A. Trial of oxybutynin
B. Bladder retraining
C. Regular toileting
D. Pelvic floor muscle training
E. Topical oestrogen cream
Answer: B
Urinary incontinence - first-line treatment:
urge incontinence: bladder retraining
stress incontinence: pelvic floor muscle training
Urinary incontinence
Urinary incontinence (UI) is a common problem, affecting around 4-5% of the UK population. It is more common in elderly females. NICE released guidance on the management of UI in 2006
Causes:
1. overactive bladder (OAB)/urge incontinence: due to detrusor over activity.
2. stress incontinence: leaking small amounts when coughing or laughing
3. mixed incontinence: both urge and stress
4. overflow incontinence: due to bladder outlet obstruction, e.g. due to prostate enlargement
Initial investigation:
1. bladder diaries should be completed for a minimum of 3 days
2. urine dipstick and culture
Management depends on whether urge or stress UI is the predominant picture.
- If urge incontinence is predominant:
1. bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
2. bladder stabilising drugs: immediate release oxybutynin is first-line
3. surgical management: e.g. sacral nerve stimulation
If stress incontinence is
1. pelvic floor muscle training (for a minimum of 3 months)
2. surgical procedures: e.g. retropubic mid-urethral tape procedures
2. A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer the patient?
A. Aspirin
B. Warfarin, target INR 2-3
C. No anticoagulation
D. Warfarin, target INR 3-4
E. Warfarin, target INR 2-3 for six months then aspirin
Answer: A
- Young AF, no TIA or risk factors, just give aspirin
Atrial fibrillation: anticoagulation
The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006The guidelines suggest a stroke risk stratification approach when determining how to anticoagulate a patient, as detailed below:
Low risk - annual risk of stroke = 1%
age < color="#ff0000">use aspirin.
Moderate risk - annual risk of stroke = 4%
age > 65 years with no high risk factors, or:
age < color="#ff0000">use aspirin or warfarin depending on individual circumstances
High risk - annual risk of stroke = 8-12%
age > 75 years with diabetes, hypertension or vascular disease (ischaemic heart disease or peripheral arterial disease)
previous TIA, ischaemic stroke or thromboembolic event
valve disease, heart failure or impaired left ventricular functionuse warfarin
3. A 3-year-old boy is brought to the surgery with chickenpox. His mother wants advice regarding school exclusion. What is the most appropriate advice to give?
A. Should be excluded until 2 days after all lesions have scabbed over
B. Should be excluded until 5 days after skin lesions first appeared
C. Should be excluded until skin lesions have disappeared
D. School exclusion is not indicated
Answer B
Chickenpox school exclusion - 5 days after skin lesions first appeared
Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion.
Chickenpox is highly infectious
spread via the respiratory route
can be caught from someone with shingles
infectivity = 4 days before rash, until all lesions scabbed over*
incubation period = 11-21 days.
Clinical features (tend to be more severe in older children/adults)
fever initially, itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
systemic upset is usually mild
Management is supportive
keep cool, trim nails
calamine lotion
school exclusion: current HPA advice is 5 days from start of skin eruption. They also state 'Traditionally children have been excluded until all lesions are crusted. However, transmission has never been reported beyond the fifth day of the rash.'
immunocompromised children and infants with peripartum exposure should receive varicella zoster immunoglobulin (VZIG). If chickenpox develops then IV aciclovir should be considered
A common complication is secondary bacterial infection of the lesions.
Rare complications include
pneumonia, encephalitis (cerebellar involvement may be seen), disseminated haemorrhagic chickenpox, arthritis, nephritis and pancreatitis may very rarely be seen
*it is now thought that patients are no longer infectious 5 days after the rash has developed - see management regarding school exclusion
No comments:
Post a Comment