregular
EEG waves) (M 588)
o funny turns (flexion/ bending forward of trunk and extended limbs)
o first year of life
o assoc. with HSP and intussusception
o Dx: Increased CRH – (corticotrope releasing hormone)
o Rx
▪ ACTH (lowers CRH) – best
- Tourette syndrome (boys)
o Multiple motor tics & 1 or more vocal tics that are recurrent many times a day for > 1 yr
o starts with motor tics
o echolalia
o coprolalia (10% only)
o 3-8 (4-15) yrs
o any stress may exacerbate it
o Rx
▪ 1. Clonidine
▪ 2. Resperidone
▪ 3. Haloperidol
▪ electrode on brain?
- Habitual tics
o Sx
▪ recurrent tics > 1yr
▪ NO echolalia, coprolalia
Syncope
o Transient loss of consciousness.
▪ Associated with blurred vision, dizziness, sweating and loss of postural tone,
followed by spontaneous full recovery results from ↓ cerebral perfusion.
o Causes vary from benign to imminently life threatening.
▪ Dx diff.
• Vaso-vagal: with prodrome – vomiting
- syncope after going to bathroom or post-op (pain), change of
position
▪ posture change by standing
206
• Neurological:
- Subarachnoid haemorrhage.
- Vertebrobasilar insufficiency. – in posterior circular problems
(vertebrobasilar), less from anterior (cerebral) circ.
• Postural (orthostatic) hypotension:
- Diabetes, hypoadrenalism (Addison’s).
- Parkinson’s disease and autonomic failure.
- Drugs: antihypertensives, diuretics, nitrates.
- Cough, micturition or defecation syncope.
- Hypoglycemia (relative).
o DIAGNOSIS:
▪ Priority: Blood glucose test strip and ECG.
▪ Send blood for FBC, U&Es, cardiac biomarkers, pregnancy test, CXR and CT scan.
o TREATMENT:
▪ Underlying condition.
TIA
o Cerebral circ. Oxford 452
o Origin
▪ 80% carotid origin
▪ 20% vertebrobasilar
o Episodes of sudden transient focal neurological deficit lasting for less than 24 hrs (usually
less than 10 min).
o 12% of patients have a stroke by 1 month (often within 1-7 days).
o types
▪ Anterior
• usually carotid artery or middle cerebral artery
▪ Posterior
• Vertebral, PICA, basilar
o CAUSES:
▪ Embolic:
• Cardiac: Post MI, AF, mitral stenosis, valve prosthesis.
• Extracranial vessels: Carotid stenosis, narrowed vertebral artery.
▪ Reduced cerebral perfusion:
• Hypotension: Hypovolemia, drugs or cardiac arrhythmia.
• Hypertension: Hypertensive encephalopathy.
• Hypercoagulable states: Protein C, S or antithrombin III deficiency.
• Vasculitis: TA, SLE, PAN.
▪ Lack of nutrients:
• Anemia
• Hypoglycemia
o CLINICAL FEATURES:
▪ Anterior - Carotid artery dysfunction – unilateral sympt.
• Hemiparesis.
• Hemianesthesia.
• Homonymous hemianopia.
• Dysphasia.
208
• Dysarthria.
• Amaurosis fugax (Transitory monocular blindness).
▪ Posterior - Vertebrobasilar territory dysfunction:
• Bilateral limb paresis.
• Crossed sensory symptoms.
• Diplopia
• Bilateral blurred vision
• 3rd cranial N palsy due to Posterior communicating artery aneurysm
(MCQ)
• Bilateral cortical blindness
• homonymous hemianopia?
• Nystagmus
• Ataxia
• Vertigo
• Cranial nerve paralysis (e.g. IX, X, etc.)
• Memory loss
• PICA – lateral medullary syndrome, due to injury to lateral part of
medulla oblongata
- vertigo
- nystagmus
- ataxia
- Horner
- dissociated sensory loss (affecting face and limbs – MCQ: Blue
Book p. 401)
▪ dorsal colum medial leminiscus fibers: Ipsilateral
sensory fibres in posterior columns (for touch,
vibration, posture) – they only cross at pons level ->
from there up all the fibres from other side are
together) + contralateral anterior and lateral column
spinothalamic fibres (pain + temperature) – they cross
at spinal cord level)
• Corticospinal tract – Motor (UMN)
o 80% of fibres cross at medulla
oblongata level--- lateral corticospinal
o 20 % don’t cross--anterior corticospinal
o DIAGNOSIS:
▪ Glucose test strip.
▪ FBC, ESR, coagulation profile, blood sugar, LFT, electrolytes and lipid profile.
▪ ECG and CXR.
▪ URGENT CT BRAIN to differentiate
• hemorrhage from
• infarction and to look for structural non-vascular lesion.
• CT aspect:
- Infarction – black
- Hemorrhage – white
- Calcification – very white
209
-
- SUBDURAL HAEMATOMA:
o Neurosurgical emergency if mass effect.
o MC (20-40%) venous bleeding, slow deterioration.
o in elderly people
o Between dura matter and arachnoid membrane.
o Imaging: Sickle shaped collection of blood. It will NOT cross the mid-line
-
212
- SAH
o massive pain (worse pain ever)
o Diffuse layering of blood below arachnoid membrane.
o Does not cause mass effect, predisposes to vasospasm.
o PICA aneurysms: Intraventricular haemorrhage.
o
o Causes
▪ Head injury.
▪ Ruptured aneurysm.
• in polycystic kidney dis. - AD
▪ HTN.
▪ Coarctation of aorta, anticoagulants
▪ AV malformation.
▪ Coagulopathy or vasculitis.
o Sx
▪ Sudden, severe ‘worst headache ever’
▪ Lethargy, nausea, vomiting, meningism
▪ A 3rd N (Oculomotor) palsy suggests bleeding from posterior communicating
artery aneurysm.
o DIAGNOSIS:
▪ Arrange a CT scan urgently to confirm diagnosis (99% caught - Amit)
▪ Lumbar puncture (1%): If CT scan is negative or unavailable (Xanthochromia =
blood in CSF)
o MANAGEMENT:
▪ O2
▪ Prevent main Cx = Vasospasm
• Nimodipine (if BP is stable) – to prevent vasospasm & Subsequent
ischemic stroke!!
• 3 H therapy:
- control HTN
- hypervolemia – overload patient
- hemodilution – thin blood
▪ Refer to neurosurgical unit.
▪ Lorazepam 0.07mg/kg, diazepam 0.2mg/kg or midazolam 0.1mg/kg for seizures
or severe agitation.
▪ Paracetamol 500 mg and Codeine phosphate 8 mg two tablets orally.
Meningitis
o CAUSES:
213
▪ Meningococcus
▪ Streptococcus pneumoniae.
▪ Listeria monocytogenes (infants under 3 months, adults over 55 yrs,
immunosuppression)
▪ Viruses.
▪ Cryptococcus neoformans.
▪ TB
o CLINICAL FEATURES:
▪ Prodromal malaise.
▪ Generalized headache
▪ Fever, vomiting
• TRIAD: fever + vomiting + headache
▪ Altered mental status with irritability and drowsiness (lethargy).
▪ Confusion, coma.
▪ Photophobia.
▪ Neck stiffness ----- Sign of meningial irritation – (also in SAH)
▪ Localized cranial nerve palsies or seizures may occur
o Always consider meningitis in:
▪ Confused elderly.
▪ Sick neonate.
▪ Generalized convulsive status epilepticus.
▪ Coma of unknown cause.
o Meningococeal septicemia
▪ early signs
• Muscle pain: Legs.
• Abnormal skin colour: Pallor or mottling.
• Cold hands and feet.
• Rigors, vomiting, headache.
▪ late signs
• Petechial rash (non-blanching).
• Impaired consciousness.
• Meningism.
o DIAGNOSIS:
▪ Blood cultures
▪ CT scan: If focal neurological signs, especially if signs of incr. ICP
▪ LP: If there are no focal neurological signs and no ↑ICP (CI if ↑ ICP is
suspected) – to confirm diagnosis.
• CSF findings (table – Jay’s notes)
- Bacterial meningitis: WBC - neutrophils incr. (85%), protein
incr. (1 – normal 0.15-0.4), Glucose decr.
- Viral – lymphocytes incr., normal glucose
- TB – Lymphocytes incr., Glucose decr.
- GBS - Prot. incr., cells normal (WBC are not incr. – 90%,
mononuclear cells incr. – 10%)
o Rx
▪ O2 and fluids.
▪ Ceftriaxone (3rd generation) 2 g IV
214
• Sumatriptan 6mg SC
•
Dihydroergotamine 1 mg IM
• Lignocaine
▪ Bridging Rx
• often needed while preventive Rx is commenced
• C/S to produce rapid suppresion of attacks (within 24-48 hrs)
- Prednisolone oral 50 mg OD for 7-10 dys then taper over 3 wks
• may recur when steroids are tapered so preventive drug must be
initiated in parallel
▪ Preventive Rx
• Verapamil 160 mg orally daily or
• Methylsergide 1 mg orally daily or
• Lithium 250 mg orally twice
Raised ICP
o signs of raised ICP
▪ deteriorating/ LOC
▪ deteriorating resp. pattern
▪ HTN with bradycardia
▪ progressive headache, worse when waking up in morning
▪ ataxia & vomiting
▪ lateralizing signs (cranial n. paralysis) – tentorial herniation
• 3rd n. palsy
- superior eyelid drop = ptosis
- dilated pupils = mydriasis
- diplopia - eye looking “down and out”
• 4th n. palsy
- diplopia in downward gaze
• 6th n. palsy (lateral rectus m.)
- diplopia – on lateral gaze
• 9th n.
- taste absent on post. 1/3rd of tongue
- Absent gag reflex on side of lesion
▪ Seizures
▪ Papilloedema – late sign
▪ usually benign
▪ seizures for 3 years, then suddenly worsening (hemiparesis, etc.)
▪ more common
o Glioblastoma multiforme – much faster
▪ seizures + hemiparesis at the same time
▪ MC malignant and most aggressive tumor
▪ adults
o Astrocytoma - less aggressive
o oligodendroglioma
o ependymoma
Coma and confusion
- Glasgow Coma Scale (GCS)
o Eye 4
▪ 1 - No response to pain
▪ 2 – Opens eye to pain
▪ 3 – Opens eyes to verbal command
▪ 4 – Spontaneous eye opening
o Mouth (Verbal command) 5
▪ 1 None
▪ 2 – Incomprehensive speech
▪ 3 – Inapropriate speech (rudeness, responds with something unrelated to the Q)
▪ 4 – Confused conversation (doesn’t know where he is)
▪ 5 - Oriented
o Hand (motor) 6
▪ 1 No response
▪ 2 (abnormal) extension response to pain (decerebrated – extended neck,
extended and internally rotated arms, extended legs)
▪ 3 (abnormal) flexion response to pain (decorticated – mummy position: flexed
arms, extended legs)
▪ 4 Withdrawing to pain
▪ 5 Localizes pain
▪ 6 Obeys commands
o Values
▪ GCS ≥ 13 -- Mild
▪ GCS 9-12 -- Moderate
▪ GCS ≤ 8 -- Severe
• Intubate
▪ GCS > 8 – Nasogastric (avoid in base of skull fractures) or orogastric tube
- Coma
o GCS ≤ 8
o Types
▪ Metabolic.: Reactive pupils + low GCS
• causes: METABOLIC
- major organ failure
- electrolyte or endocrine disorder
- toxins or temperature (hypothermia)
- acid disorder
218
- base disorder
- O2 - hypoxia
- lactate
- insulin or inf.
- cardiac output decr.
▪ Primary CNS problem: Unreactive pupils + low GCS
- Coma of unknown cause:
o give TONG
▪ Thiamine (B1)
▪ O2
▪ Naloxone
▪ Glucose
- Head injury
o Cushing’s Triad – in advanced states of incr. ICP (brain herniation is imminent!)
▪ irregular resp. (resp. depression)
▪ Bradycardia
▪ HT (incr. systolic, decr. diastolic)
o level of consciousness – Most important
- Confusion
o Postop. confusion and disorientation = Acute delirium
▪ causes
• MC = hypoxia
- due to:
▪ atelectasis
▪ analgesics
▪ anesthetic from surgery
▪ Mx/ Dx – Pulse Oximetry
o Other causes
▪ Sepsis
• MC cause of confusion in elderly – UTI
▪ Alcohol withdrawal
▪ hyponatraemia, hypoglycemia
▪ arrhythmias
▪ hypotension
o Confused elderly person
▪ Investigation
• Urine microscopy
• Blood culture
• FBE+ ESR
• Blood glucose
• Urea, creat. and elctrolytes
• Ca and PO4
• TFT
• LFT
• serum B12 and folic acid
• ECG, troponin
• Chest X-ray
219
• CT brain
• Syphilis serology
• ABG
- Brain lobes function.
o Parietal
▪ types
• Dominant
- simple arithmetical calculations (acalculia)
- writing (agraphia)
- right/ left orientation + touch his right ear with his left hand (left-
right disorientation)
- name his fingers (finger agnosia)
• Non-dom.
- recognize digits and letters written in his palm (=graphestesia)
- copy an object that is drawn: house, flower, clock, 2 pentagons
that are overlapping (constructional apraxia)
- recognize shape of objects – astrognosis, tactile agnosia
o Temporal lobe
▪ Memory
• Short term – first affected in Alzheimer
• Long term
o Frontal lobe
▪ Grasp reflex
▪ Verbal fluency – say 7-15 words that start with a certain letter
▪ Interpretation of proverbs
▪ Similarities and differences between objects, people, etc.
▪ Motor sequencing: fist-edge-palm - 5 times
o Occipital lobe
▪ Visual field – examination
- Horner syndrome:
o Due to lesion or compression of one side of the cervical or thoracic sympathetic chain,
which generates symptoms on the ipsilateral side of the body.
o symptoms:
▪ Triad:
• Miosis
• Partial (palpebral) ptosis
• Loss of hemifacial sweating
▪ (PAMELa): Ptosis, Anhydrosis, Miosis, Enophthalmos & Loss of ciliospinal reflex
o causes:
▪ 1. Tumors - often bronchogenic carcinoma (Pancoast tumor) of apex of lung
• T1 compression: affects small muscles of hand (can’t oppose thumb
against other fingers) + sensitivity affected on inner arm (above elbow)
▪ 2. PICA
▪ Syringomyelia
▪ Cluster headache - combination termed Horton's headache [6]
▪ Trauma - base of neck, usually blunt trauma, sometimes surgery.
▪ Aortic aneurysm, thoracic
220
o degen. of the posterior (dorsal) column of the spinal cord, which carry information that
help maintain a person's sense of position (proprioception), vibration, and discriminative
touch. Triad: Unsteadiness of gait + urin. Retention + lightining pains.
o Sympt. start after decades
o Rx
▪ Penicillin
- GB Syndrome
o Acute inflam. neuropathy (autoimmune) (AB destroy the myelin) of peripheral nerves,
Triggered by an infection
▪ URTI
▪ dig. – Campylobacter
o inquire about SLE, HIV, Vaccination
o Sx
▪ Progressive ascending bilat. paralysis: Legs -> Arm –> Face
▪ Hypo- to areflexia
▪ Cranial n. palsies – bulbar lesions (I, II and VIII are never affected)
▪ Paresthesias, sensory nerve loss
▪ Dysautonomia
• Tachycardia/ bradycardia
• hT/ HT
• Urinary retention
o Dx
▪ Immune stimmulus should be detected
• Monospot test - EBV
• Cold agglutinins
- CMV
- HIV
▪ 1. to confirm - CSF
• Protein ↑
• Cells normal
- WBC are not incr. – 90%
- Mononuclear cells incr. – 10%
▪ 2. Nerve conduction studies
• + EMG
o Mx
▪ Monitor resp. fc. with Forced Vital Capacity
• if FVC < 1 L -> assisted resp. (risk of resp. failure) – 30%
▪ Physiotherapy
• prevent contractures of the muscles
▪ plasmapheresis
▪ IV gamaglob. -> ↓the recovery time
▪ Steroids are NOT beneficial
- Botulism – flaccid type of paralysis, descending
- Myasthenia gravis
o autoimmune dis. which affects muscle strength
o assoc. with
▪ thymic tumours
222
- Sydenham chorea
o in Rheumatic fever + SLE
o invol. dancing moments, patient is very emotional, hypotonia
▪ rapid, uncoordinated jerking movements affecting primarily face, hands & feet
- Huntington’s disease
o AD – mutation on chromosome 4
o causes neuronal loss in frontal lobes and other parts of brain
o movement disorder (Chorea) + behaviour changes + dementia
o progression in generation - earlier onset of disease in descendents
- CT brain
o indications
▪ loss of consciousness (LOC)
▪ post traumatic amnesia
▪ vomiting or raised ICP
▪ focal neurol. sign
▪ otorrhea, rhinorhea
▪ fits, seizures
▪ penetrating wounds
▪ on warfarin
o careful in children -> incr. risk of brain tumor
- MRI – only for spine or posterior cranial fossa (brain)
- acute disseminated encephalomyelitis or postinfectious encephalomyelitis, a demyelinating
disease of brain and spinal cord, possibly triggered by vaccination or viral infection
- Cerebral palsy
o Static, non-progressive
▪ Hypoxia -> ischemic injury -> hypoxia disappears, injury stops progressing
o cause
▪ 80% antenatal cause
• Maternal inf. – chorioamnionitis
• Congenital inf. – TORCH
• Prematurity - periventricularmalacia
▪ 10% intrapartum cause (birth asphyxia)
▪ 10% postpartum cause (asphyxia, meningitis, etc.)
o Sx
▪ problem in muscle tone (usually spasticity – biplegia MC in preterm,
quadriplegia in term), posture, movement (can’t walk properly)
▪ epilepsy – 30%
▪ intellectual disability
▪ impaired vision
▪ impaired hearing
Dermatology - OK
o Description
▪ general outlook of patient
▪ location and pattern of lesions
▪ morphology of lesions
• well defined/ poorly defined
• mono/poly morphous
224
- Acyclovir
- Silver nitrate
• Oral acyclovir, famcyclovir, etc.
- only within 72 hrs of rash
- 5 days
- doesn’t cure but shortens the episode
• Analgesia
- topical – lignocaine, povidone iodine
• Ice packs
• Wear loose clothing
▪ Cx
• Postherpetic neuralgia
- Rx - amytriptiline
o if recurrent HSV, do HIV testing
- HIV – Murtagh 259
o least risk of inf. = hemophiliacs
o after travel to Thailand
o Stages:
▪ Primary HIV inf. = Erythematous maculopapular rash all over body
• Mononucleosis-like inf., with Splenomegaly and lymphadenopathy
• MCQ: fever and generalized rash erythematous maculopapular, all over
the body, mainly face and trunk, non itchy, no Hx of allergy or drugs, in
30 yr old man, fashion consultant, onset 2 days ago, splenomegaly,
lymphadenopathy. In sexual rship with another man for 2 yrs, without
condoms.
▪ Chronic HIV inf.
• 2 wks – 20 yrs.
• chronic diarrhoea, axillary & inguinal lymphadenopathy, failure to
thrive
▪ AIDS
o HIV antibody testing should not be performed routinely on pts but only after obtaining
their informed consent and after pretest counselling
o Dx
▪ Screening – ELISA:
• Positive - repeat in 12 wks
• Unprotected intercourse + negative – repeat in 12 wks
▪ Confirmation – Western blot (ELISA can be positive in EBV inf.)
▪ evaluate with: Viral load + CD4
o Cx
▪ CMV retinitis
▪ Pneumocysitis carinii pneumonia
▪ Candida inf. (Esophagitis)
▪ cryptosporidiosis – diarrhoea
▪ Cryptococcus neoformans = fungs opportunistic inf. in immunsuppressed (HIV,
kidney transplant, TB), complicated with cryptococcal meningitis
• CSF findings – like in viral meningitis
- Rx – Amphotericin B IV
227
o Mx
▪ CD4 < 200 - prophylaxis
- Scabies (scabie, riie)
o elderly in retirement places, homeless
o Mite - Sarcoptes scabiei
o Erythematous papular rash, intensely itchy -> scratch marks
o itch worse at night or when the body is worm (after shower)
o wrists, hands and web spaces (between fingers), male genitalia, elbows, feet, axilla,
ankles, nipples
o Norwegian scabies – crusted form, with millions of mites
▪ nursing homes
▪ AIDS
o transm.
▪ skin to skin
▪ clothes, bed sheets
▪ sexual contact
o MCQ: itchy rash on skin of 19 yr woman
o Dx
▪ clinical
▪ confirmed: Scrapings seen under microscopy
o Mx
▪ Permethrin cream 5% or
▪ Benzyl benzoate 25% emulsion
• apply all over body for whole night, wash in morning
▪ avoid hot bath or scrubbing body
▪ treat everybody in house
▪ wash the clothing and bedding in hot water and expose to sun
- MCQ: Pt wid scabies treated wid permethrin. After 1 month symp again developed. What next tt
option ?
a) repeat permethrin
b) corticosteroids
- Re treat the patient again after 1-2 weeks
- Prolonged itching after scabies is normal and usually requires NO ttt or cortisone
- Head lice (paduchi)
o Pediculus humanus capitis
o white spots in hair
▪ unlike dandruff, the white spots can’t be brushed off
o Rx
▪ Pyrethrins foam/ shampoo
▪ Permethrin
- Fleas (purici)
o itchy erythematous maculopapular lesions, grouped in clusters
o on arms, forearms, leg, waist
- Bed bugs
o 3 or more bites along superficial blood vessels – maculopapular red lesions
o extremely itchy
228
- exanthematous dis.
DISEASE INCUBATION PRODROME RASH OTHER FEATURES &
PERIOD INFECTIVITY
(DAYS)
Chickenpox 10-20 None Macules, papules, Infective until vesicles are crusted
(Varicella) vesicles & pustules of over
different ages
Measles 9-14 Cold, cough, Red, confluent, Koplik’s spots, may be quite ill
Paramyxovirus conjunctivitis maculopapular
Rubella 14-21 None Discrete ink, Occipital & preauricular
(German maculopapular lymphadenopathy. High fever.
measles or 3 Fetal abnormality
day measles)
▪ rash (exanthem) on face which spreads to trunk, limbs and usually fades after 3
days (known as 3-day measles). The facial rash usually clears as it spreads to
other parts of the body. The rash of German measles is typically pink or light
red. The rash causes itching and often lasts for about 3 days.
▪ Other symptoms include low grade fever, swollen glands (sub occipital &
posterior cervical lymphadenopathy), joint pains, headache and conjunctivitis.
▪ if mother is infected within first 20 wks of pregnancy, child may be born with
congenital rubella syndrome, which entails a range of serious incurable illnesses.
o Infectious mononucleosis (kissing disease, glandular fever) - from Epstein Barr Virus
▪ Sx (MCQ 2077 p70)
• Triad = Sore throat + fever + lymphadenopathy
• Maculopapular rash – 5%
- but 90-100% of pts have prescribed ampicillin or amoxycillin,
develop an extensive rash, with a purplish tinge!!
• Sore throat, pharyngitis (MC), tonsilitis, petechiae of palate. MCQ
• fever, fatigue, weight loss, malaise, loss of appetite.
• lymphadenopathy
• Splenomegaly – 50%
• Hepatitis, jaundice, hepatomegaly – 5-10 %
• Hemolysis
• Resembles acute HIV, CMV and toxoplasmosis inf.
▪ Dx
• FBE: lymphocytosis (50%) with > 10% atypical lymphocytes (incr. in
bands – immature lymphocytes) (atypical lymphocytes are incr.)
• Confirmed by Monospot or Paul-Bunnell test (for heterophil AB): Only
positive in 70% in first wk. That why repeated.
- False pos. in hepatitis, Hodgkin’s lymphoma, acute leukemia
• EBV IgM – better than Paul-Bunnell test – Murtagh 805
▪ Cx
• Splenic rupture (feels faint, collapses)
• Chronic fatigue syndrome (myalgic encephalomyelitis, chronic Epstein-
Barr syndrome, chronic neuromuscular viral syndrome)
- > 6 months
- extreme exhaustion, headache, muscle ache, poor concentration
and memory, hypersomnia, arthralgia, tender swollen lymph
glands, subjective feeling of fever, sore throat
▪ Rx
• rest, reassurance, psychological support
▪ Rx
• Bed rest
• Symptomatic treatment.
o Viral exanthema (4th syndrome, Duke’s dis.)
▪ caused by various viruses (enterov.)
▪ rubella-like rash, confined to the trunk
• no. of skin rashes:
- Measles
- Scarlet fever
230
▪ > 4 yrs :
• if EBV – no A/B
• if GAS
- if GAS:
▪ Penicillin
▪ if allergic, erythromycin
- Scarlet fever (Scarlatina)
o children, aboriginals (Strepto. inf. in general)
o GA Strepto. pyogenes which produces erythrogenic toxin (exotoxin)
o Sx
▪ prodromal sympt.: fever, sore throat, malaise, then
▪ rash appears on 2nd day, sand-paper like under touch, blanches on pressure,
spares face, palms and soles
• is worse in skin folds. These Pastia lines (where rash runs together in
armpits and groin) appear and can persist after rash is gone.
▪ Circumoral pallor
▪ Strawberry tongue
▪ recovers in 5 days – fine desquam. on recovery
o Dx
▪ PR interval can be prolonged -> may be evolving towards rheumatic fever
o Cx
▪ Rheumatic fever
▪ GN
▪ Erythema nodosum
o Rx
▪ Phenoxymethylpenicillin 250-500 mg orally q.d.s. for 10 days
- Rheumatic fever
o after a Streptococcus group A (S. pyogenes) inf.: tonsilitis, scarlet fever
o indigenous population
o Sx
▪ acute onset with fever, joint pains, malaise
▪ flitting arthralgia mainly in leg (knees, ankles) and arms (elbows, wrists)
• one joint settles as the other one gets affected
o Dx
▪ 2 or more major Jones criteria
▪ 1 major + 2 or more minor Jones criteria
▪ Major criteria:
• polyarthritis
• carditis
- MC affected = mitral valve
- can lead to congestive heart failure
• Sydenham’s chorea
• subcut. nodules
• erythema marginatum
▪ Minor criteria
• arthralgia
• ECG – prolonged PR interval
234
▪ bald head
▪ including lips (lower)
• BCC and melanoma rarely on lip
- neck
- + oral cavity, tongue, tonsil, genitalia
• more keratotic and more scaly
• MCQ: lesion on lip of 35 yrs son (SCC)
• Squamous - upper layer of skin
• although they metastasise to lymph nodes, there is no evidence that
prophylactic lymph node dissection is beneficial
• initially firm thickening of skin --> hard nodules --> ulcerate!
• Premalignant lesions
- Solar keratosis = Actinic keratosis JM1365
▪ mildest lesion caused by exposure to sun
▪ with atypical cells
▪ on areas most exposed to sun
▪ back of hands – very common
▪ involves epidermis and dermis
▪ scaly lesion with hyperemic basis that bleed easily with
trauma
• Auzpitz sign – bleeding when scratching it
▪ Rx
• Cryotherapy – liquid nitrogen
• Excision
▪ if left untreated, 15-20% progress to SCC
- Burns - burn scars
- Chronic ulcers
- Leucoplakia
▪ with dysplasia
▪ non-smoker
▪ white patch, hard to take off
- Bowen’s dis. = SCC in situ (slow growing intra-epidermal CA)
▪ scaly red plaque with clearly defined margins
▪ not much related to solar damage
▪ lower legs of females
▪ Rx
•
• Depth
- in situ – Bowen
- invasive
• Rx (Q 18 block 2 bridging course) MCQ
- Surgical excision in depth and laterally.
▪ 4-5 mm margin if diameter < 1 cm
▪ > 5 (10) mm margin if diameter > 1 cm
▪ BCC (not causing keratin scaling MCQ)
• MC skin CA in Aus.
• 80% males
236
- SCC (only in sun exposed areas)= BCC in both exposed and non
exposed areas.
- ear
▪ outer helix – SCC
▪ inner helix - BCC
o Melanotic
▪ Malignant melanoma
• MCQ: pigment mole on trunk of a 30 yr old woman; dark spot was there
for many year (many born with it) but in last few months spot has
become darker
▪ mainly in elderly
▪ slow growing intra-epidermal
▪ mainly on sun exposed area
▪ Rx - excision
- Superficial spreading
▪ MC type – 70%
▪ with strking color variation
• multiple or unusual colors – poorer prognosis
▪ grows horizontally (not vertical)
▪ Rx - excision
- Nodular – 20% (called so bc its elevated and looks nodular)
▪ vertical spread but no radial growth
▪ easy to misdiagnose (DD pigmented BCC)
• but variable colors, irregular borders
▪ blueberry appearance
▪ most dangerous
▪ EFG mnemonic:
• elevated
• firm
• growing for more than 1 month
- Acral lentiginous – 2.5%
▪ MC in palms and soles and distal phalanges
▪ poor progn.
▪ MC in dark skinned people
▪ macule -> then a nodule surrounded by a pigmented
halo
- Amelanocytic
▪ skin colored
▪ poor progn. – diagn. too late
• can involve lymph nodes – satellite nodules = late sign
• Metastases
- lungs
- liver
- brain
- small bowel -> can cause intussusception
• Dx
- ABCDE
▪ asymmetry
▪ border is irregular
▪ color – blue-black +/or variety of colors
▪ diameter – when 1st seen usually at least 7 mm in diam
▪ elevation – indicates invasion
• Rx
- Suspicious lesion MCQ
▪ local excision biopsy – 2-3 mm till mid fat layer –> send
to histopathol.
• if malignant melanoma:
239
o Rx
▪ excision + biopsy, because it looks a lot like SCC (to exclude SCC)
o Seborrheic keratosis (senile wart) --- Benign (JM 1364)
o waxy texure, painted on appearance
o very superficial, epidermis only
o like a sultana pressed on the skin
o usually multiple
o can be raised (stucco – on lower legs) or plaque like lesion with waxy texture
o hemosiderin causes brownish spots on it
o Rx
▪ excision – only if asked for, for cosmetic lesions
- Molluscum contagiosum – on whole body (JM 1363)
o Self limiting, Pox Virus
o Single or multiple lesions: vesicular papules with central umbilication.
▪ on any part of body
o Kissing lesion: Spread to areas of skin contact, e.g., from chest wall to upper arm.
o No systemic symptoms
Advice to parents
• Give the child a shower instead of a bath (the child can spread the virus to other parts of the body).
• Don’t share baths.
• Wash and dry bath toys after use.
• After showers/baths/swimming, dry areas with molluscum last and don’t share/re-use towels.
• Wash hands after touching molluscum.
• Don’t exclude children from school or playing together. MCQ
• If swimming (Avoid swimming in public pool MCQ) , reasonable precautions include
covering the lesions with waterproof tape and having personal kick-boards.
o Mx
▪ Difficult to treat
▪ Reassurance: will resolve within 1 year with no scarring (MCQ)
▪ Pin pricking – if only a few lesions
▪ Cryotherapy – variable success
- Skin infection after trauma
o Staph. Aureus not Strep pyogenes (MCQ)
o Clostridium perfringes
o Pseudomonas aeruginosa - anaerobes
- Longstanding subcutaneous swelling
o Lipoma – diagn. diff. with epidermoid cyst
▪ common benign tumor of mature fat cells in the subcut. tissue
▪ Sx
• soft, well defined, lobulated, painless, rubbery in consistency, freely
mobile
- except trunk and back – attached to skin
• may be one/ many
• any site – MC limbs (arm) and trunk
▪ family Hx.
▪ pain + tender = angiolipoma
▪ Sx
241
• reassurance (benign)
• removal – for cosmetic reasons
- recurrance is common if incompletely removed
o Ganglion (cyst)
▪ wrist
▪ deeply placed subcutaneous lump around joints or tendon sheets
▪ more proeminent on tendon contraction or joint movement.
▪ do not communicate with adjacent joint (only to one they are located on)
▪ Rx
• Aspiration – if cystic
o Bursae
▪ cystic sacs between skin and underlying bony prominences
• inf. => bursitis (e.g. olecranon)
o Epidermoid (Sebaceous, Keratinous) cyst (JM 1360)
▪ any age, any site
• MC – back
▪ traumatic origin
▪ filled with a fatty, white, semi-solid material called sebum
▪ sometimes associated with hereditary syndrome – e.g. Gardner Syndrome
▪ when infected = Cock’s peculiar tumor (on head)
• resemble SCC
▪ central punctum with keratin – attached to skin
▪ Rx
• No inf.
- enucleation
• inf.
- incision + drainage
- Dermoid cyst = congenital inclusion cyst
o true hamartomatous cyst
o in ovaries, cranium, spine
o thin wall cyst
o with fatty material and occasionally hair, even teeth
o at any age
o on face, around the eyes – attached to underlying periosteum
o Rx – excision
- Warts (over growth of skin) JM 1361
o caused by HPV
o types:
▪ common warts – HPV 2, 4
• fingers, elbows, knees
▪ plane warts – along scratch lines
▪ filiform warts – face, neck
▪ digitate warts - scalp
▪ plantar warts – HPV 1, 2, 3, 4
▪ anogenital warts – HPV 6, 11
• Condyloma accuminata (MCQ Rx in pregnancy)
- Rx Podophyllotoxin if fails… Cryotherapy, laser, electrocautry
242
▪ C/S
▪ chloral hydrate
▪ iodides or bromides
▪ Lithium
▪ Antiepileptics – e.g. Phenytoin
▪ Quinine
▪ OCP
o Response to any Rx occurs after 2 months or later
o types
▪ Mild and moderate
• Rx
- Basic regeimn – 3 months, then review
▪ Benzoyl peroxide – in morning +
▪ Tretinoin or isotretinoin cream at night (causes
photosensitivity)
• only specialist can prescribe it
• causes atrophy of sebaceous glands
• teratogenic –> do a pregnancy test first!
- alternative Rx/ if recalcitrant
▪ topical clindamycin
▪ topical erythromycin
▪ Inflammatory acne (moderate to severe papulopustular) – min. 4 mths (std. 6
mths)
• Rx
- Oral tetracyclin or doxycyclin
- Erythromycin
▪ Severe (nodular/ cystic) or non-responsive
• Rx
- Oral isotretinoin
- Spironolactone – antiandrogenic effect
- Dapsone – antibact. (leprosy), anti-malleric, antiinflam.
