11/11/21 Flashcards
Characteristics of HHS (5 points - 3 with 2 bonus)
- Severe Hyperglycaemia
- Hyperosmolarity - >320
- Severe Dehydration
- Change in Mental State
- Little or No Ketacidosis
Goals of Management of HHS? 3 points
- Slowly and Safely replace fluid and electrolyte losses and normalise the osmolality
- Slowly and safely normalise blood glucose concentrations → reduce glucose at 4-6mmol/L hour
- Treat the underlying cause
Mainstay of treatment for HHS? Be Specific
Use Sodium Chloride 0.9% → replace 50% of the estimated fluid loss within the first 12 hours and the remainder over the next 12-26 hours
Age at which knock knees are physiological and when should they resolve?
- Physiological → seen from 3-5 years of age, resolves by growth by age 8
Age at which bow legs are physiological and when should they resolve?
- Physiological Bowing → seen from birth until 2-3yo
When to investigate bow legs?
X-ray knees
- Progressive Deformity
- Unilateral Deformity
- Lack of Spontaneous Resolution
- Aged >3yo
When to investigate knock knees?
X-Ray of Knees if:
- Unilateral Deformity
- Progressive Deformity
- Lack of Spontaneous Resolution
Indications for specialist referral for knock knees?
- Persistence of significant knock knees beyond age >8yo
- Intermalleolar separation >8cm
- Asymmetrical Deformity
- Progressive Deformity or Lack of Spontaneous Resolution
- Pain
- After Trauma
- If accompanied by other skeletal deformity such as height <5th centile
Indications for specialist referrral for bow legs?
- Age >3yo
- Intercondylar Separation >6cm
- Asymmetrical Deformity
- Excessive Deformity
- Progressive Deformity or lack of resolution
- Pain
- After Trauma
- If accompanied by other skeletal deformity such as height <5th centile
New Nipple Discharge: If bilateral and only on expression and No Discrete Lesion and Negative for blood?
cease expression, mammogram if due, review in 2-3 months, do prolactin if persistent bilateral discharge
New Nipple Discharge: If bilateral and only on expression and clinical abnormal?
Mammogram/Ultrasound + referral to Breast Surgeon
New Nipple Discharge: If unilateral spontaneous discharge or age >60yo?
Mammogram/Ultrasound + referral to Breast Surgeon
Diagnostic Criteria of a Left Bundle Branch Block (3 points)
- Widened QRS Complex → >120ms
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads → (I, aVL, V5-6)
Bonus Question: Sgarbossa Criteria, what is it used for? What are the points?
- In patients with new onset LBBB → need to use modified Sgarbossa Criteria to identify and MI.
- Concordant ST elevation ≥1mm in ≥ 1 lead
- Concordant ST depression ≥1mm in ≥ 1 lead of V1-3
- Proportionally excessive discordant ST elevation in ≥1 lead anywhere with ≥1 mm ST elevation, as defined by ≥25% of the depth of a preceding S-wave
Management points for suspected ACS (5 points)
- arrange immediate transport by ambulance
- Oxygen only if patient is hypoxaemic → O2 <94%
- Aspirin 300mg PO, chewed or swallowed before swallowing
- GTN spray 400-800microg sublingually, repeat every 5 mins if pain persists up to total of 3 doses
- Morphine 2.5-5mg IV → repeated at 5-10minute intervals
Can I use the reliever in a cough with no other symptoms in a child with asthma? Can I use the reliever in an infant with noisy breathing with no signs of work of breathing? When can I use the reliever then?
- Use when wheezing episodes are associated with increased work of breathing NOT for cough alone and NOT for noisy breathing with no increased WOB.
First step if positive microscopic haematuria without albuminuria on urine dipstick?
- 1st step → repeat Urine Dipstick**
- Microscopic haematuria in the absence of albuminuria can be differentiated from transient haematuria if 2/3 reagent strips are positive
If persistent microscopic haematuria, what do you need to rule out?
rule out renal tract malignancy
Do you need to monitor patients with persistent microscopic haematuria? What does this ential and how often?
