History Counselling and Ethical TM

COMMON STATIONS
SPECIALISTS IN PLAB 2 PREPARATIONS
HISTORY, COUNSELLING
AND ETHICAL
IN
PLAB 2
Dr Elmira Yaghmaei Dr Hamed Salehi
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Copyrights © 2018 Common Stations PLAB Academy – Dr Hamed Salehi. All Rights Reserved
INTRODUCTION 2 - COUNSELLING STATIONS
The most important thing in a counselling station is to make a two-way conversation.

How to make a two-way conversation?
a. Don’t talk too much. Use short statements, not more than 30 seconds. Pause and let the
patient ask you questions.
b. If the patient doesn’t ask you questions, involve the patient by asking, “Would you like me to
explain/talk about…..”
IMPORTANT POINTS
1. It is very important to make sure your patient understands.
How can you do this?
a. At the beginning of the station, tell your patient, “If you don’t understand anything, you can
interrupt me at any point and ask me.”
b. Please use simple language. Don’t use medical terms or jargon.
For example, instead of naming the medication, please explain their function.
c. Please talk slowly and clearly.
d. It is very important to maintain eye contact while you are talking to the patient. If at any point
you see patient looks confused, you may ask the patient, “Do you have any questions or
concerns?” OR “Is there anything I can help you with?”
e. You may ask the patient a couple of times, “Do you understand?” OR “Are you following
everything I’m saying?”
2. It is very important to recognize, and address patients concerns.
How can you do this?

Don’t only talk about what you think is important.
a. Assess the patient’s knowledge to see how much they know and what they want to know.
b. Be a good listener and don’t interrupt the patient.
c. Give patient a chance to ask questions. This happens only if you give short statements and
give patients a chance to ask questions.
d. Don’t forget you need to answer the patients concerns. This means that patient will choose
the subject.
e. Sometimes there are many areas in the station to cover. The best approach is to ask the
patient what their concern is. If there is not any specific concern ,you can list them for the
patient and ask them which one they prefer to discuss.
3. Although most of the time in the station should be spent on patients concerns, you have some
time for yourself to talk about important areas that may not be asked by patient.
For example, talking about Warning Signs and Safety Net is one of the most important parts of
each station that you need to cover.
Sometimes, you will be asked in the task to address some particular area. So you need to make
sure you do this.
4. Always show sympathy and empathy. This can be done by saying phrases like “I’m so sorry to
heart that!” or, “I can imagine what you have been through”.
You can also show sympathy and empathy by changing the tone of your voice or through facial
expressions and body language.
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INTRODUCTION 3 - COUNSELLING OF A DISEASE
1. Assess patient knowledge about symptoms and condition.

NOTE: Even if the disease has been mentioned in the task, you still need to assess patient’s knowledge
about their symptoms.
These symptoms are not needed to make a diagnosis since the disease has been diagnosed, however, this
can help to build up a good rapport with your patient. Patients always love to talk to their doctor about
their symptoms even if they have already talked about it to other doctors and we should not take this
chance from them.
NOTE: We should also assess patient’s knowledge about their condition to see how much they know (for
example if the disease has been disclosed or explained) and how much they want to know. By doing that
you address what they would like to know, not what you think you should talk about.
2. Disclose Diagnosis +/- Pause for Patient Concerns

NOTE: We always pause after a short statement and wait for patient’s response. If there is any question,
we will answer. If there is no question, you ask the patient if they would like to know about the next step.
For example, “Would you like me to explain about your condition?”
3. Explain Diagnosis +/- Pause for Patient Concerns

NOTE: Please use very simple language to explain what their condition is.
NOTE: As we explain the statements should be short and you should wait for patient’s response.
The next question can be different that includes, “Doctor is it dangerous?” “Doctor is there any
complication?” “Doctor what are you going to do for me?” so please address accordingly. If there is no
question, you ask the patient if they would like to know about the next step. For example, “Would you like
me to explain what we can do for you?”
Explaining Management
4. Explain about investigations +/- Pause for Patient Concerns
NOTE: In this step, if some initial investigation has been done, we will explain the investigation and their
results.
We also discuss about any further investigations if necessary.
5. Treatment +/- Pause for Patient Concerns

In this step you need to discuss about the treatment options. This includes:
a. Non-medical: In many conditions the first line treatment or at least a part of treatment is non-medical
options. For example, lifestyle modification for many conditions such as Diabetes and high blood pressure
is a first line or should be considered along with medication therapy.
b. Medical: You man discuss about medication, which you need to prescribe for the patient. Please avoid
naming the medication unless patient asks. Instead of naming the drug, you can explain the function of
medication to the patient.
You may discuss about any possible Side Effects if patient asks.
c. Surgical: You may discuss about surgical options if necessary, however when we diagnose a medical
condition we start with non-medical and medical options. Therefore, usually we don’t talk about surgical
options unless patient has asked it, or surgical treatment is the only option.
6. General Advice, Warning Signs, Safety Net +/- Pause for Patient Concerns
In many conditions, we can give the patient general advice that will help to improve patient condition and
more importantly help to prevent this happening in the future.
Warning Signs and Safety Net are one of the most important parts of each station. This part is not usually
asked by patient and should be covered by the doctor. Warning Signs and Safety Net include any serious
complications of the disease that the patient should be able to recognize and seek help from medical
professionals. These include advice for regular check-up and follow-up if necessary.
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INTRODUCTION 5 - PAIN MANAGEMENT
1. Pain Ladder
a. Simple painkiller (Aspririn, Paracetamol, NSAIDS) +/- Adjuvants
b. Weak Opioids (Codeine, Tramadol) +/- Adjuvants

c. Stronger Opioids (Morphone, Diamorphine, Oxycodone, Pethadine, Fentanyl) +/- Adjuvants
2. Patient is on painkiller and pain is not well controlled.

- Please check the compliance first.
3. How to check compliance:

- Do you take the medicine regularly?
- Do you take the medicine as prescribed?
- Any missing dose?
4. It is very important to explain to the patient to take the medication regularly as we prescribe, not
only when you feel the pain. Tell the patient, when you take the painkiller regularly, you will prevent
the pain and prevention is always better than cure.
5. Patient is on painkiller and patient has good compliance, but pain is not well controlled.
- You can increase the dose of medication up to the maximum dose.
6. Patient is on painkiller, patient has good compliance and patient is taking maximum dose of
medication, but the pain is not well controlled.
- You can move up the pain ladder to a stronger group.
7. When we prescribe weak opioid or strong opioid, we should always have a weak painkiller like
Paracetamol or NSAID along with the Opioid painkiller.
For example, we usually prescribe Co-codamol which is a combination of Pracetemaol and Codeine).
NOTE: There are two types of Co-codamol.
a. POM (Prescribe Only Medication) 30mg Codeine + 500mg Paracetamol
b OTC (Over The Counter) 8mg Codeine + 500mg Paracetamol
8. Adjuvants play a very important role in pain management.

These are not painkillers, but they work with painkillers to optimize and minimize the pain. For
example,
Adjuvants for Bone Metastasis pain – Radiotherapy & Bisphosphonates
Adjuvants for Osteoarthritis – Steroids (Inj)/Intra-articular & Bisphosphonates
Adjucants for Neuropathic Pain – Gabapentin, Amitriptyline, Carbamazepine.
9. Before prescribing any painkiller:

- We need to Rule out C/I by asking 3+4 questions.
3 questions
i) Do you have any medical illness?
ii) Do you take any medications?
iii) Do you have any allergies to any medications?
NOTE: For example, in patients with peptic ulcer or asthma, giving NSAIDs is contraindicated.
For example, in patients who is on blood thinner such as Warfarin, giving NSAIDs is contraindicated.
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4 questions
i) Did you take any painkillers?
ii) What did you take?
iii) How much did you take?
iv) When did you take it?
NOTE: For example, for Paracetamol, the maximum dose is 1g (2 tablets every 4 hours). This means
if patient took 2 Paracetamol 2 hours ago and is still in pain, you can’t prescribe another dose of
PCM, you should consider something else.
- Choose the right Painkiller.
10. It is very important to choose the right painkiller.

How to choose the right painkiller?
11. One way of to choose a right is to know about the nature of pain.
12.The other way of choosing the right painkiller is to assess the severity of the pain.
For pain scored 1—3, simple painkiller may be helpful.
For pain scored 4—6, weak opioids may be helpful.
For pain scored 7—10, strong opioids may be helpful.
13. Always after giving painkiller, pain should be assessed in order to take any further action.
14. Usually in terminally ill patients, we need to start from weak painkillers and then step up to
strong painkillers if needed.
15. Usually for post-op pain management, we start from strong painkiller and then step down to
weak painkiller.
16. Patient is on painkiller, pain is well controlled but patient has some side effects. We try to tackle
the side effects and continue with the same painkiller.
17. Patient is on painkiller, pain is well controlled, but patient has some side effects that cannot be
tackled. We change the medication to another drug from the same group.
For example: Patient has morphine-induced hallucinations. The alternative medication is PO
Oxycodone.
18. Patient is on painkiller, pain is well controlled, but side effects cannot be treated. Sometimes not
only do you need to change the medication from the same group, you need to change the route of
administration.
For example: Patient on long-term PO Morphine will develop S/E such as vomiting and dysphagia.
The alternative medication is Subcutaneous Diamorphine.
19. When we change the medication, the dose should be adjusted.
ROUTE/DRUG DOSE COMPARED TO PO MORPHINE

PO Morphine 30mg x1
IV Morphine 15mg x2
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S/C Diamorphine 10mg x3
Fentanyl Patch 200 g (mcg) x150
20. Fentanyl Patch is a very strong painkiller. However, it is not the first choice in pain management.
We use this when:
a. There is poor compliance to PO medication.
b. Patient is on maximum dose of morphine but still in pain.
c. If there is renal impairment (GFR < 30).
d. Patient is in severe pain but wants to be mobile (when you cannot use syringe driver).
21. Usually Fentanyl patch lasts for 3 days.

When you start Fentanyl, it takes 12-24 hours to start working, so you may need to prescribe some
other painkiller to your patient when you start fentanyl patch.
It takes about 12-24 hours to be clear from the body, so if you stop this medication, you should not
give the patient painkiller within 24 hours unless patient feels pain.
22. One of the specific side-effect of Fentanyl patch is skin reaction or rash.
23. The most important cause of poor compliance of any medication including painkiller is side
effects. It is very important to discuss about S/E and the solution when you prescribe painkiller.
24. Side effects of Morphine (and to some extent all opioids)

S/E SOLUTION
1. Please stick to simple, cold and small
portions of food. Avoid spicy, creamy and
rich foods.
1. Nausea & Vomiting 2. Please take your medication a few hours
after the meal.
3. If needed, we will prescribe you anti-
sickness medication.
1. Please have plenty of fruits and vegetables
in your diet.
2. Constipation 2. Please have plenty of water and maintain
hydration.
3. If needed, we will prescribe medications.
1. You can have an ice-cube or sugar free
chewing gum.
3. Dry Mouth
2. If needed, we can prescribe artificial
saliva.
1. Don’t worry, this is usually temporary and
goes away after a few days.
2. Please do not drive.
4. Drowsiness/feeling sleepy. 3. Please do not drink alcohol.
4. Do not operate any heavy machinery
(according to patients occupation) or sign
any important documents
1. If this happens, please contact your GP. If
5. Shallow breathing. your GP is not available, please go to the
A&E.
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25. It is proven that emotional and familial support will optimize and minimize the pain. So as long
as we can control the pain and other symptoms, we can send a terminally ill patient home.
26. District Nurses play a crucial role in the primary healthcare team. They visit people in their own
homes or in the residential care homes providing complex care for pain and other symptoms to the
patients and support their family members.
27. Macmillon Palliative Nurses provide advice and support with pain and symptoms, management
for people with palliative care needs to end of life care. They support the person with cancer, their
family and the nurses and doctors who are looking after them.
28. Syringe driver is one of the options in pain management of terminally ill patients.
It is a small pump that gives you continuous dose of medication under the skin as an injection.
NOTE: Syringe driver will usually be given to terminally ill patients who have been on long term oral
morphine and have developed side effects, especially nausea, vomiting and dysphagia. The
medication that is used commonly is Diamorphine and the route is Sub Cutaneous (Sub/Cut).
29. Patient Controlled Analgesia (PCA) is one method of pain management for post-op patients.
This is a small device by which you can control the pain by pressing a button. By doing this,
medication goes into your blood vessel.
Don’t worry about overdose because we will programme the device in a way that you cannot take
more than a certain amount of painkiller in one day.
NOTE: PCA is usually used after a major surgery when patient is in severe pain. The medication that
is commonly used is Morphine and the route is IV.
30. Post-op Pain Management
a. Major Surgery: Patient may need PCA during the time he’s staying in the hospital. It can be shifted
to PO Morphine along with a simple painkiller after a while. Since the pain will subside after
operation, we can shift it to a weak opioid along with a simple painkiller such as Co-codamol. And
then possible we can shift the patient to simple painkiller such as Paracetamol.
b. Minor Surgery: Usually after such operation, patients receive a weak opioid along with a simple
painkiller such as Co-codamol. When the pain subsides you an shift the patient to a simple painkiller
such as Paracetamol.
c. Minor procedure: Usually after a minor procedure, simple painkiller such as Paracetamol or NSAID
will be sufficient.
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INTRODUCTION 6 - LIFESTYLE MODIFICATION
1. Lifestyle modification is one of the most important parts of management in many chronic diseases such
as Diabetes, Hypertension, Heart Disease and High Cholesterol.
2. For lifestyle modification it is very important to take relevant history first and then advise accordingly
3. Lifestyle modification has 5 important areas to cover. These include alcohol, smoking, diet, physical
activity and stress.
4. You may not be able to assess all aspect of lifestyle in one station. You may need to choose some
area/areas of lifestyle because lifestyle is a part of management in some stations and you need to talk
about other types of management as well.
A) DIET:
These are some general advice about diet.
1. Please have a well balanced diet.
2. Please have plenty of fruits and vegetables. It is advisable to have at least 5 portions a day.
3. Please cut down the amount of salt, sugar and fat in your diet.
4. Please try to have some white meat such as fish and chicken rather than red meat and processed meat.
5. Please try to cook at home rather than eating out or having takeaway food. These types of foods are not
usually healthy since they use high salt, sugar and fat to make it tastier whereas, you can choose healthy
ingredients to cook at home.
6. If it’s not possible to cook at home, please try healthy options such as fruits and vegetables. You may eat
grilled, steamed, boiled foods rather than fried foods.
NOTE: In some patients after giving the general advice, you can refer the patient for more specific advice
from the dietician.
NOTE: Some medical conditions need some specific advice.

For example in patients with Osteoporosis, it is important to advise to have enough dairy products, oily
fish and nuts since these foods are a good source of Vitamin D, Calcium and Omega-3.
For example, in patients with Gout, it is important to advise to have less red meat.
For example, in patients with Chronic Kidney Disease (CKD), it is important to advise the patient to take
less water and protein.
B) PHYSICAL ACTIVITY:
1. It is advisable to have at least 30 minutes of physical activity such as walking, jogging, or swimming.
2. This will protect you from having medical conditions such as Diabetes, Heart Disease, High Blood
Pressure, High Cholesterol and Stroke.
3. Usually you will hear 2 excuses from the patients:

a) “Doctor, I don’t have time.”
How to advise:
You don’t necessarily need to go to gym. You can fit your physical activity into your day-to-day life.
It does not need to be in one session, for example you can split it into 2 sessions of 15 minutes or 3
sessions of 10 minutes each.
These are a few examples that may be helpful.
- If you live in a flat, you can climb the stairs rather than using a lift.
- If you use public transport, you can get off 1 or 2 stops before your home or workplace and walk to your
destination.
- If you drive when you want to get something from local shop, please walk instead of driving.
b) “Doctor, I have some joint problem.” OR “Doctor, I get tired easily when I do physical activity.”
How to advise:
Don’t worry, we may refer you to the gym instructor or physiotherapist. These people are experts and
know how to train people with different capabilities. They will help you and support you to do physical
activity based on your ability.
C) ALCOHOL:
The recommended daily amount of alcohol is 2 units per day.
For example:
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- One large glass (250ml) of wine approximately contains 3 units of alcohol. A bottle of wine (750ml)
contains approximately 9 units of alcohol.
- One pint (585ml) of beer or lager contains approximately 2 units of alcohol.
- One shot (25ml) of spirits (example Vodka, Whiskey, Bourbon, Gin, Tequila, Cognac) contains
approximately 1 unit. One bottle (750ml) of spirit contains 30 units of alcohol.
Usually we advise patients to cut down alcohol intake, as it may not be the absolute risk factor for a
particular disease. However, in some cases it is the absolute risk factor so advise may be to stop
consumption of alcohol.
For example, in patients with gastric erosions in which alcohol is the only cause, the advice should be to
stop altogether.
For example, in patients with alcoholic neuropathy, the advice should be to stop completely.
NOTE:
Advising about alcohol is dependent on the patient’s reaction. You can observe this by maintain eye
contact with the patient. If the patient is receptive to the advice, you may discuss it further.
For example, in a patient with Gout, there are a few risk factors such as drinking beer, having too much
red meat, having high blood pressure and taking thiazide medication.
As we discussed, you can tell the patient, “Please try to cut down the amount of beer you are drinking.”
Look at the patient’s reaction. If patient is receptive to your advice, you may go one step ahead and advise,
“You may try to have wine instead of beer, if possible.”
If the patient is still receptive, you may even go one step ahead and advise, “It would be great if you could
stop altogether.”
D) SMOKING:
You can tell the patient, “I am sure it is not easy, but you need to stop smoking. We are here to help you;
we can refer you to the Smoking Cessation Clinic where they can support you in different ways to stop
smoking.
E) STRESS:
Sometimes stress is the risk for Heart Disease, High Blood Pressure and Stroke.
You can tell the patient, “You need to reduce your stress. Having physical activity such as walking, jogging,
running can reduce stress. You may try to join a yoga class or meditation session if you wish.
Sometimes, patients job is the main reason of stress. You can tell the patient, “I’m sure it’s not easy to
change your job, but you may discuss this matter with a career advisor and explore all possible options.”
NOTE: It is very important to explain to patients why they should do necessary changes in their life style.
For example, if you are dealing with a patient who is at risk of heart attack, you can approach in this way
when you are talking about smoking cession:
Smoking can damage and narrow the vessel supplying blood to your heart. This can block these vessels
and be the cause of heart attack. I am sure it’s not easy, but it would be great if you could stop smoking.
We will help you by referring you to smoking cessation clinic.
For the same patient, before giving advice about diet and physical activity, you can explain how obesity
can increase the risk of heart attack. For example, you can say:
Having a poor diet and lack of physical activity can lead to put on weight. This can increase the risk of
high blood pressure, high cholesterol and diabetes.
High blood pressure can put strain on your heart.
Diabetes can damage the lining of the blood vessels in your heart.
High cholesterol can block the blood vessels supplying blood to your heart.
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INTRODUCTION 7 - COUNSELLING OF A SURGICAL PROCEDURE
1. Assess patient’s knowledge about symptoms, condition and surgery.
It is important to assess patient’s knowledge about their symptoms and condition, which helps to build up a good
rapport with them.
Assessing patient’s knowledge about the surgical procedure, which they are going to undergo, is very important since
you can recognize how much they know and how much they would like to know.
2. It is very important to give the patient a step-wise picture about before, during and after their surgery. This
includes:
a. Pre-op assessment
b. The preparation for Operation that they need
c. The mode of Anaesthesia they will have
d. What will happen in the Operation Theatre (method and duration of surgery)
e. What will happen in the Recovery Room/ITU
f. Stay in the ward
g. Discharge from ward/hospital
h. Review (Follow-up)
3. Pre-op Assessement:
Pre-op assessment is run by a doctor or a qualified nurse, 2-6 weeks before the operation. It involves checking your
health by asking you some questions, doing physical examination and running different tests.
4. Preparation for Surgery:

Operations usually need some preparation and patients should be advised to do some things before the surgery.
For example, patient who is going to have a general anaesthesia should avoid eating and drinking 8 hours before
having the surgery.
For example if patient is on Insulin or other Oral Anti-diabetic Agents should be given necessary advice.
For example patients on blood thinners should be given necessary advice.
5. The mode of anaesthesia:

This will be decided by a senior surgeon and anaesthetist, so it will be mentioned in the task.
In the exam, for minor procedure such as skin lesion or emergency endoscopy, usually Local Anaesthesia is decided,
whereas, for other surgical procedures usually General Anaesthesia is decided.
Local Anaesthesia: We will inject some medication to numb the area. We may also give you some mild sleep
medication.
Spinal Anaesthesia: We will inject some medication into your spine. You will be awake during the procedure, but the
area being operated on will be numbed so you won't experience any pain.
General Anaesthesia: We need to put you to sleep.
Advantages of Local Anaesthesia compared to General Anaesthesia:

a. Less complications
b. Less hospital stay
c. Fast recovery
d. Less fitness is required
6. How you will do the operation:
In the exam, there are two methods of surgery
a. Open, for example: Hemicolectomy, Open Nephrectomy, Hysterectomy, Hip Replacement
b. Keyhole (Laparoscopic), for example: Ectopic Pregnancy, Female Sterilisation
In this operation, we will put you to sleep.
The surgeon will make a small cut.
One cut is usually near your belly button. Gas is injected through the cut to blow out tummy wall to make it easier to
see internal organs.
Through another cut, a laparascope which is a thin telescope with a source of light, is pushed through the tummy.
This camera is connected to a TV and a surgeon can look at it. Through the other cut instruments are pushed in the
tummy cavity so the surgeon can see the instruments on the monitor and perform the surgery.
Advantages of Keyhole Surgery:

a. Less pain after surgery
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b. Less risk of complications
c. Less hospitialization
d. Smaller scar
Disadvantages:
a. Possibility of accidental damage to the internal structures such as vein or nerve.
b. It is usually has to be done under general anaesthesia.
7. Duration of the Surgery:

This depends on the method of surgery, the extent of the surgical problem, the situation in the operation theatre, and
any complications that may arise during surgery. However, generally the duration of surgery is as follows:
- Minor procedure – up to 30 mins
- Minor surgery – up to 1 hour
- Major surgery – 2-3 hours
8. Complications:
Different surgical procedures have different complications. However, there are some general complications and
solutions, which are as follows:
a. Pain – We’ll give you painkiller
b. Infection – We can prescribe you Antibiotics
c. Bleeding – If this happens we’ll manage accordingly.
d. Damage to surrounding structures – This is rare but if this happens we’ll manage accordingly.
9. Hospital Stay:
This depends on patient’s general health, healing power, possibility of complication after surgery and social
circumstances. However, generally, the duration of hospital stay is as follows:
- For minor procedure – day case (same day discharge)
- For minor surgery – up to 2-3 day
- For major surgery – up to 4-7 days
NOTE: For many minor surgeries, such as herniorraphy, the aim is to discharge the patient at the same day of
operation as long as patient is medically and socially fit for discharge.
NOTE: Before discharging any patient, patient should be medically and socially fit. This assessment will be done by a
surgeon, physiotherapist and occupational therapist.
10. Recovery Period:

This depends on patient’s general health, healing power and presence of any complication after surgery.
For example for Minor Surgery, generally the duration of recovery period is as follows:
1 week – Household chores
2 weeks – Drive, sex
4 weeks – Go back to work (Office job)
6 weeks – Go back to work (Labour job)
11. Review:
A few days after surgery, the patient can be reviewed by GP for any necessary advice such as wound care. Usually, a
few weeks (4-6 weeks) after operation, patient should be reviewed by surgeon in out-patient clinic to review the
outcome of the surgery.
12. It is very important to take consent from patient.

Usually taking verbal consent in the exam is sufficient. You may ask, “Are you happy to go for this
surgery/procedure?”
Please do NOT take consent if in the task it has been mentioned that consent has been taken.
NOTE: In most of the surgical counseling stations, you don’t have to talk about all areas. The task may mention what
areas should be covered.
The patient will also tell you what their concern is and you need to cover that area.
For example in hemiarthroplasty station the task is to discuss about post-operative complications and management.
For example, in ankle pin removal, the task is to discuss about pre-operative assessment and patient has got some
concern about post-operative complications.
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INTRODUCTION 8 - COUNSELLING OF A MEDICATION
Ask 3 important questions
1. Do you have any allergy to any medication?
2. Do you have any medical illnesses?
3. Are you taking any other medication?
You need to cover 7 important areas:
1. Discuss about the function of medicine.
2. Dosage of the medicine – how many tablets/puffs
3. Route – PO, Injention, Inhaled
4. How often (frequency) – OD, BD, TDS, QDS, PRN
5. When it should be taken. Stat or OM, ON, either AC or PC
6. How long for. Days/months/years/lifelong
7. S/E and solution of side effects. Talk about most common and less serious first, and then talk about less
common and serious ones.
General Advice
1. Please take your medication regularly as we prescribe
2. Please do not miss any dose
3. Please do not change the dose and do not stop the medication by yourself.
4. Please seek advice from your GP before using any other drug, including OTC herbal or supplements.
5. Please keep medication our of reach of children
6. Please see your GP to re-prescribe your medication
7. Please see your GP if you have a persistent S/E
8. Don’t forget to go for Follow Up. Your doctor needs to review your symptoms and medication.
How you can find the info needed for counseling of a medication
1. Prescription (FP 10) (A5 size paper)
2. D/C Summary or TTA (To Take Away)
3. Drug label
4. BNF
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INTRODUCTION 9 - BREAKING BAD NEWS
1. Never give false reassurance

2. Please try to break the news in layers
a. Check patients’ idea/assess patients’ knowledge by asking questions such as,
“Do you have any idea what’s going on?”
b. Talk to the patient about symptoms.
c. Talk about all investigations that have been done.
NOTE: Actually patient knows about all symptoms and investigations which you
are talking about however you still talk about these things in order to postpone
breaking the bad news.
d. You can use some warning statement such as “I’m afraid I don’t have very
encouraging news for you. Would you like me to talk about it?”
e. You may ask patient if they want someone with them. “Would you like to have
someone with you while I’m talking to you?”
f. You may use a word some alternative word.

For example instead of cancer you may use the word tumour or growth in the
start, however you must eventually tell the patient the tumour is cancerous.
3. Disclose about the disease.

Usually you can see some reaction from the patient after disclosing the news or
disease. These reactions include: sadness, crying, anger or denial.
It is very important to pause after breaking the news and let the patient absorb
the news.
Let the patient start talking after breaking the news.
NOTE: Usually in such stations there is tissue and water. Politely offer if patient is
crying. Please don’t push the patient.
4. Sympathy and Empathy is very important in breaking a bad news.
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INTRODUCTION 10
HOW TO USE ICE
1. I – Ideas refers to the patient’s health beliefs – What they think is

causing their symptoms.
2. C – Concerns are the worries the patient has about their symptoms and
often the reason they have come to see the doctor
3. E – Expectations are what the patient hopes for or wants to happen next
Important Points
A) Attempt to explore all of the 3 of the Ideas, Concerns and Expectations
- However, if the patient has already told you their concerns or expectations, asking this
again may come across as not listening.
- You can explore other concerns or expectations tactfully by signposting that you have
listened to them: ‘You mentioned that you were worried that your pains were caused by
bowel cancer, but was there anything else you were worried about?’
B) Asking the patient’s ICE in this order may be acceptable

- However, be willing to be flexible otherwise you will appear as too rigid
- Allow the patient to guide you and ensure it is natural. If a patient starts with
discussing their concerns, explore this before going back to ask about their ideas and
then expectations
- Do not ask for the patient’s ideas, concerns, and expectations too quickly otherwise
you will literally ICE them: ‘I don’t know what is going on - you are the doctor you should
know!’
C) If the patient mentions a relative or friend who advised them to see you then ask what
their ideas and concerns are as well as the patient’s
- You can say for example: ‘Have you spoken to your wife about it? What did they think?
What were they worried about? Do you have the same fears?’
- Some doctors routinely ask about the patient’s ideas and concerns as well as their
partners thoughts even though the patient has not mentioned them in conversation.
Whilst it can create conversation this can waste valuable time.
D) Asking ICE very well will make it easier to structure your management plan, as you
will be able to appreciate the patient’s perspective, address them and personalise your
advice.
14
EXAMPLES OF PHRASING WHEN ASKING ABOUT
PATIENTS IDEAS, CONCERNS & EXPECTATIONS
Ideas
1. ‘Tell me about what you think is causing it.’
2. ‘What do you think might be happening?’
3. ‘Have you any ideas about it yourself?’
4. ‘Do you have any clues; any theories?’
5. ‘You’ve obviously given this some thought, it would help me to
know what you were thinking it might be’.
Concerns
1. ‘What are you concerned that it might be’.
2. ‘Is there anything particular or specific that you were
concerned about?’
3. ‘What was the worst thing you were thinking it might be?’
4. ‘In your darkest moments ...‘
Expectations
1. ‘What were you hoping we might be able to do for this?’
2. ‘What do you think might be the best plan of action?’
3. ‘How might I best help you with this?’
4. ‘You’ve obviously given this some thought, what were you
thinking would be the best way of tackling this?’
15
TM MEDICINE HISTORY 1 - ACS
DIFFERENTIAL DIAGNOSIS FOR CHEST PAIN
a. Cardiac
1. ACS
2. Angina
3. Pericarditis
4. Dissecting Aortic Aneurysm
b. Respiratory
1. Pulmonary Embolism
2. Pneumonia
3. PCP
4. Lung Cancer
5. Pulmonary TB
6. Tension Pneumothorax
c. Surgical
1. GORD
2. Oesophageal Spasm
d. Other
1. Musculoskeletal Pain
2. Trauma
SYMPTOMS
1. Chest Pain
- Central
- Sudden
- Heavy/squeezing/crushing
- Radiation to left arm, shoulder, neck or jaw
2. Shortness of Breath
3. Sweating
4. Nausea & Vomiting
5. Dizziness and lightheadedness
RISK FACTORS
1. PMH
a. Previous Episode
b. Medical Illness
- Hypertension
- High Cholesterol
- Diabetes
c. Family History
2. Personal History
- Smoking
- Poor diet
- Lack of physical activity
- Stress
3. Social History
- Occupation (stressful and sedentary)
16
MANAGEMENT OF ACS STEMI
Blood test:
- Routine including FBC and U&E, troponin.
ECG:
Any of the following findings:
- ST elevation in 2 leads or more (More than 2mm in chest leads and less than 1mm in
limb leads).
- Posterior MI (Depression 1mm in V1-V3 with or without dominant R wave in V1).
- New LBBB
Connect to the monitor:

- For BP, PR, O2 Sat and ECG.
Chest X-ray:
- Only if clinically indicated.
Resuscitation:
- Give oxygen (If O2 sat is less than 94%).
Anticoagulant:
- Aspirin 300mg
- Clopidogrel 300mg (Up to 600mg)
- Fondaparinux 2.5mg S/C:
Absolute contraindications:
Anticoagulated (On warfarin), severe renal impairment (creatinine more than 250),
active bleeding, recent intracranial hemorrhage, major surgery within 2 months, acute
bacterial endocarditis.
Relative contraindications:
Known bleeding disorder, severe uncontrolled hypertension (SBP more than 200
mmHg), severe hepatic failure, CVA (cerebrovascular accident) within 2 years,
thrombocytopenia.
Note: Discuss with senior if unsure.
Pain management:
- GTN
- Morphine (2-10 mg) + IV metoclopramide (10mg)
Treatment:
- Arrange for PCI (12 hours onset of pain within 90 minutes of admission).
- If PCI is not possible then thrombolysis unless contraindicated.
Thrombolysis contraindications:
Active internal bleeding, intracranial or intraspinal surgery or trauma in last 2 months,
intracranial neoplasm, AVM (arteriovenous malformation) or aneurysm, history of CVA,
severe or uncontrolled hypertension.
Choice of agent:
- Tenecteplase: for age less than 75 or previous streptokinase or SBP less than 100.
- Streptokinase: For all others.
17
Management of Cardiac Pain (low and moderate risk)
Blood test:
- Routine including FBC and U&E, troponin.
ECG:
- Normal or non-specific changes.
Connect to the monitor:

- For BP, PR, O2 Sat and ECG.
Chest X-ray:
- Only if clinically indicated.
Resuscitation:
- Give oxygen (If O2 sat is less than 94%).
Anticoagulant:
- Aspirin 300mg
Pain management:
- GTN
- Manage the pain accordingly
Shift to CDU:
- If the first troponin is negative, patient should be shifted to the observation unit.
- Troponin should be repeated 6 hours after the onset of the pain.
- If the second troponin is negative, troponin should be repeated 12 hours after the onset of the pain.
NOTE: Who should not be moved to observation unit?

- High risk ECG.
- Initial troponin positive.
- Chest pain within 6 weeks of Acute MI or angiography.
- Ventricular arrhythmia.
- Symptoms or signs of heart failure.
- Known IHD.
- Significant comorbidity requiring admission.
NOTE: Who should be referred from observation unit?

- Positive troponin.
- Further pain with high risk ECG changes.
Discharge:
Patient can be discharged:
- If patient is asymptomatic,
- If troponin is negative and
- If there is no change in the ECG.
Follow-up:
- Low risk: GP follow-up.
- Moderate/High risk: Cardiology follow-up as well as following.
Medication:
- Aspirin 75mg
- GTN
- B-blocker (bisoprolol 5mg OD, 2.5mg OD if borderline hypertension or bradycardia)
- Simvastatin 40mg OD
Advice to see GP within 2 days
Warning signs:
Advise to attend A&E if:
- Pain is not relieved within 15 minutes.
- Frequent attacks of pain; particularly at rest.
- Pain is severe and/or you feel very unwell.
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HEART SCORING
History
2 Scores if: Typical features of cardiac pain, for example:
Chest pain: central, heavy, radiating to left arm, shoulder, neck or jaw, relieved by GTN.
Associating symptoms: sweating, nausea, vomiting, shortness of breath, dizziness.
1 Score if: Mix of typical and atypical.
0 Score if: Atypical features, for example:
Chest pain: sharp, burning, localized or right sided.
ECG
2 Scores if: Significant ischemia (High Risk), for example:
- ST depression >1mm in 2 consecutive leads.
- Transient ST elevation.
- Dynamic T wave inversion of >2mm in 2 or more leads.
- T wave inversion in V1-V4 (LAD Syndrome).
1 Score if: Nonspecific abnormalities (Moderate Risk), for example:

- Ischemic changes, same as previous ECG.
- Fixed ST depression or T wave inversion.
- Old LBBB.
- RBBB.
- ST segment changes with LVH.
- ST segment changes with digoxin therapy.
0 Score if: Others (Low Risk), for example:

- Axis deviation and/or 1st degree heart block.
- Flat ST segment without depression.
- T wave inversion in aVR or V1.
- T wave inversion V6, III or aVL (single lead).
- Old RBBB.
Age
2 Scores if: Age 65 or more.
1 Score if: Age between 45 and 65.
0 Score if: Age 45 and less.
Risk factors
- Hypertension
- High Cholesterol
- Diabetes
- Family history
- Smoker
- Ex-smoker less than 90 days.
- BMI more than 30.
2 Scores if: There are 3 or more risk factors or any of the following:
History of: CABG, PCI, abnormal angiography, positive myocardial perfusion scan, stroke, peripheral
vascular disease.
1 Score if: There are 2 or 1 risk factors.
0 Score if: If there are no risk factors.
Troponin
2 Scores if: 3 times more than normal or more.
1 Score if: Up to 3 times more than normal.
0 Score if: Normal or less than normal.
Total Score 1-3 = Low Risk, Score of 4-6 = Moderate Risk, Score of 7-10 = High Risk.
19
TM MEDICINE HISTORY 2 - HEPATITIS
HOW TO APPROACH A PATIENT WITH HEPATITIS
Look at the LFTs first (this will give you idea what can be the possible cause)

Ask about patient’s symptoms and elaborate them.

Ask closed questions about other symptoms of Hepatitis (This helps to find the cause of
hepatitis for example in Oro-faecal hepatitis, the GIT symptoms are usually present. In addition
to this you need to know about symptoms since in Hepatitis, symptomatic treatment is very
important).

Ask questions about risk factors to find out the cause of hepatitis. (PMH, Personal History, Social
History)
PMH:
Q1 Similar episode in the past,
Q2 Recent health: (for example having diarrhea for Hepatitis A)
Q3 Chronic Medical Illness: (for example having liver disease, gallbladder, blood disorder, and
autoimmune diseases such as DM, RA, IBD, Coeliac Disease and Thyroid Disease)
Q4 Medication: (History of long-term use of medication including OTC drugs and supplements).
Ask questions about immunization history (History of receiving Hepatitis A & B vaccine)
Q5 Allergy: (You many need to be prescribe some medication for treating the symptoms).
Q6 & Q7 Hospitalisation and Surgery: (Hospital stay for investigation such as ERCP, History of
gallbladder removal or receiving blood from abroad for a surgical procedure.
Q8 Family History: (FH of Liver disease or gallbladder stones. History of autoimmune disease,
history of symptoms such as fever and diarrhea in family members).
PERSONAL HISTORY
Q1 Alcohol: (History of excessive consumption is one of the important causes of Chronic Liver
Disease and Hepatitis).
Q3 Diet: History of eating out frequently especially shellfish, raw fruits and vegetables.
Q5 Sexual History: Unprotected Intercourse, Having a new partner or multiple partners.
Q6 Recreational Drugs: History of using I/V Drugs and sharing needles.
SOCIAL HISTORY
Travel History: (History of travel to the country where Hepatitis is prevalent).
Occupation: (Healthcare professional, history of Needle Stick Injury).
20
SYMPTOMS
Initial Symptoms: (Last from a few days up to a couple of weeks)

1. Fever
3. Loss of Appetite
4. RUQ Pain
5. Fatigue/feeling tired/generally unwell
6. Musculoskeletal Pain (joint/muscle pain)
7. General Symptoms (headache, sore throat and cough)
Later Symptoms: (These happen 10 days after initial symptoms)

8. Yellowish discoloration of skin/eyes
9. Dark Urine
10. Pale stool
11. Itchy skin
12. Swollen liver
CAUSES
1. Viral
a. Blood-borne (Hepatitis B & C)
- Sexual History (Unprotected sex)
- IV drug abuse (Needle sharing)
- Tattoo / Piercing
- Blood Transfusion (from abroad)
b. Oro-faecal (Hepatitis A & E)

- GIT symptoms like diarrhoea
- Other member of family with similar symptoms
- History of eating out especially shellfish, raw fruits and vegetables
- History of travel especially to countries where Hepatitis is prevalent
2. Obstructive
a. History of Gallbladder stones
b. Ca Head of Pancreas
3. Substance abuse – Alcohol

- Excessive amounts of alcohol
4. Autoimmune
- History of other autoimmune diseases such as DM, RA, Coeliac Disease, IBD and Thyroid
Disease.
INTERPRETATION OF LFTs
   NORMAL
ALT 5-35
Viral
AST 5-35
Obstructive ALP 30-150
Alcoholic GGT 5-40
Bilirubin 3-17
21
NOTE:
Incubation period for Hepatitis A is between 15 – 50 days.
Incubation period for Hepatitis B is 1 month – 6 months.
EXAMINATION
1. Vitals
2. General
3. Abdominal Examination
INVESTIGATIONS
1. LFTs
2. Ultrasound
3. Serology
NOTE: Hepatitis A IgM antibodies can be found as early as two weeks after the first
infection. They disappear 3-12 months after infection.
NOTE: Hepatitis A IgG antibodies appear 8-12 weeks after you are first infected. They
stay in the blood and protect the body from hepatitis A permanently.
MANAGEMENT
1. Especially during the first days of this condition, you will get tired, so please get
plenty of rest.
2. It would be great if you could stop drinking alcohol for a while, because it can put
additional strain on your liver. We can tell you when it is safe for you to drink again.
3. Eat smaller and lighter meals to help reduce your sickness and retching. We may
prescribe you some anti-sickness medications if needed.
4. We don’t usually advise to take painkillers when you have liver disease. However, we
will consider giving you some simple painkillers like PCM if needed.
5. You can reduce itching by maintaining a cool ventilated environment. Wearing loose
clothes, avoiding hot bath or shower can be helpful.
6. If needed we may prescribe you some medications (anti-histamine for severe cases).
22
TM 2B MX HX HEPITITIS
Preventing the spread of infection
While you're ill, it's also important to try to reduce the risk of spreading the infection to others.
You should:
1- Stay off work or school until at least a week after your jaundice or other symptoms started.
2- Avoid preparing food for others if possible.
3- Wash your hands with soap and water regularly – particularly after going to the toilet and
before preparing food.
4- Avoid sharing towels and wash soiled laundry separately on a hot cycle.
5- Clean the toilet, flush handles and taps more frequently than usual.
6- Avoid having sex while you're infectious – hepatitis A is most infectious from around two
weeks before the symptoms start until about a week after they first develop.
7- Any close contacts, such as people who live in the same house as you, may be advised to have
the hepatitis A vaccine to reduce their risk of becoming infected.
Contact the local Health Protection Unit (HPU) immediately, who will advise on further
management if the person has not previously received hepatitis A vaccine — this may include
giving hepatitis A vaccination if exposure is within one week of the onset of jaundice, and
arranging for the administration of human normal immunoglobulin, depending on the timing
and circumstances of contact.
The advice to contact the local Health Protection Unit (HPU) reflects its expertise in assessing
each individual case as to who may benefit from post-exposure prophylaxis, identifying the
possible source of infection, and identifying and controlling suspected outbreaks, with huge
potential public health implications
Hepatitis A vaccine may be given up to 14 days after exposure providing this was within the
infectious period (commonly defined as during the prodromal illness two weeks before the
onset of jaundice, to one week after the onset of jaundice, if present). The period of infectivity
may be prolonged in people with HIV or in people who are immunocompromised
Human normal immunoglobulin may be indicated for contacts of cases of hepatitis A, and for
control during outbreaks of infection. It provides immediate protection against infection if
given within 14 days of exposure, and the effect lasts for 4–6 months
23
TM MEDICINE HISTORY 3 - GCA
DIFFERENTIAL DIAGNOSIS FOR HEADACHE
1. Life-threatening
a. Meningitis
b. SAH
c. SOL
2. Elderly
a. GCA
b. Glaucoma
3. Typical
a. Migraine
b. Cluster headache
c. Tension headache
4. Others
a. Sinusitis
GIANT CELL ARTERITIS

Giant Cell Arteritis is a condition, which causes swelling inside the wall of blood vessels.
It is called so because abnormally large cells develop in the inflamed arteries.
The arteries most commonly affected are those around the head and neck. One of the
arteries that are commonly affected is the Temporal Artery, which is located at the side
of the head. Therefore this condition is sometimes called Temporal Arteritis.
SYMPTOMS
1. Headache
a. It develops suddenly, sometimes gradually.
b. It usually affects side or front of head, sometimes back or top of head
c. It is different from the type of headache people have experienced earlier
d. It usually doesn’t respond to simple painkillers such as Paracetamol.
e. Pain usually increases while combing hair.
2. Jaw pain
a. Increases while talking
b. Increases while chewing
3. Visual problems
a. Double vision
b. Blurry vision
c. Loss of vision (seems like something’s covering the eye)
5. Other symptoms
a. Mild fever
24
b. Extreme tiredness (shoulder or hip joint aching and stiffness)
c. Loss of appetite
d. Weight loss
e. Depression
RISK FACTORS
1. Those we shouldn’t ask
a. Age: >60
b. Gender: Female
c. Race: Northern European
2. PMH
a. Medical illness
- Polymyalgia Rheumatica (approximately half of patients with GCA develop PMR)
- Other autoimmune disease
- Cardiovascular disease
- Family History
3. Personal History
- Smoking
MANAGEMENT
1. We will do some blood tests. It helps to assess the level of inflammation in your body.
(ESR/CRP)
2. We will take a sample from the temporal artery (the artery that is placed on the side
of your head) to check for damage and inflammation of the lining of the artery.
However, if GCA is suspected we will start the treatment immediately because waiting
for the result may affect your vision further.
NOTE: If patient asks, how will this biopsy be done?

D: We will numb the area around the side of your head. An incision is made close to the
hairline in front of the ear and a small sample will be sent to the lab
3. Cranial US is a simple and accurate test, but since it is new availability is limited.
4. If you have vision problems, we can arrange a same day appointment with the eye
specialist. He will check your eye for bleeding or swelling at the sight of the nerve
behind the eye that transmits signals to the brain (Optic nerve).
TREATMENT
1. Symptomatic Management: Adequate painkiller should be prescribed. Patient usually
does not respond to simple painkiller such as Paracetamol so a stronger painkiller
should be considered.
2. Prednisolone: We will give you a steroid tablet to decrease the inflammation in your
arteries. We will start with a high dose of steroid (usually 60mg/day or 1mg/kg/day).
Once your symptoms have improved, usually after a few days, we can gradually reduce
the dose of medication to reach the maintenance dose (10mg/day). This usually takes
several weeks. In some people, the condition goes away after 2-3 years. This allows us
25
to reduce and eventually stop the medication. However some people may need
treatment for several years, sometimes for life.
3. Low dose Aspirin: GCA can increase the risk of having a heart attack and stroke. We
will prescribe you mini aspirin to prevent this.
4. PPI: Taking both steroid and aspirin can increase the risk of bleeding in your gut. We
will give you a medication that will protect your gut and decreases the risk of bleeding.
5. Immunosuppressant (e.g. Methotrexate): Some people benefit from medications that
suppress the immune system. It usually helps to reduce the steroid dose.
In the case of visual loss

6. Methylprednisolone 250 mg every 6 hours (up to 3-5 days): We are going to keep you
in the hospital. We will give you a high dose of a medication called steroid through your
blood vessel as a drip to reduce the swelling in your artery.
Follow up:
We will see you every week for the first 2-3 months after your treatment commences
and then every three months. We will do blood tests, we check if you experience any
symptoms, we check if you experience any side effects of the treatment you are
receiving and we adjust the dose of your medication.
S/E of Steroids
1. Osteoporosis (thinning of the bone)
a. Medication (bisphosphonate)
Patient more than 65 or patient with risk factor such as those who have history of wrist
or hip fracture after having a fall should receive medication.
Patient less than 65 without any risk factors may be offered a DEXA Scan. If the bone
density is less than a certain level (-2.5), medication may be offered.
b. Self-help: A diet provides plenty of Calcium and Vitamin D will help to protect you
against Osteoporosis. You may be advised to take Vitamin D and Calcium supplements.
Keeping active will help keep the bones strong.
2. Weight gain: Having a well balanced diet and physical activity will prevent putting on
weight.
3. High BP: We will regularly check your BP. It can be treated if it increases.
4. High Blood sugar: We will arrange yearly blood sugar checkup if you have long-term
steroid or have a family history of DM.
5. Bleeding in the gut: We will prescribe medications to prevent it.
Steroid Card
If you need to take steroids for more than 3 weeks, we will issue a steroid card. You will
need to carry it all the time because it explains that you are on steroids and that the
medication should not be stopped suddenly.
26
TM MEDICINE HISTORY 4 – WEIGHT LOSS / HYPERTHYROIDISM
DIFFERENTIAL DIAGNOSIS (D/Ds)
a. GIT
1. Malignancy
2. IBD
3. Malabsorption
4. Malnutrition
b. Infectious Disease
1. TB
2. HIV
c. Endocrine
1. Hyperthyroidism
2. Diabetes Mellitus
d. Psychiatric
1. Anorexia Nervosa
e. Other
1. Recreational Drugs & I/V Drug users
SYMPTOMS OF HYPERTHYROIDISM
1. Unexplained or unexpected weight loss despite increased appetite.
2. Intolerance to heat/sensitivity – feeling hot when everyone feels fine.
3. Excessive sweating – having warm or moist skin.
4. Needing to pass stool or urine frequently.
5. Mood swings (anxiety, nervousness, agitation, irritability).
6. Difficulty sleeping.
7. Hyperactivity
8. Feeling tired
9. Muscle weakness.
10. Heart racing (usually fast and irregular).
11. Hand shaking.
12. Patchy hair loss (alopecia)
13. Swelling in the neck.
14. Period problems such as irregular or light periods or periods stop altogether.
15. Infertility.
RISK FACTORS
1. PMH
a. Medical Illness
- Other autoimmune conditions like RA, DM, Coeliac Disease, IBD.
b. Medication
- HIV Medication (for example HIV medication HAART, Amiodarone)
c. Surgical History
- History of thyroid surgery or any trauma to thyroid gland.
d. Family History
2. PERSONAL HISTORY
a. Smoking
b. Diet
- Increased Iodine intake / Iodine supplements
27
What is hyperthyroidism?
Hyperthyroidism is a condition where the thyroid produces more thyroxine than is needed
by the body. It is also referred to as thyrotoxicosis, or an over-active thyroid. It can occur if
you have:
1-Graves’ disease - the most common cause

2-A toxic multinodular goitre (a goitre is an enlarged thyroid gland)
3-A solitary toxic thyroid adenoma (an adenoma is a clump of cells)
4-Thyroiditis (inflammation of the thyroid gland) .It is temporary and self-limiting
5-It can also occur when too much replacement thyroxine (levothyroxine) is taken as a
treatment for an under-active thyroid (hypothyroidism).
NOTE: The majority of patients with hyperthyroidism should be assessed, at least initially,
by a specialist in thyroid disorders.
How is hyperthyroidism diagnosed?

By taking history, a physical examination and blood tests.
If the thyroid-stimulating hormone (TSH) level is low - below the reference range - and the
thyroxine (FT4) level is high - above the reference range - this usually indicates an over-
active thyroid.
Another blood test to measure the antibody levels.

This is called TSH receptor antibody.
The level of this substance in your blood can establish whether or not your problem is
Graves’ disease.
The TSI Ab, exert their effect by targeting the TSH receptors in the thyroid gland, and
activate them abnormally, thus stimulating the thyroid gland to overproduce thyroid
hormones.
This is Graves' disease and these Thyroid Stimulating Immunoglobulins are the chief cause
of it.
Rarely, your specialist may also do a thyroid scan.
What is the treatment for hyperthyroidism?

Your treatment will depend on several factors, such as the type of hyperthyroidism you
have, and the severity. The available treatments are:
1-Antithyroid drugs
medication affects production of your thyroid hormone rather than their current levels. So,
you need to take them for several weeks before you see any improvement immediately
(Usually 4-8 weeks).Therefore, it is important to take your medication
Antithyroid drugs are often used as the first treatment and are the treatment of choice for
children, and for women who are pregnant.
regularly as we prescribe.
In Britain the drug first used is Carbimazole (CMZ).

If this causes you side-effects, or if you are or plan to be pregnant, Propylthiouracil (PTU) is
used.
28
A course of drug treatment lasting up to eighteen months gives you approximately a 30-
40% chance of a cure, depending on the size of the goitre and how severe the over-activity
is.
It is important to continue to take your tablets every day as forgetting to take them will
affect your blood test results and your health.
You should not stop them unless advised by a doctor even if another illness develops.
Smoking reduces the chance of a cure after a course of antithyroid drugs.
Side effects
During the first couple of months of Carbimazole, some people experience the following
side effects:
1-Feeling sick
2-Headaches
3-Aching joints
4-An upset stomach
5-An itchy rash
These should pass as your body gets used to the medication.
A less common but more serious side effect is a sudden drop in your white blood cell level
(agranulocytosis), which can mean you're very vulnerable to infections.
1. Fever
2. Sore throat
3. Gum pain, swelling or bleeding
4. Mouth ulcer
5. Persistent cough
6. SOB
If you experience any these symptoms, stop taking the tablets and contact your doctor
immediately or go to the nearest Accident and Emergency department so a blood test can
be carried out to check your white blood cell level. In most cases it turns out to be a false
alarm and you can re-start your medication
If you notice yellowing of the eyes or skin you should see a doctor and ask for a liver
enzyme test.
Very rarely, serious liver injury has been reported in patients, including children, taking
PTU, especially during the first six months of taking the drug. Your doctor should monitor
you for symptoms and discontinue the PTU if liver injury is suspected. If you notice any
yellowing of the eyes or skin you should see your doctor immediately
2-Surgery
Surgery to remove all or part of the thyroid gland
29
Surgery is usually the treatment of choice for younger patients with large goitres, for those
with severe disease, and may be considered for those whose thyroid over-activity comes
back after a course of antithyroid drugs. After surgery you are likely to need to take
levothyroxine for the rest of your life.
3-Radioactive iodine.
Radioactive iodine is very effective, is safe and rarely causes side-effects.
Radioiodine is given as a drink or a capsule to swallow. The dose of medication is very low
and harmless. Radioiodine shrinks your thyroid glands and reduces the amount of hormone
production by thyroid gland.
You usually need to take levothyroxine for life after radioactive iodine treatment if you have
Graves’ disease but not for as long if the cause of the thyroid over-activity is a toxic
multinodular goitre or a solitary toxic thyroid adenoma.
Contraindications
1. Pregnancy
2. Breast feeding
3. Eye problem (double vision, bulging of the eye)
4. Avoid pregnancy for 6 months after use.
5. For Males: avoid fathering a child for at least 4 months after use.
4-Beta blockers (Propanolol/Atenolol):
Beta blockers are helpful to ease the symptoms. If you suffer from heart racing, hands
shaking or hyperactivity we can prescribe medications to relieve these.
These tablets are sometimes used in the first few weeks after diagnosing hyperthyroidism
as they relieve some of the symptoms while waiting for other treatments such as
radioactive iodine or antithyroid drugs to take effect.
Side Effects
1. Feeling sick
2. Fatigue
3. Cold hand/feet
4. Trouble sleeping
In some cases, the thyroid over-activity may settle down without any specific treatment
when caused by thyroiditis. The hyperthyroidism associated with thyroiditis is temporary
and settles down without any specific treatment.
Each treatment has pros and cons. Your specialist will weigh these up with you to
determine which suits your case best.
After treatment - what then?
30
Blood tests are carried out every two to six months when you first start taking antithyroid
drugs, and every 6-12 months during long term treatment.
After a single course of antithyroid drug treatment your hyperthyroidism may be cured if
the cause of the thyroid over-activity is Graves’ disease. Provided you are symptom-free and
your thyroid blood tests are normal one year after treatment you will need no further
check-ups, other than occasional thyroid blood tests. It is, however, important to see your
GP and to ask for a blood test if you notice any symptoms of hyperthyroidism in the future.
You should have frequent blood tests to check your thyroid function until you are stable, if
you have had radioactive iodine or surgery, and once a year after that, as there is a long-
term risk of developing hypothyroidism.
Symptoms of hypothyroidism include weight gain, feeling the cold, dry skin and hair, pins
and needles in the fingers, lack of energy, and puffiness of the face.
Tell your doctor if you are taking any other prescription or over-the-counter medication as
this may affect your blood tests.
If you have hyperthyroidism and are planning to become pregnant you should see your
doctor. You should use contraception in the meantime. You should have a thyroid function
test preferably before you become pregnant and very early in pregnancy, because you may
need to change your medication and have more frequent blood tests.
Do not stop taking antithyroid drugs before speaking to your doctor.
There is greater risk to the pregnancy from an untreated over-active thyroid gland than
from taking antithyroid medication.
You may have got used to increased food intake without weight gain during the period of
thyroid over-activity (increased metabolism).
Once the thyroid function and metabolism is normalised by any of the forms of treatment,
you may have to reduce your food intake to avoid undesirable weight gain.
Some important points….

-You will normally be referred to an endocrinologist - a doctor specialising in thyroid and
other endocrine disorders
-It is important to take your tablets every day. Forgetting to take your tablets will affect
your blood test results and your health
-You should not stop any thyroid medication, unless advised by a doctor, even if other
illness develops
-If you are pregnant, or are planning to have a baby, you should tell your doctor as you may
need your medication adjusted and more frequent blood tests
-Some medications can affect the blood test results, so it is important to tell your doctor
about any medication you are taking
-If you are taking antithyroid drugs and develop a sore throat, mouth ulcers, rash, or an
unexplained fever, stop taking the tablets immediately and go to your GP or nearest
Accident and Emergency department
-If you notice yellowing of the eyes or skin you should see a doctor and ask for a liver
enzyme test
-It is well recognised that thyroid problems often run in families and if family members are
unwell they should be encouraged to discuss with their own GP whether thyroid testing is
warranted
31
Extra Information -Thyroid Antibodies
The body produces antibodies as part of a normal immune response to foreign invaders, like viruses
and bacteria. It happens that certain body proteins, going peacefully about their business, can get
attacked by the immune system, even if they have done nothing wrong. When this happens the body,
cells being wrongly attacked can be damaged and destroyed.
The antibodies that appear most frequently in thyroid problems are
1-Antithyroid Peroxidase Antibody or TPO Ab (Ab is short for antibody) this is also known as
Antithyroid Microsomal Ab
The first group, the TPO Ab, are found raised in Hashimoto's disease - otherwise known as
autoimmune thyroiditis. Here the cells of the thyroid gland are attacked and slowly destroyed.
Patients with these antibodies present either have Hashimoto’s or are going to have it with
subsequent reduction of thyroid function. (Elevated levels are found in virtually all cases of
Hashimoto's disease and they will also be raised in 65% of patients with Graves' disease).
2-Antithyroglobulin Antibody or TG Ab
The next group is the TG Ab. These levels rise as well as the TPO Ab levels in autoimmune thyroiditis,
but to a lesser degree.
3-Thyroid Stimulating Immunoglobulin or TSI Ab
The TSI Ab, exert their effect by targeting the TSH (thyroid stimulating hormone) receptors in the
thyroid gland, and activate them abnormally, thus stimulating the thyroid gland to overproduce
thyroid hormones. This of course is Graves' disease and these Thyroid Stimulating Immunoglobulins
are the chief cause of it.
Although this may all sound logical and clear, life being what it is means that both the thyroid
stimulating immunoglobulin antibodies and the antithyroid peroxidase antibodies may both be
present in an autoimmune (Hashimoto's) thyroiditis and in Graves' disease in some degree at least.
Some family members may all have raised levels (or titres) of all three antibody types, yet not have
any clinical symptoms. This may well be that the thyroid is not too badly affected so far and can
compensate for the present. Nevertheless, these family members are at risk, perhaps later on, and
should have follow up checks every six months or a year or so.
Any level of antibody titre should be regarded as at least potentially suspicious of future illness. The
actual levels found on testing however depend on the laboratory and the methods of testing.
In general, however, for Thyroglobulin Antibodies, the reference range should be anything less than
200 mUI/ml or Ab Index no higher than 0.9, and for the Antithyroid Peroxidase Antibodies, anything
less than 150 mUI/ml or Ab Index no higher than 0.9.
It is perfectly possible to establish a firm correlation between the levels of antibodies present and
the severity of the illness.
32
TM MEDICINE HISTORY 5 - TIA
Transient ischaemic attack or mini stroke is caused by a temporary disruption in the blood
supply to part of brain. This results in lack of oxygen to the brain.
SYMPTOMS
Common Symptoms:
1. Facial change
a. Face may drop on once side
b. Patient may not be able to smile
c. Their mouth or eye may drop
2. Weakness or numbness of arms (patient may not be able to lift objects and keep them
rasied)
3. Speech Problem
a. Patient may have slurred speech,
b. may not be able to talk at all despite appearing to be awake
Other symptoms
4. Dizziness
5. Confusion
6. Visual Problems
a. Sudden loss of vision
b. Blurry vision
7. Difficulty in swallowing
8. Difficulty in understanding what others are saying
9. Problem with balance and coordination
10. Loss of Consciousness
11. Complete paralysis of one side of body
33
RISK FATORS
1. PMH
a. Similar Episode in the past
b. Medical Illness
- Hypertension
- DM
- High cholesterol
- Heart disease (arrhythmias e.g. AF)
c. Family History
2. Personal History
a. Smoking
b. Excessive alcohol consumption
c. Poor diet
d. Lack of physical activity
TIA is an acute loss of focal or global neurological or ocular function lasting less than 24
hours, with no obvious non-vascular cause.
CLINICAL FEATURES ACCORDING TO SITE
1. Anterior territory:
a. Aphasia
b. Monocular visual loss.
c. U/L weakness.
d. U/L sensory loss.
2. Either territory:
a. Dysarthria
b. Ataxia
c. Diplopia
d. Vertigo
e. LOC
3. Posterior territory:
a. B/L simultaneous visual loss
b. B/L simultaneous weakness.
c. B/L simultaneous sensory loss
d. Crossed sensory/motor loss.
34
INVESTIGATIONS IN A&E
1. Blood:
- Routine (FBC, U&E’s)
- INR (if clinically indicated)
2. ECG
3. Urgent CT Brain (If clinically indicated)
Indications for Urgent CT Brain:

1. Patient on Warfarin or NOAC (Novel Oral Anticoagulant eg. Rivaroxaban, Dabigatran, Apixaban)
2. Known bleeding disorder
3. Fluctuation in symptoms
4. Decreased GCS
5. Unexpected deterioration
6. Severe headache at onset
7. Papiloedema / neck stiffness/ fever
TREATMENT
Antiplatelet agent (Aspirin 300 mg STAT and continue 300 mg)
Contraindication: Allergy, Warfarin, NOAC, Cerebral haemorrhage
NOTE: If urgent CT Brain is indicated, wait for results before giving aspirin.
ABCD2 SCORE
AGE ≥ 60 years 1
< 60 years 0
BLOOD PRESSURE > 140 1
Other 0
CLINICAL Upper Limb Weakness 2
Speech Disturbance 1
Other 0
DURATION ≥ 60 minutes 2
10-59 minutes 1
< 10 minutes 0
DIABETIC Yes 1
No 0
REFERRAL
1. Refer to be seen by a specialist in Outpatient Clinic within 7 days.
(In Low Risk Patient: ABCD2 Score Less than 4).
2. Urgent Referral to be seen by a specialist in Outpatient Clinic within 24 hours.
(In High Risk Patient: ABCD2 Score ≥ 4, or recurrent TIA or patient with AF)
3. Refer to Acute Medicine Unit if:
a. Abnormal CT
b. CT normal but
- INR abnormal or above therapeutic range
- Persistent headache
- Elevated BP 200/120
- Elevated blood sugar more than 11.
35
Extra Information
Prompt recognition of symptoms of Stroke and TIA
In people with sudden onset of neurological symptoms a validated tool, such as FAST
(Face Arm Speech Test), should be used outside hospital to screen for a diagnosis of
stroke or TIA.
-In people with sudden onset of neurological symptoms, hypoglycaemia should be
excluded as the cause of these symptoms.
-People who are admitted to accident and emergency (A&E) with a suspected stroke or
TIA should have the diagnosis established rapidly using a validated tool, such as ROSIER
(Recognition of Stroke in the Emergency Room).
Risk assessment for TIA
People who have had a suspected TIA (that is, they have no neurological symptoms at
the time of assessment [within 24 hours]) should be assessed as soon as possible for
their risk of subsequent stroke using a validated scoring system, such as ABCD2.
Identifying those at high risk of stroke
People who have had a suspected TIA who are at high risk of stroke (that is, with an
ABCD2 score of 4 or above) should have:
-Aspirin (300 mg daily) started immediately
-Specialist assessment and investigation within 24 hours of onset of symptoms
-Measures for secondary prevention introduced as soon as the diagnosis is confirmed,
including discussion of individual risk factors.
NOTE: People with crescendo TIA (two or more TIAs in a week) should be treated as
being at high risk of stroke, even though they may have an ABCD2 score of 3 or below.
Identifying those at low risk of stroke
People who have had a suspected TIA who are at lower risk of stroke (that is, an
ABCD2 score of 3 or below) should have:
-Aspirin (300 mg daily) started immediately
-Specialist assessment and investigation as soon as possible, but definitely within
1 week of onset of symptoms
-Measures for secondary prevention introduced as soon as the diagnosis is confirmed,
including discussion of individual risk factors.
Referral for urgent brain imagine in suspected TIA
People who have had a suspected TIA should undergo brain imaging if
1- The vascular territory is uncertain
(In people being considered for carotid endarterectomy where it is uncertain whether
the stroke is in the anterior or posterior circulation)
2- Pathology is uncertain
(In people with TIA where haemorrhage needs to be excluded, for example long
duration of symptoms or people on anticoagulants; where an alternative diagnosis, for
example migraine, epilepsy or tumour is being considered)
NOTE: People who are at high risk of stroke should have the imaging done within 24
hours, while those who are lower risk within 7 days.
Type of brain imaging for people with suspected TIA
People who have had a suspected TIA who need brain imaging should undergo
diffusion-weighted MRI except where contraindicated, in which case CT (computed
tomography) scanning should be used.
36
NOTE: Contraindications to MRI include people who have any of the following: a
pacemaker, shrapnel, some brain aneurysm clips and heart valves, metal fragments in
eyes, severe claustrophobia.
Early carotid imaging in people with acute non-disabling stroke or TIA
All people with suspected non-disabling stroke or TIA who after specialist assessment
are considered as candidates for carotid endarterectomy should have carotid imaging
within 1 week of onset of symptoms.
NOTE: People who present more than 1 week after their last symptom of TIA has
resolved should be managed using the lower-risk pathway.
Urgent carotid endarterectomy and carotid stenting
A) People with stable neurological symptoms from acute non-disabling stroke or TIA
who have symptomatic carotid stenosis of 70–99% according to the ECST (European
Carotid Surgery Trialists' Collaborative Group) criteria:
1. Should be assessed and referred for carotid endarterectomy within 1 week of onset of
stroke or TIA symptoms
2. Should undergo surgery within a maximum of 2 weeks of onset of stroke or TIA
symptoms
3. Should receive best medical treatment (control of blood pressure, antiplatelet agents,
cholesterol lowering through diet and drugs, lifestyle advice).
B) People with stable neurological symptoms from acute non-disabling stroke or TIA
who have symptomatic carotid stenosis of less than 70% according to the ECST criteria:
1. Should not undergo surgery
2. Should receive best medical treatment (control of blood pressure, antiplatelet agents,
cholesterol lowering through diet and drugs, lifestyle advice).
37
Stroke Assessment- ROSIER
The aim of this assessment tool is to enable medical and nursing staff to differentiate patients
with stroke and stroke mimics.
NOTE: The ROSIER scale is not suitable for patients with suspected TIA with no neurological
signs when seen. Please use the ABCD2 assessment for patients with suspected TIA. This
assessment assists in the identification of patients with a high or low risk of early disabling
stroke.
Assessment: date _______ time ____________
Symptom onset: date ________ time ___________
GCS: E _____ V ____ M_____
BP: _____________
Blood glucose _______

NOTE: If blood glucose <3.5 mmol/l, treat urgently and reassess once blood glucose
normalizes
Has there been loss of consciousness or syncope? Y(-1) N(0)
Has there been seizure activity? Y(-1) N(0)
Is there a NEW ACUTE onset (or on awakening from sleep)?

* Stroke is likely if total scores are > 0. Scores of </= 0 have a low possibility of stroke but not
-Asymmetric
completelyfacial weakness
excluded. Y(+1) N(0)
- If total score > 0 (1 to 6) a diagnosis of acute stroke is likely. If total scores 0, -1 or -2 stroke
-Asymmetric
unlikely but arm weakness
is not excluded and patient should beY(+1)
discussedN(0)
with the stroke team.
- All patients admitted
-Asymmetric leg weakness with a suspected stroke, irrespective
Y(+1) of
N(0)score should be admitted to the
Emergency Assessment Unit (EAU).
-Speech disturbance
- If symptom Y(+1) acute
onset within 3 hours and score >0 contact N(0)
stroke team IMMEDIATELY for
potential thrombolysis treatment and arrange urgent CT scan.
-Visual field defect Y(+1) N(0)
Provisional diagnosis: Stroke ___________ Non-stroke (specify) ____________
38
TM MEDICINE HISTORY 6 - HAEMOPTYSIS

1. Bronchogenic Carcinoma
2. COPD
3. Bronchiectasis
4. TB
5. Pneumonia
6. PE
7. Endometriosis
SYMPTOMS
Common symptoms:
1. Cough
a. Persistent and doesn’t go away after 2-3 weeks.
b. It is progressive and becoming worse.
2. Coughing up blood (Haemoptysis).
3. Chest pain on coughing or breathing.
4. Persistent breathlessness (SOB).
5. Persistent chest infection.
General symptoms:
1. Weight loss.
2. Loss of appetite.
3. Anaemia symptoms.
Less common symptoms:

1. Change in the appearance of the nail.
2. Difficulty in swallowing.
3. Wheezing.
4. Swelling in the neck or face.
5. Hoarseness of voice (recurrent laryngeal nerve involvement)
6. Temperature (above 38)
RISK FACTORS
1. The ones we don’t ask
- Age.
- Gender: More common in Males.
2. Past medical history:
a. Medical illness:
- COPD
- Other cancers (specially in head and neck)
b. Family history:
3. Personal history:
a. Smoking
4. Social history -- occupational exposure to:

39
- Asbestos
- Coal
- Nickel
- Arsenic
- Silica
NOTE: Ask about job (builder, coal miner, shipyard worker)
EXAMINATION
Inspection:
- Finger clubbing
- Supra clavicle fullness
- Normal
Auscultation:
- Decreased or absent breath sounds due to pleural effusion
- Wheeze or asymmetric breath sounds due to lower airway obstruction
- Normal
Urgent referral to specialist from GP (to be seen within 2 weeks)

1. Smoker or ex-smoker aged above 40 with haemoptysis more than 1 week.
2. A CXR suggestive of a lung cancer (including pleural effusion and slowly resolving
consolidation).
3. A normal CXR but where there is high suspicion of cancer.
4. A history of asbestos exposure and recent onset of chest pain, SOB.
Criteria for admission in order to urgently review and plan for investigation and
treatment
1. Uncontrolled and/or severe symptoms:

- Pain.
- Dyspnoea
- Haemoptysis
- Confusion
- Nausea/vomiting
2. Sign of superior vena cava obstruction:

- SOB
- Swelling in face and arm
- Dilation of vein in neck, arm and chest.
- Headache
3. Stridor
40
INVESTIGATIONS
1. Baseline Investigations including FBC, U&Es, LFTs
2. CXR
Chest X-Ray can show:
- Peripheral circular opacity
- Hilar enlargement
- Consolidation
- Pleural effusion
- Bony secondaries
Criteria for Urgent CXR (report should be returned with in 5 days)

- Persistent symptoms more than 3 weeks
- COPD patient with unexplained change in existing symptoms.
3. CT scan (Computed Tomography Scan)

- A CT scan uses x-ray and a computer to create detailed images of the inside of your body.
- Before having CT scan, you will be given an injection.
- This is a liquid containing a dye that makes lungs show up more clearly on the scan.
- This scan is painless
- This scan takes up to 30 mins.
4. PET-CT (Positron Emission Tomography)

- A PET-CT scan may be carried out if the results of CT scan show that you have cancer in early
stage.
- A PET-CT scan can show where there are active cancer cell and this can help with diagnosis
and treatment.
- Before having PET-CT scan you will be injected with a slightly radioactive material.
- PET-CT scan is painless.
- PET-CT scan takes up to 60 mins.
5. Bronchoscopy and Biopsy

- If CT scan shows there might be cancer in the central part of the chest you will have
bronchoscopy.
- Bronchoscopy: We put a thin and flexible fibre optic telescope through your mouth or nose
down your throat into your windpipe and lung. We can see your airways and lungs. We will take
some sample from your lung.
- The procedure may be uncomfortable but we will put some medication on your throat to numb
the area. We will give you some mild sleep medication to help you relax.
6. Other types of biopsy

- If you we are not able to obtain samples in the ways described above.
- If you had one and the results were not clear.
- You may be offered a different type of biopsy
This may be:
a. A type of surgical biopsy. (Thoracoscopy / Mediastinoscopy)
b. A biopsy carried out using a needle inserted through your skin. (Percuataneous Needle
Biopsy)
41
TM MEDICINE HISTORY 7 – DRY COUGH/TB
a. Respiratory
1. Mesothelioma
2. Asthma
3. Atypical Pneumonia
4. PCP
5. URTI
6. TB
b. CVS
1. Cardiac Asthma (CCF)
c. Surgical
1. GORD
d. Others
1. Allergic
2. ACEi
3. Smoking
4. Foreign Body (if acute)
42
SYMPTOMS OF TB
a. Pulmonary symptoms:
1. Persistent cough
- Lasts more than 3 weeks.
- Usually with phlegm, sometimes with blood or may be dry cough.
- SOB (gradually becomes worse)
- Chest Pain
b. Main symptoms:
- Weight loss.
- Loss of appetite.
- High temperature.
- Night sweats.
- Fatigue.
c. Extra-pulmonary symptoms:
- Swollen glands.
- Tummy pain.
- Pain and loss of movement.
- Headache.
- Confusion.
- Seizure.
RISK FACTORS
1. PMH
a. Medical Illnesses: (Condition that can weakens our immune system)
- HIV
- DM
b. Medications: (that can weaken our immune system)
- Steroids
- Chemotherapy.
- Immunosuppressive medications (treatment of RA or IBD)
c. Surgical History
- Recent organ transplant Recipient.
- Splenectomy
a. Alcohol (Alcoholic patient has weak immune system)
b. Smoking (Smokers have a weak immune system)
c. Poor Diet (This can cause a weak immune system)
d. Sexual history (HIV)
- Those who have multiple partners.
- Those who have unprotected sex.
- Those who are I/V drug abusers who share needles.
3. Social history:
43
a. Travel history
Those who live, come from, or spend time in countries with high level of TB.
3/4 cases in the UK has positive Travel History.
b. Living status
- Those who have close contact to TB patients,
- Those who live in crowded condition such as hostel or shelter
- Those who are homeless.
c. Occupation
- Health care worker.
- Cleaner.
INVESTIGATIONS
Active TB(Investigations)
1. CXR
2. Sputum
a. AFB: Examination of phlegm in laboratory under microscope using a special dye to
show TB bug. It takes a few days to get results.
b. Culture: Growing bugs in the laboratory. It takes up to several weeks to get the
results.
We do culture when:
- TB bugs may not be found in the first sample.
- To see if TB bugs are resistant to any antibiotics.
NOTE: If patient has dry cough and there is no phlegm, Bronchoscopy and Lavage may
be considered.
Latent TB (Screening Tests)

1. Montoux test: It is a skin test.
2. IGRA(Interferon Gamma Release Assay)
Indications for IGRA:
- If Montoux is positive.
- If you previously had a vaccine(BCG). In this situation, Montoux is not reliable.
- If you just moved from a country where TB is common.
- As a part of health check when you register with a GP.
- If you are about to have treatment that supresses your immune system.
- If you are a health care worker.
44
MESOTHELIOMA
It is a type of cancer that develops in the lining that covers outer surface of lung, tummy,
heart and other organs such as testicles.
SYMPTOMS
Pleural
1. Chest Pain
2. Persistent Cough
3. SOB
4. Sweating
5. Night sweats
Peritoneal
1. Tummy pain
2. Nausea and Vomiting
3. Diarrhoea or Constipation.
General Symptoms
1. Weight Loss
2. Loss of Appetite
3. Anaemia Symptoms
RISK FACTORS
It is almost always caused by exposure to Asbestos.
Asbestos is a group of mineral made of microscopic fibres that used to be widely used in
construction. The tiny fibre can easily get in the lung where they get stuck. This
damages the lung over time. It usually takes a while for this to cause any problem.
Sometimes more than 20 years after exposure.
INVESTIGATIONS
1. Chest X-Ray
2. CT Scan
3. Fluid Drainage: If there is a build up of fluid around the lung, a sample may be
removed using a needle inserted through the skin so fluid can be collected for analysis
4. Thoracoscopy: The inside of your chest is examined with a long thin camera that is
inserted through a small cut under sedation or anaesthesia. A sample of tissue can be
removed for analysis.
45
TM MEDICINE HISTORY 8 – DRY COUGH/PCP
SYMPTOMS OF PCP
1. Cough (usually dry, it can be productive in up to 1/3rd of patients)
2. Shortness of Breath
3. Chest Pain
4. Fever
5. HIV Symptoms (Once patients’ immune system becomes severely damaged)
SYMPTOMS OF HIV
a. Initial Symptoms – A few weeks after exposure (1-2 weeks)
- Fever
- Sore throat
- Body rash
- Tiredness
- Joint pain
- Lethargy
- Muscle pain
- Swollen glands (Lymphadenopathy)
b. Asymptomatic Period
c. Later symptoms (Once patients’ immune system becomes severely damaged)

- Weight loss
- Chronic Diarrhoea
- Night sweats
- Skin problem (Kaposi’s Sarcoma)
- Oral Thrush
- Recurrent Infections
RISK FACTORS
a. Medical illness
- Immunocompromised e.g. HIV
- Connective tissue disorder e.g. RA
- Pre-existing lung cancer
- Patient with haematological malignancy.
b. Medication
- Immunosuppressants for example long-term antibiotics or steroids.
c. Surgery e.g. recent organ transplant recipient or splenectomy
d. Sexual history (HIV)
46
- Those who have multiple partners.
- Those who have unprotected sex.
- Those who are I/V drug abusers who share needles.
3. Social history:
a. Living status
- Those who live in crowded condition such as hostel or shelter
EXAMINATION
General
1. Thrush
2. Kaposi’s Sarcoma
3. Swollen glands (lymphadenopathy)
Respiratory
1. Often normal
2. Scattered crackles
3. Wheeze
4. Rarely focal consolidation
INVESTIGATIONS
a. Blood
1. Routine blood (FBC, U&Es)
2. ABG – hypoxia and hypocarbia (due to hyperventilation)
3. PCR (used for early diagnosis of HIV)
4. (1-3)-B-D-Glucan Assay: Elevated. (This is a rapid diagnostic test and can detect
fungal infection)
5. Lactate dehydrogenase: LDH elevated (Indicative of diagnosis, not highly specific or
sensitive). Elevated LDH is a general indicator of tissue and cellular damage.
b. Imaging
1. CXR
- Normal
- Perihilar fluffy shadow
- Pneumothorax
2. High resolution CT scan (100% sensitivity, 89% specificity)

3. Gallium Scan (diagnostic test looking for infection, inflammation and tumour)
c. Microbiology:
1. Sputum
- Organism cannot be cultured and is detected by the staining of the cyst wall or
trophozoite.
- Sputum can be collected following inhalation of nebulized saline and chest
physiotherapy.
- If sputum negative but PCP is still suspected, the bronchoscopy with bronchoalveolar
lavage or trans bronchial biopsy may detect the organism.
- Open lung biopsy may be considered.
47
GRADING OF SEVERITY
a. Mild:
1. History – Breathlessness on mild exercise +/- cough and sweat
2. ABG and O2 saturation: PaO2>11kpa, SaO2>96%
3. CXR: normal or minor perihilar infiltrates.
b. Moderate:
1. History – Breathlessness on minimal exercise, fever, cough +/- sweating
2. ABG and O2 saturation: PaO2 8-11, SaO2 91-96%
3. CXR: diffuse interstitial shadowing.
c. Severe:
1. History – Breathlessness at rest, persistent fever and cough.
2. ABG and oxygen saturation: PaO2<8kpa, SaoO2<91%.
3. CXR: extensive interstitial shadowing +/- alveolar shadowing.
TREATMENT
a. Mild to moderate disease:

1. Co-trimoxazole in high dosage is the drug of choice for the treatment of mild to
moderate Pneumocystis pneumonia.
2. Atovaquone is licensed for the treatment of mild to moderate pneumocystis infection
in patients who cannot tolerate Co-trimoxazole. A combination of Dapsone 100 mg daily
with Trimethoprim 5 mg/kg every 6-8 hours is given by mouth for the treatment of
mild to moderate disease.
3. A combination of Clindamycin 600 mg by mouth every 8 hours and Primaquine 30 mg
daily by mouth is used in the treatment of mild to moderate disease.
b. Severe disease:
1. Co-trimoxazole in high dosage, given by mouth or by intravenous infusion, is the drug
of choice for the treatment of severe Pneumocystis pneumonia.
2. Pentamidine isetionate given by intravenous infusion is an alternative for patients
who cannot tolerate Co-trimoxazole, or who have not responded to it. Pentamidine
isetionate is a potentially toxic drug that can cause severe hypotension during or
immediately after infusion.
3. Corticosteroids treatment can be life saving in those with severe pneumocystis
pneumonia.
ADJUNCTIVE THERAPY
In moderate to severe infections associated with HIV infection, Prednisolone 50-80 mg
daily is given by mouth for 5 days (alternatively, Hydrocortisone may be given
parenterally). The dose is then reduced to complete 21 days of treatment.
Corticosteroids treatment should ideally be started at the time as the anti-Pneumocystis
therapy and certainly no later than 24-72 hours afterwards. The corticosteroids should
be withdrawn before anti- pneumocystis treatment is complete.
48
TM MEDICINE HISTORY 9 - CONSTIPATION
CAUSES OF CONSTIPATION
1. Bowel Cancer
2. Intestinal Obstruction
3. Medicine induced (Codeine/Morphine)
4.Diverticular Disease
6. Hypothyroidism
7. Spinal Cord Injury
8. Complications of pelvic or colorectal surgery
9. Insufficient water intake
10. Insufficient fibre intake
11. Lack of physical activity / immobility
SYMPTOMS OF FAECAL IMPACTION

Common
1. Abdominal discomfort / pain
2. Abdominal bloating
3. Nausea and vomiting
4. Leakage of liquid stool
5. Feeling the need to push
Severe
1. Dehydration
2. Heart racing
3. Rapid breathing
4. Confusion
5. Agitation
6. Fever
7. Urinary Incontinence
EXAMINATION
1. Abdominal Examination
2. Digital Rectal Examination (DRE)
INVESTIGATIONS
1. X-Ray of Abdomen (if faecal impaction is suspected after DRE)
2. +/- Ultrasound
3. +/- Sigmoidoscopy
49
4. +/- Barium Enema (this test involves inserting a dye into your rectum and
then taking X-Ray of the colon and rectum).
TREATMENT
1. Laxative
a. Osmotic: One type of laxative that we use increases the amount of fluid in
your bowel. This softens your stool and stimulates your body to pass the
stool. Commonly prescribed laxatives include Lactulose and Macrogols.
Please make sure you drink enough fluid. It will usually take 2-3 days
before you feel the effect of this medication.
b. Stimulant: After a few days of using stool softener, you may need to start
taking another type of laxative called a stimulant. This type of laxative
stimulates the muscles that line your digestive tract, helping them to move
stool along your large bowel to the back passage. The most commonly
prescribed are Senna and Sodium Picosulphate. These laxatives are usually
used on a short-term basis and they start to work within 6-12 hours.
If you don’t respond to these laxatives or you have overflow diarrhoea (in
which loose stool leaks around the obstruction), you may need to receive
another medication.
c. Suppository: We will give you medication that can be inserted into your
back passage and helps pass the stool. This is usually a Bisacodyl
suppository.
2. Manual Removal
If laxative or suppository doesn’t unblock the faeces from your colon, your
doctor will remove the faeces manually. To do this, your doctor will insert
their gloved finger into your rectum and try to remove the blockage.
3. Enema
If the doctor is unable to remove the entire blockage, they will use a
medication in the form of fluid through your back passage into your rectum
and colon. This lubricates the colon and moistens the faeces and makes it
easier to dislodge. This usually contains Docusate and Sodium Citrate.
50
TM MEDICINE HISTORY 10 - AACG

1. Acute Angle Closure Glaucoma (AACG)
2. Conjunctivitis (discharge, usually in morning, gritty sensation, itchiness)
3. Foreign Body
4. Subconjunctival Hemorrhage
5. Trauma
6. Cluster headache
7. Uveitis Secondary to Ankylosing Spondylitis/IBD
8. Reiter’s / Reactive Arthritis
8. SLE/RA
SYMPTOMS
1. Eye Pain
- Sudden
- Severe
2. Redness of the eye
3. Visual Problem
- Blurry vision
- Seeing lines around light
- Sudden loss of vision
4. Headache
RISK FACTORS
- Age
- Gender – Female
2. PMH
a. Medical condition
- Long-sighted people
b. Family History
- History of AACG
TRIGGERS
1. Medication
- SSRIs / TCAs (Amitryptiline)
- Cholrpromazine (Nausea and Vomtiing)
- Ipratropium Bromide (asthma)
- Chlorpheniramine (Allergy)
- Cimetidine/Ranitidine (H2 Blockers)
2. Watching TV in a dark room

3. Stress/excitement
Acute Angle Closure Glaucoma

In this condition fluid pressure inside the eye rises quickly.
This happens when fluid in the eye can’t drain properly.
Increases in pressure inside the eye puts pressure on the nerve that transmits signals from the eye to the
brain and causes pain and visual problems.
Some people are more prone to getting AACG because of the structure of the eye.
In people who are prone to AACG, here are some triggering factors such as medications.
Initial Management
In A&E presentation, initial treatment should start immediately based on history.
1. Reduce fluid production in the eye
51
- Timolol (Eye drops)
- Acetazolamide (IV)
2. Open the obstruction by using medication that can constrict the pupil
- Pilocarpine (Eye Drops)
3. Reduce the inflammation of the eye

- Steroid (Eye Drops)
4. Managing the pain

- Appropriate painkiller
5. Managing nausea and vomiting

- Appropriate anti-emetic
6. Avoiding triggers
Referral to Ophthalmologist
After initial management, patient should be referred to the specialist to run further examination and
measure the pressure in the eye in order to confirm the diagnosis.
When pressure in your eye has decreased, further treatment is needed to prevent this happening in
future.
This usually involves laser treatment or surgery to make a small hole in the eye. This hole allows fluid to
flow freely inside the eye.
Usually the treatment will be advised for the other eye, at the same time to prevent condition in the other
eye.
Sometimes, eye drops are needed for long term to help keep the eye pressure under control.
Prognosis
The outlook/prognosis is good if treatment is started quickly in the eye. The eye can recover. Also the
further treatment (surgery or laser) can prevent problem from coming back.
If attack is severe and treatment is delayed, high pressure in the eye can damage optic nerve and blood
vessels. In this case, there is risk of permanent reduced/loss of vision in affected eye
SYMPTOMS OF CONJUNCTIVITIS
The symptoms depend on the cause, but the general symptoms are:
1. Eye Redness
2. Watery Eye
Infective
1. Burning sensation in the eye
2. Feeling of grit in the eye
3. Sticky coating on the eye lashes, usually when you wake up in the morning
4. An enlarged lymph node in front of the eye
Allergic
1. Itchy eye
2. Symptoms of Hay Fever
3. History of sneezing, runny or blocked nose
4. Use of contact lenses
52
MEDICINE HISTORY 11 - ASTHMA
DIFFERENTIAL DIAGNOSIS D/Ds OF WHEEZE
Respiratory
1. Asthma
2. Pneumonia
3. COPD
4. URTI
Cardiac
5. Cardiac Asthma – Heart Failure
Other
6. Allergic reaction
7. Foreign Body
SYMPTOMS OF ASTHMA
1. Wheeze
2. SOB
3. Chest tightness
4. Cough
RISK FACTORS
PMH
a. Medical Illness
1. Having another atopic condition
- Eczema
- Food allergy
- Hay fever
2. Having bronchiolitis as a child
3. Premature birth or low birth weight
b. Family History
- Family history of asthma or another atopic condition
PERSONAL HISTORY
a. Smoking
- Exposure to tobacco smoke as a child
- Your mother smoking during pregnancy
53
TRIGGER FACTORS
1. Upper respiratory tract infection such as cold and flu
2. Medications
- NSAIDS
- Aspirin
- B-Blocker
3. Exercise
4. Airborne irritants
- Cigarette smoke
- Fumes
- Pollution
5. Allergens
- Dust mites
- Animal fur or feather
6. Food
- Seafood
- Nut
- Food additives (Sulphate found in pickle, wine, beer and dried fruit – Tartazine: Yellow
food colouring)
7. Emotion (Stress or laughter)
8. Sudden change in temperature

- Cold/windy
- Hot/humid
9. Occupational Asthma
- Painter (spray)
- Cleaner (dust)
- Carpenter (wood dust)
- Working with animals
- Bakery (flour and grain dust)
10. Indoor conditions

- Damp house
- Carpets
54
EXAMINATION
Vitals
General Physical Examination
Respiratory examination (we look for wheeze)
PEFR
What is PEFR?
This is a peak flow meter.
By doing this test, we can measure how quickly you can blow air out of your lungs.
Actually, we use this device to perform a test in which we can assess how well your lungs
are working.
If your airways are tight and inflamed, you won’t be able to blow out quickly.
If you manage to blow out quickly and forcefully then you should get a high score. This test
tells us that your airways are open and functioning normally.
How to use the Peak Flow Meter

1. Put the pointer back to the first line on the scale, this is usually 60.
2. Stand or sit upright (choose whatever you are comfortable with and always do it the same
way)
3. Take a deep breath.
4. Make sure your mouth make a tight seal around the mouth piece.
5. Blow out as hard and as fast as you can into the meter.
6. Write down your score, which is the number next to the pointer
7. Do it 3 times in a row so you get 3 scores (record the highest of the 3 scores in your diary)
NOTE:
Make sure your patient doesn’t make any mistakes.
Please correct your patient if he makes any mistakes.
The common mistakes are:
1. Not closing the lips around the mouthpiece properly.
2. Not blowing out as hard as possible.
3. Not holding the device horizontally.
4. Bending forward rather than sitting upright or standing.
Peak Flow Score vary depending on Age, Height and Gender.

Peak Flow Score also varies at different times of day. It is normal for your Peak Flow Score to
be lower in the morning because Peak Flow falls overnight.
In order to find the normal value or patients best personal value, we need to use this chart.
First choose a curve on the graph according to patient’s gender and height.
On the horizontal axis, find your patient’s Age. Draw an imaginary line upwards from the
patients age till it meets the chosen curve. By doing this you can find the patients value.
For example: Male patient, Height 160 cm, Age 25.

From the graph, normal value will be 570L/min.
55
PEAK EXPIRATORY FLOW RATE – NORMAL VALUES
56
In asthma patients, it is very important to cover 3 important areas:
1. Explain about medications
2. Teach the correct technique of inhaler
3. Teach how to fill the Asthma Diary
Medications
Blue Inhaler (Salbutamol):
The blue inhaler relaxes your airways very quickly. This will allow you to breathe easily.
You should take 1-2 puffs whenever you have any symptoms. We will review your
condition and tell you how long you should take it for.
Like any other medication you may experience some side effects.
You may feel shaky. This feeling should soon pass.
You may experience headache. If this happens seek advice from your pharmacist for a
suitable painkiller. If the headache continues, please speak to your GP.
You may experience muscle cramps or heart racing. If any of these become troublesome,
please speak to your GP.
These symptoms usually pass within a few minutes or in a few hours at the most, and
are not dangerous.
Dosage: Salbutamol: 100-200g (1-2puffs), for persistent symptoms up to four times a

day.
Brown Inhaler (Beclometasone):

The brown inhaler is a preventer. This contains a low dose of a medication called
steroid. This medicine works over time to help prevent asthma symptoms by reducing
sensitivity, swelling and inflammation in your airways.
We will review your condition and tell you how long you should take it for.
Like any other medication you may experience some side effects.
Some of the more common side effects are mouth infection called thrush, sore throat or
hoarse voice.
You can avoid these side effects by making sure your medicine gets straight to your
lungs and doesn't stay in your mouth and throat. You can do this by using good inhaler
technique and rinsing your mouth out and brushing your teeth after using your inhaler.
Try keeping your preventer inhaler in the bathroom so you get into a routine of taking it
before you brush your teeth.
You should use your brown inhaler even if you're feeling well and aren’t getting any
symptoms because it builds up your asthma protection over time. If you stop taking
your preventer inhaler, you’ll not get the full benefits, and will be more likely to react to
asthma triggers.
Dosage: 100-400 g BD (1-4 puffs twice daily)
Steroid Tablets (Prednisolone) for Acute Exacerbation of Asthma

This medication reduces the swelling in your airways. You need to take it once a day
preferably after having food for a few days. Don’t worry about the side effects, since you
are going to take it only for three days.
Dosage: 30-40mg OD for 3-7 days
57
Inhaler Technique
- Remove the cap and shake the inhaler.
- Breathe out gently.
- Put the mouthpiece in your mouth as you begin to breathe in which should be slow
and deep, press canister down and continue to inhale steadily and deeply.
- Remove inhaler from your mouth and continue to hold your breath for 10 seconds or
as long as it is comfortable.
- Breathe out gently.
- To take another dose, repeat the whole process again, wait approximately 30 seconds
before taking the next dose.
PEFR Reading Recording

This is a peak flow diary. By recording the peak flow meter readings and patient’s
symptoms, we can keep an eye on patient’s asthma better.
1. You need to record morning and evening peak flow readings.
2. You need to tick this box if:

a. You use your reliever inhaler.
b. You have any symptoms.
c. You wake up at night with asthma symptoms.
d. You feel that you can’t keep up with your normal day-to-day activities.
3. Note down anything unusual or different that may be the reason for a lower than
usual peak flow score in a week. For example you can write ‘I was stressed’ or ‘I
exercised on Tuesday.’
58
ASTHMA DIARY
59
Exercise Induced Asthma
Some people with asthma find that exercise triggers asthma. The good news is that it is possible
to reduce the risk of this happening so that you can enjoy many benefits of exercise.
Usually you breathe through your nose, so the air is warmed and moist. When you exercise you
tend to breathe faster and through your mouth, so the air you inhale is colder and drier.
For some people changes in the temperature of the inhaled air trigger the asthma symptoms.
To avoid exercise triggering your asthma:

Please go for regular asthma review and let us know about any change in your symptoms.
I will give you some tips if you are going to do exercise.
Some tips that you can try:

1. Warm up and warm down for 10-15 minutes before and after exercise.
2. If you are exercising with someone make sure that they know about your condition and that
you have your reliever inhaler with you.
3. If you have your symptoms during exercise, please stop, take the inhaler and wait to be
comfortable.
4. During winter, symptoms are more likely during exercise because the cold air could irritate
your airways. One way to avoid this problem is to exercise indoors or have less intensive
exercise.
5. Dress appropriately during winter. Keep your chest and throat covered.
6. If you still have symptoms please talk to us so that we can review you again.
We may need to review your medication later, to add some other medications. We may need to
refer you to a specialist if required.
MEDICATION
The following medicines have been shown to give protection against exercise induced asthma:
1. Inhaled corticosteroids
2. Inhaled short-acting β2 agonists,
3. Long-acting β2 agonists
4. Theophyllines
5. Leukotriene receptor antagonists
6. Sodium cromoglicate or nedocromil sodium
The following medicines do not give protection against exercise-induced asthma at normal
doses
1. Anticholinergics
2. Ketotifen
3. Antihistamine
Long-acting β2 agonists and leukotriene antagonists provide more prolonged protection than
short-acting β2 agonists, but a degree of tolerance develops with LABA particularly with respect
to duration of action. No tolerance has been demonstrated with leukotriene receptor
antagonists.
For most patients, exercise-induced asthma is an expression of poorly-controlled asthma

and regular treatment including inhaled corticosteroids should be reviewed.
60
TM MEDICINE HISTORY 12 - FALL IN ELDERLY
CAUSES OF FALL IN ELDERLY

1. Confusion
-Infection such as UTI, and Pneumonia,
-Constipation
2. Medication
-Drugs taken for high blood pressure
3. Cardiovascular
- Arrhythmia such as AF
4. Neurological
-Stroke,
-TIA Alzheimer’s
-Dementia
-Subdural hematoma)
5. Endocrine
- Hypoglycaemia due to Insulin
-DM
-Adrenal Insufficiency
6.Age-related
-Osteoarthritis
-Refractory errors
Bone and muscle weakness
7. Environmental
-Wet floor
-Dim lights in the house
-Loose carpets/mats on floor
8. NAI
-Elderly abuse/negligence
POSTURAL HYPOTENSION
It is a drop in BP more than 20/10 mmHg within 3 minutes of standing.

Postural hypotension can cause frequent falls and syncope (fainting).
SYMPTOMS
1. Dizziness
2. Light-headedness
3. Blurry Vision
4. Weakness
5. Fatigue
6. Nausea
7. Heart racing
8. Heada
61
RISK FACTORS
1. PMH
a. Medical Illness
i) Cardiac
- Aortic Stenosis (AS)
- Arrhythmia
- ACS
- Advanced Heart Failure
ii) Endocrine
- DM
- Pheochromocytoma
iii) Neurological
- Parkinson’s
- Spinal Cord Lesion
- Alcoholic Neuropathy
b. Medication
- Antidepressants
- Antipsychotics
- Vasodilators
- Diuretic
INVESTIGATIONS
1. Blood: FBC, U&Es, Fasting Blood Glucose

2. ECG
3. Echocardiogram (if history suggests a cardiac problem)
4. Tilt-table testing
- To evaluate the cause of unexplained fainting
- We perform this test if we suspect vasovagal syncope is responsible for fainting
Tilt-table Testing
- Passive tilt-testing to an angle of between 60 and 80 for 3 minutes is recommended for
diagnosis.
- Test is considered positive if systolic BP falls 20mmHg and diastolic falls 10mmHg
- If symptoms occur, patient should be tilted back to the supine position
Prevention of Postural Hypotension

1. Review any medication being taken
2. Patient should be advised to avoid changing the position suddenly.
3. Patient should be advised to avoid triggers such as high temperature environment.
4. The patient should be educated about various factors that affect blood pressure for
example condition is often worse in the morning and after having food.
5. An early morning dose of caffeine as coffee or tablet form can be effective.
62
TM MEDICINE HISTORY 13 – HEAD INJURY
CRITERIA FOR PERFORMING CT SCAN IN ADULTS

In a patient with head injury if any of the Risk Factors is identified, a CT Scan
Head should be performed within 1 hour.
1. GCS less than 13 on initial assessment in A&E.

2. GCS less than 15 at 2 hours after head injury on assessment in A&E.
3. Suspected open or depressed skull fracture.
4. Any sign of basal skull fracture (haemotympanum, panda eyes,
cerebrospinal fluid leak from ears or nose, battle sign)
5. Post-traumatic seizure but not history of epilepsy.
6. Focal neurological deficit.
7. More than 1 episode of vomiting.
In a patient with head injury and any of the following Risk Factors is
identified, a CT Scan Head should be performed within 8 hours.
1. Patient on warfarin.
2. LOC or amnesia and any of the following:
a. Age more than 65.
b. Any history of bleeding and clotting disorder.
c. Dangerous mechanism of injury e.g.
- Fall more than 1 meter or 5 steps.
- RTA whether it is Pedestrian, Cyclist or Vehicle occupant.
d. More than 30 min retrograde amnesia of event “immediately before the
injury”
63
CRITERIA FOR PERFORMING CT CERVICAL SPINE IN ADULTS
For adults who have sustained a head injury and have any of the following risk
factors, perform a CT cervical spine scan within 1 hour of the risk factor being
identified:
1. GCS less than 13 on initial assessment.
2. The patient has been intubated.
3. Plain X-rays are technically inadequate (for example, the desired view is
unavailable).
4. Plain X-rays are suspicious or definitely abnormal.
5. A definitive diagnosis of cervical spine injury is needed urgently (for
example, before surgery).
6. The patient is having other body areas scanned for head injury or multi-
region trauma.
7. The patient is alert and stable, there is clinical suspicion of cervical spine
injury and any of the following apply: 
- Age 65 years or older
- Dangerous mechanism of injury (fall from a height of greater than 1 metre or
5 stairs; axial load to the head, for example, diving; high-speed motor vehicle
collision; rollover motor accident; ejection from a motor vehicle; accident
involving motorised recreational vehicles; bicycle collision)
- Focal peripheral neurological deficit
- Paraesthesia in the upper or lower limbs.
 
