Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2763_Библиотеки_им_академика_М_И_Перельмана
.pdf
Diagnosis & staging
https://t.me/med1917
Chapter 2: Geriatric medicine 37
STAGE 1:
Superficial
Non-blanching erythema,
intact skin (no ulcer)
skin
fat
muscle
bone
Management
STAGE 2:
Partial thickness
Shallow ulcer but
subcutaneous tissue not
exposed
19
STAGE 3:
Full thickness
Deeper ulcer and subcutaneous
tissue (fat) exposed
Refer to tissue viability
PREVENTION
• Offload pressure
▶ keep mobile/reposition (turn immobile patients every hour or 2)
▶ use equipment (protective padding, support surfaces / special mattresses)
• Other
▶ daily check for development of pressure ulcer
▶ skin hygiene (keep dry, avoid irritants, avoid friction)
▶ optimise nutrition (protein/calorie supplements, vitamin C, hydration)
STAGE 4:
Full thickness
Deep ulcer & see bone
Risk of osteomyelitis
Refer to tissue viability
Fig. 2.12
Pressure ulcers are a
on inspection
PREVENTION > CURE (ulcers hard to heal)
95% ulcers = avoidable
Moisture lesion:
NOT a pressure ulcer
Redness ± partial skin loss
Excessive skin moisture
Due to chronic exposure
to urine/faeces/sweat
clinical diagnosis
based
TREATMENT
• Wound care
▶ if it’s dry, moisten to aid healing; if it’s wet with exudate, dry it out to aid
healing
▶ cleaning – 0.9% NaCl
▶ debridement – only if necrotic tissue present
• Nutritional optimisation
• Antibiotics
▶ topical antibiotics if infection in the wound
▶ systemic antibiotics only if cellulitis present / systemic symptoms
▶ if osteomyelitis present, antibiotics needed for 6w
• Surgery
▶ only in severe cases of ischaemia/necrosis
Prevention summary
Skin assessment
Keep moving
Incontinence/irritant avoidance
Nutrition assessment
19
NICE (2014) Pressure ulcers [CG179]
38 Chapter 2: Geriatric medicine
https://t.me/med1917
Ethics and end-of-life decisions
Mental capacity
DEFINITION
Mental capacity is a person’s ability to make their own decisions and choices
→ It is DECISION- & TIME-SPECIFIC
i.e. a person may have capacity to make simple decisions, but not more complicated
ones
i.e. a person may not have capacity to make a decision when they are suffering from
delirium, but do once they recover (interventions may be delayed until capacity is
regained)
*IMCA (Independent Mental Capacity
Advocate)
An impartial, objective individual who helps
decide what is in the patient’s best interest.
Needed when someone lacks capacity but
has no one else able to represent them.
When might we need to assess capacity?
• To gain consent for procedures
• Patient refusing interventions
• Patient wants to be discharged against
medical advice
• Patient wants to be discharged without
recommended support/POC
• Patient’s behaviour puts self or others at risk
• Family members report concerns over
patient’s cognitive state
FIVE PRINCIPLES OF CAPACITY
1. Assume capacity unless proven otherwise
2. Individuals should be supported to make their own decisions where
possible (facilitated)
▶ All efforts must be made to help understanding of
information / communication of decision, e.g. hearing aids, diagrams,
demonstrations, interpreters
3. Unwise decisions must still be respected
4. If someone lacks capacity, must act in their best interests
→ Can have a ‘best interests meeting’
▶ Not based on age, appearance, etc.
▶ Consider person’s wishes, feelings, beliefs, values
▶ Consider the views of close friends/family
▶ May consider the views of any IMCA*
▶ Consider whether they will regain capacity
NB If concerned that family are not acting in best interests, can refer to Court
ofProtection
5. If someone lacks capacity, must choose the least restrictive option
20
ASSESSING CAPACITY: 2-stage test
Stage 1:
Does person have an impairment of
the mind or brain?
Temporary or permanent:
dementia, delirium, learning disability,
stroke, alcohol/drugs, head injury
Yes
Stage 2: Can the person:
• understand information?