Annually.
Similarly this population should be followed up annually with repeat testing for haematuria, albuminuria, eGFR and BP monitoring for as long as haematuria persists
Key Points to discuss with patient newly diagnosed with fibromyalgia? (4 points)
- Pain experienced by patient is real but not caused by tissue damage
- Not a progressive or deforming disease
- Fibromyalgia is frustrating → two steps forward and one step back
- Overarching aim is not to achieve a pain-free state but rather to manage the pain so function is not impacted
Non-Pharmacological and Lifestyle Changes for Fibromyalgia (4 points)
- Patient Education
- Graded Aerobic Exercises
- Good Sleep Habits
- CBT + Coping Strategies + Goal Setting
Pharmacological Management - 1st line for Fibromyalgia
- Low Dose TCA → amitypitilline 10-25mg PO in early evening → increasing dose up to 25mg every 2-4 weeks as tolerated and according to response, up to a maximum maintenance dose of 50mg each evening
- or dothiepin 25mg PO in the early evening
Clinical Features of Fibromyalgia (1 main + 6 points)
- Chronic Widespread Non-Inflammatory MSK Pain → experience in both soft tissue and joints
- Cognitive Clouding - fibrofog
- Fatigue
- Impaired Concentration
- Sleep Dysfunction
- Depression
- Gastrointestinal and Urogenital Dysfunction and Discomfort → irritable bowel and bladder
Basic Asymptomatic STI Testing for males and females. What disease(s) and what route of testing?
For all sexually active people <30yo + anyone that identifies themselves at risk
- *Males**
- Chlamydia
- First Pass Urine → NAAT
- *Females**
- Chlamydia
- Endocervical Swab → if examination takes place
- Self-Collected Vaginal Swab → if NOT examined or if patient has had hysterectomy
- First Pass Urine → only if endocervical swab/self-collected vaginal swab CANNOT be taken. Not as sensitive as the swabs.
- Ano-Rectal Swab → if anal sex or ano-rectal symptoms
Extra Tests for individuals with specific risks in regards to STI testing. (4 points)
- Heptatis B - - Blood - HBsAg, Anti-HBs, Anti-HBc → vaccinate if not immune
- HIV
- Syphillis
- Gonorrhoea -> ATSI or MSM or returned travellers
Risk Assessment for STI: Specific Questions (5 points)
- Have you ever been paid to have sex? Have you ever paid to have sex?
- Have you had any tattoos? Have you ever injected drugs?
- Have you been in jail?
- Are you ATSI? Are you a refugee or a migrant?
- Have you experienced domestic violence?
Basic Questions in a Sexual Health history? (6 points)
- When was the last time you had sex?
- Who have you been having sex with? Other than your regular partner, have you had sex with anyone else?
- How did you have sex? Vaginal/Oral/Anal? Did you use a condom?
- How your partners been male or female?
- In the last three months, how many sexual partners have you had?
- Have you been diagnosed with or thought you had an STI?
- STI Symptom - dysuria, urethral discharge, penile ulcer, rash
- Vaccination Status → Hep B
STI Testing for Asymptomatic ATSI people.
Chlamydia PCR Gonorrhoea Syphillis Serology HIV Hepatitis A and Hepatitis B
STI testing for Asymptomatic IVDU or Sex Workers
Chlamydia PCR Gonorrhoea Syphillis Serology HIV Hepatitis A and Hepatitis B Consider Hepatitis C if IVDU
What categories of the population is at highest risk of STI?
Men who have Sex with Men Unprotected Anal Sex >10 partners in the last 6 months Group Sex IVDU + Sex
In the population at highest risk of STI, what testing should be conducted?
