EPIGASTRIC PAIN

peptic ulcer disease
(5-15%)
■ gastro-oesophageal reflux
disease (5-15%)
■ gastric or oesophageal
cancer (<2%)
■ gallstones/biliary pain
■ chronic pancreatitis/
pancreatic cancer
■ coeliac disease
■ lactose intolerance
■ medications – digoxin,
theophylline, erythromycin,
potassium supplements,
corticosteroids and NSAIDs
■ infiltrative diseases of
the stomach – eosinophillic
gastritis, Crohn’s disease,
sarcoidosis
■ metabolic causes –
hypothyroidism,
hypercalcaemia,
hyperkaelemia, heavy
metals
■ hepatoma and
steatohepatitis
■ intestinal angina
■ abdominal wall pain
■ Zollinger-Ellison syndrome
■ diabetic radiculopathy
Functional dyspepsia
(up to 60%)
■ caffeine, alcohol and
smoking can exacerbate
symptoms

PERINATAL DEPRESIION

■ Women often don’t recognise
themselves as being depressed
– they hide their symptoms or
present as the baby having the
problem.
■ When symptoms (anxiety,
lowered mood, tearfulness,
fears of not being able to cope
or being a bad mother) are
recurrent, severe or continue for
more than two weeks, the diagnosis
of depression or anxiety
disorder must be considered.
■ In PND many anxieties arise
from the lack a balanced
perspective. Cognitive behavioural
therapy is well suited to
address these issues.
■ Maternal depression is associated
with poor developmental
outcomes for children with
implications for the child’s
education and the potential for
mental illness as adults.
■ Mothers’ groups can be
beneficial if they are specifically
for women with PND but general
mothers groups can alienate
women if they feel different to
the other “coping” mothers.
■ Early detection and treatment
of PND may lead to remission
of symptoms and improvement
for mother, child and family
members, but it does not
guarantee a good outcome.
For some women, mother-infant
or long-term therapy is needed

Dermatology

Skin care advice for patients with lymphoedema


■ Keep the skin supple using a non-perfumed moisturising cream such as sorbolene.
■ Avoid drying out your skin and consider using a soap-free alternative.
■ Clean any scratches, grazes or cuts immediately using an antiseptic solution,
use an antibacterial cream and cover the area with a clean, dry plaster.
■ Use an electric razor for shaving instead of a wet razor.
■ Avoid tattoos and body piercing.
■ Consider ways to protect the skin, such as wearing gloves while washing dishes,
gardening or handling pets.

Administration of Anti -D

At the first pregnancy consultation the mother's blood
group should be determined and blood taken for detection/
measurement of blood group antibodies. For
complete and incomplete miscarriages all Rh(D) negative
women who have not actively formed their own
anti-D should be given 250IU of anti-D.
There is insufficient evidence to suggest that a threatened
miscarriage before 12 weeks gestation necessitates
use of anti-D, but meta-analyses indicate that antenatal
administration of anti-D (for all indications
including miscarriage) can result in a 78% reduction
in allo-immunisation.

CLINICAL DEFINITION OF MISCARRIAGE-Australia

Complete miscarriage • No intrauterine gestational sac
• No ovarian/fallopian mass
• Products of conception passed
• No evidence of POC in uterus
• Endometrial thickness <15mm in longitudinal section Incomplete
• No intrauterine gestational sac
miscarriage • No ovarian/fallopian mass
• POC passed
• More POC seen in uterus

Missed miscarriage

• Intact intrauterine gestational sac
• Fetal pole seen
• No fetal heartbeat
• CRL >6mm
OR
• Intact intrauterine gestational sac
measuring >20mm
• Fetal pole not seen

