21 - Vertical Themes (Uni Days) Flashcards
What is a standard LFT panel?
Look at clinical picture, often LFTs are isolated on their own and this is common and normal
What are the different ducts in the HPB system?
What LFTs are raised in hepatocellular injury and cholestasis? What would cause these raised LFTs?
Hepatocellular Injury: infection, malignancy, autoimmune, alcohol, drugs, NAFLD
Cholestasis: pregancy, drugs, biliary atresia, primary biliary cholangitis, gallstones
What are some extended liver screening tests?
What are the different types of jaundice and the causes?
How does haemostasis occur?
Primary clot: see image
Secondary clot:
- Initiation
- Amplification
- Propagation
- Termination
How does post hepatic obstructive jaundice present?
Pale stools and dark urine
What is included in a basic clotting screen?
PT/INR: extrinsic clotting. FVII, V, X, prothrombin and fibrinogen
APTT: FVIII, IX, XI, XII, V, X, prothrombin and fibrinogen
Bleeding Time: platelets
Thrombin time: how long for fibrinogen to fibrin
ALWAYS TAKE FBC TO LOOK AT PLATELETS WITH CLOTTING SCREEN
What are some causes of abnormalities on clotting screens?
- Inherited deficiency of a clotting factor
- Inherited deficiency of or defective von Willibrand factor
- Consumption – clotting factors used up by DIC
- Dilution – massive blood loss when replacement is with IV fluids and red cells only
- Vitamin K deficiency or antagonism (affects factors II, VII, IX and X)
- Liver disease
- Anticoagulants
All clotting factors apart from two are made by the liver, which are these?
vWF
Factor 8
How will clotting screens (PT, APTT, fibrinogen, platelets) be affected in the following:
- Haemophillia A or B
- DIC
- End stage liver disease due to cirrhosis
Platelets adhere to vWF
How will clotting screens (PT, APTT, fibrinogen, platelets) be affected in the following:
- Over anticoagulation with warfarin
- Patient on therapeutic dose LMWH for DVT
What empirical antibiotic should you use for meningitis?
- IV Ceftriaxone
- If over 60 use Ceftriaxone and Amoxicillin for listeria cover
- If allergy use Meropenem
Once cultures have come back can switch to narrower spectrum antibiotic
Why is vancomycin not used for meningitis?
Poor penetration through the BBB
What are some risk factors for a C.Diff infection?
- Recent broad spectrum abx use
- Prolonged hospital stay
- >65
- PPI therapy
- Immunosuppressed
- Chemotherapy
What antibiotics are used for cholecystitis?
- Co-amoxiclav or Metronidazole+Ciprofloxacin or Meropenem
- Also give IV fluids, analgesia and arrange for cholecystectomy
Is meropenem safe in penicillin allergy?
Has a beta lactam ring so can still cause some reactions
Check if patient has true penicillin allergy
How long do patients need to take antibiotics for acute cholecystitis?
- If no surgery due to being too frail then 4-6 weeks
- If cholecystectomy and no perforation none needed after surgery
- If perforation then 5 days post operatively
IV fluids, analgesia, antibiotics
What is evidence based medicine?
Incorporates value based medicine
What are the benefits of value based medicine?
Never assume you and the patient hold the same values!!!
What is the difference between a sign and symptom?
Sign: objective that can be viewed by another person
Subjective: subjective that is only felt by the patient
If asked in an exam what symptoms by the examiner use jargon, if asked to ask the patients about their symptoms DO NOT use jargon
What investigations would you order for this patient?
- Bloods: FBC, U+Es, LFTs, CXR, eGFR, HbA1c, Lipid profile, NT-proBNP
- ECG
- Echocardiogram
- CXR
What signs will you see on a CXR for a heart failure patient?
- Cardiomegaly
- Pulmonary oedema (bilateral infiltrates/Batwing)
- Fluid in right fissure
- Pleural effusion
When do you refer to secondary care for suspected heart failure?
- Refer for echo within 2/52 if NT-proBNP >236
- Refer straight for echo if previous MI
What are the two options for gall bladder removal?
- Laparoscopic cholecystectomy
- Open cholecystectomy
What can you include in your management plan apart from the treatment?
- Self help advice e.g monitor BM, stop smoking
- Escalate to senior
- Analgesia and antiemetic
What do you need to remember to report on a CXR before A-D?
RIPE!!!
What is a silhouette sign?
If you lose a key line then there is consolidation in a specific place
What is this x-ray showing?
Veil Sign
Left upper lobe collapse
What is the exposure with a AXR and what review system should you use?
From diaphragm to pubic symphis
ABDO X
A: air - where it should and should not be- Should only be in the lumen, erect x rays are more sensitive
B: bowel - position, size and wall thickness- 3-6-9 rule
D: dense structures, calcification and bones- calcified renal tract/ gallstones
O: organs and soft tissues- remember lung bases
X: eXternal objects and artifacts
What should you be looking at on a pelvic x-ray?
Joints are SI and pubic symphis
What should you always look for when given an x-ray of a joint?
A second view of the joint!
What two layers is an epidural and spinal anaesthesia between?
Epidural: dura mater and arachnoid mater
Spinal Anaesthesia (subarachnoid space): arachnoid mater and pia mater