February 20

Learning points

Cochrane review shows that self management plans can reduced hosp admissions by half.

Eosinophilic inflammation of lungs
wheeze , cough, sob , reversible (cf copd)

minimal day and sleep symptoms , min blue needs , no exac , able to do excercise and work , pefv1 more than 80% , can do reviews over the phone.
Ask 3 qs - 1. sleep disturbances ? 2 . Daytime symptoms 3. Interference with work
Keep steroids below 800 beclometasone or 400 fluticasone , half that for children.
No ev that any non pharm therapies - acupuncture , homeopathy , salt mines , hypnosis work
doubling dose in exac does not work. Cochrane review shows that self management plans can reduced hosp admissions by half.
Seretide takes 20 min for onset and has flat dose response
Symbicort (budesonide+efometrol)works in 3 min and response increases with dose, can use extra when needed
when poorly use 2 puffs bd , when better ( after 1w when no blue and no night time waking) 1 bd and when worsening ( 2 bad days or 2 night time wakings ) 4bd-step down after 2 good days
oral steroids 7-10 fdays , 3-5 in chikldren
most are found to be worsening over 2w before they are hospitalized

January 24

Chronic Kidney Disease

Diagnose and refer early . do eGFR - estimated gfr according to age sex and race, proteinuria acr/pcr , give previous u and e

Over 100-120 normal
Stage 1 over 90
Stage 2 less than 90
Stage 3 less than 60
Stage 4 less than 30
Stage 5 less than 15
Kidney disease is increasing due to nsaids , diabetes , hypertension, multsystem disease and ckd is itself a risk factor for heart disease

pbc - 95p per patient to set up business plan by cluster . Savings can be reinvested in patient care , if losses over three years pct can take budget back.


Low bone mass . It is asymptomatic ie no pain and can lead to wrist hip and spine fractures . refer if there is low trauma fracture eg fall from standing height , bmi less than 30 steroid use over 5mg a day or 3 big im three times a year and these patients must be given bisphosphonates , or if age less than 65 and at risk order a dexa scan.

Secondary causes are hyperpth osteomalacia highthy osteogenesis imperfecta malabsorption malnutrition anorexia nervosa malignancy hypogonadism

Inv include xray ap and l , fbc eser ur tft pth protein electrophoresis bj urine proteins testosterone oestrogen , if valcium more than 2.5 then check pth

Learning PointsMorning sickness if not controlled with ort , do dipstick for ketones to check for dehydration and admit.

Books Gynae sims lateral speculum for prolapses Steady uterus with one or two fingers , feel uterus on abdo with left hand , left and right adenexa with right fingers for tenderness swabs endocerival for chlamydia and gonor , and entero uterine infections , behind cervix for candida and trichomonas etc.

us- 5 weeks gestational sac , 8w heart ,
hsg to outline tubes via cervix ; hysterocope to check fibroids , tumors ; laprascope for pelvic pain , sterilisation

Children -vaginal tumors and malformations ; fused labia -oe cream for 14 days ; hydrocolpos - incise , hematocolpos in teens -incise.

Abuse - specialist examination, dna test of secretions , swabs vagina , cervix , anus, check anal and vaginal area for bruises , lacerations , bleeding , counselling

Genetic may present as faliure of sex dev at puberty , eg turner's X0 , amenorrhea , short size ,

Faliure of hormones eg androgen receptor defect in males - breasts , testicular feminization , undescened testis

Hypothalamic - so check prolactin in early or delayed puberty ,

Intersex - get both sex organs at pubertyor birth

Amenorrhea - pregnancy , primary , menopause may need to check hypothalamus , pituatary (prolactinoma) , uterine agenisis , imoerforate hymen , uterine scarring , polycystic ovaries , thyroid , adrenal , ovarian faliure , sheehan's , premature menopause

Dysfunctional bleeding after excluding all causes

Ovulatory - pill , nsaid , tranxemic acid , danazol , ablation , hysterectomy Anovulatory - pill in teens ; hrt or cyclical progestrone in perimenopausal

However exclude serious cause by abdo and pelvic exams cervical smear , endometrial sampling , ultrasound , color doppler ,hysteroscopy , laprascopy