- OCP – second line
o additional advice
▪ usually not assoc. with food
• if it does (e.g. chocolate) –> avoid that food
▪ avoid oily and creamy cosmetics
▪ avoid picking and squeezing blackheads
▪ UV/ sun light helps
- Rosacea (JM 1326)
o unknown etiology
o middle aged women
o acneiform lesions on forehead, cheeks, nose, chin - with papules, pustules & erythema
o flushing and blushing precedes the rash
o telangiectasia, erythema
o photosensitivity, hypertrophy of soft tissue on nose
o improved by OCP
o worsened by topical C/S
247
o Rx
▪ 1 – Tetracyclin
▪ 1 - Erythromycin
- Dermatitis herpetiformis
o Herpes simplex-like vesicles, erupt at dermatoepidermal junction
o Extremely itchy
o Mainly over extensor surfaces of elbows, knees, trunk, shoulders
o MC assoc. with coeliac disease
o Skin biopsy is diagnostic
o Rx
▪ gluten-free diet
▪ dapsone 100 mg/ day
- Lichen planus (JM 1305)
o Idiopathic inflam. condition found on flexor surface of wrist and hand
o occasionaly triggered by drugs or Hep. C infection
o can affect skin, hair, nails, oral and genital mucosa
o Violaceous polygonal flat topped papules that show lacy white lines (Wickham’s striae)
o can form ulcers
o risk of malignant transformation of oral l.p. needs to be considered, especially in
patients with chronic ulcers and Hx of tobacco use
o Mx
▪ skin eruptions resolve in 6-9 mths, but leave discolored marks and no scarring
▪ moderately potent topical C/S ointment
▪ if not improved, oral prednisolon
- Lichen simplex chronicus: Fibrosis and thickening of skin due to excessive itching caused by
eczema, seborrhic dermatitis, psoriasis and dermatitis a process called lichenificaton.
- Lichen sclerosus (JM 1163)
o Premalignant for SCC of vulva
o Reticular white (sclerotic) lesion in vagina or genital area causing irritation, pruritis,
o Mx
▪ must do biopsy
• if no SCC is Dx – still life long surveillance.
- Nappy rash
o MC cause: simple irritant dermatitis
o itchy – fungus
o non itchy – seborrheic dermatitis
Common causes Uncommon causes Rare causes
Irritant - MC Staph. inf. Tinea
Candidiasis Strep. inf Gluteal granuloma
Seborrheic dermatitis Herpes simples Zinc deficiency
Psoriasis
Atopic dermatitis
o irritant nappy rash
▪ loss of epidermal barrier fc. due to overhydration and exposure to fecal
enzymes
▪ later becomes colonized by candida
o Mx
248
o These yeasts are normally found on the human skin and only become troublesome under
certain circumstances, such as a warm and humid environment
o Rx
▪ selenium sulphide
▪ clotrimazole, ketoconazole
- Portwine stain
o cavernous haemangiomas
o can have vasc. malformation = Sturge – Weber syndr.
▪ Rx – laser therapy
▪ trigeminal n. affected
- Erythema marginatum – rheumatic fever
- Erythema nodosum (M 259, fig. 30.1)
o acute inflam. immunol. reaction
o resolves in 2-3 wks, with discoloration but no scarring
o tender, bright, red, raised subcut. nodule on shin (usually bilat.) below knee
o can be seen in:
▪ Sarcoidosis
• Dx – chest X-ray
▪ IBD - Crohn
▪ autoimmune dis. – SLE, rheumatoid arthritis, Behcet’s syndrome
▪ inf.: strepto., viral, TB, leprosy, fungus, toxoplasmosis
▪ drug induced – sulphonamide, OCP, tetracyclines, bromides
▪ TB
▪ lepromatosus leprosy
▪ Mycoplasma pn.
▪ lymphoma, leukemia
▪ idiopathic
o Rx
▪ bed rest
▪ RICE and NSAIDS
▪ Prednisolone
- Erythema multiforme (JM 1341)
o very serious condition – can evolve to a Stevens–Johnson syndrome
o mild to severe forms
o causes
▪ HSV
▪ mycoplasma
▪ drugs
• Sulphonamides
• Trimetoprim
• Allopurinol
• NSAIDs
• anticonvulsants: phenytoin, lemotrigin
• nifedipin?
o macules, papules, wheals, vesicles (hands, feet, face, mouth) – lesions with raised edges
and central scar (target appearance)
▪ round to oval triphasic iris-like lesions known as target lesions
250
▪ fungal inf.
▪ …
o types
▪ Areata (Patchy, non scaly) – one or more discrete circular areas of hair loss
• can occur anywhere on body (not just on head)
• triad: patch of complete hair loss + clean scalp + exclamation-mark
hairs
▪ Totalis – involves whole scalp
▪ Universalis – involves eyebrows and eyelids as well
o triggers
▪ severe febrile illness
▪ severe emotional stress
o Dx
▪ FBE – Hb, thyroid, iron, zinc
▪ biopsy of scalp
▪ examine hair under microscope
• exclamation mark sign
▪ pull hair sign
▪ examine nail – psoriasis
▪ where else in body is hair loss: eyebrow, chest, etc.
o Rx
▪ aim: regrowth of hair + pyschological support
▪ initial – potent topical C/S Betamethasone 0.5% – 1 – 2 times/ day
▪ small lesion – intralesional C/S
• triamcinolone acetonide
▪ oral C/S if topical failed
▪ topical dithranol
▪ topical minoxidil
▪ adjuvant
• topical immunotherapy
• UV radiation (PUVA)
▪ drugs – each used for 3-6 months before switching to another one
o prognostic
▪ 33% chance of complete regrowth within 6 mths
▪ 50% chance of complete regrowth within 1 yr
▪ 80% chance the cured people will relapse
- 4 conditions that can be confused with alopecia:
o Tinea capitis
▪ scaly! (not clean skin as in alopecia)
o Trichotillomania
▪ they don’t have clear patches of hair loss, but patches with short/ long hair
▪ Hx of stressor (in family)
o Lichen planus – causes permanent scarring of scalp
o Discoid cutaneous lupus – causes permanent scarring of the scalp
- any hairy lesion on skin = benign until proven otherwise
Nail problems
- Ingrowing toe nail/ onychocryptosis:
253
▪ no edema
▪ less granulation tissue
▪ loss of hair
▪ ABI (Ankle brachial index) < 0.5-0.8
▪ Hx of arterial disease, smoking, DM
o Rx
▪ we need patient’s compliance
▪ promote clean granulation tissue
▪ appropriate cleansing and dressing
• avoid antiseptics and soaps
• just wash with NS
• use intrasite gel and Benzoyl peroxide
• occlusive bandages with Zinc oxide
▪ in infection or cellulitis - A/B
▪ compression banding is mainstay of Rx
• from base of toe (toe not included) to just below knee
• depending on ABI
- ABI < 0.8 – caution
▪ mild compression for 0.6-0.8
▪ Bed rest, elevation above heart level
▪ RICE:
• Rest Ice Compression Elevation
▪ encourage early mobilization and good nutrition
▪ if edema elevate leg + diuretics
• ulcers will not heal in edema
▪ treat varicose veins
▪ Unna`s boots - compression stockings + unna`s paste = 15% Zinc oxide
o + Metabolic Ulcer
▪ DM – (Neuropathic) = Trophic ulcer
• Due to diabetic neuropathy causing loss of sensation which follows an
injury of which pt is unaware.
• Deep punched out lesions over pressure points.
• MC site – ball of foot under 1st metatarsal head. Sometimes heel may
also be affected.
• Ulcers may extend to bones and joints.
• Prone to secondary infections.
• Rx
- control diabetics.
- infection with appropriate antibiotics.
▪ (IV Flucloxacillin + IV Gentamycin + IV Metranidazole)
- Sensory loss: Gloves and stockings
- Dx to confirm cause – Arterial Doppler
o + Pyoderma gangrenosum
▪ deep ulcers, usually on legs in IBS, RA, multiple myeloma, etc.
▪ oral C/S as Rx of choice in pyoderma gangrenosum (skin manif. in ulcerative
colitis)
o Infections. – Smelly discharge
256
o Dx
▪ Mantoux test:
• delayed hypersensitivity test
- evaluated after 72 hrs
• < 5 mm = negative
- do vaccination!
• 5-10 mm = past vaccination
• > 10 mm = positive
- evidence of inf.
▪ active
▪ inactive – latent TB
▪ chest X Ray
▪ if productive cough
• sputum – acid-fast bacili
- stain – Ziehl Nielson
- culture
▪ TB specific – interferon gama release assay
▪ bronchoscopy and biopsy can be considered
▪ pleural effusion – with monocytes
o Mx
▪ only by specialist! (not by GP)
▪ notifiable dis. -> Dept. of Human Services
▪ contact tracing by Dept. of Human Services
▪ bacterial confirmation and drug susceptibility testing first – only then will be
Rx
▪ no isolation!
o Rx
▪ Active TB (RIPE)
• 4 drugs (rifampicin, isoniazid, pyrazinamide, ethambutol) for 2 mths
• then 2 drugs (rifampicin and isoniazid) for 4 mths
- total 6 mths
▪ Latent TB (Mantoux positive, no sympt., no X Ray features)
• when active TB is excluded: isoniazid mono-therapy for 6-9 mths
• treat only specific groups:
- recent TB converters (Mantoux test neg., recently – within last 2
yrs - became pos.)
- children, adolescents
- close contact with patient smear-TB positive
- patient with HIV, DM uncontrolled, CRF, Ch liver Failure
- overseas trained people (immigrants)
▪ Pregnant (IRE)
• start Rx ASAP
- pyrazinamide not recommended
- isoniazid, rifampicin, ethambutol – 9months
▪ don’t cross placenta
▪ no teratogenic effect
▪ minimal conc. in milk – breast feeding is NOT CI
258
▪ Isoniazid resistant TB
• Streptomycin or Amikacin instead of isoniazide
Diarrhoea and traveller’s disease
Food poisoning
- Diarrhoea – Murtagh 470, Oxford 390
o Staph. aureus - 1-6 hrs
o Vibrio cholera – 2 hrs – 5 days
▪ Rx – Doxycycline
• Pregnant: Amoxycillin
o Clostridium perfringes – 8-24 hrs
o Clostridium botulinum – 12-36 hrs
▪ Honey, canned food
▪ Botulism – descending paralysis
o Salmonella – 12-48 hrs
▪ can return to work after 3 consecutive weekly negative stool cultures
▪ usually no A/B if not inflammatory (no blood, no fever) – just observe, give fluids
▪ if severe: ciprofloxacin
o E. coli – 12-72 hrs
▪ Rx – in moderate/ severe cases: Norfloxacin, Ciprofloxacin
o Shigella – 2-3 days
▪ Bacillary dysentery: blood in stool, fever
▪ Rx – moderate to severe: cotrimoxazole., norfloxacin
o Campylobacter – 2-5 days
▪ Rx – if prolonged: norfloxacin
o Giardia lamblia – 3-25 days
▪ MC non-viral gastroenteritis
▪ profuse watery diarrhoea, foul smelling with undigested food
• no mucous, no blood, no fever
▪ steatorrhoea, malabs. syndrome
▪ abd. distension, cramps
▪ wt. loss, FTT
▪ after camping
▪ Dx – stool microscopy
▪ Rx – tinidazole, metronidazole
o Entamoeba hystolytica – 1-4 weeks
▪ amoebiasis
• dysentery (blood, mucous in stool)
• Rx - metronidazole
o Clostridium difficile – 1-7 days
▪ Pseudomembranous colitis
• after antibiotics (Clindamycin, Cephalosporins, Penicillin based AB, like
amoxycilin)
• bloody diarrhoea, GI perforation, toxic megacolon
• Rx:
o Stop A/B
o Metronidazole
o Vancomycin
259
- Dx
▪ First 10 days ---- Blood culture
• Serology
▪ Later – urine/ stool
- Cx
▪ GIT bleeding
▪ GIT perforation
- Rx
▪ Ciprofloxacin
▪ if fever, rigors – MC = Malaria
• Malaria = returned traveller (most of them within 2 months of return) +
fever. P. Falciparum is most severe form having incubation period 2 wks.
P vivax has a long incubation period.
- return from Vietnam
- Sx
▪ Triad: fever + chills + headache
▪ abrupt onset with high fever, chills, rigors, sweating,
headache, abd. pain
▪ atypical presentation: diarrhea, abd. pain, cough,
vomiting, jaundice
▪ arrhythmia
▪ huge hepatomegaly, splenomegaly
- Dx
▪ thick and thin films (from blood)
▪ FBE: monocytosis + thrombocytopenia, Normocytic/
normochromic anemia
▪ Cerebral malaria: Periventricular changes on CT scan
- Rx
▪ admit
▪ supportive
▪ antimalarial drugs
• P. vivax, P. ovale, P. malaria – Chloroquine +
primaquine
• Chloroquine-resistant malaria -> artimisinin,
artemether, mefloquine
o artimisinin also for pregnancy & kids
• Uncomplicated P. falciparum - quinine +
doxycycline or mefloquine
• complicated P. falciparum (severe) – quinine IV
Chemoprophylaxis:
A. Doxycycline: from 2 days before travel until 2
weeks after return
B.Chloroquine: from 1 week before travel and
continued for 4 weeks after leaving endemic area
• Rx - aspirin
o Cx
▪ Thrombosis, due to blood thickening: MI, stroke, DVT, Budd-Chiari syndrome
o Dx criteria
▪ Major criteria
• incr. red cell mass
- Man 36ml/ kg
- Woman 32 ml/ kg
• SaO2 92%
• Splenomegaly – 60% - most characteristic
▪ Minor
• Platelets > 400,000
• WBC > 1200
• leucocyte Al PO4 > 1000 ?
• serum B12 > 900 micrograms/ ml ?
• unbound B12 > 2200
o Rx
▪ Venesection
- Ig stuff
o Ig that crosses placenta = IgG
o Ig related to Grave’s disease = IgG
Coagulation problems
INR, PT (extrinsic APTT (intrinsic & common Platelets Bleeding time
pathway) pathways)
DIC Incr. Incr. Decr. Incr.
Heparin Incr. Incr. N N
Warfarin, Vit. K def. Incr. Incr. N N
Hemophillia A N Incr. N N
Von Willebrand N Incr. N Incr.
Thrombocytopenia N N Decr. Incr.
HSP (vasculitis) N N N N
- DIC
o Sx
▪ Bleeding from venopuncture sites, hematuria, ↑bruising
o Dx
▪ ↓Platelets & fibrinogen
▪ incr. D-dimer = incr. fibrin degradation products
▪ + schizocytes = fragmented RBCs
o Rx
▪ fresh frozen plasma
▪ IV heparin – to stop clotting in peripheral vessels
- Bleeding problems
o Haemophilia – X-linked recessive (only in boys)
▪ A
• Fact. VIII deficiency, more common
268
• Sx
- Triad: spontaneous hemarthrosis + muscle bleeds + delayed
bleeding
- spontaneous hemarthrosis, MC in knees, ankles and elbows =
pathognomonic
- many are seropos. for HIV, HBV, HCV – transmission through
factor VIII
▪ Low platelet count – suspicion of HIV-assoc. ITP
• Rx
- Avoid aspirin
- Cryoprecipitate (contains fact. VIII and vWF)
- Fact. VIII concentrates
▪ B (Christmas dis.)
• fact. IX (Christmas factor) deficiency, less common
• Rx
- recombinant fact. IX concentrates
o von Willebrand disease --- AD
▪ Def. of von Willebrand factor => affects
• transport of fact. VIII
• platelet adhesion to each other and to vessel walls
▪ MCQ: in girls, but actually equal in both genders
▪ MC bleeding disorder (1%)
▪ mild, with excellent prognosis
▪ bleeding tendency aggravated by aspirin
▪ Sx
• Triad: ↑bleeding 1. Incision, 2. Dental, 3. Mucosal
• Man
- epistaxis
- hemarthrosis (rare)
• Female MCQ 2051 p 132
- long and intense first period (menarche) = menorrhagia
- epistaxis
- hemarthrosis (rare)
▪ Dx
• Prolonged Bleeding time
• Prolonged APTT
▪ Rx
• avoid aspirin!
• before dental or surgical procedures + to stop existing bleeding use:
- Desmopressin acetate (DDAVP –↑release of vWF from vessel
walls)
- Fact. VIII concentrate
- Tranexamic acid - antifibrinolytic
- Cryoprecipitate (fact. VIII + vWF+ other factors)
o Petechiae/ purpura/ ecchymosis:
▪ Vascular
• HSP
269
- Non-thrombocytopenic purpura
• Severe inf. – severe angitis, usually followed by DIC
- Meningococcemia
- Other septicemias
• Simple purpura (easy bruising syndrome)
- in young women
▪ bruising with minor trauma + heavy periods
▪ Platelet disorders - platelets < 50 x 109/L
• Immune thrombocytopenic purpura (ITP) = Isolated thrombocytopenia
- Autoimmune disease where IgG autoantibodies against platelets
sesnitise them for destruction. NO SPLENOMEGALY.
- Types:
▪ Acute thrombocytopenia of childhood
• child well otherwise
• viral inf. in recent Hx or drugs
• cross-reacting AB against platelets
• Dx
o BMA: Megakariocytes increased
(compensatory)
• Rx of bleeding
o C/S initially which reduce clearance of
sensitised platelets.
o IV gamma globulins: if there is an
inadequate response to C/S.
o Splenectomy
o Azathioprine: If C/S and splenectomy
have failed.
• Prognosis
o 90% self-limiting in 6 months
o 10% pass into chronic ITP
▪ Chronic ITP
• autoimmune disorder
• adult women
• Rx
o Prednisolone
o Azathioprine, methotrexate
o Splenectomy – in some pts (but risk of
subsequent severe inf., e.g. with
streptococcus pneumonia)
▪ avoided in children
- Sx
▪ Triad: Bruising + Oral bleeding + Epistaxis
▪ No splenomegaly (rare)
- Dx
▪ exclude ALL/ AML
▪ FBE:
• Platelets significantly decr.
270
• Local
- cocaine abuse
- chronic rhinitis, chronic sinusitis
- ulcers in nasal cav.
- perforation of nasal septum
- nasal polyps
• Bleeding disorders: von Willebrand dis., etc.
- Thrombophilia – Murtagh 1367
o primary tendency to coagulopathy
o types
▪ inherited
• fact. V Leiden gene mutation
• prot. C deffic.
• prot. S deffic.
• prothrombin gene mutation
• antithrombin deffic.
▪ acquired
• anti-phospholip. AB
• lupus anticoagulant
• incr. homocystein
o thrombophilia screening – all the factors above:
▪ fact. V Leiden
▪ prot. C
▪ prot. S
▪ prothrombin
▪ antithrombin
▪ antiphosphopholipid AB
▪ lupus anticoag.
▪ homocystein
▪ + anthrombin C AB?
▪ + antiocardiolipin AB?
o indic. for investig.
▪ recurrent thrombosis
▪ venous thromboembolism < 40 yrs
▪ arterial thrombosis < 30
▪ skin necrosis on warfarin
▪ recurrent fetal loss
▪ familial thromboembolism
o MCQ:
▪ daugther asking for OCP, mother had DVT
▪ woman with DVT wants to get pregnant
• -> do thrombophilia screen
Anemia
- Iron studies – Murtagh table p. 146
o 1. Serum iron
o 2. Transferrin (major iron carrying protein in blood)
▪ Transferrin conc. = TIBC (total iron-binding capacity)
272
▪ ↑ MCHC
▪ Osmotic fragility test
o Rx
▪ Phototherapy or exchange
transfusion – if kernicterus +
folic acid to prevent
megaloblastic crisis
▪ Splenectomy
• Hereditary eliptocytosis
• Thalassemia: microcytic hypochromic anemia
• Sickle cell anemia
• Defic. of G6PD
o X- linked recessive – in boys only
o African (Sudanese), Mediteranean,
Asian
o causes episodic H. anemia due to ↓
capac. of RBC to deal with oxidative
stress; precip. by
▪ inf.
▪ antioxidant drugs:
Sulphonamides, antimalarial,
nitrofurantoin, Vit. C Vit. K,
traditional medicine, high dose
aspirin, naphthalene,
cotrimoxazole
▪ broad b eans (favism)
o Neonatal jaundice
o Dx
▪ Beutler fluorescent spot test
▪ Heinz bodies (bill cell) –
Denatured Hb within RBC
▪ Peripheral smear: Bite cells
▪ sometimes with spherocytes
o no Rx
• defic. of pyruvate kinase
▪ Acquired
• ABO/ Rh immunis.
• Drug toxicity
o A/B: antimalarials, sulphamethoxazole
o Anti-inflammatory
o Penicillin, methyldopa
• Infections:
o Mycoplasma
o malaria
• DIC
• Auto immune:
o cause
278
▪ Idiopathic - 50%
▪ Non-Hodgkin lymphomas
▪ SLE
o action
▪ cold agglutinin dis. - IgM
▪ act at body temp. – Ig G -
autoimmune hemol. anemia
o Dx – direct Coomb’s test +
• 3. Anemia of chronic disease and malignancy
- enough iron, but intercellular iron transport within bone marrow
is suppressed in inflam. => erythropoiesis is suppressed
- MCQ: boy who looks pale and has chronic diarrhea.
• 4. Chronic kidney disease – defic. of erythropoietin
- Rx – adm. of erythropoietin
• 5. Endocrine disorders: hypothyroidism (can be macrocytic as well)
- with bradycardia, fatigue, constipation, lymphocytosis
• 6. Bone marrow replacement
- metast.
- myelofibrosis
- ALL, AML, CML, CLL, lymphoma
- Aplastic anemia
o destruction of hematopoesis and bone marrow stem cells
o pancytopenia + hypocellularity in bone marrow
o types
▪ Congenital – Fanconi
▪ Acquired
• idiopathic – MC
• immune
• post-viral inf.
- Parvovirus B19
- HBV
- Epstein-Barr
- HIV
o Sx
▪ no splenomegaly
▪ no hepatomegaly
▪ no lymphadenopathy
o Rx
▪ supportive
▪ RBCs, platelets transfusion
▪ A/B
▪ immunosuppresion – if immune cause
▪ Bone marrow transplant
Digestive system - OK
Jaundice and other biliary problems
- Murtagh – table P 622
- Bilirubin metabolism: MCQ 2079 P 71
279
o Old erythrocytes -> destroyed in spleen -> heme is converted to unconjugated billirubin-
> sent to liver -> conjugated bilirubin -> eliminated through bile -> some is metabolized
in large intestine to urobilinogen (-> stercobilinogen -> stercobilin, gives feces brown
color) -> some of urobilinogen is reabsorbed and eliminated through urine (along with
an oxidized version, urobilin).
o Pathology:
▪ liver problems + biliary obstruction = some of conjugated bilirubin leaks out
from hepatocytes in blood and is excreted in urine as bilirubin -> dark urine.
▪ Hemolytic anemia - ↑ unconjugated bilirubin in blood -> ↑urobilinogen in urine
• high ratio of unconjugated to conjugated bilirubin in serum.
Hemolytic Hepatic Obstructive
Function test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic Jaundice
Total bilirubin Normal/ Increased Increased
Conjugated bilirubin Increased ↑
Unconjugated bilirubin Increased Normal/ Increased Normal
Urobilinogen Normal/ Increased Decreased/ Negative
Normal Dark (urobilinogen + Dark (conjugated bilirubin)
Urine Color
(urobilinogen) conjugated bilirubin) Absence of urobilinogen
Stool Color Normal Pale
Alkaline phosphatase
Increased
levels
Normal
Alanine & Aspartate
Increased
transferase levels
Conjugated Bilirubin in Urine Absent Present
- Jaundice
o Blirubin > 17 µmol/L
o Clinical jaundice > 50 µmol/ L
- Hyperbilirubinemia:
o Unconjugated
▪ Hemolytic jaundice (Prehepatic) – starts after 4-6 mths
• Spherocytosis
• G6PD deficit, (X linked recessive), Dx by Heinz bodies
• Drugs – Methyldopa, penicillin
• Sickle cell anemia
- Dickle cell crisis
▪ sickle cells get plucked inside capillaries & cause infarcts
▪ precip. by
• infection
• cold weather
• hypoxia
• dehydration
• acidosis
• surgery
▪ types:
280
• Vaso-occlusive
• Splenic sequestration
o => infarction
o severe pain in LUQ
o Rx
▪ O2 + hydration
• aplastic
• hemolytic
▪ Cx
• unequal digits (infarction in bones)
▪ Dx
• Hb electrophoresis (HbS)
• Howell-Jolly bodies = Basophilic nuclear
remnants (clusters of DNA) in circulating
erythrocytes
o Post-splenectomy
o Sickle cell – causes autosplenectomy
o Celiac dis. – splenic atrophy
o Spleen radiation therapy - Hodgkin
o + myelodysplasia
o + megaloblastic anemia, B12 defic.
o + severe hemolytic anemia
▪ Rx
• pneumococcal vaccine
• oral penicillin till 5 yrs
• ± splenectomy
▪ ineffective erythropoiesis - megaloblastic anemia
▪ Polycytemia vera
• incr. RBC, WBC and platelets + Splenomegaly
• incr. viscosity, arterial and venous thrombosis, visual blurring (TIA)
• gross retardation at delivery
▪ MC = Gilbert’s syndrome ---- AD - 3-5%
• Defic. of glucuronyl transferase -> ↑ Unconjugated bilirubin
• No evidence of hemolysis (fatigue, tachycardia , dyspnoea, pallor)
• all other fc. test are normal (Normal LFTs except for ↑ unconjugated
bilirubin).
• jaundice when
- under stress
- fasting
- sick (cold) etc.
• Dx
- fasting bilirubin
- bilirubin after nicotinic acid
- liver biopsy - normal
• no Rx required
▪ drugs:
• A/B
281
- flucloxacillin
- amoxyclave
- erythromycin
- rifampicin
• radiographic agent
▪ Crigler Najjar syndrome --- AR (very rare)
• types
- I
▪ Uridine diphospho- glucuronyl transferase absent
▪ unconj. bilir. > 340 µmol/ L -> kernicterus, unless
treated
▪ Rx
• Phenobarbital doesn’t help
• Phototherapy, exchange transfusion, etc.
- II
▪ UDP-G decr.
▪ Unconj. bilirubin < 340 µmol/L
▪ Rx
• Phenobarbital helps
▪ Hypothyroidism
• Rx - thyroxine
▪ ABO/ Rh hemolysis
▪ Breast milk jaundice
▪ Physiological
o Conjugated
▪ familial disorders
• Rotor syndrome—AR - rare
- non-itching jaundice
- liver cells are not pigmented
- no Rx is required
• Dubin Johnson syndrome---- AR
- inability of hepatocytes to secrete conjugated bilirubin into bile
- liver is pigmented black
- no Rx is required
▪ Hepatitis
• both direct and indirect bilir. ↑
• FTT, dark urine, pale stools
▪ drug induced
• Chlorpromazine
• OCP
▪ Primary biliary sclerosis
▪ Biliary atresia
• after first week
• stools are white
• AST/ ALT incr.
• chronic cholestatic jaundice
▪ Neonatal sepsis
282
▪ Galactosemia
▪ Postop. jaundice
▪ Intraductal problems/ Obstructive Jaundice
• Gall stones/ CBD stones
• Biliary strictures
• Infection
• Malignancy – cholangiocarcinoma
▪ Extraduct problems
• Pancreatic CA
• pancreatitis
- Jaundice
o in newborn: (1g= 18mmol)
▪ Kernicterus if bilirubin > 340 µmol/ L
▪ Rx
• > 285 µmol/L -> Phototherapy
• > 360 µmol/L -> consider exchange transfusion
▪ types
• 1st 24 hrs – Pathological
- ABO incompatibility – MC
▪ Mother is group O, child is A or B
▪ direct Coomb’s test +
▪ w/ spherocytes
• DD: day 1 – ↑Unconjugated bilirubin + ↑
spherocytes + family Hx of spherocytosis =
Spherocytosis
▪ Rx
• Phototherapy immediately
- Rh incompatibility – more severe
▪ direct Coombs test +
▪ w/o spherocytes
• > 24 hrs
- Physiological jaundice – MC cause of jaundice in newborn (50%
of term babies and 80% of prematures develop jaundice in 1st wk
▪ due to immature liver enzymes
▪ starts at 2-3 days, max by day 3-5, finishes in 1-2 wks
(less than 2 wks)
▪ not very severe
▪ Rx - Phototherapy
- Breast milk jaundice (↑unconjugated bilirubin)
▪ Starts on day 4-7, lasts up to 6 wks
▪ Hormones secreted through milk are inhibiting UDP-G
▪ Child normal, feeding normal, liver enzymes normal
▪ Dx – by suspending breast feeding for 24-48 hrs =>
serum bilirubin falls = Breast milk jaundice
▪ Mx – Continue breastfeeding
- Hypothyroidism
- Neonatal sepsis
283
▪ Dx
• 1 – USG
• ERCP
• MRCP – the best
o Acute cholangitis = (obstructive) jaundice + fever, chills, rigor + abd pain
▪ Charcot triad:
• fever, chills
• jaundice
• severe pain
▪ Dx
• 1 – USG
• ERCP
• MRCP – the best, less invasive
▪ Rx
• IV fluids
• A/B: Ceftriaxone, penicillin, aminoglycosides
• ERCP surgery – Gold standard
- Biliary lithiasis
o Sx
▪ Biliary pain:
• Severe, constant pain that can last for hrs.
• History of episodes of similar pain.
• Epigastric
- referred to scapula
• If cholecystitis develops, pain typically shifts to right upper quadrant
and becomes more severe. + tenderness, guarding (Murphy’s sign +)
▪ The patient may be jaundiced if CBD is obstructed.
▪ Look for right upper quadrant tenderness.
o DIAGNOSIS:
▪ FBC
▪ U&E
▪ LFTs
▪ Lipase/ amylase
▪ Request an upper abdominal USG
• if equivocal/ technically inadequate (obese woman) => HIDA (Tc-IDA)
scan of GB (contrast injected in blood -> liver -> secreted in bile)
▪ Dilatation of CBD
• best seen with:
- I – MRCP
- II – ERCP
o MANAGEMENT:
▪ PAIN relief: Morphine 0.1 mg/ kg IV with metoclopramide 10 mg IV
▪ Advise patients to eat a low fat diet.
▪ Refer patient to Surgical OPD for follow-up.
o Cx
▪ 1. Cholecystitis = MC
▪ 2. Choledocholithiasis and jaundice
285
▪ 3. Pancreatitis
▪ 4. Ileus
- Acute cholecystitis
o Acute, CONSTANT right upper quadrant pain.
▪ Referred to scapula
o Associated with fever, anorexia, nausea and vomiting.
▪ no jaundice
o SIGNS: Localized tenderness with involuntary guarding and rebound tenderness.
▪ Murphy’s sign
o DIAGNOSIS AND MANAGEMENT:
▪ FBC, U&E, blood sugar, LFTs, lipase/ amylase and blood culture.
• ↑ CRP, ESR
▪ USG: thick walls
▪ Gentamicin, ampicillin.
▪ Refer to Surgical team for bed rest, analgesia, antibiotics and cholecystectomy.
• surgery not in acute cholecystits or cholangitis, but after treating inf.
Liver pathology
- types of hepatitis – table Murtagh p. 625
- Liver enzimes, ALP, etc. in various hepatic dis. – table Murtagh p. 622
- Hepatitis B – printout with the table
HbsAg Anti HBs HbeAg Anti Hbe AntiHBc HBV ALT, AST
DNA
Acute HBV + - + - IgM + Highly
Highly infective incr.
Chronic HBV + - + - IgG + Highly
highly infective incr.
Chronic HBV + - - + IgG Incr.
low infective
Recovery + IgG
Immunization +
o Serology guidelines
▪ HbsAg = Persistent inf. highly infectious (carrier state)
▪ anti-HBs = Past inf. and immunity (sole marker after HBV vaccination)
▪ HbeAg = highly infectious
▪ HBV DNA = circulating and replicating virus
▪ anti-Hbe = low titre of HBV (low infectivity)
▪ anti-HBc IgM = Recent inf.
▪ anti-HBc IgG = Past inf.
▪ HBcAg = O nly found in liver (biopsy), not in blood
o Transmission
▪ blood
▪ sex
• also at risk – sexually active homosexual male
▪ saliva
▪ MC Vertical - perinatal transmission mother to fetus – Asia (Chinese South
Asia) MCQ
▪ lowest risk = scientist in a pathol lab
286
o Rx
▪ Alpha interferon
▪ Lamivudine: drug of choice after 12 months treatment normalisation of liver
enzymes.
▪ Liver transplant – recurrance of HBV
o Cx
▪ Chronic hepatitis 5-10%
• Cirrhosis - 15-40%
- 6-15% in 5 yrs -> CA - risk factor for hepatocellular CA (90-100x
or 223x incr. risk)
- 20-23% in 5 yrs -> liver failure
▪ Rx – liver transplant
o Prophylaxis
▪ normal human immunglobulin – in people who sustained a needlestick injury
with blood products from a confirmed HBV donor
▪ Hep. B vaccine
• can be admin. to chronic carriers without harm
• types
- recombinant
- plasma-derived
- Hepatitis C
o MC type of infective hepatitis in Aus.
o in
▪ IV drug users and tatooing - most frequent
▪ post-transfusion
▪ hemophilia
▪ hemodialisys
▪ sex and vertical - uncommon
o Cx
▪ 60-80% chronic hepatitis = MC cause of chronic hepatitis
• Cirrhosis 10-25% in 20-30 yrs
- CA
- liver failure
o RX (No vaccine available)
▪ Ribavirin
▪ Alpha interferon
- Hepatitis A (feco-oral route)
o mild, but can cause fulminant hepatitis as well
o excretion of virus in feces diminishes at the onset of clinical dis.
o Sx
▪ jaundice – more common in childrent than in adults
o Px
▪ Gamma-globulin – within 2 wks of exposure decr. the attack rate
▪ Hep A Vaccine
- Chronic liver disease
o Sx
▪ Ascites
287
o Sx
▪ pain
o Dx
▪ amylase is N or slightly incr.
▪ some have calcification
o if associated DM -> Rx with low doses of insulin
- Dilatation of gall/ bile ducts
o Dx
▪ first – USG
▪ ERCP - best
▪ MRCP – even better – if available
- Pancreatic CA
o head of pancreas
▪ men
▪ Sx
• Triad: anorexia + wt. loss + jaundice ± epigastric pain
• distended gall bladder, which moves with respiration
• jaundice, pale stools, dark urine (Obstr. jaundice)
• Wt. loss
▪ Dx
• U/S: distended intra and extrahepatic bile ducts
- pancr. duct might be dilated as well
• Urine: conj. bilirubin, no urobilinogen.
• Blood: AST/ALT moderately elevated, incr. total and conj. bilirubin, incr.
ALP
Abdominal pain
o Pancreatitis – Hx of alcoholism or biliary stones
▪ fever + epigastric pain + radiating to back
▪ no abd. signs except for
• Cullen sign
• Gray Turner sign
o Hemorroids – small amounts of painless rectal bleeding
o Anal fissure – small amounts of painFULL rectal bleeding
o Rectal CA – tenesmus + rectal bleeding + alternate bowel habits + wt. loss
o pregnant woman with lower abd pain
▪ I trim – ectopic
▪ II trim – ovarian torsion/ twisted ovarian cyst
▪ III trim – red degeneration of fibroid
o a few wks Hx of postprandial pain = Mesenteric ischemia
Acute mesenteric ischemia Chronic mesenteric ischemia
Hx of atherosclerosis/ AF (irregular pulse)/ digoxin After eating -> abd. pain
Acute abd. pain + tenderness + no bowel sounds
Blood stained stool
o Acute mesenteric ischemia = acute abd. pain + tenderness + irregular pulse + no
bowel sounds = Mesenteric infarction (Afshan)
▪ CAUSES:
292
- surgery
o Parkinson
o Peptic stricture
▪ lower 3rd of esoph.
