y5 OSCE

AMTS

"I'm just going to ask you some questions to test your memory" O to person What is your date of birth What is your age Recognition of 2 people O to time What year is it What time (to nearest hour) O to place Where are you? Memory (registration) I'd like you to remember the following address - 42 West Street. can you repeat that to me now please? Okay I'm going to ask you that again soon Attention and concentration Count backwards from 20 to 1 Memory (recall) Years of WWII (1939-1945) or 9/11 (2001) Name of prime minister (Theresa May) or monarch (Elizabeth II) What was the address I asked you to remember earlier? 8-10 normal 4-7 moderate impairment 8-10 normal

Antenatal Hx

PC = current pregnancy LMP, normal cycle, previous contraception use, STIs, cervical smear, gynae problems BMI, health (smoking, alcohol, substance misuse, diet, exercise) Discuss further screening (eg Rh-ve) and upcoming appointments PC=APH Volume, colour. Placental position. Blood group, rh status Previous bleeding in this pregnancy - gestation and outcome Precipitating (intercourse, surgery) PC=pre-eclampsia Headache, visual disturbance, flashing lights, epigastric pain, vomiting, swelling (particularly around face + hands, SOB, weight gain), oliguria, syncope/seizures. PMHx renal disease, headaches, migraines PC=hyperemesis gravidarum Urinary symptoms, colour of urine. Had USS? (twins), any bleeding in pregnancy. POHx HG, FHx HG/twins PC=Puerperal pyrexia Mode of delivery, complications (RPoC, prolonged ROM, fever). Pain. Lochia (abdo pain, number of pads soaked, clots, tender uterus) Urine (dysuria, freq) Perineal wound (pain, offensive discharge) Chest (cough/SOB/CP, sputum) GI (change in bowel habits/diarrhoea/abdo pain) Mastitis (painful red hot breasts) DVT (pain, swelling in legs) IV site infection (rash, swelling in skin) OHx Current pregnancy Hx: Gestation/EDD, LMP, how/when pregnancy confirmed First trimester: planned or unplanned, booking visist?, consultant or midwife led? rh? N+V, RFM, abdo pain, pre-eclampsia (headache, visual disturbance, epigastric pain, swelling), pruritus, urinary/bowel problems General: fever, fatigue, weight loss Gynae Hx Pain, discharge, bleeding, cervical smears PMHx: HTN, DM, autoimmunity, VTE, cardiac, renal disease POHx PxGx. Gestation and method. Any miscarriages or terminations Antenatal (APH,pre-eclampsia,GDM), intrapartum, postnatal problems (PPH) Health + development of children UTD w/ scans, any abnormalities PSHx: uterine, cervical, pelvic, spinal, bladder FHx: DM, VTE, chromosomal abnormalities, birth defects DHx: prior to and during pregnancy SHx: planned leave, domestic abuse screen

Intusussception

6-12mo problem with bowels. Part of bowel slips into another part just beyond it, blocking peristalsis (mexican wave moving food through bowel), and blood supply to area Cause: often none, may have had viral infection Symptoms: intermittent abdo pain, pale, drawing up of legs, sleeping between. Red current stool, vomiting Treat: prevent dehydration with fluid into veins. Rest their bowel - put tube up nose + down throat to drain any buildup of fluid and air Surgery: air enema - special machine to carefully blow air up back passage to put bowels back to where they should be. 80% succeed, otherwise surgery required 99% survival, 1-5% recurrence

Ritalin

ADHD - ensure understanding. Indications include impulsivity, inattention (unable to follow instructions/listen/finish homework), hyperactivity (squirming, figeting, on go all the time, non-stop talking). Only if parental education/training, CBT, etc have failed Stimulant, not cure but can adjust behaviour (methylphenidate) - increases conc and attention span, reduces impulsivity, works in 70% One pill OD, for 1 mo then reassess. Effect takes up to 1mo. Before starting - height, weight, BP, liver function (LFTs). 3monthly check-up required. Drug holidays are encouraged to reduce SEs (decreased appetite, anxiety/insomnia/tics, HTN, seizures, growth suppression). Not addictive as long as correct doses taken. Alternatives include CBT, parental management training, family therapy, education interventions, atomoxetine (2nd line)

Discussing vaccinations

ALL VACCINES CI if - acute febrile illness, primary immunodeficiency, on steroids 6 in 1: DTaP/IPV/Hib/HBV Killed form of agents (not live) 8, 12, 16w, IM. 3 doses to ensure good immune response - time between ensures each dose has time to work. Every time new dose given, immune response boosted SE: 12-24h after fever (<1/1000 febrile convulsions), sickness, diarrhoea, small lump at injection site lasting for a few weeks. May seem miserable within 48h, 1/10 swelling/redness at site. Rarely anaphylactic shock MMR: measles (deafness, brain damage and death), mumps (hospitalisation and death), rubella (congenital anomalies). Given 1yo and 3y4mo IM. Live vaccine. SE: minor forms of measles or mumps, or a bruise-like rash a few weeks later (none infectious)

ADHD explanation

Abnormal: Common. Hyperactivity, impulsiveness and inattention >6mo Cause: unknown, but RF - FHx/genetics, antenatal drug use, obstetric problems (prologed labour, LBW), prematurity, severe neglect and deprivation Symptoms: always fidgeting, unable to sit still, blurting out answers, can't wait for their turn, easily distracted, forgetful, appears not to listen. Associated with LD, anxiety, depression, tic disorders DDX: impaired hearing, insufficiengt sleep, hyperthyroidism, drugs Investigations: info from school, observation in clinic/home, psychological testing, Conor's questionnaire Parent training programmes: teaching skills to manage and reduce problem behaviour and developing more effective ways of communicating with child Psychoeducation and social skill training for child Psych therapies (CBT) Methylphenidate (last resort) Arrange extra help in classroom, special educational needs nurse 50% grow out of it in mid teens, other half have problems that persist into adulthood

GDM

Abnormal: DM (increased blood sugar) occurring in late pregnancy Cause: hormones released by placenta cause insulin resistance, causing blood sugar to rise if extra not secreted. Not your fault. RF MBMI>30, PMHx macrosomia/GDM, FHx DM, PCOS, ethnicity (South Asian Afro-Carribean, Middle Eastern Symptoms: big baby, birth defects, problems with low blood sugar for baby after birth. Difficulty in labour (shoulder dystocia, stillbirth, emergency CS, NICU). Increased risk of developing T2DM in future investigations: OGTT at booking and 24-28w (if PMHx GDM/RFs), fasting >5.6, 2h>7.8. Regular USS for macrosomia and polyhydramnios. Post-partum check for high blood sugars persisting, safteynet for DM, test fasting at 6-13w Treatment You can do: Blood sugar diary (1h post meal TDS + fasting), dietary changes (low glycaemic index food), regular light exercise We can do: We'll see you in joint DM and antenatal clinic (MDT), and teach you about self monitoring. May need to start you on insulin (if fasting>7).

Pre-eclampsia

Abnormal: HTN, protein leaks from your kidneys Cause: idiopathic. Probably due to placental problem. RF - primip, >40yo, BMI>35, multiple pregnancy, FHx, PMHx DM, APLS, HTN, SLE Symptoms: asymptomatic. When severe, headache, visual disturbance, papilloedema, hyperreflexia, epigastric pain, swollen hands, feet and face Complications: SGA, increased risk of premature/stillbirth. Eclampsia (1/100), blood clotting disorders, HELLP (blood cells may break down, liver can be affected, can cause bleeding problems), cardiac/multi-organ failure Investigation: BP, urinalysis, USS to monitor baby growth Prevention: aspirin 5mg from 12w Rx: blood tests, labetalol/nifedipine/methyldopa to lower BP, MgSO4 IV can treat or prevent seizures. Giving birth is only cure

Menopause

Abnormal: as you get older, ovaries stop producing eggs and making oestrogen, average 51 Symptoms (80% of women) Short term (2-5yo): hot flushes (face, neck, chest, sweating, dizziness, palpitations), sweats (bed at night, disturb sleep, change clothes), periods change Long term: skin dries/thins/itches, genital dry, vagina shrinks, increased freq and UTIs. Osteoporosis (bones less strong, break more easily), CV (heart disease and stroke) HRT (cyclical until no periods 1y, then continuous) Replacement of normal o/p Ease symptoms within weeks/mo, prevents bone weakness, sleep, muscle aches and mood improvement Risks: VTE, stroke (reduced w/ patch), breast, ovarian ca CI: PMH endometrial, breast, ovarian ca, VTE, MI, angina, stroke, uncontrolled HTN, pregnancy, abnormal bleeding, undx breast lump SE: nausea, breast tenderness, leg cramps, headache, migraine, dry eyes Find lowest dose that reduces symptoms, continue for 1-3y. If mainly genital symptoms cream/pessary F/u after 3mo then every 6-12mo Contraception rules

Miscarriage

Abnormal: cervix opens, contents fall. Threatened (mild bleed, no pain), inevitable (heavy bleed, pain, open), incomplete (as above + partial evacuation), missed (SGA, dead fetus, dirty brown discharge) Investigations: TVUS (abdo less accurate), 2nd scan <1w later if unsure MANAGE Conservative: wait and see 1-2w, may require surgery Medical: PV misoprostol, bleeding continues for 3w, more pain/bleeding than surgical. No GA Surgical: vacuum aspiration, safe quick and less painful than curettage, under GA. RIsks-uterus perforation, cervix tears, bleeding. After, once bleeding stopped hcg in 3w, if +ve review AFTER: don't need to delay, but wait until emotionally ready/next normal period. Rh Prognosis: 1/5 pregnancies, best to do is not smoke and drink. >=3 in a row requires further investigation SPIKES Setting: ensure comfortable confidential room and will not be disturbed Perception: "Could you tell me what has happened so far?" "Do you have any idea what problem might be?" - aim is to get them to say dx Invitation: "I do have the result with me now, would you like a family member to be present" Knowledge: Warning shot, chunk diagnosis in stepped approach. After every statement, pause+wait, pt leads from here Emotions/Empathy: acknowledge and reflect emotions back (inc body language) - eg "I can see this news was a huge shock (pause and wait)", "you appear very anxious (pause and wait)" Strategy/Summary: agree on plan, summarise concerns. Was pregnancy wanted, who knew, support group?

ASD

Abnormal: group of similar disorders with varying degrees of severity, affecting communication and relations with other people Cause: unknown M:F 4:1, FHx, NOT MMR Triad of impaired social communication (nonverbal - eye contact, facial expression, posture, gestures. Failure to develop friendships, no social/emotional give and take, difficulty understanding unwrittent rules, prefer to be alone), language and understanding (delayed language development, unusual tone of voice, echolalia, stock phrases, difficulty with abstract concepts/sarcasm), and restricted interests and resistance to change (repetitive unimaginative play, unusual intense preoccupations (eg small parts of objects), odd repetitive movements, doesn't like change to routine). Also hyperactivity, sleep difficulties, food fads, self-injurous behaviour, epilepsy, visual + hearing difficulties, IQ<100 No cure. Maximise potential of each child - earlier input is better Educational support, SALT, OT, early intensive behavioural intervention, parental training, access to benefits Medication - anxiety, depression, OCD. Risperidone for aggressive/repetitive behaviours. 15% independent with just a little support, many need much more - grow up at family home -> residential home

SCD

Abnormal: inherited disease where body can't make haemoglobin properly. Hb in all RBCs, carries O2 to organs and muscles Cause: abnormal Hb (HbS) causes RBCs to change shape in cold, infection, dehydration, low o2 or prolonged exercise. Makes them harder and less flexible, get stuck in vessels and block Symptoms: blockage - pain crises (bones, joints, tummy), acute chest syndrome (CP, fever, SOB). Also more prone to severe infection, and haemolytic anaemia (tired, SOB, dizzy, pale, skin, large spleen). Later, slower growth and puberty, B19 aplastic anaemia Full vaccine + meningitis, HBV, annual influenza. Abx daily (pen V), folate OD for making RBCs (higher dose in pregnancy), avoid smoking/alcohol, avoid triggers (cold, dehydration, regular exercise, eat healthy) Medical: fluids for hydration, O2, painkillers and Abx for infections and crises, blood transfusions if severe, hydroxyurea can help Surgical: splenectomy may be required LE: SS 42-45, SC 62-65, crises and infections cause mortality

CP

Abnormal: loss of ability to move part of body due to problem with brain. Group of conditions that cause movement problems, depending on type of brain injury. May not be able to walk, talk, eat or play in the same way as others Cause: Unsure - non-progressive lesion obtained <2yo. 80% antenatal, 10% intra, 10% post. RF premature (es <28w), multiple preg, congenital infections, severe neonatal jaundice, maternal drug use, severe prolonged lack of O2 during birth, meningitis Symptoms Spastic (70% - hemi/di/quadraplegic): movements stiff and jerky, affected muscles permenantly contracted Athetoid: slow, writhing involuntary movements of hands, arms, feet or legs, can also affect tongue or facial muscles, stiffness can vary Ataxic: struggle with balance and find movements eg writing, muscles too relaxed Associated with epilepsy, LD, speech and language problems PT/OT prevents limb contracture or deformities, must be done regularly. Medications: botox injections relax muscles for 3-6mo, diazepam and baclofen help, anticonvulsants and analgaesia as required. Surgery loosens tight muscles or corrects joint deformity

