29 th March 2022 1 LO please insert relevant Learning objective reference here 2 The best way to use the slides These slides contain the essential things you will need to understand If there is a discrepancy between these slides and lecture slides use what the lecture says ID: 930551
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Slide1
Hamza Ikhlaq
Urology and Development 2
29th March 2022
1
Slide2LO: please insert relevant Learning objective reference here
2
The best way to use the slides
These slides contain the essential things you will need to understand .
If there is a discrepancy between these slides and lecture slides, use what the lecture says.
Grab some chai, and let the fun begin.
Slide33
We will cover…
Urological cancers
Urinary incontinence and benign prostatic hyperplasia
BPH and prostate cancer tutorial
Early environmental and biological impacts on lifelong health
Postnatal and child development
Early life nutrition and lifelong health
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4
Urological Cancers
1-BRS-URO-3: Genitourinary disorders: Summarise the pathology and pathophysiology of genitourinary disorders.
1-BRS-URO-4: Genitourinary disorders: Describe the clinical features and treatment options of genitourinary disorders.
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Kidney Cancer
Types:
Adenocarcinoma(Most Common type – 85%)
Transitional Carcinoma (10%)
Sarcoma/
Willms
Tumour
Risk Factors:
Smoking
Renal Failure / Dialysis
Obesity
Hypertension
Von-Hippel Lindau Syndrome
Presentation:
Painless Haematuria (Can be macroscopic but microscopic is a red flag symptom)
Loin Pain
Masses
Bone Pain. Haemoptysis (Mets)
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Kidney Cancer –
How would you investigate?
Painless visible Haematuria
Flexible Cystoscopy
CT
Urogram
Renal Function
Persistent non-visible haematuria
Flexible Cystoscopy
US KUB
Suspected Kidney Cancer
CT Renal triple phase
Staging CT chest
Bone scan if symptoms
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Kidney Cancer –
How would manage ?
For Most Patients
Partial nephrectomy
(single kidney, bilateral tumour, multifocal RCC in patients with VHL, T1 tumours (up to 7cm)
Radical Nephrectomy
Patients with small tumours unfit for surgery
Cryosurgery
Metastatic Disease
Receptor Tyrosine Kinase inhibitors
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TNM Staging
TNM staging of RCC
T1 – Tumour ≤ 7cm
T2 – Tumour >7cm
T3 – Extends outside kidney but not beyond ipsilateral adrenal or perinephric fascia
T4 – Tumour beyond perinephric fascia into surrounding structures
N1 – Met in single regional LN
N2 – met in ≥2 regional LN
M1- distant met
Fuhrman grade
1 = well differentiated
2 = moderate differentiated
3 + 4 = poorly differentiated
What’s the difference between stage and grade?
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SBA 1
A 65 year old man comes in to see his GP complaining of passing painless red urine. Alongside this he has said he has gone from a Medium to Small shirt size in the past 6 weeks and is feeling more tired recently. He complains of pains in his loins, which is now becoming more regular. What is the first line investigation that should be carried out?
A. US KUB
B. CT Chest
C. Flexible Cystoscopy
D. Bone Scan
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SBA 1
A 65 year old man comes in to see his GP complaining of passing
painless
red urine
. Alongside this he has said he has gone from a
Medium to Small shirt size in the past 6 weeks
and is feeling
more tired
recently. He complains of
pains in his loins
, which is now becoming more regular. What is the first line investigation that should be carried out?
A. US KUB
B. CT Chest
C. Flexible Cystoscopy
D. Bone Scan
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Bladder Cancer
Types:
Transitional Cell Carcinoma (>90%)
SCC (1-7%)
Risk Factors:
Smoking
Occupational (Aromatic hydrocarbons – DYE FACTORIES!)
Chronic UTIs
Schistosomiasis
Drugs (Cyclophosphamide)
Radiotherapy
Presentation:
Painless Haematuria (Can be macroscopic but microscopic is a red flag symptom)
Suprapubic Pain
LUTS
Bone pain/ lower limb swelling if
mets
.
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Bladder Cancer –
How would manage ?
