100 cases Flashcards
causes of hyponatraemia
acute renal failure adrenal insufficiency cirrhosis + ascites SIADH thiazide use
what is SIADH associated with?
meningitis
head trauma
pneumonia
SCLC
reasons for elevated prolactin
pregnancy
emotion stress
after epilepsy
higher the prolactin, the greater the indication a tumour is present
microadenoma >2000
macroadenom >6000
Mx for prolactin releasing pituitary adenoma
domapine agonists
- bromocriptine
- cabergoline
why do a faecal calprotectin?
what causes a raised score?
calprotectin is produced by neutrophils
elevated in concentrations in faeces associated with inflammation in the intestines
- marker of inflammatory bowel disease - UC / crohn’s / Bowel Ca
(differentiate between irritable bowel disease)
causes of hypocalcaemia
assoicated with hypophataemia
- vit D def
- malabsorption
associated with hyperphosphataemia
- chronic renal failure
- hypoPTH
acute pancreatitis
sever hypomagnesaemia
define a major haemorrhage
- loss of 1 blood volume within 24 hours (70ml/kg)
- 50% of total blood volume in <3hours
- bleeding excess of 150ml/min
clinically - blood loss leading to:
- Systolic <90
- HR >110
types of renal replacement therapy
if independent: - peritoneal dialysis High dextrose fluid draws waste products from blood into abdominal cavity 1. continuous 2. automated
- Haemodialysis
3 times a week app
surgery 8 weeks prior for AV fistula - Haemofiltration (acute setting)
- Renal Replacement - ideal
what do you have to think about in bite Mx?
tetanus screen
IM human tetnaus immunoglobulin given to high risk wounds
what is the most common infection in eczema + abx used
staphlococcus
chloramphenicol
what organisim would be specific to conjuctivitis in a neonate?
chlamydia trachomatis
gradings of diabetic retinopathy
mild
- micro-aneursyms
moderate
- micro-aneursyms
- blot haemorrhages
- cotton wool spots
- exudates
severe
- aneurysms in all 4 quadurants
what is cataracts
the opacification of the crystalline lens
due to trauma, medications or metabolic disorders
RF for cataracts
diabetes
long term steroids
eye trauma
smoking
positive signs o/e
- clouding of the lens
- absent red reflex
DDx for cataracts
loss of vision
- maculopathy
- optic neuritis
- vitreous haemorrhage
- TIA
- renal vein occulation
Mx for cataracts
comp?
phacoemulsification
lens is emulified with an ultrasonic handpiece + aspirated
aspirated fluids of ant chamber are replaced with saline
comp:
- early - posterior capsule rupture
- late - posterior capsule opacification
what is marcus-gunn pupil ?
relative afferent pupillary defect
- diagnosed using the swinging light test
can be found in patients with MS
what is arygll robertson
constricted pupil that responds to accomodation BUT not light
bilateral
associated with neurosyphillis + diabetic neuropathy
what is holmes-aide’s pupil
benign
unilateral dilated pupil reacts poorly / if at all to light
– once constricted, remains small for abnormally long time
slowly reactions to accomodation
associated absent reflexes
what is strabismus
misalignment of the visual axes
concomitant
- imbalance of extraocular msucles
- convergent is more common
paralytic
- due to paralysis of extra ocular muscles
how to detect a strabismus
corneal light reflection test
- shining light midline of patient’s face
- reflective light is seen relative to the patients pupils
normal - slightly medial to pupils
esotropia - reflection is lateral to pupil
exotropia - reflection is medial to pupil
how is dry age related macular degeneration characterised by
drusen
- yellow round spots on Bruch’s membrane
how is wet age related macular degen characterised by
wet
- choroidal neovascularisation
leakage of serous fluid + blood
worse prog
define amaurosis fugax
transient monocular visual loss (TMVL) less than 24hrs