For adults who have sustained a head injury and have neck pain or tenderness
but no indications for a CT cervical spine scan perform 3-view cervical spine X-
rays within 1 hour if either of these risk factors are identified:
1. It is not considered safe to assess the range of movement in the neck
2. Safe assessment of range of neck movement shows that the patient cannot
actively rotate their neck to 45 degrees to the left and right
ASSESSING RANGE OF MOVEMENT IN THE NECK

Be aware that in adults and children who have sustained a head injury and in
whom there is clinical suspicion of cervical spine injury, range of movement in
the neck can be assessed safely before imaging only if no high-risk and at least 1
of the following low-risk features apply. The patient:
1. Was involved in a simple rear-end motor vehicle collision
2. Is comfortable in a sitting position in the emergency department
3. Has been ambulatory at any time since injury
4. Has no midline cervical spine tenderness
5. Presents with delayed onset of neck pain.
64
PEDIATRICS STATION 3 – HEAD INJURY
CRITERIA FOR PERFORMING A CT SCAN IN CHILDREN
If any of the Risk Factors is identified, a CT Scan Head should be performed within 1
hour.
1. GCS less than 14, and for children under 1 year, GCS less than 15 on initial
assessment in A&E.
2. GCS less than 15 two hours after the injury on assessment in A&E.
3. Suspicion or signs of basal skull fracture or tense fontanelle.
4. Post-traumatic seizure but no history of epilepsy.
5. Focal neurological deficit.
6. For children under 1 year, presence of bruise, swelling or laceration of more
than 5 cm on head.
7. Suspicion of NAI.
In a patient with head injury and the following Risk Factors is identified, a CT Scan
Head should be performed within 8 hours.
1. Patient on warfarin.
For children who have sustained a head injury and have more than one of the
following risk factors a CT scan should be performed within 1 hour.
1. LOC more than 5 mins.
2. Abnormal drowsiness.
3. Three or more discrete episode of vomiting.
4. Dangerous mechanism of injury e.g.
- High speed RTA either as pedestrian or cyclist or vehicle occupant,
- Fall from a height of greater than 3 metres,
- High-speed injury from projectile or other object
5. Amnesia (Antegrade or Retrograde) lasting more than 5 mins.
Children who have sustained a head injury and have only 1 of the above risk factors
should be observed for minimum of 4 hours after head injury.
If during observation any of the risk factors below are identified, a CT scan head
should be performed in 1 hour:
1. GCS less than 15.
2. Further vomiting.
3. A further episode of abnormal drowsiness.
65
CRITERIA FOR PERFORMING A CT CERVICAL SPINE SCAN IN CHILDREN
For children who have sustained a head injury, perform a CT cervical spine scan
only if any of the following apply (because of the increased risk to the thyroid gland
from ionising radiation and the generally lower risk of significant spinal injury):
1. GCS less than 13 on initial assessment.
2. The patient has been intubated.
3. Focal peripheral neurological signs.
4. Paraesthesia in the upper or lower limbs.
5. A definitive diagnosis of cervical spine injury is needed urgently (for example,
before surgery).
6. The patient is having other body areas scanned for head injury or multi-region
trauma.
7. There is strong clinical suspicion of injury despite normal X-rays.
8. Plain X-rays are technically difficult or inadequate.
9. Plain X-rays identify a significant bony injury
For children who have sustained a head injury and have neck pain or tenderness
but no indications for a CT cervical spine scan, perform 3-view cervical spine X-rays
before assessing range of movement in the neck if either of these risk factors are
identified:
1. Dangerous mechanism of injury (that is, fall from a height of greater than
1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor
vehicle collision; rollover motor accident; ejection from a motor vehicle; accident
involving motorised recreational vehicles; bicycle collision).
2. Safe assessment of range of movement in the neck is not possible.
If range of neck movement can be assessed safely in a child who has sustained a
head injury and has neck pain or tenderness but no indications for a CT cervical
spine scan, perform 3-view cervical spine X-rays if the child cannot actively rotate
their neck 45 degrees to the left and right. The X-rays should be carried out within
1 hour of this being identified and reviewed by a clinician trained in their
interpretation within 1 hour of being performed.
In children who can obey commands and open their mouths, attempt an odontoid
peg view.
66
TM MEDICINE HISTORY 14 - SAH
Subarachnoid haemorrhage (SAH) is an uncommon type of stroke caused by bleeding

on the surface of the brain. It is a medical emergency as it can be fatal.
SYMPTOMS
1. Headache
a. Usually occipital, however sometimes patient can’t localise it.
b. Sudden onset
c. Severe – described as the worst headache ever experienced.
2. Neck stiffness.
3. Feeling and being sick.
4. Sensitivity to light (photophobia).
5. Visual problems
a. Blurry vision
b. Double vision.
Stroke like symptoms:

6. Weakness one side of the body
7. Speech problems such as slurred speech.
8. Facial problem
9. Loss of consciousness
10. Fits / Convulsions.
RISK FACTORS
1. PMH
a. Medical Condition
- High Blood Pressure (Risk Factor for Ruptured Anuerysm)
- AVM Arterio-venous Malformation
RISK FACTORS
The ones we don’t ask
- Age > 60 years
- Gender: More in Females
- Race: African origins more affected than Caucasians
PMH
a. Medical Illness
- High Blood Pressure
- Polycystic Kidney Disease
- SLE
- AV Malformation
b. Family History
Personal History
a. Smoking
b. Excessive Alcohol consumption
c. Drug abuse
67
EXAMINATIONS
1. Vitals
2. General
3. Neurological (Including assessing GCS and relevant examination to R/O Meningitis)
INVESTIGATIONS
Initial Investigations
1. Routine Bloods (FBC, U&Es, Clotting profile)
2. ECG
3. CT Scan is used to check for signs of brain haemorrhage.
4. If CT Scan is negative but symptoms are suggestive of SAH, Lumbar Puncture should
be carried out minimum 12 hours post onset of symptoms.
Who should be referred to the Neurosurgeon?

1. If CT Scan shows SAH
2. If lumbar puncture confirms the diagnosis
3. If despite negative CT Scan and Lumbar Puncture, the diagnosis of SAH is highly
suspected based on history and examination.
When diagnosis is confirmed, patient needs to be transferred to a special neurosciences

unit or intensive care unit (ICU).
Further Investigations
After confirming the diagnosis, further tests may be needed to help making treatment
plan, these tests include CT angiography (CTA) and MR angiography (MRA), these tests
are the same as regular CT and MRI but may require a dye to be injected into a vein.
Medication
1. Nimodipine: This reduces the chances of having reduced blood supply and damage to
brain (secondary cerebral ischemia) after SAH. Side effects may include flushing, feeling
sick, increased heart rate and headache.
2. Pain killers such as morphine or a combination of codeine and paracetamol.
3. Other medications include anti-convulsants to prevent seizures and anti-emetics to
prevent patient from feeling sick and vomiting.
Surgery
If the cause of SAH is found to be brain aneurysm, one of 2 main procedures may be
performed to prevent it from rupturing again, these options are:
1. Neurosurgical clipping: This involves a metal clip, which stays permanently clamped
over the aneurysm to prevent it from bleeding again.
2. Endovascular coiling: This involves a coil which is passed through a tube into the
aneurysm until it's full of coils so the blood can't enter the aneurysm again thus
preventing it from rupture.
Coiling is usually more preferred than clipping as it has lower rates of short-term
complications and it may help the patients to stay for a shorter time in the hospital.
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MIGRAINE
SYMPTOMS
Common Symptoms
1. Headache
- At front of one side, sometimes affects both sides
- Sometimes affects/radiates to neck and face.
- Throbbing pain
- Getting worse by moving
- Getting better in dark and quiet room, after taking painkiller such as
NSAID
Other Symptoms
3. Sensitivity to light and sound
4. Aura
- Visual Problems e.g. flashing lights, blurry vision, blind spot
- Numbness and tingling on hand, arm, face, lips and tongue.
- Dizziness
Rare Symptoms
5. Sweating
6. Poor concentration
7. Feeling very hot/cold
8. Tummy pain
9. Diarrhoea
NOTE:
- Symptoms vary between different patients. Not every patient experiences
all symptoms.
- Headache can take about 4 hours to 3 days (sometimes up to a week)
- Family history is one of the most important Risk Factors.
- Migraine is diagnosis of exclusion. This means other possible causes
should be ruled out by taking history, doing relevant examination, and
performing necessary investigations.
69
MEDICINE HISTORY 15 - URTI
URTI is an infection of nose, throat and other part of your upper wind-pipe.
A cold is an infection of the nose and upper airways caused by a germ (virus). They are extremely
common. An adult can expect 2-3 colds a year and a child can expect about 5-6 colds a year. Very young
children in nursery school may get as many as 12 colds a year. Many different viruses can cause a cold.
This is why colds come back (recur) and immunisation against colds is not possible.
SYMPTOMS
1. Blocked (congested) nose
2. Sore throat
3. Sneezing
4. Runny nose
5. Discharge (mucus) from the nose (it is at the beginning clear, and after 2-3 days may become thick and
yellow/green).
6. Cough
7. Fever
8. Headache
9. Musculoskeletal pain (body pains)
10. Fatigue
11. Difficulty in sleeping (due to blocked nose)
12. Poor appetite
MANAGEMENT
A main aim of treatment for an upper respiratory tract infection (URTI) is to ease symptoms whilst your
immune system clears the infection. One or more of the following may be helpful:
It is very important to have plenty of rest and get enough sleep as your body needs to heal.
Having rest can improve your condition and fasten the recovery.
Taking paracetamol or ibuprofen to reduce a high temperature (fever) and to ease any aches, pains and
headaches. Follow the instructions given with the medicine carefully and do not take more than the
advised dose. (Only give these medicines to children under the age of 5 years if they have a fever or
appear distressed.)
Having plenty to drink if you have a fever, to prevent mild lack of fluid in the body (dehydration). As
long as you do not have a fever, there is no evidence that drinking more fluid than usual makes a
difference.
Since you have cough, you may try over the counter cold and cough medications. However, they won’t
prevent the cold or shorten its duration and most have some side effects such as drowsiness. Take these
medications only as directed. Some cold remedies contain multiple ingredients such as a pain killer so
please read the label of the cold medication you take to make sure you are not taking too much of any
medication.
Keep warm. Try to avoid cold, dry air if possible.
If you smoke, you should try to stop for good. URTIs and serious lung diseases tend to last longer in
smokers.
Steam inhalation. There is not very much evidence that this helps; however, some people find it useful. It
is very important to be careful to avoid burns and scalds, particularly with children. A safe way of inhaling
steam is to sit in the bathroom with the door closed, while running a hot shower to make the room
steamy.
Vapour rubs. Vapour rubs can be bought in pharmacies and supermarkets. Some people find they help
with a stuffy nose. Rub the vapour on to the chest and/or back of the person with the cold, but avoid the
area under the nose.
Sucking sore throat lozenges (available from pharmacies and supermarkets) or boiled sweets may help
ease a sore throat.
Warm drinks with honey and lemon may help to ease a sore throat. (Do not give honey to babies less
than 1 year old as it is not known if this is safe.)
Please try to avoid alcohol, coffee and caffeinated sodas which can cause dehydration.
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Taking in warm liquids such as chicken soup might be soothing and might ease congestion by increasing
mucous flow.
Salt (saline) nose drops. These are nose drops made of a salty solution, which may help clear a blocked
nose. They are sometimes helpful for babies who are having difficulty breathing through a blocked nose
as they feed. They can be bought from a pharmacy.
ANTIBIOTICS
1- Antibiotics are not usually advised if you are normally in good health. Your immune system can usually
clear the infection. Antibiotics do not kill germs which are viruses. Even if a different type of germ (called
a bacterium) is the cause, antibiotics usually do little to speed up recovery from a URTI.
2- Antibiotics may even make symptoms worse, as some people develop side-effects such as diarrhoea,
feeling sick or a rash.
3- Using this medication unnecessarily will increase the risk of resistance to the antibiotics.
When antibiotics should be prescribed:

1- Antibiotics may be prescribed if you become more unwell, or if you already have an underlying
(chronic) lung disease.
2- They may also be prescribed if a complication develops, such as pneumonia - but this is unlikely to
occur if you are otherwise healthy.
What symptoms should I look out for?

Most upper respiratory tract infections (URTIs) do not cause complications. A URTI may trigger coughing,
wheezing and shortness of breath in people with asthma or other lung diseases. Sometimes the infection
travels to the lung tissue, sinuses, or ears. Germs (bacteria) may thrive in the mucus so some people with
colds may go on to develop a bacterial infection of the lung tissue (pneumonia), ears or sinuses.
Therefore, see a doctor if symptoms do not start to ease within two weeks, or if you suspect that a
complication is developing. In particular, symptoms to look out for that may mean more than just a URTI
include:
- If high temperature (fever), wheezing or headaches become worse or severe.

- If you develop fast breathing, shortness of breath, or chest pains.
- If you cough up blood or if your phlegm (sputum) becomes dark or rusty-coloured.
- If you become drowsy or confused.
- If a cough persists for longer than 3-4 weeks.
- If you have returning (recurring) URTIs.
- If any other symptom develops that you are concerned about.
Can upper respiratory tract infections be prevented?

Prevention is difficult. Many germs (viruses) can cause an upper respiratory tract infection (URTI). Also,
many viruses that cause URTIs are in the air, which you cannot avoid. However, the following are
suggestions that may reduce the risk of catching a URTI or of passing one on, if you have one:
- If you have a URTI do not get too close to others - for example, kissing, hugging, etc.
- If you have a URTI, wash your hands often with soap and water. Many viruses are passed on by touch,
especially from hands that are contaminated with a virus.
- Avoid sharing towels, flannels, etc, if you have a URTI, or with anyone who has a URTI.
- For children, discourage the sharing of toys belonging to a child with a URTI. If your child has a URTI,
consider washing toys with soapy water after use.
Basically, common sense and good hygiene may prevent the passing on of some viruses that cause URTIs.
Exercise may help too

An interesting research study showed that people who exercise regularly are less likely to get URTIs. The
study was on 1,002 people over 12 weeks during the winter. It found that the people who exercised on
five or more days a week had a much lower chance of developing a URTI compared with those who did
little exercise. And, if someone who exercised regularly developed a URTI, there was a good chance that
symptoms would be less severe than someone (with a URTI) who did little exercise. The researchers
thought this may be because exercise boosted the immune system and this may help us fight infections.
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MEDICINE HISTORY 16 - CHRONIC FATIGUE SYNDROME
1. There is chronic tiredness and fatigue for more than 6 months.
2. Tiredness doesn’t usually relieve by rest.
3. There is no medical cause for tiredness. All examination and investigations should be normal.
4. CFS is a diagnosis of exclusion.
SYMPTOMS
Pain.
1. Muscle pain
2. Joint pain.
3. Headache
4. Sore throat.
Psychological
1. Sleep disturbances.
2. Poor concentration
3. Forgetfulness
4. Depression
Others
1. Postural hypotension
2. Sensitivity to heat/light
3. Hot flushes
TRIGGERS
1. Infections.
2. Stress
3. Poor Diet
4. Lack of physical exercise.
5. Depression
6. Social isolation.
D/Ds
1. Malignancy
2. Anaemia
3. CKD
4. Hypothyroidism
5. DM
6. RA
7. IBD
8. Coeliac disease
9. Chronic Pancreatitis
10. Myasthenia Gravis
11. Depression
12. Medication (Blood thinner, NSAID, B-Blocker, Diuretics)
MANAGEMENT
General
1. Manage the rest (rest during the day, having frequent rest).
2. Manage the sleep.
3. Relaxation technique.
4. Having well balanced diet.
Specific
1. Graded exercise therapy- we start training you to do low intensity exercise and slowly we increase the
level of physical activity.
2. CBT - someone talks to you to improve your mood, to relive your stress.
3. Symptomatic treatment.
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Chronic Kidney Disease (CKD)
CKD is reduced ability of the kidneys to carry out these functions.

This is most often caused by the strain places on kidney, most commonly due to diabetes
and high blood pressure.
CKD usually does not cause symptoms until reaching an advanced stage.
CKD is usually detected at earlier stage by blood and urine test.
Symptoms in advance stage

1-Excessive tiredness
2-Swelling in feet, hands and ankles
3-SOB
4-Nausea and vomiting
5-Itchy skin
6-Blood in urine
Risk Factors
1-HTN
2-Diabetes
3-Medication: use of nephrotoxic drug e.g. Lithium, NSAIDs long term
4-Family history
Kidney’s role
1-Filter waste products from blood
2-Help to maintain blood pressure
3-Maintain and correct chemical products help heart and muscle function
4-Produce a type of Vitamin D
5-Produce erythropoietin, which stimulate production of RBC
Treatment:
There is no cure for CKD. Treatment can slower the progression of the disease and
prevent other complications such as stroke and heart attack.
Staging according to GFR:
Stage 1: above 90 but evidence of kidney damage

Stage 2: 60-89
Stage 3:
A) 45-59 (Further test in 6 months is needed)
B) 30-44 (Imaging such, as USG, CT or MRI is needed)
Stage 4: 15-29 (Symptomatic treatment and further tests in 6 weeks is needed)
Stage 5: below 15 (Kidney has almost lost its function)
Diagnosis is only confirmed if e GFR consistently is lower than normal over 3 months.
For stage 1, 2 and 3 GP follow up and for sage 4 and 5 Specialist is needed.
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Treatment:
Diet and life style:

1-Well balanced diet
2-Reduce salt intake
3-Reduce alcohol
4-Stop smoking
5-Not using OTC and NSAIDs
6-Fluid restriction
7-Reduce red meat, diary, egg, fish
Drugs:
1-For slower or stop the progression of disease:
Medication for blood pressure control such as ACE, ARB
2-For prevention of possible complications:
A) Aspirin and statin to prevent stroke and heart attack
B) Bisphosphonate, Vitamin D and Phosphate binder to prevent osteoporosis
3-For treating the symptoms
A) Iron tablets, injection of erythropoietin for anaemia
B) Water tablets for swelling
Dialysis and transplant:

Dialysis: filter your blood to rid your body of harmful waste, extra salt and water.
In a few people kidney disease progress to the stage where the kidneys stop working and
it becomes life threatening. This condition called kidney failure or established renal
failure (ERF).
Dialysis is required, if kidney does not work properly and therefore waste products will
build up and cause symptoms such as vomiting, itchy skin, extra tiredness, swollen feet,
hands, and ankle.
Type of dialysis:
A) Haemodialysis: Blood is transferred from your body into the machine, which filters
out waste products and excess fluids. The filtered blood is then passed back into your
body. Most people need 3 sessions per week, each lasting four hours.
Side Effects: makes you feel exhausted, itchy skin, muscle cramps.
B) Peritoneal: lining of the abdomen (peritoneum) is used as a filter. In this method

special fluid is pumped to the space surrounding your peritoneum (peritoneum cavity)
by inserting small flexible tube (catheter) to an incision. As blood moves through
peritoneum, waste products and excessive fluid are moved from blood into dialysis
fluid, and then the fluid is drained from the cavity. This procedure takes 30-40 minutes
and should be repeated 4 times a day or you can run it overnight.
Both can be done at home or at hospital. You can choose which type of dialysis you want
to have. However, in some cases a particular method can be unsuitable.
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MEDICINE HISTORY 17 PNEUMONIA/SEPTIC SHOCK
SYMPTOMS
Common
1. Cough
- Dry
- Productive (yellow, brown, green or blood stained)
2. Difficulty in breathing
3. Heart racing
4. Fever
5. Sweating/shivering
6. Loss of Appetite
Less Common Symptoms

7. Generally unwell
8. Headache
9. Fatigue
10. Nausea/vomiting
11. Joint pain/muscle pain
12. Confusion in elderly.
RISK FACTORS
1. PMH
a. Medical Illnesses: (Condition that can weakens our immune system)
- HIV
- DM
b. Medications: (that can weaken our immune system)
- Steroids
- Chemotherapy.
- Immunosuppressive medications (treatment of RA or IBD)
c. Hospital Stay
- Recent hospitalisation (hospital acquired pneumonia)
d. Surgical History
- Recent organ transplant Recipient.
- Splenectomy
3. Social history:
a. Travel history
- History of staying in hotels
b. Living status
- Those who live in crowded condition such as hostel, care home, barracks
c. Occupation
- History of working with animals and birds
SIRS (systemic inflammatory response syndrome):
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A diagnosis of SIRS is made if any 2 of the following criteria are met.
1) RR- > 20 or PaCo2< 32 mmHg
2) HR > 90
3) Total white cell count > 12
4) Temperature > 38 or < 36.
A diagnosis of sepsis made if there is a diagnosis of SIRS in the presence of any

infection.
A diagnosis of severe sepsis made if there is sepsis together with the evidence of organ
dysfunction.
Immediate action is needed if any of the criteria is present:

1) Systolic BP ≤ 90 (≥ 40 fall from the baseline)
2) HR ≥ 130
3) O2 sat < 91.
4) RR ≥ 25
5) Respond only to voice and pain/unresponsive.
6) Lactate > 2mmol.
Ix:
A) Bloods:
1) FBC.
2) U&E (looking at the hydration and organ failure)
3) LFT
4) Glucose
5) Clotting screen.
6) Blood culture.
B) Urine
C) Imaging.
1) CXR.
2) Abdominal U/S.
3) CT
Treatment:
Immediate treatment within one hour is advisable.
SEPSIS SIX:
1) High flow of O2.
2) Blood culture
3) IV antibiotics.
4) IV fluid.
5) Check Hb and serial lactate.
6) Hourly urine output measurement.
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77
ANTI-MICROBIAL POLICY FOR SEPTIC SHOCK (ADULTS)
Likely Focus First Line Agent – if contraindicated, seek Microbiology Advice

Severe Sepsis or Septic Shock
Unknown Ceftriaxone 2g bd iv
(community)
Unknown Seek Microbiology Advice
(hospital)
Respiratory - Co-amoxiclav 1.2g tds iv
community AND
Clarithromycin 500 mg bd iv
Respiratory – Tazocin 4.5 g tds iv
hospital AND (if MRSA sputum)
Vancomycin iv (as per chart)
Respiratory - Co-amoxiclav 1.2 g tds iv
aspiration AND
Metronidazole 500 mg tds iv
UTI Co-amoxiclav 1.2 g tds iv
AND
Gentamicin 5-7 mg/kg od iv
Abdominal Tazocin 4.5 g tds iv
AND
Pacreatitis Imipenem 1 g tds iv
Gastroenteritis Seek microbiology advice
Meningitis Ceftriaxone 2g bd iv (with Dexamethasone 10 mg qds
AND (if pregnant, elderly or immunosuppressed)
Amoxicillin 2g q4h iv
Cellulitis Flucloxacillin 2g qds iv
AND
Benzylpenicillin 2.4 g qds iv
AND (if rapidly spreading)
Clindamycin 1.2 g qds iv
Osteomyelitis Flucloxacillin 2 g qds iv
AND
Fucidin 500 mg tds po
Prosthetic Joint Vancomycin iv as per chart
ENT Co-amoxiclav 1.2 g tds iv
Line / Foreign Flucloxacillin 2 g qds iv
Body or IVDU AND (if ITU, tunneled line, immunosuppressed)
Neutropenic Tazocin 4.5g tds iv
AND
Gentamicin 5mg/kg iv od
AND (if line sepsis)
Vancomycin iv as per chart
Add Metronidazole 500 mg q8h iv if clostridium difficile diarrhoea
78
ANTIMICROBIAL THERAPY FOR PNEUMONIA
Infection Comment Antibiotic Days Antibiotics if severe
Respiratory
Benzylpenicillin 1.2 g qds iv

Community acquired Amoxicillin 1 g tds po AND
pneumonia AND/OR* Clarithromycin 500 mg bd po or iv
Diagnosis based on clinical & x-ray signs of
CURB-65 score each = Clarithromycin 500 mg bd PO If known COPD/CLD/recent
consolidation
1 point severe = ≥3 Amoxicillin:
Send sputum culture and urine for
Confusion Penicillin allergy: Co-amoxiclav 1.2g tds iv
Pneumococcal
Urea > 7mmol/L Clarithromycin 500 mg bd po 5-10 AND
Ag
RR ≥30 Clarithromycin 500 mg bd po or iv
14 days ABS for legionella, mycoplasma or
BP syst < 90 *use both if being admitted, Penicillin allergy:
Chlamydia
diast <60 single agent if fit for discharge Vancomycin iv as per chart
Age ≥ 65 AND
Clarithromycin 500 mg bd po or iv
Aspiration ADD (to above) ADD (to above)

5-10
pneumonia Metronidazole 400 mg tds po Metronidazole 500 mg tds iv
MRSA (sputum; previous or

Check for previous culture
current):
results.
Hospital acquired Tazocin 4.5g tds iv
Discuss with micro if penicillin allergic, Tazocin 4.5g tds iv 5-7
pneumonia AND
previously colonised with resistant
Vancomycin iv as per chart
organisms or recent antibiotics
Staphylococcal
pneumonia e.g. IVDU, lines. DM, neutropenia,
Discuss with micro
(known or very high
ETO ETOH, rapid onset, abcesses
suspicion)
If severe: (eg Pa02 < 9)

1 st line:
ADD
Co-trimoxazole 30 mg/kg qds po
Prednisolone first 40 mg bd po for 5
or iv
days then 40 mg od for 5 days then 20
Pneumocystis 2nd line:
Caution in G6PD deficiency 21 mg od for 11 days If unable to take
pneumonia Clindamycin 450 mg qds po or
po:
600 mg qds iv
Methylprednisolone iv
AND
32 mg, 32mg, 16 mg, instead of above
Primaquine 15 —30 mg po od
doses, switch to oral as soon as able
I S line:
Amoxicillin 500 mg tds po if
being discharged
Only if clinical signs infection (fever + Co-amoxiclav 1.2g tds iv
Doxycycline 200mg po stat then
COPD increased sputum purulence) 5 AND
100mg od for the remaining 4
If recent amoxicillin use clarithromycin Clarithromycin 500 mg bd po or iv
days if admitted
2nd line or Penicillin allergy:
Clarithromycin 500mg bd po
79
MEDICINE HISTORY 19 VESTIBULAR NEURITIS
DIFFERENTIAL DIAGNOSIS FOR VERTIGO
ENT:
- Vestibular Neuritis
- BPPV (Benign Positional Paroxysmal Vertigo)
- Serous Labyrinthitis
- Autoimmune ear disease
- Meniere’s Disease
Central:
- TIA
- Stroke (PICA)
- Multiple Sclerosis
- Subarachnoid hemorrhage
- SOL : Cerebellar tumour, Acoustic neuroma
- Vestibular migraine
Infective:
- Herpes zoster oticus (Ramsay Hunt syndrome):
- Meningitis.
Others:
- Drug-induced vertigo, hearing loss, or both.
- Carbon monoxide poisoning.
DESCRIPTION:
Vestibular neuritis is the inflammation of the vestibular nerve that often occurs after a viral infection. This is
the nerve that comes from the inner ear and takes messages from the semicircular canals to the brain.
SYMPTOMS:
1. Vertigo
- sudden
- spontaneous
- severe
- often incapacitating
3. Balance problem. (Gait apraxia is not a prominent feature).
4. URTI Symptoms
- Sometimes before the episode
- May be along with the episode
5. Prodromal symptoms in the week prior to the attack in 25% cases.
6. Nystagmus.
NOTE: Hearing loss and tinnitus are not features of vestibular neuronitis (but may be present in labyrinthitis).
NOTE: There are no focal neurological symptoms.
EXAMINATION:
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1. Assessment of the external ear and tympanic membrane:
- cholesteatoma
- Vesicles suggestive of herpes zoster oticus
2. Cranial nerve examination:
- Palsies
- Hearing loss
3. Nystagmus and cover-uncover test:
- fine horizontal but may be mixed horizontal-torsional.
4. Assessment of gait
5. Check for mastoid tenderness, nuchal rigidity and high fever.
6. Hearing test
7. Head impulse test
Head-Impulse Test :
This test is also known as "head thrust test". It is a sensitive and specific investigation method, which detects
unilateral hypofunction of the peripheral vestibular system.
- Advise the person to sit upright and to fix their gaze on the examiner.
- Then rapidly turn the head 20 degrees to one side and watch the eyes for corrective abnormal movements
(saccades).
- Repeat several times to the same or opposite side, randomly and unpredictably, until satisfied as to the
consistent presence or absence of the corrective saccade.
Findings: A corrective saccade represents a positive test and implies moderate to severe loss of function of the
horizontal semi-circular canal on the side to which the test is positive.
INVESTIGATIONS:
1. Blood Tests (If suspicion of a systematic infection)
- FBC
- Blood Culture
2. Imagine (Most patients do not require imaging). However:
- A CT scan to rule out mastoiditis.
- A Temporal Bone CT Scan may help in patients with cholesteatoma and labyrinthitis.
- MRI Scan if a sinister cause is suspected. (MRI is preferred over CT Scan because it provides much better
pictures of the posterior fossa and VIII nerve course).
MANAGEMENT:
1. Reassure the patient:
- They can usually be managed at home. During an acute attack the patient will want to lie still with their eyes
closed.
- Symptoms usually settle over several weeks even if no treatment is given.
- Encourage the patient to be active as soon as they can, even if it worsens the vertigo, as this is thought to
speed up the development of vestibular compensation.
2. Medications:
Prochlorperazine or Antihistamines may help vertigo, nausea and vomiting.
- Give the medication for 3 days and then on an as-required basis.
- Medication should be taken for the minimum time possible (not more than one week), as it may interfere with
the body's compensatory mechanisms and delay recovery.
NOTE: Consider buccal or deep intramuscular injection of prochlorperazine if symptoms are severe or for rapid
relief.
3. Consider admission to hospital or an emergency referral to an ENT specialist if:

- Symptoms are severe
- Patient can’t tolerate oral fluids or symptomatic drug treatment
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- The patient presents with sudden-onset unilateral hearing loss. Hearing loss can be indicative of acute
ischaemia of the labyrinth or brain stem. Emergency treatment in such cases can restore the patient's hearing if
seen within 12 hours of the onset of symptoms.
4. Referral to a balance specialist if:

- Symptoms are not typical of vestibular neuronitis (for example additional neurological symptoms).
- Symptoms persist without improvement for more than 1 week despite treatment (urgently refer).
- Symptoms persist for longer than 6 weeks — investigation to exclude other causes, or vestibular
rehabilitation may be required.
GENERAL ADVICE:
- Alcohol may have greater than usual effect on your balance so please avoid drinking alcohol.
- Excessive tiredness can also have a greater than usual effect on your balance so please have plenty of rest.
SAFETY NET
- Please do not drive and do not operate heavy machinery when experiencing symptoms of vertigo or when
taking medication for symptoms.
- Please inform your employer if vertigo poses a risk in the workplace.
- Be aware of the fact that you may have a fall during the episode of vertigo. Take necessary precautions
accordingly to reduce the risk.
WARNING SIGNS
Seek further medical care your symptoms get worse or you develop the following symptoms:
- double vision (diplopia)
- slurred speech
- gait disturbances
- localised weakness
- localised numbness
PROGNOSIS:
Symptoms of a viral vestibular neuritis or viral labyrinthitis can last anything from a few days to several weeks.
A typical case is for symptoms to be bad for 2-3 weeks and then gradually to settle down over several days.
There may be some slight unsteadiness for 2-3 months before symptoms clear completely.
However, in a small number of cases, symptoms can persist for months or years. In these cases, the viral
infection will have gone but the inflammation and damage caused by the infection may cause persisting
symptoms.
MENIERE’S DISEASE
Symptoms:
1. Vertigo (the sensation that you or environment around you is moving or spinning)
2. Tinnitus (hearing ringing sounds from inside your body rather than from outside sources)
3. Hearing Loss (with particular difficulty hearing deep or low sounds)
LABYRINTHITIS
It is usually caused by a simple flu, less commonly by bacterial infection.
Symptoms:
1. Feeling pressure inside the ear.
2. Ringing in the ears.
3. Ear pain.
5. Fever
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6. Change in vision
- Double vision
- Blurry vision
ACOUSTIC NEUROMA
It is a non-cancerous tumour growing on acoustic nerve.
Symptoms:
1. Vertigo
2. Hearing loss.
3. Tinnitus
4. Headache
5. Temporary blurry or double vision
6. Numbness, pain or weakness on one side of the face.
7. Problem with limb coordination.
BPPV (BENIGN POSITIONAL PAROXYSMAL VERTIGO)

Symptoms:
1. Dizziness
- Short time (10-20 seconds, not longer than 1 minute)
- It usually goes away completely
3. Lightheadedness
- Can last for several minutes or hours after the attack
4. Loss of balance
- Can last for several minutes or hours after the attack
Risk Factors:
1. More common in Females more than 40 years
2. Ear infection
3. Head injury
4. Ear surgery
5. Prolonged bed rest while recovering from an illness.
Triggering Factors:
Change in the head position:
- Getting out of bed
- Rolling over in bed
- Looking up
83
TM20 MED HX -Atrial fibrillation
Symptoms:
Main symptoms:
1. Heart racing
- Your heart may feel like it is pounding, fluttering, or beating irregular.
- It takes often a few seconds or possibly a few minutes.
- Your heart may beat very fast.
Other symptoms:
2. Chest pain/tightness/discomfort.
3. Breathlessness.
4. Dizziness/light headedness.
5. Tiredness.
6. Feeling faint/ black out.
Causes:
1. Heart related diseases.
- High blood pressure.
- Atherosclerosis.
- Heart valve disease.
- Congenital heart diseases.
- Cardiomyopathy.
- Pericarditis.
Other causes:
2. Hyperthyroidism.
3. Pneumonia.
4. Asthma.
5. COPD.
6. PE.
7. DM.
Triggers:
1. Drinking excessive amount of alcohol particularly binge drinking.
2. Drinking lots of caffeine such as tea, coffee or energy drinks.
3. Recreational drugs such as amphetamine or cocaine.
4. Smoking.
5. Being overweight.
6. Stress
Investigations:
1. ECG
ECG is a test that records the heart rhythm and electrical activity.
2. Holter ECG:
If you have an episode of AF during the ECG your abnormal heart rate will be recorded. This
will confirm the diagnosis. However, as it can often be difficult to capture an episode of AF,
we may ask you to wear a small portable ECG recorder. This recorder will trace your heart
continuously for 24 hours or more.
3. ECHO:
An echocardiogram is an ultrasound of the heart. It can help to identify any other heart
related problems, and is used to assess the structure and function of the heart and valves.
84
4. CXR:
A chest X-ray can help to identify any lung problems that may be causing atrial fibrillation.
5. Blood tests:
Blood tests can highlight the anaemia problems with the kidney function or an overactive
thyroid gland.
Treatment:
1. Treat the underlying cause if it has been found.
2. Medications:
a. To control the heart rate (Beta blocker such as metaprolol or bisoprolol, CCB such as
verapamil)
b. To restore the normal heart rhythm (Medications such as flecainide and digoxin)
c. To reduce the risk of strokes (Blood thinners such as warfarin or alternatively
rivaroxaban, apixaban or edoxaban)
The way the heart beat in AF means there is risk of blood clotting in the chambers. If they
enter into blood stream they can cause stroke.
3. Cardio version.
It involves giving the heart a controlled electric shock to try to restore a normal rhythm. If
the patient had atrial fibrillation for more than two days, cardio version can increase
the risk of a clot forming. In this case, an anticoagulant for three to four weeks before cardio
version, and for at least four weeks afterwards to minimize the chance of having a stroke is
given to the patient. In emergency a picture of heart can be taken to check for blood clots,
and cardio version can be carried out without going on medications first.
4. Catheter ablation.
Catheter ablation is a procedure, which destroys the diseased area of the heart and
interrupts abnormal electrical circuits. It's an option if medication hasn't been effective or
tolerated.
5. Pacemakers.
A pacemaker is a small, battery-operated device that's implanted in the chest, just below the
collarbone. It's usually used to stop the heart beating too slowly, but in atrial fibrillation it
may be used to help the heart beat regularly.
Complications:
1. Stroke.
When the upper chambers of the heart don’t pump efficiently there is a risk of blood clot
forming. These blood clots may move to the lower chambers of the heart and get pumped
into the blood supply to the lung or to the general blood circulation. Clots in the general
circulation can block the arteries in the brain-causing stroke. AF increases the risk of stroke
by around 4-5 times. However, the risk depends up on many factors including the age and
whether you have high blood pressure, heart failure, DM and previous history of heart clots.
2. Heart failure.
If your atrial fibrillation is persistent, it may start to weaken your heart. In extreme cases, it
can lead to heart failure, as your heart is unable to pump blood around your blood
efficiently.
85
TM MED CX 22-DIABETIC KETOACIDOSIS (DKA)
It is a common complication of diabetes (particularly in children and younger adults with type 1 DM). It
happens when our body is unable to use blood sugar, because there is not enough insulin to push glucose
from blood to cells. Therefore, body breakdown fat as an alternative source of fuel. This causes build up of
a by-product called ketones.
Diabetic ketoacidosis (DKA) is a medical emergency with a significant morbidity and mortality. It should
be diagnosed promptly and managed intensively. DKA is characterised by hyperglycaemia, acidosis and
ketonaemia.
1. Ketonaemia (3 mmol/L and over), or significant ketonuria (more than 2+ on standard urine sticks).
2. Blood glucose over 11 mmol/L or known diabetes mellitus (the degree of hyperglycaemia is not a
reliable indicator of DKA and the blood glucose may rarely be normal or only slightly elevated in DKA).
3. Bicarbonate below 15 mmol/L and/or venous pH less than 7.3.

However, hyperglycaemia may not always be present and low blood ketone levels (<3 mmol/L) do not
always exclude DKA.
SYMPTOMS
1. Frequency (Polyuria)
2. Feeling very thirsty (polydipsia)
3. Feeling sick and being sick.
4. Tummy pain
5. Fruity smelling breath
6. Deep or fast breathing
7. Tiredness
8. Feeling sleepy
9. Confusion
10. Passing out
RISK FACTORS
1. Infections such as UTI
2. Missing insulin dosage.
3. Some medications such as steroid, thiazides.
4. Stroke
5. MI
6. Surgery or injury.
7. Binge drinking
8. Recreational drugs.
9. Pregnancy
10. Having the periods
INVESTIGATIONS
1. Capillary blood glucose (remember to send a plasma glucose also).
2. Urine dipstick testing shows marked glycosuria and ketonuria (also send urine for microscopy and
culture).
3. Blood tests:
a. Plasma glucose will be elevated.
b. FBC - raised WCC is often seen but this does not necessarily indicate sepsis, as it may occur in DKA.
c. U&E’s:
- Na+ may be high due to dehydration, low due to interference of glucose/ketones with assay, or normal;
- K+ may be high due to the effect of acidosis, normal or occasionally low but overall there is cell depletion
of K+.
- Urea and Creatinine - elevated due to pre-renal acute kidney injury or where renal impairment is the
primary cause.
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4. Arterial blood gases - metabolic acidosis with low pH and low HCO3; pCO2 should be normal but can be
depressed by respiratory compensation; low pO2 may indicate a primary respiratory problem as a
precipitant.
5. Cardiac enzymes e.g Troponin - if myocardial ischaemia/infarction is suspected.
6. Creatine kinase - rhabdomyolysis may also exist (also increased in myocardial infarction).
7. Amylase - if pancreatitis is suspected.
8. Blood cultures.
9. 12-lead ECG.
10. CXR.
11. Abdominal X-ray - if indicated by history and examination.
12. CT/MRI Scan of the head - if there is impairment of consciousness or focal neurology.
13. Lumbar puncture - may be indicated if meningitis is a possible precipitant.
Assessment of severity: The presence of one or more of the following may indicate severe DKA.
1. Blood ketones > 6mmol/L
2. HCO3 <5 mmol/L
3. Arterial/Venous pH < 7
4. K < 3.5 (on admission)
5. SpO2 <92% on room air.
6. PR < 60 or >100
7. Systolic BP <90.
8. GCS < 12
Initial management and monitoring

1. Immediate resuscitation as required.
2. Put the patient on SaO2 monitor, continuous ECG monitor and blood pressure/heart rate monitor.
3. Obtain large-bore peripheral intravenous (IV) access or insert central venous catheter.
4. Urinary catheterisation is usually carried out to monitor urine output and will also allow urinalysis.
5. Low molecular weight heparin and thromboembolic deterrent (TED) stockings are given
prophylactically (but see local guidelines).
6. In unconscious, drowsy or vomiting patients, consider passing a nasogastric tube.
General management issues: Special patient groups

The following groups of patients need specialist input as soon as possible and special attention needs to
be paid to their fluid balance:
1. The elderly.
2. Pregnant women.
3. Young people aged 18-25 years.
4. Heart or kidney failure.
5. Other serious comorbidities.
TREATMENT
1. Fluid administration and deficits
The most important initial intervention is appropriate fluid replacement followed by insulin
administration. The main aims for fluid replacement are to restore circulatory volume, remove ketones
and correct electrolyte imbalance. Typical deficits in DKA in adults are water 100 ml/kg, Na + 7-10
mmol/kg, Cl- 3-5 mmol/kg and K+ 3-5 mmol/kg.
The deficit should be replaced as crystalloid. In patients with kidney failure or heart failure, as well as the
elderly and adolescents, the rate and volume of fluid replacement may need to be modified. The aim of the
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first few litres of fluid is to correct any hypotension, replenish the intravascular deficit, and counteract the
effects of the osmotic diuresis with correction of the electrolyte disturbance.
2. Insulin therapy
A fixed-rate IV insulin infusion calculated on 0.1 units/per kg body weight/hour is recommended. Insulin
has several effects but the most important are the suppression of ketogenesis, reduction of blood glucose
and correction of electrolyte disturbance.
3. Metabolic treatment targets

The recommended targets are a reduction of the blood ketone concentration by 0.5 mmol/L/hour, an
increase of the venous bicarbonate by 3.0 mmol/L/hour, a reduction of capillary blood glucose by 3.0
mmol/L/hour and to maintain K+ between 4.0 and 5.5 mmol/L. If these rates are not achieved then the
insulin infusion rate should be increased.
4. IV glucose concentration
The focus should be on clearing ketones as well as normalising blood glucose. When plasma glucose is
below 12 mmol/L then replace normal saline with 5% dextrose to prevent over-rapid correction of blood
glucose and hypoglycaemia. 10% glucose may be required. It is important to continue 0.9% sodium
chloride solution to correct circulatory volume. It is quite often necessary to infuse these solutions
concurrently. Glucose should be continued until the patient is eating and drinking normally.
5. Treat any precipitating illness

a. Measures to actively detect a precipitating cause should be pursued.
b. One clue to the possibility of an unrecognised underlying cause is if the pH and anion gap fail to
improve despite the aforementioned measures. In this case, review insulin therapy and consider other
further investigations - eg, serial ECGs in silent cardiac ischaemia.
c. If an underlying cause is identified then it should also be treated, as appropriate.
d. If there are reasonable clinical grounds to suspect infection as the precipitant then appropriate
antibiotic therapy should be given (usually broad-spectrum blind treatment); routine antibiotics are not
advised.
6. Monitoring
To reduce the risk of catastrophic outcomes in adults with DKA, ensure that monitoring is continuous and
that review covers all aspects of clinical management at frequent intervals.
a. Patients should ideally be managed in an HDU type of setting, or even ITU if they are severely unwell.
b. Electrolytes and venous bicarbonate must be checked at least every 1-2 hours for the first 2-4 hours
and then 2- to 4-hourly thereafter (frequency will depend upon the individual clinical scenario).
c. Monitor hourly fluid balance.
d. Monitor capillary blood glucose every hour with an aim to reduce plasma glucose by 3-5 mmol/L/hour.
e. Plasma glucose should also be checked regularly, as capillary blood glucose may be inaccurate in DKA.
f. If capillary/plasma glucose has not fallen by at least 4 mmol/L in the first hour then check adequacy of
rehydration and patency of infusion lines; if these are not at fault then double the dose of insulin for the
next hour.
g. When plasma glucose is <12 mmol/L then replace normal saline with 5% dextrose to prevent over-
rapid correction of blood glucose and hypoglycaemia.
COMPLICATIONS
1. Cerebral oedema:
a. Cerebral oedema causing symptoms is relatively uncommon in adults during DKA, although
asymptomatic cerebral oedema may be common.
b. Cerebral oedema usually occurs within a few hours of the initiation of treatment. It presents in the first
24 hours with headache, behavioural changes and urinary incontinence, progressing to abrupt
neurological deterioration and coma.
c. Cerebral oedema associated with DKA is more common in children than in adults. In the UK around 70-
80% of diabetes-related deaths in children under 12 years of age are caused as a result of cerebral
oedema.
2. Pulmonary oedema:
88
a. Pulmonary oedema has only been rarely reported in DKA. Pulmonary oedema usually occurs within a
few hours of the initiation of treatment.
b. Elderly patients and those with impaired cardiac function are at particular risk and monitoring of
central venous pressure should be considered.
3. Iatrogenic hypoglycaemia: severe hypoglycaemia is also associated with cardiac arrhythmias, acute
brain injury and death.
4. Iatrogenic hypokalaemia.
5. Cardiac dysrhythmia due to electrolyte disturbance (particularly K+) or metabolic acidosis.
6. Myocardial suppression due to metabolic acidosis.
7. Venous thromboembolism.
8. Myocardial infarction (may be a cause or a complication of DKA).
9. Diabetic retinopathic changes may be seen prior to or after therapy for DKA.
10. Hypophosphataemia - rarely has significant clinical effects. Although there is a large loss of total body
phosphate in DKA, there is no evidence of benefit of phosphate replacement but phosphate measurement
and replacement should be considered in the presence of respiratory and skeletal muscle weakness.
11. Adult respiratory distress syndrome.
PREVENTION
1. Patients with established type 1 diabetes should be given as much information as possible about risk
factors for DKA and how to monitor their own glucose and ketone levels.
2. Education programmes for patients with diabetes, particularly concerning what to do in cases of illness.
3. Structured educational programmes provide advice on how to avoid omitting insulin, increasing insulin
doses if unwell and when to test for ketones.
4. Patients should be advised to measure their ketone levels if they are unwell, as this may identify early
ketosis, which can be addressed by increasing insulin doses. They should also be encouraged to seek
medical attention if levels are increased.
5. Testing ketones in capillary blood has not been shown to be better for preventing DKA than urine
testing.
6. People with recurrent DKA may have underlying precipitating factors and psychological support may
be beneficial.
7. Drugs such as SGLT2 inhibitors (Gliflozin drugs) should be used with caution in people at high risk of
DKA.
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Viral Encephalitis
Symptoms:
Early symptoms:
The first symptoms of encephalitis can be similar to flu such as:
1-high temperature (fever) of 38C (100.4F) or above
2-Headach
3-Feeling and being sick
4-Aching muscles and joints
5-Spotty or blistery rash on skin
Serious symptoms
1-Confusion or disorientation
2-Drowsiness
3-Seizures (fits)
4-Changes in personality and behaviour, such as feeling very agitated
5-Difficulty speaking
6-Weakness or loss of movement in some parts of the body
7-Seeing and hearing things that aren't there (hallucination)
8-Loss of sensation in certain parts of the body
9-Involuntary eye movements, such as side-to-side eye movement
10-Vision problems
11-Loss of consciousness
Risk Factors:
A-PMH
1- Recent health
-Viral infections (Most common):
i. Herpes simplex viruses (cold sores, genital herpes)
ii.The varicella zoster (chicken pox and shingles
iii.measles, mumps, rubella
- Bacteria, fungi or parasites (Rare cases)
2- Medical illnesses
Problem with the immune system:
-Previous infection in another part of the body such as one of the infections mentioned above.
- A non-cancerous or cancerous growth (tumor) somewhere in the body.
3- Medication
-Problem with immune system e.g. vaccination
Complications:
1-Memory problem
2- Personality and behavioural change
3-Speech and languge problem
4-Swalloing problem
5-Repeated seizures (fits) – known as epilepsy
6-Emotional and psychological problems, such as anxiety, depression and mood swings
7-Problems with attention, concentrating, planning and problem solving
8-Problems with balance, co-ordination and movement
9-Persistent tiredness
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TM24 HX MED-HEART FAILURE TREATMENT
Stages of heart failure:

Class 1- Pt. doesn’t have symptoms during normal physical activity.
Class 2- Pt. is comfortable at rest, but normal physical activity triggers symptoms.
Class 3- Pt. is comfortable at rest, but minor physical activity triggers the symptoms.
Class 4- Pt. is unable to carry out any physical activity without discomfort and you may
have symptoms even when resting.
Causes of heart failure:

1. Coronary heart disease.
2. High blood pressure.
3. Cardiomyopathy.
4. Arrhythmias.
5. Problems with the heart valves.
6. Congenital heart disease.
7. Anaemia
8. Overactive thyroid
9. Pulmonary hypertension.
10. Excessive alcohol consumption
11. Smoking
12. Obesity
Symptoms:
1. Shortness of breath.
2. Feeling tired.
3. Swelling in the ankles and legs.
4. Persistent cough.
5. Tachycardia.
6. Dizziness.
Investigations:
1. Blood tests.
2. ECG.
3. ECHO
4. Spirometry and peak flow test.
5. Chest X-ray.
Treatment:
1. Life-style modifications:
a. Smoking:
-Encourage the patient to quit smoking.
b. Diet and fluid intake:
-Advise patients regarding good nutrition.
-Advice the patient to avoid high salt content (Should not exceed 2-3 gm/day)
-Advice the patient to restrict fluid intake.
c. Alcohol:
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-Restrict alcohol intake to one to two unit per day or advice abstention if there is alcohol
induced cardiomyopathy
d. Exercise:
- Encourage the patient to do aerobic exercise mainly supervised cardiac
rehabilitation programme.
e. Travel:
-stage 1 and 2 are not restricted for plane travel.
-stage 3 oxygen may be required.
- stage 4 oxygen is recommended.
The DVLA need not be notified for private car use but LGV drivers are disqualified if
symptomatic.
2. Drugs:
a. ACE- inhibitors:
b. Diuretics
c. Beta-blockers
d. Angiotensin-2 receptor antagonists
e. Aldosterone receptor antagonists
f. Digoxin
g. Anticoagulants
h. Statins
3. Non-drug therapies:
a. Cardiac Resynchronization Therapy (CRT)
An implanted cardiac resynchronization device is used in cardiac resynchoronization
therapy. It resynchronises the contractions of the hearts ventricles by sending tiny
electrical impulses to the heart muscle, which can help the heart pump blood
throughout the body more efficiently.
b. Implantable cardioverter defibrillator ICDs

It is a small device that’s placed in the chest or abdomen. We use this device to treat
arrhythmia’s or irregular heartbeat.
c. CRT with pacing. (CRT-P)

While functioning like a normal pacemaker to treat slow heart rhythms, a CRT-P device
also delivers small electrical impulses to the left and right ventricles to help them
contract at the same time so your heart pumps more efficiently.
d. PCI
This is a procedure in which we try to widen the vessel supplying blood in your heart,
which became narrowed. In this procedure we are putting a short wire mesh tube in
there. Therefore, the blood can flow through the vessel more freely and the heart can
work efficiently.
4. Surgery:
a. Implantation of a left ventricular assist device.
b. Heart transplantation
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TM26 HX MED-Hypothyroidism
Symptoms:
Common symptoms include:
1. Tiredness
2. Being sensitive to cold
3. Weight gain
4. Constipation
5. Depression
6. Slow movements and thoughts
7. Muscle aches and weakness
8. Muscle cramps
9. Dry and scaly skin
10. Brittle hair and nails
11. Loss of libido (sex drive)
12. Pain, numbness and a tingling sensation in the hand and fingers (carpal tunnel syndrome)
13. Irregular periods
Later symptoms of an under-active thyroid include:

1. A low-pitched and hoarse voice
2. A puffy-looking face
3. Thinned or partly missing eyebrows
4. A slow heart rate
5. Hearing problem
6. Anemia
Risk Factors:
A-female gender
B-PMH
1- Recent health
-Viral infections (less common)
2- Medical illnesses
- Other autoimmune diseases e.g. Hashimoto’s disease, Type 1 diabetes, Vitiligo
- Pituitary gland problem (less common)
3- Medication
- Previous treatment to the overactive thyroid e.g. radioactive iodine therapy
- Lithium, amiodarone, interferon
4- Surgery
-Previous thyroid surgery
4- Family history
C- Personal History
1-Diet
-Lack of dietary iodine (less common)
Complications:
1. Heart problems
2. Goiter
3. Pregnancy complications e.g. Pre-eclampsia, anemia in the mother, miscarriage, premature birth,
bleeding after birth, birth defects, stillbirth.
4. Myxedema coma
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Depression
Almost everyone may have ups and downs in their lives. This is common and normal. In true depression,
patient suffers from a low mood and other symptoms each day for at least 2 weeks. These symptoms can
be severe enough to interfere with daily activities.
Symptoms:
A) Core symptoms:
1. Persistent sadness or low mood with or without weepiness.
2. Marked loss of interest or pleasure in activities patient used to enjoy.
B) Other common symptoms:

1. Disturbed sleep either difficulty in getting to sleep or waking up early and difficulty in getting back to
sleep. Sometimes it is sleeping too much.
2. Appetite is usually poor which leads to weight loss but sometimes the patient finds comfort in eating
which leads to weight gain.
3. Loss of energy and feeling tired.
4. Agitation or slow movement.
5. Poor concentration in doing simple tasks like reading or watching television.
6. Feelings of guilt.
7. Recurrent thoughts of deaths, which may progress to actual plans to commit suicide. Patients usually
say words like "Life is not worth living".
Diagnosis of a depressive episode requires at least five of the above nine symptoms with at least one of
the core symptoms, and:
1. These symptoms cause impairment to normal daily functions.
2. Symptoms occur most of the time on most days for at least 2 weeks.
3. Symptoms are not due to medication side effects, drug or alcohol misuse or a physical disorder such as
thyroid disorder.
Severity of depression:
1. Psychotic:
Severe depression accompanied by delusions (false belief that most people from the same culture would
agree it is wrong) or hallucinations (hearing, seeing, feeling, smelling or tasting something which is not
real).
2. Severe:
Patient presents with most or all of the 9 symptoms.
3. Moderate:
Patient presents with more than 5 symptoms including both core symptoms.
4. Mild:
Patient presents with 5 symptoms with mild impairment to daily activities.
5. Sub threshold:
Patient presents with less than 5 symptoms, this is not depression but if persists for more than 2 years it
is called dysthymia.
Causes and risk factors:

1. The exact cause is not known, however, some suggest the presence of genetic factors.
Depression can be triggered by life events such as:
- Relationship problems
- Bereavement
- Illnesses
- In case of women after childbirth (Postnatal depression)
- During menopause.
Management:
94
Most people with depression will get better without treatment, however, this may take several months
(6-8 m. in average) which can be difficult and distressing, that's why many patients will opt to
medications.
Antidepressants medications:
- Usually used in moderate or severe depression. They don't alter the circumstances, however, they ease
the symptoms such as low mood, poor sleep and poor concentration.
- It takes time for these medications to start their effects (usually 2-4 weeks) so patients are advised not
to stop their medications if they didn't get the desired response in the first week.
- Normal course lasts for at least 6 months after the symptoms have eased.
- There are many types of antidepressants with each having its own pros and cons, some people may get
an improvement of their condition within few weeks.
- That's why it is important for the patient to let the doctor know if he is not improving after 3-4 weeks. If
there is no improvement the doctor may increase the dose or switch to another type of medication.
- If patient experiences any persistent side effects the doctor may switch to another type of medication.
- At the end of the course, medication should be stopped gradually over 4 weeks to prevent withdrawal
symptoms or rebound episodes of depression.
Psychological (talking) therapy:

- Combining talking therapy with medications, give better results than medications alone.
- This is usually 12-20 weekly sessions, 1-2 hours each.
- The most common forms include cognitive behavioral therapy (CBT), which aims to change the way of
thinking and coping with different circumstances.
Other types of treatment:

- Other types of treatment may include elctro-compulsive therapy (ECT), which is usually used as a last
option if the condition is severe and not controlled with medications.
Extra Points:
- Some people claim that exercise helps to lift their mood and combat depression, however, evidence has
a conflict is this matter as one study showed there is a difference between people who exercise during
treatment and those who don't but a larger research found that exercise doesn't add to the regular care.
NICE guidelines advice regular exercise as a possible treatment.
- In case of mild depression, talking therapy and self-help is tried first; medications are only used if no
improvement.
- St John's wort: this is a herbal preparation people can get from pharmacies without a prescription,
however, guidelines don't advise using it because it is not clear how it works, it has side effects even
though people think it is completely natural and it may interfere with many other medication.
- Possible new treatments:

1. Eating a Mediterranean diet, which is high in olive oil that helps increase serotonin in the brain.
2. Magnetic stimulation therapy.
3. Omega-3 supplements.
4. Ketamine.
Some "Dos" and "Don'ts" to tell the patient:

- Don't battle things alone.
- Do tell people close to you about how you feel.
- Do try to distract yourself by doing other things.
- Do eat regularly.
- Don't drink too much alcohol. Alcohol itself is depressing.
- Don't take major decisions while depressed.
- Do tell your doctor if you feel that you are getting worse or not improving
95
Pulmonary Embolism Teaching Material- 27 History based
Symptoms and Signs

The symptoms and signs of PE are not specific.
Severe cases of PE can lead to collapse or sudden death.
Some PEs are rapidly fatal. In the majority of the fatal cases the PE is not clinically diagnosed prior to death.
Symptoms
1. Shortness of breath.
2. Chest pain
- retrosternal chest pain.
- increased by breathing of coughing
3. Upper back pain.
4. Cough and haemoptysis.
5. DVT symptoms (pain, redness, swelling and hotness in the calf)
6. Heart racing.
7. Dizziness or faint (due to right heart failure in severe cases).
Signs
1. Tachypnoea
2. Tachycardia.
3. Hypoxia, which may cause anxiety, restlessness, agitation and impaired consciousness.
4. Elevated jugular venous pressure.
5. Gallop heart rhythm, a widely split-second heart sound, tricuspid regurgitant murmur.
6. Pleural rub.
7. Systemic hypotension and cardiogenic shock.
Risk factors
PMH:
Q1 - Previous episode of PE or DVT (Major)
Q3 - Medical illness:
- Malignancy: Abdominal/pelvic or Advanced/metastatic (Major)
- Cardiovascular: Congenital heart disease, Congestive cardiac failure, Hypertension, Paralytic stroke (Minor)
- Haematological: Thrombotic disorders, Myeloproliferative disorders (Minor)
-Renal: Nephrotic syndrome, Chronic dialysis, Paroxysmal nocturnal haemoglobinuria (Minor)
-Respiratory: Chronic obstructive pulmonary disease (COPD) (Minor)
-Other chronic diseases: inflammatory bowel disease, Behçet's disease (Minor)
Long-distance sedentary travel.
Obesity.
Q6 & Q7- Hospital stay/Surgery:

-Long term hospital stay eg postoperative intensive care
-Major abdominal/pelvic surgery or hip/knee replacement (risk lower if prophylaxis used) (Major)
- Fracture of lower limbs (Major)
-Varicose veins: previous varicose vein surgery; superficial thrombophlebitis; varicose veins per se are not a risk factor
(Major)
-Major trauma (Major)
-Spinal cord injury (Major)
-Central venous lines (Major)
Q8-
-Positive family history (Minor)
4Ps
-Pregnancy: Late pregnancy, Puerperium, Caesarean section (Major)
-Pills: Combined oral contraceptive, Hormone replacement therapy (Minor)
Personal history:
-Recreational drug: IV drug abuse (Major/minor)
-Smoking
-Excessive alcohol
96
Pulmonary embolism rule-out criteria (PERC):
For patients presenting with pleuritic chest pain-
PERC is negative if ALL of the following are present:-

- PE clinically unlikely ie no unexplained breathlessness/tachypnea, no thrombophilia, no cancer
- Age <50
- HR <100
- O2 sats in air 95% or more
- No prior history of DVT/PE
- No recent trauma or surgery (within 6 weeks)
- No hemoptysis
- No exogenous estrogen
- No clinical signs of DVT
Wells score for PE:

- Previous PE or DVT 1.5
- Heart rate >100 beats/min 1.5
- Surgery or immobilization within 30 days 1.5
- Hemoptysis 1
- Active cancer (within 6 months) 1
- Clinical signs of DVT 3
- Alternative diagnosis less likely than PE 3
Clinical probability-
PE low risk= score of 4 or below
PE high risk= score of 4.5 or above
Notes on D-dimer:
D-dimer is a very good index for ruling out PE.
It may be elevated in many situations such as:
- Cancer
- Infection
- Inflammation/arthritis
- Necrosis
- Aortic dissection
- Pregnancy
- Trauma
- Recent surgery
- Age over 50
-
1) If PE is ruled out on clinical assessment (PERC score negative):
1) If patient presents with breathless and/or tachypnoea (with or without hypoxia, pleuritic chest pain, & hemoptysis)
without a clear alternative diagnosis, you must consult Wells score.
2) If PE is ruled out, and PERC is negative, PE can be ruled out without the need of a D-dimer.
2) If PE is NOT ruled out on clinical assessment (PERC score NOT negative):

Assess the clinical probability of PE using Wells score.
Do a CXR and ECG to rule out other pathologies.
Admit to observation unit.
3)If PERC positive but Wells score shows low risk, a negative D-dimer rules out PE without the need for imaging.
In case of low risk (4 and below):

D-dimer only needed if low risk. A negative D-dimer doesn’t rule out PE if the patient is high risk. If the D-dimer comes back
negative, PE can be ruled out.
If D-dimer positive:
- CTPA (first line)
- Consider V/Q scan if:-
Patient under 50 years without cardiorespiratory comorbidities and normal CXR
Renal impairment
Contrast allergy
97
NOTE: If imaging cannot be completed within 1 hour, you should consider Clexane (Enoxaparin) 1.5 mg/kg s/c while
awaiting the scan unless contraindicated
If scan is negative: Advise the patient that PE is highly unlikely, but to seek further medical attention if symptoms worsen.
If scan is positive: PE confirmed
Treatment:
- Refer to medical team
- Start Clexane (Enoxaparin) 1.5 mg/kg s/c unless contraindicated
In case of high risk:

NOTE: The case is high risk if
1) If there is score of 4.5 or above OR
2) Patient is known/suspected pro-thrombotic disease OR
3) Patient is known DVT:
- CTPA (first line)
- Consider V/Q scan if:-
Patient under 50 years without cardiorespiratory comorbidities and normal CXR
Renal impairment
Contrast allergy
If scan is negative: Advise the patient that PE is highly unlikely, but to seek further medical attention if symptoms worsen.
If scan is positive: PE confirmed
Treatment:
- Refer to medical team
- Start Clexane (Enoxaparin) 1.5 mg/kg s/c unless contraindicated
3) In case of suspected massive PE:

- Collapse/hypotension
- Respiratory distress
- Distended neck veins
- Right ventricular strain on ECG
Treatment:
1) Move to resus.
2) Start on high flow oxygen via non-rebreather.
3) Do CXR.
4) Involve A&E senior and inform ICU
5) Immediate bedside echo
6) +/- urgent CTPA if stable.
7) Give heparin 5000 units IV (unless Clexane already given within 5 hours)
8) If not for thrombolysis, give Clexan 1.5 mg/kg s/c in addition
Thrombolysis:
Indications-
Suspected or confirmed massive PE with:-
1) Cardiac arrest/peri-arrest
- Alteplase 50 mg IV stat AND another 50 mg of alteplase IV over 1 hour post return of spontaneous circulation
(ROSC)
2) Clinical cardiogenic shock
- Alteplase 10 mg IV over 1-2 minutes THEN alteplase 90 mg IV over 2 hours (total dose 1.5 mg/kg if weight <65
kg)
3) Normotensive but with evidence of significant right heart strain on echo or positive troponin
- Alteplase 50 mg IV over 1 hour
NOTE: Give Clexan 1.5 mg/kg s/c once post thrombolysis
NOTE: Contraindications and cautions of Clexane (Enoxaparin)

Contraindications-
- Active bleeding
- Known bleeding controlled
- Thrombocytopenia
98
- Severe uncontrolled hypertension (SBP >200 mmHg)
- Recent intracranial haemorrhage
- Major surgery within 2 months
- Acute bacterial endocarditis
Cautions:
- Liver impairment (reduce dose)
- Renal impairment (reduce dose)
- Varices
- CVA within 2 years
Extra information:
-Provoked DVT or PE occurs in a patient
A) With an antecedent (within 3 months) and transient major clinical risk factor for venous thromboembolism (VTE).
For example, surgery, trauma, significant immobility (bedbound, unable to walk unaided or likely to spend a substantial
proportion of the day in bed or in a chair), pregnancy or puerperium
B) Or in a patient who is having hormonal therapy (oral contraceptive or hormone replacement therapy)
-Unprovoked DVT or PE occurs in a patient with

A) No antecedent major clinical risk factor for VTE who is not having hormonal therapy
(oral contraceptive or hormone replacement therapy)
B) Or active cancer, thrombophilia or a family history of VTE, because these are underlying risks that remain constant in the
patient
Principles of management of DVT/PE

A) Start the low molecular weight heparin (LMWH), fondaparinux or unfractionated heparin (UFH) as soon as possible and
continue it for at least 5 days or until the international normalised ratio (INR) is 2 or above for at least 24 hours, whichever
is longer
NOTE: If patient has active cancer and confirmed proximal DVT or PE then offer LMWH, and continue the LMWH for 6
months
at 6 months, assess the risks and benefits of continuing anticoagulation
B) Offer a VKA (vitamin K antagonist) to patients with confirmed proximal DVT or PE within 24 hours of diagnosis and
continue the VKA for 3 months. At 3 months, assess the risks and benefits of continuing VKA treatment
NOTE:Consider extending the VKA beyond 3 months for patients with unprovoked proximal DVT if their risk of VTE
recurrence is high and there is no additional risk of major bleeding
Investigations for cancer if unprovoked DVT or PE

All patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations
for cancer, should be offered:
A) A physical examination (guided by the patient's full history) and
B) A chest X-ray and
C) Blood tests (full blood count, serum calcium and liver function tests) and
D) Urinalysis
NOTE: Consider further investigations for cancer with an abdomino-pelvic CT scan (and a mammogram for women) in all
patients aged over 40 years with a first unprovoked DVT or PE who do not have signs or symptoms of cancer based on initial
investigation
-Rivaroxaban is recommended by NICE as an option for treating PE and preventing recurrent DVT and PE in adults.
-The duration of treatment recommended depends on bleeding risk and other clinical criteria.
-Short-term treatment (at least three months) is recommended for people with transient risk factors such as recent surgery
and trauma. Longer treatment is recommended for people with permanent risk factors, or idiopathic (unprovoked) DVT or
PE.
-Consider pharmacological systemic thrombolytic therapy for patients with PE and haemodynamic instability. Do not offer
pharmacological systemic thrombolytic therapy to patients with PE and haemodynamic stability.
-Offer temporary inferior vena caval filters to patients with PE who cannot have anticoagulation treatment and remove the
inferior vena caval filter when the patient becomes eligible for anticoagulation treatment.
-Consider inferior vena caval filters for patients with recurrent PE despite adequate anticoagulation treatment only after
considering alternative treatments such as increasing target INR to 3-4 for long-term high-intensity oral anticoagulant
therapy or switching treatment to LMWH.
-Ensure that a strategy exists for removing the inferior vena caval filter at the earliest possible opportunity.
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TM29 HX MED-POLYMYALGIA RHEUMATICA
Polymyalgia rheumatica (PMR) is a condition that causes pain, stiffness and inflammation in the muscles around the
shoulders, neck and hips.
Polymyalgia rheumatica (PMR) is an inflammatory condition that causes many painful muscles (poly = many, myalgia =
muscle pain). Any muscles can be affected, but it mainly affects the muscles of the shoulder and thigh.
Polymyalgia Rheumatica (or PMR) is an inflammatory disorder of the muscles and joints that typically afflicts those over the
age of 65.
Closely related to giant cell arteritis, both inflammatory disorders can set in quickly and co-exist (many doctors believe they
are different manifestations of the same condition), considering approximately half of patients with Giant Cell Arteritis
develop Polymyalgia Rheumatic at some point. Both conditions do cause similar muscle pain and stiffness to both sides of
the body, typically affecting the shoulders, upper arms, neck, buttocks, and hips.
The cause of PMR is often linked to genetics, although an environmental viral infection of the immune system is thought to
leave individuals more susceptible to PMR.
Cause and Risk Factors
The cause of polymyalgia rheumatica is unknown, but a combination of genetic and environmental factors is thought to be
responsible.
Polymyalgia rheumatica is age-related. Most people diagnosed with it are over 70, and it's very rare in people younger than
50. PMR can start at any age from 50 but mainly affects people over the age of 60.
It's also more common in women than men. Women are affected 2–3 times as often as men and it affects about 1 in 2,000
people.
1. Idiopathic
2. Genetics
3. Environmental Factors
4. Age
5. Women > Men
It's estimated 1 in every 1,200 people in the UK develop the condition every year.
Symptoms
Those who have polymyalgia rheumatica (PMR), will usually have severe and painful stiffness, which is often worse in the
morning, especially in their shoulders and thighs and usually affecting both sides. PMR often strikes suddenly, appearing
over a week or two and sometimes just after a flu-like illness.
The symptoms are quite different from the ache you may feel after exercise. The pain and stiffness is often widespread, is
worse when resting and improves with activity or as the day goes on. However, it may also wake you at night.
The eight early warning signs of PMR will strike and worsen within 2 weeks time, they include the following:
1. Pain:
The most common symptom of polymyalgia rheumatica (PMR) is pain and stiffness in the shoulder muscles, which develops
quickly over a few days or weeks.
Achy pain in the shoulders is typically the foremost sign of PMR, followed closely by pain in the areas of the neck, upper
arms, buttocks, hips, and thighs, and even the wrists and knees in some cases. Both sides of the body are usually affected.
2. Stiffness:
Stiffness happens in the same affected areas as mentioned previously. The stiffness often feels worse first thing in the
morning after patient wakes up or following long periods of inactivity and starts to improve after about 45 minutes as they
become more active.
Stiffness may be worse one side of the body at first, but as the condition progresses, rigidity will spread to the other side as
well.
3. Limited Range of Motion:
With stiffness and pain will often come limited range in motion to the affected areas of the shoulders primarily—followed by
restricted motion in the neck, arms, and hips on both sides of the body.
4. Fatigue (Extreme Tiredness):
Many patients with Polymyalgia Rheumatica often complain of a fluey feeling (i.e., achy muscles, fever, headache) as well as
a general feeling of malaise in the early stages of the condition.
5. Fever (Feeling Unwell):
A mild or low-grade fever is typical as an early PMR symptom. The fever will often spike at a mild to high temperature
between 98- to 100-degrees Fahrenheit.
6. Lack of Appetite:
Typically, it’s a sudden loss of appetite that will cause the sudden weight loss in PMR patients. The pain, sudden immobility,
and depression will often be the prime cause of loss of appetite and enjoyment from food.
6. Weight Loss:
A sudden instance of unintended weight loss—meaning you have not been cutting calories or attempting to lose weight
through exercise—will often happen in the earliest stages of a PMR diagnosis.
8. Depression (Feeling low, anxious):
Dealing with consistent pain on both sides of your body will often end up causing mood swings and even severe depression
if PMR affects your quality of life.
Diagnosis
Diagnosing polymyalgia rheumatica (PMR) can often be quite a lengthy and difficult process involving several different tests.
This is because the condition shares many symptoms with more common health conditions, such as rheumatoid arthritis,
which need to be ruled out first. These conditions will need to be ruled out before polymyalgia rheumatic is diagnosed.
NOTE: Patient must see the GP if they have symptoms of pain and stiffness that last longer than a week.
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INVESTIGATIONS
1. Blood Tests:
There's no specific test for polymyalgia rheumatica, but it's likely that a series of blood tests will be carried out. These blood
tests can be used to check the levels of inflammation in the body:
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Plasma viscosity (PV)
Blood tests can also help determine:
- FBC: Whether there's an infection in the blood. Anaemia (a lack of red blood cells) is quite common in PMR so your doctor
may test for this, but this can also occur in other conditions.
- LFTs and U&Es: How well some of the organs, such as kidneys, are working.
- TFTs: Whether they have an overactive thyroid gland or an underactive thyroid gland – both conditions can cause muscle
pain.
NOTE: If the ESR and CRP test results are normal, it’s unlikely that polymyalgia rheumatica will be diagnosed.
Sometimes the ESR may be normal and the CRP may be raised, which would be more likely to indicate a positive diagnosis.
This is why both tests are usually carried out at the same time.
As inflammation is a feature of many conditions, high levels don't automatically mean you have polymyalgia rheumatica.
2. Further tests:
Inflammation alone isn't enough to confirm a diagnosis of PMR as it's also a feature of many other conditions, including
infections and rheumatoid arthritis. Patient may therefore have tests to help rule out these other conditions and confirm the
diagnosis of PMR. Further tests may be needed to help rule out other conditions that cause inflammation.
For example, tests to rule out rheumatoid arthritis include:
- Rheumatoid factor
- Anti-CCP antibodies
3. Urine test:
You may also have a urine test to check how well your kidneys are functioning.
4. Imaging:
Different types of imaging may be used to help in the diagnosis of PMR and to help rule out other conditions. X-rays and
ultrasound scans may also be used to look at the condition of the bones and joints.
- Ultrasound/X-rays:
Ultrasound of the shoulders and hips may be used and can often show inflammation in the tissues.
- MRI/PET Scan:
Other forms of imaging, such as magnetic resonance imaging (MRI) and positron emission tomography (PET) scans, may
occasionally be requested by a rheumatologist.
5. Biopsy:
If there is suspicion of GCA, a biopsy of a small piece of artery may be taken from the scalp and examined under a
microscope.
Symptom checklist
After other possible causes of the patient’s symptoms have been ruled out, a checklist can be used to see whether their
symptoms match those most commonly associated with polymyalgia rheumatica.
A confident diagnosis of polymyalgia rheumatica can usually be made if your patient meets all of the following criteria:
1. Over 50 years of age
2. Having pain in the shoulders or hips (on both sides)
3. Having stiffness in the morning that lasts longer than 45 minutes
4. Symptoms have lasted for more than two weeks
5. Blood tests show raised levels of inflammation in your body
6. Symptoms rapidly improve after treatment with corticosteroids
Treatment:
1. Corticosteroid (Prednisolone):
Steroid medication is the main treatment for polymyalgia rheumatica (PMR).
A type of corticosteroid called prednisolone is usually prescribed.
Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside the body. It doesn't cure
polymyalgia rheumatica, but it can help relieve the symptoms.
When used to treat polymyalgia rheumatica, prednisolone is taken as a tablet. Most people will be prescribed several tablets
to take once a day.
The patient will (initially) be prescribed a high dose of prednisolone to start with, and the dose will be gradually reduced
every one to two months (over time).
Although the symptoms should improve within a few days of starting treatment, they'll probably need to continue taking a
low dose of prednisolone for about two years.
NOTE: Most people with polymyalgia rheumatica will need to take a course of corticosteroid treatment that lasts 18 months
to two years to prevent their symptoms returning.
In many cases, polymyalgia rheumatica improves on its own after this time. However, there's a chance it will return after
treatment stops, known as a relapse.
NOTE: Don't suddenly stop taking steroid medication unless your doctor tells you it's safe to do so. Suddenly stopping
treatment with steroids can make you very ill.
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Side effects of prednisolone:
About 1 in 20 people who take prednisolone will experience changes in their mental state when they take the medication.
Patient may feel depressed and suicidal, anxious or confused. Some people also experience hallucinations, which is seeing or
hearing things that aren't there.
NOTE: Patient must contact their GP as soon as possible if they experience changes to their mental state.
Other side effects of prednisolone include:

- Increased appetite, which often leads to weight gain
- Increased blood pressure
- Mood changes, such as becoming aggressive or irritable with people
- Weakening of the bones (osteoporosis)
- Stomach ulcers
- Increased risk of infection, particularly with the varicella-zoster virus, the virus that causes - Chickenpox and shingles
NOTE: Patient should seek immediate medical advice if they think they've been exposed to the varicella-zoster virus or if a
member of their household develops chickenpox or shingles.
NOTE: The risk of these side effects should improve as the dose of prednisolone is decreased.
2. Prevention of osteoporosis (Bisphosphonates):
Steroid treatments can increase the risk of osteoporosis, which means you're more likely to break a bone in a fall. Your
doctor will advise on drugs to help guard against osteoporosis, for example, bisphosphonates such as risedronate or
alendronate.
3. Pain killers:
Painkillers, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), may be recommended to help relieve
the pain and stiffness while the dose of prednisolone is reduced.
4. Disease-modifying anti-rheumatic drugs (DMARDs):
If your symptoms don’t improve with steroids, or if it’s difficult to reduce the dose over a period of time, or if you get
frequent flare-ups of your condition, your doctor may send you to see a specialist. The specialist may prescribe other drugs
alongside the steroid tablets – for example, methotrexate or leflunomide. These drugs reduce the activity of the immune
system, which in turn reduces inflammation, and may allow the steroid dose to be reduced without the symptoms flaring up.
It’s important to have regular check-ups, blood tests and blood pressure checks when you’re taking DMARDs to check for
early signs of side-effects and to check how well the treatment is working for you.
NOTE: Patient may be referred to a rheumatologist if there's any doubt about the diagnosis or if there are complicating
factors – for example, if the symptoms don't improve with steroid treatment or if patient has side-effects from the treatment.
Follow-up
Patients will have regular follow-up appointments to check how well they’re responding to treatment, whether the dose of
prednisolone needs to be adjusted and how well they're coping with the medication's side effects.
During these appointments, they'll have blood tests to check the levels of inflammation inside the body.
Follow-up appointments are usually recommended every few weeks for the first three months, and then at three- to six-
monthly intervals after this time.
NOTE: Patient must contact their GP if the symptoms return during any part of the treatment. The dosage may need to be
adjusted.
Steroid card
If patient needs to take steroids for more than three weeks, their GP or pharmacist should arrange for them to be issued
with a steroid card.
The card explains that they're regularly taking steroids and the dose shouldn't be stopped suddenly. Patient should carry the
card with them at all the time.
When taking steroid tablets, you must carry a steroid card, which shows your current dose and how long you’ve been taking
them. This will help if you need to see another doctor or healthcare professional, for example a dentist. Depending what
additional treatment you need the steroid dose may need to be adjusted. Steroid cards are available from most pharmacies.
Self-help and daily living for polymyalgia rheumatica (PMR)

Because steroid tablets can increase the risk of osteoporosis it’s important to think about any other risk factors you may
have. Factors that increase your risk include:
- Smoking
- Drinking a lot of alcohol.
Factors that can reduce your risk include:
- Eating a diet that contains plenty of calcium and vitamin D
- Doing some weight-bearing exercise.
Sitting for any length of time may cause stiffness, making driving, for instance, more difficult. Stop from time to time on a
long journey to stretch your legs, arms and shoulders.
Simple measures like a hot bath or shower first thing in the morning or after exercise can help to ease pain and stiffness.
Exercise:
You’ll need to find the right balance between rest and activity. Too much exercise is likely to make your symptoms worse,
but activity usually helps to ease morning stiffness. Physiotherapy can be helpful in reducing pain and maintaining mobility.
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Weight-bearing exercise (any exercise that involves walking or running) is best for maintaining bone strength and guarding
against osteoporosis, but walking is usually most suitable for people with PMR.
Diet and Nutrition:

Steroid tablets reduce the amount of calcium absorbed from the gut and increase calcium loss through the kidneys. To
counteract this, we recommend a daily intake of calcium of 1,000 milligrams (mg) or 1,500 mg if you’re over 60. A pint of
milk a day, together with a reasonable amount of other foods that contain calcium, should be enough.
Vitamin D is needed for the body to absorb and process calcium. Your body produces vitamin D when the skin is exposed to
sunlight. It’s also obtained from some foods, especially oily fish, and is added to some soya milks and vegetable margarines.
It’s sometimes necessary to take a daily supplement containing 10–20 micrograms (μg) (this is the same as 400 to 800
international units (IU)) of vitamin D, especially for people over 60.
Giant Cell Arthritis

Around one in five people with polymyalgia rheumatica develop a more serious condition called giant cell arteritis, in which
the arteries in the head and neck become inflamed.
Symptoms of giant cell arteritis include:
- A severe headache that develops suddenly – the scalp may also feel sore or tender
- Pain in the jaw muscles when eating
- Problems with sight – such as double vision or loss of vision
NOTE: If you have any of these symptoms, contact your GP immediately, or call NHS 111 or an urgent care service.
NOTE: Unlike polymyalgia rheumatica, giant cell arteritis requires immediate medical attention. This is because it can cause
permanent sight loss if not treated promptly.
Warning Signs
Contact your GP immediately, or call NHS 111 or your nearest urgent care service, if you've been diagnosed with
polymyalgia rheumatica (or it's suspected) and you suddenly develop:
1. A severe headache that doesn't go away, pain in the muscles of your head, tenderness at your temples.
2. Pain or cramping in your jaw muscles or the side of your face that's worse when eating.
3. Pain in your tongue when chewing.
4. Vision loss or vision disturbances, such as blurred or double vision.
Note: These symptoms may indicate a more serious condition called giant cell arteritis (temporal arteritis).
CORTICOSTEROIDS
Steroid tablets (corticosteroids) aren't the same as the steroids sometimes used by athletes and bodybuilders (which are
known as anabolic steroids). Corticosteroids are similar to steroids produced naturally in the body, which play an important
part in keeping you healthy.
Steroid treatment can have a powerful effect in reducing inflammation. They won’t cure PMR, but the symptoms often
improve significantly within about two weeks of starting treatment. The symptoms may have almost completely
disappeared after four weeks. However, you’ll probably need to continue treatment for up to two years, and occasionally
longer, to stop symptoms returning.
The steroid tablet most often prescribed is prednisolone. A starting dose of 15 mg a day usually makes symptoms disappear
completely. If you have giant cell arteritis (GCA) you’ll need higher doses than this to begin with to protect your vision.
If you're at increased risk of side-effects from steroid tablets (for example, if you have diabetes, high blood pressure, a recent
fracture, peptic ulcer, cataract or glaucoma) some doctors may suggest steroid injections (Depo-Medrone) into a muscle
instead. Your doctor may also suggest bone protection treatment to reduce the risk of osteoporosis, which can be a problem
with long-term steroid treatment.
After a time your doctor will try to gradually reduce your dose to avoid potential side-effects, such as weight gain and
osteoporosis. This will be done in stages depending mainly on your symptoms but helped by repeat ESR or CRP test results.
If your symptoms return when the dose is reduced your doctor may have to increase it for a short time. They’ll then try to
reduce it again after several weeks. Raised ESR or CRP test results alone don’t necessarily mean your steroid dose needs to
be increased.
Even when you feel well, your doctor may want to see you regularly so that they can check you for signs of a relapse or side-
effects from the steroids. They may want to check your general health or ask you to have a bone density (DEXA) scan to
assess the strength of your bones.
You shouldn’t stop taking your steroid tablets suddenly or alter the dose unless your doctor tells you, even if your symptoms
have completely cleared up. This is because your body stops producing its own steroids (cortisol) while you’re taking
steroid tablets and needs a period of time to resume normal production of natural steroids when the drug is stopped.
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TM30 HX MED-Obesity
Your GP can advise you about losing weight safely by eating a healthy, balanced diet and regular physical
activity.
They can also let you know about other useful services, such as:
local weight loss groups – these could be provided by your local authority, the NHS, or commercial services you
may have to pay for
exercise on prescription – where you're referred to a local active health team for a number of sessions under
the supervision of a qualified trainer
Diet
There's no single rule that applies to everyone, but to lose weight at a safe and sustainable rate of 0.5 to 1kg
(1lb to 2lbs) a week, most people are advised to reduce their energy intake by 600 calories a day.
For most men, this will mean consuming no more than 1,900 calories a day, and for most women, no more than
1,400 calories a day.
The best way to achieve this is to swap unhealthy and high-energy food choices – such as fast food, processed
food and sugary drinks (including alcohol) – for healthier choices.
A healthy diet should consist of:
-Plenty of fruit and vegetables
-Plenty of potatoes, bread, rice, pasta and other starchy foods (ideally you should choose wholegrain varieties)
-Some milk and dairy foods
-Some meat, fish, eggs, beans and other non-dairy sources of protein
-Just small amounts of food and drinks that are high in fat and sugar
Try to avoid foods containing high levels of salt because they can raise your blood pressure, which can be
dangerous for people who are already obese. Read some tips for a lower-salt diet.
You'll also need to check calorie information for each type of food and drink you consume to make sure you
don't go over your daily limit.
Some restaurants and fast food outlets provide calorie information per portion, although providing this
information isn't compulsory. Be careful when eating out because some foods can quickly take you over the
limit, such as burgers, fried chicken, and some curries or Chinese dishes.
Exercise
Reducing the amount of calories in your diet will help you lose weight, but maintaining a healthy weight
requires physical activity to burn energy.
Moderate-intensity activity is any activity that increases your heart and breathing rate, such as:
-Brisk walking
-Cycling
-Recreational swimming
-Dancing
Alternatively, you could do 75 minutes (one hour, fifteen minutes) of vigorous-intensity activity a week, or a
combination of moderate and vigorous activity.
During vigorous activity, breathing is very hard, your heart beats rapidly and you may be unable to hold a
conversation. Examples include:
-Running
-Most competitive sports
-Circuit training
You should also do strength exercises and balance training two days a week. This could be in the form of a gym
workout, carrying shopping bags. It's also critical that you break up sitting (sedentary) time by getting up and
moving around.
It's also important to find activities you enjoy and want to keep doing. Activities with a social element or
exercising with friends or family can help keep you motivated. Make a start today – it’s never too late.
Medication
Orlistat. It works by preventing around a third of the fat from the food you eat being absorbed. The undigested
fat isn't absorbed into your body and is passed out with your faeces (stools). This will help you avoid gaining
weight, but won't necessarily cause you to lose weight.
One orlistat capsule is taken with water immediately before, during or up to one hour after, each main meal (up
to a maximum of three capsules a day).
If you miss a meal, or the meal doesn't contain any fat, you shouldn't take the orlistat capsule.
Common side effects of orlistat include:
-Fatty or oily stools
-Needing the toilet urgently
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-Passing stools more frequently
-An oily discharge from your rectum (you may have oily spots on your underwear)
-Flatulence (wind)
-Stomach pain
-Headaches
-Upper respiratory tract infections, such as a cold
These side effects are much less likely to occur if you stick to a low-fat diet.
Women taking the oral contraceptive pill should use an additional method of contraception, such as a condom,
if they experience severe diarrhoea while taking orlistat. This is because the contraceptive pill may not be
absorbed by your body if you have diarrhoea, so it may not be effective.
Weight loss surgery
Also called bariatric surgery, it is sometimes used to treat people who are severely obese.
Bariatric surgery is usually only available on the NHS to treat people with severe obesity who fulfil all of the
following criteria:
-They have a BMI of 40 or more, or between 35 and 40 and another serious health condition that could be
improved with weight loss, such as type 2 diabetes or high blood pressure
-All appropriate non-surgical measures have been tried, but the person hasn't achieved or maintained
adequate, clinically beneficial weight loss
-The person is fit enough to have anaesthesia and surgery
-The person has been receiving, or will receive, intensive management as part of their treatment
-The person commits to the need for long-term follow-up
Bariatric surgery may also be considered as a possible treatment option for people with a BMI of 30 to 35 who
have recently (in the last 10 years) been diagnosed with type 2 diabetes.
Body Mass Index (BMI)

The body mass index (BMI) is a measure that uses your height and weight to work out if your weight is healthy.
The BMI calculation divides an adult's weight in kilograms by their height in meters squared. For example, A
BMI of 25 means 25kg/m2.
BMI ranges
For most adults, an ideal BMI is in the 18.5 to 24.9 range.
For children and young people aged 2 to 18, the BMI calculation takes into account age and gender as well as
height and weight.
If your BMI is:
below 18.5 – you're in the underweight range

between 18.5 and 24.9 – you're in the healthy weight range
between 25 and 29.9 – you're in the overweight range
between 30 and 39.9 – you're in the obese range
If you want to calculate your BMI, see How can I work out my BMI? or try our healthy weight calculator.
Accuracy of BMI
BMI takes into account natural variations in body shape, giving a healthy weight range for a particular height.
As well as measuring your BMI, healthcare professionals may take other factors into account when assessing if
you're a healthy weight.
Muscle is much denser than fat, so very muscular people, such as heavyweight boxers, weight trainers and
athletes, may be a healthy weight even though their BMI is classed as obese.
Your ethnic group can also affect your risk of some health conditions. For example, adults of Asian origin may
have a higher risk of health problems at BMI levels below 25.
You should not use BMI as a measure if you're pregnant.
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MED HX 32- CONFUSION /HYPONATREMIA
HYPONATREMIA
Hyponatraemia is a low level of sodium in the blood.
Sodium levels in the blood have to be tightly controlled.
Various chemical messengers (hormones) and organs are involved in this process. For example,
hormones involved include antidiuretic hormone and cortisol, and organs involved include the brain and
kidneys.
There is a very close relationship between body sodium and body fluid levels.
Hyponatraemia can be classified in various ways such as:
- Timing of the fall in blood sodium into acute (usually hours) or chronic (days to weeks).
- Level of body fluid as either low body fluid (hypovolaemia), excess body fluid (hypervolemia) or no
change in body fluid (euvolaemia).
CAUSES
Hyponatraemia is very common - especially mild hyponatraemia. It occurs equally in men and women.
Some patients are more at risk of hyponatraemia - such as:
- Children and the elderly (Because they are less likely to express thirst.)
- Infants with diarrhoea given tap water. They need electrolyte replacement fluid.
- Infants who are on watered-down milk formula who then become unwell.
Levels of sodium in the blood are tightly controlled. This involves a number of factors including:
- Kidneys - which can choose to remove or retain sodium in the blood.
- Antidiuretic hormone (also known as vasopressin) - a hormone which works to retain body fluid.
- Renin angiotensin and aldosterone system - regulates sodium excretion by the kidneys and levels of
fluid in the body and maintains blood pressure.
- Sodium levels are measured in the blood and an example of the normal range of blood sodium is 136-
142 mmol/L.
Mild hyponatraemia occurs when the level is less than 136 mmol/L.
Severe hyponatraemia is a level less than 120 mmol/L.
Hyponatraemia usually occurs with changes in the body fluid levels and can be divided into three groups:
- Euvolaemic - body fluid levels are normal.
- Hypovolaemia - reduced body fluid levels, the most common cause of which is dehydration.
- Hypervolaemic - increased body fluid levels, an example of which is heart failure leading to fluid
retention.
The causes of hyponatraemia can be classified in various ways but most commonly are based on the body
fluid levels. The levels of sodium in the urine are used to help determine the underlying cause.
Low body fluid (hypovolaemia)

- Being sick (vomiting).
- Diarrhoea.
- Addison's disease: adrenal glands fail to produce the necessary steroid hormones.
- Burns.
- Excessive sweating.
- Medications such as diuretics - for example, thiazide diuretics such as bendroflumethiazide or loop
diuretics.
Increase in body fluid (hypervolaemia)

- Cardiac failure.
- Cirrhosis - liver fibrosis.
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- Kidney failure.
No abnormalities of body fluid (euvolaemia) - resulting in excess antidiuretic hormone

-Neurological: brain tumour, brain trauma, multiple sclerosis, systemic lupus erythematosus, brain
haemorrhage.
- Lung disorders: lung cancer, pneumonia, asthma, tuberculosis.
- Other cancers: stomach cancer, pancreatic cancer, leukaemia and lymphoma.
- Medications: selective serotonin reuptake inhibitors (SSRIs), proton pump inhibitors, angiotensin-
converting enzyme (ACE) inhibitors.
- Other causes: pain, following surgery, stress, endurance exercise and marathon running.
Falsely low sodium levels

- Very high cholesterol levels.
- Very high blood sugar levels.
In these cases the result for the blood sodium will be low but that is due to interference from the high
cholesterol or sugar levels. The actual blood sodium level is normal. Once the high cholesterol or blood
sugar levels are corrected, the sodium will also become normal.
Symptoms and Signs

The symptoms and severity of hyponatraemia depend on the following two factors:
1- The level of the blood sodium.
2- How quickly the sodium level falls - hyponatraemia can be divided into acute or chronic. In acute there
is usually a sudden fall in blood sodium levels (over hours), whereas a chronic fall occurs over days to
weeks.
Symptoms
If the levels are only mildly abnormal the patient may feel completely fine, or only have mild symptoms.
The clinical picture can be confusing, as mild hyponatraemia can cause significant symptoms if the drop in
sodium level is sudden. On the other hand severe chronic hyponatraemia can cause no symptoms, due to
the body (especially the brain) adapting to the lower levels. Symptoms include:
- Mild hyponatraemia - lack or loss of appetite (anorexia), headache, feeling sick (nausea), being sick
(vomiting), and lack of energy and enthusiasm (lethargy).
- Moderate hyponatraemia - personality change, muscle cramps and weakness, confusion, and lack of
muscle co-ordination (ataxia).
- Severe - drowsiness and fits (seizures).
Signs
Neurological signs:
1- Reduced level of consciousness.
2- Problems with cognition such as, short-term memory loss, disorientation, confusion, depression).
3- Seizures.
In severe acute hyponatraemia the brainstem can press down on the bottom of the skull (called
herniation), leading to a large pupil that does not respond to light, coma and the patient stopping
breathing.
Signs of low body fluid (hypovolaemia):

1- Dry mucous membranes - for example, the tongue and the mouth.
2- Sunken eyes.
3- Fast heart rate.
4- Low blood pressure.
5- Dry skin or reduced elasticity of the skin.
107
Signs of an increase in body fluid (hypervolaemia):
1- Crackles when listening over the lungs.
2- Extra heart sounds as the heart is having to work harder.
3- Increased pressure in the veins seen at the neck.
4- Swelling of the tummy (abdomen).
5- Swelling of the legs.
The patient may also have symptoms relating to the underlying cause and from loss of body fluid or from
excess body fluid. For example, loss of body fluid may make the patients thirsty and they may pass less
urine. Too much body fluid on the other hand, may cause them to develop leg and tummy (abdominal)
swelling. Or, if they have a thyroid disorder, they may have an enlarged thyroid gland.
Diagnosis
The presence of hyponatraemia is based on the blood levels. However, this may yield little information
regarding why the hyponatraemia has occurred. This is why a full assessment has to be undertaken. To
determine whether the hyponatraemia is acute or chronic and be looking for clues as to the underlying
cause.
The doctor will also decide on whether urgent admission to hospital is required. By particularly assessing
for levels of body fluid, which is crucial in determining the cause. The assessment will then help guide as
to the next appropriate tests.
Some of the tests requested include:

1- Blood tests: checking sodium and potassium levels and kidney function. Thyroid function tests and the
cortisol hormone (released from the adrenal glands) will also be checked. Blood inflammatory markers,
such as C-reactive protein, may also be checked - for example, if there are other features of infection.
Sodium levels will need to be checked frequently, especially within the first 24-48 hours.
2- Urine sample: looking for sodium levels which are useful in determining the cause.
3- Urine and blood osmolality levels: osmolality is a measure of the solute concentration and may help to
determine the cause.
4- Imaging: this depends on the suspected cause and the presentation - for example, a chest X-ray may be
required in suspected heart failure, or a computerised tomography (CT) brain scan may be necessary in
patients with confusion.
5- Other investigations: some other tests which may be undertaken include a 12-lead heart tracing
(electrocardiogram, or ECG), an ultrasound scan of the heart (echocardiogram, or echo) in cardiac failure
and, in kidney disease, a renal ultrasound scan.
Management
Patients need to be immediately stabilised and resuscitated.
Patients can present after their breathing has stopped (respiratory arrest) and may require
cardiopulmonary resuscitation and may need to have a tube inserted into the trachea and be connected to
an artificial ventilator.
Patients having fits (seizures) will need medications to help with this, and medications such as
benzodiazepines (for example, diazepam or lorazepam) are used in the short-term before specific anti-
seizure medication is given (for example, phenytoin).
Patients may need to be monitored very closely and be on high-dependency units. They will need regular
observations, including pulse rate and blood pressure checks. They may also need a urinary tube
(catheter) to determine their fluid output.
Once the patient is stabilised, treatment is usually directed towards the underlying cause - for example:
Intravenous fluids in lack of fluid in the body (dehydration).
Stopping medications which may have caused the low blood sodium.
Diuretics for cardiac failure.
Antibiotics for pneumonia.
108
In the syndrome of inappropriate antidiuretic hormone, the patient's fluid intake is restricted.
The speed with which the blood sodium is corrected is vital, as too rapid correction in a patient where
low blood sodium has been present for several days or weeks, can lead to convulsions and may even be
fatal.
Once the hyponatraemia has resolved and patients are ready for discharge, a clear plan regarding
medication and prevention of further hyponatraemia is required. Some patients may also require further
investigations as outpatients. Some patients will also need to be warned that episodes of intercurrent
illness, especially diarrhoea and/or being sick (vomiting), may bring on a further bout of hyponatraemia,
so they would need to seek medical help early.
Complications
Mild hyponatraemia leads to walking abnormalities in the elderly with a risk of falls and fractures. It can
also lead to weaker bone structure making fractures more likely to occur after a fall. Mild hyponatraemia
can also lead to memory problems and difficulty concentrating.
Sudden hyponatraemia can result in life-threatening complications as a result of sudden swelling of the
brain (cerebral oedema), which can lead to coma and to fits (seizures), and which can be fatal.
Chronic hyponatraemia can also lead to cerebral oedema and permanent neurological changes - for
example, seizures. The brain usually adapts to the slower fall in sodium so that brain swelling is not
usually seen.
Too rapid correction of hyponatraemia can cause a condition called central pontine myelinolysis.
Symptoms occur 2-4 days after onset and may present with paralysis of all four limbs (quadriplegia). This
has been seen more often in those with alcohol dependency, female patients, those with low blood
potassium levels (hypokalaemia), and patients who have had a liver transplant. If hyponatraemia is
corrected at the appropriate rate these complications can be minimised.
Prevention
Advice to remain well hydrated and on use of electrolyte replacement solutions may help prevent
hyponatraemia occurring in the setting of acute diarrhoea and/or being sick (vomiting), especially in the
elderly and young.
Diuretics can lead to varying degrees of hyponatraemia. Patients should be warned of this potential side-
effect and the symptoms that may occur.
Also some patients may require blood tests to check sodium levels a few weeks after starting diuretics -
for example, a patient who has had hyponatraemia before.
109
TM 33 HX MED -PERICARDITIS
Pericarditis is the inflammation of the pericardium.

Pericardium is the protective sac that surrounds your heart.
The pericardium has an inner and outer layer.
This can become inflamed if blood or fluid leaks between these two layers.
It’s often associated with pericardial effusion, which is build-up of fluid within the structures.
SYMPTOMS
1- Chest pain
-Stabbing sensation
-Pain may feel worse when swallowing
-Pain can resolve itself if sitting forward (This allows the heart to relax within the chest cavity).
2-Pain in the neck that may extend across the shoulders and/or arms.
3- Fever
- Intermittent
4- Nausea
5- Light headedness.
6- Shortness of breath (In some cases)

-Sudden onset
-If this occurs seek urgent medical attention.
RISK FACTOR
PMH
Q2
- Following a virus or bacterial infection such as the flu.
- Following injury - For example, following a stab wound, or a severe blow to the chest
Q3
- Another inflammatory condition such as rheumatoid arthritis scleroderma, polyarthritis
nodosa and systemic lupus erythematosus (SLE)
-A heart attack
- Tuberculosis (TB)
- Kidney failure
- Some form of cancer in rare cases
Q4
- Radiotherapy to treat cancers in the chest.
Q7
-Heart surgery.
110
D/Ds
1. ACS
2. Pneumonia
3. PCP
4. PE
5. Peptic ulcer
6.Oesophagitis or GORD
7. TB
8. Trauma/Musculoskeletal pain
INVESTIGATIONS
ECG
To the patient: We trace your heart by ECG to look for changes in your heart rhythm.
Serial ECGs are sometimes helpful in detecting these changes, in cases of diagnostic difficulty or
in monitoring the development of cardiac tamponade.
Four stages have been recognised, although all four are only present in 50% of patients:
Stage I: diffuse concave-upward ST-segment elevation with concordance of T waves; ST-
segment depression in aVR or V1; PR-segment depression; low voltage; absence of reciprocal
ST-segment changes.
Stage II: ST segments return to baseline; T-wave flattening.
Stage III: T-wave inversion.
Stage IV: gradual resolution of T-wave inversion.
When tamponade complicates acute pericarditis, electrical alternans may involve the P, QRS, or
T complexes. Most often, only the QRS is involved; the QRS amplitude increases and decreases
on alternate beats. In some cases of tamponade, electrical alternans is associated with variation
in cardiac position (swinging heart). Electrical alternans is not seen in most cases of cardiac
tamponade.
CXR
To the patient: We perform chest X-ray to look for an enlarged heart due to fluid build-up.
An enlarged 'flask-shaped' cardiac silhouette may be the first sign of a large pericardial effusion.
This may not be evident in patients with small effusions (less than a few hundred millilitres)
and may present with a normal silhouette.
Blood tests
To the patient: We do different blood tests to see if there is any bug or inflammation in your
body, to see how well your kidney is working and to rule out heart attack
FBC with differential (may show leucocytosis).