Fibroids

Abnormal: non-cancerous growths of womb, 1/4 Cause: overgrowth SMCs, idiopathic. Respond to oestrogen (swell in pregnancy, shrink in post-menopause) Symptoms: Often asymptomatic, but can cause heavy periods, pain and urinary problems. Rarely subfertility Investigations: USS to diagnose, and to rule out more sinister causes Management Observation: if no problems we don't need to do anything, can treat if get worse Tranexamic acid: helps heavy periods, take 3-4/d for duration of period NSAIDs: ibuprofen/mefanamic acid ease period pain COCP: makes periods lighter, helps with pain GnRH analogues: can shrink fibroids by inducing menopause like state, but if used >6mo cause bone thinning, so only used pre-op Surgery: myeomectomy - fibroids out, womb/fertility remains. Fibroids can recur, risk of heavy bleeding and hysterectomy. Endometrial ablation: radiowave removal of endometrium, stops fertility. Hysterectomy, stops fertility. Uterine artery embolisation - thin tube insterted into leg artery, fed up into artery supplying fibroid and blocks it so that fibroid shrinks over 3-9mo

Down's

Abnormality: 1/700 trisomy 21 Cause: usually not inherited, older women more likely (1/150 >45 c/f 1/1500 at 20yo) but can happen to anyone - nothing you have or haven't done. Unlikely to happen again, but slightly higher risk (previous preg?) Problems: LD, heart, bowel, thyroid, chest, sinus problems. Delayed motor, hearing impairment, recurrent ear infections. Many get jobs, independent, but most need long term support/ongoing care Investigations: universal screening, picks up 90%. 10-14w USS collection of fluid at baby's back + blood tests (BHcG hi, PAP-A lo). If too late 14-20w Quadruple test AFP lo, oestriol lo, hCG hi, Inhibin A hi. Picks up 80% Low risk = <1/150 CVS - 11-13w, 1-2% miscarry, early results - ToP Amniocentesis - 15w, 0.5-1% miscarry, use needle to remove fluid US guided, v. low infection risk Both prelim results 2-3d, full in 2w, >99% reliable How would you feel if results +ve? can decide to - keep pregnancy (w/ support), TOP, adoption - completely up to you Down's syndrome association

Collateral dementia Hx

Always good to talk to someone familiar with daily activities and function of pt. Relationship to pt? Onset (Acute, chronic, acute-on-chonic) Progression (slowly progressive = Alzheimer's, stepwise = vascular) Triggers (infection, stress) Associated: Depression, psych (hallucinations in Lewy Body, delusions) Behavioural change: agitation, aggression, wandering, disinhibition, calling out Sleeping pattern: awake at night (alzheimer's), earl morning waking (depression), fluctuating conciousness (delerium) Cognitive disturbance: aphasia, apraxia, agnosia, difficulty planning/organising ICE - carer needs, what is pt worries about, what do they want us to do PMHx: Parkinson's, vascular disease, DM, head injury, infection, psych disorders DHx: BP/DM medication, parkinson drugs, alzheimer's drugs, any new medication FHx: dementia, vascular disease, depression SHx: living situation, carers, home support, ADLs (washing, dressing, cooking, cleaning, shopping), occupation, driving RISK ASSESS Leaving gas on, door open, wandering, aggression, risky behaviour

Inhaler technique

Asthma is a problem with the small tubes in your lung - become extra sensitive and become narrow and irritated, making breathing difficult. Different types: Reliever (blue) for when symptomatic - relaxes muscles and opens up airways, allowing more O2 in to ease your breathing Preventer (brown) used every day even when asymptomatic. Reduces inflammation, keeps airway open 1 sit/stand upright 2 remove mouthpiece cap, check it is in date 3 take 2 deep breaths in and out 4 shake inhaler 5 put it in your mouth, make good seal between lips and mouthpiece 6 Start breathing slowly and deeply and press inhaler button 7 Breathe in slowly and deeply 8 Hold breath for 10s 9 After 30s, repeat if necessary 10 wash out mouth (if steroid inhaler) Spacer: helps to deliver medication better into lungs. Doesn't require co-ordination between breathing and button pressing How to use 1 Assemble and remove cap 2 shake inhaler and insert it into end 3 put mouth securely around mouthpiece, ensuring tight seal 4 press inhaler button 5 take 5-10 deep breaths in and out, watching valve and listening for clicking 6 repeat as many times as necessary Wash with warm soapy water and leave to drip dry every month. Don't towel dry - static. Change every 6-12mo ASK PT TO DEMONSTRATE

IDA

Baby needs iron to make RBCs which carry O2 around body IDA not enough red cells in blood Cause: kids not eating properly, malabsorption, blood loss Symptoms: pallor, lethargy, SOB, problems growing Investigations: full examination to check for blood loss, red book to assess growth, take blood for tests (urea, coeliac) Dietary Normal: red meat, liver, kidney, oily fish Vegetarian: pulses, beans, dark greens (spinach, broccoli), nuts Orange juice helps uptake iron. Avoid excessive cows milk - low in iron, children get full easily and won't eat anything else Avoid tea - tannins inhibit iron uptake Iron supplements 3mo NEVER BLOOD TRANSFUSIONS

Drug dependence

Before I can agree to prescribe anything, I need to get a full understanding of how you're doing, order some investigations (eg urine sample) Why drugs used Route Freq, amount Equipment sharing How long have you been using like this When did you first take drugs? Habits changing over time? Ever overdosed? Expensive - how do you afford? Craving if you don't have for a day? Withdrawal if don't have it? Tolerance - need more for same high Effect on life LOST - memories LOVE - has it affected relationships LABOUR - has it caused problems in your job LAW - have you had problems with police LIVER - any medical problems due to alcohol (ulcers, pancreatitis, HTN, liver) Depression screen/risk assess low mood, chronic fatigue, anhedonia. Some people who feel like you do - self harm, suicide Have you ever seen things others can't see Insight: good and bad of using drug? Concerned about drug use? Would you like to cut down?

CF

Cause: CFTR, 1/25 Symptoms: Airways, intestines (neonates, increased energy requirement), pancreas (enzymes can't get into gut, impairing absorption of fat and vits), liver, fertility Rx: Airways (TDS PT, Abx, vaccination), pancreas (diet, enzymes, ADEK), liver (UDCA), fertility (IVF), definitive (Tx). Prognosis 40-50

HPV/genital warts

Caused by HPV, very common, only few develop warts. Transmitted by sexual contact, incubation up to 8mo. 6+11 cause warts, 16+18 cause cervical cancer. Warts don't increase risk of cervical ca Pregnancy: can enlarge, can obstruct labour if huge, can be transmitted causing neonatal infection of throat and genitals Prevention: had HPV vaccine? Warts regress over time (few months) Medication Podophyllin: applied in clinic 1-2/w left on for a few hours Podophyllotoxin: self-applied BD 3 days Cryotherapy

Glue ear

Ear divided into 3 parts, middle behind eardrum, usually filled with air, connected to back of nose by eustachian tube, which opens during swallowing or yawning to let air in and drain fluid out Middle ear fills with glue-like fluid instead of air Cause: Eustachian tube too narrow, blocked, or doesn't open properly, causing fluid build up due to lack of drainage Symptoms; dulled hearing, pain, may affect behaviour and development Most cases no Rx required. 50% hearing back to normal within 3mo, 90% 1y. As children grow tube widens, drainage improves If interfering w/ speech development - operation to clear fluid and insert ventilation tubes (grommets) In the meantime: talk clearly and more loudly than usual, attract child's attention before speaking to them, discuss with school, try not to smoke at home/near child

DRSABCDE paeds

D: blood, sharps R: verbal, shoulder tap, pinch S A: look = secretions, foreign object, swollen/blue lips tongue and face. Listen = stridor, snoring. Feel: breath on face. IF AIRWAY COMPRIMISE DO NOT DISTURB AIRWAY OR DISTRESS CHILD. CALL ANAESTHETIST IMMEDIATELY If no stridor, ?risk of c-spine injury. <1 neutral, 1-8 morning air, >8 HTCL. call paediatrician, anaesthetist and alert ITU B: cyanosis, accessory muscles, recession, tracheal tug. Chest expansion. Percuss/auscultate lung fields. RR SpO2. NRB C: pallor, sweating, sunken eyes, dry mucous membranes. Palpate pulses, cap refill, temp. Auscultate heart sounds. HR, BP, CR, T, UO. 2 wide boar cannulae + fluid challenge (20ml/kg over 15min) D: pupils, BM, AVPU/GCS E: RASH Anaphylaxis <6mo 150mcg (0.15ml) A + 250mcg/kg C + 25mg H 6mo-6yo 150mcg (0.15ml) A + 2.5mg C + 50mg H 6-12yo 300mcg (0.3ml) A + 5mg C + 100mg H >12yo 500mcg (0.5ml) A + 10mg C + 200mg H Repeat adrenaline every 5-10min Stridor: I don't want to upset the child. Sit them forwards on mum's lap. Avoid IV and BM if possible Mild-mod - budesanide 2mg NEB Sev - adrenaline 0.5mg/kg neb Seizures: 5ml/kg 10% dextrose if BM low. Start with lorazepam 0.1mg/kg IV/IO or buccal midazolam/PR diazepam both 0.5mg/kg. Repeat lorazepam after 10min. Consider paraldehyde 0.4ml/kg PR. Then phenytoin or phenobarbitol 20mg/kgs >50mg/min Asthma: peak flow, Blood gas. 5mg (2.5 if <3yo) salbutamol neb + ipratropium 250mcg NEB if severe, salbutamol INH (with spacer if moderate, w/o if mild. 10 puffs), IV hydrocortisone 100mg stat if severe, or pred 1-2mg/kg max 40mg PO if moderate

DRSABCDE

D: relevant PPI R: verbal, shoulder tap, pinch S: SOAPS (senior midwife, obstetrician, anaesthetist, paediatrician (APH)/porter (PPH), scribe A B: cyanosis, accessory muscles, recession. Chest expansion. Percuss/auscultate lung fields. RR SpO2. NRB C: pallor, sweating. Palpate pulses, cap refill, temp. Auscultate heart sounds. HR, BP, CR, T, UO. 2 wide boar cannulae + fluid challenge (500ml NS over 15min, whilst awaiting blood). Take FBC, CX, G+S D: check pupils, BM, AVPU/GCS E: check for site of bleeding, palpate uterus! PPH Uterine massage VE, expel clots, catheterise Slow IV syntocinon 5U Slow IV ergometrine 0.5mg Syntocinon infusion Bimanual compression Prep theatre APH: secondary survey, CTG+US, prep for theatre PPH: contact theatre

CTG

DR C BRaVADO Define Risk (see indications for EFM) Contractions: frequency (x in 10), duration. Intensity must be measured by palpation Maternal Previous CS Cardiac problems, DM Pre-eclampsia Prolonged pregnancy PROM Induction APH Fetal IUGR Prematurity Oligohydramnios Abnormal doppler velocimetry Multiple pregnancy Meconium stained liquor Breech presentation Intrapartum Oxytocin/epidural Intrapartum PV bleeding Fever Baseline Rate: 110-160bpm reassuring. 100-110/160-180 non-reassuring. <100/>180 abnormal. Bradycardia can be caused by cord compression/prolapse, maternal seizures/bblockers, epidural/spinal anaesthesia. ENSURE FHR is not actually maternal HR. Tachycardia 160-180 can be normal, >180 due to maternal pyrexia, chorioamnionitis, fetal acidosis/hypoxia, hyperthyroidism Variability: mediated by autonomic NS, 5-25 reassuring. If <5 for 30-50min or >25 for 15-25mins non-reassuring. If <5 for >50min or >25 for >25min OR sinusoidal, abnormal. Low variability caused by Fetal hypoxia Fetal sleep (40-90min) Fetal malformations (CHD) Severe prematurity Iatrogenic (methyldopa, steroids, narcotics, GA, MgSO4, etc) Accelerations: >15bpm increase for >15s reassuring (ideally 2/15min Decelerations: None, early only or variable with no concerning characteristics <90min reassuring. Variable with no concerning characteristics >90min, with concerning characteristic <50% contractions for >30min/>50% contractions for <30min/late deceleration >50% contractions <30min with no maternal or fetal RFs (PV bleeding, mec) nonreassuring. Variable with concerning characteristics >50% >30min, late deceleration >30min, acute bradycardia, prolonged deceleration >3min is abnormal Concerning features = >60s, reduced variability within deceleration, failure to return to baseline, biphasic (W), no shouldering Early decel: Peaks coincide, caused by head compression -> vagal tone, so only in late 1st/active 2nd stage, innocuous Late decl: >20s lag between peaks. Worrying, indicates fetal distress, particularly with reduced variability (preterminal). Due to insufficient uteroplacental circulation Variable decel: due to cord compression. Umbilical vein occluded -> acceleration. Umbilical artery occluded -> rapid deceleration. Reopening -> acceleration, then return to baseline. Shoulders are reassuring, no shoulders worrying. May not have any relationship to contractions, common in labour and oligohydramnios Overall Normal: all reassuring Suspicious: 1 non-reassuring AND 2 reassuring Pathological: 1 abnormal OR 2 non-reassuring features Emergency: acute brady or prolonged deceleration (>3min) If pathological, ensure no maternal factors: position, hypotension, VE, emptying bladder/bowels, vomiting, vasovagals, anaesthesia. Then do FBS. If >7.25 + lactate <4.2 repeat in 1h if CTG remains pathological. If 7.20-7.25 or lactate 4.2-4.8 repeat in 30min. If <7.2 + lactate >4.8 immediate delivery