• retain information (long enough to make decision)?
• weigh up consequences?
• communicate the decision?
If person cannot demonstrate 1 or more of the
above, this indicates that they LACK CAPACITY
related to a particular decision
No
No reason to
question capacity
20
Mental Capacity Act (2005), Section 1
HOW TO APPROACH A CAPACITY ASSESSMENT
https://t.me/med1917
• Explain to patient what you are assessing capacity for / the decision that
needs to be made.
• Explain the risks and benefits/consequences of both consenting and not
consenting to this decision,
i.e. why you want to do it & what could go wrong, as well as what could happen if
they do not consent
• Ask if they understand → get them to summarise/repeat back what you’ve
said to check understanding and ability to retain information.
• Ask them to tell you their views / their decision, based on the information
you have given them.
Lasting power of attorney (LPA)
An LPA is a legal document that appoints an individual or individuals as attorney
for the patient.
→ Attorneys are able to make decisions on behalf of the patient, should the
patient lack capacity to do so themselves.
→ Attorneys must be appointed when the patient has capacity.
→ The LPA document is legally binding.
Chapter 2: Geriatric medicine 39
There are two types:
• Financial – decisions involving finances, e.g. buying/selling property, investing
money
• Health and wellbeing – decisions on medical care, living situation, social
contacts
Liberty protection safeguards (LPS)
Article 5 of Human Rights Act: no one should be deprived of their liberty unless
in accordance with a procedure prescribed by law, e.g. if detained under the
Mental Health Act / a deprivation of liberty safeguard is in place.
According to the Mental Capacity (Amendment) Act 201921:
A doctor may deprive a patient of liberty if, by doing so, the doctor is enabling the
care & treatment of the person who lacks capacity.
To apply for deprivation of liberty the following conditions must be met:
1. Lacks the capacity to consent to care and treatment and
2. The person subject to continuous supervision and controland
3. The person free to leave
RESTRAINTS AND CONSTRICTIONS
The Mental Capacity Act allows restraints/restrictions to be used if they are in
the patient’s best interests.
Restrictions and restraints must be proportionate to the harm we are trying to
prevent.
→ Ensures the patient is managed in the least restrictive way possible
NOTE: YOU CANNOT DEPRIVE SOMEONE OF
LIBERTY IN THEIR OWN HOME
Examples of restraints/constrictions: locks/key pads, sedative medication, close
supervision/isolation, restricting contact with friends/family, physically stopping
patient doing something that will cause them harm
21
Mental Capacity (Amendment) Act (2019), Chapter 18
40 Chapter 2: Geriatric medicine
https://t.me/med1917
Advance decision to refuse treatment (ADRT)
ADRTs are ignored if a patient still has capacity
Problems with ADRT
• Patients are often unaware of ADRTs / their
legal validity
• Patients/doctors often uncomfortable
discussing such topics
• Poor transfer of an ADRT from home/primary
care to hospital
• May be too vague, e.g. refusal of
‘life-sustaining treatment’ may not help
decisions about IV fluids
• High level of competence is needed to
complete an ADRT – once patient has a
diagnosis of dementia, they may not be able
to complete one
• Made when patient has capacity for if they lose capacity
• Has same weight in law as if patient still has capacity
• Legally binding – must be authorised
• Must be very specific
▶ can set out the treatment they do not want and in which circumstances
▶ can refuse treatment, but not demand treatment, e.g. refusal of PEG if
unable to self-feed, but cannot demand to be PEG fed
Exception: if patient is detained under Mental Health Act, they can still be treated
for mental illness despite an ADRT
→ Cannot refuse basic care
CPR decision-making
CPR is a procedure we are performing on a patient and therefore, like all
procedures, it is a clinical decision. Family and patient should be informed and
the process explained, but the final decision rests with the clinical team22.
By not providing CPR to a patient, we can instead focus on their comfort and
dignity at the end of their life.