ESR and CRP levels (usually raised).
U&E levels (uraemia).
Cardiac enzymes (associated myocarditis or myocardial infarction).
111
The study shows that an elevated troponin I level was found in 32% of patients with viral or
idiopathic pericarditis. The troponin I level was related to the extent of myocardial
inflammation but was not a negative prognostic marker.
NOTE: resolving acute pericarditis (one week or less) usually does not need any further
investigations. However, if symptoms persist, the following may be indicated in order to look for
an underlying cause:
Other Blood Test :

-Blood cultures.
-Tuberculin testing with sputum for acid-fast bacilli.
-Antistreptolysin titre.
-Rheumatoid factor, antinuclear antibody, and anti-DNA values.
-Thyroid function (if significant pericardial effusion is present).
-Antibodies for HIV, Coxsackievirus, influenza virus and echovirus.
-Examination of pericardial fluid or pericardial biopsy specimens for fungi and malignant cells.
-Pericardial biopsy for culture and microscopic examination in cases of recurrent or persistent
effusion.
Echocardiography
To the patient: We scan your heart to look for excess fluid.
This is appropriate if pericardial effusion or tamponade is suspected. M-mode demonstrates

persistence of the echo-free space between the parietal pericardium and the epicardium during
the cardiac cycle. Fluid adjacent to the right atrium is an early indicator of an effusion. Other
causes of echo-free space that must be considered include pericardial masses, pleural effusion
and epicardial fat.
CT or MRI scanning
This is helpful in cases of diagnostic doubt. A pericardial thickening >5 mm may be seen. When
pericardial thickening or fluid cannot be demonstrated, the diagnosis of restrictive
cardiomyopathy should be considered.
TREATMENT FOR PERICARDITIS

Stable patients can often be managed in the outpatient setting without the need for hospital
admission.
NOTE: Patients with any of the following are associated with a higher risk and should usually be
admitted to hospital:
1- Fever (>38ºC) and leucocytosis.

2- Evidence suggesting cardiac tamponade.
3- A large pericardial effusion (i.e. an echo-free space of more than 20 mm).
4- Immunosuppressed state.
5- Patients taking warfarin.
6- Acute trauma.
7- Failure to respond within seven days to non-steroidal anti-inflammatory drugs (NSAIDs).
8- Elevated cardiac troponin, which suggests myopericarditis.
Outpatient management
112
Treatment should be given for the underlying cause.
1- Rest
All patients should be advised to rest and avoid any demanding physical activity to help minimise
symptoms.
2- NSAIDs
NSAIDs are usually given as first-line. For example, naproxen 250 mg 6 to 8 hourly.
3- Colchicine
Treatment with colchicine has been shown to result in significantly fewer recurrences and longer
symptom-free periods. In addition, when attacks occur, they are weaker and shorter in nature.
Colchicine, alone or in combination with an NSAID, can be considered for patients with recurrent
or continued symptoms beyond 14 days.
NSAIDs are usually given for 7-14 days; then the dose should be tapered until resolution of
symptoms and also improvement of serum inflammatory markers such as ESR and CRP.
4-PPIs
Gastric protection with proton pump inhibitors should be considered, especially in those patients
taking high doses of NSAIDs.
5- Anticoagulants
Anticoagulants should be avoided unless the pericarditis is secondary to acute myocardial
infarction, as they can cause intrapericardial bleeding and possibly fatal tamponade.
6- Antimicrobials.
Bacterial or mycotic infections should be treated with appropriate antimicrobials.
7- Corticosteroids
Corticosteroids should not be used for initial treatment of pericarditis unless they are indicated
for the underlying disease, the patient's condition has no response to NSAIDs or colchicine or both
agents are contra-indicated.
Surgical procedures
Pericardiocentesis under echocardiographic monitoring is occasionally used in cases of
diagnostic difficulty, especially in cases of impending tamponade. This would be recommended if
there were echocardiographic evidence of right atrial or ventricular diastolic collapse,
irrespective of whether clinical signs of tamponade were present.
If tamponade recurs, a pericardial biopsy should be performed with histological and
bacteriological examination. Endomyocardial biopsy and cardiac catheterisation may also be
indicated in cases of diagnostic difficulty.
long term effects of chronic pericarditis
Most people recover from Pericarditis quickly, but for some it can take several months or never
fully resolve, making long term sufferers vulnerable to physical and psychological issues. This can
impact on quality of life for the sufferer and their families.
Unfortunately, pericarditis can come back despite medical or surgical intervention, so patients
may uncertain about the future of their health. As this rare condition is not visible or associated
with an unhealthy lifestyle, there is often a lack of understanding about the effects of living with
pericarditis, meaning sufferers can often feel isolated, causing them to experience other effects
such as anxiety, palpitations and panic.
113
MEDICINE COUNSELLING 1A STROKE
RISK FACTORS
1. Non-modifiable
- Age
- Gender
- Previous stroke
- Family History
2. Modifiable
a. Medical Illness
- HTN
- High level of cholesterol
- DM
- Heart Disease
-Kidney Disease
b. Personal History
- Alcohol
- Smoking
- Diet
- Physical Activity
- Stress
How to prevent stroke

1. Keeping medical conditions well controlled (If there are any)
Doctors Job:
- Review the patient regularly: BP screening for HTN, Blood sugar (FBS & HbA1c) for DM, Lipid profile for high
cholesterol, U&Es, and urine tests for kidney disease
- Medication: Start, add or review the medication:
HTN: first line lifestyle modification, medication therapy for diabetic patients
DM: type 1 insulin, type 2 (first line lifestyle modification, HbA1c >6.5 metformin >7 dual therapy >7.5, triple
therapy or insulin)
High cholesterol: statin
Kidney disease: ACEI
AF: according to CHADVAS or HAS-BLED score anticoagulants such as warfarin.
Aspirin if patient is on HTN medication, if patient has previous stroke or TIA ,if patient has DM, high cholesterol
or kidney disease.
Patients Job:
- Attend follow-ups
- Compliance of medication (if there are any)
- Lifestyle modification
Rehabilitation of Stroke
- Keep patient mobile, prevent obesity, and prevent another stroke
- Improve patient’s quality of life
Types:
1. Physiotherapy
2. Occupational therapy
3. Psychotherapy
4. Speech therapy
Warning Signs
F A S T
Facial Change Arm Weakness Speech Problem Time/Telephone

(dial 999)
114
MEDICINE COUNSELLING 1B STROKE
Primary Prevention of Stroke
Risk-reduction measures in primary stroke prevention may include the use of antihypertensive medications, anticoagulants, platelet
anti-aggregants, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), smoking cessation, dietary
intervention, weight loss, and exercise.
Modifiable risk factors include the following:

- Hypertension
- Diabetes
- Dyslipidemia
- Atrial fibrillation
- Postmenopausal HRT
- Sickle cell disease
- Depression
- Cigarette smoking
- Diet and activity
- Weight and body fat
- Air pollution
Hypertension
Hypertension is the most important modifiable risk factor for stroke and intracerebral hemorrhage (ICH), and the risk of stroke
increases progressively with increasing blood pressure, independent of other factors. .
The risk of both stroke and cardiovascular events is lower when systolic blood pressures are < 140 mm Hg and diastolic blood
pressures are < 90 mm Hg. Regular blood pressure screening and a combination of behavioral lifestyle modification and drug
therapy are recommended to achieve these goals.
Diabetes
Diabetes is estimated to increase the relative risk of ischemic stroke 1.8- to nearly 6-fold, independent of other risk factors.
However, aggressive control of hypertension in diabetics reduces stroke incidence. Antihypertensive agents that are useful in the
diabetic population include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)
Dyslipidemia
Elevated total cholesterol has been linked to increased risk of ischemic stroke in a number of epidemiological studies.
Statin therapy and therapeutic lifestyle changes are recommended for patients with coronary artery disease or certain high-risk
conditions such as diabetes.
Atrial fibrillation
AF is associated with a 4- to 5-fold increase in the risk of ischemic stroke, independent of cardiac valve disease. Because a
substantial minority of AF-related stroke occurs in older patients with previously undiagnosed AF, it may be useful to screen
patients older than 65 years of age for AF in the primary care setting using pulse taking followed by an ECG.
The choice of therapy for primary stroke prevention in patients with AF depends on several factors, including estimated stroke risk,
risk of bleeding with anticoagulation therapy, and patient preference.
Asymptomatic carotid conditions
It is recommended that patients with asymptomatic carotid artery stenosis be evaluated for other treatable risk factors for stroke; in
general, these patients should be managed with appropriate medical therapy and lifestyle modifications.
Cigarette smoking
Cigarette smoking is directly correlated with an increased risk of both ischemic stroke and subarachnoid hemorrhage (SAH), with
risk for the former approximately doubled by smoking and risk for the latter increased 2- to 4-fold
Counseling, nicotine replacement, and oral smoking-cessation medications are options that should be offered to all individuals who
smoke. Cessation of smoking has been shown to reduce the risk of both stroke and cardiovascular events to levels approaching
those of individuals who have never smoked.
Diet and nutrition
Several aspects of diet and nutrition can lead to increased blood pressure, including:
- Increased salt or sodium intake
- Decreased potassium intake
- Excess weight,
A diet that is low in sodium and high in Potassium, is recommended to reduce blood pressure. Diets that promote the consumption
of fruits, vegetables, and low-fat dairy products, as well as reduced intake of saturated fats help lower blood pressure and may lower
risk of stroke.
Like following the Mediterranean diet, supplemented with nuts, and reduction of sodium intake.
This diet is also known as DASH-Style Diet (Dietary Approach to Stop Hypertension).
Physical inactivity
Physical inactivity is associated with an increased risk of stroke and other adverse effects, such as cardiovascular morbidity and
mortality. Increased physical activity may decrease the risk of stroke by 25-30%
Physical activity is also known to have a positive effect on control of blood pressure and diabetes, two significant risk factors for
stroke.
The recommended goal for physical activity for adults, is to engage in at least 150 minutes (2 hours and 30 minutes) per week of
moderate intensity or 75 minutes (1 hour and 15 minutes) per week of vigorous intensity aerobic physical activity.
Obesity and body fat distribution

In overweight and obese persons, weight reduction is recommended to reduce blood pressure and risk of stroke.
Rehabilitation after Stroke
115
Rehabilitation after stroke requires a multidisciplinary approach that involves physiotherapist, psychologist, speech therapist,
occupational therapist, nurses and doctors. People with stroke should have goals set for rehabilitation that are challenging but
achievable, with patient participation and are both short term and long term.
1. Psychological rehabilitation
The two most common psychological impacts on patients with stroke are:
- Depression where the patient may even experience intense episodes of crying, feel hopeless and may be socially isolated
- Anxiety
- Mixed feelings of anger, irritated mood and frustration may also be present in some patients.
Regular psychological assessments with counselling of its impact on family, friends and society are discussed with the patient. For
severe or long term cases mild medical therapy or CBT is also used, CBT is very effective talking therapy which aims to change the
way the patients thinks about a problem and provide a solution.
2. Cognitive rehabilitation
Depending on the damage to the brain during the stroke event one of the following cognitive functions may be damaged.
- Communication (written or verbal)
- Memory
- Concentration
- Spatial orientation
- Ability to carry out skilled activities like getting dressed and making tea.
Patient’s cognitive faculties will be assessed and rehabilitation plan is made for any disrupted behaviors. For example in patients
who have problems speaking and talking speech therapy is used. Patients may also be taught techniques and given help in the form
of memory aids and diaries to plan their routine. Most of the cognitive functions lost after stroke return with rehabilitation.
3. Movement abnormalities rehabilitation

Most of the strokes result in paralysis or weakness of some part of the body. A physiotherapist will assess the extent of patient’s
disability and make a rehabilitation plan for the patient. He will work with the patient to set goals which may be simple like picking
up things in the beginning and the level will grow along with patients progress. Ultimately harder tasks like walking or standing will
be introduced. The aim is to improve patients muscle strength.
Usually a member of the family is closely involved in this program and he is taught different exercises to help the patient all the time.
The patient will have many sessions with the physiotherapist in a week.
Occupational therapist also works in close conjunction here and specially helps patients adapt and settle at home and in working
environments with their new condition.
4. Communication Problems
When the injury to the brain is in the area that deals with the language, many people face problems with reading, understanding and
writing. Problems in speech may be due to weakness of speech muscles.
A speech therapist will help the patient train their speech muscles and help them increase control over them. They may also be
given speech and listening aids or taught other methods of communication like gestures or writing.
5. Swallowing problems
When muscles involved in swallowing are weakened by stroke, small particles of food may be inhaled into the airway causing severe
infection. A feeding tube called the nasogastric tube is used initially. It is passed into the stomach through the nose. Sometimes a
tube may be connected directly with patient’s stomach for feeding purposes using local anesthesia. This is called PEG or
gastrostomy.
6. Visual problems
Stroke my cause a set of disruptions in the visual areas of the brain. If the problem is in the interpretation of the visual information
the patient may not be able to see some part of the visual field. Sometimes there is problem in eye movement due to weakness of eye
muscles.
If one of these problems occurs the patient will be asked to see an orthoptist who will assess their problem and guide accordingly.
For example if patient has lost a part of their visual field, they may be taught eye movements that help them look towards the side of
reduced vision. They may also be taught doing a task in a different way so that the visual problem does not create much problem for
them.
7. Bladder and bowel control

Sometime the part of the brain affected is the part that controls the bladder and bowel. Usually this recovers quickly but if not the
doctor will help them with strengthening exercises, medication and use of incontinence problems.
8. Sexual rehabilitation
If patient experiences erectile dysfunction after stroke, there are a number of treatments available to restore their activity.
116
MEDICINE COUNSELLING 2A - HYPERTENSION
DESCRIPTION
- Blood pressure is the pressure of the blood inside the blood vessels.
- High blood pressure (hypertension) is a term, which is used when the blood pressure exceeds 140/90 each
time it is measured, however, depending on many factors the level at which treatment should start varies from
one person to another.
- The condition is common affecting 25% of middle-aged adults and 50% of people aged over 65.
- High blood pressure needs to be treated even if there are no symptoms because it is a risk factor in developing
cardiovascular diseases like heart attack or stroke and kidney damage.
DIAGNOSIS
- If one reading of blood pressure is found to be high, usually the patient if offered a period of observation
because one reading doesn't mean the patient is having a high blood pressure.
- The observation period is also useful to change any lifestyle factors which will help to reduce the blood
pressure. After the observation period is over, if the blood pressure remains high medications will be
considered.
- However, if the patient is diabetic or has a high risk of developing complications the use of medications is
usually considered at an earlier stage.
CAUSES
- In the majority of cases the cause of high blood pressure is not known, in this is called "Essential
hypertension", some suggest the cause to be a narrowing in the blood vessels which generate resistance against
the heart thus increasing the blood pressure.
- However, in few cases a cause can be found such as certain kidney or hormone problems, this is called
"Secondary hypertension".
RISK FACTORS
Everyone has some risk factors which will lead to narrow blood vessels and increase the risk of developing
high blood pressure.
- Some of these risk factors are fixed or non-modifiable such as:

1. Strong family history.
2. Male or early menopausal female.
3. Old age.
4. Some ethnic groups like Afro-Caribbean and Indians.
- Some of these risk factors is related to the lifestyle of individuals such as:
1. Smoking.
2. Lack of physical activity.
3. Obesity.
4. Unhealthy diet.
5. Excessive alcohol
- Some other risk factors are treatable or partially treatable such as:
1. High cholesterol level.
2. Diabetes.
3. Kidney problems.
INVESTIGATIONS
- Some tests may be required to diagnose secondary hypertension or assess the risk factors, this includes:
1. Urine test to check protein or blood in urine.
2. Blood test to check kidney function, cholesterol and sugar levels.
3. Heart tracing (ECG).
MANAGEMENT
- Blood pressure can be lowered by modifications to lifestyle and/or medications.
- Lifestyle modifications:
1. Losing weight if the patient is overweight.
2. Regular physical activity for at least five days a week.
3. Eating healthy diet with low salt intake.
4. Restricting caffeine drinks.
5. Drinking alcohol in moderation.
MEDICATION
117
1. To be given to all people with persistence of blood pressure over 160/110 even after trial of lifestyle
modifications.
2. To people with blood pressure over 140/90 after trial of lifestyle modifications if they have diabetes,
cardiovascular disease or at high risk of developing a cardiovascular disease.
3. To people with blood pressure of 130/80 if they have certain conditions such as complications of diabetes,
recent heart attack, stroke or chronic kidney disease.
4. Medication should be individualized according to patient condition, age and ethnic group.
5. The majority of people will require the medication for life.
AIM OF MANAGEMENT
- To reduce blood pressure to 140/90 or below.
-To reduce it to even lower levels according to the patient condition, for example if he suffering from diabetes
or an ongoing cardiovascular disease.
STEPWISE MANAGEMENT OF BLOOD PRESSURE ACCORDING TO NICE GUIDELINES
a. Patient under 55 years of age.

- Step 1:
1. ACE Inhibitor; if not tolerated offer an angiotensin-II receptor antagonist.
2. If both ACE inhibitors and Angiotensin-II receptor antagonist are contra-indicated or not tolerated, consider
a beta-blocker.
3. Beta-blockers, especially when combined with a thiazide diuretic, should be avoided for the routine
treatment of uncomplicated hypertension in patients with diabetes or at high risk of developing diabetes.
- Step 2:
1. ACE Inhibitor or angiotensin-II receptor antagonist in combination with a Calcium Channel Blocker.
2. If a Calcium Channel Blocker is not tolerated or if there is evidence of, or a high risk of, heart failure, give a
thiazide-related diuretic (e.g. chlortalidone or indapamide)
3. If a beta-blocker was given in step 1, add a Calcium Channel Blocker in preference of a Thiazide-related
diuretic.
- Step 3:
1. ACE inhibitor or Angiotensin-II receptor antagonist in combination with a calcium channel blocker and a
thiazide diuretic.
- Step 4: (Resistant hypertension)

1. Consider seeking specialist advice
2. Add low dose spironolactone or use high dose thiazide-related diuretic if plasma-potassium concentration is
above 4.5mmol/litre
3. Monitor renal function and electrolytes
4. If additional diuretic therapy is contra-indicated, ineffective, or not tolerated, consider an alpha-blocker or a
beta-blocker.
b. Patient over the Age of 55, Patients of any age who are of African or Caribbean family origin.
- Step1:
1. Calcium channel blocker; if not tolerated or if there is evidence of, or a high risk of, heart failure, give a
thiazide related diuretic.
- Step 2:
1. Calcium channel blocker or thiazide related diuretic in combination with an ACE inhibitor or Angiotensin-II
receptor antagonist. (An angiotensin-II receptor antagonist in combination with a calcium channel blocker is
preferred in patients of African or Caribbean family origin)
- Step 3 and step 4:

Treat as for patients under 55 years.
118
MEDICINE COUNSELLING 2B -
HOW TO APPROACH BNF (version 66)
1. Open Index (page 1084) and find Hypertension (page 107)
2. Under Drug Treatment of Hypertension, you can find treatment for patient aged < 55.
3. Under Step 1 you can find ACEi -- ACE inhibitors, if not tolerated offer angiotensin II
receptor antagonist (AII RA).
4. Then you need to find Angiotensin-II Receptor Antagonist (page 123)
5. “Azilsartan, Candesartan, Eprosartan, Irbesartan, Losartan, Olmesartan, Telmisartan and

Valsartan are AIIRA with many properties similar to those of the ACE inhibitors. However,
unlike ACE inhibitors they don’t inhibit the breakdown of bradykinin and other kinins and
thus they are less likely to cause the persistent dry cough which can complicate ACE
inhibitors therapy. They are therefore a usual alternative for patients who have to
discontinue ACE inhibitors because of persistent cough.”
If you look for Side Effects under this heading, you can find the following information:
“Side-effects are usually mild. Symptomatic hypotension including dizziness may occur
particularly in patients with intravascular volume depletion (e.g those taking high dose
diuretics). Hyperkalemia occurs occasionally; angioedema has also been reported with some
angiotensin-II receptor antagonists.”
6. If you want to find specific information about dose and Side Effect of a drug in this
category, you can open the specific page for that drug. For example:
Lostartan – page 125

If you look for side effects, under Losartan, it’s written “See notes above; vertigo; less
commonly gastrointestinal disturbances, angina, palpitation, oedema, dyspnoea, headache,
sleep disorders, malaise, urticaria, pruritis, rash; rarely hepatitis, atrial fibrillation,
cerebrovascular accident, syncope, paraesthesia; also reported pancreatitis, anaphylaxis,
cough, depression, erectile dysfunction, anaemia, thrombocytopenia, hyponatremia,
arthralgia, myalgia, renal impairment, rhabdomyolysis, tinnitus, photosensitivity, and
vasculitis (including Henoch-Schonlein purpura).”
Telmisartan – 126
119
MEDICINE COUNSELING 3 - WARFARIN
Oral Anticoagulant
An anticoagulant medication prevents harmful blood clots from forming in the blood
vessel by making blood take longer to clot.
Anticoagulant Folder
When you go to your GP or warfarin clinic for your first blood test, the nurse will give
you a folder containing:
1. A booklet or leaflet that contains all necessary information.

2. An alert card. This shows that you take warfarin. This is important in an emergency
and to inform health care professionals like your dentist or any specialist, before
receiving other treatment.
3. A record book, which indicates your treatment record, your latest blood test results,
dose of your medication and date of your blood tests.
How to take it
Take your anticoagulant once a day, about the same time, wash down with a full glass of
water.
If you miss a dose, or take the wrong dose by mistake, make a note in your booklet. Take
your normal dose the next day. If the dose you took in error greatly exceeded your
normal dose, please contact your Anticoagulant Clinic.
You may be given a number of different strength tablets to make up your dose.
In the UK, the colours of warfarin tablet are usually:
- White: 0.5mg
- Brown: 1mg
- Blue: 3mg
- Pink: 5mg
Monitoring you while you are taking Anticoagulant

You must have a regular blood test called and INR Test. INR stands for International
Normalized Ratio.
This is a standard test that measures how long your blood takes to clot.
Normally, blood that is not anticoagulated has an INR of approximately 1.
The dose of anticoagulant that you need to take will depend on your INR Results.
If your result is out of the range appropriate for your condition, your dose of
anticoagulant will be increased or decreased accordingly. The anticoagulant dose
required to achieve the target INR varies for each person.
Your anticoagulant clinic or GP will arrange your blood tests.
Repeat Prescriptions
It is important that checks are performed each time you request and receive a supply of
medication. This must include reviewing your blood test results and dose information
and ensuring that it is safe to supply you with more tablets.
When you request a repeat prescription you will be asked to provide information about
your INR Test results and the current dose of oral anticoagulant, which has been
recorded in the Record Book.
120
Side Effects of Warfarin
You may feel sick or be sick so please take simple, cold and small meals. Avoid spicy,
creamy and rich meals.
You may face diarrhoea, if it happens please take plenty of fluids.
The most serious side effect is bleeding, you need to see your GP and have a blood test if
you experience:
1. Prolonged nose bleeding (more than 10 mins).

2. Blood in vomit.
3. Blood in phlegm.
4. Passing blood in your urine or stool.
5. Passing black stool.
6. Severe bruising.
7. Unusual headache.
8. For women, heavy or increased bleeding during the period or any other vaginal
bleeding.
NOTE: If you cut yourself, apply firm pressure to the site for at least 5 minutes using a
clean, dry dressing.
Please come to A&E if you:
1. Are involved in major trauma.
2. Have significant trauma to your head.
3. Are unable to stop bleeding.
Going to the Dentist

You can still go to your dentist as usual. In majority of the cases, your dental treatment
can go ahead as normal without anticoagulant being stopped or the dose being adjusted.
However, your dentist will need to see the recent INR Test Result to ensure that it is safe
to provide treatment.
You should contact your dentist before your appointment, in case they need you to have
an extra blood test.
Other Medication
1. If you are going to buy over-the-counter medication including alternative remedies,
tell the pharmacist that you are taking an oral anticoagulant and show them your alert
card. They can then advice you on medications that are safe for you to take.
2. You should not take Aspirin unless it has been specifically prescribed by your GP.
Medications such as Diclofenac and Ibuprofen should be avoided while you are taking
Warfarin.
3. Paracetamol and Codeine based painkillers are acceptable. You should be aware that
Paracetamol “Plus” products sometimes contain Aspirin.
4. If your doctor is starting another medication, they may advice that you should do
blood test within five to seven days.
Diet
1. Do not make any major changes in your diet. If you want to lose weight please talk to
your GP or your warfarin nurse.
2. Be aware that the amount of Vitamin K in your diet can affect your INR Results. Eating
much more than usual of Vitamin K lowers your INR and eating much less than usual
121
may raise your INR.
3. You can take Vitamin K containing foods such as green leafy vegetables, chickpeas,
liver, egg yolk, oat, mature or blue cheese, olive oil or avocado. However, any major
changes in the amount of these foods in your diet can lead to changes in your blood
results. So, please avoid it.
4. Drinking cranberry juice can also affect your blood test results and should be avoided
altogether.
Alcohol
It is recommended that you do not exceed the recommended daily limit for alcohol
intake.
It is dangerous to binge drink while taking anticoagulant.
Pregnancy & Breastfeeding
Oral anticoagulant can affect the development of a baby in early pregnancy. Women
who are on anticoagulant should discuss plan for future pregnancy with their doctor
before trying to conceive.
Women who think they have become pregnant while on Warfarin should seek a
pregnancy test as soon as possible. If this is positive, an urgent appointment with doctor
is needed.
You may breastfeed while taking anticoagulant medication.
ADDITIONAL INFORMATION
Contraindications of taking warfarin:
1. Pregnancy.
2. Patient with uncontrolled hypertension.
3. Patient with a high risk of internal bleeding e.g. patient with peptic ulcer.
4. Patient with bleeding disorders.
5. Patient with liver Disease.
6. Patient with kidney Disease.
Dose:
For patient who requires rapid anticoagulation, the usual adult induction dose is 5-10
mg on the first day (an elderly patient should receive a lower induction dose).
Initiating Warfarin
Day One Two Three Four
1.5 2.1 2.6 1.6 1.8 2.0 2.4 2.8 3.1 3.6
No < > < >
INR < 1.3 – – – – – – – – – –
Test 1.5 3.0 1.6 4.0
2.0 2.5 3.0 1.7 1.9 2.3 2.7 3.0 3.5 4.0
Dose
5 5 10 5 3 1 0 10 7 6 5 4 3 2 1 0
mg
122
123
124
125
MEDICINE COUNSELLING 4 - EPILEPSY
Elaboration of Attack
- When was the attack?
- How many episodes?
- When was each episode?
Diagnosis of Epilepsy
- When was it diagnosed?
- How has it been managed since?
Assess the difference between episodes

- Have you noticed any change in your fits?
Assess the cause of poorly controlled epilepsy

1. Medication related
- Which drugs
- Check the compliance
- Side Effects
- Recent change in medication
- Other medications (drug interactions)
- Diarrhoea, vomiting
- Weight gain
2. Triggering Factors
- Infection
-Trauma/Head injury
- Alcohol
- Recreational drug
- Skipping meals
- Dehydration
- Stress
- Lack of sleep
- Spending time in front of TV, Computer
- Flashing lights, loud music
- Adventure, intensive exercise
126
DISCHARGING ASTHMA PATIENT
Sometimes patients with acute exacerbation of Asthma will be admitted. Before

discharging the patient, we should assess the fitness for discharge.
How to assess fitness for discharge

1. Taking history (asthma symptoms such as cough, SOB, chest tightness or
wheeze)
2. Respiratory Examination (to check for presence of wheeze on chest
auscultation)
3. Performing PEFR (should be more than 75% of normal value)
Discharge Checklist
a. Patients education
1. Explain about medication
2. Teaching inhaler technique
3. Explain how to record PEFR in Asthma Diary
b. GP Appointment
Clinical appointment with GP or Asthma Nurse should be arranged within 2
working days. This is important because patient should be reviewed to see if
Prednisolone should be continued or not.
c. Specialist Appointment
An appointment with the specialist should be arranged after 4 weeks.
When is it an Emergency?
Patient should come to the A&E if:
1. If the reliever inhaler is not controlling symptoms.
2. If patient is too breathless to talk.
3. If patient’s lips turn into blue.
What should be done during a Severe Asthma Attack

1. Sit up, loosen clothing and try to keep calm.
2. Take one puff of reliever every minute, preferably with a spacer up to ten puffs.
3. Repeat within 30 minutes.
If you are not improving after five minutes, then please call 999 urgently. You
should continue taking the inhaler until help arrives.
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MEDICINE COUNSELLING 7 SMOKING CESSATION
Cigarettes contain more than 4,000 chemicals. These include substances such as tar, arsenic, formaldehyde,
hydrogen cyanide, nitrogen oxides and ammonia. The addictive part of a cigarette is nicotine but this isn’t the
substance that causes the most health problems. It is the other 4,000 chemicals, along with a gas called carbon
monoxide, which cause the most harm.
What are the benefits of stopping smoking?

It is never too late to benefit from stopping smoking and we are here to help you do it
Immediate benefits of stopping

- Your breath, clothes and hair won't smell of stale tobacco
- Your home will be smoke-free
- Your sense of smell and taste will improve
- You will save money (A 20-a-day smoker = approx. £3,500 a year)
- Better rates of insurance policies
- You are likely to feel good about yourself
Health benefits of stopping

A) Within 24 hours
Carbon monoxide will be removed from your body.
B) 2-12 weeks
Your blood circulation improves. This makes all physical activity, including walking and running, much easier.
You will also give a boost to your immune system, making it easier to fight off colds and flu. The increase in
oxygen in the body can also reduce tiredness and the likelihood of headaches. Skin appearance will improve
due to better oxygen supply in the blood.
C) 3-9 months
Coughs, wheezing and breathing problems will improve, with lung function increasing by up to 10%
D) After 1 year
The risk of heart attack falls to around half that of a smoker
E) After 10 years
The risk of lung cancer falls to around half that of a smoker
F) After 15 years
The risk of heart attack falls to the same level as someone who has never smoked
If you have already had a heart attack, stopping smoking reduces your risk of a fatal heart attack by 25%
Methods used to stop smoking

1. Talk to your GP
GP’s can help patients quit smoking. They can do a lot, such as enrolling patients in a 'stop smoking' clinic and
prescribing nicotine replacement therapy such as patches and gum, or stop smoking medication.
2. Join your local stop smoking service

Services staffed by trained stop smoking advisors are available all over the country.
You can join a local group that meets once a week, or have one-to-one support if you prefer. You usually go for a
few weeks and work towards a quit date.
3. Find online support

The NHS Smokefree website has been designed to give a range of evidence-based support for you.
It's available for free and can boost your chances of success whatever method you are using.
4. Have an emergency phone number to hand

Keep an emergency number for your local stop smoking service or the national helpline. They can talk about
why you want to smoke and how to deal with your cravings.
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5. Consider using a nicotine-containing product
Cigarettes are addictive, and self-control alone might not be enough for you to stop entirely. The main reason
that people smoke is because they are addicted to nicotine.
NRT is a medication that provides you with a low level of nicotine, without the tar, carbon monoxide and other
poisonous chemicals present in tobacco smoke.
It can help reduce unpleasant withdrawal effects, such as bad moods and cravings, which may occur when you
stop smoking.
Give yourself a better chance of success by using nicotine replacement therapy (NRT). This is available on
prescription from your GP, from your local stop smoking service, or from a pharmacist.
You could also consider trying e-cigarettes. While they're not risk free, they are very much safer than cigarettes
and can help people stop smoking.
6. Other medical therapies

- Varenicline (brand name Champix) is a medication that works in two ways.
It reduces cravings for nicotine like NRT, but it also blocks the rewarding and reinforcing effects of smoking.
Evidence suggests it's the most effective medication for helping people stop smoking.
Varenicline is only available on prescription, so you'll usually need to see your GP or contact an NHS stop
smoking service to get it.
It's taken as one to two tablets a day. You should start taking it a week or two before you try to quit.
- Bupropion (brand name Zyban) is a medication originally used to treat depression, but it has since been found
to help people quit smoking.
It's not clear exactly how it works, but it's thought to have an effect on the parts of the brain involved in
addictive behaviour. A course of treatment usually lasts around 12 weeks, but it can be continued for longer if
necessary.
What happens in a “Smoking Cessation Clinic”?
Stop smoking clinics by NHS are designed to help the people who are trying to stop smoking. Physicians and
nurses help to bring changes to the smoking habits and bring changes to the lifestyle. The service helps to build
and maintain motivation and courage using research proved methods of smoking cessation. It has been shown
that treatment for smoking cessation, when combined with proper counseling and help, are more successful
and have a lower chance of recurring.
The first appointment at the stop smoking clinic is about half an hour long and aims to address and discuss the
stages of smoking cessation.
- Pledging to stop smoking
- Planning about how the cessation process is going to progress
- Setting a target date to quit
- Maintain the cessation by changing smoking habits and lifestyle
- Dealing with relapses and staying positive
At the clinic nurses help to explain the immediate and the long term benefits of smoking cessation.
Smoking and Stress

When it comes to stopping smoking, many smokers claim that it helps them relax and relieve stress. It is very
important to learn how to deal with stress.
The withdrawal from nicotine between cigarettes can heighten feelings of stress. As the stress of withdrawal
feels the same as other stresses, it's easy to confuse normal stress with nicotine withdrawal. So, it can seem
like smoking is reducing other stresses whereas this is not the case.
In fact, scientific studies show people's stress levels are lower after they stop smoking.
If you're finding that you are prone to stress, then replacing smoking with a healthier, better way of dealing
with stress can give you some real benefits.
1. Be active
2. Connect with people – A good support network of colleagues, friends and family can ease your work troubles
and help you see things in a different way.
3. Have some 'me time' – We all need to take some time for socialising, relaxation or exercise.
4. Challenge yourself – Setting yourself goals and challenges, whether at work or outside, such as learning a
new language or a new sport, helps to build confidence. This will help you deal with stress.
5. Avoid unhealthy habits – Don't rely on alcohol, smoking and caffeine as your ways of coping. Over the long
term, these crutches won’t solve your problems. They’ll just create new ones.
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TM MEDICINE COUNSELLING 8A – DIABETIC RETINOPATHY
What is Diabetes?
It is a condition in which level of sugar in blood becomes higher than normal. There are
two types:
1. Type I: When the body cannot provide enough substance (insulin), which regulates
Blood Sugar.
2. Type II: When the body does not respond well to this substance (insulin).
One of the complications of Diabetes is damage to blood vessels. Damage to large blood
vessels will cause heart disease and kidney disease. Damage to tiny blood vessels in the
back of the eye is called Retinopathy.
Retina is made up from special cells (rods and cones), which lie in the back of the eye.
They have a very important role in vision by passing messages to the optic nerve.
Retinopathy:
This is usually due to damage to tiny blood vessel in back of your eye (retina). It is
commonly caused by diabetes, but it can also be caused by high blood pressure.
How does Diabetic Retinopathy occur?

Symptoms:
1. Most people don’t have any symptom.
2. Initial symptoms: blurred vision, seeing floaters, flashers.
3. Without treatment, it can gradually become worse and lead to visual loss or
blindness.
Different Types of Diabetic Retinopathy

Diabetic retinopathy is classified into two types:
1. Non-proliferative diabetic retinopathy (NPDR) is the early stage of the disease in

which symptoms will be mild or nonexistent. In NPDR, the blood vessels in the retina
are weakened. Tiny bulges in the blood vessels, called microaneurysms, may leak fluid
into the retina. This leakage may lead to swelling of the macula.
2. Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease.
At this stage, circulation problems deprive the retina of oxygen. As a result new, fragile
blood vessels can begin to grow in the retina and into the vitreous, the gel-like fluid that
fills the back of the eye. The new blood vessels may leak blood into the vitreous,
clouding vision.
Risk Factors:
1. Duration of DM (90% of patients with DR have DM for more than 30 years)
2. Poor glucose control
3. High Blood Pressure
4. Kidney Disease
5. Pregnancy
6. Other:
- Smoking
130
- Cholesterol
- Obesity (poor diet and lack of physical activity)
How can Diabetic Retinopathy be controlled?

1. Controlling Blood Sugar
2. Controlling High Blood Pressure
3. Controlling High Cholesterol
This can be achieved by:

1. Well balanced diet
2. Exercise
3. Medication
Eye check for Diabetic Retinopathy

Annual check
1. Testing Vision
2. Digital Photograph
a. If the result comes back normal or mild (background changes) patient should be
reviewed within 12 months.
b. If there are severe changes patient should be referred to specialist urgently (within 2
weeks)
Patient with severe changes may need a Fluoroscein Angiogram.

It is injection of a special dye into one of the veins in the arm. The dye goes to the blood
vessel of eye and a camera shows any swollen, leaking or abnormal blood vessels.
Treatment of Diabetic Retinopathy:
1. NPDR – No specific treatment is required; only the Risk Factors (BS, HTN, High
Cholesterol) should be controlled.
2. PDR – Patient may need laser treatment or an operation.
- Laser treatment: Laser can seal leaks from blood vessel by burning. Laser prevents DR
getting worse, loss of vision or blindness.
- Operation: if there is bleeding into vitreous humour an operation is needed.

It cannot restore vision that is already lost.
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TM MEDICINE COUNSELLING 10 LIFESTYLE MODIFICATION AFTER MI
Recovery and prevention of heart attacks
Recovering from a heart attack can take several months. Cardiac rehabilitation should be started
while the patient is still in the hospital, however, it is important not to rush to rehabilitation.
Exercise:
It is recommended to start exercising by light activities such as walking up and down the stairs a few
times a day or taking a short walk, then gradually increase the amount of activity you do each day
over several weeks.
Rehabilitation program should contain a range of different exercises depending on the patient age
and ability.
Adults should reach 150 minutes weekly of moderate-intensity aerobic activity such as cycling or
fast walking (30 minutes 5 days per week)
Returning to work:
Most patients are able to return to work after having a heart attack, but how quickly will depend on
their health.
If job involves light duties like working in an office, patient may return to work in just 2 weeks,
however, if the job involves heavy manual work or heart was extensively damaged, patient may take
several months before returning to work.
Sex:
Patients are usually able to have sex again once they feel well, usually in 4 to 6 weeks after heart
attack.
Some patients may suffer from erectile dysfunction either because of emotional stress following
their attack or due to some medications, if the condition persists some medications may be offered
to stimulate the blood flow to the penis.
Driving:
If the patient is driving a car or a motorcycle, he doesn’t need to inform the Driver and Vehicle
Licensing Agency (DVLA), however, DVLA recommends that all patients should stop driving for at
least 4 weeks after a heart attack.
If the patient is a bus, coach or lorry driver they must inform the DVLA and stop driving for at least 6
weeks and only restart driving when your doctor tells you it’s safe.
Depression:
Having a heart attack can be frightening and traumatic and it is common to have anxiety afterwards.
The patient is advised to contact his GP.
Reducing the risk of having another attack

Diet: It's recommended to eat 2 to 4 portions of oily fish a week as they contain a type of fatty acid
called omega-3 which can help lower cholesterol levels.
- Patient is advised not to take any food supplements without medical opinion as they may contain
beta-carotene, which can be harmful.
- It's recommended to eat Mediterranean- style diet, this means more bread, fruit, vegetables, fish
and olive oil.
Smoking: It's strongly recommended to quit smoking.

Alcohol: Alcohol consumption should not exceed 14 units a week with avoidance of binge drinking.
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Weight loss: If obese.
Physical Activity: Should be regular.
Medications:
There are mainly 4 types of medications:
1. Angiotensin-converting enzyme (ACE) inhibitors:
- These medications are usually used to lower blood pressure as they block the actions of some of the
hormones that help regulate blood pressure. By stopping these hormones, medication is able to
reduce the amount of water in the blood and also widen the arteries. This medication also prevents
any possible change in the structure of the heart after a heart attack (heart remodelling).
- Side effects may include:
a. Dizziness.
b. Feeling tired.
c. Persistent dry cough.
d. Headaches.
e. Kidney problems, as these medications reduce the blood supply to kidneys so blood and urine
tests may be required for follow-up.
2. Anti-platelets:
- These medications prevent blood clots; they work by reducing the stickiness of platelets, which are
tiny particles that help the blood to clot.
- Patient is usually prescribed low-dose aspirin, which acts also as a painkiller.
- Another medication, Clopidogrel, may be prescribed as well either in addition to aspirin or as an
alternative if patient is allergic to aspirin.
- Side effects may include:
a. Indigestion and heartburn.
b. Diarrhoea.
c. Bruising or bleeding.
d. Abdominal pain.
- Warfarin may also be used if the patient has atrial fibrillation or have sustained severe damage to
the heart. The most serious side effect is excessive bleeding.
3. Beta-blockers:
- These medications protect the heart from further damage after a heart attack. They also help to
relax the heart's muscles by slowing down the heart beats.
- Side effects include:
a. Feeling tired.
b. Cold hands and feet.
c. Slow heartbeats.
d. Diarrhoea.
e. Feeling sick.
f. Less common side effects include sleep disturbances and erectile dysfunction.
4. Statins:
- These medications lower the blood cholesterol level.
- Side effects include:
a. Constipation.
b. Diarrhoea.
c. Headaches.
d. Abdominal pain.
e. Muscle pain and weakness.
133
TM MEDICINE COUNSELLING 11 A CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DESCRIPTION
Chronic obstructive pulmonary disease (COPD) describes a group of lung conditions that make it difficult
to empty air out of the lungs because the airways have been narrowed.
This group of conditions includes chronic bronchitis and emphysema, which can also occur together.
Bronchitis means the airways are inflamed and narrowed. People with bronchitis often produce sputum
or phlegm.
Emphysema affects the air sacs at the end of the airways in your lungs. They break down and the lungs
become baggy and full of holes which trap air.
These processes narrow the airways. This makes it harder to move air in and out as a person breathes,
and lungs are less able to take in Oxygen and get rid of Carbon dioxide.
SYMPTOMS
1. Increasing breathlessness when active.
2. Persistent cough
3. Phlegm.
4. Wheezing in cold weather
5. Frequent chest infections.
These symptoms may occur all the time, or they might appear or get worse when you have an infection or
breathe in smoke or fumes.
RISK FACTORS
1. The condition starts to affect smoker people over 35 years of age, but diagnosis is usually made when
patients are over 50.
2. Some causes are fumes, dust, air pollution and genetic disorders.
INVESTIGATIONS
Diagnosis is made following consultation and breathing tests.
- Breathing test (Spirometry): This measures the total amount of air you can breathe out from your lungs
and how fast you can blow it out. You will be asked to take a very deep breath and blow out as fast as you
can into a mouthpiece until no more air comes out.
- Your doctors will arrange for you to have a blood test and a Chest X-Ray to rule out other causes of
your symptoms.
- You may need more tests to give a better picture of your condition.
MANAGEMENT:
1. Damage of lungs is already established in COPD and cannot be reversed, however, efforts are made to
slow down the progression of the disease.
2. Stopping smoking is effective in slowing the progress of the disease.
3. Medications can be used in COPD
- Inhaler to make breathing easier which work by dilating airways (Reliever – B-Agonist).
- Inhaler to prevent inflammation and swelling in airways (Preventer - Steroid)
- Tablets or syrups to make sputum thinner and easier to cough up (Mucolytics)
4. Pulmonary rehabilitation may also help increase the amount of exercise patient is able to do.
5. Patient may need Oxygen therapy if the Oxygen levels are low. This is not a treatment for
breathlessness.
6. Surgery is only an option in a small number of patients. This includes:
- Lung Volume Reduction Surgery: Some people with emphysema may benefit from this surgery. This
involves removing the worst affected areas of the lung. This allows the remaining healthier part to work
better.
- Lung Transplantation: If patient has very severe COPD and has not gotten better with treatment they
may need a new lung.
Patients with mild/moderate/severe (stages 1 to 3) COPD:

Should be reviewed at least once per year, or more frequently if indicated
Review should cover the following issues
-Smoking status and desire to quit
134
-Adequacy of symptom control - breathlessness, exercise tolerance, estimated exacerbation frequency
-Presence of complications
-Effects of each drug treatment
-Inhaler technique
-Need for referral to specialist and therapy services
-Need for pulmonary rehabilitation
-Measurement of - FEV1 and FVC, BMI, MRC dyspnea score
Patients with very severe (stages 4) COPD:
Should be seen at least twice a year
Specific attention should be paid to the following issues
-Smoking status and desire to quit
-Adequacy of symptom control - breathlessness, exercise tolerance, estimated exacerbation frequency o
presence of cor pulmonale
-Need for long-term oxygen therapy
-Patient's nutritional state
-Presence of depression
-Effects of each drug treatment
-Inhaler technique
-Need for referral to specialist and therapy services
-Need for pulmonary rehabilitation
-Measurement of - FEV1 and FVC, BMI, MRC dyspnoea score, SaO2
NOTE: The severity of airflow obstruction should be assessed according to the reduction in FEV1
as shown in table
Post- FEV1 % Severity of Severity of Severity of Severity of

bronchodilator predicted airflow airflow airflow airflow
FEV1/FVC obstruction obstruction obstruction obstruction
Using NICE Using ATS/ERS Using GOLD Using NICE
clinical 2004 2008 clinical guideline
guideline 12 101 (2010)
(2004)
Post- Post- Post-

bronchodilator bronchodilator bronchodilator
< 0.7 >80% Mild Stage 1 - Mild Stage 1 - Mild
Stage
< 0.7 50-79% Mild Moderate Stage 2 - Stage 2 -
Moderate Moderate
< 0.7 30-49% Moderate Severe Stage 3 - Severe Stage 3 - Severe
< 0.7 < 30% Severe Very severe Stage 4 - Very Stage 4 - Very
severe severe
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TM MEDICINE COUNSELLING 12 PSEUDOMEMBRANOUS COLITIS (CLOSTRIDIUM DIFFICILE)
Pseudomembranous colitis (PMC) is an acute, exudative colitis usually caused by Clostridium difficile. Spores formed by the
organism are implicated in spread of infection and have implications for hygiene and prevention of infection. C. Difficile is an
anaerobic Gram-positive rod which secretes two types of toxin (A and B), which cause disruption to the barrier function of the
colonic mucosa. Transmission of infection is via an indirect faeco-oral route, through spores left on surfaces. The spores can survive
for months and patients can become carriers. The risk of colonization increases with length of hospital stay.  
To the patient:  
Clostridium difficile (C. difficile) is a germ (bacterium). It lives harmlessly in the gut of many people. About 3 in 100 healthy adults
and as many as 7 in 10 healthy babies have a number of C. difficile bacteria living in their gut. The number of C. difficile bacteria that
live in the gut of healthy people is kept in check by all the other harmless bacteria that also live in the gut. So, in other words, some
of us normally have small numbers of C. difficile bacteria living in our guts, which do no harm. C. difficile produces spores (like
seeds) which are very hard and resistant to high temperatures. Spores are passed out with the stools (faeces) of people who have C.
difficile in their gut. Spores can persist in the environment (for example, on clothes, bedding, surfaces, etc.) for several months or
years. The spores can also be spread through the air (for example, when shaking bedclothes when making a bed). They may get on
to food and into the mouth and gut of some people. Spores that get into a human gut develop into mature bacteria. So, this is how
some people end up with C. difficile living harmlessly in their gut. However, if the number of C. difficile bacteria increases greatly
in the gut then it can cause problems. The most common reason why this occurs is due to taking antibiotics.
Aetiology:
Infection with Clostridium difficile most commonly occurs in people who have recently had a course of antibiotics and are in
hospital. This can spread easily to others. Anyone who takes a course of an antibiotic is at risk of developing C. difficile infection.
However, the risk of C. difficile infection is usually very low and depends on the type of antibiotic.   
Mechanism: 
If you take antibiotics for any infection, as well as killing the bacteria that cause the infection, the antibiotics will also kill many of the
harmless bacteria that live in your gut.  C. difficile bacteria are not killed by many types of antibiotic. If the other harmless bacteria
are killed then this allows C. difficile to multiply to greater numbers than it would normally do. The bacteria also start to produce
poisons (toxins). These toxins are what cause the symptoms.  Therefore, if you take certain antibiotics and if you have any C.
difficile bacteria in your gut, the bacteria may thrive and cause an infection. This is a problem that may occur with taking many of
the commonly used antibiotics.
The exact number of cases that occur in hospital patients is difficult to determine. However, it is common. Also, outbreaks can occur
in hospitals and care homes. About 3 in 10 people who become infected develop symptoms. Commonly this is just a mild or
moderate bout of diarrhoea. However, it sometimes develops into pseudomembranous colitis.
How you get C. difficile

To the patient:
C. difficile bacteria are found in the digestive system of about 1 in every 30 healthy adults. The bacteria often live harmlessly
because the other bacteria normally found in the bowel keep it under control.
However, some antibiotics can interfere with the balance of bacteria in the bowel, which can cause the C. difficile bacteria to
multiply and produce toxins that make the person ill.
When this happens, C. difficile can spread easily to other people because the bacteria are passed out of the body in the person's
diarrhoea.
Once out of the body, the bacteria turn into resistant cells called spores. These can survive for long periods on hands, surfaces (such
as toilets), objects and clothing unless they're thoroughly cleaned, and can infect someone else if they get into their mouth.
Someone with a C. difficile infection is generally considered to be infectious until at least 48 hours after their symptoms have cleared
up.
Risk factors:
1. Prolonged courses of antibiotics:  
2. Multiple antibiotic usage. C. difficile mostly affects people who have been treated with broad-spectrum antibiotics (antibiotics
that work against several types of bacteria) or several different antibiotics at the same time, or those taking long-term
antibiotics.  
3. Increasing age (over 65 years old):  C. difficile infection is more common in older people. Over 8 in 10 cases occur in people over
the age of 65. This is partly because older people are more commonly in hospital. Also, older people seem to be more prone to this
infection. It is rarely a problem with children. Although previously much less common in children, C. difficile infection has become
more common in children in recent years.
4. Severe comorbidity. 
5. Non-surgical invasive gastrointestinal procedures / people who have had surgery on their digestive system.  
6. Presence of a nasogastric tube. 
7. Inpatient residence on ITU.  
8. Increasing duration of hospital stay; patients in long-term care facilities. C. difficile mostly affects people who have had to stay in
a healthcare setting, such as a hospital or care home, for a long time. As a rule, the longer the stay in hospital and the older you are,
the greater your risk of developing C. difficile infection.  
9. Immunocompromised patients:  C. difficile infection is more likely in people who have a weakened immune system or other
underlying health problems. C. difficile mostly affects people who have certain underlying conditions, including inflammatory
bowel disease (IBD), cancer or kidney disease. It also affects people who have a weakened immune system, which can be because of
a condition such as diabetes or a side effect of a treatment such as chemotherapy or steroid medication.   
10. Infection also seems to be more common in people who are taking a group of medicines called proton pump inhibitors. These are
medicines such as omeprazole and lansoprazole that are taken to suppress acid production in the stomach as a treatment for acid
reflux and indigestion. 
136
11. If you have had C. difficile infection once, you have about a 1 in 4-5 chance that you will have infection again in the future.
Patients with recurrent C. difficile infections that fail to respond to antibiotics and other treatments may be considered for specialist
stool (faecal) microbiota transplant treatment.
Presentation:
C. difficile germs (bacteria) make poisons (toxins) that can cause inflammation and damage to the inside lining of the lower gut (the
colon, also known as the large bowel). There are different strains of C. difficile, and some can cause a more serious illness than
others. The severity of the infection and illness can vary greatly.  Strain 027 produces more toxins than most other strains and is
more likely to cause severe illness.
Colonisation with C. difficile can be associated with a range of possible clinical states:
1. The asymptomatic carrier state.
2. Mild self-limited diarrhoea:  Many people develop mild or moderate watery diarrhoea. They may also have some crampy tummy
(abdominal) pains, a feeling of sickness (nausea) and a high temperature (fever). This is similar to the symptoms that occur with
many other mild or moderate bouts of gut infection (gastroenteritis). Symptoms may last from a few days to several weeks. In mild
cases, symptoms often clear away without any specific treatment.
3. Pseudomembranous colitis:
Pseudomembranous colitis occurs in some cases and is more serious. Colitis means inflammation of the colon. Pseudomembranous
means that if you were to look inside the colon, you would see membrane-like patches on the inside lining of the colon. This can
cause bloody diarrhoea, abdominal pain, a distended colon and abdomen, and fever; it can make you very unwell. In some cases it
becomes severe and life-threatening (fulminant colitis) and the colon may perforate (rupture). This can lead to serious infection and
sometimes death.
4. Fulminant colitis.
Signs and Symptoms:

- Generally there is a history of antibiotic exposure together with risk factors for colonisation. 
- In most cases, the symptoms start within a few days (5-10 days) of starting the antibiotic. 
- Occasionally patients will not have had antibiotic exposure. 
- Most patients become unwell during their course of antibiotics, however, in some cases (25-40%), symptoms develop up to 10
weeks after finishing a course of an antibiotic.  
- As a rule, the longer the course of the antibiotic, the greater the risk of developing C. difficile infection.  
- Most affected individuals experience:  
1. watery diarrhoea (varies from self-limiting to severe and debilitating) ± blood-stained stools, 2. Abdominal cramps,  
3. Feeling sick,  
4. Fever (especially so in severe cases) of above 38C (100.4F),  
5. Signs of dehydration, such as a dry mouth, headaches and peeing less often than normal,  
6. Loss of appetite,  
7. Weight loss,  
8. Rigors  
9. ± Sepsis 
10. Severe abdominal pain is uncommon but may mimic an acute abdomen. In some cases, serious complications can develop, such
as:  
- damage to the bowel or 
- severe dehydration, which may cause drowsiness, confusion, a rapid heart rate and fainting.
Note: Frank rectal bleeding suggests other causes (for example, inflammatory bowel disease).
Differential Diagnosis:  
- Crohn's disease. 
- Ulcerative colitis. 
- Diverticular disease. 
- Other infections: Gastroenteritis, Campylobacter, Salmonella, Shigella, Cholera, Amoebiasis 
- Acute abdomen due to surgical pathology. 
- Ischaemic colitis.  
Diagnosis:  As a general guide, the diagnosis of C. difficile infection should be suspected in:  
1. Anyone who develops diarrhoea who has had antibiotics within the previous two months; and/or 
2. When diarrhoea develops during a hospital stay or within a few weeks of coming out of hospital.
However, you should remember that diarrhoea is often due to other causes. For example, food poisoning or viral infections. Also,
diarrhoea after a course of antibiotics may not necessarily be due to C. difficile infection. For example, some antibiotics such as
erythromycin can cause diarrhoea as a side-effect because the antibiotic medicine speeds up stomach emptying. Also, because
antibiotics can upset the balance of the harmless germs (bacteria) in the gut that normally help to control our bowel movements,
diarrhoea after a course of antibiotics can also occur for this reason. Only around 1 in 5 people who develop diarrhoea after a course
of antibiotics actually have C. difficile infection.
Investigations:  
1. Bloods:  
- FBC (WCC elevated in 80%, often very high). 
- Renal function tests and electrolytes. 
- Hypoalbuminaemia may be present (due to a protein-losing enteropathy).
2. Stool Sample:  Diagnosis in CDI and PMC focuses on detection either of C. difficile or of its toxins in stool samples. The particular
137
method used will depend on the laboratory.  Generally, repeat testing on three stool samples is recommended. Samples can
usually be frozen or refrigerated if more than a four-hour delay in processing is expected. Liaison with the laboratory may be helpful
to avoid delay. Results may be available within 48 hours. Methods of testing include:
a. The stool cytotoxin test, which has high sensitivity (94-100%) and specificity (99%) and has been the standard test (it relies on
detection of cytotoxic effect on cultured fibroblasts, negated by a specific antibody).
b. Enzyme-linked immunoassay techniques. Toxin can be demonstrated in the stool but these have varying sensitivity and specificity
(69-87%).
c. Culture of C. difficile directly from the stool is the most sensitive diagnostic test but does not differentiate between toxin-
producing and non-toxin-producing bacteria.
d. PCR testing appears to be rapid, sensitive and specific but needs further evaluation before it can be recommended for routine
testing.
Note: Testing for C. difficile or its toxins should be performed only on diarrhoeal (unformed) stool, unless ileus due to C. difficile is
suspected. Testing of stool from asymptomatic patients is not clinically useful.
3. Sigmoidoscopy (or colonoscopy) ± Biopsy:

- Can show the characteristic pseudomembranous plaque appearance in about half of affected patients.
- May require biopsy to confirm diagnosis.
- Is not used routinely but is usually performed if rapid diagnosis is needed or in a patient who has ileus (often as part of work-up
for other colonic disease).
4. Imaging studies:
- Plain X-rays and CT scanning may be helpful.
- Useful in severe disease but not likely to be helpful in early or mild colitis.
- Can detect complications (perforation, toxic dilatation).
- Barium enemas can be harmful and should be avoided.  
To the patient:  A stool (faeces) sample can be tested in the laboratory to confirm the diagnosis. The test looks for the poison
(toxin) that is produced by C. difficile in the stool sample. Blood tests, an X-ray of your tummy (abdomen) or a CT scan may be
suggested if you have more severe infection.  
Treatment:  The decision to treat C. difficile infection and on the type of treatment depends on the severity of the illness.  No
treatment is needed if you have no symptoms but are known to carry the germs (bacteria) in your gut. However, if symptoms
develop, some of the treatments below may be needed. If you are not already in hospital, people who have mild infection can often
be treated at home. However, if the infection is more severe, you will usually be admitted to hospital so that you can be treated and
closely monitored. 
1. Ceasing the causative antibiotic (if possible):
If at all possible, the antibiotic that has caused the problem should be stopped. This allows resolution in ~3 days in 22%. This will
allow the normal harmless bacteria to thrive again in the gut. The overgrowth of C. difficile should then reduce and symptoms often
ease. Stopping the antibiotic may be the only treatment necessary if you just have mild or moderate diarrhoea. In fact, many people
will have stopped the antibiotic anyway, as the course of antibiotics may have just been for a few days.  
2. Starting a different antibiotic:
People with more severe diarrhoea or inflammation of the colon (colitis) will normally be given an antibiotic that is known to kill C.
difficile (This is usually vancomycin or metronidazole, taken for 10 to 14-days). Symptoms then usually ease within 2-3 days. In
severe cases, prompt treatment with vancomycin or metronidazole may ease any colitis and prevent perforation (rupture) of the
colon.
- Consider changing to an antibiotic less likely to cause PMC - aminoglycosides, macrolides, vancomycin or tetracyclines. -
Metronidazole and vancomycin have been the mainstays of therapy, with some recent data supporting the expanding role of
vancomycin in the treatment of severe CDI.  - Adjunctive therapy with probiotics, IV immunoglobulin, or rifampin has been used in
refractory or recurrent CDI.  - Vancomycin is the drug of choice for an initial episode of severe CDI.  
Note: Most studies have found no statistically significant difference in efficacy between vancomycin and other antibiotics, including
metronidazole, fusidic acid, nitazoxanide or rifaximin. Teicoplanin may be another option.  Fidaxomicin is now available in the UK
for the treatment of CDI in adults.
Note: There is insufficient evidence of any benefit with probiotic therapy as an adjunct to antibiotic therapy for C. difficile colitis.
There is no evidence to support the use of probiotics alone in the treatment of C. difficile colitis.
 3. Fluid replacement:
Correct fluid losses or electrolyte imbalance with oral or intravenous (IV) electrolyte solutions.
As with any cause for diarrhoea, it is important that you replace the fluids that are lost in the diarrhoea. This may be by drinking
extra fluids. Sometimes, if you have severe diarrhoea and become lacking in fluid in the body (dehydrated), fluids need to be given.
This is done either by a tube that passes through your nose directly into your stomach (a nasogastric tube) or via a drip into your
veins.   
4. Surgery in rare cases:  In a small number of cases that progress into fulminant colitis, surgery may be needed, especially if the
colon perforates. Surgery may be life-saving for patients with acute severe colitis.
Referral for a surgical opinion is required if the patient: 
- fails to respond to treatment  
- or has signs of an acute abdomen,  
- radiological signs of acute disease,  
- a rising white blood cell count,  
- a rising creatinine concentration,  
- or a rising lactate concentration.
Criteria for a diagnosis of severe colitis:

Stool frequency: >6 in 24 hours, and at least one of the following:  
- pulse rate >90 beats/minute,  
138
- temperature >37.8°C,  
- haemoglobin <10.5 g/L,  
- ESR >30 mm in first hour.
5. Treatments to avoid:
- Antiperistaltic agents:  Antidiarrhoeal medicines such as loperamide should not be used if C. difficile infection is suspected. This
is because it is thought that they may slow down the rate at which the poisons (toxins) produced by the bacteria are cleared from
your gut.  
- Probiotics: Probiotics are bacteria and yeasts that resemble the protective bacteria of the gut and they are also not recommended
at present. This is because evidence that they are helpful in clearing the infection is lacking. - Opiates:  Avoid opiates (codeine)
because of the risk of retention of toxins in the lumen. 
Prognosis:
- Most people with C. difficile infection recover, some even without any treatment. However, the diarrhoea can be unpleasant and, in
some cases, can last for several weeks. 
- If needed, treatment with metronidazole or vancomycin gives a good chance of clearing the infection quickly. In healthy individuals
a good response to treatment is usually expected but the illness can cause severe debility and prolonged hospital stays. 
- CDI is implicated as a significant cause of morbidity and mortality among hospitalised patients. Severe inflammation of the colon
(colitis) due to C. difficile infection occurs in some cases. This accounts for most of the serious complications such as perforation
(rupture) of the colon, and death. Most people who die of C. difficile infection are elderly people who are frail or ill with other things
and who develop the infection during a hospital stay. Early identification of CDI and prompt initiation of therapy with the most
appropriate agent are critical to minimise morbidity and mortality.
- As mentioned above, once you have had C. difficile infection, you have around a 1 in 4-5 chance of the infection returning in the
future. Recurrent colitis and diarrhoea occur in approximately 25% of patients.
Note: you should remain off work or school until you have been free from diarrhoea for 48 hours.
Complications:
Complications of severe C. difficile colitis include:  
- dehydration,  
- electrolyte disturbances,  
- hypoalbuminaemia,  
- toxic megacolon,  
- bowel perforation,  
- hypotension,  
- acute kidney injury,  
- systemic inflammatory response syndrome,  
- sepsis and death.  
Extraintestinal manifestations are rare and include: 

- Bacteraemia. 
- Splenic abscess. 
- Osteomyelitis. 
- Reactive arthritis or tenosynovitis.
Looking after yourself at home:
If you're well enough to be treated at home, the following measures can help relieve your symptoms and prevent the infection
spreading:
- Make sure you finish the entire course of any antibiotics you're prescribed, even if you're feeling better.
- Drink plenty of fluids to avoid dehydration and eat plain foods such as soup, rice, pasta and bread if you feel hungry.
- Take paracetamol for tummy pain or a fever.
- Don't take anti-diarrhoeal medication, as this can stop the infection being cleared from your body.
- Regularly wash your hands and contaminated surfaces, objects or sheets
- Stay at home until at least 48 hours after your last episode of diarrhoea.
Your GP may contact you regularly to make sure you're getting better. Call them if your symptoms return after treatment finishes, as
it may need to be repeated.
Prevention:
- Administration of currently available probiotics is not recommended to prevent primary CDI, as there are limited data to support
this approach.
- Overall preventative measures, such as strict handwashing and patient isolation policies for patients with diarrhoea, seem to be
effective. There is less evidence of benefit for environmental cleansing measures.
- Handwashing should be done correctly to be effective. Alcohol gels do not kill spores and are not recommended.
- Appropriate antibiotic prescribing; minimise the frequency and duration of antimicrobial therapy and the number of antimicrobial
agents prescribed.
To the patient:
Preventing the spread of infection to others:  You, and those caring for you, also need to follow strict hygiene measures if you have
C. difficile infection. This will help to prevent the spread of infection to others. If you are in hospital, the following measures are
usually suggested:
1. If possible, you should have your own room, washbasin and toilet facilities. 
2. You should regularly wash your hands thoroughly, especially after each time you have been to the toilet. 
3. Those caring for you should wear disposable gloves and aprons and wash their hands with soap and water before and after
attending to you. Hand gel is not an alternative to soap and water but may be used after hand washing. This is because hand gel may
not kill the C. difficile spores. 
4. Toilets, surfaces, floors, bedpans, bedding, etc., should be washed regularly. 
5. Visitors should also wear disposable gloves and aprons and wash their hands as they enter and leave your room.
139
TM Medicine Counseling 13A OSTEOPOROSIS
Description:
Osteoporosis is a condition that weakens bones making them fragile and more likely to
break.
Symptoms:
Patient usually presents with fractures including wrist, hip, vertebrae and less
commonly arm, ribs and pelvis.
Causes
Losing bone is a normal part of the ageing process, but sometimes it can lead to
osteoporosis and an increased risk of fractures.
Risk factors include:

1. History of previous hip or wrist fracture after
2. Medical conditions such as Rheumatoid arthritis, Ankylosing Spondylitis, CKD,
Hyperparathyroidism IBD and coeliac disease.
3. People taking steroids medication for more than 3 months.
4. Women who have had their ovaries removed
5. Family history of osteoporosis.
6. Postmenopausal women.
7. Excessive alcohol consumption.
8. Smoking.
9. Poor diet. (Lack of calcium, vitamin D and omega 3 or people with an eating disorder
such as anorexia or bulimia)
10. Lack of physical activity and prolonged immobility.
Investigations:
If osteoporosis is suspected, patient should be referred for a scan to measure his bone
mineral density. This type of scan is known as a DEXA scan. It's a short, painless
procedure.
Management:
- Treatment for osteoporosis is based on treating and preventing fractures and using
medication to strengthen bones. The decision to start treatment will depend on many
factors such as age and results of DEXA scan.
- Some general advice include:

1. Taking regular exercises. (weight bearing and resistant training)
2. Eating healthy foods rich in calcium and vitamin D.
3. Making lifestyle changes such as stopping smoking and reducing alcohol
consumption.
140
INDICATIONS FOR STARTING BISPHOSPHONATE
CONFIRMED RISK FACTORS and/or INDICATORS OF LOW BONE

AGE
BY DEXA DENSITY
75 or > 75 N/A 2 or more RF or Indicators
70 – 74 YES 1 RF or Indicator
65 – 69 YES 1 RF
< 65 YES 1 RF + at least 1 indicator
Independent Risk Factors (RF) for Fracture

1. Parental history of hip fracture
2. Alcohol consumption more than 4 units per day
3. Rheumatoid Arthritis
Indicators of Low Bone Density

1. Ankylosing Spondylitis
2. Crohn’s Disease
3. BMI less than 22
4. Prolonged immobility
5. Untreated premature menopause.
About Bisphosphonates
1. They can be taken once a day, once a week or once a month.
2. It should be taken first thing in the morning before eating or drinking anything.
3. Patient needs to swallow with a full glass of water and sit upright for 30 mins
4. The most common side effects are:
- Being sick
- Indigestion
- Heartburn
- Tummy pain
- Diarrhea
- Constipation
All of these usually occur in the first month of treatment and usually resolve after this.
141
TM 14 MED CX-Diabetic retinopathy
Stage one: background retinopathy

This means that tiny bulges (micro aneurysms) have appeared in the blood vessels in the back
of your eyes (retina), which may leak small amounts of blood. This is very common in people
with diabetes.
At this stage:
-Your sight isn't affected, although you're at a higher risk of developing vision problems in the future
-You don't need treatment, but you'll need to take care to prevent the problem getting worse.
-The chances of it progressing to the stages below within three years is over 25% if both of your eyes
are affected
Stage two: pre-proliferative retinopathy

This means that more severe and widespread changes are seen in the retina, including bleeding into
the retina.
At this stage:
-There's a high risk that your vision could eventually be affected
-You'll usually be advised to have more frequent screening appointments every three or six months
to monitor your eyes
Stage three: proliferative retinopathy

This means that new blood vessels and scar tissue have formed on your retina, which can cause
significant bleeding and lead to retinal detachment where the retina pulls away from the back of the
eye.
At this stage.
-There's a very high risk you could lose your vision
-Treatment will be offered to stabilize your vision as much as possible, although it won't be possible
to restore any vision you've lost
Diabetic maculopathy
In some cases, the blood vessels in the part of the eye called the macula (the central area of the
retina) can also become leaky or blocked. This is known as diabetic maculopathy.
If this is detected:
-There's a high risk that your vision could eventually be affected
-You may be advised to have more frequent specialised testing to monitor your eyes
-You may be referred to a hospital specialist to discuss treatments that can help stop the problem
getting worse
Abbreviations
DR = diabetic retinopathy
NPDR = non-proliferative retinopathy
NVE = new vessels elsewhere
IRMAs = intraretinal microvascular abnormalities (part of severe pre-proliferative retinopathy,
vessels will not leak with angiogram, otherwise they would be 'new vessels' making the condition
'proliferative')
dd= disc diameter
MO= macular oedema
MA= microaneurysms
142
NSC International Term Symptoms Features (see) Action
R0 No DR None Normal retina. Grade 0 (US) annual rescreen
Haemorrhages & microaneurysms, only Inform diabetes
Mild non-proliferative (mild
RI None see photo Grade 1 (US). Very minor team
pre-proliferative)
IRMAs see M1
Previously termed mild pre-proliferative.
Moderate non-proliferative, Extensive Microaneurysm, intraretinal refer HES
R2 None
Moderate pre-proliferative haemorrhage, and hard exudates. See see R2
photo and photo Grade 2 (US)
Previously termed severe pre-
proliferative. Venous abnormalities, large
blot haemorrhages, cotton wool spots
Severe non-proliferative urgent refer HES
R2 None (small infarcts), venous beading, venous
Severe pre-proliferative see R2
loop, venous reduplication, IRMA, See
photo and photo .
Grade 3 (US)
New vessel formation either at the disc
(NVD) or elsewhere (NVE).
Floaters, sudden visual urgent refer HES
R3 Proliferative retinopathy Photos: flat new
loss see R3
vessels, raised, florid Grade 4a
(US)
Extensive fibrovascular proliferation,
retinal detachment, pre-retinal or
Pre-retinal fibrosis+/- Floaters, central loss of vitreous haemorrhage, urgent refer HES
R3
Tractional retinal detachment vision glaucoma. Grade 4b (US).
Traction photo and photo. Subhyaloid
haemorrhage photo
Treated proliferative no haemorrhages or exudates or new
R3s annual rescreen
retinopathy (s = stable) vessels, laser ('P' added)
M0 no maculopathy annual rescreen
The macula is defined as a circle centred
on the fovea, with a radius of the
distance to the disc margin. If the
leakage involves or is near the fovea the
condition is termed clinically significant
macular oedema (CSME).
Exudative maculopathy presents with
leakage , retinal thickening,
microaneurysms, hard exudates at the
macula. Ischaemic form can have a
featureless macular with NVE and poor
vision. refer HES
M1 Diabetic maculopathy Blurred central vision
Photos: moderate, severe see M1
Milder forms:
• exudate < or = 1DD of centre of fovea
• circinate or group of exudates within
macula
• any microaneurysm or haemorrhage
• < or = 1DD of centre of fovea only is
associated with a best VA of <
or = 6/12
• retinal thickening < or = 1DD of
centre of fovea (if stereos
available)
Reduced night vision, Small retinal scars through out the
P Photocoagulation
glare peripheral retina. Grade 4b (US)
Un-gradable is usually due to cataract,
OL/
Other lesion / Un-gradable other lesions usually referred for
UG
assessment
143
Diabetic Clinical signs What to do What to do What you could say to your patients
retinopath (screening/primary eye (retinal clinic)
y stage care)
No diabetic No abnormalities Encourage patient to Review in 12 Diabetes can affect the inside of your eyes at any time. It is important that
retinopathy come again in 12 months months you come back in twelve months so we can examine you again. This will
help to prevent you losing vision or going blind.
Mild non- Microaneurysms only Encourage patient to Review in 12 Your diabetes is affecting your eyes. At the moment your vision is good,
proliferative come again in 12 months months but we must check your eyes in 12 months' time to see if these changes are
diabetic getting worse. If the damage becomes severe, we will need to treat your
retinopathy eyes to stop the diabetes affecting your sight.
Moderate More than just Encourage patient to Review in 6–12 Your diabetes is damaging your eyes. At the moment your vision is good,
non- microaneurysms but come again in 6–12 months but we must check your eyes in six months' time as it is likely that these
proliferative less than severe non- months changes will get worse. If the damage becomes severe, we will need to treat
diabetic proliferative your eyes to stop the diabetes affecting your sight. Unless you are treated
retinopathy retinopathy promptly, you risk losing vision or going blind.
Severe non- More than 20 Refer to retinal clinic. Perform Your diabetes has damaged your eyes quite severely, although your vision
proliferative haemorrhages in each All patients with severe peripheral retinal is still good. You are likely to need treatment soon to ensure that you don't
diabetic quadrant; or venous non-proliferative DR photocoagulation lose vision or go blind. We must check your eyes in six months' time.
retinopathy beading in two should be in the care of if follow-up is However, if you think you may not be able to come then, we may treat your
quadrants; or an ophthalmologist. The unreliable; eyes now, so we can be sure you don't lose vision later.
intraretinal patient should be re- otherwise review
microvascular examined every six in 6 months
abnormalities (IRMA) months
Proliferative Any new vessels at the Urgent referral to retinal Peripheral retinal Your diabetes has damaged your eyes very severely. Although your vision
diabetic disc or elsewhere, clinic photocoagulation may be good, you are at great risk of losing your sight over the next year.
retinopathy vitreous/pre-retinal or vitrectomy if You need urgent treatment to save your sight. Treatment will not improve
haemorrhage there is vitreous your eyesight, but should preserve the vision you have.
haemorrhage or
retinal detachment
Macular oedema
Macular No exudates or retinal Review in 12 months Review in 12 As for “No diabetic retinopathy” above.
oedema thickening in posterior months
absent pole
Mild Exudates or retinal Review in 6 months Review in 6 Your diabetes is damaging your eyes. At the moment your vision is good,
macular thickening at posterior months but we must check your eyes in six months' time as it is likely that these
oedema pole, >1dd from fovea changes will get worse. If the damage becomes severe, we will need to treat
your eyes to stop the diabetes affecting your sight. Unless you are treated
promptly, you risk losing vision or going blind.
Moderate Exudates or retinal Refer to retinal clinic. Laser treatment if Your diabetes has damaged your eyes severely. Although your vision may
macular thickening at posterior Encourage patient to clinically be good at present, it is likely to get worse over the next year or two. You
oedema pole, 1dd or less from manage their blood sugar significant need laser treatment to stop your sight deteriorating. The treatment will not
fovea, but not and blood pressure, and macular oedema improve your eyesight, but should preserve the vision you have.
affecting fovea refer them to available (CSMO). Review
services for help if they in 6 months if no
are not sure how to do CSMO
this
Severe Exudates or retinal Refer to retinal clinic Laser treatment or You have probably noticed your eyesight has got worse. This is because
macular thickening affecting intravitreal your diabetes has damaged your eyes very severely. You need urgent
oedema centre of fovea injections of anti- treatment to prevent further loss of vision. The treatment may not improve
VEGF drugs your eyesight, but if you are not treated, your vision will get worse and you
may even become blind.
144
Needle-stick Injury MEDICINE Cx 15
Hepatitis Post Exposure Prophylaxis

If you've been exposed to the hepatitis B virus and have not been vaccinated before, you should seek
medical advice immediately, as you may benefit from the hepatitis B vaccine.
Vaccination and immunoglobulin may be recommended dependent upon:
-The immune status of the person
NOTE: The first three doses are given as part of the 6-in-1 vaccine at 8, 12 and 16 weeks for all babies born
on or after August 1 2017.
NOTE: The schedule for occupational health is zero, one, and six months.
-Whether the source is known to be positive or not.
In some situations, you may also need to have an injection of antibodies, called specific hepatitis B
immunoglobulin (HBIG), along with the hepatitis B vaccine.
Dosage:
0-4 yrs 200 i.u.
5-9yrs 300 i.u.
>10 yrs 500 i.u.
Immunoglobulin should be given by intramuscular injection as soon as possible, preferably within 12 hours
and ideally within 48 hours. Not later than a week after exposure.
HBV status of HBsAg positive Unknown source HBsAg negative Continued risk No further
person exposed source source risk
≤1 dose HB Accelerated Accelerated Initiate course of Initiate course of No HBV

vaccine pre- course of HB course of HB HB vaccine HB vaccine prophylaxis.
exposure vaccine vaccine Reassure.
HBIG x 1
≥ 2 doses HB One dose of HB One dose of HBA Finish course of Finish course of No HBV
vaccine pre- vaccine followed vaccine HB vaccine HB vaccine prophylaxis.
exposure (anti- by second dose 1 Reassure.
HBs not known) month later
Known Consider booster Consider booster Consider booster Consider booster No HBV
responder to HB dose of HB dose of HB dose of HB dose of HB prophylaxis.
vaccine (anti HBs vaccine vaccine vaccine vaccine Reassure.
> 10mlU/ml)
Known non- HBIG x 1 HBIG x 1 No HBIG No HBIG No
responder to HB Consider booster Consider booster Consider booster Consider booster prophylaxis.
vaccine (anti-HBs dose of HB dose of HB dose of HB dose of HB Reassure.
<10IU/ml 2-4 vaccine. A vaccine. A vaccine vaccine
months post- second dose of second dose of
immunization) HBIG should be HBIG should be
given at 1 month given at 1 month
An accelerated course consists of three doses at zero, one and two months.
Tetanus Post Exposure Prophylaxis

145
Tetanus bacteria can survive for a long time outside the body and are commonly found in soil and the
manure of animals such as horses and cows.
If the bacteria enter the body through a wound, they can quickly multiply and release a toxin that affects
the nerves, causing symptoms such as muscle stiffness and spasms.
The bacteria can get into your body through:

-cuts and scrapes
-tears or splits in the skin
-burns
-animal bites
-body piercings, tattoos and injections
-eye injuries
-injecting contaminated drugs
Tetanus can't be spread from person to person.

If your doctor thinks you could develop tetanus but you haven't had any symptoms yet, they'll clean your
wounds and give you an injection of tetanus immunoglobulin. They may also give you a dose of the tetanus
vaccine if you haven't been fully vaccinated in the past.
Tetanus immunoglobulin is a medication containing antibodies that kill the tetanus bacteria. It provides
immediate, but short-term, protection from tetanus.
A tetanus vaccination is given as part of the NHS childhood vaccination programme.

The full course of the vaccination requires five injections, usually given on the following schedule:
The first three doses are given as part of the 6-in-1 vaccine at 8, 12 and 16 weeks for all babies born on or
after August 1 2017.
A booster dose is given as part of the 4-in-1 pre-school booster at age three years and four months.
A final booster is given as part of the 3-in-1 teenager booster at age 14.
This course of five injections should provide long-lasting protection against tetanus. However, if you or
your child has a deep or dirty wound, it's best to get medical advice.
HIV
HIV PEP consists of a 28 day course of anti-retrovirals. If indicated, PEP should be started as soon as
possible, ideally within one hour of the injury or within 72 hours post exposure.
Children who have sustained a significant exposure should be referred to a paediatrician or infectious
diseases consultant who is experienced in the treatment of children with HIV.
Extra information: NHS Vaccination Program

6-in-1 vaccine: diphtheria, hepatitis B, Hib (Haemophilus influenzae type b), polio, tetanus, and whooping
cough (pertussis)
4-in-1 vaccine: diphtheria, polio, tetanus, and whooping cough (pertussis)
3-in-1 vaccine: diphtheria, polio, and tetanus
-The first three doses are given as part of the 6-in-1 vaccine at 8, 12 and 16 weeks for all babies born on
or after August 1 2017.
-A booster dose is given as part of the 4-in-1 pre-school booster at age three years and four months.
-A final booster is given as part of the 3-in-1 teenager booster at age 14.
146
TM MEDICINE COUNSELING 17 – TEACHING MATERIALS
High cholesterol:
Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It's mainly made by
the liver but can also be found in some foods.
Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your health.
High cholesterol itself doesn't usually cause any symptoms, but it increases your risk of serious health conditions.
Evidence strongly indicates that high cholesterol can increase the risk of:
1. Narrowing of the arteries (atherosclerosis)
2. Heart attack
3. Stroke
4. Transient ischemic attack (TIA) – often known as a "mini stroke"
5. Peripheral arterial disease (PAD). This is because cholesterol can build up in the artery wall, restricting the blood
flow to your heart, brain and the rest of your body. It also increases the risk of a blood clot developing somewhere in
your body.
6. Your risk of developing coronary heart disease also rises as your blood's cholesterol level increases. This can
cause pain in your chest or arm during stress or physical activity (angina).
Many factors can increase your chances of having heart problems or a stroke if you have high cholesterol.
These include:
1. An unhealthy diet – in particular, eating high levels of saturated fat
2. Smoking – a chemical found in cigarettes called acrolein stops HDL transporting cholesterol from fatty deposits to
the liver, leading to narrowing of the arteries (atherosclerosis)
3. Having diabetes or high blood pressure (hypertension)
4. Having a family history of stroke or heart disease
As a general guide, total cholesterol levels should be:

5mmol/L or less for healthy adults
4mmol/L or less for those at high risk
As a general guide, LDL levels should be:
3mmol/L or less for healthy adults
2mmol/L or less for those at high risk
If you've been diagnosed with high cholesterol, you'll be advised to make changes to your diet and increase your level
of exercise.
After a few months, if your cholesterol level hasn't dropped, you may be advised to take cholesterol-lowering
medication.
Changing your diet, stopping smoking and exercising more will also help to prevent high cholesterol developing.
Diet
Eating a healthy, balanced diet that's low in saturated fats can reduce your level of "bad cholesterol" (LDL).
Try to avoid or cut down on the following foods, which are high in saturated fat:
1. Fatty cuts of meat and meat products, such as sausages and pies
2. Butter, ghee and lard
3. Cream, soured cream, crème fraîche and ice cream
4. Cheese, particularly hard cheese
5. Cakes and biscuits
6. Milk chocolate
7. Coconut oil, coconut cream and palm oil
Cholesterol-lowering medication
There are several different types of cholesterol-lowering medication that work in different ways.
The most commonly prescribed medications are:

Statins
Statins block the enzyme (a type of chemical) in your liver that helps to make cholesterol. This leads to a reduction in
your blood cholesterol level.
You'll usually be started on a medication called atorvastatin. Other statins include simvastatin and rosuvastatin.
Statins will only be prescribed to people who continue to be at high risk of heart disease, because they need to be taken
for life. Cholesterol levels start to rise again once you stop taking them.
147
Aspirin
In some cases, a low daily dose of aspirin may be prescribed, depending on your age (usually over 40 years old) and
other risk factors.
Low-dose aspirin can help to prevent blood clots forming, particularly for someone who's had a heart attack, has
established vascular disease, or a high risk of developing cardiovascular disease (CVD).
You may also be advised to have periodic blood tests to ensure your liver is functioning well.
Side effects of statin:

1. Nosebleeds
2. Sore throat
3. A runny or blocked nose (non-allergic rhinitis)
4. Headache
5. Feeling sick
6. Problems with the digestive system, such as constipation, diarrhoea, indigestion or flatulence
7. Muscle and joint pain
8. Increased blood sugar level (hyperglycaemia)
9. An increased risk of diabetes
Statin side effects What can I do if I experience this?

Feeling sick, indigestion, wind (flatulence), stomach This can be managed by sticking to simple foods, and
cramps avoid rich and spicy foods.
Headache For this you may drink lots of water. If it becomes

bothersome, you can ask your pharmacist for a suitable
painkiller.
Muscle pain and cramps Commonly manifests at night. If it occurs, please see
your doctor immediately.
Dizziness, feeling tired, or having a itchy rash Please see your doctor about it.
QRISK Assessment:
QRISK2 is a prediction algorithm for cardiovascular disease (CVD) that uses traditional risk factors (age, systolic blood pressure,
smoking status and ratio of total serum cholesterol to high-density lipoprotein cholesterol) together with body mass index, ethnicity,
measures of deprivation, family history, chronic kidney disease, rheumatoid arthritis, atrial fibrillation, diabetes mellitus, and
antihypertensive treatment.
A QRISK2 over 10 (10% risk of CVD event over the next ten years) indicates that primary prevention with lipid lowering therapy (such
as statins) should be considered.
Well woman clinic

Many GP surgeries offer a well woman clinic, where you may be seen by a female doctor or practice nurse.
The well woman clinic will often provide advice on:
1. Gynaecological problems
2. Family planning (including fitting an IUD coil)
3. Cervical smears
4. Breast disease
5. Menopause
They may also provide emergency contraception.

You can also discuss your general health and have your urine, weight, cholesterol and blood pressure checked.
Some local hospitals also run well woman clinics. To use these, you don't need a referral from your GP, and an appointment isn't
always needed. Ring your GP surgery for information.
If neither your GP surgery nor local hospital runs a well woman clinic, many practice nurses are able to give breast awareness advice,
do cervical smears, and provide information and advice on contraception and hormone replacement therapy (HRT).
148
TM 18 MED CX-DVLA notification by drivers or healthcare professionals
Applicants and license holders have a legal duty to:

-Notify the DVLA of any injury or illness that would have a likely impact on safe driving ability
-Respond fully and accurately to any requests for information from either the DVLA or healthcare professionals
-Comply with the requirements of the issued license, including any periodic medical reviews indicated by the DVLA
Doctors and other healthcare professionals should:

-Advise the individual on the impact of their medical condition for safe driving ability
-Advise the individual on their legal requirement to notify the DVLA of any relevant condition
-Treat, manage, and monitor the individual’s condition with ongoing consideration of their fitness to drive
-Notify the DVLA when fitness to drive requires notification but an individual cannot or will not notify the DVLA themselves
Reporting concerns to the DVLA:

If a patient has a condition or is undergoing treatment that could impair their fitness to drive, you should:
-Explain this to the patient and tell them that they have a legal duty to inform the DVLA
-Tell the patient that you may be obliged to disclose relevant medical information about them, in confidence, to the DVLA if they
continue to drive when they are not fit to do so
-Make a note of any advice you have given to a patient about their fitness to drive in their medical record
-If a patient is incapable of understanding this advice (like dementia), you should inform the DVLA as soon as possible
-If a patient refuses to accept the diagnosis, or the effect of the condition or treatment on their ability to drive, you can suggest that
they seek a second opinion, and help arrange for them to do so.
-If you become aware that a patient is continuing to drive when they may not be fit to do so, you should make every reasonable
effort to persuade them to stop. If you do not manage to persuade the patient to stop driving, or you discover that they are
continuing to drive against your advice, you should consider whether the patient’s refusal to stop driving leaves others exposed to a
risk of death or serious harm. If you believe that it does, you should contact the DVLA promptly and disclose any relevant medical
information, in confidence, to the medical adviser.
-Before you contact the DVLA, you should try to inform the patient of your intention to disclose personal information. If the patient
objects to the disclosure, you should consider any reasons they give for objecting. If you decide to contact the DVLA, you should tell
your patient in writing once you have done so, and make a note on the patient’s record.
Driving and diabetes:

Information sent to drivers
Insulin-treated drivers are sent a detailed letter from the DVLA explaining the licensing requirements and driving responsibilities.
Insulin-treated diabetes
Impaired awareness of hypoglycaemia
The Secretary of State’s Honorary Medical Advisory Panel on Driving and Diabetes has defined impaired awareness of
hypoglycaemia for Group 1 drivers as “an inability to detect the onset of hypoglycaemia because of total absence of warning
symptoms”. Group 2 drivers must have full awareness of hypoglycaemia.
Severe hypoglycaemia
The law defines ‘severe’ as an episode of hypoglycaemia requiring the assistance of another person.
Group 1 Group 2
Car and motorcycle Bus and lorry
! - Must meet the criteria to drive and must notify the DVLA. ! - Must meet the criteria to drive and must notify the DVLA.
All the following criteria must be met for the DVLA to license All the following criteria must be met for the DVLA to license
the person with insulin-treated diabetes for 1, 2 or 3 years: the person with insulin-treated diabetes for 1 year (with
annual review as indicated last below):
■ adequate awareness of hypoglycaemia ■ full awareness of hypoglycaemia

■ no more than 1 episode of severe hypoglycaemia while ■ no episode of severe hypoglycaemia in the preceding 12
awake in the preceding 12 months or the most recent episode months
occurred more than 3 months ago ■ practises blood glucose monitoring with the regularity
■ practises appropriate blood glucose monitoring as defined defined below
below ■ must use a glucose meter with sufficient memory to store 3
■ not regarded as a likely risk to the public while driving months of readings as detailed below
■ meets the visual standards for acuity and visual field ■ demonstrates an understanding of the risks of
■ under regular review. hypoglycaemia
■ no disqualifying complications of diabetes that would mean
a licence being refused or revoked, such as visual field defect.
A Guide to Insulin Treated Diabetes and Driving

Drivers who have any form of diabetes treated with any insulin preparation must inform DVLA
149
HYPOGLYCAEMIA
Hypoglycaemia (also known as a hypo) is the medical term for a low blood glucose (sugar) level.
Severe hypoglycaemia means the assistance of another person is required.
The risk of hypoglycaemia is the main danger to safe driving and this risk increases the longer you are on
insulin treatment. This may endanger your own life as well as that of other road users. Many of the accidents
caused by hypoglycaemia are because drivers carry on driving even though they get warning symptoms of
hypoglycaemia . If you get warning symptoms of hypoglycaemia whilst driving, you must always stop as soon
as safely possible – do not ignore the warning symptoms.
EARLY SYMPTOMS OF HYPOGLYCAEMIA INCLUDE:
Sweating, shakiness or trembling, feeling hungry, fast pulse or palpitations, anxiety, tingling lips.
If you don’t treat this it may result in more severe symptoms such as:
-Slurred speech
-Difficulty concentrating
-Confusion
-Disorderly or irrational behaviour, which may be mistaken for drunkenness.
If left untreated this may lead to unconsciousness.
DRIVERS WITH INSULIN TREATED DIABETES ARE ADVISED TO TAKE THE FOLLOWING PRECAUTIONS.
- You should always carry your glucose meter and blood glucose strips with you. You should check your blood
glucose no more than 2 hours before the start of the first journey and every two hours whilst you are driving.
-If driving multiple short journeys, you do not necessarily need to test before each additional journey as long as
you test every 2 hours while driving. More frequent testing may be required if for any reason there is a greater
risk of hypoglycaemia for example after physical activity or altered meal routine. The intention is to ensure that
blood glucose is always above 5.0mmol/l while driving.
-In each case if your blood glucose is 5.0mmol/l or less, take a snack. If lt is less than 4.0mmol/l or you feel
hypoglycaemic, do not drive.
-If hypoglycaemia develops while driving, stop the vehicle as soon as possible.
-You should switch off the engine, remove the keys from the ignition and move from the driver’s seat.
-You should not start driving until 45 minutes after blood glucose has returned to normal (confirmed by
measuring blood glucose). It takes up to 45 minutes for the brain to recover fully.
-Always keep an emergency supply of fast-acting carbohydrate such as glucose tablets or sweets within easy
reach in the vehicle.
-You should carry personal identification to show that you have diabetes in case of injury in a road traffic
accident.
-Particular care should be taken during changes of insulin regimens, changes of lifestyle, exercise, travel and
pregnancy.
-You must take regular meals, snacks and rest periods on long journeys. Always avoid alcohol.
EYESIGHT
-All drivers are required by law to read, in good daylight (with glasses or corrective lenses if necessary), a car
number plate from a distance of 20 metres. In addition, the visual acuity (with the aid of glasses or contact
lenses if worn) must be at least 6/12 (0.5 decimal) with both eyes open, or in the only eye if monocular.
LIMB PROBLEMS
-Limb problems/amputations are unlikely to prevent driving. They may be overcome by driving certain types
of vehicles e.g. automatics or one with hand controls.
YOU MUST INFORM DVLA IF:
-You suffer more than one episode of severe hypoglycaemia (needing the assistance of another person) within
thelast 12 months. For Group 2 drivers (bus/lorry) one episode of severe hypoglycaemia must be reported
immediately. You must also tell us if you or your medical team feels you are at high risk of developing
hypoglycaemia.
-You develop impaired awareness of hypoglycaemia. (difficulty in recognising the warning symptoms of low
blood sugar)
-You suffer severe hypoglycaemia while driving.
-An existing medical condition gets worse or you develop any other condition that may affect you driving safely.
150
TEACHING MATERIAL HX CX 19A - Hypoglycaemia
Risk factors:
- Tight (good) glycaemic control
- Previous severe hypoglycaemia
- Long duration of diabetes/old age
- Lipohypertrophy/injection technique/poor monitoring
- Impaired hypoglycaemia awareness
- Hepatic dysfunction/renal impairment
- Terminal illness/acute illness
- Other endocrine disorders e.g. Addison’s, hypothyroidism
- Exercise
- Alcohol
- Pregnancy/breastfeeding
- Malabsorption/celiac/missed meal/low BMI
- Drugs: warfarin, aspirin, sulphonamides, quinine, MOAIs, SSRIs, NSAIDs
Clinical features:
- Headache
- Nausea
- Sweating
- Palpitations
- Shaking
- Confusion
- Drowsiness
- Odd behaviour
- Ataxia
- Seizure
- Stroke mimic
Review medication:
- Type of insulin (short/long/combined)
- Sulphonylureas can cause further hypoglycaemic episodes
- Metformin, thiazolidinediones, DPP-4 inhibitors, GLP-1 analogues, and SLGT2 are unlikely to cause
hypoglycaemia in isolation
Diagnosis:
Blood sugar <4.0 mmol/L
- Assess risk factors
- Treat underlying cause
- Review diabetes medication and oral intake
A) If the patient able to swallow:

Give oral glucose: -
- Fruit juice 150-200 mL or
- Water with 3-4 tsp sugar or
- Glucogel in special circumstances
Reassess the patient:

Is the blood sugar ≥ 4.0 mmol/L after 10-15 minutes?
If yes:
Is patient able to swallow?
- Long acting carbohydrate (half sandwich/piece of fruit/200-300 ml of milk, meal if due)
Is the patient unable to swallow?
151
- Consider 10% glucose
Then:
Review diabetes medication. Discuss with diabetes team for advice.
Changes to medication not usually required if clear cause on background of good control.
Consider:
- Reducing insulin by 10%. Do not omit insulin. Note dose in particular if high risk.
- Halve dose of sulphonylureas or stop if possible.
Discharge criteria:
- Patient should be able to tolerate oral fluid and food
- Their medication should be reviewed and altered if indicated
- The cause(s) should be identified
- They should be compliant with medication
- There should be adequate social support
Ensure follow up with diabetes nurse or GP
B) If the patient unable to swallow:

- 20% glucose 75 mL over 5 minutes
- 10% glucose 150 mL over 5 minutes (observe for phlebitis)
- Glucagon 1mg IM if unable to get IV access
Reassess the patient:

Is the blood sugar ≥ 4.0 mmol/L after 10-15 minutes?
If no:
- Repeat glucose as above
- Have senior review
- Consider 10% glucose at 100 mL/hour
Then:
- Review diabetes medication. Discuss with diabetes team for advice.
- Changes to medication not usually required if clear cause on background of good control.
Consider: -
- Reduce insulin by 10%. Do not omit insulin. Note dose in particular if high risk.
- Halve dose of sulphonylureas, or stop.
After:
Admit for observation if any of the following are present: -
- Unable to tolerate oral fluid/food
- Hypoglycemia due to long acting insulin/sulphonylurea
- Hypoglycemia resistant to initial treatment
- Recurrent hypoglycaemia within 48 hours
- Underlying cause or comorbidities requiring admission
- Hypoglycemia in non-diabetic patient (usually significant underlying pathology)
Extra information:
Causes of hypoglycemia in non-diabetic patients:
Exogenous drugs (alcohol, beta blockers)-
- Pituitary insufficiency
- Liver failure
- Addison’s disease
- Islet cell tumors
- Non-pancreatic insulin secreting tumors
- Sepsis
152
Prevention
If you have diabetes, sticking to your medication plan and eating regular meals can help prevent hypoglycaemia.
It's also important to monitor your blood glucose levels.
Monitoring blood glucose

Regularly monitoring your blood glucose levels can help you keep your blood glucose as normal and stable as
possible and will help you spot the signs and symptoms of hypoglycaemia quickly.
Your blood glucose level can vary throughout the day, so you may need to check it several times a day, depending on
the treatment you're taking.
You can monitor your blood glucose levels using a blood glucose meter, a small device that measures the
concentration of glucose in your blood.
Food and alcohol

If you have diabetes, strenuous physical activity can lead to hypoglycaemia. Eating extra carbohydrate-based foods
before and during exercise can help reduce the chances of this happening.
If you're taking insulin, your doctor may advise you to lower your dose before you do strenuous physical activity.
Alcohol can also affect your body's ability to release glucose. If you have type 1 diabetes, it's recommended that you
drink no more than 2 to 3 units of alcohol a day and eat a snack after drinking alcohol.
Spotting the signs

As hypoglycaemia can develop suddenly, it's important to be aware of the symptoms of hypoglycaemia so you can
treat it quickly. Tell your family and friends about the signs to look out for and let them know how to treat it.
People with diabetes are advised to carry a form of identification with them that states their condition, so they can be
helped quickly and efficiently.
Keep treatment with you

If you're at risk of hypoglycaemia, you should carry sugary food and drink with you at all times to treat mild cases as
soon as possible.
If you have diabetes, particularly type 1 diabetes, your doctor may recommend medications such as glucose gel to
carry with you. This can be used to treat hypoglycaemia that doesn't respond to normal treatment.
If you're being treated with insulin, you'll usually be given a kit that contains an injection of a medication called
glucagon. Family members or your carer can be trained to carry out the injection, which should be used if you lose
consciousness because of severe hypoglycaemia.
Preventing hypoglycaemia at night

It's important to avoid recurrent hypoglycaemia during the night (nocturnal hypoglycaemia) as it can reduce the
early symptoms of daytime episodes.
If you experience nocturnal hypoglycaemia, you can try:
keeping something sugary by your bedside
having a snack before bedtime, such as biscuits and milk
checking your blood glucose levels between 3am and 4am, when hypoglycaemia is most likely to occur
Hypoglycaemia and driving

As hypoglycaemia can cause confusion, drowsiness, or even unconsciousness, this can present a significant risk to
you or other road users.
If you have diabetes that requires treatment with insulin, you must:
inform the DVLA and your insurance company
test your blood sugar before driving and at regular intervals (at least every two hours) while driving
avoid driving if your blood glucose is low
avoid driving for 45 minutes after treating hypoglycaemia
carry rapid-acting carbohydrates with you in the vehicle at all times
If you experience hypoglycaemia while driving, pull over and stop as soon as it's safe to do so. Remove the keys from
the ignition and get out of the driver's seat before treating hypoglycaemia in the normal way.
If you have two or more episodes of hypoglycaemia that require assistance in a 12-month period, it's a legal
requirement to stop driving and inform the DVLA.
If you're a group two driver (you hold a licence to drive buses, coaches or lorries), you're legally required to stop
driving group two vehicles immediately and inform the DVLA if you have a single episode of hypoglycaemia that
requires assistance.
Inform your diabetes care team if you start having problems recognising hypoglycaemia or you start to have more
regular episodes, even if there were warning symptoms and you were able to treat them without assistance.
153
TM 19 B MED CX- HYPOGLYCAEMIA (LOW BLOOD SUGAR)
A low blood sugar, also called hypoglycaemia or a "hypo", is where the level of sugar (glucose) in your blood drops
too low.
It mainly affects people with diabetes, especially if you take insulin.
A low blood sugar can be dangerous if it's not treated promptly, but you can usually treat it easily yourself.
Symptoms of low blood sugar

A low blood sugar causes different symptoms for everybody.
You'll learn how it makes you feel if you keep getting it, although your symptoms may change over time.
Early signs of a low blood sugar
1- Feeling hungry
2- Sweating
3- Tingling lips
4- Feeling shaky or trembling
5- Dizziness
6- Feeling tired
7- A fast or pounding heartbeat (palpitations)
8- Becoming easily irritated, tearful, stroppy or moody
9- Turning pale
If not treated, you may then get other symptoms:

1- Weakness
2- Blurred vision
3- Difficulty concentrating
4- Confusion
5- Unusual behaviour, slurred speech or clumsiness (like being drunk)
6- Feeling sleepy
7- Seizures (fits)
8- Collapsing or passing out
Hypos can also occur while sleeping, which may wake you up during the night or cause headaches, tiredness or damp
sheets (from sweat) in the morning.
If you have a device to check your blood sugar level, a reading of less than 4mmol/L is too low and should be treated.
Treatment for low blood sugar
A) Treating a low blood sugar, yourself

Follow these steps if your blood sugar is less than 4mmol/L or you have hypo symptoms:
1- Have a sugary drink or snack – try something like a small glass of non-diet fizzy drink or fruit juice, a small handful
of sweets, or four or five dextrose tablets.
2- Test your blood sugar after 10-15 minutes – if it's 4mmol or above and you feel better, move on to step 3. If it's still
below 4mmol, treat again with a sugary drink or snack and take another reading in 10-15 minutes.
3- Eat your main meal (containing carbohydrate) if you're about to have it or have a carbohydrate-containing snack –
this could be a slice of toast with spread, a couple of biscuits or a glass of milk.
4- You don't usually need to get medical help once you're feeling better if you only have a few hypos but tell your
diabetes team if you keep having them or if you stop having symptoms when your blood sugar goes low.
B) Treating someone who's unconscious or very drowsy

Follow these steps:
1- Put the person in the recovery position and don't put anything in their mouth – so they don't choke.
2- Give them an injection of glucagon medicine – if it's available and you know how to do it. Call 999 for an ambulance
if an injection isn't available or you don't know how to do it.
3- Wait about 10 minutes if you've given them an injection – move on to step 4 if the person wakes up and starts to
feel better. Call 999 for an ambulance if they don't improve within 10 minutes.
4- Give them a sugary drink or snack, followed by a carbohydrate-containing snack – the drinks and snacks used to
treat a low blood sugar yourself should work.
5- Tell your diabetes care team if you ever have a severe hypo that caused you to lose consciousness.
154
C)Treating someone having a seizure (fit)
Follow these steps if someone has a seizure due to low blood sugar:
1- Stay with them and stop them from hurting themselves – lie them down on something soft and move them away
from anything dangerous (like a road or hot cooker).
2- Give them a sugary snack once the seizure stops – if the seizure stops in a few minutes, treat them as you would
treat a low blood sugar yourself once you're able to.
3- Call 999 for an ambulance if the seizure lasts more than five minutes.
4- Tell your diabetes care team if you ever have a severe hypo that caused you to have a seizure.
Causes of low blood sugar

In people with diabetes, the main causes of low blood sugar are:
1- Taking too much diabetes medicine – especially too much insulin, medicines called sulphonylureas (such as
glibenclamide and gliclazide) or medicines called glinides (such as repaglinide and nateglinide)
2- Skipping or delaying a meal
3- Eating less carbohydrate-containing food than usual, such as bread, cereals, pasta, potato and fruit
4- Exercise or activity, especially if it's intense or unplanned
5- Binge drinking or drinking alcohol on an empty stomach
Note: Sometimes there's no obvious reason why low blood sugar happens.
Preventing low blood sugar

If you have diabetes, these tips can help reduce your chances of getting low blood sugar:
1- Check your blood sugar regularly and be aware of the symptoms of a low blood sugar so you can treat them
quickly.
2- Always carry a sugary snack or drink with you, such as dextrose tablets, a carton of fruit juice or some sweets. If
you have a glucagon injection kit, keep it with you at all times.
3- Don't skip meals.
4- Be careful when drinking alcohol. Don't drink large amounts in a short space of time, and avoid drinking on an
empty stomach.
5- Take care when exercising. Eating a carbohydrate-containing snack before exercise can help reduce the risk of a
hypo. If you take insulin, you may be advised to take a lower dose before or after doing strenuous exercise.
6- Have a carbohydrate-containing snack, such as biscuits or toast, before going to bed to stop your blood sugar level
dipping too low while you sleep.
7- If you keep getting low blood sugar, talk to your diabetes care team about things you can do to help prevent it.
Low blood sugar without diabetes

Low blood sugar is uncommon in people who don't have diabetes.
Possible causes include:
1- Eating large carbohydrate-based meals – this is called "reactive hypoglycaemia"
2- Binge drinking
3- Fasting or malnutrition
4- Having a gastric bypass (a type of weight loss surgery)
5- Other medical conditions – including Addison's disease; a non-cancerous growth in the pancreas (insulinoma); or a
problem with the liver, kidneys or heart
6- Some medicines, including quinine (taken for malaria)
See your GP if you think you keep getting low blood sugar. They can arrange some simple tests to check if your blood
sugar level is low and try to find out what's causing it.
Management in hospital
A. Adults who are conscious, orientated and able to swallow.
1) Give 15-20g quick acting carbohydrate of the patient’s choice where possible. Some examples are:
• 5-7 Dextrosol® tablets (or 4-5 Glucotabs®)
• 1 bottle (60ml) Glucojuice®
• 150-200ml pure fruit juice e.g. orange
• 3-4 heaped teaspoons of sugar dissolved in water
Note: Patients following a low potassium diet (due to chronic kidney disease) should not use orange juice
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to treat hypoglycaemia due to its potassium content.
Note: Sugar dissolved in water is not an effective treatment for patients taking antidiabetic medication such as
acarbose as it prevents the breakdown of sucrose to glucose. It should also only be considered if no other treatment
options are
readily available.
2) Repeat capillary blood glucose measurement 10-15 minutes later. If it is still less than 4.0mmol/L, repeat
step 1 (no more than 3 treatments in total).
3) If blood glucose remains less than 4.0mmol/L after 30-45 minutes or 3 cycles, contact a doctor. Consider:
• 1mg of glucagon IM (may be less effective in patients prescribed sulfonylurea therapy or under the
influence of alcohol)
• 150-200ml of 10% glucose over 15 minutes (e.g. 600-800ml/hr). Care should be taken with infusion
pump settings if larger volume bags are used to ensure that the whole bag is not inadvertently
administered. Volume should be determined by clinical circumstances
4) Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate
of the patient’s choice where possible, taking into consideration any specific dietary requirements.
Examples include:
• Two biscuits
• One slice of bread/toast
• 200-300ml glass of milk (not soya)
• Normal meal if due (must contain carbohydrate)
Note: Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen
stores (double the suggested amount above) although nausea associated with glucagon injections may
be an issue.
5) DO NOT omit insulin injection if due However, insulin regimen review may be required.
6) Patients who self-manage their insulin pumps (CSII) may not need a long acting carbohydrate but should
take initial treatment as outlined and adjust their pump settings appropriately. Many patients will have a
locally devised hypoglycaemia protocol that should be checked to ensure that it remains appropriate for
use in the inpatient setting.
7) If the hypoglycaemia was due to sulfonylurea or long acting insulin therapy then be aware that the risk of
hypoglycaemia may persist for up to 24-36 hours following the last dose, especially if there is concurrent
renal impairment.
8) Document event in patient’s notes. Ensure regular capillary blood glucose monitoring is continued
for at least 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged. Give
hypoglycaemia education or refer to local Diabetes Inpatient Team.
B. Adults who are conscious but confused, disorientated, unable to cooperate or aggressive but are able to
swallow:
1) If the patient is capable and cooperative, follow section A in its entirety.

