16/05/22 Flashcards
heart failure management
is oxygen given? if so when/why
Iv loop diuretics
only when sats are below 94%
nitrates- ONLY if not aortic stenosed or hypotensive
cpap
HF when in hypotension?
management
why does it happen?
drugs like loop diuretics and nitrates can make things worse
give inotropic agents: dobutamine
vasopressor agent: norepinephrine
mechanical assistance: intra aortic balloon
what regular meds can be continued in HF?
beta blockers
acei
but beta blockers stop if HR <50
chronic HF mx
1st line
if preserved ejection fraction?
2nd line- what needs to be monitored at this point?
1- acei and beta blocker
2- spironolactone - K+ risk of hyperkalaemia
3-digoxin
what can better outcome in heart failure
implantable cardioverter device as risk of death from arrythmias
pleural aspiration
21g needle and 50ml syringe
lights criteria
exudate?
transudate
have a protein level of >30 g/L
25-35 g/L
exudative causes of pleural effusion
these increase the capillary permeability
infection such as pneumonia or TB
malignancy: mesothelioma/ lung cancer
inflammatory cause: RA, lupus
if a pneumonia caused a pleural effusion what would the aspiration be
protein?
LDH
pleural fluid : protein ratio >0.5
pleural fluid to serum LDH >0.6
ldh >2/3
as this would be an exudative cause of effusion
what is a transudative cause of a pleural effusion?
this is when interstitial fluid is imbalanced due to starling forces
like conditions that increase cap hydrostatic pressure
congestive HF
or cap oncotic pressure is reduced like cirrhosis, nephrotic syndrome / coeliac
HF is the most common cause
guidelines for pneumothorax
when can you discharge?
rim of air <2cm
and NOT breathless
if a pneumothorax is 3cm on a 25yr old and he is sob ?
aspiration attempt
then chest drain
when do you put a chest drain for a pneumothorax straight away?
> 50yrs and secondary >2cm and SOB
when do you admit and give oxygen over 24hours if pneumothorax rim is 1cm?
if secondary
complications of pneumothorax
fitness to fly
2 weeks after a successful
1 week post xray
testicular torsion of appendage
Testicular appendage torsion is the twisting of a small piece of tissue above a testicle. The appendage doesn’t have a function in the body. But it can twist and cause pain and swelling that gets worse over time. It is not the same as testicular torsion
blue dot is signifying
tender nodule with blue discoloration on the upper pole of the testis
what drugs are commonly used to treat UTI?
and what are the common side effects?
nitrofuntein- pulmonary fibrosis
trimethopram - folate metabolism so avoid in first trimester
lung nodule
diarrhoea
facial flushing
asthma
what Ix ?
urinary 5-HIAA excretion
what type of lung nodules does RCC present with?
cannon ball mets
in whihc case EPO
nicotine replacement
if pregnant?
NRT / varencline/ buproprion
NRT only
prescription for NRt??
2 weeks after stop date
prescription for buproprion / varencline
end date ?
3-4 weeks
which is most effective smoking cessation drug?
varenicline
acute asthma attack what abg finding is most alarming and requires escalation?
normal Paco2 as it indicates exhausation
life threateneing asthma
what should you give when giving salbutamol? in an asthma attack?
potassium IV 20mmol / 6 hours
as salbutamol drives K+ into cells
how can you treat deteriorating acute asthma patients further?
IV magnesium
IV salbutamol/ theophylline
ventillatory support
life threatening asthma?
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
haemopytsis differential
saddle nose/ flat nose
granulomatosis with polyangitis
haemoptysis with glomerulonephritis
differentials?
good pastures - systemically unwell, nauses
Granulomatois with polyangitis - saddle nose, URT signs
30-49% fev1
copd stage?
severe
3
what is very severe stage 4 copd?
fev1 <30%
SCLC
associated with which endocrine
with neuro condition?
acth and adh
hypokalaemia, hyponatraemia, cushings
lambert eaton syndrome
In MG why is it important to do one imaging?