THINGS TO CONSIDER
• Survival chances
• Quality of life after resuscitation – hypoxic brain damage/pain/broken ribs, etc.
• Will ITU be willing to support this patient post-arrest?
23
Survival rates following CPR
23
Most cardiac arrests occur in the community.
Following out-of-hospital cardiac arrest, 30% of
people achieved return of circulation, but only
9% survive to hospital discharge. Following
in-hospital cardiac arrest, 53% achieved return of
circulation with 23.6% surviving to discharge.
DNACPR
• Only pertains to CPR (once heart stops) and NOT other treatments that may
aid recovery, i.e. ABX, IV fluids
• It is a medical decision but should be discussed with patient and family
▶ need a medical reason other than age, e.g. not fit for ITU post-arrest/
frailty/terminal illness
▶ team decision should be signed by a consultant
ReSPECT (Recommended Summary Plan for Emergency Care and
Treatment)
• Personalised recommendations for clinical care in future, where the patient
is unable to make or express decisions
• More holistic summary of end-of-life care; covers details other than just
CPR, e.g. use of IV fluids/ABX
• Relevant for people with complex health needs / nearing the end of their
lives / at risk of sudden deterioration
• Is NOT legally binding. Often used as part of an Advanced Care Plan (ACP)
to help a patient and family discuss end-of-life wishes, which may help avoid
unnecessary admissions to hospital.
22
General Medical Council (2010) Cardiopulmonary resuscitation guidance
23
Resuscitation Council UK (2021) Epidemiology of cardiac arrest guidelines
Elder abuse
https://t.me/med1917
‘A single or repeated act or lack of appropriate action, occurring within any
relationship where there is an expectation of trust, which causes harm or
distress to an older person.’
Types of abuse
• Financial
▶ misusing a patient’s money in a way that controls or limits their life and/or
actions
sales scams, spending older person’s money on themselves, pressuring older
person to sign over their property / change their will
• Emotional/psychological
▶ treating someone in a way that makes them feel threatened/belittled/
embarrassed
shouting at person, insulting them, threatening them, ignoring them
• Physical
▶ physically hurting someone
slapping, hitting, rough handling, restraining
• Sexual
▶ touching someone in a way that they don’t want to be touched
▶ also use of inappropriate sexual language / forcing someone to watch
sexual material
• Neglect/abandonment
▶ neglecting someone’s needs: NOT ALWAYS INTENTIONAL
(passiveneglect)
denied access to bathroom/food/phone
left in soiled sheets / unsafe environment
incorrect dose / timing of medication
24
Chapter 2: Geriatric medicine 41
May happen if there are frustrated relatives or
poorly trained carers
Recognising abuse
Physical signs:
• Bruising (may be hidden – examine carefully)
• Unkempt appearance / soiled clothes
• Malnourished
• Low mood/self-esteem
Other signs:
• Behaviour/mood changes
• Strained relationships / spoken to harshly
• Appearing fearful/nervous around people
• Withdrawal from social activity
• Struggling financially
OUR RESPONSIBILITY
If you are concerned, you MUST TAKE ACTION
• Document concerns and escalate to someone more senior
• Consider an adults’ safeguarding referral via Multi Agency Safeguarding Hub
Never agree to keep things secret
• Try to talk to the patient and reassure them that you are there to help
24
WHO (2021) Elder abuse factsheet
https://t.me/med1917
43
https://t.me/med1917
GYNAECOLOGY
Abnormalities of the uterus ............................................44
Disorders of the ovaries
Disorders of the vulva & vagina
Conditions of the cervix
Gynae-oncology
......................................................................50
The menstrual cycle
Subfertility
..................................................................................55
ABBREVIATIONS
AFP – Alpha fetoprotein
