Emma OSCE guide thingy*

*
 = specific points from actual past OSCE marking guides I found
• = other stuff (books, tuts, PBLs, etc)
Hypertension
Hx:
 compliance with medications Top 5DDx:
 exercise 1 essential (95%)
 diet and salt intake 2 Renal:
 'explore secondary causes” (see below) Diabetes!!
 'cofactors': weight and alcohol use chronic GN, PCKD (have been in past OSCEs)
 stress ('how is everything at work/home') some renovascular disease
3 endocrine:
Examination ↑ aldosterone (conns, adrenal hyperplasia)
• General inspection: cushinoid features, oedema Pheochromocytoma, Cushings, hypothyroid
(nephritic syndrome/HF/pregnant) 4 other:
• Eye exam: fundoscopy for grade of hypertensive coarctation of aorta
retinopathy Pregnancy
• CVS exam:look for LHF (to assess severity), steroids, COC
• coarction (radiofemoral delay/weak pulses),
• renal bruits • For Px, look for retinopathy, LHF, proteinuria
• Abdo exam:masses/palpable kidneys
• Thyroid exam and lymph nodes Counselling
• Explain risks
Investigations: • Explain treatment goals 140/85
If not done, get • 130/80 if DM
 U+E • Lifestyle: Good chance they may
 U/A (MSU) need to lose some fucking weight, you bastards
 FBC • Tell ‘em to quit smoking, start walking and clean up
 weight their diet (salts, alcohol)
If those done, then get • Then bring ‘em back another day to discuss
 BSL + insulin (DM) lipids/sugars etc
 ECG/echo (for hypertrophy, cardiomegaly)
 protein/creatinine ratio (renal causes) Management:
 fasting lipids (good for Px) Treat any causes, refer to who ever (diabetes education,
endocrinologist, nephrologist, onchologist)
 renal U/S (renal causes duh)
Meds: start with a thiazide diuretic
 cardiac stress test (for heart failure)
Warn ‘em about: hypoK, ↓ glucose
 TFTs (thyroid causes) tolerance, cholesterol
 aldosterone/cortisols (endocrine causes) Watch out for: gout
Start with ACEI if under 55, DM, LHF
Ruling out 2ndary causes: Warn ‘em about: cough, postural
• are you pregnant? hypotension, renal failure, ↑K
• Changes in weight Watch out for: renal disease
• tiredness/lethargy Add Ca blocker, thiazide or ACEI as 2nd and 3rd
• urinary Sx drugs
• PMHx: DM, lipids, IHD/HF, stroke, renal disease Then add B-blockers or spiranolactone – B-
• Medications (OCP, steroids, MAOIs) blockers good in pregnancy, pheochromo
• Renal Qs: oedema, blood in urine, urinary Sx, abdo Warn about: hypotension
pain Watch out for: asthma
• DM Qs: polyuria, nocturia, fatigue, thrush If used as a 1st drug, add Ca-blocker
• Cancer Qs: night sweats, bone pain and NOT THIAZIDE
• Thyroid Qs: cold intolerance, hair/skin changes
CXR script
This is the PA chest X ray of [name], a [age] [sex] There is cardiomegaly (STEMI)
The film is well penetrated + well centred signs of [Right / Left] [atrial / ventricular] hypertrophy
The mediastinum is..normal size

Lung fields …decreased lung volume…

Lung fields….are clear
There is/are [a/symmetrical]
Infiltration / opacification
Patchy consolidation
of/in the [left / right / bilateral]
[upper / lower / mid zones / hemi-thorax]
obscuring the costophrenic angles / left hemi-
diaphragm
and the presence of air bronchograms
There is/are calcification/plaques
along the L/R hemi-diaphragm / pleura
solitary pulmonary nodule
There is a solitary [left / right]…
[peripheral / central / hilar] mass … with …
◦ [smooth / irregular] outline
◦ satellite nodules
◦ [hilar / para-tracheal / mediastinal]
lymphadenopathy
◦ associated destruction of the L/R
[numbers] anterior ribs
◦ pleural effusion
◦ [complete / partial] [L/R] [upper / mid /
lower] lobe collapse

There is air visible under the L/R hemi-diaphragm (There are multiple rounded lung lesions)

Heart failure
…thickened upper lobe veins…
…interstitial pulmonary oedema…+ interstitial
thickening (Kerly B lines) CXR: positioning, penetration, lung fields
…alveolar pulmonary oedema  patchy consolidation heart size = enlarged heart
(bats wing consolidation) abnormal shape of heart – for stemi

Lung Fx guy
Hx
AB man SOB and smokes

if he smokes
how much he smokes
how long he has smoked for
What medications has he used in the past (no asthma)

Counsel about SOB

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

Counsel about QUIT

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

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

• Rate is [rate] • There are [normal T waves]
◦ [inverted T waves]
◦ [no identifiable T waves]
• 'The trace is in [sinus rhythm] ◦

• There is/are [no P wave conduction]

◦ [NO P WAVES]
◦ with [irregular baseline]
BBB and heart block
• The trace is in [first/second/third] degree heart block • There is [RBBB/LBBB]

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

little square: 40ms
big square: 200ms

• There is [right / left] axis deviation R-R intervals

[normal cardiac axis] 2 big squares: 150/min
3 big squares: 100/min
4 big squares: 75/min
QRS complexes, ST segments and T waves 5 big squares: 60/min
6 big squares: 50/min
• There normal [QRS complexes, ST segments and T waves]

• There are [ir/regular], [broad/widened/narrow] QRS P wave: 80-100ms

complexes [of ab/normal shape] and rate [rate] PR interval: 120-200ms
QRS complex: <120ms
• There is/are [normal ST segments] QTc interval: 300-440ms
◦ [depressed/raised ST segments] at leads [ ] ST segment: 80-120ms
◦ [ST elevation] at leads [ ]
30F with palpitations  no other tests needed
ECG  no jargon, but reassure
 name, rate, rhythm, axis 68M past STEMI with palpitations
 VPBs (ventricular extrasystole)
ECG results: explain
What does it mean – use diagram!! AF with rapid ventricular response
 normal heart Problems associated with AF
 extra beats are from the ventricle Thromboemboliv events like stroke
 doesn't mean there is a problem Tachycardia
 but the heart is irritable, from external factors Hypotension
Angina with patient has IHD
Heart failure
Ventricular extrasystole Management
Slow ventricular rate
• early QRS with no P wave B-Blockers
• wide, abnormally shaped QRS Ca blockers (verapamil / diltiazem)
• abnormally shaped T wave Digoxin
• Next P wave is on time Anticoagulation
Heparin initially (UFH or LMWH)
Advise about risk factors Warfarin
 coffee Cardioversion: hazardous if >2 days
may be able to TOE to exclude intercardiac
 lack of sleep
thrombus
 smoking – give advise for quitting for anticoagulate for 4 weeks first
 best not to use drugs to suppress them – makes it
worse
Reassure

Counselling for people who fail at life

A) Big guy with dizzy spells
Ventricular extrasystole causes
Assessment for risk factors Cardiac: IHD, mycarditis, MI
 Smoking Lifestyle: stress/poor
 ETOH - quantify sleep/caffeine/tobacco/ETOH,
 caffeine intake Drugs: Digoxin, TCAs
 Exercise? Electrolyte imbalance (↓K/MG), thyroid
 Overweight?
 BP? when last checked?
Mx
ECG  healthy food – less salt and fats, maybe draw
 Name, rate, rhythm triangle? - who cooks in the house? Take away?
 axis  Lose weight
 sinus rhythm with VEB in leads v4, v5  reduce ETOH (I'm concerned about the amount
 atrial ectopic you drink)
 Quit smoking – bring up quite dates, champix, GP
Counselling support
• “These extra beats in your heart can be caused by  exercise – suggestions like parking away from
a number of factors, such as your office and walking a bit, going for walks with family,
◦ weight team sports
◦ ETOH and caffeine use  coping and relaxation – suggest 'family time', away
◦ your smoking from phone and computer, baths, yoga
◦ your diet
• I'm also concerned that you are at risk of heart Further Ix
problems, like heart attacks and stroke. “  Blood tests: fasting cholesterol, glucose
 exercise ECG
 echocardiography

• Make a follow up plan, bring him back in 2 weeks

to discuss lifestyle changes
• If dizziness gets worse or chest pains, go to
hospital
• Refer to dietician

B) 60F with STEMI to assess cardiac status

Hx:
 chest pain? Describe Top complications of MI
 palpitations?
 Nocturnal dyspnoea? arrhythmia
 Orthopnoea? heart failure
 Exercise tolerance? recurring ACS/angina
 Ankle swelling/weight gain pericarditis
LV aneurism and mural thrombus
CXR: positioning, penetration, lung fields DVT/PE
heart size = enlarged heart stroke
abnormal shape of heart
ECG:
 Name  Dx: left ventricular aneurism
 rate  Further Ix: echocardiography
 rhythm  Mx: ACEI or diuretics
 axis  refer to cardiologist
 Describe ST segments and T waves
Normal ECG → raised ST segments (6 hours)
→ normalised ST segments
→ inverted T waves (24 hours)
 “persistent ST elevation for >8 weeks is significant”
Diabetes M (the M stands for MacDonald’s)
Ax of ulcers (PBL) Blurred vision
• Hx: smokes?
• Exam: look for PVD, do neuro exam (esp Top Ddx
sensation) Structural: refraction, cataracts, ulcers
• Ix: swab ulcer for micro Diabetic retinopathy
Doppler
plain film Xray for OM – bone scan and
MRI are much better
Rule out other neuro causes - B12, foliate,
thyroxin Leg ulcers
• Mx: dress ulcer and refer to podiatrist
• Augmentin/cephalexin + metronidazole Top Ddx
1 venous (70%)
Diagnosing DM 2 ischaemic/arterial (5%)
• Sx: thirst, polyuria, weight loss, visual blurring 3 mixed (20%)
4 neurogenic (DM)
• fasting >7
5 trauma, infection, cancer
• random >11.1 (and later redone)

First round Ix Explaining consequences

 U/A for glucose and proteins  kidney damage
 random blood glucose → GTT  heart problems
 blindness
Further Ix  foot problems – numbness, ulcers, risk of
 HbA1c (<7%) amputation
 fasting lipid profile Lifestyle issues
 albumin/creatinine ratio on urine  Diet – preliminary advice, offer referral to dietician
 podiatrists review or monofilament foot check by or AHW
nurse/AHW  exercise- quantify – suggest options
 ophthalmologist review or retinal screen  smoking and ETOH – Ax risk, quantify use

Ix for autonomic neuropathy (PBL) Meds

• ECG (loss of beat to beat variation in R-R interval) Metformin – overweight, diet treated patients
• postural hypotension NOT in renal/hepatic disease
• valsalva ratio then add sulfonylurea
BP control

Screen: >55 or >35 indigenous, islanders, Chinese

heart disease, GDM, PCOS, obese
>45 if BMI>30, 1st degree FHx, HTN

Counsel for Transfusion

Pros and cons
 for Explain
 low Hb  Correct cross-matching blood and patient checks
 risk of further bleeding still present  Close monitoring during transfusion
 endoscopy is safer if transfused
Safety
 more rapid recovery
 Australian blood supple one of the safest in the
 against
world but not without risk
 normal vital signs
 HIV very rare but possible (1:10000,000)
 asymptomatic
 Other risks
 risk of transfusion
 Fever / rigors, hives / itch – common
often mld
Alternatives
 Fluid overload – shortness of breath,
 IV fluids to maintain circulatory volume
heart failure
 Reassess Hb: transfuse if dropping
 Blood incompatibility – haemolytic
 Monitor vitals: transfuse if deteriorate
reactions, kidney failure, coagulopathy,
 Await endoscopy outcome and assess bleeding anaphylaxis
risk
 Acute lung injury – respiratory failure
 Discuss with more senior Dr
 Contamination – infections HTLV,
 Explains if not transfused, replete bone marrow will HBC, HCV, CMV, EBV, very rare, or bacterial
correct anaemia
 Delayed haemolysis  anaemia’s,
jaundice, delayed thrombocytopenia 
 bruising stage
 Consent not obtained, so will not proceed at this

Bleeding ♀

Common bleeding DDx

• purpura simplex Vascular disorders
• senile purpura • HSP
• steroid induced Coagulation
• trauma • Haemophilia A/B
• vWD
• DIC
Hx • liver disease
• purpura / bruises (describe) ◦ Vit K deficiency
◦ injuries? Bumps or falls? ◦ alcoholism
◦ joint swelling • Warfarin
• epistaxis / gum bleeding Thrombocytopenia
• blood in: urine / stools • ITP
• women • drug induced thrombocytopenia
◦ Menorrhagia ◦ chemotherapy
◦ PPH/surgical bleeding ◦ anticonvulsants
• FHx of bleeding or bleeding disorders ◦ diuretic (thiazide)
• medications • marrow failure
◦ aspirin • TTP
Platelet dysfunction
◦ Warfarin / Heparin / Clopidogrel
• drug induced
• PMHx:
• inherited disorders
◦ recent viral illness
◦ ETOH use
◦ dental work Ix
◦ liver disease or SLE/RA • Urine U/A (blood)
◦ cancer screen • FBC + blood film
◦ platelets <50 = thrombocytopenia
Examination • coag profile
• vitals: haemodynamically stable? ◦ APTT: ↑ = coagulation cause
• haemorrhagic lesions (echymoses, purpura) ◦ Prothrombin Time: ↑ = vitamin K deficiency
◦ senile purpura = hands • fibrinogen = DIC, liver disease
◦ petechiae = platelet/vascular cause • platelet function analyser
◦ thighs + buttocks = HSP ◦ measures time to form platelet plug
◦ joint swelling ◦ CEPI: if prolonged then do
• GIT ◦ CADP: if normal = aspirin effect
◦ splenomegally prolonged = platelet dysfunction
◦ lymphadenopathy
◦ hepatomegally / jaundice Further Ix
• coag factor assays
◦ vWD:
▪ ristocetin cofactor
▪ vWF antigen
◦ Haemophilia: FVIII + FIX
◦ APPT 50:50 corrects in vWD, not in drugs
• platelet aggregate studies
◦ ADP, collagen, adrenalin, ristocetin
 Counselling vWD
 a bleeding disorder
lack of or poorly functioning vWF
 milder then haemophilia
 normal lifestyle and life span can be achieved
Haemophilia  risk at time of operations, births
• X-linked recessive  need specialist care: refer to a HAEMOTOLOGIST
• A factor VIII
• B factor IX (Christmas) Mx and risks
→ unstable plug + excessive bleeding  Importance of prophylactic treatment before procedure
• Sx  DDAVP, factor 8 concentrate, TA
◦ haematoma • Desmopressin (DDAVP): release vWF
◦ haemarthrosis from cells
◦ haematuria • prophylactic for menstruation + minor ops
• effective for 2-3 days
von Willebrands Disease • Biostate: blood product with FVIII + vWF
• Type 1 autosomal dominant • just recombinant FVIII is useless
◦ Type 3 is severe • tranexamic acid: good as mouthwash
• Sx (1/3 no Sx)  If need blood products: risk of HIV
◦ easy bruising  Hep B vaccination
◦ nose/gum/post dental bleeds
◦ menorrhagia Risk to my child
◦ haematomas + haemarthrosis  Inherited risk uncertain
 Each pregnancy 50% chance it will be passed to child
(AD) but effects individuals differently (variable
penetrance)
 Severity varies over time

Been tired lately, is from vWD?

 Blood from menorrhagia may be causing Fe deficiency
 Need Fe studies

Young woman with PE

Hx
 Recent travel
 Recent trauma  Mx counselling
 FHx: thromboembolism
 OCP or other medications + OTC  Duration and monitoring
 ETOH  Start on Heparin + Warfarin
 Aspirin  Heparin starts acting ASAP, but Warfarin
 NSIADs  takes 5-7 days to work properly
 Contraindications  It stops the parts that protect against clots
o pregnancy before the parts that help clots form
o peptic ulcers / GI bleeds
 Take blood to check your INR (clotting) for 4
o bleeding disorders
days, then we can tweak the amount of
o liver failure
Warfarin
 AIMS: INR<1.4 before we start, want you
 Ix – Counsel between 2-3 once Warfarin is stable
 Procoagulant screen
 Lupus anticoagulant  Heparin injection once a day for about a week
 Factor V mutations  Warfarin for 6 months
 Protein C + S
 Anti-thrombin III
 Side effects
 What is it?  Bleeding, easy bruising (?aspirin)
 Inhibits reductase enzyme for vit K  If blood in cough, stool, urine come back in,
regeneration may need to adjust dose
 Warfarin induced skin necrosis: very rare and
never with Heparin
 Rarely hypersensitivity reaction, purple toe
Elderly with poor urine output + weakness
Hx o Masses (obstruction)
• Fluid loss
o Urine output Hx
o Vomiting, diarrhoea, bleeding
o Urinary Sx (blood) or flank pain
 Nocturia = CRF
• Fluid intake Pre-renal (50%)
• dehydration: thirst, postural dizziness, weight loss • hypovolaemia
• PMHx: • heart failure
◦ HTN • renal artery insufficiency/stenosis
◦ RF or renal disease
◦ HF Intrinsic
◦ Prostate or stones or cancers • ATN
• recent illness? • glomerular
◦ vomiting, diarrhoea
◦ fevers, chills Post-renal
◦ GI blood / haematuria • urethral / ureter
◦ HTN?? • prostate
• Drugs
◦ NSAIDs Mx
◦ ACE-I • IV fluid resuscitation
◦ radiocontrast • Cease NSAIDs, ACEI
◦ aminoglycosides • Hold on K replacement
◦ methotrexate • failure to regain OU with fluids = ATN or intrinsic
◦ IVDU, opioids (rhabdomyolysis)
If oliguria keeps getting worse:
Examination
• vitals Ruling out ATN (Dx of exclusion)
• hydration • fluid resus → ↑ UO and ↓ creatinine
• infections = pre-renal ARF
• fundi: retinopathy suggests pre-existing renal insult • clear block → dilated pelvises + ↓ creatinine
= post-renal ARF
• Chest: heart failure
• HTN, proteinuria, haematuria
• Abdo
= rapidly progressive GN
o Kidneys
• fever, rash, eosinophilia, HTN, haematuria
o Bruits (RAS)
= acute interstitial nephritis
(NSAIDs, penicillin, strep)
Ix
• atherosclerosis + vascular bruits + eosinophilia
Bloods
= atheroembolic ARF
• U+E
◦ Hypovolaemia Mx for ATN
◦ Raised 1:20 ratio • admit + fluid resuscitation
◦ Need prior creatinine to Dx CRF • stop diuretics, ACEI, NSAIDs
• K: the killer in ARF high K foods, K retaining drugs
• FBC • monitor
◦ ↑HB in hypovolaemia ◦ Hourly: fluid balance, body weight, volume
◦ normocytic in CRF status, U+E
• ABG ◦ Daily: FBC, Ca, Phos
◦ ARF  metabolic acidosis • Then add:
• ◦ inotropes (Dopamine)
◦ Vomiting  alkalosis ◦ Frusemide
• CK  rhabdomyolysis (ATN) • Fluid restriction: previous day's UO + 500 ml, slight
• Glucose, Ca, LFTs (causes) over hydration
Urine
• U/A + MCS
◦ SG in hypovolaemia), proteinuria, haematuria,
culture if septic
◦ Hyaline casts = ATN + hypovolaemia
• Electrolytes: urine:serum creatinine >10 = pre-renal
Renal U/S
• Smooth, normal size = acute pre-renal
• Dilated / calculi = post-renal
• Small, scarred, echogenic = chronic
 • Urine
• CXR
• ABG, VQ
• ECG for arrhythmias
• CT head, neuro exam, drug screen

