Summarised clinchers created for the exam

For distal end radius fracture

>> Colle's # = dorsal/posterior angulation = dinner fork deformity.

>> Smith’s # (reverse Colle's) = ventral angulation = garden spade deformity.

Colle’s # = Outward, Smith’s # = Inward

Asthma management

1st step inhaled SABA (short acting beta agonists)

2nd step add inhaled steroids (Beclomethasone dipropionate, Budesonide, Budesonide/Formoterol,

Fluticasone)

3rd step will depend on age.

>5 years: add LABA (long acting beta agonists)

2-5 years: leukotriene antagonist

<2 years: refer paediatric specialist

4th step: increase inhaled steroids dose.

Contraception clinchers

1. Young woman, not sexually active (patients who don't need contraception)

>>Menorrhagia only - tranexamic acid

>>Menorrhagia with dysmenorrhoea - mefenamic acid

 >>Menorrhagia/dysmenorrhoea/metrorrhagia (irregular menses) - COCP

2. Sexually active woman and require contraception

>>Menorrhagia/dysmenorrhoea or those suffering from fibroids - IUS Mirena (1st line)

Sometimes questions will also mention possible contraindications for COCP like
obesity/smokers/history of thromboembolism and etc.

3. Sickle cell woman with menorrhagia: Depo provera IM

4. Emergency contraception

>>Within 72 hours of unprotected sex: Levonelle pill

>>Within 120 hours of unprotected sex: IUCD or ellaOne pill.

For post-partum contraception - just remember:

1. Breastfeeding mothers - COCP only after 6 months.

2. Non breastfeeding mothers - COCP after three weeks.

In both cases, the period before they can start using COCP, they can use male or female condoms and
progesterone only preparations.

IUS/IUCD can be inserted 48 hours after birth or 6 weeks later.

Criteria for resolution of DKA

Plasma glucose <11.1mmol/L

Serum bicarbonate >18mmol/L

Venous pH >7.3

Anion gap <10

Choose UBT (Urea Breath Test) for only two reasons

1. To diagnose and confirm H Pylori infection.

2. To check eradication after treatment. This must be done after 4 weeks of therapy completion.
Cervical Smear Clinchers

In UK, cervical smear it's a national screening programme. We can only do it when it's due.

1. If the woman comes to you and she's 25 years old with bleeding ectropion, DO a smear test first.

Reasons:

-She's due age for cervical screening

-Always rule out malignancy first.

2. If a woman comes to you within the screening age group with bleeding ectropion, rule out possible
CAUSES first.

e.g. Infection/COCP etc.

This is where you need to perform an endocervical swab and treat accordingly with antibiotics if
infection is suspected.

- The ultimate treatment however is via cautery or cold coagulation and this can only be done via
COLPOSCOPY. (Therapeutic)

Rubella in pregnancy

If exposed:

1. Check previous immunity/vaccination history (regardless of the status > Contact the health
protection unit -HPU)

2. If infected

Less than 20 weeks gestation: refer to obstetrician for congenital rubella assessment.

More than 20 weeks gestation: Reassurance.

Vertigo clinchers

Vertigo with hearing loss

1. Meniere's disease - Associated with tinnitus, fullness in ear, n & v

2. Labyrinthitis - Usually precipitated by infection history (viral)

Vertigo without hearing loss

1. BPPV- remember Dix-Hallpike maneuver

2. Vestibular neuritis - due to viral infection.

Cervical Smear Interpretation

Normal - back to routine screening

Inadequate - repeat smear in 3 months.

Abnormal

1. Borderline changes + mild/low grade dyskaryosis = do HPV testing, if positive then colposcopy.
If negative, back to routine cervical screening.

2. Moderate and High grade dyskaryosis - colposcopy within four weeks.

3. Suspected cancer/glandular neoplasia - urgent colposcopy within two weeks.

Pneumonia clinchers

For the purpose of exam, there are three possibilities of cavitating pneumonia.

1. Mycobacteria Tuberculosis (TB)

- Look for typical TB symptoms. (night sweats/chronic cough/loss of weight /appetite)

- Usually bilateral upper lobe cavitation

2. Klebsiella pneumonia

- Very very rare especially in elderly population (alcoholic /DM)

- CXR: similar as TB usually upper lobes cavitation.

3. Staphylococcal pneumonia

- Immune-compromised patients /IVDU

- CXR: bilateral lungs cavitating lesions

Opioids clinchers

For the purpose of the exam, 4 rules on opioids

1. For all types of opioids. Remember that Morphine is first line. Having said that I mean ONLY oral
or subcutaneous routes can be used as first line morphine.

So, say that patient having good pain control with oral morphine, but unable to swallow. Next choice
should be subcutaneous routes. If subcutaneous is not in the options, do not choose IV or IM. Change
to other preparations such as patches. (E.g. fentanyl patches).

2. Diamorphine is one step higher or potent compared to conventional morphine. Choose

Diamorphine ONLY for two reasons
 i) Pain is not controlled with conventional morphine.

ii) Patient is already on maximum dose of conventional morphine (E.g. if patient is injecting high
dose SC morphine, you can switch straight away to diamorphine)

3. Post-operative analgesia of choice is always and I mean ALWAYS morphine (regardless of routes
Oral/IV/SC/)

4. Oxycodone is always used as a replacement for those who cannot tolerate morphine side effects.
(P/S although oxycodone can have similar or worst side effects profile than morphine - don't worry
about it)

These are potential COCP enzyme inducers

Antibiotics: Rifampicin/rifabutin

Anticonvulsants: Phenytoin/Carbamazepine

Other drugs: Spironolactone/Alcohols/St John wart/Griseofulvin

If the woman on COCP takes any of the above >Advise her for additional barrier contraception
(condoms)

Say if she takes rifampicin for one week or etc., and then use condoms on top of COCP for that whole
week.