AIDS – Acquired immune deficiency
syndrome
AMH – Anti-Müllerian hormone
ART – Anti-retroviral treatment
BMD – Bone mineral density
BPH – Benign prostatic hyperplasia
BSO – Bilateral salpingo-oophorectomy
BV – Bacterial vaginosis
CF – Cystic fibrosis
CIN – Cervical intraepithelial neoplasia
CL – Corpus luteum
COCP – Combined oral contraceptive pill
Cu – Copper
DEXA – Dual-energy X-ray absorptiometry
EC – Emergency contraception
ERPC – Extraction of retained products
ofconception
FCU – First catch urine
FISH – Fluorescence in situ hybridisation
FR – Failure rate
FSH – Follicule-stimulating hormone
FSU – First-stream urine
GBS – Group B Streptococcus
GDM – Gestational diabetes mellitus
GnRH – Gonadotrophin-releasing
hormone
HIV – Human immunodeficiency virus
HMB – Heavy menstrual bleeding
.....................................................46
...................................47
.....................................................48
..............................................................52
HNPCC – Hereditary non-polyposis
colorectal cancer
HPV – Human papillomavirus
HRT – Hormone replacement therapy
HSV – Herpes simplex virus
IAP – Intra-abdominal pressure
IBS – Irritable bowel syndrome
ICSI – Intracytoplasmic sperm injection
IMB – Intermenstrual bleeding
IUD – Intrauterine device
IUI – Intrauterine insemination
IUS – Intrauterine system
LBW – Low birth weight
LH – Luteinising hormone
LLETZ – Large loop excision
oftransformation zone
LMP – Last menstrual period
LN – Lymph node
LNG – Levonorgestrel
MS – Multiple sclerosis
MSU – Mid-stream urine
NAAT – Nucleic acid amplification test
(N)NRTI – (Non)-nucleoside reverse
transcriptase inhibitor
OCP – Oral contraceptive pill
OHSS – Ovarian hyperstimulation
syndrome
PCB – Post-coital bleeding
PCO – Polycystic ovaries
03
Menopause..................................................................................58
Urogynaecology
Contraception
Unintended pregnancy & abortion
Genital tract infections.......................................................66
Infections of the uterus & pelvis
......................................................................60
...........................................................................62
...........................65
..................................69
PCOS – Polycystic ovary syndrome
PCP – Pneumocystis pneumonia
PCR – Polymerase chain reaction
PGD – Pre-implantation genetic diagnosis
PI – Protease inhibitor
PID – Pelvic inflammatory disease
PMB – Post-menopausal bleeding
PMS – Premenstrual syndrome
POP – Progesterone-only pill
PROM – Premature rupture of membranes
PUFR – Perfect use failure rate
PV – Per vagina
RPOC – Retained products of conception
RUQ – Right upper quadrant
SNRI – Selective noradrenaline reuptake
inhibitor
SSRI – Selective serotonin reuptake
inhibitor
STI – Sexually transmitted infection
TOP – Termination of pregnancy
TSH – Thyroid-stimulating hormone
TUFR – Typical use failure rate
TV – Transvaginal
UPA – Ulipristal acetate
UPSI – Unprotected sexual intercourse
VDRL – Venereal disease research
laboratory test
VE – Vaginal examination
VIN – Vulval intraepithelial neoplasia
44 Chapter 3: Gynaecology
https://t.me/med1917
Abnormalities of the uterus
Polyps
Risk factors for polyps
• 40–50y
• high oestrogen (e.g. tamoxifen Tx)
*Morcellation = cutting uterine/fibroid tissue into
smaller pieces to allow laparoscopic or hysteroscopic
removal
→ small, benign tumours of the uterine cavity – endometrial origin
↳ 0.2–1.5% become malignant
SYMPTOMS: may be asymptomatic
• HMB & IMB
• May prolapse through cervix
MANAGEMENT OPTIONS: (80% managed with outpatient hysteroscopy)
• Hysteroscopic resection with diathermy
• Hysteroscopy + morcellation* if large
• Avulsion (twist & tear off polyp with forceps)
→ removed polyp sent for histology
INVESTIGATIONS:
• TV USS
• Hysteroscopy
Complications of
bleeding & infection
HRT can cause continued growth after
menopause