Mx
• needs dialysis
◦ life threatening hyper kalaemia → IV Ca →
salbutamol inhaled ± insulin+glucose
If it keeps getting worse:
Indications for emergency dialysis
Uraemia
progressive accumulation of nitrogenous waste/fluid • ↑↑↑K (>7mmol/L)
• ↑ K → weakness + arrhythmia • pulmonary oedema
• metabolic acidosis → Kussmaul resps • worsening metabolic acidosis (<7.2, BE<-10)
• uraemic encephalopathy → confusion, tremor • Uraemia encephalopathy
◦ ↑ reflexes + upgoing toes
Counseling dialysis
• platelet dysfunction → bleeding
• her symptoms are from kidneys being shut down
• pericarditis
• chemicals are building up in her body
• ↓↓ BP + ↓↓ temperature
• her kidneys can recover, but will take time
Ix • the dialysis will remove the bad chemicals and let
the kidneys rest
• Bloods
• may have to stay on it for 1-2 weeks
◦ FBC (sepsis), CRP
◦ cultures
◦ U+E
• drugs
• steroids
Jaundice • OCP
Hx • PSC / PBC
• Jaundice: duration, level
• Fatigue
• Vomiting and nausea
• Drugs, medications, ETOH
• Hep risks
• Travel
• IVDU / tattoos / piercings
• transfusions
• Other Sx
• Pain
• Pale stool, dark urine
• Itching/pruritis

Pre hepatic (haemolytic)

• Dyserythropoiesis
• Gilberts
Hepatic
• HC damage ± cholestasis
• Hepatitis (CMV, EBV, AIH)
• Drugs
• Paracetamol
• Statins
• Valproate
• ETOH / cirrhosis
• liver mets / abscess
• haemochromatosis
• septicaemia
• RHF
Cholestatic/post-hepatic/obstructive
• Conj spills over into blood  dark urine, pale
stool, pruritus
• Gallstones
• pancreatic cancer
Examination
• Vitals: temperature, confusion
• lymphadenopathy
• General:
• jaundice
• gynaecomastia
• hepatic flap
• Skin:
• spider naevi
• palmer erythema
• scratch marks (obstructive)
• needle marks
• abdo:
• Liver: large or small, firm, tender
• splenomegally
• Masses
• ascites

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

LFTs
↑↑↑ALP = cholestasis = obstruction, cancer
↑↑↑ GGT = obstruction / ETOH
↑↑↑AST = hepatocellular damage – hepatitis, ETOH
↑↑ bilirubin = hepatitis, obstruction
↑↑ unconjugates bilirubin = pre-renal + Gilberts
Young woman with abdo pain + bloody
diarrhoea
Hx
• pain Hx
• travel, shellfish
• Abx use Mx of IBD
• infected contacts? • Truelove regimen
• Sexual Hx ◦ IV steroids acutely 100mg 6hrly to induce
• animal contacts remission ~5 days
• diarrhoea Hx → oral pred ~50mg/day
• fever, pain, dehydration ◦ Abx: ciprofloxicin + metronidazole
• duration of illness • add immunosuppresion: takes 8 weeks for full
effect, so need steroids
Examination ◦ if mild, use sulfasalazine
• general: toxic ◦ if sulfur allergy or severe: 6-MP, azathioprine
• Vitals • monitor for bowel obstruction
• hypovolaemia
• abdo exam Counseling
◦ tenderness • Long term: 13% active chronic, 73% intermittent
◦ rebound, guarding chronic
◦ masses (ectopics) • Half will need surgery at some point
• DRE • pregnancy:
• Murphy’s sign ◦ Lower fertility. No increased risks if not active
• Rovsing's sign at time of conception
◦ active → PTL, LBW
Ix ◦ Safe meds in pregnancy: steroids, TPN,
• bloods sulfasalazine
◦ FBC: anaemia, WCC (infect or inflamm)
◦ U+E (dehydration, renal failure)
◦ LFT (albumin + total protein) ABDO pain Ddx
◦ ESR/CRP/platelets: inflamm • obstruction
• urine: bHCG, U/A + culture • perforation
• stool: leucocytes (IBD), culture (parasites, dificile) • inflammation
• plain AXR (obstruction, toxic megacolon, ◦ IBD
perforation) ◦ IBS
• plain CXR: perforation (gas under diaphragm) ◦ toxic megacolon
• infection
Mx bowel obstruction ◦ UTI, PID
• admit → decompression with NGT ◦ ABx related
• fluid resuscitation ◦ appendix, diverticular, abscess
• analgesics ± antiemetics • vascular (aneurism)
• antibiotics • pancreatic / biliary
• refer surgeon

Acute-on-Chronic abdo pain DDx

• IBD
• appendicitis ♀ RIF pain
• pancreatitis • appendix
• coeliac disease • ovarian cyst
• gallbladder stones • pregnancy / ectopic
• IBS • intestinal lymphoma
• ectopics • UTI
• UTI

Further Ix
• abdo CT: for cause of bowel obstruction
• sigmoidoscopy/colonoscopy: to confirm IBD
• ± Fe studies
Haemochromatosis • Gynaecomastia
• Palmar erythema
• Testicular atrophy
• CVS/chest: HF (+ crackles), arrhythmias
Causes
• ↓ rennin, ↓ aldosterone
• HH type 1
• transfusions
Ix
• chronic liver disease
• LFTs
• Thalassaemia / sideroblastic anaemia
• Bloods
• Diet + ETOH
• Transferrin sats >80%
Hx • Ferritin
• Sx • Phlebotomy requirements
• bronze • Tf receptor
• tired, weight loss • HFE genotyping
• swollen fingers / joint pain • Glucose
• abdo pain • Joint Xray
• loss of libido • Liver biopsy
• itchiness • Bone marrow
• DM Sx • Perl’s stain for Fe loading + severity
• Nocturia • MRI for Fe loading
• polyuria • ECG/Echo
• FHx: Thalassaemia, haemochromatosis
• Lifestyle Mx
• ETOH use • Venesection: ~1 unit/wk until Fe deficient – every
• Diet: meat, OJ + white wine with meal 2-3 months
• PMHx: • AIM: MCV <0.5, ferritin < 100/L, transferrin
sats <40%
• Anaemias
• Arthritis • Monitor: DM: HbA1c – falsely low
• OTC: NO Fe in vitamins!!
• Transfusions
• Liver problems • Diet: well balanced low-Fe diet. Drink tea, coffee,
red wine with meals (↓ absorption). Don’t drink fruit
Examination juice, white wine with meals
• General • Minimal ETOH, HBV vaccine
• Bronze • Screening
• Pruritus, scratch marks, jaundice • Serum ferritin + HFE genotype in 1st degree
• Spider angioma
Px
• Swollen hands
• Normal life expectancy with venesection – if no
• Abdo
cirrhosis or DM
• Hepatomegally (95%)
• Gonadal failure irreversible
• Splenomegally
• If cirrhosis, >10% get HCC
• Portal HTN:

• ↑ Hepcidin  ↓ Fe absorption, ↓ release

• from Fe + IL6, IL1
• ↓ Hepcidin  ↑ Fe absorption + release
• from hypoxia, erythropoietin, anaemia
• Type 1 Hereditary haemochromatosis
• in Europeans: homozygous for C282Y
mutation of HFE
• males get it earlier, period is protective
Px
• 70% progressive Fe overload
• 50% clinical
• 25% liver injury
• <10% cirrhosis
• ↑ intestinal Fe absorption
• deposits in organs: joints, liver, heart,
pancreas, pit, adrenals, skin
• less Fe in spleen
Liver problems masses, fever
• DDX: PUD, oesophageal spasm, GORD, NUD,
Pancreas: acute + chronic pancreatitis, pancreatic IBS, renal colic, IHD
cancer Painless jaundice + palpable GB = not stones
Biliary: gallstones, cholecystitis, cholangitis Ix
FBC
Hx U+E
• Drugs and ETOH LFTs
• Sx: itch, pain, jaundice, dark urine, pale stools, Glucose
nausea, steatorrhoea INR+coags
• Signs: painless jaundice, Murphy’s sign,
Special Ix
Blood cultures
Amylase + lipase
Tumour markers Ca19-9
Malabsorption: vitamins ADEK, B12
Multi-organ failure: Ca, ABG

Imaging
AXR: stones, air
Abdo U/S: stones/mass
CT abdo: mall lesions, liver mets
Cholangiography
Biopsy

Organ Fx tests
Biliary isotope scanning HIDA/DISIDA
Pancreatic Fx tests
SLE and ANA – potential counselling Qs
Explaining ANA to a patient – draw a picture
• when someone has SLE, their body makes ANA = antinuclear antibodies
• we take serum from your blood sample and put them on a slide with cells on it
• If your blood has ANA, they will attach themselves to the cells
• Then we add another type of antibody that's fluorescent – this one attaches itself to the cells already joined with
the ANA
• We look at the slide under a UV microscope and if there are fluorescent cells its positive
• We dilute the sample until negative – we can't find any more cells

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

The reported titre would be 1:160

• we would call anything above 1:40 a high titre

Does mean I definitely have it?

• Not a very specific test - there are other things that can cause it – SS, RA, AI hepatitis, scleroderma
• Even some healthy people without any of these can have a high titre
• The higher the titre, more accurate it is likely to be
• We use other tests that are more specific for SLE
◦ Ssa and Ssb for Sjogrens syndrome
◦ Sm for SLE
◦ dsDNA is found in SLE with kidney involvement

How do we know if I'm getting better?

• May not go down with remission, so not good for monitoring
◦ we use dsDNA, C3, C4, urinary protein, creatinine and ESR
◦ SLE haemolytic anaemia – we use Hb, reticulocytes
◦ liver disease- we use LFTs
◦ SLE nephritis- we use urine, creatinine
Tiredness PMHx
 DM
 Chronic disease
Uber common DDx  Blood loss
 Depression  Thyroid disease
 Post viral (up to 6 months)  For anaemia:
 Sleep apnoea  PMHx: liver disease
 DM  PMHx: chronic pancreatitis
 PMHx: thyroid disease
RULE OUT  Surgery: gastrectomy/terminal ileum
 Cancer  intestinal bacterial overgrowth – stasis from
 Arrhythmia intestinal surgery or anatomical lesion
 Anaemia /
 hypothyroid Ddx of the young tired ♀

 1 Fe deficiency/anaemia
Hx  2 psychosocial/depression
 Sleep  3 hypothyroid
o How have you been sleeping  4 pregnancy
o Do you snore?
o Feel tired when you wake up DM/scleroderma/a
o Nocturia (DM) Ddx of the older tired ♀
 Smoking and ETOH (quantify)
 medications and allergies  1 diabetes
 2 hypothyroid
Anaemia screen  3 psychosocial/depression
 Heavy periods (menorrhagia) / no periods at all  4 anaemia
(pregnant)
myloid
 Diet (meat?) + appetite
 FHx: pernicious anaemia

Cancer screen Ix:

 WEIGHT LOSS AND NIGHT SWEATS  FBC
Shortness of breath  Fe studies
Changes to stools
 TFT
 U+E
Thyroid screen
 BSL
 Unusually cold this winter?
 LFT
 Noticed changes to your hair or skin?
consider bHCG, b12, foliate, no marks though
 Weight / appetite
Anaemia Ix
Depression screen
 B12
 How are things at work / home?
 foliate levels (ETOH foliate deficiency)
 Sleep / appetite?
 thyroid test – to monitor meds
 How’s your mood been?
 pernicious anaemia = anti-parietal cell
antibody/anti-intrinsic factor
microcytic  intestinal infection = bacterial overgrowth,
Fe deficiency tropical sprue, fish tapeworm
chronic disease
Thalassaemia Counsel: explain and reassure
sideroblastic anaemia Mx: oral thyroxine – 50-100mcg daily
Further Ix: recheck TFTs in 6-8 weeks and thyroid ABs
normocytic
blood loss Counsel about
chronic disease  folate/B12 intake
renal failure  schillings test/ABs , gastroscopy
hypothyroidism
 meds for thyroid Fx
haemolysis
 ETOH use
pregnancy
 wont need blood transfusion
macrocytic
B12 / foliate deficiency
ETOH/liver disease
myelodysplastic syndromes
Chronic Headache
Hx
• Pattern of pain
• Location Migraine Tension
• Aggravating/relieving factors • Unilateral • Bilateral
• Auras before / during • With prodrome / aura • No auras
• Vision changes • Throbbing • Constant
• FHx: migraines, cancer, HTN, IHD • Vomiting • No vomiting
• How’s everything at home / work • Worse with ETOH/pill • Better with ETOH
• Usually starts <20yo • Daily
Ruling out problems • Family Hx • No FHx
 When did it start
 How bad is it
 Is it getting better or worse
 Raised ICP (infection, tumour, space occupying Migraine
lesion) Counselling
 Disturb sleep or worse on waking • Acknowledge difficulty
 Worse on coughing / bending over • Gage effect on work / school
 vomiting • Identify triggers: choco, citrus, cheese, red wine,
 Fevers, chills caffeine
 Any neuro changes (confusion/memory loss) • Stress, lack of sleep
 Fits, faints, funny turns • Look after self + relax
 Other
Acute attacks
 Happened before
• Start treatment with earliest sign
 Any trauma
• Dark lights, try to sleep
 ETOH
• Try ergotamine or sumatriptan (not both)
 Medication (aspirin/codeine)
• Aspirin + paracetamol + NSAIDs
Counsel • Antiemetic (metaclopromide)
 Has symptom of a serious underlying disorder
Cluster
 A differential is raised intracranial pressure
• Daily like clockwork
 Malignancy is a possibility (space
• Over one eye
occupying lesion)
• ± lacrimation, horners
 Idiopathic intracranial HTN
• Reassure that usually resolves 4-6wks
 Subdural haematoma
• Ergotamine / sumatriptan
Examination • Antiemetics, ± local
 Neuro Examination
Temporal Arteritis
 Fundoscopy for ICP
• OVER 50
Further Ix • Unilateral
 CT/MRI • Daily, constant ache
ESR for temporal arteritis • Worse in morning
CT for meningitis or SAH • Blurred vision
• DO ESR IF SUSPICIOUS!

Benign intracranial hypertension = young fat women

Top DDx
• URTI
• Tension
• Migrane
• Combination
• Cervical
RULE OUT
• SAH
• Temporal arteritis
• Venous thrombosis
• Meningitis
• Subdural haematoma
Back pain Hx
• Pain:
• Where? Referral to legs? Deep/surface
DDx uni/bilateral?
• Vertebral dysfunction • Onset, frequency, duration
• Strains/sprains • Better worse
• OA • Wake at night? (arthritis, cancer)
RULE OUT • Worse with sitting = disc
• Cancer • Other Sx
• OM/abscess/discitis/PID • Psoriasis
• AAA • Joint pain
• Cauda equina • Fever, rigors
• Drugs: steroids / anticoagulants?
RED FLAGS
• Pain Counsel
• > 1 month: how long had pain?
• explain
• constant? • advise:
• cancer: weight loss, cough
• avoid best rest
• cauda equina: • maintain normal activities
• saddle anaesthesia: numbness between your
• XRays not routine unless
legs?
◦ <25yo
• recent bladder dysfunction: any changes to
◦ red flags
your bladder habits ?
• Mx: paracetamol + NSAIDS (GI upset?)
• severe neuro deficit: legs feeling wobbly or
weak? • Physio can be helpful in the first 6 weeks
• Depression screen

Inflammation mechanical
• Sneaks up • past Hx
• Throbbing • deep, dull
• Morning stiffness • transient stiffness
• Better with activity • better with rest
• Bilateral • unilateral
• Localised • diffuse
• Night + morning • in afternoon

Knee pain in adult • Weight loss, tired?