CT
because it presents with thymoma
anterior mediastinal mass.
what causes nephrotic syndrome inchildren - affects eyes; bitemporal periorbital oedema
minimal change disease - non proliferative glomerulonephritis
what joints are spared in RA?
what deformaties occur
distal interphalangeal joints
radial deviation of wrist
z deformaty thumb swan neck
boutonniere and trigger finger
what causes ataxia?
finger to nose ataxia is caused by cerebeller hemisphere lesion
headache dull
fever
down and out eye
with nausea and seizure
on fundoscopy - pappiloedema seen
what mx?
brain abscess?
due to focal neurology signs of infection - fever and raised ICP
dexamethasone
cepholosporin and metronidazole
presents with hand weakness and inability to use the fingers on associated hand
24hours
strong association with hypertension
common sites include the basal ganglia, thalamus and internal capsule
lacunar stroke
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
posterior inferior cerebellar artery
what happens with a brainstem stroke?
Brainstem infarction
may result in more severe symptoms including quadriplegia and lock-in-syndrome
nause and vomiting
decrease in. conciousness
headache
seizure
is more common in what type of stroke
Brainstem infarction
may result in more severe symptoms including quadriplegia and lock-in-syndrome
criteria for thrombolysis
no haemorrhages - no hyperdensity
>4.5
always give 300mg of aspirin
when is an urgent neuro assemenet required within 24 hours
when within 7 days?
TIA
if tia within 7 days
is outside of 7 days
in a stroke a contrast CT head is done
T/F?
false
non contrast
typically show areas of hyperdense material (blood) surrounded by low density (oedema)
haemorrhagic stroke
what is Rosier used for
stroke
how long after ischaemic stroke can AF medication be started?
14 days
Offer thrombectomy between 6 hours and 24 hours?
confirmed occlusion of anterior. circ
and limited infarct core volume
offer thrombectomy - 6 hours
with alteplase if within 4.5hrs
or 6 hours alone if proximal anterior circulation
CTA / MRA
when can you consider thrombectomy if its within 24 hours
basilar / posterior cerebral artery
limied infarct core volume
when is a carotid artery endarterectomy recommended
should only be considered if carotid stenosis > 70% according ECST** criteria
or > 50% if symptomatic
sudden transient loss of vision in one eye
(amaurosis fugax)
TIA sign
PT has SLE
presents with a DVT
on examination has a mottled lace like appearance of skin
recently had a miscarriage
on blood results there is thrombocytopenia
CLOT
antiphospholipid syndrome Clots Livedo reticularis Obstetric loss Thrombocytopenia
what IX confirms anti phospholipid syndrome?
anti cardiolipin
anti beta2GPI
lupus - anti dsdna , ana
Nicotinic acid deficiency
pt presents with dermatitis, diarrhoea, dementia
brown scaly rash on sun-exposed sites - termed Casal’s necklace if around neck
what TB drug can also cause this?
pellagra vit b3 deficiency
isoniazid
carcinoid syndrome can also cause this
how is carcinoid tumour investigated?
urinary 5 HiAA
what causes glossitis
b12 deficiency - pernicious anaemia
embryo sign?
obstructed bowel
defn
caecum volvulus
stomach or loop of bowel twist on its own mesentery
Coffee bean sign?
sigmoid volvulus
stomach or loop of bowel twist on its own mesentery
in raised ICP you get cushings reflex what is the criteria?
bradycardia
hypertension
weird breathing
complete heart block JVP sign?
a wave is increased
adenosine?
what is the one side effect to warn pt of?
to restore rhythm in supraventicular tachycardia
3mg
this is emergency
if haemodynamically stable then vagal moves first
chest pain as they already have it so might think theyre getting worse
what is flucloxacillin used for?
soft cell and tissue infection
eg cellulitis
treats staph aureus as it is gram +
RA spares what part of spine?
thoracic and lumbar
it only affects the C part
what is the most common se of dialysis ?
dialysis induced hypotension
how should you image prostate? first line?
MRI
what electrolyte is an indicator of pancreatitis severity
calcium
hypocalcaemia
hypercalcaemia can cause pancreatitis
HF medication step wise
acei
beta blocker
add hydrazalineif acei not possible
2) loop diuretics furesomided/ bumetanide
3)spironolactone / epelerone
hydrazaline and a nitrate - if afro-caribbean
ivabradine - sinus rhythm and impaired ejection fraction
arb
4) digoxin
when is cardiac resynchronistaion indicated?