▪ Cx of reflux oesophagitis
▪ rare today with current treatments
▪ Dx
• Barium swallow
• Endoscopy
▪ Rx
• dilate stricture
• treat reflux
o Globus hystericus = lump in the throat
▪
o Pharyngeal pouch (Zenker’s diverticulum)
▪ post. pharyngeal diverticulum, pushing the esophagus
▪ elderly
▪ Sx
• dysphagia, food regurgitation, gurgling in neck
• coughing immediately after eating (food regurgitated in airways)
• halitosis
• no pain
o Esophageal diverticulum
▪ usually sec. to an underlying motility problems -> sympt. due to primary pbm
▪ hiatal hernia
o Achalasia
▪ Failure of relaxation of lower oesophageal sphincter + ↑muscle tone
▪ women, 30-40 yrs
▪ Sx
• dysphagia for liquids and solids organic, mechanical causes usually have
dysphagia only for solids!)
- if severe: has more difficulty in swallowing liquids than solids
- usually not progressive!
• wt. loss
• regurgitation
- at night
- when lying down
• chest pain, hiccups, aspir. pneumonia
▪ Dx
• 1. Plain X Ray
- air-fluid level behind heart
- absence of gastric air bubble
• 2. Barium swallow
- distended esoph. - S-shaped + narrowing of contarst in barium
swallow = “rat-tail” (not charact.) + fluid level
• 3. Manometry - high tension at lower end of esophagus
• 4. Endoscopy – exclude CA
▪ Cx
295
• Stricture
• Esophageal CA
▪ Rx
• Botox inj. – Short term relief
• Drugs:
- Nitrates—relaxes lower esoph. sphincter
- Ca channel blockers
• Pneumatic dilatation – may recur
• Laparoscopic cardiomyotomy (Heller’s myotomy) – the best
o Esophageal CA
▪ Barrett’s esophagus = Premalignant lesion for adeno CA of esoph. = metaplasia
with columnar-lined epithelium in lower 3rd of esophagus + ulcer inside +
stricture (blue book MCQ 3.106) P 250
• due to prolonged reflux
▪ types
• SCC CA
• Adeno CA
▪ Sx
• Triad: fatigue + gradual dysphagia + wt. loss
• severe dysphagia at beginning of meal + painful swallowing + severe
wt. loss
- gradual (increasing) dysphagia initially for solids, then for liquids
• dysphagia + hoarseness of voice = Esoph. CA
▪ Dx
• Barium swallow – apple core
• Endoscopy: narrowing of esophagus + ulcer
- + Biopsy
▪ if initially negative (especially with premalignant
lesion), repeat (MCQ)
Upper GI hemorrhage
o Mortality: 5-10% related to age over 60 years, comorbid disease, shock and coagulopathy.
o CAUSES:
▪ Peptic ulceration: Over 40% of cases.
• 1. Duodenal Ulcer.
• Gastric Ulcer (less common).
▪ Gastric erosions or gastritis.
• Post-alcohol.
• Drug-induced (Salicylates, NSAIDs, steroids).
▪ Mallory-Weiss tear (partial esophageal tear following vomiting or retching).
• bouts of protracted vomiting or cough -> blood
- tear of mucosa at gastroesophagal junction
- self limiting
- Dx – esophagoscopy
▪ 2. Bleeding esophageal or gastric varices associated with portal HTN
• MC in alcoholic cirrhosis
▪ Reflux esophagitis.
▪ Others: Gastric neoplasm, coagulation disorders.
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o PRESENTATIONS:
▪ Hematemesis:
• Fresh red blood.
• Altered blood ‘coffee grounds’.
▪ Melaena.
▪ Collapse and shock.
▪ Syncope and postural hypotension.
▪ Hematochezia (bright red rectal bleeding).
▪ Signs of CLD: Jaundice, bruising, palmar erythema, clubbing, gynecomastia,
spider naevi, hepatomegaly and encephalopathy.
▪ Signs of portal HTN: Splenomegaly and ascites.
o MANAGEMENT: General
▪ High-dose oxygen.
▪ Fluid replacement.
▪ Cross-matched blood if patient is shocked or bleeding is continuing.
▪ Disease specific:
• Peptic ulcer: PPI
- Omeprazole 40-80mg IV followed by and infusion at 8 mg/h.
• Varices: Octreotide 50µg IV(↓portal vessel pressures in bleeding varices)
▪ Urgent endoscopy: to differentiate the cause of bleeding +
• allow injection therapy or banding for varices.
• adrenaline injection in ulcer’s edges
▪ Sangstaken-Blackmore tube
• with 2 balloons
• after being introduced and inflated, it has to be checked every 2 hrs
- did it stop bleeding?
- prevent mucosal ischemia
- Stomach CA
o Risc factors
▪ gastric resection > 25 yrs before (CA on gastric stump)
▪ ↑age (> 40 yrs)
▪ smoking
▪ blood group A
▪ atrophic gastritis
o Male 3:1
o Metastases
▪ left supraclavicular node
▪ ovary – Krukenberg tumor
▪ liver
o Sx
▪ Triad: anorexia + dyspepsia + wt. loss
o Rx - Gastrectomy
▪ Cx
• Dumping syndrome
- types
▪ Early
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- failed Rx after 1 yr
- complic.
▪ uncontrollable bleeding
▪ perforation
▪ pyloric stenosis
- suspicion of malignity in GU
- recurrent ulcer after previous surgery
- + elderly – tolerate less well the blood loss
• types
- GU
▪ partial gastrectomy +
• Billroth I (gastroduodenostomy)
• Billroth II (gastrojejunostomy)
- DU
▪ Vagotomy
• truncal
• highly selective
- Apendicitis
o CLINICAL FEATURES:
▪ Anorexia, nausea, vomiting, diarrhoea or constipation.
▪ Low-grade pyrexia.
▪ Localized abdominal pain: Epigatrium, periumbilical region, RIF.
▪ Tenderness and guarding in RIF.
▪ Rectal examination: To help diagnose a retrocecal or pelvic appendix.
o Typical march of symptoms (J.B Murphy):
▪ Prodromal mild bowel upset.
▪ Development of abdominal pain, which progressively worsens.
▪ Anorexia (key word), nausea, vomiting.
▪ Moderate (not high) fever.
▪ Signs of focal peritonitis over inflammed appendix.
o DIAGNOSIS:
▪ Physical examination: Abdominal auscultation, palpation, percussion.
▪ FBC and Urinalysis: Leukocytosis, rule out UTI.
▪ Pregnancy test: Female adolescents.
▪ USG: Female (doubt and no peritonitis).
▪ CT: For doubtful cases only.
o MANAGEMENT:
▪ Normal saline infusion.
▪ Give gentamicin 5 mg/kg IV, ampicillin 1 g IV and metronidazole 500 mg IV if
rupture is suspected with peritonitis.
▪ Refer to Surgical team.
- Meckel’s diverticulum: (MC presentation is asymptomatic anomaly noted during surgery for
another cause)
o most frequent malformation of gastrointestinal tract
o rule of 2s
▪ 2% population
▪ 2 inches in length
300
▪ 2% are symptomatic
• usually discovered during abd. surgery for a different problem
▪ 2 feet from ileo-cecal valve (distal ileum)
▪ age group – 2 yrs
▪ male:female = 2:1
▪ 2 types of ectopic tissue:
• gastric
• pancreatic
o Sx
▪ painless rectal bleeding (not mixed with feces), malena or blood loss anemia
▪ acute/ chronic bleeding
▪ umbilicus fistula
o Dx – Tc99m pertechnetate scan, laparotomy
o Cx
▪ intestinal obstruction
o Rx – surgical resection
- Diverticular disorder (large bleeding not accompanied by fecal mater)
o 90% in descending colon
o due to lack of fibres
o over 40 yrs
o 1/3 people > 60 yrs
o Sx
▪ usually asympt. = diverticulosis
• sometimes - irregular bowel habits, constipation
▪ diverticulits – sympt. (< 10% of people with diverticulosis)
• This follows inflammation of one or more colonic diverticulae.
• LOWER abdominal pain radiating to left iliac fossa + tenderness in LIF
• can occur anywhere (e.g. small bowel)
• Bloody diarrhea
• Sometimes with sudden PROFUSE rectal bleeding (without feces).
• Sx
- triad: acute pain + left-sided irradiation + fever
- Low-grade fever.
- Abdominal tenderness in LIF
- pain increased with walking and change of position
- Guarding on LIF with a palpable mass.
• Complications:
- Perforation.
- Paracolic abscess
- Severe bleeding (elderly).
- Fistula formation (Colovesical fistula + vagina, small bowel).
MCQ 2045 P128.
- Bowel obstruction.
• DIAGNOSIS
- Request an erect CXR if perforation is suspected.
- USG, CT scan – detect fistula or perforation
- Sigmoidscopy
301
• Rx
- Commence an IV infusion to treat dehydration or shock.
- Analgesia.
- Antibiotics: Gentamicin, ampicillin and metronidazole.
- Refer to surgical team.
- Profuse rectal bleeding
o diverticular Disease
o angiodysplasia
o ulcerated CA
o IBD
o ischemic colitis
Inflammatory bowel disease (IBD)
Ulcerative colitis Crohn (terminal ileitis) disease
Main Sx Long history of bouts of diarrhea + blood Triad: colicky abd. pain + diarrhoea +
in young adult (15-40 yrs) fever Recurrent diarrhea (with blood
May present as a fulminating attack. and mucus in stools) in a young person
(20-40 yrs) + abd. Pain.
Fever, tachycardia and hypotension. Malaise, wt. Loss. May present acutely
Risk factors: family Hx, previous attacks, with obstruction, perforation or RIF
low-fibre diet pain. CAN MIMIC acute appendicitis.
Site Colon only (begins in rectum, continues All GIT, mouth to anus (terminal ileus),
proximally) lead pipe deformity repeated perianal lesions (abscesses,
fistulas), mouth ulcers – caused from
granulomas (granulomas in Crohn - non-
caseating - and TB - caseating)
½ ileocolic, ¼ - small bowel only, ¼-
colon only
Rectal Rectum always involved Lump in right iliac fossa + rectal changes
(e.g. fistula)
Systemic Wt. loss, fever, lethargy are UNCOMMON Wt. loss, fever, lethargy, etc.
Sx
Lesions The whole colon involvemt but superficial Skip lesions but affecting whole width
mucosal only of intestinal wall. Fine granular mucosa
FBE ESR Incr.
Dx Extensive mucosal ulceration may leave X Ray: Free air associated with
normal mucosal islands (pseudo-polyps) perforation may be seen.
visible on plain film. Stenotic regions are best visualized with
Dilation of the transverse colon > 6 cm Ba follow-through studies or on
indicates presence of toxic megacolon. colonoscopy.
Sigmoidoscopy: granular red proctitis, Sigmoidscopy: Cobblestone appearance
with contact bleeding (patchy mucosal edema) Aphthous
1st Step: Stool culture - exclude a ulceration
gastrointest. Infection Colonoscopy – Dx diff. with UC
CA Colon CA more often, > 7 yrs (colon CA more rare)
100 x incr. risk for adenoCA in affected
portion (terminal ileum)
Extrainte Arthritis, ankylosing spondylitis, sclerosing Arthritis, ankylosing spondylitis,
302
o
o DIAGNOSIS:
▪ Send blood for FBC.
▪ Urea and electrolytes.
▪ Lipase.
▪ Amylase.
▪ Blood sugar levels.
▪ Request erect and supine abdominal X Rays and look for following features:
- SMALL BOWEL OBSTRUCTION - LARGE BOWEL OBSTRUCTION
304
▪ Not USG
o Duke’s classif.
Stage Extension 5 yr survival
A Mucosa and submucosa 90%
B Muscularis or serosa 75-85%
C Regional lymph nodes 30-40%
D Distant metastases <5%
▪ Duke A – 75% detected with FOB
o Rx
▪ Duke A, B – surgery
• pancolectomy
• paucy surgery
▪ C,D – surgery + radiation
- Peutz-Jehgers – AD = hereditary intestinal polyposis syndr.
o dev. of benign hamartomatous polyps in the GIT -> strong tendency to dev. CA in multiple
sites (breast, liver, pancreas, etc.), while the polyps don’t have malignant tendency
o lowest malignant potential (2%) for colon CA
▪ may undergo malignant transf. into adenocarcinoma
o hyperpigmented (black) macules on the lips and oral mucosa
- Tumors in small bowel – predom. benign
o types
▪ Adenocarcinoma
• 100 x incr. risk in Crohn in the affected portion (distal ileum)
▪ Lymphomas
• terminal ileum
• proximal jejunum – assoc. with celiac dis.
▪ Carcinoids
▪ Familial adenomatous polyposis
• incr. risk of duodenal and small bowel carcinoma
▪ Peutz-Jehgers – hamartomas, may undergo malignant transf. into
adenocarcinoma
- Adenoma with incr. malignant potential (benign tum. of colon)
o villous
o > 2 cm
o multiple
o with dysplasia
- benign villous adenoma
o Sx - clear discharge
o Cx - causing marked electrolyte imbalance = depletion syndrome - prerenal azotemia,
hyponatremia, hypokalemia
Anal pathology
- anal anatomy:
o lower ½ of the anal canal – sensitive, painful
o upper ½ of the anal canal – where the hemorrhoids start from
▪ separated by the dentate line
- Anal fissure
o mid-posterior position (6 o’clock)
308
• slow growth
• better prognosis: stage 1 - 98% 5 year survival rate
• 90% diagnosed at stage I
• lymphatic spread
- -> retroperit. lymphnodes -> mediastinal -> left cervical with
worst prognosis (eval. with CT)
• tumor markers - normal
- purple book: raised in a large proportion of seminomas?
• sensitive to radiotherapy
• non-sensitive to chemotherapy
▪ non-seminoma (teratoma)
• 60%
• rapid growth
• poorer prognosis: stage 1 - 75% survival at 5 yrs
• 60% Dx at stage I
• tumor markers – markedly incr.
- 1 - alfa fetoprot.
- 2 - beta HCG
• blood stream metastases to liver and lungs
- + lymph. nodes involv.
• sensitive to chemotherapy
o staging
▪ I – only testis
• orchidectomy
▪ II – paraaortic lymphnodes involved (below diaphragm)
• orchidectomy + lymphnode resection
▪ III – lymphnodes above the diaphragm
• radiotherapy or chemotherapy
▪ IV - lungs, liver metastases
• radiotherapy or chemotherapy
o Dx
▪ 1. USG
▪ 2. tumor markers:
• alfa fetoprot.
• beta HCG
- Alpha-fetoprotein (AFP, a-fetoprotein)
▪ In adults, levels over 500 nanograms/milliliter of AFP
are seen in only three situations: Hepatocellular
carcinoma, Germ cell tumors, and metastatic cancer in
the liver originating from other primary tumors
elsewhere.
- Beta HCG (human chorionic gonadotrophin)
▪ raised in testicular cancer
- Carcinoembryonic antigen (CEA)
▪ serum from individuals with colorectal carcinoma,
gastric carcinoma, pancreatic carcinoma, lung
carcinoma and breast carcinoma, as well as individuals
311
- U/S
- no aspiration (can spread the CA)
▪ in children
• types
- Bilat – usually disappears at 1 yr
- Unilat – tense
▪ Might persist after 1 yr -> 90% will resolve by 18 mths
▪ > 2 yrs -> refer for surgical intervention.
o Cryptorhidism:
▪ 2-4% at full term
▪ 20% in premature babies
▪ 1% at 1 yr
▪ 2/3 are in superf. inguinal pouch – can be palpated
▪ types
• Undescended
• Retractile – can be manipulated into the scrotum
• Ectopic – 5%
• Ascending
▪ risk for
• 1. Torsion
• 2. Testic. CA (seminoma) – 5-10 x incr. risk
• testic. dysplasia
• infertility
• most assoc. with indirect inguinal hernia??
- Hernias – Murtagh 1081
o types
▪ Inguinal
• Direct
- men
- doesn’t go to scrotum
- doesn’t usually strangulate (least often)
- through the post. wall of the inguinal canal, above the inguinal
ligament, above and lateral to pubic tubercle.
• Indirect
- at external inguinal ring, above and medial to pubic tubercle
- cough impulse +ve
- pain referring to testicle
- disappears when lying down, usually reducible
▪ but can strangulate
- if inguinoscrotal -> you can’t get above swelling (continues
toward abd.)
- Dx – Clinical!
▪ Femoral
• below the inguinal ligament, below and lateral to pubic tubercle
• female, after multiple pregnancies or wt. loss
• often irreducible
• most prone to strangulation. So If diagnosed immediate urgery
315
▪ Endoscopy
▪ Manometry
- Rx
▪ Antisecretory drugs
• PPI
• H2 receptor blockers
▪ if severe sympt. – surgery: Nissen fundoplication
• prophylactic AB least needed in fundoplication
o Rx
▪ surgical repair
▪ conservative
• truss to control a small inguinal hernia, with a perineal band to control
slipping
• in
- asympt. patients
- associated medical conditions, with significant operative risk
o Sx
▪ Obstruction – w/o any previous abd surgery -> hernias:
• I - femoral
• II - indirect inguinal
• III - direct inguinal
▪ (Obstruction – w/ previous abd surgery
• adhesions!!)
Renal, urinary and male pathology - OK
- Renal function.
o Plasma urea & creatinine
o Most accurate tests: eGFR (new standard) or creatinine clearance test
- Renal failure
o CRF
▪ Def. = GFR < 60 ml/min/1.73m2 for ≥ mths w/ or w/o evidency of kidney dis.
▪ causes
• MC – DM
• HT
• GN
- MC with IgA nephropathy
• Analgesic nephropathy
• Polycystic kidney dis.
• Reflux nephropathy
• Gout
• Drugs:
- Aminoglycosides: Gentamicin, etc.
- Vancomycin
- Tetracyclines
- Cephalosporins - some
- NSAIDs, COX-2 inhibitors
- ACE inh. and AIIRA antagonists
- Lithium
317
• 4. systemic vasculitis
▪ II. Nehprotic syndrome: edema + hypoalbuminemia +proteinuria
• 1-4 yrs
• Sx
- triad: proteinuria + generalised edema + waxy pallor
- proteinuria + dysmorphic hematuria + RBC casts = glomerular
origin
- proteinuria > 3g/ 24 hrs
- generalized gravitational edema (anasarca), ascites, periorbital
puffness
- hypoalbuminemia < 25g/L
- normal BP, No hematuria
• causes
- 1/3: systemic kidney dis. (DM, HBV, malaria, etc.)
- 2/3 (90%): idiopathic nephrotic syndrome
▪ Dx: kidney biopsy
• Minimal change dis. – MC (85%)
o modest if any hematuria
o responds to C/S!
• focal segmental glomerular sclerosis - FSGS =
GN (10-15%)
o frequent in HIV
o = GN
▪ HT
▪ significant hematuria
▪ RBC casts
o no response to prednisolone!
▪ Mx – renal biopsy to conform
the type of lesion
• membranous nephropathy
o hyaline, granulous casts in urine
• membranoprolif. GN
• Rx
- C/S - prednisolone
▪ -> if they fail -> renal biopsy:
• MC
o minimal change nephritis/dis. in
children or
o membranous glomerulonephritis in
adults?
• CA?
▪ III. asympt.
- Proteinuria
o N: < 100 mg/ 24 hrs
o Pathol. > 300 mg/ 24 hrs (> 150 mg/ 24 hrs in adults)
▪ > 1 g/ 24 hrs – serious problem
▪ ≤ 1 g re-examine
322
• orthostatic
• fever
• …
o causes
▪ orthostatic
• 5-10%
• adolescents
• usually self-limiting
- can foreshadow serious kidney dis.
▪ DM – Diabetic microalbuminuria
• first sign of DM nepropathy = Kimmelstiel-Wilson lesion (diabetic
glomerulosclerosis)
- UTI
o types
▪ sterile pyuria
▪ asympt. bacteriuria
• treated only
- if recurrent in pregnancy
- if recurrent after sexual intercourse
▪ acute cystitis
• dysuria, urinary frequency
▪ acute pyelonephritis
• loin pain, fever, rigors, nausea, vomiting
• dysuria, urinary frequency
▪ urethral syndrome
• dysuria and frequency, but nothing in the cultures
• e.g. interstitial cystitis
- continuous pain relieved briefly by bladder emptying
- small hemorrhages on distension of the bladder
o Dx
▪ (MCQ recalls: urine sample
• 0-12 mths: suprapub. (SPA)
• 1-3 yrs: catheter
• > 3 yrs: MSU
▪ URINE COLLECTION:
• > 3-4 yrs
- Midstream specimen (MSU)
- Catheter specimen (CSU)
▪ in women with failed MSU
• < 3-4 yrs
- Suprapubic aspirate collection (SPA): Any growth indicates
infection.
▪ Urinary dipstick test: Only a screening test for UTI.
• leucocytes
• nitrites - bacteria
- but not in all the inf. nitrites are present!! (e.g. some Gram-pos.
cocci don’t produce nitrites)
323
▪ Microscopic exam.
• > 5-10 WBCs/ HPF
- = > 5-10 x 106 WBC/ L
• > 8000 WBC/mL in phase-contrast microscopy
▪ Culture
• MC: E. coli + Staph. saprophyticus > 90%
• > 105/ ml (108/ L) in fresh MSU
o Rx
▪ Acute cystitis:
• AB - TG (Alena)
- 1 – Trimethoprim – not in pregnancy
- 2 – Amoxiclave – also in pregnancy
- 3 – Cefalexin – Drug of choice in pregnancy
- 4 – Nitrofurantoin – also in pregnancy
• duration of Rx
- 5 days in women
▪ 10 days if known urinary tract abnormality
▪ MSU – 3 wks later
▪ + make the urine alkaline with sodium citrotartrate
- 14 days in men
▪ + investigate underlying abnormalities, e.g. prostatitis
▪ Acute pyelonephritis
• same AB – use for 10 days
• ciprofloxacin – if resistance
• severe inf. + septicemia: Amoxycillin + Gentamicin – 14 days
▪ in recurrent UTIs after coitus (in women)
• Rx
- A/B before or after each coitus
▪ trimethoprim
▪ nitrofurantoin
- prophylactic coitus-time A/B: as effective as continuous Rx
▪ Pyelonephritis in pregnancy and puerperium
• 2% of women
• when unilat., MC on right side
• anorexia, nausea, vomiting
• cause - due to dilatation and slower emptying of the urinary tract, due
to high progest. in pregnancy
• MC agent is E.coli
▪ Pregnancy
• Cephalexin 500 mg orally 12 hrls for 10 days – class A
• amoxy + clavulanate (500 + 125 mg) 12 hourly for 10 days
- class B in pregnancy (some teratogenicity)
• nitrofurantoin 50 mg orally 6 hourly for 10 days– class A
▪ Children
• Sx
- Non-specific: fever, irritability, poor feeding and vomiting.
324
▪ horshoe kidney
▪ polycystic kidney
• bilat. large kidneys, with multiple cysts
• Sx
- renal pain
- hematuria
- UTI
- progressive renal impairment
▪ hydronephrosis
o trauma of kidney
- 1 kidney smaller than the other
o causes
▪ normal
▪ hypofc. kidney
o Dx. diff
▪ Doppler U/S – blood flow
▪ renal isotope scan – renal fc.
- Urinary retention
o acute – BPH
▪ painful
o chronic
▪ painless
- Acute urinary retention
o PREDISPOSING FACTORS:
▪ Prostatic hypertrophy.
▪ Urethral stricture.
▪ Bladder neck obstruction by fecal loading or pelvic mass
▪ Pelvic neoplasm.
▪ Anticholinergic drugs.
▪ Pregnancy.
▪ Local painful conditions such as genital herpes.
▪ Neurogenic: Multiple sclerosis.
o often precipitated by extreme cold or alcohol
o CLINICAL FEATURES:
▪ Enlarged bladder is easily palpable.
▪ Dull to percussion.
▪ Painful.
o Dx
▪ Rectal examination:
• assess perineal sensation.
• empty any fecal impaction
▪ Examine leg reflexes in all patients. – neurol. cause?
▪ catheterisation to relieve obstruction
▪ if drug induced -> drug withdrawal + catheterisation for 48 h
▪ give a trial of prazosin -> if it works, use it as a long term Rx for BPH
- Urinary ret. in women
o causes
329
▪ spinal tumor
▪ fibroid
▪ vaginal herpes
▪ enlarged retroverted uterus
▪ NOT - HPV
- Urinary schistosomiasis (bilharziasis)
o small trematode flat worm – Schistosoma sp.
o endemic in Egypt
o UTI (cystitis) + terminal haematuria in a male patient from Egypt
▪ + haemospermia
o primary inf. transm. from water - “swimmer’s itch”
o worms live in vesical veins or intestinal veins
o chronic hepatitis, fibrosis, cirrhosis
o Dx - urine microscopy
o Rx - praziquantel
Male pathology
- ED – Murtagh 1120
o causes
▪ psychosocial – young
▪ elderly
• DM
• hyperlip.
- Premature ejaculation
o persistent or recurrent ejaculation before, on or shortly after penetration
▪ time from penetration to ejaculation < 2 min
o MC male sexual dysfc.
o MC cause = performance anxiety
o can be
▪ primary – since beginning of sexual life
▪ sec. – developed later
o Rx
▪ short term
• topical anesthetics
- lignocaine 2.5% + pilocaine 2.5% cream to glans penis ½ hr
before intercourse
▪ long term
• SSRI (fluoxetine, sertraline, paroxetine) + clomipramine => relieve
anxiety
- 3-5 hrs before intercourse
• squeeze technique no longer advised
- Balanitis
o inflam. of glans penis + foreskin
o MC – candida
o children – wet nappies
o adults – immunocompromised people, DM
o Sx
▪ saline bath
330
▪ topical C/S
▪ topical nystatin
▪ topical myconazol
- balanitis xerotic obliterans
o thickening of the foreskin + skin pallor
o Sx
▪ topical C/S
▪ circumcision
- Prostate CA
o 80% at 80 yrs
o risk factors
▪ 1. age > 75 yrs
▪ 2. relative Dx with prostate CA < 60 yrs – most important!
• family Hx is responsible for 5-10% of cases
o MC CA in men
o structure
▪ central/ transitional -> BPH
▪ periph. -> CA
• peripheral -> doesn’t usually give urinary sympt. (like BPH or prostatitis -
central)
o metastases
▪ lymphatic -> pelvic nodes (not groin)
▪ blood
• Osteosclerotic mets in the bones: Pelvis, spine
o CA that doesn’t metastasize to brain = Prostate
o Sx
▪ obstruction
▪ acute retention
▪ back pain
▪ hematuria, uremia – 5%
o Dx
▪ screening – controversial
• PR
- signs of CA:
▪ Hard lump
▪ Asymmetry/ irregular
▪ Induration
▪ Loss of median sulcus
• PSA:
• can be elevated without cancer (e.g. BPH, exercise, infection,
instrumentation, recent ejaculation)
• must be tested with DRE is prostate specific, not prostate cancer specific
• No PSA testing over age 70
- > 10 ng/ mL suggestive of prostate CA
▪ > 20 – most probably advanced CA with mets
- 4-10- prostatitis, benign hypertrophy
- Normal < 4
331
• 1. urethral catheter
• 2. suprapubic drainage if 1 fails
▪ drugs
• alpha blocking drugs (inh. contr. of muscle in bladder neck and urethra)
- phenoxybenzamine
- prazosin
- terazosin
• 5-alpha-reductase inhibitors (reduce prostatic volume)
- finasteride
▪ surgery
• indic.
- renal failure
- upper tract dil.
- retention
- bladder stones
• methods:
- TURP
▪ Cx
• retrograde ejaculation - MC
• ED – 5%
- laser ablation
- transurethral incision of prostate (TUIP) – for small glands
- open prostatectomy – less used these days (<1%)
- Prostatitis
o Sx:
▪ triad: dysuria + fever + perineal pain
▪ PR: very tender prostate, swollen, firm
o Rx:
▪ Amoxycillin + gentamicin
Electrolytes, ABG, dehydration, burns - OK
- Electrolyte disorders
o K
▪ Normal: 3.5-5 mmol/l
▪ usually intracellular
▪ hyperkalemia
• MC electrolyte disorder associated with cardiac arrest.
• CAUSES:
- ↑ K intake: banana, low fat milk, beans, sweat potato.
- Increased production – when cellular membranes are ruptured!
▪ e.g. Rhabdomyolisis, burns, ischemia, hemolysis.
- ↓ renal excretion: Acute and chronic renal failure, Addison’s
disease, hypoaldosteronism, drugs (K⁺ sparing diuretics –
Spironolactone, amiloride; ACE inhibitors and AIIRA, NSAIDs).
- Transcellular compartmental shift: acidosis, hyperglycemia, low
insulin, digoxin poisoning, β blockers
▪ Drugs:
• Digoxin
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• Indomethacin
• IV Benzyl penicillin (contains K)!
• Sx
- Weakness, ascending paralysis, loss of deep tendon reflexes and
respiratory failure
• types:
- MILD: 5-6 mmol/L
- MODERATE: 6-7 mmol/L
- SEVERE: more than 7 mmol/L - ECG changes:
▪ (5.5-6.5mmol/L) Tall, peaked T waves.
▪ (6.5-7.5 mmol/l) Prolonged PR interval with flattened P
waves.
▪ ST segment depression.
▪ (7-8 mmol/L) - QRS widening, absent P waves and
sinusoidal wave pattern.
▪ VT, VF, PEA and (> 8 mmol/L) asystole
- MANAGEMENT:
▪ SEVERE:
• Immediate cardioprotection: 10% Ca gluconate
• Other therapies to shift K into cells, and
eliminate potassium from body (IV insluin &
loop diuretics)
▪ MODERATE:
• Shift K intracellularly with 10% dextrose 500 ml
IV/ glucose ē 25 units of insulin over 20 min
• 8.4% Sod bicarbonate 20 ml IV over 5 min
• Salbutamol 5-10 mg nebulized
• + cation exchanging enema while waiting for
dialysis
▪ MILD:
• Remove potassium from the body with:
o Furosemide 40-80 mg IV
o Potassium-exchange resin orally or
enema
▪ Hypokalemia
• ↑ incidence of cardiac arrhythmias esp. if pre-existing heart disease.
• CAUSES:
- Inadequate intake of K, e.g. Alcoholism, Starvation.
- Abnormal GIT losses: Vomiting, diarrhoea, laxative abuse
- Abnormal renal losses: Cushing syndrome, ectopic ACTH
production, hyperaldosteronism, diuretics and steroids.
- Compartmental shift: Metabolic alkalosis, insulin.
• types
- normal - Potassium levels less than 3.5 mmol/L
- SEVERE: L.
• CLINICAL FEATURES:
- muscle weakness, fatigue, leg cramps and constipation.
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▪ Hyponatraemia
• Serum sodium level < 130 mmol/L
• Clinical Features: The more rapid the fall the greater the symptoms:
- >125 mmol/L: usually asymptomatic.
- 115-125 mmol/L: lethargy, weakness, ataxia and vomiting.
- <115 mmol/L: confusion, headache, convulsions and coma.
- PSEUDOHYPONATREMIA - Associated with hyperglycaemia,
(hyper osmolar hyponatremia) hyperlipidemia, hyperproteinemia, azotemia.
- Zinc deficiency
o after prolonged IV fluid admin.
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▪ Gelatins (3.5%)
• no serious SE
• very common in use
• 2 hr of plasma expanding properties
▪ Hydroxyethyl starch – very good but also very expensive
• 6%, 10%
• no complic
• 4 hr of plasma expanding properties
• best solution in severe hypovolemia
▪ Albumin – 5%, 25%
• hypoalbuminemia: burns, malignancies, cirrosis, ascitis, etc.
o Blood components
▪ RBC (packed cells)
• indic. when volume replacement is not the issue
- e.g. Hb = 6.0
▪ FFP
• indic. in warfarin toxicity, advanced liver disease (causing
coagulopathy), antithrombin III deficiency
▪ Platelet concentrates
• the only ones that can be stored at room temp.
• can also be stored as powder
• but usually a solution
• indic. – thrombocytopenia
▪ Cryoprecipitate – contain fact. VIII , XIII, von Willebrand factor & fibrinogen
• indic. – Von Willebrand dis., hemophilia
- Blood transfusion
o 1 unit = 450 ml
o before – compatib. test
▪ ABO -> blood group
▪ Rh typing -> test with Anti-D AB, (RH + or -)
▪ cross matching – check other AB
▪ AB screening for other diseases (HBV, etc.)
o Cx
▪ Allergic reaction: itching, shivering, rigors, rash, anaphylactic shock
▪ hemolytic reaction:
• acute
- ABO incompat.
▪ MC cause – human error
▪ intravascular hemolysis: hemoglobinuria (acute RF)
• delayed
- Rh incompat.
▪ extravascular hemolysis
▪ Dx – Coombs test
▪ inf.
• HCV
• HIV
• CMV – MC inf. in organ transplant
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• Epstein Barr v.
▪ metab.
• hyperkalemia (cellular destruction)
• hypocalcemia
• acid-base abnormalities
▪ coag. problems
• dilutional coagulopathy – dilutional thrombocytopenia
e.g. in massive blood transfusion: > 5 l in 24 hrs
- dilutional coagulopathy – dilutional thrombocytopenia
- DIC
▪ hypothermia
▪ immune suppression
▪ tissue hypoxia
- Blood loss
o 5-10% body can compensate
o > 20% - body can’t compensate anymore
o 30% = clinical shock (loss of 1.5-2l)
- Dehydration assessment – see printout from Afshan
o most specific indicator = lethargic and irritable (nervous system affected)
o water content by age group
▪ 12 wks fetus – 90 % water, 55% is extracel. fluid
▪ newborn – 80%, 40 % extracel.
▪ 12 mths – 60%, 25% extracel.
▪ adult – 60%, 20% extracel.
o clinical classif.
▪ mild
▪ moderate
▪ severe
% of body wt. loss Clinical
Mild 4 Dry mucosa
(70 kg man lost 3 L) (<5) Thirst
HTN, tachycardia
capil. refil > 2 sec (N < 2 sec)
Decr. skin turgor
Moderate 5-8 adults Dry mucosa, firm dry tongue, sunken eyes, decr.