Schizophrenia

Disorder of unusual thinking, behaviour and perceptions affecting 1/100 Caused by imbalance of the chemicals that control nerve pathways in the brain. RF genetic (parent affected = 10x risk), first presents due to stressful events (trigger not cause) or drug use Symptoms: can cause delusions, hallucinations, hearing voices. Also a lack of motivation, social withdrawal and poverty of speech and thought. Does not cause split personalities (although name means split mind) Antipsychotics mainstay of treatment (dopamine blockers, excess of dopamine in the brain): lots of SEs, so important to find right medication and dose. Typical (more likely to cause movement disorders) and atypical This + psychological treatments (CBT), occupational therapy, family therapy and social support work May need to be admitted to hospital if they have a particularly severe episode We can get in touch with care facilities eg supported accommodation that may be able to help the patient live a more supervised life Higher rates of CVD so will work to reduce risk factors 20% recover completely after 1st episode, but 70% will have future episodes Some patients can manage illness v well, with only occassional episodes Some will have more frequent episodes, many of which require hospital admission Some need very high levels of support

General paediatric Hx

General: fever, behaviour, apathy, rashes, growth/weight CRS: cough, noisy breathing, dyspnoea, cyanosis GI: vomiting, abdo pain, diarrhoea/constipation GU: wetting/nappies/toilet trained, dysuria, freq NM: seizures/fits, headaches, abnormal movements ENT: sore throat, snoring, ear ache, noisy breathing INFECTIOUS CONTACTS BFGD Birth: pregnancy - any problems, maternal drug use/illness. Gestation, birth weight, place of birth. Mode of delivery, birth complications. Neonatal problems (jaundice, fits, fevers, bleeding) Feeding: Diet - breast or bottle (which formula), how much (150-200ml/d or brest feed/2h. Weaning (6-12mo), solid meals, cows' milk (>12mo). Toilet training (dry by day at 2yo, by night 3-4yo), frew (~5 soaking wet/d and 3 yellow stools) Growth: weights/growth charts in the red book (<5yo), puberty if older Development: any concerns, school progress + attendance, developmental screen (smiling by 6w, sitting by 9mo, turn to sound by 6mo, first words by 18mo, walng by 18mo, 2 word sentences by 3yo DHx: immunisation up to date? FHx: newborn complications, atopy SHx: family unit - who's at home, anyone smokes? Housing situation, social services involvement. Playgroup (2-5yo), nursery (3-4yo), school (5-16yo) ICE: how has it affected family - has it kept child from attending nursery/school? Febrile seizures: Meningitis (bulging fontanelle, lethargy/irritability, rash), neurology (recurrent seizures, obvious trigger, focal neurology) Jaundice: abdo pain, distension, change in bowel habit, dark urine, pale stools, poof feeding, fever, crying, irritability Vomiting: after feeding? every feed? Is it forceful? Crying, appetite, weight gain/loss, bowel change? when last opened bowels? Regular wet nappies, normal stream? Cough: wheeze/stridor, increased RR, apnoea, nasal flaring, recessions, too breathless to feed. Snotty nose/fever, diarrhoea, ear ache. PMHx Downs, CHD, long standing lung disease Intussusception: abdo pain, draw legs up, episodic intermittent crying, pallor, red currant stool, mass in belly, eating and drinking, temp Nocturnal enuresis: freq, daytime enuresis? Bowel habit - soiling/constipation? UTI (urine smelly, fever), DM (polyuria, polydipsia, weight loss), Stress (bullying, pressure at school), Access (to toilet during day and night) Anaemia: Afro-caribbean, Mediterranean, Indian (haemoglobinopathies). Pallor, low energy, breathlessness, jaundice, cyanosis. V+D, rash, fever, cough, UTI. Fussy eater, predominantly milk drinker, veggie/vegan. PMHx renal disease, prematurity, GI symptoms of malabsorption, blood loss Asthma: symptoms worsening or improving? Wheeze, sob, CP, fever, cough (worst at night, productive, haemoptysis). Precipitating (cold, pets, exercise, smoking, hx atopy), impact (how much work/school missed, sport and general activities). Exacerbation freq + severity (previous hospital/ITU admissions). Current medication, freq of usage, route and compliance Limp: other joint involvement, fever, recent illnesses, any trauma, open wounds? RoM? PMHx of hip problems as baby? FHx arthritis, TB, SCD, infections Check Gillick competency station

Febrile convulsions

Dramatic seizure due to fever, as developing brain cannot withstand rapid increases in temp. V. common, 4% children 6mo-6y. NOT epilepsy, no damage to brain Cause: viral infection. High temp cuases abnormal firing of nerve cells, leading to jerking movements Symptoms: generalised switching between jerking and clenching, lasting <15min (usually <5min), no recurrence within 1d, recovery within 1h. If simple, no brain damage or impact on intellectual performance Complications: 1/3 chance of recurrence (more likely if FHx or <6mo). 1-2% chance developing epilepsy, similar to b/g (4-12% if severe) Education: prophylactic paracetamol/calpol when child has temperature. When having one, move from danger and place on side. Time, if >5min call 999. Get child checked at GP to rule out serious cause (meningitis). PR diazepam/buccal midazolam if >5min

Clozapine

Drug used to treat schizophrenia in patients who have already tried other medications that have not worked How to take: PO BD - 1 small dose in morning and larger dose before bed. Start at low dose (12.5mg/d) and build up over a few weeks to 300-450mg, adjusting based on patient response. Drug must be taken long term to prevent recurrence of symptoms Started at hospital, can be managed in community if community nurse can do extensive f/u We'll do some tests before starting drug: FBC (agranulocytosis), BMI/fasting lipids/ECG (CVS risk), fasting CBG/HbA1c (DM risk), BP (postural hypotension Monitoring: you'll be registered with a monitoring service (clozaril clinic) for weekly blood tests in first 18w, then fortnightly for first y, then monthly Agranulocytosis: FBC Myocarditis (first mo only): vitals, ECG, CRP, troponin CVS: Weight, Hba1c, BP SE: agranulocytosis, DM, myocarditis, sedation, hypersalivation, postural hypotension, tachycardia, constipation (eat fibre, fluids), weight gain, PE, sudden death Neuroleptic malignant syndrome: within 4-11d of initiation of treatment or change of dose (often haloperidol/metaclopramide to parkinsons pt) Symptoms - severe rigidity, fluctuating consciousness, hyperthermia, labile BP, rapid pulse, sweating Ix - raised CK Rx: stop antipsychotic, cool pt, monitor vitals, U+Es. Dantrolene to reduce muscle spasm, bromocriptine to reverse dopamine blockade. Can last 5-7d after discontinuation Missing doses: if miss more than 2d, clozapine must be restarted at 12.5mg and built up again

Antenatal screening

During booking app all offered screening tests Hx: current health, previous pregnancies, health of kids, PMHx/PSHx, mental health, DHx FBC: increased risk of anaemia, baby uses as much iron as it needs despite your requirements, which is why you may become tired - retested at various points Blood group: Rh, risks for future preg. If -ve and +ve baby, Abs form, won't affect this preg but next cross placenta, attack RBCs. We check for Rh and Abs. Anti-D if non-sensitied 28,32 SCD, thalassaemia: can be carriers, so test father BM: hormones released by placenta in pregnancy can insulin resistance, causing BM rise if you don't make enough insulin. Baby grows too big and both have T2DM risk - test throughout pregnancy, can manage Syphilis: can be passed mum-baby HBV: serious infection affecting liver. Many asymptomatic, can be passed mum-baby. postpartum vaccine prevents transmissino HIV: passed mum-baby, greaty reduced w/ Rx, requires specialist care Down's screening: indicate, CVS/amniocentesis to confirm. 11-14w combined, 15-20w quadruple USS (growth, abnormalities, fluid levels, placental position), BP (pre-eclampsia), urine dip (UTI)

RhD screening

Establishes understanding, what means for pregnancy Rh is like ABO Abnormal: 15% -ve, not a disease, no congenital abnormalities or need for CS If baby Rh+ve, blood enters mum, immune response (Abs) Usually during childbirth, also ToP, miscarriage, APH, amniocentesis Previous pregnancies, ectopics, miscarriages, terminations? Any APH this pregnancy? Abs destroy RBCs. Not dangerous this preg, but next. Memory of foreign cells, Abs cross placenta Haemolytic disease of the newborn: baby jaundiced, extremely ill or stillbirth Management: Anti-D to prevent, given at 28 and 34w (one or 2 dose). After delivery Kleinhauer blood test to determine if more anti-D needed Anti-D safe for baby, but may arely cause allergic reaction so have to stay for 20min after injection. So long as given with every pregnancy, no problems with subsequent pregnancies Only required if father rh+ve, as rh-ve baby is no risk, explain genetic inheretence, enquire partner status

Safeguarding children

Everything we talk about today is confidential, however if I think you or someone else is at risk of harm I will have to tell someone about it Confidentiality breach: risk of neglect, sexual, physical or emotional abuse Sexual abuse - <13 (automatically rape), obvious big differences in age, maturity and power between partners, sexual partner having position of trust (eg teacher), force, pressure, bribery, payment have occured, drugs or alcohol have been used to influence child, partner has had previous abusive relationships with children Physical - delayed presentation, hx not consistent w/ or unexplained injuries, bruising/injury in children who aren't mobile, unusual location for accidental injury, bruising in shape of hand/ligature/implement. <1y + swelling on head>5cm - CT scan needed. RED FLAGS - rib/metaphyseal #s, retinal haemorrhage Need to discuss with another colleague (senior member of team ASAP) unless will put child at risk) - try to gain child's consent I understand what you're telling me. A minor fall may cause a # like this but it's unlikely. It is reassuring that your child is otherwise healthy. When a child has a significant injury like this there are guidelines we have to follow to protect the small number of children who may have suffered an inflicted injury. These state that we have to inform social services - a worker will come to talk to you about your child's care Body maps to record injuries, perform skeletal surveys. Document concerns and actions meticulously

Sore throat + Abx

Explain consult Brief history, ICE early Examine for centor (fever>38, tender cervical lymphadenopathy, tonsillar exudate, no cough) Penicillin V BD 10d Viral: rhinorrhoea, conjunctivitis, cough From what you've told me, this seems like virus Unfortunately don't have drugs that kill these like we do for bacteria Don't want to give because: upsets stomach, interacts with medication, can make natural bugs resistant so won't work when you need it Supportive care: analgaesia (paracetamol), fluids, rest, avoid whispering, regularly gargle warm salt water + LA If symptoms aren't better in 7d, come back. If fever worsens >38deg, or develop neck swelling that makes it hard to swallow/breathe, call urgently

High cholesterol counselling

Explain purpose Find out what pt already knows Cholesterol is a type of fat that circulates in the blood. 2 types, good (HDL) and bad (LDL). Results today show that HDL is low and LDL is hi, ideally would like it to be the other way around Consequences: too many fats in blood vessels can clog up your arteries and prevent blood from reaching vital organs eg heart (heart attack) or brain (stroke), or kidney. Thankfully you haven't experienced any of these, we will be doing a full risk assessment today RF for CVD: previous raised cholesterol, FHx, HTN, smoking, diet and exercise, diabetes, overweight Lifestyle: alcohol intake, diet, smoking Secondary causes: hypothyroidism, familial, nephrotic syndrome FHx DHx + allergies Lifestyle: exercise/lose weight. Unsaturated (plant) over saturated (animal). Small changes first (switch to margerine, add salad) Medicine: statins protect vessels, lower cholesterol. Use if CVD>20% in 10y (QRISK) Leaflet f/u: book appointment in a month to see how you're getting on. Monitor HDL/LDL regularly

Smoking cessation

Explain purpose pack year history, cigarettes vs roll ups Why do you want to quit? Why now? Motivation for quitting 1-10. Why not higher? Lower? Previous attempts What method? How long did you stop for? What happened to make you start again? It's great that you'd like to give up smoking! ST: more money, improved sense of smell/taste, more energy, feel better in self, look better, BP and pulse reduce LT: reduce ca risk., COPD. CHD, osteoporosi, ulcers, increased exercises tolerance We're here to help as it can be very difficult Is there a method that you think would suit you? Cold turkey Nictonie replacement (patch, gum, inhalator, nasal spray) Buprpion: antidepressant, stops cig enjoyment. SE - GI, taste change, dry mouth, insomnia, tremors, rarely seizures (CI if Hx) Vareniciline: blocks nicotine receptors. SE - GI, appetite/taste change, dry mouth, headache, dizziness CI: <18, pregnant, breastfeeding Come to joint decision Advise about smoking cessation clinic, health advisor/practice nurse, gosmokefree.com, friends and family Any Q? Leaflet? f/u: book appointment in 1mo time to check how getting on

Innocent murmur

Extra sound on top of normal sounds, 1/3 of kids Sometimes underlying heart condition, but vast majority normal. Louder in infection and anaemia as heart works faster - reexamine when well to check murmur gone Worrying: radiates throughout chest, can feel with fingers, child unwell, breathing distress, low o2 sats, hard to feel pulses in groin, diastolic If heard, document. Organise f/u with paediatrician and further Ix to rule out serious condition (echo, ecg, cxr). If show innocence, we will tell you. May never disappear, but not a sign of disease or illness