2) If the patient is not capable and/or uncooperative, but is able to swallow give either 1.5 -2 tubes 40%
glucose gel (Glucogel) squeezed into the mouth between the teeth and gums or if this is ineffective,
give glucagon 1mg IM (may be less effective in patients prescribed sulfonylurea therapy/patients
currently under the influence of alcohol).
3) Repeat capillary blood glucose levels after 10-15 minutes. If it is still less than 4.0mmol/L repeat steps 1
and/or 2 (no more than 3 treatments in total and only give IM glucagon once).
4) If blood glucose level remains less than 4.0mmol/L after 30-45 minutes, contact a doctor. Consider
intravenous glucose (i.e. 150-200ml of 10% glucose over 15 minutes delivered at an infusion rate of
600-800ml/hr). Care should be taken with infusion pump settings if larger volume bags are used to
ensure that the whole bag is not inadvertently administered. Volume should be determined by clinical
circumstances.
5) Once blood glucose is above 4.0mmol/L and the patient has recovered, give a long acting carbohydrate
of the patient’s choice where possible, taking into consideration any specific dietary requirements.
Examples include:
• Two biscuits
• One slice of bread/toast
• 200-300ml glass of milk (not soya)
• Normal meal if due (must contain carbohydrate)
Note: Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen
stores (double the suggested amount above).
Note: Patients who self-manage their insulin pumps (CSII) may not need a long acting carbohydrate but
should take initial treatment, continue their pump and assess for the cause of the episode.
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6) DO NOT omit insulin injection if due. However, insulin regimen review may be required.
7) Patients who self-manage their insulin pumps (CSII) may not need a long acting carbohydrate but should
take initial treatment as outlined and adjust their pump settings appropriately. Many patients will have a
locally devised hypoglycaemia protocol that should be checked to ensure that it remains appropriate for
use in the inpatient setting.
renal impairment.
hypoglycaemia education or refer to Diabetes Inpatient Team.
C. Adults who are unconscious and/or having seizures and/or are very aggressive
1) Check: Airway (and give oxygen)

i. Breathing
ii. Circulation
iii. Disability (including GCS and blood glucose)
iv. Exposure (including temperature)
2) If the patient has an insulin infusion in situ, stop immediately
3) Request immediate assistance from medical staff (e.g. “fast bleep” a doctor)
4) The following three options (i-iii) are all appropriate; local agreement should be sought:
i. If IV access available, give 75-100ml of 20% glucose over 15 minutes, (e.g. 300-400ml/hr). A 100ml
preparation of 20% glucose is now available that will deliver the required amount after being run
through a standard giving set. If an infusion pump is available use this, but if not readily available the
infusion should not be delayed (see Appendix 5 for administration details). Repeat capillary blood
glucose measurement 10 minutes later. If it is still less than 4.0mmol/L, repeat.
ii. If IV access available, give 150-200ml of 10% glucose (over 15 minutes, e.g. 600-800ml/hr). If an
infusion pump is available use this, but if not readily available the infusion should not be delayed. Care
should be taken if larger volume bags are used to ensure that the whole infusion is not inadvertently
administered. Repeat capillary blood glucose measurement 10 minutes later. If it is still less than
4.0mmol/L, repeat (refer to Appendix 5 for administration details).
iii. If no IV access is available then give 1mg Glucagon IM. Glucagon 1mg IM may be less effective in
patients prescribed sulfonylurea therapy and may take up to 15 minutes to take effect. Glucagon
mobilises glycogen from the liver and will be less effective in those who are chronically malnourished
(including those who have had a prolonged period of starvation), abuse alcohol or have severe liver
disease. In this situation IV glucose is the preferred option.
5) Once the blood glucose is greater than 4.0mmol/L and the patient has recovered give a long acting
carbohydrate of the patient’s choice where possible, taking into consideration any specifc dietary
requirements. Some examples are:
a. Two biscuits
b. One slice of bread/toast
c. 200-300ml glass of milk (not soya)
d. Normal meal if due (must contain carbohydrate)
N.B. Patients given glucagon require a larger portion of long acting carbohydrate to replenish glycogen
stores (double the suggested amount above).
N.B. Patients who self-manage their insulin pumps (CSII) may not need a long acting carbohydrate.
6) DO NOT omit insulin injection if due. However, insulin regimen review may be required.
7) If the patient was on IV insulin, continue to check blood glucose every 15 minutes until above
3.5mmol/L, then re-start IV insulin after review of dose regimen to try and prevent hypoglycaemia
recurrence. Consider concurrent IV 10% glucose infusion at 100ml/hr and/or stepping down the insulin
increments on the variable scale if appropriate (check local Trust guidance)
renal impairment.
hypoglycaemia education or refer to DISN(Diabetic In patient Specialist Nurse) or Diabetes Inpatient
D. Adults who are ‘Nil by Mouth’

1) If the patient has a variable rate intravenous insulin infusion, adjust as per prescribed regimen, and seek
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medical advice. Most variable rate intravenous insulin infusions should be restarted once blood glucose is
above 4.0mmol/L although an infusion rate adjustment may be indicated.
2) Options i and ii (intravenous glucose) as above in section C are both appropriate treatment options.
Again, local agreement should be sought.
3) Once blood glucose is greater than 4.0mmol/L and the patient has recovered consider intravenous
infusion of 10% glucose at a rate of 100ml/hr (refer to Appendix 5 for administration details) until
patient is no longer ‘Nil by Mouth’ or has been reviewed by a doctor.
renal impairment.
hypoglycaemia education or refer to DISN.
E. Adults requiring enteral/parenteral feeding

Patients requiring total parenteral nutrition (TPN) should be referred to a dietitian/nutrition team and
diabetes team for individual assessment
Risk factors for hypoglycaemia
• Blocked/displaced tube
• Change in feed regimen
• Enteral feed discontinued
• TPN or IV glucose discontinued
• Diabetes medication administered at an inappropriate time to feed
• Changes in medication that cause hyperglycaemia e.g. steroid therapy reduced/stopped
• Feed intolerance
• Vomiting
• Deterioration in renal function
• Severe hepatic dysfunction
Treatment – To be administered via feed tube:
Do not administer these treatments via a TPN line
In patients receiving TPN, treatment should be administered orally or intravenously as appropriate.
1) Give 15-20g quick acting carbohydrate of the patient’s choice where possible. Some examples are:
– 1.5 - 2 tubes 40% glucose gel (Glucogel)
– 1 bottle (60ml) Glucojuice®
– 150-200ml orange juice
– 110 – 140ml Fortijuice (NOT Fortisip) to give 15-20g carbohydrate
– Re-start feed to rapidly deliver 15 – 20g carbohydrate
N.B. All treatments should be followed by a 40-50ml water flush of the feeding tube to prevent tube
blockage.
2) Repeat capillary blood glucose measurement 10 to 15 minutes later. If it is still less than 4.0mmol/L,
repeat step 1 (no more than 3 treatments in total).
3) If blood glucose remains less than 4.0mmol/L after 30-45 minutes (or 3 cycles), consider 150-200ml
of 10% glucose administered intravenously over 15 minutes, (e.g. 600-800ml/hr). Care should be
taken with infusion pump settings if larger volume bags are used to ensure that the whole bag is not
inadvertently administered.
4) Once blood glucose is above 4.0mmol/L and the patient has recovered:
– Restart feed
– If bolus feeding, give additional bolus feed
– 10% IV glucose at 100ml/hr. Volume should be determined by clinical circumstances
5) DO NOT omit insulin injection if due (However, insulin regime review may be required).
renal impairment.
for at least 24 to 48 hours. Ask the patient to continue this at home if they are to be discharged.
Give hypoglycaemia education or refer to DISN. Ensure patient has been referred to a dietician for
individualised hypoglycaemia treatment advice
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TM MED CX-VASCULAR DEMENTIA- 20
Vascular dementia is a common type of dementia caused by reduced blood flow to the brain.
Around 17% of people diagnosed with dementia will have vascular dementia.
It's estimated to affect around 150,000 people in the UK.
"Dementia" is the name for problems with mental abilities caused by gradual changes and damage in
the brain. It's rare in people under 65.
Vascular dementia tends to get worse over time, although it's sometimes possible to slow it down.
It is the second most common form of dementia in the over 65 age group
Vascular dementia can start suddenly or come on slowly over time.

Symptoms:
-Slowness of thought
-Difficulty with planning and understanding
-Problems with concentration
-Mood, personality or behavioural changes
-Feeling disorientated and confused
-Difficulty walking and keeping balance
-Symptoms of Alzheimer’s disease, such as problems with memory and language (many people with
vascular dementia also have Alzheimer's)
These problems can make daily activities increasingly difficult and someone with the condition may
eventually be unable to look after themselves.
Risk factors:
Modifiable
PMH
-Hypertension
-High cholesterol
-Diabetes
-Atrial fibrillation and other types of heart disease
Life Style
-Smoking
-Unhealthy diet
-Lack of exercise
-Being overweight/obese
-Excessive alcohol consumption
Non-modifiable
-Age – the risk of vascular dementia increases as you get older, with people over 65 most at risk
-Ethnicity – if you have a south Asian, African or Caribbean background, your risk of vascular
dementia is higher, as related problems such as diabetes and high blood pressure are more common
in these groups
-Family history – your risk of problems such as strokes is higher if a close family member has had
them
- Gender: vascular dementia is diagnosed in slightly more men than women.
The different types of vascular dementia have some symptoms in common and some symptoms that
differ. Their symptoms tend to progress in different ways.
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What causes vascular dementia?
Vascular dementia is an umbrella term for a group of conditions caused by problems with blood
circulation to the brain.
It is caused by small blood clots preventing oxygen reaching the brain tissue.
The small clots are sometimes known as Transient Ischaemic Attacks or TIAs.
Damage to the blood supply can also be caused by blocked arteries (atherosclerosis) or bursting of
blood vessels in the brain (haemorrhage).
What happens?
The progression of vascular dementia can be quite erratic as the person may not have a series of
TIAs for some time.
After a series of TIAs the person will also experience a very small amount of recovery so appear to be
‘getting better’. This is a temporary situation, as the damage to the brain could eventually lead to
difficulties e.g. with daily living, attention, memory, decision making and motivation. The term ‘step
wise progression’ is often used to describe this.
Types of vascular dementia

1- Stroke-related dementia
A stroke happens when the blood supply to a part of the brain is suddenly cut off. In most strokes, a
blood vessel in the brain becomes narrowed and is blocked by a clot. The clot may have formed in
the brain, or it may have formed in the heart (if someone has heart disease) and been carried to the
brain. Strokes vary in how severe they are, depending on where the blocked vessel is and whether
the interruption to the blood supply is permanent or temporary.
2- Post-stroke dementia
A major stroke occurs when the blood flow in a large vessel in the brain is suddenly and
permanently cut off. Most often this happens when the vessel is blocked by a clot. Much less often it
is because the vessel bursts and bleeds into the brain. This sudden interruption in the blood supply
starves the brain of oxygen and leads to the death of a large volume of brain tissue.
Not everyone who has a stroke will develop vascular dementia, but about 20 per cent of people who
have a stroke do develop this post-stroke dementia within the following six months. A person who
has a stroke is then at increased risk of having further strokes. If this happens, the risk of developing
dementia is higher.
3- Single-infarct and multi-infarct dementia

These types of vascular dementia are caused by one or more smaller strokes. These happen when a
large or medium-sized blood vessel is blocked by a clot. The stroke may be so small that the person
doesn't notice any symptoms. Alternatively, the symptoms may only be temporary - lasting perhaps
a few minutes - because the blockage clears itself. (If symptoms last for less than 24 hours this is
known as a 'mini-stroke' or transient ischaemic attack, in short TIA).
If the blood supply is interrupted for more than a few minutes, the stroke will lead to the death of a
small area of tissue in the brain. This area is known as an infarct. Sometimes just one infarct forms in
an important part of the brain and this causes dementia (known as single-infarct dementia). Much
more often, a series of small strokes over a period of weeks or months lead to a number of infarcts
spread around the brain. Dementia in this case (known as multi-infarct dementia) is caused by the
total damage from all the infarcts together.
4- Subcortical dementia
Subcortical vascular dementia is caused by diseases of the very small blood vessels that lie deep in
the brain. These small vessels develop thick walls and become stiff and twisted, meaning that blood
flow through them is reduced.
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Small vessel disease often damages the bundles of nerve fibres that carry signals around the brain,
known as white matter. It can also cause small infarcts near the base of the brain.
Small vessel disease develops much deeper in the brain than the damage caused by many strokes.
This means many of the symptoms of subcortical vascular dementia are different from those of
stroke-related dementia.
Subcortical dementia is thought to be the most common type of vascular dementia.
5- Mixed dementia (vascular dementia and Alzheimer's disease)

At least 10 per cent of people with dementia are diagnosed with mixed dementia. This generally
means that both Alzheimer's disease and vascular disease are thought to have caused the dementia.
The symptoms of mixed dementia may be similar to those of either Alzheimer's disease or vascular
dementia, or they may be a combination of the two.
Diagnosis:
-An assessment of symptoms – for example, whether there are typical symptoms of vascular
dementia
-A full medical history, including asking about a history of conditions related to vascular dementia,
such as stroke or high blood pressure
-An assessment of mental abilities –this will usually involve a number of tasks and questions
-A brain scan, such as an MRI scan, CT scan, or a single photon-emission computed tomography
(SPECT) scan – this can detect signs of dementia and damage to the blood vessels in the brain
Preventing vascular dementia

Individuals can reduce their risk factors by:
1- Having regular health care checks with your GP, if you have a long-term condition like diabetes or
thyroid problems, is important to keep these conditions well managed.
2- Take advantage of ‘well-person health checks’ at your GP surgery so that your blood pressure,
weight and cholesterol levels are well managed.
3- If you are prescribed medication make sure you understand what it is for, you are compliant with
the dosage and that you have regular reviews with your GP.
4- If your weight has changed over the years seek support with your diet and monitoring of weight
loss to ensure you are eating healthily and the weight loss is maintained.
5- If you smoke ask your GP about a smoking cessation programme so you have some support and
care and are successful in giving up.
6- Keeping physically fit is very important, so taking regular exercise like walking, swimming and
group activity like tennis and fitness classes.
7- Making sure you keep socially active is important, so that you are talking to people in a group
situation as well as one to one.
8- Hobbies like art, woodwork, needlework, knitting, puzzles and listening to music help stimulate
different areas of the brain and help with attention and concentration.
Managing the effects of vascular dementia

Symptoms of vascular dementia can vary depending on which area of the brain has been affected.
Changes in mood, behaviour, ability to perform daily activities can be affected.
Diet and brain health

Recent studies have concluded that the MIND diet (Mediterranean-DASH Intervention for
Neurodegenerative Delay) can aid brain health. It is a combination of a diet to reduce blood pressure
(DASH) and the Mediterranean diet.
10 “brain healthy” foods

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- Green leafy veg
- Other colourful veg
- Nuts
- Berries – e.g. blueberries, strawberries
- Beans, lentils, soya
- Wholegrains
- Fish
- Poultry
- Olive oil
- Red wine – in moderation!
5 “unhealthy” foods
- Red meats
-Butter and margarines
- Cheese
- Pastries and sweets
- Fried and “fast foods”
Should you follow the MIND Diet?

We understand it may be hard to follow it rigidly, however in the studies even those people who
partly followed the diet obtained some benefit. Making your diet more “MIND like” will make it
easier to follow long term. Diet is important, but it is only one aspect of lifestyle changes associated
with reduced risk.
Planning ahead if you have received a diagnosis

Talk to your family and the people close to you about the future. Think about what help you would
like.
You may also like to think about things you would really like to do, people you would like to meet,
holidays you would like to plan. Having some plans in place helps with a positive outlook on the
future and opens up conversations with people who care about you and would like to support you.
Thinking about your future health needs can be difficult and feel like an unnecessary step but it will
help you and the people who know you well to choose treatments and services that you would prefer
in the future. You can put a Health and Welfare Power of Attorney in place and an Advance Care Plan.
Putting these things in place will give you and your family time to look at treatments and support
that is available and make sure you are aware of all the choices that are available to you for the
future.
Gaining some financial advice as soon as you can will help you get your finances in order and make
sure your finances are protected. A Lasting Power of Attorney is an important safeguard for you and
anybody who is helping you with your finances. It is best to get support from a solicitor or an
organisation like Age UK to help you with this.
Financial support is available to you regardless of you financial status. You can claim for Attendance
Allowance (which is non-means tested) if you are over 65 years or Personal Independence Payment
if you are under 65 years. If you live with another person you can also claim a 25% council tax
reduction from your local authority.
There are a variety of housing options to choose from. If you are renting you can get support from
you local authority housing department. There are also choices of housing in the assisted living and
sheltered housing options.
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TM 22 MED CX-AMLODIPINE and BP Mx in DM
AMLODIPINE
About amlodipine
Amlodipine is a calcium-channel blocker
It is taken once a day.
You can take the tablets before or after meals.
When you first start taking amlodipine you may get a headache or feel flushed and hot. These symptoms tend to go
after the first few days.
Amlodipine is given to treat high blood pressure (hypertension).
It is also taken to help prevent angina chest pain.
The patient may have been prescribed it for either of these reasons.
Amlodipine works by causing some of your blood vessels to relax and widen.
This lowers the blood pressure. It also reduces the force and the rate of the heartbeat, and this helps to prevent
angina chest pain. It does these things by blocking the amount of calcium that goes into the 'smooth' muscle cells in
the walls of your arteries and in the heart. Calcium is needed for muscles to contract, so reducing the amount of
calcium causes the muscle cells to relax.
Amlodipine is also available as a combination tablet with other medicines to reduce high blood pressure.
Combination tablets help to reduce the total number of tablets the patient need to take each day.
Before taking amlodipine

Some medicines are not suitable for people with certain conditions, and sometimes a medicine may only be used if
extra care is taken. For these reasons, before taking amlodipine it is important that your doctor knows:
1- If you are pregnant or breast-feeding.
2- If you have problems with the way your liver works.
3- If you are taking or using any other medicines. This includes any medicines you are taking which are available to
buy without a prescription, as well as herbal and complementary medicines.
4- If you have ever had an allergic reaction to a medicine.
How to take amlodipine

1- Amlodipine is taken once a day. It is usual to be prescribed the 5 mg strength tablet to take at first, although the
strength of your tablets may be increased to 10 mg after a short while.
2- You can generally choose a time of day to take your tablets that you find easiest to remember but try to take your
doses at the same time of day each day. This will help you to avoid missing doses.
3- Swallow the tablet with a drink of water. You can take amlodipine before or after meals.
4- If you forget to take a dose at your usual time, take it as soon as you remember. If you do not remember until the
following day, leave out the missed dose. Do not take two doses together to make up for a forgotten dose.
Getting the most from your treatment

1- Try to keep your regular appointments with your doctor. This is so your doctor can check on your progress.
2- Your doctor will discuss with you the possibility of unwanted side-effects. When you first start taking amlodipine
you may experience headaches, feeling flushed, and some dizziness. These effects usually only last for a few days, but
if they continue or become troublesome, you should let your doctor know.
3- If you drink alcohol, ask your doctor for advice. Your doctor may recommend that you do not drink alcohol while
you are on this medicine, as it may increase the chance that you experience side-effects, such as feeling dizzy or light-
headed.
4- Treatment with amlodipine is usually long-term unless you experience an adverse effect. Continue to take the
tablets unless you are told otherwise by your doctor. If it is necessary for you to stop, your doctor may want you to
reduce your dose over a few days, as suddenly stopping taking amlodipine can cause your symptoms to return.
5- If you buy any medicines, always check with a pharmacist that they are suitable to take with your other medicines.
Some anti-inflammatory painkillers may reduce the effectiveness of amlodipine.
6- If you need to have an operation or any medical treatment, always tell the person carrying out the treatment which
medicines you are taking. Amlodipine may interfere with the way some anaesthetics work.
7-It is not advisable for you to drink large quantities of grapefruit juice. This is because a chemical in grapefruit juice
may increase the amount of amlodipine in your bloodstream and this could make side-effects more likely.
Can amlodipine cause problems?

Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences
them. The table below contains some of the most common ones associated with amlodipine.
The unwanted effects often improve as your body adjusts to the new medicine, but speak with your doctor or
pharmacist if any of the following continue or become troublesome.
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Common side effect of Amlodipine
Common amlodipine side-effects (these affect less than 1 in 10 people)
Side effect solution

1- Headache, feeling flushed or hot. These may occur during the first few days but usually
soon go. Speak with your doctor if they continue
beyond a few days.
2- Abdominal discomfort, feeling sick (nausea) Stick to simple meals - avoid rich and spicy foods
3- Swollen ankles Raise your legs on to a low stool when you are sitting
4- Feeling dizzy or tired If this happens, do not drive and do not use tools or
machines until you feel better
5- The sensation of having a 'thumping' heart If troublesome, speak with your doctor
(palpitations)
ENALAPRIL
About Enalapril
The first dose of enalapril can make you feel dizzy. It is best taken at bedtime.
Enalapril is generally well tolerated but if you develop a troublesome cough, you must let your doctor know.
Some painkillers and indigestion remedies can interfere with enalapril. Ask your pharmacist for advice before you
buy any medicines 'over the counter'.
Enalapril belongs to a class of medicines called angiotensin-converting enzyme (ACE) inhibitors.

You may have been prescribed it to reduce high blood pressure (hypertension), or to prevent (or treat) heart failure.
Heart failure is a condition where your heart does not work as well as it should.
ACE inhibitors like enalapril prevent your body from creating a hormone known as angiotensin II. They do this by
blocking (inhibiting) a chemical called angiotensin-converting enzyme. This widens your blood vessels and helps to
reduce the amount of water put back into your blood by your kidneys. These actions help to decrease blood pressure.
Although people with high blood pressure often do not feel unwell, if left untreated, high blood pressure can harm the
heart and damage blood vessels, leading to a heart attack or stroke.
Enalapril can be used on its own or alongside other medicines which reduce blood pressure.
In heart failure, there can be too much circulating fluid in your blood vessels because your heart is not working as
efficiently as it once did. Enalapril helps to reduce this. It also appears to have a protective effect on the heart and
slows the progression of the heart failure.
Before taking enalapril

Some medicines are not suitable for people with certain conditions, and sometimes a medicine can only be used if
extra care is taken. For these reasons, before you start taking enalapril it is important that your doctor knows:
1- If you are pregnant or breast-feeding.
2- If you have any problems with the way your kidneys work, or any problems with the way your liver works.
3- If you are lacking in fluid in the body (dehydrated) - for example, if you have had diarrhoea or sickness very
recently.
4- If you have been told you have a build-up of fatty deposits on the walls of your arteries, a condition called
atherosclerosis.
5- If you have a particular type of poor circulation called peripheral arterial disease.
6- If you have collagen vascular disease - this includes conditions such as systemic lupus erythematosus (SLE) and
scleroderma.
7- If you have been told you have heart muscle disease (cardiomyopathy), or narrowing of the main blood vessel from
your heart (aortic stenosis).
8- If you have ever had a reaction where your face, tongue or throat swells (angio-oedema).
9- If you are having desensitisation treatment to protect against bee and wasp stings.
10- If you are having dialysis treatment, or treatment to remove cholesterol from your blood by a machine (LDL
apheresis).
11- If you are taking any other medicines. This includes any medicines you are taking which are available to buy
without a prescription, as well as herbal and complementary medicines.
164
12- If you have ever had an allergic or unusual reaction to any other ACE inhibitor (such as captopril, ramipril or
perindopril), or to any other medicine.
How to take enalapril

1- Before you start the treatment, read the manufacturer's printed information leaflet from inside the pack. It will
give you more information about enalapril and will provide you with a full list of side-effects which you could
experience from taking it.
2- Take the tablets exactly as your doctor tells you to.
3- If you are being treated for high blood pressure: enalapril is taken once a day. You will be advised to take your very
first dose at bedtime. This is because you can feel quite dizzy when you first start taking it. After the first dose, you
can generally take enalapril at a time of day you find easy to remember. For most people this will be in the morning.
4- If you are being treated for heart failure: your doctor will give you a small once-daily dose to begin with, and then
your dose will be increased gradually over a few weeks. Once the dose has been increased, enalapril is commonly
taken as two doses a day, one taken in the morning and the other in the evening. Increasing your dose slowly like this
helps to avoid unwanted side-effects, such as dizziness.
5- Try to take your doses at the same time(s) of day each day as this will help you to remember to take your doses
regularly. You can take enalapril tablets either with or without food. It is best to swallow the tablet with a drink of
water.
6- There are several strengths of enalapril tablet. Your doctor will prescribe the strength which is suitable for your
condition. Each time you collect a new supply, check to make sure the tablets are the strength that you are expecting.
7- If you forget to take a dose at your usual time, take it as soon as you remember (unless it is nearly time for your
next dose, in which case do not take the forgotten dose but take the next dose when it is due). Do not take two doses
together to make up for a missed dose.
Getting the most from your treatment

1- Try to keep your regular appointments with your doctor. This is so your progress can be monitored. Your doctor
will want you to have some blood tests from time to time to check that your kidneys are working well.
2- It is very important that you follow any dietary and lifestyle advice that you have been given by your doctor. This
can include advice about eating a healthy diet, not smoking, and taking regular exercise.
3- If you buy any medicines, check with a pharmacist that they are suitable to take with enalapril. This is because
some medicines (such as anti-inflammatory painkillers and indigestion remedies) can interfere with your treatment.
4- It is likely that your doctor will advise that you do not use salt substitutes while you are taking enalapril. These
products have a high content of potassium which could be harmful for you.
5- If you drink alcohol, ask your doctor for advice about drinking alcohol while you are on enalapril. Alcoholic drinks
can make you feel light-headed or dizzy, and they may not be advisable for you.
6- If you have diabetes you may need to check your blood glucose more frequently, as the tablets can lower the levels
of sugar in your blood. Your doctor will advise you about this.
7- If you are having an operation or dental treatment, tell the person carrying out the treatment that you are taking
enalapril. This is because some anaesthetics could cause your blood pressure to drop too low.
8- Treatment with enalapril is often long-term unless you experience an adverse effect. Continue to take the tablets
unless you are advised otherwise.
Can enalapril cause problems?

Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences
them. The table below contains some of the more common ones associated with enalapril.
Very common enalapril side-effects (these affect more than 1 in 10 people)
1-Dry irritating cough:

If this continues, speak with your doctor, as an alternative medicine may be better for you
2-Feeling dizzy or weak:
Getting up more slowly should help. If you begin to feel dizzy, lie down
so that you do not faint, then sit for a few moments before standing. If this continues beyond the first few days, speak
with your doctor. Do not drive and do not use tools or machines while you feel dizzy
3-Blurred eyesight:
Do not drive and do not use tools or machines while affected.
4-Feeling sick:
Stick to simple foods and avoid fatty or spicy meals.
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Common enalapril side-effects (these affect less than 1 in 10 people)
1-Headache:
Ask your pharmacist to recommend a suitable painkiller.
2-Tummy (abdominal) pain, diarrhoea:
Stick to simple foods and avoid fatty or spicy meals.
3-Low mood, feeling short of breath, taste disturbances, feeling faint, skin rash:
If any of these become troublesome, speak with your doctor.
4-Changes to the results of some blood tests:
Your doctor will check for this.
Note: If you experience any of the following potentially serious symptoms, stop taking enalapril and contact your
doctor for advice straightaway:
1- Any difficulty breathing, or swelling of your face, mouth, tongue or throat. These are signs of an allergic reaction.
2- Any yellowing of your skin or the whites of your eyes. These may be signs of a liver problem called jaundice, which
is a rare side-effect.
3- A severe skin rash.
If you experience any other symptoms which you think may be due to the tablets, speak with your doctor or
pharmacist for further advice.
Blood pressure management in diabetes patients
1- Measure blood pressure at least annually in an adult with type 2 diabetes without previously diagnosed
hypertension or renal disease. Offer and reinforce preventive lifestyle advice.
2- For an adult with type 2 diabetes on antihypertensive drug treatment when diabetes is diagnosed, review blood
pressure control and medications used. Make changes only if there is poor control or if current drug treatment is not
appropriate because of microvascular complications or metabolic problems.
3- Repeat blood pressure measurements within:
1 month if blood pressure is higher than 150/90 mmHg
2 months if blood pressure is higher than 140/80 mmHg
2 months if blood pressure is higher than 130/80 mmHg and there is kidney, eye or cerebrovascular damage.
Provide lifestyle advice (diet and exercise) at the same time.
4- Provide lifestyle advice if blood pressure is confirmed as being consistently above 140/80 mmHg (or above
130/80 mmHg if there is kidney, eye or cerebrovascular damage).
5- Add medications if lifestyle advice does not reduce blood pressure to below 140/80 mmHg (below 130/80 mmHg
if there is kidney, eye or cerebrovascular damage).
6- Monitor blood pressure every 1–2 months and intensify therapy if the person is already on antihypertensive drug
treatment, until the blood pressure is consistently below 140/80 mmHg (below 130/80 mmHg if there is kidney, eye
or cerebrovascular damage).
7- First-line antihypertensive drug treatment should be a once‑daily, generic angiotensin‑converting enzyme (ACE)
inhibitor. Exceptions to this are people of African or Caribbean family origin, or women for whom there is a
possibility of becoming pregnant.
8- The first-line antihypertensive drug treatment for a person of African or Caribbean family origin should be an ACE
inhibitor plus either a diuretic or a generic calcium‑channel blocker.
9- A calcium-channel blocker should be the first‑line antihypertensive drug treatment for a woman for whom, after
an informed discussion, it is agreed there is a possibility of her becoming pregnant.
10- For a person with continuing intolerance to an ACE inhibitor (other than renal deterioration or hyperkalaemia),
substitute an angiotensin II‑receptor antagonist for the ACE inhibitor.
11- Do not combine an ACE inhibitor with an angiotensin II‑receptor antagonist to treat hypertension.
12- If the person's blood pressure is not reduced to the individually agreed target with first‑line therapy, add a
calcium‑channel blocker or a diuretic (usually a thiazide or thiazide‑related diuretic). Add the other drug (that is, the
calcium‑channel blocker or diuretic) if the target is not reached with dual therapy.
13- If the person's blood pressure is not reduced to the individually agreed target with triple therapy, add an
alpha‑blocker, a beta‑blocker or a potassium‑sparing diuretic (the last with caution if the person is already taking an
ACE inhibitor or an angiotensin II‑receptor antagonist).
14- Monitor the blood pressure of a person who has attained and consistently remained at his or her blood pressure
target every 4–6 months. Check for possible adverse effects of antihypertensive drug treatment – including the risks
from unnecessarily low blood pressure.
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TM 23 MEDCIINE COUNSELLING - COELIAC DISEASE
Coeliac disease mainly affects the part of the gut called the small intestine. It can occur at any age. Coeliac disease is
caused by a reaction of the gut to gluten.
Gluten is part of certain foods - mainly foods made from wheat, barley and rye.
Gluten is found in any food that contains the above cereals, including: Pasta, cakes. breakfast cereals. most types of
bread, certain types of sauces and in some types of ready meals. In addition, most beers are made from barley
Various symptoms can develop including tummy (abdominal) pains, tiredness and weight loss. Symptoms go if you
do not eat any foods that contain gluten.
What is celiac disease?

Coeliac disease is a condition that causes inflammation in the lining of part of the gut (the small intestine).
Coeliac disease is not a food allergy or a food intolerance. It is an autoimmune disease. The immune system makes
white blood cells (lymphocytes) and antibodies to protect against foreign objects such as bacteria, viruses and other
germs. In an autoimmune disease, the immune system mistakes part or parts of the body as foreign. Other
autoimmune diseases include type 1 diabetes, rheumatoid arthritis and some thyroid disorders.
The lining of the small intestine contains millions of tiny tube-shaped structures called villi. These help food and
nutrients to be digested more effectively into the body. But, in people with coeliac disease, the villi become flattened
as a result of the inflammation. This means that food and nutrients are not so readily digested by the body.
Who is affected by coeliac disease?

Coeliac disease affects about 1 in 100 people in the UK. Anyone, at any age, can develop coeliac disease. It is a
condition that used to be associated with young children. However, it is now much more commonly diagnosed in
adults. It is most commonly diagnosed in people aged between 50 and 69. About 1 in 4 cases are first diagnosed in
people aged over 60.
Coeliac disease often runs in families. If you have a close family member who has coeliac disease (a brother, sister,
parent or child) then you have a 1 in 10 chance of developing coeliac disease. It is also more common in people who
have other autoimmune diseases - for example, some thyroid diseases, rheumatoid arthritis and type 1 diabetes.
What causes coeliac disease?

The cause is a sensitivity to gluten. Gluten occurs in common foods including wheat, barley and rye, and any foods
made from these such as bread, pasta and biscuits. Some people with coeliac disease are also sensitive to oats.
People with coeliac disease make antibodies against gluten. Antibodies are proteins in the immune system that
normally attack bacteria, viruses and other germs. In effect, the gut mistakes gluten to be harmful and reacts against
it as if it were fighting off a germ. These antibodies lead to inflammation developing in the lining of the small
intestine.
Coeliac disease can develop in babies. Older children or adults who have not previously had problems may also
become gluten-sensitive at some point in their lives and develop coeliac disease. It is not known why the immune
system of some people becomes sensitised to gluten.
Symptoms of coeliac disease

The inflammation in the lining of the gut (small intestine) stops food from being properly absorbed. You then do not
absorb nutrients very well into your body. A variety of symptoms may then develop.
Babies
Symptoms first develop soon after weaning when the baby starts eating solid foods containing gluten.
The baby may fail to grow or to gain weight.
As food is not being absorbed properly, the stools (faeces) may be pale and bulky.
Smelly diarrhoea may occur.
The tummy (abdomen) may become swollen.
The baby may be sick (vomit) repeatedly.
Older children
The symptoms of coeliac disease in older children may be similar to those in babies.
Poor absorption of food may cause deficiencies of vitamins, iron and other nutrients. This may cause anaemia and
other problems.
As the fat part of the diet is poorly absorbed, the faeces may be pale, smelly and difficult to flush away.
Diarrhoea may develop. However, the symptoms may not be very typical or obvious.
If the gut and bowel symptoms are only mild then the first thing that may be noticed is poor growth.
Adults
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Poor absorption of food may cause deficiencies of vitamins, iron and other nutrients.
Anaemia due to poor absorption of iron is common.
Other common symptoms include abdominal pains which tend to come and go, excess wind, bloating, diarrhoea and
tiredness or weakness.
Mouth ulcers may occur.
You may lose weight due to poor absorption of food. However, most adults with coeliac disease do not lose weight
and are not underweight.
Occasionally, an itchy skin condition called dermatitis herpetiformis can occur in some people with coeliac disease.
If the common symptoms described above develop, the diagnosis may be made quickly.
However, common or typical symptoms do not always develop. Particularly in adults, the areas affected in the gut
may be patchy. Symptoms may then be mild, or not typical, and it may be a while before the diagnosis is made. The
average time from first symptoms to diagnosis is 13 years in the UK.
Diagnosing coeliac disease

If coeliac disease is suspected, a blood test to detect a certain antibody that occurs in coeliac disease may be advised
by your doctor. It is important that you are eating a diet containing gluten for at least six weeks before the blood test
is performed.
If the blood test is positive then you may be referred to a specialist who may arrange for a biopsy to be taken.
A biopsy is a procedure in which a small sample of tissue is taken. For coeliac disease testing, it is taken from the
inside lining of the gut (small intestine). The sample is looked at with a microscope to see if the typical changes of
coeliac disease are present. The biopsy is usually taken by a thin flexible tube (endoscope) which is passed down the
gullet (oesophagus), through the stomach and into the small intestine.
Other tests may be done to find out how much the poor absorption of food and nutrients has affected you. For
example, blood tests for anaemia and for the levels of vitamins, iron, protein, etc. You may be advised to have a
special bone scan (a DEXA scan) to see if your bones have become affected due to poor absorption of calcium and
vitamin D.
Note: If you suspect that you may have coeliac disease from your symptoms. Do not treat yourself by going on a
gluten-free diet without a confirmed diagnosis. If you do go on a gluten-free diet before the diagnosis is confirmed
then any tests done at a later time may not be conclusive and may even give negative results. So, get it checked out
first - and then treat it if it is confirmed.
Tests for coeliac disease

Coeliac disease tends to be under-diagnosed. There are certain groups of people who are much more likely to have
coeliac disease than others. They should have a test for coeliac disease even if they have no or few symptoms. This
includes people with:
1- Type 1 diabetes: If available, children should be tested for the most common gene types that are associated with
coeliac disease. These are HLA-DQ2 or HLA-DQ8. If they do not have these types, they are extremely unlikely to
develop coeliac disease. If this test is not available they should have the blood test for the specific antibody, every
three years.
2- Close relatives (parent, child, brother/sister) of a patient with coeliac disease.
3- Down's syndrome
4- Autoimmune conditions such as thyroiditis, Sjögren's syndrome or arthritis.
Coeliac disease treatment

Gluten-free diet
The main treatment for coeliac disease is not to eat any food that contains gluten for the rest of your life. The
symptoms then usually go within a few weeks. The main foods to stop are any that contain wheat, barley or rye. Many
common foods contain these ingredients, such as breads, pasta, cakes, pastries and some cereals. Potatoes, rice,
maize, corn, fruit, dairy products and soya-based foods are fine.
Foods made from gluten-free, uncontaminated (not mixed with other types of cereals) oats are usually safe to eat.
However, some people with coeliac disease have symptoms if they eat these oats.
You should get advice from a dietician. Coeliac UK also provides advice about which foods are suitable. You can buy
special gluten-free flour, pasta, bread and other foods. These are also available on prescription, from health food
shops, by mail order and via the internet. There are many diet sheets with food alternatives and recipes.
Unfortunately, many processed foods, ready-made meals and fast foods contain gluten. Food labels should now
always say whether the food contains gluten or not.
Avoiding gluten is for life. If you eat gluten again, symptoms will return. Even small amounts of gluten can sensitise
the gut (small intestine) again. To avoid symptoms and complications, you must be strict about avoiding all foods that
contain gluten.
You may have to accept some restriction on lifestyle. However, the many foods that are allowed are varied and
interesting
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Other treatments
In addition to avoiding gluten, you may be advised to take some vitamin, calcium and iron supplements, at least for
the first six months following diagnosis. This is to replace any deficiencies and also to make sure you get enough of
these whilst the gut lining is returning to normal.
Having coeliac disease can cause your spleen to work less effectively, making you more vulnerable to infection from
certain germs. If your spleen is working less effectively, you may need to have several immunisations including:
1- The flu (influenza) jab.
2- The Hib vaccine - which protects against blood poisoning, pneumonia and Hib meningitis.
3- The pneumococcal vaccine - which protects against infections caused by the germ (bacterium) Streptococcus
pneumoniae.
Are there any complications?

Although there is no once-and-for-all cure for coeliac disease, the symptoms can be kept away by having a diet free
from gluten. Also, having a gluten-free diet reduces the risk of developing complications in the future.
Apart from the symptoms listed above, people with coeliac disease have an increased risk of the following:
1- Developing 'thinning' of the bones (osteoporosis) due to the nutritional deficiencies which occur with coeliac
disease.
2- Developing a type of cancer (called lymphoma) of the gut in later life. This is rare.
3- Developing other immune-related diseases (autoimmune diseases) such as type 1 diabetes, an underactive thyroid
(hypothyroidism), Sjögren's syndrome and primary biliary cirrhosis.
4- Having a baby that has a low birth weight or is born prematurely if you become pregnant.
A common mistake is to eat small amounts of food which contain gluten. This may be unintentional. However, some
people wrongly think that a small amount won't matter. It does. A well-known example is thinking that the small
amount of bread in a communion wafer will not matter. Even this small amount of gluten is sufficient to cause
symptoms and to maintain the increased risks associated with coeliac disease detailed above.
Some people with coeliac disease may not realise they are taking small amounts of gluten. They may feel well, or
ignore mild symptoms such as bloating or mild diarrhoea. Again, the increased risks (osteoporosis, etc) still remain if
any gluten is eaten.
If you do not eat any gluten, you can expect to be free of symptoms and to have a normal healthy lifespan. The
increased risk of developing other autoimmune disorders reduces. Eating a gluten-free diet also reduces the risk of
developing lymphoma.
Follow-up
Once you have been diagnosed with coeliac disease, you are likely to have regular follow-up appointments. This may
initially be after three and six months to ensure that you are making satisfactory progress and managing your gluten-
free diet. Depending on your age and other factors, you may be monitored to see if you have developed 'thinning' of
the bones (osteoporosis).
You can expect to live a life free of the symptoms of coeliac disease if you totally avoid gluten.
Gastroscopy
A gastroscopy is a procedure where a thin, flexible tube called an endoscope is used to look inside the oesophagus
(gullet), stomach and first part of the small intestine (duodenum).
It's also sometimes referred to as an upper gastrointestinal endoscopy.
The endoscope has a light and a camera at one end. The camera sends images of the inside of your oesophagus,
stomach and duodenum to a monitor.
Why a gastroscopy may be used

A gastroscopy can be used to:
1- Investigate problems such as difficulty swallowing (dysphagia) or persistent abdominal (tummy) pain
2- Diagnose conditions such as stomach ulcers or gastro-oesophageal reflux disease (GORD)
3- Treat conditions such as bleeding ulcers, a blockage in the oesophagus, non-cancerous growths (polyps) or small
cancerous tumours
Note: A gastroscopy used to check symptoms or confirm a diagnosis is known as a diagnostic gastroscopy. A
gastroscopy used to treat a condition is known as a therapeutic gastroscopy.
Diagnosing conditions
A gastroscopy is also used to help confirm (or rule out) suspected conditions, such as:
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- stomach ulcers (sometimes known as peptic ulcers) – open sores that develop on the lining of the stomach and small
intestine
- gastro-oesophageal reflux disease (GORD) – where stomach acid leaks back up into the oesophagus
- coeliac disease – a common digestive condition, where a person has an adverse reaction to gluten in food
- Barrett's oesophagus – abnormal cells on the lining of the oesophagus
- portal hypertension – where the blood pressure inside the liver is abnormally high, causing swollen veins (varices)
to develop on the lining of the stomach and oesophagus
- stomach cancer and oesophageal cancer
As well as examining the oesophagus, stomach and duodenum, the endoscope (a thin, flexible tube that's passed
down your throat) can be used to remove small samples of tissue for testing. This is known as a biopsy.
Treating conditions
A gastroscopy can also be carried out to treat some problems affecting the oesophagus, stomach and duodenum.
For example, a gastroscopy can be used to:
- stop bleeding inside the stomach or oesophagus, such as bleeding caused by a stomach ulcer or enlarged veins
(varices)
- widen a narrowed oesophagus that's causing pain or swallowing difficulties – this can be caused by GORD,
oesophageal cancer, or radiotherapy to the oesophagus
- remove cancerous tumours, non-cancerous growths (polyps) or foreign objects
- provide nutrients – a gastroscopy can help doctors guide a feeding tube into the stomach, when a person is unable to
eat in the normal way
The gastroscopy procedure

A gastroscopy often takes less than 15 minutes, although it may take longer if it's being used to treat a condition.
It's usually carried out as an outpatient procedure, which means you won't have to spend the night in hospital.
Before the procedure, your throat will be numbed with a local anaesthetic spray. You can also choose to have a
sedative, if you prefer. This means you will still be awake, but will be drowsy and have reduced awareness about
what's happening.
The doctor carrying out the procedure will place the endoscope in the back of your mouth and ask you to swallow the
first part of the tube. It will then be guided down your oesophagus and into your stomach.
The procedure shouldn't be painful, but it may be unpleasant or uncomfortable at times.
How it's performed

Instructions about how to prepare for a gastroscopy should be included with your appointment letter.
Preparing for a gastroscopy

If you're referred for a gastroscopy, you'll be told whether you need to stop taking any of your medications
beforehand.
You may need to stop taking any prescribed medicines for indigestion for up to 2 weeks before the procedure. This is
because the medication can mask some of the problems that a gastroscopy could find.
If you're taking any of the following medications, you should phone the endoscopy unit before your appointment,
because special arrangements may need to be made:
1- any medication used to treat diabetes, such as insulin or metformin
2- any blood-thinning medication (used to prevent blood clots), such as low-dose aspirin, warfarin or clopidogrel
It's important that your stomach is empty during a gastroscopy, so the whole area can be seen clearly. You'll usually
be asked not to eat anything for 6 to 8 hours before the procedure, and to stop drinking 2 to 3 hours before the
procedure – follow the instructions given to you by the hospital.
The procedure
The procedure will usually be carried out by an endoscopist (a healthcare professional who specialises in performing
endoscopies) and assisted by a nurse. You'll meet the nurse before the procedure and they'll be able to answer any
questions you have and you'll also have an opportunity to ask the endoscopist.
A local anaesthetic spray will be used to numb your throat for the procedure and you'll be asked beforehand if you'd
like to have a sedative injection. Young children may have the procedure under general anaesthetic, which means
they'll be asleep while it's carried out.
The sedative will help you feel drowsy and relaxed during the procedure, but you'll need to stay in hospital for a bit
longer while you recover, and you'll need someone to pick you up from the hospital and stay with you for at least 24
hours. You won’t able to work or drive during this period.
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Before the procedure starts, you'll be asked to remove any glasses, contact lenses and false teeth. You won't usually
need to get undressed, but you may be asked to wear a hospital gown over your clothes.
The local anaesthetic spray is then given and a small plastic mouth guard placed in your mouth, to hold it open and
protect your teeth.
You'll be asked to lie down on your left-hand side and the endoscopist will insert the endoscope into your throat.
They'll ask you to swallow it to help move it down into your oesophagus. This may be uncomfortable at first and you
may feel sick or gag, but this should pass as the endoscope is moved further down.
Diagnosing a condition
If the gastroscopy is being used to diagnose a certain condition, air will be blown into your stomach once the
endoscope is inside. This allows the endoscopist to see any unusual redness, holes, lumps, blockages or other
abnormalities.
It may feel a bit uncomfortable when the air is blown into your stomach, and you may burp or feel bloated. This
should start to improve once the procedure is finished.
If abnormalities are detected, a tissue sample (biopsy) can be removed and sent to a laboratory for closer
examination under a microscope. You won't feel anything while the sample is removed.
Afterwards
After the procedure, you'll be taken to the recovery area.
If you didn't have a sedative, you can usually go home soon after the procedure is finished.
If you had a sedative, you'll need to rest quietly for a few minutes or hours until the sedative has worn off. You'll also
need to arrange for someone to take you home and to stay with you for at least 24 hours.
Even if you feel very alert, the sedative can stay in your blood for 24 hours and you may experience further episodes
of drowsiness.
During this time, you shouldn't:
1- drive
2- operate heavy machinery
3- drink alcohol
4- take sleeping tablets
5- go to work
6- sign any contracts or legal documents
7- be responsible for small children or dependents
Before you're discharged, the nurse or doctor may be able to explain the results of the procedure to you. Sometimes,
you may need to have an appointment with the doctor or your GP a few days or weeks later to discuss the results.
You'll be told if you need to make any changes to your diet during the hours or days after going home.
When to seek medical advice

It's normal to feel bloated or have a sore throat for a day or 2 after a gastroscopy.
You should contact your GP or the endoscopy unit immediately if you develop signs of a more serious problem, such
as:
1- severe or worsening chest pain or abdominal (tummy) pain
2- passing dark or "tar-like" poo
3- persistent vomiting or vomiting blood
4- shortness of breath
5- a high temperature of 38C or above
What are the risks?

A gastroscopy is a very safe procedure, but like all medical procedures it does carry a risk of complications.
Possible complications that can occur include:

1- Reaction to the sedation
2- Bleeding
3- Perforation (tearing)
Sedation
Sedation is usually safe, but it can occasionally cause problems, such as:
- feeling or being sick
- a burning sensation at the site of the injection
- small particles of food falling into the lungs and triggering an infection (aspiration pneumonia)
- an irregular heartbeat
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- breathing difficulties
Very rarely, complications from sedation can result in a stroke or heart attack.
Bleeding
Sometimes, during a gastroscopy, the endoscope can accidentally damage a blood vessel, causing it to bleed.
However, significant bleeding is very rare.
Signs of bleeding can include vomiting blood and passing black or "tar-like" poo.
The site of the bleeding can usually be repaired during a further gastroscopy. A blood transfusion may also be
required to replace lost blood.
Perforation
During a gastroscopy, there's a very small risk of the endoscope tearing the lining of your oesophagus, stomach or the
first section of your small intestine (duodenum). This is known as perforation.
Signs of perforation can include:
- neck, chest or stomach pain
- pain when swallowing
- a high temperature of 38C or above
- breathing difficulties
If the perforation isn't severe, it can usually be left to heal by itself. You may be given antibiotics to prevent an
infection occurring at the site of the tear. Surgery may be needed to repair more serious perforations.
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SURGERY HISTORY 1A TEACHING MATERIALS - BPH
SYMPTOMS
1. Frequency/Nocturia
2. Urgency
3. Dribbling
4. Hesitancy
5. Poor stream
6. Poor emptying
7. Haematuria
RISK FACTORS BPH

1. Age
2. PMH
a. Medical illness
- DM
- HTN
- Heart Disease
- High cholesterol
- Peripheral Arterial Disease (PAD)
b. Medication
- B-Blocker
c. Family History
3. Personal History
a. Smoking
b. Poor diet
c. Lack of physical activity
MANAGEMENT OF BPH
A. GP Examination and Tests
A urinary frequency-volume chart 
This will give a record of how much water you normally drink, how much urine you pass, and
how often you empty your bladder on a daily basis, as well as any leakage you have. This chart
needs to be filled for a minimum of 3 days and nights, not necessarily in a row.
International Prostate Scoring System (IPSS)

We will give you a questionnaire to complete in order to assess your symptoms. Each question
has 5 possible answers that carry a score and overall score is used to assess the severity of your
symptoms.
The questions are:
Over the past few months
- How often have you had the sensation of not completely emptying your bladder after
urination?
- How often have you had to urinate again less than 2 hours after finishing urination?
- How often have you found that you stopped or start again when urinating?
- How often have you found it difficult to postpone urination?
- How often have you had a weak stream urine?
- How often have you had to push or strain to begin urination?
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- How often have you had to get up during the night to urinate?
Digital Rectal Examination (DRE):

We need to examine your back passage to feel your prostate gland.
Prostate cancer can cause the prostate gland to become hard and bumpy. By doing this
examination, your doctor will be able to check whether the surface of the gland has changed.
It is important to note that prostate cancer does not always cause changes to the prostate gland.
So, some more specialized tests may be needed to rule it out.
The procedure will feel a little uncomfortable, but is not usually painful.
Urine test:
We need to do a urine test to check if your symptoms are caused by infection in your kidney or
bladder.
Blood Test (U&E’s):

We will do some blood test to check that your kidneys are working properly.
Prostate Specific Antigen (PSA):

We need to do a special blood test to measure the amount of substance produced by the
prostate gland.
A raised PSA Level indicates enlargement of the prostate and a significantly raised level may
indicate prostate cancer. However, as with rectal examination, a PSA Test can not provide a
definitive diagnosis of prostate cancer.
B. Referral to Specialist (Urologist)

Trans Rectal Ultrasound (TRUS):
We will measure the size of your prostate gland by using a special Ultrasound (through your
back passage). This type of scan can be used to rule out a diagnosis of prostate cancer.
CT Urogram:
We will do a special CT Scan to check if there is any blockage in your urinary system. It can also
be used to detect any damage in the urinary tract.
During a CT Urogram, you will be injected with a harmless radioactive dye, which will be visible
on X-Ray. After 30-60 minutes, the dye should have passed into your urinary tract and a series
of X-Ray will be taken.
Uroflowmetry:
By doing this test, we can measure the pressure of your bladder and we can see how well your
bladder works when you urinate.
We will put a flexible tube called catheter through your penis into your bladder. The area will be
number before the tube is inserted. Water will then be injected through this tube into your
bladder. A computer connected to the catheter measures the pressure inside the bladder and
can assess how well your bladder is working. This test is a good way of determining what type
of treatment will help to control your symptoms.
MANAGEMENT
Treatment:
1. Non-medical
a. Avoid drinking liquids for 1-2 hours before going to bed.
b. Stop/cut down on alcohol and caffeine.
c. Moderate exercise such as walking for 30-60 mins.
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d. Going to the loo before having a long journey or when you know you won’t be able to reach
toilet easily.
e. Wait a few minutes after you have finished passing urine before trying to go again. It can help
you to empty your bladder properly (Double Voiding).
f. Eating fruits and vegetables. This will help you avoid constipation, which can put pressure on
the bladder and worsen symptoms of an enlarged prostate
g. Checking your medicines Check with your doctor whether any medicines you take, such as
anti-depressants or decongestants, may be making your urinary symptoms worse.
Bladder training Exercise:

It is an exercise program that aims to increase the time between urination and the amount of
urine your bladder can hold. You will be given a target such as waiting at least 2 hours between
each time you urinate.
You will be given a bladder-training chart to record each time you pass urine and the volume of
urine passed.
You will be taught exercises such as breathing, relaxation and muscle exercises to help take your
mind off the need to urinate.
2. Medication
a. Finasteride
This medication blocks the affect of hormones on the prostate gland and helps to reduce the size
of the prostate.
You may experience an immediate improvement in your symptoms, however you will need to
take it for at least 6 months to get the maximum benefit and your doctor will monitor you every
year.
One of the side effects is to affect your sperm, so it is important to use condoms if you are
sexually active (risk of birth defects). It can also cause impotence (reduced sperm count). These
side effects are usually temporary and will improve as your body gets used to the medication.
See you GP if side effects are troubling you.
b. Alpha-Blockers (Tamsulosin)
This medication helps relax the muscles of your bladder, making it easier to pass urine. The side
effects include dizziness, headache and weakness. It is advisable to begin taking this medication
over a restful weekend when you are not planning to drive because they may cause low blood
pressure and fainting.
c. Anticholinergics
This type of medication relaxes the bladder muscle if it is overactive.
d. Diuretics
They speed up urine production. If taken during the day, it reduces the amount of urine
produced overnight.
e. Desmopressins
This medication slows down urine production, so less urine is produced at night.
3. Surgery
Surgery is usually recommended for moderate to severe symptoms of benign prostate
enlargement that have failed to respond to medication.
Transurethral resection of the prostate (TURP) 

TURP involves removing part of the prostate gland, generally using a tube that passes through
the urethra (the tube connecting your penis to your bladder). This procedure is suitable for men
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who have an enlarged prostate.
TURP is carried out using a device called a resectoscope, which is a thin metal tube containing a
light, camera and loop of wire. This is passed along your urethra (tube connecting your penis to
your bladder) until it reaches your prostate, which means no cuts (incisions) need to be made in
your skin.
The loop of wire is then heated with an electric current and is used to cut away the section of
your prostate that is causing your symptoms. A thin tube called a catheter is then inserted into
your urethra to pump fluid into the bladder and flush away pieces of prostate that have been
removed.
Either you will be put to sleep for this procedure or you will receive a numbing agent in your
spine, where you are awake but the lower half of your body is number.
Open prostatectomy 
An open prostatectomy involves removing the prostate gland through a cut in your body. This
procedure is suitable for men who have an enlarged prostate, over a certain size.
Cystoplasty
Cystoplasty is a procedure to increase the size of the bladder by sewing a piece of tissue from
the intestine into the bladder wall. This intervention may help men whose bladder muscle
contracts before it is full.
Botulinum toxin 
This procedure involves injections of botulinum toxin into the walls of the bladder. This
intervention may help men whose bladder muscle contracts before the bladder fills.
Implanted sacral nerve root stimulation 

A small electrical device is implanted under the skin and sends bursts of electrical signals to the
bladder and urine system for better control. This is suitable for men whose bladder muscle
contracts before the bladder fills.
Urinary diversion 
Urinary diversion involves linking the tubes connecting the kidneys to the bladder directly to
the outside of the body, so the urine can be collected without flowing into the bladder. This
method is suitable for men whose symptoms cannot be managed by self-management and
medicine, and who cannot have, or do not want, cystoplasty or sacral nerve root stimulation.
COMPLICATIONS
1. Urinary Tract Infection (UTI)
Since you are not able to empty your bladder properly, the bug in your urinary system
(waterworks) won’t get flushed out and will spread through the urine which can cause UTI.
2. Acute Urinary Retention (AUR)

This is a medical emergency because without immediate treatment urine may be passed back
up into the kidneys, which can damage the kidneys.
If you experienced any of the following symptoms, you should come to the A&E immediately.
- Sudden inability to pass urine
- Severe lower tummy pain
- Swelling of the bladder that you can feel with your hand.
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SURGERY HISTORY 2 TEACHING MATERIAL– OESOPHAGEAL CANCER
DIFFERENTIAL DIAGNOSIS OF DYSPHAGIA
A. Mechanical:
1. Esophageal Carcinoma
2. Gastric Carcinoma
3. Pharyngeal Pouch
4. Stricture
a. Corrosive burn
b. GORD
c. Stricture
B. Motility:
1. Achalasia Cardia
2. Esophageal Spasm
3. Bulbar Palsy
4. Myasthenia Gravis
SYMPTOMS
Most common:
1. Difficult in swallowing
a. Food is getting stuck
b. Swallowing is uncomfortable or painful
c. Difficulty in swallowing starts with solid food
d. It may progress to difficulty with swallowing liquids
e. Difficulty in swallowing is continuous
Other Symptoms:
2. Persistent heartburn and indigestion
3. Pain in chest, breast bone or back
4. Persistent vomiting (bringing up food soon after eating)
5. Persistent cough (specially when swallowing)
General Symptoms:
6. Weight Loss
7. Loss of Appetite
8. Anemia Symptoms
RISK FACTORS
- Age > 55yrs
- Gender – more common in males
2. PMH
a. Medical Illness
- GORD: In this condition, the muscles above stomach are weak so acid can travel up to gullet. 1 out of 10
patients with GORD develop Barrett’s Oesophagus.
- Barrett’s Oesophagus: This is characterized by change in the lining of gullet. 1 in 10-20 patients with this
condition develop Carcinoma
b. Family History
3. Personal History
a. Alcohol (especially spirits)
b. Smoking
c. Poor Diet (fatty food, not enough fruits and vegetables)
d. Lack of Physical Activity
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GASTRIC CA
SYMPTOMS
Initial:
1. Persistent indigestion and heartburn
2. Trapped wind and frequent burping
3. Feeling very full or bloated after food
4. Pain in stomach or sternum
5. Difficulty swallowing (dysphagia)
Advanced:
1. Blood in stool or black/dark stool
2. Loss of appetite
3. Weight loss
4. Anaemia symptoms
5. Lump or swelling in stomach caused by build up of fluids
RISK FACTORS
1. Age > 55 years
2. Gender (males are twice as likely)
3. PMH
a. Medical Illness
- H. Pylori infection
- Peptic Ulcers
- Pernicious Anaemia
- Carcinoma such as oesophageal carcinoma, Non-Hodgkin Lymphoma
b. Family History
4. Personal History
a. Smoking
b. Diet (salted, smoked, pickled foods)
INVESTIGATIONS
1. Initial Blood tests
2. Stool tests
3. Endoscopy +/- Biopsy
4. Barium meal X-Ray
5. LFTs, Liver Ultrasound, CT Scan
PEPTIC ULCER
SYMPTOMS
1. Epigastric Pain/Burning in tummy
2. Indigestion
3. Heartburn
4. Loss of appetite
5. Being sick
RISK FACTORS
1. PMH
a. Medical Illness
- H. Pylori Infection
b. Medication
- Long-term use of NSAID or Aspirin
INVESTIGATION
1. Initial blood tests
2. Endoscopy
3. H. Pylori testing
4. X-Ray if suspecting perforation
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TM 2B HX SX -Eating advice for patients with oesophageal Cancer
Oesophageal cancer can cause problems with swallowing and make it hard to eat well.
It’s important to eat and drink enough calories and protein to maintain your weight and
strength.
Eating when swallowing is difficult

-You will need to eat soft foods.
-Make sure that you eat slowly and avoid eating late in the day.
-Have plenty to drink during and after meals to soften your food and prevent blockages.
-Eating smaller amounts more often is easier than having large amounts.
-You will find that you can eat most of your favourite foods with a few changes.
Soft diet suggestions

A soft diet can help you eat more comfortably. Try scrambled egg, soups and well-cooked pasta.
You can also:
1- Use sauces and gravies to moisten food and make it easier to swallow.
2- Soften meat and vegetables with long, slow cooking.
3- Finely chop meat and vegetables in a food processor before or after cooking.
4- Blend or process meat or vegetable casseroles or curries to make soups.
5- Make fruit smoothies in a blender.
6- Try tinned fruit and add custard or cream.
7- Have ice cream, yoghurts and mousse.
Foods to avoid
Avoid foods that are hard to swallow and might stick in your throat, like:
1- Raw fruit and vegetables.
2- Tough meat.
3- Soft, doughy bread.
You can use a blender to process solid foods.
How to build yourself up

You can help to maintain your weight by boosting calories in everyday foods. You can:
1-Have porridge for breakfast – add syrup or sugar and cream.
2-Make instant soups or gravies with milk instead of water.
3-Mix mashed potato with an egg or grated cheese or cream.
4-Make instant coffee with all milk.
5-Drink liquid food supplements such as Ensure plus and Fresubin and sip them throughout the
day.
6-Make ice lollies out of smoothies or liquid food supplements.
7-Have extra protein.
Increase the amount of protein you have by:
A) Adding a couple of teaspoons of dried milk powder to each pint of milk to use like ordinary
milk for drinking and cooking.
B) Adding protein powders and high energy powders to everyday foods.
Feeding tubes
You may need a feeding tube down your nose or into your small bowel if you can’t eat and drink
enough.
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TM SURGERY HISTORY 3A – LOIN PAIN / CALCULI
SYMPTOMS
1. Pain is not relieved by taking anything – patient is restless.
3. Colicky/intermittent nature of pain (pain comes and goes)
4. History of dysuria
5. History of passing stone
6. History of poor stream while urinating
7. History of hematuria
8. +/- UTI Symptoms
PATTERN OF PAIN ACCORDING TO SITE OF STONE

1. Renal – Pain in flank area / Back pain
2. Ureteric
a. 1/3 upper – Loin to groin
b. 1/3 middle – Right (mimics appendicitis), Left (mimics Diverticulitis)
c. 1/3 lower – Males (pain in penis and scrotum), Female (pain in labia majora)
3. Bladder – Suprapubic pain
RISK FACTORS
1. PMH
a. Previous history of Calculi
b. Medical Illness
- Recurrent UTI
- Gout
- Hyperparathyroidism
- HTN
- IBD
- Colitis (chronic diarrhoea can cause dehydration and electrolyte imbalance)
- Sarcoidosis
c. Medication
- Diuretics
- Aspirin
- Antacid
- Calcium supplements
- Vitamin supplements
d. Surgical History – history of gastric/intestinal bypass
e. Family History
2. Personal History
a. Diet
- Water intake (reduced)
- Food
i. High Protein
ii. High Sodium
iii. High Sugar
iv. Low Fibre
3. Social History
a. Inactive or bed bound.
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TYPES OF KIDNEY STONES
1. Calcium stones
These are the most common type of kidney stones and form if there is too much Calcium in urine
which can be due to:
- an inherited condition called hypercalcemia
- an overactive parathyroid gland which regulates the amount of Calcium in our body.
- kidney disease
- sarcoidosis
- some cancers
2. Struvite Stones
These are often caused by prolonged urinary tract infection.
3. Uric Acid Stones

These can form if there is a large amount of uric acid in your urine, which can be due to:
- eating a high protein diet that includes lots of meat
- medical condition such as gout
- chemotherapy
INVESTIGATIONS
1. Urine test, to check for presence of:
- bug
- blood
- or piece of stone
2. Blood test, to check:

- how well kidneys are working
- check the level of substance such as Calcium that can cause stones
3. Imaging
- CT Scan (CT KUB)
This is a CT Scan of your Urinary System (waterworks) including kidney, ureters (the tubes
connecting your kidneys to your bladder) and bladder.
CT Scan is a series of X-Rays at slightly different angles. Images are fed to the computer that puts
them together to create a detailed picture.
NOTE: CT Scan is the preferred imaging method because it is more accurate compared to other
imagine techniques.
Other imagine techniques include:

- X-Ray
It is an imaging technique that uses high-energy radiation to highlight abnormalities in body tissue.
- Ultrasound (U/S)
This test uses high frequency sound waves to create an image of the inside of the body.
- Intravenous Urogram/Pyelogram (IVU/IVP)
A dye that shows up on X-Ray is injected into a vein in your arm. The X-Ray image highlights any
blockage as the kidney filters the dye out of your blood and into your urine.
TREATMENT
Most kidney stones are small enough, less than 4mm (in diameter), to be passed out in your urine
and can probably be treated at home.
The treatment includes:
1. Painkillers – even small kidney stone can be painful. This usually lasts for a couple of days and
disappears when the stone has passed.
2. If you are feeling sick, you may receive anti-sickness medication. This medication can be given
through blood vessels as a drip initially in the hospital. You may be also prescribed some anti-
sickness medication to be taken by mouth at home if needed.
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3. You may be given a medication to relax the muscles of your urinary tract and help to pass the
stone easily (Alpha-blocker such as Tamsulosin).
4. If you have urinary infection, antibiotics should be prescribed for you.
Self-Care
1. In order to help pass the stone easily, it is advisable to have enough water. If your urine is yellow
or brown, you should drink enough water to make it colourless.
2. You may be advised to wait until you pass your kidney stone when you go to the toilet and to try to
collect it from your urine. You can do this by filtering your urine through gauze or stocking. These
stones should be given to your GP so that they can analyze it to help determine any further
treatment that you may need.
Who should be admitted in the hospital?

1. If symptoms don’t improve within an hour of being given painkillers or anti-sickness medication.
2. If patient is dehydrated because of excessive vomiting and needs to receive fluid through blood
vessels.
3. If patient is over 60 years of age.
4. If patient is pregnant.
5. In high risk patient, for example those who have only one kidney.
When to seek urgent medical attention?

1. If patient has any symptoms of pyelonephritis, including high temperature and an episode of
shivering.
2. If the pain gets worse particularly if it is sudden and severe.
3. If patient cannot pass urine.
Treatment of a large urinary stone.

If a kidney stone is too big to pass naturally (6-7 mm), you may need some procedure in order to
remove it.
1. ESWL (Extracorporeal Shockwave Lithotripsy)

It uses Ultrasound waves to break the stone into smaller pieces so it can be passed in urine. It is
usually done after giving painkiller. It is very effective (99%) for stones up to 20mm in size.
2. Ureteroscopy (also known as Retrograde Intrarenal Surgery RIRS)

If a kidney stone is stuck in the ureter, this procedure can be done. It involves passing a long thin
telescope through the urethra and into your bladder. It is then passed into the ureter where the
stone is stuck. For stones up to 15mm, this procedure is effective in 50-80% of cases.
You will be put to sleep in order to have this procedure.
3. PCNL (Percutaneous Nephrolithotomy)

It is usually done for large stones or when ESWL is not appropriate (e.g. obese person). It involves
using a thin telescopic instrument called nephroscope. A small incision is made in the back and
nephroscope is passed into the kidney. The stone is either pulled out or broken into smaller pieces
using a laser or pneumatic energy.
It is quite effective (86%) for stones 21-30 mm in size.
You will be put to sleep in order to have this procedure.
4. Open Surgery
This procedure is rarely done nowadays. It is used for very large stones or in a person with
abnormal anatomy. An incision is made in the back for the surgeon to access the kidney and ureter
to remove the stone.
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SURGERY HISTORY 3B/6B – LOIN PAIN
DIFFERENTIAL DIAGNOSIS (D/Ds) OF ABDOMINAL PAIN
RUQ
1. Acute cholecystitis
2. Acute hepatitis
3. Biliary Colic
4. Cholangitis
R/L UQ
1. Renal calculi
2. Pyelonephritis
3. Kidney tumour
4. Polycystic Kidney Disease
5. Lower lobe pneumonia
RIF
1. Appendicitis
LIF
1. Diverticulitis/Diverticulosis
R/L LQ
Male
1. Testicular torsion
183
2. Epididymo orchitis
Female
1. Ectopic pregnancy
2. Ovarian cyst rupture
3. Ovarian cyst torsion
4. PID
Male and female

1. UTI
2. Obstructed/strangulated hernia
3. Ureteric/bladder stone
Epigastric
1. Pancreatitis
2. APD
3. GORD
4. ACS
Other
1. Bowel Cancer
2. IBD
3. Gastroenteritis
184
SURGERY HISTORY 4A TEACHING MATERIAL BACK PAIN
1. Secondary to Cancer
a. Male
-Prostate
b. Female
- Breast
c. Both Male & Female
- Lung
2. Carcinoma
a. Ca Head of Pancreas
b. Renal Cell Carcinoma
c. Multiple Myeloma
3. Common Conditions
a. Disc Prolapse
b. Pancreatitis
c. Pyelonephritis
d. Kidney Stone
e. Polycystic Kidney Disease
f. Musculoskeletal /Muscle strain
g. Trauma
4. Elderly
a. Osteoarthritis
b. Osteoporosis
5. Young Patient
a. Ankylosing Spondylitis
6. Others
a. Pott’s Disease
b. Paget’s Disease
c. Cauda Equina Syndrome (CES)
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CA PROSTATE
SYMPTOMS
a. Urinary
1. Frequency/Nocturia
2. Urgency
3. Dribbling
4. Hesitancy
5. Poor stream
6. Poor emptying
7. Haematuria
b. General
1. Weight Loss
2. Loss of Appetite
3. Anaemia symptoms
RISK FACTORS
1. Age > 55, Afro-Caribbean
2. PMH
a. Family History (brother or father before 60s)
3. Personal History
a. Low level of Physical Activity
b. Diet (high fat, low fibre, high Calcium)
c. Smoking
d. Alcohol
EXAMINATION
1. PR Examination
INVESTIGATION
Prostate
1. Blood test:
a. Routine blood tests including FBC.
b. Special blood test which measures amount of substance produced by prostate gland
(PSA).
2. US Guided Biopsy(TRUS): We may take some sample from your prostate by using a
fine needle. This is usually done with the aid of a special Ultrasound.
Staging/Metastasis
1. X-Ray
2. Bone Scan (Isoptope scan): A special scan to detect the areas of bone where are
abnormal cells, damage, or infection)
3. CT/MRI
4. Ultrasound Abdomen
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CA PANCREAS
SYMPTOMS
Common:
1. Back pain
a. Upper back
b. Comes and goes
c. Increased by lying down
d. Relieved by bending forward
2.Pain in stomach area

a. Comes and goes
b. Increased by lying down
c. Relieved by bending forward
3. Jaundice (and other symptoms such as pale stools)
General:
1. Weight Loss
2. Loss of Appetite
3. Anaemia Symptoms
Other:
1. Nausea/vomiting
2. Indigestion
3. Fever/shivering
4. Change in bowel habit
5. Diabetes symptoms
RISK FACTORS
1. Age
2. PMH
a. Medical Illness
- DM
- Chronic Pancreatitis
- Stomach ulcers
- H. Pylori infection
b. Family History
3. Personal History
a. Smoking
b. Alcohol
c. Poor diet
d. Lack of physical activity
EXAMINATION
1. General examination
2. Abdominal examination
INVESTIGATIONS
1. Blood tests including FBC, LFTs
2. Urine
3. Ultrasound
4. CT
5. MRI
Other Investigations:
1. Endoluminal Ultrasonography (EUS) Endoscopy:
It is a type of endoscopy that allows close up ultrasound pictures of pancreas to be taken.
2. Endoscopic Retrograde Cholangiopancreatography (ERCP):

It is a type of endoscopy that is used to inject special dye into your bile and pancreatic ducts. The dye will show up on
X-Ray and highlight any tumour.
3. Laparoscopy: A surgical procedure that allows the surgeon to see inside your body, with the help of a laparoscope
(a thin and flexible tube with a microscopic camera attached).
187
SX HX TM 4B Referral for suspected prostate cancer
1. Refer men using a suspected cancer pathway referral (for an appointment within 2
weeks) for prostate cancer if their prostate feels malignant on digital rectal examination
NOTE: Consider a prostate-specific antigen (PSA) test and digital rectal examination to
assess for prostate cancer in men with:
A-Any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy,
urgency or retention
B-Erectile dysfunction
C-Visible haematuria
2. Refer men using a suspected cancer pathway referral (for an appointment within 2
weeks) for prostate cancer if their PSA levels are above the age-specific reference.
PSA Cut-off Values
Age (years) PSA Cut-off
40-49 2.0 nanogram/mL or higher
70 or older 5.0 nanogram/mL or higher
There are no age-specific reference limits for men older than 80 years of age.
188
SURGERY HISTORY 5A TEACHING MATERIALS - CA BLADDER
DIFFERENTIAL DIAGNOSIS HAEMATURIA (D/Ds)
Cancer
1. Bladder cancer
2. Renal cancer
3. Prostate cancer
Calculi
4. Renal calculi
5. Ureteric calculi
6. Bladder calculi
Benign
7. BPH
8. UTI
9. Polycystic Kidney Disease
General
1. Bleeding disorder
2. Blood thinner
3. Instrumentations
4. Trauma
SYMPTOMS
1. Urinary Symptoms
a. Haematuria (most common and usually painless)
b. Frequency
c. Urgency
d. Dribbling
e. Burning sensation
2. Pain
a. Lower abdominal pain
b. Pelvic pain
c. Bone pain
3. General symptoms
a. Weight loss
b. Loss of Appetite
c. Anaemia symptoms
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RISK FACTORS
1. Age > 55, Male gender
2. PMH
a. Medical Illness
- Recurrent UTI
- Pyelonephritis
- Urinary Calculi
- BPH
- Schistosomiasis
b. Medication
- Radiotherapy
- Chemotherapy
- Medication for Type II DM
c. Family History
3. Personal History
a. Smoking
b. Alcohol
c. Lack of Physical Activity
d. Poor Diet
4. Social History
a. Occupation -- Exposure to chemicals such as dyes, textiles, rubber, paint, plastic.
INVESTIGATIONS
1. Urine test (Dipstick, MSU, C/S, Cytology and Microscopy)
2. Cystoscopy +/- Biopsy: We put a flexible tube with a camera attached through the
penis into bladder to have a close look inside the bladder to see if there are any
abnormalities. We may take a sample to check for abnormalities (biopsy)
3. CT Urogram: We do some special Scan to see if there is any defect in your urinary
system.
4. CT/MRI
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TM HX SX 5B Referral for suspected bladder cancer
1. Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks)
for bladder cancer if they are:
Aged 45 and over and have:
A-Unexplained visible haematuria without urinary tract infection or
B-Visible haematuria that persists or recurs after successful treatment of urinary tract infection,
or
C-Aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised
white cell count on a blood test
2. Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or
persistent unexplained urinary tract infection.
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SURGERY HISTORY 6A TEACHING MATERIAL – LOWER UTI (CYSTITIS)
SYMPTOMS
1. Suprapubic/Loin Pain
2. Fever
3. Urinary symptoms
a. Dysuria (pain/burning while passing urine)
b. Frequency
c. Urgency
d. Incontinence
4. Change in urine
a. Smelly urine
b. Cloudy urine
c. Haematuria
5. +/- Nausea & Vomiting
6. +/- Rigors
7. Confusion (elderly patients)
RISK FACTORS UTI

1. Female (because the tube that passes out urine from bladder (urethra) is shorter in women
and opens nearer to the back passage).
2. PMH
a. Medical Illness
- Previous UTI or Renal Tract Infection
- History of stone or BPH
- Constipation
- Diabetes Mellitus
- Vaginal Prolapse
b. Medication
- Long-term Antibiotics
- Long-term Steroids
- Chemotherapy
c. Surgical History
- Instrumentation
- Catheterisation
3. Pregnancy, Period, Pills

- Being pregnant
- Having had menopause (after menopause the lining of tissue around genital area may become
more fragile and this makes it harder for defend against infections. This is called atrophic
vaginitis).
- Inserting tampon
- Using a diaphragm for contraception
4. Personal History
a. Sexual history
- Unprotected sex
INVESTIGATIONS
1. Urine dipstick for nitrates/leukocytes
2. MSU for culture & sensitivity (C/S)
192
Further tests are not usually necessary if patient is well and has a one-off infection. However,
further tests may be advised if an underlying problem in kidneys, bladder or prostate is
suspected.
Underlying problem is more likely if:
- the infection does not clear with antibiotic medication.
- patient has symptoms that suggest a kidney infection (pyelonephritis)
- patient has recurrent urine infection (2 or more episodes in a 3 months period).
- patient has problem with kidney in the past such as stones
- patient has symptoms that suggest an obstruction
Some of the further tests include:
1. Blood Tests (FBC, U&E’s)
2. PSA to measure the amount of substance produced by prostate gland.
3. Ultrasound Scan of Kidney, Bladder and Prostate.
4. Other imaging tests for the diagnosis of urinary stones (X-Ray, CT-KUB).
5. Cystoscopy to look inside of your bladder with the help of special telescope.
6. Tests to see how well your bladder is functioning (Urodynamic tests).
TREATMENT
Mild cases, particularly in women, will often get better by themselves within a few days.
However, women who have recurrent infection, pregnant women, women who are
immunocompromised, men and children usually need antibiotic treatment.
Medication
a. Paracetamol or NSAID (Ibuprofen) will usually ease pain, discomfort or high temperature.
b. A course of an antibiotic medication will usually clear the infection. The symptoms usually
improve within a few days after starting medication. However, if your symptoms don’t improve,
you need to see your doctor since your antibiotic may need to be changed based on the bug that
caused your infection. Some bugs causing cystitis can be resistant to some types of antibiotics so
you may need alternative medication.
Antibiotic of Choice:
1. Trimethoprim 200mg BD.
Usually for 3 days, for severe cases and most male patients up to 7 days.
NOTE: Cautions for use of Trimethoprim

1. Predisposition to Folate Deficiency
2. Elderly
NOTE: Since Trimethoprim has teratogenic risk in first trimester (Folate antagonist), its advised
to be avoided.
NOTE: Side effects of Trimethoprim are:

2. Diarrhoea
3. Itching and rashes
2. Nitrofurantoin 100mg BD (50 mg QDS).

NOTE: Some of the cautions for use of Nitrofurantoin is Anemia, Diabetes, Vitamin B and Folate
Deficiency.
NOTE: Common Side effects of Nitrofurantoin are:

1. Loss of appetite
193
3. Diarrhoea
Alternative medication:
1. Amoxicillin 500mg BD (250mg QDS). The dose of Amoxicillin can be increased up to 1000mg
QDS in severe cases.
NOTE: Cautions for use of Amoxicillin are previous history of allergy and erythematous rash
common in glandular fever.
Side Effects of Amoxicillin are:

Common
2. Diarrhoea
Other
1. Rashes
2. Antibiotic associated colitis
2. Oral Cephalosporin
The dose varies according to the choice of antibiotic from this group.
For example, for Cefalexin the dose is 250 mg QDS increased up to 1–1.5g for severe infections.
NOTE: Uncomplicated lower urinary-tract infections often respond to trimethoprim,

nitrofurantoin, or amoxicillin given for 3 days (up to 7 days; those caused by fully sensitive
bacteria respond to two 3-g doses of amoxicillin. Widespread bacterial resistance to ampicillin,
amoxicillin, and trimethoprim has been reported. Alternatives for resistant organisms include
co-amoxiclav (amoxicillin with clavulanic acid), an oral cephalosporin, nitrofurantoin,
pivmecillinam, or a quinolone.
PREVENTION
General
- Going to the loo as soon as you need to pee and always emptying your bladder fully.
- Staying well hydrated.
- Having a shower rather than a bath. This avoids exposing your genital area to cleaning
products for too long.
Young females
- Wiping from front to back after using the loo.
- Emptying your bladder as soon as possible after having sex.
- Not using a diaphragm for contraception.
- Wearing underwear made of cotton and avoiding wearing tight jeans and trousers.
Elderly
- Eating plenty of fruits and vegetables and drinking enough fluids to avoid constipation.
- Treating the underlying medical problem that may be causing urinary infection.
For elderly woman with atrophic vaginitis
- Hormone replacement creams may be considered.
For some people with recurrent infection
- A low dose of antibiotic taken continuously may be prescribed.
194
SURGERY HISTORY 6B – TEACHING MATERIAL
USE OF BNF –ANTIBIOTICS FOR UTI
ANTIBIOTIC THERAPY FOR UTI – USING BNF v 66
First go to the index and find Urinary Infections.
And then go to the page of Urinary-tract Infections (page 345), you can see:
Medications of choice are:
1. Trimethoprim
2. Nitrofurantoin
It is mentioned, “Suggested duration of treatment 7 days but short course (e.g. 3 days) is
usually adequate for uncomplicated Urinary Tract Infection in women.
Alternative medication:
1. Amoxicillin
2. Oral Cephalosporin
It is mentioned, “Suggested duration of treatment 7 days but short course (e.g. 3 days) is
usually adequate for uncomplicated Urinary Tract Infection in women.
Now, you need to find the page of the first choices from the index.
Go to the page of Trimethoprim (page 383):
INDICATIONS
Urinary Tract Infection.
Acute and Chronic bronchitis.
Pneumocystis Pneumonia.
CAUTIONS
1. Predisposition to Folate Deficiency
2. Elderly
3. Manufacturer recommends blood counts with long-term therapy
CONTRAINDICATIONS
1. Blood dyscrasias.
RENAL IMPAIRMENT
Use half of normal dose after 3 days if eGFR is 15-30 mL/minute/1.73m2
PREGNANCY
Teratogenic risk in first trimester (Folate antagonist).
Manufacturer advises to avoid.
BREASTFEEDING
Present in milk. Short term use not known to be harmful.
SIDE EFFECTS
Common
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2. Diarrhoea
Other
1. Pruritis and rashes
2. Hyperkalemia
3. Depression of hematopoiesis
DOSE
Acute infections: 200mg BD
Go to the page of Nitrofurantoin (page 395):

INDICATIONS
Urinary tract infection
CAUTIONS
1. Anaemia
3. Electrolyte imbalance
4. Vitamin B and Folate Deficiency
5. Pulmonary Disease
6. On long-term therapy monitor liver function and monitor for pulmonary symptoms
specially in elderly.
7. If patient is susceptible to peripheral neuropathy
8. False positive urinary glucose
9. Urine may be coloured yellow or brown
CONTRAINDICATIONS
1. Children under 3 months of age.
2. G6PD Deficiency
3. Acute porphyrias
HEPATIC IMPAIRMENT
Use with caution, cholestatic jaundice and chronic active hepatitis reported.
RENAL IMPAIRMENT
Avoid if eGFR < 60 mL/minute/1.73m2, risk of peripheral neuropathy. Ineffective
because of inadequate urine concentrations.
PREGNANCY
1. Avoid at term. May produce neonatal hemolysis.
BREASTFEEDING
1. Avoid – only small amount in milk but could be enough to produce hemolysis in G6PD
Deficient infant.
SIDE EFFECTS
Common
1. Loss of appetite
196
3. Diarrhoea
Other
4. Hypersensitivity reaction (angioedema, anaphylaxis, sialadenitis, urticaria, rash and
pruritis)
5. Pulmonary reactions (pulmonary fibrosis reported)
6. Peripheral neuropathy (reported)
DOSE
Uncomplicated infections in women: 100mg BD (50 mg QDS) with food for 3 days
usually adequate.
Severe chronic recurrent infection: 100 mg QDS with food for 7 days.
If for some reason (Contraindication or caution), you don’t want to prescribe

Trimethoprim or Nitrofurantoin, go and check for the page of alternative choice,
which is Amoxicillin in the index page.
INDICATIONS
Urinary Tract Infections, Otitis Media, Sinusitis, Oral Infections, Bronchitis, Low or
moderate severity Community Acquired Pneumonia
CAUTIONS
1. History of allergy.
2. Erythematous Rash common in glandular fever.
CONTRAINDICATIONS
1. Penicillin hypersensitivity
RENAL IMPAIRMENT
Reduce the dose if eGFR is < 10 mL/minute/1.73m2
PREGNANCY
Not known to be harmful
BREASTFEEDING
Trace amount in milk but appropriate to use.
SIDE EFFECTS
Common
2. Diarrhoea
Other
1. Rashes
2. Antibiotic associated colitis
DOSE
197
When you check, you can find the dose, which is between 0.25 – 1g QDS
198
SURGERY HISTORY 7 -HEMETAMESIS TEACHING MATERIAL
CAUSES OF UPPER GI BLEED (UGIB)
1. Peptic ulcer
2. Oesophagitis
3. Barret’s Oesophagus
4. Erosive gastritis or duodenitis
5. Esophageal varices
6. Mallory-Weiss tear.
7. Malignancy
SYMPTOMS
1. Epigastric Pain
2. Abdominal pain (burning in tummy)
3. Indigestion
4. Heartburn
5. Loss of appetite
6. Being sick
7. Bleeding (Haematemesis, Malaena, PR Bleeding)
8. Feature of Shock (Pallor, cool extremities, oliguria, confusion, delirium)
9. Dehydration
RISK FACTORS
1. PMH
a. Previous upper GI Bleeding
b. Medical Illness
- H. Pylori Infection
- Chronic Renal Failure
- Liver Disease
c. Medication
- Long-term use of NSAID or Aspirin, Corticosteroids, SSRIs
2. Personal History
- Alcohol Abuse
- Smoking
ASSESSMENT
Bleeding severity can be assessed by:
- The extent of blood loss.
- The degree of shock.
Initial assessment may provide an indication of the cause of UGIB:

1. Abdominal pain – e.g., epigastric pain, diffuse abdominal pain.
2. Bleeding:
a. Haematemesis: bright-red haematemesis usually implies active haemorrhage. Patients presenting with
haematemesis have a higher mortality than those presenting with melaena alone.
b. Coffee-ground vomit refers to the vomiting of black material, which is assumed to be blood; it implies that bleeding
has ceased or has been relatively modest.
c. Melaena: black tarry stools, usually due to acute UGIB but occasionally bleeding from the small bowel or right side
of the colon.
d. Haematochezia: passage of fresh or altered blood per rectum, usually due to colonic bleeding but occasionally due
to profuse upper gastrointestinal or small bowel bleeding.
3. Loss of blood: shock, syncope, pre-syncope.
4. Features of underlying cause – e.g., dyspepsia, weight loss, jaundice.
5. Risk factors:
- Alcohol intake.
- Drug history is important. Drugs such as NSAIDs, aspirin and corticosteroids are an important cause of bleeding.
Iron and bismuth may mimic melaena.
6. Past history of bleeding (haematemesis or melaena) or of anaemia.
7. Retching may precede bleeding with a Mallory-Weiss tear.