(lost 4-6 L) 4-6% children skin turgor
Have to admit him! (5-10) capil. refil > 2 sec
Tachycardia
Oliguria (<0.5 ml / kg / hr)
(Normal 1 ml / kg / hr)
Orthostatic HTN
(keep the pt standing 5 min – systolic BP drops >
15-20 mm) Depreesed fontanelle in Child
Severe 8-10 Dry mucosa
(lost 7 L) > 7% children Thirst
(>10) capil. refil > 2 sec
Decr. skin turgor
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Tachycardia
Oliguria (<0.5 ml/ kg/ hr)
(Normal 1 ml/ kg/ hr)
hT
Cardiovasc. collapse
- Dehydration - Afshan
o Mild < 5%
▪ no clinical signs, only thirst
▪ (deficit: 50 ml/ kg)
o Moderate 5-9%
▪ loss of skin turgor
▪ sunken eyes
▪ dry mucous membranes
▪ no tears
▪ depressed fontanelle in children
o Severe ≥ 10%
▪ circ. failure, shock
• hT
• tachycardia
• cold and clammy skin
• oliguria (< 0.5 ml/ kg/ hr)
• capil. refil > 2 sec (N < 2 sec)
▪ lethargy or irritability
▪ (deficit: 100ml/ kg)
- I. Hypovolemia
o e.g. 1: 1 yr old child, 10 kg,10% dehydration and shock
o e.g. 2: 20 yrs old man, 50 kg, 7% loss
o I. Maintenance/ongoing losses: (replacement of fluid)
▪ Infant, child < 5 yrs (Maria, Afshan)
• 0-3 mths: 120 ml/kg/24h
• 4-12 mths: 100 ml/kg/24h
• >12 mths: 80 ml/kg/24h
• e.g.1: 100 x 10 = 1000 ml / 24 hrs for the child
• (Amit- by body weight
- first 10 kg: 100 ml/ kg/ 24 hrs
- 11-20 kg: 75 ml/ kg/ 24 hrs
- > 20 kg: 50 ml/ kg/ 24 hrs
- e.g.1: 100 x 10 = 1000 ml/ 24 hrs) = Maintenance fluid
▪ Adult, child > 5 yrs (Amit, Maria)
- In eg, 2 of an adult of 50 kg.
- first 10 kg: 100 ml/ kg/ 24 hrs = 1000ml
- 10-20 kg: 50 ml/kg/24 hrs = 500ml
- > 20 kg: 20 ml/ kg/ 24 hrs = 600ml
- e.g. 2: 1000 + 500 + 600 = 2100 ml/ 24 hrs = Maintenance fluid
o II. Estimation of volume deficit (fluid loss due to dehydration)
▪ 5%
▪ 5-10%
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▪ > 10%
o % Dehydration x body weight in kg x 10 in ml
▪ e.g. 1: 10 % x 10 kg x 10 = 1000 ml/ 24 hrs child
▪ e.g.2: deficit: 50 x 7 x 10 = 3500 ml/ 24 hrs man
o e.g. 1: total fluid to give: 1000 + 1000 = 2 L
o e.g.2: total fluid to give: 2100 + 3500 = 5600 ml
o steps:
▪ I. if severe dehydration with shock:
initial bolus – 20 ml/ kg of NS
• if still in shock, repeat with another 20 ml/ kg of NS
- e.g.1: 20 x 10 = 200 ml bolus, repeated one more time if needed
- e.g.2: 20 x 50 = 1000 ml bolus
▪ II. give half of the amount in the first 8 hrs (Amit)
• e.g.1: 2000/ 2 =1000 – 200 bolus = 800 ml
• e.g.2: 5600/ 2 = 2800 – 1000 bolus = 1800 ml
▪ III. Give the rest in remaining 16 hrs
• e.g.1: 1000 ml
• e.g.2: 2800 ml
▪ (II. Afshan - give more in the first 6 hrs
• 100 ml/kg in infants
- 100 x 10 = 1 L in the first 6 hrs – 200 ml bolus = 800 ml after the
initial bolus in the first 6 hrs
• 50 ml/kg in adults
▪ III. give the rest in the remaining 18 hrs
• 2L – 200 ml bolus – 800 ml = 1 L in the remaining 18 hrs of the first day )
- II. Intraop. fluid management - Amit
o 4-2-1 formula
▪ e.g. 50 kg patient
• up to 10 kg body wt. 4ml/kg/hr = 40
• 10-20 kg 2 ml/kg/hr = 20
• 20-50 kg 1 ml/kg/hr = 30
- total 90 ml/hr
- III. post-op rehydration (especially in abd. surgery)
o always 3 L daily requirements for adult
▪ 2 L NS + 1 L dextrose
o + losses, divided between normal saline and dextrose, based on the patient (he doesn’t
eat -> give more dextrose, etc.)
o + 70-90 ml of K
▪ e.g. blood loss of 2L + hypokalemia -> 3L normal saline + 2L 5% dextrose + 100
ml K
- IV. Burns
o rehydration: 2-4 ml / kg / % burned in the first 24 h + maintenance fluids
▪ 50% in the first 8 hrs
▪ 50 % in the other 16 hrs
▪ using ½ Hartman solution (with K+) and ½ NS
o minimum required urine output: 0.5-1 ml / kg /h
▪ min. 40-50 ml/h = 1000 ml/24hrs
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o Rule of 9s
▪ head & neck 9%
▪ arm 9% (4.5% each)
▪ leg 18% (9% each leg)
▪ trunk
• front - 18%
• back - 18%
▪ perineum 1%
o MC common cause of death: renal failure – in first 2-3 days
▪ then death from inf. (after first 3-5 days)
▪ shock in major burn in first day (M 1381)
o indication for intubation
▪ horseness of voice
▪ stridor
▪ coughing black materials
▪ facial swelling
▪ nasal hair burned (singed)
▪ resp. distress
- Fluid replacement - Amit
o urgent – intravasc. fluid resuscitation (bolus) – only in severe cases
▪ hypovolemic shock or severe dehydr.
• 0.9% NS - 20 ml / kg IV ASAP stat run (bolus)
- e.g. 50 kg pacient = 1L
▪ vasodilatory shock: sepsis, anaphylaxis, spinal shock
• 0.9% NS - 20 ml / kg IV ASAP stat run (bolus)
▪ cardiogenic shock
• 0.9% NS - 10 ml / kg IV ASAP stat run (bolus)
▪ moderate dehydr., without shock
• 0.9% NS - 10 ml / kg IV ASAP stat run (bolus)
▪ minimum volume resusc.
• titrate perfusion in order to maintain a systolic BP of min. 90 /60)
• e.g. ectopic pregnancy, penetrating chest wounds, rupture of aortic
aneurysm
Respiratory/ lung pathology - OK
Lung volumes
- These values vary with the age and height of the person; the values that follow are for a 70 kg
(154 lb), average-sized adult male [2]:
o RF-
o Dx
▪ X Ray: small cavity with fluid level
▪ best investig: CT chest
▪ Bronchoscopy
o Rx
▪ O2, strong analgezic
▪ postural drainage, tapping
▪ IV A/B:
• Clindamycin (active on anaerobs; SE – Pseudomembranous colitis) +
Cephalosp. (ceftriaxone)
(Iv penicillin or clinda)
• Cephalosp. + flucloxacillin
Bronchitis
o Acute - sore throat, runny nose, persistent cough especially at night and in the morning,
small amount of yellow sputum
▪ Rx
• Symptomatic
• bronchodilators
• Amoxycillin or Doxycycline (if fever or sputum, usually not needed)
• A 23-year-old-male presents with a one week history of cough productive of whitish sputum. This was
preceded one week prior by an URI. He denies chills, night sweats, shortness of breath or wheeze. Temperature is
99.9°F (37.7°C)
Presentation
-patient with persistent cough > 5 days following an URTI with mild or no fever or constitutional symptoms
Management
o initial test:do a radiograph to exclude pneumonia if:
o fever >100.4°F(38°C)
o signs of consolidation on exam
o definite therapy:rehydration and antipyretics
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o Chronic - persistent cough especially at night and in the morning, large amount of yellow
sputum
o Dx
▪ X Ray
▪ pfts
▪ Biopsy (gold std)
A 46-year-old female presents to her primary care physician for follow-up for a severe,
unrelenting, productive cough that she had had on and off for more than two year
1) One of two major presentations of Chronic Obstructive Pulmonary Disease (COPD)
i) including chronic bronchitis and emphysema
2) Characterized by decreased lung function in the setting of airflow obstruction
3) Defined by productive cough for >3 months per year for two consecutive years
4) Patients identified as "blue bloaters"
i) color indicative of hypoxia observed in bluish tint of skin and mucous membranes
ii) barrel-chested secondary to hyperinflation of the lungs due to outflow obstruction
Asthma
o Causes/ triggers
▪ Infections
▪ Allergies-house dust mites are the most common triggeR
▪ Cigarette smoke
▪ Sudden change in weather or temperature
▪ Drugs that can exacerbate asthma:
• β blockers
• Aspirin
• NSAIDs:
• Foods causing asthma
• Sulfites and metabisulfites preservatives
• MSG
• Sea food
• Nuts – peanuts
▪ stress
▪ exercise in a cold atmosphere
o Sx
▪ Triad: Dyspnoea, wheeze(exp) & cough
o Lab:
▪ FEV1/ FVC (FEV1%) – most accurate test (Forced expiratory volume at 1 sec/
Forced vital capacity)
• normal 75–80%.
• <75% = Obstruction
▪ PEFR - maximal flow or speed achieved during the maxim. forced expiration
initiated at full inspiration, measured in L/ min. It is measured with a peak flow
meter or mini peak flow meter.
• in children over 6 years and adults
• compared to graphs of predicted normal values based on a person's sex,
age and height
▪ Methacholine challenge
▪ used for definitive diagnosis
▪ tests for bronchial hyperactivity in a well patient
o types of attack
▪ mild
▪ moderate
▪ Severe – dangerous signs:
• SaO2 < 90%
- SaO2 <92% - give O2
• PEFR < 100 L/ min
• FEV1/FVC < 40%
• RR > 50 in children or > 25 adults
• HR > 120
• using access. resp. muscles = chest retractions = intercostal recession of
muscles
• sternal notch
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• nasal flaring
• too breathless to talk or feed
• exhaustion, sleep deprivation, drowsiness, confusion
• silent chest
• cyanosis
o Drugs:
▪ Bronchodilators
• Beta receptor agonists:
- Short acting beta agonists (SABA) - effect starts after 1-2 min,
max. at 10-20 min.
▪ Salbutamol (albuterol USAN)
▪ Terbutaline
- Long acting beta agonists (LABA)
▪ Salmeterol
▪ eformoterol
- Adrenaline – sc, im or iv
• Anticholinergic medications:
- ipratropium bromide
• Methylxanthines: – limited use due to side effects and limited efficacy
- theophylline - Oral
- aminophylline – Injection(drip)
• Anti-IgE agents:
- Omalizumab
- Mauzumab
▪ Antiinflammatory - Long term control
• Glucocorticoids are the most effective treatment available for long
term control. (Best preventer)
- inhaled
▪ fluticasone (Best preventer)
▪ beclomethasone
▪ budesonide
▪ ciclesonide (single daily dose)
- Oral – for exacerbations
▪ prednisolone
• Mast cell stabilizers – inhaled; adverse effects are uncommon!
- sodium cromglycate
- nedocromil sodium
• Leukotriene antagonist – chewable tablets
- montelukast
- zafirlukast
o routes of delivery
▪ <3 yrs - metered dose inhalation (MDI) + small volume spacer + face mask
▪ 3-5 yrs - MDI + small volume spacer
▪ 5-8 yrs – MDI + large volume spacer
▪ > 8 yrs – MDI
o Sx - patterns in children – Murtagh 1280
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o Sx
▪ Small PE: Sudden dyspnoea, pleuritic pain and pleural rub, and possibly
haemoptysis, with few physical signs
▪ Major PE: Dyspnoea, chest pain and light-headedness or collapse/ syncope,
followed by recovery.
▪ Look for cyanosis, tachycardia, hypotension, raised JVP and loud delayed
pulmonary 2nd sound (due to pulmonary HT)
o Dx
▪ FIRST: X-Ray: Mainly to exclude pneumonia, pneumothorax.
▪ SECOND & Best: CT Pulmonary angiogram (CTPA).
▪ THIRD - if CTPA unavailable or CI (e.g. renal failure – no contrast): Ventilation-
Perfusion isotope lung scan (V/Q scan)
• V/Q ratio (ventil/ perfusion)- isotope scanning ē Technetium Tc-99m
Low probability Perfusion deficit with matched ventilation deficit Non diagnostic
V/Q ratio measurement used to assess the efficiency and adequacy of matching of two variables:
"V" - ventilation - the air which reaches the lungs
"Q" - perfusion - the blood which reaches the lungs
- A lower V/Q ratio (with respect to expected value for a particular lung area in a defined position)
impairs pulmonary gas exchange and is a cause of low arterial partial pressure of O2 (paO2).
Excretion of CO2 is also impaired but a rise in paCO2 is very uncommon because this leads to
respiratory stimulation and the resultant increase in alveolar ventilation returns paCO2 to within
the normal range. These abnormal phenomena are usually seen in chronic bronchitis, asthma
and acute pulmonary edema.
- A high V/Q ratio increases paO2 and decreases paCO2. This finding is typically associated with
pulmonary embolism (where blood circulation is impaired by an embolus), but can also be
observed in COPD as a maladaptive ventilatory overwork of the undamaged lung parenchyma.
• High-dose O2
▪ Heparin: LMW 1mg/ kg s.c 12 hourly or UH 5000 units IV bolus followed by 1000
units/ h infusion
▪ Massive PE in shock (acute heart failure, hypotension): Thrombolysis with rt-
PA
o Cx
▪ Consolidation -> bronchial breath sound
• Q62 p. 19/176 in purple book
Pneumothorax
Spontaneous Traumatic Iatrogenic
a. Normal thin tall male Tension pn. = emmergency
b. Lung disease, COPD, asthma,
a. CVP line in subclavian vein
cystic fibrosis, b. Pleural biopsy
Excessice coughing c. Rx for hyperhidrosis – blocking
stelate sympathetic ganglion
Rx Rx.
a. Needle aspiration -> observe -> didn’t Needle aspiration 2nd ICS
resolve, repeast aspiration -> still didn’t medioclavicular line.Then replace
resolve, chest tube with chest tube under water seal (5th
b. chest tube for drainage ICS mid-axillary or anterior axillary
line)
Sx: Hyperresonance, decreased vocal resonance on auscultation, shift of trachea to opposite site
Rx
Sympt – treat
Asympt < 2 cm – Observe
> 2 cm treat
> 15% loss of lung volume - Treat
- Needle aspiration
o Tension pneumothorax
o Spontaneous pneumothorax
- Chest tube
o Tension pneumothorax – after doing needle aspir.
o Sec. spontaneous pneumothorax
o Most traumatic pneumothoraxes
o Malignant pleural effusion
o Hemopneumothorax
o Empyema
Dx: Not done in emergency
Chest X Ray in expiration
357
- Pneumohemothorax
o If not urgent – do chest tube directly, without doing the needle first.
Pleural pathology
- Pleural effusion
o Sx
▪ Dullness on percution
o Dx
▪ Pleural fluid contains
• Mononuclear cells predominantly = TB
• Transudate vs. exudate
- Criteria for exudate:
▪ Ratio of pleural fluid protein to serum protein > 0.5
▪ Ratio of pleural fluid LDH and serum LDH > 0.6
▪ Pleural fluid LDH > 0.6 or 2/3 times the normal upper
limit for serum.
358
359
Lung CA
o 2nd MC CA in Australia after non-melanoma skin CA
o Most lethal CA in Aus.
o Prognosis at 5 yrs – 12-14%
o Risk factors
▪ Smoking
▪ Silicosis, working in a mine
▪ Asbestos
o Relationship with smoking:
▪ smoker
• squamous
• small cell
▪ non-smoker
• adenocarcinoma – MC in non-smokers
o Sx
▪ Triad: malaise + wt. loss + cough
▪ Hemoptisis
▪ Superior vena cava compression syndrome
• Jugular veins proeminent, subcut veins on upper chest dilated.
▪ Paraneoplastic phenomena
• Squamous cell carcinoma
- Parathyroid hormone-related peptide (PTHrP) - hypercalcemia
▪ Sx - fatigue,
• Small cell carcinoma
- SIADH – Hyponatremia (120mm/l or less) bc of ↑ total body water----Hypo-
osmolar hyponatremia.
- Ectopic ACTH secretion – Cushing syndrome: Moon face buffalo hump, central
obesity, striae and bruising ↑ secretion of melanocyte secreting horomone
(MSH) -> ↑ Pigmentation of mucosal membranes and skin. Hypokalemic
alkalosis bc of excess glucocorticoid and muscle weakness.
▪ Pancoast tumor/ Hornor syndrome:
• + compression on T1
- all small muscles of hand, including thenar and hypothenar eminences
- difficulty of precision grip and opposition of thumb to fingers, weakness
spreading and bringing together the fingers
- in time – claw hand
o types
▪ Small cell (SCLC) - 15-20%
• Rx
- Chemotherapy
- Radiotherapy - palliative
▪ Non-small cell (NSCLC)
• Squamous – 20-30%
• Adenocarcinoma – 20-30%
• Large cell carcinoma – 20-30%
• Rx
- surgery
- chemotherapy
- radiotherapy - palliative
o Dx
▪ sometimes incidental finding at chest X Ray
▪ Bronchoscopy and biopsy (if close to a bronchi)
360
Mesothelioma:
o Risk factors
▪ Asbestosis (boiler worker, electricity-generating plants) decades after(10 yr)
▪ Smoking
o Sx
▪ cough
▪ pleuritic pain
▪ massive recurrent hemorrhagic pleural effusion
▪ pleural plaques
o Dx
▪ Percutaneous biopsy(pleural)
361
o Rx
▪ surgery
▪ chemotherapy
▪ radiotherapy
o prognosis – very poor
Asbestosis:
o after a lag of 10-20 yrs or more from the exposure
o fibrosis/ scarring of the lungs
o assoc.
▪ mesothelioma
▪ TB more assoc. with silicosis (not asbestosis)
OCCUPATIONAL PULMONARY DISEASE-559
BRonchiectasis-475
362
TB
o Triad: Malaise + cough + wt. loss ± erythema nodosum
▪ Primary TB
• Sx – cough, hemoptysis, sweating , fever, malaise, anorexia
- Murtagh – in most cases asympt.
• X Ray: infiltrates in middle and lower zones + hilar lymph nodes
(unilat.) known as Ghon Complex
▪ Latent TB - MC
• Mantoux test – positive
• no clinical features
• usually no X Ray changes
• 10% (if weak immune system) will progress (progressive primary TB) to
reactivation =>
▪ Active secondary TB, within first 2 yrs of exposure
• clinical
- constit. – fatigue, night sweats, wt. loss
- site dependent sympt.
▪ Pulmonary TB – MC
• Sx
o chronic productive cough
o +/- hemoptysis
• X Ray
o infiltration and cavitations in upper
lobes (apical area)
o No hilar lymphadenopathy
o pleural effusion
o past. inf. - apical calcif. and scarring –
can still have surviving bact.
▪ Miliary TB
• X Ray: multiple small bilat. seed-like lesions
▪ Extrapulm TB
• Pericarditis, peritonitis, meningitis,
osteomyelitis, epididymitis or tubal TB
o MCQ: Constrictive pericarditis with
previous TB exposure (ventricular
failure, edema, JVP extremely high, abd.
distension)
▪ X Ray - infiltr. in apical lobes +
pleural effusion
o Dx
▪ Mantoux test:
• delayed hypersensitivity test
- evaluated after 72 hrs
• < 5 mm = negative
- do vaccination!
363
Cardiac pathology - OK
- Infective endocarditis
o causes
▪ MC – Strepto. viridans > 50% (after dental work)
▪ in IV drug users – MC Candida and Staph. aureus
• MC affected valve = Tricuspid (blood goes to right side of heart first)
▪ Staph. aureus (50% of acute forms)
▪ Coxiella burnetti – Q fever
o Predisposing factors
▪ Valvular dis.
▪ Cardiac defects
▪ Prosthetic valves
▪ IV drug use
▪ after
• Dental work (dental extraction, etc.)
• Instrumentation (urethral dilatation, etc.)
• Minor or major surgical procedures (tonsillectomy, abortion)
• Central venous catheters
o mortality 6-30%
o 15% previously Dx with heart dis.
o Sx
▪ may be with no murmur
▪ Triad: fever of unknown origin + cardiac murmur + embolism
▪ presentations
365
• Acute endocarditis
• Subacute endocarditis
• Prosthetic endocarditis
o Mx
▪ take blood cultures, then
▪ start ASAP empiric Rx with:
• Benzyl penicillin + Flucloxacilin + Gentamicin x IV
- HOCM
o family Hx of father who died early – usually AD
o Sx
▪ exertional syncope
• collapse during physical effort (plays football) due to arrythmia
▪ ejection systolic murmur (same as aortic stenosis) non radiating
• non radiating & exacerbation with Valsalva manouver = HOCM
o Dx
▪ 1 – Echocardiography – every 5 yrs
• LVH
• Subaortic septal hypertrophy -> pushes valve -> similar to Aortic Stenos
o Rx
▪ No digoxin (can ↓ ejection fraction)
- JVP – internal jugular vein
o raised if > 4 cm
o Components:
▪ a wave – atrial systole
▪ c wave – closure of tricuspid valve (not normally visible)
▪ x descent – ventricular systole
▪ v wave – atrial filling against a closed tricuspid valve
▪ y descent – opening of the tricuspid valve
o Pathology:
▪ raised JVP with normal waveform: Right heart failure, fluid overload
▪ raised JVP with absent pulsation: SVC obstruction
▪ large a wave – Pulmonary hypertension, Pulmonary stenosis
▪ cannon a wave – right atrium contracts against a closed tricuspid valve -
complete heart block
▪ absent a wave – atrial fibrillation
▪ large v wave – tricuspid regurgitation
▪ high plateau of JVP with deep x and y descents – constrictive pericarditis
▪ absent JVP – reduced circulatory volume
o Positive abdomino-jugular reflux sign – rise in JVP presistent after 15-60 sec of abdominal
compression = right ventricular failure
- Cardiac tamponade
o Sx
▪ Beck triad
• hypotension
• muffled heart sounds
• increased JVP, distended neck veins
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- prolong survival!
- bisoprolol, carvedilol, metoprolol
• 4. + digoxin
- if indicated
▪ e.g. AF
- CI in bradycardia
• 5. + Spironolactone
- careful when combining with ACE inh. (risk of hyperkalemia)
• 6. + consider vasodil.
• 7. + consider transplant
o highest risk for non-cardiac operation: heart failure (> Hx of of DVT or MI)
o 50% will die in 5 yrs
Cardiac arrhythmias
- Arrhythmias
o causes:
▪ I - Medications: Side effect.
▪ II - Exclude myocardial ischemia from ACS as a priority.
▪ III - Electrolyte disturbances: Hyperkalemia.
▪ Hypoxia
▪ Hypovolemia
▪ Thyroid disease
▪ Septicemia
o types:
▪ Bradycardia < 60
• can be:
- SINUS
▪ Rx
• Bolus of atropine 0.5-0.6 mg IV
o Repeat if it persists (up to 3 mg IV)
• if pt conscious: Consider insertion of a
temporary transvenous pacemaker (2nd or
complete heart block)
- JUNCTIONAL
- AV BLOCK = Prolongation of PR interval to > 200 ms
▪ First degree: Benign
• PR > 0.2 s (5 small boxes)
• Rx
o none, unless sympt.
▪ Second degree:
• types:
o Mobitz I (Wenckebach Phenomon)
– Progressive prolongation of PR
interval then drop of a QRS complex
▪ AV node is blocked
▪ Rx - none
o Mobitz II
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▪ intermittently nonconducted P
waves not preceded by PR
prolongation and not followed
by PR shortening.
▪ PR is constant (not progressively
prolonged) but 1:1, 1:2, 1:3, …
for every 1-3 P waves, a QRS is
dropped
▪ Rx – Pacemaker, especially
after myocardial infarction
▪ Third (complete) – no relationship between P waves
and QRS complexes, complete AV block, ventricles
contract at lower rate than atria.
• HR: 25-50
• Large volume pulse
• Increased JVP (CANNON WAVE)
• Systolic murmur
• Rx
o temporary pacemaker then arrange for
permanent pacemaker
o First check drugs, if no response give
treatment
o atropine?
- Atrioventricular blocks
o Grade I – PR extended > 0.20 sec - digitalis
o Grade II – PR extended and certain SA impulses are missed (do not make it to ventricles)
▪ Mobitz type I (Wenkebach) – digitalis
▪ Mobits type II – usually not from digitalis
o Grade III – complete AV block, ventricles contracting at lower rate than atria
- Atrioventricular dissociation
o Ventricles contracting at a higher rate than atria (unlike AV block Grade III)
▪ Tachycardia
• Broad-complex: (VT, VF, SVT with block)
▪ VT
• Broad QRS
• > 300/ min, regular, usually post MI
• Rx
o Pulseless VT or unconscious, unstable:
Give a synchronized DC shock 120-150 J
and repeat up to 3 times.
o with pulse, conscious, stable:
Amiodarone 300 mg IV over 20-60 min
followed by an infusion of amiodarone
900 mg over 24 hours.
▪ VF
• no QRS complex
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• Rx
o cardioversion
▪ adrenalin
▪ CPR
o drugs: amiodarone, lidocaine
- WPW:
▪ Short PR interval on ECG
▪ Delta wave
▪ wide QRS
▪ Rx
• radiofrequency ablation of accessory pathway.
• Stable - IV procainamide (class Ia)/
Amiodarone
• Unstable – DC cardioversion
▪ CI
• Avoid adenosine, verapamil, digoxin and
diltiazem as they block the AV node and may
worsen a pre-excited AF leading to VT.
• Narrow-complex: SVT (presents with rapid palpitations in a young pt
after extercise).
- Sinus rhythm, narrow QRS complexes, 150-200/ min
- if unstable: Synchronized DC cardioversion 70-120 J.
- if stable:
▪ 1. Vagal stimulus such as:
• carotid sinus massage: Young, stable, with no
carotid bruit, no history of TIA or CVA.
• Valsalva manouver
▪ 2.a. Adenosine: 6 mg rapidly over 2-5 seconds IV
followed by 12 mg IV after 1-2 min, then further 12 mg
once more if still no response.
• SE – cardiac arrest
▪ 2.b. Alternatively Verapamil 2.5-5 mg as a bolus.
• pregnant woman: IV β blockers (verapamil is
teratogenic)
• Irregular narrow-complex tachycardia: AF
- Prevalence: 0.1% less than 55 years, 10% above the age of 80.
- risk factors
▪ HT – 20% cases of AF
- More prevalent in men.
- HR = 350-550/ min
- irregularly irregular rhythm + absent P waves
- Common underlying causes: IHD, thyrotoxycosis and HTN
(rheumatic fever in developing countries)
- Risk of stroke: 2.5-3% below age of 65, over 10 in older
population
- High risk of femoral artery embolism.
- Rx
370
▪ Alena
• acute onset (< 48 hrs) young age (<65 yrs), no
structural damage (no MI), stable -> rhythm
control: amiodarone + heparin
o Do first US to exclude thrombus in heart
o rate control – digoxin (Murtagh) or β
blocker (Oxford)
• unstable – cardioversion
• elderly pt, with risk factors, previous MI, etc.
o rate control: digoxin, beta blocker
o anticoag.
▪ (Maria) Unstable: Synchronized DC cardioversion 120-
150 J.
▪ Stable: more or less than 48 hours?
• Acute - less than 48 hours: Rate control, rhythm
control, anticoagulation.
o I - Rate control (Maria?):
▪ 1. digoxin – don’t give for low
BP (< 90/60) –(with heart
failure,exercise) Murtagh 779
▪ 2. Verapamil, diltiazem
▪ 3. Β blocker – metoprolol,
atenolol
o (Maria) II - Rhythm control (Amit = I =>
rate will be controlled as well):
▪ Murtagh: if symptomatic +
recent onset (< 6 mths)!!
▪ electrical cardioversion – if
unstable
▪ chemical – if stable: Flecainide
(don’t use in systolic heart
failure)(class Ic), Amiodarone
(class IIa), Sotalol (risk of acute
heart failure).
o Anticoagulation - heparin, then
▪ > 60 yrs, with risk factors –
warfarin (Jay)
▪ < 60 yrs, w/o risk factors –
aspirin
• 2. More than 48 hours
o main goal: rate control
▪ beta blocker
▪ digoxin –( AF and signs of
cardiac failure.)
o Anticoagulation: Enoxaparin 1 mg/kg or
UF heparin 5000 IV as a bolus followed
by an infusion.
o failure to revert chemically => DC shock
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MI
- Coronary ischemic syndr.
o stable angina
o acute coronary syndrome (ACS)
▪ STEMI
372
▪ NSTEACS
• NSTEMI
• unstable angina
- AMI
o STEMI
▪ if coronary block is not relieved, MI will progress over next 6-12 hrs (4 hrs =
window period)
▪ main goal of Rx is reperfusion
▪ causes of new systolic murmur post MI
• V septal rupture
• papillary muscle rupture
• papillary muscle dysfc. in ant. MI
• func. mitral regurgitation sec. to LV dil.
• pericardial friction rub, limited to systole
▪ Dx
• First step in management: ECG within 10 minutes of patient arrival.
- ECG: ST elevation in two or more contiguous leads:
▪ Inferior MI: II, III, aVF
▪ Anterior MI
• anteroseptal – V1-V3
• anterolateral – V3-V4
▪ Lateral: I, aVL, V5-V6
▪ Posterior: Mirror-image ST depression V1-V4
• Repeat ECG after 5-10 min if non-dx ECG.
- repeat ECG every 2-3 hours
• Send blood for laboratories: Cardiac biomarkers.
- Second step = Troponin I or T
▪ normal < 0.02
▪ rise after 4-6 hours after symptom onset.
▪ Repeat in 6-8 hours if normal.
▪ Indicate myonecrosis.
▪ Remains elevated for 5-14 days (not useful for re-
infarction).
▪ More sensitive for myocardium than CK-MB.
▪ can also be elevated in CRF – due to renal destruction
• Dx diff with CRF:
o do also CK – not elevated in CRF
o if troponin is gradually increasing – MI
▪ constantly increased = CRF
- + CK-MB, CK.
▪ If troponin is unavailable.
▪ rise after 4 hrs
▪ not specific for myocard infarction
• CK-MB is more specific than total CK
▪ Returns to normal within 72 hrs
• May be used to confirm re-infarction
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-
▪ complic.
• LVF: pulm. congestion
- Rx: diuretics
- O2
- morphine
- digoxin is CI – ↑force of contr. -> risk of rupture
• cardiogenic shock – 90% mortality
- Rx – dopamine, dobutamine
• aseptic pericarditis (Dressler syndrome)
- Rx
▪ NSAIDS, paracetamol, aspirin
▪ C/S
▪ Mx
• I. MONA
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• absolute
o Intracerebral or subarachnoid hemrhg.
o Intracranial neoplasm ever.
o Stroke in previous 6 months.
o Active GI bleeding in last month.
o Major surgery or trauma in previous 3
wks
o Known bleeding diathesis.
o CRP > 10
o Aortic dissection
▪ first rule out aortic disection
before giving thrombolysis ->
can kill a patient with aortic
dissection
• relative
o Oral anticoagulant therapy
o Pregnancy within 1 week post-partum.
o Central line.
o Refractory hypertension.
o Infective endocarditis.
o Severe hepatic or renal disease.
▪ indic.
• ST elevation > 1 mm in limb leads
• ST elevation > 2 mm in chest leads
• new LBBB
• post MI-ST depression in V2-V3-> ask for V7-V9
▪ after 12 hrs, thrombolysis is still considered if:
• persistent pain
• preservation of R waves in infarct-related ECG
leads (not replaced by pathological Q wave)
• major complic. – cardiogenic shock
- Antiplatelets
▪ Aspirin 300 mg
▪ Clopidogrel 300 mg
-Heparin.
• III. After reperfusion
- Antiplatelet agents
- Cardioselective β blockers – increase the survival (MCQ)
▪ Atenolol
▪ Metoprolol
- ACE inh. – within 24-48 hrs after MI
- Statin therapy – regardless of cholesterol level
- + Warfarin
▪ drugs that ↓mortality in MI
• 1. β blockers
• 2. ACE inh. (if no renal failure)
• 3. aspirin
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• 4. statins
- Neha:
o cardiac chest pain
▪ MONA -> hospital: ECG, Trop
No pain Hx of pain at rest or repetitive
pain or prolonged pain
No ECG/ enzyme changes Low risk Intermed. risk
ECG /enzyme changes High risk High risk
o Mx
▪ Low risk -> stress test
▪ Intermed -> reassess patient, repeat ECG and
troponins in 8 hrs -> if any risk factors
(↑cholesterol, fam. Hx, etc.) -> heparin SC
▪ High risk -> coronary angiography (PCI)
▪ if refractory pain – IV GTN (rare)
o NSTEMI
▪ Dx
• ECG: Within 10 min of patient arrival:
- ST depression
- T-wave inversion or flattening
- Non-specific or transient changes
- Normal
• Rise in troponin and CK-MB
▪ types – Afshan’s diagram for ACS
• high risk:
- > 10 min or elevation of troponins
• intermed. (>48 hrs)
• low risk – same as for stable angina (pain only on exertion)
▪ Mx
• MONA
• NO THROMBOLYSIS
• Heparin: LMW heparin such as enoxaparin 1mg/ kg or UF heparin 5000
units IV as a bolus followed by an infusion of 1000 units/ h.
- Angina
o types
▪ Stable (effort angina)
• ST depression
▪ Unstable – due to unstable plaque
• smaller rise in cardiac biomarkers, normal ECGs, normal stress test
• special types
- nocturnal a.
- decubitus a.
- variant a. or Prinzmetal a. (spasm a.)
▪ ST elevated
• don’t give β blockers!
o Rx
▪ acute
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• GTN subling.
• isosorbide dinitrate subling.
• nifedipine capsules – suck or chew
▪ chronic
• Aspirin 150 mg daily
- or clopidogrel
• Nitrates
- GTN
- Isosorbide mononitrate
• β Blockers
- Atenolol
- Metoprolol
• Ca Channel blockers
- Nifedipine
- Amlodipine
- Felodipine
- Diltiazem
- Verapamil
- Recurrent pain in ACS
o consider IV nitrate infusion
o maximize dose of β blocker
o consider Amlodipine or Nifedipine
o if high risk pain (persistent)
▪ GP IIb/IIIa (strong antiplatelets): abciximab
▪ transfer patient for PCI
- Coronary artery bypass grafting indic. (otherwise – angioplasty)
o triple vessel disease: all 3 arteries > 50%
▪ left anterior descending (LAD)
▪ left circumflex a.
▪ right coronary artery
o 2 vessel disease + DM
o main one – left anterior descending > 50%
ECG
o Normal impulse conduction
▪ Sinoatrial node (right atrium) – 60-100 beats/ min
▪ AV junction – delay, so A can contract before V (including atrial kick at the end
of A contr.)