Resp

GI (dysmorphism, work of breathing, colour, alertness, nutritional status) LISTEN: wheezing, stridor, grunting, secretions Hands inspection: clubbing Hands palpate: temp, pulse, RR (ideally 1 min) Face: as before Neck palpate: tracheal deviation "might feel a bit funny") Chest inspection: "hand on hips like cross) - scars, barrel chest, Harrison's sulcus, pectus carniatum (all asthma). Work of breathing (tracheal tug, supraclavicular/intercostal/subcostal recession, accssory muscles - head bobbing due to SCM, abdo breathing, nasal flaring) Chest palpate: apex beat, expansion Percuss: front and back Auscultate: (breaths in if crying) LNs while sat forwards Hepatomegaly, PEF, O2 sats/obs, ENT, growth chart

Developmental assessment

GROSS MOTOR Newborn: head lag on pulling to sit, head extension in ventral suspension 6w: lifts head 45deg on lying prone and moves it from side to side 3mo: holds head upright when held sitting. Moro reflex lost 4mo: rooting reflex lost 6mo: palmar, stepping, asymmetric neck tonic reflex (ANTR) lost. Sits unsupported w/ rounded back, rolls prone to supine (vice versa slightly later) 7.5mo: straight back sitting 9mo: stands holding on 12mo: Babinski lost, 50% walking independently (9-18mo) IF NOT sitting by 12mo of walking by 18mo, refer for evaluation 16mo: run 18mo: jump 2y: runs tiptoe, walks up stairs w/ 2 feet on each step, throws ball at shoulder level 2.5y: kicks ball 3yo: hops on one foot for 3 steps, walks upstairs one foot/step, downstairs 2 feet/step, pedal tricycle 4yo: can balance on 1 leg for a few seconds, go up+down stairs 1 leg at a time, pedal a bicycle w/ stabilisers 5yo: can skip on both feet FINE MOTOR Newborn: fix and follow near face or light moving across field of view 6w: infant more alert, turns head through 90deg to follow object 3-4mo: hand regard (spends a lot of time watching hands) 6mo: palmar grasp (5mo), holds objects w/ both hands and bangs together, transfers objects between hands 9mo: inferior pincer grip, object permanence 10mo: neat pincer grip 12mo: index finger to point at objects, casting objects, stacks 2 bricks 18mo: scribbles, 4 bricks 2y: builds 8 brick tower, draws vertical line, puzzles (random <2yo, matching >2yo), turns several pages at once in book 2.5y: horizontal line 3y: draws circle, copies/makes bridge or train, single cuts, griffiths beads, turns one page at a time 3.5y: cuts pieces 4y: draws cross, copies/makes steps (3 levels), 12 blocks, cuts paper in half, small beads 4.5y: draws a square 5y: draws triangle or person, steps (4 levels) IF STILL casting objects at 18mo refer Hand preference <12mo old is abnormal and an indicator of CP SPEECH AND LANGUAGE Newborn: quieten to voices, startle to loud noises 6w: respond to mother's voice 12w: vocalise alone/when spoken to, begin to coo and laugh 6mo: consonant monosyllable babble (ba, da, etc), turns head to loud sounds 7mo: understands bye bye and no 8mo: 2 syllable babble (mama, dada) 9mo: responds to name, imitates adult sounds 12mo: understands nouns (where's mummy?) 13mo: 2 syllable words become more appropriate, 3 word vocab 15mo: points to own body parts 18mo: understands nouns (show me the ____), 6 word vocabulary, demonstrate 6 parts of body 2y: understands verbs (what do you draw with), combine 2 words together (get drink) 2.5y: understands prepositions (put cat on the bowl), 3-4 words joined together 3y: understands negatives (which of these is not an animal) and adjectives (which is red), knows age, name, several colours 3.5y: understands comparisons (which circle is bigger than this one) 4y: understands complex instructions (before you put x in y, give this to mummy), uses complex narrative/sequences to describe events SOCIAL 6w: starts smiling, becomes increasingly socially responsive (no smiling at 10w abnormal) 6mo: puts objects into mouth (stops at 1y), shakes rattle, reaches for bottle/breast 9mo: feed self using fingers, separation anxiety when separated from parents/wary of strangers (9mo-2yo). Plays peekaboo 12mo: begins to wave goodbye, hand clapping, plays alone if familiar person nearby, drink from beaker w/ lid, helps in dressing, Plays pat-a-cake 18mo: imitates every day activities, takes off shoes,hat but can't replace, plays alone contentedly 2.5y: eats w/ spoon, parallel play 3y: interactive play (sharing toys w/ friends), taking turns, following simple rules. Plays alone w/o parents, eats w/ fork and spoon, bowel control 4y: concern/sympathy for others if hurt, has best friend, imaginative play, eats w/ little help, dresses and undresses (not laces and buttons) 4.5y: bladder control, observes rules of play 5y: handles knife Bladder and bowel training variable, some trained by 2y but can be older. 10% of 5yo enuresis

Gynae history

General, GI, uro, 4Ps (PV bleeding (menorrhagia, PMB, IMB, PCB), PV discharge, Pain (pelvic, dysmenorrhoea, dyspareunia), Pregnancy MOSCC Menstrual: LMP date, menarche, menopause, regularity/length of cycle, dduration of period, heaviness, flooding, pain Obstetric: number, ages, weights, delivery, abnormalities (ante, intra, post). Miscarriages (stage, complications, Rx), ToP (stage, method, problems after) Sexual: regular partner M/F how long, how many partners in past 3mo. Type of intercourse, infertility, STI screening Cervical smear: date of last, results Contraception DHx: HRT FHx: gynaeonc Pelvic pain: ovarian cysts Discharge: volume, colour, smell, consistency Dragging sensation: feeling of lump? location? Precip (end of day)?, interferes w/ intercourse. UUI/SUI/nocturia? Interrupting sleep? Been caught out? Type, volume and timing of fluid intake Menorrhagia: quantify (pads/tampons, number, freq/constant, passing clots, flooding), anaemia (SOB, diziness, fatigue), ca (abdo masses, bloated, oedema, varicosities), PMHx/FHx of bleeding disorders (easy bruising, bleeding gums, epistaxis PMB: number, freq, volume. Vaginal dryness during intercourse. General, anaemia. DHx - HRT use? How many years? FHx ovarian/breast ca Emergency contraception: detail UPSI, contraception/reason for failure, already taken during cycle? STI risk? Infertility: how long trying to conceive? regular UPSI? On any contraception now/before? Hx of oligomenorrhoea/amenorrhoea, hirsutism, DM, weight problems, acne. PMHx of fibroids, PCOS, PID, TVUS. Previous Rx for infertility. Partner - any children from previous relationship, investigated/treated for subfertility Menopause: Hot flushes, insomnia, poor conc, anxiety, lethargy, reduced libido, dyspareunia, hair/skin changes. What do you know about HRT? PMHx VTE migraine, breast symptoms, HTN, ca. Risks - breast/ovarian ca, VTE, stroke ToP: Consider alternatives (eg adoption), allow time for consideration. Partner support?

Suicide attempt

How are you feeling? If it's OK, I'd like to talk to you about everything that has happened in a bit more detail so I can try and understand a bit more about it BEFORE What made you feel like you had to take your life? Have you been feeling low a lot recently? Planning: did you plan for this? Did you get tablets beforehand? Seeking help: did you tell anyone about attempt? Did you try to get help? Precautions: did you take precautions against getting caught/discovered Final acts: did you make will/leave note DURING What did you do How, when, where? Meaning: did you think it would kill you? Were you under influence of drugs/alcohol? Discovery: How were you found AFTER Feeling: how do you feel now (angry, regretful) Still have thoughts of taking your life What's stopping you How do you see the future SHx relationship, children, working? Stressful? Insight: do you feel you need help? Would you accept if offered? Going home risk: if you were to go home today what would you do? Who would you be with? Would you try again? Mild risk: send home w/ family member/friend, arrange quick GP f/u, antidepressants Mod-severe risk: admit + monitor, get psych review

HIV f/u

How have you been? Any problems since last visit? Any symptoms? Sexual health Celibate, single, monogomous, open Disclosed to partner? Partner status? Condom use? STI screen indicated? Women: contraception, pregnancy plans, cervical smears Mental health How have you been in yourself since diagnosis? How is mood? Anxiety, depression, memory problems Risk assess - self harm, suicide Support network Treatment Have you started ART If not taking: can cause immunosuppression (AIDS), resulting in further co-morbidities (HBV/HCV), and spreading vertically and horizontally If already on: are you taking it? Properly? Struggling with pill burden? Side effects? Have you run out? Do you think treatment will work? Suffering from guilt, depression, addiction? Have you seen benefit (check <50/ml - undetectable) Other medication: P450 (phenytoin, rifampicin), PPIs (ART absorption requires stomach acid) SE: FBC, U+E, LFT, lipids, proteinuria, check for rash (first 4w), diarrhoea/GI upset, jaundice. If Efavirenz - vivid dreams, insomnia, severe psychosis, depression

Weight loss

How much? Over what time period? How did you find out? Did you intend to lose weight? How? Eating disorder: Do you still consider yourself overweight? how often do you weigh yourself? Appetite? Talk me through a normal day of eating for you Malignancy: night sweats, fever Malabsorption: change in bowel habits, blood in stool DM: polydipsia, polyuria Hyperthyroidism: irritation, energy levels, tremor Psych: mood ICE PMHx CHF, COPD, renal failure, malignancy (weight loss of chronic disease) FHx DM, thyroid, malignancy, TB SHx travel, sexual Ddx reduced intake (psych), malabsorption (IBD, coeliac), increased consumption (hypert, DM), chronic disease

FGM

Hx: in some countries it is common to have operations on genitalia. Have you ever had operations on your genitalia in this country or abroad? Type? How old? Anyone in family similar? Any sisters/daughters? How old? plans for them to be circumcised? Pressure from husband/family? Are you aware this is illegal in UK? Do you know consequences of this kind of operation? Abnormal: partial/total removal of genitalia for nonmedical reasons, illegal in UK Red flag symptoms: Difficulty walking, standing or sitting, long time in bathroom/toilet, prolonged school absence, behavioural change - depression, withdrawal Acute complications: shock, bleeding, pain, infection, urine retention, death Long term: reduced libido, painful sex, obstetric complications (higher risk of death in childbirth), chronic pain/infections, difficulty menstruating and passing urine, subfertility, PTSD Under 18 - illegal to perform, aid, abet or procure FGM on UK citizen, even if carried out elsewhere, 14y sentence. If immediate risk, <5yo to health visitor, >5 to school nurse

Needlestick

I understand you've just pricked yourself with a needle you've used on a pt Initial management: dispose of sharp safely, rinse wound in water, squeeze area to remove additional blood. Don't scrub, use antiseptic or put area in your mouth. Inform consultant, OH, A+E Risk HIV 0.3% HCV 1.8% HBV 5% or 30% if HBeAg +ve Injury: volume of blood loss, depth of needle into skin, type of implement PPE: wearing gloves (transmission reduced by 50%) Pt RF: IVDU, sexual hx, known HIV/end stage disease Vaccinated against HBV? Tested for HIV? Pt must consent to have bloods taken for HBV/HCV/HIV. If unconscious must wait for them to wake up. Ask if pt would like to know results as well. Bloods must be taken by someone else Recipient blood taken, serum saved. Tested only if pt has infection. If pt doesn't consent, or has infection, test, then retest at 2w, 1mo, 3mo, 6mo Prophylaxis: offer until results known. HBV booster, HIV PEP

Alcohol dependence

I'd like to talk to you about your health, in particular your drinking habits When did you start? Any triggers to start drinking more? HOW much per day/week WHAT type of drink WHEN do you drink WHERE do you drink WHO do you drink with HOW long have you been drinking like this ICE CAGE Ever felt like you should cut back? Ever tried? Ever joined organisation to help? Ever annoyed by people criticising your drinking Ever guilty about drinking Ever had eyeopener Dependence screen Withdrawal symptoms (Sometimes if people don't drink for awhile they feel shaky, sweaty and anxious - has this ever happened to you) Interest: would you say alcohol is the most important thing in your life? Do you neglect other hobbies/interests? Tolerance: do you find you have to drink more alcohol to get the same effect than you used to? Harms: are you aware of harms of alcohol Difficulty controlling: if you ahve one drink do you find it hard to not have more Reduction: have you tried cutting down in the past Effect on life LOST - memories LOVE - has it affected relationships LABOUR - has it caused problems in your job LAW - have you had problems with police LIVER - any medical problems due to alcohol (ulcers, pancreatitis, HTN, liver) Depression screen/risk assess low mood, chronic fatigue, anhedonia. Some people who feel like you do - self harm, suicide Have you ever seen things others can't see FHx alcoholism SHx how do you afford it Insight: do you feel you need help/would accept it if offered

HBV

Infection by HBV affecting liver. Exposed through needle sharing and sexual transmission Acute (jaundice, abdo pain, fatigue): 90% clear, no longer infectious and immune to further infection. 10% develop chronic hep B Chronic: virus still present 6mo after initial detection. Many remain well with inactive infection. May have recurrent active infections. 1/5 get cirrhosis (liver scarring) leading to low alcohol tolerance, sensitivity to bruising/bleeding and medications, may need liver Tx Pregnancy: can be passed on, likely to develop neonatal chronic hepatitis. Screened in antenatal care Treatment for infectious pts, pts with high levels of virus, or affected livers. Can't be cured but progression can be slowed PO tenofovir or IM interferon, avoid alcohol, retest in 6mo to see if virus cleared

Meningitis

Inflammation of the lining covering the brain and spinal cord Cause: bacteria (meningococcus, pneumococcus, Hib, E. coli, Listeria), viruses, fungi, TB Symptoms Early warning signs: leg pains, cold hands/feet, pale, dusky or blue colour of skin around lips Look out for rash: red/purple, look like little bruises, if don't fade immediately with glass test, call help immediately Other: excessive crying, fast breathing, fever, dislike of bright lights, not taking feeds, irritability, drowsiness, sleepiness, bulging fontanelle, jerky movements, floppy Long term: hearing loss, LD, epilepsy, kidney, joint and bone problems Prevention: immunisation Bacterial: hospital for Abx Viral: supportive, immune system usually clears Most recover well if Rx early, but can kill v quickly.