Top DDx
• Ligament sprains Examination:
• Osteoarthritis • Knee Examination
• Patellofemoral syndrome (runner’s knee) • Check other joints
• Prepatellar bursitis (housemaid’s knee) • Psoriasis
• Fever
RULE OUT
• Crutiate lig tear Ix
• DVT • None really needed if not suspicious
• Cancer (bone) • In OA, Xrays are only useful as baseline reference
• Septic arthritis
Counselling OA
• RA
• Degrading of the cartilage cushions in the joint, and
later bone
Hx
• With mild inflammation
• Happened before? Any past sports injuries?
• Factors make you more likely to develop OA:
• An injury
overweight + past injuries, DM
• What happened? Twist? Swelling?
• Weight loss will help pain
• Dealing with work?
• Refer to physio
• Pain:
• Walking sticks, cushioned shoes
• After exercise / stairs?
• Drugs:
• Morning / night / wake you from sleep / night
• Glucosamine
sweats
• Analgesia: panadol good, neurofen only when
• Swelling
acute
• Sudden = ACL tear
• Long term, you will need a knee replacement
• Days = bursitis
• Steroid injections
• Chronic = runner’s knee, RA
Aboriginal kid with ear pain
Hx
• general health Counselling
◦ URTIs • 20% of kids at any one time
◦ acute OM • 30-70%: have CSOM with hearing loss
◦ atopy, allergies • affects language, speech, schooling, legals
• development and schooling, speech • Abx only shortens course by 1 day
◦ Hearing loss?
• otalgia? Otorrhoea? • Follow up in 4 days. If not better, give ABx
• irritable? poor feeding?
◦ How long for? Probable Dx
• sleep: not sleeping?  chronic suppurative OM
◦ How is sleep usually?  acute OM with perforation
◦ Snores? (OSA)  foreign body
 OE
Red flags  cholesteatoma
• speech delay
• cranio-facial abnormality A acute OM
• neuro deficit • tired, flushed child with pink ear
• febrile convulsions • analgesia and follow up
• Abx if bulging or AB
Ex
 ENT exam: both ears, throat, teeth, nose, B acute OM + effusion
cervical nodes
• healthy child
 systemic – CVS and resp – chest, heart, lungs,
• analgesia and monitor for 3 months
pulse, RR, skin, temperature
• if persists, consider grommet
 hearing test Webber and rinne
 observe general appearance: alert, active, C recurrent OM
engaging
• 6 in a year
consider 3-4 weeks Abx, grommet
 Examine drum with kid on mums lap
 ear wash out with 1:20 of dilute betadine and Otitis externa (swimmer’s ear)
mop dry • sore, itchy + discharge
 ± pneumatic otoscopy • pre-auricular tenderness
• Mx:
Ix
• Tissue spears
 audiology
• Topical Abx
Mx • IV Abx + admit if cellulitis or severe pain
 dry mopping • Avoid water in ear
 bd ear wash with 1:20 db + dry
 Abx ear drops bd weekly review for 2 weeks

Obstructive sleep disorder

Hx
• Repeated episodes of ↓ URT airflow in sleep
• Snoring
• Trouble sleeping
• Sleepy, wake up tired Ix
• rhinorrhoea • Lateral Xray
• Daytime mouth breathing • PST
• School performance • Sleep studies

Examination Adeno-tonsillar hypertrophy

• centiles • Common
• Mouth breathing • Adenotonsillectomy improves 90-95%
• Lines under eyes • Can try allergy Mx, nasal CPAP
• Nasal obstruction
• Tonsils, palate, tongue Recurrent tonsillitis
• Speech • Viral: Mx: symptomatic
• Acute follicular: serious
• Consider adenotonsillectomy
Asthma kid • CXR: Only to exclude DDx
Hx
• Sx
• Wheeze: night, morning, exercise
• SOB
Mx
• Chest tightness
• Reliever : Ventolin (Salbutamol)
• Cough (night-time)
• Preventer : Flixotide (steroids)
 FHx of asthma/allergy/atopy • Controller : Seretide: steroids and Salmetarol (LAB)
 triggers • Avoid triggers and SMOKING
 exercise
Mx
 cold air
 arrange follow up
 allergies
 safety net – warning signs of severe asthma
 viral illness
and Mx
 dust
 care of device
 SMOKING
 correct dose
 Hospital visits + days off school
 warn of steroid effects
 attitude towards condition ?
 ACTION PLAN
 Patient understanding of role of preventers vs
 FBP / finger prick haemacue
relievers
 adherence to meds Counselling: about asthma
• The airways are hyper-sensitive
Assess Pattern / Severity
• They react to triggers
• infrequent episodic
 inflammation, airway constriction, mucus production
• >2 months apart
• few Sx / signs between attacks Counselling: how to use an inhaler
• reliever (Ventolin)  able to demonstrate how to use
• frequent episodic  show patient how to use
• <6 weeks apart  advise use of spacer
• some Sx between attacks, but Ex normal  shake canister
• Preventer + reliever  hold correctly
• persistent  breathe out
• daytime Sx 2/ week  breathe in and hold breathe
• night Sx 1/week
• attacks <6 weeks apart When to come into hospital
• hospital visits • Using reliever more than once every 3 hours
• preventer, reliever + controller • Sx get worse quickly
• Sx continue after reliever taken
Ix • Severe Sx:
• Spirometry • Gasping
• If over 6yo • Cannot speak
• Obstruction = FEV1 <80%, FEV1/FVC <75% • Blue lips
• 12% improvement with SAB (eg 8089)
• exercise challenge
• 70% can be exercise induced
• look for 15% drop

Acute Attack Mild

• SAB 100mcg 3-4 hrly
• Vitals: HR, RR, sats • <6yo = 6 puffs
• O2 via face mask if sats RA <92% • >6yo = 12 puffs
• Oral steroid
Assess severity • Pred 1mg/kg daily up to 50mg
mild
• cough, wheeze Moderate
• relaxed, no muscle use • SAB 2-4 hrly
• sats >95 in RA • Steroids (Pred)
• PEF >60
Moderate Severe
• Less breath sounds • SAB ½ - 2 hrly
• Accessory muscles used • Steroids
• Sats 92-95 in RA • Pred oral OR
• PEF 40-60 • IV hydrocort 4mg/kg 6hrly
Sever • Switch to nebulised SAB if:
• Gasping • Can’t use spacer or spacer not helping
• Pale, sweaty, cyanosed
• O2 sats <92 in RA
• PEF <40%
Sexual Hx of male with discharge
Hx
 urethral discharge + urethral pain on urination Ix
 sores / ulcers on penis  Urethral swab
 past history of STIs  First pass urine test (PCR)
 constitutional Sx: fever, joint pain, rash  Serology for baseline status
 number of sexual partners (in past 3 months)
o last sexual activity? Mx
 Antibiotics: Azithromycin + Ceftriaxone
 high risk practices + oral sex
o CONDOMS  Safe sex education
o I’d like to have a talk with you about
o anal
condoms
 sexual orientation
o Do you usually use condoms?
o Why was this time different?
• Hep vaccines
 Contact tracing
• Allergies / meds
 No sex with partner
• IVDU / piercings / tattoos
o Need to treat all recent partners
Counselling o No sex until you and your partner are
 Explain diagnoses cleared
o Retest in 7 days
 Gonorrhoea
 Chlamydia  Window period follow up
How much do you know about G + C – these are
bacterial that can be sexually transmitted
Given what you told me, It’s more than likely you have Probabe DDx
one or both of these Urethritis
So I’d like to take some swabs around the tip of the • Gonorrhoea
penis and get a urine sample so we can see • N-G-U: Chlamydia
exactly what the best treatment for you is

Vaginal discharge • Cervix: inflamed, ectropion

Hx • Abdo / adnexal tenderness

colour / type DDx

• Normal discharge
Clear normal / • Vaginitis (90%) (BV, candida,
neoplasia trichomonas)
Cheese curds: candida • Cancer
Grey, watery: bacterial • Infection: G / C  PID
vaginosis • Herpes?
Green, purulent: • Endometriosis
trichomonas
• Atrophic vaginitis
Brown:
endometriosis, ectopics
Blood: infection, Ix
neoplasia, • STI screen
menstruation, miscarriage • MCS:
◦ Clue cells = BV
• Discharge ◦ Hyphae = thrush
• When did you notice it ◦ Motile trichomonads
• Has it happened before • ECS + HVS
• Pain / Itching • Pap smear
• Urinary Sx • Vaginal pH
• Coital pain / blood ◦ High pH: BV, trichomonas, atrophic
• Health generally
• fever, joint pain, rash Bacterial vaginosis
• ABx • Too few lactobacilli, too many anaerobes
• Cause can be sexually transmitted, can I enquire? • ±itch ± pain
• Number of sexual partners • whiff test
• CONDOMS • risky in pregnancy
• The pill or Other contraception • Clindamycin / Metronidazole
• Anal or oral • Yoghurt
• Past history of STIs
Thrush (candidia)
Examination • Itchy, burning, red
• PE: note discharge • With OCP, Abx, pregnancy
• Inflamed vagina: thrush, trichomonas • Mx: Clotrimazole, Nystatin
◦ Treat partner
 • Mx: Tinidazole
Trichomonas ◦ Treat partner
• Red, sore

Contraception
Counsel for mirena
Hx  benefits – effective, no loss of spontaneity or need
 contraceptive Hx to remember, less menstrual blood loss, lasts up to
 family size – completed? 5 yrs but can be removed at any time
 Medical Hx  risks – slight risk of infection with insertion, very
contraindications slight risk of perforation, need condoms for STI
▪ pelvic infection  side effects – irregular spotting
▪ abnormal bleeding  insertion – ensure not pregnant / via spec in dr
▪ pregnant rooms / may be uncomfortable / may need swabs
▪ high risk of infection prior to insertion
 patients needs to check thread to ensure IUD insitu
Counselling post menstruation
 action
▪ prevents implantation Communication
▪ releases progesterone  information clear and sufficient to facilitate choice /
▪ thins endometrium offers written information
▪ efficacy – 99%  offers to discuss other choices
 offers other forms of IUD
 allows questions

Counsel for OCP

Hx
 previous contraception
 medical Hx + surgical Hx + allergies Side effects
 menstrual Hx (brief)  breakthrough bleeding
Contraindications  fluid retention
 HTN  weight gain
 smoking  breast enlargement/tenderness
 migraines  nausea
 FHx of clotting  acne
 prior DVT/PE  depression
 currently pregnant  loss of libido

Examination Instructions
 BP  importance of taking pill as instructed
 HCG urine  pill missed within 12hrs can be taken
 7 day rule – need contraception for the first 7 days
Counselling or if missed for 24 hrs
action  If you miss a pill and there are less than 7 active
 inhibits ovulation pills in the pack, go straight to a new pack
 cervical mucus changes  reduced efficacy if Abx / other meds / gastro upset
 decreased receptivity of endometrium  COC for contraception only – still need safe sex
▪ 95% efficacy practices with unfamiliar partners
 try linking taking pill with a daily habit
▪ make sure patient understands !!!

Counselling for emergency contraceptive pill

Hx
 how many hours ago had unprotected sex
 condom use? Usually use condoms?
 Sexual Hx Counselling
◦ do you have a regular sexual partner?  Only effective in first 72hrs
◦ Other sexual partners?  Not 100% effective
 Have you used other contraception?  Side effects – what to expect
 Menstrual Hx  nausea and vomiting – need to take again
 abdo pain
 “I'm gonna give it to you, but lets talk”  fatigue
 headache
 dizziness
 Needs follow up
  Should not be used as a regular contraception • STI screen or agree to full screen on follow up
• don't let them leave without contraception
Health promotion • Pap smear
Heavy + Irregular Bleeding

Hx
• Gyn Hx Menorrhagia
 LNMP DDx
 Cycle • ectopic
 Volume • growths
 IMB • fibroids / polyps
 Pain: related to bleeding? • endometriosis
 pap smear • tumours
 COC/HRT • IUD / COC
 Post Coital Sx • PID
• Fe tablets • Systemic
• Polycystic ovaries PCOD
 Contraception • Hypothyroid
 STIs + sexual activity • Bleeding diseases
 PMHx: thyroid, anaemia, bleeding, cancers • fat fat fat
 pelvic operative or problems
Metorrhagia
 FHX
DDx
 Meds, allergies
• OCP / IUD
Examination • Fibroids / polyps
 PE for masses / tenderness • PID
 Spec for infection / trauma • Endometriosis
• Cancer
Ix • Pregnant
 Pap smear for CIN
 Swabs for C + G
 HVS for other infections
 Pelvic U/S: fibroids, pregnancy, polyps, cancer
 bHCG
• bloods: FBC (HB, WCC)
• Fe studies
• Clotting studies
• TFT
• progesterone
• MSU U/A
• Hysteroscopy, SHG, CT

Perimenopausal irregular bleeding

Sx of menopause  pap smear
 hot flushes
 mood changes
 libido changes DDx
 poor sleep • HRT break through
 vaginal dryness, dyspareunia • Atrophic
contraindications to HRT • Cancer
 breast cancer
 liver disease
 DVT/PE
Counsel about HRT
Ix  risks
 benefits
 oestrogen  side effects
 FSH  mode of delivery (tablet, patch, cream)
  oestrogen only vs combined
 LH Counsel about natural therapies
 TFTs  phyto-estrogens
screening  evening primrose oil
 CVS risk factors ▪ red clover
 mammogram
 bone density
 Low grade 30+yr, no negative
CIN Cytology in 3yrs =
immediate colp or
Biopsy repeat pap in 6m
CIN I: atypical cells in lower third of epithelium
CIN II: lower 2/3 repeat pap
CIN II: full thickness / carcinoma in situ in 12m

Risk factors:
• Early first sex
• Multiple partners Negativelow grade high grade
• A partner with multiple partners
• SMOKING
• ICP
Repeat pap Any
Transformation zone: everts in puberty  acid  In 12m Glandular
columnar becomes squamous Colposcopy findings
HPV 16, 18, 31, 33 high risk
• HPV clearance is 8-14months
• Gardasil does 6, 11, 16, 18
Negative
Squamous
• most low grade lesion regress quickly (10 months)
• low grade  high grade ~8years
• cancers develop over years from CIN3
• many CIN2/3 spontaneously resolve Routine
screening
Glandular
• very rare
• leads to adenocarcinoma Post treat follow up of CINII + CIN III
• 26 = atypical glandular cells, no Sx  immediate After treatment
colposcopy • colposcopy at 4 months
• paps at 4, 12, 24 months
• GP HPV typing at 12, 24 months
• If paps + HPV negative  2yr routine testing
 Fibroids
Counselling Ix
• benign smooth muscle tumour • Examination: uterus enlargement
• in 20% of reproductive women • U/S: if large enough
• grows with estrogen and shrinks away with • HSG
menopause
Mx
Hx • Watch it
• obesity • Hormones: mirena, Xoledex
• pregnancy • But not permanent
• HRT, COC, tumours • Myomectomy
• Sx • Less invasive than hysterectomy
• Menorrhagia, pain, fullness • Keeps some fertility
• Urinary Sx
• Subfertility

Endometriosis
Hx Mx
• nullipara • NSAIDs + analgesia
• 35-45yo European • Hormones (↓ estrogen)
• FHx • GnRH analogue: Zoledex)
• Sx ◦ Maximum of 6 months
• Pelvic pain  back / flank • OCP: monophasic
• Dysmenorrhoea: starting days before and • Progestin’s: Mirena – effective
worsening • Danazol (testosterone analogue)
• Dyspareunia (esp in period) ◦ Not very good
• Menorrhagia • Surgery:
• Urinary + bowel Sx • laproscopic, but relapse is common
• PMHx: problems conceiving ◦ Very effective in severe cases
• hysterectomy
Examination
• Abdo: tender abdomen Counsellng
• PE: • lining of uterus develops outside the uterus
• Nodular utero-sacral ligament ◦ 15% of fertile women
• Tender uterus + adnexa ◦ 40% of subfertile women
• Fixed, retroverted uterus ◦ not everyone with it has problems
• Adnexal mass = endometrioma • Px
• Watch+wait: conception is 55-75%
Ix • 1/3 relapse in 5 years
• U/S for endometroima (choc cyst) • lap: 66% show improvement
• Lap: grey / red lesions • stops with menopause
• Adhesions • support groups
• Café au lait spots

Polycystic ovarian syndrome • masculine traits

Sx
• virilization Ix
◦ hair: male pattern baldness, hirsutism • bloods
◦ acne • ↑↑LH (but no surge)
◦ voice changes • Normal estrogen, FSH
◦ muscle growth • ↑ testosterone
• oligomenorrhoea + infertility • U/S
• ↑insulin + insulin resistance • Ovaries >8cm
• obesity • >8 cysts
• echogenic stroma
Examination Mx
• stimulate ovulation, resect ovaries • electrolysis + Anti-androgens + Diane-35
• weight reduction • Metformin

Amenorrhoea • PMHx
DDx • Thyroid
Pregnancy + lactation • Steroids/pred
Primary or Secondary • Radiation / pelvic surgery
• hypothalamic • FHx of menstrual problems
• anorexia • OHx / lactation + pregnancy
• exercise, stress • Menopause?
• Cushings • Weight change, exercise, diet
• Pituitary
• Sheehans syndrome Examination
• Adenoma • Height + weight
• Thyroid • Thyroid Examination
• Ovary • Cushings: obesity, HTN, striae, thinning hair,
• PCOD hirsutism
• Premature ovarian failure • Breast + hair development
• XO • Full PE
• Tumours
• Uterine scarring: Asherman’s syndrome Ix
• Imperforate hymen • TFT
• Prolactin levels
Hx • Sex hormones
• Puberty milestones • Progestin challenge
• Gyn Hx if secondary amenorrhoea • U/S for pregnancy, mass
• Thyroid screen • bHCG!!