HOW TO TREAT MISCARRIAGE

INITIAL MANAGEMENT

When a woman describes
bleeding in early pregnancy
the treating doctor must first
determine whether she has
heavy bleeding and/or severe
pain. Saturation of pads
and/or passing clots larger
than a 20 cent piece implies
heavy bleeding. If either is
present this scenario must betreated as a clinical emergency.
The possibility of cervical
shock should always be considered.
A speculum examination
should be performed,
and any products of conception
(POC) should be removed
from the cervix . This is the
only way to reverse shock associated
with this condition.
Basic life support principles
apply. It is important to:
• Ensure that the woman has
a clear airway and adequate
breathing before the speculum
examination is performed.
• Gain IV access with a cannula
of at least 16G diameter
and start IV crystalline
fluids at a rate that maintains
adequate blood pressure
(>100/60) and pulse
rate (<100 beats per minute).
• As the IV is inserted, take
blood for blood group typing
and FBC, and arrange
cross-match of four units of
packed cells.
If analgesia is required, small
bolus doses of IV morphine
2mg titrated to pain at 5-
minute intervals gives quick
relief but should be accompanied
by metoclopramide 10mg
IV as an anti-emetic.
If shock cannot be controlled
despite adequate IV fluids
and removal of POC, the
woman must be prepared for
emergency D&C. Surgery
should not be delayed due to
haemodynamic instability; it
should be performed before
blood and fluid losses have
been replaced. Sometimes surgical
evacuation of the uterus
is needed to resolve shock.

Differential Diagnosis of snake bites ?

DIFFERENTIAL DIAGNOSIS OF VENOMOUS SNAKEBITE
■ non-venomous snakebite
■ bite or sting by other venomous creature
(arthropod, including spider, octopus, jellyfish)
■ CVA
■ ascending neuropathy, eg Guillain-Barre
syndrome
■ AMI
■ allergic reaction
■ hypoglycaemia/hyperglycaemia
■ drug overdose
■ closed head injury
The combination of neurological disturbance and
evidence of defibrination in a patient with an
appropriate history is strongly suggestive of severe
envenomation.

Snake Bites Australia How to investigate

In managing the patient with suspected
snakebite, it is necessary to
establish whether significant envenomation
has occurred and to attempt
to identify the type of snake
involved. A significant proportion of
venomous snakebites don’t result in
envenomation. The use of antivenom
should be reserved for those cases
with clinical or pathologic evidence
of envenomation.

1.Snake venom Detection Kit

2.Clotting Studies

3.Creatinine Kinase-Indicating Myolysis

4.Urinalysis-Haemoglobin,Myoglobin

5.Renal Function-May be impaired secondary to Myoglobinuria or other mechanism.

Austrlian Snake Bites Overview

Effects of Australian snake bite venom are usually
species specific, but in general include:

■ neurotoxins
■ procoagulants
■ anti-coagulants
■ rhabdomyolysins
■ haemolysins (weak).

Presentation



Symptoms and signs of
envenomation may include:
■ EARLY (within 30 minutes)
- headache, nausea/vomiting,
abdominal pain
- coagulopathy
■ LATE (within several hours)
- cranial nerve palsies
(ptosis, ophthalmoplegia,
dysarthria, dysphonia,
dysphagia)
- limb and truncal weakness
- respiratory failure
- haemorrhage
■ VERY LATE (delayed
presentation,
wrong/inadequate treatment)
- prolonged paralysis
- renal failure
- uncontrollable haemorrhage
Features suggestive of snakebite
Identification of snakes is often
unreliable: polyvalent antivenom
should be used if the
type of snake cannot be identified
in all areas of Australia
apart from Tasmania, where
both tiger snake and copperhead
bite may be successfully
treated with tiger snake
antivenom, and Victoria, where
bites should be treated with
combined tiger/brown snake
antivenom


How to treat

Identification of snakes is often
unreliable: polyvalent antivenom
should be used if the
type of snake cannot be identified
in all areas of Australia
apart from Tasmania, where
both tiger snake and copperhead
bite may be successfully
treated with tiger snake
antivenom, and Victoria, where
bites should be treated with
combined tiger/brown snake
antivenom.



Important to remember

■ Correct diagnosis of snakebite
may be delayed because the
bite may not be dramatic or
painful, and snake venom
generally causes little local
pain or tissue destruction.
■ Identification of snakes is often
unreliable: polyvalent
antivenom should be used if
the type of snake cannot be
identified in all areas of
Australia apart from Tasmania,
where both tiger snake and
copperhead bite may be
successfully treated with tiger
snake antivenom.
■ Children are more likely to
sustain multiple bites and may
be more quickly and severely
affected by snakebite than
adults because of their lower
body weight.
■ The combination of
neurological disturbance and
evidence of defibrination in a
patient with an appropriate
history is strongly suggestive of
Severe envenomation