sudden painless visual loss
- retinal detachment
- ischaemic / vascular (RAO/RVO)
- vitreous haemorrhage (leaking of blood into areas around the vitreous humour of the eye)
vitreous is the clear fluid filling the space between the lens and the retina
what is blephritis
- meibomian gland dysfunction (common, posterior blepharitis)
- seborrhoeic dermatiitis / staphlococal infection (ant. blephritis)
meibomian glands secrete oil on the eye surface to prevent rapid evaporation of the tear film
glaucoma Ix
- slip lamp exam w/ pupil dilation to assess optic n and fundus
- applanation tonometry to measure IOP
open glaucoma mx
1 - prostaglandin analogue - increases uveoscleral outflow
2 - BB, carbonic anhydrase inhib
BB / carbonic / sympotahomimetics - reduces aqueous production
difference between preiorbital + orbital cellulitis
peri (eyelid swelling, )
- absence of painful movements
- no diplopia
- no visual impairment
orbital (tissues behind the orbital septum)
- protosis
both:
- common in children
Herpes zoster ophthalmicus
reactivation of the varicella-zoster virus suppling the ophtalmic division of the trigeminal nerve
accounts for 10% of shingles
associated with ant. uveitis
what is hutchinson’s sign
rash on tip / side of the nose
- in herpes zoster opthalmicus
indicates nasociliary involvement + strong risk factors for ocular involvement
Herpes zoster ophthalmicus Mx
1 - anti-viral / aciclovir
< 72hrs
2 - topical corticosteroid - inflammation
most common cause of perisistent watery eye in infant
nasolacrimal duct obstruction
caused by imperforated membrane –> lacrimal duct massage
acute glaucoma Mx
1 - admit hosp immediately
2 - cholinergic / constricts pupil to increase outflow (pilocarpine)
how is papilloedema seen on fundoscopy
blurring of the optic disc
loss of optic cup + venous pulsation
what is a chalazion
meibomian cyst
presents as a firm painless lump in the eyelid
resolve spontaneously
- some require surgical drainage
myopia vs hypermetropia RF for glaucoma
closed - hypermetropia / far sighted
open - myopia / short sighted
causes of papilloedema
- raised ICP
- space occupying lesion
- hydrocephalus
- hypercapnia
ARMD Ix
- slit lamp microscopy
- fluorescein angiogrpahy (neovascularisation suspected)
- tonometry
Mx:
- vascular endothelial growth factor
(increases vascular permability)
- laser photocoagulatopathy
flashes and floaters indicate what?
retinal / vitreous detachment
what is strongly associated with diabetic retinopathy?
vitreous haemorrhage
name the classes and individual drugs of Alzheimer’s
all patients:
cholinesterase inhibitors
- donepizil
- rivastigmine
severe:
NMDA receptor antagonist:
- Memantine
what is a urethroplasty?
repairing of the ureter walls
gold standard for uretheral strictures
why do they give prophylatic abx for surgery?
what do they give?
bowel / prostate /
- disrupting organ flora
Mx - cipro (+/- metron)
what is refeeding syndrome
develops when eating after long periods of starvation
body shifts back from fat metabolism to carb
- electrolytes move into cells
low potassium
low magnesium
low phosphate
hyperglycaemia
thiamine deficiency
Mx of refeeding syndrome
- adequate electrolytes, vitamins (thiamine), folate, B6
2. micronutrient
oesophageal bleeding
- prophylaxis
- treatment
- propanolol - vasodialator / reduced MAP + resistance
2. terlipressin - vasoconstrictor / narrowing vessels to reduce blood loss
why do coeliac patients get given the pneumococcal vaccine?
they have a degree of functional hyposplenism
booster every 5 years
influenza vaccing on an indiviual basis
what is gilbert’s syndrome
benign disease - inability to metabolise bilirubin due periods of stress / illness
Ix - rise in bilirubin following prolonged fasting
Mx - no treatment
what is histologically characteristic of gastric cancer?