199
EXAMINATION
The main aim of examination is to
1. Assess blood loss and look for signs of shock.
- Pallor
- Pulse and blood pressure.
- Postural hypotension may be detected and usually indicates a blood loss of 20% or more.
- Other signs of shock: Cool extremities, Chest pain, Confusion, Delirium
- Evidence of dehydration (dry mucosa, sunken eyes, skin turgor reduced).
2. Look for signs of underlying disease and significant comorbid conditions

- Stigmata of liver disease may be present (jaundice, gynaecomastia, ascites, spider naevi, flap, etc).
- Signs of a tumour may be present (nodular liver, abdominal mass, lymphadenopathy).
INVESTIGATIONS
A) Blood Tests
1. FBC: haemoglobin is measured serially (4- to 6-hourly in the first day) to help assess trend. The requirement for
transfusion is based on initial haemoglobin and a clinical assessment of shock.
2. Crossmatch blood (usually between 2 and 6 units according to rate of active bleeding).
3. Coagulation profile: prothrombin time with activated partial thromboplastin time and an international normalised
ratio (INR), fibrinogen level:
NOTE: A consumptive coagulopathy may occur with UGIB. This may be associated with thrombocytopenia. A platelet
count of less than 50 with active bleeding requires platelet transfusion and fresh frozen plasma to try to make up for
depleted clotting factors.
NOTE: Coagulopathy may be a marker also for advanced liver disease. Low fibrinogen and abnormal LFTs may also
indicate liver disease.
4. LFTs to detect underlying liver disease
5. Renal function tests and electrolytes. A serum urea nitrogen:creatinine ratio of more than 30 (with urea and
creatinine levels measured in mg/dL) increases the likelihood of a UGIB
B) Endoscopy
Endoscopy is the primary diagnostic investigation in patients with acute UGIB:
- Endoscopy should be undertaken immediately after resuscitation for unstable patients with severe acute UGIB.
- Endoscopy should be undertaken within 24 hours of admission for all other patients with UGIB.
C) Imaging
1. X-Ray
a. CXR: may identify aspiration pneumonia; pleural effusion, perforated oesophagus.
b. AXR: Erect and supine AXR to exclude perforated viscus and ileus.
2. CT scan and Ultrasound

Can help identify
- Liver disease.
- Cholecystitis with haemorrhage.
- Pancreatitis with haemorrhage and pseudocyst.
- Aortoenteric fistulae.
3. Nuclear medicine scans have been used to identify areas of active haemorrhage.
4. Angiography may be useful if endoscopy fails to identify site of bleeding.
Hospital Admission
Consider for admission and early endoscopy (and calculation of full Rockall score) if any of the following
1. Aged ≥60 years (all patients who are aged >70 years should be admitted)
2. Witnessed haematemesis or haematochezia (suspected continued bleeding)
3. Haemodynamic disturbance (systolic blood pressure <100 mm Hg, pulse ≥100 beats per minute)
4. Liver disease or known varices
5. Significant comorbidity (especially cardiac disease, malignancy)
MANAGEMENT
Resuscitation and initial management
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Shocked patients should receive prompt volume replacement. It has been demonstrated that early and aggressive
resuscitation reduces mortality in UGIB.
1. Correct fluid losses (place two wide-bore cannulae and also send bloods at the same time). Either colloid or
crystalloid solutions may be used to achieve volume restoration prior to administering blood products; red cell
transfusion should be considered after loss of 30% of the circulating volume.
2. Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for
managing massive bleeding. Major haemorrhage protocols should be in place.
3. Decisions on blood transfusion should be based on the full clinical picture; over-transfusion may be as damaging as
under-transfusion.
4. Platelet transfusions should not be offered to patients who are not actively bleeding and are haemodynamically
stable.
5. Platelet transfusions should be offered to patients who are actively bleeding and have a platelet count of less than
50 x 109/L.
6. Fresh frozen plasma should be used for patients who have either a fibrinogen level of less than 1 g/L, or a
prothrombin time (INR) or activated partial thromboplastin time greater than 1.5 times normal.
7. Prothrombin complex concentrate should be used for patients who are taking warfarin and actively bleeding.
8. Recombinant factor Vlla should not be used except when all other methods have failed.
Proton pump inhibitors (PPIs) should not be used prior to diagnosis by endoscopy in patients presenting with acute
UGIB.
Management of non-variceal bleeding

Endoscopy is now the method of choice for controlling active peptic-ulcer related UGIB. Endoscopic therapy should
only be delivered to actively bleeding lesions, non-bleeding visible vessels and, when technically possible, to ulcers
with an adherent blood clot. Black or red spots or a clean ulcer base with oozing do not merit endoscopic intervention
since these lesions have an excellent prognosis without intervention.
Adrenaline (epinephrine) should not be used as monotherapy for the endoscopic treatment of non-variceal UGIB. For
the endoscopic treatment of non-variceal UGIB, one of the following should be used:
1. A mechanical method (eg, clips) with or without adrenaline (epinephrine).
2. Thermal coagulation with adrenaline (epinephrine).
3. Fibrin or thrombin with adrenaline (epinephrine).
4. Interventional radiology - should be offered to unstable patients who re-bleed after endoscopic treatment. Refer
urgently for surgery if interventional radiology is not immediately available.
NOTE: Acid-suppression drugs (PPIs or H2-receptor antagonists) should not be offered before endoscopy to patients
with suspected non-variceal UGIB. PPIs should be offered to patients with non-variceal UGIB and stigmata of recent
haemorrhage shown at endoscopy.
Treatment after first or failed endoscopic treatment

1. Repeat endoscopy, with treatment as appropriate, should be considered for all patients at high risk of re-bleeding,
particularly if there is doubt about adequate haemostasis at the first endoscopy. A repeat endoscopy should be
offered to patients who re-bleed with a view to further endoscopic treatment or emergency surgery.
2. Interventional radiology should be used for unstable patients who re-bleed after endoscopic treatment.
Percutaneous angiography may be used to localise the bleeding point and embolisation of the artery using foam and
coils to stop bleeding. The benefits of embolisation have to be balanced against the risk of causing ischaemic necrosis
of the gastrointestinal tract.
3. Refer urgently for surgery if interventional radiology is not immediately available.
Surgical intervention
Surgical intervention is required when endoscopic techniques fail or are contra-indicated. Clinical judgement is
required and consideration given to local expertise.
In general, it is recommended:
- To inform surgeons early of the possibility of surgery.
- To use the most experienced personnel available.
- To avoid operations in the middle of the night.
The particular procedure required depends on a number of factors, not least the site of bleeding. Gastric ulcers are
probably best excised. There are few studies comparing the different techniques.
Medical management post-endoscopy

Helicobacter pylori eradication:
1. All patients with a bleeding peptic ulcer should be tested for H. pylori – e.g., urea breath test or biopsy specimen.
2. Patients who test positive should receive a one-week course of eradication therapy.
3. This should be followed by three further weeks with ulcer healing treatment.
4. All therapy can be discontinued after successful healing of peptic ulcers provided patients are not taking NSAIDs.
5. A negative urea breath test should be confirmed on the initial biopsy specimen taken prior to diagnosis and before
any PPI therapy was given.
201
6. Two weeks after successful therapy and stopping of all medication, a repeat urea breath test should be performed
to confirm successful eradication.
7. Unsuccessful eradication should be treated with second-line therapy.
Control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel

1. Continue low-dose aspirin for secondary prevention of vascular events in patients with UGIB in whom haemostasis
has been achieved.
2. Other NSAIDs (including cyclo-oxygenase 2 (COX-2) inhibitors) should be stopped during the acute phase in
patients presenting with UGIB.
3. Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) in
patients with UGIB with the appropriate specialist (e.g., a cardiologist or a stroke specialist) and with the patient.
Continuing other medication

1. Anticoagulants and antiplatelet agents should be stopped during the acute phase and restarted later only if there is
a clear indication.
2. Patients who have healed ulcers and were H. pylori-negative and require aspirin or NSAIDs or COX-2 inhibitors,
should be given concomitant PPI.
3. Selective serotonin reuptake inhibitors (SSRIs) should be used in caution in patients at risk of UGIB or who have
had a previous UGIB (especially if other drugs such as aspirin or NSAIDs are used).
4. Corticosteroids will also need to be used carefully and probably with concomitant PPI in high-risk patients or those
on high doses.
PREVENTION
1. The most important factor to consider is treatment for H. pylori infection. Eradication of H. pylori reduces the risk
of both recurrent ulcers and recurrent haemorrhage.
2. Primary prophylaxis for acutely ill patients in critical care:
3. Acid-suppression therapy (H2-receptor antagonists or PPIs) should be offered for primary prevention of UGIB in
acutely ill patients admitted to critical care (using the oral form of the drug if possible).
4. The ongoing need for acid-suppression drugs for primary prevention of UGIB in acutely ill patients should be
reviewed when they recover or are discharged from critical care.
PROGNOSIS
Rockall score <3 is associated with good prognosis.
Rockall score of 8 or more is associated with high mortality.
Rockall Scoring:
1. Age
60-79 – 1 point.
>= 80 – 2 points
2. Shock
No shock SBP> 100, Pulse<100 – 0 point
Tachycardia- SBP>100mmhg, Pulse> 100 – 1 point
Hypotension SBP< 100 – 2 points.
3. Co-morbidity
No major comorbidity – 0 point
Cardiac failure, IHD or any major co-morbidity – 2 points.
Renal or liver failure, disseminated malignancy – 3 points.
4. Diagnosis
Mallory-Weiss tear, no lesion seen nor SRH – 0 Points.
All other diagnosis – 1 point.
Malignancy of upper GI tract – 2 points.
5. Major stigmata of recent haemorrhages (SRH)-

None or dark spot only – 0 points.
Blood in the upper GI tract, adherent clot, visible or spurting vessel – 2 points
202
TEACHING MATERIAL BACK PAIN
CAUSES OF BACK PAIN
Often, it's not possible to identify the cause of back pain. We call this "non-specific" back pain.
Sometimes the pain may be a result of an injury such as a sprain or strain, but often it occurs for
no apparent reason. It's very rarely caused by anything serious.
Occasionally back pain can be due to a medical condition such as:
- A slipped (prolapsed) disc – where a disc of cartilage in the spine presses on a nearby nerve
- Sciatica – irritation of the nerve that runs from the pelvis to the feet
These conditions tend to cause additional symptoms – such as numbness, weakness or a tingling
sensation – and they're treated differently to non-specific back pain.
SPRAIN OR STRAIN
It's likely to be a sprain or strain if:
1. You have pain, tenderness or weakness – often around your ankle, foot, wrist, thumb, knee,
leg or back
2. The injured area is swollen or bruised
3. You can't put weight on the injury or use it normally
4. You have muscle spasms or cramping – where your muscles painfully tighten on their own
Is it a sprain or a strain?
A) Sprains
1. Torn or twisted ligament (tissue that connects the joints)
2. Most common in: wrists, ankles, thumbs, knees
B) Strains
1. Overstretched or torn muscle (also known as a pulled muscle)
2. Most common in: knees, feet, legs, back
Treatment
A) Self treatment
For the first couple of days, follow the steps known as PRICE therapy to help bring down the
injury:
1. Pain killer - Painkillers like paracetamol will ease the pain and ibuprofen will bring down
swelling. However, you shouldn't take ibuprofen for 48 hours after your injury as it may slow
down healing. Speak to a pharmacist about the best treatment for you. They might suggest
tablets, or a cream or gel you rub on the skin.
2. Rest – stop any exercise or activities and try not to put any weight on the injury.
3. Ice – apply an ice pack (or a bag of frozen vegetables wrapped in a tea towel) to the injury for
up to 20 minutes every 2 to 3 hours.
4. Compression – wrap a bandage around the injury to support it.
5. Elevate – keep it raised on a pillow as much as possible.
203
To help prevent swelling, try to avoid heat – such as hot baths and heat packs – alcohol and
massages for the first couple of days.
When you can move the injured area without pain stopping you, try to keep moving it so the
joint or muscle doesn't become stiff.
Prevention of sprains and strains

Sprains and strains happen when you overstretch or twist a muscle.
Not warming up before exercising, tired muscles and playing sport are common causes.
How long it takes for a sprain or strain to heal

After 2 weeks, most sprains and strains will feel better.
Avoid strenuous exercise such as running for up to 8 weeks, as there's a risk of further damage.
Severe sprains and strains can take months to get back to normal.
B) GP Surgery / Minor injuries unit:

You may see your GP or go to minor injuries unit if:
- The injury isn't feeling any better after treating it yourself
- The pain or swelling is getting worse
Treatment at a minor injuries unit

You may be given self-care advice or prescribed a stronger painkiller.
If you need an X-ray, it might be possible to have one at the unit or you may be referred to
hospital.
NOTE: Minor injuries units and urgent care centres can treat:
- sprains and strains
- broken bones
- wound infections
- minor burns and scalds
- minor head injuries
- insect and animal bites
- minor eye injuries
- injuries to the back, shoulder and chest
If there is not a minor injuries unit in your area, these services will also be provided by an A&E
department.
C) Go to A&E or call 999 if:

-You heard a crack when you had your injury
-The injured body part has changed shape
-The injury is numb, discoloured or cold to touch
You may have broken a bone and will need an X-ray.
D) Physiotherapy for sprains and strains

If you have a sprain or strain that's taking longer than usual to get better, your GP may be able
to refer you to a physiotherapist.
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DISC PROLAPSE
SYMPTOMS:
A slipped disc (also called a prolapsed or herniated disc) can cause:
1. Lower back pain – the most common symptom

2. Numbness or tingling in your shoulders, back, arms, hands, legs or feet
3. Neck pain
4. Problems bending or straightening your back
5. Muscle weakness
6. Pain in the buttocks, hips or legs if the disc is pressing on the sciatic nerve (sciatica)
Not all slipped discs cause symptoms. Many people will never know they have slipped a
disc.
CAUSES / RISK FACTORS:

They can happen because of:
1. Ageing
2. Exercising too hard
3. Lifting heavy objects the wrong way
4. Vibration – from driving or operating machinery
5. Being inactive or overweight
TREATMENT:
A) Self-treatment:
1. Keep active
If the pain is very bad, you may need to rest at first. But start gentle exercise as soon as
you can, it will help you get better faster.
The type of exercise isn't important, just gradually increase your activity level.
2. Take painkillers
Alternate painkillers such as ibuprofen and paracetamol.
Paracetamol on its own isn't recommended for back pain.
Take them regularly (up to the recommended daily amount) rather than just when the
pain is particularly bad. This will help you to keep moving.
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen aren't suitable for

everyone. Speak to a pharmacist if you're not sure.
Stronger painkillers containing codeine may help for pain that has just started. But
these types of painkillers can cause addiction and should only be used for a few days.
B) See a GP if:
1. Your painkillers aren't helping
2. The pain is no better after a month
3. See a GP urgently or go to A&E if you have back pain and you:
- have numbness around your bottom or genitals
205
- can't pee
- lose feeling in one or both legs
- can't control when you pee or poo
- have a very high temperature or you feel hot and shivery
- have unexplained weight loss
- have a swelling in your back
- notice the pain is worse at night
- got it after a serious accident, such as a car accident
What happens at your appointment

Your GP will usually be able to tell if you have a slipped disc from your symptoms. You
may also have a physical examination. Your GP might ask you to raise your arms or do
simple leg exercises to find out where the slipped disc is.
Treatment from your GP

Your GP might prescribe a stronger painkiller, a steroid injection or a muscle relaxant to
use in the short term. If your symptoms don't get better your GP might recommend
further tests, like an MRI scan.
They might also refer you to a physiotherapist.
C) Surgery for a slipped disc

Surgery isn't usually needed but your GP might refer to you a specialist to discuss
surgery if your symptoms:
- haven't improved using other treatments

- include worsening muscle weakness, or numbness
D) Alternative treatments for slipped disc

There's some evidence that manual therapies like osteopathy can help ease lower back
pain.
You'll usually have to pay for this treatment privately.
206
TM 10 HX SX- Heart burn (GORD)
HEARTBURN
Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat, which is called acid
reflux.
If it keeps happening, it’s called gastro-oesophageal reflux disease in short GORD.
SYMPTOMS
1- Heartburn (a burning sensation in the middle of your chest).
2- An unpleasant sour taste in your mouth, caused by stomach acid.
3- A cough or hiccups that keep coming back
4- A hoarse voice
5- Bad breath
6- Bloating and feeling sick
Note: The symptoms will probably be worse after,

- Eating
- When lying down
- When bending over.
RISK FACTOR
PMH
Q3
- A hiatus hernia – when part of the stomach moves up into the chest
Q4
- Some medicines, such as anti-inflammatory painkillers like ibuprofen
4Ps
- Pregnancy
Personal History
- Smoking
- Alcohol
- Diet (Unhealthy diet, which causes obesity, certain food such as coffee and spicy foods.)
- Lack of physical activity, which causes obesity
- Stress
DIFFERENTIAL DIAGNOSIS
1- GORD
2- Oesophagitis from swallowed corrosives or drugs like NSAIDs.
3- Infection (especially in the immunocompromised): cytomegalovirus, herpes, candidiasis.
4- Peptic ulcer.
5- Gastrointestinal (GI) cancers.
6- Non-ulcer dyspepsia.
7- Oesophageal spasm.
MANAGEMENT
Life style modifications

In order to stop or reduce heartburn, life style modifications should be done.
Do
1-Eat smaller, more frequent meals
2- Raise one end of the bed 10 to 20cm by putting something under the bed or mattress. By doing this your chest and head
will be above the level of the waist, so stomach acid doesn't travel up towards the throat.
3- Try to lose weight if overweight
4- Try to find ways to relax
Don't
1- Have food or drink that triggers your symptoms
2- Eat within 3 or 4 hours before bed
3-Wear clothes that are tight around your waist
4- Smoke
5- Drink too much alcohol
6- Stop taking any prescribed medicine without speaking to a doctor first
207
Speak to a pharmacist
Speak to a pharmacist for advice if you keep getting heartburn.
They can recommend medicines called antacids that can help ease the symptoms.
It's best to take these with food or soon after eating, as this is when you're most likely to get heartburn. They may also work
for longer if taken with food.
See a GP if:
1- Lifestyle changes and pharmacy medicines aren't helping
2- You have heartburn most days for 3 weeks or more
3- You have other symptoms, like food getting stuck in your throat, frequently being sick or losing weight for no reason
4- Your GP can provide stronger treatments and help rule out any more serious possible causes of your symptoms.
Treatment from the GP

To ease your symptoms, the GP may prescribe medicine that reduces how much acid the stomach makes. One the commonly
used medication is Proton pump inhibitors (PPIs) such as Omeprazole or Lansoprazole
You may be prescribed one of these medicines for a month or two to see if your symptoms stop.
Go back to your GP if your symptoms come back after stopping your medicine. You may need a long-term prescription.
Proton pump inhibitors (PPIs) reduce the amount of acid made by your stomach. They are commonly used to treat acid
reflux and ulcers of the stomach and part of the gut called the duodenum. Most people who take a PPI do not develop any
side-effects.
Proton pump inhibitors

PPIs are commonly used:
1-To treat ulcers in the stomach and the part of the gut called the duodenum.
2- To reduce acid reflux which may cause heartburn or inflammation of the gullet (oesophagitis). These conditions are
sometimes called gastro-oesophageal reflux disease (GORD).
3- As one part of treatment to get rid of Helicobacter pylori. Helicobacter pylori a germ (bacterium) found in the stomach,
which can cause ulcers.
4- To help prevent and treat ulcers associated with anti-inflammatory medicines called non-steroidal anti-inflammatory
drugs (NSAIDs).
5-In a rare condition called Zollinger-Ellison syndrome.
6- In other conditions where it is helpful to reduce acid in the stomach.
How do PPIs work?

Upper GI Tract and acid
Your stomach normally produces acid to help with the digestion of food and to kill germs such as bacteria. This acid is
corrosive, so your body produces a natural mucous barrier which protects the lining of the stomach from being worn away
(eroded).
In some people this barrier may have broken down allowing the acid to damage the stomach, causing an ulcer.
In others there may be a problem with the muscular band at the top of the stomach called the sphincter that keeps the
stomach tightly closed. This may allow the acid to escape and irritate the gullet (oesophagus). This is called 'acid reflux'
which can cause heartburn and/or inflammation of the gullet (oesophagitis).
PPIs stop cells in the lining of the stomach producing too much acid. This can help to prevent ulcers from forming or assist
the healing process. By decreasing the amount of acid, they can also help to reduce acid reflux-related symptoms such as
heartburn.
They are called 'proton pump inhibitors' because they work by blocking (inhibiting) a chemical system called the hydrogen-
potassium adenosine triphosphatase enzyme system (otherwise known as the 'proton pump'). This chemical system is
found in the cells in the stomach lining that make stomach acid.
Can I buy PPIs?

Most of these medicines are prescription only. You can buy omeprazole and pantoprazole over-the-counter at pharmacies.
However, if you need to use this medicine for more than four weeks you should consult your doctor.
How do I take PPIs?

Your doctor will advise you of the dose needed and how often you should take it. Some of these medicines need to be taken
in a certain way, such as on an empty stomach.
How quickly do PPIs work?

Generally, PPIs are well absorbed by the body and may provide quick relief for some problems. For example, heartburn
caused by acid reflux. However, if you are taking them for other reasons, such as to heal an ulcer, it may take longer for the
medicines to have an underlying effect.
Will my symptoms return after treatment with a PPI?

It is possible that your symptoms might come back if you stop your medication. If this happens, see your doctor again.
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Who should not take PPIs?
PPIs may not be suitable for some people - for example, people with certain liver problems. Breast-feeding or pregnant
mums should avoid them apart from omeprazole which is deemed to be safe.
Side effects
Most people who take a PPI do not have any side-effects. However, side effects occur in a small number of users. The most
common side-effects are:
1- Constipation
2- Diarrhoea
3- Wind (flatulence)
4- Headaches
5- Feeling sick (nausea)
6- Tummy (abdominal) pain
7- Being sick (vomiting)
Drug interaction
In particular: tell your doctor if you are taking the blood-thinning medicine warfarin, or a medicine for epilepsy, called
phenytoin, or medicines called digoxin, methotrexate or cilostazol.
Taking a PPI can affect how well these medicines work or can even cause serious 'drug reactions'.
Also, lansoprazole possibly affects how well oral contraceptives might work.
If you are taking antacids you should try to avoid taking them at the same time as you take your other medication, including
PPIs. This is because antacids can affect how well your medication is absorbed.
Tests and surgery for heartburn and acid reflux

If medicines don't help or your symptoms are severe, your GP may refer you to a specialist for:
1- Tests to find out what's causing your symptoms, such as a endoscopy, where a thin tube with a camera is passed down the
throat.
2- An operation to stop acid reflux, called a laparoscopic fundoplication
Gastroscopy
A gastroscopy is a procedure where a thin, flexible tube called an endoscope is used to look inside the oesophagus (gullet),
stomach and first part of the small intestine (duodenum).
It's also sometimes referred to as an upper gastrointestinal endoscopy.
The endoscope has a light and a camera at one end. The camera sends images of the inside of your oesophagus, stomach and
duodenum to a monitor.
A gastroscopy can be used to:

1- Diagnose conditions such as stomach ulcers or gastro-oesophageal reflux disease (GORD)
2- Investigate problems such as difficulty swallowing (dysphagia) or persistent abdominal (tummy) pain.
3- Treat conditions such as bleeding ulcers, a blockage in the oesophagus, non-cancerous growths (polyps) or small
cancerous tumours.
A gastroscopy used to check symptoms or confirm a diagnosis is known as a diagnostic gastroscopy.

A gastroscopy used to treat a condition is known as a therapeutic gastroscopy.
Procedure
It's usually carried out as an outpatient procedure, which means you won't have to spend the night in hospital.
Before the procedure, your throat will be numbed with a local anaesthetic spray.
You can also choose to have a sedative (mild sleep medication), if you prefer. This means you will still be awake but will be
drowsy and have reduced awareness about what's happening.
The doctor carrying out the procedure will place the endoscope in the back of your mouth and ask you to swallow the first
part of the tube. It will then be guided down your oesophagus and into your stomach.
The procedure shouldn't be painful, but it may be unpleasant or uncomfortable at times.
Complications
A gastroscopy is a very safe procedure, but like all medical procedures it does carry a risk of complications.
1- A reaction to the sedative, which can cause problems with your breathing, heart rate and blood pressure
2- Sore throat and tummy pain for which simple painkiller such as Paracetamol can be prescribed.
3- Infection for that antibiotic can be prescribed if needed.
4- Damage and tearing of the lining of your oesophagus, stomach or duodenum. This can be healed by itself sometimes.
5- Internal bleeding, which is rare.
Note: Serious problems are rare, occurring in less than 1 in every 1,000 cases.
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3-We may need to do a test called Barium swallow or barium meal in this test you will first given some harmless substance,
then series of X-rays are taken. This test assesses your swallowing ability and look for any blockages or abnormalities in
your gullet.
4- We may need to do a test called Manometry which is used to assess how well the ring of muscle at the end of your
oesophagus is working, by measuring the pressure in your oesophagus.
Operative treatment
Laparoscopic (keyhole) fundoplication which is an operation to relieve chronic heartburn when it cannot be controlled with
medication and/or life style modification.
The surgeon will make 4-5 small cuts in your abdomen and insert instruments to carry out the operation.
The surgeon will wrap the top part of your stomach around the lower part of the patient gullet to form a collar. This tightens
the closing mechanism at the lower end of the gullet, creating a one-way valve which prevents stomach acid from moving
back into your gullet.
Operation usually takes 60-90 minutes.
Operation will be done under general anaesthesia (putting the patient asleep throughout the procedure).
Patient usually stay in hospital for 2-3 days after the operation.
Complication:
General:
1- Pain.
2- Infection
3- bleeding from the site of operation
4- damage to surrounding structure.
Specific
1-The most common complication is difficulty in swallowing which is common immediately after the procedure and
gradually improves. The patients may need to eat more slowly than they did before the operation.
2- burping, bloating, and increased wind are also common.
Most of these symptoms settle with time.
3- injury to gullet, stomach, blood vessel and nearby organs. These complications are very rare, and the surgeon may convert
to open surgery to repair any damage.
4- 1% of patient may need further corrective surgery to reduce persistent difficulty in swallowing and/or abdominal
bloating.
5- A hernia may develop at one of the wound sites which may need repairing. This may happen when the patient put any
strain through that area while it is healing.
Special diet
The patient need to cut up or blend all the food for up to 6 weeks.
They should be able to eat only food which can be swallowed as a paste without any solid lumps during this period.
If the patient try to eat things which have to be swallowed in one lump such as toast and chicken there is a risk they will
stuck, which can be very uncomfortable.
Also, patients are advised to avoid fizzy drinks, a burping may be difficult or impossible for a while after surgery.
Driving
The patients can drive when they can confidently perform an emergency stop. This is usually after about 10 days.
Returning to work
Patients will usually need 3-6 weeks off depending on the nature of their work
Lifting and strenuous exercise may resume after 6 weeks.
Safety net
Contact your doctor if any of the following symptoms developed
1- fever
2- unusual degree of pain
3- nausea and vomiting and cannot eat properly.
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SURGERY COUNSELLING 3 - PRE-OPERATIVE
ASSESSMENT
Pre-op assessment is run by a doctor or a qualified nurse. It involves checking your health
physically and through different tests before you undergo anaesthesia or surgery.
This assessment is important so surgery due to unforeseen circumstances can be avoided.
The information is also important for anaesthetist to choose the type of anaesthesia.
HISTORY:
- Recent health (recent infections, fever, cough)
- Chronic illnesses (How long, how well controlled and any complications).
1. Heart disease.
2. Lung disease.
3. Epilepsy.
4. Asthma.
5. COPD.
6. Blood clot.
7. Blood disorders.
- Medications: (How long and dosages).

1. Blood thinners.
2. Insulin.
- Previous surgery or anaesthesia

1. Any surgery.
2. Any complication.
- Anatomical problem
1. Movement of the neck.
2. Loose dentures.
GENERAL EXAMINATION:
- Height and weight
- BP, pulse and temperature.
- Physical examination
1. Cardiovascular (murmurs).
2. Respiratory (added breath sound)
3. Abdominal (mass-scar)
4. Skin (MRSA Screening)
- Airway assessment
1. Obesity
2. Short neck.
3. Limited neck movement.
4. Swelling at the back of mouth.
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INVESTIGATIONS:
- Blood:
1. FBC: To decrease the risk of hypoxia during the surgery, avoid any delay in wound healing,
baseline to assess blood loss after the surgery.
2. Urea and electrolytes: Assess the risk of acute kidney failure after major surgery, Calculation
of the drug dose, check calcium level (heart rate and rhythm during operation)
3. LFT: Assess any clotting problem.
4. Cross match and save.
- Urine: Check on existing or diagnosis of DM, check for infections, check for kidney problem.
- ECG
- Spirometry: If patient has COPD.
- Pregnancy: In female patient.
PRE OPERATIVE ADJUSTMENT OF INSULIN:-

1. Basal bolus regimen
- AM surgery: Omit morning and lunch short acting and keep basal unchanged.
- PM surgery: Halve the morning dose and omit the lunch time dose.
NOTE:
Lanctus ( 20-24 hrs), Levemi ( 12-16 hrs) are Long acting.
Novarapid- short acting ( 15-30 mins)
2. Premix:
- AM surgery- half the morning dose, omit the lunch time dose, check blood sugar on admission.
- PM surgery- Take the morning dose, omit the lunch time dose, check blood sugar on admission.
NOTE:
Humalog mix - Insuman comb.
TARGET BLOOD GLUCOSE RANGE:-

Target level Upon waking Before meal At least 90 mins
after meal
Non-diabetic - 4-5.9 Under 7.8
Type 2 diabetes - 4-7 Under 8.5
Type 1 diabetes 5-7 4-7 5-9
Paed. DM type 1 4-7 4-7 5-9
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SKIN MELANOMA TEACHING MATERIAL
Symptoms:
1. Getting bigger
2. Change in shape.
3. Change in colour.
4. Bleeding
5. Itching
6. Soreness
ABCDE checklist:
A- Asymmetrical.
a. Two different halves.
b. Irregular shapes.
B. Border.
a. Ragged.
b. Notched.
C. Colour- Mixed of two and more colours.
D. Diameter- Larger than 6 mm
E. Enlargement- Change in size over the time.
Risk factors:
1. Pale skin that doesn’t tan easily.
2. Red or blonde hairs.
3. blue eyes.
Q1- Previous history of any skin cancer.
Q2- Having a lot of mole on body particularly
a. larger than 5mm
b. unusual shape
Q3- Immunosuppressed (HIV)
Q4- Immunosuppressants (Medicines that suppresses the immune system)
Q5 Family history.
5. Personal history.
a. Smoking.
b. Alcohol.
c. Physical activity.
d. Diet
6. Social history:
a. Exposure to sun (Job)
b. Sun bed/tan.
Treatment:
We will refer you to the specialist
a. Dermatologist
b. Plastic surgeon
c. Oncologist.
d. pathologist
Treatment mainly depends upon:

a. The type of cancer.
b. The stage of the cancer.
c. Your general health.
The doctors will assess you further to see which treatment should be done :
Stage1-
We will remove the skin lesion and a small area around it (Surgical excision) and the sample will be sent to the
lab for the closer examination.
Stage 1B to 2C-
To assess if the disease is spread or not and we might take samples from the lymph nodes.
Stage 3-
If melanoma has spread to nearby lymph nodes surgery may be needed to remove it.
Stage 4-
We use some medications to improve your immune system and kill the abnormal cells of your body.
You may need radiotherapy.
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STATION 10 COUNSILING BASED -BASAL CELL CARCINOMA
TYPES OF BCC:
1. Nodular:
a. Solitary, cystic, shiny red nodule with large telangiectatic vessels.
b. Mainly on the face.
c. May ulcerate sometimes.
2. Superficial:
a. Often multiple, equal distribution on the face, trunk and limbs.
b. Erythematous well demarcated scaly plaques.
c. Slow growth and less likely to erode.
3. Morphoeic (Sclerosing or infiltrative):
a. Thickened yellow plaques.
b. Mainly present on the mid facial sites.
c. Prone to recurrence after surgery.
4. Pigmented:
a. Brown, blue, or greyish lesion.
b. Nodular or superficial.
c. Mainly present in dark skin.
5. Basosquamous:
a. Mixed BCC with SCC.
SYMPTOMS AND SIGNS:
1. Small shiny pink or pearly white lump.
2. Red scaly patch or translucent waxy appearance.
3. Sometimes brown or black colour.
4. May become crusty and bleed.
5. May develop into painless ulcer.
RISK FACTORS:
1. Increasing age and male sex.
2. Pale skin.
3. Previous non-melanoma skin cancer.
4. Moles or freckles.
5. Immunocompromised patients
6. Immunosuppressant’s.
7. Family history of skin cancer.
8. Ultraviolet light exposure.
D/D’s:
1. Squamous cell carcinoma.
2. Molluscum contagiosum.
3. Discoid eczema.
4. Psoriasis.
5. Sebaceous hyperplasia.
6. Malignant melanoma of the skin.
INVESTIGATIONS:
1. Inspection of the lesion and removal for histology.
2. When non-surgical treatment is considered, an incisional biopsy must be sent before treatment for confirmation of the diagnosis.
3. CT/MRI scan is indicated where bony involvement is suspected.
Low risk BCC:

1. Patient age more than 24.
2. Lesion present below the clavicle.
3. Size of the lesion less than 1 mm with clearly defined margins.
3. Not a recurrent or persistent BCC after incomplete excision.
4. Not located over the important underlying anatomical structures (Large vessels and nerves).
TREATMENT
Surgical options:
1. Surgical excision with primary closure, flaps and grafts with excision margin of 4mm around the tumour.
2. Mohs micrographic surgery: In this excision of the lesion is carried out in stages and each stage checked histologically.
High risk BCC are treated by this.
3. Curettage and electrocautery is performed using curette to remove soft material from the tumour. It is done for low risk BCC.
4. Cryotherapy is used for treating low risk lesions.
Non-surgical options:
1. Topical treatment:
a. Imiquimod 5% cream for small superficial BCC
b. Topical flurouracil 5% cream for the treatment of multiple superficial BCC.
2. PDT (Photodynamic therapy): It involves the use of light therapy in combination with a topical photosensitizing agent to destroy
the cancer cells.
3. Radiotherapy: The main indication of radiotherapy is incomplete excision, recurrent and nodular BCC.
4. Electrochemotherapy.
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Squamous cell carcinoma:
Risk factors:
1. Chronic UV rays exposure.
2. Chemicals carcinogens like arsenic and chromium.
3. Human papilloma virus infection.
4. Ionising radiation exposure.
5. Immunodeficiency.
6. Chronic inflammation like near chronic ulcer, around chronic sinuses, lupus vulgaris.
7. Genetic conditions like Xeroderma pigmentosum and albinism.
8. Premalignant conditions like Bowen’s disease, multiple actinic keratoses.
Presentation:
1. Non healing ulcer in the sun exposed areas, mostly in head and neck.
2. Ulcerated lesion with hard, raised edges.
3. Slow growing ulcer or reddish skin plaques.
4. Bleeding may occur.
5. Give rise to local metastasis and can spread to lymph nodes.
Differential diagnosis:
1. Keratoacanthoma.
2. BCC (Basal cell carcinoma)
3. Malignant melanoma.
4. Solar (Actinic) keratoses.
5. Pyogenic granuloma.
6. Seborrhoeic warts
7. Planter warts.
Investigations:
1. Skin biopsy:
a. Excisional biopsy (Whole lesion is excised)
-Small lesions which are accessible and not in cosmetically sensitive areas.
- Can be done under local anaesthesia.
-full thickness skin should be removed to determine the depth of spread.
b. Incisional or punch biopsy:
- If the lesion is large.
- in cosmetically sensitive areas.
- When close to vital structures.
2. Imaging including CT and MRI (to see bone or soft tissue spread particularly cervical
lymph nodes)
3. Fine needle aspiration or excisional biopsy for clinically enlarged nodes.
Referral:
1.Suspected cancer pathway referral Within 2 weeks for people with a skin lesion that
raises the suspicion of SCC.
2. The Scottish Intercollegiate Guidelines Network (SIGN) guideline recommends
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prompt early referral if there have been high levels of cumulative psoralen plus
ultraviolet A photochemotherapy, rapid tumour growth, poorly defined clinical margins
or pain/dysaesthesia.
Management:
-There should be two levels of multidisciplinary teams: local hospital skin cancer
multidisciplinary teams (LSMDTs) and specialist skin cancer multidisciplinary teams
(SSMDTs).
-People with pre-cancerous skin lesions should either be treated entirely by their GP or
referred for diagnosis, treatment and follow-up to doctors working in the community,
who are members of the LSMDT/SSMDT.
-If there is any doubt about the diagnosis, people with pre-cancerous lesions should be
referred directly to their local hospital skin cancer specialist. Where appropriate,
follow-up of these patients may be undertaken by their own GP.
-All patients with an SCC or where the diagnosis is uncertain should be referred
urgently to a doctor trained in the specialist diagnosis of skin malignancy, normally a
dermatologist, who is a member of either an LSMDT or an SSMDT.
-In England, the target for patients with SCC referred through the two-week urgent GP
referral route is that they must start their first definitive treatment within 62 days of GP
referral. For all other patients with SCC in England, the target is that they must start
their first definitive treatment within 31 days of the decision to treat.
-Patients with a high risk of recurrence of skin cancer or of new primary cancers should
normally be followed up in hospital but should still be instructed in self-examination
and provided with written and photographic information
Management options:
1. Standard effective treatment is complete surgical excision and send all excised
specimen should be sent to histopathological examination.
2. Curettage and cautery/ electrodesiccation:
-used to treat small in situ SCCs less than 1cm and precancerous lesions.
-safe, well tolerated, good cosmetic outcome and suitable for multiple lesions.
3. Cryotherapy/ Cryosurgery.
4. Topical treatment
-Imiquimod 5% cream is effective in treating actinic keratosis.
-Fluorouracil
-Diclofenac 3% gel is licensed for the treatment of actinic keratoses.
5.Photodynamic therapy (PDT):
-Is used in the treatment of in situ SCCs and actinic keratosis.
6.Electrochemotherapy:
-Chemotherapy drugs are given first, either intravenously or directly into the tumour.
7. Mohs' micrographic surgery:
-Is a precise technique in which excision of the skin lesion is carried out in stages and
each stage checked histologically.
It is advocated for use in cases where it is critical to obtain a clear margin while
preserving the maximum amount of normal surrounding tissue.
This procedure is more often used in the treatment of BCCs.
8.Radiotherapy:
Is a useful treatment for patients who cannot be, or prefer not to be, treated by surgery.
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Factors affecting metastatic potential of cutaneous squamous cell carcinoma
a. Site: tumour location in order of increasing metastatic potential:
-SCC arising at sun-exposed sites excluding the lip and ear.
-SCC of the lip.
-SCC of the ear.
-Tumours arising in non-sun-exposed sites (eg, the perineum, sacrum, sole of foot).
-SCC arising in areas of radiation or thermal injury, chronic draining sinuses, chronic
ulcers, chronic inflammation or Bowen's disease.
b. Diameter: tumours greater than 2 cm in diameter are twice as likely to recur locally
and three times as likely to metastasise.
c. Depth: tumours greater than 4 mm in depth (excluding surface layers of keratin) or
extending down to the subcutaneous tissue (Clark level V) are more likely to recur and
metastasise compared with thinner tumours.
d. Histological differentiation: poorly differentiated tumours have a poorer prognosis,
with more than double the local recurrence rate and triple the metastatic rate of better-
differentiated SCC.
e. Tumours with perineural involvement are more likely to recur and to metastasise.
f. Host immunosuppression: tumours arising in patients who are immunosuppressed
have a poorer prognosis.
g. Previous treatment and treatment modality: the risk of local recurrence depends
upon the treatment modality:
-Locally recurrent disease itself is a risk factor for metastatic disease.
-Local recurrence rates are considerably less with Mohs' micrographic surgery than
with any other treatment modality.
Prognosis:
-The overall mortality rate of cutaneous SCC metastasis is low (<5%), but where distant
metastases are present, the five-year survival rate is poor at around 25-40%
-Up to 95% of metastases and local recurrences are detected within five years of initial
treatment, with 70-90% occurring within the first two years.
Prevention:
-Avoiding sun exposure is the key to prevention, including
-Staying indoors or in the shade as much as possible between 11 am and 3 pm.
-Covering up with clothes and a wide brimmed hat when out in the sunshine.
-Applying sunscreen of at least sun protection factor (SPF) 15 (SPF 30 for children or
people with pale skin) which also has high ultraviolet A (UVA) protection
-Secondary prevention by early detection and effective management is also very
important.
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ETHICAL 1, 2, & 3 - INCIDENT FORM
Reporting patient safety incidents:
It is important that patient safety incidents that could have or did harm a patient
receiving NHS funded care are reported so they can be learnt from and any
necessary action can be taken to prevent similar incidents from occurring in the
future.
What is a Patient Safety Incident?
A patient safety incident is any unintended or unexpected incident which could
have or did lead to harm for one or more patients receiving NHS care.
This may include:
- Harm to an individual
- Financial loss to an individual
- Damage to the property of an individual
When should incidents be reported?

There is no time limit but it is advised to report incidents as soon as possible so
the person can still remember the details. Ideally an incident form involving
patients should be recorded as soon after the incident as possible, no later than
the end of the workday on which it occurred or was discovered to have occurred.
The NPSA (National Patient Safety Agency) encourages the reporting of all
patient safety incidents.
This includes:
1. Incidents that you have been involved in;
2. Incidents that you may have witnessed;
3. Incidents that caused no harm or minimal harm;
4. Incidents with a more serious outcome;
4. Prevented patient safety incidents (known as ‘near misses’).
Who should report the incident?

Any person who is employed by the Trust on a permanent or temporary basis
may complete an incident form.
1. Ideally the person who was directly involved in the incident, should complete
the incident form as soon as possible after the event.
2. Where this is not possible a witness, the one who first discovered the incident,
the one most familiar with the incident or a supervisor may complete the form,
ideally by the end of the shift.
What information should we have while filling out the form?
- Incident details - Patient details - Medications being given - Devices being
used - Staff details and staff summary
Note: Please do not include personal identifiable information in your incident
report including staff, patient, carer or relative names or addresses and patient
hospital numbers.
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How to report?
Action may need to be taken both locally and on a national level, so we encourage
healthcare staff to report all incidents via their local incident reporting
systems. All NHS trusts in England and some other healthcare providers
routinely share the incidents reported to them by uploading them to the National
Reporting and Learning System (NRLS). If you cannot use a local reporting
system, you can report incidents directly to the NRLS.
Are we always open when things go wrong?
Communicating effectively with patients and their carers is a vital part of dealing
with errors or problems in their treatment.
Confidentiality:
An incident form is an administrative document, not part of the medical record.
They must be kept confidential:  1. Do not indicate in the patient’s chart that an
incident form was completed.
2. Do not make copies of an incident report for patients or their family members
or for yourself, as that would be a breach of patient confidentiality and hospital
policy.
3. Incident reports are kept in a locked file.
The incident report is considered confidential and cannot be used against the
healthcare professional. However, if copies are made or the chart reflects that an
incident report was completed, the incident report can then be used by the
patient against the defendants in court.   What is the advantage of an
incident form?
The objective of an incident report is not to punish a health professional but to
determine the cause of the problem.
It helps in improving the conduct of the hospital staff and helps in building up a
better healthcare for the patients ensuring their safety and reducing the future
risks for the patients. It also helps to make any necessary managements, if
needed in the hospital.
Medication safety:
Medication incident reports are those which actually caused harm or had the
potential to cause harm involving an error in the process of prescribing,
dispensing, preparing, administering, monitoring or providing medicines advice.
Over 90 per cent of incidents reported to the NRLS are associated with no harm
or low harm.
The most frequently reported types of medication incidents involve:
- Wrong dose.
- Omitted or delayed medicines.
- Wrong medicine.
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ETHICAL 5 MENTAL CAPACITY
- Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the
mental capacity to make their own decisions about their care and treatment. It applies to
individuals aged 16 and over.
- Health care professionals must work on the presumption that every adult has the capacity to
make decision about his care and treatment.
- Health care professionals must not assume that an individual lacks capacity solely because of
his age, appearance, behavior or disease.
- Capacity can change according to type of decision so someone can lack capacity to make some
decisions but has the capacity to make other types of decisions.
- Capacity can change with time so someone can lack capacity at certain point of time but can
have capacity to make the same decision at a later point.
- The Mental Capacity Act applies to all professions (doctors, nurses, social workers, ...), staff
should be trained on how to implement it
How to assess mental capacity?

- The MCA sets a two-stage process to determine capacity:
1. Does the individual have an impairment such as disturbance in brain function or taking
alcohol or drugs?
2. Does this impairment affect the individual to make a specific decision they have to make?
- The MCA states that patients can be deemed to lack capacity if they cannot:
1. Understand the information relevant to the decision.
2. Retain that information relevant to the decision.
3. Use or weigh up that information as a part of the process of making the decision.
If the patients cannot do any of the three things above they are treated as unable to make the
specific decision in question.
- Before deciding that an individual lacks capacity to make a certain decision, appropriate steps
should be taken to enable him to make the decision by themself, for example:
1. Does the individual have all the information he needs?
2. Have they been given information on any alternatives?
3. Could the information have been explained in an easier way?
4. Have different methods of communication been explored?
5. Could anyone else help with communication?
6. Is there another time when the individual will have a better understanding?
7. Is there another place where the individual will be on ease to make a decision?
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ETHICAL 6 – WITHOLDING CANCER DIAGNOSIS
Why we should disclose the diagnosis of cancer to the patient
1. It is patient’s information and not anyone else, so the patient is entitled to that
information.
2. There will always be additional decision to make even if the diagnosis is terminal.
So, the patient needs to be informed of diagnosis and prognosis as they need to
make a decision, for example: consent for further test, procedure or palliative care.
3. Disclosure prevents the member of healthcare team to lie or deceive the patient.
4. Research shows most patient already suspect their diagnosis or will find out at
some point. So open disclosure helps to maintain a trust between patient and
member of healthcare team.
Should we ignore the family’s request about withholding the diagnosis from the
patient?
1. Family will know the patient better than the healthcare provider and they may
have the right concern about how harmful the information might be.
2. Often cultural factors play an important role. In some cultures it is standard
practice for family members to make decision about their sick patient.
3. Although most patients want to know about their diagnosis, some of them do not
want to know.
Reliable strategy to resolve the issue:

1. Validate the families concern but explain to them that patient has the right to
know about the diagnosis.
2. Explain to them that the conversation will be handled in a sensitive and
sympathetic way.
3. Reassure the family that the diagnosis will not be forced upon the patient.
4. Explain to them you will ask the patient if patient wants you to explain the result
to them or they prefer to speak with their family.
5. Explain to them if patient wants to know, you will ask them how much detail they
want.
6. Explain to them if patient wants to know, you will ask the patient if they want to
be with their family when you are going to tell them about the results.
7. Explain to them if patient wants to know, the diagnosis will be disclosed slowly.
8. Explain to them if there is specifically some concern about the use of word cancer,
you will use words such as tumour or growth.
9. If you use any alternative word such as tumour, you need to tell the family that if
patient asks what the words mean, we need to explain to the patient the diagnosis is
cancer. Almost all patients will ask about this.
10. Explain to them you will talk to the patient about all possible options and next
steps. Make sure patient is never left with the impression that there is nothing to do.
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ETHICAL 7 DOMESTIC VIOLENCE
When to suspect domestic violence:
1. Injury in consistence with the explanation
2. Unexplained symptoms / non-specific symptoms
3. Delayed presentation
4. Frequent attendance in A and E or GP
5. Depression
6. Genital injury
7. STI
Risk factors for Domestic violence:

1. Female
2. Young age
3. Pregnancy (30% of domestic violence starts in pregnancy)
4. Previous domestic violence and sexual assault
5. Cultural factors (immigration status, language barrier, isolation)
6. Leaving a violence partner
7. Substance abuse
What to do if you suspect domestic violence:

1. Talk to your patient in a sympathetic and non-judgmental manner.
2. Ensure they are safe.
3. Reinforce the confidential nature of discussion.
4. See them on their own without partners or children.
The reasons why people may be reluctant to disclose their suffering from domestic violence:
1. Fear their children may be removed from their care.
2. Fear of an unsympathetic response or not being believed.
3. Shame or embarrassment.
4. Not believing that you can do anything to help.
Indirect questions:
1. With whom do you live?
2. Is everything alright at home?
3. Are you getting on with your partner?
Direct questions
- 4 HARK questions
H – Humiliation
- Does your partner make you feel bad about yourself?
- Have you become emotionally abused by your partner?
A – Afraid
- Are you afraid of your partner?
- What does your partner do that scares you?
R- Rape
- Have you been raped by your partner or forced to have any kind of sexual act?
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- Do you ever feel that you have to have sex with him, when you don’t want to?
K- Kick
- Have you been physically hurt by your partner?
- Does your partner threaten to hurt you?
Management
1. Establish if there is any immediate risk to safety for the person or any children. If so, consider
contacting local police. Initiate child protection procedure where relevant.
2. Discuss and address the needs of any children involved.
3. Know who designated (responsible) person for domestic violence is, arrange an appointment with
that responsible person for initial assessment and document domestic violence.
If there is no immediate risk:

You can call:
1. The free 24-hour national domestic help line.
2. Police domestic violence officer.
3. 999 in emergency situation.
4. Child line.
NOTE: Sometimes patient doesn’t want to leave an abusive partner.

1. Please be supportive and non-judgmental.
2. Please find out the reasons and try to address them.
Reasons for it:

1. Worry about children
2. Financial
3. Fear
4. Loss of self-confidence
5. Embarrassment
6. Cultural reason
7. They may still love the partner
Duties of the designated person

1. Make an initial risk assessment (CADA - risk check list)
2. Advice the patient about the service available depending of the risk level (self – manage the
personal support, refer to and liaise with local MARAC coordinator, multi-agency risk assessment
conference)
3. Provide a safety plan and detail of available resources if patient doesn’t want to engage at this
time.
4. Initiate child protection or adult safe guarding procedure
MARAC
It is a regular consultation between professionals to ensure the safety of those at high risk from
domestic violence.
The MARAC will coordinate resources between police, social services, housing department, school
service, healthcare, probation service, victim support service and substance abuse services.
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ETHICAL 8 POST-MORTEM
What is Post Mortem?
A post mortem examination also known as autopsy, is the examination of a body after death. The aim of a post-
mortem is to determine the cause of death. It is carried out by pathologists. (Doctors who specialise in
understanding the nature and causes of disease).
Post-mortems provide useful information about how, when and why someone died, and they enable pathologists
to obtain a better understanding of how diseases spread.
If your child, partner or relative has died and a post-mortem is to be carried out, hospital bereavement officers
can offer you support and advice. They also act as the main point of contact between you and the staff carrying
out the post-mortem.
When post-mortems are carried out
A post-mortem examination will be carried out if it's been requested by:
- A coroner – because the cause of death is unknown, or following a sudden, violent or unexpected death
- A hospital doctor – to find out more about an illness or the cause of death, or to further medical research and
understanding.
- Sometimes, the partner or relative of the deceased person will request a hospital post-mortem to find
out more about the cause of death.
In most cases, a doctor or the police refer a death to the coroner. A death will be referred to the coroner if:
- it's unexpected, such as the sudden death of a baby (cot death)
- it's violent, unnatural or suspicious, such as a suicide or drug overdose
- it's the result of an accident or injury
- it occurred during or soon after a hospital procedure, such as surgery
- the cause of death is unknown
Which organs to remove?
- Coroners post-mortem: You will not be asked for any consent. Samples and organs may be kept for months or
years if needed.
- Hospital post-mortem (requested by relatives): Hospital post-mortem examinations can be limited to certain
areas of the body, such as the head, chest or abdomen, and this will be discussed with you when your consent
is sought. You will be asked for consent and only the organs you agreed will be removed. HTA recommends
relative should be given at least 24 hours to consider their decision and also they should be given the details of
someone to contact in case they change their mind.
Who should give the consent?
- The deceased person before death
- Representative of the dead appointed by the deceased
- If above 2 do not apply, the consent should be taken from someone who is in a qualifying relationship with the
dead immediately before death.
The Process:
The post-mortem examination will be carried out as soon as possible and usually within two to three
working days after the death. It may be possible to arrange it within 24 hours if necessary. The
examination will be carried out in a post-mortem examination room, rather like an operating theatre, which is
licensed and inspected by the HTA. During a standard post-mortem examination the body is opened and organs
are removed for examination. Most of the time, a diagnosis can be made by looking at the organs and they will
be returned to the body but sometimes we need to take sample for further investigation
There are two parts to the physical examination of the body: the external and internal examination. Toxicology,
biochemical tests and/or genetic testing often supplement these and frequently assist the pathologist in
assigning the cause or causes of death.
External examination:
After the body is received, it is first photographed. The examiner then notes the kind of clothes and their position
on the body before they are removed. Next, any evidence such as residue, flakes of paint or other material is
collected from the external surfaces of the body. Ultraviolet light may also be used to search body surfaces for
any evidence not easily visible to the naked eye. Samples of hair, nails and the like are taken, and the body may
also be radiographically imaged. Once the external evidence is collected, the body is removed from the bag,
undressed, and any wounds present are examined. The body is then cleaned, weighed, and measured in
preparation for the internal examination.
Internal Examination:
For the internal examination there are a number of different approaches available:
A large and deep Y-shaped incision can be made starting at the top of each shoulder and running down the
front of the chest, meeting at the lower point of the sternum. This is the approach most often used.
A T-shaped incision made from the tips of both shoulder, in a horizontal line across the region of the collar
bones to meet at the sternum (breastbone) in the middle.
A single vertical cut is made from the middle of the neck (in the region of the 'Adam’s apple' on a male body)
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In all of the above cases the cut then extends all the way down to the pubic bone (making a deviation to either
side of the navel).
Bleeding from the cuts is minimal, or non-existent, because the pull of gravity is producing the only blood
pressure at this point. At this point, shears are used to open the chest cavity. It is also possible to utilise a simple
scalpel blade. Organs are removed one by one. To examine the brain, an incision is made from behind one ear,
over the crown of the head, to a point behind the other ear. When the autopsy is completed, the incision can be
neatly sewn up and is not noticed when the head is resting on a pillow in an open casket funeral. The scalp is
pulled away from the skull in two flaps with the front flap going over the face and the rear flap over the back of
the neck. The skull is then cut with a circular (or semi-circular) bladed reciprocating saw to create a "cap" that
can be pulled off, exposing the brain. The brain is then observed in situ.
Reconstitution of the body:
An important component of the autopsy is the reconstitution of the body such that it can be viewed, if desired,
by relatives of the deceased following the procedure. After the examination, the body has an open and empty
chest cavity with chest flaps open on both sides, the top of the skull is missing, and the skull flaps are pulled
over the face and neck. It is unusual to examine the face, arms, hands or legs internally.
In the UK, following the Human Tissue Act 2004 all organs and tissue must be returned to the body unless
permission is given by the family to retain any tissue for further investigation. Normally the internal body cavity
is lined with cotton wool or an appropriate material, the organs are then placed into a plastic bag to prevent
leakage and returned to the body cavity. The chest flaps are then closed and sewn back together and the skull
cap is sewed back in place. Then the body may be wrapped in a shroud and it is common for relatives to not be
able to tell the procedure has been done when the body is viewed in a funeral parlour after embalming.
What happens after a post-mortem?
After a post-mortem, the pathologist writes a report of the findings.
If the post-mortem was requested by a hospital doctor, you'll have to request the results from the hospital
where the post-mortem took place. You may be charged a small fee for this.
You can arrange to discuss the results with the doctor in charge of the deceased person's care while they were
in hospital (if applicable), or with your GP.
Why do organs and tissue need to be retained?
In around 20% of adult post-mortem examinations the cause of death is not immediately obvious. A diagnosis
can only be made by retaining small tissue samples of relevant organs for more detailed examination. The
Pathologist may need to retain a whole organ for a full assessment to allow an accurate diagnosis of the cause
of death to be made. These full assessments often take weeks or even a few months to complete, depending on
the extent of the investigations required. Once they are complete, the Pathologist will produce a report for the
medical staff responsible for the care of the person before they died.
Bereavement support
For many people, understanding the reason for a loved one's death helps them come to terms with their loss.
Talking and sharing your feelings with someone can also help. Some people find that relying on the support of
family and friends is the best way to cope.
Your GP will be able to put you in touch with bereavement services in your area. You can also contact the national
Cruse helpline or a local Cruse centre.
How long will the deceased stay at the OCME?
- In most cases, the deceased can be released to a funeral home immediately following the autopsy, usually
within 24 to 48 hours of arrival at OCME. However, the deceased may remain at OCME (Officer of the Chief
Medical Examiner) for as long as required to make the necessary funeral arrangements.
- Once release papers have been issued, the undertakers you've appointed will be able to collect the body from
the mortuary in preparation for the funeral. (NHS choices)
IMPORTANT
- It usually takes 2-4 hours for an autopsy.
- In hospital autopsy consent must be taken from relative for preservation of organs or tissue for research or
study purpose.
- Disposal of tissues if retained:
1. Disposal by burial, cremation or other lawful means by the pathologist.
2. Return the material to relatives to make their own arrangements.
3. Further retention for research or other purpose after taking consent.
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ETHICAL 9 DEMENTIA
What is dementia?
Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. This
includes problems with:
- Memory loss
- Thinking speed
- Mental agility
- Language
- Understanding
- Judgement
People with dementia can become apathetic or uninterested in their usual activities, and have problems controlling their emotions.
They may also find social situations challenging, lose interest in socialising, and aspects of their personality may change.
Other symptoms can include:
- Increasing difficulties with tasks and activities that require concentration and planning
- Depression
- Changes in personality and mood
- Periods of mental confusion
- Difficulty finding the right words
Causes of Dementia:
Dementia is caused by gradual changes and damage in the brain. The most common causes of dementia include diseases in which
the brain cells degenerate and die more quickly than they would as part of the normal ageing process. The changes usually happen
because of a build-up of abnormal proteins in the brain. This damage leads to a decline in a person's mental and, sometimes,
physical abilities.
- Vascular dementia is caused when the brain's blood supply is interrupted. It may be caused by Atherosclerosis or Stroke.
- Alzheimer's disease is the most common form of dementia. In Alzheimer's, the loss of brain cells leads to the brain shrinking.
- Causes of dementia with Lewy bodies:
Lewy bodies are small, circular lumps of protein that develop inside brain cells. It is not known what causes them. It is also unclear
how they damage the brain and cause dementia.
- Frontotemporal dementia is caused by damage and shrinking in two areas of the brain. The areas of the brain affected are called
the temporal lobe and the frontal lobe. This type of dementia is one of the more common types seen in people who are under 65
years of age. Motor neurone disease is sometimes associated with frontotemporal dementia.
Other causes of dementia or dementia-like conditions may be treatable or non-progressive (meaning they do not continue to get
worse with time). These can include:
- depression
- infections, such as encephalitis and HIV-related infections
- some brain tumours
- a lack of vitamin B in the diet
- a lack of thyroid hormone
- head injury
- long-term alcohol misuse
- Hypoxia
- Simple and normal pressure hydrocephalus
There are also rarer causes of neurodegenerative dementia, including:
- Huntington's disease (a rare genetic condition that causes progressive brain damage)
- progressive supranuclear palsy
- corticobasal degeneration
- Unusual forms of Alzheimer's disease, such as posterior cortical atrophy, which usually presents with visual difficulties, rather
than memory problems.
Complications:
Possible complications of dementia, regardless of its cause, include the following:
- loss of ability to function or care for self
- loss of ability to interact with others
- reduced lifespan
- increased infections anywhere in the body
As the disease progresses, additional complications may include:
- forgetting recent events or conversations
- difficulty performing more than one task at a time
- difficulty solving problems
- taking longer to perform more difficult activities
- language problems, such as trouble finding the names of familiar objects
- misplacing items
- getting lost on familiar routes
- personality changes and loss of social skills
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- losing interest in things previously enjoyed, flat mood
- difficulty performing tasks that used to be easy, such as balancing a checkbook, playing complex games (such as bridge), and
learning new information or routines
- forgetting details about current events
- forgetting events in your own life history, losing awareness of who you are
- change in sleep patterns, often waking up at night
- difficulty reading or writing
- poor judgment and loss of ability to recognize danger
- using the wrong word, mispronouncing words, speaking in confusing sentences
- withdrawing from social contact
- hallucinations, arguments, striking out, and violent behaviour
- delusions, depression, agitation
- Difficulty doing basic tasks, such as preparing meals, choosing proper clothing, and driving
- Difficulty swallowing both foods and liquids
- Incontinence
Mild cognitive impairment does not always lead to dementia. Depending on the cause, some dementias might be reversible.
However, most dementia is progressive. This means it gets worse over time. Treatments focus on relieving the symptoms and
slowing the progression. Each case is different. Dementia may progress quickly or slowly. This often depends on the cause. In
general, dementia shortens life expectancy. This varies with the patient and the cause.
Diagnosis of Dementia:
Tests for dementia are mainly tests of mental abilities, blood tests and brain scans.
- People with symptoms of dementia are often given questionnaires to help test their mental abilities, to see how severe any
memory problems may be. One widely used test is the mini mental state examination (MMSE).The MMSE assesses a number of
different mental abilities. The MMSE is not a test to diagnose dementia. However, it is useful for assessing the level of mental
impairment that a person with dementia may have.
- A person with suspected dementia may have blood tests to check their overall level of health. These blood tests can also rule out
other conditions that may be responsible for their symptoms, such as thyroid hormones and vitamin B12 levels.
For Example,
A blood test can be used to:
- Assess your general state of health
- Check if you have an infection
- See how well certain organs, such as the liver and kidneys, are working
- Screen for certain genetic conditions
Brain scans are often used for diagnosing dementia once other simpler tests have ruled out other problems. They are needed to
check for evidence of other possible problems that could explain a person's symptoms, such as a major stroke or a brain tumour.
A computerised tomography (CT) scan can be used to check for signs of stroke or a brain tumour. However, unlike an MRI scan, a
CT scan cannot provide detailed information about the structure of the brain.
The National Institute for Health and Care Excellence (NICE) recommends using a magnetic resonance imaging (MRI) scan to help
confirm a diagnosis of dementia.
Positron emission tomography (PET) scan, may be recommended if the result of your CT or MRI scan is uncertain. These scans look
at how the brain functions and can pick up abnormalities with the blood flow in the brain.
In some cases, an electroencephalogram (EEG) may be taken to record the brain's electrical signals (brain activity).
Care at home for people with advanced dementia:

Palliative care services may sometimes be offered in the home, rather than in a hospice building. "Hospice-at-home" services have
staff that are usually on call 24 hours a day and can visit people at home.
Your GP can arrange for community palliative care nurses to provide care in the home. Your local authority may also provide social
care services and equipment for the home. Read more about care at home.
Hospice-care for advanced dementia:

Hospices are specialist residential units run by a team of doctors, nurses, social workers, counsellors and trained volunteers.
They are smaller and quieter than hospitals and feel more like a home.
Hospices can provide individual care more suited to individuals in a gentler, calmer atmosphere. There is no charge for hospice
care, but patients must be referred to a hospice through their GP. Find hospice services near you.
Palliative care in a care home:

Palliative care is available in residential care homes. If someone with dementia is already in a residential home, they may want to
stay there for their palliative care. This may make them more comfortable and less distressed than having to go into hospital, unless
that is necessary.
You should ask if the residential home is accredited by the end of life Gold Standards network, which means that the home has
specially trained staff and good links with local GPs.
Palliative care for dementia as a hospice day patient:

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If someone who has dementia prefers to remain living at home, they may be able to visit a hospice during the day. This means
they can receive the care and support they need without permanently leaving their home.
As a day patient, they will be able to access more services than could be offered if they stayed at home. Such services might
include creative and complementary therapies and rehabilitation, as well as nursing and medical care. They will also meet other
patients. Hospices often provide transport to and from the hospice.
Dealing with incontinence in someone with dementia:

Incontinence can be difficult to deal with and can be very upsetting for the person you care for. It's common for people with
dementia to experience incontinence. This can be due to urinary tract infections, constipation causing added pressure on the
bladder, or medication.
It's important to be understanding, retain a sense of humour and remember that it's not their fault. You may also want to try the
following:
- Put a sign on the toilet door, such as a photo of the toilet.
- Keep the toilet door open and make sure that the person you care for can access it easily.
- Make sure they can remove their clothes – some people with dementia can struggle with buttons and zips.
- Look out for signs that they may need to go to the toilet, such as fidgeting and standing up and down.
- Get adaptations to the toilet if necessary – you may be able to get these through a care and support needs assessment.
- If you're still having problems with incontinence, ask your GP to refer you to a continence advisor, who can advise on things like
waterproof bedding or incontinence pads.
Helping patient with sleep problem:

"Sleep hygiene" measures are best for people with dementia – for example, no naps during the day, regular bedtimes, and
avoiding alcohol or caffeine at night.
Personal Hygiene:
The person you care for may not want to be left alone or they may resist washing, because they find the lack of privacy undignified
and embarrassing. Try to do what's best for them.
Health and nutrition:
Common food-related problems for people with dementia include:
- not recognising foods
- forgetting what food they like
- refusing or spitting out food
- resisting being fed
- asking for strange food combinations
This behaviour is usually due to confusion, or irritation in the mouth caused by dental problems, rather than wanting to be
awkward. If you're concerned about the person's eating behaviour, speak to your GP.
Involve the person you care for. For example, if they cannot feed themselves, you could put the cutlery in their hand and help
guide it to their mouth. You could also involve them in preparing food, if they are able to.
Try to stay calm. If you feel stressed at mealtimes, the person you care for will probably be stressed too. Make sure you have
plenty of time for meals, so you can deal with any problems that arise.
Try to accommodate behaviour changes. It's likely that the person you care for will change their eating patterns and habits over
time. Being aware of this and trying to be flexible will make mealtimes less stressful for both of you.
If you think the person you care for may have health or dental problems, get help from your GP or dentist. You could also contact
a local carers' group to speak to other people who may have experienced similar difficulties.
You may also be advised to take special nutritional supplements which can increase your energy and protein intake. You'll be
helped to set targets and your progress will be regularly monitored.
Dressing:
Make sure the person with dementia wears clothes that are suitably warm or cool, depending on the weather, that they have on
layers if necessary and that they are dry.
Mobility:
If the person with dementia develops mobility problems, they may benefit from using a wheelchair outside the home. They are
more likely to need an attendant-propelled wheelchair, in which case, as a carer, you will need to consider what works for you as
well as the person sitting in it. This includes issues such as whether you want a wheelchair that can be folded to fit into a car.
Aggressive behaviour:
Dementia can have a big impact on a person’s behaviour. It can make them feel anxious, lost, confused and frustrated. If you are
experiencing these kinds of behaviour, or are looking after someone who behaves in this way, it's important to remember that this
is an attempt to communicate how they're feeling. They are not being deliberately difficult. If you stay calm and work out why
they're expressing themselves in this way, you may be able to calm them down.
Care options for people with dementia:
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Many people with dementia stay in their own home if they have adequate support, either from family carers, community nurses
or paid care workers. Being in familiar surroundings can help people cope better with their condition. Many people with dementia
will eventually need support in a residential care home. This could be a care home or a nursing home, depending on their needs.
The Alzheimer’s Society has reported that around two-thirds of people in care homes have some form of dementia. However, not
all care homes are suitable for people with dementia.
If you care for someone with dementia and they have to go into a care home, try to make their room as familiar as possible. For
example, put photos of family and friends where they will see them every day. Favourite pictures, furniture and ornaments could
also make them feel more at home.
Admiral Nurses:
Admiral Nurses are specialist dementia nurses who work with people with dementia, their families and carers. They aim to
improve the quality of life for carers and people with dementia.
To talk to a trained specialist dementia nurse about caring for someone with dementia, call Admiral Nursing Direct
Charities:
There are several dementia charities that can offer excellent advice and support. The leading dementia charity is the Alzheimer’s
Society. Its website contains essential information on dementia and Alzheimer’s disease, including how to live well with the
disease and how to find help near you.
Dementia UK is a national charity that aims to improve the quality of life for people with dementia. As well as Admiral Nurses, it
provides training for those working with people with dementia, and also runs Uniting Carers, a network for people to access the
support they need.
If you are looking after someone with dementia, it’s important that you know how to get help and support for yourself as well.
The Carers Trust is a good place to start looking for information and advice on how to get help and support, and even a break
from caring.
Alzheimer's Research UK carries out dementia research, but it also answers questions about dementia and dementia research –
including how you and your loved ones can get involved. Talking Point is the Alzheimer’s Society’s forum. It has people with
dementia sharing their information and advice, and supporting each other.
Carers can also turn to online communities on the Carers UK forum and the Carers Trust forum.
Dementia books on prescription
Reading Well Books on Prescription for dementia offers support for people diagnosed with dementia and their relatives and
carers. GPs and other health professionals can recommend titles from a list of 25 books on dementia. The books are available for
anyone to borrow for free from their local library.
Medications:
The following are used to temporarily improve dementia symptoms.
1. Cholinesterase inhibitors:
These medications — including donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) — work by boosting levels
of a chemical messenger involved in memory and judgment.
Side effects can include: nausea, vomiting and diarrhoea.
2. Memantine:
Memantine (Namenda) works by regulating the activity of glutamate, another chemical messenger involved in brain functions,
such as learning and memory. In some cases, memantine is prescribed with a cholinesterase inhibitor.
A common side effect of memantine is dizziness.
3. Other medications:
Your doctor might prescribe medications to treat other symptoms or conditions, such as depression, sleep disturbances or
agitation.
Therapies:
Several dementia symptoms and behaviour problems might be treated initially using nondrug approaches, such as:
1. Occupational therapy: An occupational therapist can show you how to make your home safer and teach coping behaviours. The
purpose is to prevent accidents, such as falls; manage behaviour; and prepare you for the dementia progression.
2. Modifying the environment: Reducing clutter and noise can make it easier for someone with dementia to focus and function.
You might need to hide objects that can threaten safety, such as knives and car keys. Monitoring systems can alert you if the
person with dementia wanders.
3. Modifying tasks: Break tasks into easier steps and focus on success, not failure. Structure and routine also help reduce
confusion in people with dementia.
4. Alternative medicine
- Several dietary supplements, herbal remedies and therapies have been studied for people with dementia. Some may be
beneficial.
- Use caution when considering taking dietary supplements, vitamins or herbal remedies, especially if you're taking other
medications. These remedies aren't regulated, and claims about their benefits aren't always based on scientific research.
Some alternative medicines for Alzheimer's disease and other forms of dementia that have been studied include:
- Vitamin E. Evidence for taking vitamin E to slow Alzheimer disease is soft. Doctors warn against taking large doses of vitamin E
because it may have a higher risk of mortality, especially in people with heart disease.
- Omega-3 fatty acids. There is some evidence that eating fish three times a week might lower your risk of dementia.
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ETHICAL 11A - INSOMNIA
Description:
Insomnia is difficulty getting to sleep.
Symptoms:
1. Difficult to fall asleep.
2. Lie awake for long periods at night.
3. Wake up several times at night.
4. Wake up early morning and inability to get back to sleep.
5. Not feel refreshed when waking up.
6. Feel it's hard to nap during the day despite feeling tired.
7. Difficult to concentrate during the day.
Causes and risk factors:

1. Stress and anxiety such as bereavement, problems at work or financial difficulties.
2. Poor sleep routine and sleeping environment such as inconsistent times, nap during the day, uncomfortable bed or the bedroom
being too bright, noisy, hot or cold.
3. Lifestyle habits such as drinking alcohol, smoking cigarettes and caffeine products.
4. Mental health conditions such as mood disorders, anxiety disorders or psychotic disorders.
5. Physical health conditions such as heart, lung, neurological, hormonal, joint or muscle, genital or urinary problems.
6. Medications such as certain antidepressants, epilepsy medications, steroids, beta-blockers and NSAIDs.
MANAGEMENT
General Management
Insomnia will often with changing in lifestyle habits.
- Daytime habits:
1. Set a specific time for getting up each day and stick to it.
2. Don't nap during the day.
3. Daily exercised as walking or cycling.
- Bedtime habits:
1. No coffee or tea few hours before bedtime.
2.No alcohol or smoking shortly before going to bed.
3. No big meals before bedtime.
4. Going to bed only when feeling tired.
5. Create a relaxing bedtime routine such as taking a bath or listening to music.
6. Avoid over-the-counter sleeping tablets.
7. Avoid watching the clock.
- Bedroom environment:
1. Use thick blinds or curtains or eye mask to block light.
2. Make sure bedroom temperature is comfortable for sleeping.
3. Wear ear plugs.
4. Make sure mattress and pillows are comfortable.
5. Avoid using bedroom for any activities other than sleeping and sex.
Specific Management
1. Cognitive behavioral therapy insomnia (CBT-I): This is a specific type of CBT directed towards insomnia, the aim is to change
unhelpful thoughts and behaviors that may contribute to insomnia.
2. Sleeping tablets: Their use is less often nowadays, they are usually used in severe insomnia as a temporary measure for short-
term insomnia or if the other measures are not helping.
3. Over-the-counter sleeping pills: They are formed of anti-histamine which makes the patient drowsy. Generally, they are not
recommended in insomnia patients because it's not clear how effective they are.
4. Insomnia can cause tiredness, that's why patients are advised not to drive when feeling tired or sleepy.
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Ethical 12- CONTRACEPTION IN YOUNG PERSON
CONFIDENTIALITY
It is important to maintain confidentiality while you are dealing with the young patient as long
as they are competent enough.
Young patient under 16 should be encouraged to involve their parents about their health and
care. You may advice them to share the information with their family however if they refuse you
should respect their decision and you cannot force them to inform the family.
You cannot also breach their confidentiality by informing their parents.
When dealing with a request for contraception for someone under 16 it is important to establish
a rapport, give support and give time to make an informed decision. This can be done by
discussing the emotional and physical implications of sexual activity including the risk of
pregnancy, STI and HIV.
GILLICK COMPETENCE.
Before prescribing OCP pt. should have Gillick competency this means:
1. A young person must be able to understand and retain the information in order to make a
decision about their care.
2. A young person must be able to use information to consider whether or not they should
consent to the treatment, which has been offered to them.
3. A young person must be able to communicate their decision to others.
BREACHING CONFIDENTIALITY
Maintaining a young patient’s confidentiality is very important, however, where there may be a
risk to health, safety or welfare of young person or others, doctor should follow child protection
procedure and the young patients family should be involved.
If doctors realize that a young patient is in an abusive relationship he can breach the
confidentiality.
The following factors may suggest an abusive relationship:
1. A young person is too immature to understand or give consent.
2. Big differences in the age, maturity or power between sexual partners.
3. A young patients sexual partner has a position of trust.
4. Force, emotional or psychological pressure to engage in sexual activity.
5. Drug or alcohol to influence young patient to engage in sexual activity.
6. If young patients sexual partner is known to the police or children protection agency as
having abusive relationship with children or young people.
ETHICAL AND LEGAL ISSUES – GIRLS UNDER 16 YEARS

1. Explore their understanding and consider informing young people of the law in relation to
sexual activity.
2. The legal age of consent to sexual activity is 16 years in the UK.
- Sexual activity under the age of consent is an offence even if consensual.
- Offences are considered more serious (statutory rape) when the person is younger than 13
years of age.
3. Reassure her that the consultation is confidential but explain the circumstances in which
confidentiality may need to be breached (for example, suspected child protection issues,
exploitation, or coercion).
4. Assess her competency to independently consent to treatment, and document in her case
notes that she meets (or does not meet) the Fraser Criteria.
5. If the Fraser Criteria are not met, consider breaching confidentiality and seeking parental
consent.
6. Consider child protection issues.
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- If non-consensual sex or sexual abuse is suspected, follow appropriate child protection
procedures and refer to a paediatrician if necessary.
7. Counsel her on the emotional and physical implications of sexual activity, including the risks
and consequences of pregnancy and the risk of sexually transmitted infections (STIs).
FRASER CRITERIA
In England and Wales, it is lawful to provide contraceptive, abortion and STI advice and
treatment, without parental knowledge or consent, to young people under 16 provided that the
practitioner is satisfied that all the Fraser criteria for competence are met.
The criteria are that:
1. The young person understands all the aspects of the advice and its implications given to her
by the health care professional.
2. The young person cannot be persuaded to inform her parents, or to allow the healthcare
professional to inform them.
3. In relation to contraception and STIs, it is likely that the young person will begin or continue
to have sexual intercourse, with or without the use of contraception.
4. The young person's physical or mental health may suffer as a result of withholding
contraceptive advice or treatment.
5. It is in the best interests of the young person for the clinician to provide contraceptive advice
or treatment, or both, without parental knowledge or consent.
SUMMARY
In summary, when prescribing contraceptive pills these areas should be considered by the
doctor:
1. She has actually showed a degree of maturity by coming to discuss about this issue.
2. Assess Fraser Criteria and Gillick Competency.
3. Encourage to consider telling and involving her parents.
4. Assess why she is requesting the pills?
5. Assess the nature of her relationship that has made her to seek advice.
6. Assess factors which may suggest an abusive relationship.
7. Assess the risk of current or potential harm, asses risk to her health and safety.
8. Assess risk of pregnancy and STIs.
9. Assess ethical and legal issues.
10. Establish the details of her social network, support and whether her parent(s) or carers
know about her decision.
11. Assess the sex and relationship education given at school.
12. Give support.
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ETHICAL 15 MORNING AFTER PILL
Emergency Contraception (Morning after pill, IUD):
- Emergency contraception can prevent pregnancy after unprotected sex or if your contraceptive method has
failed – for example, a condom has split, or you've missed a pill.
- There are two types:
a. The emergency contraceptive pill (sometimes called the morning after pill)
b. The IUD (intrauterine device, or coil)
- There are two kinds of emergency contraceptive pills:
a. Levonelle has to be taken within 72 hours (three days) of sex.
b. EllaOne has to be taken within 120 hours (five days) of sex.
- Both pills work by preventing or delaying ovulation (release of an egg).
- The IUD can be inserted into your uterus up to five days after unprotected sex, or up to five days after the
earliest time you could have ovulated. It may stop an egg from being fertilized or implanting in your womb.
How the emergency pill works:
- They prevent pregnancy mainly by preventing or delaying ovulation.
- It does not interfere with your regular method of contraception.
- They do not continue to protect you against pregnancy. This means that if you have unprotected sex at any
time after taking the emergency pill you can become pregnant.
- Even if you are starting or continuing another method of hormonal contraception, it may not be effective
immediately. You will need to use condoms or avoid sex until the contraception is working effectively.
- The time it takes for contraception to become effective depends on the emergency contraceptive pill and the
method of hormonal contraception being started. Your doctor or nurse will tell you when you can start
hormonal contraception and how long you will need to take additional precautions to prevent an unintended
pregnancy.
- Levonelle and ellaOne are not intended to be used as a regular form of contraception. However, you can use
emergency contraception more than once in a menstrual cycle if necessary.
- The sooner you take Levonelle or ellaOne, the more effective it will be.
Advantages:
- Both types of emergency contraception are effective at preventing pregnancy if they are used soon after
unprotected sex. Less than 1% of women who use the IUD get pregnant, whereas pregnancies after the
emergency contraceptive pill are not as rare. It’s thought that ellaOne is more effective than Levonelle.
- If you use the IUD as emergency contraception, it can be left in as your regular contraceptive method.
- There are no serious side effects of using emergency contraception.
- Emergency contraception does not cause an abortion.
- It can be used in those who cannot use estrogen-based contraception such as combined contraceptive pill,
contraceptive patch or vaginal ring.
- Girls aged under 16 years old can also use the emergency contraceptive pill.
Disadvantages:
- Levonelle or ellaOne can make you feel sick, dizzy or tired, or give you a headache, tender breasts or
abdominal pain.
- Levonelle or ellaOne can make your period earlier or later than usual.
- If you use the IUD as a regular method of contraception, it can make your periods longer, heavier or more
painful.
- You may feel some discomfort when the IUD is put in – painkillers can help to relieve this.
- Some medicines including medications for HIV, epilepsy, medications used to make your stomach less acidic
(an antacid such as omeprazole) and some antibiotics used for treatment of conditions such as tuberculosis and
meningitis (Rifabutin, Rifampicin) can reduce the effectiveness of ellaOne, thus it cannot be used if you are
already taking one of these medicines, as it may not be effective. Levonelle may still be used, but the dose may
need to be increased – your doctor or pharmacist can advise on this.
Contraindications:
Levonelle:
- The WHO does not identify any medical condition that would mean a woman shouldn’t use Levonelle.
ellaOne:
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- The manufacturer of ellaOne advises that it should not be used:
a. If you are allergic to any of the components of the drug.
b. If you have severe asthma that is treated with glucocorticoids (steroid) tablets.
c. If you have certain rare hereditary problems with lactose metabolism.
d. ellaOne may not be effective in women who are taking liver enzyme-inducing medication.
Side Effects:
Taking the emergency contraceptive pill has not been shown to cause any serious or long-term health
problems. However, it can sometimes have side effects.
Common side effects include:

- Tummy pain
- Headache
- Irregular menstrual bleeding (spotting or heavy bleeding) before your next period is due.
- Feeling sick
- Tiredness
Less common side effects include:

- Breast tenderness
- Dizziness
- Vomiting (seek medical advice if you vomit within two hours of taking Levonelle, or three hours of taking
ellaOne, as you will need to take another dose or have an IUD fitted)
Breastfeeding:
- Levonelle can be taken while breastfeeding. Although small amounts of the hormones contained in the pill
may pass into your breast milk, it is not thought to be harmful to your baby.
- The safety of ellaOne during breastfeeding is not yet known. The manufacturer recommends that you do not
breastfeed for one week after taking this pill.
If you are already using the pill, patch, vaginal ring or contraceptive injection:
- You may need to take the emergency pill if you:
a. forgot to take some of your regular contraceptive pills, or
b. did not use your contraceptive patch or vaginal ring correctly, or
c. were late having your contraceptive implant or contraceptive injection.
- If you have taken Levonelle, then you should:

a. take your next contraceptive pill, apply a new patch or insert a new ring within 12 hours of taking the
emergency pill.
You should then continue taking your regular contraceptive pill as normal.
- You will need to use additional contraception, such as condoms, for:

a. the next seven days if you use the patch, ring, combined pill (except Qlaira), implant or injection
b. nine days for the combined pill Qlaira
c. the next two days if you use the progestogen-only pill
- If you have taken ellaOne, you will need to wait at least five days before taking your next contraceptive pill,
applying a new patch or inserting a new ring. You should then use additional contraception, such as condoms,
while waiting to restart your contraceptive method and then for:
a. the next seven days if you use the patch, ring, combined pill (except Qlaira), implant or injection
b. nine days for the combined pill Qlaira
c. the next two days if you use the progestogen-only pill
Can I get the emergency contraceptive pill in advance?
- You may be able to get the emergency contraceptive pill in advance of having unprotected sex if:
a. You are worried about your contraceptive method failing.
b. You are going on holiday.
c. You cannot get hold of emergency contraception easily.
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SPIES PROTOCOL
Questions asking how you would deal with a difficult colleague come in different shapes and forms.
The level of difficulty varies from simple lateness to training-related underperformance and attitude
problems, to sheer criminal acts. In these questions, the level of seniority of the colleague in question
also varies from a junior doctor to someone more senior, such as a consultant for example.
The scenarios are daunting and these questions often strike fear into the heart of the candidate –
most of us imagine the worst case and the thought of having to remove our drunken boss from the
ward. Psychologically, part of the difficulty is to overcome the fear of what would happen to “me” if I
blew the whistle. Your interviewers will demand that you understand the broad implications of the
scenario not only for patients but also the team and your colleague. They will be testing your ability
to address all the relevant issues appropriately. Having the SPIES structure as the basis for your
answer allows you to deal with any of the questions by applying the same principle.
At the interview, you will be expected to demonstrate that you can handle the situation in a
responsible and mature manner, ensuring patient safety at all times whilst also resolving the matter
sensitively.
To ensure that you cover all angles, you will need to consider the following:
1. Seek Information
Before you can do anything, you need to understand the nature of the problem. In some cases, it will
take a fraction of a second (e.g. if a colleague is drunk). In others, it may take longer (e.g. if a
colleague does not appear motivated). This may involve discussing the matter with the individual
concerned or with other colleagues, if appropriate.
2. Patient Safety
Once you have assessed the situation, you must make sure that patients are protected. If the person
is in an immediate threat to patients (e.g drunk or about to do the wrong operation) then you must
remove them from the clinical area or tell them to stop doing whatever they are doing (this could be
done by having a quiet word with the individual in question, or in the worst-case scenario calling for
help to have them removed).
3. Initiative
Is there anything that you can do by yourself that will help resolve the problem. In practice, this will
only apply to minor issues, where there is no real threat to patient safety.
If the colleague is drunk, there is little that you can do to help. However, if it is just an issue of a
junior colleague being a bit slow, then there are things that you could do to help out in the first
instance (e.g. individual coaching or a discussion).
4. Escalate
If the situation is too serious for you to deal with, then you must involve other colleagues at
appropriate levels of seniority. For a problem with a junior colleague, this could be the registrar, the
education supervisor or the underperforming colleague or another consultant.
For an underperforming consultant, this would need to be the clinical director. If the situation is not
resolved, you may need to escalate further to the medical director, the chief executive or even the
GMC. If you don’t know what to do, you can seek advice from other organisation (e.g. the BMA, any
medical defence organisation, the GMC)
5. Support
There are reasons for the colleague to behave in this way. As an individual he will need support to
deal with the problem. Your team will also need support if it is one person down.
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TM ETHICAL 24 PIGN
Symptoms:
1- Fluid retention with generalised swelling;
- Oedema: swelling or puffiness in different parts of the body, especially around the eyes,
face, arms, legs, feet and ankles.
- Ascites: Rarely
2- High blood pressure

3- Hematuria: (like a cola drink - Coca-Cola colored urine)
4- Proteinuria: Frothy or foamy urine
5- Oliguria: urinating less often or decreased amounts of urine.
6- Joint stiffness and joint pain.
7- Breathlessness: This happens rarely when fluid builds up around their lungs.
Other symptoms and signs:

8- tiredness, low energy or difficulty concentrating
9- decreased appetite
10- nausea or vomiting or diarrhoea
11- abdominal pain
12- headaches that keep coming back or that do not go away.
13- pain, stiffness or swelling of the joints.
Risk Factors:
A- Age: This condition can occur at any age. However, it is mostly common in children aged
2 to 12.
B- Gender: This condition is also known to affect twice as many males than females.
C- PMH
Recent health
-Previous Streptococcal infection (Most Common):
I. Strep Throat (Streptococcal pharyngitis): Strep throat is a disease that causes a sore throat
(pharyngitis). It is an infection with a germ called group A streptococcus bacteria.
II. Streptococcal skin infections (such as Impetigo)
-Less common pathogens are non-streptococcal bacteria, viruses, parasites, rickettsiae, and
fungi.
Complications:
1-Hypertension
2-Rapidly Progressive Glomerulonephritis (RPGN)
3-Acute Kidney Injury (AKI)
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Herbal Regulations UK- Ethical 31A
Herbal medicines are those with active ingredients made from plant parts, such as leaves, roots
or flowers. But being 'natural' doesn't necessarily mean they're safe for you to take.
Herbal medicines, just like conventional medicines, will have an effect on the body and can be
potentially harmful if not used correctly. They should therefore be used with the same care and
respect as conventional medicines.
Risks associated with herbal medicine:

-They may cause problems if you're taking other medicines. They could result in reduced or
enhanced effects of the medicine(s), including potential side effects.
-You may experience a bad reaction or side effects after taking a herbal medicine.
-Not all herbal medicines are regulated. Remedies specially prepared for individuals don't need
a licence and those manufactured outside the UK may not be subject to regulation.
-Evidence for the effectiveness of herbal medicines is generally very limited. Although some
people find them helpful, in many cases their use tends to be based on traditional use rather
than scientific research.
Taking a herbal medicine may not be suitable for:

-People taking other medicines
-People with serious health conditions, such as liver or kidney disease
-People due to have surgery
-Pregnant or breastfeeding women
-The elderly
-Children – as with as with all medicines, herbal medicines should be kept out of sight and reach
of children
They should especially not be taken before surgery because:

-Some herbal medicines might interfere with anaesthesia and other medicines used before,
during or after procedures
-Some herbal medicines may interfere with blood clotting and blood pressure, which may
increase the risk of bleeding during or after surgery
Regulations regarding herbal medicine:

If you want to try a herbal medicine, look out for a traditional herbal registration (THR) marking
on the product packaging.
This means the medicine complies with quality standards relating to safety and manufacturing,
and it provides information about how and when to use it.
But you should be aware that:

-THR products are intended for conditions that can be self-medicated and don't require medical
supervision, such as cough, colds, or general aches and pains
-Using THR products for more serious conditions could be harmful, especially if you delay
seeking medical advice
-Claims made for THR products are based on traditional usage and not on evidence of the
product's effectiveness
-A THR mark doesn't mean the product is completely safe for everyone to take
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Neuroblastoma- Ethical 31B
Neuroblastoma is a rare type of cancer that mostly affects babies and young children.
It develops from specialised nerve cells (neuroblasts) left behind from a baby's
development in the womb.
Neuroblastoma most commonly occurs in one of the adrenal glands situated above the
kidneys, or in the nerve tissue that runs alongside the spinal cord in the neck,
chest, tummy or pelvis. It can spread to other organs such as the bone marrow, bone,
lymph nodes, liver and skin.
It affects around 100 children each year in the UK and is most common in children
under the age of 5. The cause is unknown. There are very rare cases where children in
the same family are affected, but generally neuroblastoma doesn't run in families.
Symptoms:
The symptoms of neuroblastoma vary depending on where the cancer is and whether it
has spread.
The early symptoms can be vague and hard to spot, and can easily be mistaken for those
of more common childhood conditions.
-A swollen painful tummy, sometimes in association with constipation and difficulty

passing urine
-Breathlessness and difficulty swallowing
-A lump in the neck
-Blueish lumps in the skin and bruising, particularly around the eyes
-Weakness in the legs and an unsteady walk, with numbness in the lower body
-Constipation and difficulty passing urine
-Fatigue, loss of energy, pale skin, loss of appetite and weight loss
-Bone pain, a limp and general irritability
-Rarely, jerky eye and muscle movements
Tests for neuroblastoma:

-A urine test – to check for certain chemicals produced by neuroblastoma cells that are
found in urine
-Scans – such as ultrasound scan, CT scan, and MRI scan of various parts of the body to
look at these areas in detail
-An MIBG scan – this involves the injection of a substance taken up by neuroblastoma
cells
NOTE: MIBG (metaiodobenzylguanidine) scans help locate and diagnose certain types of
tumors in the body. MIBG is a substance that gathers in some tumors,
particularly neuroblastoma tumors. When MIBG is combined with radioactive iodine
(tracer), it provides a way to identify primary and metastatic (spread) disease. MIBG
scans are helpful for locating both bone and soft tissue tumors.
238
-A biopsy – the removal of a sample of cells from the tumour tissue for examination
under a microscope so the type of cancer can be identified
-Bone marrow biopsies – to see if there are cancer cells in the bone marrow
Stages of neuroblastoma:
This indicates if it has spread and, if so, how far.
-Stage L1 – the cancer is just in one place and hasn't spread, and can be removed by
surgery
-Stage L2 – the cancer is in one place and hasn't spread, but can't be removed safely by
surgery
-Stage M – the cancer has spread to other parts of the body
-Stage Ms – the cancer has spread to the skin, liver or bone marrow in children aged less
than 18 months
Treatment:
-Surgery to remove the cancer
-Chemotherapy – this may be the only treatment needed or it may be given to shrink the
cancer before surgery
-Radiotherapy – this may sometimes be used after surgery to destroy any remaining
cancer cells in the affected area
-High-dose chemotherapy followed by a stem cell transplant– where stem cells from
your child are collected, frozen and stored prior to intensive chemotherapy, and are
given back to them afterwards
-Immunotherapy – where a medication that directly targets the neuroblastoma cells is
given, although this isn't used routinely yet
Some babies and infants less than 18 months old with either stage L1 or Ms
neuroblastoma who have no symptoms may not need any treatment, as the cancer can
sometimes go away on its own.
The outlook for neuroblastoma varies considerably, and is generally better for younger
children whose cancer hasn't spread. Your doctors will be able to give you more specific
information about your child.
Almost half of neuroblastomas are a type that can return despite intensive
treatment. Further treatment will often be necessary in these cases.
Chemotherapy side effects:

-Feeling sick (nausea) and being sick (vomiting)
-Diarrhoea
-Weight loss
-Hair loss
-Increased risk of infection
-Bruising and bleeding
-Tiredness
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TM 34 ETHICAL - HOSPITAL POLICIES
RESPECTING THE RELIGIOUS AND CULTURAL NEEDS OF PATIENTS
The patients we care for come from a wide variety of religious and cultural backgrounds. The purpose of this document is to
help staff understand more fully and appreciate the religious and cultural needs of all for whom they care.
All patients need to be treated with respect and understanding when supporting their individual need, ensuring that you
understand the dialogue established between care giver and patient/relative in order to ensure their needs are met.
It is always advisable to talk sensitively with the patient about their needs. The patient may also be able to provide a contact
number for their own spiritual advisor.
Christian Patients
About the faith

A Christian is the name given to a person who believes in the divinity of Jesus Christ. The Christian religion today is
represented by many different churches, these as a whole represent one third of the world population. The common thread
to all their beliefs is the teaching of God as a Trinity; Father, Son and Holy Spirit.
God is seen as the creator of the world, which has been saved through Jesus Christ.
The bible is seen as a unique collection of books telling of the revelation of God.
Sacraments are practised by Christians as outward and visible signs of spiritual gifts.
Tradition recognises seven sacraments although some churches only recognise two or three. Baptism marks the entry of a
person into the Christian faith and churches accept each other’s baptism.
The Eucharist is the principle sacrament and is also called the Lord’s Supper, Holy Communion or Mass. In this, bread and
wine are used to symbolise the body and blood of Jesus Christ and are distributed to the congregation.
Another sacrament often associated with hospital is anointing the sick with oil.
Christian denominations
Anglican: These include The Church of Ireland and The Scottish Episcopal Church, The Church of England and The Church of
Wales.
Free Church: These include Methodists, Baptists, The Salvation Army, The United Reform Churches, The Society of Friends,
Presbyterian, The Church of Scotland and others.
Roman Catholic: The Roman Catholic Church is the religious group which accept the Pope as their spiritual leader.
The Trust employs Chaplains who represent all of these denominations.
Admitting a Christian patient

Ask the patient if they would like the Hospital Chaplain to call. Messages may be left on the Chaplaincy answer phones.
Practicing Catholic patients usually wish to see the priest whilst in hospital.
Staff should never hesitate to call in the priest for the patient or their family.
Patients may wish to receive Holy Communion regularly whilst in hospital.
Anointing with oil is a very important aspect of Catholic patient’s care and this together with confession may be sought
before an operation or if a patient deteriorates.
Anglican and Free Church patients may also wish for prayers, Holy Communion or anointing. Please ask the patient about
this. There are no particular requirements.
Some may wish to abstain from meat on a Friday, and others may wish to fast before receiving Holy Communion.
Other considerations
Post mortem: There are no religious objections to this.
Organ donation: There is no religious objections to this. A body may be donated for teaching or research purposes.
The church will offer a memorial service and later a funeral service for donated bodies.
Fasting
During Lent, the 40 days of preparation for Easter, many people choose to observe some kind of fasting. This may mean
moderating the diet or total abstinence for that period of time. Fasting is a recognised part of an Orthodox Christian’s life.
Wednesday and Friday each week, and a long period before Christmas and Easter have traditionally been times when no
meat, fish, dairy products or alcohol have been consumed.
In the Roman Catholic Church, Ash Wednesday and Good Friday are days when meat is avoided and only one main meal and
two lighter snacks are taken. This does not apply to those under 7 or over 60, or to those who are sick. Latter-day Saints hold
regular fast days, usually on the first Sunday of each month during which neither food nor drink are taken.
This is not expected of children, of the sick or women who are pregnant or breast feeding.
Festivals
Sunday has been celebrated since the beginning of Christianity as the day of Jesus’ resurrection from the dead. Most
Christians meet for worship on this day.
They also try to honour the day by avoiding unnecessary work. The important feast days are Christmas Day (25th Dec),
celebrating the birth of Christ, Easter, remembering his death and resurrection, and Whitsun/Pentecost, which celebrates
the coming of God’s spirit and the birth of the church.
240
Most Orthodox Christians celebrate Christmas Day on 25th December but some follow the Julian calendar and celebrate it on
7th January. The orthodox Christians celebrate Easter on a date which is often considerably later than the Western Easter.
The Western dates of Whitsun and Easter vary, and they are linked to old Pagan festivals of spring and are based on a lunar
calendar. There are many ancient symbols associated with Christian festivals, some of which are also shared by people
outside the church.
Pastoral care and social concern

Pastoral care is a very important aspect of the Christian Ministry. It is particularly important in times of stress. All Christians
have the responsibility to show compassion and offer support to others, but at various moments in their lives Christians may
want to see a priest for guidance or confession.
In hospitals, prisons, colleges or the armed services there are usually Christian Chaplains on hand.
It is important to take seriously the pastoral needs of children. It is equally important to consider the pastoral and spiritual
needs of elders, particularly if they are cut out from their regular support networks and are unable to continue with
established and valued patterns of worship.
Prayer
The Lord’s Prayer taught by Jesus to his disciples, is treasured by Christians and is used both in private and public worship.
“Our Father, who art in heaven, hallowed be thy name, thy Kingdom come, they will be done on Earth as it is in Heaven. Give
us this day our daily bread and forgive us our trespasses as we forgive those who trespass against us, and lead us not into
temptation but deliver is from evil. For thine is the Kingdom, the power and the glory, for ever and ever. Amen.”
Dying patients
Christians believe in life after death. As death approaches some may wish prayers to be said or anointing to take place. The
Chaplain is also available to comfort the family and is also available to support non-believers or non-practicing people. Ask
the patient or family about their needs. In the Roman Catholic Church, the sacrament of the sick is administered to patients
and is adapted according to the seriousness of the illness and can be repeated if circumstances change.
This sacrament symbolises forgiveness, healing and reconciliation. It is more important for the priest to be called out before
a patient dies. If the health of the patient deteriorates and it is their wish or wish of the relatives, do not hesitate to call the
priest.
When a Christian patient dies

Anglican and Free Church: Ask the family about their needs. Prayers may be said by the bedside at the point of death or over
the body soon afterwards. Sometimes prayers are said in the mortuary viewing chapel. The last offices can be carried out
according to normal practice. Burial and cremation are both acceptable.
Roman Catholic Church: The priest is often called at the point of death or soon afterwards to administer the Last Rites. The
last offices can be carried out according to normal practice. Traditionally burial has been preferred but cremation is
acceptable. The main reason to call the priest out when the patient dies is to pray with and help console relatives. It may not
be necessary to call the priest out when there are no relatives present.
Greek, Russian and Syrian Orthodox Churches: Can be referred to the Church of England Chaplain.
PALLIATIVE CARE
Some religions believe that suffering is part of life and leads to a better state of existence – for them, cutting suffering short
means interfering with progress towards liberation/salvation/atonement (for example, in the afterlife in Christianity and
Islam; and in Nirvana, the end of all suffering, in Buddhism).
Palliative care aims at the enhancement of the quality of life for terminally ill patients as well as their relatives/family. Both
the physical and the spiritual aspects of individual patients are considered, allowing for individual religious views on the
relationship between body, mind, soul and spirit. The inclusion of family is particularly relevant in religious communities
where large emphasis is placed on familial bonds. Where palliative care includes families and relatives in the care of
patients, it is particularly important that the staff involved are aware of religious attitudes towards disease, suffering, dying
and death and religious practices (such as anointing of the sick in Christianity, and prayer in Islam), as well as views on
familial responsibilities and traditions. They will be facing these attitudes when administering care. In Islam, for instance,
prayer is key to the life of the believer and maintaining a level of consciousness close to normal is of great importance to
allow for observance of worship rites for the longest period possible before death. For this reason, some patients might
prefer to endure pain for the sake of greater consciousness. In these cases, families should also be involved in decision
making, and alternative methods of pain relief that do not interfere with consciousness should be explored. Palliative care is
often welcomed by religious communities as a way of alleviating suffering without destroying the opportunity of using it for
the purpose of spiritual growth. Painkilling drugs may permit the best use of the patient’s remaining energies and
consciousness and are not illicit in most religious communities. In Islam, for instance, where the use of opioids and other
drugs that affect the senses is strictly prohibited, medically prescribed opioids are generally considered permissible, but it is
always advisable to ask.
It would be useful to have a readily available list of religious leaders/priests/ministers who can be contacted on request to
attend terminally ill or dying patients. In most cases the hospital healthcare chaplain will hold such a list, and will have good
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links with local religious/faith groups. However, it is important to note that many patients would prefer their usual spiritual
care giver to be present. It would be good practice to ask in the first instance.
It is equally important to be aware of those people who not hold any religion or belief and therefore would not want to be
attended by a religious person at such a vulnerable time. Individual views and requirements in these cases should be
ascertained as early as possible.
END OF LIFE CONCERNS
Many religions and beliefs include in their teachings views on dying, death and the afterlife. Increasingly, with medical
progress and life-extending technologies such as respirators, antibiotics and feeding tubes, the process of dying has moved
into the medical domain, where the event of death takes place.
For many religions, life does not end with death. Often the process of dying is seen as an opportunity for spiritual insight. In
Buddhism, Hinduism and Sikhism, for example, the way in which one dies may influence one’s rebirth. Where death is seen
not as the end, and where dying is viewed as an opportunity for moving closer to the holy power(s) that for the believer
rule(s) life and the afterlife, decisions about continuing treatment or allowing death to take place by forgoing or terminating
such treatment have an immediate impact on the spiritual wellbeing of the dying person.
Against this background it is of paramount importance for the NHS to be aware of its employees’ and patients’ views of
dying and death, particularly in the context of intensive care, persistent vegetative state (PVS), palliative care and dealing
with terminally ill people.
The knowledge of religious practices and practical procedures after death is also crucial when it comes to the handling of the
corpse and funeral rites. The time when the deceased has to be buried, for instance, might clash with requirements for
autopsy. In Buddhism it is believed that the death process is not over when breathing ceases, so the patient should be
disturbed as little as possible in the period from shortly before death until as long as possible after breathing stops.
However, views are never uniform within one religion, and personal and cultural differences of interpretation always need
to be taken into account when addressing these issues with Buddhist, Christian, Muslim or other patients.
Particular practices that are adhered to by one tradition within one religion may not be universally adhered to by all
members of the religion. All religions and cultures have different ways of expressing grief and mourning the dead, and
awareness around these issues will help NHS staff when dealing with grieving relatives. For instance, in Buddhism the
viewing of the body is seen as a reminder of the impermanence of life, so relatives may wish to gather for some time after
the death. In Hinduism the body is normally cremated within 24 hours of death, and immediately after the death an oil lamp
is lit near the deceased. The dying Muslim patient may wish to sit or lie with his/her face towards Mecca. Another Muslim,
usually a relative, may whisper the declaration of faith into the ear of the dying person. A dying Jewish patient may wish to
hear or recite special psalms, particularly Psalm 23, and the special prayer (the Shema). A Catholic patient may wish to
receive the last sacrament of anointing by a priest, and to receive Holy Communion.
In the event of a death, NHS staff should consult the patient’s relatives to determine their preferences with regard to
preparation of the body and other religious requirements. It is important to remember that early burial is a requirement in
some religions.
QUIET TIME
Hospitals aren’t known for promoting relaxation. But thanks to the new “Quiet Hours” policy, the hospital has become, at
least for a couple of hours each day, a little more peaceful.
The irony of hospitals has always been that, while uninterrupted sleep is essential for healing, no one gets any rest in a
hospital. By their very nature, hospitals are bustling, fast-paced places. Phones ring. Nurses and doctors are in and out of
patients’ rooms. Blood pressure and temperature is checked. Meals get delivered. And all of it happens quickly.
But having hours set aside for peace and quiet is a practice that’s been gaining momentum in recent years.
Everything has been getting calmer and quieter in all inpatient areas of the hospital each day. Lights are dimmed, doors to
patients’ rooms are closed, overhead paging is reduced, ringer volume on phones is decreased and hospital rounds come to a
halt – unless there’s a critical need.
Prior to the daily quiet hours, nurses check on patients to ensure all their needs are met, so rest time can actually be restful.
Family members and friends are encouraged to visit outside quiet hours. If visitors are at the hospital when quiet hours
begin, they’re encouraged to spend the hour in a family/visitor lounge.
The quiet hours give everyone – staff included – an opportunity to refresh and rejuvenate.
The staff knew quiet hours would benefit patients. But they have been surprised by how beneficial the quiet time is for them,
too. It’s not as if they suddenly go off duty from their typical 12-hour shift. But it does give staff time to catch up on
reviewing patient records and documentation duties.
Sleep and rest are essential for good health and healing.
Things to consider:
- Restriction of staff movement, treatments, and visitors during quiet time
- Providing information in brochures for patients and families
- Decreasing equipment alarms
- Silencing pagers and mobile devices of medical staff
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- Promoting pain relief prior to quiet time and comfortable positioning of patients
- Reduction of environmental stressors including hallway conversations, lighting, telephone/radio noise
Restricted visiting hours can be more beneficial than unrestricted visiting hours for patients, to promote sleep.
Patients and their families need to be educated on the importance of quiet time and the benefits.
The noise levels within the critical care unit, should not exceed the WHO recommendations and action needed to be taken to
address this. It is a busy unit with some environmental noise origins but also a high density of staff and relatives.
By considering the issue of noise and developing strategies that result in sustainable reductions in noise levels, we are
aiming to improve both the patients’ experience of their critical care stay and their health outcomes.
Visitors should follow the following guidelines:

- Respect the privacy of patients and families.
- Only two visitors per bed at one time.
- Children must be accompanied by an adult and be supervised at all times.
- Parents of children in hospital are welcome to visit often and stay overnight as they wish.
- Please keep noise to a minimum at all times.
- No smoking is permitted.
- To protect patients, relatives and friends should not visit if suffering from colds, flu, vomiting or diarrhoea (or any other
infectious condition). If you have had symptoms of diarrhoea or vomiting, do not visit until you have been symptom-free for
at least 48 hours. If you are uncertain, please telephone the ward to ask nursing staff for advice.
SUMMERY
Prayers:
-Practicing Catholic patients usually wish to see the priest whilst in hospital.
-Staff should never hesitate to call in the priest for the patient or their family.
-Ask the patient if they would like the Hospital Chaplain to call.
-Patients may wish to receive Holy Communion regularly whilst in hospital.
-Anointing with oil is a very important aspect of Catholic patient’s care and this together with prayers and confession
may be sought before an operation or if a patient deteriorates.
-As death approaches some may wish prayers to be said or anointing to take place. The Chaplain is also available to
comfort the family and is also available to support non-believers or non-practicing people.
-Ask the patient or family about their needs. In the Roman Catholic Church, the sacrament of the sick is administered
to patients and is adapted according to the seriousness of the illness and can be repeated if circumstances change.
-It is more important for the priest to be called out before a patient dies. If the health of the patient deteriorates and it
is their wish or wish of the relatives, do not hesitate to call the priest.
-Ask the family about their needs. Prayers may be said by the bedside at the point of death or over the body soon
afterwards.
-It would be useful to have a readily available list of religious leaders/priests/ministers who can be contacted on
request to attend terminally ill or dying patients. In most cases the hospital healthcare chaplain will hold such a list,
and will have good links with local religious/faith groups. However, it is important to note that many patients would
prefer their usual spiritual care giver to be present. It would be good practice to ask in the first instance.
-The chaplaincy team is available to patients, their families and friends of all faiths or none. The team visits wards
regularly or by request at other times.
-The chaplains can also put you in touch with a faith representative of your choice. If you would like to receive a visit
from a member of the team, please let one of the nurses know. We both have a chapel and prayer facilities.
Only two visitors per bed at one time:

-Please limit visitors to no more than two at a time. More than this can be tiring and rest is a very important part of
patient’s care.
-Children may visit at the discretion of the nurse in charge, however all children must be accompanied by a
responsible adult.
-Noise in hospital can be upsetting so please ask your visitors to be respectful of this and keep noise to a minimum.
-Visitors must respect the privacy of other patients and their families.
Quiet time:
-We discourage visiting during the quiet time. Visiting during this period is not permitted as this is when clinical staff
carry out their duties, and ensures patients have some quiet time, which is essential to their recovery.
-In most hospitals, there is a quiet time between 2pm and 5pm so that patients can sleep and relax after their lunch.
Sleep and rest are essential for good health and healing.
-Family members and friends are encouraged to visit outside quiet hours. If visitors are at the hospital when quiet
hours begin, they’re encouraged to spend the hour in a family/visitor lounge.
-However, close relatives/carers of very ill patients may visit at any time. Please speak to the Senior Charge Nurse for
further detai
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PEDIATRICS 1 - FEBRILE CONVULSIONS
- Febrile convulsions are seizures (fit) that usually happen in children aged 6 months to 5 years associated with fever,
without other underlying causes such as CNS infection or electrolyte imbalance.
By definition, there should be a temperature of more than 37.8 or there should be a clinical history and examination that
indicates febrile condition.
- 5 in 100 children have febrile convulsions before their 6th birthday.
- Most commonly it occurs between ages 18 months and 3 years.
- It’s rare in less than 3 months and more than 6 years of age.
CLASSIFICATION
A. Simple Febrile Convulsions:
- It is the most common type and occurs in 15 out of 20 cases.
1. It is a generalized tonic clonic seizure.
2. It lasts less than 15 minutes.
3. It doesn’t recur within 24 hours.
4. The child appears to be normal within an hour.
Pattern
Before:
- Febrile convulsions most often occur early in the illness when the child’s temperature is starting to rise.
During:
- Child may look hot and flushed.
- Their eyes may appear to roll backwards.
- Their body may go stiff.
- Their body shake generally.
- The child may become unresponsive and unconscious.
- The child may wet themselves.
- The seizure doesn’t last long. It may be a few seconds and it is unusual for it to last more than 5 minutes.
After:
- The child may be sleepy for some minutes.
- The child will usually appear a lot better within 1 hour. (This happens when child’s body temperature has come down).
- It doesn’t recur within 24 hours.
B. Complex febrile convulsions:
- It occurs in 4 out of 20 cases.
- At the presence of one or more of the following, the seizure is called complex:
1. If it is focal. This means rather than a generalized body shaking, only a part of the body may shake for example just one leg
or arm.
2. If the fit lasts more than 15 minutes.
3. If it recurs within 24 hours.
4. If the child is not fully recovered within 1 hour. This means it takes more than one hour for the child to look and behave
more like their normal self.
C. Febrile Status epilepticus:
- It occurs in 1 out of 20 cases.
- This is a febrile convulsion lasting longer than 30 minutes.
Causes of fever in children with febrile convulsion
Common:
1. Viral infection (Chicken pox, Influenza)
2. Otitis media
3. Tonsillitis
Less common
1. Gastroenteritis
2. Post-immunization
Serious illnesses which need to be excluded:

1. Meningitis
2. UTI
3. Lower respiratory tract infection
Assessment
A. History
Including:
- Eyewitness account of the seizure: conscious level prior to seizure, duration, focal or generalized, time taken to recover and
state of the child afterwards.
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- Symptoms of meningitis or septicemia, such as: rapid onset of illness, abnormal behavior or cry, stiffness or floppiness,
vomiting, (and meningism in older children).
Early symptoms are: leg pains, cold hands and feet, pallor or mottled skin.
- Establish whether it was a febrile seizure. This may be difficult to decide if the seizure occurs early in the illness. Parental
perceptions of fever are valid.
- Past/family history of febrile seizure or epilepsy.
B. Examination
- Vital signs, conscious level, rash (blanching or non-blanching), fontanelle, meningism.
- Look for focus of infection.
Note: For babies and young children, clinical examination (more than history) is important in detecting serious illness. The
vital signs are informative (temperature, pulse rate, respiratory rate and effort, capillary perfusion and oxygen saturation -
compare with the normal range for the child's age).
When to refer urgently
- First febrile seizure.
- Serious illness not excluded.
- Previous history of febrile seizure with:
- Child <18 months of age (meningitis is harder to detect in this age group).
- Diagnostic uncertainty about the cause of the present seizure.
- A complex seizure (as defined above - these are more likely to recur or be due to intracranial infection compared with
simple seizures).
- Antibiotics taken currently/recently (in case these mask signs of meningitis).
- Early review by a doctor is not possible.
- Home circumstances are unsuitable.
- Also, consider referral if no focus of infection is found. Referral is for a period of observation and to investigate for UTI.
Admission and investigations
A. Admit and treat with antibiotics, if the child has clinical features of meningitis, such as:
- Drowsy before fits.
- GCS less than 15 at one hour after the fit.
- Non-blanching rash.
- Neck stiffness.
B. Admit and review within 2 hours:
- Children less than 12 months should have an LP unless a pediatrics registrar decides against LP and will review within 2
hours.
- The next four groups should be reviewed within 2 hours by pediatrics registrar to consider LP:
1. Children within 18 months
2. Children who have received antibiotics
3. Children with complex seizures
4. When no focus of infection is found
Contraindications for LP
- Reduced consciousness (GCS less than 13 or falling consciousness level).
- Septicemic shock (Poor perfusion, tachycardia, low blood pressure).
- Signs of intracranial pressure (Coma, High blood pressure, low pulse, papilledema).
- Bleeding tendency (known or clinically suspected).
- Focal neurological deficit.
- Likely invasive meningococcal disease (rapid onset, hemorrhagic rash).
Note: Blood sugar should be measured:
1. If seizure is longer than 15 minutes.
2. If patient has a depressed level of consciousness for a prolonged period of time following the seizure.
3. At bedside.
Note: Other investigations such as blood culture or urine test can be considered.
What parents should know and what they will ask
Immediate first aid
- Note the time it started.
- It is important to put the child in a safe position and stay with them while the convulsion is happening. Lay the child on
their side with her head slightly tilted backwards (recovery position). This will ensure that the child will not swallow any
sick (vomit) and prevent tongue from rolling back. This helps to keep the airway clear.
- Remove any sharp objects if there are any around.
- When the fit stops you can try and reduce the temperature to make her more comfortable.
- Don’t put anything in her mouth.
After immediate first aid

- Please call an ambulance if the fit lasts more than five minutes.
- Call an ambulance or contact her doctor if:
a. She doesn’t improve quickly once a short seizure is over.
b. She has difficulty breathing.
c. She wasn’t fully conscious before the fit or one hour after the fit.
- The child should be seen by a doctor as soon as the fit is over.
Recurrence
- It may happen again. Febrile seizures recur in about 30%.
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- Most children will grow out of this condition.
- Febrile seizures do not recur beyond the age of five years approximately.
- Risk factors for recurrence are:
a. Family history of febrile seizures.
b. Onset age less than 18 months.
c. Lower temperature or short duration of fever at onset.
Prevention
Although, there is little research based evidence to prove this, a fever can make the child feel uncomfortable and irritable so
keeping a child’s temperature down during a feverish condition is always advisable.
- Try to remove her excessive clothing and keep child lightly dressed.
- Give child lots of cool drinks.
- If child is uncomfortable and distressed due to high temperature (more than 38) or pain, you can give the child
Paracetamol (One of the commonly used brand in the UK is Calpol which is Paracetamol in the form of suspension).
- Tepid sponging or excessive cooling is not recommended.
Epilepsy vs. Febrile Convulsions
Febrile convulsions and epilepsy are two different conditions. The cause of febrile convulsions is related to a feverish illness.
However, epilepsy causes seizures without a high temperature and is because of some abnormal activities in the brain.
While it is true that children who have a history of febrile seizures have an increased risk of developing epilepsy, it should be
stressed that the risk is still small. About 2 in 100 children who have a febrile seizure develop epilepsy in later childhood.
This is very slightly higher than the chance of epilepsy developing in children who have not had a febrile seizure. But this is
probably because a small number of children are prone to develop both epilepsy and febrile seizures. So having a febrile
seizure does not cause epilepsy to develop.
Medication for prevention
There are some medications that can be used to stop the fit. These include:
- Rectal diazepam 0.3mg/kg
- Buccal midazolam 0.5 mg/kg
We will prescribe it only:

- If the child has recurrent fits (or prone to it)
- If there is prolonged fit (more than 5 minutes)
- If the child’s family lives at a significant distance from the medical help (door to door more than 2 hours).
This medication can be put into the back passage or side of the mouth so that it gets absorbed into the blood stream quickly.
OTITIS MEDIA
Infections of middle ear that cause redness and swelling and sometimes a build up of fluid behind the ear drum.
SYMPTOMS
1. Ear pain
2. Temperature
3. Nausea
4. Fatigue
5. Slight hearing loss.
6. Discharge
RISK FACTORS
1. PMH
-URTI
-Immunocompromised patient
- Chronic Sinusitis
2. Personal History
- Smoking (Active/Passive)
3. Social History
- Swimming
INVESTIGATIONS
1. Culture of discharge
2. CT/MRI to exclude complications
3. Tympanometry
It is a test that measures how the eardrum reacts to change in air pressure.
TREATMENT
- It resolves by itself without treatment.
- Symptoms improve within 24 hours in 60% of children.
- It settles within 3 days in 80% of children.
MEDICATION
- Analgesia should be given in all cases that includes paracetamol or NSAIDS.
- Antibiotics should be avoided in mild to moderate cases and when there is diagnostic uncertainty in children aged 2 years
and less.
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Admission criteria
Admit in:
- Children under 3 months with temperature of 38o or more.
- Children with suspected acute complications of otitis media such as meningitis, mastoiditis and facial nerve paralysis.
Consider admission in:

- Children who are systemically very unwell.
- Children under 3 months.
- Children 3-6 months with temperature of 39o or more.
Antibiotic therapy
Most children adapt to a ‘No antibiotic prescribing strategy’ or to a ‘detailed prescribing strategy’.
1. No antibiotic prescribing strategy

Reassure that antibiotics are likely to make little difference to symptoms but may have adverse effect and can lead to
antibiotic resistance.
2. Delayed antibiotic prescribing strategy

Advise that antibiotics should be started if symptoms are not improving within 4 days of onset of symptoms or if there is a
significant worsening at any time.
Note: For both strategies advice review if the condition worsens or if symptoms are not improving within four days of onset
of symptoms.
Immediate antibiotic Prescription criteria

Offer immediate Antibiotic prescription to:
- Children who are systemically unwell but don’t require admission.
- Those at high risk of complication because of significant heart, lung, kidney, liver or neurovascular disease or who are
immuno-compromised.
- Those whose symptoms have lasted 4 days or more and not improving.
Consider offering immediate antibiotics to:

- Children younger than 2 years with bilateral otitis media.
- Children of any age with perforation and/or discharge.
Medication of Choice
Treatment of choice for Otitis Media:
Amoxicillin X 5 day
For Child 1–11 months
125 mg 3 times a day; increased if necessary up to 30 mg/kg 3 times a day.
For Child 1–4 years
250 mg 3 times a day; increased if necessary up to 30 mg/kg 3 times a day.
500 mg 3 times a day; increased if necessary up to 30 mg/kg 3 times a day (max. per dose 1 g).
500 mg 3 times a day; increased if necessary up to 1 g 3 times a day, use increased dose in severe infections.
For Adult
500 mg every 8 hours, increased if necessary to 1 g every 8 hours, increased dose used in severe infections.
If patient is penicillin allergic
Erythromycin - 500 mg QDS x 5 days

Clarithromycin – 500mg BD x 5 days
If allergic – Nasal or Oral Steroid
Note: A warm compress over the affected ear may reduce the pain
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PAEDIATRICS 2A NAI
Child abuse is often an ongoing process. If the diagnosis is missed, children may go on to be more seriously abused, which
can prove fatal. Universal screening has yet to show a significant impact on the identification of abused children.
A detailed history, followed by a thorough examination, is critical in making the diagnosis of physical child abuse. The range
of injuries caused by physical abuse include bruising, fractures, oral injuries, bites, head and spinal injuries, abdominal
injuries, and burns.
The challenge for the clinician is to distinguish inflicted injuries from those that have occurred accidentally. Finding one or
more of the above injuries in a child should warrant a full further evaluation to look for other injuries typical of abuse.
Many children who have suffered some form of abuse present to the accident and emergency department or clinic; however,
none of the screening markers currently used to identify children who should be assessed further for possible abuse or
neglect (e.g., repeated presentation, age, injury type) have been found to be sufficiently accurate. Therefore, clinicians should
maintain a high level of suspicion for abuse in injured children who present to the A&E department or clinic with or without
these specific characteristics of abuse.
Clinical prediction rules are being developed to assist professionals in identifying children that would most benefit from an
abuse work up as well as reduce the variability in practice of which a child is affected by an abuse work up. One such clinical
prediction rule, the TEN-4 rule, is highly specific and sensitive for identifying high-risk bruising that requires an abuse work
up in a paediatric intensive care population. A bruise on a child’s torso, ears, neck, or any part of the body of an infant <4
months old (TEN-4) should trigger an abuse evaluation.
History suggestive of non-accidental injury (NAI)

Determining whether injuries have been caused accidentally or represent abuse may be challenging. A detailed history
should include explanations for the injury present. The following considerations may be helpful in making the diagnosis of
NAI:
- A history of trauma inconsistent with the injuries, a changing or inconsistent history, other unexplained co-existent
injuries, or previous history of injuries.
- Injuries that do not fit with the developmental age of the child (e.g., if children are not yet independently mobile, they may
be unlikely to fall against certain objects). Details of the proposed mechanism of injury may help to determine whether the
explanation is compatible with the injury and the developmental level of the child.
- Children known to social services, particularly if parental/carer risk factors are also present.
- Faltering growth or failure to thrive.
- Poor parent-child bonding.
- Parental attempts at excusing or justifying the injury inappropriately or blaming a younger sibling or pet.
To exclude non-abusive causes, the clinician should ask questions about the perinatal history (including birth-related
trauma), any history of prematurity, physiotherapy and other possible iatrogenic causes, and medicines. Past medical
history of fractures or bleeding disorders is important. Questions about family history of fractures, blue sclera, and deafness
can help to exclude osteogenesis imperfecta. Other family history, such as that of clotting disorders or metabolic disease, is
also important.
It is vital to ascertain all relevant information about the child's family and/or carers, including previous attendance in
primary or secondary care, any previous registration with social services, and relevant information on other adults and
children in the home. Any history of drug dependency or previous convictions should be noted.
Head Injuries
Brain injury is one of the most severe consequences of physical abuse. Abusive head trauma (AHT) is the most common
cause of fatal physical abuse, with mortality ranging from 11% to 33%. Up to two-thirds of those who survive their injuries
are left with long-term disability. Some children die before they reach hospital, and the first presentation is to the
pathologist.
AHT and related injuries are the result of shaking alone, shaking with impact, or impact alone. Presenting features range
from severe neurological compromise (coma) to symptoms such as seizures, lethargy, irritability, vomiting, poor feeding,
and increasing head circumference. Identifying the abused child who presents with such non-specific symptoms is
particularly challenging, resulting in missed cases.
Distinguishing AHT from accidental head trauma involves a careful interpretation of the history in association with the
presenting signs and symptoms. Clinical prediction rules have been developed to decrease missed cases of AHT. Based on
these validated tools, features that should prompt serious concern for AHT include:
- Subdural haemorrhages in children <1 year of age
- Bilateral or interhemispheric subdural haemorrhages.
- Significant head injury with no explanation of trauma, or with an explanation involving a low fall (<150 cm) or trivial
injury.
- Co-existing apnoea or some other form of acute respiratory compromise.
- Co-existing bruising to the head or neck.
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- Co-existing bruising to the torso.
- Retinal haemorrhages.
- Rib or long-bone fractures.
- Skull fractures other than a simple linear parietal skull fracture
- Seizure without prior history of seizure disorder or fever.
Skull fractures are prevalent in non-abuse and abuse. The most common type of fracture in both situations is a linear
parietal fracture.
Retinal haemorrhages in multiple retinal layers and extending to the periphery is highly specific for AHT, and it is seen in
approximately 85% of cases. A few retinal haemorrhages confined to the posterior pole are regarded as non-specific. There
are other medical causes of retinal haemorrhages (e.g., birth, coagulation disorders, carbon monoxide poisoning) that should
be considered and may be confirmed on diagnostic tests. Retinal haemorrhages have also been recorded following
accidental high-impact trauma, which should be evident on history. Infants <6 weeks of age may have minor retinal
haemorrhages following birth, particularly after a ventouse or other instrumental delivery. However, retinal haemorrhages
associated with these medical causes have distinctly different characteristics than those seen in inflicted and significant
trauma.
Subdural haemorrhages are the most common intracranial injury seen in AHT, and may occur in combination with other
extra-axial haemorrhages or injuries to the brain itself. Physical abuse is the most common cause of subdural haemorrhage
in children <1 year of age. Subdural haemorrhages in AHT are typically small and multiple. They occur commonly over the
convexity and in the intrahemispheric fissure. They may have different or mixed densities on CT or MRI.
Other intracranial haemorrhages such as subarachnoid haemorrhage can be seen in association with subdural haemorrhage
in AHT. Epidural haemorrhages, however, are more commonly seen with accidental head trauma.
Injury to the brain itself, such as hypoxic ischaemic injury, is more commonly seen in AHT than accidental head trauma.
Fractures
Up to one third of children <2 years of age who have experienced physical child abuse sustain fractures. These are
frequently occult and not suspected clinically. Abusive fractures occur predominantly in babies and toddlers; fractures
sustained after accidents, in contrast, are more frequent in school-age children. Any long-bone fracture in a pre-mobile child
should have a clear accidental explanation, and if not, abuse should be actively excluded.
Abusive fractures have been recorded in every bone or group of bones in the body.
- Rib fractures are the strongest predictors of child abuse in infants in the absence of major trauma or pathological causes,
and are due to either the squeezing of the chest or a direct blow. They are characteristically multiple and can occur at any
point on the ribs.
- Fractures of long bones in pre-mobile children are very worrying for abuse but can occasionally be seen in accidental
injury. The history given by carers should be consistent with a fracture mechanism in the accidental injury scenario.
Fractures of long bones with an adequate history for injury in ambulatory children are more commonly accidental. Spiral
fracture is one such type of fracture suggestive of non-accidental injury.
- Classic metaphyseal lesions (also called metaphyseal fractures, corner fractures, or bucket handle fractures) are highly
specific for abuse in infants under 1 year of age. These fractures occur from shearing strain across the metaphysis from
vigorous flailing, pulling, or twisting of an extremity.
- Supracondylar fractures of the humerus are far more common in accidental falls.
- Simple linear skull fractures are equally prevalent in abusive and non-abusive injuries. However, skull fractures that are
diastatic, complex, or associated with other injuries are more prevalent in inflicted injury.
The differential diagnosis of abusive fractures includes

- accidental trauma,
- osteogenesis imperfecta, (family history of fractures, blue sclera, and deafness)
- osteopenia of prematurity,
- rare metabolic conditions that result in bone fragility,
- and birth injury.
An orthopaedic surgeon and child abuse paediatrician should be involved in cases of suspected physical child abuse when
fractures are present, especially in patients with fractures who are less than 3 years of age, and particularly less than 1 year
of age.
Bruising
Bruising is one of the most common accidental injuries that children sustain during normal day-to-day activities. However,
bruising is also the most common manifestation of physical abuse. Distinguishing between these causes is crucial.
Accidental bruising
- Typically occurs in independently mobile children on the front of the body and over bony prominences. The bruises are
predominantly on the legs and shins. Bruising is uncommon in areas such as the back, buttocks, forearm, cheeks or face,
ears, abdomen or hip, upper arm, posterior leg, foot, or hand. Bruising to the hands is extremely rare in children <2 years of
age, and if found a clear explanation for the injury should be sought.
- Accidental bruises to the head are most commonly found over the forehead, nose, upper lip, or chin, in contrast to abusive
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bruises, found on cheeks, ear, neck, or peri-orbital area.
- Although accidental bruising increases with age, developmental stage is a more relevant parameter. Less than 1% of
babies not yet crawling or independently mobile have bruising (usually relating to birth injury), as opposed to 17% of those
cruising around the furniture. This increases to 52% of children walking unaided.
Non-accidental bruising
- In abused children, the head and face is the most common site of bruising, along with bruises on buttocks and over soft
tissues. The scalp should be carefully examined for bruises as these may be associated with traumatic brain injury; 11% of
children with abusive head injuries present with facial or scalp bruising. The TEN-4 rule is a highly specific and sensitive
clinical prediction rule for identifying high-risk bruising. It requires an abuse work-up in a paediatric intensive care
population. A bruise on a child’s torso, ears, neck, or any part of the body of an infant <4 months old (TEN-4) should trigger
an abuse evaluation.
- Abusive bruises often occur in clusters and may show a pattern of defensive injuries (e.g., bruising to outside of the
forearm and thighs). Abusive bruising may reflect a positive or negative patterned image of the object used (e.g., belt buckle,
dog collar) or it may be interspersed with abrasions (e.g., in rope injury).
- Abusive bruises tend to be larger and more numerous than those found on children who have not been abused. Petechiae
in association with bruises are significantly associated with abuse.
- Severe, even fatal, abuse from head or abdominal injuries may occur without any external evidence of bruising. Fractures
will not necessarily be accompanied by any external bruising.
Burns
Scalds
- The most common burns in childhood, both abusive and accidental, are scalds. It takes only a second for a young child to
sustain a full-thickness scald from a liquid at 60°C Boys sustain more scalds, both intentional and accidental.
- Accidental scalds are typically the result of a "spill over" event (e.g., the child reaches up and pulls over a cup or pan of hot
liquid). The history is key in differentiating accidental from abusive scalds, and it is important to understand the ages at
which a child is able to perform certain actions (e.g., climb into a bath unattended). Unusual accidents do occur and although
a particular pattern of injury may seem unlikely, it may be explained by what the child was doing at that time (e.g., if the
child was in a "walker", pooling of the liquid may lead to extensive injuries). Accidental immersion scalds may also rarely
occur.
Typically, an accidental scald has the following characteristics:

- Distribution: accidental scalds usually involve the face, head, neck, upper trunk, and 1 upper limb.
- Pattern: mixed depth, superficial to partial-thickness, with the deepest burn at the first site of contact (usually face, neck, or
upper trunk) and becoming more superficial as it goes down the body. The outline is likely to be irregular, without clear
margins. Accidental flowing water scalds are likely to have irregular edges and asymmetrical involvement of limbs.
- Extent: this varies widely, predominantly based on the quantity of liquid involved and the speed and appropriateness of
first aid given.
- Intentional scalds are typically immersion injuries and are most commonly caused by hot water as opposed to other
liquids. If a burn is suspected to be intentional in origin, it is vital that further enquiries are made about the child's wider
social/medical history. In addition, a home visit may provide essential information (e.g., domestic hot water temperature,
height of surface the child is supposed to have reached/climbed onto). All children <2 years of age with a burn that is
suspected of being inflicted should have a full skeletal survey, as occult fractures are well described in inflicted burns.
Typically, an intentional scald has the following features:
- Distribution: typical distribution is to the lower extremities, with or without the buttock or perineum. Sometimes there is
sparing of the flexures behind the knee or on the buttocks because the child has drawn their legs up tightly to protect
themselves or their bottom is pressed against the relatively cold surface of the bath ("doughnut" sign).
- Pattern: the depth is often uniform, with partial- or full-thickness burns and clear margins. Symmetrical involvement of the
limbs is not uncommon.
- Extent: immersion burns are usually extensive, involving a large total body surface area, although this is not a
distinguishing feature.
Contact and caustic burns

- Intentional contact burns are the most common non-scald burn described in abuse. They are most frequently noted on the
back, shoulders, and buttocks; are usually clearly demarcated; and in some cases can be precisely matched to the burn agent
(e.g., hairdryer or cigarette lighter). Accidental contact burns to the hands are common in toddlers, typically from grabbing
items such as curling tongs or touching hot stoves.
- While cigarette burns are a frequently cited contact burn in children, the true characteristics of inflicted versus accidental
burns are not well described. Inflicted cigarette burns are circular, full-thickness, approximately 0.8 cm to 1 cm in diameter,
and in areas where the child is unlikely to receive an accidental burn, although published evidence for distinguishing
accidental and intentional cigarette burns is lacking. Accidental cigarette burns are superficial, may leave no pattern or a
cone-shaped mark, and occur on exposed areas of skin.
- Abused children may also be subjected to caustic burns (acid or alkali placed in mouth, in eyes, or on skin). Caustic burns
may not cause any pain initially (in contrast to scalds, which are immediately and exquisitely painful). Accidental caustic
burns may occur from leaking batteries or salt crystals. A detailed history followed by examination of the child's clothes to
find the chemical agent is necessary.
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Investigations
Children <2 years of age are at particular risk of severe forms of abuse. They may have occult injury and are unable to give
their own history of events. A more comprehensive investigation is therefore required in this age group.
Initial investigations in all patients:

1. Skeletal survey: a 22-film skeletal survey (including oblique views of the ribs) should be performed in any child <2 years
old where physical abuse is suspected. A full skeletal survey should be performed on children with abdominal injuries if they
are clinically stable. Even when the initial skeletal survey is negative or equivocal, a repeat skeletal survey performed 11 to
14 days after the initial investigation will give further information about ambiguous findings, identify further fractures, and
add information about the age of a fracture.
2. FBC with platelet count and a clotting profile, particularly if the child has bruises or evidence of bleeding.
3. A urinalysis to screen for occult blood.
4. LFTs and serum amylase to screen for occult abdominal injury.
5. Bone metabolism investigations to include serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone, and
25-hydroxyvitamin D, if a child is found to have fractures. However, an elevated alkaline phosphatase may occur with
healing fractures and does not necessarily indicate bone disease.
6. Photo-documentation of any possible injuries: it is vital that appropriate photographs are taken of bruises, burns, bites,
and any other cutaneous injuries. In cases of suspected bite, the precise dental pattern can be reconstructed from
photographs in the event that the original injury is no longer visible at the time of forensic assessment. The photograph
should be taken with a right-angled measuring device and in at least 2 planes, if the bite is on a curved surface.
Suspected head and/or spinal injuries (in addition to the initial investigation)
1. CT brain: can identify intracranial bleeds, skeletal and soft-tissue injury, and parenchymal injury with or without cerebral
oedema. This investigation should be strongly considered in: children who are <1 year of age in all cases of suspected
physical abuse; children with neurological symptoms and/or signs; and all children with head injury. Head CT should also be
considered if abusive abdominal injury is found. Research suggests non-contrast head CT aids in identifying occult head
injury in children and is the standard of care for first-line evaluation of possible AHT. The signs that have been found to be
significantly associated with abusive head trauma include:
- multiple or bilateral subdural haemorrhage over the parenchymal convexities;
- interhemispheric haemorrhages;
- hypoxic-ischaemic injury;
- and cerebral oedema.
If abnormalities are seen, an MRI of the brain should be performed in 3 to 5 days.
2. Dilated fundoscopy: an ophthalmologist must conduct a detailed examination of the fundi using indirect fundoscopy with
the pupils dilated and RetCam (wide-field digital paediatric retinal imaging). These techniques have the capacity to visualise
the periphery of the retina, where retinal haemorrhages in AHT are most often seen.
3. Brain MRI (± spinal MRI): should be performed within 3 to 5 days if any abnormalities are found on CT brain. The scan
should include diffusion-weighted imaging (DWI), T1- and T2-weighted sequences, and fluid-attenuated inversion recovery
(FLAIR). This will enable full delineation of the extent of the injury. DWI sequences may also help with prognosis. MRI
should be extended to include the vertebral column if spinal injury is suspected.
Suspected skeletal injury (in addition to the initial investigation)

- Radionuclide bone scan: in some countries this may be performed as an alternative to a repeat skeletal survey in children
with suspected fractures when the initial skeletal survey is negative or equivocal. A bone scan becomes positive within 4
hours of a fracture occurring, but remains positive for many months, so does not contribute to the dating of fractures. It is of
no value in detecting skull fractures and is less sensitive in identifying metaphyseal lesions. Plain films should also be
obtained, and the tests may confirm fractures seen as hotspots. However bone scans have a high sensitivity for identifying
rib fractures and can be considered if acute rib fractures are suspected, since acute rib fractures in plain films can be difficult
to detect prior to healing.
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PEDIATRICS 4 - INTUSSUSCEPTION
Intussusception occurs when one part of the bowel slides into another part of the bowel
like a telescope. This causes the bowel to become blocked. It is the most common
tummy emergency in small children, mostly between the ages of 3 months and 2 years.
SYMPTOMS
1. Sudden onset
2. Excessive crying
3. Episodes of colicky abdominal pain
- Each episode lasts for 2-3 minutes
- Child may appear well between episodes
- Child sometimes looks, pale, tired and floppy between episodes
- After 12 hours the pain becomes constant and child may vomit
4. Early vomiting (might become bile stained)
5. Palpable sausage shaped mass (often in the RUQ)
6. Symptoms of dehydration including dry mouth, dry nappy and lethargy
7. Symptoms of shock
- Pallor
- Going floppy
- Sudden alteration of consciousness
8. Sweating
9. Increased temperature (late symptoms)
10. Red jelly stool (late symptom) might have blood and mucus
RISK FACTORS
1. Recent infection
2. Associated with Rota Virus vaccine
3. Pathological like Lymphoma, Polyps, Cystic Fibrosis and Meckel’s Diverticulum
EXAMINATION
- Vitals
- General Physical Examination
INVESTIGATIONS
- FBC (to check if there is any neutrophilia).
- U&Es (to assess dehydration level).
- Abdominal X-Ray (to check if there is any dilated gas-filled proximal bowel, paucity of
gas distally and multiple fluid level but may be normal in early stages).
- Abdominal Ultrasound, which is the investigation of choice (to check if there is any
doughnut or target sign, pseudo-kidney/sandwich appearance. It is very effective and
many consider it to be the investigation of choice).
- Bowel Enema –Barium has been gold standard (crescent sign, filling defect) but air and
water-solube double contrast now available. Each has its pro’s and con’s. The choice is
left to Radiologist.
- CT/MRI Scanning (More often used in adults than children)
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MANAGEMENT
1. Pain Management
2. Resuscitation (Drip and Suck)

- IV Fluids: A drip is put into the child’s vein, to give fluids.
- NG Tube: A ‘nasogastric tube’ is often passed from the nose into the stomach to drain
any stomach/bowel contents and get rid of any pressure that may build up due to the
bowel blockage.
3. Antibiotics: They may be required.
4. Air enema: If the US Scan confirms the intussusception, the doctors first try a
treatment called ‘air enema’. In this procedure air is introduced through a tube into
your child’s bottom while X-ray pictures are taken. The pressure of the air pushes back
the telescoping parts of the bowel (‘reduction’), which can be seen directly on the X-ray
images. This is successful in 8-9 out of 10 patients.
5. Surgical Laparotomy (Reduction/Resection):

Indications
- Peritonitis
- Perforation
- Prolonged history > 24 hours
- High likelihood of pathological lead point
- Failed air enema
How the surgery will be done

We will take your little one to the anesthetic room. You can accompany your little one to
the room. You can stay there until he is asleep.
It may be possible to give the medication while your child is sitting on your lap.
There are different ways to put him to sleep. We can give your child an anesthetic gas to
breathe or an injection through his blood vessel.
If we give the medication through his blood vessel, we can use some cream to numb his
hand or arm before the injection so it won’t hurt that much.
If we use gas, it will take a while for your child to be asleep while injection works very
quickly.
During the operation an incision is made to open the tummy and the bowel is exposed.
The surgeon gently separates the telescoping segments of the bowel. If any bowel tissue
has died due to lack of blood supply, or if any obvious cause (‘lead point’) of the
intussusception is found, this affected segment needs to be cut out (‘resection’). The two
surrounding ends are then stitched back together. (‘Primary anastomosis’).
NOTE:
It is unlikely for this condition to resolve by itself and medical intervention is usually
required.
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TM PAEDIATRICS 5 – EXTRADURAL HAEMORRHAGE
EXTRADURAL HAEMATOMA
In the head, the epidural space is the 'potential' space between the skull and the dura mater. Dura mater is the
outer protective lining that covers the brain. The dura mater is usually bound quite firmly to the inside of the
skull. An extradural haematoma that occurs in the head is called an intracranial extradural haematoma.
Simply speaking, an intracranial extradural haematoma/haemorrhage is a collection of blood in the extradural
space, which is the space between the outside of the brain covering and skull.
CAUSES OF INTRACRANIAL EDH

An extradural haematoma usually occurs inside the head, most commonly after a fractured skull caused by a
head injury.
The fractured skull bone can cause separation of the dura mater from the inside of the skull and can cause
damage to a blood vessel (usually an artery). The damaged blood vessel causes blood to leak and collect in the
potential epidural space between the skull and the dura mater. This build-up of blood can cause the pressure
inside the head to rise. This can put pressure on the brain and cause injury to the brain if it is not treated
quickly. Typically, an extradural haematoma is caused by a severe head injury - for example, in a road traffic
accident.
The blood usually collects in the epidural space soon after a head injury and symptoms of an extradural
haematoma are usually noticed quickly. So, most extradural haematomas are 'acute' injuries. Occasionally,
bleeding can occur more slowly and an extradural haematoma may cause few symptoms (and so not be
noticed) until some days after a head injury.
Who gets an intracranial extradural haematoma?

The peak age range in children is between 11 and 16 years. It is less common over the age of 60 because the
outer protective lining that covers the brain (the dura mater) becomes stuck more closely to the skull and
makes it more difficult for blood to collect in the 'potential' epidural space. In young people, the dura mater is
not as firmly attached to the skull.
Someone who drinks excessive amounts of alcohol may be more likely to develop an intracranial extradural
haematoma. This is partly due to the fact that they are more likely to fall and injure their head. An intracranial
extradural haematoma is also more common in men than in women.
SYMPTOMS
What are the symptoms of an intracranial extradural haematoma?
1. Loss of consciousness
2. Drowsiness
3. Severe headache
5. Confusion
6. Weakness of an arm or leg on one side
7. Speech difficulties
8. Fits (Seizures)
You may lose consciousness at the time of the head injury but this does not always happen. Classically,
someone who develops an intracranial extradural haematoma loses consciousness at the time of the head
injury and then has a 'lucid interval' of a few hours after the head injury where they appear relatively well and
normal. Later, they deteriorate and lose consciousness again as the haematoma forms. However, not everyone
shows this classic pattern.
If you do not lose consciousness after the initial head injury, or if you regain consciousness, you may experience
drowsiness or a severe headache. You may also feel sick (have nausea) and/or be sick (have vomiting). You
may become confused and may develop weakness of an arm and/or a leg on one side of your body and/or
speech difficulties. Sometimes a fit (seizure) can occur. Some people with an intracranial extradural
haematoma can be talking one minute and appear relatively well and can then become very ill and lose
consciousness the next.
DIAGNOSIS
1. Neurological Examination
2. Fundoscopy
3. Blood tests
4. CT Scan of head
5. Other imaging such X-Ray of neck if indicated
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Someone with a suspected intracranial extradural haematoma should be seen in a hospital. It is a serious
condition and emergency treatment is needed. The doctors and nurses will be able to perform a full
examination to look for signs of a possible intracranial extradural haematoma and also signs of any other injury
that you may have. They will be able to check your level of consciousness, look for any signs of arm or leg
weakness and also examine your eyes to look for any signs of raised pressure within the skull.
Blood tests may be taken to look for other possible reasons for confusion and/or loss of consciousness. Blood
tests may also show any problems with blood clotting/abnormally 'thin' blood. A CT Scan of the head is good at
detecting an intracranial extradural haematoma. It can also show any skull fracture that may be present. You
may need other scans or X-rays depending on whether any other injuries are suspected. For example, an X-Ray
of your neck may be taken to rule out any co-existing neck injury.
TREATMENT
1. Resuscitation
2. Medication
3. Surgery
If you have an intracranial extradural haematoma, the priority is first to stabilise your condition. For example,
you may need treatment to stabilise your blood pressure. If you have breathing difficulties or your
consciousness level is affected, you may need help with your breathing using a ventilator. If there are signs of
raised pressure inside your head, emergency treatment is needed. Medicines may be given and/or surgery is
needed (see below).
If intracranial pressure is raised, it may be treated with osmotic diuretics such as IV Mannitol, hypertonic saline
(it is increasingly considered a safer and more effective alternative). In the trauma situation, it has the
advantages of preserving intravascular volume, rather than increasing fluid loss by diuresis.
Small intracranial extradural haematoma

A small intracranial extradural haematoma that is not producing any symptoms (or the symptoms are not
severe) can sometimes be treated just by careful monitoring and observation. The blood clot may clear (re-
absorb) by itself. Repeated physical examinations are usually carried out to assess your level of consciousness
and look for any symptoms that may appear such as headache, arm or leg weakness, etc. Repeated CT scanning
may also be used to ensure that the haematoma is not getting any bigger. Surgery is needed to treat an
intracranial extradural haematoma if symptoms start to appear and your condition deteriorates.
Large intracranial extradural haematoma

However, surgery is generally needed to treat a large intracranial extradural haematoma. This is usually
carried out by a neurosurgeon and involves removal of the haematoma. Most commonly, surgery either
involves making 'burr holes' in the skull or an operation called a craniotomy.
Burr Hole Surgery

Burr holes are small holes that are drilled through the skull over the area where the haematoma has formed.
They allow the blood to be removed, or 'sucked out', through the holes. Stitches or staples are then used to
close the burr holes.
Craniotomy
A craniotomy is a procedure in which a portion of the skull is removed so that the brain and meninges are
exposed. It can relieve any raised pressure inside the skull and also means that the clotting blood in the
extradural space can be removed. The section of skull that was removed is then replaced and fixed back in
place, re-attaching the outer protective lining that covers the brain (the dura mater) to the skull bone.
Close follow-up is needed after the operation, usually in an intensive care unit.
OUTLOOK/PROGNOSIS
Provided that quick treatment is carried out, the outlook is generally good. In those people who are conscious
before they have surgery, death is extremely unlikely and surgery usually has a very good outcome. However,
the outlook is not as good in those who are unconscious before they have surgery.
There is a risk of permanent brain injury even if an intracranial extradural haematoma is treated. This may lead
to, for example, weakness on one side of the body, speech problems, fits (seizures), etc. Sometimes these
symptoms can improve over time with treatments such as physiotherapy or speech therapy. Medication may
be needed to control seizures.
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TM PAEDIATRICS 6 MMR
What is MMR?
MMR is a safe and effective combined vaccine that protects against three separate illnesses – measles,
mumps and rubella (German measles) – in a single injection.
Why is MMR vaccination required?

Measles, mumps and rubelle are highly infectious conditions that can have serious, and potentially fatal
complications including meningitis, swelling of the brain(encephalitis) and deafness.
They can also lead to complications in pregnancy that affect the unborn baby, and can lead to
miscarriage.
It is rare for children in the UK to develop these serious conditions. However, outbreaks happen and the
chances increase when children are unvaccinated. There have been cases of measles in recent years, so
it's important to ensure that you and your children are up-to-date with the MMR vaccination
Dosage schedule:
1st dose: 1 year
2nd dose: 3 years and 4 months.
In case of an outbreak it can be given at 6-9 months of age.
Is there any correlation between MMR and autism?

There is evidence that suggests that there is no causal link between the MMR vaccine and autism.
The jab has been linked to autism since 1998, when a study of 12 children published in The Lancet linked
the measles, mumps and rubella (MMR) jab to the development of autism. That research has since been
discredited and two major studies have been published subsequently which also failed to show any link.
MMR Vaccine Side Effects

The MMR vaccine is very safe and most side effects are mild and short-lived.
Because the MMR vaccine combines three separate vaccines in one injection, each vaccine can cause
different side effects that can happen at different times.
There's less chance of side effects after the second dose of MMR than the first.
Common side effects of the MMR vaccine:

1. About a week to 11 days after the MMR injection, some children get a very mild form of measles. This
includes a rash, high temperature, loss of appetite and a general feeling of being unwell for about two or
three days.
2. About three to four weeks after having the MMR injection, one in 50 children develop a mild form of
mumps. This includes swelling of the glands in the cheek, neck or under the jaw, and lasts for a day or
two.
3. One to three weeks after receiving the rubella vaccine component of MMR vaccine, some adult women
experience painful, stiff or swollen joints, which can last for around three days.
Rare side effects of the MMR vaccine:

1. Bruise-like spots:
In rare cases, a child may get a small rash of bruise-like spots about two weeks after having the MMR
vaccine. This side effect is linked to the rubella vaccine and is known as idiopathic thrombocytopenic
purpura (ITP).
It's been estimated that ITP develops in one in every 24,000 doses of the MMR vaccine given. There is a
greater risk of developing ITP from measles or rubella infection than there is from having the vaccine.
ITP usually gets better without treatment but, as with any rash, you should seek advice from your GP as
soon as possible.
2. Seizures (fits):
There is a small chance of having a seizure (fit) six to 11 days after having the MMR vaccine. It sounds
alarming, but it's rare, and only happens in only about one in every 1,000 doses. In fact, MMR-related
seizures are less frequent than seizures that occur as a direct result of a measles infection.
Allergic reaction to the MMR vaccine

In extremely rare cases, a child can have a severe allergic reaction (known medically as anaphylaxis)
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immediately after having the MMR vaccine. It's an alarming prospect, but if the child is treated quickly,
they make a full recovery. Medical staff who give vaccines are trained to deal with allergic reactions.
Contra-indications:
1. Acute illness (postpone until the condition has resolved) but note that minor illness without fever or
systemic upset - e.g., mild otitis media, upper respiratory tract infection (URTI) and diarrhoea - is not a
contra-indication.
2. Severe local or generalised reaction to a previous dose of MMR vaccine - when in doubt, seek specialist
advice.
3. Allergy to neomycin or gelatin.
4. Untreated malignant disease or impaired immunity - e.g., immunosuppression, steroids, radiotherapy,
cytotoxic drugs or within six months of receiving such treatment. (Immunisation can still be possible in
some circumstances depending on dosage and combination of drugs - check with the specialist treating
the condition or the local community paediatrician.)
5. Within three months of receiving blood products, such as immunoglobulin.
6. If immediate protection against measles is required in someone who has recently received a blood
product, MMR vaccine should still be given. To confer longer-term protection, MMR should then be
repeated after three months.
7. Pregnancy - but note that the Department of Health does not recommend termination, as studies failed
to demonstrate a link between rubella immunisation in early pregnancy and fetal damage.
Note that the following are NOT contra-indications:

1. Family history of any adverse reactions following immunisation.
2. Previous history of infection with pertussis, measles, rubella or mumps.
3. Contact with an infectious disease.
4. Asthma, eczema, hay fever or rhinitis.
5. Treatment with antibiotics or locally acting (e.g., topical or inhaled) steroids.
6. The child being breastfed or mother being pregnant.
7. History of jaundice after birth.
8. Being over the age recommended in the immunisation schedule.
9. 'Replacement' corticosteroids.
10. Allergy to eggs (recent research has found no link between allergy to dietary eggs and anaphylactic
reactions to MMR vaccine).
11. Neurological conditions are not a contra-indication although, if the condition is poorly controlled (e.g.,
epilepsy), immunisation should be postponed.
12. MMR should ideally be given at the same time as other live vaccines, such as BCG. However, if live
vaccines cannot be administered simultaneously, a four-week interval is recommended.
Frequently Asked Questions by Parents

P: Can my child have the Hib/MenC jab with the MMR and pneumococcal jabs?
D: Yes, these vaccines can be given together.
The childhood vaccination schedule recommends that MMR is given at around 12 to 13 months of age,
and at the same time as the Hib/Men C vaccine and the pneumococcal jab.
P: My child is allergic to eggs. Can she have the MMR vaccination?

D: Yes, the MMR vaccine can be safely given to children who have a severe allergy to egg. This is because
the MMR vaccine is grown on chick cells, not the egg white or yolk. If you have any concerns, however,
talk to your health visitor, practice nurse or doctor.
P: Can the MMR vaccination be given as three separate injections?

D: No, not on the NHS. The MMR vaccine consists of a combination of three individual vaccines against
measles, mumps and rubella in a single shot.
The NHS does not recommend single measles, mumps or rubella vaccines, as there is no evidence to
support their use or to suggest that they are safer than MMR.
Having single vaccines could also put your child at risk of catching measles, mumps or rubella in the time
between the doses of each of the vaccines.
Some private clinics in the UK offer single vaccines against measles, mumps and rubella, but the NHS does
not keep a list of them because clinics that offer these privately are unlicensed, which means there are no
checks on their safety and effectiveness.
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No country in the world recommends MMR and then offers parents a choice of having single vaccines
instead. Every independent expert group around the world (including the World Health Organization)
supports the use of MMR, and none support the use of single vaccines.
P: I do not know if my teenage daughter has had her second MMR jab. What should I do?
D: For full protection, two doses of MMR are recommended. If you're not sure whether your daughter has
had one or both doses of MMR, ask her GP. The Red Book would also tell you her vaccination history, if
you still have it.
Your daughter could have one MMR dose now and the second MMR dose in three months' time. An extra
MMR dose will not cause any harm.
P: Does the MMR jab contain thiomersal (mercury)?

D: No, the MMR vaccine has never contained thiomersal – a preservative containing mercury that is used
in some vaccines.
P: My son is due for his MMR jab, but I am concerned about the connection between autism and MMR.
Could I put him at risk?
D: This really shouldn't be a worry, as there is no evidence of any link between MMR and autism.
P: Our son was born six weeks prematurely. Should we delay getting him vaccinated?
D: No. Babies should receive their vaccinations according to the recommended schedule, at around 12 to
13 months of age, irrespective of whether they are born prematurely.
P: A month after I got vaccinated for MMR, I found out I was pregnant. Will my baby be ok?
D: Almost certainly, yes. Evidence from clinical trials suggests that there will be no harm to your baby.
However, it's worth mentioning this to your midwife or GP at the earliest possible opportunity, just to be
on the safe side.
P: Can my child have the MMR vaccine if they have single vaccines?
D: Yes, your child can still have the MMR vaccine on the NHS if they've already had single vaccines
privately.
Be aware, though, that MMR is a "live" vaccine, so the two doses should be given at least four weeks apart.
If your child has received a "live" single vaccine, they will have to wait at least four weeks until they can
have the MMR vaccine.
P: My son is 18 and has been asked to have a second MMR jab before university. Is this sensible?
D: Many universities recommend that their students have a shot of MMR before they arrive, because there
have been outbreaks of mumps among unprotected students. Mumps vaccine is only available on the NHS
as the MMR vaccine.
If your son never had MMR as a child, or was only partially vaccinated, see your GP to arrange for him to
have MMR vaccination. Even if he has already had two doses of MMR, having a third dose to make sure he
is protected against mumps will not cause any harm.
P: If my child develops a mild case of measles after their first MMR vaccine, are they contagious to non-
vaccinated children?
D: No. Post-vaccination symptoms are not infectious, so your child will not pass anything on to non-
vaccinated children.
P: My baby had measles at the age of six weeks. Can I get the vaccine without the measles component?
D: No, the MMR vaccine is not available without the measles component, but it won't do your baby any
harm to be vaccinated against measles, even after having the illness. MMR vaccination will help to protect
your baby against mumps and rubella, and will also boost the antibodies they have already developed
against measles.
P: We're going travelling and my 14-month-old son is due to have his MMR jab three weeks before we
leave. Will he have developed immunity in time?
D: Immunity to measles, mumps and rubella starts to develop after two weeks, so having his MMR three
weeks before travelling is fine. It is also fine for him to have his other travel vaccines on the same day as
the MMR.
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P: My child is receiving their MMR jab tomorrow. How long should I leave it before taking them
swimming?
D: There is no reason why your child cannot resume normal activities, including swimming, straight after
receiving their MMR jab.
P: How long does protection from MMR last?

D: It seems to be very long lasting.
Virtually everyone (more than 99%) will be protected against measles and rubella for more than 20 years
after two doses of MMR.
Protection against mumps after two doses of MMR is a little lower (90-95%) and appears to gradually
decline. Mumps in vaccinated people is, however, much less likely to lead to complications such as
meningitis or orchitis (painful swelling of the testes), and vaccinated people are less likely to require
admission to hospital.
P: I have heard that mumps is going around. I thought that MMR prevented mumps, so why is this
happening?
D: You need two doses of mumps vaccine to be best protected. Mumps vaccine is only available on the
NHS as a component of the MMR vaccine.
MMR was introduced in 1988, with a second dose introduced in 1996, so many young adults may have
had only single vaccines of measles and rubella and/or combined measles-rubella vaccines. This led to a
large epidemic of mumps among this age group in 2004/2005.
Since then, we've continued to see smaller outbreaks of mumps in universities and colleges every three to
four years.
During these outbreaks, the highest risk is to completely unvaccinated students, but milder cases have
also occurred in students who have had one or two doses of MMR. So, it's likely that some vaccinated
students can catch mumps and pass the infection on to their close contacts without even knowing it.
If you've never had the MMR vaccine, you should have one dose now and another one month later.
P: My child had one dose of MMR and still caught measles. Why didn't the vaccine work?
D: Up to 1 in 10 children with measles received a single dose of vaccination. This is to be expected, as a
single dose of MMR vaccine protects only 9 in 10 children. That's why children need a second dose. After a
second dose, 9 in 10 of those who didn't respond to the first dose will be protected – so the second dose
boosts protection to almost 100%.
P: Should MMR vaccination be speeded up when there's a measles outbreak?

D: To get the best protection, children should be vaccinated with the MMR vaccine at the scheduled times
– between 12 and 13 months of age and again at 3 years, 4 months.
In areas where there are measles outbreaks, the gap between doses can be reduced so that the children
who didn't respond to the first dose are protected with the second more quickly.
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TM PAEDIATRICS 7 PYLORIC STENOSIS
PYLORIC STENOSIS
This condition is caused by diffuse hypertrophy and hyperplasia of the smooth muscle of the antrum of the stomach
and pylorus. It usually occurs in infants aged 2-8 weeks. The pyloric muscle hypertrophy results in narrowing of the
pyloric canal, which can then become easily obstructed.
To the patient:  The outlet of the stomach into the small intestine is called the pylorus. Stenosis means a narrowing.
Pyloric stenosis means a narrowed outlet of the stomach. It occurs in some new-born babies. Food and drink pass
down the gullet (oesophagus) into the stomach. Here they mix with acid and are partially digested. The stomach then
normally passes the food and drink into the small intestine to be fully digested and absorbed into the body. A
narrowed or blocked outlet from the stomach (pyloric stenosis) can lead to a serious illness unless it is treated.  
AETIOLOGY 
The muscle in the wall of the outlet of the stomach into the small intestine (pylorus) is abnormally thick. This causes
the outlet from the stomach to become narrowed (stenosed). It is not known why this occurs. Pyloric stenosis
affects around 2-4 out of 1,000 babies. Boys are affected more commonly than girls. It can sometimes run in families.
SIGNS AND SYMPTOMS

Symptoms typically begin in a baby aged 2-4 weeks who is otherwise healthy. In some cases, first symptoms can take
up to two months to start.
1. Vomiting:  Typical presentation is onset of vomiting at 2-8 weeks of age (late presentation up to 6 months can
occur but is very rare).  Characteristics:  - Non-bilious, often but not always projectile and usually 30-60 minutes
after a feed, with the baby remaining hungry. - Vomiting increases in frequency over several days. - Vomiting also
increases in intensity until it becomes projectile. - Slight haematemesis may occur.  To the patient:  Being sick
(vomiting) after a feed is the main symptom. The vomiting often starts like a 'normal' vomit and milk just dribbles
down the front of the baby. Sometimes the vomiting is forceful and milk may be vomited quite a distance like a
fountain. This is called projectile vomiting.
2. Persistent hunger:  The baby remains hungry and will usually feed well - only to vomit the milk back soon after
feeding. The vomiting tends to become worse and worse over several days. The milk in the stomach often curdles
before the baby is sick.
 3. Weight loss
4. Dehydration
5. Lethargy
6. Infrequent or absent bowel movements may be seen.

Little food or drink passes through the narrowed pylorus which becomes narrower over time. This means that little
or no food reaches the bowels, so babies often pass little poo (faeces). Affected babies do not gain weight and are in
danger of quickly becoming lacking in body fluid (dehydrated) and seriously ill if the condition is not treated. Your
baby may also become lethargic and have less nappies.   
7. Stomach wall peristalsis may be visible.
8. Olive shaped mass.

An enlarged pylorus, classically described as an 'olive', may be palpated in the right upper quadrant or epigastrium of
the abdomen: 
- The 'olive' is best palpated at the start of a feed but is often missed.
- With the infant supine and the examiner on the child's left side, gently palpate the liver edge near the xiphoid
process. 
- Then displace the liver superiorly; downward palpation should reveal the pyloric olive just on, or to the right of, the
midline. 
- It should be possible to roll the pylorus beneath the examining finger.
NOTE: it can be very common for new-born babies to vomit. The vast majority of babies who vomit do not have
pyloric stenosis.
 
DIFFERENTIAL DIAGNOSIS 
1. Feeding problem or milk intolerance. 
2. Gastro-oesophageal reflux. 
3. Gastroenteritis. 
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4. Duodenal atresia, oesophageal atresia or other bowel obstruction in the newborn. 
5. Intestinal malrotation/acute midgut volvulus.
EXAMINATIONS 
Abdominal Examination:  
A doctor may examine the baby's abdomen whilst they are feeding. A typical bulge next to the stomach can often be
felt as the muscles in the stomach and stomach outlet (pylorus) contract.  
To the patient:  
The doctor admitting your baby will take a full medical history and examine him or her and will feel your baby’s
tummy. In many babies the thickened pylorus can be felt during this examination. Sometimes this is easier if the baby
is feeding. This is known as a test feed. The test feed may have to be done more than once to confirm the
diagnosis.  
INVESTIGATIONS
1. Serum electrolytes (for correction of imbalances before surgical repair); there is often metabolic alkalosis with
severe potassium depletion. ABG’s may be useful.  However, biochemical disturbances are now much less common
with earlier diagnosis.
Before your baby can be operated on, they will need to have regular blood tests until this balance is corrected.
 NOTE: The correction of blood chemistry normally happens within 24 to 48 hours after receiving the fluid given via
the drip.
2. Ultrasound is reliable and easily performed and has replaced barium studies as the main investigation. There is a
normal variation of pylorus muscle measurements with age and gestation but ultrasound has a very high sensitivity
and specificity. An ultrasound scan may be done if there is doubt about the diagnosis. This painless test is very
reliable at detecting the thickened pylorus.  
TREATMENT 
1. Pre-operative management is directed at correcting the fluid deficiency and electrolyte imbalance. 
To the patient:  
If your baby has been unwell and vomiting for a few days then he or she will probably be dehydrated. Fluid will be
given through a cannula (a small tube into a vein attached to a drip), to correct this.  Dehydration usually leads to an
alteration in the chemical balance of your baby’s blood. 
2. Nasogastric Tube:  
All feeds will be stopped until after the operation as the baby’s stomach needs to be empty. We will place a small tube
into your baby’s nose and slide it down into the stomach. The tube will be taped to your baby’s check to stop it falling
out and a small bag will be attached to the end.
3. Operation:  
The operation that your baby needs is called a pyloromyotomy. The thickened muscle needs to be divided to allow
milk to pass through.  
There are two ways of doing this: 
- Keyhole surgery 
- Open surgery 
The consultant will discuss these options with you.  
PYLOROMYOTOMY  
A small operation, done under a general anaesthetic, normally cures the problem. A small cut is made in the skin over
the stomach outlet (pylorus). This operation is called a pyloromyotomy. The pylorus is found and the muscle in the
pylorus is then cut. This allows the pylorus to widen into a normal size. This means that food and milk can pass easily
out of the stomach into the bowel. This operation is usually done by keyhole surgery. This uses only a tiny cut to the
skin to allow fine instruments into the tummy (abdomen) to cut the pylorus muscle. The operation is usually totally
successful. Normal feeds are started again shortly after the operation. Most babies recover quickly and have no
further problems.  
a. Ramstedt's pyloromyotomy:  
Ramstedt's pyloromyotomy is easily performed and is associated with minimal complications.
  
b. Laparoscopic pyloromyotomy:  
Laparoscopic pyloromyotomy is also performed and is an effective alternative where suitable facilities are available.
 
 c. Double-Y pyloromyotomy:  

Double-Y pyloromyotomy has also been safely and effectively performed.  
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NOTE: Time to achieve full enteral feeding has been found to be significantly shorter (18.5 hours) in those treated
laparoscopically vs those having open pyloromyotomy (23.9 hours).  
COMPLICATIONS
1. Vomiting can lead to:  
- dehydration,  
- weight loss,  
- and severe electrolyte disturbance (hypokalaemic and hypochloraemic metabolic alkalosis).
2. Operative complications include:  

- mucosal perforation, 
- continued postoperative bleeding (very rare) 
- persistent vomiting due to incomplete pyloromyotomy (rare).
3. Foveolar cell hyperplasia (FCH) has been reported as a rare cause of persistent gastric outlet obstruction in
patients with IHPS. An extended pyloromyotomy is required to manage this.
PROGNOSIS
Prognosis is excellent unless diagnosis is delayed and prolonged severe dehydration occurs.
Mortality is rare after pyloromyotomy.
FREQUENTLY ASKED QUESTIONS BY MOTHER
P: Can I be with my baby before the operation?

D: A nurse and parent can accompany the child to the anaesthetic room. Your child may take a toy.
It is possible to give the anaesthetic medicine while the child is sitting in your lap.
The anaesthetic may by given as a gas or as an injection through a cannula.
If it is given as a gas, it may take some time and your child may become restless as the gases take effect.
If it is given as an IV, the child may become unconscious very quickly. Some parents find this very frightening.
P: When can I see my baby after the operation?

D: You will be able to join your child in the recovery room as soon as he/she is awake.
P: When will my baby be able to take feeds again?

D: For the first 4-8 hours after surgery, your baby will not be able to have any feeds by mouth. This is to allow the
stomach and intestines to rest. We will feed your baby through an IV drip. We will slowly increase the amount of food
according to the advice from the surgeon. It is quite normal for your baby to continue to vomit for a few weeks after
the operation, but it will not be the large amounts of projectile vomit like before.
P: What are the risks of the operation?

D: This is a generally safe operation and the risk of complications is small. However, like any other operation, this
operation has some risks. These are:
- wound infection (we can prevent this with antibiotics)
- incomplete pyloromytomy (it is possible that the operation may not succeed and your child may require repeat
surgery) and
- perforation (if this happens we will stitch it immediately).
P: When can I take my baby home?

D: You will be able to take your baby home after about 2-4 days.
Your baby will be discharged when they are getting an adequate amount of feed.
Your baby will soon gain weight. If the wound has a dressing, this will need to be taken off after 4-5 days.
Your child’s surgeon may ask to see you in outpatients several weeks after operation. In this case you will get an
appointment letter by post. We will also write to your child’s GP to tell them about the operation. This letter is sent
electronically.
If you have any problems after you get home, please contact your GP. If needed, you can even contact us directly.
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TM 8 PEADIATRIC PEADIATRICS AMOXICILLIN
Amoxicillin is a penicillin antibiotic, and is given to treat bacterial infections.

It is mainly prescribed for:
- Sinus infections,
- Chest infections,
- Urine infections,
- Ear infections,
- Some dental infections,
- H.Pylori eradication therapy (alongside other medications)
Cautions for use of Amoxicillin

1. If you have ever had an allergic reaction to Amoxicillin or other Penicillin, you should not take it.
2. If you have ever had a severe hypersensitivity reaction to any other antibiotic, you should not take
it.
3. If you have a condition called Infectious Mononucleosis or Glandular Fever, you should not take it.
Infectious mononucleosis usually presents with fever, sore throat, swollen glands in the neck, rash
and fatigue.
4. If you suffer from kidney disease you may require a lower than normal dose.
5. If you are taking other medications such as:
- Blood Thinners such as Warfarin: Your blood clotting time, INR should be monitored more
frequently.
- Methotrexate: Amoxicillin may decrease removal of this medication from the body, which could
increase the risk of its Side Effects. You may need extra check up and blood test while you are taking
a course of this antibiotic.
- Allopurinol: There may be an increased risk of experiencing rash as a side effect of Amoxicillin if
you are taking this medication.
NOTE: Prescribing Amoxicillin in the absence of proven or strongly suspected bacterial infection is
unlikely to provide benefit to the patient and increase the risk of development of drug-resistant
bacteria.
Side Effects
Many people who think they are allergic to antibiotics may in fact be experiencing the side effects of
the drugs, which are in no way related to the allergic reactions. The infection itself can also cause
symptoms, which will resolve as the infection is cleared.
Common side effects

These side effects are not serious, but you may need to discuss them with your doctor if they become
troublesome.
1. Diarrhoea
- Drink plenty of water and fluids
2. Nausea and/or vomiting
- Stick to simple foods.
- Have the medication with a meal.
3. Headache
- Seek advice from your doctor or pharmacist for a suitable painkiller
4. Redness and itching in the mouth or vagina (thrush)
- Seek advice from your doctor.
Other side effects

If you experience any of the following events, stop taking your medication and tell your GP or come
to the A&E immediately
1. Rash
2. Hypersensitivity or severe allergic reaction (anaphylaxis)
3. Discoloration in skin or eyes, having dark urine or pale stools.
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4. CDAD (Clostridium Difficile Associated Diarrhoea)
Hypersensitivity Reaction to Penicillins

Penicillin allergy occurs when your immune system responds to the drug as if it were a harmful
substance instead of a helpful remedy. Your immune system creates antibodies to attack the
medication. Chemicals released by your immune cells can cause the signs and symptoms
associated with an allergic reaction.
The most important side-effect of the penicillins is hypersensitivity which causes rashes and
anaphylaxis and can be fatal. Allergic reactions to penicillins occur in 1–10% of exposed
individuals; anaphylactic reactions occur in fewer than 0.05% of treated patients. Patients with
a history of atopic allergy (e.g. asthma, eczema, hay fever) are at a higher risk of anaphylactic
reactions to penicillins.
Anaphylaxis Reaction
Anaphylaxis a severe, life-threatening, generalised or systemic hypersensitivity reaction which
is likely when both of the following criteria are met:
- Sudden onset and rapid progression of symptoms.
- Life-threatening airway and/or breathing and/or circulation problems.
Signs and Symptoms of Penicillin Allergy

The most common signs and symptoms of penicillin allergic reactions include:
1. Rashes (hives)
2. Itchy eyes and skin,
3. Wheezing
4. Swollen lips, tongue or face (angioedema).
5. Dizziness or fainting because of hypotension
Other Signs and Symptoms

1. Slurred speech,
2. Rapid or weaker pulse rate,
3. Blueness of skin, lips and nail beds,
4. Diarrhoea,
5. Nausea and vomiting.
TREATMENT
If you are having an allergic reaction after taking penicillin you should stop taking the
medication and contact your doctor for advice.
In most cases penicillin allergy prevention consists of avoiding penicillin and using another
antibiotic instead.
Treatment for signs and symptoms depends on what kind of reaction you have.
Anaphylaxis can be life-threatening and requires an injection of epinephrine (adrenaline) and
emergency care to maintain blood pressure and support breathing.
Rashes or hives may improve when treated with an antihistamine such as chlorphenamine
(Piriton®). More severe reactions may require treatment with oral or injected steroids.
NOTE: It is very important to confirm and document patient’s allergy status.

Documentation should include the medication and the symptoms.
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AMOXICILLIN RASH
You've probably heard that taking antibiotics, may cause side effects like diarrhoea. But some
antibiotics, such as amoxicillin, can lead to a rash.
Here, we'll look at what the amoxicillin rash is, how to identify it, and what you need to do if
your child develops the rash.
What is an amoxicillin Rash?

Most antibiotics can cause a rash as a side effect. But the antibiotic amoxicillin causes a rash
more frequently than other types. Amoxicillin and ampicillin are both derived from the
penicillin family. Penicillin happens to be one of those common medications that a lot of people
are sensitive to.
About 10% of people report being allergic to penicillin. But that percentage may be high. People
often mistakenly think they are allergic to penicillin, even when they aren’t.
In reality, a rash is a common reaction after using penicillin.
What causes an amoxicillin rash?

While hives are most commonly caused by allergies, doctors aren't sure what causes the
maculopapular rash to develop. If your child gets a skin rash without hives or other symptoms,
it doesn’t necessarily mean that they are allergic to amoxicillin. They may simply be reacting
slightly to the amoxicillin without having a true allergy.
More girls than boys develop a rash in reaction to taking amoxicillin.

Children who have infectious mononucleosis or glandular fever and then take antibiotics may
be more likely to get the rash. Infectious mononucleosis usually presents with fever, sore throat,
swollen glands in the neck, rash and fatigue. A high percentage of patients with this condition
who receive Amoxicillin develop some skin rash.
What does the amoxicillin rash look like?

There are two types of amoxicillin rashes, one that’s more commonly caused by an allergy and
one that isn’t.
Hives
If your child develops hives, which are raised, itchy, sore, white or red bumps on the skin that
appear after one or two doses of the medicine, they may be allergic to penicillin.
If you notice your child has hives after taking amoxicillin, you should call your doctor right
away, as the allergic reaction could get worse. Don’t give your child another dose of the
medication without talking to your doctor. You should call the ambulance or go to the A&E if
your child is having difficulty breathing or shows signs of swelling.
Maculopapular rash
This is another type of rash that looks different. It often appears later than hives. It looks like
flat, pink/red patches or spots on the skin. Smaller, paler patches usually accompany the red
patches on the skin. This is described as a “maculopapular rash.”
They will remain on the trunk of the body, but they may spread to the face in more serious
cases. These spots should be small and flat and should not itch or cause discomfort.
This type of rash usually occurs between 3 and 10 days of starting the antibiotic, however, it
may occur earlier or later than this.
NOTE: Unfortunately, rashes are one of those symptoms that can be very confusing. A rash could
mean nothing. Or, a rash could mean that your child is allergic to amoxicillin. Any allergy can be
very serious quickly, and even put your child at risk for death.
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Is the amoxicillin rash dangerous?
An amoxicillin rash by itself is not dangerous. But if the rash is being caused by an allergy, the
allergy could be dangerous to your child. Allergic reactions tend to get worse the more the
allergen is exposed. Your child could develop an anaphylactic reaction and stop breathing if you
continue to give them the medication.
See your doctor if your child has hives or is showing any other symptoms, such as wheezing or
difficulty breathing. You may need to head to the A&E right away.
You should also call your doctor if the rash doesn’t get better or appears to get worse even after
the medication is finished.
How do you treat an amoxicillin rash?

1. In most cases it is not necessary to treat an amoxicillin rash. If the rash is not causing any
discomfort it will simply disappear once you or your child finishes their prescription. Symptoms
will typically last around three days, but can range from 1-6 days depending on the severity of
the reaction.
2. An amoxicillin rash is not usually severe and can often be managed at home. This sort of rash
may be treated with over-the-counter antihistamine, especially if it is uncomfortable, for
example, becoming itchy or has lasted for several days.
3. If at any point, the rash becomes worse you should see a doctor. This includes developing
hives. You should also contact a doctor if the rash lasts longer than six days without any sign of
improving.
4. If there’s residual itchiness, your doctor may recommend a steroid cream to apply on the skin.
Home remedies. If the rash is causing some discomfort or you are concerned about its
presence, some home remedies can be used to treat your condition.
1. Drink plenty of fluids,

- Having water helps your body clear toxins from the blood stream more effectively. This will
also help rid your body of the bacteria causing your infection.
- Dress lightly
- Maintain a well-ventilated environment
Additional Symptoms
Sometimes additional symptoms will accompany an amoxicillin rash. These include chills, fever,
headaches, dizziness, heartburn, flu-like symptoms, body aches, nausea, vomiting, and watery or
bloody stools. These side effects may also be the result of the infection that you are
experiencing, but they can also be a sign of an allergic reaction to the medication. Any additional
symptoms that accompany your rash should be reported to your doctor.
Some patients will develop a yeast infection or infections in the mouth when they experience an
amoxicillin rash. This may include the development of swelling and hives in the mouth if the
infection is serious. Yeast infections can appear as a "hairy tongue" or white patches throughout
the mouth. Vaginal yeast infections may also become more common if you are developing a
negative reaction to amoxicillin.
If you develop watery or bloody diarrhoea in addition to your rash, tell your doctor right away.
This is especially important if you have stopped taking your medication and then restarted. It
may be a sign that you have developed a more severe bacterial infection that the medication
cannot treat.
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TM 9 PAEDIATRICS - EPILEPSY
My child has been diagnosed with epilepsy
It means that a child has had at least one seizure and is at risk of having more. And although some children will have
epilepsy for life, other children will grow out of it.
Who should I tell about my child’s epilepsy?
For your child’s safety, it’s important to tell anyone who will be caring for them about their epilepsy and seizures. Depending
on their age, you might need to talk to their childminder, teacher, out of school activity leaders, and other members of your
family.
When talking to other people, it’s important to be as honest and open as you can about what happens before, during, and
after your child’s seizures. To help you with this, you could write up an epilepsy care plan with your child’s doctor or
epilepsy nurse. Information in the care plan will tell people what they need to do to keep your child safe. It will also give
information about the medicines they take, and who to contact in an emergency.
If your child's school want to know more about epilepsy, they could use our training for schools.
Getting the name right
It's important to find out the right name for your child's seizures or syndrome, so that you can explain their epilepsy to
people who might look after them.
How do I keep my child safe?
If your child is still having seizures, they may be at risk of being injured during a seizure. This is more likely if they have
learning disabilities or their epilepsy is part of another condition. Although it’s not possible to prevent all their injuries,
there are safety precautions you could try, to keep your child as safe as possible.
What is SUDEP?
Every year, around 40-80 children in the UK die because of their epilepsy. Some children die because they have a seizure in a
dangerous place. Or the seizure itself could have caused their death. But, for some children who die, no cause can be found.
When a child with epilepsy dies suddenly, and no reason can be found, it is called sudden unexpected death in epilepsy
(SUDEP).
If a child has epilepsy, they have a 1 in 4500 risk of SUDEP. This means that 1 child will die, but 4499 will not. Children who
have 3 or more generalised tonic-clonic seizures a year are at the highest risk of SUDEP. This is particularly so if they happen
in their sleep.
The good thing is that knowing about the risks means you can do things to keep these to a minimum. It’s worth talking to
your child’s doctor or epilepsy nurse about any risks for your child.
Can people treat my child differently because of their epilepsy?
In the UK, there are equality laws that make it illegal to discriminate against people with epilepsy. The Equality Act protects
children in England, Scotland and Wales. The Disability Discrimination Act (DDA) protects children in Northern Ireland.
The equality laws state that anyone who provides goods or services must make sure that children with epilepsy are treated
fairly. And service providers may need to make reasonable adjustments so that your child is not disadvantaged because they
have epilepsy. A reasonable adjustment would be their teacher providing written information for them if a seizure has
caused them to miss part of a lesson.
How will my child's epilepsy be treated?
You have probably already talked with your child’s doctors about how their seizures should be treated. The most common
way is with epilepsy medicines. These are introduced slowly, and gradually increased until they get to the right level. They
are taken every day.
Daily epilepsy medicines

It can be worrying when you are told your child needs to take epilepsy medicines every day, sometimes for several years.
And some parents, when they see the list of possible side-effects would rather their child didn’t take them. But for most
children, the benefits of taking epilepsy medicines are greater than the possible side-effects from the medicine. This is
because some seizures can be unpleasant and can cause injury. And some children feel embarrassed about having seizures,
especially in front of their friends, so prefer to try the medicines instead.
There is a range of different epilepsy medicines available to treat children. The one your child is given will depend on:
- Their age and sex
- The type of seizures or syndrome they have
- Whether they have any other medical conditions
Sometimes, if one epilepsy medicine doesn’t control a child’s seizures, another might be added. Or the first medicine may be
swapped over to a different one. This will take some time to do. But with the right dose of the right medicine, around 7 in
every 10 people with epilepsy can have their seizures controlled.
My child has been given a different epilepsy medicine for seizures that last a long time. Why is that?
Many children have seizures that last for less than 5 minutes and stop without any treatment. But some children have
seizures that last longer than 5 minutes. Seizures that last longer than 30 minutes or a cluster of shorter seizures that last for
30 minutes or more can cause damage to the brain, or even death. In both cases, this is known as status epilepticus. Seizures
lasting for more than 5 minutes need treating before they turn into status epilepticus.
The 2 most commonly used medicines to prevent status epilepticus are midazolam and diazepam. Midazolam is given by a
dropper, inside the child’s cheek or nose. This can be given by anyone who has been trained to do it, as well as healthcare
professionals. If diazepam is given by a medical professional, they will usually give it by injection. But it can be given by non-
healthcare professionals with the right training. In this instance it will usually be given rectally (into the back passage).
If your child has been prescribed emergency medicines to stop their seizures, the doctor who prescribes the drug should
write a care plan. This will show exactly when and how much emergency medicine needs to be given.
How often should my child have a review?
To make sure your child is still on the best treatment for their epilepsy, they should have a review of their epilepsy and
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treatment at least once a year. This is particularly important when being transferred from children’s to adult services, as
their treatment may be different from when they were younger.
Are there any other ways of treating epilepsy?
In the UK, if your child’s epilepsy is difficult to control, they may be considered for epilepsy brain surgery. This is done by
very specialist surgeons at one of four Children’s Epilepsy Surgery Service (CESS) centres. Before surgery is considered, your
child will have to go through a very thorough assessment. And only once it has been decided that surgery could reduce, or
stop their seizures, without causing any other problems, would it become an option.
If surgery isn’t possible for your child, the doctor may discuss the possibility of vagus nerve stimulation (VNS) or the
ketogenic diet.
VNS therapy involves a small electrical device, like a pacemaker, which is implanted under the skin of your child’s chest. The
device sends electrical impulses to their brain through a nerve in their neck called the vagus nerve. The aim is to reduce the
number of seizures they have and make them less severe.
The ketogenic or modified diets are higher in fats and lower in carbohydrates than a typical diet. If none of the other
treatment has stopped or reduced your child’s seizures, they may be offered a trial of one of these diets.
Help and support for children
Is there any help I can get for my child?
Some children with epilepsy have more needs than other children. The local authorities in the different countries of the UK
have a duty to provide a range of services for children in need. These are likely to include:
- Day care
- Advice, guidance and counselling
- After school activities
- Help with transport and holidays
- Short-term or respite care
- Cultural, social and leisure activities
If your child has more needs than other children, speak to your family doctor, epilepsy specialist nurse, health visitor, or
staff at your local social services agency, or local authority. They can tell you more about these services.
How do I support my child with epilepsy?
Some children deal with their epilepsy and seizures in a very matter-of-fact way. Others feel embarrassed about having
seizures, especially if they happen at school, or with their friends. You can support them by talking to them about their
concerns. You could take information into school, so that staff can explain epilepsy to the other children.
Some children have triggers for their seizures. These can be things like late nights, tiredness, not eating well, stress or being
unwell. In some children, avoiding triggers can reduce their number of seizures. You could work with your child to see if
they can identify any triggers, and help them to decide how to avoid them.
If your child wants to find their own information, they can look on our children’s and teenage websites.
How do I support other children in the family?
Having epilepsy in the family affects everyone, not just the child with seizures. Some brothers and sisters of children with
epilepsy need more information about what is happening to their sibling. They may feel anxious about seeing a seizure, or
not really understand what is going on. We have information about epilepsy for brothers and sisters.
Help and support for parents and carers
It’s natural to have concerns when you are told your child has epilepsy. You might worry about how their epilepsy will affect
them, or be concerned about side-effects from their epilepsy medicines. You might worry that family, friends and neighbours
will not know much about epilepsy, or how to deal with it. Finding out as much information as possible about your child’s
epilepsy and treatment, and sharing it with other people could be helpful. Once they understand, they are more likely to
offer you support.
Who can I talk to about my concerns?
Your family doctor can give you information and advice about your child’s epilepsy, but probably won’t have the time for
long discussions. If there is an epilepsy specialist nurse attached to your child’s epilepsy clinic, they should be able to offer
you advice and support. Or you could speak with an advisor on the Epilepsy Action Helpline.
Sources of further information
- ACE Education Adviceline
- Carers UK
- Citizens Advice
- Contact a family
- Disabled Living Foundation
- Dyspraxia Foundation
- IASS Network
- Independent Panel for Special Education Advice (IPSEA)
- Local services
- National Autistic Society
- NHS Choices
- YoungMinds
Safety assessments
If you have unpredictable seizures you could be at risk of injuring yourself at home. To be as sure as possible that you are
doing everything you can to reduce risk, you could ask your local Social Services to arrange for an occupational therapist
(OT) assessment of your home. You could also discuss safety with your epilepsy specialist nurse. If you have learning
disabilities, you could ask your learning disabilities nurse to do a formal risk assessment.
Bathing
If you have seizures, you will need to do everything you can to reduce the risk of drowning during bathing. One way of doing
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this is to have someone in the bathroom with you or just outside. You will, however, want to balance this against your need
for privacy.
A shower is considered to be safer than a bath for people with epilepsy. However, neither is entirely risk free.
Showers
A shower should ideally be in a separate cubicle, rather than over the bath. If possible, the cubicle should have a flat floor,
instead of a shower tray. This is because water could collect in a shower tray, increasing the risk of drowning. The shower
screen should be made of plastic or safety glass. A shower curtain is an alternative.
You may also need to look at your bathroom fittings. These need to be as flush to the wall as possible. This will reduce the
risk of injury, if you have a seizure and fall. If fittings stick out, or if you use a shower over a bath, you could cover the fittings
with protective material. Even a thick towel can be effective in reducing the risk of injury if you fall. It is important that the
temperature control works well. It should have a safety ‘cut-off’, in order to avoid scalding yourself. Taking a shower while
sitting, if this is possible, will reduce the risks of injury if you have a seizure.
Baths
If you use a bath, it’s best to keep the water depth shallow to reduce the risk of drowning. However, this will not remove the
risk entirely. The taps should be turned off before you get into the bath. Some people prefer to wash with running water,
without putting in the plug. If you decide to do this, you could use a shower attachment. This way the water can be mixed to
a comfortable temperature. However, shower attachments don’t have a safety ‘cut-off’, so can’t prevent scalding if the water
temperature changes.
Bathroom doors
You could use an ‘engaged/vacant’ sign to protect your privacy, instead of locking the bathroom door. If possible, the door
should be hinged so that it opens outwards. This way, if you have a seizure and fall against the door, you won’t block
someone getting into the bathroom if you need help. If it’s not possible for the door to open outwards, you could consider
having a ‘concertina’ door (where it folds open and closed).
Kitchen safety
It’s safer to use a microwave oven than a gas or electric cooker. If you use a cooker, turn saucepan handles away from the
edge so you are less likely to knock the saucepan over. It will reduce the risk of scalding if you take plates or dishes to the
cooker, rather than carrying hot pans to the table. Using a toaster can avoid the danger of leaving a grill on. Kettle tippers
and teapot pourers are available to avoid lifting containers of hot liquid, although these will not remove the risk completely.
There may be other safety aids that could be helpful. Contact the Disabled Living Foundation for further details. A limited
range is also available from some shops, such as DIY stores. Some of these safety aids may be mainly intended for child
safety, but could still be useful.
If you have memory problems, you could forget you’ve turned on the grill or cooker. You might, therefore, decide to get a
smoke detector. The smoke alarm will sound when smoke hits the sensor, for example from burning food.
Ironing
If you have unpredictable seizures, you may decide not to iron when
alone in the house.
Electric flexes
It is wise to avoid having trailing flexes. This is particularly important where they are attached to appliances which could
cause a fire, or burns, if pulled over. You can use cable tidies, available from DIY stores, to make sure that flexes are kept out
of the way. You could also consider using a cordless kettle and iron.
Heating
If you have free-standing heaters, try to place them where they are least likely to be knocked over during a seizure. Some
modern electric heaters have a safety cut-off if they are knocked over. However, you will still need to think about having
guards on your heaters or radiators to minimise the risk of being burned if you fell against them. If you have an open fire be
sure to use a substantial fixed fire guard.
Flooring
If at all possible, avoid having very hard floor surfaces as they can increase the risk of injury during a seizure. Different types
of flooring are available which will provide a softer landing if you should fall. Examples are vinyl cushion, linoleum, cork and
rubber. Carpets with a high wool content are less likely to cause friction burns during a seizure than those with a high
synthetic content.
Stairs
If you have frequent and unpredictable seizures, stairs can be a major hazard. Even so, it is possible to reduce the risks. For
example, keep your staircase clear of obstructions at all times. And consider having a soft rug or carpet at the bottom of the
stairs. This will help to cushion any falls.
Lifts
If you have mobility difficulties, you may need to use a stair lift or vertical lift. Neither of these options is risk-free if you also
have seizures.
Vertical lifts
If you use a vertical lift, it should, if possible, have a padded interior to reduce the risk of injury if you have a seizure.
Stair lifts
Most stair lifts have simple lap straps. These are unlikely to cause injury if
you have a seizure. Some people may need the added protection of a full harness, to prevent them falling. Where this is the
case, it’s important to be aware that the harness could cause injury during a seizure.
There is no perfect solution where stairs or lifts are concerned. To a certain extent, it is a matter of arriving at a compromise
between the safest option and what is practical in your home.
Electric wheelchairs
If your seizures are not controlled and you want to use an electric wheelchair, you will need to think about safety. You could
discuss this with your doctor.
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They would consider what dangers there might be for you, if you had a seizure while using an electric wheelchair. They
would also consider the type of seizures you have and if you have a warning of your seizures.
Glass doors and windows

Falling against glass doors or windows could cause serious injury. You can reduce the risk by using toughened safety glass,
or by covering ordinary glass with safety film. Contact your local glass merchant or DIY store for more information and
advice. You may also want to make sure that any wide-opening upstairs windows, or doors from upper balconies, have
suitable locks in place so that you can’t fall from them.
Sharp edges
You may want to cover sharp edges, or any that stick out, for example on furniture. You could use padding, such as pieces of
foam rubber that come in sheets, or tubes that are designed for lagging pipes. A DIY store may stock other options. When
buying new furniture, you could consider making sure these have rounded edges or corners.
Protective headgear
If you have frequent, unpredictable seizures, which might cause injury to your head or your face, you may wish to consider
wearing a protective helmet. Your hospital consultant can prescribe one if they feel it is appropriate. You can also buy these
privately.
Alarms
Some people are worried about having seizures when they are alone. There are different types of alarms that can alert other
people that you may need help.
- Baby intercoms can pick up sound.
- Bed alarms can sense different things when someone’s asleep, such as unusual sound, movement or dribble.
- Fall alarms can be used when someone has fallen to the ground.
- Telephone alarms, operated by remote control, can be used to call someone for help.
Before investing in any of these alarms, you need to consider whether they are necessary and if they would be effective for
you. For example, there would need to be somebody else available to hear a fall alarm. Baby intercoms only pick up noise,
not movement. Generally, you would need to have a warning of a seizure for a telephone alarm to be useful. However, a
telephone alarm can be used when the seizure is over to call for help if you need to.
Beds
If your seizures involve convulsions or jerking movements, try to avoid placing your bed against a wall or next to a radiator.
This can prevent you knocking your limbs on the wall, or burning yourself.
Placing protective cushions or a mattress around the bed can help to reduce any injury caused by falling out of bed. The
lower the bed, the less distance there is to fall. This will reduce the risk of injury. It is also a good idea to keep sharp-edged
objects, and furniture such as bedside tables, away from the bed, to prevent injury.
Parents with epilepsy caring for young children
If you are a parent with epilepsy you may worry about your children’s safety, if you have a seizure. Besides following general
safety measures for all parents of young children, there may be other ways to reduce the risk of injury and accidents. These
include, for example, fitting a safety brake to the pram, and special ways of feeding, bathing and looking after your baby or
young child. Child reins, harnesses and wrist straps can keep your child close to you when you are out and about. If you fall
during a seizure you may pull your child over. However, this is safer than allowing your child to wander off unsupervised.
Sport and leisure
Most sport and leisure activities are possible for people with epilepsy, as long as common sense precautions are taken,
where relevant. Sports on or near water, or at heights, may need extra safety measures or supervision.
Carrying identification
You may feel reassured by carrying or wearing some form of identification, particularly if you are out on your own. Epilepsy
awareness cards, or medical identity jewellery, are available.
What should other people do when I have a seizure?
Most people get very frightened when they see a non-epileptic seizure. However, it is best, if people who are there when a
seizure happens try to stay calm. Here are some “Do’s” and “Don’ts” for people helping you during a nonepileptic seizure:
Do’s:
- Make sure that the person having the seizure is safe. This may involve removing dangerous objects or carefully placing a
pillow or soft clothing under their head.
- Speak calmly to the person having the seizure.
Non-epileptic seizures often stop more quickly if the person having the seizure is addressed in a calm, reassuring way.
- Remember that non-epileptic seizures do not cause any damage to the brain, even if they go on for several minutes.
- Call for an ambulance if you do not yet know whether someone’s seizures are non-epileptic or epileptic, and if the seizure
goes on for more than five minutes. This is because longer epileptic seizures (status epilepticus) can damage the brain.
Don’ts:
- Do not hold the person down during the seizure. Holding people down can make the seizure worse and cause injury.
- Do not try to give them medication, as drugs have no role in the treatment of non-epileptic seizures.
- Do not immediately call for an ambulance. If an ambulance has to be called because a seizure simply won’t stop or has
caused an injury it is important to tell the ambulance about the diagnosis of non-epileptic seizures. Note that it is rarely
necessary to call an ambulance with this kind of seizure.
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TM PAEDIATRICS 11 HIGH-IMPACT UNSTABLE PELVIC FRACTURES
1. Patients present with pain and shock
2. Pelvic instability is likely.
3. Deformity may not be initially obvious.
INVESTIGATIONS
1. Blood test:
- Serial hemoglobin and hematocrit measurements to monitor ongoing blood loss
- Group and cross-match.
2. X-rays:
- Anteroposterior pelvic X-ray
3. CT scan:
- For first-line imaging in people under 16 with suspected high-energy pelvic fractures:
a. CT should be used rather than X-ray when CT of the abdomen or pelvis is already
indicated for assessing other injuries.
b. Consider CT rather than X‑ray when CT of the abdomen or pelvis is not indicated for
assessing other injuries.
4. Ultrasound:
- To detect intrapelvic bleeding or fluid.
5. Arteriography:
This is radiography of vessels after introduction of contrast material through a catheter
inserted into an artery.
- It is used if the patient is haemodynamically unstable, and ultrasound, CT scan or
peritoneal tap excludes significant intraperitoneal bleeding.
- It allows for determination of the bleeding site and potentially embolization as a means of
control.
MANAGEMENT:
Unstable fractures:
1. Pain management: intravenous morphine
2. Assess for and treat hypovolemia, anticipate coagulopathy and ensure blood is rapidly
available, as a massive transfusion may be required.
3. Initial aim is reduction of blood loss by reducing pelvic volume, stabilizing clot formation
and reducing ongoing tissue damage.
This can be achieved by:
a. Binders,
b. Sheets
c. Stabilization by external fixation.
NOTE: External fixation involves long screws inserted into the bones from the sides and a
large external frame. It allows the surgeon to address the potential internal neurovascular
and soft tissue injuries.
4. For first-line invasive treatment of active arterial pelvic bleeding, use Interventional
radiology (embolization), if emergency laparotomy
is not needed for abdominal injuries.
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NOTE: Catheter embolization places medications or synthetic materials called embolic
agents through a catheter into a blood vessel to block blood flow to an
area of the body. It may be used to control or prevent abnormal bleeding,
Arterial access is usually obtained using a common femoral approach generally on the side
opposite to pelvic or lower-extremity injuries.
In a patient with poor or non-palpable pulses, ultrasound guidance is very helpful to obtain
arterial access.
A contrast material then is injected through the catheter and a series of x-rays are taken to
locate the exact site of bleeding or abnormality. The medication or embolic agent is then
injected through the catheter. Additional x-rays are taken to ensure the procedure was a
success and that there is loss of blood flow in the target vessel.
In general, large vessels require coils; smaller vessels can be treated with particles, gelatin
sponge or micro coils.
5. Pelvic packing if emergency laparotomy is needed for abdominal injuries.
NOTE: In pelvic packing sites of bleeding in the abdomen are addressed and the pelvis is
packed with laparotomy pads prior to closure. Anticipation is for early return to the
operating room for further intervention and/or repacking.
6. Further Management:
- Some require traction.
- Some may require internal fixation with plates or screws
- In some cases external fixation will be sufficient
NOTE: Early fixation is important for Mobilization, Pain control, Prevention of deformity
and chronic instability.
COMPLICATIONS
- Increased incidence of thrombophlebitis.
- Intrapelvic compartment syndrome.
- Continued bleeding from fracture or injury to pelvic blood vessels.
- Associated bladder, urethral, prostate or vaginal damage is common.
- Associated thoracic and abdominal injuries occur in 10-20%; massive internal
hemorrhage may occur.
- Sexual dysfunction may be a long-term problem.
PROGNOSIS
- Prognosis varies depending on severity of fracture and associated injuries.
- High-energy fractures may have significant complications including:
1. Bleeding: severe blood loss is the main threat to life. Pelvic fracture associated with
hemodynamic instability has mortality in excess of 40%.
2. Organ damage,
3. Infection,
4. Venous thrombosis and embolism.
5. Prolonged physiotherapy and rehabilitation will be needed for a return to full fitness.
6. Subsequent problems may involve long-term effects on internal pelvic structures which
may leave patients with symptoms such as persistent pain, impaired mobility or sexual
dysfunction.
7. Regardless of fracture type, neurological injury is a strong predictor of
poor outcomes.
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PSYCHIATRY 1 - MMSE
1. MMSE is one of the screening tests to assess patient’s cognitive function.
2. Your patients are usually elderly patients who have problem with short-term memory.
3. It is very important to talk clearly and slowly.
4. Please do not push the patient by talking too fast to complete the station.
5. Please give clear instructions to patient so you don’t have to repeat yourself.
6. Patient cannot answer many questions. He may push himself. It is your job to encourage
patient and move on to the next question.
7. Sometimes answers by patient to many questions will be funny. You should not laugh at
patient – control yourself and behave professionally.
8. Please do not give an impression to the patient that his answer is right or wrong. For example
if you say “Well done” to right answer, and behave differently when he gives wrong answer,
patient will understand.
9. It is very important to explain to the patient about purpose of visit since patient has no idea
what you are going to do.
10. In this station you will see A4 papers and pen to write scores after each question, but please
don’t loose eye contact while scoring your patient.
11. According to the NICE guidelines, scores of 25-30 are considered normal.
Scores of 21-24 are considered as mild cognitive impairment and scores of 10-22 are
considered as moderate cognitive impairment and scores of below 10 are considered as severe
impairment.
HOW TO DO MMSE
Time Orientation
You need to ask five questions of time form broadest to most narrow (year, season, month, date and
day) and for each correct answer you should give one score.
Place Orientation
You need to ask five questions of place form broadest to most narrow (Country, county, town/city,
street and building) and for each correct answer you should give one score.
Registration
You should name three unrelated objects clearly and slowly and then ask the patient to repeat them
after you. You may remind him to remember them since you will be asking him to recall them later.
You may use the words: Apple – Table – Penny
Attention
In order to assess attention, give your patient a 5-letter word and ask him to spell it backwards. You
may use the word “WORLD”. The correct answer is: D-L-R-O-W.
For each correct answer, give him one score.
NOTE: An alternative way of assessing attention, mainly used if English is not their language, is:
“Could you take seven away from hundred? I’d like you to keep taking seven away from each new
number until I tell you to stop.”
If patient makes a mistake, do not stop them. Let the patient carry on and check his answers.
Stop after five answers.
The correct answers, will be: 93, 86, 79, 72, 65.
Please give one score for each correct answer.
Recall
You should ask your patient to recall the three words you asked him to remember earlier. For each
word that he could remember, give him one score.
Repetition
Ask the patient to speak back a phrase. You may use this phrase “No ifs, ands, or buts”. If could
repeat it after you correctly, give him one score.
Language
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You should show your patient to simple objects, such as pen and pencil and ask him to name them.
For each correct answer, please give him one score.
Complex Command (3 Stage Command)
You need to give your patient 3 commands. Give one score for each correct task.
For example: “Please take a piece of paper from the table, fold it in half and give it to me,”
Complex Command (Reading)
You should give your patient a written instruction and ask him to read it and do what it says. If he
follows your instruction correctly, please give one score.
Complex Command (Writing)
You should give your patient a pen and a piece of paper and ask him to make up and write a
sentence about anything. If he writes a meaningful sentence that contains a noun and a verb
without any spelling or grammar mistake, please give him one score. (Usually he writes a meaningful
sentence, however, sometimes he may make spelling mistakes.)
Complex Command (Drawing)
You should draw the following picture on a piece of paper. Give your patient a pen and a blank piece
of paper and ask him to copy your picture. If he draws it correctly, please give him one score. (All ten
angles must be present and two angles must intersect.)
MANAGEMENT
1. Full history specially past medical history, family history and drug history.
2. Full examination for possible cardiac and neurological abnormalilties.
3. Laboratory tests including FBC, U&Es, LFTs, S. Calcium, S. Vitamin B12, TFTs.
4. Imaging tests including CT, PET Scan, MRI Brain
5. EEG
The assessment of cognitive impairment, which is not associated with any physical illness or
structural abnormality, can be assessed by further tests.
6. Neuropsychological testing.
7. Electroencephalogram and evoked potentials.
8. Some advanced cognitive assessment should also be done by senior psychiatrist.
NOTE: Assessment of patients social status is very important.
Patients Living Status should be found out to see if he lives alone or with family or in a care home.
Necessary arrangement for support such as a carer and involvement of social services should be
done.
Communicating with the family and GP in order to gather precise information is necessary.
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PSYCHIATRY 2A – DELUSIONAL DISORDER
PSYCHIATRIC/MENTAL HEALTH ASSESSMENT
Identity:
- Including marital status, education, occupation, cultural and spiritual identity.
Presenting complaint:
- Use open-ended questions but quickly narrow down on the diagnosis and look for supporting evidence.
- Find out the nature of the problem.
- The date of onset and whether it was slow or sudden.
- Why and precisely how the person presented at this time.
- What precipitated the problem.
- The severity and its course and effect on work and relationships, as well as physical effects on appetite, sleep and
sexual drive.
- Previous episodes, including dates, treatments and outcomes of similar episodes.
- The description of the problem will also enable an assessment of the patient's insight into their situation.
- Some patients may deny the existence of a problem and it may be necessary to obtain a history of the illness from a
family member or close friend.
Personal history:
- Should cover different aspects of the patient's life, from early childhood.
- Work history: jobs held, reasons for changing jobs, level of satisfaction with employment and ambitions.
- Assess how the disease is affecting their job.
- Marital history and relationship history with others (intimate or sexual relationships).
- Establish whether there is anyone they currently feel able to confide in.
- Family history: close family, including names, ages and their past and present mental and physical health.
- Illegal activities/violence: criminal record and any previous episodes of violence or other acts of aggression.
- Present social situation: establish what support they currently have at home.
- Pre-morbid personality: note how the patient would describe his or her personality before becoming unwell.
- Establish the patient's overall mood or temperament, for example, anxious, obsessional, solitary or social.
- If necessary, include detail on: Character traits, confidence, religious and moral beliefs, ambitions and aspirations,
social relationships with family, friends, workmates, alcohol and illicit drug misuse (past and present) and full
current drug history (prescribed medications, self-prescribed or recreational).
Mental state assessment:
- Appearance and behaviour: appearance, motor behaviour and attitude to situation and examiner.
- Speech: rate, volume, quantity of information; disturbance in language or meaning.
- Mood and affect: mood (depressed, euphoric, suspicious) and affect (restricted, flattened, inappropriate).
- Content of thought: delusions, suicidal thoughts, amount of thought and rate of production, continuity of ideas.
- Perception: hallucinations, other perceptual disturbances (derealisation, depersonalisation, heightened/dulled
perception).
- Cognition: level of consciousness, memory (immediate, recent, remote), orientation (time, place, person),
concentration: serial 7s, abstract thinking. Mini-mental state examination can be used as a screening tool for
cognitive impairment.
- Insight: extent of the patient's awareness of the problem.
Assessing suicidal intent:
- The risk of self-harm is increased if:
a. The patient is pessimistic or feels hopeless.
b. There is a previous history of self-harm or no social support.
- Ask whether things are so bad at the moment that they have thought about ending their life and whether they think
there is a real chance that they would attempt this.
- Establish whether they have made any preparations and plans and whether they have decided how they would end
their life.
- Ask what has stopped them from killing themselves up to now.
Physical examination and investigations:
- To exclude physical (organic) causes for current mental problems.
- Investigations such as blood tests for anaemia, B12 deficiency, TFTs or syphilis serology may be required depending
on the presentation.
DELUSIONAL DISORDER
A patient with delusional disorder cannot tell what is real or imagined.