TURB
Trans-
uretehral
resection of the bladder
Non-Muscle Invasive
Cystoscopic
surveillance
Intravascular chemo
Muscle Invasive
Cystectomy
Radio +/- Chemotherapy
Palliative Care
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Bladder Cancer Staging
TNM staging of Bladder cancer
Ta – non invasive papillary carcinoma
Tis – carcinoma in situ
T1 – invades subepithelial connective tissue
T2 – invades muscularis propria
T3 – invades
perivesical
fat
T4 – prostate, uterus, vagina, bowel, pelvic or abdominal wall
N1 – 1 LN below common iliac
birufication
N2 - >1 LN below common iliac
birufication
N3 – Mets in a common iliac LN
M1- distant
mets
WHO classification
G1 = well differentiatedG2 = moderate differentiatedG3 = poorly differentiated
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SBA 2
An 80 year old retired dye factory worker has recently been diagnosed with bladder cancer. Which of the following symptoms was he most likely to have presented to his GP with when first presenting?
A. Loin to Groin Pain
B. Retrograde ejaculation
C. Bone Pain
D. Increased frequency and urgency when urinating
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SBA 2
An 80 year old retired
dye factory
worker has recently been diagnosed
with bladder cancer.
Which of the following symptoms was he most likely to have presented to his GP with when first presenting?
A. Loin to Groin Pain
B. Retrograde ejaculation
C. Bone Pain
D. Increased frequency and urgency when urinating
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Prostate Cancer
Types:
Adenocarcinoma
Risk Factors:
Age
Western Nations (Scandinavia)
African American Males
Presentation:
Usually an incidental finding, unless metastases have arisen.
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Prostate Cancer –
How would you investigate?
Blood Tests
PSA*
MRI
MRI are used to show which areas to biopsy, which has shown to be better than the random biopsies that were previously done.
Trans perineal Prostate Biopsy
Takes biopsies of the prostate
Used over a trans-rectal approach as it reduced infection risk and allows for sampling of all areas of the prostate.
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Prostate Cancer –
How would manage ?
Treatment side effects? – Damage to the cavernous nerves
Incontinence
Impotence
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Prostate Cancer Staging
TNM staging of Prostate cancer
T1 – non palpable or visible on imaging
T2 – palpable tumour
T3 – beyond prostatic capsule into periprostatic fat
T4 – tumour fixed onto adjacent structure/pelvic side wall
N1 – regional LN (pelvis)
M1a- non regional LN
M1b- bone
Gleason score
Since multifocal two scores based on level of differentiation
2-6 = Well differentiated
7 = Moderately differentiated
8 – Poorly differentiated
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Urinary incontinence and BPH
What is the main influencing hormone for the development of the prostate?
Where does the arterial blood supply to the prostate arise from?
Which is the plexus for the venous drainage of the prostate?
What is the function of the prostate?
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Urinary incontinence and BPH
What is the main influencing hormone for the development of the prostate?
Dihydrotestorone
(DO NOT SAY JUST TESTOSTERONE)
Where does the arterial blood supply to the prostate arise from?
Inferior Vesical Artery
Which is the plexus for the venous drainage of the prostate?
Peri-prostatic Venous Plexus
What is the function of the prostate?
Liquefy Ejaculate
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Urinary incontinence and BPH
10% of the glandular Tissue of the Prostate
25%of the glandular Tissue of the Prostate
65%of the glandular Tissue of the Prostate
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Urinary incontinence and BPH
10% of the glandular Tissue of the Prostate
25%of the glandular Tissue of the Prostate
65%of the glandular Tissue of the Prostate
Slide24BPH
Increased number of epithelial and stromal cells in response to the androgens.
Increased urethral resistance due to peri-urethral pressure increase.
Compensatory changes from the bladder leads to increased detrusor pressure to maintain urinary flow.
= LUTS symptoms (reduced flow, increased frequency, urgency & Nocturia)
The size of the prostate does not directly correlate to the degree of the obstruction. Other factors such as urethral resistance and the prostatic capsule relate to this, so it is more of an anatomical thing.
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BPH Exam-Style Questions
SBA 3 : What is the most abundant adrenoceptor subtype in the prostate?
A: Alpha-1
B: Alpha – 2
C: Beta - 1
D: Beta - 2
E: Beta - 3
SAQ 1:
Explain why LUTS symptoms are seen in men with BPH (2 Marks)
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BPH Exam-Style Questions
SBA 3 : What is the most abundant adrenoceptor subtype in the prostate?
A: Alpha-1
B: Alpha – 2
C: Beta - 1
D: Beta - 2
E: Beta - 3
SAQ 1:
Explain why LUTS symptoms are seen in men with BPH (2 Marks)
Occur due to changes in bladder function (NOT OUTFLOW OBSTRUCTION) – 1 MARK
There is reduced bladder compliance/instability – 0.5 Mark
Therefore, there is reduced detrusor contractility – 0.5 mark.