• AV node – 40-60 pacemaker
• Bundle of His
▪ Bundle branches (left and right)
▪ Purkinje fibers
▪ Ventricular cells – 20-45 beats/ min
o Small square=0.04sec, large square=0.2 sec
o ECG interpretation: RRAHIM
▪ Rate
▪ Rhythm
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▪ Axis
▪ Hypertrophy
▪ Interval
▪ MI and miscellaneous
o 1. Calculate rate:
▪ Vertical bar every 15 large squares
▪ I. count 30 large squares (6 sec) – count the no. of R waves in those squares,
multiply by 10 -> in regular and irregular rhythms
▪ II. look for R wave falling on a line, then see where the next R wave falls – in
regular rhythms only
• 300 - next line in large square (300:1)
• 150 – next line … (300:2)
• 100 (300:3)
• 75 (300:4)
• 60 (300:5)
• 50 (300:6)
• …
▪ III. 300/ no. of large squares between 2 QRS complexes – in regular rhythms
o 2. determine Rhythm (RR intervals are regular?):
▪ Regular
▪ regularly irregular
▪ irregularly irregular – AF
o 3. Assess P waves – do they exist? are they followed by QRS? are they all same in size and
shape?
▪ MAT = Multifocal atrial tachycardia ≥ 3 P waves, each different, in same ECG
o 4. Determine PR interval – beginning of P to beginning of R
o 5. Determine QRS duration
o 6. QT interval – beginning of Q to end of T (T= terminal)
o Components
▪ P waves = Atrial depolarization (contraction) - best appreciated in lead II
• Present
• absent - AF
• relationship to QRS complexes (no rship. = AV block)
▪ PR interval: 0.12-0.2 (3-5 boxes)
▪ QRS complexes = Ventricular depolarization = 0.04-0.12 (1-3 boxes)
• narrow (supraventric)
• widened (> 0.12 s) (ventric.)
▪ ST segment
▪ T waves = Ventricular repolarization
• Elevated
• depressed
• inverted (ischemia)
▪ U wave = after repolarization
o Leads
▪ I, II, III – Limb leads
▪ aVR (right arm), aVL (left arm), aVF (feet) = Augmented limb leads
▪ V1-V6 = Chest leads (V1 = right -> V6 = left)
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• V1-V2 = medial
• V2-V3 = septum
• V4-V6 = lateral
▪ Rhythm strip = longer strip of II
o Problems
▪ Sinus bradycardia
▪ Sinus tachycardia
▪ 1 extra atrial focus firing = Normal sinus rhythm with PAC-Premature atrial contc
▪ 1 extra ventricular focus = PVC
• wide and bizarre QRS (slower conduction of impulse from ectopic foci)
• can be
- Uniform. arises from single focus
▪ Bigeminism (normal QRS, ectpioc beat after 2 normal
QRS)
▪ trigeminism ectpioc beat after 3 normal QRS
▪ couplet: normal PVC PVC – 2 consecutive ectopic beats
▪ triplet: normal PVC PVC PVC- 3 consecutive ectopics
▪
-
- Polymorphic: arises from multiple foci
▪ Multiple extra atrial foci firing = A Fib
• 1. absent Ps
• 2. irregularly irregular rhythm
• 3. narrow (normal) QRS
▪ Multiple extra foci in V = V Fib
• 1. absent Ps
380
• PE – S1Q3T3
- I – Deep S
- III – Deep Q and T wave inversion (positive)
• Hypokaleima:
ST depression, T wave inversion. Prol onged QT, Elevation of U wave
• Hyperkalemia
Tall tended T wave, Shortened QT interval, Wide QRS, Prolonged PR
interval, P flattens then disappears
Digoxin: ST depression, T wave inversion, Shortened QT interval,
Prolonged PR.
Vascular pathology - OK
- Surgery indication
o Carotid occlusion
▪ > 70% carotid occlusion
▪ 60-70% - grey area
• surgery in DM, elderly, hyperlip., recurrent TIP
▪ < 60%
• Rx – aspirin low dose
o > 50% coronary artery occlusion
- Angiodysplasia > 55 yrs
o AV malformation in intestine
o in ceceum + right colon
o Sx
▪ multiple episodes of profuse rectal bleeding
▪ assoc. with CREST syndrome
o Rx
▪ surgical resection
Arterial pathology
- Vasculary problems/ surgery
o Arterial
▪ Risk factors
• smoking
• DM
• HTN
• hypercholesterolemia
• family Hx
• AF
▪ Acute/ sudden onset = “cold white leg” – very painful
• causes:
- thrombosis
- embolism
- traumatic contusion
• MC site – common femoral artery
• Sx
384
• stop smoking
• keep legs warm and dry
• proper care of foot
• aspirin
• if ABI < 0.3 -> refer for urgent surgery
o endarterectomy or bypass grafting
- Resting pain: Constant severe burning pain in forefoot at rest
▪ During night time
▪ Pain in the forefoot, toes, heels
▪ Relieving factor: hanging the foot out of bed
▪ Emergency condition => refer to surgeon immediately
• indic. for vascular surgeon – Murtagh 719
o unstable claudic. of recent onset,
deteriorating
o severe claudic. – unable to maintain a
normal life
o rest pain
o tissue loss – ulcers, heel’s cracks, dry
gangrenous patches, inf.
Venous pathology
- Varicose veins
o predisposing factors
▪ family Hx.
▪ female
▪ pregnancy
▪ multiparity
▪ previous DVT
▪ extrinsic venous compression – intraabd. tumors, etc.
▪ occupation – dentist, etc.
▪ diet – low in fibre
o Rx
▪ High-fibre diet
▪ supportive stockings or tights
▪ Surgery
• Sclerotherapy
- for small, isolated veins
• Surgical ligation and stripping
- DVT
o risk factors
▪ Family Hx
▪ Hx of previous thrombo-embolism
▪ Thrombophilia
▪ Drugs: OCP, HRT, tamoxifen
▪ > 40 yrs
▪ Varicose veins
▪ significant illness: heart failure, CA
▪ Malignancy (in idiopathic DVT)
386
▪ Recent surgery
• Major/ orthopedic surgery
▪ Immobility
▪ Long flights
▪ Pregnancy/ puerperium
▪ Obesity
▪ Dehydration
o Recurrent DVT – pancr. CA
o Unilat. sudden onset of DVT – Ovarian CA
o Sx
▪ “Hot blue leg” = Acute venous obstruction
▪ painful, tender
▪ edema
o Dx
▪ Gold standard = Doppler U/S
▪ contrast venography – if U/S doubtful
▪ D-dimer – to exclude DVT when doubtful (if negative)
▪ don’t do Hoffman sign (plantar dorsiflexion causes pain) since it might
mobilise the thrombus
o Cx
▪ PE
• 20%
- of these 30% will be fatal
▪ varicose veins => venous ulcer
o Rx
▪ heparin, then
▪ warfarin
• 3-6 mths
• we need to treat at least for 3 mths (with warfarin)
• do not give aspirin
▪ mobilisation
▪ compression stockings
- Thrombophlebitis
o Red cord-like vein, tender on palpation
o Usually in superficial varicose veins
o Migratory superficial thrombophlebitis = Pancreatic CA
o Rx
▪ early mobilisation
▪ bed rest
▪ compression with uniform pressure over the vein
• prevent propagation of thrombus
▪ limb elevation
▪ NSAIDs
Aortic pathology
- Coarctation of aorta
o narrowing of distal ductus arteriosus and subclavian artery
o male 2:1
387
o Sx
▪ asympt. always
▪ headache, epistaxis, claudication, cold legs
▪ BP difference between upper and lower limbs
▪ weak delayed pulse in legs
▪ mid to late systolic murmur over aortic area
▪ infraclavicular murmur
o Rx
▪ surgical resection of the narrowed portion – if HTN
▪ angioplasty
- widened mediastinum + systolic murmur – can be:
o aortic aneurysm
▪ leaking aneurysm
• Sx
- severe abd. pain
- moderate abd. rigidity
- shock
- if leaked posteriorily -> pain radiates to back and down into
genitalia
- intense lower back pain
▪ ruptured aneurysm
• Sx
- lower abd. pain, generalised
o Aortic dissection – with shock, chest pain, etc.
- Aortic abdominal aneurysm
o risk factors
▪ Marfan syndrome
o Sx
▪ pulsating palpable mass in abd
▪ abd pain, back pain
o Cx
▪ Rupture
• Sudden abdominal pain.
• Radiating to back or groin.
• Syncope, collapse or unexplained shock.
• Feel for a tender mass with expansible pulsation on examination.
• Classic triad:
- Abdominal or back pain
- shock
- pulsatile or tender abdominal mass in men over 45 years.
• Dx
- Perform a rapid bedside USG to confirm presence of abdominal
aneurysm.
- X Ray – midline opacity with calcified border
▪ Dx diff. with chronic pancreatitis – calcifications like a
chain (2 parallel lines)
- CT scan
388
• Rx
- High-flow O2 by face mask.
- Slow IV infusion: avoid giving massive fluid replacement, as this
leads to coagulopathy, hypothermia, ↑ bleeding.
- Refer urgently to vascular surgical team.
o Rx
▪ < 5 cm – observe, elective surgery
▪ > 5 cm – urgent surgery
▪ no matter what size + symptoms = urgent surgery
• method: stenting
- Aortic dissection
o PREDISPOSED BY:
▪ HTN
▪ pre-existing aortic aneurysm
▪ Marfan syndrome
▪ inflam. vasculitides (temporal arteritis, syphilitic aortitis, Takayasu arteritis)
▪ Bicuspid aortic valve.
▪ Coarctation
▪ Iatrogenic trauma.
o Sx
▪ Abrupt onset with sudden pain.
▪ Sharp or tearing pain, radiating to back
▪ Retrosternal, interscapular or lower in back, migratory, severe, resistant to
opiates
▪ Unequal radial artery pulses ± decr. or absent pulses at femoral arteries
▪ Difference of BP in arms.
▪ Diastolic murmur if Aortic Regurgitation occurred.
o Dx
▪ 1. investig. of choice = contrast CT
• 2. if renal fc. is abnormal -> transesophageal U/S
▪ X Ray – wide mediastinum
o Rx
▪ Morphine
▪ β blocker – relaxes muscles of aorta, decr. the extension of dissection
• or Ca channel blockers – if β blockers are CI
▪ + sod. nitroprusside – vasodil.
▪ Surgery – stent graft for type A (MCQ)
o Cx.
▪ MI – dissection before origin of coronary arteries will cause MI
• (inferior) MI with wide mediastinum
- Dx: transoesophageal U/S
▪ if aortic dissection, don’t give thrombolysis (can kill the
person) and don’t give aspirin (gets worse with aspirin)
▪ Aortic incompetence (regurgitation) – diastolic murmur
▪ Cardiac tamponade
▪ Pleural effusion
▪ Intestinal ischemia
389
▪ actions:
• increases water reabsorption
• increases Na and Cl reabsorption
• increases K elimination
• increases Ca elimination
▪ modified:
• increase in Hyperaldosteronism
- Sx
▪ weakness (hypokalemia)
▪ polyuria, polydypsia
▪ HTN
- Primary (hyporeninemic)hyperaldosteronism (MCQ 2022, P52)
▪ causes:
• Bilateral adrenal hyperplasia (90%)
• Adrenal adenoma – Conn’s syndrome
• Adrenal CA
▪ Diagnostic:
• low renin: If there is primary
hyperaldosteronism, decreased renin (and
subsequent decreased angiotensin II) will not
lead to a decrease in aldosterone levels (a very
helpful clinical tool in diagnosis of primary
hyperaldosteronism)
o Usually, renin levels are suppressed,
leading to a very low renin-aldosterone
ratio (< 0.0005)
• hypertension
• hypokalemia (normal Na and Cl)
▪ Rx
• Spironolactone
• resection of adrenal adenoma
• ACE inh. do not help (aldosterone works
outside the renin-angiotensinogen system)
- Secondary (hyper reninemic) hyperaldosteronism
▪ causes
• a juxtaglomerular cell tumor (renin producing
tumor) leads to increased aldosterone, as the
body's aldosterone production is normally
regulated by renin levels.
• renal artery stenosis in which the reduced
blood supply across the juxtaglomerular
apparatus stimulates the production of renin
▪ diagnostic
• high renin
• hypertension
• hypokalemia (normal Na and Cl)
• decreased in Addison’s disease.
391
▪ Antagonists:
• Spironolactone, eplerenone – competitive antagonist for aldosterone’s
receptors
o ADH (vasopressin) – synthesized by pituitary gland
▪ increases water reabsortion (main effect)
• ADH secretion is increased when body osmolality increases (more
concentrated blood; ADH reabsorbs more water, to dilute the blood) =>
more concentrated urine
• ADH defficiency leads to hypernatremia (more water than Na is lost)
▪ increases reabsorption of urea
▪ increases Na and Cl reabsorption
▪ ↑ peripheral vascular resistance and thus increases arterial BP
- High blood pressure
o Measurement
▪ Sphygmomanometer – use 3 sizes:
• types
o child
o adult
o large adult (obese)
• rules:
o cuff’s
▪ Width
• 40% of arm circumference (Murtagh)
• cover 2/3rd of arm (not more) – AMC
o children - cuff width should cover 75%
of arm (Murtagh)
• cuffs that are too wide underestimate BP, cuffs
that are too narrow overestimate it (AMC)
▪ Length
• at least double the arm circumference
(Murtagh)
▪ bladder length should not completely encircle the limb
(but only 80%) - AMC
• bladder width is half the length of bladder- AMC
o types of drugs used
▪ 1. Diuretics
• Thiazides
o actions:
▪ ↑Na and Cl excretion (inhibiting reabsorption of Na+
and Cl- ions from distal convoluted tubules in kidneys by
blocking the thiazide-sensitive Na+- Cl- symporter)
▪ ↑ K+ excretion
▪ ↑ serum uric acid
o side effects
▪ hypokalemia, hyponatraemia (SIADH), loss of Mg
▪ hyperuricemia
▪ hyperglycaemia
392
▪ Felodipine
o Non dihydropyridine
▪ Verapamil
▪ Diltiazem
▪ 4. ACE inhibitors & AIIRA (Angiotensin II receptor antagonist, more selective
than ACE inhibitors, do not produce cough)
• actions
o vasodilation
o ↓ aldosterone (diuresis)
• indications:
o Hypertension
o Heart failure
o Peripheral vascular disease
o Diabetes
o Cardioprotective after a heart attack
• side effects
o dry cough
o disturbance in taste (dysgeusia)
o rash
o hyperkalemia
o first dose hypotension
o angioedema
• contraindications
o bilateral renal artery stenosis, precaution in CRF
o pregnancy
o hyperkalemia, avoid K sparing diuretics
o hypersensitivity to ACE inhibitors
• examples:
o ACE inhibitors
▪ captopril
▪ enalapril
▪ lisinopril
o AIIRA
▪ irbesartan
▪ losartan
▪ 5. Central-acting agents
• actions
o α 2 agonists - stimulate α 2 receptors in brain, which decreases
cardiac output and peripheral vascular resistance, lowering BP.
• indications:
o Hypertension – in asthma, pregnancy
• side effects
o sedation
o dry mouth
o constipation
o impotance
• contraindications
395
▪ DM, dyslipidemia
• ACEI/ AIIRA
• Ca channel blockers
o Verapamil, diltiazem
o Nifedipine, felodipine
▪ coronary heart dis. (MI/ Ischemia)
• β blockers
• Nifedipine, felodipine
▪ congestive heart failure
• diuretic
• ACE inh./ AIIRA
- Cx in HTN
o HTN retinopathy – stages:
▪ I – Silver lining (silver wiring)-(Narrowing + ↑ reflectivity of vessels walls).
▪ II – Arterial & venous nipping (crossing over)
▪ III
• flame-shaped micro hemorrhages
• soft exudate (cotton wool)
▪ IV - Papilledema
o HTN ENCEPHALOPATHY
▪ Acute and malignant hypertensive crisis.
▪ Severe HTN (diastolic > 140 mmHg).
• very high BP (systolic > 200)
▪ Severe headache, confusion, vomiting and blurred vision.
▪ Focal neurological signs, seizures and coma may develop later.
▪ Fundoscopy: retinal hemorrhages, exudates and papilledema. (Grade IV
changes)
▪ DIAGNOSIS:
• ECG and CXR
• Examine a MSU for proteinuria and send it for microscopy to look for
evidence of renal disease, with casts or abnormal urinary RBC ( > 70%
dysmorphic)
▪ MANAGEMENT:
• Aim for O2 of 94%
• Aim to initially reduce main arterial pressure gradually by 25% or aim for
a diastolic BP of 100-110 within first 24 hours.
• Use Oral treatment with Labetalol 100 mg, Atenolol 100 mg or long
acting Nifedipine 20-30 mg.
Dyslipidemia
- Hyperlipidemia
o risk factors for
▪ Coronary artery dis.
• ↑ LDL and ↓HDL
• LDLC/ HDL > 4
▪ Pancreatitis
• TG > 10 mmol/L
o Goal:
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▪ Nicotinic acid (Niacin, Vit. B3) – lowers cholesterol, increases HDL, lowers TG
▪ Probucol – lowers cholesterol absorption
▪ Estrogen – in postmenopausal women
▪ Omega-3 fatty acids in fish oil– lowers TG and cholesterol (VLDL)
o usage:
▪ Elevated LDL Cholesterol:
• statin + ezetimibe
• statin + resin
▪ Elevated TG:
• fibrates
• or nicotinic acid, n-3 fatty acids
• + decr. alcohol
▪ Mixed (CT and TG elevated):
• if TG < 4 – statin
• if TG > 4 – fibrate
- Familial hypercholesterolemia – Xanthoma (Yellowish plaque) on Achilles
- Familial combined hyperlidpidaemia – Xanthelasma ( yellowish plaque on superior & inferior
eyelid )
Rheumatology - OK
- Arthritis disorders:
o Simple analgezics – aspirin, paracetamol
o NSAID, Cyclo-oxygenase-2 (COX-2) specific inhibitors
o Disease-modifying agents
▪ Rheumatoid arthritis
• sulphasalazine
• hydroxychloroquine
• gold
• D-penicillamine
• methotrexate
• cyclosporin
• cyclophosphamide
• azathioprine
• leflunomide
• biological DMARDS
• fish oil – omega 3
▪ Systemic lupus erythematosus
• hydroxychloroquine
• azathioprine
▪ Spondylarthropathies
• sulphasalazine
• methotrexate
▪ Osteoarthritis
• glucosamine
• chondroitin
o Disease-suppresant agents
▪ corticosteroids
o Intra-articular injections
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▪ corticosteroids
▪ hylan (hyaluronic acid)
o Surgery
▪ synovectomy
▪ joint replacement
▪ arthrodesis
- Gout
o men
o symptoms:
▪ arthritis
• monoarthritis 90%
- metatarso-phalangeal 75%
- other toes
- ankles
- knees
▪ tophi – in ears, elbow, big toes, fingers, Achilles tendon
▪ renal calculi
▪ high fever, fatigue
o risk factors:
▪ alcohol
▪ diuretic (thiazides)
▪ β blockers (?)
▪ niacin, aspirin, cyclosporin
▪ fructose sweetened drinks
▪ meat, seafood (purine-rich)
o precipitate an acute attack of gout in a susceptible individual
▪ alcohol
▪ surgery
▪ starvation
▪ drugs
• thiazides
• frusemide
• probenecid
• aspirin
• sulphonylpyrazone
o Dx
▪ monosodium urate crystals in synovial fluid or in tophus with strong negative
birefringence in polarized light microscopy
▪ hyperuricemia – 70%
▪ X Ray – punched out erosions at joints margins
o Rx of attacks
▪ 1. Indomethacin (or other NSAIDs) 50 mg until symptoms abate (3-5 days),
then taper to 25 mg until cessation of attack
▪ 2. Colchicine
• SE – diarrhoea
▪ 3. C/S intra-articular
▪ ACTH in difficult cases
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▪ antiendomysial AB
o Anti-thyroid microsomal AB - Hashimoto
o ANCA – antineutrophil cytoplasmic AB
▪ c-ANCA – Wegner granulomatosis
▪ p-ANCA – microscopic polyangitis, Churg-Strauss syndrome, Goodpasture?
o Anti-GBM – Goodpasture
o Anti acetycholine receptors AB – Myasthenia Gravis
o Anti smooth-muscle – Chronic active hepatitis
- Reiter vs. Behcet
Reiter (reactive arthritis) Behcet
Gender Men 10:1 Men 2:1
HLA HLA B27 HLA B51
Triad Triad: non-specific urethritis + conjunctivitis A rare immune mediated
(± iritis) + arthritis vasculitis (small arterioles) of
(similar, but w/o ocular and mucocutanous multiple organs
lesions = reactive arthrits)
Ulcers Painless ulcers Traid of oral, genital (scrotal,
labial ulcers) ulcers + Uveitis
Vision Conjunctivitis Uveitis, retinitis (severe pain
problems in eye,↓ eye vision)
Long term Rare Inevitable – prompt referral
ocular disability required!
Arthritis – long Frequent – 50% Rare (knees)
term Spondylitis, sacroilitis common + knees, ankle,
involvement toes polyarthritis
Cause After an acute inf. with specific venereal or Genetic, race
dysenteric organisms: Multiorgan dis. (vasculitis)
SARA (Shigella), CARA (Chlamydia)
Rx NSAIDs C/S, Immunosupressants
- Uveitis – always part of connective tissue/ autoimmune dis. (not inf. dis.)
o causes
▪ Behcet’s disease
▪ Reiter’s syndrome
▪ Ankylosing spondylitis
▪ IBS
▪ Psoriasis
▪ SLE
▪ (Sarcoidosis, Juvenile RA)
o Rx – treat underlying condition
- Connective tissue disorders
o WHEN TO SUSPECT?
▪ Middle aged person.
▪ Female: More common.
▪ Multisystemic involvement.
▪ Skin lesions + arthritis + other features
- SLE
o MC connective tissue disorder.
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▪ ANA antibodies
▪ Skin biopsy
- Vasculitis
o Inflammation and necrosis of blood vessels resulting in ischemia and infarction.
o Any organ system can be involved.
o Keys to diagnosis: Clinical suspicion, laboratories are not specific, biopsy will confirm.
Small vessel Medium vessel Large vessel
o Rx
▪ Immunoglobulin IgG – 3-5 days + most imp to reduce aneurysms (MCQ)
▪ high doses of aspirin – risk of thrombosis
▪ If coronary artery disease: Anti-thrombotic therapy.
▪ NO C/S!!!
- Temporal arteritis
o Untreated can lead to blindness: 20-25%
o Commonly associated with Polymyalgia Rheumatica: 30% of pts.
o Peak onset: Over 50 yrs.
o MC in females.
o > 60% neurol. sequelae
o Sx
▪ Triad = fatigue + headache + jaw claudication
▪ Unilateral Temporal headaches and scalp tenderness.
▪ Sudden, painless loss of vision.
▪ Tongue and jaw claudication.
▪ Symptoms of polymyalgia rheumatica if present.
o DIAGNOSIS:
▪ Clinical Diagnosis.
▪ first test - Dramatically increased ESR.
▪ Increased CRP.
▪ Best test - Temporal artery biopsy: Confirms diagnosis.
o TREATMENT:
▪ High dose of prednisolone until symptoms resolve (1mg/ kg)
• IV – if visual symptoms present
• PO – if no visual sympt.
▪ Immunosuppressant drugs if refractory (?).
- Polymyalgia rheumatica (MCQ 2123 P 86)
o 30% association with temporal arteritis
o may be associated with carpal tunnel syndrome
o F:M=2:1, > 50yrs
o inflammatory condition of muscles: pain or stiffness usually in neck, shoulders and hips.
o Most PMR sufferers wake up in morning with pain in their muscles which are tender on
palpation.
o Sx
▪ triad: malaise + painful shoulder girdle + morning stiffness > 20 yrs
▪ pain and early morning stiffness (no weakness – but blue book MCQ 3.068
says: with proximal weakness) in proximal muscles or shoulder and pelvic
girdle, symmetrical
▪ Painful restriction of movement of shoulders and hips.
▪ O/E: Painful and tender muscles but no weakness or atrophy.
▪ weight loss, malaise, anorexia, fever, tiredness
▪ depression
o DIAGNOSIS: Requires:
▪ Age > 50 yrs.
▪ More than 2 affected muscle groups: Neck, hip and shoulder girdles, thighs.
▪ At least 2 wks duration
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▪ EMG
▪ Anti Jo-1, Anti MI-2 AB
▪ best - Muscle biopsy
o TREATMENT:
▪ Physical therapy
▪ Assessment of organ involvement
▪ High dose of C/S
▪ Immunosuppressive agents
▪ Immunoglobulin IV
▪ Malignancy surveillance (Ovarian, stomach, prostate, BCC, SCC increased)
- Sjogren’s syndrome:
o Chronic inflammatory disorder.
o CD4/ CD8 cell mediated infiltration and destruction of salivary and lacrimal glands.
o Pt’s with Sjogren’s syndrome are at higher risk of non-Hodgkin’s lymphoma.
o MC assoc. with RA
o CLINICAL FEATURES:
▪ Dry mouth: Difficulty swallowing food without drinking, carries, erythema of
oral mucosa.
▪ Bilateral swelling of salivary glands (parotids, submand.)
▪ Ocular: Burning, dry, painful eye relieved by tears, foreign body sensation,
blepharitis.
o DIAGNOSIS:
▪ Autoantibodies: Anti-Ro, Anti-La, RF
▪ Salivary flow measurements
▪ Salivary gland biopsy (MCQ)
▪ Schirmer test – shows ↓ lacrimal production
o TREATMENT:
▪ Good dental hygiene.
▪ Artificial tears
▪ Hydroxychloroquine, C/S, immunosuppressants for severe systemic
involvement
- Rheumatoid arthritis
o affects multiple joints, most commonly small joints of hands, feet and cervical spine,
symmetrically but larger joints like the shoulder and knee can also be involved.
o AB attack synovium – initially joint space is wider, then becomes narrow (not use it as an X
Ray criterion)
▪ then attack the bone (osteopenia, erosion)
o attacks synovium everywhere => symmetrical
o Sx
▪ Synovitis can lead to tethering of tissue with loss of movement and erosion of
joint surface causing deformity and loss of function
▪ Morning stiffness
▪ affects tendons and ligaments => Ulnar deviation of hands (Subluxation of
joints)
• Rx – fixation with metal rod in straight position (arthrodesis)
▪ Rheumatoid nodules – often subcut. usually found over bony prominences/
pressure points, such as olecranon, calcaneal tuberosity, metacarpophalangeal
joint or other areas that sustain repeated mechanical stress.
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• Nodules are associated with a +ive RF titer and severe erosive arthritis
▪ fatigue, malaise
▪ carpal tunnel syndrome
o lab:
▪ Rheumatoid factor – if negative, seronegative arthritis – 15% of patients
▪ anti-citrullinated protein antibodies (ACPAs). Like RF, these tests are positive in
only a proportion (67%) of all RA cases but are rarely positive if RA is not
present, giving it a specificity of around 95%.
• anti-CCP AB (cyclic citrullinated peptide) test and the Anti-MCV assay
(antibodies against mutated citrullinated Vimentin)
• RF and anti-CCP present = Worst prognosis
▪ ESR and CRP are elevated
o diagnostic - American College of Rheumatology has defined (1987) the following criteria
for classification of RA - at least 4 criteria have to be met for classification as RA
▪ Morning stiffness of >1 hr most mornings for at least 6 wks.
▪ Arthritis and soft-tissue swelling of > 3 of 14 joints/ joint groups, present for at
least 6 wks
▪ Arthritis of hand joints, present for at least 6 wks
▪ Symmetrical arthritis, present for at least 6 wks
▪ Subcutaneous nodules at specific places
▪ RF at a level above 95th percentile
▪ Radiological changes suggestive of joint erosion
o Murtagh 355 – DD of various arthritis types
o Rx
▪ Splintage
▪ Exercise
▪ Bed rest
▪ drugs
• Aspirin, paracetamol, fish oils
• C/S
• Methotrexate
• + sulfasalazine
• + hydrochloroquine
RA Osteoarthritis Gout
Primary joints MCP, PIP, wrist First MCP of thumb,DIP DIP
Symmetrical Cervical, lumbar spine, hips & knees joints
Heberden’s nodes on DIP Absent Frequently present
joint (osteophytes) +
Bouchard’s nodes (PIP
joint) less common
Joints Soft, warm, tender Hard and bony
Stiffness Worse after If present, worse after effort
resting (morning (evening stiffness)
stiffnes)
RF Positive Negative
anti-CCP AB Positive Negative
ESR and CRP ↑ Normal
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o young men
o sacroiliac joints and spine – pain and stiffness
o also hips, shoulders, knees, ankles
o Morning stiffness
o Iridocyclitis, Uveitis
o Dx: XRAY of Sacro-iliac joint, investigation of choice.
o Rx
▪ Exercise
▪ NSAIDs
▪ Infliximab
- Psoriatic arthritis:
o Fingers and toes - DIP involvement
o Sacroilitis – like in Akylosing spondylitis
o RF neg.
- Goodpasture’s syndrome
o Hemoptysis + hematuria
o sore throat, cough, runny nose
o anti-GBM AB
o Dx
▪ Anti-glomerular basement membrane (anti-GBM) from lungs and kidneys
▪ p-ANCA?
o Rx
▪ C/S
▪ Immunosupressants
- Wegener granulomatosis
o Triads:
▪ Physiopathol: URT granuloma + fleeting pulmonary shadows (nodules) + GN
▪ Sympt: Malaise + URTs (rhinits, sinusitis), LRTs (wheeze, cough).
o 40-50 yrs
o Sx
▪ LRT + URT sympt.
▪ Polyarthritis
▪ Eye involv. – Orbital mass
▪ Oral ulcers
▪ GN 75%
o Dx
▪ C XRay: Multiple nodes (rubbery pulmonary masses) and cavitations
▪ c-ANCA (Antineutrophil cytoplasm AB)
▪ Dx confirmed by open lung biopsy
o Rx
▪ Cyclophosphamide
▪ Fatal w/o Rx!
- Takayasu’s arteritis – (Pulseless disease)
o Young Japanese females
o Large vessel vasculitis
▪ affects arch of aorta and other major arteries
o Sx
413
o Dx
▪ CK
▪ urine
• Blood
• Myoglobin
o Rx – Supportive
- Myoglobinuria/ hemoglobinuria (not hematuria) – no RBCs on microscopy.
Endocrinology - OK
- Insulinoma
o incr. insulin, proinsulin and C-peptide levels
o hypoglycemia improved by eating
o U/S – pancr. tumor
- Paraneoplastic syndromes
o in CAs of lung, liver, stomach
o Sx
▪ hypercalcemia
▪ hypokalemia
▪ hypoglycemia
▪ etc.
o e.g.
▪ Squamous cell carcinoma
• Hypercalcemia – production of parathyroid hormone-related peptide
(PTHrP)
- Sx - fatigue, constipation, polyuria, confusion, coma
▪ Small cell carcinoma
• SIADH – hyponatremia (less than 120mmol/L) with hypervolemia.
• Ectopic ACTH secr. – (Cushing syndrome) Stimulates melanocytes -> ↑
skin and mucosal pigmentation.
o Dx diff. with carcinoid syndr. –> here Sx appear long before the local growth and metast.
▪ Carcinoid syndrome
• Symptoms sec to carcinoid tum. (which can occur anywhere in GIT +
lung).
- MC in appendix, ileum, rectum, caecum, lungs
• due to incr. production of serotonin metabolyte: 5-HIAA
• flushing of the skin, wheezing, bronhoconstr., diarrhoea, abd. pain, hT,
right side of heart affected (tricuspid valve dis. syndrome - prolif. of
myocytes on the valve)
• Dx
- urine 5HIAA
- chromograffin test
• Rx
- octretide
- tumor resection
• Bouts of flushed face
- w/ diarrhoea – Carcinoid syndr. – Dx. 5-HIAA
- w/o diarrhoea – Phaeochromocytoma
- Acromegaly
415
o Sx
▪ Triad: Nasal problems + fitting problems (rings, shoes, etc.) + incr. sweating
▪ excessive growth of hands, tissues (nose, lips, face), feet, jaw and tongue
▪ Weakness, sweating, headaches
▪ Amenorrhoea, loss of libido
▪ Sleep apnoea
▪ Glycosuria
o Dx
▪ Measurement of GH levels after glucose challenge test (OGTT)
• hyperglycemia inhibits release of growth hormone in normal people
▪ Insuline-like growth factor 1 (IGF-1) – Key test
Hyperprolactinemia
o causes
▪ Physiol. –Pregnancy, breast-feeding, intercourse, sleeping, stress
▪ tumors
• Prolactinoma = prolactin-producing tumor in anterior pituitary gland
- very high levels of prolactin (especially in macroadenomas)
• Pituitary adenoma - tum. that compress stock of pituitary gland (releases
dopamin which inhibits release of hormones from Anterior pituitary - FSH,
LH, ACTH, Prolactin - or Posterior - Vassopresin, Oxytocin)
▪ Hypothyroidism, PCOS, POF – through -ve feedback, stimulate pituitary gland
▪ sarcoidosis
▪ renal failure
▪ cirrhosis
▪ silicosis
▪ breast trauma
▪ breast herpes zoster
▪ drugs
• drugs that inhibit dopamine
- typical antipsychotics (haloperidol) and some atypical
antipsychotics (risperidone, amisulpride)
• fluoxetine (SSRI)
• metoclopramide
• ranitidine
• estrogen (HRT) – MC cause
• methyldopa
• Ca channel blockers
• estrogen
- (drugs causing gynecomastia:
- digoxin
- isoniazide
- spironolactone, steroids
- cimetidine
- omeprazole
- metyhldopa, marijuana
- estrogen
- + calcium antagonists, amiodarone, TCAs
416
• sweating
• palpitations
• angina can occur
• Bouts of flushed face
o w/o diarrhea - Phaeocromocytoma
o w/diarrhea- carcinoid syndr. – Dx. 5-
HIAA
- Dx
▪ 24 hrs urinary free catecholamines – incr.
o Cortex (CSR)
▪ Produces:
• Glucocorticoids (Cortisone, Corticosterone)
• Mineralocorticoids - Aldosterone
• Androgens – Testosterone
▪ diseases
• Addison’s disease – deficit of glucocorticoids and mineralocorticoids
- causes
▪ TB in adrenal glands
▪ Amyloidosis
▪ Autoimmune destruction
▪ Adrenoleukodystrophy
- Symptoms:
▪ triad: fatigue + a/n/v + abd. pain + skin discoloration
▪ orthostatic hypotension– which doesn’t respond to NS
▪ fatigue, malaise
▪ hyperpigmentation on knuckles, creases of palms,
elbows and scars, oral mucosa, gums
▪ hyponatremia and hyperkalemia - deficit of
aldosterone
▪ hypoglycemia
▪ metabolic acidosis
▪ hypercalcemia
▪ Addisonian crisis:
• Symptoms aggravated after infection, sudden
steroid withdrawl or adrenal hemorrahge
• can be lethal if untreated
• Rx – Hydrocortisone IV
- Dx
▪ confirm:
• cortisol
• ACTH
- Rx - hydrocortison
• Cushing’s syndrome
- causes:
▪ taking glucocorticoid drugs
▪ Cushing’s disease – adenoma of pituitary gland that
produces too much ACTH (pituitary Cushing).
