1 - Induction Week Flashcards
What risks do you need to consider when requesting imaging?
IRMER 2000
- Radiation Risks: Carcinogenosis, Genetic, Fetal developmental risks
- IV Contrast Risk: Anaphylaxis, Compartment Syndrome, Contrast-induced nephropathy
What can be some of the issues with Gadolinium and Iodine contrast?
Iodine
- Allergy/Anaphylaxis
- Contrast induced nephropathy if eGFR<30
- Compartment syndrome if soft tissue extravasation of contrast (ice and elevate arm)
What are some contraindications for an MRI?
Which patients cannot have a CT colonogram as buscopan is required?
How do you make a referral for imaging?
SPOTIQR
How do you make a referral for interventional radiology?
- Hb
- G+S
- Coagulation screen
How do you prepare a patient on the ward on the day of interventional radiology?
Why do we need to be careful when requesting a CTPA for young women??
Risk of breast cancer as young and over heart/breast tissue
What condition should not be referred to liaison psychiatry?
DELIRIUM
Can use MCA for DOLS, doesn’t need MHA
What is the main issue with malnourishment in hospital?
SARCOPENIA
They lose muscle over fat
How do you monitor patients on parenteral nutrition?
Make sure plastic bag stays on to prevent lipids and vitamins degrading
How do you monitor patients on parenteral nutrition?
Make sure plastic bag stays on to prevent lipids and vitamins degrading
What are the risks with PN?
THROMBOSIS
What should you do if a patient has pyrexia and is on PN?
Only restart if temperature drops
What are some signs of a hickman line infection?
- Pyrexia on feeding
- Rigors on feeding
- Muscle pains
How much fluids do people require a day?
30ml/kg/day + losses
What are the issues with normal saline for maintenance fluids?
What should you do before prescribing fluids?
Check U+Es!!!!!
If potassium persistently low then check Mg
When can you switch from IV to PO abx?
If a patient grows MRSA on a blood culture post-surgery, where could the source of infection be?
- Wound site
- Catheter
- Line
- Epidural site
How do gram-negative bacteria lead to septic shock?
Endotoxins that lead to vasodilation
What antibiotic do you need to add to Benzylpenicillin for necrotising fascitis?
Clindamycin
Consider early IVIG
What is an inquest?
When does a coroner have to perform an inquest?
- Unexpected death
- Custody inc MHA, DOLS, Custody
What should you do if a patient dies in your care and is likely to go to inquest?
Write an account in your own words as soon as possible!!!!
How do you write a statement to the coroner?
It is a factual summary, do not speculate or give hearsay (second or third hand)
If asked a question and it is not in your area of expertise you should say this
What is a problem representation?
What is Murtagh’s method for diagnostic reasoning?
- Most likely diagnoses
- 2 less likely diagnoses
- 2 not to be missed diagnoses
How do you receive a handover and what questions are important to ask when receiving this?
(IMPORTANT CARD TO PRACTICE)
ISBAR
- What is the NEWS and what are they scoring on?
- PMHx
- Does the senior know about this?
- Do they have an escalation plan or a DNACPR?
- What have you done already?
- What would you like me to do?
What is included in a discharge letter?
- Elective or Emergency?
- Main Diagnosis
- PMHx
- Clinical Hx: include if new DNACPR in place
- Ix
- Follow up plans
Need extra letter for anticoagulation or emergency EoL plan
How do you commence warfarin in hospital?
LMWH bridging therapy until 2 INRs within therapeutic range
What should patients do if they miss a dose of warfarin for DVT treatment ?
Target INR: 2-3
Just miss it and take the next dose as normal as warfarin has a long half life
If a patient has a VTE provoked by malignancy what treatment should they be given?
DOAC >LMWH
Usually Apixaban or Rivaroxaban. Avoid rivaroxaban in GI malignancy as associated with GI bleeds
Dabigatran and Edoxaban require bridging
If a patient has a low eGFR and CKD but has septic shock how do you fluid resuscitate?