Explaining

Introduce What's happened up to now? What do you know already? Describe structure (I'm going to talk about A, then B, then C, does that sound helpful? Anything else you want to discuss?) ICE Consider diagram. CHUNK AND CHECK DISEASE: Normal phys -> abnormality -> cause -> problems/complications -> investigations -> Rx PROCEDURE: What? Why? before, during, after. Risks. Benefits. Consent Rx: Check for CIs, check understanding of condition. Explain ATHLETICS (Action, Timeline, How to take, Length of Rx, Effect (how long), Tests, Important SEs, Complications, Supplementary advice) summarise, make a plan, give a leaflet

End of life care

LPA for health: only valid once capacity for specific decision is lost, must act in pt best interests, may or may not include decisions regarding life-sustaining treatment AD: should be written down, signed, witnessed, and dated. Can only refuse treatment. Must be specific (not I don't want any abx, " for a chest infection even if life is at risk AS: expression of general attitudes and wishes regarding potential treatment, but must be taken into consideration when determining best interests Withholding Rx: stopped when treatment is futile, not in pt best interests, doesn't provide clinical benefit, pt refusal/prior refusal Withholding information: when pt doesn't want to know - consider pt behaviour and family opinion. To avoid serious harm (risk of self-harm/suicide) Assisted dying Euthanasia: death deliberately caused for pt's pwn good w/o assistance/active involvement of pt. Active (act to end pt life) illegal. Passive (withdrawing life prolonging Rx) illegal unless fulfils withholding Rx criteria Assisted suicide: final act carried out by pt, illegal in UK Request for assisted dying: why do they want this? Address fears. Will keep you comfortable when time comes Arrange support and follow up visit

Herpes

Lifelong infection by HSV (similar to cold sores - common, most asymptomatic, can transmit when asymptomatic, condoms reduce transmission 1st occurence worst (painful ulcers, dysuria, constipation, fever, headache), may never get future occurrence but most get shorter self limiting recurrent episodes of blisters and ulcers Pregnancy: first infection in preg can cause LBW, prem delivery, stillbirth, miscarriage, neonatal herpes (CS). Not if secondary (NVD) Acyclovir 200mg for 5d

Lithium

Mood stabiliser used in mania, bipolar, and treatment resistant depression How to take: Tablet, capsule or syrup OD/BD We'll do some tests before starting the drug: FBC, U+E, TFTs, pregnancy test, ECG After starting dose titrated up slowly, levels must be tested 12h after dose Monitoring: weekly blood tests for first 4w, then every 3mo. Li levels 0.5-1.0 therapeutic, >1.5 toxic - hyperactive tendon reflexes, convulsions, coarse tremor, ataxia, muscle weakness, dysarthria TFTs, U+Es, calcium at 6mo SE GI - abdo pain, nausea, metallic taste Fine tremor Nephrogenic DI: polydypsia, polyuria, weight gain Precipitates/worsens skin problems hypothyroidism, leucocytosis, teratogenicity T-wave flattening/inversion on ECG Discuss CI: pregnancy 1st trimester, breast feeding, renal insufficiency, cardiac disease, thyroid disease Interactions: renal insufficiency/hyponatraemia, diuretics, NSAIDs, ACEi can increase Li levels

Benign breast disease

Most lumps, esp in young women, not caused by ca. Can involve connective tissue of chest wall, fatty tissue or lobules Fibrocystic: normal swelling + tenderness related to cycle, starting week before period, relieved when period starts Fibroadenoma: non-cancerous, women <40yo, due to excessive growth of glands + connective tissue, round firm rubbery lumps highly mobile, painless, disappear spontaneously and after menopause Breast cysts: fluid filled lumps, more common when approaching menopause, appear 2w before period, disappear soon after. Can aspirate fluid Fat necrosis: following trauma, heal and go away spontaneously To be absolutely certain, can refer to one stop clinic (full H+E, imaging, biopsy), this will give us definitive diagnosis

NVD vs CS

NVD What Why Benefit: shorter hosp stay/recovery time (24-48h). Can hold/breastfeed sooner after delivery, less likely to have resp problems, bacterial exposure in birth canal can boost immune system, protect GIT Risks: Vaginal injury (stretch, tear - may need stiches, lead to pelvic floor damage - SUI), lingering perineal pain CS What Why: elective (malpresentation, placenta praevia, twins with T1 noncephalic, >1 previous CS), emergency (obstructed labour, malpresentation/position, pathological CTG/FBS, APH, severe pre-eclampsia Benefit: more convenient and predictable, less painful 2nd stage, cleaner and more clinical, less urogenital problems Risk: longer hosp stay 48-96h, pain/scar at incision, blood loss, infection, VTE, bladder, bowel injury, more likely to have future CS, problems with placental placement

Psoriasis

Normal skin made of layers. Top cells gradually fall off, new cells constantly being made to replace top layer Faster turnover of skin cells, more cells made, build up on top layer, forming flaky plaques on skin surface. Also inflammatory infiltrate. Cause unknown, but FHx RF and stress, infections, trauma, drugs, alcool, smoking can trigger 1/50, patches/plaques of red scaly skin Unfortunately once it's developed tends to come and go throughout life Avoid triggers: smoking, skin injuries, alcohol. Check with GP that not on Li, NSAIDs, bblockers, antimalarials Moisturising cream softens hard skin and plaques, and reduces scaling/itch Refer to support group (60% depression) Dovobet (betamethasone + calcipotriol) UV therapy if very bad Drugs that modify the immune system (etanercept/infliximab, methotrexate)

Endometriosis

Normal: endometrium is lining of womb, that sheds every mo Abnormal: found outside uterus - pelvic area, tummy, rarely other places. Can be sticky and cause organs to stick or move into weird positions Cause: unknown, several theories Symptoms: 10-15% have to some degree. painful periods, sex and general pelvic pain. Generally worse days before and during period. Can cause subfertility Investigations: laparoscopy for diagnosis Rx: analgaesia, NSAIDs, GnRHa, COCP, IUS. Surgery to remove larger patches (improves fertility) or hysterectomy if no more kids wanted

PCOS

Normal: ovaries are pair of glands sitting either side of womb, make eggs and hormones. Every month several start to grow, one selected to be released Abnormal: 1/10. 3 things - balance of hormones altered, so testosterone increased. >12 cysts on ovary. So many follicles develop each mo that none develop fully, no ovulation occurs (<6/y) Cause: unclear. May have genetic component, may be to do with insulin resistance Symptoms: subfertility, menstrual disturbance, hirsutism, acne, obesity, acanthosis nigricans Investigations: hormone panel, TVUS Rx: no cure. Weight loss, metformin (increases insulin sensitivity), COCP (regulate cycle). Shaving, waxing, eflornithine. Rx acne. Fertility - specialist, comifene, 5mg folate

Urethral discharge

ODCSPRAP quantity, colour, odour dysuria/polyuria Problems passing stool Itch, lumps, ulcers, bleeding, pain Does discharge change throughout menstrual cycle TESTICULAR PAIN: • dysuria • urinary frequency • urethral discharge • swelling • erythema • V/N • fever Sexual history Gynae history Obstetric Hx General Hx PMHx STIs (when, how treated), HIV test (when, result)

COCP

PMHx Migraines w/ aura, VTE, breast/cervical ca, liver disease, stroke/IHD, HTN, DM. DHx P450 modulators. FHx VTE, breast/cervical cancer, migrane w/ aura. SHx SMOKING, BMI. ICE (any contraception in mind? What do you know about options/LARCs) COCP: 99% effective Benefits: lighter, less painful, regular periods, less PMS, reduced CRC/ovarian/endometrial risk SE: nausea, headaches, sore breasts, tiredness, change in libido, breakthrough bleeding, skin/mood changes, rise in BP CI: above Reduces ovarian/endometrial but increases breast/cervical ca Warns pill increases VTE risk - safety net for severe migraines, swollen legs, severe chest pains ONLY protects against pregnancy, not STIs, which require barrier Additional pill if D+V or P450 inducers (eg Abx) Tell doctor before starting new pill or before surgery (6w before) How to take, when it starts working (restart even if still bleeding), pill rules FRASER: age of partner, how they met, how long it's been going on for, have you felt pressured into doing something you didn't want to? Full gynae history w/ full sexual Hx Do you understand everything I've told you? Are you willing to discuss with parents? Would it be okay if I discussed with them? What would you do if I wouldn't prescribe the pill? How would you feel? Well I think having the pill is in your best interests and I'm confident that you've understood everything I've told you.. IF <13 INFORM CHILD PROTECTION SERVICES

BPH

Prostate found in all men, lies beneath bladder, normally size of chestnut with urethra running through it. Produces fluid of sperm (semen) BPH: enlarges with age Symptoms: poor stream, hesitancy, dribbling, poor emptying. May irritate bladder causing freq, urgency Complications: DOES NOT increase risk of prostate ca. Can get BOO requiring catheter. Chronic urinary retention can increase UTI risk Lifestyle: reduce fluid intake to 1.5L/d, double voiding, reduce coffee/alcohol intake, stop smoking (irritates bladder) Medication: alpha blockers (relax prostate/bladder neck, improve urine flow), 5ARi (block testosterone effect on prostate, shrinking it) Surgery: TURP - if symptoms get really bad, small camera inserted into bladder and we cut out small chips of prostate (SE - impotence, incontinence)

PSA counselling

Prostate is a gland that sits below bladder, around tube through which urine is passed. Secretes the fluid that comes out as sperm if you ejaculate (semen). Sometimes cells proliferate out of control, secrete PSA Indications: any man>50yo who asks, men with unexplained symptoms or LUTS that could be caused by prostate ca Benefits: early detection before symptoms, treatment started before ca mets Limitations: false reassurance (15% with prostate ca have -ve PSA), unnecessary anxiety (65% with +ve PSA don't have prostate ca), unnecessary investigation (biopsy, imaging), unnecessary Rx (of slow low grade ca that would never have caused any problem) causing urinary incontinence and sexual dysfunction Before: avoid sex, masturbation or vigorous exercise 48h before test. Statins, NSAIDs, finasteride, supplements, UTI, previous prostate surgery (within 6w), prostatitis can all affect PSA level Results: threshold for referral 40-49 >2.5ng/ml 50-59 >3.5 60-69 >4.5 70+ >6.5 Higher level = higher risk. If hi repeat in 4-6w, consider benign causes. If lo, perform DRE, if +ve refer

MHA

Pt suffering from mental disorder of nature and degree to merit hospital Rx AND such treatment can't be provided without detention AND there must be a significant risk to the patient or safety of others Section 2: 28d assessment order, can be upgraded to section 3 once in hospital Section 3: 6mo treatment order - pt with established psychiatric diagnosis, AMHP and 2 docs have seen pt within 24h Section 4: emergency treatment order, 72h, when S2 too slow, can be changed to S2 on hospital arrival Section 5(2): 72h doctor's holding power - hospital pt trying to leave and must have suspected psychiatric disorder Section 5(4): 6h nurse's holding power Section 135: Warrant to enter property and take person to place of safety (police station, A+E, etc) - magistrate approval Section 136: Police powe to take person from public place to place of safety if suspected mental disorder conferring immediate risk. Once in place of safety, assessed by duty psychiatrist for section 2/3 Assessment requires One section 12 approved doctor, another doctor and an approved mental health practitioner (AMHP) - medical recommendation form given to AMHP to apply for section

UTI counselling

Purpose of consult Recap history - dysuria, freq, urgency, abdo pain, haematuria fever Urine test result suggests you have a urinary tract infection (UTI), common in women, caused by bacteria anywhere in urinary tract RF: DM, pregnancy, problems with waterworks as child (renal scarring) Very common 20-40%, due to spread of bacteria from anus or vagina. Urinary stasis - not been going toilet very often, urine collects in bladder, allowing infection to occur Sex Trimethoprim 200mg BD (SE N+V). Occasionally potassium citrate used Prophylaxis Urinate more frequently, increase fluid intake, double voiding (once gone, stand up, then after 5-10min sit back down and go again), urinate after sex, wipe front to back Leaflet

Derm history

RASH Site, inital lesion, spread, progression Associated: pain, pruritus, blistering, bleeding, discharge. Mucositis, conjunctivitis, scalp involvement Exacerbated by sunlight, soap Severity: previous hospital admissions, treatments, missing work/school, social/personal life, psych impact General PMHx atopy, psoriasis, childhood skin problem, systemic diseases. For lesions - BCC, SCC, melanoma, KA DHx drug eruptions, cosmetic and moisturising cream FHx atopy, psoriasis, anyone else in family affected Shx: sun exposure (occupation, regular burns, hobbies, travel, growing up abroad, sun beds)