Murmurs

Pan systolic murmurs

1. Mitral regurgitation (apex)

2. VSD (LLSE)

3. Tricuspid regurgitation.

4. Mitral prolapse.

Ejection systolic murmurs

1. Aortic stenosis (URSE)

2. If there's split S, then ASD, if no then PS. (both can be found at ULSE)
Early diastolic murmurs

1. Aortic regurgitation

2. Pulmonic regurgitation

Mid diastolic murmurs - Mitral stenosis

Continuous Murmur - PDA- radiating to the back

Holosystolic Murmur - Tricuspid Atresia

Stones clinchers

Treatment depends on anatomical location (kidney/ureter/bladder)

Any stones which is less than 5mm > conservative mx

Kidney: if <2cm: ESWL, if >2cm PCNL

Ureters: if > 7mm ESWL is always the first choice. If contraindicated or fails > Ureteroscopy > PCNL

Bladder: if > 7mm, can be removed via transurethral method.

Neuropathic pain

1. For trigeminal neuralgia, use carbamazepine - first line.

2. NICE recommend that for neuropathic pain, with the exception of trigeminal neuralgia,

Amitriptyline, gabapentin, duloxetine and pregabalin are equally acceptable 1st line options. So which
one to choose?

BMJ and GP updates recommend Amitriptyline as 1st line

Fluid resuscitation

ALWAYS use isotonic crystalloids (0.9% NS, or occasionally Ringer's) bolus for both paediatrics and
adults

For maintenance:

- In Paediatrics we use 0.45 % NS/5% Dextrose solution.

- In Adults 0.9 % NS
Tonsillectomy indications

1. 5 or more episodes of sore throat per year

2. Symptoms have been occurring for at least a year

(There’re few others which are not relevant for exam)

When to give antibiotics? There's something called Centor criteria to decide.

Remember these 4 points,

i) Tonsillar exudate

ii) Tender anterior cervical adenopathy

iii) Fever over 38°C by history

iv) Absence of cough

If you have any 3 or more features mentioned in the question, then start antibiotics. If less, 1st
reassurance with symptomatic treatment (PCM/Ibuprofen)

Acute treatment for both Ischaemic stroke and TIA

High dose Aspirin 300mg for two weeks

Prophylactic/Long term treatment for both Ischaemic stroke and TIA

1st line: Clopidogrel 75mg monotherapy

2nd line (if not tolerable to Clopidogrel): Aspirin 75mg plus Dipyridamole 200mg

My clinchers on enuresis

General rule to remember is behavioural/ toilet training is 1st initial step for any child regardless of
age.

Having said that,

If child is under 5 years old - Give reassurance to parents that it's normal

Treatment/ Action: give advice for behaviour/toilet training

If child is 5 years old and above – 1st line is behavioural training, if failed then sleep alarms

If say sleep alarm fails or if alarm treatment is undesirable or inappropriate then we start Desmopresin
My clinchers for ear foreign bodies

See what the question is asking for (either initial step/next or most appropriate management)

For insects or live creatures in ear:

i) (First Initial or next step): Kill it by filling the ear canal with a liquid such as olive oil,
methylated spirit, or lignocaine, alcohol drops
ii) (Most Appropriate): Syringing with warm water and remove the dead insect. (make sure
TM is not perforated, otherwise it's contraindicated)

General points to remember for foreign bodies in ear

1. If deep inside ear canal close to TM > refer ENT for removal

2. If not deep, then remove it under direct vision. > If failed then refer ENT

3. If not cooperative or mentally retarded patients > refer ENT for removal under GA

4. If adhesive objects sticking to TM > refer ENT.

When to use hook or forceps?

Hook - Hard/Spherical/Rounded like plastic beads

Forceps- only for soft objects like cotton and paper.

Unless specifically mentioned, GA is to be preferred ONLY where the patient is uncooperative or

removal of a foreign body proves difficult. So there's no such thing as all children requires GA. (BMJ)

Delirium clinchers

Basically in summary, just remember the following:

(In any situation always offer oral route first whenever possible)

1. Alcohol related withdrawals or delirium tremens:

1st line oral lorazepam, if not possible then parenteral (IM/IV lorazepam)

2nd line: antipsychotics (haloperidol /olanzapine)

2. Non-alcohol related delirium

1st line: antipsychotics (haloperidol/olanzapine)

Acute OM

Usually preceded by upper respiratory tract infection

FEVER + EAR PAIN

TM findings: Hyperemic /bulging (due to pus), can be dull

OM can complicate into

1. OM with effusion

2. Secretory OM

3. Glu ear

All the three means the same thing

Fluids collection in middle hear, and that's the reason for conductive hearing loss (need to raise TV
volume)

Usually PAINLESS. They are associated with conductive hearing loss in the long run.

TM findings: dull (due to pooling of fluids behind TM)

Ectopic Pregnancy

Next step management of scenarios with

If in Shock = Laparotomy

If Abd S/S = Laparoscopy

If No Abd S/S = βHCG