signet ring cells
higher number –> worse the prognosis
RF for gastric cancer
h pylori
blood group a (gAstric cAncer)
pernicious anaemia
smoking
what is hepatorenal syndrome
the development of renal failure in the presence of liver failure
- vasomediators cause splanic vasodilation
- systemic vascular resistance reduced
- hypovolaemia of the kidneys
- RAAS gets activated but no enough to counterbalance effects of splanic vasodilation
what are you concerned about?
metabolic acidosis w/ partial resp comp (high anion gap)
raised ketones
normal / low glucose
alcoholic ketoacidosis
DKA will have a raised glucose
alcoholic ketoacidosis
a form of euglycaemic ketoacidosis
- common in alcoholics
- due to poor diets
- vomiting food when they do eat
food stores deplete and so move onto lipids
what is the hartmann’s procedure
rectum + sigmoid resection
closure of the anorectal stump + formation of the end colostomy
small intestine causes of malabsorption
crohn’s
coeliacs
lactose intolerance
small bowel bacterial overgrowth
complications of coeliacs
MALABSORPTION
- osteoporosis
- anaemia
MALIGNANCY
- intestinal lymphoma
- oesophageal + small bowel carcinoma
how does paracetamol damage the liver?
- paracetamol get converted into toxic metabolite
- toxic metabolite is inactivated by glutathiano
- glutathiano stores are depleted
- toxicity of metabolite increases –> necrosis of hepatocytes
damage peaks at 72 - 96 hours
how to assess encephalopathy bedside
- draw 5 point star
- concentric circles
- hepatic liver flap
complications of hepatic failure
encephalopathy hepatorenal syndrome coagulopathy cerebral oedema / ascites (hypoalbumin?) hypoglycaemia (reduced glycogenesis)
how to treat paracetamol OD?
activated charcoal if <1hr
n-acetylecysteine
hep A pathophysiology
+ associations
hepatocyte necrosis
associated with:
developing country
contaminated water supply
shellfish
reasons for ascites in liver failure
hypoalbuminaemia
activated RAAS
salt + water retention
mechanism is the leaking of fluid from the lymph
multi-factorial:
- high cardiac output
- increased hydrostatic pressure in splanic organs
in a patient who has an a long term alcohol Hx
how would you manage them?
- seizures prevention - chlordiazepoxide reducing regime
- restore deficiencies - thiamine (B1) + B12
for abstinence + maintainance
- acampostate
- naltrexone
pathophysiology of haemochromatosis
autosomal recessive
HFE mutation
excessive iron absorption in gut excessive tissue deposits in organs - heart - pancreas - pituitary - liver
Comps:
- HCC
- cirrhosis
Mx for haemochromatosis
regular venesection
desferoxamine - binds to iron to be eliminated by the kidneys
features of wilson’s disease
EYE
kayser-fleisher rings - copper deposits in the eye
abnormal extraocular movements
BRAIN
dementia
tremor
speech problems
HEPATIC DISEASE
haemolytic anaemia
liver
brain
cornea
pathophysiology of wilson’s
Ix
autosomal recessive
failure of proper biliary copper excretion
so deposited in organs
serum caeurloplasmin + copper
urinary copper (24hr)
liver biopsy
how do you assess for fluid status on bed side examination? (4)
JVP
postural BP
basal lung crackles
peripheral oedema
go through hypo / iso / hyper volaemia causes
- check serum os
- check fluid status
HYPO (water loss) Extra renal: - Vomitting - Diarrhoea - Fluid shift
Renal:
- adrenal insufficiency
- diuretics
- nephropathy (pylonephritis)
ISO (normal status) SIADH (urine os - high) water intoxification (urine os - low) hyperthyroidism renal failure
HYPER: CCF renal failure liver failure nephrotic syndrome
vascular disease affecting conditions about the chest
BRAIN
vascular dementia
stroke
EYES
retinopathy (RAO / RVO)