This is a severe type of mental health disorder.
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The person is likely to feel persecuted and more likely to seek help from a lawyer or police than from a mental health professional.
People with delusional disorder may believe they are being followed, poisoned, deceived, or loved from a distance.
People with delusional disorder can often continue to socialize and function normally and apart from with the subject of their delusion
generally do not behave in an obviously odd or bizarre manner. This is unlike people with psychotic disorder who also might have delusions
as a symptom of their disorder. In some cases however, people with delusional disorder might become so preoccupied with their delusions
that their lives might be disrupted.
Delusions are the most obvious symptoms of this disorder. A person might be also irritable, angry or sad.
DIAGNOSIS
- Patient should have delusions for more than one month.
- Delusions should not be accompanied by characteristic symptoms of other psychiatric disorders.
CAUSES
1. Genetic such as history of delusional disorder or schizophrenia in the family.
2. Biochemical factors such as imbalance in neurotransmitters (which can interfere with the transmission of messages, leading to symptoms).
3. Environmental/Psychological factors such as:
- Excessive stress
- Alcohol
- Drug abuse
- Social isolation
- Being unmarried
- Being unemployed
- Low socioeconomic status
Medical
- Neurodegenerative disorders for example Multiple sclerosis.
- Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
- Infectious disease such as HIV.
- Metabolic disorders such as Hypercalcemia, Hyponatremia.
- Endocrine disorders such as Addison disease, Cushing syndrome and thyroid problems.
- Vitamin deficiencies such as vitamin B12, Folate, Thiamine, Niacin deficiency.
- Medications such as anabolic steroids, corticosteroids, cimetidine and some antibiotics such as penicillin.
- Substance abuse such as Amphetamines, Cocaine, Alcohol, Cannabis.
Related Psychiatric Disorders
- Schizophrenia,
- Delirium
- Mood disorders with delusional symptoms (manic or depressive type)
- Obsessive-compulsive disorder.
MANAGEMENT
- A full and complete medical history should be taken.
- A complete physical examination must be performed for example neurological and cardiovascular examinations.
- Further investigations must be carried out.
INVESTIGATIONS
- Blood tests must be done to rule out infectious disease, metabolic and endocrine disorders and vitamin deficiencies.
- Imaging such as CT scan or MRI of the brain should be performed to rule out other medical conditions that are commonly present with
delusions such as tumours.
HOW TO TREAT
Treatment for delusional disorder usually includes medication and psychotherapy.
Delusional disorder is highly resistant to treatment with medication alone.
Psychotherapy
Psychotherapy is primary treatment for delusional disorder. Psychological treatment, which includes:
- Minimizing the risk factors that may increase the symptoms.
For example if the patient lives alone and this should be addressed.
- Individual psychotherapy:
This can help a person recognize and correct the underlying thinking that has become distorted.
- Cognitive Behavioral Therapy (CBT):
This can help the person learn to recognize and change thought patterns and behavior that lead to troublesome feelings.
- Family Therapy:
This can help the family understand the patient’s problem and enable them to contribute to a better treatment outcome.
- Insight Oriented Therapy:
This can help patient understand and recognize their problem.
- Other supportive therapy:
Social skills training such as not discussing delusional beliefs in social settings.
Medication
- Conventional anti-psychotics
- Atypical anti-psychotics
- Tranquilizers (if patient has high level of anxiety and sleep problem)
- Anti-depressants (Depression often occurs in delusional disorder)
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PSYCHATHRY 3B- CONSENT IN YOUNG PATIENT
The capacity to consent depends more on young people’s ability to understand and weigh up
options than on age. When assessing a young person’s capacity to consent, you should bear in
mind that:
a) at 16 a young person can be presumed to have the capacity to consent.
b) A young person under 16 may have the capacity to consent, depending on their maturity and
ability to understand what is involved.
It is important that you assess maturity and understanding on an individual basis and with
regard to the complexity and importance of the decision to be made. You should remember that
a young person who has the capacity to consent to straightforward, relatively risk-free
treatment may not necessarily have the capacity to consent to complex treatment involving high
risks or serious consequences.
Sharing information with the consent of the child or young person:

Sharing information with the right people can help to protect children and young people from
harm and ensure that they get the help they need. It can also reduce the number of times they
are asked the same questions by different professionals. By asking for their consent to share
relevant information, you are showing them respect and involving them in decisions about their
care.
If children and young people are able to take part in decision-making, you should explain why
you need to share information, and ask for their consent. They will usually be happy for you to
talk to their parents and others involved in their care or treatment.
Sharing information without consent:

If a child or young person does not agree to disclosure there are still circumstances in which you
should disclose information:
a) when there is an overriding public interest in the disclosure
b) when you judge that the disclosure is in the best interests of a child or young person who
does not have the maturity or understanding to make a decision about disclosure:
- tell the child or young person what you propose to disclose and why, unless that would
undermine the purpose or place the child or young person at increased risk of harm
- ask for consent to the disclosure, if you judge the young person to be competent to make the
decision, unless it is not practical to do so.
c) When disclosure is required by law.
If a child or young person refuses consent, or if it is not practical to ask for consent, you should
consider the benefits and possible harms that may arise from disclosure. You should consider
any views given by the child or young person on why you should not disclose the information.
But you should disclose information if this is necessary to protect the child or young person, or
someone else, from risk of death or serious harm. Such cases may arise, for example, if:
a) a child or young person is at risk of neglect or sexual, physical or emotional abuse.
b) The information would help in the prevention, detection or prosecution of serious crime,
usually crime against the person.
c) A child or young person is involved in behaviour that might put them or others at risk of
serious harm, such as serious addiction, self-harm or joy-riding.
If you judge that disclosure is justified, you should disclose the information promptly to an
appropriate person or authority and record your discussions and reasons. If you judge that
disclosure is not justified, you should record your reasons for not disclosing.
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Note: At 16 it is legally presumed that young people have the ability to make decisions about
their own care.
Note: Young people, should be encouraged to involve their parents or another appropriate
person in decisions about their health and care.
Children, young people and parents may not want you to disclose information about them if
they think they will be denied help, blamed or made to feel ashamed. They might have had bad
experiences or fear contact with the police or social services. You should help them understand
the importance and benefits of sharing information. But you must not delay sharing relevant
information with an appropriate person or authority if delay would increase the risk to the child
or young person or to other children or young people.
SUMMARY
16-18 year olds:
Once children reach the age of 16, they can agree to examination or treatment just like adults.
People providing health care do not then have to ask you for consent as well.
A young person (anyone aged 16-17) is presumed to be capable of consenting to their own
medical treatment. Consent will only be valid if it is given voluntarily by a young person who
has received and understood the appropriate information. As with adults, a young person has
the right to refuse to consent to treatment.
Under 16s:
The rules say that children under 16 may still be able to give consent for themselves, provided
they are mature enough to understand fully what is involved.
A child (anyone under 16 years old) can consent to treatment as long as they have enough
understanding and intelligence to fully appreciate what is involved in their treatment. This is
known as being "Gillick competent". Additional consent by a person with parental responsibility
is not required.
GILLICK COMPETENCE.
To assess if a young patient is competent enough to consent, patient should have Gillick
Competency. This means:
1. A young person must be able to understand and retain the information in order to make a
decision about their care.
2. A young person must be able to use information to consider whether or not they should
consent to the treatment, which has been offered to them.
3. A young person must be able to communicate their decision to others.
Note:
Although your child might be grown-up enough to consent to a meningitis vaccination, for
instance, it might be too much to expect him or her to grasp all they need to know for
consenting to a heart operation.
Even if your child is grown-up enough to give consent independently, people providing
treatment will still encourage them to involve you in their decision. However, if children refuse
to share information with parents, health care professionals must normally respect their
wishes.
Note:
You are entitled to agree to treatment on behalf of a child up to age 18 for whom you have what
is called “parental responsibility”.
A person with parental responsibility means someone with the rights and responsibilities that
parents have in law for their child, including the right to consent to medical treatment for them,
up to the age of 18 in England, Wales and Northern Ireland and 16 in Scotland.
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PSYCHIATRY 4 & 5 – DEPENDANCY SYNDROME
Description:
- A cluster of psychological, behavioral and cognitive phenomena in which
the use of a substance takes on a much higher priority for a given individual
than other behaviours that once had a greater value.
- A central descriptive characteristic of the dependence syndrome is the
strong desire to take drugs or alcohol.
Diagnosis:
- A definite diagnosis should be made if three or more of the following have
been present together over the past 12 months:
1. A strong desire or sense of compulsion to use drug or alcohol.
2. Experience of withdrawal symptoms when stopping or reducing the
substance use.
3. Evidence of tolerance such as the necessity to increase the dose of the
substance in order to achieve the same effects originally produced by lower
doses.
4. Progressive neglect of other pleasures because of substance use.
5. Persistent use of substance despite the clear evidence of its harmful
effects.
Assessment of drug/alcohol dependency
- Good assessment for dependency requires a trained competent clinician.
- An empathetic non-judgmental approach should be used when addressing
the patient.
- The full assessment may take several consultations and the patient may
present at a time of a crises so an exhaustive long initial assessment is not
advised, as the patient may not engage, however, enough information
should be obtained in the initial consultation to assess the presenting
problems safely.
History to assess current drug/alcohol use:
1. Types of drugs/alcohol.
2. Quantity and frequency of use.
3. Route of administration of the drug.
4. Symptoms of dependence.
5. Source of drug and preparation method.
6. Prescribed medications.
7. Tobacco use.
Assessment of risk:
1. Risk of overdose.
2. Polydrug and alcohol misuse.
3. Unsafe injecting practice.
4. Unsafe sexual practice.
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5. Self-harm or harm to others.
6. Risks to children:
- Children ages and level of contact.
- Effect of drug on parent's functioning.
- Effect of drug seeking on children such as being left unsupervised.
- Funding of drug use and its effect on family income.
- Does dependency affect their parenting and support?
- Effect on family routines.
- Are the drugs stored safely?
NOTE: Local child protection procedures should be followed if there is a
risk to children.
Assessment of social functioning:
1. Partners, family and support.
2. Housing.
3. Education.
4. Employment.
5. Domestic violence.
6. Financial problems and benefits.
7. Childcare issues.
Assessment of criminal involvement and offending:
1. Arrests, warrants and charges.
2. Probation.
3. Imprisonment.
4. Violent offences and criminal activity.
5. Fines.
Assessment of physical and psychological health:
1. Presenting symptoms.
2. Past medical history.
3. Psychiatric history.
4. Drug related complications such as abscesses, venous thromboses,
septicemia or endocarditis.
5. History of accidental overdose.
6. Current or past infection with a blood borne virus.
7. In women, cervical screening, menstrual and pregnancy history.
8. Sexual history.
9. Oral health.
10. Current medications.
11. Allergies and sensitivities.
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PSYCHIATRY 4 – ALCOHOL DEPENDANCE
HOW TO APPROACH
In some scenarios, patient doesn’t know that you are going to talk to them about their alcohol habit. So it is important
to first explain, why you are planning to talk about their drinking habit.
For example, in one of the scenarios, patient was admitted in the hospital due to abdominal pain. Endoscopy has been
and suggests gastric erosion. All medical causes of gastric erosions have been ruled out. The medical team believes
the reason for patient’s problem is alcohol habit. So the patient has been referred to you to discuss about the matter.
In this case, you may start:
“As you know, you have been admitted to the hospital because of your tummy pain. The camera test showed that you
have bleeding in your gut, which is called gastric erosion. I am here to talk to you to find out the cause of bleeding in
your gut. There are many possible causes for your problem. One of them is alcohol. So if you don’t mind, I am going to
talk to you about your alcohol habit. “
Elaboration
5 General Questions for Alcohol
1. Do you drink alcohol?
2. What do you drink?
3. How much do you drink?
4. How often do you drink?
5. How long have you been drinking?
Special Questions
CAGE
A well-validated technique used to assess whether a person has an alcohol misuse is known as “CAGE”, which makes
use of 4 questions:
1. Cut-down: Have you ever felt you need to Cut-down on your drinking?
2. Annoyance: Have people Annoyed you by criticising your drinking?
3. Guilt: Have you ever felt Guilty about drinking?
4. Eye-opener: Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves
or get rid of a hangover?
NOTE: Answering yes to 2 or more questions may indicate that patient has an alcohol problem.
DWT
1. Dependancy: Are you able to do you day-to-day task without drinking alcohol?
2. Withdrawal symptoms: Do you experience any symptoms if you don’t drink alcohol?
3. Tolerance: Do you need to increase the amount of alcohol in order to get the same feeling as you had before?
PSYCHTRIC ASSESSMENT (selectively)

1. Mood
2. Insight
3. 4 F’s: Family, Friends, Finances, Forensics
4. Mental and Medical Background
If necessary, you need to do a complete psychiatric assessment .
MANAGEMENT OF ALCOHOL ABUSE

Different types of treatment options are available for people with alcohol abuse. These include both medical and non-
medical therapies. The choice depends on the extent of drinking and the symptoms of withdrawal.
Non-Medical Treatment
1. Brief intervention
It is the initial measure for those patients who are willing to give up on drinking or had alcohol related accident. The
session is about 5 to 10 minutes and covers the risks associated with drinking according to your habits, advice about
measures to reduce drinking and advice about social help while attempting to quit.
2. Self help group
Alcoholic Anonymous (AA) is one of such groups which has a 12 step programme designed to help everyone quit. The
initial step involves realizing the problems and accepting that a solution is required for it.
3. Twelve step facilitation therapy
It uses the same steps as devised by AA but instead of a group the patient talks one to one with a counselor.
4. Cognitive Behavioral Therapy
CBT is a talking therapy with a problem solving approach towards alcohol dependence. It involves identifying the
beliefs that may be causing hindrance in quitting alcohol for example thought lie I will not be able to work without
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alcohol. It then helps to set motivational goals. CBT therapist also identifies and helps to avoid or eliminate triggers
for alcohol drinking.
5. Family Therapy
Family support to the patient immensely impacts the efficacy of treatment. The family members are counseled about
the problem and the approach towards it.
6. Drinking Diary
Recording your alcohol intake in a diary regularly will help to show you and your therapist how well you are doing
and how soon will you reach the target.
Medical Treatment
The medications recommended by NICE to treat alcohol abuse are as follows.
1. Acamprosate
2. Disulfiram
3. Naltrexone
4. Nalmefene
Acamprosate (Calcium Acetyl–homotaurine)

The drug helps to reduce alcohol cravings and is most effective when combined with conseling and other therapies
for abstinence. It blocks GABA and reduces N-methyl-D-aspartate (NMDA) receptor glutamate related excitation. It is
prescribed for six months usually.
Disulfiram
This drug is usually given to people who have a history of relapses or who have a high risk of relapse. It reacts with
alcohol to cause a very unpleasant reaction so that you may not want to drink again. You may feel nausea, vomiting,
chest discomfort and dizziness.
If you are using this drug it is important to stay away from all alcohol-based products like after shaves, perfumes or
soaps. The unpleasant symptoms may continue a week after stopping disulfiram. The prescription of disulfiram is
followed up every two weeks in the first two months and then every month for the following 4 months.
Naltrexone
It antagonizes the pleasant effects of alcohol by blocking the opioid receptors where endogenous opioids released by
alcohol act. It is used to prevent relapses or reduce the amount of drinking. The opioids drugs like morphine and
codeine used for pain relief may not act if you are taking this drug.
Nalmefene
It is a newer agent and works in the same way as naltrexone. It may be recommended if:
- Patient is still drinking more than 7.5 unit a day (men) or more than 5 units a day (women)
- You do not have physical withdrawal symptoms
- You need to reduce your drinking and not stop immediately
The drug should only be prescribed in conjunction with continuous psychosocial support.
NOTE:
Detoxification is needed if the patent takes more than 15 units a day.
Patient should be admitted if:

- There is a risk of suicide
- There is no social support with the patient
- History of severe withdrawal symptoms
Treatment of acute withdrawal:
1. The patient should be admitted and nursed in a quiet and calm surrounding
2. Long acting drugs like diazepam or cholrdiazepoxide are used to reduce withdrawal symptoms like agitation and
tremors. The clinician should keep in mind dependence on benzodiazepines and short courses only where extremely
necessary should be advised.
3. IV vitamin B complex is given for the initial couple of days and later oral thiamine is used.
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PSYCHATRY 5-DRUG DEPENDANCY METHADONE
Heroin addiction:
Addiction to or dependence on heroin can cause withdrawal symptoms within a day or so of the last dose. Therefore,
if one is addicted to heroin, they need a regular dose to feel “normal”.
Withdrawal symptoms can include:

- Sweating
- Feeling hot and cold
- Runny eyes and nose
- Yawning
- Being off food
- Stomach cramps
- Feeling sick (nausea) or being sick (vomiting)
- Diarrhoea
- Tremor
- Poor sleep
- Restlessness
- General aches and pains
- Just feeling awful
Withdrawal symptoms tend to ease and go within 5 days. However, patients may then have persistent craving for
heroin, remain tired and have poor sleep for quite some time afterwards.
Methadone:
- Methadone is a drug that is similar to heroin, although it lasts a lot longer in the body.
- Methadone can be prescribed and is in liquid form.
- It is used to prevent or decrease the severity of heroin withdrawal symptoms. It stays For a long time in the body
and it can help users:
1. Stop using heroin
2. Improve physical health and nutrition
3. Have more stable relationships with family and friends
4. Stop injecting
5. Stop committing crimes to get money for drugs
- Switching from heroin to methadone allows you to access:

1. Counselling
2. Medical care
3. Education
4. Training
5. Recovery programmes
Who prescribes methadone, and when?

1. Typical Care Plan
1. A nurse or drugs worker will briefly assess the patient and agree the next stage with them. This could be an
appointment for a fuller assessment with your GP or community drug team.
2. Most GPs will refer you to a community drug team to be assessed.
Note: Some GPs who are specially trained may assess some cases and prescribe without the need for referral.
3. Following assessment, a member of the community drug team will usually contact your GP to recommend a dose of
methadone and a plan for follow-up.
2. Assessment:
What happens in Assessment?
This usually includes:
1. Taking details of patient’s health.
2. Taking details of patient’s social circumstances.
3. Taking details of patient’s past and current drug taking.
4. Assessing whether methadone is needed or appropriate.
5. A physical examination.
6. A urine test (or a mouth swab test) to confirm the drugs that patient is taking.
7. An assessment of what patient thinks he needs at this present time.
8. Agreeing on a care plan and set goals to achieve.
9. Supporting and encouraging patients to share information with their family and friends.
If patient has been injecting drugs such as heroin, it is also common to advise:
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1. A blood test which includes testing for HIV, Liver function tests and checking for Hepatitis A, B and C.
2. Immunization against Hepatitis A, Hepatitis B and tetanus (if not previously immunised)
3. If appropriate, immunisation against Hepatitis B for their partner and children.
It is also advisable to give patient information/advise about:

4. Safer injection and the dangers of injecting.
2. The dangers of using shared needles and syringes.
3. The other ways to reduce harm to the patient.
Past Medical History:

Before prescribing methadone, details of patient’s health must be taken. These include:
1. Medical Conditions:
1. Allergy to methadone
2. Heart problems
3. Kidney problems
4. Liver problems
5. Epilepsy/fits
6. Head injury
7. Breathing problems
8. Bowel problems
9. Alcohol problems
10. Thyroid problems
11. Prostate problems
2. Medications:
1. Antidepressants
2. Antibiotics
3. Strong painkillers
4. Medicines for drug misuse
3. Pregnancy
4. Breastfeeding
Starting off with methadone:

- Methadone is usually started sometime after assessment when the results of the urine tests are back.
- The aim is to prevent withdrawal symptoms. However, methadone overdose can cause serious harm, or death.
- So, at first the doctor will prescribe a fairly low dose to ‘play safe’ (Initial dose usually 30ml/day).
- Patient will then be seen frequently to adjust the dose.
- The initial dose is usually gradually increased to a regular maintenance dose (Up to 60-120ml/day).
Note: Patients may have some, or partial, withdrawal symptoms until the correct dose is found.
Note: Patient may be asked to have an ECG if they need a high dose of methadone (100mg).
Time Methadone takes to act:

1. Methadone takes 2-4 hours to reach its peak effect in the blood and its effects last for about 25 hours. However, the
time it takes to produce its maximum effect can vary from person to person.
2. Methadone accumulates in the body. So, patients will feel a greater effect of the drug over a few days even without
increasing the dose.
3. Usually the first prescription will increase the dose of methadone every three or four days until the dose is reached
that the doctor feels should be right for the patient.
4. It may take a few weeks to get to the correct dose, which prevents all withdrawal symptoms.
How to take methadone:
1. It is best to take methadone at about the same time each day.

2. It is best to rinse the mouth with water afterwards as this will help to cut down on tooth decay.
3. Methadone can be taken with or without food.
4. Not more than the prescribed dose should be taken.
The correct dose of methadone:

1. varies from person to person. Some may only need 30ml of methadone, but most will need a dose of between 60
and 120ml daily.
2. depends on:
a. How much heroin they were using.
b. How their body deals (metabolises) with the methadone.
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The ideal dose will:
1. Stop patient suffering withdrawals.
2. Allow patient to stop using other drugs.
3. Not make patient too drowsy.
Maintenance and coming off (detox):

- Once established on a regular dose, most people stay on Methadone for a long time or even long-term. This is called
maintenance and helps patients to keep off street drugs.
- Some people gradually reduce the dose of methadone and come off it. This is called detoxification, or ‘detox’.
- The doctor will reduce the dose gradually in order to avoid withdrawal symptoms.
- However, it usually takes months and sometimes years before most people are ready to consider ‘detox’.
- It is often safer to stay on methadone than to ‘detox’ before patient is ready.
Taking methadone:
Supervised Consumption:
- Methadone is usually prescribed as a once-daily dose in liquid form.
- Patient will usually be asked to take it under the supervision of the pharmacist who dispenses the methadone to
them.
- Patients should take their dose in a private area in the pharmacy and rinse their mouth with water afterwards.
- This supervision can be relaxed, if patient is stable, after a few months (12 weeks) of them taking a regular
maintenance dose.
Advantages of supervised consumption:

1. Attending a pharmacy daily for supervised consumption of methadone can help the patients’ recovery and reduce
the risk of overdose.
2. This means there can be no doubt about how much methadone they take at each dose.
3. It provides structure and routine and gives patients daily access to medical support.
Until when one should attend a pharmacy for supervised consumption?

- As patient becomes more stable, they may be able to take home some dose.
- The doctor or drug worker will consider someone to be stable when they:
1. Attend their appointments.
2. Take all their doses of methadone.
3. Do not take other drugs that have not been prescribed.
4. Are not drinking heavily.
5. They will also have to consider if patient is able to store methadone safely and if any children might have access to
it.
Note: If their recovery suffers a setback, they may have to return to supervised consumption. This is to give support
to regain stability.
Missing Dose:
- It is essential to take the methadone regularly.
Tolerance:
- If patient misses three or more daily doses, their body may lose its ability to break down the drug (tolerance).
- They can still continue with the withdrawal programme but they may need to start again with a lower dose.
- If this happens, the pharmacist will contact patient’s doctor or drug worker before giving him another dose. The
dose may be reduced for a few days before increasing slowly to the previous dose.
Support, Care and Review:

Patient is more likely to succeed in staying off heroin if they have support and counselling during this difficult time.
This may be from:
1. A local drug community team.
2. Self help or voluntary groups or other agencies may also be of help.
3. Family and friends.
4. Keyworker:
- Patients will have a keyworker who will see them regularly to talk about how things are going and help them make
plans for the future.
- Keyworker may suggest that patient needs extra help from another service and will help them sort this out.
- Patients will also have the chance to look at their progress at regular intervals.
- Keyworker will see patients less frequently as time goes by if all is going well.
Follow-up:
Patient will be asked to give a urine sample from time to time by their doctor.
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Contraindications:
1. Some prescribed medicines may interfere with methadone:
For example, some medications used to treat tuberculosis and epilepsy. However, most medicines can be taken in the
normal way.
2. Other street drugs:
Such as benzodiazepines (‘benzos’) are very dangerous to be mixed with methadone. There is a danger of overdose.
So, it’s better not to take any other drugs.
3. Alcohol:
Alcohol can affect methadone. So, it’s better not to take too much alcohol.
Warning Signs:
1. Overdose:
If patient feels drowsy in the first day or so of treatment, there is a risk of overdose.
2. Driving:
If one uses heroin, methadone or similar drugs, they should tell the DVLA and complete form DG1. They are likely to
be banned from driving.
However, if they are on a supervised methadone programme, they may be allowed to drive again subject to an annual
medical review.
3. Safe storage of take-home doses:
Patient must keep methadone and any other drugs out of reach of children.
If patient lives with young children, we will talk to them about how to store their methadone safely so there are no
risks to them.
4. See you doctor as soon as possible if you develop problems which may need urgent attention:
- Allergic reaction like itching, rash, swelling, breathing difficulties
- Seeing, hearing or feeling things that are not there
- Changes in your mood
- Itching and flushing of skin
- Difficulty passing urine
- Sexual problems, breast and period problems
- Chest pain, changes in your heart beat
- Shallow slow breathing, shortness of breath
Side effect of methadone:

Common:
- Constipation
- Dry mouth, eyes and nose
- Difficulty in passing urine
Less common:
- Sweating
- Itching and/or flushing of the skin
- Nausea
- Mood change and/or levelling of emotions
- Reduced energy and/or drowsiness or sleep
- Slower, shallower breathing
- Reduced or absent menstrual periods
- Reduced sexual drive
Rare:
1. Heart problems (Arrhythmias):
Heart problems have been reported in those taking high dose methadone (100mg) and taking some other drugs.
2. Overdose:
Overdose can be fatal, especially in the early days of treatment, in non-opiate users and in children.
Note: Methadone does not cause bone pain or dental decay, but you may become more aware of pain when you are
not using heroin.
Overdose:
Being in treatment and methadone reduces the risk of overdose, but risk of overdose greatly increases if patient:
1. Takes other drugs and/or alcohol
2. Misses doses of methadone (Especially at the start of treatment, or if patient misses three or more doses and
doesn’t inform their doctor).
3. Detoxes without support to prevent relapse.
Note: Patients can prevent this from happening by going to an overdose prevention training session with a friend or
family member.
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Paracetamol Overdose:
Toxic dose of paracetamol may cause severe hepatocellular necrosis and renal tubular necrosis.
Symptoms of paracetamol overdose:

1. Nausea and vomiting are the earlier features of paracetamol poisoning and usually settle
within 24 hours.
2. Right subcostal pain and tenderness usually indicates hepatic necrosis.
3. Yellowing of the skin and eyes (jaundice)
4. Loss of co-ordination
5. Encephalopathy
6. Haemorrhage.
7. Hypoglycaemia.
8. Cerebral oedema.
Liver damage is maximal after 3-4 days after paracetmol overdose. Despite a lack of significant
early symptoms, patients who have taken an overdose of paracetamol should be transferred to
the hospital immediately.
N acetyl cysteine (NAC) protects the liver if infused up to and possibly beyond 24 hours of
ingesting paracetamol. It is most effective if given within 8 hours of ingestion, after which
effectiveness declines.
Acute overdose:
Hepatotoxicity may occur after a single ingestion of more than 150 mg/kg paracetamol taken in
less than an hour. Rarely hepatotoxicity may develop with single ingestion as low as 75 mg/kg
of paracetamol taken in less than one hour. Patients who have ingested 75 mg/kg or more of
paracetamol in less than 1 hour should be referred to the hospital.
Administration of activated charcoal should be considered if paracetamol in excess of 150
mg/kg is thought to have been ingested within the previous hour.
Patients at risk of liver damage and therefore, requiring N acetyl cysteine can be identified from
a single measurement of the plasma paracetamol concentration related to the time from the
ingestion provided this time interval is not less than 4 hours, earlier sample may be misleading.
The concentration is plotted on a paracetamol treatment graph with a reference line.
N acetyl cysteine should commence immediately in patients:

1. Whose plasma paracetamol concentration falls on or above the treatment line on the
paracetamol treatment graph.
2. Who present 8-24 hours taking an acute overdose of more than 150 mg/kg of paracetamol,
even if the plasma paracetamol concentration is not yet available.
N acetyl cysteine can be discontinued if the plasma paracetamol concentration is later reported
to be below the treatment line on the paracetamol treatment graph provided that the patient is
asymptomatic and liver function tests, serum creatinine and INR are normal.
The prognostic accuracy of a plasma paracetamol concentration taken after 15 hours is

uncertain. But a concentration on or above the treatment line on the paracetamol graph should
be regarded as carrying a serious risk of liver damage. If more than 15 hours have elapsed since
ingestion, or there is doubt about appropriate management advice should be sought from the
national poisons information service.
Staggered overdose, uncertain time of overdose:
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A staggered dose involves ingestion of a potentially toxic dose of paracetamol over more than an
hour.
The paracetamol treatment is unreliable if a staggered overdose is taken, if there is uncertainty
about the time of the overdose or if there is therapeutic excess. In these cases patients who have
taken more than 150mg/kg of paracetamol in any 24 hours period are at risk of toxicity and
should be commenced on N acetyl cysteine immediately, unless it is more than 24 hours since
the last ingestion and the patient is asymptomatic, the plasma paracetamol concentration is
undetectable and liver function test, serum creatinine and INR are normal.
Rarely toxicity can occur with paracetamol doses between 75-150 mg/kg in any 24 hours
period, clinical judgement of the individual case is necessary to determine whether to treat
those who have ingested this amount of paracetamol. For small adults, this may be within the
licenced dose, but ingestion of a licenced dose of paracetamol is not considered an overdose.
Significant toxicity is unlikely if, 24 hours or longer after the last paracetamol ingestion, the
patient is asymptomatic, the plasma paracetamol concentration is undetectable, and liver
function test, serum creatinine and INR are normal.
Patients with clinical features of hepatic injury such as jaundice or hepatic tenderness should be
treated urgently with N acetyl cysteine.
If there is uncertainty about a patient risk of toxicity after paracetamol overdose, treatment
with N acetyl cysteine should be commenced.
Advice should be sought from the national poisons information service wherever necessary.
Acetyl cysteine dose and administration:

For paracetamol overdose N acetyl cysteine is given in a total dose that is divided into 3
consecutive intravenous infusions over a total of 21 hours. The required dose of N acetyl
cysteine is added to glucose intravenous infusion 5%.
First infusion (Based on acetyl cysteine dose of approx. 150mg/kg) add require volume of acetyl
cysteine concentration for intravenous infusion to 200 ml Glucose intravenous infusion 5%
infuse over 1 hour.
Second infusion (Based on acetyl cysteine dose of approx. 50mg/kg start immediately after the
completion of the first one) add require volume of acetyl cysteine concentration for intravenous
infusion to 500 ml Glucose intravenous infusion 5% infuse over 4 hour.
Third infusion (Based on acetyl cysteine dose of approx.. 100mg/kg start immediately after the
completion of the second one) add require volume of acetyl cysteine concentration for
intravenous infusion to 1 lt Glucose intravenous infusion 5% infuse over 16 hours.
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TM 7 PSYCH-Diagnosis, Treatment, and Complications of Anorexia Nervosa
Diagnosis
History:
When trying to determine whether you have an eating disorder, your GP will probably ask questions
about your weight and eating habits.
For example, they may ask:
- if you've lost a lot of weight recently
- how you feel about your weight and whether you're concerned about it
- If you make yourself vomit regularly
- whether your periods have stopped and, if so, for how long
- If you think you have an eating problem
It's important to answer these questions honestly. Your GP isn't trying to judge you or catch you
out – they just need to accurately assess your condition.
Examination:
1.Weight and BMI:
Your GP will usually check your weight. The weight of a person with anorexia nervosa is at least 15%
below average for their age, sex and height.
Your GP may also calculate your body mass index (BMI). For adults, a healthy BMI is 18.5 to 24.9,
although sometimes doctors may be concerned if a person's BMI is below 20. Adults with anorexia
generally have a BMI below 17.5.
2.Other tests:
Your GP may not need to carry out any tests to diagnose anorexia nervosa, but they may check your
pulse and blood pressure, take your temperature, and examine your hands and feet to see whether
you have signs of any complications of anorexia.
3.Physical exercises:
Your GP may also ask you to carry out some simple physical exercises, such as moving between
sitting, squatting and standing, to assess your muscle strength.
Investigations:
1.ECG:
If you have anorexia, you have a higher risk of developing some heart conditions, such as an
irregular heartbeat (arrhythmia) Sometimes an ECG may be needed.
2.Blood tests:
Your GP may also carry out blood tests to check your general health and the levels of chemicals or
minerals such as potassium.
Referral to a specialist:
If your GP thinks you may have anorexia, they may refer you to a specialist in eating disorders for a
more detailed assessment and treatment, although they will sometimes carry out this assessment
themselves.
NOTE:
Sometimes it is necessary to rule out other causes of weight loss, such as diabetes, thyroid problems
or some other medical cause before a diagnosis of anorexia nervosa can be confirmed.
Treatment:
Before anorexia can be treated, a physical, psychological and social needs assessment will need to be
carried out by a GP or an eating disorders specialist. This will help them work out a suitable care
plan.
In most cases, treatment will involve a combination of psychological therapy and individually
tailored advice on eating and nutrition to help gain weight safely.
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The treatment for anorexia nervosa usually involves a combination of psychological therapy and
supervised weight gain.
It's important for a person with anorexia to start treatment as early as possible to reduce the risk of
serious complications of anorexia, particularly if they've already lost a lot of weight.
The treatment plan:

GPs are often closely involved in ongoing treatment, although other healthcare professionals are
usually involved, including:
- specialist counsellors
- psychiatrists
- psychologists
- specialist nurses
- dieticians
- paediatricians in cases affecting children and teenagers
Before treatment starts, members of this multidisciplinary care team will carry out a
detailed physical, psychological and social needs assessment, and will develop a care plan.
Most people with anorexia are treated as an outpatient, which means they visit hospitals, specialist
centres or individual members of their care team for appointments, but return home in between.
In more severe cases, a person may need to stay in hospital or a specialist centre for longer periods
during the day (day patient), or they may need to be admitted as an inpatient.
1.Psychological treatment:
A number of different psychological treatments can be used to treat anorexia. Depending on the
severity of the condition, treatment will last for at least 6 to 12 months or more.
A) Cognitive analytic therapy (CAT):

Cognitive analytic therapy (CAT) is based on the theory that mental health conditions such as
anorexia are caused by unhealthy patterns of behaviour and thinking developed in the past, usually
during childhood.
CAT involves a three-stage process:
- reformulation – looking at past events that may explain why the unhealthy patterns
developed
- recognition – helping people see how these patterns are contributing towards the anorexia
- revision – identifying changes that can break these unhealthy patterns
B) Cognitive behavioural therapy (CBT):

Cognitive behavioural therapy (CBT) is based on the theory that how we think about a situation
affects how we act and, in turn, our actions can affect how we think and feel.
In terms of anorexia, the therapist will attempt to show how the condition is often associated with
unhealthy and unrealistic thoughts and beliefs about food and diet.
The therapist will encourage the adoption of healthier, more realistic ways of thinking that should
lead to more positive behaviour.
C) Interpersonal therapy (IPT):

Interpersonal therapy (IPT) is based on the theory that relationships with other people and the
outside world in general have a powerful effect on mental health.
Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt caused by
problems interacting with people.
During IPT, the therapist will explore negative issues associated with your interpersonal
relationships and how these issues can be resolved.
D) Focal psychodynamic therapy (FPT):

Focal psychodynamic therapy (FPT) is based on the theory that mental health conditions may be
associated with unresolved conflicts that occurred in the past, usually during childhood.
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The therapy encourages people with anorexia to think about how early childhood experiences may
have affected them. The aim is to find more successful ways of coping with stressful situations and
negative thoughts and emotions.
E) Family interventions:
Anorexia doesn't just impact on one individual – it can have a big impact on the whole family. Family
intervention is an important part of treatment for young people with anorexia.
Family intervention should focus on the eating disorder, and involves the family discussing how
anorexia has affected them. It can also help the family understand the condition and how they can
help.
2.Gaining weight safely:

The care plan will include advice about how to increase the amount eaten so weight is gained safely.
Physical health – as well as weight – is monitored closely.
The height of children and young people will also be regularly checked to make sure they're
developing as expected.
To begin with, the person will be given small amounts of food to eat, with the amount gradually
increasing as their body gets used to dealing with normal amounts.
The eventual aim is to have a regular eating pattern, with three meals a day, possibly with vitamin
and mineral supplements.
An outpatient target is an average gain of 0.5kg (1.1lbs) a week. In a specialist unit, the aim will
usually be to gain an average of around 0.5-1kg (1.1-2.2lbs) a week.
3.Compulsory treatment:
Occasionally, someone with anorexia may refuse treatment even though they're severely ill and their
life is at risk.
In these cases, as a last resort doctors may decide to admit the person to hospital for compulsory
treatment under the Mental Health Act. This is sometimes known as sectioning or being sectioned.
4.Treating additional problems:

As well as the main treatments mentioned above, other health problems caused by anorexia will also
need to be treated:
-If you make yourself vomit regularly, you'll be given dental hygiene advice to help prevent stomach
acid damaging the enamel on your teeth.
For example, you may be advised not to brush your teeth soon after vomiting to avoid further
abrasion to tooth enamel, and to rinse out your mouth with water instead.
Avoiding acidic foods and mouth washes may be recommended. You'll also be advised to visit a
dentist regularly so they can check for any problems.
-If you've been taking laxatives or diuretics in an attempt to lose weight, you'll be advised to reduce
them gradually so your body can adjust. Stopping them suddenly can cause problems such as nausea
and constipation.
5.Medication:
Medication alone isn't usually effective in treating anorexia. It's often only used in combination with
the measures mentioned above to treat associated psychological problems, such as obsessive
compulsive disorder or depression.
Two of the main types of medication used to treat people with anorexia are:
1. Selective serotonin reputake inhibitors (SSRIs) – a type of antidepressant medication that

can help people with co-existing psychological problems such as depression and anxiety.
2. olanzapine – a medication that can help reduce feelings of anxiety related to issues such as
weight and diet in people who haven't responded to other treatments
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SSRIs tend to be avoided until a person with anorexia has started to gain weight because the risk of
more serious side effects is increased in people who are severely underweight. The drugs are only
used cautiously in young people under the age of 18.
Help and support:

If you have an eating disorder or know someone who does, you may find it useful to contact a
support group.
Outlook:
It can take several years of treatment to fully recover from anorexia, and relapses are common. For
example, a woman may relapse if she tries to lose weight gained during pregnancy.
Around half of people with anorexia will continue to have some level of eating problem despite
treatment.
If anorexia remains unsuccessfully treated for a long time, a number of other serious problems can
develop. These can include fragile bones (osteoporosis), infertility, an irregular heartbeat, and other
heart problems.
Despite being an uncommon condition, anorexia is one of the leading causes of mental health-related
deaths. This can be because of the effects of malnutrition or as a result of suicide.
Complications:
If anorexia nervosa isn't treated, it can lead to a number of serious health problems.
In some cases, the condition can even be fatal.
Other health problems

Long-term anorexia can lead to severe complications and health problems, often as a result
of malnutrition. Some complications may improve as the condition is treated, but others can be
permanent.
Health problems associated with anorexia include:
- problems with muscles and bones – including weakness, fragile bones osteoporosis and
problems with physical development in children and young adults
- sexual problems – including absent periods and infertility in women, and loss of sex
drive and erectile dysfunction in men
- problems with the heart and blood vessels – including poor circulation, an irregular
heartbeat, low blood pressure, heart valve disease, heart failure and swelling in the feet,
hands or face (oedema).
- problems with the brain and nerves – including fits (seizures) and difficulties with
concentration and memory
- other problems – kidney damage, liver damage, anaemia and low
blood sugar (hypoglycemia).
NOTE: Some people with anorexia develop another eating disorder called bulimia nervosa. This
is where a person binge eats and then immediately makes themselves sick, or uses laxatives to rid
their body of the food.
Pregnancy complication:
If you have anorexia and are pregnant, you'll need to be closely monitored during pregnancy and
after you've given birth.
Anorexia during pregnancy can increase the risk of problems such as:
- miscarriage
- giving birth early (premature birth)
- having a baby with a low birth weight
- needing a caesarean section
You're also likely to need extra care and support during pregnancy if you previously had anorexia
and recovered from it.
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OBG 1 PRE-ECLAMPSIA
Pre-eclampsia:
- Is defined as pregnancy-induced hypertension in association with proteinuria (>0.3 g in 24 hours) with or without oedema,
usually during the second half of pregnancy (from around 20 weeks) or soon after the baby is delivered.
- Pre-eclampsia can range from mild to moderate. Mild pre-eclampsia is common, and affects up to one first-time mum-to-be
in 10. Severe pre-eclampsia is, thankfully, much less common.
Aetiology:
- The aetiology and pathogenesis of pre-eclampsia still remain poorly understood.
- It is characterised by suboptimal utero-placental perfusion associated with a maternal inflammatory response and
maternal vascular endothelial dysfunction. This in turn leads to vascular hyperpermeability, thrombophilia and
hypertension, which may compensate for the reduced flow in the uterine arteries.
To patient: Pre-eclampsia means your blood pressure is high and you have an abnormal amount of protein in your urine.
It is thought to happen when the afterbirth (placenta) isn’t working properly. Pre-eclampsia causes the flow of blood
through the afterbirth (placenta) to be reduced (It’s thought that the blood vessels in the placenta do not develop properly).
This means that your baby won’t get enough oxygen and nutrients, which may restrict his growth. This condition can make
you and your baby quite ill if you don’t receive the treatment you need. Early monitoring and treatment will help to keep you
and your baby well.
Pre-eclampsia can be treated. So it's important that you go to all your antenatal appointments, so it can be picked up and
managed as early as possible.
Presentation:
Pre-eclampsia is defined by systolic BP >140 mm Hg or diastolic BP >90 mm Hg in the second half of pregnancy, with ≥1+
proteinuria on reagent stick testing.
Symptoms:
- Severe headache – Usually frontal
- Sudden swelling of face, hands or feet
- Liver tenderness
- Visual disturbance (e.g. blurring or flashing lights in front of the eyes)
- Severe pain just below the ribs
- Heartburn that doesn’t go away with antacids
- Vomiting
- Feeling generally unwell
- Fetal distress – Reduced fetal movements
Signs:
- Platelet count falling to below 100 x 109/L (a falling platelet count predicts severe disease and these women need urgent
referral and further investigation).
- Abnormal liver enzymes (ALT or AST rising to above 70 IU/L).
- Clonus.
- HELLP syndrome: Haemolysis, Elevated Liver enzymes, Low Platelets.
- Papilloedema.
- Small for gestational age infant.
Risk Factors:
1. Moderate Risk factors:
The following features put a woman at moderate risk of developing pre-eclampsia:
- 10 years or more since the last pregnancy.
- First pregnancy.
- Age 40 years or more.
- Body mass index (BMI) of 35 or more at presentation (You were obese before you were pregnant, with a body mass index
(BMI) of 35 or more at the start of your pregnancy).
- Family history of pre-eclampsia (in mother or sister).
- Multiple pregnancy (You are expecting twins or triplets).
Note: If two or more of these apply to you, your doctor will recommend that you take a daily low dose of aspirin from 12
weeks of pregnancy. You will be offered cardiotocograph (CTG) monitoring after 26 weeks of pregnancy if your midwife is
concerned about your baby's wellbeing.
2. High Risk factors:

Women with the following conditions are at the highest risk of developing pre-eclampsia:
a. Pre-eclampsia, eclampsia or hypertension in any previous pregnancy (About one in six gets pre-eclampsia again).
b. Certain underlying medical conditions:

- Pre-existing hypertension.
- Pre-existing chronic kidney disease.
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- Pre-existing diabetes mellitus (type 1 and type 2).
- Certain autoimmune disease (eg, systemic lupus erythematosus (SLE) or antiphospholipid syndrome).
c. Research suggests that donor-egg pregnancies are also at high risk of developing pre-eclampsia. If this applies to you, talk
to your midwife or doctor about your options for extra appointments.
Note: If any of these apply to you, your midwife will recommend that you take a daily low dose of aspirin (75 mg) from 12
weeks of pregnancy. You may also be offered extra antenatal appointments to check your baby's growth.
Referral:
Women should be admitted if they have:
- Raised BP (≥ 140/90 mm Hg) with proteinuria ≥+1.
- Systolic BP ≥160 mm Hg.
- Diastolic BP ≥100 mm Hg.
- Any clinical symptoms or signs of pre-eclampsia.
Complications:
- If pre-eclampsia goes from mild to severe, it starts to affect other systems of your body as it worsens. This means you may
get more serious symptoms as the condition sets in, and you may need to go to intensive care or a maternity high
dependency unit.
- If you have pre-eclampsia but remain undiagnosed, you won't get the right care. This may result in the following serious
complications:
1. Eclampsia:
Pre-eclampsia can progress to eclampsia with epileptic fits and sometimes other neurological symptoms, including focal
motor deficits and cortical blindness.
This is a rare but serious condition that happens when the membranes of your brain (cerebral membranes) become
irritated. It can lead to seizures or convulsions and can put both you and your baby at great risk.
Eclampsia can develop during pregnancy and birth. It can also happen in the weeks after your baby is born, particularly in
the first few days, and especially if your pre-eclampsia was severe.
2. HELLP syndrome:
This is a rare liver and blood-clotting disorder that can develop before pre-eclampsia has been diagnosed. HELLP stands for:
H: haemolysis, which means the breaking down of red blood cells.
EL: elevated liver enzymes, which is a sign that your liver is not working properly.
LP: low platelet count, which means you may not have enough platelets to help your blood to clot.
HELLP is most likely to develop after the birth. However, it can sometimes develop from mid-pregnancy onwards, or in rare
cases, even earlier.
3. Other complications:
These can include:
- Liver and kidney failure
- Haemolysis
- Disseminated intravascular coagulation
- Stroke (cerebral haemorrhage)
- Adult respiratory distress syndrome
- Fluid in the lungs (pulmonary oedema)
- Blind patches
Management:
- Patients can usually be managed conservatively (i.e. without delivery of the baby) until at least 34 weeks, as long as they
are haemodynamically stable, without coagulation abnormalities and in the absence of HELLP.
- The only complete cure for pre-eclampsia is to deliver the baby. At delivery the placenta is also delivered.
Offer women with pre-eclampsia an integrated package of care covering:

- Admission to hospital
- Treatment to control potentially dangerous hypertension
- Measurement of blood pressure
- Testing for proteinuria (Urinalysis)
- Blood tests to monitor biochemical markers
- Plan for a safe delivery
Depending on severity, pre-eclampsia can be managed as:

- An in-patient on the antenatal ward
- An emergency on the labour ward
1. Examination:
On examination a pregnant woman, the doctor will be looking at the following:
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- What the woman is saying: How she feels, whether she has a headache, visual disturbance or any vaginal bleeding
suggestive of placental abruption.
- Blood pressure, pulse, result of urine analysis
- Respiratory system: Fine inspiratory crepitations which may indicate pulmonary oedema
- Abdominal examination: Right upper quadrant pain or epigastric tenderness, symphysis-fundal height, fetal
presentation, liquor volume and fetal heart beat
- Neurological examination: Pre-eclamptic women can have brisker than usual reflexes
2. Investigations:
For the mother:
A. Urine:
- Urine dipstick to look for protein (an automated reading is more accurate)
- Protein: Creatinine ratio or 24-hour urine collection to quantify the amount of protein in the urine and creatinine clearance
- Urinalysis: send for microscopy, culture and sensitivities if proteinuria is present.
Interpretation of the urine tests:

Protein: creatinine ratio:
Diagnose significant proteinuria if the urinary protein: creatinine ratio is greater than 30 mg/mmol
Validated 24-hour urine collection:

Diagnose significant proteinuria if result shows greater than 300 mg of protein over 24 hours.
B. Blood:
- Frequently monitoring of full blood count, liver function tests, urea and electrolytes and uric acid to identify values to help
guide the decision as to when to deliver.
- Clotting studies if there is severe pre-eclampsia or thrombocytopenia.
Interpretation of the blood tests:

Full blood count (FBC):
- Haemoglobin: Should be a good level for safe delivery; also a low level can indicate HELLP syndrome.
- Platelets: A low level or rapid fall in platelet may indicate the development of HELLP syndrome. (HELLP syndrome: platelet
count falling below 100 x 109/L)
Urea, electrolytes and uric acid (U&E’s):
- Raised amounts of waste products such as creatinine, urea and uric acid in the blood are evidence that the kidneys are
being affected by pre-eclampsia.
Liver Function (LFT):

- Rising ALT or AST are features of HELLP syndrome and suggest liver involvement.
(HELLP syndrome: abnormal liver enzymes ALT or AST >70 IU/L)
C. Cerebral imaging (MRI or CT):

Is not indicated in uncomplicated eclampsia. However, imaging is necessary to exclude haemorrhage and other serious
abnormalities in women with focal neurological deficits or prolonged coma.
For the baby:

A. Ultrasound Assessment:
Perform ultrasound scan to assess:
- Fetal growth
- The Amniotic fluid volume
- Umbilical artery Doppler velocimetry
B. Cardiotocography (CTG):
Note: Perform ultrasound examination and cardiotocography whenever pre-eclampsia is diagnosed.
Note: If the results of all fetal monitoring are normal in women with pre-eclampsia, do not routinely repeat
cardiotocography more than weekly. Repeat cardiotocography if any of the following occur:
- The woman reports a change in fetal movement
- Vaginal bleeding
- Abdominal pain
- Deterioration in maternal condition.
Note: In women who are at high risk of pre-eclampsia, only carry out cardiotocography if fetal activity is abnormal.
Note: In women with pre-eclampsia, do not routinely repeat ultrasound fetal growth and amniotic fluid volume assessment
or umbilical artery Doppler velocimetry more than every 2 weeks.
Note: For women with pre-eclampsia, write a care plan that includes all of the following:
- The timing and nature of future fetal monitoring
- Fetal indications for birth and if and when corticosteroids should be given
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- When discussion with neonatal paediatricians and obstetric anaesthetists should take place and what decisions should be
made.
Treatment of Mild, Moderate and Severe Pre-eclampsia:

Until the baby is delivered, treatments that may be considered include:
- Medication to reduce blood pressure: Medication to reduce blood pressure may be an option for a while if pre-eclampsia is
not too severe.
- Rest: Rest is often recommended although there is little evidence that this makes much difference.
Note: Always ask about headache and epigastric pain each time BP is taken, to be alert for any indication of progression
towards eclampsia.
Assess severity of high BP:
1. Mild Pre-eclampsia (BP 140-149/90-99 mmHg):

- Perform initial assessment and tests
- Refer to obstetric care
- Admit to hospital
- Monitor BP at least four times per day
- Twice-weekly blood test for FBC, electrolytes, renal function and LFTs
- Thromboprophylaxis – TED stockings and blood thinners
- Regular monitoring of the fetus and placenta with cardiotocography (CTG) and ultrasound.
To the patient: You will continue to be monitored closely to check that you can safely carry on with your pregnancy. You'll
have your blood pressure checked at least four times a day and blood tests to check for complications. Depending on the test
results, you may be able to go home and rest, and attend further check-ups as an outpatient. Or you may need to stay in
hospital for longer to be monitored.
You are likely to be advised to have your baby at about 37 weeks of pregnancy, or earlier if there are concerns about you or
your baby.
This may mean you will need to have labour induced or if you are having a caesarean section, to have it earlier than planned.
2. Moderate Pre-eclampsia (BP 150-159/100-109 mmHg):

- Refer to obstetric care
- Admit to hospital
- Start antihypertensive with oral labetalol (alternatives are methyldopa or nifedipine) and aim to keep systolic BP <150 mm
Hg and diastolic BP between 80-100 mm Hg.
- Monitor BP at least four times per day.
- Blood tests three times per week
To the patient: You'll have your blood pressure checked at least four times a day and have medication to lower your blood
pressure. You'll have ultrasound scans, which will probably include Doppler scans, to measure the flow of blood from the
placenta to your baby.
If your baby is well, and your condition improves over the following days, you may be able to go home before your baby is
born. If you haven't had your baby by the time you are between 39 weeks and 40 weeks pregnant, you may be offered an
induction. This means your labour will be started artificially, before you become overdue.
3. Severe Pre-eclampsia (BP ≥160/110 mmHg):
- Admit to hospital
- Start antihypertensive labetalol (alternatives are methyldopa or nifedipine) to keep systolic BP <150 mm Hg and diastolic
BP between 80-100 mm Hg.
- Strict fluid balance: all intake and output should be recorded.
- Blood should be taken for cross matching if delivery is anticipated.
- Blood tests three times per week
- Monitor BP more than four times per day, depending on circumstances.
- The incidence of eclamptic fits can be reduced with an intravenous infusion of magnesium sulphate.
Note: Intravenous medication (Labetalol, Hydralazine) can be used if oral anti-hypertensives are not controlling blood
pressure.
To the patient: You'll most likely need to stay in hospital if you have severe pre-eclampsia. You can then be monitored even
more closely, with frequent blood pressure, urine and blood tests, as well as medication (either tablets or via a drip) to
control your blood pressure.
Your baby will also be checked carefully. His growth and wellbeing will be monitored via scans, and his heart rate will be
measured.
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Hospital staff will do all they can to prevent you from developing complications. Your fluid levels will be controlled, and you
may be put on a drip that contains magnesium sulphate. Magnesium sulphate will lower your risk of developing eclampsia.
Sometimes, severe pre-eclampsia can cause a fit, and magnesium sulphate also helps to prevent a fit from recurring. We
usually give this medication if your baby is expected to be born within the next 24 hours or if you have experienced an
eclamptic fit.
If your blood pressure can't be controlled, and your doctor is concerned about your baby's wellbeing, your baby may need to
be born earlier than expected. Your doctor should look carefully at your circumstances, and explain all your options. You
may be advised to have your labour induced, or to have your baby by caesarean.
Even if your baby has to be born early, he is likely to be fine. Every case of pre-eclampsia is different. So a lot will depend on
how early he was born, and how much he weighed when he was born.
Drug information:
- Aim to keep BP <150/100 mmHg.
- Oral antihypertensives should be used in the initial treatment however, intravenous antihypertensives will be needed as
well if blood pressure doesn’t respond to oral therapy or if there is severe hypertension e.g. BP >170/110.
Oral Preparations:
1. Labetalol:
- Labetalol 200mg orally stat (caution in asthma)
- Check BP every 5 minutes for 15 minutes
- If BP <150/100 mmHg commence maintenance oral therapy
- If BP >150/100 mmHg commence intravenous treatment
Labetalol is licensed for the treatment of hypertension, including during pregnancy and is already used widely in UK
obstetric practice, but the SPC advises that it should only be used during the first trimester of pregnancy if the potential
benefit outweighs the potential risk, and that breastfeeding is not recommended. Informed consent on the use of labetalol in
these situations should be obtained and documented.
2. Nifedipine:
- This acts as a direct smooth muscle dilator.
- Nifedipine 5mg orally stat
- Repeat at 20 minute intervals until BP is controlled, to a maximum of 4 doses
- Start Adalat Retard once target BP reached
- If non-responsive, consider Hydralazine
Two Nifedipine preparations are useful in this situation:

1. Nidefipine Capsules (5mg):
- Acts within 10-15 minutes.
- Treatment should commence with this preparation.
2. Adalat Retard (slow release tablets, 20mg):

- Acts within 60 minutes.
- Sustained action
- Useful for continuing treatment.
Nifedipine is licensed for the treatment of hypertension and is already used widely in UK obstetric practice, but the SPC
advises that it is contraindicated in pregnancy before week 20, and that it should not be administered during the entire
pregnancy or in women who may become pregnant. It also advises that nifedipine should not be used during breastfeeding.
Informed consent on the use of nifedipine in these situations should be obtained and documented.
Intravenous Treatment:
If blood pressure control requires intravenous treatment then the level of care should be increased:
1. Labetalol IV treatment (caution in asthma):
Labetalol Bolus:
- 20 mg over a period of 5 minutes slow intravenous administration, recheck BP every 5 minutes for 20 minutes.
- If BP not controlled after 20 minutes, give 40mg, 40mg, and 80mg at 10 minute intervals up to a maximum dose of 180mg.
Labetalol Infusion:
- Draw up 40mls Labetalol (5mg/ml)
- Start infusion at 20mg/hr (i.e. 4ml/hr)
- Double every 30 minutes until a satisfactory response, (BP <150/100 mmHg) or to a maximum infusion rate of 160 mg/hr
2. Hydralazine IV treatment:
This acts as a vasodilator, expanding intravenous volume.
In an undelivered patient, volume expansion of up to 500ml Hartmann’s should be considered prior to administration of
Hydralazine.
Hydralazine Bolus:
- 5mg over a period of 10 minutes slow intravenous administration, recheck BP every 5 minutes for 20 minutes.
- If BP not controlled after 20 minutes, can repeat 5mg bolus at 20 minute intervals to a maximum of 4 doses.
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Hydralazine Infusion:
Hydralazine is incompatible with Dextrose. It should be infused via a syringe driver as follows:
- Mix 50 mg of Hydralazine with Normal Saline to make up to 50ml, i.e. 1mg/mi.
- Start infusion at 5mg/hr
- The rate can be doubled every 30 minutes, titrate according to response.
- Maximum rate is 40/hr
- The BP should be taken manually every 5 minutes.
- Aim for systolic BP ≤160 and diastolic BP 90-100 mmHg.
- Thereafter the BP recordings should be repeated every 30 minutes if stable.
- The BP should be lowered slowly as rapid alterations of the BP can cause cerebral hypoxia.
- The fetal hear rate should be continuously monitored as Hydralazine can cause fetal distress.
Timing of Birth:
- Manage pregnancy in women with pre-eclampsia conservatively (that is, do not plan same-day delivery of the baby) until
34 weeks.
- The decision to deliver should not be made until the woman is stable, blood pressure control is achieved and appropriate
senior personnel are present.
- If the blood pressure is reduced it may help to allow the pregnancy to progress further before delivering the baby.
- If the pre-eclampsia is not too severe, then postponing delivery until nearer full term may be best.
- If pre-eclampsia is severe, then delivery sooner rather than later is best.
The best time to deliver the baby has to balance several factors including:
- Severity of the pre-eclampsia in the mother and the risk of complications occurring.
- How the baby is affected.
- The chance of a premature baby doing well. Generally, the later in pregnancy the baby is born, the better. However, some
babies grow very poorly if the placenta doesn’t work well in severe pre-eclampsia. They may do much better if are born,
even if they are premature.
- Gestation of the pregnancy
- The woman’s previous obstetric history
- The views and needs of the parents must always be considered sympathetically.
1. Women with mild or moderate hypertension:

- Offer birth to women who have pre-eclampsia with mild or moderate hypertension at 34+0 to 36+6 weeks depending on
maternal and fetal condition, risk factors and availability of neonatal intensive care.
- Recommend birth within 24–48 hours for women who have pre-eclampsia with mild or moderate hypertension after 37+0
weeks.
2. Women with severe hypertension:

- Offer birth to women with pre-eclampsia before 34 weeks, after discussion with neonatal and anaesthetic teams and a
course of corticosteroids has been given if:
1. severe hypertension develops refractory to treatment
2. maternal or fetal indications develop as specified in the consultant plan
- Recommend birth for women who have pre-eclampsia with severe hypertension after 34 weeks when their blood pressure
has been controlled and a course of corticosteroids has been completed (if appropriate).
Mode of Birth:
- Choose mode of birth for women with severe hypertension, severe pre-eclampsia or eclampsia according to the clinical
circumstances and the woman's preference.
- It is common practice to induce labour if pre-eclampsia occurs late in pregnancy. The risk to the baby is small if he or she is
born a few weeks early.
Maternal indications of early induction:

- Severe hypertension which is unresponsive to medication
- Deteriorating kidney function indicated by low urine output, raised urea and creatinine
- Falling platelet count
- Rising or profoundly elevated liver function tests ALT and AST
- Persistent symptoms
Indications of premature birth due to pre-eclampsia:

- Evidence of intrauterine growth restriction on ultrasound
- Suspected fetal distress identified on CTG
- Threat to maternal survival if pregnancy allowed to continue
Indications for transfer to delivery suite:

- Uncontrollable blood pressure
- Eclampsia
- Severe maternal symptoms
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- Fetal compromise
- Renal failure
Management of pregnancy with pre-eclampsia

Degree of MILD MODERATE SEVERE
Hypertension Hypertension Hypertension Hypertension
(140/90 to 149/99 (150/100 to 159/109 (160/110 mmHg or higher)
mmHg) mmHg)
Admit to Hospital Yes Yes Yes
Treat No With oral Labetalol as first- With oral Labetalol as first-

line treatment to keep: line treatment to keep:
- Diastolic BP between 80- - Diastolic BP between 80-
100 mmHg 100 mmHg
-Systolic BP less than 150 -Systolic BP less than 150
mmHg mmHg
Measure BP At least four times a day At least four times a day More than four times a day,
depending on clinical
circumstances
Test for Proteinuria Do not repeat Do not repeat quantification Do not repeat quantification
quantification of of proteinuria of proteinuria
proteinuria
Blood Tests Monitor using the Monitor using the following Monitor using the following
following tests twice a tests three times a week: tests three times a week:
week: - Kidney function - Kidney function
- Kidney function - Electrolytes - Electrolytes
- Electrolytes - Full blood count - Full blood count
- Full blood count - Transaminases - Transaminases
- Transaminases - Bilirubin - Bilirubin
- Bilirubin
Note: Only offer women with pre-eclampsia antihypertensive treatment other than Labetalol after considering side-
effect profiles for the woman, fetus and newborn baby.
Alternatives include Methyldopa and Nifedipine.
Management of severe pre-eclampsia:

Delivery of the fetus and placenta is the only cure. However, preterm delivery may adversely affect neonatal outcome,
with complications resulting from prematurity and low birth weight. The management plan for delivery, including
thresholds for early delivery, should be discussed by the consultant and the woman on an individual basis and
documented in the notes.
1. Antihypertensives (Blood Pressure):

- Antihypertensive treatment should be started in women with a systolic BP over 160 mmHg or a diastolic BP over
110 mmHg. Treat women with severe hypertension who are in critical care during pregnancy or after birth
immediately with one of the following:
- Labetalol (oral or intravenous)
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- Nifedipine (oral)
- Hydralazine (intravenous).
In women with severe hypertension who are in critical care, monitor their response to treatment:
- To ensure that their blood pressure falls.
- To identify adverse effects for both the woman and the fetus.
- To modify treatment according to response.
Note: In women with severe hypertension who are in critical care, aim to keep systolic blood pressure below 150
mmHg and diastolic blood pressure between 80 and 100 mmHg.
Note: Consider using up to 500 ml crystalloid fluid before or at the same time as the first dose of intravenous
hydralazine in the antenatal period.
Note: Atenolol, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor antagonists and diuretics
should be avoided although may be indicated postpartum.
Note: Antihypertensive medication should be continued after delivery, as dictated by the BP. It may be necessary to
maintain treatment for up to three months, although most women can have treatment stopped before this.
2. Anticonvulsants (Magnesium Sulphate):

Indications:
1. Eclampsia: If a woman in a critical care setting who has severe hypertension or severe pre-eclampsia has or
previously had an eclamptic fit, give intravenous magnesium sulphate.
2. Any woman with severe pre-eclampsia where birth is planned within 24 hours and where there is one other of the
following criteria:
a. Hypertension with diastolic BP ≥110 mmHg or systolic BP 170mmHg on two occasions and proteinuria ≥3+
b. Hypertension with diastolic BP ≥100 mmHg or systolic BP ≥ 150mmHg on two occasions and proteinuria ≥2+ (0.3
g/day) and at least two of the following:
- Epigastric pain, vomiting, liver tenderness
- Headache, visual disturbances, Clonus (≥ 3 beats)
- Haematological or biochemical evidence of developing HELLP syndrome: platelet count < 100, ALT >50 IU/L
- Creatinine > 100 or Creatinine Clearance < 80
If considering magnesium sulphate treatment, use the following as features of severe pre-eclampsia:
- severe hypertension and proteinuria or
- mild or moderate hypertension and proteinuria with one or more of the following:
- symptoms of severe headache
- problems with vision, such as blurring or flashing before the eyes
- severe pain just below the ribs or vomiting
- papilloedema
- signs of clonus (≥3 beats)
- liver tenderness
- HELLP syndrome
- platelet count falling to below 100 x 109 per litre
- Abnormal liver enzymes (ALT or AST rising to above 70 IU/litre).
Prevention of seizures:
- Magnesium sulphate should be considered in severe pre-eclampsia when there is concern about the risk of
eclampsia.
- Magnesium sulphate reduces the risk of eclampsia by more than half.
Control of seizures:
Magnesium sulphate is the therapy of choice to control seizures. Use the Collaborative Eclampsia Trial2 regimen for
administration of magnesium sulphate:
- A loading dose of 4 g is given by infusion pump over 5-10 minutes, followed by a further infusion of 1 g/hour
maintained for 24 hours after the last seizure.
- Recurrent seizures should be treated with either a further bolus of 2 g of magnesium sulphate or an increase in the
infusion rate to 1.5 g or 2.0 g/hour.
Note: Do not use diazepam, phenytoin or lytic cocktail as an alternative to magnesium sulphate in women with
eclampsia.
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3. Corticosteroids:
If birth is considered likely within 7 days in women with pre-eclampsia:
- Give two doses of betamethasone 12 mg intramuscularly 24 hours apart in women between 24 and 34 weeks.
- Consider giving two doses of betamethasone 12 mg intramuscularly 24 hours apart in women between 35 and 36
weeks.
4. Fluid balance and volume expansion:

- Fluid restriction is advisable to reduce the risk of fluid overload in the intrapartum and postpartum periods.
- Pulmonary oedema has been a significant cause of maternal death in eclampsia/pre-eclampsia, often associated
with excess fluid administration.
Note: In women with severe pre-eclampsia, total fluids should usually be limited to 80 ml/hour or 1 ml/kg/hour
unless there are other ongoing fluid losses (for example, haemorrhage).
Note: Do not use volume expansion in women with severe pre-eclampsia unless hydralazine is the antenatal
antihypertensive.
5. Delivery:
- The decision to deliver should be made once the woman is stable and with appropriate senior personnel present.
- If the fetus is less than 34 weeks of gestation and delivery can be deferred, corticosteroids should be given, although
after 24 hours the benefits of conservative management should be reassessed.
- Conservative management at very early gestations may improve the perinatal outcome but must be carefully
balanced with maternal well-being.
- The mode of delivery should be determined after considering the presentation of the fetus and the fetal condition,
together with the likelihood of success of induction of labour after assessment of the cervix.
- Measure blood pressure continually.
- Active management of the third stage: The third stage should be managed with 5 units of intramuscular/slow
intravenous Syntocinon. Ergometrine and Syntometrine should not be given for prevention of haemorrhage, as this
can further increase the BP.
- Prophylaxis against thromboembolism should be considered.
- Continuous CTG monitoring.
Intrapartum care:
Women with hypertensive disorders during pregnancy should be given advice and treatment in line with
'Intrapartum care: management and delivery of care to women in labour', unless it specifically differs from
recommendations of NICE guideline.
1. Blood pressure:
During labour, measure blood pressure:
- Hourly in women with mild or moderate hypertension.
- Continually in women with severe hypertension.
Continue use of antenatal antihypertensive treatment during labour.
2. Haematological and biochemical monitoring:

Determine the need for haematological and biochemical tests during labour in women with mild or moderate
hypertension using the same criteria as in the antenatal period even if regional analgesia is being considered.
3. Care during epidural analgesia:

Do not preload women who have severe pre-eclampsia with intravenous fluids before establishing low-dose epidural
analgesia and combined spinal epidural analgesia.
4. Management of the second stage of labour:

Do not routinely limit the duration of the second stage of labour:
- In women with stable mild or moderate hypertension or
- If blood pressure is controlled within target ranges in women with severe hypertension.
Recommend operative birth in the second stage of labour for women with severe hypertension whose hypertension
has not responded to initial treatment.
Prognosis:
- Pre-eclampsia is also associated with intrauterine growth restriction, low birth weight, preterm delivery, small for
gestational age infants and infant respiratory distress syndrome.
- The maternal mortality rate of eclampsia is 1.8%.
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- Pre-eclampsia recurs in around 15% of women who had pre-eclampsia in their first pregnancy, although this risk
may be as high as 25% if the pre-eclampsia led to birth before 34 weeks and as high as 50% if birth was before 28
weeks.
- Women who have had pre-eclampsia are at an increased risk of hypertension and heart disease in later life,
although it is not known whether this is due to an effect of pre-eclampsia or a common cause of both cardiovascular
disease and pre-eclampsia.
- There is an increased risk of cardiovascular death in women with preterm pre-eclampsia in their first pregnancy
and who have no subsequent children.
Will I make a full recovery from pre-eclampsia?

You are very likely to make a full recovery from pre-eclampsia. But you will need to rest and recover in hospital for a
few days after your baby's birth, so your blood pressure can be monitored.
Your blood pressure should return to normal within weeks of giving birth. Routine checks after your baby's birth may
show that you had high blood pressure before you were pregnant. If this is the case, you may need to continue with
treatment for high blood pressure.
You should have a follow-up with your GP 6-8 weeks after birth for a final blood pressure and urine check.
Rarely, serious complications such as eclampsia or HELLP can have long-term effects on your health, such as kidney
problems. However, most cases of pre-eclampsia are picked up and treated in time to prevent this.
If you had severe pre-eclampsia or eclampsia, your doctor should explain what happened, and whether or not it may
affect your future pregnancies. Pre-eclampsia puts you at risk of developing high blood pressure and related
problems in later life, so checking your blood pressure regularly will be important. Always ask your doctor or
midwife if you have any questions about your treatment.
Water Birth:
There are circumstances when a water birth isn’t recommended. In general, if there have been any complications in
your pregnancy, such as bleeding in late pregnancy, you go into labour early, or your baby is showing signs of
distress, you’ll be advised against it. You’ll also be steered away from it if:
- You have high blood pressure or develop pre-eclampsia.
- Your baby is very small or has not been growing well during your pregnancy.
- You have a chronic health condition such as diabetes, heart disease or kidney disease; or a health problem that can
be easily transferred in water, such as herpes.
- If you have been experiencing excessive bleeding.
- Your labour has been induced.
- You’re having twins or more.
- Your baby is breech (feet or bottom first).
- If you have toxaemia.
- If there is severe meconium (Your midwife will keep an eye out for this and advise accordingly).
- If you want to have a water birth at your local maternity unit, it also depends on access to a midwife with experience
of water births when you go into labour. If there isn’t one on duty, you’ll probably be asked to get out of the birth pool
for the actual delivery.
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OBG 2 - GONORRHOEA
Introduction:
- Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria called Neisseria gonorrhoeae or gonococcus. It
used to be known as 'the clap'.
SYMPTOMS
- Gonorrhoea in most men (90-95%) and in half of women is asymptomatic.
- Symptoms of gonorrhoea usually develop within about two weeks of being infected, although they sometimes don't appear
until many months later.
- If gonorrhoea is left undiagnosed and untreated, you can continue to spread the infection and there is a risk of potentially
serious complications, including infertility.
A) FEMALE
1. Discharge from vagina
- usually thick green or yellow
- rarely thin or watery
- The most common symptom (in up to 50%)
2. Pelvic or lower abdominal pain

- It presents in up to 25% women
- Possible pain on intercourse.
3. Bleeding between periods and after sex

- The least common vaginal symptom
4. Dysuria
5. Rectal infection
- Itching
- Pain and spasm of back passage
- Discharge
- Bleeding
5. Pharyngeal Infection
- It is asymptomatic in 90% of women
B) MALE
Genital infection is usually symptomatic in men. Symptoms usually develop 2–5 days after exposure, although they may
appear after 10 days or more.
1. Urethral Discharge
- In 80 % of men
- White, yellow or green discharge from tip of penis
- Initially it is scant and mucoid, becoming purulent after 1–2 days.
2. Dysuria
- In about 50 %
3. Rectal Infection
- Itching
- Pain and spasm of back passage
- Discharge
- Bleeding
4. Pharyngeal Infection
- It is asymptomatic in 90% of men.
SIGNS
A) FEMALES
1. Mucopurulent endocervical discharge (not a sensitive predictor of infection).
2. Easily induced contact bleeding of the endocervix.
3. Pelvic/lower abdominal tenderness (uncommon, 5%).
4. Normal examination (very common).
B) MALES
1. Mucopurulent or purulent urethral discharge.
2. Epididymal tenderness/swelling or balanitis (rare).
RISK FACTORS
1. Young age.
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2. History of previous STI.
3. Co-existent STIs - 40% of homosexual males with gonorrhoea had co-existing HIV infection.
4. Positive Sexual History
- New or multiple sexual partners.
- Recent sexual activity abroad.
- Certain sexual activities e.g. anal intercourse, frequent insertive oral sex.
- Inconsistent condom use.
- History of drug use or commercial sex work.
EXAMINATION
A) FEMALES
In most women, no abnormal findings are present on examination. Examination may show:
1. Most commonly, purulent or mucopurulent endocervical discharge, or easily induced endocervical bleeding. However, this
is not a sensitive predictor of cervical infection (occurring in less than 50% of women).
2. Less commonly, purulent discharge from the urethra.
3. Abdominal tenderness if pelvic inflammatory disease is present.
B) MALES
1. A mucopurulent or purulent urethral discharge.
2. Less commonly epididymal tenderness.
3. Swelling.
4. Balanitis.
INVESTIGATIONS
A) FEMALES
1. Endocervical and urethral swabs.
2. A rectal swab if rectal symptoms are present, or in women who are sexual contacts of men with confirmed infection.
3. A pharyngeal swab if pharyngeal symptoms are present.
B) MALES
In men this may include:
1. A first pass urine sample.
2. A urethral swab.
3. A rectal swab if rectal symptoms are present, or in men who have sex with men (MSM).
4. A pharyngeal swab if pharyngeal symptoms are present, or in men who have sex with men.
WHO SHOULD GET TESTED?

- It's possible to be tested within a few days of having sex, but you may be advised to wait up to a week.
- You can be tested even if you don't have any symptoms.
- Early diagnosis and treatment of gonorrhoea reduces the risk of any complications developing. Complications that arise
from long-term infection are much more difficult to treat.
It's recommended you get tested if:

- You or your partner think you have symptoms of gonorrhoea.
- You’ve had unprotected sex with a new partner.
- You or your partner have had unprotected sex with other people.
- You have another STI.
- A sexual partner tells you they have an STI.
- You’re pregnant or planning a pregnancy.
NOTE:
You can attend Genitourinary Medicine (GUM) or Sexual Health Clinic, or your GP, or a Contraceptive and Young People’s
Clinic and all results are treated confidentially.
TREATMENT
Treat for Gonorrhoea:
1. If the result for swab came back positive.
2. If a diagnosis of gonorrhoea is suspected from symptoms and examination, treat empirically whilst waiting for laboratory
confirmation.
3. If the person is a recent sexual partner(s) of someone with confirmed gonococcal infection.
1. REFERRAL
Ideally, refer all people with suspected or confirmed gonorrhoea to a genito-urinary medicine (GUM) clinic or other local
specialist sexual health service.
Genito-urinary medicine clinics and other specialist sexual health services have the resources to ensure effective diagnosis
and treatment of gonorrhoea, as well as screening for other sexually transmitted infections (including HIV), counselling,
follow up, and contact tracing (partner notification).
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NOTE: Referral is particularly important in:
1. Men who have complications caused by gonorrhoea (such as epididymitis or prostatitis) require specialist management
(for example extended courses of antibiotics).
2. Pregnant women.
3. Women with suspected ascending infection.
2. ADMISSION
Admission to hospital is required for:
1. People with suspected disseminated gonorrhoea:
- Systemic symptoms such as fever, malaise, joint pain and swelling, and rash may be present.
- Because it can develop into life-threatening infection (for example gonococcal meningitis).
- Treatment in secondary care will typically involve higher doses of an intramuscular or intravenous cephalosporin for up to
a week.
2. Women with pelvic inflammatory disease if it is severe or there are complications.
3. ANTIBIOTICS
For confirmed or suspected uncomplicated anogenital gonorrhoea, prescribe:
• Ceftriaxone 500 mg intramuscular (IM) injection as a single dose
• Plus azithromycin 1 g orally as a single dose.
Note: If an IM injection is contraindicated or refused, offer:

• Cefixime 400 mg orally as a single dose.
• Plus azithromycin 1 g orally as a single dose.
Note: If cephalosporins are contraindicated (for example the person has a true allergy to penicillin-type antibiotics),
consider:
• a fluoroquinolone (ciprofloxacin 500 mg, single oral dose or ofloxacin 400 mg, single oral dose).
• Plus azithromycin 1 g, single oral dose.
Only prescribe a fluoroquinolone if the infection is known to be sensitive to fluoroquinolones (that is, culture and sensitivity
results are available for the person or recent sexual partners).
Note: If these regimens are unsuitable or unavailable, contact the local microbiology or genito-urinary medicine clinic for
advice.
Antibiotics in pregnancy
- The benefits of antibiotics for gonorrhoea outweigh the risks in pregnancy. If left untreated, gonorrhoea in pregnancy will
lead into complications.
- Cefixime and ceftriaxone are not specifically licensed in pregnancy but 'are not known to be harmful'. Although
cephalosporins cross the placenta, there is no evidence to indicate that they are toxic to the embryo or the foetus, and no
harms have been shown in observational studies of pregnant women who have been exposed to cephalosporins.
- Fluoroquinolones are contraindicated in pregnant and breastfeeding patients unless in serious or life-threatening
conditions.
4. SEXUAL ABSTINENCE
Advise the person to abstain from sex until they and any partners have completed treatment; if azithromycin is used, this
will be 7 days after treatment is given.
5. TREATING SEXUAL PARTNERS
- Sexual contacts of people with confirmed infection should be offered testing as above and empirical treatment for
gonorrhoea.
- If empirical treatment is not given, a second set of tests should be performed in people who present within 3 days of sexual
contact. These tests should usually be done 14 days after contact.
Partner Notification:
- Partner notification is essential for all people with newly diagnosed gonorrhoea.
- For people with symptomatic anogenital gonorrhoea, all partners within the preceding 2 weeks should be notified, or their
most recent partner, if this was longer than 2 weeks ago.
- For people with asymptomatic gonorrhoea, or gonorrhoea at other sites, all partners within the preceding 3 months should
be notified.
- Three methods of partner notification are used. For each method, the healthcare professional should document all actions
and outcomes:
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1. Patient referral: the person with gonorrhoea is encouraged to notify their past and present partners. This is the usual
method used in primary care and the only practical option if provider referral is not available.
2. Provider referral: the healthcare professional notifies the person's partners on their behalf. This option is recommended,
but is often not available in primary care. Ideally, provider referral should be facilitated by a trained health adviser in a GUM
clinic. If referral to a GUM clinic is not possible, a primary healthcare professional who has undergone appropriate training
and has support from healthcare advisers in GUM is the next best option.
3. Contract referral: the person with gonorrhoea is encouraged to notify their partners, with the understanding that a
healthcare professional will later notify those partners who do not visit the health service within an allotted time. This
option is not usually suitable in a primary care setting.
- Patient notification in primary care:
If referral to a GUM clinic (or to a general practice providing an enhanced sexual health service) is not possible, contact
tracing should be undertaken in primary care, and this should be documented
6. SEXUALLY TRANSMITTED INFECTIONS (STIs) AND HIV SCREENING:
- Offer screening for other sexually transmitted infections (STIs) and for HIV.
- Notified partners should be screened for sexually transmitted infections (prior to giving antibiotics if possible) and treated
empirically whilst waiting for results.
7. FOLLOW UP
Follow up is recommended for all people with gonorrhoea about 1 week after treatment to:
- Verify the success of treatment.
- Confirm adherence to treatment and resolution of symptoms.
- Confirm that partner notification has been carried out.
- Ask about recent sexual history (and the possibility of re-infection), and reinforce advice about safe sexual practice.
8. TEST OF CURE
A test of cure is recommended for all people who have been treated for gonorrhoea. However, if it is not possible to test
everyone, prioritize people:
- With persistent signs or symptoms.
- With pharyngeal infection.
- Who have been treated with anything other than the first-line recommendation.
9. ADVICE AND INFORMATION GIVING
- Advise the person to practice safe sex in the future.
- Discuss the long-term implications if gonorrhoea is left untreated for the health of the person and their partners.
- When advising to attend GUM Clinic, inform the person that these services have the resources to ensure effective
management and partner notification, and that they are confidential and non-judgemental.
COMPLICATIONS
If treated early, gonorrhoea is unlikely to lead to any complications or long-term problems. However, without treatment, it
can spread to other parts of body and cause serious problems. The more times you have gonorrhoea, the more likely you are
to have complications.
A) FEMALES
1. Bartholin's abscess:
- Bartholin's abscess may present as a local complication of infection, although it is usually caused by more than one
pathogen (usually multiple pathogens).
2. Pelvic inflammatory disease
- Pelvic inflammatory disease is thought to occur in 10–20% of women who contract gonorrhoea.
- The main concerns of pelvic inflammatory disease are infertility, chronic pelvic pain, ectopic pregnancy and peri-hepatitis
caused by ascending infection.
Gonorrhoea in pregnancy:
1. Spontaneous abortion.
2. Premature labour.
3. Miscarriage.
4. Early rupture of fetal membranes.
5. Perinatal mortality.
6. Gonococcal conjunctivitis in the newborn:
- If the baby isn't treated with antibiotics promptly, there's a risk of progressive and permanent vision damage.
7. Corneal scarring and blindness from neonatal ophthalmic infection.
B) MALES
Acute complications that may rarely occur include:
1. Epididymitis.
2. Prostatitis/Acute Prostatitis
3. Seminal Vesiculitis
4. Urethral scarring and stricture
Note: In men, gonorrhoea can cause painful infection in the testicles and prostate gland, which may lead to reduced fertility
in a small number of cases
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OBG 3 - PID
SYMPTOMS
Many episodes of PID go unrecognized as PID often doesn’t cause any obvious symptoms and
women often have absent/mild or atypical symptoms.
1. Pain
- Lower Abdominal Pain
a. B/L, can be U/L
b. Sometimes radiates to Legs
- Pain during sex
- Pain during urination
2. Bleeding
- Between periods
- After sex
3. Period abnormalities
- Menorrhagia (heavy periods)
- Dysmenorrhea (painful periods)
4. Vaginal/Cervical Discharge
Other Symptoms
5. Severe lower abdominal pain
6. High Temperature
7. Nausea/Vomiting
8. Urinary Symptoms
Complications:
1. Recurrent PID
2. Pregnancy related
- Ectopic
- Miscarriage
- Premature labour
- Stillbirth
3. Infertility
4. Chronic pelvic pain/back pain
5. Pre-hepatitis
6. Reactive Arthritis
7. Tubo-ovarian Abscess
RISK FACTORS
1. Age (less than 25)
2. PMH
- Previous PID
- History of recurrent STI (herself/partner)
- Insertion of IUCD within 6 weeks.
- Recent Instrumentation e.g. termination of pregnancy
3. Personal History – Sexual History

- Starting sex at young age
- Multiple partners
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- New partner within 3 months
- Unprotected intercourse
1. Causes of Lower Abdominal Pain
- Ectopic Pregnancy
- Acute appendicitis
- Threatened abortion
- Corpus Luteal Rupture
- GI cause such as IBS
2. Causes of abnormal vaginal bleeding

3. Causes of vaginal discharge – Foreign body
4. Causes of dyspareunia – Endometriosis
5. C/O Ovarian Cyst such as Torsion and Rupture
6. UTI
EXAMINATION
1. General
a. Temperature more than 38 (Although it is often normal)
2. Abdominal
a. Lower Abdominal Tenderness
3. Bimanual Examination
a. Adnexal tenderness (with or without palpable adnexal mass)
b. Cervical motion tenderness (cervical excitation)
c. Uterine tenderness
4) Speculum Examination
a. Discharge (Cervical and Vaginal)
b. Cervicits
c. Proctitis (Inflammation of lining of rectum)
INVESTIGATIONS
1. Pregnancy test
NOTE: If patient is pregnant and diagnosed with PID – Admit the patient.
2. Swab
Triple swab
a. High Vaginal Swab (HVS) for
i. Bacterial vaginosis
ii. Trichomonas Vaginalis
iii. Candida
iv. Group B Streptococcus
b. Endocervical Gonorrhea Swab
c. Endocervical Chlamydia Swab
Dual Nucleic Acid Amplification Test (NAAT)

- Single sample for chlamydia/gonorrhea
3. Vaginal Smear for Microscopy
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- Look for pus cells – if pus is absent, PID is unlikely.
4. Blood Test
- FBC
- ESR
- CRP
5. Urine Dipstick/Culture Study
6. Imaging
- TVUS
- MRI/CT
- Laparoscopy
- Endometrial Biopsy
7. Screen for STI and HIV
Ultrasound
- Ultrasound is the first line diagnostic imaging.
- It mainly detects abnormalities associated with PID and complications.
- Early finding is difficult to appreciate.
Ultrasound findings in Acute PID

1. Uterus
- Enlarged
- Thickened
- Indistinct border
- Fluid in the endometrium
2. Ovaries
- Enlarged
- Increased number of follicles due to inflammation
- Inflammed
- Formation of tubo-ovarian complex
- Formation of tubo-ovarian abscess
3. Fallopian Tubes
- Salpingitis – Oedema
- Tubal blockage
- Pyosalpinx (fallopian tube is filled and distended with pus)
- Cogwheel Sign (dilated tube with thickened fold)
- Beads on a string sign
- Hyperemia of the wall and folding (increased vascularity)
4. Increased echogenicity of peritoneal fat
TREATMENT
Mild and Moderate – Oral Antibiotic
Severe – Hospital Admission + IV Antibiotic
Admission:
1. If you can’t rule out:
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a. Ectopic
b. Appendicitis
2. Lack of response/intolerance to oral medication
3. Clinically Severe
a. Nausea/Vomiting
b. Temperature more than 38
c. Pelvic peritonitis
d. Tubo-ovarian abscess
MEDICATION
1. Antibiotics
Mild: [Ofloxacin 400 mg BD PO + Metronidazole 400 mg BD PO] x 14 days
If high risk of Gonorrhea e.g. partner with gonorrhea or severe symptoms: Ceftriaxone 500 mg
IM +
[Doxycycline 100 BD PO + Metronidazole 400 mg BD PO] x 14 days
Severe:
Single dose of Ceftriaxone 2g IV OD
+ Doxycycline (100 mg BD PO x 14 days)
+ Metronidazole 500 mg IV TDS (if clinical improvement after 24 hours, switch to oral
Metronidazole 400mg TDS PO x 14 days if patient tolerates)
2. Painkillers
3. Rest
4. HIV Screening
5. Treat the partner
6. Not having sex till complete treatment
7. IUCD Removal
- If patient requests after Antibiotic has been started
- Patient symptoms have not resolved after 72 hours (IUCD can be cause)
8. Advice to use condoms
9. Follow-up 72 hours
a. If there is no clinical improvement on examination, patient should be admitted.
b. Check for antibiotic sensitivity from swab
10. Review
- 14 days to check if treatment has been successful
- Within 30 days
a. To check treatment has been successful
b. Discuss about complications of PID
c. Confirm sexual partner screening and treatment
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OBG 4 ECTOPIC PREGNANCY
SYMPTOMS
1. Develops between 4-12 weeks.
- Ask LMP
- Any pregnancy test
2. Abdominal Pain
a. Usually U/L
b. It can be Sudden or gradual
c. It can be Persistent or it comes and goes
3. Vaginal Bleeding or Spotting

a. With or without clot
b. Often starts and stops
c. Watery or dark brown
d. Heavy or lighter than normal period
4. Pelvic Pain
Other Symptoms
5. Shoulder tip pain
6. Urinary Symptoms
7. Rectal pain or pain in defecation
8. GI Symptoms (diarrhoea/vomiting)
9. Breast tenderness
SYMPTOMS OF RUPTURED ECTOPIC PREGNANCY

1. Very intense pain (sudden/sharp)
3. Signs of shock
- Looking pale.
- Dizziness
- Fainting/collapse.
RISK FACTORS
1. Age 35-40
2. PMH
a. Previous ectopic pregnancy
b. Medical illness
-PID/Recurrent STI
- Endometriosis
- History of infertility
c. Medication
- IUCS/IUS
- POP (not very common)
- Treatment of infertility
3. Personal History
a. Smoking

Threatened miscarriage
- in ectopic pregnancy, pain starts first
- in miscarriage, vaginal bleeding is predominant feature and pain may come later.
Other DDs of LIF and RIF pain
EXAMINATION
1. Abdominal
2. Bimanual
Common findings:
1. Pelvic tenderness
2. Adnexal tenderness
3. Abdominal tenderness
INVESTIGATION
1. Urine pregnancy Test
2. Ultrasound
a. Transvaginal (TVUS)
- Identify the exact location of pregnancy
- Whether or not there is a foetal pole and heartbeat
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- Allows the examiner to look at the mobility and tenderness of the organs in the pelvis (this helps to make a diagnosis)
b. Transabdominal
- If TVUS not accepted by patient or not available
3. Blood test (B-HCG)

- To identify ectopic pregnancies that are not found with U/S. It should be done twice, 48 hours apart.
- Level of B-HCG Lower
- Rises more slowly over time
- Stays the same over time
NOTE: In normal pregnancy it rises 63% every 48 hours till it rises to 10,000-20,000.
4. Keyhole Laparoscopy
If diagnosis is still not clear
TREATMENT
The choice of treatment depends on:
1. How many weeks of pregnancy
2. Symptoms and Clinical Condition
3. Level of B-HCG
4. U/S Result
5. Fertility Status
6. General Health
7. Personal view
8. Pregnancy plans
9. Options available in your local hospital.
Always admit the patient as an emergency if diagnosis of ectopic is a possibility.

1. Expectant (Wait and Watch)
a. First line if:
- Pregnancy is less than 6 weeks
- There is bleeding
- Patient is not in pain
b. It is possible if:
- There is minimal pain
- B-HCG is low or declining
- Patient can attend for follow-up
Repeat urine pregnancy test within 7-10 days.