Chlamydia PCR → urine, throat and rectal swab Gonorrhoea PCR → throat and rectal swab HIV Serology Syphillis Hepatitis A and Hepatitis B
Investigations for Early Language Delay in children? (4 points)
- Audiometry
- FBE
- Blood Lead Levels
- Fe Studies
Red Flags for Language Delay at Birth or Any Age?
- Nil response to sounds, particularly parent’s voice
Red Flags for Language Delay at 6-9 months?
- Does not babble
Red Flags for Language Delay at 12 months?
- Does not use mama, dada or papa or equivalent to call parent
Red Flags for Language Delay at 15 months?
- Does not use specific single word or word approximation other than mama, dada or papa to request or comment.
- Does not use a point to request something out of reach
Red Flags for Language Delay at 18 months?
- Does not have at least 5 words used spontaneously to make requests or to comment on or label objects (how does she ask for things?)
- Does not follow familiar one-step direction without gesture
- Does not point to something in order to share enjoyment or excitement with another person - joint attention
Red Flags for Language Delay at 24 months?
- Uses fewer than 50 words
- Does not combine 2 words together to create new meaning
What is the issue with contraception in patient with epilepsy?
- Enzyme inducing epileptic drugs → phenytoin, topiramate, carbamazepine → contraceptives may be affected (COCP, Patch, Nuvaring, Injectable Contraceptives, Progestin-Only Pill)
- Can use LARC → Mirena, Copper IUD, or Depot
Clinical Presentation of Hyponatraemia (4 points)
Confusion, Gait Disturbance, Impaired Consciousness and Seizures
Drugs that can cause hyponatraemia (3 points)
- diuretics → indapamide and hydrocholorothiazide
- SSRI and SNRI → paroxetene/sertraline or venlafaxine
- Carbamazepine
Causes of Hypovolaemic Hypoatraemia (2)
- Sodium Loss with free water intake → vomiting and/or diarrhoea, burns
- Thiazides and related diuretics → indapamide and hydrochlorothiazide
- Other Sodium wasting states
- Hypopituitarism
- Addison’s Disease (Adrenal Insufficiency)
Causes of Euvolaemic Hyponatraemia (3)
- SIADH: Drug Induced → carbamazepine, SSRIs, SNRIs, Cerebral or Pulmonary Pathology, Malignancy Associated
- Hypothyroidism
- Psychogenic Polydipsia
- Pain
- Nausea
- Secondary Adrenal Insufficiency
Causes of Hypervolaemic Hyponatraemia (3)
- Heart Failure
- Liver Cirrhosis
- Kidney Failure
- Nephritic Syndrome
Treatment of Hyponatraemia at each volume status.
Hypovolaemic Hyponatraemia → IV NaCl 0.9%
Hypervolaemic Hyponatraemia → Fluid Restriction
Euvolaemic Hyponatraemia → treatment depends on: central nervous system symptoms (unconsciousness, seizure, drowsiness, headache), severity and rate of development
Fluid Restriction → 500ml-1L per 24 hours. Monitor Cr, Serum Electrolytes and Urine Output daily or twice daily.
Markers for End-Stage OA
- Significant Joint Pain
- Swelling and Deformity of the joint
- Sleep Disruption
- Severe Reduction in Walking Distance
- Marked Restriction in ADLs → rising from a chair or toilet seat
Lifestyle and Non-Pharmacological Management of OA
- Regular Exercise
- Weight Management
- CBT
- Heat Packs or Hot-Water Bottles
- Using a cane or other assistive devices
- Short course of manual therapy or massage
- Transcutaneous Electrical Nerve Stimulation (TENS)
Pharmacological Management of OA
- Oral and Topical NSIADs
- Paracetamol
- Corticosteroid Injections for short-term relief but repeated injections can cause harm
- Duloxetine
When to refer for surgical intervention for management of OA?
Total Joint Replacement Surgery is most cost-effective and clinically effective treatment for end-stage OA
- Refer when all appropriate conservative options have been delivered for a reasonable period of time and failed
- Refer based on significant decline in quality of life secondary to established end-stage OA