Risk factors for fibroids/leiomyomata
• Peri-menopausal
• Afro-Caribbean
COCP/progesterones = PROTECTIVE
Complications of fibroids
• Torsion of pedunculated fibroid
• Degenerations
▶ Red: pain, haemorrhage, necrosis
▶ Hyaline/cystic: liquefied & soft
▶ Calcification: post-menopausal
• Malignancy: leiomyosarcoma (0.1%)
Trial tranexamic acid, NSAIDs,
progesterones to control HMB: will be
ineffective if HMB due to fibroid
• FHx polyps
• Nulliparous
Fibroids/leiomyomata
→ benign tumours of the uterine cavity – myometrial origin
↳ 25% women
PATHOLOGY
• Location: subserosal, intramural, submucosal
• Size varies: mm to cm
• Growth due to oestrogen/progesterone (stop & calcify after menopause)
SYMPTOMS
• Asymptomatic: 50%
• HMB: 30%
• IMB – if submucosal/polypoid
• Pressure effects: urinary freq./retention, hydronephrosis
• Subfertility
INVESTIGATIONS
• History & examination: palpable, solid mass in pelvis/abdo
• Bloods: Hb may be if HMB, or if fibroid secretes EPO
• TV USS: shows mass continuous with uterus
• MRI/laparoscopy: distinguish from ovarian mass & adenomyosis
• Hysteroscopy: assess uterine distortion
MANAGEMENT
1. No treatment: if asymptomatic & slow growth
2. Medical: preserves fertility
• GnRH: temporary shrinkage (max 6m use)
→ often used for 2–3m pre-surgery
3. Surgical: only myomectomy preserves fertility
• Hysteroscopic transcervical resection of fibroid (TCRF) ± morcellation:
ifpolypoid or submucosal <3cm
• Myomectomy: failed medical Tx but want to preserve fertility
• Hysterectomy: most effective
4. Other:
• Uterine artery embolisation (UAE) → cut off blood supply to fibroid
1
can form intracavity polyps
1
NICE (2018, updated 2021) Heavy menstrual bleeding [NG88]
Adenomyosis
https://t.me/med1917
→ endometrial tissue growth within the myometrium
↳ exact cause unknown
SYMPTOMS: may be asymptomatic
• HMB & IMB
• Dysmenorrhoea
• Enlarged, tender uterus
INVESTIGATIONS
• MRI gives definitive diagnosis
Chapter 3: Gynaecology 45
Risk factors for adenomyosis
• >40y
• endometriosis
• fibroids
MANAGEMENT
Medical:
• IUS/COCP ± NSAIDs (control
2
Surgical:
• Hysterectomy (usually required)
HMB/dysmenorrhoea)
Endometriosis
→ endometrial tissue growth outside of uterus
↳ Affects 10% of women of fertile age
PATHOLOGY
• Growth: oestrogen-dependent (regress after menopause)
• Location: anywhere in pelvis* (uterosacral ligaments & on/behind ovaries
=common) (rarely spreads outside pelvis)
• Disease process: inflammation, progressive fibrosis & adhesions
SYMPTOMS: may be asymptomatic if mild
• CHRONIC PELVIC PAIN = cyclical
• Dysmenorrhoea before menstruation (peaks day 1)
• Deep dyspareunia
• Pain on passing stools
• Subfertility → endometriosis found in 25% subfertility Ix
SIGNS
• Retro-uterine/adnexal tenderness &/or thickening
• Uterus may be retroverted & immobile
• Nodule of endometrial tissue may be palpable on VE
Risk factors for endometriosis
• 30–45y
• nulliparous
• genetics
*Rarely spreads outside pelvis
Complications of endometriosis
• Chocolate cyst (endometrioma):
accumulated, dark brown blood in ovaries
→rupture causes acute pain
• Frozen pelvis: in very severe cases pelvic
organs immobile due to adhesions
INVESTIGATIONS
• TV USS
• Laparoscopy ± biopsy gives definitive diagnosis
• MRI: r/o adenomyosis
• Barium studies: assess ureteric, bladder, bowel involvement if necessary
MANAGEMENT
No treatment: if asymptomatic
Medical: no improvement in fertility
• Analgesia: NSAIDs ± paracetamol or opiates
• Back-to-back COCP, POP, GnRH, IUS – suppress ovarian function & oestrogen
levels
Surgical: may improve fertility
• Laparoscopic excision or laser/bipolar diathermy (ablation of lesions)
• Adhesiolysis
• Cystectomy of ovarian endometrioma
• Hysterectomy + bilateral salpingo-oophorectomy (BSO) if conservative Mx fails
& fertility is not important
2
NICE (2018, updated 2021) Heavy menstrual bleeding [NG88]
3
ESHRE (2013) Management of women with endometriosis
3
Fig. 3.1 Endometrioma.