Ear Hx

Severity: u/l or b/l, impact on life Associated: tinnitus, vertigo, pain, discharge, weight loss, headache, speech Triggers: noise exposure, trauma, infection, Abx FHx/PMHx of ear problems/surgery

HIV pretest counselling

REEBWAAO CONFIDENTIALITY PMHx: shingles, pneumonia, eye infections, Kaposi's, Meningitis, diarrhoea Reason for testing: routine (GUM), risky behaviour, red flag diagnosis, request (why now? Who's idea?). REFLECT BACK! Ever been tested before? (when was last -ve test). If not explain, that it is just a fingerprick test that takes a few minutes Exposure: do you know how HIV is trasmitted? any seroconversion illness? RF - IVDU? sex with person from HIV endemic region? Sex with man? Sex with MSM? Paid/paid for sex? Blood transfusions/invasive procedures outside of UK Benefits: HIV explanation - NOT AIDS. HIV incurable but manageable condition w/ current treatment. With medication, can expect normal life expectancy. Also prevention of onward transmission - can inform others to get tested. Earlier we catch, easier to treat Window period: takes up to 3mo to show in blood, so if test -ve didn't have HIV 3mo ago. To be sure retake in 3mo time. How long for results, how will they be given Assessment of response to results: what do you think result will be? How would you feel if +ve? Lots of support services we can put you in touch with if +ve. Reassure again about treatability Agreement: Do I have consent to carry out this test? If no, why not? (insurance - must disclose if +ve but insurance company can't ask if you've had test, confidentiality - you don't have to give your name) Opportunistic screening: We offer all pts at clinic a full STI screen, would you be happy for us to test your blood, swab, urine for other infections? Advise on safe sex practices

Cervical smear results

Reason for smear? Routine? symptomatic? Previous smear results? Gynae Hx NORMAL: no abnormal cells, back to routine screening INADEQUATE: couldn't be fully interpreted. Not enough cells or infection masking. Repeat in 3mo ABNORMAL Low grade/borderline: abnormal cell changes, very close to normal, may disappear w/o Rx. HPV -ve v. low risk, back to routine High/moderate grade Result does not mean ca. Has abnormal cells (CIN - needs biopsy) that, if left unRx and unmonitored, may develop into ca in future - so must be Rx and removed, colposcopy best Colposcopy: special microscope to examine cervix, similar to cervical screening but can identify extent of abnormal cells and whether Rx needed. Biopsy or LLETZ Rx to prevent cervical ca (bleeding, infection) Befores: day case in clinic by doctor or nurse specialist. Sedation and GA not required. Ensure not on period, do not have sex, wear tampons or ue pessaries or cream for at least 24h pre-procedure During: speculum, then special microscope (doesn't enter vagina, like pair of binoculars focused on vagina). Long swab applies 2 different liquids to identify abnormal cells, may take biospy under LA. Rx (diathermy, laser, LLETZ) may be done, generally after discussion of biopsy results. Takes 15-20min After: return to work same day, may have small amount of bleeding/dark discharge for 3-5d, so bring sanitary pad and avoid tampons, pessaries or sex until bleeding stops. Thought to be association between cervical Rx and pre-term labour, so inform obstetritian early (may need scan)

General psych Hx

Schizo: 1st rank symptoms + delusions - erotomania, persecutory, grandiose, jealous, somatic, delusion of reference Hallucinations: how many voices, saying what, 3rd person? Who? (talking about her?) Have they ever told you to harm yourself or others? Children depression: standard Hx + irritability + eating disturbance + risk assess + effect on day to day activities + parental conflict/divorce/bereavement Mild: depressed/irritable + anhedonia/tiredness + 2 others Moderate: depressed/irritable + 5/6 others Severe: 7 symptoms +/- delusions, hallucinations, stupor (40% children of depressed parents have psych disorder, due to poor family function (less to do with genetics). Official assessment, then mild 2-3mo group CBT/self-guided help, mod-severe CBT/IPT/FT 3mo, fluoxetine if unresponsive Bipolar Duration of episode Manic: grandiosity, increased pleasurable activity without thought of consequences, increased talkativeness, decreased need for sleep, flight of ideas, increased goal-driven activity Psychotic: hallucinations, special powers/delusions PTSD: When (onset within 6mo) Re-experiencing events ("do thoughts of event X distress you"): Images, thoughts, flashbacks. Acting or feeling as if event was reoccurring, distressing dreams of event ("do you find yourself reliving the event"), physiological distress (heart pumping, sweating) Persistent avoidance: avoid thoughts/conversations/places/activities associated with trauma - "Do you avoid thinking/talking about the event", feeling of detachment from others, blunting of emotions, effect on mood Increased arousal: sleep problems, irritability, easily startled, hypervigelant (do you feel constantly on edge) Anyone at home you can talk to about this? How are you coping? Who is at home? (mild symptoms <4w - watchful waiting, mod-severe: CBT +/- eye movement desensitisation and reprocessing (recall distressing images while moving eyes side to side, develop more adaptive coping mechanism for distressing memories)) Eating disorders SCOFF: have you ever felt so uncomfortably ill that you've had to make yourself Sick? do you worry that you have lost Control Over how much you eat? do you believe yourself to be Fat when others say you are too thin? would you say that Food dominates your life Weight: current weight and height, amount of weight loss, time period, intentional. Do you consider yourself to still be overweight. How often do you weigh yourself Diet/compensatory behaviours: amount and type of food eaten in an average day, do you ever diet/fast? Binge eat - what, how much, how often, how do you feel? Do you ever cause yourself to vomit? How often, how induced? Drugs: laxatives, diuretics, emetics, appetite suppressants, stimulants Physical exercise Impact on life: school/work/relationships, psych complications (substance abuse (medications, alcohol, smoking, rec drugs)), depression, self harm/suicide, menstrual periods OCD Obsessions (contamination, dirty, bodily fears): form, content, recurrent, intrusive, anxiety provoking Compulsions (checking, counting, symmetry): type, freq, duration, relieve anxiety? Associated: aggression, hoarding Impact: school/work/relationships, psych (substance misuse, depression, selfharm, suicide) Anxiety Physical: dry mouth, sweating, tachycardia, palpitations, GI upset, hyperventilation (SOB, dizziness, tingling), tension (sleep, muscle tension, tremor), hyperthyroid screen (weight loss, feel warm) Thoughts: describe mood. Is there anything in particular you worry about most? Do you feel like something bad is going to happen? Concentration, irritability, risk assess Triggers: did anything happen that you feel caused this? Is it made worse if you think about anything in particular (phobia)? Is it made worse by leaving the house or being in a situation from which escape will be difficult or embarrassing (agoraphobia)? Do you get anxious in social situations, like speaking in front of people or making conversation (social phobia)? Do you ever have panic attacks that make it feel like you can't breathe? PMHx of panic disorder: first episode, freq, duration, state between attacks, location, more or less freq now (CBT/graded exposure, SSRIs, benzos) 1st rank symptoms: 3rd person auditory, running commentary, delusions of thought (insertion, broadcasting, withdrawal), delusion of control (external force controlling their actions), delusional perception Depression screen (core, CPP SLAM) Risk assess (harm to self, suicide, homocide) Memory loss, insight PMHx previous psych dx, first and last episodes, how many episodes, how many admissions, mental health worker, other (any contact with mental health services or counselling in past) FHx: psych conditions SHx: illicit drugs, forensic involvement, personal upbringing, support network PREMORBID PERSONALITY

PEP consent

Sexual encounter: When, type of sex, partner status, casual/regular, MSM, sub-saharan Africa, contraception used. 100% effective <24h, <50% if >72h PEP is a course of anti-HIV medication to reduce chance of becoming HIV +ve - prevents HIV from making capies of itself and spreading throughout body Indicated if risk of transmission >1 in 1000 Receptive anal with HIV+ve/african migrant/MSM Insertive anal, vaginal or sharing injection equipment with HIV+ve 2 medications every day for 28d Truvada OD Kaletra BD SE: headaches, N+V+D, myalgia HIV test required first (if already +ve, may develop drug resistance) f/u 1w, 1mo, 4mo Whilst on PEP must use condoms, can't donate blood Meant for uncommon situations, repeated uses may lead to resistance - PrEP (daily Truvada) for months or years Safe sex and support counselling

Breast Hx

Site, Size, Shape, Colour, Consistency, Tenderness, Temp, Pain, related to menstrual cycle? Nipple discharge (how often, amount, colour u/l or b/l, how many ducts, how hard squeezing), skin changes (nipple retraction, skin tethering, redness), general (weight loss, lethargy, fever), back pain/pain elsewhwere, LN swelling Menstrual Hx OHx - brestfed? PMHx - breast surgery/trauma/investigations, gynae, malignancy DHx COCP, HRT, antipsychotics. FHx ca, what age, which relative

Acne

Skin has lots of gland at bottom which produce oil that keeps skin soft and smooth As teenager, extra hormones cause glands to produce more sebum (oil). Sometimes pores get blocked and sebum builds up underneath, causing spots. Trapped oil can then get infected by bacteria. Body responds to this with inflammation, making the skin go red and the spots become large and fill with pus. Each spot then heals individually Most common cause of spots (90% teenagers), affecting most 12-25yo (F >25yo sometimes) Avoid: thick makeup, picking/squeezing spots, wearing tight clothes, using anabolic steroids. Don't wash more than BD with soap and warm water Medication to reduce sebum production - can dry out skin: benzyl peroxide cream - reduces production, unblocks pore, slight antibiotic. Takes >4w for improvement to be seen, need to be patient. Stay on for a few years to prevent flare-ups

NRDS

Surfactant prevents air sacs from closing. RDS due to surfactant deficiency, so air sacs collapse leading to increased work of breathing Prematurity is cause, altho second twin, male IDM, APH are RFs Complications: IVH from increased work of breathing leading to hydrocephalus and VP shunt Rx: O2 nasal, ETT + surfactant bolus (risk of air leaks)

Recurrent tonsillitis

Symptoms: otalgia, sore throat, temp, swollen nodes, dysphagia, cough Impact on life (time off work) Length and no of episodes PMHx quinsy Rest of Hx Tonsillectomy indications: recurrent sore throats are due to acute tonsillitis, episodes of sore throat are disabling and prevent normal functioning AND >=7 documented sore throats in preceding 2y, >=5/y for 2y or >=3/y for 3y OR airway obstruction (OSA) Risks: pain, bleeding, infection, anaesthesia reactions Will be referred to ENT specialist. Will need to go to hospital for procedure. Will be on painkillers to manage post-op pain

Abdo

WIP (both child and parent) ERQQ GI Hydration assessment (wet nappies, mucous membranes, skin turgor, CRT, HR) hand inspection: clubbing, palmar erythema, cannulation scars hand palpate: temp, radial pulse Face: conjunctival pallor, jaundice, central cyanosis Neck: carotid, supraclavicular LNs Chest: scars, spider naevi Abdo: Inspect (distention, grey turners, cullens, scars). I'm just going to feel your tummy, I need you to let me know if it hurts okay? (constipation in umbilical + LIF, liver up to 2cm) "I'm just going to play on your tummy like a drum" "I'm just going to listen to your lunch - let me try to guess what you had!" Inspect back, CVA tenderness External genitalia, perineal exam, urine dip, stool sample. Obs, growth chart, ENT exam

ED counselling

Very common 1/10 men Cause: <40 otherwise healthy - stress related. >55 pretty normal, likely to have less firm erections, smaller amount of semen, less intense ejaculations, longer recovery time. diabetes, HTN, high cholesterol Lifestyle: stop smoking, reduce alcohol intake, address issue causing stress, lose weight, talk to partner (less pressure to perform) Medication: PDE-5i (viagra/cialis - never with nitrate), mental + physical stimulation needed. SE postural hypotension, priapism (persistent painful erection) Vacuum pump: plastic cylinder connected to pump, draws blood in then ring placed around base to maintain Hormone: older men refractory to PDE5i most likely low testosterone Injection: Alprostadil (pge1) relaxes muscles and bc feeding into penis - taught how to inject directly into shaft of penis Medicated urethral system for erections (MUSE): small pellet of alprostadil inserted into urethra using disposable applicator Penile prosthesis: last resort, splint inserted surgically into penis, pump implanted which hydraulically inflates prosthesis, allowing sex NHS criteria: DM, MS, Parkinson's, prostate ca, SCI, dialysis for ESRD, Hx radical pelvic surgery, prostatectomy or kidney Tx

Alzheimer's

Very common, most common type of dementia. Gradual deterioration of memory and other cognitive functions - memory, orientation, concentration, attention, word finding, speech, language, problem solving. Causes difficulties in daily life - leaving doors open, gas on, wandering Not a part of normal aging, due to abnormal protein deposits in the brain. RF - older, FHx, low educational attainment Starts mild: memory loss, confusion, mood swings, speech problems then moderate: hallucinations, delusions, disturbed sleep, incontinence Severe: difficulty swallowing, moving, loss of appetite, more infections ASSESS RISK leave door open? Leave gas on (lit or unlit, freq)? Wandering? Leaving other appliances on (sink/bath taps)? Not necessarily necessary to move to care home in early stages, support can be provided - home carers, day centres. Once disease reaches severe stage, carers unable to cope, will get a care manager who can give you all the advice you need Some risks can be managed - gas detectors, buzzer that sounds when door left open Important to consider pt wishes, and to assess capacity No cure, but medicines can delay symptom progression Cholinesterase inhibitors (donepezil, rivastigmine - bradyarrhythmias), NMDA antagonist (memantine, if severe) Cognitive stimulation therapy + crosswords and puzzles Avoiding isolation through social activities Healthy diet, exercise, avoiding excessive alcohol Alzheimer's society, dementia relief trust