Pelvic pain + Dysmenorrhoea

chronic
Hx • 2ndary dysmenorrhoea, IUD
 menstrual Hx • Gyn:
 LMP • Endometriosis
 Regularity • PID
 Cycle length • Cancer
 Duration • Adhesions
 Relation to pain • Non-gyn:
• Pap, post-coital Sx, OCP • Diverticulitis
• Other Sx
• Urinary Sx / bowel Sx
• discharge or burning Examination
• Fevers, sweats, weight loss • Vitals: signs of infection or shock
• OHx • Pelvic Examination
• Pregnant • GIT Examination
• Subfertile • Weight + lymphadenopathy
• PMHx
Ix
• Smoking
• Urine
• Gyn problems / cancers / operations
• U/A + Chlamydia culture
• FHx: gyn cancers
• bHCG
DDx • bloods
Acute • FBC: HB + WCC (left shift etc)
• Primary dysmenorrhoea • ESR
• Gyn: • Blood cultures
• PID • Swabs (Chlamydia, HVS, ECS) for culture and pap
• Torsion of fibroid / ovarian cyst • Pelvic U/S
• Pregnancy (ectopic, MC) • AXR
• Non-gyn:
Counselling for primary dysmenorrhoea (adolescent)
• Appendicitis
 advise that change 5 months after menarche is due
• UTI / cystitis
to ovulation and is normal
• Diverticulitis, IBD, IBS etc
  very common at this age, often incapacitating -
>50%, 10% are incapacitated
 recognise and is sympathetic to nature
 explains likely to go or improve with first pregnancy
Mx
 suggest meds taken monthly at onset or just prior
to period
 name meds: ponstan, aspirin, NSAIDs
 asks about vomiting – suggest taking meds a day
earlier
 discuss COC if these don’t work
 Ask if sexually active and ask about contraception
 Advise would be good to do a check for STIs, offer
at least PCR screen - urine, vaginal swab for C +
G
Early pregnancy bleeding Hyperemesis
Severe N+V in 1-2% of pregnancies
Hx • peaks at 8-12wks, gone by 20wks
• LNMP • mild - <2 vomits/day, some ketones, needs anti-
• Bleeding emetics
• Amount, clots, placenta • severe - >2 vomits/day, much ketones, needs IV
• Colour hydration
• freq, onset • Ix: MSU (ketones)
• pain • U+E (hydration)
• Faintness, shoulder tip pain • U/S: exclude mole / multiples
• Pregnancy Sx: vomiting, nausea, breast pain • TFT if suspect
• CONTRACEPTION • Mx:
• Sexual active • Small meals
• PMHx • Multi vitamins
• STIs or PID • IV Hartmann’s if severe
• pelvic surgery, sterilization, IUD • Metoclopramide (Maxalon) is category A :
• Prior pregnancies + OHx better
• Meds, allergies etc • Stemetil is category C

Examination
• Vitals
• Abdo palp: for Fundal height vs gestation
• Spec
• Is there cervical dilatation?
• Fibroids, polyps etc
• Bi-manual
• Doppler
• Fetal heart at 5wks
• Fetal pole at 6wks

Ix
• U/S
• Empty gestation sac: fetus should be visible
>25mm
• Pseudo sac : ectopic
• Pole but no FH
• Empty uterus : ectopic / complete MC
• Bloods
• FBC, G+H, Xmatch, quants, Rhesus
• Spec: HVS + ECS for STI/CIN
• U/S: sac, pole, FH
• Urine: MSU U/A + bHCG

Mx
• Expectant
• Misoprostol
• D+C
• Anti-D
 • • OPEN CERVIX
FH+
DDx
• Miscarriage Incomplete (some retained products)
• Ectopic • Sx
• Molar pregnancy • Bleeding +++
• Not pregnant: trauma, infection, cancer • Pain +++
• Mx: expectant ok if <15mm on TVS

Miscarriage <8 weeks Missed (>4 weeks after)

• Sx
Threatened • Amenorrhoea / spotting
• Sx • No fetal movements
• Bleeding but FH+ • Examination
• Abdo cramps • No uterine growth
• Examination • Regression of hormonal breast changes
• CLOSED CERVIX
• Soft, non-tender uterus Septic (Emergency )
• Appropriate size • Temp >38
• Mx • Foul smelling discharge
• 75% settle: try bed rest
• watch out for PROM Molar
• Benign, proliferative, cystic growth
Inevitable • Presents like miscarriage
• Sx • HUGE bHCG
• Bleeds • No embryo, no sac
• Painful cervical contraction
• ± ROM Councelling
• Examination • 50% of EPL is for a chromosomal abnormality

Ectopic Pregnancy • U+E: hypovolaemic

Hx
• Smoke DDx
• Infectons • Torted / rupture ovary / fibroid / cyst
• STI or PID • Threatened miscarriage
• Endometriosis • Appendicits
• Pelvic surgery • PID salpingitis
• TOP, D+C •
• Ectopics
• IUD
Counselling
Sx before rupture • What it is
• Amenorrhoea / missed period • Of early pregnancy bleeding, ~10% have ectopics
• Dull unilateral, colicky pelvic pain • 10-20% will have another ectopic: more if ‘infertile’
• PV spotting: brown • 50% will have a normal pregnancy
• Examination • 30% will become sterile
• Adnexal tenderness + mass
Mx
Sx after rupture = EMERGENCY • IM/local Methotrexate if
• Acute suprapubic / abdo pain  chest / shoulder • Tubal
• Examination • <35mm
• Peritonism + gaurding • no fetal cardiac activity
• Blood loss + shock • bHCG <10,000
◦ Pallor, ↑HR, ↓ BP, clamminess, faint • not ruptured
• laparoscopic salpingectomy or salpingotomy
Ix
• bHCG: high
• U/S: no gestational sac
• Empty uterus ± pseudosac
• if shocked:
• FBC: septic, acidosis

• must
Termination of pregnancy • be <20wks
 • counselling by 2 medical practitioners • <14wks surgery
• if >20wks, needs panel approval • suction curette
• if <16yo, one parent must be informed • D+C with forceps
• Risks of surgery
Hx • >14wks medical
• GHx • PV Misoprostol
• Support systems • SE: vomiting, diarrhoea, abdo pain, fever,
palpitations
Counselling • may need general anaestheic removal of
• Discuss the options: keep baby, foster/adopt, TOP placenta
• Discuss contraception!!!
• Period may take 4-6wks to return Risks
• Pregnancy test stays + for 3wks • failure rate is low
• Victims of sexual assault • haemorrhage
• Consent (<16) • infection
• Less risky <12wks • trauma: cervical tears, uterine perforation, bowel
injury
Ix • retained products
• Confirm pregnancy • later:
• Confirm dates (LMP / U/S) • cervical incompetence
• Rhesus group, G+H • infertility
• psych: grief, regret
• sexual + relationship difficulties

Follow up: 2 weeks

Mx
37F infertility
 identify importance of both partners  STI
 acknowledge a stressful issue  UTI
 testicular injury/infection
Female Hx  varicocoele
 primary or secondary – for how long  undescended testis
 contraception Intake:
 timing and frequency of intercourse  smoking
 menstrual Hx: full, with dysmenorrhoea,  drugs
dyspareunia  ETOH
 galactorrhoea, hirsutism
PHMx: Counselling
 renal disease Age
 thyroid disease  fertility drops rapidly from 35ys
 PID  >35 yrs genetic issues like trisomy
 STIs
 peritonitis Ix
 endometriosis  semen analysis
Intake: ◦ 2 types
 Meds ◦ abstain from intercourse for 3 days
 drugs ◦ needs to attend for an appointment
 smoking  confirm ovulation
 alcohol ◦ day 21 progesterone, measure FSH/LH,
Male Hx serum prolactin, TFTs, basal body temp,
 pregnancies to other partners cervical mucous change
PMHx:  referral for tubal fx Ax – lap and dye, or a HSG

Antenatal Care  any PV blood loss

 baby’s movement pattern changes
If worried about age, ask about  constant headache / visual disturbances
 folic acid supplements before/during preg
 multivitamins during Scans and screens
 FHx: congenital abnormalities  not all inheritable diseases can be picked up
by the tests – examples and %
Booking tests  discuss in a realistic fashion what screen can
• Hb and cannot offer
• Blood group, Rhesus, antibodies
• Rubella titre • 6-7wks : dating scan
• HBV / HCV / HIV  11-13wks : first trimester screen
• Syphilis • for Downs syndrome
• Chlamydia • nuchal folds : 70-90% sensitive
• MSU: U/A • FALSE + 3.8%
 11-14wks : chorionic villus sampling
Routine Ax  optional: for anomalies
• Weight  much more accurate
• BP  1-2% MC risk
• U/A  15-17wks : maternal serum screening “triple test”
• Pelvic Examination • downs + neural tube defects
 fundal height to monitor fetal • with age, gestation, bHCG, aFP, oestriol
growth • 60% sensitive
 lie to ensure longitudinal • more sensitive in women >35, so more likely to
 presentation to exclude pick up abnormalities
malpresentation  15-17wks : amniocentesis
 liquor volume to ensure adequate  more reliable, but risk is higher
 fetal back for fetal position (from 36  0.5% MC risk
weeks)  18-20wks : anatomy scan
 descent of presenting part into pelvis • for fetal age + anomalies
 fetal movement for wellbeing (from 16 • placenta location
weeks)
• 28wks
When to come to hospital • Hb
 when membranes rupture • Anti-D + rhesus antibodies
 regular contractions (every 5 minutes) • GTT / GCT as needed
 constant abdo pain
• 36wks • ±Hb
• Anti-D • LVS + rectal swab for GBS

Rhesus isoimmunisation
• after 2-3 weeks: will need to retest
Antibodies ◦ + : still in blood, fine
• surface glycoprotein D (and others) ◦ - : needs more anti-D
• No risk = LEB, LEA, LEP ◦ +++ : really needs anti-D
• Medium risk = other
• High risk = K (attacks marrow), D, c, E

risk 15% are D negative, but babe is unknown

• Need group and antibody screen Sources of isoimmunisation
• if antibody screen is + 1 any bleeding in pregnancy
→ type antibodies (take twice as much blood) ◦ TOP, miscarriage
◦ threatened miscarriage
First baby
◦ ectopic pregnancy
First, take a Hx
◦ delivery
 obstetric screen (told N if unimportant)
◦ PV bleeding >12 weeks
 is father neg or pos?
◦ amniocentesis, CVS, ECV
2 blood transfusions: organ transplant + trauma
Counselling Rhesus
3 IVDU
“Your baby's blood group
is a combination of the
mothers and the fathers
blood groups” Second baby Anti-D titre 1:32
If babes blood get meets First, take a Hx
yours, mum's body sees • first pregnancy – how was it?
that babe's blood is • Any bleeding? ECV?
different, your body • Rhesus of mum, dad, babe
makes antibodies to get • Any Mx, when was it given? - during pregnancy or
rid of them. during birth
• How was birth?
This won't do much to the • Any phototherapy needed?
first baby, but can hurt
the second Positive baby. Maternal antibodies remain in neonate for 12 weeks
Mum's antibodies cross the placenta and break down 2nd
baby's blood. Rh disease therapy by severity
mild
Explain the plan.. • fetal anaemia
When is prophylactic anti-D needed?
• jaundice at delivery
• At 28, 34, 36 weeks
◦ mild use lights
• with any bleeding or trauma
◦ severe use many lights and biliblanket
• with any amnios or CBS
◦ can cause kernicterus and CP
• with MC or delivery
• exchange transfusion: O neg
Routine screen at 28, 34, 36 • top up transfusion for 6-8 weeks
higher risk of sensitisation in • in utero transfusion (intravascular)
Caesarean Section severe: hydrops: dead
manual removal • Most babe have mild disease
• abruption • With each subsequent pregnancy, jaundice
• needling appears 10 weeks earlier
• threatened MC
Ix before anti-D
625U at 28 and 36 weeks antibody screen
Within 96hr of onset of bleeding Kleihauer test: for fetal blood in maternal circulation, and
1st trimester 250IU how much Anti-D needed
2nd/3rd trimesters 625IU
Screening
Bleeds occurring soon after Anti-D needle booking and 34/40
if <10IU/ml disease unlikely, recheck every 2 weeks
• anti-D in maternal circulation depends on what it
if >10IU/ml investigate
has to bind to (babies blood)
• more babies blood in mum = Anti-D used up Ax severity in utero
sooner Ax haemolysis with amniocentesis if titre >1:8
• 1 week after Anti-D given: should be fine
All neonates of Rh- mother need • bilirubin
• FBC • indirect coombs
• Rh group
• film

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

Pre-eclampsia
Ix
Counselling • MSU for U/A
Complications • Bloods
• Mum • FBC: platelets + MCV
• CNS • U+E (creatinine, uric acid)
◦ Eclampsia • LFTs (AST)
◦ CVA • CTG + biophysical profile >28wks
• Liver/blood • U/S (AFI, weight)
◦ HELLP
◦ DIC / bleeding (thrombocytopenia) Mx
◦ Liver rupture • Can manage as outpatient if mild
• Kidneys: renal failure • BP 140/90 < > 160/110
• Pulmonary oedema <5g/d proteinuria
• Retinal detachment Asymptomatic
• babe • BP + U/A twice a wk
• IUGR • U/S every 2 wks
• Placental abruption • Admit if:
• Distress + death • >160/110
• >5g/d proteinuria
Hx • symptoms
• Sx • fetal compromise
• Neuro: headache
• CLONUS, REFLEXES -- 1 BP control
• Nausea, vomiting, RUQ pain • Nifedipine  Hydrazaline
• Gestation (>20wks) • Maintenance = methyldopa
• ± multiples • Useless for mild PE
• GP (Nuulipara at risk) • Keep >140/80 for placental perfusion
• Prior PE with same partner
• Family Hx 2 MgSO4
• SMOKING + obesity • When: persistently high BP with drugs
• PMHx • CNS dysfunction or HELLP
• HTN • Monitor for
• DM, renal • ↓Deep tendon reflexes
• Clotting disorders • RR <12
• UO <30ml/hr
Examination
• BP Delivery
• Oedema (may not find) • Waiting is only for fetus
• Neuro : clonus + reflexes • Deliver if
• Fundi • >34wks
• Abdo Examination for pain • Fetal compromise
• Uncontrollable HTN
• Eclampsia
• DIC
• HELLP
• CVA

Eclampsia • pre-eclampsia  eclampsia in <1%

• Tonic-clonic seizure, 60-90 seconds
•  cerebral haemorrhage, renal failure, hepatic Mx
failure • ABC, remove danger, don’t restrain
• IV MgSO4 4g in NS over 5min • ANY Haemolysis
• Monitor RR • ↑LFTs: ALT, LDH twice of normal
• Diazepam can depress fetus • ↓ platelets <100
• Hydralazine: boluses PRN every 20min if >160/110 • Mx
• Deliver with epidural • Platelet transfusion antenatal / postnatal
• Prednisalone
HELLP
• 1-2% maternal mortality
• severe if

Gestational DM Complications
Hx • Mother
• Risky people • DKA
• GP + gestation • Pre-eclampsia
• Age >30yo • Pregnancy
• Obesity • Polyhydramnios  PPROM
• Ethnicity (aboriginal, asian, middle eastern) • Preterm labour (50%)
• Family Hx of DM or GDM • Obstructed labour
• This pregnancy: • Fetal
• HTN before 20wks • Congenital abnormalities
• polyhydramnios ◦ Cardiac + neural
• Past pregnancies • IU death
• Unexplained stillbirths • Neonates
• Past GDM • RDS
• Macrosomic babies • Hypoglycaemia
• Sx: • Hypocalcaemia
• Thirst • Fetal hypoxia  polycthemia + jaundice
• nocturia
Mx Plan
Examination • Educate: see DM nurse
• BMI • Diet: 5-6 low GI meals/day
• Fundi • Limit energy if obese
• Abdo palp + spec • Exercise: 30min/day
• fetal height (macrosomia) • Not working after 2 wks:
• polyhydramnios • Insulin: 4 injections/day, 4-8U
• Usually before meal or at night
Ix
• MSU U/A for glucose Monitor
• Glucose testing • BGL: self monitoring
• If low risk: 24-28wks : glucose challenge test • Aim: <5.5 fasting
• If high risk: • <7.0 2hrs post food
• Random BSL <24wks • Once a trimester bloods
• >5.5  glucose tolerance test ASAP • HBA1c
• <5.5  GTT can wait until 26wks • TFT
• Always GTT if symptomatic or macrosomic • U+E, LFT
• Ophthalmologist
• podiatrist
• U/S
• 1st trimester screen ~11wks
• anatomy ~18-22wks
• fetal growth/AFI scan ~34
• ± ~37 if suspect macrosomic

Thromboembolic disease 10-20x in caesarean

Hyper-coagulable state
↑clotting factors Hx
↑ fibrinogen age >35
obesity
↓ fibrinolysis
Pregnancy:
stasis in lower limbs
GDM
trauma to pelvic veins at delivery
Pre-eclampsia
current infection
Risks
grand multipara
12x in pregnancy
 emergency CS in labour Ix
3 days of bed rest Duplex doppler for femoral v
PMHx: Venography has radiation – only use if doppler fails
Thrombophilia VQ scan for PE (even with the risks) – good negative
Previous TED value
Family Hx of clots
Mx
Sx SC Heparin, 20-40mg/day
Red, swollen leg TED stockings
Lower abdo pain (iliac v) 6-12 wks anticoagulation
PE (SOB, cough, pleuritic pain)  then screen for thrombophilia

Caesarean section Injury to pelvic structures

Indications Bladder
Obstructed labour, Cephalopelvic disproportion Uterus
Placenta previa Colon
Fetal distress ureters
Severe PE or DM Thromboembolism
IUGR Both epidurals + general have risks
Malpresentations Risks to fetus
FTP Cut by scalpel
Dystocia ↑ transient tachypnoea of the newborn
Prolapsed cord
Twins / higher order multiples It will have an effect on delivery of the next pregnancy
Prior CS Long term risks
Some congenital malformations: hydrocephalus Abnormal placentation
Maternal HIV, herpes Scar complications
Uterus Rupture
The procedure: yeah, that’s not happening
Post operative instructions
Consenting Early mobilisation
There are some risks with any surgery. Early oral intake
They’re very unlikely, but I want to let you know Watch for oliguria
Infection Monitor BP
Endometritis Opioids analgesia  NSAIDs
Wound infection Staples out 3-7 days later
Bleeding: PPH No heavy lifting/squatting for first 2 weeks

VBAC counselling Success rate 55% at KEMH

↑ success
Benefits • elective ceasareans for non-recurring problems
• Less incidence of o breech
◦ tranfusions o cord prolapse
◦ bleeding • prior vaginal deliveries
◦ hysterectomy • normal BMI
◦ infection • smaller baby size
• shorter hospital stay • spontaneous labour