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SAQ2 : Clinical Case
John is an 80 year old man. He has come to see you today complaining of difficulty maintaining his urinary stream. He says he doesn’t feel like he can completely empty his bladder. He also says it burns when he urinates and he is needing to go 5 times in the night on average. His PSA comes back as 10ng/mL (NR 4ng/mL) and DRE reveals a smooth enlarged prostate. Name 2 classes of medications John could be prescribed and give a NAMED example for each class. (2 Marks)
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SAQ2 : Clinical Case
John is an
80 year old man.
He has come to see you today complaining of difficulty maintaining his
urinary stream
. He says he
doesn’t feel like he can completely empty
his bladder. He also says it
burns when he urinates
and he is needing to go
5 times in the night
on average. His
PSA comes back as 10ng/mL
(NR 4ng/mL) and DRE reveals a
smooth enlarged prostate.
Name 2 classes of medications Joh could be prescribed and give a NAMED example for each class. (2 Marks)
Alpha-Adrenergic Antagonists (Tamsulosin)
5-alpha reductase inhibitors (Finasteride)
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Urinary Incontinence – Learn your Key Terms
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Risk Factors for UI
Age
Pregnancy & Vaginal Delivery
Obesity
Constipation
Drugs (ACE inhibitors)
Smoking
FHx
Prolapse/Hysterectomy/Menopause
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SBA 4
A 22 year old female enters your clinic complaining that she must change her underwear throughout the day because they become soaked with urine every time she laughs or sneezes. She smokes 20 a day for the past 5 years and has had 1 child child vaginal delivery. Her BMI is also 30. What type of UI is this?
A. Urge
B. Continuous
C. Stress
D. Nocturnal
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SBA 4
A
22 year old
female enters your clinic complaining that she must change her underwear throughout the day because they become soaked with urine every time she
laughs or sneezes
. She
smokes 20 a day
for the past 5 years and has had 1 child child
vaginal delivery
. Her
BMI is also 30.
What type of UI is this?
A. Urge
B. Continuous
C. Stress
D. Nocturnal
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Urinary Incontinence Tx
Lifestyle
Weight Loss
Smoking Cessation
Modify Fluid Intake
Pelvic Floor Exercises
Bladder retraining
Pharmacological Therapy
Oestrogen therapy
Oral Medications
Surgery
Occlusive e.g. bulking, compressive (AUS)
Supportive (mid-urethral sling,
colposuspension
)
Ileal conduit diversion
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Urge Urinary Incontinence
Overactive Bladder = Increased urinary frequency, urgency, nocturia with/without leak.
Management:
Lifestyle
Decrease caffeine
Stop Smoking
Lose Weight
Pharmacological Therapy
Anti-Cholinergic Drugs (
Trospium
)
Beta-3 agonist (
betmiga
)
Surgery
PTNS.
BOTOX
Neuromodulation
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35
BPH & Prostate Cancer Tutorial
Questions:
Why has there been a shift from random biopsy to imaging prior to biopsy for suspected prostate cancer?
What is ‘watchful waiting’ and why is it used?
Which nerve has been damaged in a man presenting with erectile dysfunction after a radical proctectomy?
What should the PSA of a man after a proctectomy be? But also, why does Hamza think PSA is a bit BS for most men unless it’s massively raised?
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BPH & Prostate Cancer Tutorial
Questions:
Why has there been a shift from random biopsy to imaging prior to biopsy for suspected prostate cancer?
Radom biopsies were associated with an under detection of high grade prostate cancer and over detection of low grade prostate cancer. Several large RCT’s have shown MRI before biopsy is better.
What is ‘watchful waiting’ and why is it used?
Most men die of prostate cancer than with it. Treatment like radical surgeries and medications can lead to reduced libido, urinary incontinence, ED and reduce the quality of life for many men. Most patients will require quarterly PSA and DRE and annual MRI coupled with prostate biopsies.
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BPH & Prostate Cancer Tutorial
Questions:
Which nerve has been damaged in a man presenting with erectile dysfunction after a radical proctectomy?
Damage to the cavernous nerve to the prostate (which provides neural innervation to the bladder and urethra)
What should the PSA of a man after a proctectomy be? But also, why does Hamza think PSA is a bit BS for most men unless it’s massively raised?