418
Thyroid pathology
- Murtagh – P 221 – table for Sx
Hypothyroidism Hyperthyroidism
Risk factors Autoimmune dis. (Hashimoto) Graves’
Down’s Excessive thyroxine
Turner’s Hot nodules
Rx: Radioiodine, Amiodarone, Lithium Amiodarone – less frequently
Thyroid surgery Inf. (De Quervain’s subacute
Postpartum (Sheehan’s syndrome) thyroiditis)
S/s General Tiredness, lethargy, cold intolerance Anxiety, agitation, restlessness,
heat intolerance
Psychiatric Depression, psychosis Psychosis
MSK Weakness, decr. reflexes, myalgia, carpal Weakness, incr. reflexes, clonus,
tunnel syndrome proximal myopathy, fine tremor
pain in shoulders due to calcific
tendinitis -> adhesive capsulitus
Skin Dry, cold, coarse Warm skin, moist or sweaty
Myxedema (non-gravity dependant)
Thin hair, brittle
Face Puffy Exophtalmos, lid lag
Cardiovasc. Bradycardia, AMI, cardiomyopathy, Tachycardia, heart failure, AF, HTN
cardiomegaly (Systolic) wide pulse pressure
419
TSH T4 T3 Rx
Primary hypothyroid. Incr. Decr. Decr. Thyroxine:
Non-vasc. Pt: Start with 50 µg/day
Vasc. patient, > 65: do ECG (address any
vasc. problems first), then start 25
µg/day (thyroxine can cause an Acute
Cor. Synd.) Test TSH, T4 every 4-6 wks
until you reach desired level: if needed
↑ in increments of 25 µg. Then 1-2
times after 6 mths. Then yearly. In
pregnacy: check at least every trimester
Sec./ central hypothyr. N or Decr. N or ↓ Inx MRI
(hypothalamus) decr.
Hyperthyr. Decr. Incr. Incr. 1. β blockers (for tachycardia & palpit.)
2. First try Propylthiouracyl (PTU) or
Carbimazole (in pregnancy)
3. Radio iodine (before surgery)
4. Surgery
5. in subacute thyroiditis: symptomatic
Sick euthyroid N or a N or a N or a Only symptomatic (self-limited)
(post-op. – response to bit bit bit
stress: cortisol ↑ ≥ decr. decr. decr.
TSH, T3, T4 just a bit ↓
but with symptoms
- thyroid problems
o Sx
▪ dysphagia
• painful in inflamation – Hashimoto
• complete – anaplastic carcinoma
▪ stridor – requires urgent surgery
o Dx
▪ blood hormones: T1, T3, TSH, calcitonin, Ca
▪ U/S
▪ FNAC
• thyroiditis?
• nodules
▪ thyroid scintigraphy - scan
• diffusely increased activ.
- Graves dis.
• diffusely decreased activ.
- subacute thyroiditis
420
- silent thyroiditis
- post-partum thyroiditis
• diffusely heterogenous activity
- toxic multinodular goitre
• focally increased activity
- hyperfc. adenoma
o thyroglossal cyst
o thyroid cyst
▪ Dx – U/S
o nodules
▪ single – benign
▪ multinodular goitre – benign
• less likely to be malignant than a single nodule
• a multinodular goiter is with hyperthyr.?
▪ Toxic nodule
• Dx
- Localized increased uptake of radioiodine
▪ Cold nodule
• Dx
- Localized decreased uptake of radioiodine
- CA?
o Thyrotoxycosis
▪ types
• Primary = Grave’s disease
- autoimmune
- Sx
▪ Diffuse goitre
▪ Exopthalmia, lid lag
- Dx
▪ Diffusely increased uptake of radioiodine
• Secondary
- hot nodule
- De Quervain’s subacute thyroiditis
▪ post. inf. – Viral, URTI
▪ initially hyperthyr., then hypothyr.!
▪ Sx
• fever
• enlarged painful thyroid
• tender lump or swollen goitre
▪ Dx
• diffusely decr/ no uptake of radioiodine
• incr. T3 and T4, decr. TSH
• no AB
o Dx diff from Graves
▪ Rx
• Propranolol
• Paracetamol
421
▪ Self-resolving
▪ Sx
• triad: anxiety + wt. loss + weakness
• amenorrhoea (everything else incr.)
▪ Rx
• Antithyroid drugs (thyrostatics) - inhibit production of thyroid hormones:
carbimazole, methimazole, propylthiouracil
• β-blockers: propranolol, metroprolol
• Radioactive iodine therapy ( I131)
• Surgery
o Thyroid crisis (thyroid storm)
▪ An emergency life threatening condition caused by sudden rise in thyroid
hormones. Sx precip. by surgery or inf. in undiagnosed patient.
▪ Rx
• emmergency admission!
• antithyroid drugs
• C/S
• anti-heart failure and antiarrhythmic drugs
o Hyperthyroidism in pregnancy
▪ dangerous for baby
• Premature delivery
• IUGR
• Fetal death
• Malformations
▪ Rx
• medical
- Propylthiouracil
▪ passes less to baby
▪ risk of hypothyroidism in mother
• check level of T4 in mother regularly
- Carbimazole – if propylthyouracil doesn’t work
▪ long acting thyroid stimulator -> protector? detect
status of baby
• if not working -> surgery
• radioactive Rx is prohibited!
o Hypothyroidism
▪ Sx
• Triad: tiredness + husky voice + cold intoleration
• Menorrahagia (everything else decr.)
▪ Rx
• Thyroxin – monitor TSH levels:
- check every month, till stable
▪ check every 2-3 months, till stable
• check every 2-3 yrs
o Hashimoto’s thyroiditis
▪ autoimmune
422
o contralateral Horner?
o cavernous sinus pathology
o intraorbital pathology
- Stridor post-thyroidectomy (due to haematoma) -> open wound/ all (superficial/ deep)
sutures in ward
Hyperparathyroidism
Ca PO4 ALP PTH
Multiple myeloma Incr. Incr. or N N N
Paget’s dis. N N Very very incr. N
Primary hyperparathyr. Incr. Decr. Slightly incr. or N Very very incr.
Osteoporosis N N N N
Osteomalacia (↓bone density) Decr. Decr. N N
Malignancy Incr. Incr. Incr. N
CRF Decr. Incr. Incr. or N N
o Types
▪ Primary
• Parathyroid adenoma →↑ PTH→ ↑ Ca
▪ Secondary
• ↓ Ca →↑ PTH
o MC cause of isolated (asymptomatic) hypercalcemia
o Sx
▪ Moans – muscle aching
▪ abd. groans – abd. pain, gastroesoph. reflux, constipation
▪ Stones - Renal
▪ Bones – pain, back pain
▪ Psychic overtones - fatigue, depression
o Dx
▪ PTH very incr.
DM
- Murtagh – 194 – Dx + 1320 Rx + Jay’s notes
- Sx
o Polyuria + polydipsia + Wt. loss
o Lethargy
o Neuropathy
▪ diabetic foot ulcer is MC cause of prolonged hospital stay in DM
▪ if DM is properly controlled, amputation can be reduced by 50%
▪ if untreated, 1/3 of DM patients will have amputation due to DM neuropathy
▪ with presence of normal pedal pulse, dev. of foot ulcer is unlikely
▪ types:
• MCQ: burning pains in feet, pins and needles in fingers and toes,
weakness and unsteadiness of legs, distal wasting and weakness in all
limbs, glove and stocking sensory loss of all modalities, areflexia.
• 1. Sensory polyneuropathy – Bilateral peripheral symmetrical (glove
& stocking distribution) ē numbness, tingling, pain often worse at night
- Rx
▪ Paracetamol/ aspirin
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▪ Gabapentin
▪ TCA
• 2. Moneneuritis - cranial nerve neuropathy
- III, IV
- difficult to Rx – C/S
• 3. Amyotrophy – asymetrical motor neuropathy
- a. Painful wasting of quadriceps (lumbosacral radiculopathy)
▪ Dx – EMG
- b. focal neuritis – pain & tingling of anterior surface of thighs
▪ Rx - Immunglobulins
• 4. Autonomic neuropathy
- heart – Orthostatic hypotension, tahycardia
- GIT – Gastroparesis (bloating, early satiety)
▪ usually slower GIT movement => bacterial overwgrowth
=> diarrhoea
- Urine retention
- ED
▪ Rx
• Amytryptilline
o HbA1C < 6.5% normal
▪ control in last 3 months
o Childhood DM
▪ Polyuria, Polydypsia, wt. loss (despite polyphagia)
• Rx
- insulin: 2 divided doses
- 0.5 unit/kg/day - honeymoon period (first 2 weeks after Dx)
- 1 unit/kg/day – older child
- 1.5 unit/kg/day adolescent
▪ 2/3 in the morning + 1/3 in the evening
▪ 2/3 long / intermed. + 1/3 short acting
• Dx – blood sugar
o Rx
▪ types of drugs
o Insulin
o Oral hypoglycemic agents
▪ Insulin secretagogues
• sulfonylureas: glipizide, gliclazide, glibenclamide,
tolbutamide, chlorpropamide
• (me)glitinides: repaglinide
▪ Insulin sensitisers
• Biguanides: metformin
• Glitazones: pioglitazone, rosiglitazone
▪ alpha-glucosidase inhibitors - slow the digestion of starch in the
small intestine, so that glucose from the starch of a meal enters
the bloodstream more slowly, and can be matched more
effectively by an impaired insulin response or sensitivity
• acarbose
425
▪ Peptide analogs
• incretin mimetics
o GLP analogs: exenatide
• DPP-4 inhibitors
o vildagliptin
▪ Amylin analogs
▪ approach
• type II
- start with lifestyle changes – 2-3 month trial
- if not controlled, then start Metformin – incr. dose to max.
- then add Gliclazide – incr. dose
- then add Acarbose – incr. dose
- then insulin
• type I
- insulin
▪ ultra-short: Lispro
▪ short acting: neutral
▪ intermediate acting: Isophane, Protophane
- Cx
o 1. Hypoglycemia
▪ glucose < 3 mmol/L
▪ Sx - sweating, anxiety, hunger, palpitations, confusion, drowsiness, seizures,
coma
▪ types
• Mild-moderate = conscious patient
- Oral food containing glucose (20-25 g glucose)
• Severe = unconscious or delirious
- 20-30 ml of 50% glucose/ dextrose IV (hospital) in cubital fossa
(not in hand – high glucose concentration could cause
thrombosis of small veins) or
▪ 1 ml glucagon IM (at home, in ambulances)
- in kids – 10% glucose (50% could cause complic.?)
- neonatal hypoglycemia
▪ 5ml/ kg 10% dextrose IV over 5 min
▪ then 100 ml/kg/day IV infusion
- at home – apply instaglucose – rub gel on gums
o 2. DKA (Diabetic Ketoacidosis)
▪ Hyperglycemia + dehydration + ketonuria +hyperosmolality+ high anion gap
▪ Ketonuria = production of ketone bodies is a normal response to a shortage of
glucose, meant to provide an alternate source of fuel from fatty acids.
• causes
- in DM – especially type 1
- in significant dehydration and electrolyte loss (e.g. massive
vomiting)
- in starvation
▪ MCQ: K+ shifts to extracel space → K+ in blood is incr., but total body K+ (intra
+ extracel) is low (due to renal loss)
426
•
• carotid body tumor
• carotid aneurysm
• lateral thyroid tumor (metastases)
▪ Post neck triangle
• developmental remnants
- Cystic hygroma
-
▪ can be huge
▪ soft, transilluminated
▪ May be macrocystic or microcystic
▪ MRI is gold standard for radiologic evaluation
- Bronchial sinuses and cysts
• Pancoast tumor (from lung apex)
• cervical rib
▪ Midline
• thyroid nodule
• Thyroglossal duct cyst:
- Midline lesion anywhere from foramen cecum and thyroid gland
- May contain ectopic thyroid tissue
- May contain all functioning thyroid
- Ultrasound, thyroid scans
- moves with protrusion of tongue + moves with swallowing
- Rx
▪ Surgical excision - Sistrunk procedure
429
o
• dermoid cyst – beneath the chin
• midline cervical lymph node swelling
▪ anywhere/ widespread
• sebaceous cyst
• lipoma
▪ submandibular
• salivary gland tumor
• cervical actinomycosis
• sternocleidomastoid tumor
ENT - OK
- uvula is shy (away from the lesion) and the tongue is bold (towards the lesion)
Laryngeal pathology
- Laryngitis
o acute
▪ hoarseness
▪ loss of voice
o chronic
▪ due to
• smoking
- active
- passive (in barmaids, etc.)
• voice abuse
- Laryngeal CA
o Hx of chronic laryngitis and smoking
o might be preceeded by leukoplakia
o hoarseness of voice + lump (cervical l. node) + sore throat + cough + stridor + earache
o Rx
▪ Radiotherapy, laser therapy
▪ Laryngectomy.
- Laryngomalacia
o MC cause of stridor in infants
▪ Usually presents as inspiratory stridor within first 6 months of life.
o 90% of pts will have spontaneous resolution of symptoms usually by 12 mths of age (18
mths – 2 years).
▪ 10% require surgery.
430
▪ Play audiometry
o 6 years +
▪ Modified play audiometry
o 8 years +
▪ Standard adult audiometry
1. Rinne test - Place a vibrating tuning fork (512 or 256 Hz) initially on mastoid process until sound
is no longer heard, tuning fork is then immediately placed just outside ear. Normally, sound is
audible at ear. It’s a test of outer and middle ear.
2. Weber test - A vibrating tuning fork (either 256 or 512 Hz) is placed in middle of forehead, chin,
head equidistant from patient's ears. Pt. is asked to report in which ear sound is heard louder.
a. A patient with a unilateral conductive hearing loss would hear tuning fork loudest in
affected ear (because conduction problem masks ambient noise of room, whilst well-
functioning inner ear picks up sound)
b. A patient with a unilateral sensorineural hearing loss would hear sound louder in normal
ear (because affected ear is less effective at picking up sound even if it is transmitted
directly by conduction into inner ear.)
Normal ear, air conduction (AC) is better than bone conduction (BC) AC > BC = + Rinne
In conductive hearing loss, bone conduction is better than air AC < BC = - Rinne
In sensorineural hearing loss, BC and AC are both equally depreciated,
AC > BC = + Rinne
maintaining relative difference of bone and air conductions
MCQ 2012, P 49
Conductive hearing loss
Criteria Sensorineural hearing loss
(weird behavior!)
Anatomical Inner ear, cranial nerve VIII or central processing Middle ear (ossicular chain), tympanic
Site centers membrane or outer ear
Hearing Loss
o Degrees
▪ normal: 0-20 dB (20 = soft speaking voice)
▪ mild: loss of 20-40 dB (40 = normal speaking voice)
▪ moderate: 40-70 (70 = shout)
▪ severe: 70-90 dB
▪ profound: > 90 dB
432
o MC causes
▪ Impacted cerumen (wax)
▪ Serious otitis media
▪ Otitis externa
▪ Children – congenital deafness
▪ Elderly - presbyacusis
o Types
▪ Conductive Hearing Loss
• acquired or congenital, caused by blockage or damage in outer or middle
ear. Bone conduction is normal.
• A conductive hearing loss leads to a loss of loudness and can often be
helped by medical or surgical treatment.
• Causes:
- Blockage of ear canal by impacted wax or foreign objects
- Otitis externa
- Middle ear infection (glue ear)
- Perforated eardrum (due to infection or trauma)
- Otosclerosis
- Partial or complete closure of ear canal.
▪ Sensorineural Hearing Loss
• acquired or congenital and is caused by damage to or malfunction of
cochlea (sensory part) or hearing nerve (neural part).
• leads to a loss of loudness as well as a lack of clarity. Quantity & quality
of sound are affected and sometimes may limit benefit of a hearing aid.
• Causes:
- Presbyacusis - Ageing process (MCQ 2064 P66)
▪ bilat. high frequency (s, f, th) progressive hearing loss
- excessive noise exposure (occupational and traffic noise)
- meningitis and Meniere's disease
- viruses, such as mumps and measles
- Ototoxic drugs
- head injuries
▪ Mixed Hearing Loss
• Mixed hearing loss results when there is a problem in both conductive
pathway (in outer or middle ear) and in nerve pathway (inner ear).
• An example of a mixed hearing loss is a conductive loss due to a middle-
ear infection combined with a sensorineural loss due to damage
associated with ageing.
o Rx
▪ Hearing aid – in conductive hearing loss
▪ Cochlear implant - effective if implanted early
• children > 2 yrs
• adults
- Otosclerosis (MCQ 2099 P78) 3022 P 214
o Disease of bone surrounding middle ear and is MC cause of CHL in adults with a normal
tympanic membrane.
o Normal middle ear bone is replaced by vascular, spongy bone that becomes sclerotic
433
-
434
o
o 2/3rd of children have at least one episode by age of 3 yrs, 90% by school entry
o 2 cardinal features
▪ Inflammation & effusion
o Clinical Features:
▪ Earache, pulling of ear, reduced hearing, irritability, anorexia, lethargy
▪ Fever, vomiting – bacterial -> A/B
o EXAMINATION:
▪ Usual middle ear landmarks are not well seen.
▪ Tymp membrane is dull and opaque with loss of light reflex and may be
bulging, yellow-grey colour
▪ Fluid level might be seen
▪ On pneumatic otoscopy TM mobility is reduced
▪ May have associated signs of URTI
o CAUSES:
▪ Streptococcus pneumonie 35-40%
▪ H. Influenzae 25-30%
▪ Viral: 25%
▪ Moraxella catarrhalis 15-20%
▪ least common – Staph.
▪ Do not accept otitis media as sole diagnosis in a sick febrile young child
without elimination of a more serious cause
• Meningitis – frequently assoc. with otitis media
o Rx
▪ try to avoid using A/B
• never use A/B in children, except for this!
▪ > 1 yr old, mildly unwell, immuncompetent
• just observation for 12-24 h, analgezia, no A/B
• if symptoms not resolving or severely ill (Vomiting, fever---Bacterial)
- First line = Amoxycillin
- still not resolving after 48 hrs
▪ 2. Cefaclor or
▪ Amoxycillin + clavulanic acid – if resistance is
suspected
▪ < 1 yr, moderate/ severe, immuncompromised
- amoxycillin
- still not resolving after 48 hrs
▪ amoxycillin + clavulanic acid
o Complications:
▪ Effusion – 70%
435
•
- Cholesteatomas are expanding lesions of the temporal bone
composed of a stratified squamous outer epithelial lining and a
desquamated keratin centre
- Clinically defined as an abnormal extension of skin into middle
ear and mastoid air cell spaces
- The point of entrance of skin into middle ear is reliably
identifiable on otoscopic examination
- Otoscopy is the most reliable and sensitive means of diagnosing
a cholesteatoma
▪ Signs of an unsafe perforation on otoscopy:
• Superior and or posterior edge of tympanic
membrane perforation
• Perforation involving fibrous edge or annulus
of tympanic membrane
• Associated granulation tissue
• White mass within middle ear seen through
perforation
• Bone erosion
Dizziness (a condition of faint, wekness and unsteady gait)
o can be with
▪ Central cause – brain, cerebellum
• acoustic neuroma
• MS
• head injury
• vertebrobasilary insuf.
▪ Peripheral cause – inner ear
• Meniere
• Benign Paroxysmal Positional Vertigo
• Vestibular neuritis/ labyrinthitis
o causes:
▪ COMMON
• Benign Paroxysmal Positional Vertigo
• Vestibular neuritis/ labyrinthitis (unilateral peripheral vestibulopathy)
• Meniere’s syndrome
• Vestibular migraine
• Psychogenic
• Idiopathic
▪ LESS COMMON
437
• Acoustic neuroma
• Vertebro-basilar transient ischaemic attack/stroke
• Multiple sclerosis
• Posterior fossa tumours
• Arnold-Chiari malformations
• Autoimmune inner ear disease
• Perilymph fistula/semicircular canal dehiscence
• Invasive middle/inner ear disease (e.g. otomastoiditis, tumours,
cholesteatoma)
• Bilateral peripheral vestibulopathy (if asymmetric)
o Diagnostic Triads (J.Murtagh)
▪ only vertigo caused by movement = BPPV
▪ Acute vertigo + nausea + vomiting = Vestibular neuronitis
▪ (acute vertigo + nausea + vomiting) + hearing loss ± tinnitus = Acute
labyrinthitis (similar symptoms to Meniere). Symptoms upto days.
▪ Vertigo + vomiting + tinnitus + SNHL = Meniere’s syndrome
▪ (unilateral) Tinnitus + SNHL + unsteady gait = Acoustic neuroma
- duration of common causes of vertigo
Seconds Benign positional vertigo
Minutes Vertibrobasillar insuf., migraine
Hours Meniere’s disease
Days Vestibular neuritis, labyrinthine infarcts
o 4 common causes
▪ 1. Benign paroxysmal positional vertigo (BPPV)
• MC of vertigo seen by otolaryngologists (20-40% of pts with peripheral
vestibular disease)
• Affects all ages.
• Approximately 50% of people > 70y have experienced at least 1 episode
• Symptoms & signs are brought about by changes in head position, in
relation to gravity, 5-10 sec later, lasts 10-60 sec.
• May be associated with closed head injury, infections, surgery and
prolonged bed rest.
• Pathophysiology:
- Otoconia become dislodged and pass through endolymphatic
space of vestibule into one of the semicircular canals.
• Pathognomonic sign:
- nystagmus towards affected ear on doing a Dix-Hallpike test
• Treatment:
- Epley repositioning maneuver
- Brandt-Darrof exercises
▪ 2. Vestibular neuronitis – M 508
• 20-40 yrs
• only vestibular portion of VIII N is affected, unilateral & no hearing loss
- if both vestibular and auditory portions (hearing loss) are
affected = labyrinthitis
• 2nd MC disorder affecting labyrinth
438
-
- Vertigo, fullness in ear (due to distension labyrinthitis)
- Tinnitus
- Nausea and vomiting
- hearing better in noisy environment MCQ
- Deafness (progressive) – sensorineural hearing loss
- + nystagmus during attack
• Treatment:
- Vestibular sedative, antiemetic for acute episodes
▪ Prochlorperazine
▪ urea crystals in orange juice
▪ Diazepam
▪ Betahistine
- Low salt diet ± diuretic for maintenance treatment
- Meniett device
- Intra-tympanic gentamycin or surgery for refractive cases
▪ 4. Acoustic neuroma = Vestibular schwannoma
• tumor of Schwann cells on 8th cranial n.
• slow growing –> brain has time to adjust => less vertigo
• 78% of all cerebellopontine angle tumors
• 0.8% to 2.7% of population: 0.7 to 1 per 100,000
440
•
• Symptoms:
- Unilateral progressive SNHL 85% (handbook 401 )
- Sudden hearing loss 15%
- Tinnitus 56%
- Vertigo 19%
- absence of corneal reflex
- Facial paresthesia from 5th cranial N irritation.
- (7th 9th 10th and 11th N involvement) - Diplopia, facial weakness
and hypoaesthesia, Cerebellar ataxia (Unsteadiness of gait) MCQ.
• Treatment:
- Observation
▪ 50-55% show little or no growth in 1-3 years
▪ less than 0.2mm/ year
▪ Repeat MRI to monitor growth
- Surgical resection
▪ Translabyrinthine, middle fossa or suboccipital
retrosigmoid approaches
▪ Stereotactic radiosurgery (gamma knife)
- Vertigo + Nystagmus + Horner Syndrome = Cerebellar lesi on = PICA (MCQ)
- Nystagmus: (Dancing eyes) involuntary rapid eye moevemts, can be horizontal, vertical or
rotatory.
o VOR: Head movement (vestibular stimulation) in one direction stimulates eye movement
in opposite direction. Important in reading as head constantly moves a little.
o Physiological = Part of vestibulo-oculo reflex (VOR)
▪ tested with caloric reflex test (VIII N nucleaus)
• Syringing of ears with warm water: eyes will turn towards the
contralat. ear + horizontal nystagmus towards the ipsilateral ear
• with cold water – opposite effect
o Pathological
▪ caused by lesions of
• Inner ear
• VIII nerve
• Brainstem
• Cerebellum
• Cortex
441
Ophtalmology - OK
-
o normal left eye fundus
- Dx
o vision
▪
6/4
▪
6/5
▪
6/6
▪
6/60
▪
…
▪
count fingers at 6 m
▪
count fingers at 1 m
▪
see fingers?
▪
perception of light
o Optic disc - nasal
▪ clear contour
o Retinal vessels
▪
narrower arteries
▪
wider veins
o Macula – temporal
▪ no blood vessels in the middle
▪ darker in color
- Cranial nerves for eye muscles
o III
▪ MR
▪ SR
▪ IR
▪ IO
▪ levator palpebral superioris
▪ palsy:
• Ptosis + fixed (non reactive) dilated pupil + down & out eye
- DM or any ischemic problem – pupil normal (peripheral fibres
will still get supplied, here are ones for the pupil)
• causes
- DM (diplopia with normal pupil) or other ischemic problems
- cavernous sinus lesions
- sup. orbital fissure
442
o IV
▪ SO
▪ Palsy: diplopia on downward (vertical) and lateral gaze
▪ Diabetic ocular neuropathy: Vertical binocular diplopia with normal pupil (MCQ
3023 P 214)
o VI
▪ L.R
▪ Palsy: divergent squint on lateral gaze
- Diplopia
o Monocular – persists after occluding 1 eye
▪ causes: in same eye!
• early cataract
• dislocated lens
• severe astigmatism
• psychogenic/ functional
▪ Rx – not urgent
o Binocular – (doesn’t persist when ocluding 1 eye)
▪ REFER URGENTLY!!
▪ causes: in higher nerve centres
• ocular nerve palsy – III, IV, VI
- CVA or TIA
- tumor
- aneurysm
- DM ocular neuropathy
- arthritis
- head injury
- migraine (ophtalmic) - transient
• blow out fractures (MCQ)
• concussion
• MS – recurrent diplopia
• myasthenia gravis
• hyperthyroidism
- Blocked naso-lacrimal duct
o repeated inf.
o usually self-corrected between 6-12 mths
o Rx
▪ repeated bathing with normal saline
▪ massage over lacrimal sac
▪ local A/B for inf.
▪ refer – probing of lacrimal sac, if
• severe blockage or
• if not self-corrected by 12 mths
o Cx
▪ Dacryocystitis – inf. of lacrimal sac sec. to obstruction
▪ Rx
• Systemic A/B – Flucloxacillin
• Drainage
443
▪ septicemia
• neonatal conj. (+ chlamydia)
• Rx
o IV cephalosporins or penicillin
o topical sulfacetamide
▪ Chlamydia
• brick red follicular conj. with stringy mucus
discharge
• types
o neonatal
o young patient with venereal inf.
o isolated Aboriginal people with
trachoma
▪ MC cause of blindness in world
▪ recurrent & untreated => lid
scarring & inturned lashes
(endtropion) ē corneal
ulceration & visual loss
• Dx
o swabs for culture and PCR
• Rx
o local sulfacetamide eye drops
o systemic
▪ neonates – Erythromycin
▪ children > 6 kg: Azithromycin
- Dx
▪ clinical
▪ swab
- Rx
▪ severe cases - cloramphenicol eye drops
▪ milder cases
• saline irrigation
• antiseptic – propamidine isothionate
• Viral
- MC assoc. with an URTI
- highly contagious –> good hygiene
- Hx of infected contacts
- resolves in 3 wks
- caused by adenovirus
- Cx – sec. bact. inf.
- preauric. Lymph node
- Rx —cool compress and topical lubricants (artificial tear
preparations), naphazoline (e.g. Albalon), vasoconstrictors (e.g.
phenylephrine) or saline bathing.
▪ C/S are CI
▪ Non-infectious
• from welding (actinic)
445
▪ Allergic
• types
- assoc. with hay fever
▪ Rx
• topical antihistam.
• topical sodium cromoglycate
• topical C/S
- contact hypersensitivity
▪ assoc. with topical opthalmic drugs (A/B) contact lens
sol., cosmetics, etc.
▪ Rx
• remove cause
• naphazoline
• topical C/S
- Episcleritis
o no discharge
o no watering
o N vision
o self-limiting
o Rx
▪ topicl and oral C/S
- Scleritis – assoc. with autoimmune dis. FIGURE 51.1 JM P 577
o painful loss of vision
o urgent referral
- Uveitis
o acute
▪ anterior uveitis = iritis and iridocyclitis
• Sx
- photophobia
- iris is sticky and sticks to lens => adhesion => constricted/
irregular pupils
- blurred vision, floaters in field of vision
• causes
- 80% isolated
- 20% Reiter, ankylosing sponditlytis, Crohn, IBS, psoriasis
(seronegative arthropaties), SLE – HLA B27
• Rx
- referral
- pupil dil. with atropine
- topical C/S
- systemic C/S
• frequently recurrs after Rx
▪ post. uveitis = choroiditis
o chronic
▪ Sx
• pupil is bound to the lens by synechiae and distorted
▪ Cx – loss of vision due to:
446
• glaucoma
• cataract
- Refractive errors
o Presbyopia
▪ > 45 yrs
o Myopia
▪ image formed IN FRONT of the retina (long eye or steep cornea)
▪ Rx – concave lenses
▪ Cx in high myopia
• retinal detach.
• macular degen.
• glaucoma
o Hypermetropia
▪ image formed BEHIND retina (long eye or steep cornea)
▪ Rx – convex lenses
▪ Cx – closed angle glaucoma
o astigmatism
▪ causes – conical cornea (keratoconus – e.g. Down)
o pinhole test – 1 mm hole
▪ corrects any refractive error
▪ if not => not just a refraction error!
▪
▪ Cx – Closed angle glaucoma.
- Acute visual loss
o flashers and floaters
▪ causes
• constant – less of a concern
- age
447
- myopia
- eye surgery
• fresh onset = concern
- retinal detachment
o Retinal detachment
▪ types
• Posterior vitrous degen. and detachment – in everybody
- sudden onset of floaters
- flashing lights = Traction on retina
- Rx – Urgent referral
▪
• some people – pathol. detachment
- causes
▪ trauma
▪ high myopia (thin retina)
▪ previous surgery (e.g. cataract)
▪ DM retinopathy
- Sx
▪ no pain
▪ more dangerous if affecting macula
▪ sudden onset of: (the 4 Fs)
• flashes
• floaters (spots, dots, cobwebs)
• field loss
• fall in visual acuity
o Partial
o Total – if macula detached
▪ then suddenly irreversible blindness.
• “a curtain came down over the eye”
• if revers. = carotid stenosis and embolism
- Dx
▪ Opththalmoscopy: detached retinal fold as a large grey
shadow in the vitreous cav.
- Mx
▪ transport to the hospital ASAP!
• can’t transport by air
▪ tilt head back and cover eye
• keep pressure on the detached retina
o Upper curtain (MC) – lower
detachment – keep head up.
448
▪
▪ Sx
• Acute painless loss of vision (usually profound) with sudden onset.
- “curtain descending over one eye.”
- Irreversible.
• Waxy, swollen, pale retina, thin arteries.
• chilly red spot in macula – init. still vascularization but then same color
as the rest of retina.
▪ Rx
• lower intraocular pressure (glaucoma medication)
• inhale CO2 (paper bag).
▪ poor prognostic, unless treated within 30 min.
o Central retinal vein occlusion (CRVO)
▪
449
Embolic occlusion of central retinal artery Due to blood clot in central retinal vein
Sudden Gradual (hours/ days)
Painless loss of vision Painless loss of vision
Unilateral Unilateral Often hypertensive
Mx: Mx:
Exclude GCA & TIA Elective referral to ophthalmologist within
Refer ophthalmologist 1 wk
Ocular massage Screen for HTN, DM &
Acetazolamide oral – reduce IOP Hypercholesterolemia
o Ischemic optic neuropathy – irrevers.
▪ Temporal arteritis:
• sudden and often bilat. occlusion of the short ciliary aa. supplying the
optic nerve.
• Sx
- revers. loss of vision, then can lead to irreversible
- sudden loss of central vision
▪ unilat., can rapidly become bilat.
- assoc. temporal headache, temporal aa. tender, thickened and
nonpulsatile.
• Dx
- ESR (> 40), CRP (sometimes ESR can be normal, then we do CRP)
- FBE (Hb – anemia; gives you higher ESR)
- temporal a. biopsy – confirm Dx
• Rx – Predisolone for 18-24 mths
- IV if patient has transitory loss of vision
- after 10 days of Rx – changes biopsy result (modif. have
disappeared)
o Optic (retrobulbar) neuritis Most Common Dif Dx = MS (MCQ)
• neurosyphilis
• toxins
▪ woman, 20-40 yrs
450
▪ Sx
• retrooc. discomfort with eye movement
• central field loss (central scotoma)
- or peripheral circumferential blindness
▪ Dx: Visual evoked potentials (VEPs) are an important means of evaluating
patients with suspected optic neuritis. They may be abnormal even when MRI of
the optic nerve is normal
• optic disk swollen, then atrophic, then disc pallor
▪ Rx
• IV C/S
• most pts recover spontaneously but are left with diminished acuity
o Migraine:
▪ zigzag lines and lights
▪ multicolored flashing lights
▪ unilat. or bilat. field deficit
• self-resolution within a few hrs
o Hysteria
▪ bilat. loss of vision, with tunnel vision
o Vitreous haemorrhage
▪
▪ assoc. with
• trauma
• DM retinopathy
• tumor
• retinal detachment
▪ Sx
• sudden onset of floaters
• loss of vision
▪ Dx
• clots of blood that move with the vitreous (black swirling cloud)
▪ Mx
• urgent referral – exclude retinal detach.
• may resolve spontaneously
• surgical vitrectomy for persistent haemorr.
o Closed angle glaucoma (see below)
- Chronic loss of vision
o in children = Amblyopia = ↓visual acuity due to abnormal visual experience in early
childhood
▪ strabismus
451
▪
cataracts
▪
refractive errors
▪
retinoblastoma
o Glaucoma (Optic n is slowly damaged bc of ↑ IOP)
▪ Dx for incr. intraoc. pressure
• Cup: Disc
- N ≤ 30%
- if > 30% = raised intraocular pressure
• Tonometry
- Normal 10-22 mm Hg
▪ incr. – can go up to 55-60
▪ Acute angle closure glaucoma: (Acute painful Red eye) 3024,P 215
• acute -> acute loss of vision
- ciliary flush (hyperemia)
- Common in middle aged or elderly hypermetropes.
- Narrowed anterior chamber.
- Precipitated by pupillary dilation – in the evening, (peripheral iris
blocks aqueduct outflow and an abrupt rise in intraocuolar pressure)
- Sx – similar with migraine without aura, but with visual Sx –
diagn diff.!
▪ Severe throbbing pain.
▪ Headache.
▪ Nausea and vomiting.
▪ Weakness.
▪ Visual changes:
• Vision is ↓ with HALOES around lights/ objects.
• The cornea is HAZY/edematous.
• Fixed and DILATED oval pupil.
• corneal or scleral injection
• On palpation: eye feels firm/ stony hard.