Pelvic examination

WIP ("internal exam from down below, inserting specilim/2fingers into vagina. If uncomfortable or want to stop at any point, say. Do you need to go to the toilet?) Get chaperone LMP, bleeding, discharge, contraception, last smear, any chance you could be pregnant ER: you will need to undress from waist down, put your heels together touching your bottom, then flop your knees down and cover yourself w/ sheet QQ Bedside inspection Pt inspection (look acutely ill?) External genitalia, secondary sexual characteristics, hair distribution BIMANUAL: abdo exam. Inspect for distention, scars. Feel for masses, tenderness, feel groin for inguinal lymphadenopathy External exam: gloves, part labia w/ thumb and forefinger of left hand. Inspect for tumours, warts/ulcerations, cysts, erythema, atrophy, labial fusion, discarge/bleeding. Identify clittoris, urethral meatus, vaginal introitus. Cough/bear down - look for prolapse, stress incontinence. Palpate labia majora BIMANUAL Brief re-explanation, lubricate fingers. Index, then middle, sideways, then rotate (watch face for pain). Move along post vaginal wall Cervix: excitation, position, mobility, consistency, dilatation Uterus: push down abdominally while pushing up on posterior fornix of cervix. Size, position (verison), tenderness, mobility, shape Adnexa: L/RIF and laternal fornix. Tenderness (salpingitis) or masses Remove fingers, check for blood or discharge. Provide swab/tissue, thank, recover, tell to redress. To complete, speculum + smear + HVS or TVUS CERVICAL Assemble correct equipment (gloves, lubricant, speculum - correct size, smear pot, brush, tissues) Warm, check clean and not broken, assemble. Lube up. Hold speculum in dominant hand, separate labia in non-dominant. Insert on side with blades closed, then rotate, maintain downwards pressure, open, lock. Adjust light Inspect: ectropion, gowths/polyps, ulcerations, blood/discharge, cervicitis Insert brush, rotate 5 times clockwise, remove brush, insert into vial, shake, reseal [for slide - transfer into slide w/ painting action, fixate w/ fixative] Remove speculum a bit, release lock, then remove. Give pt tissues, tell to redress. Complete form, label sample Results in 2-3w If nothing by 4w contact If get letter asking to come back, not necessarily abnormal If everything normal, get letter asking to come back routinely

HC, height, weight

WIPER "measure baby's head to assess growth" Inspect for any obvious craniofacial abnormality Cotton tape measure between hairline/glabella to occipital prominence posteriorly, measure 3 times, take largest Plot on age and sex appropriate chart with dot not cross Ask for previous measurements Check height and weight, plot Check HC of parents Enquire about neurodevelopment of child, neuro exam Assess head shape, fontanelles, sutures, hi ICP (irritability, lethargy, seizures, vomiting, behaviour change Gestational + birth hx (prem, mode of delivery, congenital infections) Macrocephaly: normal variant, hydrocephalus, brain tumour, hypothyroidism, rickets Microcephaly: normal variant, congenital infection craniosynostosis, PKU

Methadone/Buprinorphine

WIPER Explain reason for consult Assess prior knowledge Similar to heroin, but lasts longer in body and helps to prevent withdrawal symptoms (sweats, cramps, vomiting, diarrhoea, tremor) DHx: How much, how often, method, when, where, with whom, how is it funded. BBV? Previous screening? PMHx: epilepsy and TB medications interfere with methadone Why do you want to do it: why now? Will you continue to use heroin? Examination and urine test: methadone can't be taken while drugs are still in system Blood tests: HIV, Hep, LFTs Immunisations: Hep A/B, tetanus Referral to drug clinic Can get appointement in the next day or 2 - doctors will evaluate how much you need, but will start on low dose. Both medications OD Methadone (green liquid) Buprinorphine (tablet under tongue) Have to go in every day to take medication in front of nurse at clinic Do this for 3mo w/o problems and we may start giving prescriptions for a few days worth to be picked up from local pharmacy Takes 2-4h to reach peak effect. Accumulates in body so effect will increase after a few days w/o increasing dose Can take a few weeks to find the perfect dose,. Can stay on it long term, or slowly reduce it until you can come off it entirely You have a duty to tell the DVLA Referral to counselling or local drug community team improves likelihood of staying off heroin long term Confirm understanding, invite questions, leaflet, etc

Newborn exam

WIPER Congratulate! Labour: how long since, type, problems, medications Mum: temp, health in pregnancy, Any Hx of heart, lung, hip problems? Baby Have they passed urine? Opened bowels? Started feeding? Breathing okay? Any Hx of heart, lung, hip problems? Birth weight, gestational age, birth weight centile Expose baby down to nappy GI: plethoric, pale, jaundiced. Cry (pitch, strength), dysmorphic (micrognathia, low set ears), posture tone movements Measure + plot HC, length and weight Look for cephaloheamatoma, caput succedaneum and subconjunctival bleeds palpate fontanelles + sutures Face: dysmorphic features (check ears for low set, skin tags, deformity), red reflex, central cyanosis, look in mouth, finger in mouth to check suck reflex and cleft palate UL: inspect neck and clavicle, palpate, inspect upper limb (symmetry, palmar crease, no of digits), grasp reflex Chest: RR, abnormal sounds, resp distress. Inspect chest. Auscultate heart (110-160) and lung fields, central CRT Adbo: Inspect (distension, scaphoid, umbilical stump bleeding/discharge). palpate liver, spleen, kidneys, check umbilical and inguinal area for hernias, palpate femoral pulses Perineum: remove nappy, inspect for urethral and anal patency, labial fusion, foreskin, hypo/epispadias, testicular descent LL: symmetry, deformities, femoral creases, number of digits, calcaneovalgus/talipes move knee and ankle joint for RoM Moro reflex Turn over: check muscle tone, inspect + palpate (spina bifida, natal cleft) back for midline defects (dimples, hairy tufts, lipomas, mongolian blue spots) Hips: save for last, may upset baby. Barlow's and Ortolani To complete, OAE, social Hx, record in red book

DRE

WIPER QQ CHAPERONE 1 gloved well lubricated finger into rectum. Pts tend to find it uncomfortable but shouldn't be painful, can stop at any time. Important part of investigations Intimate but necessary for: assessment of prostate, rectal bleeding, constipation, change of bowel habit, urinary/faecal continence "I need you to undress from the waist down, lie on your left side, bring your knees up to your chest and cover up with sheet until ready" Chaperone + consent Gather equipment: gloves, lubricant, gauze/tissues GI: weight loss, indicators of mets (#s, back/bone pain, SOB), bed sores Close inspection Part buttocks: blood, rashes, fistulae, fissures, haemorrhoids, warts Ask to bear down: look for prolapse Squeeze bottom: anal sphincter competency Examination Lubricate gloved finger, advance to anus, wait for sphincter to relax, then advance inside: presence and consistency of faeces Pt bear down: presence of any high rectal lesions that are brought lower Pt squeeze: assess anal tone 360 sweep: masses, wall thickening Prostate: massess, symmetry, consistency (rubbery and firm, with smooth surface and palpable sulcus), size (3.5cm wide, 1cm into rectal lumen) Remove finger and wipe on gauze: faeces, mucus, blood Clean anus Thank pt, cover up, document findings + chaperone details Full Hx, PSA, rectal USS Prostate ca: enlarged assymetrical hard irregular nodular, no midline groove BPH: enlarged, slightly distorted, but rubbery + firm, smooth, with palpable midline groove

MSE

WIPERQQ Appearance/behaviour Apparent age, racial origin, body habitus Style of dress, level of cleanliness Abnormal involuntary movements (tics, grimaces, dyskinesias, tremor) Appropriateness of behaviour (anxiety, aggression, suspicion, paranoia) Eye contacr Speech Volume Rate (pressured, slow) Tone (monotonous) Quantity and fluency Emotion: mood/affect Affect = momentary (broad = emotionally labile, blunted = flat), mood is a prolonged emotion How are they - objective and subjective Perceptions Hallucinations - auditory, visual, tactile, sensation "Have you ever seen or heard something you can't explain?" "Can you ever hear other people commenting on what you do?" Thought Form - linear, disordered (knights move (derailment),, flight of ideas, word salad, circumstantiality (returns to point), tangential, echolalia, perseverence) Content - delusions, overvalued ideas, preoccupations, obsession "Have you been having any strange thoughts" "Can anyone interfere with or hear your thoughts" "Do you ever get thoughts which keep going round and round your head" Insight Do you think your experiences are the result of an illness? Do you understand why you nedd medical help? Will you accept medical advice and treatment? Cognition Attention and concentration O x3 Level of comprehension Short term memory Risk assess Self harm, suicide, harm to others Summarise

Parkinson's exam

WIPERQQ What happened when first presented w/ this condition? How is it affecting you? When is your tremor worst? Problems with balance/coordination, turning in bed, getting in and out of car? GI: walking aids Tremor Resting: hands on lap, close eyes, count down from 20 (asymmetrical pill rolling 4-6hz accentuated by clenching c/l hand, reduced w/ finger nose test) Postural: hold arms out Intention: finger nose test Gait (walk with them): shuffling (reduced stride length), hesitant (slow initiating and turning), festinating (faster and faster so not to fall over), lack of arm swing (increased tone), unsteadiness (tendency to fall forwards or back) FACE Inspect: hypomimia (mask-like, expressionless, reduced blinking), drooling Glabella tap: blinking fails to ceaase with continued tapping Speech (what have you done today?): hypophonia (soft, faint, hard to understand), slow thinking UL Tone: lead pipe, cogwheel (tremor superimposed onto hypertonia) Bradykinesia: slow to open and close index to thumb, gets smaller LL Bradykinesia: foot stamping FUNCTION Writing: micrographia, button undoing PARKINSON'S PLUS Up and down (PSP) Side to side (nystagmus in MSA) TO COMPLETE Cerebellar exam (MSA) Postural BP (MSA) MMSE (Lewy body) Drug char (Parkinsonism) Full Hx

Derm examination

WIPERQQ GI Site Distribution: generalised/localised, symmetrical, flexor/extensor aspects Morphology: colour, size, borders, elevation, spatial relationship Secondary lesions: scaling, lichenification, crusting, excoriations, erosions, ulceration, scarring Palpate: consistency, blanching Nails, hands, anterior arms, posterior arms, axilla (hands behind head), scalp, face, inside mouth, chest, abdo, back, perineum, legs, feet, toe nailshair, scalp, mucous membranes Lymphadenopathy Pedal pulses To complete, suspicious moles with dermatoscope, other relevant system examination

CVS paeds

WIPERQQ general inspection ("I'm just going to look around the bed to see if you've brought anything with you") ("he looks tall enough for his age but I would like to plot weight and height on a growth chart"): dysmorphism, colour, alertness/interest in surroundings hands inspect: clubbing (point up, then down, then together) Face: conjunctival pallor ("pull a funny face"), mouth and tongue (central cyanosis "can you stick your tongue out") Neck (only if >8yo): JVP, carotid "can you put your hands on your hips like you're really cross" - inspect chest and axillae for scars Palpate Apex beat (4th ICS <4yo, 5th at 7yo), heaves, thrills, cap refill Auscultate: use radial pulse, repeat sitting forward, carotid bruit Sit up, palpate for sacral oedema, listen for pulm oedema To complete - hepatomegaly, femoral pulses, peripheral oedema, BP, ECG, urine, fundoscopy

Neck examination

WIPERQQ (expose neck, position in chair with room behind, get glass of water) GI: patient well, cachexia, fever, lethargy, over/underdressed for weather, sweaty Closer inspection (front and side): masses/lymphadenopathy, surgical scars, goitre. Stick tongue out and swallow Palpation: check no pain, examine from behind LN - submental, submandibular, jugulodigastric, ant cervical chain, post cervical chain, occipital, preauricular, postauricular Thyroid - size, consistency, abnormal massess, 2 lobes and isthmus. Get pt to swallow, stick tongue out Then examine from front: supraclavicular LNs, carotid artery, tracheal deviation Percussion: retrosternal goitre Auscultation: thyroid bruit, carotid bruit ANY LUMP 3S: Site, Size, Shape 3C: Consistency, Contours, Colour 4Ts: Tenderness, Temp, Transillumination, Tethered/mobile ANY LN 3S, consistency, tethering To complete Examine areas drained by palpable LNs US/biopsy any suspicious LNs Assess thyroid function + TFTs, FBC