PSA should be undetectable or <0.01 ng/ml. PSA is not very specific. It can be elevated naturally with age, trauma, even thinks like riding a bike can lead to increased PSA.
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Break – 5 Mins
Top Up Cha
SBA 5: Which enzyme is inhibited by finasteride?
A: Aromatase
B: Tyrosine Kinase
C: 5a-Reductase
D: 17a- Hydroxylase
E: HMG-CoA Reductase
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Break – 5 Mins
Top Up Cha
SBA 5: Which enzyme is inhibited by finasteride?
A: Aromatase
B: Tyrosine Kinase
C: 5a-Reductase
D: 17a- Hydroxylase
E: HMG-CoA Reductase
Slide4040
We will cover…
Urological cancers
Urinary incontinence and benign prostatic hyperplasia
BPH and prostate cancer tutorial
Early environmental and biological impacts on lifelong health
Postnatal and child development
Early life nutrition and lifelong health
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Development: Impacts on Health
Nature Vs Nurture:
Barker Hypothesis:
Small at birth
Thin at 2
Yrs
Showed that the more rapidly a person gained weight in childhood (like 2yrs+), the greater their risk of a coronary event, even when compared to weight gain at a later age.
Soo… undernutrition in utero
overnutrition as a child = Increased risk of ‘Metabolic Syndrome’
Idea of ‘PROGRAMMING IN UTERO’, leading to epigenetic changes.
Associations between early environmental exposures and:
Cardio-vascular disease
Type 2 diabetes
Lung disease
Cancer risk
Neurological, special sense and intellectual development
Allergic and auto-immune diseases
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Genograms
Used to pictorially illustrate the biological, psychological and social information in a family tree type map
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NHS Healthy Child Programme
Aims to promote good heath and prevent disease
It is universal and aims to reduce health inequalities through:
Health Promotion (Obesity prevention is a key aspect)
Supporting care giving and care givers
Screening
Immunisation
Identification of high-risk families/ individuals for additional support
Signposting
accident prevention
dental hygiene
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Screening Contd
Screening checks include:
Newborn
check,
newborn
hearing screen, blood spot check.
SAQ 3: A new screening programme has been implemented for a new virus. Give 2 properties that the virus must have for this screening programme to be successful and 2 features of a successful screening programme (2 Marks)
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Screening Contd
Screening checks include:
Newborn
check,
newborn
hearing screen, blood spot check.
SAQ 3: A new screening programme has been implemented for a new virus. Give 2 properties that the virus must have for this screening programme to be successful and 2 features of a successful screening programme (2 Marks)
The Disease it is screening for
Should be able to identified early/before critical point
Treatable
prevent/reduce morbidity/mortality
Screening
Programme
Must Be:
Acceptable/easy to administer
Cost effective
Reproducible and accurate results
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SBA 6
Patricia is 50 and has recently suffered an MI. When looking through her medical notes on your firms you notice she was underweight at birth. However, in her NHS screening service records it shows she was overweight at her 11 and 16 year old weigh ins. What theory does Patricia's case support?
Obedience
Conditioning
Programming
Nature Vs
Nuture
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SBA 6
Patricia is 50 and has recently suffered an MI. When looking through her medical notes on your firms you notice she was underweight at birth. However, in her NHS screening service records it shows she was overweight at her 11 and 16 year old weigh ins. What theory does Patricia's case support?
Obedience
Conditioning
Programming
Nature Vs
Nuture
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SBA 7: Comms
Patricia returns to you 2 weeks after her MI saying she would like to lose weight. You need to counsel her. What is the most appropriate thing to say?
‘It’s your genes. You shouldn’t worry’
‘Eat less. You are fat’
‘
I don’t care. I am busy, I have real patients to see.’
‘We can text you some healthy eating links from the NHS website and you can talk to one of our HCAs on some lifestyle changes you can implement. Would that be okay with you ?’
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SBA 7: Comms
Patricia returns to you 2 weeks after her MI saying she would like to lose weight. You need to counsel her. What is the most appropriate thing to say?
‘It’s your genes. You shouldn’t worry’
‘Eat less. You are fat’
‘
I don’t care. I am busy, I have real patients to see.’
‘We can text you some healthy eating links from the NHS website and you can talk to one of our HCAs on some lifestyle changes you can implement. Would that be okay with you ?’