QRS interval <120ms, high risk sudden cardiac death, NYHA class I-III QRS interval 120-149ms without LBBB, NYHA class I-III QRS interval 120-149ms with LBBB, NYHA class I
what is medium sized AAA?
what is guideline ?
4.5-5.4
repeat ultrasound 3 months
high risk of rupture of AAA?
> 5.5
surgery within 2 weeks
low risk of AAA rupture but repeat ultrasound yearly?
3-4.4cm
when is there no need to repeat uss for AAA
if it is less than 3cm
normal
what immune conditions are risk factors for PE?
anti phospholipid syndrome
factor V leiden
what is a sign of sub massive PE?
right heart strain
what is a sign of massive PE?
hypotension
IV fluids <90
mx of massive PE?
when is embolectomy indicated?
IV alteplase
DOAC - apixaban
massive PE with thrombolysis contraindicated
wells score of 4?
PE unlikely
arrange a d dimer
if + CTPA > interim doac
if - consider alternative
wells score of 5?
PE likely
CTPA
doac in interim
if ctpa - consider DVT uss
when is V/Q scan preferred
renal impairment and pregnancy
what is an insulinoma?
how to Ix?
functional neuroendocrine tumour of pancreas
72hour fast
at moment of true hypoglycaemia - measure plasma insulin and pre insulin and ketones
has chronically swollen feet and ankles for the last 10 years. X-rays demonstrate destruction and deformities of the joints, mainly affecting the tarsometatarsal joints. The bones are dense and there is limited sensation in a glove and stocking distribution. What is the most common aetiology underlying this presentation?
diabetes this is charcots arthropathy
sore throat treated in 18yr old presents week later with rash
what is the rash called?
what has happened?
amoxicillin given and pt has EBV - morbilliform eruption
Autoimmune hepatitis serology?
anti smooth muscle ab
and ana
lft raised ALT and bilirubin with midly raised alp
igG hypergammaglobulinaemia
14yr pt has PMHx graves?
autoimmune hepatitis palpable liver edge fatigue loss of appetite splenomegaly
PR interval prolongation on ecg
pt has splinter haemorrhage
osler nodes and janeway lesions
and a new murmur
in a patient with Infective Endocarditis this is an indication for surgery as it can be secondary to aortic root abscess
if a pt with variceal bleed must take an NSAID say for RA which one is best?
celocoxib
coagulase - staphylococci
which abx?
vancomycin - this is nephorgenic however
Upper GI series may show the ‘string sign of Kantour
crohns
narrowed terminal ileum
peri-anal abscess mx?
ceftriaxone + metronidazole.
under anaesthetic and incision and drainage.
crohns cx
peri-anal fistulae
what complication do you want to avoid?
seton drainage trans sphincteris fistuale
division of anal sphincter and incontinence
perianal pain and swelling
no bleeding
fluctuant peri anal swelling
PR not tolerated
what is this?
mx?
anorectal abscess
early drainage- surgical immediately LA
reinfarct MI
diagnostic serum marker?
why?
CK MB clear 72hours
more than 3x upper limit indicative
troponin remains high for 2 weeks
tall tented t waves and a VBG showing hyperkalaemia
nausea vomiting, disturbance in colour vision and palpitations
how do you manage
digoxin toxicity
give digiband
what antibodies associated with psoriatic arthritis?
none - it is seronegative
RA abx?
anti ccp
causes of a long QT interval?
TIMMES
toxins- anti arrhythmatics tricyclin inherited: lange nielson ischaemia myocarditis mitral valve prolapse electrolyte imbalance :hypokalaemia/hypocalcaemia subarachnoid haemorrhage
salmonella and shigella treated with?
ciprofloxacillin
camplylobacter?
macrolide - erythromycin
cholera mx?
tetracycline
high SAAG
what does this mean?
cirrhosis
HF
budd chiari
constrictive pericarditis
hepatic failure
raised portal pressure forcing water into peritoneal cavity whilst albumin remains in vessels = high {difference} between serum and ascitic fluidlow saag causes?
Causes of a low SAAG (<1.1g/dL)
biliary leak Cancer of the peritoneum Tuberculosis and other infections Pancreatitis Nephrotic syndrome