- MANAGEMENT:
▪ Ocular emergency.
• Urgent referral to the Ophthalmology team.
▪ 1. Miotic drops (Pilocarpine every 5 min for up to 1 hr).
▪ 2. Acetazolamide (carbonic anhydrase inhibitor) 500
mg slowly IV then 250 mg orally t.d.s. – diuretic
▪ 3. Peripheral iridotomy – perforation in the iris to
evacuate the liquid
▪ Antiemetic such as metoclopramide 10 mg IV and
▪ analgesia such as morphine 2.5 mg.
- DM
- HTN
• Screening
- > 40 yrs – every 2-5 yrs
- if family Hx – start from 30 yrs, every 2 yrs
• Sx
- Progressive painless loss of vision (tunnel vision) + cupping of
optic disc + raised intracranial pressure.
▪ also in
• retinitis pigmentosa
• hysteria
▪ central vision is N
• Rx – for life!
- drugs
▪ β blockers: timolol, betaxolol
▪ acetazolamide (diuretic)
▪ pilocarpine - parasympathomimetic alkaloid
▪ latanoprost - PG analogue
▪ dipivefrine – prodrug of epinephrine, converted to
epinephrine in the eye
- surgery or laser therapy – if drugs failed
o Cataract
▪ cause
• age – everybody > 80 yrs have opacities
• DM
• trauma
• C/S
• UV light
• uveitis
▪ Sx
• blurring of vision in bright light
▪ Dx
• diminished red reflex
• change in appearance of lens
▪ Rx
• lens extraction + intraoc. lens implant
- CI:
▪ Intraoc. inflammation
▪ Severe DM retinopathy
▪ Px – UV sunglasses
▪ Cx
• Hypopyon (puss in ant. chamber of eye)
453
-
- causes
▪ in case of endophtalmitis after
• penetrating injuries
• surgery
▪ cataract
- urgent referral!
- Rx
▪ avoid movt.
▪ avoid smoking/ alcohol
▪ don’t give heparin
▪ bed rest 5 days
▪ sedative
▪ check daily
• if floaters / flashes -> emmergency!
• bleeding 2nd, 3rd, 4th day?
o Retinitis pigmentosa
▪ displacement of melanin-containing cells from pigment epithelium into more
superficial parts of retina
▪ Sx
• night blindness in childhood
• tunnel vision
• blind by adolescence/ middle age
▪ Dx
• patches of dark pigment especially at the periphery
•
o Macular degeneration
454
▪
▪ causes/ risk factors
• age related
• high myopia
▪ types
• acute – exudative
• chronic – pigmentary (slow onset)
▪ drusen (neovasc. membranes which develop under the retina of the macular
area and leek fluid or bleed ) + visual loss
▪ Sx
• central visual loss
- acute – sudden fading of central vision
- eventually central vision is completely lost
• distorted images = macular degen.!
- lines of the words bend / seem wavy while reading
▪ Dx
• screening: using a grid pattern (Amsler chart)
- shows distorted lines
- cannot see the central dot
-
• ophthalmoscopy – white exudates, haemorrhage in the retina
• fluorescein angiography
▪ can be
• wet – acute?
- hemorrh., fluid leaks in macula
- Rx
▪ laser photocoagulation
▪ inj. inside the eye – vascular growth factor inhibitor =
new Rx
• stabiliz.
• 1/3 improve
• dry – chronic?
- “worn-out jumper”
- Rx
455
▪ nutritional supplements
• antiox. – Vit. A, C, E + Zn
- corneal disorders
o Keratoconjunctivitis sicca - “dry eyes”
▪ causes
• ageing, menopause
• systemic dis.
- RA
- SLE
- Sjogren
• drugs
- Beta blockers
▪ Rx
• artificial tears – hypromellose, polyvinyl alcohol
o Keratitis
▪ causes
• UV light (“arc eye”)
• herpes simplex
• herpes zoster ophthalmicus
• superficial punctate keratitis
- in various conditions:
▪ e.g. UV light exposure = flash burns
• microbiol keratitis
- risk factors
▪ contact lenses – MC with pseudomonas
▪ corneal trauma or surgery
▪ post-herpetic corneal lesion
▪ etc.
▪ Cx
• perforation and blindness
▪ Rx
• urgent referral!
• topical A/B – ciprofloxacin oint.
o Abrasion/ ulceration
▪ causes
• trauma
• contact lenses
• fingernails
• UV burns
• dendritic ulcer
- primary herpes simplex I inf.
▪ can also cause follicular conjunctivitis
- Dx
▪ stain with fluorescein
- Rx
▪ Acyclovir
▪ atropine – prevent reflex spasm of the pupil
456
▪ Dx
• slit lamp and fluorescein staining
▪ Rx
• chloramphenicol oint.
• eye pad
- Pterygium
o
o fleshy overgrowh of the conjunctiva onto the nasal side of the cornea
o in dry, dusty, windy areas
o Rx
▪ surgical excision
- Pinguecula
-
o yellowish elevated nodular growth of the cornea
o Rx
▪ surgery – if uncomfortable
- corneal ulcer with hypopyon - emmergency
o rheumatoid arthritis
o contact lenses abuse
- Blepharitis
o inflam. of lid margins
o freq. assoc. with seborrhoeic and atopic dermatitis and rosacea
o types
▪ seborrhoeic
▪ staphylococcus
▪ assoc. with rosacea
o Rx
▪ eyelid hygiene – mainstay of Rx
▪ topical C/S
▪ topical A/B
• tetracycline
• chloramphenicol
- Stye (hordeolum ext.) – inflam. external glands (2026, P 54)
457
o
o Acute abscess of eye lash follicle
o Staph. aureus
o Red tender swelling of lid margin, usually on medial side
o Rx
▪ Hot compress
▪ Lash epilation
▪ Chloramphenicol oint.
- Chalazion (Internal hordeolum, Meibomian cyst)
o
o Granuloma of the Meibomian glands (embedded in tarsal plates)
o Inflammed tender irritant lump in the eyelid
o Chronic – Chalazion
o Rx
▪ Hot compress
▪ Chloramphenicol oint.
▪ If large and uncomfortable -> surgery – incision and curretage under LA
- Herpes zoster ophtalmicus (Shingles)
o Ophtalmic distribution of V nerve (trigeminal)
o Respects the midline!
o Ocular problems: conjunctivitis, uveitis, keratitis, glaucoma
o Rx
▪ Topical acyclovir
▪ Systemic acyclovir – Oral, IV
- Penetrating eye injury
o not a lot of pain
o do not give pain killers – Morphine, etc. – can cause vomiting, making things worse
▪ small dose + antiemetic (metoclopramide)
o no local anestetic eye drops – can be retinotoxic
o don’t put bandage (pressure), just a shield or cone
o urgent referral!
▪ if delay – give systemic A/B
- Ectropion – rolling outward of the eye lid
458
o cause
▪ age – involution
▪ facial nerve palsy
o Rx – lubricant Rx
- Entropion – rolled inward
o irritation of the cornea
o Rx – attach eyelid to the cheek
- Lid tumor
o BCC 90 %, SCC 9 %, other 1%
o with loss of eye lashes (madarosis) – serious!
- Subluxated lens
o
o Marfan syndrome
o trauma
- MRI – don’t do if metalic foreign body in the eye (magnetic)
- burn
o acid – injury just on the spot
o alkaline – injury keeps evolving
▪ wash with excess water for 30 min
- Leukoria- White eye reflex
-
- Retinoblastoma!, Toxocariasis, Retrolental fibroplasias, Coat’s diease
- Retinopathy
o typical
▪ Cotton wool (intra-retinal infarcts) - DM
▪ Flame shaped haemor., AV nicking - HTN
o DM
▪ Non-proliferative
•
• Related to ischaemia of blood vessels and include:
459
▪
• Proliferative: Changes in blood vessels in response to ischaemia to retina.
- New vessel formation.
- Vitreal hemorrhage.
- Retinal detachment.
• can leak, rupture with hemorrhge in vitreous, healing with fibrosis,
retractional retinal detachment
- Rx - Panretinal argon laser photocoagulation
o HTN
▪ Grade 1: ‘Silver wiring’ of arteries only.
▪ Grade 2: Grade 1 plus arteriovenous nipping or nicking.
▪ Grade 3: Grade 2 plus flame shaped hemorrhages and cotton wool exudates
(soft or hard).
▪ Grade 4: Grade 3 plus papilledema.
▪ deposits around macula – cartwheel
- Papiloedema – bilat. disc edema due to ↑intracranian pressure
o vs. disc edema
- Lymph drainage
o Preauricular -> submandibular nodes
- Hyperemia
o Ciliary – close to the centre – central (eye) origin
o Conjunctival – peripheral
460
▪
- Visual field problems – M 837 + Jay’s notes
o Retrobulbar neuritis -> circumferential blindness
o Optic nerve affected -> complete loss of vision in that eye
o Partial lesion of chiasma (perichiasmal area) -> unilat. nasal hemianopia
o Optic chiasma lesion -> Bitemp. Hemianopia (or bitemporal upper field blindness)
▪ cause - pituitary adenoma (MCQ)
• macroadenoma of pituitary gland
- init. upper bitemp. hemianopia
- then complete bitemp. hemianopia
o Homonymous hemianopia (e.g. left temporal and right nasal hemianopia)
▪ Optic tract
▪ Optic radiation
▪ Visual cortex (occital lobe)
o Quadrantanopia (same side quarter in both eyes – e.g. left in both eyes)
▪ Sup. quadrants – temporal lobe
▪ Inf. quadrants – parietal lobe
Emergency medicine - OK
- Emmergency situations >- Rapid primary survey = assess ABCD (disability) E (exposure)
o 1. Airway
• Secure airway
461
▪ response
▪ A
▪ B
▪ C
• CPR
o how:
▪ 30 compress. : 2 breaths
▪ chest depression: 4-5 cm
▪ rate of compressions: 100/min
o most important sign of successful
resuscitation: Pupillary light reflex OK
o how long to continue CPR: as long as
you can, till specialized team has
arrived (usually max. 45-50 min)
o if cardioversion is not available, IV
adrenalin should be given every 3 min.
▪ Disability
• neurological signs
• Defibrillation
o use it right away if available
o for a witnessed cardiac arrest, using a
manual defibrillator:
▪ give 3 consecutive shocks in
first defibrillation attempt
▪ further shocks –> single shock
o 1st shock: 200 J Biphasic (before 360 J
monophasic – no longer used)
o continue CPR for 2 min
o 2nd shock:200 J Biphasic-> max. 3shocks
o Shockable rhythms:
▪ Unstable VT
▪ VF
o Non-shockable rhythms:
▪ Asystole (no pulse)
▪ Pulseless electricl activity (PEA)
• Advanced life support (specialized team has arrived)
- continue CPR
- in shockable rhythms (VT/ VF) - defibrillate again
- non-shockable rhythms – drugs only
- drugs
▪ Adrenalin 1 mg IV or intracardiac repeat every 3 min
during defibrillation
▪ Atropine 1-3 mg
• in asystole or severe bradycardia
▪ Amiodarone – 300 mg bolus
• in VT or VF
▪ Mg – muscle relaxation, etc.
464
▪ tender lymphadenopathy
o Cx
▪ greatest danger: Resp. obstruction and failure
▪ neurological – Ptosis
▪ hematological (anticoag.) – affects clotting
▪ +don’t rely on abdominal sympt.!
▪ + cardiology
▪ + nephrology
o Mx
▪ 1st aid: firm bandage, starting from distal to proximal + splint 2 limbs together
• if on buttocks – no bandage but do not move
• not too tight, no turniquet, no ice.
• make window in bandage to do the swab (don’t displace the bandage)
▪ No sympt. – no treat.
• observe patient for 12 hrs, then release
• no helicopter/ air transportation
▪ Sympt. – Antivenom + antihistamine + C/S (to avoid Serum sickness – if it
happens, use adrenaline)
• Venom detection kit: Take swab (if scratch marks) or use fresh urine and
detect type of snake.
- Monovalent antivenom preferred (e.g. specific for tiger snake)
over polyvalent (since it can cause anaphylaxia).
- if we can’t detect the type of snake -> polyvalent.
- Dilute antivenom 1: 10 in NS, prolonged 30 min. infusion
- Air transportation
o CI in:
▪ Snake bite
▪ Retinal detachment
- Spider bite
o Only one spider is life-threatening – Sydney funnel-web spider (Murtagh 1346)
▪ Sx
• Muscle fasiculation, salivation and lacrimation, piloerection, dyspnea,
neurological symptoms.
▪ Mx – like for snake bites
• Resuscitation
• Specific antivenom
o Red-back spider and black widow spider can also cause envenomation
▪ rarely fatal, more serious in the young, frail, elderly
▪ Mx
• Antihistamine
• Antivenom x IM
o Rest – life support
▪ Mx
• Apply ice pack
• No bandage
CA metastases - OK
- Murtagh p. 242-243
468
- 1. Lymph Nodes
o Supraclav. nodes
▪ Right – 1. Breast (women), lung (men)
• also lung (Pancoast tumor)
▪ Left – Gastric (small percentage of gastric – to right as well) – Troisier’s sign
• also lung (Pancoast tumor)
- by location/ destination
o Metastases in brain (same as lungs)
▪ Breast
▪ Lung
▪ colon
▪ lymphoma
▪ kidney
▪ melanoma
▪ prostate
•
o
o Metastases in the lungs (same as brain)
▪ 1. breast – MC - Murtagh
▪ 2. lung
▪ 3. colon
▪ 4. (MC at MCQ course) kidney – cannon ball
▪ 5. testis
▪ melanoma
▪ + thyroid – cannon ball
o Metastases in bone – all are osteolytics, except for prostate CA (osteosclerotic)
▪ from
• Breast – MC (Murtagh) mixed
469
▪ lungs
▪ liver
▪ brain
▪ small bowel
o Testicular CA metastasizes to
▪ lungs
▪ liver
o Prostate CA metastasizes to
▪ bones: pelvis, spine
▪ brain
- Malignant ascitis
o source
▪ Ovary - MC
▪ Uterus
▪ Colorectal
▪ Stomach
▪ Liver
o can be associated with:
▪ nodules on PR
▪ hepatic bruit
▪ supraclavicular lymph nodes
▪ absent ankle edema
Genetic diseases - OK
- inheritance patterns – Murtagh 167
o AD – Anatomical/ morphol. defects = 50% of all MCQ (male or female) inherit the dis.
▪ Familial adenomatous polyposis (FAP)
▪ Huntington’s disease
▪ Von Willebrand
▪ Neurofibromatosis
▪ Marfan’s syndrome
• Triad: tall stature + dislocated lens and myopia + coarctation of aorta
• tall and thin
• long fingers
• mitral v. prolapse
▪ Gilbert’s disease
▪ Tuberous sclerosis
▪ Hereditary spherocytosis
▪ Achondroplasia
▪ Noonan’s syndrome
▪ Acute intermittent porphyria
o AR – enzymes = 25% Cystic Fibrosis, 50% unaffected, 25% carrier, if both mother and
father are carrying the dis.
▪ Cystic fibrosis
▪ β thalassemia
▪ Hemochromatosis
▪ Wilson’s disease
▪ Phenylketonuria
471
- moderate analgezic
- moderate antipyretic
- anti-inflammatory
• side effects:
- affects stomach (ulcers, stomach bleeding)
- has an antiplatelet effect (by inhibiting production of
thromboxane, which under normal circumstances binds platelet
molecules together)
• Dosage:
- 600 mg 4 hourly (max. 4 g / day)
o NSAIDs – it takes 10 days for them to achieve maximal effectiveness (recommend
intermitent 14 day courses). Most NSAIDs act as nonselective inhibitors of enzyme
cyclooxygenase (COX), inhibiting both (COX-1) & (COX-2) isoenzymes. COX catalyzes
formation of prostaglandins and thromboxane from arachidonic acid. Prostaglandins act
as messenger molecules in process of inflammation.
▪ types by chemical structure
• Propionic acid derivatives
- Ibuprofen – short half-life
- Naproxen
▪ long half-life – in bony metastases in cancer
- Fenoprofen
- Ketoprofen
- Flurbiprofen
- Oxaprozin
• Acetic acid derivatives
- Indomethacin – short half-life
- Sulindac
▪ long half-life – in bony metastases in cancer
- Etodolac
- Diclofenac – short half-life
• Enolic acid (Oxicam) derivatives
- Piroxicam - non-selective cox inhibitor - analgesic antipyretic
▪ long half-life – in bony metastases in cancer
- Meloxicam - preferential inhibitor of COX-2 over COX-1
- Tenoxicam
▪ long half-life – in bony metastases in cancer
- Droxicam
- Lornoxicam
- Isoxicam
• Fenamic acid derivatives
- Mefenamic acid
- Meclofenamic acid
- Flufenamic acid
- Tolfenamic acid
• Selective COX-2 inhibitors = coxibs – don’t have G. intestinal side effects
of COX-1 inhibitors, but they can cause CV problems (high BP,
thrombosis – fatal MI & stroke), kidney problems
473
• transdermal
• epidural
▪ efficacy similar to morphine but with fewer side effects
(10 mg morphine SC = 150 micrograms fentanyl SC)
- hydromorphone – 5 - 7 times more potent than morphine
▪ high risk of dependence
- tramadol – atypical, with opiod and non-opiod features
▪ more and more popular
• analgesia without sedation or respiratory
depression
• low abuse/ dependence
- buprenorphine
▪ limited use, in opioid dependence
- pentazocine – not recommended
- diamorphine = heroin
▪ side effects:
• nausea, vomiting
• constipation
• respiratory depression
• dysphoria
• tolerance/ physical dependence/ psychological dependence
o Combined analgesics: Paracetamol/ aspirine + opioid (codeine)
▪ not recommended – rather prescribed separately
o Methoxyflurane – inhalatory – in emergencies, roadside accidents (ambulance)
o in neuropathic pain:
▪ Tricyclic antidepressant (TCA) – Amitryptilin – 1st choice in diabetic neuropathy
▪ Antiepileptics:
• Carbamazepine - trigeminal neuralgia
• Gabapentin – newer - diabetic neuropathy (2nd choice after TCAs), post-
herpetic neuralgia)
o by age:
▪ Children
• Paracetamol
• Aspirin – not used < 18 years – risk of Reye’s syndrome (fatty liver,
encephalopathy)
• Opioids
- Oral
- Parenteral
▪ bolus – IM, IV, SC
▪ continuous infusion – IV, SC
▪ Elderly – more sensitive, lower doses
- Psychogenic pain
o Periumbilical
o during the day
o not referred
o exclude from Hx: constipation, UTI, dairy product allergy
o Hx – emotional changes in family
475
o Rx
▪ enough dietary fibre and fluids to have normal transit
▪ family meeting to support the child (do not punish the child)
Radiology - OK
- X Ray
o Abdomen
▪ Erect/ supine
▪ Chest – pneumonia in lower lung lobes, can cause abd. pain
▪ Bowel obstruction
• location
- Small bowel – center
- Large bowel – periphery
• folds
- Small – continuous from side to side---valvulae coniventi
- Large – can’t see whole fold--Haustration
• size
- Small – 3 cm
- Large – 6 cm
▪ Cecum – 9 cm
▪ Sigmoid volvulus
• inverted U, pointing up and right (distended sigmoid loop)
- bed-ridden elderly people, chronic constipation -> stretching ->
twisting
- young paralyzed people, bed-ridden
▪ Cecal volvulus – small bowel obstruction
▪ Emphysematous cholecystitis – air in the wall of gall bladder
▪ Gas in the liver
• Biliary tracts
• Portal vein
▪ Hydatic cyst – multilocular, with multiple daugther cysts inside a big cyst
▪ Cyst vs. abscess – abscess might have air inside
▪ U/S can’t see through air – e.g. Retrocecal apendix
o Fractures
▪ cortical disruption
▪ Colles - post. dislocation of distal fragm. compared to the proximal fragment
▪ Pathological fracture (malignancy) = Fracture through lucency
- CT Brain
o Bleeding
▪ Intra-axial bleeding – inside brain
▪ Extra-axial bleeding – outside brain
• SAH
- cause
▪ Aneurysm, trauma, anticoagulation
▪ AV malformation
• Surgery – immediate effect
• Radiotherapy - after 12 months they scar;
during these 12 months they can still bleed
476
- Dx
▪ CT scan
• 75% show up on CT scan
• 25% - small amount of bleeding not seen on CT
o do a lumbar puncture
▪ to locate aneurysm or AV malformation
• contrast angiogram
• U/S through fontanelle – till 12 (max. 18) mths
• CT angiogram
• MRI angiogram
• Subdural hematoma
- elderly
- Multiple minor trauma
- Sx – confused
- Venous
- Sickle-shape (crescent) concavo-convex
- With dark areas inside (chronic, acute on chronic hemorrhage)
- can cause midline shift (if large)
• Extradural
- young
- major trauma
- Sx – headache
- arterial (middle meningeal)
- biconvex
- can cause midline shift (if large)
• Scalp hematoma after head injury
- Rx – with no loss of consciousness -> observe them for 4hrs., then
discharge them
▪ Blood = white
• would be at the botton of the pic/ bottom of the ventricles as the
patient is in supine position (heavier than CSF)
o Stroke
▪ cause
• Emboli
- if multiple vessels obstructed, MC with emboli (2 emboli coming
from a proximal source)
▪ e.g.
• Elderly – AF
o Dx U/S – clot in a heart chamber
• Young
o HOCM
o Mitral valve dis.
o DVT + patent foramen ovale -> could
cause an emboli to brain
• Thrombus
▪ types
• Ischemic
477
▪ Folic acid
▪ Vit. C and Ca
- Edema
o Pitting – pressing with finger leaves an indentation that persists for some time
▪ cardiac
▪ hepatic
▪ renal
▪ DVT/ varicose veins/ thrombophlebitis
o Non-pitting oedema
▪ Lymphoedema
• lymphatic obstruction – do abdmino-pelvic CT to look for tumors
• check for DVT - Doppler U/S??
▪ Myxedema
- Hereditary angioedema – bouts of abd. pain and facial edema
o Dx – C1 esterase inhibitor
- Autonomic nervous system
o Sympathetic
▪ originate from thoracolumbar region of spinal cord (levels T1 - L2, specifically) -
"thoracolumbar outflow"
o Parasympathetic
▪ arise from CNS with the:
• III, VII, IX and X cranial nerves
• S2, S3, and S4 spinal nerves
• "craniosacral outflow"
- CNS membranes and spaces
o Epidural (or peridural) space – just in spine
o Dura mater
o Subdural space – virtual, becomes real in cases of haemorrage (subdural hematoma)
o Arachnoid
o Subarachnoid space – contains CSF
▪ hemorrhage from aneurysms
o Pia mater
- Types of tissues
o epithelium is classified as a primary body tissue - cells which line the cavities and surfaces
of structures throughout the body. It is also the type of tissue of which many glands are
formed. Epithelium lines both the outside (skin) and the inside cavities and lumen of
bodies.
o connective tissue
o muscle tissue
o nervous tissue.
- Marital disruption – single most powerful sociodemographic predictor of stress-related dis.
- greatest predictor of cardiovasc. dis. and DM = low educational level
- prevention
o primary – prevent the disease from occurring
o secondary – stop or delay the progression of dis.
▪ screening and early detection of dis.
479
o 18.5-24.9 = normal
o 25-29.9 = overweight
▪ Rx – lifestyle changes
o 30-34.9 = Grade 1 obesity
▪ Rx - Supervised lifestyle changes
o 35-39.9 = Grade 2 obesity
▪ Rx
• Supervised lifestyle changes
• Medical Rx:
- local
▪ bulking agents – methycellulose
▪ lipase inh. - xenical
- central
▪ decr. hunger – amphetamines derivates: Phentermine,
diethylpropion
▪ incr. satiety – SSRI
o ≥ 40 = Grade 3 (morbid) obesity
▪ Rx – as above +
• consider Gastric banding
- SaO2 < 92% - give O2
o in COPD – cut off value = 88%
- Adrenergic receptors
Receptor Agonist
Location / Action Mechanism Agonists Antagonists
type potency order
Smooth muscle. In blood
vessels the principal effect is
vasoconstriction. Blood (Alpha
vessels with α1 receptors are blockers)
Gq:
present in the skin and GI phenoxyben
α1: phospholipa noradrenaline
noradrenaline≥ system, and during the fight- zamine
ADRA1A, se C (PLC) phenylephrine
adrenaline >> or-flight response phentolami
ADRA1B, activated, methoxamine
isoprenaline vasoconstriction results in ↓ ne
ADRA1D IP3 and Cirazoline
blood flow to these organs. prazosin
calcium up
This accounts for an tamsulosin
individual's skin appearing terazosin
pale when frightened. In GI
tract, effect is relaxation.
Gi:
clonidine (Alpha
α2: adrenaline > adenylate
Pre- and postsynaptic nerve lofexidine blockers)
ADRA2A, noradrenaline cyclase
terminals. Mediates synaptic xylazine yohimbine
ADRA2B, >> inactivated,
transmission. Tizanidine rauwolscine
ADRA2C isoprenaline cAMP
Guanfacine idazoxan
down
isoprenaline > Heart and cerebral cortex. In Gs: noradrenaline (Beta
β1:
noradrenaline heart, agonists enhance adenylate isoprenaline blockers)
ADRB1
> adrenaline myocardial contractility and cyclase dobutamine metoprolol
482
- in delusions - Haloperidol
- hypoxia - O2 40%
- C/S?
o 10 days + fever + mucous diarrhea = Pelvic abscess
▪ without fever: resolved paralytic ileus
o Serosanguinous discharge = Wound dehiscence (rupture)
▪ Surgical emergency: Rx – return to OT: wound toilet and resuturing
▪ in first 10 days after op.
▪ Wound dehiscence = Paralytic ileus (MC cause)
▪ MC with Vertical incisions
o Pulmonary emb. with pulmonary infarction – Chest pain, hemoptysis, pleural friction
rub on 10th day Post-op
o Postop. confusion and disorientation = Acute delirium
▪ causes
• Hypoxia – MC, due to:
- Atelectasis
- Analgesics
- Anesthetic from surgery
- Lifestyle changes
o SNAP
▪ Smoking
▪ Nutrition
▪ Alcohol
▪ Physical exercise
Psychiatry - OK
Main pathology
Defense mechanisms (MCQ 2071 p146)
- types: http://en.wikipedia.org/wiki/Defence_mechanism
o I. Pathological
▪ 2. Denial = Avoid to become aware of some painful aspect of reality, you’re
not ready to accept it
• e.g. patient doesn’t accept that he has cancer (“no, you are lying”)
• Rx – don’t confront him, just give him time to accept it (unless he’s
dealing with a life-threatening situation)
▪ 3. Splitting = external objects are divided into “all good” or “all bad”
• e.g. patient doesn’t talk to any nurse because doctors are better than
nurses; morning stuff is better than evening stuff
• mainly in borderline personalities.
• Resistance refers to the conscious and informed decision of a patient not
to change behaviour or comply with treatment. e.g, refuses for ECT
o II. Immature – MC in adolescents, often also in adults
o Blocking, regression, somatisation, introjections, projections are examples of immature
defense mechanism (MCQ)
o
▪ 1. Projection=projecting your own vicious thoughts/ feelings onto someone else
484
• e.g. husband is cheating on wife -> tells her “I think you are cheating on
me”
▪ 5. Somatisation = Phsychic derivatives are converted into bodily symptoms
• e.g. you think of an exam and you develop symptoms (e.g. diarrhoea)
o III. Neurotic – in adults
▪ 6. Displacement = An emotion or drive is shifted to another that resembles
original in some aspect.
▪ e.g. stressed from work/ boss, get home, take it on your partner/ family/ pet.
7. Intellectualization = excessive use of intelectual processes to avoid affective
expression (mood) but emotions are missing in the talks/ arguments.
• e.g. patient finds out he has cancer, he researches it, he talks about it like
in a speech, with no emotion
▪ 8. Rationalization = rational explanations are used to justify unacceptable
attitudes or behaviour (blame game)
• e.g. blaming something else for your mistakes
▪ 9. Isolation = Separation of an idea from the emotional effect that
accompanies it
• e.g. when seeing body of her dead son, mother is very cold and detached
▪ 11. Repression: Ideas or emotions which the person finds painful or
unacceptable are forced out of consciousness and are forgotten.
▪ 10 Suppresion: Suppression refers to conscious or 'semi-conscious' decision of
an emotionally mature, healthy adult to postpone dealing with conflict ideas.
e.g., in interview a pt avoids discussion of certain topics
▪ 12. Reaction formation: Unacceptable impulse is transformed to its opposite
• e.g. we are afraid of an exam, but when asked we tend to say “I’m fine”
• Choosing medicine as a career solely to treat other’s illness as a defence
against ones own death or illness anxieties.
• Pyromanic becomes firefighter
▪ 13. Regression = you don’t behave according to your age (but like a younger
person) MC in males
• e.g. after sister born a boy (6yrs) start sucking his thumb & wetting
bed. MCQ 2071 p146
• after his parents’ divorce, a 7 yrs old boy starts to wet his bed again
14. Jealousy: A normal human emotion.
• 15. Compensation or counter dependancy: a form of denial where
individuals respond to limits being recommended by taking more work,
responsibilities or becoming more energetic.
Example, CHF patient who has been told by doctors to remain in home
and not to do exercise recently attends aerobic classes and do 2 km
jogging every day
• Acting out: a dramtic or sometimes aggressive behaviour that occurs under
stress/ anxiety eg. throwing tantrums, shouting and yelling.
o IV. Normal, healthy, mature
▪ 14. Sublimation = impulse gratification has been achieved but the aim or
object has been changed from unacceptable to acceptable.
• the most mature one
485
▪
+ Passive-aggressive personality? (purple book) – negativistic attitudes and
passive resistance to demands for adequate performance at work or in other
social contexts, always complaining about these demands.
Thought broadcasting: A belief of pt that his ideas and thoughts are known by people in the
surroundings.
Types of disorders
o I. Anxiety disorder
▪ components
• Psychological comp. – always worried, hypervigilance, restlessness,
difficulty concentrating, sleep disturbance
• Physiological comp. – hyperactivity: tahic., hands shaking, dry mouth,
tension headache, constip. or diarhhoea, etc. (adrenal release –
syndrome)
▪ types:
• 1. Panic disorder = unexpected and recurrent panic attacks + avoidance
behaviour (avoiding what could trigger the panic attack)
Example: 19-year-old ballet dancer presents because of extreme anxiety on stage. She repots that she fell 3
months ago at a national ballet competition and since then suffers extreme anxiety, trembling, diaphoresis, a
breathlessness when she has to go on stage. She denies any problems with ballet practice and has no other medical
problems.
- MC people coming to the ED
- panicogens: lactate, CO2, caffeine
- young women (mid twenties)
- reach peak within ½ min
- +/- agoraphobia = afraid of public spaces (scared of having panic
attacks in public)
- they fear they will lose their mind / go crazy
- ABG: pH incr., PaCO2 decr., SaO2 normal
- Sx
▪ panic attacks:
• Lasts minutes to hours: 20 minutes.
• Self-limited.
• Occurs in pts with or without chronic anxiety.
• Spontaneous – no significant trigger
• Age of presentation: Mid 20s
• Variety of somatic symptoms (not faked).
o Sympathetic discharge: Release of
noradrenaline which produces
cardiovascular and other autonomic
symptoms.
o Palpitations, chest pain and tightness,
sweating, dizziness, trembling,
chocking, abdominal pain.
o Hyperventilation: Exhaling carbon
dioxide, increasing pH which affects
neuromuscular transmission (chest
tightness).
488
• DIFFERENTIAL DIAGNOSIS:
o Panic attack secondary to a medical
condition.
o Panic attack secondary to medications.
o Caffeine intox. – no chest tightness
o Other anxiety disorders: Panic attack
are unexpected. The fear is of having an
attack, not of a specific situation.
• TREATMENT:
o CBT/ Relaxation, training or
desensitization.
o SSRI, Benzodiazepines or TCAs.
▪ long term – between attacks
• 1. Breathe in paper bags or relaxation
techniques
• 2. SSRIs
• 3. TCAs
• 2. Phobic disorders
- irrational fear focused on certain things (not generalized like in
the generalized anxiety) disorder
- with insight – the person recognizes that the fear is irrational and
out of proportion with the real danger
- resistance is usually minimal and unsuccessful
- types:
▪ Agora phobia – fear of the market, public, busses or
confined places, far from home, you cannot run away
from there
• untreated may culminate in a panic attack
▪ Social phobia – talking / eating / socializing with
people; ok 1 on 1, but not with a larger group of people
(public speaking, "stage fright," urinating in public
restrooms)
• may be a predisposing factor for alcoholism
(alcohol is anxiolytic)
▪ Specific phobias
• Fear of spiders, snakes, illness, contamination,
etc.
- Rx
▪ 1. CBT:
• systematic desensitization
• assertive thinking
▪ 2. SSRI
▪ in social phobia (stage fear):
• Beta blockers (control the physiological comp.)
• 3. OCD
- Recurrent and obtrusive false thoughts (Obsession) with insight,
they know it’s wrong but can’t help it + repeated action
489
▪ 2. group therapy
▪ 3. SSRI
▪ for nightmares: zopiclone, zolpidem (non-benzos
anxiolytics)
• 5. Generalized anxiety disorder – anxious about everything
- mild, > 6 mths
- charact. = anticipatory feelings, especially in the morning (things
will go wrong today) + physical sympt.
- difficulty falling asleep (thinking about what happened during
the day) and then walking up during the night.
- women
- Rx
▪ 1. CBT
▪ 2. SSRI
• 6. Adjustment (reactive) disorder
an acute reaction to overwhelming stress (minor stress like accident) at
any age, who have no underlying mental disorder.
▪ Rx
• all antidepressents: SSRI, SNRI, TCA
• Benzodiapines – with a clear time limit (otherwise – addicted)
• CBT
- Relaxtion + gradual exposure to trigger
o II. Somatoform disorder (MTB3 477)
▪ Physical sympt. with no medical explanation
• transform psychological emotions to physical problems, without being
able to connect the 2.
▪ types:
• 1. Somatisation disorder – Classical form - never seen
- Young women (starts < 30 yrs)
- 8 or more complaints:
▪ 4 of pain
▪ 2 GI
▪ 1 Neurol.
▪ 1 Sexual
- + atypical forms – with less complaints
- Rx
▪ CBT
▪ keep rescheduling their appts., don’t confront
• 2. Conversion disorder
- MC in women
- Psychological symoptoms (stress) convert into physical symptoms
(paralysis or blindess).
- e.g. husband had MI => woman can’t move her legs, but on
physical examination reflexes are normal and she can sit up.
- Woman fell from horse and complains of paralysis of leg.
- Rx
▪ CBT – comforting
491
• usually low IQ. Pyromania is not the diagnosis if the motive is personal
gain (i.e., insurance money) or to show anger, which differentiates
• this from conduct disorder.
▪ 4. Trichotillomania
• pull their hair out when stressed
• Life change (parents separated, new father, etc.)