Risks ↓ success
higher incidence of rupture: 1 in 200 • cephalopelvic disproportion
higher with assymptomatic deherence • obstructed labour
0.5% hysterectomy rate • induction of labour
0.07% perinatal death rate stillbirth • malposition
Complications of surgery (very uncommon) • high BMI
infection
bleeding Contraindications
organ damage • >2 CS
anaesthetics • placenta previa
• malpresentation • Adequate pelvis
• CPD • No other uterine scars or previous rupture
• classical CS • Physician immediately available
• prior rupture • Anaesthesia and personnel available for
• uterine surgery- hysterotomy, myomectomy emergency c-section
• high BMI >35
• ?twins Mx
CTG, esp IOL
Trial of Labour: Epidural is safe (can still feel rupture)
• Only 1 previous LUSCS Manage prolonged labour
Antepartum haemorrhage Placenta Previa Placenta Abruption
PV bleeding >24wks Small bleed = small shock Huge shock for small loss
No pain Constant pain
DDx Non-tender Tender uterus
Placenta previa Normal fetal heart Fetus distressed
Placental abruption Small bleed  large bleed Beware of DIC
Show Abnormal lie Can be concealed
Cervicitis Non-engagement
trauma
Mx
Placental abruption
Hx
• Syntocinon IV or ceaser
Bleeding
• Transfusion / platelets / FFP
Onset
Amount (pads?) • IDC
Trauma, post-coital Placenta previa
Bright, dark, clots, watery If LLP at 24wks : rescan at 30wks, 34wks
Has it settled Can discharge if no further bleeding
Pain or tightenings If stable, can go to 36wks
Fetal movement: normal or reduced Vaginal delivery ok if placenta is >2cm from
Happened before? margin
Placenta previa
Past pregnancies: APH, other problems, CS
Placenta Previa
Examination • Minor
ABCDs  Haemodynamically stable? o Lower segment
Pallor, vitals, CRT o Marginal: of internal os
Abdo palp • Major
Fundal height, lie, presentation o Partial: partially covers os
Descent (for PP) o Complete
Tenderness, tone (for abruption) • At 24wks: 5% have low lying placenta
Fetal heart (BAD abruption) • 9 in 10 move away when lower segment forms
NO VE or SPEC UNTIL PLACENTA FOUND • PP grows too quickly for the isthmus and shears
Risk Factors
Ix Multipara, multiples
• U/S for fetus and placenta location VBAC
• CTG (will be ↓ in abruption)
• Speculum + swab Abruption
• IV access Risk Factors
o G+H SMOKING
o Coags, FBC, Rhesus ABs PE/eclampsia
o Fluid resuscitation Renal disease
o analgesia Rapid uterine growth: polyhydramnios, twins
Infection
Trauma
VBAC
Post term Induction of labour
Post term = >42weeks Indications
5-10% 41 +3 wks
RFs IUGR
Nullipara PE
Previous post term Hydrops
FHx TTTS
Severe HLA
Complications Severe maternal medical condition
Maternal
Difficult labour Contraindications
Perineal tears • CPD (absolute)
↑ CS • Malpresentation (not breech/face)
fetus • Fetal distress
macrosomia • Placenta previa
placental insufficiency • tumour
fetal distress • cervical surgery
prolonged labour
meconium Risks
• Infection
Mx
• Bleeding
get accurate gestational age
biophysical profile • Cord prolapse
fetal HR • Uterine rupture
contraction stress test • PPH
Timing: 38-39wks if high risk, look at • CS + instrumental delivery
fetal Ax: fetal compromise, ↓AFI,
oligohydramnios Ripen Cervix
Cervix favourability: Bishops 95% of term cervixes are ripe
IOL with unripe cervix: prolonged labour, distress, CS
-3 -2 -1 Use Foley catheter unless medical reason for using PG-
Station E2
0 1 2 Monitor
0cm 1 -2cm 3-4cm Foleys:
Dilation Check every 2hours
0 1 2 If falls out after 12 hours – review
3 2 1 Maternal: vitals 4hrly
Length Fetus 4hrly, CTG only if concerned
0 1 2 PG:
Firm Medium Soft Every4 hrs
Consistency Needs CTG!!
0 1 2 DO NOT use PGE2 if
VBAC
Posterior Mid-position Anterior
Grand multip
Position
Cephalopelvic disproportion
0 1 2
High fetal head
Abnormal trace
Severe asthma (constricts)
Favourable
>7 : low risk of IOL failure
Mx of Hyperstimulation
 membrane sweep then IOL when ready Stop oxytocin
good fetal monitoring Remove catheter / gel
Tocolysis (Terbutaline)
Unfavourable
<7 Artificial Rupture of Membranes
use cervical ripening agents CTG monitoring needed
IOL with Foleys catheter or PG-E2 Syntocinon 10mg, start at 6/hr, double every 30 mins
Good fetal monitoring Until contractions 4:10
Breech presentations • CTG + U/S
• Tocolytics + anti-emetic + anti-D
50-70% extended • Monitoring
5-10% flexed • can’t do it if
10-40% footling • Absolute
◦ Multiples
Risk Factors ◦ APH
• prematurity ◦ ROM
• extended legs ◦ Placenta previa
• uterine anomolies ◦ Concerning trace
• placenta previa, fibroid, twins • Relative
• fetal anomoly – hydrocephalus, anacephalus ◦ Pre-eclampsia
◦ VBAC (lower segment only)
Counselling
◦ Rhesus –ve
• may still turn itself
◦ Anterior placenta / obese
• 16% at 32/40
• 3-4% at term Can you have a breech vaginal birth?
• Risks of a breech delivery • Adequate pelvis
• cord prolapse • 37-42wks
• entrapment of head behind cervix  asphyxia • EFW 2500-3700g
• intracranial haemorrhage • Extened or flexed breech only
• trauma to spleen etc • Flexed head
• Normal labour
External Cephalic Version – 36-37 weeks
• ±VBAC
success rates about 50%

Tears + episiotomy • bleeding

Risks • infection + tissue breakdown
• macrosomia • haematoma
• precipitant labours • pain
• poor head flexion
• dystocia
• forceps Twins
• narrow arch Antenatal care
• U/S at 11wks
1st degree: superficial only
• To confirm
2nd degree: involve perineal muscle: suture in
• Viability
delivery suite
3rd degree: involve anal sphincter: send to theatre, • Chorionicity
needs GA + ABx • Nuchal folds
4th degree: rectal mucosa • Regular ANC more frequent
Post-op: high fibre diet + faecal softeners for 10
days TTTS
• MC twins
Prevention
• massage Analgesia
• episiotomy Nitrous

Problems with episiotomy

•
Preterm labour VE ONLY IF CANT SEE CERVIX
Labour = coordinated uterine contraction + cervical
dilation + effacement  fetus + placenta expelled
1/3 from wrong dates DDx of TPL
Cervical incompetence : no contractions
Preterm uterine contractions : no cervical
Hx change, self limiting
• GP
• Confirm gestation (by dates / U/S)
• Contractions
• Onset Ix
• Duration + Frequency in 10 minutes Swabs
• abdo tightening / lower back pain / pelvic Fibronectin (good if negative)
pressure HVS, LVS, ARS for culture
• PROM or APH Other
• Rhesus status Urine: U/A, MCS
U/S: fetal size, position, placenta
• Placenta previa
• Infection Mx
• fever 50% cease spontaneously
• urinary Sx 1 expectant (>34 wks)
• Abdo tenderness Maternal / fetal need
• PMHx / Meds / FHx Chorioamnionitis
• HTN GBS +
• obesity APH
• anaemia IUGR
• Social risk factors Labour gone to far
• Age <18 or >40
• SMOKING 2 intervention (24-34 wks)
Steroids
• ETOH
Betamethasone IM at 0 + 24hrs
Tocolysis
Exam
low success if ROM or >4cm
Vitals: BP, pulse, temp
Nifedipine
Abdo palpation
Blocks oxytocin + PGs
FH, lie, pres, liquor, uterus tone
Not with MgSO4, low BP
Doppler for fetal heart + wellbeing
Salbutamol
CTG if
Monitor
More than 1 : 10
U+E, LFTs
>30 weeks
30minly BP, HR, RR
want pain relief
CTG continuous
Spec: >1cm dilation, >2cm effaced
Abx
Look for ROM / blood
GBS = Pen
Swabs
UTI = Cephalexin
PROM o Fern test
2-3% of deliveries
prolonged PPROM >18 hrs until labour Ix
• U/S:
Hx • AFI
• gestation • Fetal wellbeing
• GP (multigravids) • Infection:
• Rh status • FBC (WCC, CRP)
• Hx of fluid • Genito: LVS (GBS), HVS (if purulent)
• Sudden Gush of fluid / bloody show • ± urine for U/A, MCS
• Sensation of wetness
• Blood Complications
• Contractions / tightenings • Preterm delivery (most deliver in 48hrs)
• infection • Infection (chorioamnionitis)
• fever • Cord prolapse
• PV/PU blood • Placental abruption
• Abdo tenderness
• Cervical surgery/incompetence Mx
• Status of mum + fetus (Hydramnios) • Give antibiotics (IM erythromycin)
• FHx/PMHx or PROM • >34/40 Induce labour after 12 hours
expectant Mx
Examination • 24-32 Abx + steroids ± tocolytics
• Abdo palp: FH, lie, presentation, position, FMF (Nefidipine)
o Uterine tenderness, irritability, • 18-22 Waiting can risk infection
contractions
• Doppler: Fetal Heart Chorioamnionitis
e.coli, GBS, anaerobes
• Temp, BP, pulse
Sx
Confirm ROM • Fever
NO VE • Uterine tenderness
• Speculum: • ↑HR (mum>100 or fetus >160)
o Pooling of amniotic fluid in posterior fornix • leukocytosis: daily (also rises from steroids, labour)
o Fluid with valsalva manoeuvre • offensive liquor
o Dilation / effacement of cervix • Mx Bloods, IV Abx, Labour ASAP
• Swab:
o Amnicator + fibronectin: only negative is
useful

Post Partum Haemorrhage

 past caesarean
Top Ddx  prolonged labour – how long was labour
 retained placenta  2nd degree tear – any tears
 atonic uterus  Assessment
 vaginal tear  vital signs
 ruptured uterus  amount of blood lost

Mx of PPH shock
If not given, ask for:  call for help (Dr or midwife)
 name  recognise that this is a medical emergency
 G&P (hypovolaemic shock)
 gestation  airway, breathing, circulation
 PMHx  give oxygen
 meds  elevate legs
 allergies  ask about IV access + organise large bore
cannulas
Essential info to ask for  order IV fluids, crystalloid, rapid
 is placenta delivered and complete infusion/bolus
 estimate of blood loss
 asks if syntocinon / ergotamine Specific Mx of PPH
 massages uterus or organises it
Hx 
 Risk factors:
 empty bladder: IDC insertion
 blood for Xmatch + FBC
 orders misoprostol 1000mcg / syntocinon infusion
 gentle traction to deliver placenta
 pad + pressure to vaginal tear  repair
Further measures
 bimanual compression, P F2a, balloon catheter,
laparotomy (B-Lynch suture), internal iliac ligation

Neonate first aid

Predictors Blue, inadequate breaths, HR>100
• fetal distress on CTG • rub + dry
• mec • ± suction to open + clear airway
• low scalp pH • CALL FOR HELP
• preterm • no response → ventilate
• instrumental delivery
Meconium + non-vigorous, HR<100
Ax of baby • DO NOT rub or dry
• colour: pink / blue / pale • assess airway
• breathing: adequate? • intubate and suction (or suction under direct vision)
• Heart rate: should be >60/min – umbilicus or apex • THEN rub and dry
• reassess
Pink, regular breathing, HR>100 • ventilation
• keep warm + dry
• pass to folks Pale, shocked, apnoeic, HR<60
• maintain airway
Blue, breathing, HR<100 • reassess HR
• rub + dry • no response to ventilation → add cardiac
• Reassess compressions
• ± open + clear airway • no improvement → adrenalin
• bag and mask 30 breaths in 30 seconds ◦ >34/40 1ml of 1:10,000
• reassess after 30 seconds ◦ <34/40 0.5ml of 1:10,000
• blood loss or poor perfusion → 10ml/kg in 1-2min
via UV

Neonatal respiratory distress

Clinical features • GDM
• General wellness: colour • Twin 2
• Signs of infection • FHx of HMD
• ↑ or ↓ temperature • ↑ over 12-24hrs
• Tachytachyhypo • hypothermia
• • Mx: O2 + assisted ventilation (CPAP, IPPV)
• Resp distress: • Surfactant therapy
• RR>60 • Keep sweet + warm
• Central cyanosis
• Recession DDx
• Flaring • Hyaline membrane disease
• Grunting • Transient tachypnoea of the newborn
• GBS pneumonia
Ix • Mec aspiration
• bloods • Pneujmothorax
• U+E
• FBC (Hb, WCC)
• BGL TTN
• Culture • In caesareans + maternal analgesia
• Gastric aspirate MC/S • Mild resp distress, not ‘ill’ looking
• Ear swab MC/S • Lasts 1-2 days
• CXR • Mx: ± 30% O2
• HMD: ‘ground glass’ + bronchograms
◦ Pneumonia looks the same GBS/E. coli pneumonia
• TTN: ‘streaking, wet’ lung • Severe, rapid
• Mec: hyperinflation, consolidation • Mx: Amoxycillin + Gentamicin

HMD Mec aspiration

• few T2 pneumocytes for surfactant, small lung volume, • Pulmonary HTN
causes collapse and shunt • R-L shunting
• In: • Mx: O2 ± CPAP
• <30wks • Abx
 ◦ O2 concentration >40%
Pneumothorax ◦ inflammation
• Worsens if not treated ◦ poor nutrition
• Mx: intercostal catheter + underwater drain • Linked to HMD
• Presents with
chronic lung disease ◦ becoming O2 dependent on ventilator
• 28 days on ventilation + CXR changes ◦ respiratory distress: recession
• caused by ◦ FTT
◦ high volume and pressure

First day check  observe chest / check for respiratory distress

 observe infant + comment on colour (jaundice /
pallor / plethora) and posture
 discuss taking weight, length, head circumference,
importance of plotting these on percentile chart
 palpate abdomen for liver, spleen, kidneys and
hernias. Check umbilicus for infection
 examines genitalia

 checks anterior fontanelle  checks femoral pulses

 observes face – notes symmetrical / position of  examines for developmental dysplasia of hips
ears / shape of eyes
 checks tone of infant including head lag
 looks inside mouth for cleft of hard or soft palate
 turns infant over / checks spine. Checks patent
 ascultate heart and comment on heart sounds and anus
murmurs

Prematurity • weigh daily

• <37 weeks
• low birth weight <2500g
• very low birthweight <1500g DDx of SGA
• extremely LBW <1000g • wrong dates
• constitutional
50% survival at 24wks • IUGR
90% survival at 27wks • Oligohydramnios

Thermoregulation
• have
• high surface area:weight ratio
• ↓ brown fat stores
• non-keratinised skin Small for gestational age
• ↓ glycogen supply
• Mx: warmers/incubator, head coverings
Wrong dates
Hypoglycaemia • 6wk scan ±1 day
• Have • 12wk ± 1 week
• ↑ stresses • 20wk ± 2 weeks
• ↓ glycogen stores
• Mx: check BGL before each 3hrly feed Hx
• <2.5 needs dextrose infusion + maintenance • double check dates
• OHx:
Fluids + electrolytes • SGA in other pregnancies
• have • Smoker, drug use
• immature renal function • HTN, autoimmune disease
• Mx:
• Daily U+E, urine output Ix
• Day 1-2 : 100ml/kg/day • Fundal height
• Day 3-7 : 150ml/kg/day • AFI: should be 5-24
• Day >8 : 200ml/kg/day • S:D ratio of umbilical artery: high means babe is
unhappy
Breastfeeding • Biophysical profile U/S (BPD, HC, Abdo C, femur
• Within 90minutes of delivery length, EFW)
• 8 feeds/day • Symmetrical: small, but head and abdo
• otherwise use NGT or IV circumference are in proportion
 • Asymmetrical: blood shunted to brain instead • placental
of liver (↓abdo circ) • IUGR: assymetrical
◦ Maternal HTN / pre-eclampsia
1 well + small ◦ Smoking
• symmetrical ◦ Multiple gestation
• check ethnicity • Post-placental
• Infection: TORCH ± hydrocephaly
2 sick + small • Aneuploidy: trisomy 13 / 18
• preplacental ◦ Symmetrical
• maternal cyanotic heart defect • Structural: gastroschesis
• anaemia
• high altitude
Neonatal jaundice

24hrs to 2 weeks, can be physiological

All develop ↑ SB in first week Ix
 heel prick SBR with unconj/conj ratio
A Unconjugated  BSL (consider hypoglycaemia)
• Haemolytic (pre-hepatic) • FBC + Blood film
o Breast feeding • Blood grouping for rarer incompatibility
o Haemolytic anaemia – ABO, Rh, drugs • Direct Coombs for rhesus
o Sepsis • Syphilis / TORCH screen
• Non-haemolytic
o Hypothyroidism Mx
o Sepsis • Treat cause
o Gilberts • Phototherapy
o Pyloric stenosis o Check chart
B Conjugated (BAD) o Naked, no nappy
• Hepatic o Give 30ml/kg/day more water
o Hepatitis + cholestasis o Harms: temperature, eye damage,
o TORCH diarrhoea, separation, fluid loss
o Sepsis o Stop when levels fall >25umol/L below
o CF threshold
• Post-hepatic • IV immunoglobulin
o Biliary atresia • Exchange transfusion
o Obstruction o Warmed blood 160ml/kg over 2 hrs
o Removes bilirubin + Abs, corrects
Hx anaemia
 onset (not first day) o Only in severe disease or G6PD
• Early day 1-2
o Haemolytic jaundice
o sepsis Counselling
• Normal day 3-10  Explains reasoning to mother
• Prolonged >2wks  Improve feeding – express and feed, S26, top
o Breast milk ups etc
o Conjugated (sepsis, CF, cholestasis)  phototherapy
o Inherited enzyme deficiency (G6PD)
Sequelae
 mother’s blood group
 kernicterus
 FHx of blood disorders / CF
 ? birth trauma / swallowed blood peripartum
 mode of feeding, feeding problems, engorgement,
let down
 weight loss, bowel/bladder output