active lesions = red vesicles/marks
less active lesions = white scars/brown spots
(‘powder burn’)
Fallopian
Endometriosis
tube
Uterus
Endometrium
Fig. 3.2 Common locations of endometriosis.
Risks of surgery
Damage to bowel, bladder, vessels, ureters
46 Chapter 3: Gynaecology
https://t.me/med1917
Disorders of the ovaries
Ovarian cyst accidents
Functional cyst: persistent corpus luteum
• very common & no Mx needed if <5cm
Mucinous cyst: can become enormous
• can cause pressure Sx (e.g. urinary freq.)
• 5% become malignant
• Mx: oophorectomy & histology
Dermoid cyst: contain hair/skin/teeth
Worrying cyst features:
>5cm / rapid growth, multi-loculated,
post-menopausal development, ascites
Diagnostic criteria
PCO = ≥12 small follicles in an enlarged ovary
PCOS = ≥2 of:
• PCO on TV USS
• irregular menstrual periods (>35d apart)
• hirsutism ( acne/hair or serum
testosterone)
1. Rupture of cyst contents into peritoneal cavity → intense pain
2. Haemorrhage into peritoneal cavity → pain + hypovolaemic shock
3. Torsion of ovarian pedicle → severe pain + ovary/tube infarction
↳ urgent surgery needed
Polycystic ovary syndrome (PCOS)
PATHOLOGY
Raised LH (disordered production) & insulin levels (due to resistance) cause
androgen production in the ovaries
→ disrupts folliculogenesis = multiple small follicles
→ disrupts menstrual cycle = oligo-/amenorrhoea
→ physical manifestations = hirsutism
SYMPTOMS
• Infertility – cause of 80% anovulatory cases
• Obesity
• Acne / hair (hirsutism)
• Oligo-/amenorrhoea (periods >35d apart)
INVESTIGATIONS: exclude other causes for symptoms
1. Blood tests: LH levels
• For anovulation: FSH, prolactin, TSH, day 21 progesterone
• For hirsutism: serum testosterone
2. TV USS: for PCO
3. Other: fasting glucose & lipids (DM screen)
albumin-bound
Complications of PCOS
• T2DM (50% women)
• GDM (30% women)
• Endometrial cancer
Risk factors for PCOS
• Genetics
• weight
• DM/FHx DM
FSH interpretation re anovulation
Raised: ovarian failure
Low: hypothalamic disease
Normal: PCOS
MANAGEMENT
• Diet & lifestyle advice: insulin resistance to improve symptoms
• Metformin insulin sensitisation & improve hirsutism
If fertility not required:
• COCP (2nd line = anti-androgens) regulate menstruation & improve hirsutism
If fertility required:
• Joint 1st-line: clomifene (anti-oestrogen) triggers –ve feedback loop to
LH & FSH production & follicle development
• Joint 1st-line: letrozole (aromatase inhibitor) prevents conversion of
androgens to oestrogens, FSH & ovulation
• Laparoscopic ovarian diathermy
• Gonadotrophins (FSH ± LH) if clomifene has failed
4
4
ESHRE (2018) International evidence-basedguideline for the assessment and management of
polycystic ovary syndrome
Соседние файлы в папке Библиотека им академика М.И. Перельмана