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Child Development: Neuro
Neuro Development
4 weeks:
Prosencephalon (Forebrain)
Mesencephalon (Midbrain)
Rhombencephalon (Hindbrain)
5 weeks:
Prosencephalon
Telencephalon & Diencephalon
Mesencephalon
Midbrain
Rhombencephalon
Pons and Medulla
Brain Divisions:
Forebrain
telencephalon (cerebral cortices) + diencephalon (thalamus + hypothalamus)MidbrainHindbrain
metencephalon
(pons + cerebellum) +
myelencephalon
(medulla)
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Neuro Development
Neuro Development
CSF:
LV ----> 3rd Ventricle ----> Aqueduct ----> 4th Ventricle
Cephalic flexure
Pontine
flexure
Cervical flexure
(4 wk)
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Neuro Development
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Neuro Development
Reflex = An autonomic response to a stimulus that involves a nerve impulse passing inward from a receptor to a nerve centre and then outward to an effector, without reaching the level of consciousness.
5 Components:
Sensory Receptor
Sensory Neurone
Integrating Centre -
Usually interneurons which relay information from sensory to motor neurones.
Motor Neurone
Effector
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Primitive Reflexes
Primitive reflexes are involuntary reflexes that a baby is born with that are there to help survive its first few months of life.
These primitive reflexes should disappear by about 18 months of age and be replaced by more mature patterns of response (postural reflexes).
Primitive reflexes, if retained beyond about 18 months, are often linked to later issues with behaviour, learning and both gross and fine motor skills.
The Palmar Reflex causes the fingers to curl towards the palm when the palmar surface of the hand is stroked, in an attempt to grasp an object.
Retention of the Palmar Reflex can lead to children having trouble with fine motor, like writing, because they have a poor pincer grip. They may also have difficulty with speech and articulation as movements of the hands and mouth are often linked.
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What is development?
When
do we see these?
- Opportunistically
- In planned programme of reviews.
Who
sees this?
- Parents , Doctors, Nursery, Teachers
Global impression
of a child, encompassing: growth, increase in understating, acquisition of new skills and more sophisticated responses and behaviour.
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Development Milestones Summarised
Credit to JJ
Teh
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Development Milestones From Lecture Slides
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SBA 8
A 20 month year old child has been brought into clinic because her mother is concerned she is not developing like other children around her. Upon examination, the smiling child is able to walk and run independently but she still retains her palmar reflex and still babbles only being able to say the word ‘light’ and ‘nice’. Which developmental domains are likely to be affected?
A. Psychosexual development
B. Fine motor and speech
C. Gross Motor
D. Emotional
E. Height
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SBA 8
A 20 month year old child has been brought into clinic because her mother is concerned she is not developing like other children around her. Upon examination, the smiling child is able to walk and run independently but she still retains her palmar reflex and still babbles only being able to say the word ‘light’ and ‘nice’. Which developmental domains are likely to be affected?
A. Psychosexual development
B. Fine motor and speech
C. Gross Motor
D. Emotional
E. Height
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60
More Questions…
What are the 3 components of the healthy child programme (1.5 Marks)
SBA 9 : Becky is 14. She is in school and learning about healthy emotional and sexual relationships in class, including how to not get an STD. What aspect of healthy child programme is being addressed here?
A. Screening
B. Immunisation
C. Child Health Reviews
D. Health Promotion
E. Teenage Pregnancy and Abstinence
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More Questions…
What are the 3 components of the healthy child programme (1.5 Marks)
Screening
General Examination and immunisation
Health education/promotion
SBA 9 : Becky is 14. She is in school and learning about healthy emotional and sexual relationships in class, including how to not get an STD. What aspect of healthy child programme is being addressed here?
A. Screening
B. Immunisation
C. Child Health Reviews
D. Health Promotion
E. Teenage Pregnancy and Abstinence
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Causes of delayed development
Global
Chromosomal abnormalities
e.g.
Down’s syndrome
, Fragile X
Metabolic
e.g. hypothyroidism, inborn errors of metabolism
Antenatal and perinatal factors
Infections, drugs, toxins, anoxia, trauma, folate def
Environmental-social issues
Chronic illness
Motor
Cerebral palsy
Global delay
eg
Down’s syndrome
Congenital dislocation hip
Social deprivation
Muscular dystrophy-Duchenne’s
Neural tube defects: spina bifida
Hydrocephalus
Language
Hearing loss
Learning disability
Autistic spectrum disorder
Lack of stimulation
Impaired comprehension of language
-Developmental dysphasia
Impaired speech production
-stammer, dysarthria
Slide6464
Why may a child have one stiff leg?
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