Neonatal sepsis
Mostly GBS, E.coli, Listeria
• GBS: 10-15% death
• 50% start in utero Ix
In utero or on delivery • Bloods
Prematurity risks nosocomial infection • FBC + CRP
• Culture
Hx, Ex • BGL, ABG
• Respiratory distress / apnoea • SPU urine culture
• Temperature instability • LP for culture + film
• Irritability • CXR
• Poor feeding / vomiting / diarrhoea / jaundice • ± stool, PNA for viral PCR
• Bloods: ↑ neutrophils, thrombocytopenia,
coagulopathy Mx
• <48hrs = GBS+E.coli = BenPen + Gentamicin
First.. • Late onset infection >48hrs = coag neg staph =
• Clear airway, intubate + ventilate (should correct vancomycin
acidosis)
• IV access  colloid 20ml/kg Hypoxic ischaemic encephalopathy
Diseases in pregnancy HBV
• Vertical transmission
Epilepsy • Fetal: 90-95% become chronic
• Pregnancy  epilepsy: 10% gets worse, 50% • Vaccinate neonate: offer everyone in first 5 days
unchaged • + Ig if mum is positive
• Medication adherence • 95% protective with both
• Altered drug metabolism
• Vomiting HCV
• Epilepsy  pregnancy: mostly has no effects • no interferon / riboviron
• Drugs can be teratogenic (↑ risk of malformation) • only 2-8% vertical transmission with positive maternal
• population malformation rate is 4% RNA
◦ anti-epileptic drugs is 19% • labour:
◦ depends on drug • keep membrane intact till last minute
◦ monotherapy is better • no fetal scalp electrode
◦ as low a dose as possible • check RNA viral load
◦ NO VALPROATE  spina bifida, clefts, heart • neonate: yes to breastfeeding
disease, short limbs ◦ not if cracked nipples or mastitis
• Seizure risks: dual hypoxia
• Recurrent fits  fetal intracranial haemorrhages HIV
• HIV mother 1/10,000 LB
Counselling • ↑ risk
• Stay on your meds • preterm labour
• Routine screening • low birth weight
• Monitor drug levels in 1st and 2nd trimesters • vertical transmission (IU, birth, breastfeeding)
• Twice in 3rd • Mx: refer, monitor viral load, CD4 counts
• Supplements • Labour: membranes intact
• Folate before 13wks ◦ No instrumental
• Vitamin K from 36wks ◦ Usually CS
• Delivery ◦ Give IV Zidovudine
• Recommend epidural • Neonate: no breastfeeding
◦ Pain, emotion, ↑RR  ↑ seizure risk ◦ Check loads
• Seizure rate is 1-2%
• Post natal UTI
• Recheck drug levels and gradually reduce • Uterus presses bladder
• Need ↑ estrogen in contraception: mirena is good • Smooth muscle relaxation  stasis + reflux
• Breastfeeding • Can cause
• Drugs can accumulate, but not usually a problem • PROM ± chorio
• Preterm labour
• Low birth weight
• Mx: Cefelexin / Nitrofuintoin
• NO Trimethoprim

Large head circumference

DDx
• Familial
• Skull bones
• Subdural: haematome, emphyema
• Brain: metabolic disturbance, neurofibromatosis
• Ventricles: hydrocephalus
• Meningitis, obstruction, congenital

• Hx: FHx of large heads

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

• Ix: head U/S / CT if fontanelle closed

• Refer!!!
 Drug users in pregnancy • Other kids?
1-2% of pregnant women are IVDU • Pap smears
• Drug Hx (specific)
Social risks Risks to baby • What taken, when, how often, route, needle use
Tend to present Infection • Pattern of use
late IUGR/SGA • Screening Hx: STIs, rhesus, BBV
Low Fetal alcohol syndrome • Social Hx + supports
socioeconomic Preterm labour • Is she functional enough to look after kids
status IVDU  abruption • PMHx: DVT, jaundice, liver disease
No social Neonatal abstinance
support syndrome (esp opiates) Mx
Polydrug use Congenital abnormalities WANDAS: non judgemental, with links to other groups
Smoking Miscarriage • Aim is to make them stable
Less STI Fetal distress
screens • Everyone in one place
SIDS
Psychiatric Hx • Nutritionist, Social worker, Clinical psychologist,
Poor diet: Parent education, Home midwife
anaemia, folate • Screening
• STIs
Smoking in pregnancy • Pap smear
• Preterm labour • Anatomy scan
• IUGR • LFTs
• Adult disease: allergy, asthma, DM
• Stillbirth Birth
• Abruption • Pain relief: no morphine
• ↓ PE • Respiratory depression – can’t give naloxone on
babe of IVDU
ETOH in pregnancy: fetal alcohol syndrome • Aggression
• animal facies: flat nose, cheek hypertrophy • High or withdrawling during labour
• IUGR • Continuous monitoring
• Neonatal ↓ IQ
• CNS: microcephaly Neonatal withdrawal
• Up to 10 days
Hx • Irritable, jittery
• OHx + GHx • Poor feeding
• LMP • High pitched cry (benzos, morphine)
• Yes to breastfeeding!
The always crying child

Top Ddx Examination

1 colic • centiles + development
2 reflux • localised infections
3 constipation ◦ ear
4 lactose intolerance / cow's milk allergy ◦ fontanelles for ICP
5 infection ◦ UTI
(6 pyloric stenosis) ◦ sepsis

Hx Ix
• crying pattern • stool: clinitest tablet
• feeds • U/S (pyloric stenosis)
• vomiting, stool frequency and consistency • AXR (constipation)
• noticed anything sets her off? • skin prick / RAST
◦ Position
◦ foods Mx
• weight gain • change of position or thickened feeds for GOR
• otherwise well? • removing lactose
◦ allergy Sx
Counselling (colic)
◦ fever
• reassure: common, but don't minimise
• Parent response and support
• usually resolves around 3 months
◦ who looks after bub?
• motion might help
◦ Any one who could baby sit?
• baby might cry no matter what
◦ Mother's groups or Ngala
• its ok to take a break
• refer to Ngala or hospital for respite
Baby vomiting (GORD)

DDx GOR (lower oesophageal sphincter relaxation)

• GOR • 60% have GOR vomiting
• Pyloric stenosis • from 2-3 weeks
• UTI • GOR resolves by 9 months
• URTI Pyloric stenosis
• Dramatic onset in 2-6 weeks
• Low K, high Cl = met alk + dehydration
Hx
• Family Hx
 fever or infection
• FTT suddenly
 vomiting – freq, amount, colour, timing to feeds,
projection • Projectile vomiting ± blood
 constipation/diarrhoea
 position – worse prone, more irritable lying down
Counselling
 complications – cough
 reassure – should resolve with time
 weight gain
 pyloric stenosis is unlikely
FHx of pyloric stenosis
 Ix – U/S and blood test
social Hx
 maternal support
Mx GOR – none is fine, or
 how are you coping?
 Positioning (30o)
 thickening feeds
Examination
• centiles ◦ less volume more often
 omeprazole now/later
• general:
• febrile
 Need to return for follow up
• Active / quiet / lethargic
• Hydration: Pink + well perfused Mx pyloric stenosis
• Fontanelles • Rehydrate
• abdo • Correct met alkalosis
• Pyloric stenosis • surgery
◦ Abdo distended
◦ Olive in midline
◦ Peristalsis

Ix
• U/S
GOR PS
• varied volumes • Large volume
• Sooner or later after • Straight away after
some feeds every feed
• Thrive • FTT
• Not dehydrated • dehydrated
Failure To Thrive
Hx
• chronic conditions Nutritional Ax
◦ CP
◦ seizures Intake
 Pregnancy Hx Milk
◦ smoking/ETOH • Breast or bottle?
◦ medications/illness • What type of formula?
• nutritional assessment • How often? (on demand or 2-5hrs)
• Family Hx: siblings • How long? (5-30minutes)
• social Hx • How much? (bottle 60-80ml/kg/day on day 1
-> 100 -> 120 -> 140 -> 160 -> 180 ->
Ddx 200/kg/day)
A non-organic What do they eat on a normal day?
 constitutional  Solids – from 6/12 (blended cereal, veg, fruit)
 feeding problem  Meat: from 6/12
 psychosocial !!  Cup drinking from 7/12
B organic  Semi-solids from 8/12
 congenital: CHD, cleft  Normal food from a year – also milk down to
 chronic illness: CF, asthma, chronic infection (TB, 600ml/day
HIV, UTI)
Output
 losses:
• 4 wet nappies/day
 vomiting: PS/GOR/coeliac/hirschprung
• Bowel: with feeds
 stool: diarrhoea
• Vomits
 urine: polyuria and metac - DM
 Metabolic (galactoseamia, PKU)
Birth Hx
• Gestation
• Birth weight
Exam • Complications
 Weight, height, Hc
 General: HR, BP, RR, chest+heart History
 Any systemic disease? • Illnesses
 Body • Infections
◦ Muscle
◦ Fats (buttox folds) and subcut Family Hx
◦ Hydration  Growth pattern
◦ Anaemia  Illnesses
◦ Teeth
Short boy
Hx  LFT
 height compared to other kids  Ca, Phosphate
 how long has he been shorter?  girls get chromosomes
 Impact – r\teasing at school, performance?
 Birth Hx
 PMHx Ddx
 development • emotional
 height and puberty in siblings? • chronic illness

Examination length > weight

• centile of child and parents • nutritional
• growth velocity
• puberty signs length < weight
 skeletal proportions- lower segment >50% • bone (bone dysplasia, rickets)
 inspection • endocrine (thyroid, GH, PHT)
◦ turners, downs
◦ cafe au lait spots length = weight
◦ thyroid • constitutional
• short family stature
Ix • chromosomal (metabolism errors,
 bone age Xray turners)
 TFTs
 FBC/ESR (IDB),
 UAE
 urine culture Then
 coeliac tests TTG  GH test
Anaemia / pale child • TFT, U+E

DDx Thalassemia
microcytic Ix
• Fe deficiency • ↓Hb, ↓MCV, ↓ ferritin, microcytic
• chronic disease • Dx: Hb electrophoresis
• Thalassaemia
normocytic B Thalassemia minor: HbA↑
• blood loss • mild pallor, splenomegally
• renal disease
• hypothyroidism B Thalassemia major (2 minor parents): ↑ HbF
• haemolysis: sicle cell, G6PD, rhesus • ↑a chains  shortened RBC survival, marrow over
macrocytic function
• B12 / foliate deficiency • Sx
• Marrow failure • presents 3mths – 1yo
• pallor
Hx • hepatosplenomegally
• abdo distension
• Duration, speed of onset (blood loss, infection)
• Lethargy • jaundice
• Exam: growth retardation
• Otherwise well?
• Weight loss (coeliac, cancer) • poor muscle development
• Fe skin pigment
• Bruising / bleeding
• Jaundice
Mx
• infections
• 3-4 weekly transfusions to suppress haemopoiesis
• medication
• Aim: keep Hb above 100mg/L
• Diet (meat, green veg, legumes)
• Leads to Fe loading  needs chelation
• Birth Hx
• Folic acid
• FHx bleeding, G6PD
• HBV vaccine
Examination
Counselling
• General: pallor, sepsis
• Disorder of gene for B globin, part of Hb in your red
• Weight loss, skin folds, bruising, jaundice blood cells
• Recessive: ¼ risk if both are carriers
Ix
• Px: Death in 10yr from HF, arrhythmia, infection
• FBC + film + differentials + retic count
• Fe studies
• Hb electrophoresis (thalassemia)

Cancers
Leukemia
75% ALL, 2-5yo
more in downs
Tumour lysis syndrome: tumour cell breakdown products can be toxic
Mx: hyperhydrate + bicarb to clear toxins
• Allopurinol

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

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

Ix
• Bloods
• FBC + film + retics
• Blood culture
• U+E
• LDH (high cell turnover)
• CXR (thymic mass)
• Bone marrow: L1 blasts), LP
Respiratory infection

Hx DDx
• Cough Cough + unwell
• Duration + Onset • URTI
• Pattern: • croup
◦ Fits (pertusis, bronchiolitis, FB) • bronchiolitis
◦ night (asthma, croup), morning (GOR) • pneumonia
◦ Barking (croup) • foreign body
• Sputum / blood • pertusis
◦ Wheeze or Stridor Cough but well
• What’s the general state of him? • GOR
• Feeding, sleeping, irritable • Post-nasal drip
• Stupor • CF
• Other Sx • Passive smoking
• Fever • Post viral, habit
• Vomiting Chronic cough
• Rhinorrhoea • Asthma
• Rash • CF
• What was his health like before? • IFB
• Allergy, asthma • Chronic Infections
• GORD, CF • TB
• Developing in track
Croup (parainfluenza)
• General wellness
• Sx
• Infectious contacts / smokers
• 1-3 days fever, flu-like 
• Vaccinations HIB FOR EPIGLOTTITIS
• barking seal cough
• FHx : asthma, CF, CHD
• stridor
Examination • irritable, not sleeping
• Centiles • Examination
• General: AVPU, distress, colour • unwell, upset
• Vitals: fever, RR, HR, hydration • inspiratory stridor
• Chest: respiratory distress • ↑ RR, ↑HR
• Crackles, wheeze, stridor • Mx
• ENT: obstruction • steroids
• nebulised adrenalin in short term
Ix • if severe, admit + intubate
• FBC (WCC, left shift), CRP, cultures, U+E
• Sputum culture Pneumonia
• PNA • Sx
• CXR • Respiratory distress (GRUNT)
• Fever, tired
• Productive cough
Bronchiolitis (respiratory syncitical virus) • Vomit, abdo pain
• Risks • Not eating, not sleeping, miserable
• <1 year
• SMOKERS Neonates  GBS
• Prematurity Rapid, VERY unwell  S.aureus
• CHD FAST, URTI Sx in under 3s  Strep pneumoniae
• CF Others: Hib, mycoplasma, viral (flu)
• Sx
Mx
• coryza  Cough + wheeze
• admit if: <3months old, very sick, ↑ consolidation
• Low grade fever
• O2 if sats <92
• Tired, poor feeding, not sleeping
• Abx
• Examination
• amoxy + gent
• Vitals: febrile, ↑HR, ↑RR
• fluclox is severe
• Chest: nasal flare, recession, inspiratory crackles
• roxithromycin if atypical
• Admit if Cyanotic, stupor, sats <92
DDx
Acute stridor Chronic stridor Wheeze
• croup • Laryngomalacia • Asthma
• tonsillar abscess • Subglottic stenosis • Bronchiolitis
• anaphylaxis • Vascular rings, webs • Pertusis
• epiglottitis • Transient viral wheeze
• FB

Resp script
Openers Breathing
X is a Xxyears old B/G who was brought in..... • X is tachypnoeic / breathing comfortably
S/He appears • There are signs of respiratory distress:
• alert ◦ sternal / subcostal / intracostal recession
• restless ◦ nasal flaring
• drowsy ◦ grunting
• pale, limp • With:
• toxic ◦ inspiratory / expiratory stridor
• crying/ smiling ◦ inspiratory / expiratory wheeze
• colour: pink, blue, pale, yellow, dusky, mottled ◦ cough: barking (croup), whooping (pertusis),
• with tubes / oxygen mask / ventilation / sputum
cups / IV access
breaths
40-60 in neonate
Hydration
first 3 months = 30-50
• appears well hydrated 3 months to 2 years = 20-40
• Signs of mild / moderate / severe dehydration 2-10 years = 14-24
◦ skin turgur >10 yrs = 12-20
◦ sunken fontanelles
◦ low urine output
◦ CRT >3 (poor peripheral perfusion)
◦ high RR, HR, low BP
◦ dry mucosa

Allergy  Sx treatment
Urticaria + Angioedema  calamine lotion
Hx  tepid baths
• Sx:  oral steroids – if all else fails
• Rash  be aware of possibility of anaphylaxis
• Itching
• Swollen eyelids, lips, tongue Food hypersensitivity
• Breathing problems • Most lost with age : egg, milk, soya
 FHx of allergy, atopy, asthma • Persistant : peanut, nut, shellfish
 triggers • Sx
 illnesses • Urticaria, angioedema
 medications • Abdo distension, D+V
 foods eaten • Laryngeal oedema, asthma
 contacts – plants, soap, wool • Anaphylaxis
 recent infectious illness • Delayed onset: diarrhoea + AD

Exam Ix
inspect RAST vs skin prick
 angioedema lips, mouth, throat • Skin prick is
 eye for rhinoconjunctivitis • Cheap and faster
 lymph glands • Less error
 Fever • Antihistamine false negatives
 joints • AD false positives
 chest – stridor and wheeze
 heart Anaphylaxis
• Mx
• ABC
 Favoured Dx: urticaria
• IM adrenalin 0.01ml/kg 1:1,000
Counselling ◦ Epi jr = 1:10,000
 a reaction to an allergen or recent viral illness ◦ Every 10-15 min
 is not an Abx allergy • IV access, O2, intubate?
 maybe a food • Mx for future
 testing is not usually helpful • Immunotherapy reduces risk to <1%
 may help to keep a food diary ◦ Expose to tiny amount of antigen, gradual add
to it
Mx ◦ Maintenance once a month
 non-sedating anti histamine (Claratine) • avoid food
 • Food challenge: in hospital • NO decongestants
• School liaison - Dietician • NO SMOKING
• Refer for fluvax safety

Counsel
• Risk of a major future reaction
• <1% if was small
• s50% if major systemic reaction Atopic Dermatitis
• EPIPEN: don’t leave without one Hx
• Have one at school + ACTION PLAN • Sx
• Medical alert bracelet • Lesion: site, duration
◦ Has it moved
Allergic rhinitis ‘hay fever’ ◦ Itchy, pain
Hx • Rhinorrhoea, sneezing
• Sx • Swelling, breathing probs
• Blocked nose, rhinorrhoea • Triggers: water, plants, soap, wool
• Morning sneezes • Link to foods or drugs
• Allergic ‘salute’ • General health
• Link to seasons • recent infectious illness
• Specific triggers • FHx of allergy, atopy, asthma
• Snoring / poor sleep / sleepiness
• School performance Examination
• FHx of allergy, atopy, asthma • Centiles
• SMOKERS in the house • Skin:
• PMHx • Dry lichenified dermatitis
• Atopy • Face, trunk, limbs
• medications • Bacterial infection, weeping
• Xerosis
Examination • Pruritic, scaly
• Centiles
• Face Ix
• Allergic shiners (under eyes) • High total IgE + specific IgE to allergens
• Mouth breathing • SPT only useful if negative
• Tender sinus
Counselling
• Nose
• Over active immune system in the skin
• Nasal crease
• We don’t know why, but we do know there is a broad
• Pale, swollen nasal turbines
range of triggers
• Nasal discharge
• So we need to take a many-faceted approach
• Eyes: conjunctivitis
• Has triggers + irritants
• Throat: enlarged tonsils, secretions
• Steroid phobia
Counselling
Mx
• Over active immune system in URT
Stop the itch-scratch cycle
• Seasonal : older kids, from pollens etc
• Remove trigger + irritants (food, dust mites)
• Year round: kids under 10
• Prevent dryness: emolients (sorbeline)
• Most grow out of it or to milder form
• Ointment steroids, not creams!!
• Inflammation: topical steroids/antihistamines
Mx
• Sigmacort for face
• Infants: saline nose drops
• Celestone for body
• Kids: steroid nasal spray (most respond)
• Infection: ceflex
• Rhinocort, Becanase
• Stress management
• Mat cause nose bleeds
• Serious flare ups can admit to hospital
• Non-sedating Antihistamines for flares (Clarytine)