• Some also eat their hair => Bezoars of hair causing intestinal obstruction
• with unequal areas of balding and hair shafts of different lengths.
• Dx diff – KOH preparation to exclude a fungal infection
o V. Adjustment disorder
▪ an acute reaction to overwhelming stress (minor stress like accident) at any
age, who have no underlying mental disorder.
▪ inability or maladaptive reaction to an identifiable stressful life event like:
divorce, family crisis, failing exams, etc.
▪ Sx must occur within 3 mths of event and shouldn’t persist longer than 6 mths
▪ females
▪ genetic comp.
▪ Sx = Variety of disturbances at home or work, like: rage, shame, guilt, anxiety,
depression
o VI. Delusionals disorder (A fixed false belief)
▪ just delusions – non-bizarre, initially seem reasonable, but upon investig. no
foundation is found for them
▪ no insight
▪ personality doesn’t desintegrate, well inserted in society
▪ types
• Paranoid disorder (MC)
- subtype – pathological jealousy
- can occur as a psychological reaction to deafness
▪ tinnitus may produce or aggravate auditory
hallucinations
• Erotomanic – they believe a celebrity is in love with them
▪ can be dangerous – if their delusion refers to another person
• e.g. pathological jealousy, Othello`s syndrome, attracted to a celebrity
• could kill the person they fantasize about
▪ Rx very difficult, don’t usually respond to antypsychotics
• early detection is very important
o VII. Eating disorders –
o Anorexia nervosa – feeling fat (MTB 480) feeling fat, overvalued idea of body image –
even tough they are skin on bone
▪
• 90% women- a young female who is underweight.
• 11-21 yrs -MC
• Risk factor Athlete (MCQ)
• Sx
- stop eating
▪ subtype/ some patients – binge eating (like in bulimia)
- Heavy exercise – this keeps them healthy for a long time!
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• disorganized behaviour
• psychomotor disturbance
- agitation
- retardation – catatonic
• saccidic eye movement – when asked to follow an object with their eyes,
they do it in steps
▪ Negative sympt.
• Lack of motivation
• Blunted affect/ emotional blunting
• Poverty of speech (Alogia ---- Inability to speak)
• Anhedonia- lack of interest in pleasureable activities.
• Social withdrawal
o types:
▪ Paranoid
▪ Disorganized – bizarre
▪ Catatonic
• psychomotor disturbance (agitation or retardation)
• catalepsy - keep their body in weird positions for a long time, e.g. with
the head above the pillow
- diff. from cataplexy – sudden loss of muscle tone + temporary
episodes of paralysis
▪ part of the narcolepsy syndrome
o Rx
▪ Typical (conventional) antipsychotics – not used very much; very few used
these days (5-6 out of 25-30) due to SE
• Dopamine receptor antagonists, most effective for +ve features of
Schizo.
- dopamine hypothesis in schizophrenia: positive features in Sch.
are due to overactivity of dopaminergic pathways
• e.g.
- Haloperidol – tablet, inj long or short acting
- Droperidol – PO only
- Chlorpromazine , Thioridizine, fluphenazine
- trifluperazine
- flupenentixole – inj long acting
- zuclupentixol – inj long acting
• SE (MTB 3 463 table)
- Extrapyramidal
▪ 1. Acute dystonia – within hrs to days of Rx
• young males at higher risk
• severe sustained painful agonizing spastic
contr. of axial muscles: around the eyes
(oculogyric crisis – eyes rolled up and open –
“the look-ups”), tongue (protrudes to 1 side),
spasm of the masticatory muscles (trismus),
neck (torticolis), dysarthria, dysphonia,
dysphagia.
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• avoided in elderly
▪ Block histamine => sedation, Wt. gain
▪ Block α receptors => hypotension
▪ Atypical antipsychotics good for both positive and negative symptoms of
schizophrenia. Typical only for positive symptoms.
o act on 3 tracts in the brain:
▪ 1. tuberoinfundibular tract -> decr. dopamin -> incr. prolactin
▪ 2. nigrostriatal tract
• important in Parkinson: dopamine goes down, acethycholine goes up
• cause extrapyramidal effects.
▪ 3. meso-limbic tract -> Clozapine works only here => no endocr. effects (1), no
extrapyr. effects (3)
• but not a first line drug (but as the 3rd line of attack, after 2 drug failure),
due to the life-threatening risk of agranulocytosis
- I choice in psychosis = Risperidone (causes least sedation)
- II – e.g. Olanzapine
- III – Clozapine = indic. no. 1
▪ also indicated in tardive dyskinesia = indic no. 2
▪ SE:
• Hypersalivation, drooling of saliva
• Wt. gain
• Diabetogenic
• leucopenia or agranulocytosis – 1% of pts.
o 85% in the first 9 months
o FBC once a week
o Check FBC for neutropenia in any pt
presenting with fever, sore throat or
other infection.
▪ CI
• myeloprolif. disorders
• severe CNS depression
• previous Hx of leucopenia or agranulocytosis
o types:
▪ Typical = pure D2-antagonists
• Butyrophenones
- Haloperidol – the only one available IV
▪ e.g. ED – pacient with agitation
• 1 – lorazepam (other benzodiapines)
• 2 – haloperidol – available IV
- Droperidol – p.o. only
• Phenothiazine
- chlorpromazine
▪ Atypical
• D2-5HT2 (serotonin)
- Risperidone
• D2-D4-5HT2
- Clozapine
501
(3-5 days) pregnancy have fallen abruptly during preg. have fallen abruptly
Due to hormonal Mother doesn’t want the baby to be Mother has psychotic sympt.:
changes. Mother a sad/ unhappy like her – she thinks life believes or hears voices telling
bit sad/ depressed is not worth living her that the baby is evil/ devil
and she must kill him. They may
also harm themselves.
Baby is at risk!
(Purple book)
- 1 in 500 births
- MC in primiparous women, Hx of major psychiatric illness or family Hx of
major psychiatric history.
- clinical pictures: organic, affective (MC – predom. with manic disorders)
and schizophrenic
- abrupt onset with insomnia, followed by confusion, fluctuating agitation
and labile mood.
Recurrence in future pregnancies – as high as 20%
Also risk of relapse of mood disorder independant of future pregnancies.
Rx – just family Rx: Rx:
support - antidpressants in milder forms - antipsychotics (Olanzapine)
- ECT in severe depression - if not responding early -> ECT
▪ type - Psychogenic depression = Depression (predom.) with psychotic elements
• Rx – ECT
▪ Rx
• Antidepressants
- 1. TCA – not used so much anymore
▪ e.g.
• Amitriptyline
• Nortriptyline
• Imipramine
Clomipramine
• dophiepin
• Paroxetine
• Citalopram
• Escitalopram, Sertraline
• Fluvoxamine
- 3. SNRI (serotonin-norepinephrine reuptake inhibitor)
▪ e.g.
• Venlafaxine
• duloxetine
• Mirtazapine – not commonly used (Samir
Ibrahim = part of a SSRI subgroup - serotonin
agonists)
o heavy sedation, crazy stimulation of
appetite -> wt. gain
o takes effect very fast compared with
the other drugs
• Venlavaxan
• Desvenlavaxan
▪ SE for SSRI and SNRI
• headache, nausea (serotonin surge)
• drowsiness, sedation, lack of sleep
• impotence (10-35%) – become depressed over
this
• SNRI – more cholinergic side effects
- 4. MAOI – not used today
▪ SE - food with tyramine (cheese reaction) – surge in
catecolamines – HTN emmergency -> crisis (can cause
death).
▪ pts had to avoid 50% of the the food items
▪ subtype: RIMA (reversable inhibitor of MAO)
• just 1 drug – moclobemide
• weak antidepressant, but used when SSRIs
cause ED
• SE – same as SSRI
o but no ED!!
- 5. Lithium – mood stabilizer
▪ SE
• fibrosis of thyroid -> hypothyroidism (check
every 3 mths)
• renal failure (check every 3 mths)
- 6. Dopaminergic
▪ wilberton (Zyben) – used only for cessation of smoking
• very expensive
• not used in Aus. for depression
- if stopping antidepressive medication, do it gradually over 2 wks
• ECT (MCQ 2146 P 94)
- treatment of choice if pt has suicidal ideation
- consent from pt. is required
507
• work on
- norepinephrine, serotonin, dopamine receptors (block their
reuptake) -> increase in the brain
- alpha receptors
- muscarinic rec.
- histamine
• e.g.
- Imipramine
- Clomipramine – OCD, premature ejaculation (MCQ)
- Amitryptiline – Diabetic neuropathy, chronic back pain, post
herpetic neuralgia.
▪ 2. MAOI – MAO breaks down norepinephrine, serotonin, dopamine; MAOI
causes incr. in norepinephrine, serotonin, dopamine
• e.g. Tranycypromine, selegiline, phenelzine.
• Can’t have cheese, red wine, chocolate, sausages – (all foods containing
high tyramine) => HTN crisis: headaches, nose bleeds, palpitations
▪ 3. SSRI – only work on serotonin (hence the name SSRI)
• 1,2,3 have the same efficiency, but SSRI preferred due to less SE
- Fluoxetine (Prozac) 1st indic. in adolescents ē major depression
- paroxetine (Aropax)
- sertraline (Zoloft)
- citalopram
- escitalopram
▪ 4. Newer antidepressants (Atypicals)
• Trazodone - used if insomnia is a major problem (highly sedating)
• Buproprion - least sexual dysfc.
- also used in quiting smoking
▪ acts on dopamine, which is responsible for causing
craving and hunger, (CI in pts with eating disorder)
o General SE
▪ Sedation (antihistaminic effect) – less with SSRIs
▪ HTN and tachycardia – more with TCAs
▪ anticholinergic – more with TCAs
▪ cardiac problems – only with TCAs (hypokalemia, prolongation of QT interval -
> risk for torsade de pointes)
▪ decreases the seizure threshold--> should be stopped before ECT
• ↑depending on the washout period: 2-3 days in SSRI, 2-3 weeks TCA
• if anxious, non-benzodiazepine anxiolitic = zolpidem (because BD also
decr. the seizure threshold)
▪ Sexual dysfc. (ED, ejaculatory dysfc.) – more with SSRIs, less with escitalopram
▪ MCQ: nausea, vomiting, diarrhea, abdominal pain – SSRIs (especially
sertraline) switch to another SSRI
o TCA intoxication:
▪ SE
• Anticholinergic (dry mouth, constipation, urinary retention & sedation)
• Cardiotoxic: Cardiac arrythmias, prolongation of QT interval
▪ Overdose Rx:
511
-
- washout periods
From To Washout period
Short acting SSRI Short acting SSRI Nil
512
- Schizoaffective disorder
- Adjustment disorder
• admin.
- 750-1000 mg P O in 2-3 divided doses
▪ incr. by max. 250-500 mg/ day
- plasma level
▪ maintain at start 0.8-1.4 mmol/L
▪ chronic users 0.6-0.8 mmol/ L
▪ very narrow therapeutic range – keep blood level at
0.6-1 (< 0.6 not effective, > 1.2 toxic, > 1.6 fatal)
- monitor every 1-3 months!
- Pregnancy: Stop in 1st trimester (Ebstein’s anomaly in babies) Use
ECT for 1st trimester manic episodes, Use lamotrigene in 2nd and
3rd trimester.
• CI - in kidney disease
• SE
- Acne and wt gain MC problems (MCQ)
- nausea, vomiting, diarrhoea
- metallic taste
- headache
- afects the cardiac conduction
- hypothyroidism (used in hyperthyr.)
- Polyuria – nephrogenic diabetes insipidus
- kidney failure (very small risk)
▪ test thyroid and kidney evey 2-3 months
• toxicity
- sympt. – indic. to decr. the dose
▪ fine tremor
▪ apathy, lethargy, slurred speech
▪ muscle weakness
▪ ataxia, anorexia, nausea
▪ muscle fasciculations
▪ choreoathetosis, convulsions, coma, death
- for pt - important not to get:
▪ Dehydrated
▪ Hyponatraemic
• -> both incr. lithium toxicity (by ↑ renal
reabsorbtion)
- Rx
▪ stop drug
▪ dialysis
• indic.
o Convulsions, coma
o Lithium > 4 mmol/L
o in renal failure
▪ 2. Valproic acid (sodium valproate)
• Indic.
514
o MMSE < 24
o 1 in 10 over 65 years.
o 1 in 5 over 80 years.
o CAUSES:
▪ Degenerative cerebral diseases:
• Alzheimer’s disease: 60%
• Dementia of frontal type: (up to 10%)
• Dementia with Lewy bodies: (up to 10%)
▪ Vascular: 15% (after stroke) – is reversible
▪ Alcohol excess: (5%)
o Forgetfullness and loss of cognitive functio.
o Dx of exclusion – after excluding organic causes
o Types
▪ 1. ALZHEIMER’S DISEASE:
• Insidious onset (Prgressive dementia of degenerative cause).
• Initial forgetfulness.
- Forgets: I time, then II place, then III person (faces)
• Progresses to severe memory loss.
• Dx at autopsy – post mortem
▪ 2. FRONTAL LOBE DEMENTIAS:
• Young age
• Personality changes (rudeness).
• Alteration of behaviour including social dysfunction (running naked,
cursing, masturbatingh in front of nursing station (MCQ) hypersexual –
inhibitions from frontal lobe are erased).
• Progressive aphasia.
▪ 3. LEWY BODIES:
• Visual hallucinations and fluctuating confusion.
• Spontaneous motor parkinsonism.
• Fluctuation in the mental state.
▪ 4. VASCULAR (Multi infarct, stroke):
• Sudden onset.
• Focal neurological signs
• Hx of HTN or stroke
o Differential diagnosis: Depression which is termed pseudodementia.
DEMENTIA PSEUDO
DEMENTIA
o incidence – 3%
- Creutzfeld-Jacobs disease
o Mad-cow disease
o spongiform disease of brain
o rapidly progressive mental deterioration + myoclonus
o Death within 1 year of symptom onset
Behavioral emmergencies
o Situations where pts show behaviour that potentially “put them or other people at risk of
physical harm”.
o Requires immediate intervention.
o The criteria for defining behavioural emergencies are vague.
o WORKING DEFINITION:
▪ Refusal to cooperate
▪ Intense staring
▪ Motor restlessness
▪ Purposeless movements
▪ Affective lability
▪ Loud speech
▪ Irritability
▪ Intimidating behaviour
▪ Aggression to property
▪ Signs of imminent intentional or unintentional self-harm
▪ Demeaning or hostile verbal behaviour
o DIAGNOSIS: May be unknown or provisional:
▪ 1. Medical disorders: Usually associated with delirium
▪ 2. Substance intoxication or withdrawal with or without delirium
▪ 3. Psychiatric disorders – after ruling out 1 and 2
• Schizophrenia
• Mania
• Psychotic depression
• Personality disorder
• Post-traumatic stress disorder
o LEGAL AND PROFESIONAL OBLIGATIONS:
▪ Treatment without consent is conducted under relevant mental health act.
▪ Those treating an acutely disturbed person in such an emergency will need to be
aware of the provisions of relevant legislation and be satisfied that the person
meets criteria for involuntary treatment.
▪ When situation is too dangerous for medical personnel to intervene (weapons
are involved or there is a high likelihood of extreme violence) emergency
personnel such as security staff or police will be required to disarm and restrain
pt.
o Rx
▪ INITIAL STEPS IN MANAGEMENT:
• In approaching the patient, care should be taken to ensure the safety of
yourself, other patients and staff, and of the patient.
• Measures that can reduce the risk of harm include:
- Room with two exits.
518
- Delirium:
o Confusion + hypo or hyperactive behaviour
o Usually affects elderly people admitted to hospital.
o 10% to 15% are delirious on arrival.
o 5% to 40% will develop delirium while inpatients.
o Pts with dementia are at particular risk.
o Children and the seriously ill are also more likely to develop delirium.
o Impaired cognitive function (especially in orientation and memory) and reduced ability to
focus, sustain or shift attention.
o Psychomotor changes:
▪ Agitation or withdrawal.
▪ Drowsiness.
▪ Illusions, hallucinations, delusions.
o Symptoms develop over hrs to days.
o CAUSES:
▪ Infection: especially systemic but also pulmonary, urinary or ear infections.
▪ Toxicity due to drugs: especially anticholinergic drugs or narcotic analgesics.
▪ Withdrawal from sedative drugs or alcohol: This should be suspected when
tremors, sweating and visual hallucinations are present.
o DD
▪ Mania.
▪ Schizophrenia.
▪ Dementia: especially dementia with Lewy-bodies.
o PREVENTION is most important
▪ Adequate hydration and nutrition.
▪ Adequate pain relief.
▪ Promotion of sleep.
▪ Correction of visual and hearing impairments.
▪ Avoidance of restraints.
▪ Provision of lighting appropriate to the time of day.
▪ Close involvement of family members.
o MANAGEMENT:
▪ Identification.
▪ Treatment of its underlying cause.
▪ The delirious pt must be nursed in a setting where they can be observed at all
times, because behaviour may be unpredictable.
▪ UTI (MC cause of confusion in elderly)
▪ FBE – U & E, Blood sugar
▪ X Ray
o Rx
▪ Frequently no medication will be needed.
▪ If delusions or hallucinations are causing distress or if behavioural disturbance
threatens pt's treatment or care or is causing significant threat to others, then
use Haloperidol 1-5 mg orally.
• If oral administration is impossible: Haloperidol 2.5-5 mg IM.
• If significant extrapyramidal adverse effects:
- Benztropine 1 to 2 mg orally.
- Benzhexol 2 mg orally.
520
- Avoid chlorpromazine.
Child psychiatry
- ADHD
o Boys 6:1
o 5 % of school age children
o in 60% no complete recovery
o can’t be Dx < 4 yrs
o Age: 7 yrs, going to school
o Dx. of exclusion
o Dx diff. with autism
o Family Hx
o Very common
o Sx
▪ very easily distracted – can only focus for 1 min to the TV
▪ usually only picked up in school (not noticed by parents)
▪ attention + behavior: attention deffict +
• with hyperkinesis ADHD
- non-goal directed behav. (he doesn’t want to achieve something
specific)
- can’t help it
• without hyperkinesis ADD
▪ impulsiveness and hyperactivity
• inattention
• hyperactivity, impulsiveness
o Dx
▪ first exclude other causes
• Always need to check vision, hearing, lead level first
• Exclude outside causes for the child’s behavior: e.g. if his parents
divorced, etc. – talk to both parents (MCQ)
• Psychometric assessment– exclude intellectual impairment & learning
disorders
▪ 2 situations – home and school
• obtain behavioral rating scales from both
▪ sympt. present for at least 6 mths, causing significant functional impairement
o Dx diff. with conduct disorder – were antisocial during childood
▪ Angry child
▪ Abused by parents – friends
▪ is goal directed + full of anger
o Mx
▪ Refer to child phychiatryst
▪ Confirm from family/ home or school
• exclude social causes, social disruption
▪ Speech therapist
▪ Involve teacher
▪ Audiometry
▪ Drugs:
• Dexamphetamine
521
• Methylphenidaze (ritalin)
Autism ADHD
Before 36 mths < 7 yrs, (5 % of school going children)
No family Hx. Family Hx – Boy inherited from father
Criteria: 2 situations – home and school
Autistic spectrum 3 specific issues: Impulsiveness + overactivity + loss of
1. Verbal problems concentration
2. Non-verbal communication and
no social interaction (hugging, etc.)
3. Fixation/ specific focus on
something (e.g. he likes dinosaurs) &
doesn’t like when his life is changing
Asperger – only 2 and 3
Any sex Boys
Rx - Refer to child psychiatrist Ask for school report
Dexamphetamine –> ↓hyperactivity
o Autism
▪ Autistic spectrum disorder – many subtypes
• e.g. Asperger syndrome – very mild form of autism
- many will have an almost normal life
- sedentary, isolated life
- avoid eye contact
- normal speech
- some are very good in mathematics
- communication through language is preserved
Autism Asperger
Boys 4:1 Boys 8:1
Onset before 3 yrs (30 mths) after a period of normal development
Low IQ Normal or high IQ
No social interaction, use of 2 word phrases only Can speak, normal speech, likes friends
Lack joint attention: Fascination with things
No eye contact. No pointing No eye contact
Lack of pretend play (feeding doll)
Lack of social interest (no peekaboo)
Lack of social play (plays alone)
Lack of communication (verbal, non-verbal) communication is preserved
Lack of peer-rship
Lack of spontaneous seeking
Stereotype repetitive behav.
Don’t like change in routine Rigid to routine
Assoc. with: tuberous sclerosis, epilepsy,
rubella, tourette syndr.
No Rx. Need regular check-ups (don’t complain Rx: behav. therapy, individual assessment,
even when sick or in pain) speech therapists
▪ used to be called childhood schizophrenia
▪ 25% develop epilepsy during adolescence
522
o Sx
▪ recent onsef of irritability, angry outbursts, anxiety symptoms or depression
then memory problems and confusional episodes.
▪ memory disturbance
• short term memory only is affected
• long term/ autobiographic memory is preserved
▪ episodic confusion
▪ hallucinations
▪ paranoid ideation
▪ insomnia
▪ psychomotor seizures
▪ history: recent onset of irritability, anger outbursts, anxiety or depression ->
then memory and confusional problems (MCQ).
o Rx
▪ C/S
▪ plasma exchange
▪ immunomodulation
▪ cyclophosphamide
- hypnagogic hallucinations – vivid dreamlike hallucinations occuring at the onset of sleep
- REM sleep disorder – acting out (yelling, punching, etc.) of dreams that are vivid and intense
Ekbom syndrome
o types
▪ 1 - they believe they have an insect/ worm on their body
▪ 2 - restless legs syndrome
• middle-aged, elderly
• up to 10% of population
• familial Hx – AD with variable penetrance
• precip. factors
- anemia
- hypothyroidism
- renal failure
- DM
• Sx
- irresistible urge to move legs, “tingling, burning and crawling” of
the skin, from thighs to feet
- occurs when sitting down or lying in bed
- worse during the evening and at night before sleep
- relieved by walking
- typically pt complaints of limb discomfort at rest and then urge to
move the affected part, relieved by walking.
• Rx
- mild
▪ lifestyle changes – good sleep hygiene (bed just for
sleeping: no reading, TV, etc.)
▪ Levodopa
▪ Benserazide
▪ Dopamine agonists – amantadine, selegilin
525
- Illusion - there is something there, but incorrectly interpreted (interpreting string as a snake)
o diff. from hallucination (there’s nothing there)
- types of thoughts
o Overvalued idea – quantitatively different from reality
▪ in anorexia nervosa, morbid jealousy, hypochondriasis, querulous paranoia,
body image disturbance
o Delusion – qualitatively different from reality (fixed false belief)
o Phobia – with excessive arousal or anxiety in presence of the trigger, with minimal
resistance to it
o obsession – recognized by the patient as senseless and irrational and is resisted by him
▪ rumination – more complex obsessional thoughts, which are repetitive,
intrusive, unwanted and upsetting
- reassurance should only be offerred when the pt’s concerns have been fully understood and
investigated
- Vaginismus
o Spasm of perineal musculature of the lower 1/3 of vagina
o Young women of high socioeconomic standard
o can be caused by:
▪ a sexual trauma (rape, childhood sexual abuse) or very strict upbringing (sex =
sin)
▪ scarring following episiotomy
o can be assoc. with a phobic anxiety of anticipating vaginal intercourse, e.g. in the
presence of an inexperienced partner
- Diogenes – people who like to collect garbage or have a dirty life style.
- Charles Bonnet - Visual hallucinations due to organic reasons in blind or partilly sighted elders
o if organic reason (occipital or ocular disease) is resolved, the hallucinations will go away
- Cotard syndrome – they believe they have lost body parts, blood, their soul, they are dead or
never born.
- Folie-a-deux
o rare
o one psychotic sympt. is transm. from one person to another (sympt. manifest only when
they are together)
- amygdala – in the temporal lobe, regulates affects
o regulates limbic system
- corpus calossum – responsible for sexual dimorphysm
- cingulate gyrus – part of limbic system, involved in emotion formation, processing, learning and
memory
- Transient global amnesia < 8 hrs
o loss of both recent and biographical memory
o in vertebro-basilar insufficiency
- which psychiatric dis. is increasing in incidence = Dementia (incr. ageing population)
- Paraphilias
o unusual sexual preferences, “perverts”
o types:
▪ 1. Exhibitionism – Recurrent urge to expose oneself to strangers
▪ 2. Fetishism – use/ collection of non-living objects (e.g. bras, etc.) usually assoc.
with the human body
▪ 3. Pedophilia – Recurrent urge or arousal towards pre-pubescents (children)
526
▪ Legal age for sex, including abortion and OCP – 16 yrs (South Aus. and
Tasmania – 17)
• > 16 yrs – OK to prescribe OCPs or perform abortion at her request/ with
only her consent.
• 14-16 Gillick test (or the stem will tell me that she lives alone, she is
mature, etc.) – asses whether:
- Mature minor – treat as a 16 yrs old
▪ lives independently of her parents + is mature and
understands the potential risks and complications of
the required medical procedure.
▪ e.g. pregnant girl, 14 yrs, asking for abortion – blue
book 573
• if she is mature (Gillick test)
• and if it was by consent
o OK
▪ even if > 2 yrs between her and
her boyfriend
▪ even though it’s illegal, she is
under 16 yrs
- Immature minor – treat as a kid and request her parents’
consent.
• < 14 yrs - request her parent’s consent.
- mom wants her mentally retarded girl to have an hysterectomy
o we can’t do that (we refuse) – the girl is entitled to have her uterus (human rights)
o mom can make a request to the child health court (?)
▪ she will probably be refused
- mentally retarded girl - contraception
o under institutional care – OCP
o alone – contact guardianship court
- consent form checked by
o HMO
o nurse
o anesthetist
o surgeon – he is the only one legally responsible
- adopted children have the right to be informed they were adopted
o but this remains the decision of their parents at least until the child is 18 yrs old
- consent in incompetent patients (e.g. elderly demented people)
o 1. advance directive from the patient
▪ The first source of guidance for doctors on the treatment to be offered to an
incompetent patient is the patient’s own advance directive given BEFORE he or
she became incompetent.
▪ This may state whether pt wishes to have particular treatment or to refuse it.
o 2. Surrogate decision maker appointed by the patient (Health attorney, medical agent or
enduring guardian).
▪ If a patient is incompetent and has not previously consented to treatment or
refuse it, a person appointed in advance by the patient may have authority to
decide on the patient’s behalf.
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▪ Most Australian jurisdictions now have legislation enabling patients who are
over the age of 18, while competent, to appoint someone else to make
medical decisions for them if they later become incompetent.
o 3. Guardian appointed by a board, tribunal or court.
▪ If a patient is not competent (and, in jurisdictions that have legislation allowing
people to make advance directive or to appoint their own substitute decision
maker, has not done so), it may be necessary for a substitute decision maker to
be appointed by a guardianship body.
▪ A guardianship body will not intervene by appointing a guardian unless that is
NECESSARY.
• IF THE PERSON’S RELATIVES ARE CARING FOR THE PERSON
SATISFACTORILY, IT IS GENERALLY CONSIDERED THAT THERE IS NO
NEED FOR A GUARDIAN.
• If, however, there is a dispute between family members about the
person’s care, a formally appointed guardian may be needed to make or
review decision about the person.
o 4. The bottom line: Relatives and carers.
▪ If there is no person who has been formally appointed as a surrogate decision
maker, either by the patient or by a guardianship body, a relative or carer may
be able to consent.
▪ This Acts set out a hierarchy of people to decide the ‘person responsible’
including relatives and carers, for consenting to treatment (different
depending on state).
• e.g. Victoria:
1. A person appointed by the patient under the Medical
Treatment Act.
2. A person appointed by the Victorian Civil and Administrative
Tribunal to male decisions in relation to the proposed
treatment.
3. A person appointed under a guardianship order with power to
make such decisions.
4. An enduring guardian appointed by the patient while
competent.
5. A person appointed by the patient with power to make such
decisions.
6. The patient’s spouse of domestic partner.
7. The patient’s primary carer.
8. The patient’s nearest relative.
Prevalence Incidence
New vaccine introduced Decr. Decr.
Disease that kills patients Decr. Constant
Drug that cures a disease Decr. Constant
Drug that doesn’t cure the dis. but extends life Incr. Constant
- Sensitivity & Specificity
Disease present Disease absent
Test pos. A = true positive B = false positive
Test neg. C = false negative D = true negative
o Prevalence: A+C/ (A+B+C+D) = Incidence x Duration
o Accuracy: A+D/A+B+C+D
o Sensitivity – Ability to detect true positives
▪ Sensitivity = A/(A + C) = (true pos./total pos.) = TP/ TP + FN
▪ not related to prevalence
o Specificity – Ability to detect true negatives
▪ Specificity = D/(B + D)= (true neg./ total neg.) = TN/ TN + FP
▪ not related to prevalence
o Positive predictive value – Proportion of true +ves identified in a defined population.
▪ PPV = A/(A + B) = (true pos./ total population)
▪ PPV = TP/TP+FP or (sensitivity x prevalence)/(sensitivity x prevalence) + (1 –
specificity) x (1 – prevalence)
▪ computation of sensitivity, specificity and prevalence
▪ When prevalence is low = PPV ↓ and NPV increases. (MCQ 3339 P 352) test
loses PPV when prevalence is low.
▪ Sensitivity and specificity are inversely related.
o An ideal test would be 100% sensitive and 100% specific. No test can attain this ideal. In
screening population one needs a highly sensitive test for screening.
o Negative predictive value – Proportion of true -ves identified in a defined population =
TN/TN+FN
▪ NPV = D/(C + D) = (true neg./ total p opulation)
▪ Computation of sensitivity, specificity and prevalence.
- All these above 4 formulas have A& D always up
- Odd Ratio: AD/ BC
- Number need to teat: is the no of pts required to be treated to prevent bad oucome. NNT =
1/incidence = 1/Absolute risk reduction.
- Absolute risk reduction: Incidene in unexposed – Incidence in exposed.
- Reliability how well a test performs when repeated 2nd time and or by 2nd tester (test-retest
reliability) and how well test items correlate with each other. It is not affected by prevalence
- Likelihood ratio: an explnation for Likelihd ratio what it means. e.g If LR + = 9 for a test say
ELISA, then it means that likelihood of ELISA test to be positive in HIV pts is 9 times more than
not having HIV.
- LR + = Sensitivity/ 1-Specificity
- LR - = 1- Sensitivity/ Specificity
- Case fatality rate: total no of deaths/ total no of diseased.
- Standard Deviation.
o Mean BP + 2 std. deviation = Systolic (CI)
o Mean BP – 2 std. deviation = Diastolic
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Normal values
Australia: (Murtagh – p. 148)
Adult Male:
17-50 years 1-10 mm/h
> 50 years 2-15 mm/h
Adult Woman:
17-50 years 3-12 mm/h
> 50 years 5-20 mm/h
> 100 mg/L 80% sensitivity and 88% specificity for bacterial infection
10-40 mg/L 69% & sensitivity and 54% specificity for viral infection
Renal fuction
Creatinine: 0.04 – 0.1 mmol/L
Urea: 3-8 mmol/L
eGFR > 60 ml/min/1.72 m2
Normal urinary output = Normal 1 ml/ kg/ hr.
Hematology
Red cells 4.5-6 x 1012/ L male, 4-5.5 female
Reticulocytes 0.5 – 2 % (1%) (immature cells in circulation)
Leucocytes 4.5-11 x 109/ L
Platelets 150-400 x 109/ L
Neutrophils 2-7.5 x 109 / L
Eosinophils 0.2-0.4 x 109 / L (<0.44)
Lymphocytes 1-4 x 109 / L (<4.5)
Monocytes 0.2-0.8 x 109 / L (<0.8)
Basophils ?
Coagulation Profile:
Bleeding time 2-8 min
Fibriongen
Prothrombin time – (12-15) seconds
Prothorombin international normalized ratio (INR) 1-1.2
533
- The prothrombin time is the time it takes plasma to clot after addition of tissue factor
(obtained from animals). It measures quality of extrinsic pathway (as well as the common
pathway) of coagulation.
- The speed of extrinsic pathway is greatly affected by levels of factor VII in body. Factor VII
has a short half-life & its synthesis requires Vit. K.
- The prothrombin time can be prolonged as a result of deficiencies in vit. K, which can be
caused by warfarin, malabsorption, or lack of intestinal colonization by bacteria (such as in
newborns). In addition, poor factor VII synthesis (due to liver disease) or increased
consumption (in disseminated intravascular coagulation) may prolong the PT.
- A high INR such as INR = 5 there is a high chance of bleeding, if INR = 0.5 there is a high
chance of having a clot. Normal range for a healthy person is 0.9–1.3 and for people on
warfarin therapy, 2.0–3.0, although target INR may be higher in particular situations, such
as for those with a mechanical heart valve, or bridging warfarin with a LMW heparin (such as
enoxaparin) perioperatively.
SaO2 98%
Lipids:
Total Plasma cholesterol: < 4 mmol/L
Triglycerides: < 1.5 mmol/L (Use mono or PUFA, marine Omega 3 (fish oil) and fibrates as Rx)
HDL cholesterol > 1mmol/L (Gemfibrozil and nicotinic acid increases HDL)
LDL cholesterol < 2.5 mmol/L (Simvastatin and Ezetimibe as Rx to lower). Ezetimbe decreases
cholesterol absorption.
Predictors of effects of obesity on health: Waist to Hip ratio (MCQ) and Waist circumference and these
are less accurate than BMI alone
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Trachoma prophylaxis:
a. Contacts of cases identified through community screening:
Active trachoma community prevalence in 5-9 year old Aboriginal and Torres Strait Islander children:
i. ≥ 20%: Treat all people > 3kg living in households with children <15 years of age.
ii. ≥ 5 to < 20% and there is no obvious clustering of cases: Treat all people > 3kg living in households
with children <15 years of age.
iii. ≥ 5 to < 20% and cases are obviously clustered within several households and health staff can easily
identify all household contacts of cases: Single-dose azithromycin to all people > 3kg living in households
with an active trachoma case.
iv. < 5%: Treat all people > 3kg living in households with an active trachoma case.
regardless of any of these measures. The somatostatin analogue octreotide, given before meals, has
been shown to be useful in some individuals and the long-acting preparation may also be
useful. However, this treatment can lead to the development of gallstones and it does not help the
diarrhoea from which many patients with dumping also suffer. Revisional surgery may be occasionally
required. In patients with a gastroenterostomy, the drainage may be taken down or, in
the case of a pyloroplasty, repaired. Alternatively, antrectomy with Roux-en-Y reconstruction is often
effective, although the procedure is of greater magnitude; following gastrectomy, it is the
revisional procedure of choice.
#Late dumping syndrome :
This is reactive hypoglycaemia. The carbohydrate load in the
small bowel causes a rise in the plasma glucose level, which, in
turn, causes insulin levels to rise, causing a secondary hypoglycaemia.
This can be easily demonstrated by serial measurements
of blood glucose in a patient following a test meal. The treatment
is essentially the same as for early dumping. Octreotide is very
effective in dealing with this problem.