Active Rx of 3rd stage

WIPERQQ (semirecumbant). Recommended for all, some w/ low risk for PPH can choose not to. Continuous monitoring of pt + blood loss required throughout Ensure empty bladder (can prevent contractions) IM syntocinon ASAP after delivery (wait until cord stopped pulsating and been clamped) Clamp cord in 2 places then cut, placing maternal end in recieving dish Palpate for contraction and signs of placental seperation CCT (steady downwards+backwards traction) + guarding (pushing upwards) contracted uterus. Stop for 1min if resistance felt Once placenta visible at vulva, traction applied upwards, guarding stopped, placenta recieved, document time of birthing (should be <30min) Assess condition of uterus, lood loss, HR, BP, genital tract trauma Inspect cord: 2a 1v Placenta: cup in 2 hands. Assess no of cotyledons, calcifications (smoking, postdate, HTN), offensive discharge, active bleeding/sections missing. Amnion and chorion, any missing. bv entering and leaving, succenturiate lobe. Weight (1/6 fetal weight)

Breast exam

WIPERQQ (sitting, expose top half) Chaperone Arms relaxed to side, shoulders level Scars, asymmetry, swellings/lumps, skin (erythema, dimpling, peau d'orange), nipple (Paget's, inversion, bleeding, ulceration. Shape, size, colour) Raise arms above head, press against hips, lean forwards. Asymmetry, nipple retraction, skin puckering, tethering Lie pt to 30deg, arms behind head. Ask pt where abnormality is, star from other side. Feel quadrants, axillary tail and areola. Ask pt to express discharge 3S: Site, Size, Shape 3C: Consistency, Contours, Colour 4Ts: Tenderness, Temp, Transillumination, Tethered/mobile LN exam: gloves. Pt arm rest on your shoulder. Apical, lateral, medial, anterior, posterior, supraclavicular, cervical Thank, cover, present Triple assessment: Hx+exam, imaging (USS<35yo, Mamogram>35), histology for each (P, U/M, B) 1-5 1: normal 2: benign (cyst/fibroadenoma) 3: probably benign 4: probably malignant 5: malignant

Catheterisation

WIPERQQ + CHAPERONE "It will involve me passing a tube down the penis, will numb the area beforehand which can sting very slightly but will prevent further discomfort throughout the procedure" Indications: retnetion, monitor fluid balance CI: blood at meatus, enlarged prostate, pelvic #, scrotal haematoma Consent, recent trauma, any bleeding, allergic to lignocaine or latex Prepare and clean trolley Catheterisation pack (pour cleansing solution into gallipot), sterile gloves, PVC disposable gloves, urethral catheter, drainage bag, lignocaine gel 2%, normal saline/water for cleaning, plastic apron Reconfirm pt happy to proceed. Expose, put incontinence pads or sheet underneath Wash hands. Put on BOTH pairs of gloves. Make hole in sterile sheet and place over penis. Wrap gauze sling around penis and hold. Ask pt to retract foreskin, clean meatus and glans (from meatus down). Insert lignocaine gel ("may sting a little"). Allow 3 to 5min Discard top pair of gloves Attach catheter bag to catheter, insert to level of bifurcation, inflate with water, noting how much inserted. Withdraw catheter until resistance REPLACE FORESKIN Document: indication, volume of water added, residual volume + appearance I would inspect the urine, dip and send for MC&S

Male genital exam

WIPERQQ + CHAPERONE "involve me looking at, then feeling testicles and penis" (whole exam can be done lying or standing first, offer to rpt accordingly) Gloves GI around bed, stable, pain/discomfort, cachexia, body hair loss, gynaecomastia Inspect suprapubic area, both groins Whole scrotum: testicles present, level, swelling, oedema, masses Shaft: rashes, ulcers, erythema Retract foreskin (glans + meatus): epi/hypospadias, vesicles, discharge Skin: erythema, rashes, excoriation, scars, ulcers Palpation (lying, then standing for varicocele) Check for pain, "tell me if you feel any pain" Both testes: inferior, middle, superior parts, size, consistency, lumps/masses Epididymis: posterior aspect of each testis Spermatic cord: neck of scrotum with thumb anterior and index finger post Reflexes Phren's (testicular pain relieved by elevating) Cremasteric (stroke inside of leg and watch scrotal skin tighten) LNs (inguinal, supraclavicular) Cover, ask to redress Hx, abdo + hernia exam, DRE, USS (bulky/painful mass in scrotum or impalpable testes)

Pregnant abdo

WIPERQQ, position at 15deg, expose from beneath breasts to pubis CHAPERONE Inspect around bed General: comfortable, SOB, pallor Head+neck: chloasma, anaemia/jaundice in eyes, facial oedema Legs/feet: oedema, varicose veins Abdo: distension, fetal movements, scars (Pfannsteil, laparoscopic-ectopic), skin (linea nigra, striae gravidarum/albicans, excoriations, distended superficial veins), cough to assess for hernias Palpation (check for pain, warm hands): fundal height (tape measure inside out, av of 3, fundus to pubic symphisis). Leopold's manoeuvre (4 grips) To identify lie, presenting part (Head hard and round, breech soft and broad) and presentation. Ballot fluid to estimate liquor volume Auscultate: ant shoulder, sonicaid from 12w, pinnard from 24w, feel mum's pulse at same time BP urine dip weight height, oedema + clonus to complete

Anaphylaxis/epipen

What happened last time to cause epi-pen prescription Anaphylaxis is a severe form of allergy causing airway to swell up, making breathing difficult. When happens, call 999, use epipen (may relieve symptoms temporarily) Epipen is a device with adrenaline that can work quickly to help you breathe during an anaphylactic attack. Use if child becomes unwell rapidly after contact with allergen Look for: lip/tongue swelling, hives, wheezing, dizzines, fast HR, feeling sick Always know where it is, keep spare if possible, make sure in date Remove from case Hold in fist grip Remove blue cap Point orange side towards child Aim for outer part of thigh, through clothing if necessary Lift arm, swing and push against child hard enough to hear click Hold and apply pressure for 10s (SWING, CLICK, HOLD) Call 999, telling them 1 epipen has been administered

Amniocentesis

What: removal of fluid in sac Why: to confirm screening results Before: hospital >15w During: Trained professional USS guided needle enters amniotic sac, aspirates 15-20ml for cellular genetic analysis. Mild short-lived discomfort on needle insertion. FHR assessed throughout After: home later that day. Beware abdo pain, contractions, PV bleeding, watery vaginal discharge, fever. Prelim result 2d, full 2w, >99% reliable Risks: rare, 1% miscarry, amniotic fluid leak/injury to baby, infection Benifits: How would you feel if results +ve? can decide to - keep pregnancy (w/ support), TOP, adoption - completely up to you Although you can talk to your husband, has no right to veto or be consulted

Labour

When: 37-42w Early Signs: lightening, freq, heavy sensation/discomfort in upper thighs/pelvic area, lower back ache. Increased braxton hicks, ripened cervix, spurt of energy/nesting instinct, generally unwell True signs: painful rhythmic uterine contractions, cervical dilation, bloody show, RoM Stage 1: onset to 10cm. Latent (3cm, ~6h) and active (0.5-1cm/h. Longest stage). 90% cephalic, flexed, presenting with vertex (BPD and SOBD 9.5cm Stage 2: 10cm - expulsion of fetus. Descent (head enters in transverse), flexion, internal rotation (LOA most common, shoulders enter in transverse), extension (crowning - doesn't slip back in), external rotation (shoulders rotate to AP, then head restitutes), lateral flexion (place hands either side of head) Stage 3: separation + expulsion of placenta/membranes and control of maternal bleeding. Phys vs active (syntocinon, CCT). Check placenta for Cotyledons (30), membranes (amnion and chorion), cord insertion, 3 vessels (2a 1v)

Induction of labour

Why: >41w, HTN/pre-eclampsia, PROM CI: placental praevia, abnormal lie, CPD, active primary herpes Before: abdo (check lie, position, uteral tone/volume), cervix (dilatation, effacement, consistency, position) During membrane sweep: Assess cervix. Then finger inserted, moved, stimulates prostaglandins. Can stimulate labour within 48h Can be uncomfortable/painful, stimulate cramps/spotting/irregular bleeding, no infection risk to baby PG PV: gel, pessary Syntocinon: IV drip increasing uterine contractability AROM After: supervision + CTG monitoring for 30min after each ntervention Risks: hyperstimulation (fetal distress, hypoxia), uterine rupture (multiparous), infection, prolapsed cord (ARM with poor engagement)

Emergency contraception

Why: UPSI or think contraception might have failed SAFEGUARDING: check consensual, do you feel safe/supported in current relationship. Confidential Location: any GP clinic w/ contraception services, any sexual health/GUM clinic, most pharmacies, NHS walk-in centre Sexual history 3 types: IUD, EllaOne, PlanB IUD What: Small plastic and copper T shaped device that can be fitted in womb up to 5d post-UPSI or ovulation, toxic to ovum and sperm Effective: <1% Pros: effective, 10y of contraception, no effect on other meds (eg antiepileptics), no hormones Cons: irregular bleeding for a few days, heavier/more painful periods, uncomfortable 5min procedure Risks: IUD expulsion (will teach how to check), damage to womb (0.2%, make hole in womb, requires surgery), infection (STI screen before, safteynet), Ectopic (overall chance less, but if preg hi risk) Before: preg test, STI test, paracetamol+ibuprofen 1h before procedure. Bimanual to assess version During: speculum, LA into cervix, surgical instrument stabilise womb. Small plastic tube to determine size of womb, then IUD inserted using another tube. T arms open up to secure device. May cramp whilst inserting. 2 threads trimmed. Takes 5min After: cramps and light PV bleeding, so rest and painkillers. Removal is simple procedure. Do during next period, don't have sex 1w before EllaOne (Ulipristal acetate) What: one pill that should be taken 5d after having unprotected sex. Inhibits ovulation Effective: 1-2% Pros: no procedure, very few side effects Cons: N+V (if V within 3h, come back), changes to next period PlanB (Levonorgestrel) What: progesterone, stops ovulation. One pill 3d after UPSI Effective: 1-2.6% Pros: no procedure, very few SEs Cons: N+V (<3h return), changes to next period, shorter window, high BMI issues (BMI>26 needs special dosing) FOR ALL If you feel pregnant, if no period for 3w or hormonal contraception started soon after (restart 12h after planB, 5d after EllaOne), preg test.

LP

Why: diagnostic, therapeutic Before: lie on bed, curl into ball, must stay still, nurse will help During: wash skin, LA (may sting), then needle, 1-2min (very small amount), then sent to lab (prelim results v quickly) After: plaster, can have hypotensive headache (takes 2d to replace CSF) - lie flat for >=4 hours, give pain relief Pros: identifies bug Cons: uncomfortable - can give sedation. Important for parents to stay calm. Risk of bleeding, site infection, meningitis, ambiguous result

Neonatal jaundice

Yellowing of skin and eyes due to pigment called bilirubin Physiological (2-14d): neonate has more rbcs with lower t1/2 than adult, so more bilirubin. Neonatal liver immature, can't cope with so much, so more stays in blood. This deposits in skin and eyes causing yellow colour. This is prolonged by breast feeding, but harmless Within 24h (pathological): may be G6PD, spherocytosis, sepsis or ABORh incompatibility Complication: bilirubin deposits in brain, causing kernicterus (CP, LD, deafness) May need to insert tubes into baby's veins to give Abx and fluid Phototherapy: shining bright blue light onto baby converting bilirubin into water soluble compound Exchange transfusion: if severe. Taking blood through one tube, tranfuse through other

UTI in child

infection of urinary tract, anywhere from kidneys, bladder or urethra Cause: Bacteria get from anus or vagina into urinary tract. Relatively uncommon in children, so investigate after resolution to check for underlying problems Symptoms: freq, dysuria, abdo pain, fever. 1/10 children have renal scarring after first UTI, 35% get recurrent if >2y - important to identify and treat promptly Investigations: confirm with clean catch urine. USS (similar to scan you had when you were pregnant, to check for obstructive uropathies), DMSA (uses radioactive chemical to create special pictures of kidneys to show if they are damaged or scarred), MCUG (produces XR images of bladder and urinary tract, VUR) Treat: trimethoprim 7-10d

Chickenpox

itchy spotty rash starting on head/trunk spreading downwards. Mild systemic upset, infective from 2d before onset to 5d after. Can recur later in life in dermatomal distribution (shingles) Cause VZV Complications: pneumonia, encephalitis/cerebellitis, disseminated haemorrhagic chickenpox, secondary bacterial infection (GAS - nec fasc), arthritis, nephritis, pancreatitis Pregnancy 1-2 trimester: congenital varicella syndrome (IUGR, skin, brain, GI, GU effects - Dx by cordocentesis) 3rd trimester: neonatal chickenpox (pneumonitis, hepatitis, meningoencephalitis, 30% mortality). If 21-7d prepartum unlikely (due to ab transfer). If 7d pre to 28d after, or siblings have, then baby VZIg, consider IV acyclovir Shingles during pregnancy is not problem - Abs present Supportive: fluids, emollients, analgaesia, anti-pyretics. If immunocomprimised VZIg If pregnant w/ contact: test for immunity (Ig), give VZIg if seronegative. Give acyclovir if symptomatic

PGALs

just going to see how your skeleton works, is that okay? WIPERQQ Pain in any bones or joints? Dress on your own? Go up and down stairs without problems GI from front, side, back. Growth/height plot and see Gait: normal walk, heal, tip toe, heel-to-toe Spine: inspect, ear to shoulder, bend down and touch toes w/ fingers on spine Arms: arms to the sky, arms behind head like you would brush your hair, arms out in front, squeeze MCP, prayer + phalen Legs: inspect legs and feet, assess flexion and extension at kee, patellar tap, hip abduction and adduction Hyperextension: fingers, thumb, knees, elbows