Paediatric resuscitation
Compressions
 Correct airway, breathing, circulation approach 1  pulse check<10 seconds brachial or femoral
 Check response, call for help 0.5  chest compressions
 Airway opening manoeuvres, chin lift, jaw thrust, no  hand position lower half of sternum, 2
sweep mouth 1 fingers 1
 Look, listen, feel 0.5  depth, one third chest of wall1
 2 rescue breaths, gentle rise and fall of chest noted  rate, achieving close to 100
1 compressions per minute 1
 minute) 1
Ventilation
 Ventilation technique, notes and achieves good Drugs
rise and fall of chest 2  IV fluid normal saline bolus given 10-20 ml/kg 0.5
 High flow oxygen used or requested 1  Adrenaline IV given, correct dose of 10 mcg/kg 0.5
 Ratio 15:2, accept 30:2, approx 2 cycles per minute 1000mcg = 1mg
1
 Continues for 2 minutes (accept check after 1
Congenital heart check ◦ ECG: abnormal T wave
• Asymptomatic murmur – 30-50% have murmur at • Mx: create ASD  surgical correction
some point
Acyanotic
Hx VSD
• Cyanosis (onset, duration) Perimembranous or muscular
• Generally well? A Small VSD
• FTT • Pan-systolic murmur over left sternal edge
• Feeing problems • High pitched ± thrill
• Shortness of breath on excersion • May not hear for 6 weeks
• Squatting to breathe B Large VSD
• Chest infections • Displaced apex
• Heart failure, arrhythmias • FTT
• SOB
Examination • Hepatomegally
• CVS • ↑RR
• Pulse: collapsing / femorals • Ix
• Radio-femoral delay • CXR: cardiomegaly, pulmonary vascular markings
• Displaced apex • ECG: ventricular hypertrophy
• Heart + maneuvers • Px: 50% resolve, some  pulmonary HTN
• Resp: ↑ RR
• Abdo: hepatomegally ASD
• Diagnosed clinically, CXR, ECG, echo Foremen ovale primum / secondum
• No Sx in chilhood
Innocent • Adult: FTT, AF
• Vibratory “stills” murmur ES • Ejection systolic, pulmonary flow murmur
• pulmonary flow murmur • parasternal heave
• quiet or vibratory • no pulmonary HTN
• position dependent • Ix: CXR: cardiomegaly, pulmonary markings
• otherwise well • ECG: RBBB
• heard with bell • Mx: good surgical options

Sinister PDA
• Thrill or loud murmur A Small PDA
• Pansystolic BAD • Continuous murmur in pulmonary / sternal area
• NO FEMORAL PULSES • Starts like VSD
• Displaced apex B Large PDA
• Collapsing pulse
Cyanotic (R L shunts) • Displaced apex
Tetrology of fallot • FTT
1 VSD • SOB
2 Pulmonary stenosis • Chest infection
3 over-riding aorta • Ix: cardiomegaly, LV hypertrophy
4 right ventricular hypertrophy • Mx
• Premature: Indomethicin (too young to respond to
• Hx O2)
• low sats  cyanosis develops over months • Term: ligation, low risk
• with crying + excersion (squatting)
• hypoxic Pulmonary stenosis
• ejection systolic murmur on left sternal edge  back Thickened leaflets + partially fused commisures
• spells (SOB, pallor) • No Sx in childhood
• FTT • Ejection systolic murmur at pulmonary area  back
• Clubbing • ± thrill
• Ix: ECG: RV hypertrophy • Ix: convex upper left heart border (pulm A.)
• Mx • Mx: mostly benign, or use balloon catheter
• Repair VSD + PS early as possible
◦ Create systemic to pulmonary shunt Coarctation of the Aorta
A early + severe
• B-blockers
 shock, no flow to lower half of body (pink vs
• Px: MI, CVA, death
blue)
Transposition of great arteries • ↓ femoral pulses
• Hx • Ix: cardiomegaly + pulmonary congestion
• Cyanosis within a few hours  met acidosis • Mx: PGE (keep PDA)  urgent surgery
• Survive via foramen ovale + ductus (up to a month)
B late + mild (PDA remains)
• left sternal heave
• Systolic murmur
• Ix: CXR: normal size, egg on side shape
• Radio-femoral delay •  intracranial haemorrhage
• Ix: rib notching (intercostal collaterals)

Seizures
 establish report, be understanding to his anxieties

Hx
• Seizure
• LOC / staring / awake
• Jerking / stiffening / face gestures
• Duration
• Happened before?
• Post-ictal: recovery
• Pre-ictal
• sleeping
• Generally well
• Fever
• N+V+D, cough, headache, ear pain
• Injury / operations
• FHx: seizures / epilepsy

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

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

Ix: not routine, use to find source of fever

• FBC (WCC, ESR), BSL
• Clean catch urine U/A
• EEG: developmental delay, focal signs
• Can’t predict epilepsy

DDx
Non-epileptic Other
• sleep jerks • syncope
• day dreaming • migraine
• breath holding • benign
Parasomnias paroxysmal
• night terrors vertigo
• sleep walking • pseudo-seizures

• ↑ ICP/sepsis
Neonatal seizures starring, fear expressions
• focal or generalised Febrile convulsions
• causes: HIE • Generalised tonic-clonic <5mins
• metabolic (glucose) • rapidly rising fever
• infection: Neiserria, TORCH • Post-ictal period 30min
• cerebral malformation
• Mx: treat cause + Phenobarbitone
Counselling
Infantile spasms • NOT epilepsy
• causes: infection, malformation, injury • common: 3% of kids 5months – 5years
• 1-2 min of slow myoclonic jerk) • connected to a viral infection, especially when
• EEG: disorganised, high voltage rapid fever
• can be scary to watch, but
Absence epilepsies • are benign, usually no serious complications
• 4-12 years • repeated in 30-40%
• <15 seconds of staring, blinking, fidgeting • risk of epilepsy in 2-7%, similar to population
• 1) typical: 3Hz spike and wave
• 2) teens: faster spike EEG Fever care
• Mx: Na Valproate, Ethosuximide, Lamotragine • minimal clothing, keep cool
• do not recommend
• Most have remission
◦ sponging, baths: don't help
Benign Focal Epilepsy (25%) ◦ paracetamol – only for pain
1) Rolandic: During SLEEP First aid
• orofacial movements • stay calm!
• drooling, choking  hand/arm jerks • Do
◦ Place child on soft surface, on side or back
• EEG: centrotemporal spikes
◦ time convulsion
2) Occipital: stares, eye deviation
• do not
Idiopathic generalised Tonic-Clonic epilepsy ◦ restrain
• Fhx: seizures ◦ put anything in mouth (even fingers) they wont
• EEG: spike-wave or polyspike swallow their tongue
• PMHx: absence or febrile convulsions • call 000 if
• Type: tonic → stop breathing → fall → clonic jerks ◦ last more than 5 minutes
• Lasts minutes ◦ doesn't wake up afterwards
• Recovery: post-ictal drowsiness ◦ looks very ill afterwards
• no memory
Hospital care
• Mx: Na Valproate
• place in recovery position
Temporal Lobe epilepsy • maintain airway, give )2 if needed
Causes: developmental lesions • >5, can give diazepam
• simple / complex partial • monitor consciousness, vitals
• Ix: BSL, UAE, Ca, FBC, blood culture
Vomiting ± diarrhoea

Ddx: diarrhoea + vomiting

Ix
• gastro / any systemic infection
/ UTI  RECOGNISE SEPTIC BOY
• antibiotic induced  suggest septic screen
• surgical  Blood culture (+ meningococcal PCR)
◦ Appendicitis  CXR
◦ onstruction  urine (clean catch: U/a + MC/S)
• DKA  ±LP, PNA
 insert IV/IO
Hx Mx of sepsis
 Duration, frequency, colour  oxygen
◦ Drinking / eating  NS bolus 20ml/kg
◦ Keeping anything down  empirical Abx
 Diarrhoea ◦ Ceftriaxone ± Amoxycillin
 Fever ◦ Amoxycillin + Gentamycin if <6weeksold
 localising signs (ENT, chest, urine)  plan transfer to larger centre (PMH/joondie)
◦ cough, rash, runny nose, stiff neck
 risk factors Hydration at the hospital
◦ Infectious contacts • IV bolus 20ml/kg normal saline
◦ PMHx + general state of health • Continuing fluids
◦ vaccines (eg. 10kg kid, 7.5% loss)
• if ~7yo, DM screen • Deficit = weight x %loss x 10
(10 x 7.5 x 10 = 750)
Examination • Maintenance = 100ml/kg for first 10kg
 Quantify dehydration ◦ 50ml/kg for nest 10kg
◦ weight loss ◦ 20ml/kf for any extra kg
◦ AVPU (100 x 10 = 1000)
◦ pallor
◦ turgor • Continuing Fluids = maintenance + deficit
◦ ↑ RR, ↑HR (1000 + 750 = 1750ml/24hrs)
◦ ↓ perfusion • Oral: given over 6 hrs instead
◦ ↓ BP (1000/4 + 750 = 1000ml/6hrs)
◦ dry membranes
 identifies abnormal and worrying signs of sepsis Counselling for hydration at home
◦ BP  probably gastro, the main problem is dehydration
◦ CRT >3 (perfusion)  vomiting and diarrhoea in kids can have other
◦ ↑HR, ↑RR (acidosis) causes
◦ confusion  Mx
◦ fever  water / oral rehydration fluid + reason why
◦ respiratory distress  frequent small sips
◦ hydration  avoid hypertonic fluids (sprite/juice) +
• localizing signs reason
• stiff neck, rash  what to watch out for
• resp Examination  poor fluid intake or still vomiting
• ENT exam  pallor / lethargy / drowsy / sunken eyes
 poor urine output
 high fever / headache / urinary Sx
Limp and pale 2 year old
 bile stained vomit / abdo pain
Ddx
 he has enough energy reserves to carry him
• hypoglycaemia
through fasting
• infection
 early introduction of food promotes recovery
◦ respiratory
 antiemetics not good in kids: cause dystonic
◦ GIT reactions
◦ UTI  careful hand washing to stop spread
◦ pyelonephritis
• anaemia
Fever and rash • Meningococcal PCR

Hx DDx
• Rash: duration, site, appearance • thrombocytopenia
• Come and go? • Sepsis: MENINGOCOCCAL
• pain • leukemia
• Itch (scabies, AD) • ITP
• Sx: • TTP
• fever • Drugs
• sore throat, URTI • Trauma
• Vomiting • Viral + post viral (HSP)
• Stiff neck, meningism • ↑↑ venous return (coughing)
• Focal neuro
• Eating + sleeping Neonates
• Infectious contacts • TORCH
• PMHx: • HLA
• Past rashes • Cancer
• allergies, psoriasis, SLE • trauma
• Generally well?
• Medications, vaccinations Meningitis
• Neonates = GBS, E.coli
Examination • S. pneuoniae
• General: febrile / drowsy / well • N. meningitides
• Sepsis: fever, BP • Enteroviruses
◦ cushing reflex: ↑BP, ↓ HR, irregular breathing • Hib etc
• Rash: maculopapular, vesicular, purpuric
• Blanching! Infants
• Scattered / clusters • Fever, irritability, drowsy
• Neuro • vomit, seizures, poor feeding
• Meningism, ↑ICP • bulging fontanelles
• fundi (pappiloedema)
• focal changes (6th N palsy) Kids
• Kernig’s sign • fever, headache, vomiting, photophobia
• • stiff neck, rash
• Lymphadenopathy / Splenomegally • delirium, seizure

Ix Mx
• Septic screen • IV access, O2, fluid resus
• Blood cultures, FBC • Ceftriaxone
• Urine U/A, MC/S • admit
• CXR
• LP if no signs of ↑ICP

Idiopathic thrombocytopenia purpura

Hx
• acute bruising + petechiae
• mucosal bleeding
• post viral infection / URTI

Ix
• ↓ platellets, but no good test
• WCC, RBC normal

Mx
• benign, 80% resolve in 6 months
• steroids may help to ↑ platelets
• ±splenectomy if doesn’t resolve
Diabetes Mellitus type 1 and DKA
Hx of DKA Ix
 nature of vomiting – freq, colour • U/A: glucose, ketones
 presence of diarrhoea • Bloods
 fever • Random BGL >11.0
 diarrhoea • fasting BGL >7.0
 infectious contacts and recent illness • U+E
• ABG
Hx of diabetes • Septic screen (FBC, cultures)
 polyuria + nocturia • HbA1c
 eating and drinking (polydypsia) • To Dx: islet cell Abs, insulin Abs, TFT
 energy (fatigue)
 weight loss Counsel
 funny smell on breath (ketotic)  explain JODM to parents
 abdo pain  explain DKA: convey urgency of initial Mx
 General state of health
• Steroids Mx of DKA
• Resp distress  initial resuscitation and paediatrician r/v at PMH
• thrush • IV access + O2
• fluid : NS 20ml/kg bolus
Ddx ◦ oral after 24hrs if stable
 juvenile onset DM • insulin: aim for BGL 10-12mmol/L
• steroid use ◦ 0.1unit/kg/hr
• UTI + sepsis ◦ Aim for 5mmol/L drop per hour
• Gastro • K: start with insulin
• DM2 (rare) • Bicarb: if still acidotic
 will need specialist input (peads, endocrine, DM
Examination edu nurse) – get to PMH
 dehydration assessment
 consciousness Mx plan
 temperature • refer to paediatrician
 look for sepsis • DM education nurse
Acute abdo pain
Hx Acute
• duration, pattern, location, colicky • colic
• Sx • gastro
• fever • intussusception
• Vomit / bile • appendicitis
• Stools: diarrhoea, blood • obstruction (malrotation, constipation)
• Dysuria (UTI) • testes torsion
• Cough (pneumonia) • pneumonia, UTI
• What was his health like before? • HSP
• HSD, GORD, CF • DM
• Developing on track Recurrent
• General wellness • IBD
• Feeding + sleeping • HSP
• Infectious contacts • Menstruation
• Vaccinations (rota) • functional

Examination
• centiles Malrotation w volvulus
• Sepsis Incomplete or non-rotation of mid-gut around SMA
• Hydration • Hx
• Fever • 1 week – 1 month
• Abdo : RUQ sausage • with other GIT malformations
• Peritonism • malabsorption
• Intussusception: RUQ masses, distention • Sx
• Malrotation: distention, tinkling BS • Bilious vomit
◦ Feaces felt in HSD • Distension+ colicky pain
• Bowel sounds • PR blood = necrosis from volvulus
• Jaundice • IMMEDIATE SURGICAL REFERRAL
• Chest : pneumonia, CF • Fluid/electrolytes, Abx, NGT  LADD procedure
• testes
Intussusception
Distal ileum into distal bowel
Ix
• Hx
• bloods
• Male
• FBC, culture, CRP
• 2 months – 2 years
• U+E if vomit
• PMHx: Hirschsprungs, CF
• BGL
• Sx
• Urine: U/A + MC/S
• Colicky pain every 3min  drawn up legs
• AXR, U/S
• Vomiting ++  bilious
• Double bubble sign of obstruction
• ‘red current’ stools
• Barium enema (intussusception, HSD)
• Tired, not feeding
Hirschsprung’s disease • Mx  theraputic barium enema
Congenital abscense of ganglia in segment of colon  • Correct dehydration
infrequent, narrow stools, obstruction, megacolon • Surgery
• Causes  ulcers, bleeds, enterocolitis
• DRE: thin pellets only Torsion of testes
• Ix: sigmoidoscopy + barium enema • Painful, enlarged  Black swelling
• Mx: remove segment ± colostomy • VV painful RIF
• Ix: theatre within 6 hours ± MSU
Chronic diarrhoea
Hx
• duration, frequency of bowel motions Exam
• Stools • abdo exam
◦ watery/frothy (milk) with raw buttocks ◦ tender? Masses? Distension?
◦ offensive and fatty (coeliac) ◦ Rectal exam
◦ bloody (IBD) • general
• vomiting ◦ pale? Ill? Wasting? Skin folds?
• Abdo pain and fever (IBD, infection) • Chest exam (CF)
• feeding
◦ started any new foods? Ix
◦ Added milk add into diet? Diarrhoea when milk • bloods
still given? ◦ FBC + ESR/CRP
• weight loss (coeliac, IBD, infection) ◦ LFT
• FHx: IBD, coeliac, CF, allergy ◦ coeliac screening serology
◦ cultures
Ddx • stool
• sugar intolerance ◦ microscopy + cultures (aerobic and anaerobic)
• cows milk allergy ◦ feacal fat test
• CF ◦ lactose/glucose clinitest tablet (sugar/lactose
intolerance)
• coeliac
• infection: giardia (mimmicks
Further Ix as needed
coeliac), salmonella,
• biopsy
campylobacter, yersinia,
entamoeba H • sigmoidoscopy
• IBD • trial lactose restriction

Coeliac disease
◦ antiendomysial and antigliadin antibodies: IgA:
• permanent sensitivity to a-gliadin of gluten → 95% specific
mucosal damage and loss of villi of proximal small ◦ antibody of tissue transglumaninase = v v
bowel → malabsorption good
• presents usually between 9 + 18 months • stool: faecal fat test

Presents with: Further Ix (If serology is suggestive)