500mls over 15 minutes, shock takes priority and their eGFR may be low due to the sepsis
Which of the following drugs need to be stopped if there is an eGFR of less than 30?
- Metformin
- Citalopram
- Ramipril
- Gliclazide
- Metformin: risk of acidosis
- Gliclazide: hypo risk, put on sliding scale
- Ramipril: nephrotoxic
Ciprofloxacin is hepatically excreted so can continue
What are the three principles of treatment for anaphylaxis?
Adrenaline, Oxygen, Fluids
Can give non-sedating antihistamine once acute phase is over
If the source of sepsis is known how does this change your sepsis 6?
Use narrow spectrum antibiotics e.g Flucloxacillin IV for cellulitis origin
How are Gentamicin and Vancomycin prescribed?
Need to base next dose on levels before so daily levels are needed. Also need U+Es
Be careful as Red Man Syndrome (antihistamine release) and Ototoxic!!!
Why do you need to be careful when stopping a prescription of oxybutynin in a patient with Parkinson’s?
It is an anticholinergic and the ratio of acetylcholine:dopamine affects balance in Parkinson’s
What sedation is appropriate for a patient with PD?
Appropriate: Lorazepam (can increase agitation in 10%), Olanzapine, Quetiapine
Not appropriate: Haloperidol and Chlorpromazine as D2 antagonists
If a Parkinson’s patient is NBM what can you switch their meds to?
Rotigotine patch but takes 24 hours to kick in so will be temporary drop in functioning
How do you confirm a death?
Time of death is when it is confirmed by Doctor not when they take their last breath for example
How do you certify a death?
Remember 1b caused 1a
What can you NOT write in 1a on a death certificate?
1a should be the disease, illness or complication which led to death and not a mode of dying
What are some reasons to refer a death to the coroner?
What is essential to be included on a cremation form 4?
If there is a pacemaker as it can explode
If a woman has a high output ileostomy how can we work out the fluid replacement including potassium needed?
(IMPORTANT CARD)
Fluids (using fluid balance chart)
- Work out maintenance for 24 hours (25ml x kg)
- Work out deficit for 24 hours (do loss/hr x 24)
- Add together
- Take away fluid intake
Potassium Replacement
- 3.5 - actual potassium
- Above x daily requirement x 0.4 gives deficit
- Deficit plus daily requirement
When prescribing in DKA what is very important to continue prescribing?
Normal long acting insulin in the background
DO NOT GIVE A MIXED INSULIN AS THEIR BACKGROUND
How should you adjust someone’s insulin after a hypo?
20% decrease in dose
How should you adjust someone’s insulin if there are having persistently high BMs?
10% increase
What can cause normal BM in DKA?
SGLT2 Inhibitors
How do you take someone off of a DKA protocol once their DKA has resolved?
Eating and drinking: Give them s/c insulin, let them eat, 30 minutes later take off
Not eating and drinking: Go to sliding scale
What are the premises of prescribing in DKA?
Insulin: 0.1 units/kg/hr, if delay of more than half hour give stat of 10 units s/c
Fluids: Start with sodium chloride, Add potassium to next bags if necessary but no more than 10mmol/hr
Switch to 10% dextrose if BM<14
How often should you check BM in sliding scale?
- Hourly
- Use 5% dextrose with K+ as fluids
- Keep long acting insulin prescribed, if NBM then decrease to 80%
Who should you not give glucagon to in a hypo and what should you give them instead?
Anyone with liver disease or emaciated e.g elderly with low muscle mass
Give them 50ml/hr 20% IV dextrose
What is the difference in treatment between DKA and HHS?
Only give fluids in HHS
If significant ketonuria give 0.05 units/kg/hr of insulin
How do gram-negative bacteria lead to septic shock?
Endotoxins that lead to vasodilation