If Positive – Return to Hospital
If Negative – Pregnancy has miscarried
If symptoms continue/worsen – Return to hospital
2. Medical
(Methotrexate 50mg/m2 IM)
Before injection, blood test should be done.
a. First line if:

- Patient is haemodynamically stable
- Patient can return for follow-up/regular test
- All following:
i. No significant pain
ii. No Medical Illness(Liver disease, anemia, leucopenia, thrombocytopenia)
iii. Not breastfeeding
iv. Ultrasound:
- Unruptured ectopic
- Adnexal mass less than 35mm
- No visible heartbeat
v. Serum B-HCG less than 1500/3000
3. Surgical
a. First line if:
- There is significant pain
- There is adnexal mass more than 35 mm
- There is visible foetal hearbeat
- B-HCG is more than 5000
NOTE: You can offer either medical or surgical treatment if:
- B-HCG is 1500-5000
- Patient is able to return to follow up
- There is no significant pain
- On U/S you can see
i. Unruptured ectopic
ii. Adnexal mass less than 35
iii. No visible heartbeat
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OBG 5 CONTRACEPTION
COCP
Advantages:
- It is very effective. If taken correctly, there will be no chance of pregnancy in %99 of the cases.
- It does not interfere with sexual activities.
- Periods are usually regular, lighter and less painful.
- It relieves premenstrual symptoms in some women.
- It can sometimes reduce acne.
- It decreases the risk of pelvic infection. It causes the mucus to thicken so it prevents the entry of germs in your womb.
- It reduces your risk of cancer of the ovaries, womb and colon.
- It may reduce the risk of fibroids, ovarian cysts and non-cancerous breast disease.
- Normal fertility return as soon as you stop using it.
Disadvantages:
- It does not protect you against sexual transmitted disease (STI), so the use of condoms for protection is necessary.
- It may increase blood pressure, so blood pressure monitoring every 6 months is needed.
- It has no side effects in some women, however, some may feel sick, developing headache, mood changes, tiredness, and skin
changes or find their breasts sore.
If these do not go after a few months, it may help to change to a different pill.
- It may increase the risk of you developing a blood clot in your legs or your lungs (DVT or PE). The developing of a blood clot, can
block a vein or an artery which may lead to a heart attack or stroke.
- It increases the risk of breast cancer.
- It may cause some light bleeding and spotting between your periods which usually settles after a few months (by finishing of the
third pack).
- Missing pills, vomiting or severe diarrhea can make it less effective.
- Some medicines including medications for HIV, epilepsy and some antibiotics used for treatment of conditions such as tuberculosis
and meningitis (Rifabutin, Rifampicin) can reduce the effectiveness of pills.
Please ask your GP, practice nurse or pharmacist to check that your medicines are safe to take with the pills. They may advise you to
use an alternative or additional form of contraception while taking any of these medicines.
- Research is ongoing into the link between breast cancer and the pill. Research suggests that users of all types of hormonal
contraception have a slightly higher chance of being diagnosed with breast cancer compared with women who do not use them.
However, 10 years after you stop taking the pill, your risk of breast cancer goes back to normal.
- Research has also suggested a link between the pill and the risk of developing cancer of the neck of the womb and a rare form of
liver cancer.
Contraindications:
- If you are pregnant.
- If you are breast feeding.
- If you are a smoker or stopped smoking within a year ago and you are 35 or older.
- If you are very overweight (BMI >35).
- If you have any heart abnormality or heart disease such as angina or high blood pressure.
- If you have severe migraine or migraine with aura.
- If you have breast cancer.
- If you have gallbladder or liver disease.
- If you have diabetes with complications or you have been diabetic for 20 years or more.
- If you or any of your first degree relatives have ever had a blood clot in their legs or lungs.
- If you have any circulation problem in your legs (Peripheral arterial disease).
- If you have any autoimmune disease such as SLE or Raynaud’s disease.
- If you take certain medicines.
Contraceptive Patch:
- The contraceptive patch is a sticky patch, a bit like a nicotine patch, measuring 5x5cm.
- It delivers hormones into your body through your skin.
- In the UK, the patch's brand name is Evra.
- It contains the same hormones as the combined pill.
How it works:
- It changes the body’s hormonal balance. In this way it stops the ovaries from releasing an egg (Ovulation).
- It works by thickening the mucus at the neck of your womb so it makes it difficult for the sperm to enter the womb to fertilize the
eggs.
- It makes the lining of your womb thinner so that the fertilized egg cannot attach to the womb.
Advantages:
- It is very effective. If it is used properly, there will be no chance of pregnancy in %99 of the cases.
- Unlike the combined oral contraceptive pill, you do not have to think about it every day – you only have to remember to change the
patch once a week.
- The hormones from the contraceptive patch do not need to be absorbed by the stomach, so it is just as effective even if you vomit
or have diarrhoea.
- Like the pill, it tends to make your periods more regular, lighter and less painful.
- It can help with premenstrual symptoms.
- It may reduce the risk of ovarian, womb and bowel cancer.
Disadvantages:
- It may be visible.
- It can cause skin irritation, itching and soreness.
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- Some women get mild temporary side effects when they first start using the patch, such as headaches, nausea (sickness), breast
tenderness and mood changes; these side effects usually settle down after a few months.
- Bleeding between periods (breakthrough bleeding) and spotting (very light, irregular bleeding) is common in the first few cycles of
using the patch; this is nothing to worry about if you are using the patch properly, and you will still be protected against pregnancy.
- Some medicines can make the patch less effective. If you are prescribed new medicine or are buying an over-the-counter medicine,
ask the doctor or pharmacist for advice. You may need to use an extra form of contraception while you are taking the medicine, and
for 28 days afterwards.
- The patch slightly increases your chance of developing a blood clot, which can block a vein or an artery which may lead to a heart
attack or stroke.
- Current research suggests that people who use hormonal contraception, such as the contraceptive patch, are at a slightly increased
risk of being diagnosed with breast cancer compared with people who do not use hormonal contraception. However, further
research is needed to provide more definitive evidence.
- Research also suggests there is a small increase in your risk of developing cancer of neck of the womb with the long-term use of
oestrogen and progesterone hormonal contraception.
Contraindications:
- If you are pregnant or think you may be pregnant.
- If you are breastfeeding.
- If you smoke and are 35 or over.
- If you are 35 or over and stopped smoking less than a year ago.
- If you are very overweight.
- If you take certain medicines, such as some antibiotics or medicines used to treat epilepsy, tuberculosis (TB) or HIV.
- If you have or ever had blood clots in a vein or artery.
- If you have a heart problem or a disease affecting your blood circulatory system (including high blood pressure).
- If you have migraine with aura (warning signs).
- If you have breast cancer.
- If you have any disease of the liver or gallbladder.
- If you have diabetes with complications, or diabetes for more than 20 years.
Vaginal Ring:
- Vaginal ring is a small, soft plastic ring that you place inside your vagina.
- It’s about 4mm thick and 5.5cm in diameter.
- You leave it in your vagina for 21 days, then remove it and throw it in the bin (not down the toilet) in a special disposal bag.
- Seven days after removing the ring, you insert a new one for the next 21 days.
- The ring continually releases estrogen and progesterone.
How it works:
- It changes the body’s hormonal balance. In this way it stops the ovaries from releasing an egg (Ovulation).
- It works by thickening the mucus at the neck of your womb so it makes it difficult for the sperm to enter the womb to fertilize the
eggs.
Advantages:
- It is very effective. If it is used properly, there will be no chance of pregnancy in %99 of the cases.
- One ring will provide contraception for a month, so you don’t have to think about it every day.
- It is easy to put in and remove.
- The hormones from the vaginal ring do not need to be absorbed by the stomach, so it is just as effective even if you vomit or have
diarrhoea.
- It tends to make your periods more regular, lighter and less painful.
- It can help with premenstrual symptoms.
- It may reduce the risk of ovarian, womb and bowel cancer.
Disadvantages:
- It may not be suitable if you don’t feel comfortable inserting or removing it from your vagina.
- Spotting and bleeding while the ring is in your vagina can occur in the first few months.
- It may cause temporary side effects, such as increased vaginal discharge, headaches, nausea, breast tenderness and mood changes.
and meningitis (Rifabutin, Rifampicin) can reduce the effectiveness of vaginal ring.
Please ask your GP, practice nurse or pharmacist to check that your medicines are safe to take with the vaginal ring. They may
advise you to use an alternative or additional form of contraception while taking any of these medicines.
- The ring slightly increases your chance of developing a blood clot, which can block a vein or an artery which may lead to a heart
attack or stroke.
- Current research suggests that women who use hormonal contraception, are at a slightly increased risk of being diagnosed with
breast cancer compared with those who do not use hormonal contraception. However, further research is needed to provide more
definitive evidence.
- Research also suggests there is a small increase in your risk of developing cancer of neck of the womb with the long-term use of
oestrogen and progesterone hormonal contraception.
- Some research suggests a link between oestrogen and progesterone hormonal contraception and a very rare liver cancer.
Contraindications:
- If you have had a blood clot in a vein or artery.
- If you have had heart or circulatory problems, including high blood pressure.
- If you are 35 or older and smoke, or stopped smoking in the past year.
- If you have severe migraine with aura (warning symptoms).
- If you have had breast cancer in the past five years.
- If you have diabetes with complications.
- If you are overweight.
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- If you take certain medicines.
- If you have vaginal muscles that can’t hold a vaginal ring.
Progestogen-only pills (POP / Mini-pill):
- It contains the hormone progesterone but does not contain oestrogen.
- There are two different types of progestogen-only pill:
a. The three-hour progestogen-only pill must be taken within three hours of the same time each day. Examples are Femulen,
Micronor, Norgeston and Noriday.
b. The 12-hour progestogen-only pill (desogestrel pill, such as Cerazette) must be taken within 12 hours of the same time each day.
How it works:
- They work by thickening the mucus at the neck of your womb so it makes it difficult for the sperm to enter the womb to fertilize
the eggs.
- They make the lining of your womb thinner so that the fertilized egg cannot attach to the womb.
- The 12-hour pill can also affect your ovaries in a way that they do not release an egg (In 97 cycles out of 100).
Advantages:
- It can be used in those who cannot use estrogen-based contraception such as combined contraceptive pill, contraceptive patch or
vaginal ring.
- It is safe to be taken while you are breast-feeding.
- It contains lower doses of hormone in compare to oral contraceptive pills.
- You can use it at any age even if you smoke or if you are aged over 35.
- Normal fertility return as soon as you stop using it.
- It can reduce the symptoms of premenstrual syndrome (PMS) and painful periods.
Disadvantages:
- Your periods may become irregular, lighter or more frequent.
- Some people may experience spotting in between their periods and sometimes periods stop altogether.
- It does not protect against sexual transmitted disease (STI),
So the use of condoms for protection is necessary.
- It has to be taken at the same time every day.
and meningitis (Rifabutin, Rifampicin) can reduce the effectiveness of mini-pills. Therefore, if you are using any of these medications
(Antibiotics for example) for a short term, it is suggested that you use additional contraception such as condoms during your course
of treatment and for 28 days afterwards. However, if you are using any of these medications for a long term (For example
medications used for HIV or epilepsy), you may wish to consider using an alternative or additional form of contraception.
- Rarely some people develop side effects such as acne, breast tenderness or enlargement, mood changes, headache, nausea or
vomiting, cysts (small fluid-filled sacs) on your ovaries, stomach upset and weight gain, however, they will generally improve over
time and should stop within a few months.
- Research is continuing into the link between breast cancer and the progestogen-only pill. Research suggests that women who use
any type of hormonal contraception have a slightly higher chance of being diagnosed with breast cancer compared with people who
don’t use hormonal contraception. However, 10 years after you stop taking the pill, your risk of breast cancer goes back to normal.
- Missing pills, vomiting or severe diarrhea can make it less effective.
Contraindications:
- If you have history of heart disease or stroke.
- If you have history of liver disease.
- If you have breast cancer or family history of breast cancer.
- If you have ovarian cysts.
- If you have unexplained vaginal bleeding.
Contraceptive Injection (Depo Provera, Sayana Press, Noristerat):
- This injection contains a hormone called progestogen.
- It is injected in the first five days of your period.
How it works:
- It affects your ovaries in a way that they do not release an egg (Ovulation).
- It works by thickening the mucus at the neck of the womb so it makes it difficult for the sperm to enter the womb to fertilize the
eggs.
Advantages:
- It is very effective. If taken correctly, there will be no chance of pregnancy in %99 of the cases.
- It lasts 8, 12 or 13 weeks depending on the type. (Noristerat 8 weeks, Depo Provera 12 weeks and Sayana Press 13 weeks)
- It can be useful for women who might forget to take the contraceptive pill every day.
vaginal ring.
- It is safe while you are breast-feeding.
- It does not have any interactions with other medicines.
- It protects you against womb cancer and decreases the risk of pelvic infection (PID).
Disadvantages:
- Your periods may become more irregular or longer, heavier, shorter, lighter or stop all together. This may settle down after the
first year, but may continue as long as the injected progestogen remains in your body. If this happens please seek help from your
doctor or your nurse.
- You may put on weight after using the injection, particularly if you are under 18 years old and if you are overweight (with a body
mass index of 30 or over).
- It may cause headache, mood swings, acne, loss of sex drive or breast tenderness.
- It takes around 8 to 12 weeks for the injection to leave your body. However, sometimes it may take up to a year for your fertility to
return to normal. Thus, it may not be suitable for you if you wish to have a baby in near future.
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Contraindications:
- If you think you might be pregnant.
- If you want to keep having regular periods.
- If you experience bleeding in between your periods or after sex.
- If you have arterial disease or a history of heart disease or stroke.
- If you have a blood clot in your lung or in your legs. (thrombosis)
- If you have any liver disease including cirrhosis or liver tumours.
- If you have migraines.
- If you have breast cancer or have had it in the past.
- If you are at risk of osteoporosis (For example if you have low oestrogen level or you have medical conditions such as: rheumatoid
arthritis, Irritable bowel syndrome, ankyloses spondylitis, chronic kidney disease, coeliac disease or family history of osteoporosis).
If you are under 18 your body is still making bone at this age thus a careful evaluation by your doctor is necessary before the
injection.
Contraceptive Implant:
- The contraceptive implant is a small flexible tube about 40mm long that's inserted under the skin of your upper arm.
- It's inserted by a trained professional, such as a doctor, and lasts for three years.
How it Works:
- It releases a hormone called Progesterone.
- It affects your ovaries in a way that they do not release an egg (Ovulation).
- It works by thickening the mucus at the neck of the womb so it makes it difficult for the sperm to enter the womb to fertilize the
eggs.
Advantages:
- It works for up to 3 years.
- It can be useful for women who might forget to take the contraceptive pill every day.
vaginal ring.
- It is safe while you are breast-feeding.
- The thickened mucus at the neck of your womb may stop bacteria entering your womb. In this way it decreases the risk of pelvic
infection (PID).
- It may also give some protection against womb cancer.
- It reduces the pain of periods and makes the bleeding lighter after the first year of use.
- Your fertility will return to normal as soon as implant is removed.
Disadvantages:
- Around 1 out of 5 women using the implant will have no bleeding, and almost 1 out of 2 women will have infrequent or prolonged
bleeding. Bleeding patterns are likely to remain irregular, although they may settle down after the first year.
- It may cause headache, nausea, mood swings, acne, loss of sex drive or breast tenderness. These side effects usually settle after a
few months.
- Some women may put on weight, however, there is no evidence to support that implant causes weight gain.
and meningitis (Rifabutin, Rifampicin) can reduce the effectiveness of implant. Therefore, if you are using any of these medications
for a short term, it is suggested that you use additional contraception such as condoms or a single dose of contraceptive injection,
during your course of treatment and for 28 days afterwards. However, if you are using any of these medications for a long term, you
may wish to consider using another method of contraception. If you are using implant, please inform your doctor before being
prescribed any medications.
- In rare cases, the site of implant may get infected. If this happens the infected area will be cleaned and may be treated with
antibiotics.
Contraindications:
- If you think you might be pregnant.
- If you want to keep having regular periods.
- If you have bleeding in between periods or after sex.
- If you have arterial disease or a history of heart disease or stroke.
- If have a blood clot in your lung or in your legs. (thrombosis)
- If you have any liver disease including cirrhosis or liver tumours.
- If you have migraines.
- If you have breast cancer or have had it in the past.
- If you are at risk of osteoporosis.
Intrauterine System (IUS):
- It is a small T-shaped plastic tube, which sits inside your womb.
- The device is inserted into your womb by a specially trained doctor or nurse.
- There are two threads attached to it which pass out and lie in your vagina. You can check if it is placed inside by the presence of
these two threads.
- It releases a hormone called Progesterone.
How it works:
- It works by thickening the mucus at the neck of your womb so it makes it difficult for the sperm to enter your womb to fertilize the
eggs.
- In some women it also stop the ovaries from releasing an egg but most women will continue to ovulate.
Advantages:
- The IUS is a long-acting reversible contraceptive (LARC) method.
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- It works for five years (Mirena) or three years (Jaydess), depending on the type.
- It can be removed at any time by a specially trained doctor or nurse with normal fertility returning rapidly.
- Unlike the combined oral contraceptive pill, you do not have to think about it every day.
- You can use it whether or not you've had children. Most women can use an IUS, including women who have never been pregnant
and those who are HIV positive.
- It is one of the most effective forms of contraception.
- It makes your periods lighter and shorter and sometimes less painful. They may stop completely after the first year of use.
- It can be used in those who cannot use estrogen based contraception such as combined contraceptive pill, contraceptive patch or
vaginal ring.
- It is safe to use an IUS when you're breastfeeding, and it won't affect your milk supply.
- There are no side effects such as weight gain, increasing the chance of cancer of womb, neck of womb and ovaries.
- There's no evidence that an IUS will affect your weight.
- There’s no evidence that having an IUS fitted will increase the risk of cancer of the neck of the womb, cancer of the womb or
ovarian cancer.
Disadvantages:
- Some women may experience irregular bleeding and spotting in the first 6 months. Your periods may stop altogether, but this is
not harmful and will subside with time.
- Some women experience headaches, acne, breast tenderness, skin changes, changes in mood and libido after having the IUS fitted.
- Sometimes small fluid filled sacs (Cysts) may appear on the ovaries, however, they usually disappear without treatment.
- If you get pregnant, there's a small increased risk of pregnancy out of the womb (Ectopic pregnancy). However, since you're
unlikely to get pregnant, the overall risk of ectopic pregnancy is lower than in women who don't use contraception. Please seek
advice immediately if you experience one sided tummy pain. Your IUS should be removed as soon as possible if you are continuing
with the pregnancy.
- Occasionally, the IUS is rejected (expelled) by the womb or it can move (this is called displacement). This is not common and is
more likely to happen soon after it has been fitted. Your doctor or nurse will teach you how to check that your IUS is in place.
- There's an extremely small risk of getting pelvic infection after it is inserted. Pelvic infections may occur in the first 20 days after
the IUS has been inserted.
- It can be uncomfortable when the IUS is put in, although painkillers can help with this.
- Most women who stop using an IUS do so because of vaginal bleeding and pain, although this is uncommon.
- Hormonal problems can also occur, but these are even less common.
- In rare cases an IUS can damage your womb by making a hole in (perforate) the womb or neck of the womb when it is put in. This
can cause pain in the lower yummy, but doesn't usually cause any other symptoms. If the doctor or nurse fitting your IUS is
experienced, the risk of perforation is extremely low.
However, if perforation occurs, you may need surgery to remove the IUS. Contact your GP straight away if you feel a lot of pain after
having an IUS fitted. Perforations should be treated immediately.
Contraindications:
- If you have breast cancer, or have had it in the past five years.
- If you have cancer of the neck of the womb.
- If you have any liver disease.
- If you have unexplained vaginal bleeding between your periods or after sex.
- If you have arterial disease or history of serious heart disease or stroke.
- If you have an untreated STI or pelvic infection.
- If you have problems with your womb or the neck of your womb.
- An IUS may not be suitable for women who have untreated STIs. A doctor will usually give you a check-up to make sure you don't
have any existing infections.
Intrauterine Device (Copper IUD):
- An IUD is a small T-shaped plastic and copper device that’s inserted into your womb by a specially trained doctor or nurse.
- There are two threads attached to it which pass out and lie in your vagina. You can check if it is placed inside by the presence of
these two threads.
- The IUD releases copper.
- There are types and sizes of IUD to suit different women.
How it works:
- Copper changes the make-up of the fluids in your womb and tubes.
- This stops the sperm and egg from surviving in your womb or tubes.
- It may also prevent a fertilized egg from implanting in your womb.
Advantages:
- It works as soon as it's put in and lasts for up to ten years or until it’s removed.
- It can be removed at any time by a specially trained doctor or nurse with normal fertility returning rapidly.
- It is safe while you are breastfeeding.
- You can use an IUD whether or not you've had children. Most women can use an IUD, including women who have never been
pregnant and those who are HIV positive.
- It is very effective in which there will be no chance of pregnancy in more than %99 of the cases.
vaginal ring.
- There's no evidence that having an IUD fitted will increase the risk of cancer of the neck of the womb, cancer of the lining of the
womb (endometrial cancer) or ovarian cancer.
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- There is no evidence that the IUD affects weight.
Disadvantages:
- Your periods may become heavier, longer or more painful in the first three to six months after it is put in, but they're likely to settle
down after this.
- Some women may experience spotting or bleeding between their periods in the first 6 months.
- There's a very small chance of pelvic infection in the first 20 days after the IUD is fitted.
- Having the IUD put in can be uncomfortable. Ask your doctor or nurse about pain relief.
- If you get pregnant, there's a small increased risk of pregnancy out of the womb (Ectopic pregnancy). However, since you're
unlikely to get pregnant, the overall risk of ectopic pregnancy is lower than in women who don't use contraception. Please seek
advice immediately if you experience one sided tummy pain. Your IUD should be removed as soon as possible if you are continuing
with the pregnancy.
- Occasionally, the IUD is rejected (expelled) by the womb or can move (this is called displacement). This is more likely to happen
soon after it has been fitted, although this is uncommon. Your doctor or nurse will teach you how to check that your IUD is in place.
- An IUD may not be suitable for you if you've had previous pelvic infections.
- Some women experience changes in mood and libido, but these changes are very small.
- The most common reasons that women stop using an IUD are vaginal bleeding and pain.
- In rare cases, an IUD can damage your womb by making a hole in (perforate) the womb or neck of the womb when it's put in. This
can cause pain in the lower tummy, but doesn't usually cause any other symptoms. If the doctor or nurse fitting your IUD is
experienced, the risk of this is very low. However, if perforation occurs, you may need surgery to remove the IUD. Contact your GP
straight away if you feel a lot of pain after having an IUD fitted as perforations should be treated immediately.
Contraindications:
- If you have an untreated STI or a pelvic infection.
- If you have problems with your womb or neck of the womb.
- If you have any unexplained bleeding from your vagina – for example, between periods or after sex.
- Women who have had an ectopic pregnancy or recent abortion, or who have an artificial heart valve, must consult their GP or
clinician before having an IUD fitted.
- You should not be fitted with an IUD if there's a chance that you are already pregnant or if you or your partner are at risk of
catching STIs. If you or your partner are unsure, go to your GP or a sexual health clinic to be tested.
Female Sterilization:
Female sterilisation is usually carried out under general anaesthetic, but can be carried out under local anaesthetic, depending on
the method used.
How it works:
- The surgery involves blocking or sealing the fallopian tubes, which link the ovaries to the womb.
- It works by preventing eggs from travelling down the fallopian tubes and reaching sperm.
- This means a woman's eggs cannot meet sperm, and fertilization cannot happen.
- Eggs will still be released from the ovaries as normal, but they will be absorbed naturally into the woman's body. The tubes that
connect the ovary to the womb are cut or clipped so that the egg from the ovary cannot reach the uterus.
Advantages:
- It is very effective in which there will be no chance of pregnancy in more than 99% of the cases.
- Blocking the fallopian tubes (tubal occlusion) and removal of the tubes (salpingectomy) should be effective immediately –
however, doctors strongly recommend that you continue to use contraception until your next period
- Hysteroscopic sterilisation is usually effective after around three months – research collected by NICE found that the fallopian
tubes were blocked after three months in 96% of sterilised women
- There are rarely any long-term effects on your sexual health.
- It will not affect your sex drive.
- It will not affect the spontaneity of sexual intercourse or interfere with sex (as other forms of contraception can).
- Sterilisation can be carried out at any stage of the menstrual cycle. It won't affect hormone levels.
- You'll still have periods after being sterilised.
Disadvantages:
- The sterilization operation is difficult to reverse. This involves removing the blocked part of the fallopian tube and rejoining the
ends, and reversal operations are rarely funded by the NHS.
- A 2015 US study found that around 1 in 50 women who had a hysteroscopic sterilisation required further surgery due to
complications such as persistent pain.
- With tubal occlusion, there is a very small risk of complications, including internal bleeding and infection or damage to other
organs.
- You will need to use contraception until the operation is done and until your next period or for three months afterwards
(depending on the type of sterilization).
- There is a small risk for sterilization to fail. Blocked tubes can rejoin immediately or years after and make you fertile again,
although this is rare.
- If you do get pregnant after the operation, there is an increased risk of pregnancy out of the womb (ectopic pregnancy). Thus if you
miss a period, take a pregnancy test immediately. If the pregnancy test is positive, you must see your GP so that you can be referred
for a scan to check if the pregnancy is inside or outside your womb.
- With hysteroscopic sterilisation, there is a small risk of pregnancy even after your tubes have been blocked.
- Research collected by NICE has shown that possible complications after fallopian implants can include:
a. Pain after the operation
b. The implants being inserted incorrectly
c. Bleeding after the operation – many women had light bleeding after the operation, and nearly a third had bleeding for three days
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TM OBG 7-Miscarriage
Most common signs and symptoms:
1.Vaginal bleeding:
-From light spotting or brownish discharge to heavy bleeding and bright red blood.
-May come and go over several days.
Other symptoms and signs:
1. Cramping and pain in lower abdomen
2. A discharge of fluid from vagina
3. A discharge of tissue from vagina
4. No longer experiencing the symptoms of pregnancy, such as feeling sick and breast tenderness
Causes:
First trimester miscarriages:.
1. Chromosome problems
2. Placental problems
Risk Factors:
Age:
- in women under 30, 1 in 10 pregnancies will end in miscarriage
- in women aged 35-39, up to 2 in 10 pregnancies will end in miscarriage
- in women over 45, more than half of all pregnancies will end in miscarriage.
Other risk factor

-Smoking during pregnancy
-Alcohol more than two units per week
-Drinking more than 200mg of caffeine a day
-Poor diet (Obesity)
-Lack of Physical Activity (Obesity)
-Drug misuse during pregnancy
Second trimester miscarriages:.
PMH:
1. Infections:
- Rubella (german measles)
- Cytomegalovirus
- Bacterial Vaginosis
- HIV
- Chlamydia
- Gonorrhoea
- Syphilis
- Malaria
-Food poisoning:(Listeriosis, Toxoplasmosis, Salmonella)
2. Long-term health conditions:

- Diabetes (poorly controlled)
- Severe high blood pressure
- Lupus
- Kidney disease
- Hyperthyroidism
- Hypothyroidism
- Fibroids
- PCOS
3. Medications:
- Misoprostol
- Retinoids
- Methotrexate
- NSAIDs
4. Surgery:
Cervical incompetence (Weakened Cervix)
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TM OBG 7-Dermoid Cyst Teaching
What is a dermoid cyst?

The ovaries are a woman’s reproductive organs, which produce female hormones and release an egg
from a follicle each month. Occasionally, a cyst (which is a fluid-filled sac) can develop on or in the
ovary. An ovarian cyst can vary in size from a few centimetres to the size of a large melon. They may
be thin-walled an only contain fluid (this is known as a simple cyst) or they may be more complex
and contain thick fluid, blood, or solid areas.
Three types of cysts can occur before menopause:
-Simple cyst: This is usually a large follicle that has continued to grow after an egg has been released.
These are the most common to occur before menopause, and most typically disappear within a few
months.
-Endometrioma: Endometriosis, where cells of lining of the womb are found outside the womb,
sometimes causes ovarian cysts and these are called endometriomas.
-Dermoid cyst: These develop from the cells that make eggs in the ovary, and often contain
substances such as hair and fat.
Symptoms
Ovarian cysts are quite common, and most women are unaware that they even have a cyst as they
often cause no symptoms and tend to disappear spontaneously with time. Most tend to be
diagnosed by chance, for example during a routine examination or if you have an ultrasound scan for
another reason.
-Sometimes they do cause one or more of the following symptoms:
-Lower abdominal pain
-Painful periods
-Change in the pattern of periods
-Pain during sex
-Swollen abdomen
-Difficulty in becoming pregnant
-Change in appetite/feeling full more quickly
Complications
Occasionally complications can arise from these cysts. These can occur if the cyst ruptures, is very
large, or is blocking the blood supply to the ovaries (torsion). Very rarely, an ovarian cyst is an early
form of ovarian cancer, however 95% of them are non-cancerous.
Why do they occur?
Certain conditions can predispose an individual to develop ovarian cysts. If a person has
endometriosis, they can develop ovarian cysts. Endometriosis occurs when pieces of the tissue that
line the womb (the endometrium) are found outside the womb in areas such as the fallopian tubes,
ovaries, bladder, bowel, vagina, or rectum. Sometimes, blood-filled cysts can form in this tissue.
Another condition ,which can lead to cysts is polycystic ovarian syndrome (PCOS), where lots of
small, harmless cysts develop on the ovaries. The cysts develop if there is a problem with the
balance of hormones that are produced by the ovaries.
How can they be diagnosed?
Many go undiagnosed as most are symptomless, but occasionally they may be found during a pelvic
examination or during an unrelated ultrasound. Sometimes if an ultrasound shows a partially solid
cyst, a blood test may be done to measure the levels of a protein called CA125, which is often
elevated in cases of ovarian cancer.
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How can they be treated?
Treatment depends on the following:
-Appearance and size
-If there are any symptoms
-Whether or not menopause has already occurred
In a majority of cases, a policy of ‘watchful waiting’ is recommended, as most cysts will disappear after a
few weeks without any need for treatment. A follow-up ultrasound will usually confirm if this proves to
be the case.
If the cyst is large, or if it is causing symptoms, it will need to be removed. There are two types of
operations, which are usually carried out under general anaesthesia. They are:
-Laparoscopy
-Laparotomy
In laparoscopy, smaller cysts are typically removed. It is a type of keyhole surgery where small cuts are
made in your lower abdomen and gas is blown into the pelvis to lift the wall of the abdomen away from
the organs inside. Then, a laparoscope (which has a light on the end), is passed into your abdomen so the
surgeon can view the internal organs. Using tiny surgical tools, the surgeon will be able to remove the
cyst through the small cut in the skin.
After the procedure, the cuts are closed with dissolvable stitches. It can take about half an hour to
perform, and most women can go home on the same day as the operation. It is the preferred approach
as it causes less pain, helps to preserve fertility, and lets you resume normal activity sooner.
In laparotomy, a larger cut is made to give the surgeon better access to the cyst. The whole cyst and
ovary is removed and sent to the laboratory to check whether it is cancerous. The skin is then stitched
closed, and the patient may have to stay at the hospital for a few days.
What about fertility?
If only one of the ovaries are removed, the remaining ovary will still release hormones and eggs as
normal, so fertility should remain unaffected. If both ovaries need to be removed, this may trigger early
menopause, but it is still possible to have a baby by having a donated egg implanted into the womb.
What if it is cancer?
If the cyst is found to be cancerous, both ovaries along with the womb and some surrounding tissue may
need to be removed. This too would trigger early menopause and leave the patient unable to have
children.
(A dermoid ovarian cyst is more rounded and larger than the normal ovary. A cyst with an irregular border directs to a cancerous lesion.)
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COMBINED MANNEQUIN 2 - URINARY RETENTION
Obstruction
1.BPH
2. CA Prostate
3. UTI
4. Calculi
5. Prostatitis
6. Urethral stricture
7.Constipation
Neurogical
1. MS
2. CES (Cauda Equina Syndrome)
3. PID (Prolapsed Intervertebral Disk)
4. Malignant spinal cord compression
5. DM (Diabetic Neuropathy)
Medication
1. Anticholinergic
2. Antihypertensive
3. Tricyclic Antidepressant
MANAGEMENT
1. Pain score pre and post catheter.
2. Measure and record BP (Lying and standing)
3. Urine test
4. Bloods: U&E, FBC.
5. PSA if patient is above 50
6. IV Cannula if residual volume more than I L.
7. Tamsulosin
8. Antibiotic Gentamycin 5 mg/kg if patient presents with signs of infection prior to retention or if there is evidence of
UTI in investigation (no longer than 30 min before catheterization)
9. Patient will be sent to the observation unit (CDU) for minimum of 2 hours.
10. Urine Output recorded every 60 min.
NOTE: In observation unit, we need to assess if patient is fit for discharge after necessary steps or if patient should be
referred.
Refer if:
1. There is evidence of macroscopic haematuria.
2. Catheter becomes blocked (urine output stops and patient feels pain similar to admission)
3. Urine output is 400ml/hr or more than 3 L, 2 hours after catheterization.
4. There is inability to manage catheter at home.
What should be done before discharge?

1. Prescribe Tamsulosin
2. Education about how to change the catheter bag and how to record urine output.
3. Arrange for outpatient referral (TWOC)
4. Giving warning signs for UTI and Urinary Retention
What is TWOC?
It stands for Trial Without Catheter.
Your TWOC involves 2 visits to clinic, 4 hours apart. First visit takes 15 minutes and the second one takes up to 30
minutes.
Your catheter will be removed.
You will be asked to fill your bladder safely by drinking a glass of water once per hour for 4 hours.
When you feel you need to pass urine you should use toilet.
After 4 hours you will have an US of your bladder.
At the end of trial we discuss the result with you. If you are able to pass urine normally you will be sent back home
without catheter, otherwise we will re-catheterise you and discuss about further management.
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COMBINED MANNEQUIN 3 A - PARACETAMOL OVERDOSE
BRIEF HISTORY
Paracetamol
1. What did you take?
2. When did you take it?
3. How much did you take?
4. How did you take it? (In one go or scattered dose)
5. Did you take anything else with it? (Alc/rec. drug/other med)
6. What did you do after that? (Any induced vomiting?)
Symptoms
1. Any nausea/vomiting
2. Any tummy pain.
PMH
1. Medical Illness (Liver or Kidney Disease)
2. Any regular medication (Including OTC and supplements)
3. Allergy
MANAGEMENT
-Administration of activated charcoal if paracetamol in excess of 150 mg/kg is thought
to have been ingested within the previous hour.
- Plasma Paracetamol Concentration should be done after 4 hours of paracetamol
ingestion.
-We need to start the medication (N-Acetyl Cysteine), if the level of Plasma Paracetamol
Concentration is above the treatment curve.
-Medication will be given as an IV Infusion and in total takes about 21 hours. (1+4+16)
-We need to start NAC for those who present 8-24 hours taking an acute overdose even
if Plasma Paracetamol Concentration is not yet available.
When we will stop the medication?

1. If patient develops following side effects:
- Allergic reaction (symptoms of mild fever or rash): Treat with Anti-Histamine.
- Asthma like symptoms: Treat with Nebulised Salbutamol
2. If Plasma Paracetamol Concentration is not ready and patient took more than
150mg/kg in the last 8-24 hours, you need to start NAC without blood results.
However, you need to stop the medication if:
- PPC comes back normal
- Patient is asymptomatic
- Blood tests are normal (LFTs, serum creatinine and INR)
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MANNEQUIN 3 B -Paracetamol Overdose:
Toxic dose of paracetamol may cause severe hepatocellular necrosis and renal tubular necrosis.
Symptoms of paracetamol overdose:

1. Nausea and vomiting are the earlier features of paracetamol poisoning and usually settle
within 24 hours.
2. Right subcostal pain and tenderness usually indicates hepatic necrosis.
3. Yellowing of the skin and eyes (jaundice)
4. Loss of co-ordination
5. Encephalopathy
6. Haemorrhage.
7. Hypoglycaemia.
8. Cerebral oedema.
Liver damage is maximal after 3-4 days after paracetmol overdose. Despite a lack of significant
early symptoms, patients who have taken an overdose of paracetamol should be transferred to
the hospital immediately.
N acetyl cysteine (NAC) protects the liver if infused up to and possibly beyond 24 hours of
ingesting paracetamol. It is most effective if given within 8 hours of ingestion, after which
effectiveness declines.
Acute overdose:
Hepatotoxicity may occur after a single ingestion of more than 150 mg/kg paracetamol taken in
less than an hour. Rarely hepatotoxicity may develop with single ingestion as low as 75 mg/kg
of paracetamol taken in less than one hour. Patients who have ingested 75 mg/kg or more of
paracetamol in less than 1 hour should be referred to the hospital.
Administration of activated charcoal should be considered if paracetamol in excess of 150
mg/kg is thought to have been ingested within the previous hour.
Patients at risk of liver damage and therefore, requiring N acetyl cysteine can be identified from
a single measurement of the plasma paracetamol concentration related to the time from the
ingestion provided this time interval is not less than 4 hours, earlier sample may be misleading.
The concentration is plotted on a paracetamol treatment graph with a reference line.
N acetyl cysteine should commence immediately in patients:

1. Whose plasma paracetamol concentration falls on or above the treatment line on the
paracetamol treatment graph.
2. Who present 8-24 hours taking an acute overdose of more than 150 mg/kg of paracetamol,
even if the plasma paracetamol concentration is not yet available.
N acetyl cysteine can be discontinued if the plasma paracetamol concentration is later reported
to be below the treatment line on the paracetamol treatment graph provided that the patient is
asymptomatic and liver function tests, serum creatinine and INR are normal.
The prognostic accuracy of a plasma paracetamol concentration taken after 15 hours is

uncertain. But a concentration on or above the treatment line on the paracetamol graph should
be regarded as carrying a serious risk of liver damage. If more than 15 hours have elapsed since
ingestion, or there is doubt about appropriate management advice should be sought from the
national poisons information service.
Staggered overdose, uncertain time of overdose:
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A staggered dose involves ingestion of a potentially toxic dose of paracetamol over more than an
hour.
The paracetamol treatment is unreliable if a staggered overdose is taken, if there is uncertainty
about the time of the overdose or if there is therapeutic excess. In these cases patients who have
taken more than 150mg/kg of paracetamol in any 24 hours period are at risk of toxicity and
should be commenced on N acetyl cysteine immediately, unless it is more than 24 hours since
the last ingestion and the patient is asymptomatic, the plasma paracetamol concentration is
undetectable and liver function test, serum creatinine and INR are normal.
Rarely toxicity can occur with paracetamol doses between 75-150 mg/kg in any 24 hours
period, clinical judgement of the individual case is necessary to determine whether to treat
those who have ingested this amount of paracetamol. For small adults, this may be within the
licenced dose, but ingestion of a licenced dose of paracetamol is not considered an overdose.
Significant toxicity is unlikely if, 24 hours or longer after the last paracetamol ingestion, the
patient is asymptomatic, the plasma paracetamol concentration is undetectable, and liver
function test, serum creatinine and INR are normal.
Patients with clinical features of hepatic injury such as jaundice or hepatic tenderness should be
treated urgently with N acetyl cysteine.
If there is uncertainty about a patient risk of toxicity after paracetamol overdose, treatment
with N acetyl cysteine should be commenced.
Advice should be sought from the national poisons information service wherever necessary.
Acetyl cysteine dose and administration:

For paracetamol overdose N acetyl cysteine is given in a total dose that is divided into 3
consecutive intravenous infusions over a total of 21 hours. The required dose of N acetyl
cysteine is added to glucose intravenous infusion 5%.
First infusion (Based on acetyl cysteine dose of approx. 150mg/kg) add require volume of acetyl
cysteine concentration for intravenous infusion to 200 ml Glucose intravenous infusion 5%
infuse over 1 hour.
Second infusion (Based on acetyl cysteine dose of approx. 50mg/kg start immediately after the
completion of the first one) add require volume of acetyl cysteine concentration for intravenous
infusion to 500 ml Glucose intravenous infusion 5% infuse over 4 hour.
Third infusion (Based on acetyl cysteine dose of approx.. 100mg/kg start immediately after the
completion of the second one) add require volume of acetyl cysteine concentration for
intravenous infusion to 1 lt Glucose intravenous infusion 5% infuse over 16 hours.
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Combined Mannequin 4 Sudden Loss of Vision
D/Ds for sudden loss of vision

1. GCA
2. TIA (amarousis fugax)
3. Central retinal artery occlusion (CRAO)
4. Central retinal vein occlusion
5. Migraine
6. Optic neuritis (due to conditions such as MS)
7. Posterior vitreous detachment
Central retinal artery occlusion

Symptoms:
1. Sudden loss of vision
2. Painless
3. Redness in eye
Risk factors:
1. GCA
2. HTN
3. Diseases causing atherosclerosis eg diabetes
Central retinal vein occlusion

Symptoms:
1. Sudden/gradual (from days to weeks)
2. Painful blindness
3. Photophobia
4. Redness
Risk factors:
1. Blood disorders
2. HTN
3. Diabetes
4. Clotting disorders
5. Excessive alcohol consumption
Retinal detachment
Symptoms:
1. Floaters
2. Loss of central vision
3. Visual field defect (like a black curtain)
Risk factors:
1. Posterior vitreous detachment
2.History of intraocular surgery such as cataract
Posterior vitreous detachment

Symptoms:
1. Flashing light
2. Shadow in peripheral visual field (curtain like)
Risk factors:
1. Aging
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COMBINED MANNEQUIN 5 - BREECH PRESENTATION
In early pregnancy breech is very common. As pregnancy continues a baby usually turns
naturally into the head first position. Between 37 and 42 weeks, most babies are lying head first
ready to be born. Breech presentation is usually temporary presentation during the third
trimester. If your baby is breech you may feel discomfort under your ribs and become
breathless as your baby‘s head presses up under your diaphragm. You may also feel some sharp
kicks to your bladder.
Why some babies are breech:

Sometimes it is just a matter of chance that a baby doesn’t turn and remains in the breech
position.
At other times certain factors makes it difficult for the baby to turn. This includes:
a. The amount of fluid in your womb (either too much or too little)
b. The position of after birth.
c. If there is more than one baby in the womb.
Is it serious?
The vast majority of breech babies are born healthy.
For few babies breech may be a sign of problem with the baby. However, all babies will have a
new born examination.
What can be done?

First option:
If you are 36 weeks pregnant and the baby is in breech presentation your doctor or mid-wife
should discuss external cephalic version (ECV) in which they try to turn your baby to a head
down presentation by applying gentle pressure on your tummy that helps the baby to turn in
the womb to lie in head first. This procedure will be done in a maternity unit.
NOTE 1
ECV is usually offered from
a. 36 weeks for the first baby.
b. 37 weeks if you had a baby before.
ECV can be done right up until you give birth.
NOTE 2
ECV is not recommended for those:
a. Who have had vaginal bleeding recently.
b. Who are expecting twins or more.
NOTE 3
ECV is more likely to work:
a. If you have given birth previously.
b. If you have plenty of amniotic fluid.
NOTE 4
You will be given the medication during the procedure to relax the muscle of your womb. This
medication will not affect the baby.
NOTE 5
If the baby doesn’t want to turn, it is possible to have a second attempt on another day.
If baby doesn’t turn after second attempt your doctor or mid-wife will discuss your option for
birth.
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Is ECV safe for mum and baby?
ECV is generally safe and doesn’t cause labour to begin.
The baby heart will be monitored before and after the procedure.
Complications of ECV:
1 in 200 babies need to be delivered by emergency C- section immediately after the procedure
because of
a. Bleeding of the after birth
b. Changes in the baby heartbeat.
Is ECV painful?
It can be uncomfortable. Tell your doctor or mid-wife, if you have pain so they can move their
hand or stop.
Warning Signs (Call to hospital):

1. Bleeding.
2. Tummy pain
3. Contractions.
4. Reduce movements after ECV.
Is there is anything else I can do to help my baby turn?

There is no research based evidence that lying down or sitting in a particular position can help
your baby to turn.
What is my choice for birth if ECV didn’t work?

Second option:
C- Section.
Most breech babies in the UK are born by C- section as it is considered to be the safest way for
the breech babies to be born.
Third option:
Vaginal breech delivery
a. If you prefer breech vaginal birth your doctor may be supportive if:
1. You have given birth vaginally before.
2. There is no factor that will make giving birth vaginally more risky.
b. Your doctor may strongly advice you against a vaginal birth if :

1. Your baby is footling breech.
2. Your baby is large
3. Your baby is small.
4. Your baby is in certain position e.g. hyperextended neck.
5. You have had C- section delivery in previous pregnancy.
6. You have a narrow pelvis.
7. You have a low lying after birth.
8. You have pre-eclampsia.
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TM COMBINED MANNEQUIN 6 OTOSCOPY
Infections of middle ear that cause redness and swelling and sometimes a build up of
fluid behind the ear drum.
SYMPTOMS
1. Ear pain
2. Temperature
4. Fatigue
5. Slight hearing loss.
6. Discharge
RISK FACTORS
1. PMH
-URTI
-Immunocompromised patient
- Chronic Sinusitis
2. Personal History
- Smoking (Active/Passive)
3. Social History
- Swimming
INVESTIGATIONS
1. Culture of discharge
2. CT/MRI to exclude complications
3. Tympanometry
It is a test that measures how the ear drum reacts to change in air pressure
TREATMENT
1. Control the pain
2. Control the fever
3. Give antibiotics
Treatment of choice for Otitis Media:
Amoxycillin 500mg TDS x 5 days
If patient is penicillin allergic
Erythromycin - 500 mg QDS x 5 days
Clarithromycin - 500 BD x 5 days
4. If allergic – Nasal or Oral Steroid
ADMISSION
- If patient is systematically unwell
- If complications
1. Meningitis
2. Mastoiditis
3. Facial Nerve Paralysis
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TM COMBINED MANNEQUIN 7 - BREAST EXAMINATION
BENIGN BREAST LUMPS
A) Fibroadenosis – Fibrocystic Breast Disease
Symptoms:
1) Pain
a. One or both breasts
b. It can only effect a part of one breast
c. It can be a discomfort or very painful
d. It starts before or during period
e. It usually disappear after periods
2) Increase in size of breast

3) Lumpiness of breast
B) Fibroadenomas
1. Characteristics
a. Smooth
b. Well-rounded
c. Solid
d. Moveable around with breast
2. They can disappear on their own.

3. They can grow larger during pregnancy
4. They don’t usually disappear after period
5. They are more common in
a. Premenopausal woman
b. Postmenopausal on HRT
C) Breast Cyst
1.Types
a. Fluid-filled sacs
b. Smooth
c. Firm
2. Common age 30-60
3. It can be single or multiple in one or both breast
4. Usually without symptoms (may present pain).
D) Breast Abscess (painful collection of pus)

Symptoms
1. Pain
2. High Temperature
3. Redness
4. Swelling
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BREAST CARCINOMA
Symptoms
1. New lump with or without pain
2. Near thickened tissue
3. Dimpling on Skin
4. Change in Size of breast
5. Change in Shape of breast
6. Change in the appearance of nipple
7. Discharge from nipple
8. Rash around the nipple
9. Swelling in arm pit
10. Pain in armpit
Risk Factors
1. Age over 50 years
2. PMH
a. Medical illness (Breast Cancer / Benign Lump)
b. Medication (OCP/HRT / Radiotherapy)
c. Family History of Breast/Ovarian Cancer
d. Period (Starting periods early or finishing late)
e. Pregnancy (Not having a baby or having a baby in later age)
3. Personal History
a. Alcohol
b. Obesity (Poor diet and lack of physical activity)
c. Smoking
Referral by GP:
Although most lump are not breast cancer, any unusual change into breast should be checked by
a GP as soon as possible. If GP finds a lump on examination, patient should be referred to a
specialist.
GPs follow guidance when deciding whether or not to refer you to a breast clinic.
Anyone suspected of having a breast cancer should be seen within two weeks of being referred.
According to NICE Guidelines:

NICE recommends that GPs refer anyone with a breast problem for an urgent breast clinic
appointment (to be seen within two weeks) if they are:
1. Aged 30 and over and have an unexplained breast lump with or without pain
2. Aged 50 and over with any of the following symptoms in one nipple only:
a. Discharge (liquid)
b. Retraction (the nipple becoming pulled in)
c. Other changes of concern
3. They should also consider an urgent appointment for people:

a. With skin changes that suggest breast cancer
b. Aged 30 and over with unexplained lump under the arm (axilla)
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GPs should also consider making a non-urgent referral for people aged less than 30 with an
unexplained breast lump with or without pain. However, any referral decisions must be made
on a case-by-case basis.
All other non-urgent referrals will be seen as soon as possible on a case-by-case basis. In
England this could still be within two weeks.
If you have any queries about the waiting time of your appointment, talk to your GP.
Screening Test:
For a patient above 50, every 3 years a mammogram should be done.
If you’ve been recalled to a breast clinic after having a routine mammogram as part of a national
breast-screening programme, you should receive a letter within two weeks of your
mammogram explaining when your breast clinic appointment will be.
About four women in a hundred are called back to a breast clinic following routine screening
because they need more tests. This happens more often after a woman’s first mammogram,
usually because there are no other mammograms to compare with. Something that may look
unusual on your mammogram may be entirely normal for you, and most women who are
recalled for assessment will not have breast cancer.
What to expect at the breast clinic.

Your visit to the breast clinic may take several hours so that all necessary tests can be carried
out.
You may be asked to fill a short questionnaire before you are seen by a doctor or a specialist
nurse. This includes questions about any family history of breast problem, any medication you
are taking, including contraceptive pill and hormone replacement therapy.
1. Examination
This is followed by a breast examination. As a part of examination it is normal to examine the
lymph nodes (glands under your arm and around your neck).
You may then need to have further tests. These usually include one or more of the following:
2. Imaging
These can be a mammogram or an Ultrasound Scan.
a. Mammogram
They may consider a mammogram, which is a simple procedure that uses X-Ray to create an
image of the inside of your breast. Younger women (under 40) usually have denser breasts than
older women, which makes changes more difficult to identify. So you may have an Ultrasound
instead.
If you need to have an X-Ray, Specialist will position one of your breast on a flat X-ray plate. A
second X-Ray plate will press down on your breast from above so your breast will be
temporarily flattened between the two plates. An X-Ray will be taken which will produce a clear
image of inside of your breast.
After the first X-Ray has been done, the same procedure will be carried our on your other
breast.
It may be a bit uncomfortable but it takes only a few minutes.
b. Ultrasound
If you are under 40, a breast U/S may be recommend because your breast tissue may be too
dense for a mammogram.
This test helps us to know if a lump in your breast is solid or it contains liquid.
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This scan uses high-frequency sound waves to produce an image of inside of your breast. An U/S
probe or sensor will be placed on your breast to create an image on monitor. The images will
highlight any lump or abnormalities in your breast.
3. Biopsy
Fine Needle Aspiration
A needle will be inserted through your skin. Ultrasound Scan or X-Ray will be used to help the
doctor guide the needle to exactly the right place. When the needle is in position, it will suck out
a sample of tissue.
A numbing medication will be usually used so you won’t feel pain or discomfort during the
procedure.
Mammogram biopsy
Vacuum-assisted biopsy also known as mammogram biopsy is another type of biopsy. During
the procedure a needle is attached to a gentle suction tube, which helps to obtain a sample and
clear any blood from the area.
Having a breast examination, breast imaging and tissue sampling is known as triple
assessment. This may be necessary to make a definite diagnosis.
However, not everyone will need to have a triple assessment; it depends on your symptoms, age
or the findings from your other assessments. For example, women under 30 with breast pain
are unlikely to have any imaging as it isn’t helpful in making a diagnosis. A biopsy or FNA may
not be needed in women under 25 if the breast examination and imaging appear normal or
benign (not cancer).
Your assessment may be done in a one-stop clinic. This is where all of these tests are carried
out during your visit to the clinic with the results available later that day. In some areas you may
be asked to make another appointment to finish your tests or to get your results. If this happens,
you may have to wait about a week for your test results.
Getting results:
Having investigations for a breast problem can be a worrying and stressful time.
The staff in the breast clinic will know that you want the results as soon as possible and your
specialist may be able to tell you what they think the outcome might be. However, the results of
all the investigations you’ve had are usually needed before you can be given more detailed
information. If you are anxious about your results or would like to talk to someone about any
concerns you can call our Helpline.
The breast clinic will let you know how and when you’ll get your results. You’ll usually be given
an appointment to return for your results, but occasionally your results may be given in a phone
call or a letter. A summary of your breast assessment and results will then be sent to your GP;
and a copy of this letter will usually be sent to you.
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COMBINED EXAMINATION 1 – CHRONIC DIARRHOEA
BOWEL CANCER
SYMPTOMS
Bowel Symptoms
1. Change in Bowel habit
2. Altered bowel habit
3. Per rectal bleeding
4. Tenesmus
Other Symptoms
5. Abdominal Pain
General Symptoms
6. Weight loss
7. Loss of appetite
8. Anaemia Symptoms
RISK FACTORS
1. The ones we don’t ask.
a. Age
b. Gender: More in males
2. PMH
a. Medical Illness
- IBD
- Polyps
b. Family History
3. Personal History
a. Smoking
b. Poor diet (low fibre diet and high in protein especially red and processed meat)
c. Lack of physical activity
d. Alcohol
INVESTIGATION
1. Routine Bloods (Including FBC)
2. Colonoscopy / Sigmoidoscopy +/- Biopsy
3. LFTs, Ultrasound and CT Scan
4. CEA
SCREENING
FOB (Faecal Occult Blood)
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CROHN’S DISEASE
SYMPTOMS
Common
1. Diarrhoea (With blood or mucus or pus)
2. Abdominal pain
3. Mild fever
4. +/- Weight Loss
Other
5. Eye problem
6. Joint problem
7. Skin changes
8. Mouth ulcers
RISK FACTORS
PMH
1. Exacerbating Factor – URTI
2. Other autoimmune disease such as DM, RA, Coeliac Disease & Thyroid Problem.
3. NSAIDS
4. Family History
Personal History
1. Smoking.
EXAMINATION
On General Examination, you can look for the following:
- Weight loss
- Anaemia
- Skin Tag
- Clubbing
- Conjunctivitis
- Joint Pain
- Mouth Ulcer
Vitals
1. Increased Pulse Rate
2. Increased Temperature
3. Decreased Blood Pressure
INVESTIGATIONS
1. Blood Test
- FBC
- CRP
-U&E
2. Stool Culture
3. Colonoscopy
4. CT Scan
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DIVERTICULAR DISEASE
DIVERTICULOSIS SYMPTOMS
Most Common
1. Abdominal Pain
a. LIF
b. Intermittent
c. Increases after eating
d. Decreases after passing stool
Other
a. Constipation
b. Diarrhoea
c. Episode of constipation that is followed by diarrhoea
3. Bloating

a. Dark purple
b. Usually after diarrhoea
DIVERTICULITIS SYMPTOMS & SIGNS

1. Abdominal Pain
a. Usually starts below belly button and then moves to LIF (sometimes right)
b. Sudden
c. Constant
d. Severe pain
2. Change in bowel habits.

3. Bloating
4. Bleeding PR
5. Fever (Above 38)
6. Nausea/Vomiting
7. Fast pulse (tachycardia)
8. Shock features e.g. hypotension (Sometimes)
9. Palpable mass in lower quadrant
10. Reduced bowel sounds.
RISK FACTORS
1. PMH
a. Previous Episode
b. Constipation
c. NSAIDs
d. Family History (age under 50)
2. Personal History
a. Smoking
b. Diet (obese patients)
c. Physical Activity (obese patients)
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D/D’s:
1. Irritable bowel syndrome
2. Acute appendicitis
3. Crohn’s disease.
4. Colorectal cancer.
5. Ischaemic colitis (In elderly)
In female patients
6. Ruptured ovarian cyst
7. Ovarian torsion
9. PID
COMPLICATIONS
1. Perforation
2. Abscess
3. Fistula, stricture or obstruction.
4. Haemorrhage (mainly in proximal colon)
INVESTIGATIONS
1. Full blood count.
2. CXR.
3. Abdominal X-Ray
4. Contrast Enemas
5. Contrast CT
6. Endoscopy - Generally avoided in acute diverticulitis because of the risk of perforation. It is used to
exclude other possibilities only when the diagnosis is unclear.
7. Flexible sigmoidoscopy or colonoscopy to localize the lesion.
TREATMENT
1. Maintain hydration. Initially clear fluids only. Gradually introduce solid food.
2. Pain killer (mainly Paracetamol)
3. Broad spectrum antibiotics such as Co-Amoxiclav. If Penicillin allergic – Ciprofloxacin and
Metronidazole.
4. Mesalazine (helps in improving and preventing the symptoms)
General advice:
1. High fibre diet
2. Avoid NSAIDs and opioids.
3. Bulk forming laxatives
Hospital admission IF:

1. Pain not controlled by Paracetamol.
2. Oral fluids and antibiotics are not tolerated.
3. Immunocompromised individual.
4. Any complication like rectal bleeding, fistula, abscess or perforation occurs.
5. Symptoms persist after 48 hours of conservative treatment.
Indication of surgery:
1. Peritonitis.
2. Uncontrolled sepsis.
3. Fistula.
4. Obstruction.
5. Inability to exclude cancer.
6. Recurrent attacks
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Teaching Material Combined Examination 1B
IBS is a common condition that affects the digestive system.

It causes symptoms like stomach cramps, bloating, diarrhoea and constipation. These tend to
come and go over time, and can last for days, weeks or months at a time.
It's usually a lifelong problem. It can be very frustrating to live with and can have a big impact
on your everyday life.
There's no cure, but diet changes and medicines can often help control the symptoms.
The exact cause is unknown – it's been linked to things like food passing through your gut too
quickly or too slowly, oversensitive nerves in your gut, stress, and a family history of IBS.
Symptoms:
The main symptoms of IBS are:
-Stomach pain or cramps – usually worse after eating and better after doing a poo
-Bloating – your tummy may feel uncomfortably full and swollen
-Diarrhoea – you may have watery poo and sometimes need to poo suddenly
-Constipation – you may strain when pooing and feel like you can't empty your bowels fully
There may be days when your symptoms are better and days when they're worse (flare-ups).
They may be triggered by food or drink.
Other symptoms of IBS:

-Farting (flatulence)
-Passing mucus from your bottom
-Tiredness and a lack of energy
-Feeling sick (nausea)
-Backache
-Problems peeing – like needing to pee often, sudden urges to pee, and feeling like you can't
fully empty your bladder
-Not always being able to control when you poo (incontinence)
Tests for IBS:

There's no test for IBS, but you might need some tests to rule out other possible causes of your
symptoms.
Your GP may arrange:
-A blood test to check for problems like coeliac disease
-Tests on a sample of your poo to check for infections and inflammatory bowel disease
Diet, lifestyle and medicines:

There's no single diet or medicine that works for everyone with IBS. But there are lots of things
that can help if you've been diagnosed with it.
General tips to relieve IBS symptoms:
DO
-Cook homemade meals using fresh ingredients when you can
-Keep a diary of what you eat and any symptoms you get – try to avoid things that trigger your
IBS
-Try to find ways to relax
-Get plenty of exercise
-Try probiotics for a month to see if they help
DON'T
-Delay or skip meals
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-Eat too quickly
-Eat lots of fatty, spicy or processed foods
-Eat more than 3 portions of fresh fruit a day (a portion is 80g)
-Drink more than 3 cups of tea or coffee a day
-Drink lots of alcohol or fizzy drinks
How to ease bloating, cramps and farting

-Eat oats (such as porridge) regularly
-Eat up to 1 tablespoon of linseeds a day
-Avoid foods that are hard to digest – like cabbage, broccoli, cauliflower, brussels sprouts, beans,
onions and dried fruit
-Avoid products containing a sweetener called sorbitol
-Ask a pharmacist about medicines that can help, like peppermint oil
How to reduce diarrhoea

-Cut down on high-fibre foods, like wholegrain foods (such as brown bread and brown rice),
nuts and seeds
-Avoid products containing a sweetener called sorbitol
-Ask a pharmacist about medicines that can help, like loperamide
-If you keep getting diarrhoea, make sure you drink plenty of water to avoid dehydration.
How to relieve constipation

-Drink plenty of water to help make your poo softer
-Increase how much soluble fibre you eat – good foods include oats, pulses, carrots, peeled
potatoes and linseeds
-Ask a pharmacist about medicines that can help (laxatives)
Seeing a dietitian for IBS

Your GP may be able to refer you to an NHS dietitian if general diet tips for IBS aren't helping.
They can suggest other changes you can make to your diet to ease your symptoms.
Low FODMAP diet

A dietitian may recommend a diet called a low FODMAP diet.
This involves avoiding foods that aren't easily broken down by the gut, such as some types of:
-Fruit and vegetables
-Milk
-Wheat products
IBS medicines from a GP

If pharmacy medicines aren't helping, your GP may prescribe a stronger medicine such as:
-Amitriptyline
-Citalopram
These are antidepressants, but they can also help ease IBS symptoms. They may take a few
weeks to start working and can cause side effects.
Your GP may refer you to a specialist if you have severe symptoms and other medicines haven't
helped.
Psychological therapy for IBS

If you've had IBS for a long time and other treatments aren't helping, your GP may refer you for
therapy such as cognitive behavioural therapy (CBT).
This can help if stress or anxiety is triggering your symptoms. It can also help you cope with
your condition better.
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COMBINED EXAMINATION 2 – DIABETIC SCREENING & MANAGEMENT
1. Weight check (BMI)
We check your weight once a year, even if you are healthy weight. If you are overweight we measure it.
2. BP check (screening)
3. Foot examination
It should be done twice a year. We check for any cut, burn or ulcer. We also check for circulation and the level of
feeling in your feet for any signs of nerve damage.
4. Blood glucose control check (Hba1C)
This test measures how well controlled the blood sugar has been in the past few months. The higher it is the greater
the risk of complications. It should be done at least once a year. Taken at intervals of 3, 6 or 12 months.
5. Kidney function test (Kidney Screening)
We usually do two tests:
a. One is urine to check for protein
b. Blood samples
6. Lipid Blood Check (Cholesterol Screening)
Usually taken a couple of weeks before the annual diabetic care review.
7. Retinopathy screening
Each year a picture is taken of the back of the eye that is the retina. It is done at a hospital or at an optician’s.
Additional checks:
1. Individual diabetic care plan
It is an agreement between you and the doctor for the management of your DM.
a. Goals, for example:
- Keeping Hba1C below a certain level
- To fit half an hour activity into each day
- Quit smoking
b. Support services from NHS
c. Medication that you are taking
d. A diet plan
e. Exercise plan
2. Diabetes education
You can join a diabetes education course.
3. Support to quit smoking
4. Psychological support
People with DM are more likely to be diagnosed with depression. This can have a serious impact on their wellbeing
and their ability and motivation to self-manage their condition
5. Access to medical specialist:
You will be given access to a range of specialists such as dietician, podiatrist if needed
MEDICATION AND TYPE II DM

1. If HbA1C rises to 6.5% on life style intervention, you can offer metformin
Support the patient to aim for 6.5%.
2. If rises to 7, consider dual therapy:

a. Metformin along with
i. DPP-4i OR
ii. Pioglitazone OR
iii. Sulfonylurea OR
iv. SGLT-21
Support the patient to aim for 7.
3. If it rises above 7.5,

a. Triple therapy with:
i. Metformin, a DPP-4i and an SU
ii. Metformin, Pioglitazone and an SU
iii. Metformin, pioglitazone/SU and an SGLT-2i
b. Insulin based treatment

Support the patient to gain a level of 7.
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Target blood glucose levels:
Target level Upon waking Before meal At least 90 minutes after

meal
Non- diabetic - 4-5.9 <7.8
Type II - 4-7 <8.5
Type I 5-7 4-7 5-9
Children with type I 407 4-7 5-9
Diagnosis of DM
TEST NORMAL PREDIABETES DIABETES
Random <11.1 N/A >11.1
Fasting <6.1 6.1-6.9 >7
Two hours post meal <7.8 7.8-11 >11.1
Random blood sample can be taken at any time. It’s used for diagnosis for type 1.
Fasting Blood sugar is taken after at least 8 hours of fasting and usually is taken in the morning.
Oral Glucose Tolerance Test (OGTT):

This test involves taking a first fasting blood sample and then taking a very sweet drink containing 75gm of glucose.
After this drink, patient needs to stay at rest until the blood sample is taken after 2 hours.
Hba1C Test
This doesn’t measure directly how much glucose is there at the time, instead it tells us the blood sugar control of the
past 2-3 months.
Indications of diabetes/pre-diabetes:
Normal <6% (42 mmol/mol)
Pre-diabetes 6-6.4% (42-47)
Diabetes 6.5% and more 48 or more
Target is 6.5% or 48 for diabetics.
342
COMBINED EXAMINATION 3 NEUROLOGICAL EXAMINATION OF
LOWER LIMB
Peripheral neuropathy develops when nerves in the hands, feet, legs and the arms are
damaged. The symptoms depend on which nerves are affected.
Causes:
1. Diabetes is the most common cause of neuropathy in the UK.
It is probably caused by the high levels of glucose in your blood, damaging the tiny
blood vessels that supply your nerves.
2. Excessive alcohol drinking for years is the other cause of peripheral neuropathy.
Alcohol can be toxic to nerve tissue. People who drink too much may start to feel pain
and tingling in their limbs known as alcoholic neuropathy.
3. Other:
- Low level of Vitamin B12
- Physical damage to nerves
- An underactive thyroid gland (Hypothyroidism)
- Infections such as shingles, Lyme disease, diphtheria and HIV
- Chronic kidney disease or chronic liver disease
- Certain types of cancer such as lymphoma or multiple myeloma
- Conditions caused by over activity of the immune system such as Lupus or
Rheumatoid arthritis
4. Medications:
- Some types of chemotherapy for cancer (especially for bowel cancer, lymphoma or
myeloma)
- Long term use of some antibiotics such as Metronidazole or Nitrofurantoin
- Long term use of epilepsy medications such as Phenytoin
Symptoms of Alcoholic Neuropathy:

A) Sensory Neuropathy:
Symptoms of sensory neuropathy can include:
1. Tingling sensation in the affected body part (pins and needles)
2. Numbness and less of an ability to feel pain or changes in temperature, particularly in
your feet
3. A burning or sharp pain, usually in the feet.
4. Feeling pain from something that should not be painful at all, such as a very light
touch (allodynia).
5. Loss of balance or co-ordination caused by less ability to tell the position of the feet or
hands (sensory ataxia).
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B) Motor neuropathy:
Symptoms of motor neuropathy can include:
1. Twitching and muscle cramps.
2. Muscle weakness or paralysis affecting one or more muscles.
3. Thinning (wasting) of muscles
4. Foot drop – difficulty lifting up the front part of your foot and toes, particularly
noticeable when walking
C) Autonomic neuropathy:
Damage to the autonomic nerves can result in a wide range of symptoms depending on
where in the body the damage occurs.
Symptoms of autonomic neuropathy can include:
1. Constipation or diarrhoea, particularly at night.
2. Feeling sick, bloating and belching.
3. Low blood pressure (postural or orthostatic hypotension), which can make you feel
faint or dizzy when standing up.
4. Rapid heartbeat (tachycardia).
5. Excessive sweating or a lack of sweating.
6. Problems with sexual function, such as erectile dysfunction in men.
7. Difficulty fully emptying your bladder of urine.
8 bowel incontinence (loss of bowel control).
D) Mononeuropathy:
Depending on the specific nerve affected, symptoms of mononeuropathy can include:
1. Altered sensation or weakness in the fingers.
2. Double vision or other problems with focusing your eyes, sometimes with eye pain.
3. Weakness of one side of your face (Bell's palsy).
4. Foot or shin pain, weakness or altered sensation.
Investigations:
1. Alcohol makes the body unable to use or store certain vitamin and minerals.
Blood test will be ordered to check for a deficiency of:
B12, B6, Pantothenic Acid and Biotin, B1, Folic Acid, B3, Vitamin A, Vitamin E
2. Other blood tests include: LFT, U&E, TFT and blood sugar.
3. A nerve conduction test (NCS) may be carried out by a neurologist to confirm

peripheral neuropathy.
In this test small metal wires called electrodes are placed on your skin which release
tiny electric shocks that stimulate your nerves; the speed and strength of the nerve
signal is measured.
4. An Electromyography (EMG) may also be carried out by a neurologist to confirm
peripheral neuropathy.
In this test a small needle is inserted through your skin into your muscle and used to
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measure the electrical activity of your muscles.
Note: NCS and EMG are usually carried out at the same time.
5. Occasionally, a nerve biopsy may be carried out as part of your diagnosis. This is a
minor surgical procedure where a small sample of a peripheral nerve is removed from
near your ankle so it can be examined under a microscope.
It's then checked for changes that could be a sign of certain types of peripheral
neuropathy. However, nerve biopsies are rarely needed.
Treatment:
1. Treating the underlying cause: Stop drinking.
2. Vitamin supplements and diet plan:

Having a proper diet plan and vitamin supplements can improve nerve health.
Note: Nerve damage because of alcoholic neuropathy is usually permanent, however,
avoiding alcohol and improving diet can sometimes lead to recovery.
3. Controlling symptoms:
A. Pain:
You may also require medication to treat any nerve pain (neuropathic pain) you're
experiencing.
Unlike most other types of pain, neuropathic pain doesn't usually get better with
common painkillers, such as paracetamol and ibuprofen and other medications are
often used.
i. The main medications recommended for neuropathic pain include:
- Amitriptyline – also used for treatment of headaches and depression.
- Duloxetine – also used for treatment of bladder problems and depression.
- Pregabalin and gabapentin – also used to treat epilepsy, headaches or anxiety.
ii. Capsaicin cream:

If your pain is confined to a particular area of your body and you can't, or would prefer
not to, take the medications above, you may benefit from using capsaicin cream.
Capsaicin is the substance that makes chilli peppers hot and is thought to work in
neuropathic pain by stopping the nerves sending pain messages to the brain.
A pea-sized amount of capsaicin cream is rubbed on the painful area of skin three or
four times a day.
Side effects of capsaicin cream can include skin irritation and a burning sensation in the
treated area when you first start treatment.
345
Don't use capsaicin cream on broken or inflamed skin and always wash your hands after
applying it.
iii. Lidocaine plaster:
This is a large sticking plaster that contains a local anaesthetic. It's useful when pain
affects only a small area of skin. It's stuck over the area of painful skin and the local
anaesthetic is absorbed into the skin that's covered.
iv. Tramadol:
Tramadol is an opioid painkiller that can be used to treat neuropathic pain that doesn't
respond to other treatments.
It will usually only be prescribed for a short time. Tramadol can be useful to take at
times when your pain is worse.
B. Treating other symptoms:

i. If there is light headedness or dizziness while standing up, wearing compression
stockings, eating extra salt and sleeping head elevated can be considered.
ii. If there is any urinary problem manual expression of urine, intermittent
catheterisation or some medications will be considered.
iii. Any other problems associated with peripheral neuropathy such as erectile
dysfunction, constipation or the slow movement of food through your stomach
(gastroparesis) may be treatable with medication.
C. Maximising ability of function independently:

i. if you have muscle weakness, you may need physiotherapy to learn exercises to
improve your muscle strength.
ii. You may also need to wear splints to support weak ankles or use walking aids to help
you get around.
D. Preventing injuries:
i. Checking the temperature of bath water to prevent burns.
ii. Changing footwear.
iii. Frequently inspecting the feet and shoes to reduce injury caused by pressure or
objects in the shoes.
346
CEREBELLAR ATAXIA TEACHING MATERIAL
Causes of Ataxia:
A) Recent Health
1. Bacterial Infection such as Meningitis or Encephalitis
2. Viral Infections such as chicken pox or measles
3. Severe head injury
B) Medical Illness
4. Brain Tumour
5. Stroke or TIA
6. Cerebral Palsy
7. Multiple Sclerosis
8. Underactive Thyroid
C) Medication
9. Some medications such as Benzodiazepines
D) Family History
10. Family history of similar problem
E) Personal History & Social History

11. Long-term alcohol misuse
12. Vitamin B12 Deficiency (Vegetarian/Vegan)
Diagnosis and investigation:

1. Blood test
2. Urine test
3. Genetic testing can detect the mutations responsible for Friedreich's ataxia, ataxia-
telangiectasia and most of the spinocerebellar ataxias.
4. Brain scans, MRI and CT.
Other tests: Some of the other tests you may have to help diagnose ataxia and determine how
severe it is can include:
1. Lumbar puncture
2. Nerve conduction studies and electromyography (EMG)
3. Videofluoroscopy – a continuous moving X-ray taken while you swallow
4. Electrocardiogram (ECG) – an assessment of the electrical activity of the heart.
5. Echocardiogram – an ultrasound scan of the heart
Treatment:
Multidisciplinary team (MDT), who will work with you to come up with a care plan. Your MDT
will probably include a neurologist, physiotherapist and specialist nurse, among others.
Treating the symptoms depending on the symptoms patient have:
1. Speech and language therapy
2. Treat muscle, bladder and eye problems
3. Treat Fatigue and Nerve pain
4. Treat Cardiomyopathy and depression
5. Treat the underlying cause.
347
TM-COMBINED EXAMINATION 13 - ARLD
DESCRIPTION
Drinking too much alcohol can lead to three main types of liver conditions:
1. Fatty Liver
2. Hepatitis
3. Cirrhosis (Scarring of the liver)
Alcoholic fatty liver:
A build-up of fat occurs within liver cells in most people who regularly drink heavily.
- Usually asymptomatic
- Usually reverses if patient stops drinking heavily
Alcoholic Hepatitis:
a. Mild
- No symptoms
- Deranged LFT’s.
b. Moderate
- Feeling sick.
- Jaundice.
- Generally feeling unwell.
- RUQ Pain.
c. Severe – Liver Failure
Cirrhosis
- Feeling sick
- Weight loss
- Loss of appetite
- Swelling in the ankles and tummy
- Bleeding into the gut (it may present as vomiting blood or passing blood into the stool)
- Deep Jaundice
- Blood clotting problems
- Confusion
- Coma
EXAMINATION
- Hepatomegaly is very common.
- Splenomegaly with or without portal hypertension may occur with cirrhosis.
- Signs of chronic liver disease may be seen in patients with cirrhosis (jaundice, ascites, oedema, spider naevi).
INVESTIGATIONS
Blood
1. LFTs
2. GGT: if alcohol is the cause
3. Other blood tests are part of the work-up for associated causes.
- FBC.
- Clotting profile
- Fasting lipids (usually raised).
- Fasting glucose.
- Viral studies (hepatitis).
- Iron studies.
- Vitamin B12
- Caeruloplasmin.
- Autoimmune studies (ANA, ASMA may be raised in NASH – Non-alcoholic Steatohepatitis).
Imaging
4. Ultrasound
5. CT scanning may be helpful to monitor the course of the disease.
6. MRI scan can be used to exclude fatty infiltration and the course and extent of this and other liver disease
Definitive Diagnosis
7. Liver Biopsy and Histopathological analysis.
MANAGEMENT
Alcohol-related fatty liver is managed by stopping alcohol intake and maintaining an adequate diet.
- Abstinence can reverse alcohol-related steatosis.
- For dietary advice, patient can be referred to the dietician.
- For severe cases, patient may need to be admitted in the hospital.
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DIVERTICULAR DISEASE
DIVERTICULOSIS SYMPTOMS
Most Common
1. Abdominal Pain
a. LIF
b. Intermittent
c. Increases after eating
d. Decreases after passing stool
Other
a. Constipation
b. Diarrhoea
c. Episode of constipation that is followed by diarrhoea
3. Bloating

a. Dark purple
b. Usually after diarrhoea
DIVERTICULITIS SYMPTOMS & SIGNS

1. Abdominal Pain
a. Usually starts below belly button and then moves to LIF (sometimes right)
b. Sudden
c. Constant
d. Severe pain
2. Change in bowel habits.

3. Bloating
4. Bleeding PR
5. Fever (Above 38)
6. Nausea/Vomiting
7. Fast pulse (tachycardia)
8. Shock features e.g. hypotension (Sometimes)
9. Palpable mass in lower quadrant
10. Reduced bowel sounds.
RISK FACTORS
1. PMH
a. Previous Episode
b. Constipation
c. NSAIDs
d. Family History (age under 50)
2. Personal History
a. Smoking
b. Diet (obese patients)
c. Physical Activity (obese patients)
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D/D’s:
1. Irritable bowel syndrome
2. Acute appendicitis
3. Crohn’s disease.
4. Colorectal cancer.
5. Ischaemic colitis (In elderly)
In female patients
6. Ruptured ovarian cyst
7. Ovarian torsion
9. PID
COMPLICATIONS
1. Perforation
2. Abscess
3. Fistula, stricture or obstruction.
4. Haemorrhage (mainly in proximal colon)
INVESTIGATIONS
1. Full blood count.
2. CXR.
3. Abdominal X-Ray
4. Contrast Enemas
5. Contrast CT
6. Endoscopy - Generally avoided in acute diverticulitis because of the risk of perforation. It is used
to exclude other possibilities only when the diagnosis is unclear.
7. Flexible sigmoidoscopy or colonoscopy to localize the lesion.
TREATMENT
1. Maintain hydration. Initially clear fluids only. Gradually introduce solid food.
2. Pain killer (mainly Paracetamol)
3. Broad spectrum antibiotics such as Co-Amoxiclav. If Penicillin allergic – Ciprofloxacin and
Metronidazole.
4. Mesalazine (helps in improving and preventing the symptoms)
General advice:
1. High fibre diet
2. Avoid NSAIDs and opioids.
3. Bulk forming laxatives
Hospital admission IF:

1. Pain not controlled by Paracetamol.
2. Oral fluids and antibiotics are not tolerated.
3. Immunocompromised individual.
4. Any complication like rectal bleeding, fistula, abscess or perforation occurs.
5. Symptoms persist after 48 hours of conservative treatment.
Indication of surgery:
1. Peritonitis.
2. Uncontrolled sepsis.
3. Fistula.
4. Obstruction.
5. Inability to exclude cancer.
6. Recurrent attacks
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TM 17 COM EX - REACTIVE ARTHRITIS
Reactive arthritis is a condition that causes inflammation (redness and swelling in various places in the body).
Reactive arthritis is a form of seronegative (without presence of certain antibodies in the blood)
spondyloarthritis clinically associated with inflammatory back pain, additive or migratory oligoarthritis
(Arthritis affecting up to 6 joints during the first 6 months of the disease) and extra articular symptoms.
Reiter’s Syndrome is a sub-type of reactive arthritis with the presence of:

1. Large joint oligoarthritis.
2. Urogenital Infection.
3. Uveitis.
Symptoms of reactive arthritis typically follow gastrointestinal or urogenital infection by a minimum of 1 and
maximum of 3-6 weeks.
Symptoms:
A. Joint involvement:
1. Joint pain (usually in weight- bearing joints such as knees, feet and ankles)
2. Swelling (usually in weight- bearing joints such as knees, feet and ankles, as well as fingers and toes)
3. Stiffness (Particularly in the morning)
4. Back pain and buttocks pain.
B. Eye involvement:
1. Red eyes.
2. Watery eyes.
3. Painful eyes.
4. Swollen eyelids.
C. Urogenital involvement:
1. UTI symptoms.
2. STI symptoms.
Other symptoms:
1. Fatigue
2. Fever
3. Weight loss
4. Rash
5. Abdominal pain
6. Mouth ulcer
7. Painless white patches inside the mouth.
8. Tick and crumbly nails.
9. Bouts of diarrhoea.
Risk Factors:
1. Previous episodes of reactive arthritis.
2. STI (such as chlamydia or gonorrhoea).
3. Gastrointestinal infections (campylobacter or salmonella bacteria, both of which can cause food poisoning)
4. Genetic/Family history (Those with HLA- B27 have the significantly increased chance of developing reactive
arthritis, as well as related condition such as ankylosing spondylitis.
Differential Diagnosis:
1. Ankylosing spondylitis.
2. Gout.
3. Inflammatory bowel disease.
4. Rheumatoid arthritis.
5. Septic arthritis.
6. Psoriatic arthritis.
7. Haemoarthrosis
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8. Sport injury trauma.
Investigations:
1. Bloods.
- ESR (Usually raised)
- CRP (Usually raised)
- FBC (Normocytic normochromic anaemia, mild leucocytosis and thrombocytosis during acute phase)
- HLA B27 (this is positive in majority of cases. Rheumatoid factor and antinuclear antibodies are absent)
- Serology for detection of chlamydia (PCR)
-Serology for Yersinia, Campylobacter, Salmonella and Shigella species
2. Culture of stool, throat and urogenital tract sample to identify causative organisms.
3. X-ray (usually normal in early stage. In advanced or long term disease, they may show periosteal reaction
and proliferation at the sites of tendon insertion, planter spurs, and marginal erosions with adjacent bone
proliferation in the hands and feet and less often, features of sacroilitis and ankylosing spondylitis.
4. ECG (In patients with prolonged disease to assess for conduction disturbances)
Treatment:
Reactive arthritis is usually temporary and the treatment can help to relieve the symptoms.
Most people will make a full recovery in 6 months, although in 5 cases lasts a year or more and small number of
people experienced long term joint problem.
A. Self care:
1. Rest.
2. Avoid using affected joints.
3. Exercise:
- As your symptoms improve you should begin gradual exercise to strengthen the affected muscles and
improve the range of movements in the affected joints.
4. Physiotherapy.
5. Ice packs/Heat pads.
B. Medications:
1. NSAIDs
- These are the main medications used for reactive arthritis to reduce inflammation and to relieve pain.
2. Corticosteroids
-Usually if symptoms don’t respond to NSAIDs or NSAIDs are contraindicated.
-Prednisolone is usually the preferred choice.
-Steroids work by blocking the effects of some of the chemical in the immune system uses to trigger the
inflammation.
- It can be given as an injection in the joint or as a tablet.
- Eye drops can be prescribed if there is conjunctivitis.
3. DMARDs (Diseases Modified Anti- Rheumatic Drugs):
- DMARDs work by blocking the effects of some of the chemical in the immune system uses to trigger the
inflammation.
- It can take up to few months before patient notice DMARDs working.
-Sulfasalazine is usually the preferred option.
- The common side effects of sulfasalazine are feeling sick, loss of appetite and headache. However, they usually
improve once the body get used to the medications.
- DMARDs may also cause changes in blood and liver so regular blood tests will be done during the course of
medication.
4. Antibiotics:
-Antibiotics may not help to treat reactive arthritis but they are sometimes prescribed if they have an on going
infection such as STI.
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GOUT
Signs and symptoms of gout:

1. Severe pain in one or more joints
2. The joint feeling hot and very tender
3. Swelling in and around the affected joint
4. Red, shiny skin over the affected joint
Pattern of symptoms
Attacks of gout tend to:
1. Occur at night, although they can happen at any time
2. Develop quickly over a few hours
3. Last between three and 10 days
4. Come back – attacks every few months or years
5. Become more frequent over time if not treated
Risk Factors:
Past Medical History
A. Medical condition
1. High blood pressure
2. Diabetes
3. Kidney disease
4. High levels of fat and cholesterol in your blood
5. Osteoarthritis
6. Psoriasis (a skin condition that causes red, flaky, crusty patches of skin covered with silvery
scales)
B. Medication
1. Diuretics
2. Beta-blockers and ACE inhibitors
3. Low-dose aspirin
4. Some chemotherapy medicines
C. Family History
• Around one in five with gout have a close family member with the condition.
Personal History
A. Diet
1. Red meat – such as beef, lamb and pork
2. Seafood – especially shellfish and oily fish
3. Offal – such as liver, kidneys and heart
B. Alcohol:
Beer, fortified wines like port, and spirits.
NOTE: Moderate consumption of wine – one or two glasses a day – shouldn't significantly
353
increase your risk of gout.
C. Sugary drinks:
Certain sugary drink such as coke can increase the risk of gout.
Management
What is Gout?
Gout is a condition, which causes pain and swelling in one or more joints. Gout is caused by high
level of substance called uric acid in our blood. If your makes too much uric acid or your kidneys
don’t pass enough uric acid, the amount of this substance in blood increases and tiny crystals
may form and collect in the joint.
Investigations:
1. We will do some blood tests to measure the amount of uric acid in your blood. We usually do
this test 2 to 4 weeks after an attack of gout.
2. A sample of fluid may be taken from the affected joint. The fluid can be checked for the small
crystals that cause gout.
3. We may consider an ultrasound scan to detect crystals in the joint and deep in the skin.
4. An X-ray is sometimes used to assess whether there has been any joint damage due to
repeated attack of gout.
Treatment:
1. You can take painkiller such as diclofenac
2. It is advisable to rest and raise your leg.
3. Keep the joint cool by applying an ice pack.
4. Take enough water.
5. Avoid damaging the effected joint.
Prevention:
1. Lifestyle modification
2. Medication to reduce the level of uric acid in your blood. One of the commonly used
medications is called Allopurinol. We usually prescribe this medication one to two weeks after
the symptoms of your gout attack have been settled down. We will do regular blood test to see
how effective is the medication and we will adjust the dose accordingly. It is advisable to
continue a low dose diclofenac along with allopurinol.
354
Acute Atrial Fibrillation - Teaching Material
Causes:
For all patients with fast AF, evaluate for underlying cause and treat appropriately:
1-Infection
2-Hyperthyroidism
3-Myocardial infarction
4-COPD
4-Hemmorhage
5-Medication error
6-Poisoning
Anti-Arrhythmics - cautions and contra indications:

1-Amiodarione: Sino-atrial block and conduction disturbance, severe hypotension, thyroid
disease, CCF, preganncy and breast-feeding.
2-Flecainide: Atrial flutter, CCF, structural heart disease, recent MI
3-B-blockers: asthma/COPD, uncontrolled heart failure, sick sinus syndrome, heart block,
hypotension, severe peripheral vascular disease
4-CA channel blockers: heart failure, hypotension, sick sinus syndrome, heart block, AF with
WPW, VT, pregnancy and breast feeding
5-Digoxin: heart block, WPW, VT
Investigations:
For all patients:
1-FBC
2-VBG
If it is a new AF:
3-TFT
4-LFT
5-CXR
6-Additional tests if condition required.
Haemodynamic compromise due to AF:

Compromise due to AF is rare. Compromise is more frequently due to underlying condition,
which must be treated first; eg sepsis causing hypotension, chronic LV dysfunction, AMI
causing chest pain.
If unsure that fast AF is the primary problem, seek senior advice.
If there are NO signs of haemodynamic compromise due to AF:
A) If AF known to have started within 48 hours (If not certain, Assume NO):
Rate control: If rapid rate control is needed, use IV doses.
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1-Metoprolol 25 mg TDS PO /Metoprolol 5 mg IV (repeat if necessary) OR
2-Verapamil 40 mg TDS PO / Verapamil 5 mg IV OR
3-Digoxin 500 mcg PO/IV repeat after 4 hours (A third dose may be given).
Maintenance dose: 62.5-250 mcg depending on age, weight and renal function.
Use Digoxin first choice in elderly, immobile and CCF. OR
4-If haemodynamically unstable or shock resistant: Amiodarone 150-300 mg IV over 20
mins.
Anticoagulate:
Indicated:
-If CHA2 DS2 VASc score of 2 or more (Score 1 or more if male).
-If HAS BLED 3 or more discuss with senior.
NOTE: Prescribe clexane 1.5 mg/kg SC OD until seen in anticoagulation clinic.
CHA2DS2-VASc Score
C = History of CCF 1
H = History of hypertension 1
A = Age 75 years or more 2
D = Diabetes Mellitus 1
S = History of stroke 2
V = Vascular Disease 1
A = Age 65-74 1
S= Sex (female) 1
HAS- BLED
H = History of hypertension 1
A = Abnormal Renal function 1
A = Abnormal liver function 1
S = Stroke 1
B = Bleeding 1
L = Labile INR 1
E = Elderly more than 65 1
D = Drugs/Alcohol 1
Discharge Criteria:
1- No haemodynamic compromise
2- Heart rate < 110 for 2 hours
If first presentation:
-Request ECHO.
-Cardiology OPD referral
-Anticoagulant clinic follow-up if needed.
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B)If AF NOT known to have started within 48 hours:
Rhythm control: If there are symptoms or signs of heart failure or structural heart disease,
request urgent ECHO.
NOTE: Rate control may be preferred if there are significant co-morbidities or in elderly
patients.
If none of the above, ECHO is not required.
IF ECHO is normal or not required, follow:

-Rate control
-Anticoagulate
-Discharge as mentioned before.
IF ECHO is abnormal:
Option 1:
-Synchronised DC cardioversion (70-90% success rate)
Option 2:
-Flecainide 2 mg/kg IV over 30 -60 mins (40-70% success rate)
Has Patient cardioverted to sinus rythym?

If No, follow rate control and anticougulate.
If Yes, assess for discharge.
If there ARE signs of haemodynamic compromise due to AF:

-Synchronised DC cardioversion (200 J Or 360 J)
-Consider amiodarone if resistant to 2nd shock
Is it converted to sinus rhythm?

If NO:
-Follow rate control and anticogulate.
If YES:
-Assess for discharge criteria.
Admission criteria for monitored bed:

-ACS with on-going chest pain (Even if ECG normal).
-Ischaemic ECG (Unless 6 hours troponin negative).
-AF persists with rate >130.
-Haemodynamic instability.
-GCS less than 15 post sedation.
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Management of Acute Exacerbation of Severe Asthma
Severe if any of:
1. PEFR 33% - 50%

2. Respiratory rate >25
3. Pulse rate >110
4. Unable to complete sentence in one breath
5. Using accessory muscles
Management:
1. High flow oxygen

40% - 60% (6 Litre/minute) up to 100% (15 Litre/minute) to maintain O2
saturation of 94%-98%.
2. Nebulised Salbutamol 2.5-5mg every 5-15 minutes
3. Ipratropium bromide (Atrovent) 500 microgram
4. Corticosteroids:
- Prednisolone 40 mg PO
or
- Hydrocortisone 100-200 mg IV
Involve senior
5. Magnesium 2 gr IV over 20 minutes

6. Salbutamol 250 microgram IV bolus
7. Salbutamol infusion 5-20 microgram/min
Alternative:
- Aminophylline 5 mg/kg IV over 20 minutes loading (Unless on oral
therapy)
- Aminophylline 0.5 – 0.7 mg/kg/hr
If patient on oral aminophylline or theophylline, check blood levels on
admission and daily if infusion started.
358
TM 3 SimMan - Allergic reaction
Anaphylaxis
Anaphylaxis is an extreme and severe allergic reaction.
The whole body is affected, often within minutes of exposure to the substance which causes the
allergic reaction (allergen) but sometimes after hours.
Anaphylaxis is a life-threatening systemic hypersensitivity reaction with A,B, and C involvement
A (stridor),
B (bronchospasm) and/or
C (shock) involvement.
Reaction may be biphasic (recurrence of symptoms within 72 hours).
Death has never occurred > 6 hours from exposure (Usually <5 min if IV, 10-15 min if venom and 30-
35 min if ingested).
Causes:
1- Drugs: antibiotic, NSAID’s, contrast media, suxamethonium, opiates, gelofusin.
2- Food: common in children; peanuts, tree nuts (e.g. almonds, walnuts, cashews, and Brazil nuts),
sesame, fish, shellfish, dairy products and eggs, legumes,
3- Venom
4- Latex
5- Blood transfusion
5- Idiopathic
6- Rare: exercise induced, semen
Systemic allergic reactions

1- Angioedema
It may be allergic( mast-cell mediated, associated with urticaria) or non-allergic (bradykinin
mediated, without urticaria, typically more gradual onset).
Causes include C1 esterase inhibitor deficiency, ACE inhibitors (20%), NSAID’s, statin, SLE,
lymphoma and idiopathic.
2- Urticaria:
This may be acute or chronic (occurring daily for >6 weeks, rarely associated with allergy).
Causes of acute: allergy, viral or bacterial infections, idiopathic.
Causes of chronic: idiopathic (75%, often triggered by stress), SLE, thyroiditis, physical stimuli (heat,
cold, exercise, sunlight), menstruation, urticarial vasculitis ( lasting > 36 hours and causing bruising/
pain), urticaria pigmentosa ( reddish brown macules)
1- Anaphylaxis
A: Stridor, hoarse voice, throat closure
B: Difficulty in breathing, chest tightness, wheeze, cyanosis
C: Signs of shock - presyncope or syncope, pale, clammy, reduced GCS
Note: This may be associated erythema, urticaria, angioedema, itch, nausea, vomiting, abdominal
pain, diarrhoea.
Treatment
1- Move the patient to the resus.
2- Adrenaline 0.5 ml of 1:1000 (500mcg) IM.
Note: Repeat at 3-5 min intervals if required
Note: If peri-arrest or shock not responding to IM treatment, titrate 0.5ml 1:10,000 (50mcg) IV and
seek senior advice
3- Fluids: 500-1000 ml bolus 0.9% saline (20 ml/kg) if signs of shock despite adrenaline
4- Antihistamine: chlorpheniramine 10 mg IV
5- Steroids: hydrocortisone 200 mg IV
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6- Nebulizers: 5 mg salbutamol if wheeze - repeat as required. Stridor neb adrenaline 5 ml 1:1000
(5mg)
Note: If allergen is identified remove that. For example, stop IV drug or blood transfusion.
Note: Patient on b blockers with refractory hypotension may require glucagon 2-10 mg IV, followed
by an infusion of 50 mcg/kg/hr. Stop B blocker after discussing with senior.
Investigations
1- Tryptase:
This should be taken as soon as possible following emergency treatment. The 2nd sample should be
taken within 1-2 hours, no later than 4 hours post onset.
2- FBC, VBG
3- ECG
Note: Non-specific ST ECG changes are common post adrenaline and with anaphylaxis.
Exclusions to CDU (observation unit) admission

1- Use of 3 or more doses of IM adrenaline
2- Use of iv adrenaline
3- Refractory shock
4- Severe bronchospasm at any time
5- Known biphasic reaction
6- Co-morbidity requiring in patient
A: If the patient has any of these, refer to medical team.

B: If not the patient should be admitted to the CDU.
Medication on discharge for anaphylaxis

-EpiPen x 2, 0.3 mg
-Prednisolone 40 mg OD for 3 days
-Antihistamine e.g. chlorpheniramine 4mg QDS or Loratadine 10 mg OD for 3 days (or until
resolved).
2- Angioedema
If the patient has angioedema you can find, deep muco-cutaneous swelling affecting face, throat,
bowel, digits and genitals.
If the patient shows signs of anaphylaxis (urticaria, bronchospasm, rapid onset), follow the
treatment of anaphylaxis.
Treatment
A: if patient is a known C1 esterase deficiency.
1- C1 esterase concentrate 20 units/ kg IV over 10 min.
Note: You can repeat it every 2 hours if required.
2- 2nd line: Icatibant 30 mg in 3 ml SC
3- 3rd line: FFP 2-4 units
Note: Icatibant and C1 esterase concentrate should be obtained via on-call pharmacist.
Note: Investigation not usually required.
Note: Check the exclusion criteria to CDU admission.
If there is any exclusion criteria refer the patient to medical team.
If there is no exclusion criteria to CDU admission, admit the patient in the CDU.
B: If the patient is not a known C1 esterase deficiency.

1- If it is mild, no treatment is needed, it will resolve within hours or days.
- Discontinue potential triggers e.g. ACEIs or blood transfusion.
- Consider antihistamine and steroids but unlikely to respond if no allergic signs
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2- If it is sever:
1st line: Icatibant 30 mg in 3 ml SC.
2nd line: FFP ( Fresh Frozen Plazma) 2-4 units.
Note: The investigations only needed if there is no clear trigger:
1- C3 ( low in SLE)
2- C4 ( low in SLE, c1e esterase deficiency)
3- C1e
4- D dimer
5- FBC,CRP, LFT
Note: If there is anaphylaxis you have to consider Tryptase.
Note: Check the exclusion criteria to CDU admission.
If there is any exclusion criteria refer the patient to medical team.
If there is no exclusion criteria to CDU admission, admit the patient in the CDU.
3-Urticaria
If the patient has urticaria he must have pruritic migratory erythematous plaques, occurs alone or in
association with angioedema.
Note: If the patient has the signs of anaphylaxis, follow the treatment of anaphylaxis.
Treatment
1- Antihistamines:
-Loratadine 10 mg PO
-Chlorpheniramine 4mg PO
2- Consider prednisolone 40 mg OD for 3 days if severe and unresponsive to antihistamines
Note: patient usually not require any investigations.
Discharge the patient

Note: Ask GP to refer to the allergy clinic if there is any red flag presents.
Note: The red flags are:
1- If the rash persists more than 6 weeks (chronic)
2- If it is painful.
3- If it is fixed staining ( non-blanching area within urticaria).
4- Allergy to foods, insect venom or drugs.
Note: please ask the GP to organize blood tests prior to clinic if it is chronic:
- FBC
- CRP
- U&E
- C3 and C4
- ANA ( anti-nuclear antibody)
- TFT
Follow up
Note: If there is urticaria refer to allergy clinic
1- Chronic urticaria more than 6 weeks
2- Allergy to foods, insect venom or drugs
3- Urticarial vasculitis
Note: If there is an angioedema refer to immunology clinic

1- C1 esterase inhibitor deficiency
2- Isolated angioedema
Note: if there is anaphylaxis please refer to allergy clinic.
361
Extra information:
Symptoms of a severe allergic reaction
1- Generalised flushing of the skin
2- Nettle rash (hives) anywhere on the body
3- Sense of impending doom
4- Swelling of throat and mouth
5- Difficulty in swallowing or speaking
6- Alterations in heart rate
8- Severe asthma symptoms
9- Abdominal pain, nausea and vomiting
10- Sudden feeling of weakness (drop in blood pressure)
11- Collapse and unconsciousness
Note: Patient would not necessarily experience all of these symptoms in the same episode.
There are several different types of reaction which could occur:
1-Uniphasic – these come on quickly and symptoms get rapidly worse, but once treated, the
symptoms go and don’t return.
2- Bi-phasic – these are reactions which may be mild or severe to start with, followed by a period of
time when there are no symptoms, and then increasing symptoms with breathing and blood-
pressure problems.
If a patient has an anaphylactic reaction, they will need an observation period in hospital after they
have recovered in case they experience a biphasic reaction. Most biphasic reactions occur within
hours of the initial reaction but rarely they can be more delayed. On very rare occasions, a biphasic
reaction has been known to occur as long as 72 hours after the initial reaction.
The length of the observation period would be for the treating doctor to decide. The National
Institute for Health and Care Excellence (NICE) recommends that people who have had a severe
allergic reaction should be monitored for 6 – 12 hours within a hospital setting because of the risk of
a bi-phasic reaction.
Children are likely to be admitted to hospital at least overnight.
3- Protracted anaphylaxis – this can last for several days and may need treatment in hospital for
some time.
Why does anaphylaxis occur?

Any allergic reaction, including the most extreme form, anaphylactic shock, occurs because the
body’s immune system reacts inappropriately in response to the presence of a substance that it
wrongly perceives as a threat.
The symptoms are caused by the sudden release of chemical substances, including histamine, from
cells in the blood and tissues where they are stored. The release is triggered by the interaction
between an allergic antibody called Immunoglobulin E (IgE) and the substance (allergen) causing
the anaphylactic reaction.
This mechanism is so sensitive that minute quantities of the allergen can cause a reaction.
The released chemicals act on blood vessels to cause swelling.
In people with asthma, the effect is mainly on the lungs.
There may also be a fall in blood pressure.
Treatment for a severe reaction

Adrenaline auto-injectors are prescribed for those believed to be at risk. Adrenaline (also known as
epinephrine) acts quickly to constrict blood vessels, relax smooth muscles in the lungs to improve
breathing, stimulate the heartbeat and help to stop swelling around the face and lips.
1- Antihistamines
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Antihistamines are useful for controlling mild symptoms of allergy.
Cetirizine (known as Benadryl, Piriteze and Zirtek) and Loratadine (known as Clarityn) are two
which may be recommended. Both are non-sedating antihistamines, meaning they are unlikely to
make the patient feel drowsy. Chlorphenamine (Piriton) is an ‘old school’ antihistamine, which can
make the patient sleepy, and shouldn’t be used by anyone driving or handling machinery.
For people at risk of anaphylaxis, antihistamines are usually prescribed alongside injectable
adrenaline. They are intended for mild or early symptoms, but adrenaline should always be used
when a severe allergic reaction is suspected.
2- Adrenaline
Adrenaline (also called epinephrine) is the recommended first line treatment for people with
anaphylaxis.
The forms of Adrenaline
Pre-loaded adrenaline injection kits, Emerade, EpiPen or Jext, are available on prescription for those
thought to be at risk of a severe reaction.
Emerade is the most recent single-use adrenaline auto-injector to become available in the UK. It
follows the UK Resuscitation Council’s Guidelines for the emergency treatment of anaphylactic
reactions.
Epipen has a spring-loaded concealed needle that delivers a single measured dose when the pen is
jabbed against the muscle of the outer thigh.
Is adrenaline dangerous?
Used correctly, adrenaline injectors are safe for the vast majority of people who carry them. Used
incorrectly (such as injected into the wrong place) there could be problems. Training and re-training
are essential. Based on the current evidence, the benefit of using appropriate doses of adrenaline
into the correct site (the muscle of the outer thigh) far exceeds the risk.
Adrenaline interactions
Anaphylaxis may be made worse by Beta blockers and these drugs decrease the effectiveness of
adrenaline. Other drugs may also be contra indicated.
Severe allergic reaction or anaphylaxis

-Allergic reactions occur when patients have antibodies that react with proteins in transfused blood
components.
-Anaphylaxis occurs where an individual has previously been sensitised to an allergen present in the
blood and, on re-exposure, releases immunoglobulin E (IgE) or IgG antibodies. Patients with
anaphylaxis become acutely dyspnoeic due to bronchospasm and laryngeal oedema and may
complain of chest pain, abdominal pain and nausea.
-Individuals with severe IgA deficiency may develop antibody to IgA and, with repeated transfusion,
are at high risk of allergic reaction.
-Urticaria and itching are common within minutes of starting a transfusion.
-Symptoms are usually controlled by slowing the transfusion and giving antihistamine and the
transfusion may be continued if there is no progression at 30 minutes.
-Pre-treatment with chlorphenamine should be given when a patient has experienced repeated
allergic reactions to transfusion.
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TM SimMan 4 Sepsis Teaching Material
Sepsis performa: screening
For deteriorating patients with possible/ known infection
What to look out for:

Signs of deterioration
1- NEWS 3 or above.
2- patient looks sick.
Signs of infection
1- 2 out of 4 SIRS criteria.
2- Localised signs of infection, e.g. positive urine dipstick, cough etc
SIRS criteria
1- Temperature below 36 C or above 38 C.
2- Heart rate above 90 beats/ min.
3- Respiratory rate above 20 breaths /min.
4- White cell count less than 4 or greater than 12 x 10^9 /L.
A-If one or more new high-risk criteria present, start SEPSIS 6 within 1 hour, if not, move to B
below.
1- Heart rate (above 130/min).
2- Respiratory rate (25 breaths/ min or above).
3- Systolic BP (90 mmHg or below).
4- New need for oxygen: (5 L /min or more).
5- Not passed urine for 18 hours (for catheters less than 0.5 ml/kg/hr for 2 hrs).
6- New confusion (GCS less than 15).
7- Mottled/ ashen skin/ lips/ tongue/ or non-blanching rash.
8- Recent chemotherapy.
B- Systolic BP 91-100mmHg or 2 other moderate-risk criteria

1- Heart rate 91-130/ min.
2- Respiratory rate 21-24/ min.
3- New onset arrhythmia.
4- Temperature less than 36 c.
5- Not passed urine for 12-18 hours, (for catheters less than 0.5-1ml/kg/hr for 2 hours).
6- Signs of potential infection (swelling, redness and discharge).
7- Recent deterioration in physical or mental ability.
8- Trauma, surgery or other invasive procedure in last 6 weeks.
9- Possible immune compromised immunity. (illness or drugs including steroids)
Note: If none of the criteria had been met then it is a low risk for sepsis, so you should
1- Obtain senior review within 3 hours.
2- Start antibiotic.
3- Seek alternative cause of deterioration.
Note: if any of the above criteria met, then take blood for lactate and creatinine
1- If the Lactate is above 2 mmol/L or
364
2- if creatine is more than 1.5 times above baseline (AKI).
You should start SEPSIS 6.
If not then it is a low risk for sepsis, so you should
1- Obtain senior review within 3 hours.
2- Start antibiotic.
3- Seek alternative cause of deterioration.
Sepsis performa: management

When you need to start SEPSIS 6 you should contact a senior doctor for immediate review.
You can use SBAR.
SEPSIS 6 - complete within one hour of diagnosis

3 in
1- give antibiotics (take blood for culture first)
- Refer to microbiology guidelines.
- Check for allergies.
2- Give fluids
500 mL bolus of plasma-Lyte or Hartmann’s solution over 10 mins, assess response after bolus.
Repeat if:
- Lactate is greater than 2 mmol/L.
- Systolic BP is 90mmHg or under.
- There are other concerns.
3- Give oxygen
To achieve SpO2 of 94% or above. (in COPD SpO2 88-92%)
3 out
4- Take peripheral blood sample to send for culture.
Note: You need to find the source of infection if possible. Consider

- Culture central line blood.
- Culture CSF, sputum, urine, wound swab etc.
- Organize imaging e.g. CXR, CT scan.
- Organize source control e.g. drainage/ surgery.
5- Take blood for lactate

If above 2 mmol/L, you should re-measure after one hour.
6- Start fluid balance chart.

- Update the chart hourly.
- Insert urinary catheter if required.
Note: At the end of first hour.

-If patient is improving, keep on hourly observation.
-If patient fails to improve seek senior review.
-Contact CCOT if:
1- Lactate is above 4 mmol/L or
2- Systolic BP 90 mmHg or below.
Note: CCOT stands for Critical Care Outreach Team which is team of clinicians who bring critical care
expertise to the bed side.
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History Counselling and Ethical TM

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History Counselling and Ethical TM

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COMMON STATIONS

SPECIALISTS IN PLAB 2 PREPARATIONS

Dr Elmira Yaghmaei Dr Hamed Salehi

The most important thing in a counselling station is to make a two-way conversation.

2. It is very important to recognize, and address patients concerns.

How can you do this?

1. Assess patient knowledge about symptoms and condition.

2. Disclose Diagnosis +/- Pause for Patient Concerns

3. Explain Diagnosis +/- Pause for Patient Concerns

5. Treatment +/- Pause for Patient Concerns

b. Weak Opioids (Codeine, Tramadol) +/- Adjuvants

2. Patient is on painkiller and pain is not well controlled.

3. How to check compliance:

8. Adjuvants play a very important role in pain management.

9. Before prescribing any painkiller:

- Choose the right Painkiller.

10. It is very important to choose the right painkiller.

19. When we change the medication, the dose should be adjusted.

ROUTE/DRUG DOSE COMPARED TO PO MORPHINE

Fentanyl Patch 200 g (mcg) x150

21. Usually Fentanyl patch lasts for 3 days.

24. Side effects of Morphine (and to some extent all opioids)

30. Post-op Pain Management

NOTE: Some medical conditions need some specific advice.

3. Usually you will hear 2 excuses from the patients:

4. Preparation for Surgery:

5. The mode of anaesthesia:

General Anaesthesia: We need to put you to sleep.

Advantages of Local Anaesthesia compared to General Anaesthesia:

Advantages of Keyhole Surgery:

7. Duration of the Surgery:

10. Recovery Period:

12. It is very important to take consent from patient.

Ask 3 important questions

1. Do you have any allergy to any medication?

2. Do you have any medical illnesses?

3. Are you taking any other medication?

You need to cover 7 important areas:

1. Discuss about the function of medicine.

2. Dosage of the medicine – how many tablets/puffs

3. Route – PO, Injention, Inhaled

4. How often (frequency) – OD, BD, TDS, QDS, PRN

5. When it should be taken. Stat or OM, ON, either AC or PC

6. How long for. Days/months/years/lifelong

1. Please take your medication regularly as we prescribe

2. Please do not miss any dose

5. Please keep medication our of reach of children

6. Please see your GP to re-prescribe your medication

7. Please see your GP if you have a persistent S/E

1. Prescription (FP 10) (A5 size paper)

2. D/C Summary or TTA (To Take Away)

1. Never give false reassurance

f. You may use a word some alternative word.

3. Disclose about the disease.

4. Sympathy and Empathy is very important in breaking a bad news.

HOW TO USE ICE

1. I – Ideas refers to the patient’s health beliefs – What they think is

B) Asking the patient’s ICE in this order may be acceptable

Connect to the monitor:

Connect to the monitor:

NOTE: Who should not be moved to observation unit?

NOTE: Who should be referred from observation unit?

Advice to see GP within 2 days

Assessment: date _ time ______

Symptom onset: date time ___

GCS: E _ V M_

Provisional diagnosis: Stroke _ Non-stroke (specify) __