• FTT after weaning (cereal in diet) • small bowel biopsy: gold standard Dx
• poor feeding and weight loss ◦ before diet change
• chromic diarrhoea + steatorrhoea ◦ ± retest after diet changes
• irritability • ± gluten challenge
• vomiting
• late childhood: Counselling
◦ anaemia • body decides that gluten is harmful and wants to
◦ FTT without GIT Sx destroy it. It destroys cells n your bowel that have
◦ delayed puberty, short stature the gluten. It makes it hard for your body to absorb
the nutrients it needs.
Examination • Life long, will go into remission
• miserable + pale • many gluten free products available now
• abdo distension, but wasted • pregnancy: risk of fetal loss and abnormalities
• buttock wasting and skin folds
Mx
Ix • strict lifelong gluten-free diet: wheat, barley, rye
• FBC: • oats are ok
◦ microcytic (Fe deficiency) or • vitamin and Fe supplements
◦ macrocytic (B12, foliate) • pancreatic enzyme supplements may help with
• Ca (low) weight gain
• LFTs: hypoalbuminaemia
• serology (screening only)
Swollen joint child
Hx • fat toes and knees + eye inflammation! + limb
• PMHx and general growth overgrowth!
• limp:
◦ onset E psoriatic
◦ trauma? • with psoriasis (dactylitis, nail abnormalities, 1st
◦ Duration degree relative)
◦ pattern • bad eye inflammation, variable px
◦ triggers/relievers
• Pain: F enthesitis related
◦ where does it hurt most • boys over 8 years old
◦ diurnal pattern? • with enthesitis
◦ Night (bone tumour) • link to B27+ + ankylosing spondylitis
◦ non-weight bearing? • feet, neck or back + iritis
• JIA Hx • treat hard and fast for back
◦ rash?
Mx
◦ psoriasis/ itching
• physiotherapy and OT
◦ Eye inflammation
• NSAIDS – DMARDS and cytotoxics
◦ neck/back pain
steroids – local, IV, low dose oral, eye drops
• Septic Hx
◦ fever Examination
• gait
Juvenile idiopathic arthritis
• skin
• common
◦ signs of trauma
• 6 weeks of pain before 16 years old
◦ rash (maculopapular)
◦ psoriasis
A systemic arthritis
• joints
• 2 weeks fever + arthritis + rash (maculopapular)
/organomegally ◦ inflammation
• high ESR, CRP, WCC ◦ number of joints
• muscles
B polyarthritis RF+ • lymph glands / organomegally
• in teen girls • fever
• 4 or more joints • eye exam for iritis
• treat hard and fast to prevent erosion
Ix
C polyarthritis RF- • CRP/ESR, RF, FBC
• more common • Xray, bone scan
• ? • MRI for tumour

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

Developmental dysplasia of the hip

• Clicky hips, be suspicious if: Screening
• Abnormal femoral head movement • General: barlows + ortolani
• Limited hip movement • Selective screening: hip U/S
• FHx ◦ Exams in the first year
• Breech ◦ Xray if >3months
• Ix: hip U/S
Counselling
Risk factors for DDH • 1 in 80 have clicky hips in first few days
• First born • 1 in 800 will need some management
• Female • caught early enough, will walk normally, fully functioning
• Breech hip
• CS • refer to paediatric orthopod
• FHx
Mx
• Foot abnormalities
• The earlier the better
• 0-6months: Brace in abduction with a Pavlick harness
• 8-18months: will need open reduction + osteotomy
Child with Limp
Limp of DDx • Xray, bone scan
• DDH • Mx: admit, culture (blood, joint fluid), ABx
• Perthes
• SCFE Perthes disease
• Transient sinovitis • inadequate growth of blood supply
• Septic arthritis • avascular necrosis capital femoral epiphysis f femoral
• Trauma, OM, cancer head
Hx
• male ~7yo
Hx • Sx
• Sx • Painless limp on exercise
• Pain •  Hip/groin pain  knee / thigh
◦ Location  knee, thigh • antalgic gait
◦ Pain with walking, exercise • cause
◦ Affect on school/home • idiopathic
• Limp: when? • DDH
• Trauma • steroids
• Generally well? • trauma
• DDH Examination
• Steroids • general: wasted quads on one side
• Recent illness • legs unequal
• Weight loss, pain at night • move: ↓ internal rotation
Ix : Xray
Examination Mx: splint, osteotomy
• gait
• General: septic? SCFE (slipped capital femoral epiphysis)
• Fever, pallor • in fat teenage boys
• Rash • Sx
• Lymphadenopathy / organomegally • Gradual Pain + limp  knee / thigh / groin
• Limb length: true + apparent Examination
• Limb • Antalgic gait
• Red, swollen, tender, hot • ↓ internal rotation
• Atrophy • joint irritability
Ix: Xray in frog lateral view
• movement
Mx: surgical screws to stop slip
Ix • don’t push back (vessel damage)
• Xray (SCFE, trauma, infection, tumours, perthes)
• ±bone scan (OM, stress)
• FBC + film, ESR

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

Septic arthritis + Osteomyelitis

• red, swollen, hot, tender joint
• can not weight bear
• all movements painful
• septic child
• Ix: ↑ ESR, WCC
Headache child
Hx
• pain
◦ location
◦ onset First acute headache
◦ duration Ddx
◦ frequency • first migraine
◦ pattern • tension / cluster headache
• Red flags • viral illness / sinusitis / OM
◦ worse at night, on waking • CNS infections (men, enceph, ICPup)
◦ vomiting and visual changes • Pneumonia
◦ progressive • HTN / vascular
◦ cognitive change • minor trauma
◦ weight loss • exertional
◦ under 5 years • hypoglycaemia
• state between attacks
• head trauma
• development + schooling Migraine
• FHx of migraines, cancers Counselling
• education
Examination • simple analgesia
• vitals: BP, HR, temperature • ± metaclopromide
• inspect: toxic? Unwell? Rash? • ± cyproheptadine
• ENT: cervical nodes, teeth, sinus, ears • nasal sumatriptan
• centiles • sleep
• neuro exam Prevention
◦ fundi • avoid triggers
◦ confusion • cyproheptadine, pizotifen, B-blockers, amitryptiline
◦ visual fields
◦ tender / stiff neck
◦ tense fontanelle •
• cranial bruits

Head trauma child

Hx ▪ intact consciousness
• What happened? ▪ seizures
• Falls • any other injuries?
◦ What surface? What part of body?
◦ How high?
• Before:
◦ black out / fitting
◦ did they roll / crawl / climb
• during: Examination
Vitals
◦ witnessed?
• breathing: Cheyne-Stokes respirations (Midbrain
◦ NAI?
herniation)
• After:
• HR + BP in Cushings triad of high ICP
◦ concussion signs (few hours only)
• AVPU, confusion, drowsiness
▪ loss of consciousness
▪ confusion Head
▪ vomiting • trauma
▪ amnesia • racoon eyes and battle's sign (basilar skull fracture)
◦ Worry about cerebral contusion if • depressed skull
▪ drowsy Eyes
▪ headache or vomiting • epidural
▪ focal neuro signs ◦ ipsilateral dilatation
◦ worry about epidural haematoma if ◦ papilloedema
▪ hit from side • subdural: retinal haemorrhage
▪ fluctuating confusion and lucidity ENT
◦ worry about subdural haematoma if • CSF otorrhoea + rhinorrhoea (basilar skull fracture)
▪ shaking baby Neck/chest
 • immobilise cervical spine → palpate spinous • bilateral = subdural
processes • reflexes
• soft tissue / rib trauma
Neuro Ix
• focal signs = contusion, haematoma • cervical spine films
• unilateral = epidural • contrast CT (ICP, fracture, penetrating injury)
Fracture Burns
• Hx First Aid
• How did it happen? • Stop burning: run under cool water for 20 minutes,
• Any blood no ice.
• Other injuries – hit his head? • Carefully remove jewellery + clothes

Examination Survey
• General: distressed ABCDEF + vitals
• Signs of shock or occult blood loss, confusion • O2 mask
• Limb • Pulse + BP
• Closed or open • Elevate burned areas
• Deformity / swelling (acute = #) • Hx: how + when
• Neuro distal – sensation, movement • PMHx: allergies, tetanus status, medical problems
• Pulses distal to injury
Mx
Ix • Fluid resus
• Xray • IV access + bloods
• Site + section (diaphyseal, metaphyseal, • Hartmann’s : % x weight x 2
epiphyseal ◦ <18months >8%body area
• Fracture line: transverse, oblique, spiral, ◦ >18months >10% body area
comminuted • elevate burn area
• Displacement • monitor UO
• tetanus prophylaxis
Mx • IV morphine
• Analgesia
• Spling Examination
• Xray • Extent
• Plaster • Teens can use rule of 9s, younger kids can’t
• At home: written instructions • Distribution
• Limb elevation, wear sling for 48hrs • Concern for
• Xray at 1 weeks ◦ Face
• Plaster for 3-6 wks ◦ Neck
• No contact sports for 8-12wks after plaster ◦ Hands
◦ Feet
◦ Perineum
◦ joints
• depth
• superficial: dry, red, blister (sun, splash)
• superficial partial thickness: moist, red, broken
blisters (spills, oil, flame)
• deep partial: moist, red-white slough, pressure
but no pain (spill, oil, flame)
• deep full thckness: whyte, dry, charred, no
pain (flame, steam, chemical, electrical)

Ix
• FBC, U+E, G+H, albumin, BGL
• urine

Teenagers

Get parents out of room

Confidentiality
I write confidential medical notes
Everything you say will stay between you + me.
I won’t tell your parents and I won’t tell anyone else unless you tell me its ok I think that someone’s going to get hurt.

Issues
•

H
How is everything at home
Getting along with everyone
E
Hows everything at school
Whats your favourite subject
A
D
Has anyone in your been using drugs. Have your friends. Have you?
S
S

30M with testicular lump – U/S and counselling

BBN ▪ depends on grade + stage
 setting scene: seating, no interuptions
 telling news: direct and honest manner Further Mx
advise that further Ix in tertiary centre will be  refer to consultant surgeon
needed ◦ orchidectomy
 CT ▪ ± prosthesis
 blood tests (AFP, HCG, LDH) ▪ ± cryo=preservation of sperm
 surgery  adjuvant treatment
advise of possible treatment options depending on ◦ seminoma  radio
tumour type: surgery, chemo, radio
 ends consultation with good closure and offer Testicular cancer
some hope of cure • Germ cell tumours=
• Teratoma: most common 15-30
Further Ix • Seminoma: 30-50 – most common
 blood tests • Non-germ cell tumours = lymphoma
▪ FBP Risk factors
▪ aFP • FHx
▪ HCG • XXY + feminisation
▪ LDH • ? exogenous oestrogens
 CT Hx
 CXR • scrotal mass – firm
• painless teste enlargement, tender, assymetrical
Counsel • lymph node spread  back pain or mets (SOB)
 prognosis
◦ Non-seminoma  chemo
◦ seminoma is good (highly radiosensitive)
◦ Depends on stage and grade
▪ 95% 5yr survival
▪ size, LN, mets
◦ non-seminomas less good

counselling for chemotherapy

preventing nausea in ppl having chemo therapy

Instructions
• Ondansetron: 1 capsule each morning and night before eating
• Dexamethasone: 1 tab 2x/ day with food, about 4pm for 2nd
• Metoclopramide: 1 or 2 as needed
• Maxalon: if need extra help

when to start?
• Ondansetron and Dexamethasone the morning after chemo
• will be given anti-nausea meds with chemo at hospital on the first day

Should take if feeling ok?

• Yes, they are to prevent nausea, so should keep using Ondansetron and Dexamethasone even if you feel ok. If
feeling well, dont have to add metoclopramide.
side effects
• Ondansetron
▪ constipation
▪ headache
▪ dry mouth
• Dexamethasone: short term toxicities
▪ heartburn
▪ more appetite
 ▪ insomnia
▪ high blood sugar
• Metoclopramide
▪ restlessness
▪ dystonia

Student with lymphoma  regular follow up

Support structures
Hodgkin’s Lymphoma: Reed-Steinberg cells  letter of support to university
Types  discussion with family
Nodular sclerosis (70%)  counselling
lymphocyte rich
lymphocyte depleted Non-Hodgkin’s Lymphoma
mixed cellularity Types
Nodular lymphocyte predominant Mostly B cell
Hx Nodular best
Painless, rubbery cervical lymphadenopathy Diffuse worst
Constitutional Sx Also NK cell and T cell
Tiredness, weight loss Hx
Fever, night sweats painless lymphadenopathy
Pruritus extranodal sites: skin, GIT
ETOH induced LN pain constitutional Sx
Examination sweating
lymphadenopathy ± organomegally
±organomegally Examination
adenopathy, organomegally
masses: testes, abdo, skin, liver
Ix
Bloods
FBC + differentials Treatment
ESR, LDH, LFTs  outline likely scenario of staging disease,
FNA of node chemotherapy, DXRT
Staging: HL: Curable
CXR, CT all over Radio/chemo: ABVD
Marrow biopsy NHL: varies greatly
usually radio ± chemo (CHOP)
Dx with LN biopsy + histology
Prognosis
Staging (Ann-Arbor)
 overall px depending on staging
I : one node area
 HL has best overall px
II : 2 or more nodes on same side of diaphragm
HL: very predictable
III : both sides of diaphragm
Stage I 90%
IV : disseminated / extra-nodal, or in liver / marrow
Stage IV 65%
Relapse common
Counselling
NHL: unpredictable + variable
 BBN: points for setting the scene, empathy
 nature of diagnosis
 further mx:
 onchology referral
Skin cancer consult
Presents with: Prognosis
A Asymmetry: usually asymmetrical Overall Australian survival >80%
B Borders: well defined + irregular Poorer PX in
C Colour: blue-black / multicoloured thickness (Breslow classification)
D Diameter: >7mm usually up to 0.75mm 100% 5YS
E Elevation = invasion 0.76mm – 1.5mm 80%
Bleeding / ulceration >1.5mm <40%
Lymphadenopathy depth: levels 4 or 5 = BAD (into reticular dermis +
5% amelanitic = BAD subcutaneous tissue)
head, trunk, neck
Hx men >50 years
 previous sun exposure
 previous skin problems/operations Melanoma
 spot changes ages 30-50
o bleeding pale skin, blondes, redheads
o itching common locations: lower limbs + upper back
o change in size
 duration of lesion Types
outdoor job or hobbies superficial spreading (70%) takes months to years
do you use sun screen lentigo: old: slow growing
nodular (2%) = BAD – trunk and limbs of young
Examination Acral: palms and soles – in dark skin
dermoscopy
lymph node exam amelanotic
ulcerated
Ix
Dermoscopy + excision of lesion By stage
2mm margin stage 1/II: localised 89-96%
lymph node sampling – sentinal node biopsy if tumour stage III: regional spread 60%
>1mm mets 14%

Treatment Counselling
excise with 2-3mm margins ± dissection of lymph nodes for  advises patient of Dx of melanoma
biopsy o breaking bad news
if <1mm depth: recut 1cm  need for review and seriousness of lesion
if >1mm depth: recut 2cm  urgency of this review!!
adjuvant: interferon or combination chemo

Cough and weight loss in smoker with CXR

• Introduction: set the scene for breaking bad news

• break news in a direct and honest manner
◦ “the report says it’s likely to be cancer, but need more tests to confirm. Not good news but not certain at this
stage and not taking away all hope”
• Allow time for the patient to respond
• opportunity to return and discuss again with partner and family member

Ix
• Advise about further Ix in a tertiary centre
• CT
• sputum cytology
• bronchoscopy
For tissue diagnosis
52F with lump in breast

Hx
• aware of
▪ lump
▪ pain
▪ nipple discharge
• does she do her own breast self examination
• has she had regular mammograms/paps
• Past history
▪ breast lumps
▪ breast cancers / other cancers
• oestrogen risk factors
▪ age at menarche and menopause
▪ use of HRT or OCP
▪ Did she breastfeed? How many kids?
• FHx of breast cancer
• smoking and ETOH

Examination counselling
Inspection:
• arms by side
• hands on hips
• hands up in the air
• look for skin: irregularities, dimpling, peau d'orange, nipple inversion
Palpation:
 systemic, plus palpate for nipple discharge
 exam of lymph nodes: axillary and supraclavicular

Explanation
 raise issue of breast cancer
 offer hope

Further Ix
 “this may or may not be breast cancer, so we need to arrange further definitive testing”
 mammogram and ultrasound
 FNA or core biopsy – TODAY IF SERIOUS
 referral to breast surgeon or breast clinic

“this must be shock for you, if you need time for this to sink in, I suggest we meet again in a few days so I can answer all
you questions. You can bring your partner or relative, whichever you choose”
(If it is cancer question, you need to cover tests to confirm, treatment, and prognosis)

▪ Oncology
• Had to describe the CXR in an orderly manner (you should know this from 4th/5th year gen med!!!) – If you do,
you should pick up the missing breast shadow in seconds. There is a complete whiteout of the left, lower
segment. We were expected to discuss differentials including malignant pleural effusions, discuss management
and investigations. That is if you got that far. you had to request MC+S(microbiol)/biochem/cytology/immuology
of pleural aspirate, cytology would show up malignant cells. Rx of underlying cause, plus drain effusion if
symptomatic. [Cancer]
 Look at and comment on a CT chest and abdomen with primary lung cancer, nodal involvement and liver
metastases then discuss TNM classification and treatment options.
 Breaking bad news – Tell patient that they have a meningioma and counsel them about the prognosis.
Large masses in pancreas BBN
• CT – lung cancer with met to liver  TNM stage, Mx options, discuss/define performance status
 Oncology: a discussion with the consultant of a 42 year old woman with moderate to poor prognosis breast
cancer and how you would treat her (including surgery, chemo, radio, treatment for nausea)
 Giving bad news. 49yr old woman presents wanting to know the results of a CT scan, which revealed multiple
large masses in the head of pancrease, scan inconclusive but highly suspicious of malignancy
• 65yr old woman presents with a lump in breast which after investigation was T3N2M0, how would you treat her,
what is involved in her management? Must discuss everything, then they start firing well what if she was 70,
what if she was ER negative, what if she was M1, how about T4? What antinauseant do you know
Chesna’s family recipe for key word circling
ARF => acute/chronic/a-on-c + baseline/daily
Demographics weight + when rehydrate “aim to maintain
urine output at 0.5-1.0 mL/kg/hr)
female, childbearing age => LMP, bHCG
COPD => ? CO2 retention (ABG: HCO3-
child => immunisation, hydration will be increased in chronic retention,
otherwise titrate O2)
Comorbidities
ulcers/bone related => exclude osteomyelitis
diabetes => glucose & medical manamgent
Critical Care
ETOH => thiamine
ABCDE => tube in every hole (including 2x
Presentation wide bore cannulas) => AMPLE => critcal
Ix => detailed Hx => secondary survey
pain => analgesia
****never forget C-spine or glucose****
fever => septic screen
increased RR => O2 and ABG (exclude resp
SOB / chest pain / collapse => consider PE failure)

hypotension/hypovolaemia => always check bradycardia + hypotension + not responding

postural BP first to IVF => ? inotropes

pregnancy + bleed => anti-D GCS < 9 => call anaesthetist + intubate

abdo pain => remember lipase (pancreatitis) asthma => CXR (exclude pneumothorax)
& ECG (cardiac causes)
Drugs
surgical => DVT prophyalxis + coags, G&H,
X match (if bleeding/risk of) + AB opiods => anti-emetics
prophylaxis + anticoagulation issues
insulin => check K
DM/HT => endorgan damage (inc
fundoscopy) salbutamol => check K, check glucose