1. Natural - coitus interruptus - not effective.
2. Rythm - Fertile from 2 days after ovulation to 7 days before ie 9 days in a month , check length of periods befoer advising , 25% fail rate, tempr rise at ovulation and also cervical mucus becomes watery
3.Condom - 3% fail if nonoxyl cream is used
4. Diaphragm , cervical cap , vault cap etc from family planning, leave for six hours after
5.Combined pill - most effective , acts on hypothalamus-gnrh and pituatary- fsh and lh and stop evolution , the progestrone bit makes cervical mucus hostile, 7 days off- do not give if focal migraine , tumors sensitive(breast , endometrium , trophoblast) , blood clots , arterial disease , valve heart disease , clotting and liver problems. Smoking , diabetes and hypertension are relative contradictions
6.POP take daily 4hrs before intercourse , less effective, Depo- 12weekly , or 8w with noristerate, wt gain and bleeding 7.Emergency - one step within 72hrs, 2% fail ,or iud within five days
8.IUD - copper or mirena , not if h of pid
9.Sterilization - clip , diathermy 0.1% fail

Miscarriage - 25% in first 28w , mainly due to ch abnormalities ,diff diag is dysfunctional bleeding ,ectopic , Invs if more than 3 in a row- rarely uterine ab, sle , cervix incomp , mole , threatened if os closed and can do us , inevitable if os open , incomplete if some part expelled . If tender may be ectopic.

Missed period , pregnancy test positive ,tender lower abdo or in fornix . May have previous pid , do us and operate .. diff diag is pelvic infection , miscarriage
Mole- no fetus but trophoblast is present , irregular bleeding and uterus may be larger than normal , beta hcg very high ,us shows snowstorm , may invade lung , operation is needed , no preg for one year

Abortion - ru 486 first 9 weeks , suction till 14 w and prostaglandin pessary followed by suction after this till 24w.
Infections -discharge normal with sex excitement , ovulation , pregnancy , atrophy- lower genital

Swab high vaginal

Candida - not std ,can be asymptomatic , yeast , thick white discharge which clings to walls , give clotirmazole , nystatin or oral fluconazole or ictaconazole
Trichomonas-std frothy , watery, yellow offensive , flagellate parasite seen in saline drop of high swab , red vagina and cervix , strawberry cervixtreatement flagyl
Vaginosis - offensive , gardenella , amine positive , clue cells , flagyl
Gono and chlamydia cause symptoms if spread up to uterus and tubes
Warts -std , needs paint or cautery
Herpes - type 2-tingling , vesicles, lymohadenopathy shallow ulcers , needs aciclovir , diag by viral culture from lesions , needs c section or may kill baby, may spread to meningitis , recurrent infections less florid


4 per gp per year , May be silent or florid with pelvic pain , discharge ,dyspraeunia , cervical tenderness . Do endocervical swabs for chlamydia and gonorrhea and refer to gu clinic . Dd is ovarian cyst , endometritis , ectopic , bowel problems . Comp are chronic pain , ectopic etc.


secondary infection with candida , cryptosporoid , pneumocystics carinii , toxoplasmosis of brain


Endometrial tissue outside uterus , may cause period pains and adhesions . Treatment is coc pill for 9months without 7 day breaks , or progestrone injections , danazol which raises testosterone levels and suppresses oestrogen , or nasal sprays of lhrh analogues or surgery. Diagnosis is by laparscope.


After 12m of trying , affects 15% , may be secondary infertility , Male -check two sperm levels - ok if 50 % motile and 50 % normal , 20m per ml .If low check fsh , lh and testosterone levels , check frequency , normal genitals.Female - ask if periods regular , gynae history , do fsh lh day 1, day 21 pro to see if ovulating , chlamydia test , hsgdye us , laprascopy,etc.

Can do IUI -intra uterine insemination , or bypass blocked tubes with IVF after stimulating ovarian follicles with hcg or cloimiphene; steroids to male ifantisperm antibodies . Counselling.

POCS - cysts in ovary due to some enzyme defects and can lead to increased lh . Excess by products can cause hirsuitism , oligo or amenorrhea , obesity , infertility - common 5-30%, check prolactin , fsh lh testosterone dheas androstenedione , us , ovarian biopsy . Treatment ocp with low androgenic progestogen , anti androgenin eg cuyproterone , spirinolactoone, diet ; ocp to induce withdrawl bleeds , cloimphemine . Risk of em hyperplais and cancer in later life prevented by ocp ?